versão impressa ISSN 1519-3829
Rev. Bras. Saude Mater. Infant. v.8 n.3 Recife jul./set. 2008
ARTIGOS ORIGINAIS ORIGINAL ARTICLES
Sexual activity among female teenagers: a comparison between two groups of middle class adolescents from a private clinic according to pregnancy status
Atividade sexual em mulheres adolescentes: uma comparação entre dois grupos de adolescentes de classe média de clínica particular de acordo com estado gravídico
Alexandre Faisal-CuryI; Paulo Rossi MenezesII
IHospital Section of Epidemiology. University Hospital. University of São Paulo. Av. Prof. Lineu Prestes, 2565. São Paulo, SP, Brasil. CEP: 05.508-900. E-mail: firstname.lastname@example.org
IIDepartment of Preventive Medicine. University of São Paulo. São Paulo, SP, Brasil
OBJECTIVES: to investigate patterns of sexual activity among teenagers.
METHODS: a cross-sectional study was conducted between July 1998 and September 2000, among 117 sexually active female adolescents from a private clinic, in the city of the Osasco, State of São Paulo, Brazil. They were divided into two groups: one pregnant group (PG) comprised 62 adolescents that were either pregnant (46) or had previously been pregnant (16); another group of 55 female adolescents that had never been pregnant (NPG). During consultations with these subjects, a physician conducted a semi-structured interview. Knowledge, attitudes and practices relating to sexual activity were evaluated. The comparison between the two groups was carried out using Student's t test, the chi-square test or Fisher's exact test.
RESULTS: the two groups showed considerable similarities in terms of sexual behaviour, having engaged in the first sexual intercourse at the age of 15 and having had an average number of sexual partners of 1.5. Nevertheless, adolescents in the PG group had initiated sexual life earlier and tended to use less contraceptive methods during the first intercourse. Despite widespread knowledge of contraception, a large number of the adolescents did not use any contraceptive method during first sexual intercourse. In their current sexual life, an average of 81% of the participants referred to attaining orgasm.
CONCLUSIONS: knowledge about contraceptive techniques is not enough to avoid unplanned pregnancies, suggesting the importance of investigating other psychosocial aspects of motherhood and maternal identity among teenagers.
Key words: Adolescents, Pregnancy, Contraception, Sexuality
OBJETIVOS: investigar padrões de atividade sexual em adolescentes.
MÉTODOS: estudo transversal realizado entre julho de 1998 e setembro de 2000, com 117 mulheres adolescentes sexualmente ativas oriundas de clínica privada, em Osasco, São Paulo, Brasil. Foram constituídos dois grupos: um grupo de grávidas (PG) com 62 adolescentes que estavam grávidas (46) ou tiveram gravidez prévia (16); outro grupo não grávidas (NPG), com 55 adolescentes que nunca engravidaram. Uma entrevista semi-estruturada foi conduzida pelo médico durante consulta clínica. Foram avaliados o conhecimento, atitudes e práticas acerca da atividade sexual. A comparação entre os grupos foi feita por meio do teste t de Student, qui-quadrado e teste exato de Fisher.
RESULTADOS os dois grupos eram similares quanto aos aspectos sexuais, sendo a coitarca na idade de 15 e a média do número de parceiros, 1,5. Entretanto, adolescentes no PG iniciaram vida sexual mais cedo e usaram menos métodos contraceptivos na primeira relação sexual. Apesar do grande conhecimento sobre contracepção, parte considerável das adolescentes não usou nenhum método durante a coitarca. Na vida sexual atual, cerca de 81% das participantes refere atingir orgasmo.
CONCLUSÕES: o conhecimento sobre técnicas contraceptivas não é suficiente para evitar gestações não planejadas, sugerindo a importância de investigar outros aspectos psicosexuais da maternidade e identidade materna entre adolescentes.
Palavras-chave: Adolescentes, Gravidez, Anticoncepção, Sexualidade
Adolescents comprise a unique subset of obstetric-gynaecological patients, ranging from those in early adolescence (aged 10-15 years) to those in later adolescence (aged 16-19 years). Adolescence is a period of life characterised by a variety of changes and decisions, many of which are centred on growing awareness and expression of sexuality and individuality.1 Adults have been always concerned about adolescence sexual behaviour, sexual intercourse and its consequences. Recently, there has been a significant change in parents', health professional's and educators'ability to prevent the serious consequences of these behaviours and to help adolescents avoid behaviours that put them at risk.2 Special attention should be given to specific pro-blems, including sexually transmitted diseases, contraception, and pregnancy.
For a young mother, having an intercourse at an early age, not using contraceptives and having a child are linked to depression, low self-esteem and little sense of control over their lives.3 In addition, adolescent mothers and their infants are at risk because of socio-economic disadvantages, limited job opportunities, the school dropout rate and poor education, lack of access to health care, inadequate parenting skills, and repeated pregnancies. Nevertheless, by the age 19, 71.4% of unmarried women in urban areas report at least one experience of coitus.4
The beginning of sexual activity and choice of contraception may be influenced by factors such as gender, and socio-economic and marital status. In the United States, Santelli et al.5 found a lower risk of young age at first coitus among married women. In Nicaragua, Zelaya et al.6 observed that age at first pregnancy was lower among those having less formal education.
In Brazil, pregnancy in adolescence is a serious public health problem, associated with low levels of formal education. Nevertheless, there has also been a significant increase in pregnancy rates among teenagers from higher level socio-economic groups. In the city of São Paulo, during the year 2002, there were 22,482 deliveries among adolescents served by the public sector, corresponding to 21.4% of all deliveries.7
The objective of our research was to investigate knowledge, attitudes and patterns of sexual activity among middle-class teenagers, attending a private clinic, and to discover whether there are any significant differences between adolescents who have never been pregnant (never pregnant group) and those adolescents who are pregnant or have previously been pregnant (pregnant group). Data for adolescents from private services may be important, since 36.4% of women, aged between 15 and 24 years, in the State of São Paulo, in 1998, had private health insurance.7
We performed a cross-sectional study between July 1998 and September 2000 involving sexually-active female adolescents from a private clinic, in the city of Osasco, State of São Paulo, Brazil. Osasco is located on the western side of the greater metropo-litan area of São Paulo.
The obstetrics-gynecology clinic serves middle-class women, most of them with private health insu-rance. Participants were recruited among adolescent girls aged 14 to 20, seeking routine gynaecological consultation. Participation in the study was voluntary. All participants were attended by the same professional (AFC). Written informed consent for participation was obtained in all cases. The study was approved by the Ethics Committee of the Renascença Hospital. One hundred and seventeen sexually-active teenagers accepted the invitation. None refused.
After data was collected, patients were divided in two groups, according to pregnancy status. One pregnant group comprised 62 adolescents that were either pregnant or had previously been pregnancy; another comprised female adolescents who had never been pregnant. Results will be presented according to these aspects, given that they are associated with patterns of sexual behaviour.
The physician conducted a structured interview in the course of the consultation. The interview focused on demographic data, obstetrical history, and patterns of emotional and sexual behaviour, knowledge of contraception and the contraception method employed during the first experience of intercourse. Adolescents were asked to classify their parent's attitudes to sexual education into three categories: educator, absent or repressive.
Descriptive and univariate analyses were carried out. Comparison between groups was performed using Student's t test (for continuous data) and the chi-square test or Fisher's exact test (for qualitative data). The level of significance was set at 5%. Statistical analysis was performed using the Stata 8 software.
One hundred and seventeen teenage girls were included: 62 either were pregnant or had a history of pregnancy, and 55 had no history of pregnancy. A comparison of demographic features showed that the two groups were similar. The average age of these patients was close to 18 years old (PG=17.9 x NPG=18.0; p=0.70) and menarche had occurred around 12 years of age (PG=12.2 x NPG=12.0; p=0.24). The partner's age at first intercourse (PG=21.2 x NPG=20.7; p=0.59) and the age of the current partner were similar (PG=24.3 x NPG=22.9; p=0.12). There was no difference in level of education between the two groups (p=0.13). Nevertheless, living with a partner was commoner in the PG (79.0% x 13.0%; p<0.001). Almost all participants were in school at the time of the interview.
In the case of sexual factors, there were few significant differences between the groups. Adolescents in the PG had first had sexual intercourse at an average age of 15.2, while adolescents in the NPG had had sexual intercourse on average by the age of 16.0 (p=0.01). Although 43% of participants said they could foresee the possibility and opportunity of a first sexual relation, over 40% of adolescents in the PG did not take any contraceptive precautions. In the NPG this figure was 13.7% (p=0.002). Most teenagers reported that they knew of contraceptive methods at the time of their first experience of sexual intercourse (PG=85.5% x NPG=86.8%). Condoms (45.0%) and oral contraception (23.0%) were the most commonly used methods during the first experience of intercourse. In their current sexual life, over 80% of the adolescents reported having reached orgasm. The teenagers in the PG had sexual intercourse more frequently per month (12.7 x 8.9; p=0.01). The average number of sexual partners was 1.5, showing no difference between groups (p=0.54). Categorical and conti-nuous data are summarised in Tables 1 and 2.
This study compares the knowlegde, attitudes and practices of the two groups of adolescents: one that was (or had been) pregnant (pregnant group) and another of nulliparous women (never pregnant group). Before presenting our data, we should mention that our paper has a number of limitations. The study design does not allow any conclusions to be drawn regarding the causal relationship between the adolescents' socio-demographic characteristics and previous attitudes and the risk of becoming pregnancy. Since most participants were students at the time of interview, we could not obtain any information about income. Another factor is that some of the responses may be "socially acceptable". We would expect that adolescents with a large number of partners to feel too embarrassed to mention this fact. Finally, the study involves only a small sample of adolescents that are covered by private health insurance. These results could be different for other groups of adolescents.
The results for the characteristics of sexual activity among female teenagers reveal five relevant features. First, although these teenagers initiated sexual activity around the age of 15, this did not necessarily lead to subsequent extensive sexual experimentation, given the mean number of partners of 1.5. Over 90% of the adolescents had had the same partner since their first experience of intercourse. In the NPG this figure was as high as 98.4%, which borders on the statistically significant (p=0.06). Research among other Latin American populations has found similar results.8 However, authors have observed an even lower mean age for first coitus, in the United States9 and Africa.10 A large number of sexual partners may be limited to a small group of adolescents. It is possible that a small subset of adolescent girls that report having multiple sexual partners are more likely to report other problem-prone health behaviours (such as cigarette use and drinking).
Second, despite the widespread knowledge of contraception, over 40% of adolescents in the PG did not use any contraceptive method during their first experience of sexual intercourse. It is possible that, at this time (first intercourse), this attitude of "taking less precaution" may suggest that the teenagers thought that there was only a very small chance of pregnancy occurring on this occasion. The hypothe-sis also needs to be considered that some of these patients either did not mind whether they got pregnant or unconsciously desired to become pregnant. It is possible that magical and omnipotent defensive thoughts and defensive mechanisms interfere in such behaviours. Nevertheless, an association between lower level of education and pregnancy has been observed.6 On the other hand, the fact that the PG adolescents initiated sexual activity earlier and used less (or no) contraceptive methods suggests there are some differences between these two groups of teenagers. It can at least be speculated that adolescents in the PG were less worried about pregnancy in the early stages or at the beginning of their sexual life. Given the fact that both groups of teenagers come from the same environment and share the same demographic background, it is hard to establish the influence of specific psychological characteristics of the PG adolescents that contribute to a different form of sexual behaviour. The fact is that studies in Brazil have shown changes in the social status of teens that became pregnant, at least in the lower socio-economic strata of the population. Motherhood and married status are associated with higher status in these communities for the adolescents, particularly for women.11
A qualitative study involving Latin American adolescents has shown that, when there is a lack of information and family beliefs prohibiting birth control use and sexual activity, sexually active teenagers have higher rates of contraceptive non-use and rely on irregular use of condoms and withdrawal for pregnancy prevention.12
Condoms (45.0%) and oral contraceptives (23.0%) were the most commonly used methods during the first intercourse. Overall, almost 30% of adolescents did not use any method on this occasion. According to a Brazilian study carried out in São Paulo with students aged between 12 and 18 years, in 1998, one of the forms of behaviour that brings the highest risks for health among public schools students was not using a condom during the last sexual inter-course (34% among those sexually active).13 Other studies have also addressed the issue of knowledge and attitudes regarding sexuality among various samples of teenagers and young adults. In a quali-quantitative study, of 925 university students, Pirota and Schor14 found that 80% of females had their first intercourse by the age of 19. Considering the group as a whole, 44.5% and 16.4% were using condom and oral contraceptive, respectively. Only 4.0% of the sample was not using any method. Belo et al.15 carried out a study involving 156 pregnant teenagers aged 19 or over. The first sexual intercourse was at the age of 14.5 and almost 70% were not using any contraceptive method before getting pregnant. Interestingly, the main reason reported for not using any contraceptive method was "wanting to get pregnant". Similar to our results, both studies have shown that most adolescents are well aware of the importance of contraceptive methods, particularly condoms and oral contraception. Nevertheless, one study clearly showed that there is a significant decreased in condom use from the first sexual intercourse to the most recent one. Prevalence of condom use drops from 80.7%, for females, and 88.6%, for males, at the beginning of sexual life, to 38.8% and 56%, respectively, on the occasion of the last act of sexual intercourse.16
Third, in all three groups, 60% of adolescents did not foresee their first sexual relation, suggesting that impulsive behaviour may play a role in initiating sexual activity. However the complexity of this subject is well known. For instance, according to Brazilian teenagers, the beginning of sexual activity is not restricted to the first intercourse, but occurs over an extended period involving a variety of sexual practices. Moreover, female teenagers have to deal with their partners and with their own beliefs in order to decide on a specific contraceptive method. In this way, the inadequate (or lack of) use of any contraceptive method may be regarded as a vulne-rable moment in a specific social context and particular relationship.11
Fourth, the adolescents seem to be satisfied with their sexual life, as suggested by the high numbers reporting attaining orgasm. It seems that, even though the beginning of their sexual life was not planned, somehow they managed to adapt to it and enjoy it. The adolescents in the PG had a higher frequency of monthly sexual relations. This may be explained by the fact that they frequently started living together once they got pregnant, shortly after initiating sexual activity. A planned marriage is very uncommon among these adolescents.
Finally, we could not find any association between the way the adolescents see their parents regarding sexual education and risk of having had a pregnancy. Few papers have described the importance of connectedness to family and father's participation in adolescents sexual education as a protective factor, associated with diminished risk-related behaviour and the initiation of sexual activity.8,17 A Brazilian study involving pregnant adolescents showed that over 70% of them were in the care of their mothers.18 Likewise, adolescents that are able to discuss sexual matters with their mothers have a lower risk of becoming pregnant.19
We may conclude that knowledge of contraceptive techniques is not enough to avoid unplanned pregnancies, suggesting the importance of investigating other psychosocial aspects of motherhood and maternal identity among teenagers. In this middle class group of teenagers, pregnancy was associated with age and use of any kind of contraception during first intercourse. It is possible that once they get pregnant, adolescents started living with the partner and began to have intercourse more. Programs addressing sexual activity and risk-related behaviour among teenagers are needed to tackle this issue.
1. ACOG (American College of Obstetricians and Gynecologists). The adolescent obstetric-gynecologic patient. Washington, DC; 1990 (Technical Bulletin 145). [ Links ]
2. Brown RT. Adolescent sexuality at the dawn of the 21st century. Adolesc Med. 2000; 11: 19-34. [ Links ]
3. Kowaleski J, Mott FL. Sex, contraception and chilbearing among high-risk youth: do different factors influence males and females? Fam Plann Perspect. 1998; 30: 163-9. [ Links ]
4. McAnarney ER, Hendee, WR. Adolescent pregnancy and its consequences. JAMA. 1989; 262: 74-7. [ Links ]
5. Santelli JS, Brener ND, Lowry R, Bhatt A, Zabin LS. Multiple sexual partners among US adolescents and young adults. Fam Plann Perspect. 1998; 30: 271-5. [ Links ]
6. Zelaya E, Marin FM, Garcia J, Berglund S, Liljstrand J, Persson LA. Gender and social differences in adolescents sexuality and reproduction in Nicaragua. J Adolesc Health. 1997; 21: 39-46. [ Links ]
7. SEADE (Fundação Sistema Estadual de Análise de Dados). Partos e média de permanência de internação no Sistema Único de Saúde de São Paulo - SUS/SP, por tipo de parto, segundo grupos de idade da mãe 2002 [monografia online][acessada em: 10 jul. 2008] Disponível em: www.seade.gov.br/produtos/msp/index.php?tip=met4&opt=s&tema=SAU&subtema=2. [ Links ]
8. Padilla de Gil M. Salud sexual en la adolescencia en El Salvador. Rev Soc Chil Obstet Ginecol Infant Adolesc. 2001; 8: 85-94. [ Links ]
9. Coyne-Beasly T, Ford CA, Waller MW, Adimora AA, Resnick MD. Sexually active students' willingness to use school-based health centers for reproductive health care services in North America. Ambul Pediatr. 2003; 3: 196-202. [ Links ]
10. Abdulkarim AA, Mokuolu OA, Adeniyi A .Sexual activity among adolescents in Ilorin, Kwara State, Nigeria. Afr J Med Med Sci. 2003; 32: 339-41. [ Links ]
11. Brandão ER, Heilborn ML. Sexualidade e gravidez na adolescência entre jovens de camadas médias do Rio de Janeiro, Brasil. Cad Saúde Pública. 2006; 22: 1421-30. [ Links ]
12. Gilliam ML, Warden MM, Tapia B. Young latinas recall contraceptive use before and after pregnancy: a focus group study. J Pediatr Adolesc Gynecol. 2004; 17: 279-87. [ Links ]
13 Carlini-Cotrim B, Gazal-Carvalho C, Gouveia N. Health behaviors among students of public and private schools in S.Paulo, Brazil. Rev Saúde Pública. 2000; 34: 636-45. [ Links ]
14. Pirotta KCM, Schor N. Intenções reprodutivas e práticas de reprodução da fecundidade entre universitários. Rev Saúde Pública. 2004; 38: 495-502. [ Links ]
15. Belo MAV, Pinto e Silva JL. Conhecimento, atitude e prática sobre métodos anticoncepcionais entre adolescentes gestantes. Rev Saúde Pública. 2004; 38: 479-87. [ Links ]
16. Teixeira AMFB, Kanuth DR, Fachet JMG, Leal AF. Adolescentes e uso de preservativos: as escolhas dos jovens de três capitais brasileiras na iniciação e na última relação sexual. Cad Saúde Pública. 2006; 22: 1385-96. [ Links ]
17. Anteghini M, Fonseca H, Irelad M, Blum RW. Health risk behaviours and associated risk and protective factors among Brazilian adolescents in Santos, Brazil. J Adolesc Health. 2001; 28: 295-302. [ Links ]
18. Lima CTB, Feliciano KVO, Carvalho MFS, Souza APP, Menabó JBC, Ramos LS, Cassundé LF, Kovacs MH. Percepções e práticas de adolescentes grávidas e de familiares em relação à gestação. Rev Bras Saúde Matern Infant. 2004; 4: 71-83. [ Links ]
19. Heilborn ML, Aquino EML, Knauth D, Bozon M. O aprendizado da sexualidade: um estudo sobre reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: FIOCRUZ; 2006. [ Links ]
Recebido em 2 de setembro de 2006
Versão final apresentada em 4 de março de 2008
Aprovado em 16 de maio de 2008