Review: similar social factors influence young people’s sexual behaviour worldwide
BIDS, PsycINFO, PubMed, CIHAHL, Ovid journals and books, Web of Science, EMBASE/Excerpta Medica, Anthropology plus, library catalogues, reference lists, experts, and hand searches of key journals.
Study selection and assessment:
English-language, qualitative empirical studies of the sexual behaviour of young people (10–25 y) that were published between 1990 and 2004 and reported empirical, non-numerical data. Studies that focused exclusively on commercial sex work or child sexual abuse were excluded. 268 studies met the selection criteria. Individual studies were assessed for quality and classified as primary (high quality studies providing theoretical insight into sexual behaviour or thorough descriptions of particular contexts) and secondary (lower quality studies that had simple, non-detailed descriptions or did not support statements with evidence).
7 key themes emerged. (1) Young people subjectively assess the risks from sexual partners on the basis of whether they are “clean” or “unclean.” Young people determined the disease risk of a potential partner by indicators such as social position or appearance. (2) Sexual partners have an important influence on behaviour in general. The nature of partners’ relationships influenced sexual behaviour. Some people saw sex as a way to strengthen a relationship, please a partner, or keep a partner through pregnancy. Some feared physical violence or retribution if they refused sex. (3) Condoms can be stigmatising and associated with lack of trust. Women feared that asking their partners to use condoms implied that they were sexually experienced, which was viewed as inappropriate or undesirable. Asking one’s partner to use a condom was felt to show a lack of trust or suspicion that they were diseased. (4) Gender stereotypes are crucial in determining social expectations and behaviours. Across societies, a double standard for men and women prevailed. Men were expected to be heterosexually active, and vaginal penetration was often viewed as a masculine rite of passage. Women, however, were often expected to be virgins at marriage. Women who desired sex could be considered promiscuous. Pregnancy prevention was considered predominantly women’s responsibility. (5) There are penalties and rewards for sex from wider society. Social status could be fostered among men by having many partners or among women by being chaste or in exclusive stable relationships. Pregnancy outside marriage could be stigmatising, but women sometimes saw it as an escape from the parental home. Sex could also be a way to obtain money and gifts. (6) Reputations and social displays of sexual activity or inactivity are important. Sexual behaviour was a crucial aspect of one’s social reputation. It was important for men to display heterosexual behaviour through means such as pushing for sexual access, having several female partners, visiting brothels, and reporting sexual experiences to their peers. Women’s reputations were damaged by having too many partners or even mentioning sex at all. (7) Social expectations hamper communication about sex. Young people avoided talking openly to partners about sex, which led to ambiguity and miscommunication. Women sometimes avoided saying yes to sexual activity in case they were viewed as inappropriately willing. Young people also avoided discussing sex because advances could be rejected and lead to loss of face, or they could appear inappropriately forward, which could damage their reputation. Not discussing sex made it difficult to take precautions, and so sexual activity was more likely to be unplanned and unprotected.
The sexual behaviour of young people has similarities worldwide. Personal relationships, gender stereotypes, social pressures and expectations, and personal reputation are evident in sexual behaviours.
While Marston and King claim that their review is analogous to meta-analysis, they do not draw on the extensive literature on qualitative meta-synthesis,1 specify a particular method, or address the methodological challenges of meta-analysis that surface in their analysis.* However, as a systematic review, it provides a timely contribution to understanding the social context of sexual behaviour, HIV risk, and sexually transmitted disease prevention.2 The work helps to explain why information campaigns may be, at best, insufficient, and at worse, ineffective and emphasises why health services need to address gendered, social, economic, cultural, and political inequities.3
At the individual level, clinical advice and preventive strategies must take into account how power and gender stereotypes and roles operate and the realities of gender expectations, sexual coercion, and sex as a survival strategy. Service planners and policy makers must account for local culture and seek to create the social conditions that will reduce teen pregnancy, sexually transmitted diseases, and HIV. Risk prevention that relies on an individual’s limited resources and power to act, and leaves risk environments unchanged, will not have an appreciable effect.4
HIV infection cannot be separated from concern for individual and societal power, the position of women in society, and violence, sexual coercion, comodification, and exploitation.
For correspondence: Dr C Marston, London School of Hygiene and Tropical Medicine, London, UK.
Source of funding: UK Department for International Development Knowledge Programme.