Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 16 nº 3 - Jul/Sep - 2019

Original Article Imprimir 

Páginas 93 a 101


Sexual Behavior in Adolescence

Comportamiento sexual en la adolescencia

Comportamento Sexual na Adolescência

Autores: Heloisa Beatriz Fuchs1; Leonardo Novo Borges2; Iolanda Maria Novadzki3; Beatriz Elizabeth Bagatin Veleda Bermudez4

1. Medical student in Medicine at the Federal University of Paraná (UFPR). Curitiba, PR, Brazil
2. Graduating in Medicine from the Federal University of Paraná (UFPR). Curitiba, PR, Brazil
3. Master in Child and Adolescent Health from the Federal University of Paraná (UFPR). Medical by the Federal University of Paraná (UFPR). Curitiba, PR, Brazil
4. Doctor and Master in Child and Adolescent Health from the Federal University of Paraná (UFPR). Doctor and Teacher at the Federal University of Paraná (UFPR). Curitiba, PR, Brazil

Beatriz Elizabeth Bagatin Veleda Bermudez
(beatriz_bvb@hotmail.com ou beatrizbagatin@ufpr.br)
Universidade Federal do Paraná (UFPR), Ambulatório de Adolescentes, Hospital das Clínicas
Rua General Carneiro, 181, Centro
Curitiba, PR, Brasil. CEP: 33601-800

Submitted on 01/30/2019
Approved on 06/18/2019

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Keywords: Adolescent; Sexual Behavior; Sexual and Reproductive Health.
Palabra Clave: Adolescente Comportamiento sexual; Salud Sexual y Reproductiva.
Descritores: Adolescente; Comportamento Sexual; Saúde Sexual e Reprodutiva.

Abstract:
OBJECTIVE: Evaluate the sexual behavior among patients from 10 to 20 years old at an outpatient clinic of a public university hospital.
MATERIALS AND METHODS: A cross-sectional study was carried out through data collection of 1,400 forms of the CLAP-PAHO/WHO Adolescent History, applied at the first outpatient clinic, between 2006 and 2018. Statistical analysis of the data was performed by R Core Team 2018 software.
RESULTS: Of 1,400 patients, 62% were females, and the mean age was 14.9 years, with the median age of menarche/spermarche of 12 years, and 37.2% (521) reported first intercourse with the median of 15 years of age. A condom was used in all sexual relations by 53.5% of adolescents, and hormonal contraception by 47.2%. Boys had first intercourse earlier (median 14 years) than girls (15 years), 96% reported to have heterosexual relations, 4% homosexual or bisexual, and 24 (6.7%) adolescents had children. The need for information on sexuality was reported by 239 (20.2%). Earlier sexual initiation occurred in males, children of adolescent mothers, individual and/or family legal problems, intrafamily violence, personal and/or family psychological disorder and work.
CONCLUSION: The findings were compatible with a similar study in 59 countries, including Brazil. Most had their first sexual relationship in a stable relationship. It is essential to emphasize the importance of health professionals to stimulate dialogue on sexual and reproductive health among adolescents in different settings, mainly parents.

Resumen:
OBJETIVO: evaluar el comportamiento sexual de pacientes de 10 a 20 años que fueron tratados en la clínica ambulatoria de un hospital universitario público.
MATERIALES Y MÉTODOS: estudio transversal mediante la recopilación de datos de 1400 formularios de historia adolescente de CLAP-OPS/OMS, aplicados en la primera consulta ambulatoria entre 2006 y 2018. El análisis estadístico de los datos fue realizado por el software R Core Team 2018.
RESULTADOS: De los 1.400 pacientes, el 62% eran mujeres, con una edad media de 14,9 años, con una edad media de menarquia/espermarquia de 12 años, y el 37,2% (521) se referían a una sexarquia de 15 años de edad. El uso del condón en todas las relaciones sexuales fue reportado por el 53.5% de los adolescentes y la anticoncepción hormonal en el 47.2%. Los adolescentes tenían una sexarca anterior (mediana de 14 años) que las niñas (15 años), el 96% informó tener relaciones heterosexuales, el 4% fue homosexual o bisexual y 24 (6,7%) adolescentes tuvieron hijos. La necesidad de información sobre sexualidad fue reportada por 239 (20.2%). La iniciación sexual anterior se produjo en varones, hijos de madres adolescentes, problemas judiciales personales y / o familiares, violencia intrafamiliar, trastorno psicológico personal y/o familiar y laboral.
CONCLUSIÓN: Los resultados fueron consistentes con un estudio similar en 59 países, incluido Brasil. La mayoría tuvo su primera relación sexual dentro de una relación estable. Se enfatiza la importancia de los profesionales de la salud para estimular el diálogo sobre la salud sexual y reproductiva de los adolescentes en diferentes áreas, especialmente con los padres o tutores.

Resumo:
OBJETIVO: Avaliar o comportamento sexual de pacientes de 10 a 20 anos incompletos, atendidos no ambulatório de adolescentes de um hospital universitário público.
MATERIAIS E MÉTODOS: Estudo transversal por meio da coleta de dados de 1400 formulários da História do Adolescente do CLAP-OPS/OMS, aplicados na primeira consulta ambulatorial, entre 2006 e 2018. A análise estatística dos dados foi feita pelo software R Core Team 2018.
RESULTADOS: Dos 1400 pacientes, 62% eram do sexo feminino, com média de idade de 14,9 anos, com a idade mediana de menarca/espermarca de 12 anos, e 37,2% (521) referiram a sexarca na média de 15 anos de idade. O uso de preservativo em todas as relações sexuais foi relatado por 53,5% dos adolescentes e contracepção hormonal em 47,2%. Os adolescentes meninos tiveram sexarca mais precocemente (mediana 14 anos) que as moças (15 anos), 96% referiram possuir relações heterossexuais, 4% homossexuais ou bissexuais e 24 (6,7%) adolescentes tinham filhos. A necessidade de informação sobre sexualidade foi relatada por 239 (20,2%). Iniciação sexual mais precoce ocorreu no sexo masculino, filhos de mães adolescentes, problemas judiciais pessoais e/ou na família, violência intrafamiliar, transtorno psicológico pessoal e/ou familiar e trabalho.
CONCLUSÃO: Os achados observados foram compatíveis com um estudo semelhante em 59 países, incluindo o Brasil. A maioria teve sua primeira relação sexual dentro de um relacionamento estável. Ressalta-se a importância de os profissionais de saúde estimularem o diálogo sobre saúde sexual e reprodutiva dos adolescentes nos diferentes âmbitos, principalmente com os pais ou responsáveis.

INTRODUCTION

The World Health Organization (WHO) considers adolescence to be the stage of the life cycle that covers the age group between 10 and 19 years. It begins with the body changes of puberty and ends when the individual consolidates his growth and personality, progressively gaining his economic independence. This period is characterized by a transition phase between childhood and adulthood, marked by intense physical and psychosocial transformations.

In Brazil, 15.16% of the population is between 10 and 19 years old, being 7.73% male and 7.43% female1. It is important to know these data, because in Brazil the pregnancy rate is above the Latin American average in adolescents aged 15-19 years, this number being 68.4 for every thousand adolescents in Brazil, in Latin America 65.5/1000, and in the world the average is 46/10002. The vast majority of sexually transmitted infections are not compulsorily reported, with scarce data on their epidemiology and, even among punctual data, a likely underreporting among adolescents.

The importance of knowing the sexual behavior of adolescents lies in health and education, to adapt public policies related to sexual and reproductive health, such as preventing the transmission of sexually transmitted infections and unplanned pregnancy, as well as vaccination campaigns, as against human papillomavirus, and addressing this issue in schools to minimize vulnerability at this stage of life.

In particular, pediatricians, gynecologists and family physicians need to know the factors that can lead to early sexual initiation to recognize them and foster dialogue between the adolescent and his or her family, to avoid risky behaviors and to promote healthy sexuality throughout life.

In South Korea, in 2012, for example, it was observed that condom use decreased in those who started sexual activity before 16 years, compared with those who started after this age, with an Odds Ratio (OR) of 1.79 for boys and 4.37 for girls3.

In another study, conducted in the cities of Porto Alegre, São Paulo and Campinas, earlier than average sexual initiation was associated with higher HPV infection and cytological changes on pap smears4.

The aim of this paper is to analyze the sexual behavior of patients treated at a Teen Outpatient Clinic of a public university hospital.


METHODS

This is an analytical, observational and cross-sectional study of data from the CLAP-OPS/WHO Adolescent History form (Latin American Commission on Pediatrics/Pan American and World Health Organization). All patients (n = 1400) attending the Adolescent Outpatient Clinic of the Federal University of Paraná Clinical Hospital between 2006 and April 2018 were included in the study. The profile of these patients is adolescents between 10 to 20 years old, referred to the Clinical Hospital through the Municipal Health Department, or the State Health Department.

The instrument was applied at the first consultation of the outpatient clinic (attached). All completed forms were included in the study, but only the completed fields were considered for analysis. The questions regarding lifestyle, sexuality, body image were asked alone with the adolescent, asking the companion to leave the office, respecting the principles of confidentiality and confidentiality.

The statistical tests used were the Kruskall-Walis test, Fischer's exact test, Mann Whitney's chi-square test and Spearman correlation, calculated using the R Core Team 2018 software.


RESULTS

Over 1.400 adolescents were served, 853 (62%) female and 521 (38%) male. The median age was 15 years for females and 14 for males. The age group from 14 to 17 years was the most prevalent, with 612 (44.15%) adolescents. Most were from Curitiba and the mother followed the first consultation in 56.9% of the cases (Table 1). The educational level of parents or guardians was incomplete elementary school (48.5%) followed by high school (30.5%).




Among the patients, 86% studied, 37.4% had at least one year of failure and 12% had dropped out of school, and 31% were in work.

The median age of menarche or sperm was 12 years. The adolescents did not have regular cycles 40.63% of the time, and 15% could not inform the date of the last period. Sexual abuse was reported in 21 cases, 19 (90.5%) by girls.

Most patients (62.8%) reported that they had not initiated sexual activity, with no significant difference between genders. The incidence of sexarche varied according to the age group analyzed: in the early adolescent group (10-13 years), only 4.1% had had sex (4.9% of girls and 3.1% of boys); in middle adolescence, 30.2% (30.2% of girls and 30.2% of boys); and in late adolescence the incidence increased to 62.6% (64.2% of girls and 59.4% of boys).

The frequency of sexual initiation was higher among those who claimed to have a boyfriend (72.7%), and lower in the group with impaired body image and in those who had abnormal development (21%).

The average and median age of the sexarche were 13.7 years and 15 years, respectively. The median age of sexarche was 14 years in boys and 15 years in girls.

Regarding the type of sexual relationship, 96% reported having heterosexual relationships, 4% had homosexual or bisexual relationships. There were no differences between the median age of sexarche between those who had heterosexual or homosexual relationships or both (p <0.001).

Most (88.1%) had a single partner and 47.2% always used hormonal contraception and 13.36% sometimes used it. However, 53.5% of adolescents used condoms in all sexual relations, 26.1% had occasional use and 20.4% never used, although 81.8% claimed to have information about sexuality. 2% of respondents had a history of abortion or pregnancy.

Factors that led to a reduction in the age of sexual initiation: male gender, intrafamily violence (p = 0.006), child of an adolescent mother (p = 0.03), personal (p <0.001) and family (p = 0.025), personal psychological disorder (p = 0.0012) and family (p = 0.03), and work (p <0.001) (Table 2). All of these factors led to a reduction in the median of 1 year (from 15 years to 14 years), except for judicial problems where this reduction was even more significant (2 years).




The number of partners, the type of sexual intercourse (whether straight, homo or bisexual), the incidence of sexual intercourse problems, whether or not to study, and problems with alcohol or drugs in the family had no influence on age at onset sexual.

Moderate impact on sexual initiation was the age of alcohol onset (rho = 0.4785) and onset of work (rho = 0.4691). Illicit substance use was associated with a higher incidence of multiple sexual partners (p <0.001). Of the patients who did not use illicit substances, 22% had multiple sexual partners, with an increase in the rate to 70% among users of these substances (p <0.001).


DISCUSSION

The incidence of sexarche obtained in this study was higher when compared to the results of the National School Health Survey (PeNSE)5, conducted by the Brazilian Institute of Geography and Statistics, and the Study of Cardiovascular Risk in Adolescents (ERICA) 6. This can be explained by the inclusion of adolescents up to 20 years of age incomplete in the sample of the present study, while in the surveys cited adolescents up to 17 years old were interviewed, since the older they are, the greater the chance that the young person has had sexual intercourse. The fact that the incidence of sexarche is increased in the group claiming to have a boyfriend may indicate that most adolescents have their first sexual intercourse within a romantic relationship7.

The median age at the time of the first relationship was 15 years, slightly below the average found in the review by Lancet8 in 2006 of 16.5 years. At the time, the average age of sexarche ranged from 17.3 to 18.5 in industrialized countries. This outcome can be explained by a decrease in the average age of sexual initiation in the last 12 years and by the sample reflecting a portion of the population from public education, which has a higher sexarche index in all age groups analyzed by the National Health Survey from school5.

The difference between developed and developing countries is quite clear in the study by Taquette (2012)9 comparing Brazil and France. This study showed that the age of sexual onset in France is 17.5 years and 18 years for males and females, respectively. Since 2001 a program established by law mandates three annual sessions of sexual and affective education in schools. The use of contraception is more frequent than found in our research, occurring in 87.6% male adolescents and 84.2% female in the first sexual intercourse. By contrast, in Brazil, where these policies are not consistent, the median of the sexarche is 15 years in girls and 14 years in boys. In addition, the French have access to adolescent-specific health services with multiprofessional staff, laboratory and imaging tests, contraceptives and sex education.

In a literature review of 36 studies, it was shown that girls who postponed their first sexual intercourse until age 16 are physically and psychologically healthier than those who began sex before age 16, and that adolescents who had sex with men 14 years or older are at higher risk for depression and lower self-esteem10. In another study, girls who had their first sexual intercourse before age 17 were more likely to have depression, with an odds ratio of 2.2911. Thus, it is difficult to establish whether the psychological disorder is the cause or consequence of early sexual initiation.

A meta-analysis of 50 studies has shown that early puberty can lead to earlier sexual début 12. However, this relationship was not significant in our study. This shows that, besides the age of menarche and sperm, it is important that the adolescent has a good perception of his own body, his body image, and good self-esteem, which explains the lower frequency of sexarche in the group that has difficulty with the image, impairing the relationship with others.

The relationship between an absent father between 6 and 13 years of age and earlier sexual début for girls was also evidenced in the Georgetown University study, which explained this finding due to less parental monitoring13. Another study conducted in the Netherlands, with 5,642 adolescents aged 12 to 16 years, found that stricter and more concrete rules of conduct by parents prevent not only early sexual début but also alcohol and tobacco consumption14.

This evidence corroborates that intrafamily violence, psychological disorders, and family judicial problems contribute to earlier sexual initiation, as noted in our study, by poor parenting of adolescents and/or worse adolescent-family relationships. Nogueira et al. (2018)15 concluded that, in the Netherlands, the quality relationship between adolescents and their parents, especially between mothers and daughters, can help to protect against early sexual initiation.

Considering the fact that 56.9% of the patients came to the consultation accompanied by their mother, they are the ones who exert the greatest participation in the health of their children. In their study of the relationship between mothers and children, Price et al. (2018)16 concluded that mothers play an important role in determining the age of sexual initiation of their adolescent children. In addition, some publications point out that being raised by a mother who had children in adolescence can lead to an active sex life at an early age or pregnancy in this age group17.

Other studies corroborate our findings that mothers with depressive symptoms18 and alcoholism19 may lead to the same outcome to their children.

The relationship found between the age of alcohol onset and age of sexarche is worrisome, since the first relationship under the influence of alcohol was associated with risk partners, higher chances of being non-consensual and less positive evaluations19,20. In a survey of college students in Beirut, 10% of respondents admitted to having used alcohol or drugs prior to their first sexual experience20, twice as likely to engage in some kind of sexual act they did not want. In another study, conducted with high school students from Curitiba, 47.3% reported having used alcohol before having sex21.

The use of some type of contraceptive method is uncommon because hormonal contraception was performed by less than half of adolescents with active sex life (47.17%). The condom is not remembered by adolescents in Brazil, as it was detected in all relationships in 53.47% and sporadic in 26.08%. In a study in the same city, Dallo et al. (2018)21 found that condom use was 81%, much higher than in our sample. However, they found a decrease to 41.7% among students who drink alcohol on their first sexual intercourse21.

In addition to alcohol use, tobacco also correlates with lower condom use, as observed by a South Korea study with an odds ratio of 1,493. Adolescents with sexarche before 16 years were found to be less likely to use condoms, with an odds ratio of 1,793.

The number of sexual partners was influenced by the use of illicit substances, corroborated by a study in Pelotas - Rio Grande do Sul22, where the increase in the number of sexual partners in young people who had used drugs in the last month was higher than who did not use any illicit substances, with an odds ratio of 1.82. The use of licit and illicit substances usually add up, not being isolated facts, which further increases the risk factors for multiple sexual partners.

We conclude that sexual initiation remains precocious in middle adolescence, with low adherence to contraception and prevention of sexually transmitted infections, and that family factors leading to less parental control and a poor parent-child relationship may lead to early sexual intercourse. in about a year. It is noteworthy that the possible risk factors studied are not isolated in each patient, but add to each other, having a cumulative effect. Preventive interventions, intersectoral approach are needed to promote human rights with access to adolescent health services, quality education with longer schooling, safety, sex education, in addition to equitable development, combating early marriage and involvement of male adolescents and youth23 .


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