THE STATISTICS

Sexual Activity

In 1995, the Centers for Disease Control's (CDC's) national school-based Youth Risk Behavior Survey (YRBS) 13 found that 53% of students in all grades reported being sexually experienced, with 17% having been involved with four or more lifetime partners. By the end of their senior year, nearly three out of every four male students (70%) and two-thirds of all female students (66%) had experienced sexual intercourse at least once, and 7% reported that they either had been pregnant or had impregnated a partner. Nine percent had even initiated sexual intercourse before they were age 13. African-American students (73%) were significantly more likely than White and Hispanic students (49% and 58%, respectively) to have ever had sexual intercourse (Table 20.1). These data were not singularly different from those found in the 1993 YRBS.14

The proportion of adolescent females who report being premaritally sexually experienced not only has increased dramatically over the past two decades but is the culmination of a trend that began at the turn of the 20th century and clearly suggests a fundamental and permanent societal change in teenage girls' sexual behavior. Despite their many statistical flaws and dominantly Caucasian subjects, Kinsey's surveys in the 1940s still provide significant information.15,16 Kinsey found that among women born before 1900, only 3% were premaritally sexually experienced by age 18—and this usually during the period of engagement with their fiancé But for those born just a few years later, or after 1900, the number increased sixfold to 18%, again primarily with a fiancé The incidence of sexual activity among adolescent boys, however, has not changed a great deal. In Kinsey's time, 40% of men reported that they were experienced by age 15 and 60% by age 17. The cardinal difference between past and present patterns of adolescent male sexual activity is

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TABLE 20.1 PERCENTAGE OF HIGH SCHOOL
STUDENTS WHO REPORTED ENGAGING
IN SEXUAL INTERCOURSE BY ETHNICITY/
RACE, GRADE, AND HAVING FOUR
OR MORE LIFETIME PARTNERS—UNITED
STATES, 1993 AND 1995

1993			1995
	Female	Male	Total	Female	Male	Total
SOURCES: Centers for Disease Control (1995 [14],1996 [13]).
Ethnicity/race
White	47.4	49.8	48.4	49.0	48.9	48.9
Black	70.4	89.2	79.7	67.0	81.0	78.4
Hispanic	48.3	63.5	56.0	53.3	62.0	57.6
Grade
9th	31.6	43.5	37.7	32.1	40.6	36.9
10th	44.9	47.4	46.1	46.0	50.0	48.0
11th	55.1	59.5	57.5	60.2	57.1	58.6
12th	66.3	70.2	68.3	66.0	67.1	66.4
Four+partners	15.0	22.3	18.8	14.4	20.9	17.8
Total	50.2	55.6	53.0	52.1	54.0	53.1

that much of the earlier cohort's experience was with prostitutes in contrast to the dating partner of today. Among women born somewhat later (between 1938 and 1940), approximately one in four was sexually experienced by age 18. There was a modest increase of 25% for the 1947–1949 birth cohort but a 100% increase among those born between 1956 and 1958 (Figure 20.1).17 In subsequent years there again has been a further doubling in the prevalence of sexual activity with approximately twice as many 15-to 19-year-old young women (53%) being sexually experienced in 1995 as were experienced in 1970 (28%) (Figure 20.2).18,19

There has, however, been a recent modest drop in the proportion of both teens who are sexually active, as evidenced in the CDC's series of high school youth surveys,13,14,19 and females, as seen in the 1995 National Survey of Family Growth (NSFG).20 In the 1990YRBS, 59% of all students reported that they were sexually experienced as compared to 55% in 1991 and 53% in 1995. Over the same period, there was a drop of 3%, from 40% to 37%, in the number of students reporting two or more lifetime partners and a decrease of 6% for four or more partners.

In the 1995 NSFG, the percentage of teenage females aged 15 to 19 years declined to a slightly greater degree (Figure 20.2), with only

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50% reporting that they ever had sexual intercourse as compared to a peak of 55% found in 1990. According to a series of surveys conducted by the Urban Institute for the National Institute of Child Health and Development, a similar reversal in trends has been reported for teenage males, with a decline in the number of males who report that they are sexually active declining from 60% in 1988 to 55% in 1995.21

Despite the overall drop in the percentage of sexually active youth found in these surveys, a return to universal teen abstinence is highly unlikely. First, taking an overall figure is misleading in not considering the data by both ethnicity and age (Table 20.1). A closer examination of YRBS findings reveals that three-quarters of all Black adolescents continue to be sexually active, that rates among Hispanic girls are increasing, that more 11th-grade females of all ethnicities were sexually active in 1995 than in 1993, and that the percentage of sexually active 12th-grade females has not changed. Second, the trend toward an increasing incidence of premarital sexual intercourse, particularly among teenage girls, has taken place over a span of nearly nine decades and can only be seen as reflecting a major and persistent societal change in normative adolescent behavior. It is clear that a substantial number of teenagers will continue to be at risk from sexual activity and that initiatives promoting abstinence alone will be far from sufficient to meet the task of protecting our adolescents from serious health harm.

The initiation of sexual activity appears to be determined by the interaction of a number of biological, psychological, cultural, and social factors, either singly or severally, including early pubertal onset (particularly in girls), cognitive immaturity, ethnicity, dysfunctional home situations, past physical or sexual abuse, chronic depression, poor self-esteem, absence of future plans, poor schooling, and economic disadvantage.22–33 Most of these studies also show a significant association of an early coital debut, multiple partners, choice of a high-risk partner, and nonuse of protection with a wide range of other problem behaviors, such as alcohol use, marijuana use, school problems, minor delinquent acts, depression, and suicide attempts. Only Stanton 34 showed no such relationship in a survey of African-American youths in a public housing project. These adolescents perceived sex as being in a very different domain.

None of these studies, however, assess the degree to which these other associated risk behaviors are within the experimental or committed range and the degree to which they can be considered truly dysfunctional and deviant. Further, all persons are sexual beings from the time of birth, and the exploration of intimacy in general is a normal behavior for adolescents

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as well as adults. It is the progression of intimacy to sexual intercourse prior to marriage that violates conservative moral values. But when the increase in the incidence of adolescent female sexual intercourse has taken place over the course of many decades and when half of all teenagers are sexually experienced, this behavior can well be interpreted as reflecting fundamental cultural change and as now being within the range of normal behavior for older teens. The risk is not so much in the fact of being sexually active, provided that the couple are relatively mature, no exploitation is involved, and the choice has been willingly, rationally, and responsibly made as it is in the adverse consequences when protection is not used. Younger adolescents who are cognitively immature and have not yet established effective decision-making skills are quite another matter and do cause developmental concern; they are far less likely to be discriminating in their partner choice or to use consistent protection and much more likely to be coerced into sexual intercourse against their will or otherwise exploited.

Pregnancy

As previously noted, about one million teenagers become pregnant each year.2 In 1990, 11% of all adolescent girls became pregnant, 5% gave birth, 3.3% had an out-of-wedlock birth (although many in-wedlock births were premaritally conceived), 4.6% had an abortion, 1.5% experienced a miscarriage, and only 0.13% gave up their baby for adoption.35 Another way of looking at this epidemic is to state that 43% of the approximately 17 million teen females in the United States will become pregnant at least once before they reach their 20th birthday.36 Further, the vast majority of current teen births are out of wedlock. In 1960, only 15% of all adolescent births were to single mothers, but by 1993 this figure had increased nearly fivefold to 72% (Figure 20.3).37 Rates are highest among teenagers of Mexican, Puerto Rican, and African-American ethnicity, as they are for Mexican, Puerto Rican, and African-American women of all age-groups.38

There has, however, been a recent reversal in the birth rate to teens (Figure 20.3). Although the rate among 15- to 19-year-olds rose by nearly 10% from 53.0 births per 1,000 in 1980 to a high of 62.1 per 1,000 in 1991, the subsequent three years saw a drop of 3% to a rate of 58.9 per 1,000 in 1994.37 This drop, however, was considerably less (only 1%) when 18- to 19-year-olds were excluded, with rates for 1980, 1991, and 1994 among 15- to 17-year-olds being 32.5%, 38.7%, and

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37.6%, respectively. It is apparent that efforts to reduce the pregnancy rate among younger high school girls have been limited at best.

Whatever decrease in adolescent birth rates has occurred is almost exclusively due to more effective contraception (particularly among older teens), not a higher incidence of abortions—which actually has declined—or a reduction in the percentage of sexually active youths, which has only modestly changed. Further, despite this recent decline, the 1994 teen pregnancy rate is still higher than in any year prior to 1990.

California is no exception to high teen birth rates and, in fact, has a substantially higher 15- to 19-year-old rate (68 per 1,000) than the national average (58.9 per 1,000).39 Here too, however, there has been a significant drop of 5.5% from 69.9 births per 1,000 population in 1993 to 64.4 per 1,000 in 1995. These statistics, however, do not reflect the wide geographic variation within the state with singularly high teen birth rates ranging from 92 to 100 per 1,000 15- to 19-year-olds and comprising 18% to 20% of all births reported in Fresno, Kern, Kings, Madera, Merced, and Tulare, all agricultural counties, with the largest number of births (both adolescent and adult) being to mothers of Hispanic ethnicity.40 Nor do these figures represent the true scope of the problem, as California has an even higher adolescent pregnancy rate than reflected in teen birth statistics alone. In 1992, this state had both the highest total number of estimated abortions (338,700) and the highest abortion ratio (564 abortions per 1,000 live births) of any state in the United States.41 As approximately one in five of all abortions are in teenage girls, it can be concluded that California has one of the highest, if not the highest, teen pregnancy rate in the nation.

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The cost of births to adolescents alone argues for a greatly expanded program of contraception. Few teen mothers place their babies for adoption (only 2%), and most establish families of their own, often as single parents. In a 1989 study by the Center for Population Options, it cost $21.55 billion to support these young families, or 53% of the public funding spent for Aid to Families with Dependent Children (AFDC), food stamps, and Medicaid (Medi-Cal in California).42 By 1992, this figure had risen to $34 billion,43 with the typical AFDC household receiving $1,426 per month in benefits, or $17,112 per year.44 Effective contraceptive programs could result in substantial savings, particularly in California, where teen births impose a singularly high toll on our financial resources. For every $1 spent on family planning services in this state, $7.70 is saved by averting an unintended birth and its attendant health and welfare costs as compared to an average national savings of $4.40.45 These costs are but the tip of the iceberg when one considers all that is required to support teenage families. In 1992, for example, more than 1,900 kindergarten classes were needed in California to serve just the children born to teen mothers five years earlier and cost the state almost $262 million.46

The United States fares poorly when measured against teen pregnancy and pregnancy outcomes in other developed countries. Rates in this country for 15- to 19-year-olds are twice as high as in England, New Zealand, or Canada; three times as high as in Sweden; and nine times as high as in the Netherlands.2,47 In a detailed comparative study conducted in 1981,48 the average pregnancy rate in selected European countries was 36 per 1,000 adolescent girls, with one-third terminating in abortion and two-thirds resulting in a live birth. In the United States, there were three times as many conceptions, or 98 per 1,000 (Figure 20.4). Moreover, the adolescent abortion rate in the United States alone exceeded the total conception rate of any of the comparison countries. Somewhat more recent data reveal even more dire findings, with 1989 teen pregnancy rates having substantially declined throughout Europe to 13% in Germany, 8.6% in the United Kingdom, and 0.9% in the Netherlands and Denmark49 at a time when the teen pregnancy rate in this country was at a high of 38.7%.19 The primary difference in both studies was not in the incidence of sexual activity—it was similar in all countries—but rather in public policy. The European countries had adopted a vigorous primary prevention approach and provided comprehensive sex education and readily available contraception to all adolescents in need. The United States, on the other hand, approached the issue by promoting abstinence

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at one end of the sexuality spectrum and dealt with the problem of pregnancy only once it had occurred at the other end, giving scant attention to protecting sexually active youth before the pregnancy occurred.

Abortion

Between 1980 and 1990, the annual ratio of legal abortions to live births for all age-groups in the United States remained relatively constant at approximately 350 per 1,000. Since 1990, however, this ratio has gradually declined to 321 per 1,000, as has the total number of abortions (from a high of 1,429,577 in 1990 to 1,267,415 in 1994).50 The proportion of all abortions occurring in adolescents 19 years of age or less has decreased from a high of 32.6% in 1972 to 20.2% in 1994, although this latter figure has decreased less than 1% since 1991 (21%) and reflects a lesser effect of prevention efforts in this age-group than in others (Table 20.2). Adolescents aged 15 to 19 years are 1.5 times more likely than adults to terminate a pregnancy, with an abortion ratio of 440 per 1,000. When broken down for each year of age, the ratios for younger adolescents are even higher. In 1992 (the latest date for which detailed data are available), the abortion ratio was 790 per 1,000 for those 14 years of

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TABLE 20.2 SELECTED DATA ON REPORTED LEGALLY INDUCED ABORTIONS
IN ADOLESCENT FEMALES—UNITED STATES, 1972–1994

Year	All abortions in 10- to 19-year-olds[a] (%)	Total no. of abortions in 10- to 19-year-olds (in 1,000s)[a]	Abortion ratio in 10- to 14-year-olds[b]	Abortion ratio in 15- to 19-year-olds[b]	Abortion rate in sexually active 10- to 14-year-olds[c]	Abortion rate in sexually active 15- to 19-year-olds[c]
aFrom Centers for Disease Control, Abortion surveillance: Preliminary data—United States, 1994, Morbidity and Mortality Weekly Report 45(1997), 1123.
bNumber of legally induced abortion per 1,000 live births in age-group (from S. K. Henshaw and J. Van Vort, Abortion services in the United States, 1991 and 1992, Family Planning Perspectives 26 [1994], 100).
cNumber of legally induced abortions per 1,000 sexually active females in age-group (from A. M. Spitz, P. Velabil, L. M. Koonin, et al., Pregnancy, abortion and birth rates among US adolescents—1980, 1985, and 1990, Journal of the American Medical Association 275[13, 1975], 989).
1994	20.2	256.0	—	—	—	—
1993	20.0	266.0	—	—	—	—
1992	20.1	273.2	—	—	—	—
1991	21.0	291.7	502	379	—	—
1990	22.4	320.2	515	403	41.7	55.5
1985	26.3	349.4	624	462	48.0	73.7
1980	29.2	378.9	—	—	41.2	78.3
1976	32.1	317.2	—	—	—	—
1972	32.6	191.3	—	—	—	—

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age or less, 553 per 1,000 for 15-year-olds, and 477 per 1,000 for 16-year-olds.44

Sexually Transmitted Diseases

The prevalence of STDs among adolescents at risk from sexual activity is higher than among at-risk individuals of any other age. In 1995, the rate of gonorrhea among 15-to 19-year-olds was 665 per 100,000, with rates of 840 per 100,000 for teen females and 498 per 100,000 for teen males (Table 20.3).51 There were striking differences, however, when race and ethnicity was taken into account. Rates in African-American adolescents were more than 20times those who were White or Hispanic. Teen females led all age-groups in reported prevalence; teen males were second only to 20- to 24-year-olds. If these data were modified to include only those individuals who were sexually active and at actual risk, the teenage rate would be even higher; considerably fewer adolescents are sexually active (50%–55%) as compared to older populations (80%–90%).52 It is true, however, that there has been a significant drop in reported gonorrhea rates since 1992 for all age-groups, including adolescents, with a greater decline in males than females.51,53 Nonetheless, inter-age-group gonorrhea ratios remain the same, and teen females continue to have the highest prevalence of this disease even when not factored for at-risk status.

The gonorrhea data parallels the high prevalence of other common STDs in adolescents and often is a comorbid infection. Cervical and vaginal cultures of various sexually active female adolescent populations find an average of 11% (range: 3%–18.3%) positive for gonorrhea, 22% (range: 15%–37%) for chlamydia, 21% (range: 6%–48%) for trichomonas, and 39% (range: 32%–46%) for human papilloma virus as detected by positive cervical cytology or DNA probe. Among urethral cultures in sexually active adolescent males, an average of 6% (range: 3%–9%) are positive for gonorrhea and, in one study, 3% for chlamydia.35

The greater incidence of STDs in sexually active adolescents as compared to older sexually active populations is attributed to a combination of an early coital debut, exposure to a greater number of partners, and a less frequent use of the condom. The highest STD rates are seen in disadvantaged inner-city teens, for whom these behaviors are even more prevalent than in advantaged youths.35 The primary exception is human papilloma virus infection, which has been found to be as frequent in college-age females as in female juvenile detainees.54

Pelvic inflammatory disease (PID) is one of the most serious complications

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TABLE 20.3 REPORTED RATES OF
GONORRHEA PER 100,000 ADOLESCENTS
AGES 15 TO 19 YEARS BY GENDER
AND RACE/ETHNICITY—
UNITED STATES, 1992–1995

	1992	1993	1994	1995
SOURCE: U.S. Department of Health and Human Services, Public Health Service, Division of STD Prevention, Sexually Transmitted Disease Surveillance, 1995 (Atlanta: Centers for Disease Control, 1996).
All races/ethnicities
Total	869	733	739	665
Male	770	616	590	498
Female	974	857	897	840
White, non-Hispanic
Total	166	137	151	143
Male	72	49	50	45
Female	264	230	258	246
Black, non-Hispanic
Total	4,979	4,333	4,328	3,843
Male	4,888	4,062	3,893	3,267
Female	5,073	4,611	4,772	4,433
Hispanic
Total	279	280	257	NA
Male	209	207	180	NA
Female	359	361	343	NA

of infection, with gonorrhea and chlamydia and the leading cause of ectopic pregnancy and infertility. When factored for sexual activity, African-American 15- to 19-year-olds have the highest PID rate of all races and all age-groups; White teen women have the same rate as their African-American 20- to 24-year-old counterparts.55,56

From 1981 through 1991, syphilis rates among both male and female 15- to 19-year-olds accounted for 10% to 12% of all primary and secondary cases, with a 1991 rate of 18 cases per 100,000 males and 35 cases per 100,000 females.57 Although rates were highest among 20- to 29-year-olds of both sexes throughout this period, between 1987 and 1990 rates for adolescents rose by 41% among 15- to 19-year-old males and by 112% for 15-to 19-year-old females, contributing significantly to the overall 21% increase in the prevalence of primary and secondary syphilis that occurred during this time. By 1991, the rate for 15- to 19-year-old females (35 per 100,000) was almost twice that of males, reflecting a dramatic increase among women of all ages in the latter half of the 1980s.

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Acquired Immunodeficiency Disease (AIDS/HIV)

As of December 1996,58 a cumulative total of 2,754 cases of clinical AIDS had been reported in 13- to 19-year-old adolescents; 63% of these cases occurred in males and 37% in females (Figure 20.5). Among 20to 24-year-olds, who most likely became infected as adolescents, there was a cumulative total of 21,097 cases with a male-to-female ratio of three to one. This represents a dramatic increase in total AIDS cases since just 1993, when only 157 cases among 13- to 19-year-olds were reported.59 Data about AIDS cases prior to this time are difficult to interpret, as the diagnostic criteria were greatly expanded in 1993, admitting a far greater number of cases than before. Cumulative 1996 data for HIV seropositivity revealed a total of 3,193 cases in 13- to 19-year-olds for nearly a one-to-one male-to-female ratio, with females predominating (1,563 and 1,630 cases, respectively).

The adolescent age-group is the only one to demonstrate such a high proportion of HIV/AIDS cases occurring in females. All other groups

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TABLE 20.4 CUMULATIVE REPORTED
AIDS CASES IN ADOLESCENTS AND YOUNG
ADULTS THROUGH DECEMBER 1995
BY EXPOSURE CATEGORY

	13–19 years	20–24 years
Exposure Category	N	(%)	N	(%)
aIncludes patients pending medical record review; patients who died, were lost to follow-up, or declined interview; and patients whose mode of exposure to HIV remains undetermined.
SOURCE: Centers for Disease Control, U.S. HIV and AIDS cases reported through December 1995, HIV/AIDS Surveillance Report 7(2, 1996), 1.
Males
Men who have sex with men	501	(33)	9,084	(63)
Injecting drug use	97	(6)	1,803	(13)
Men who have sex with men and inject drugs	77	(5)	1,562	(11)
Heterosexual contact	646	(42)	539	(4)
Hemophilia/coagulation disorder	38	(2)	505	(4)
Recipient of blood transfusion, blood components, or tissue	66	(4)	101	(1)
Other/undetermined[a]	109	(7)	802	(6)
Total	1,534	(100)	14,396	(100)
Females
Injecting drug use	132	(16)	1,430	(31)
Coagulation disorder	9	(1)	12	(<1)
Heterosexual contact	440	(54)	2,338	(51)
Recipient of blood transfusion, blood components, or tissue	60	(7)	105	(2)
Other/undetermined [a]	179	(22)	674	(15)
Total	820	(100)	4,559	(100)

show a three-to-one male-to-female ratio or greater. This discrepancy is probably best accounted for by the growing prevalence of HIV/AIDS in females in general. At the same time, homosexual transmission is a significant cause of teenage male AIDS/HIV, as it is among adults, although transfusions necessitated by hemophilia or other coagulation disorders remain the most common source of infection among male adolescents and young adults (Table 20.4). Among teen females, transmission is primarily through heterosexual contact.60

While the incidence of HIV/AIDS infection in adolescents is low compared to older individuals, certain youth populations show an alarmingly high prevalence of HIV infection (Table 20.5). For comparison, the

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TABLE 20.5 PREVALENCE OF HUMAN
IMMUNODEFICIENCY VIRUS INFECTION
IN DIFFERENT ADOLESCENT POPULATIONS

Group	Age (Years)	% HIV Positive
SOURCE: U.S. Congress, Office of Technology Assessment, Adolescent Health—Volume 2 (Washington, D.C.: U.S. Government Printing Office, 1991).
Military active duty five-year conversions	17–19	0.01
Military applicants	17–19	0.03
College youth	College age	0.2
Juvenile detainees	16–17	0.2
Job Corps enrollees	16–21	0.4
Youths seen in an inner-city adolescent clinic	15–18	0.7
Adolescents attending an STD clinic	15–19— males	2.0
	15–19— females	2.5
Runaway and homeless youth	15–18	3.0

lowest seropositivity rate has been found in 17- to 19-year-olds on active military duty.61 Higher rates have been reported among adolescents known to engage in high-risk behaviors. This includes inner-city adolescents attending an adolescent medical clinic, juvenile detainees, 16- to 21-year-old Job Corps enrollees, 15- to 19-year-olds attending STD treatment clinics, and runaway and homeless youth.62–64 The wide demographic variability in HIV seropositivity is documented in a study of 16- to 21-year-old Job Corps enrollees.65 HIV testing on entry into the program is mandatory. The highest seropositivity rates were found in African-American and Hispanic adolescents (5.3 per 1,000), inner-city youths from large urban areas in the Northeast (5.5 per 1,000), and a surprisingly disproportionate number from rural areas and small towns in the Southeast (4.2 per 1,000). For African-American and Hispanic youths from large northeastern cities, seroprevalence increased by 4.3 per 1,000 at each year of age to a high of 24.8 at age 21. Males and females had similar rates of 3.7 and 3.2 per 1,000, respectively.

Risk Taking: Contraceptive and Condom Use

Risks of pregnancy, STDs, and HIV seropositivity are all greater in those sexually active youth who fail to use protection and in those who use protection, but inconsistently. In the CDC's 1995 YRBS,13 slightly more than half of all sexually active high school students (54%) used a condom

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at their last sexual encounter with 49% of females and 61% of males reporting this behavior. Use was highest for 9th- and 10th-graders (63% and 60%, respectively) and lowest for 11th- and 12th- graders (52% and 50%). African-American students (61%) were more likely to use condoms than Caucasian (53%) or Hispanic students (44%). These condom use rates were only slightly higher than the rates reported in 1993, when use at the last sexual encounter was reported by 53% of all students, again with the highest percentage of use being among younger youths and those of African-American ethnicity.14 Both the 1993 and the 1995 surveys found significantly higher condom use than in 1990, when condom use at the last sexual encounter among all students was only 45%.19 Birth control pill use was much lower than use of condoms. In 1995, pill use at the last encounter was only reported by one in five high school girls (20%). The frequency of use among different class and ethnic groups, however, was the reciprocal of condom use, with senior girls (29%) and Caucasian females (25%) reporting being on the pill at the last sexual encounter more frequently than others. Pill use in 1995 was up only 2% from use in 1993 (18%).

Data from the 1995 NSFG shows a similar trend employing somewhat different questions.²⁰ Among 16-year-old females, 57% had used some method of protection at their first coital episode, with 15% relying on the pill and 32% on the condom. For teen women less than 20 years of age, use of any method was lowest among Hispanics (53%) and highest among non-Hispanic Whites and non-Hispanic Blacks (83% and 72%, respectively).

Other studies support a picture of wide variability in contraceptive and condom practices depending on the population studied. Different surveys have found that anywhere from 31% to 80% report that they always use a method, and from 16% to 58% state that they never use one. ^21-24,66-69 When adolescents themselves are asked why they do not use protection, two-thirds (65%) state that sex was unexpected, one in four (25%) do not know how to obtain protection or where to go, one in four (24%) fear parental discovery or method side effects or are too embarrassed to seek out services, and one in six (15%) believe that they are safe without birth control and will not get pregnant.⁷⁰ Although condom and pill use appears to be slowly increasing among sexually active adolescents as a class, a significant number continue to remain unprotected at least some if not all of the time.

Not all teenagers seek to avoid pregnancy, as much as one might think to the contrary. Any efforts to promote contraceptive use among these

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young women only fall on deaf ears. Several surveys of teen girls have shown that poor contraceptive use may well be associated with a definite intent to become pregnant or at least the absence of any objection.71,72 Such intents often remain unspoken while the unknowing clinician diligently provides careful but unavailing contraceptive instruction. Adolescents in this group perceive pregnancy and parenthood as a desirable state and as providing answers to some other dilemma, such as having no future goals other than parenthood and drifting aimlessly in the interim.

Factors that have been found to support contraceptive and condom use include the following: 20,24,–28,61,63,73,74

• Having educational goals
• Doing well at school
• Ability to pay
• Married parents
• An older partner
• Fewer other risk behaviors
• A belief in the efficacy of condom use against HIV infection
• Suburban residence
• Cognitive maturity, older age
• Prior satisfactory contraceptive use
• Higher parental educational level
• Fewer life-time partners
• Friends who use condoms
• A low perception of undesirable aspects of condom use

It is significant to note that HIV knowledge, fear and anxiety about HIV infection, or intentions toward avoiding other risk behaviors were not found to have any substantial effect on sexual risk taking or on contraceptive and condom use.24,25,63,65