DRAFT: Pregnancy risks, p. 1
Risky Sex and Risks of Teen-Age Pregnancy
Art Maerlender, Ph.D. & Kathy Kovner-Kline, M.D., M. Div.
Human reproduction can be seen as a significant stage in the cycle of human sexuality. From birth to adulthood, stages of development reflecting different levels of meaning and expression have been identified. Besides the physical aspects of sexuality, there are complex cognitive and social-emotional developmental processes including capacity for intimacy, affiliation, communication, mutual respect and responsibility. A variety of risks may affect sexuality development at any stage and facet of it, including the timing and situation of pregnancy (Haka-Ikse, K., 1997[1]).
Adolescent pregnancy is seen as an inappropriate expression of sexuality in modern American culture. It has been identified as one of the Dept. of Justice’s (DOJ) serious psychosocial maladjustment problems. Adolescence is usually too young an age to become a parent in the contemporary United States. This is largely because raising a child takes patience and resources that are acquired in advanced societies gradually with age, education, and experience. Moreover, among adolescents, it is those who are least well prepared to nurture and raise a child who are most likely to become parents. That is, adolescents who have substance abuse and behavior problems, who are not doing well in school, who have low aspirations for their own educational attainment, and who live in economically disadvantaged families and communities tend to start sexual intercourse at younger ages. For those, contraception is less effective, and they have unintended pregnancies (Moore, ?[2]). Sexually active teenagers are also at increased risk for contracting sexually transmitted diseases (STD) such as HIV.
This review considers data and research regarding the risks of adolescent (teen-aged) pregnancy in the United States. Teenage pregnancy includes not only those who have live births, but those who become pregnant and lose their children through miscarriage or abortion. The studies reviewed include girls who are married and unmarried, as well as those who have second or more births while under the age of 20. Some research also has looked at the role of male behavior and attitudes in teen pregnancy.
Engaging in sexual intercourse is, of course, one risk factor for pregnancy. However, with current birth control methods, sexual behavior need not be a predictor of pregnancy. Yet early sexual activity is a clear risk factor for later pregnancy, and as such is one rather obvious area of study (i.e., who are the people more likely to engage in early sexual activity), although it, by itself, is not the only risk factor studied. Risk factors for teen pregnancy are, like other psychosocial maladjustment problems, are multi-factorial. Although there is good news regarding the incidence of teen pregnancy, the factors that put children at risk continue to be problematic and point to socio-cultural and well as bio-psychological factors that continue to plague society.
Trends throughout the 1990s have shown a steady reduction in teen birth rates that are now significant for all 50 states. Rates have declined for all adolescent age groups, for all racial and ethnic groups, and for both first and second births to teens. Throughout the 1990s, black teens have had the largest declines in teen childbearing rates of any group. However, U.S. teen pregnancy rates remain among the highest in the industrialized world, and birth rates for Hispanic and black teens continue to be substantially higher than those for non-Hispanic white and Asian or Pacific Island youth (HHS, 2000).
Birth rates for teenagers 15-19 years generally declined in the United States since the late 1950s, except for a brief, but steep, upward climb in the late 1980s until 1991 (Ventura & Mathews, 2001). The youngest group, aged 10-14, showed the lowest birth rates since 1967. The latter decline occurred despite the fact that the population of girls in this age group actually increased during this time period (HHS, 2000). Overall the range of decline in State rates for ages 15-19 years was 11 to 36 percent. Analysis of National census and demographic data indicated that the factors accounting for these declines included decreased sexual activity. The decline was felt to reflect several factors: changing attitudes towards premarital sex, increases in condom use, and adoption of newly available hormonal contraception, implants, and injectables (Ventura & Mathews, 2001).
In reviewing the causes of the explosion in teen birthrates in the 1980’s, Manlove et al (2000) identified specific factors associated with this increase, including negative changes in family environments (such as increases in family disruption) and an increase in the proportion of teenagers having sex at an early age. These authors used data from the 1995 cycle of the National Survey of Family Growth to compare the experiences of three cohorts of teenage females in the 1980s and 1990s. Based on this analysis, they identified several factors associated with the recent decline in the teenage birthrate. These included positive changes in family environments (such as improvements in maternal education), formal sex education programs and discussions with parents about sex, stabilization in the proportion of teenagers having sex at an early age and improved contraceptive use at first sex.
However, even with these improving statistics, almost one million adolescents become pregnant each year ( 19 percent of those who have had sexual intercourse)[3]. Among women aged 15 to 19, 78 percent of pregnancies are believed to be unintended[4].. Another disturbing trend is that in the mid- 1990s age of first intercourse was happening younger than in the 1980s thus expanding the age-range and increasing the risks of becoming pregnant while a teenager (Manlove et al, 2000).
Eisen et al (2000) analyzed the YRBS data and found that those who engaged in any “risk behaviors” tended to take part in more than one risky behavior, and that many health risk behaviors occurred in combination with other risky activities[5]. Other studies have found that prior substance use increases the probability that an adolescent will initiate sexual activity, and sexually experienced adolescents are more likely to initiate substance use – including alcohol and cigarettes (Mott & Haurin, 1988; this finding was replicated in Lammers, 2000)[6]. The 1997 YRBS data confirmed that teens who use alcohol or drugs are more likely to have sex than those who do not: Adolescents who drink are seven times more likely, while those who use illicit substances are five times more likely – even after adjusting for age, race, gender, and parental educational level (CASA, 1999). Thus, engaging in many types of risky behavior often includes sexual activity that can lead to pregnancy and unintended fatherhood.
Drugs and Sex
In this regard, the role of substance use and sexual activity is of particular concern. Sexual activity and substance use are common among youth today. These are behaviors that are far more acceptable in adults, but appropriately unacceptable in teenagers. According to the Centers for Disease Control and Prevention, 79 percent of high-school students report having experimented with alcohol at least once, and a quarter report frequent drug use[7]. As noted above, half of all 9th -12th graders have had sexual intercourse, and 65 percent will by the time they graduate. While it has been difficult to show a direct causal relationship, there is some evidence that alcohol and drug use by young people is associated with risky sexual activity[8].
Results from a Kaiser Family Foundation survey, together with other recent research, paints a troubling picture of the relationship between alcohol use, sexual activity and unintended pregnancies among adolescents. One-quarter of sexually active 9-12 th grade students report using alcohol or drugs during their last sexual encounter, with males (31%) more likely than females (19%) to have done so (Centers for Disease Control, 2000). Up to 18 percent of young people aged 13 to 19 report that they were drinking at the time of first intercourse, and among teens aged 14 to 18 who reported having used alcohol before age fourteen, 20 percent said they had sex at age fourteen or earlier (compared with seven percent of other teens: CASA, 1999).
The use of condoms has been proposed as an important preventative method for the transmission of sexually transmitted diseases and an effective contraceptive method for those who choose to engage in premarital sexual intercourse. Use of condoms is a factor in the link between sexual activity and drug abuse. The more substances that sexually active teens and young adults have ever tried, the less likely they are to have used a condom the last time they had sex: Among those aged 14 to 22, 78 percent of boys and 67 percent of girls who reported never using a substance said that they used a condom, compared with only 35 percent of boys and 23 percent of girls who reported ever having used five substances[9]. Teen girls and young women aged 14 to 22 who have recently used multiple substances are less likely to have used a condom the last time they had sex: 26 percent of young women with four recent alcohol or drug use behaviors reported using a condom at last intercourse, compared with 44 percent of those who reported no recent alcohol or drug use. By their own report, fifty percent of adolescents surveyed acknowledge that having sex while drinking or on drugs is often a reason for unplanned teen pregnancies[10] (CASA, 1999, KFF, 1996).1,15 Thus, youth who engage in sex while using drugs are less likely to use condoms and are at greater risk of unintended pregnancy. Of course, this makes perfect sense as the effects of drugs interfere in rational thought processes, or controlled behavior.
BIOLOGICAL RISK FACTORS
In a review of the research on teen pregnancy, Miller at al (2001) noted several biological factors that were related to adolescent pregnancy risk, notably timing of pubertal development, hormone levels, and genes. These factors were relevant because of their association with adolescent sexual intercourse.
Early puberty, looking older, etc., are likely genetically linked, but the consequences are manifest within later psycho-social contexts. These physical traits has been associated with other psycho-social maladjustment problems that in themselves increase the risks of pregnancy (see Orr, 1991[11]), such as self-esteem (Anderson et al, 1989) depression (Angold et al, 1992) and delinquency (Silberstien et al 1989). In addition, early puberty is probably less a risk factor in an optimal family-social environment (Miller, 2001). Thus, early physical maturation impacts development in ways that put the child at risk later in life, so they are not as notable early on.
PSYCHOLOGICAL FACTORS
Sexual Behaviors
In 1997, Resnick noted a sharp increase in sexual behavior between 7th-8th graders and 9th-12th graders. Approximately 17% of 7th and 8th graders and nearly half (49.3%) of 9th through 12th graders indicated that they had ever had sexual intercourse. Further, among sexually experienced females aged 15 years and older, 19.8% reported having ever been pregnant.
A history of pregnancy was associated with length of time since age of sexual debut, thus, the earlier the onset of sexual behavior, the greater the risk of becoming pregnant by the end of high school (Manlove et al, 2001; Resnick, 1997). Protective factors included perceived (negative) consequences of becoming pregnant and use of effective contraception at first and/or most recent intercourse (Resnick, 1997).
Of concern is the increasingly sexualized behavior of younger and younger students. While no studies have yet been published, a number of 3rd and 4th grade teachers have reported to the first author of their concern about the sexual talk and actions of students in their classrooms. Inappropriate language and grabbing behaviors are reportedly on the rise. Descriptions of adult sexual activity is frequent.
Cognitive Status
Intelligence has generally been shown to be inversely related to problem behaviors. A very few studies have looked at the role of intelligence and the initiation of sexual activity. Unfortunately, potential sampling biases have made many of them susceptible to criticism of inflated relationships. Halpern (2000) reports on only two studies that suggested a relationship between early sexual activity and intellectual functioning, both demonstrating the same inverse relationship[12].
Halpern et al (2000[13]) analyzed data from two large samples (National Longitudinal Study of Adolescent Health and The Biosocial Factors in Adolescent Development), looking specifically at the relationship of a general measure of verbal-intellectual function and the timing of first intercourse. They found distinct differences in results for early adolescents (those younger than 15 years old) and older adolescents. For the older adolescents, both lower and higher scores on the test appeared to be protective of sex initiation, while more middle, or average scores were a risk factor. After controlling for age, pubertal development, and mother's education, adolescents who were at the upper and lower ends of the test score distribution (i.e., ±1 standard deviation or more) were less likely to have had sex. Racial differences were not significant, but the relationship did vary by age. Among early adolescents (<15 years old), the relationship is primarily linear and inverse; that is, lower test scores indicate a greater likelihood of having intercourse, while higher test scores indicate a lower probability. The data also indicated that even pre-coital behaviors, such as holding hands and kissing, were inversely related to test scores. The authors noted that this finding suggested that higher intelligence was associated with a generalized delay in the onset of all partnered sexual activities (Halpern, et al, 2000).
Halpern et al comment that the range of scores reflecting greatest risk was between an IQ equivalence of 75 and 90 (2000). This is the same range noted for higher risks for may problem behaviors. They note that scores in this range are likely reflective of other processes. Adolescents with higher intelligences do demonstrate stronger commitments to conventional attitudes and institutions (see Social factors, below). These values serve to help postpone sexual activity (though they have no relationship to sexual interest). On the other end of the spectrum, those with the lower scores appear to be protected by fewer opportunities as well as adult “gatekeepers” who exert protective influence.
Attitudes and beliefs
A variety of different personal attitudes and beliefs are associated with risks for teen pregnancy. In Lammers’ study (2000), high levels of body pride were associated with higher levels of sexual activity for all age and gender groups. In addition to the links between drugs and sexual behavior in adolescents, there is also a link between attitudes towards violence. Steuve, et al (2001) found that positive attitudes towards early initiation into sex for both girls and boys was related to violence. These individuals also held positive attitudes to a wide range of conduct problems, including violence, and substance abuse. This is supported by other studies that show that aggressive females are at greater risk for teen pregnancy.
There is some growing evidence that fear of contracting sexually transmitted diseases (STD) is protective against early intercourse and early pregnancy (see Kirby, 2001[14]). Thus, it would seem that those without the knowledge or fear of STD’s might be at greater risk. In support of an education as protective argument, several studies have shown that comprehensive sex education classes are responsible for delays in first intercourse experiences, while abstinence-only education has not been shown to be effective. Bearman and Bruckner (2001[15]) studied the outcome of a substantial faith-based movement within the Baptist Church. A movement to take “virginity pledges” was initiated in 1993 with over 2.5 million youth vowing to maintain virginity until marriage. This movement gained considerable publicity because of its acknowledged success in reducing the rate of teen pregnancy within that population. The results of the movement and the study were over-interpreted (see Risman and Schwartz (2002[16]). Both Risman and Schwartz, and Bearman, and Bruckner in the original article, point out that the effectiveness of abstinence pledges was related to a group membership phenomena and thus highly restricted in its effectiveness. Age effects were noted, as well as a group phenomenon. It appeared that the pledges only served as protective within ‘groups’ of a particular size. That is, when adolescents pledged as part of a small group activity, it was effective. When that group became too large, or too small, it was not as effective.
Violence and Aggression
As noted above, patterns of childhood aggression are related to adolescent pregnancy. Miller-Johnson replicated an earlier study that demonstrated (i.e., M. K. Underwood et al, 1996) that girls who were aggressive as children (3rd-5th grade) were more likely to become mothers as teenagers. In addition, girls who displayed stable patterns of childhood aggression were at a significantly higher risk not only to have children as teenagers, but to have more children and to have children at younger ages (Miller-Johnson, 1999).