Parents, peers, and the acquisition of an STD

JOURNAL OF ADOLESCENT HEALTH 1995;16:45~t9

ORIGINAL ARTICLE

Parents, Peers, and the Acquisition of an STD Developmental Changes in Girls

SUSAN L. ROSENTHAL, Ph.D., FRANK M. BIRO, M.D., SHEILA S. COHEN, Ph.D., PAUL A. SUCCOP, Ph.D., AND LAWRENCE R. STANBERRY, M.D., Ph.D.

Purpose: The purpose of this study was to examine the relationship between age and number of sexually transmitted diseases (STD) episodes in sexually active girls with their perceptions of the interpersonal implications of STD acquisition. Methods: The sample consisted of 248 girls (mean age = 16.9 years); 74% had an STD history. Adolescents responded to statements using a five-point Likert scale regarding their interpersonal expectations, and rated the perceived prevalence of STD among their friends and among all adolescents. Results: The results of logistic regression analyses indicated that older girls were less likely to tell their parents but did not perceive parental support differently than younger girls. Older girls were more likely to tell their partners and to be more embarrassed by the acquisition. Those with a greater number of STD episodes perceived the acquisition as a less negative event. Girls with a greater number of STD episodes perceived the prevalence of STD to be significantly greater among their friends and among all adolescents than those girls with fewer episodes. Overall, the perceived prevalence among friends (40%) was significantly lower than the perceived prevalence among teens in general (74%). Conclusions: Future research and practice in aiding adolescent girls to manage STD acquisition must incor-

From the Department of Pediatrics (S.L.R., F.M.B., L.R.S.), Division of Adolescent Medicine (S.S.C.), and Department of Environmental Health (P.A.S.), University of Cincinnati College of Medicine, Children's Hospital Medical Center, Cincinnati, OH. Address reprint requests to: Susan L. Rosenthal, Ph.D., Division of Adolescent Medicine, Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229. Manuscript accepted March 29, 1994.

porate developmental theory, and, when appropriate, methods to involve families while preserving privacy. KEY WORDS:

Sexually transmitted diseases Sexual behavior Females Parents Peers

Sexually transmitted diseases (STD) represent a major health concern for adolescents and are associated with significant morbidity (1-3). It is critical that adolescents seek appropriate medical care for STD, as well as reduce the risk of psychological morbidity(4) and subsequent infection (5). Although theorists and researchers have pointed to the relevance of the social context for health care decisionmaking, little is known about the relationships of these variables in an adolescent's response to an STD. Research on factors that facilitate healthy psychological development of adolescents, particularly regarding the reduction of risk-taking behaviors, has emphasized the importance of the family. Important influences include perceived parental support or degree of family closeness (6-8), communication among family members (9-12), parenting style (13), and parental supervision and monitoring (14-17). These factors have been shown to be related to the timing of initiation of sexual intercourse; however, there has been little research on the parental factors 45

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that are related to managing an STD. In fact, the research has focused predominately on the need for confidential care in adolescence (18) rather than on the various roles parents may assume. Little is known about the adolescent's perception of their peer group with regard to the acquisition of an STD. Research on coping with the diagnosis of herpes by adults indicates that social support specific to the diagnosis was a critical variable in the stress-recurrence relationship (19). The likelihood that a person may seek social support from friends may be related to their perception of their peers' responses (20). This study examined the perceptions of sexually active adolescent girls' regarding both their parents' and their peers' reactions to the diagnosis of a common STD, Neisseria gonorrhoeae (GC). In addition, perceptions of the prevalence of STD among their friends, as well as all adolescents, were examined. Thus, the following two hypotheses were tested: Girl's perceptions of the interpersonal implications of the acquisition of an STD would be significantly related both to age and the number of STD episodes experienced. Specifically, those adolescents with a greater number of STD episodes would view the acquisition of GC as a less negative event. Younger adolescents would be more likely to view their parents as involved, and less likely to view partners as involved. Adolescents with a greater number of STD episodes would view STD as more prevalent among their friends and among all adolescents.

Methods Subjects

Adolescents were recruited from a primary care adolescent clinic within a large urban teaching hospital, and those with a history of an STD were overrecruited. They were given $10.00 to participate in a study described as one examining the seroprevalence rate of herpes simplex virus with an interview by a female research assistant. Parents/guardians gave informed consent for all girls under 19 years of age. All of the adolescents, regardless of age, also gave informed consent. The study and consent forms were approved by the Institutional Review Board. The sample consisted of 248 sexually active adolescent girls between 12 and 21 years of age (mean age = 16.9 years). Twenty percent of the adolescents were Caucasian; 80% were African-American. Their age of first consenting sexual intercourse ranged

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from 10-18 years (mean age = 14.40, SD = 1.62). The majority (74%) of the adolescents had had a history of at least one episode of an STD (range 1-10). Of those who had had an STD, 53% had a history of GC. Measures Adolescents were asked questions regarding their sexual history, including their age at menarche and first sexual intercourse and the number and types of STD episodes. They were asked to respond using a five-point Likert scale (never to always) to 11 statements regarding their expectations of the diagnosis of GC in terms of the social context (i.e., peer, partner, and parental reactions). The phrase "When you get gonorrhea (GC) . . . . " was followed by these statements: (1) you would feel embarrassed; (2) you would tell your partner; (3) your partner would know even though you didn't say anything; (4) your partner would leave you; (5) nobody would want to have sex with you ever; (6) you would tell your parents; (7) your parents would think you were a bad person; (8) your parents would be helpful; (9) you would tell a friend of the same sex as you; (10) your friend would think you were a bad person; (ll) your friend would be helpful. They were asked to rate the frequency of sexually transmitted diseases among their sexually active friends and among sexually active adolescents in general. Age was chosen as an estimate of developmental level. Although age is an imprecise measure of developmental progression, it can be reliably measured. Data analysis was conducted using the Statistical Analysis System (SAS) for personal computers (21). The first hypothesis was evaluated by logistic regression with the number of episodes of an STD and age as the independent variables and their responses to each of the 11 "Likert-type" questions as the dependent variable. The Wald chi-square statistic was used to evaluate significance and an alpha of 0.05 was selected for testing the significance of all effects. A logistic regression analysis using the Wald chi-square statistic also was performed to test the hypothesis that perceptions of prevalence would be related to age and STD experience. Differences between perceptions of prevalence among friends and among all adolescents were tested by comparing the means of the adolescents' responses to these two questions. The prevalence distributions were approximately normalized by applying the logit transformation.

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Table 1. Modal Response by Adolescent Girls for Answers to "When you get GC... ,,a Modal Response (%)

Response You would feel embarrassed You would tell your partner Your partner would know even though you didn't say anything Your partner would leave you Nobody would want to have sex with you ever You would tell your parents Your parents would think you were a bad person Your parents would be helpful You would tell a friend of the same sex as you Your friend would think you were a bad person Your friend would be helpful

Always (65%) Always (71%) Always (27%) Sometimes (36%) Sometimes (25%) Always (48%) Never (51%) Always (63%) Always (34%) Never (65%) Always (59%)

aFive possible responses on Likert scale (always, most of the time, sometimes, rarely, never).

Results It was hypothesized that adolescent's interpersonal expectations regarding STD would be related both to their age and their experience of an STD. Table 1 presents the modal response for each of the 11 statements. The results indicated that younger adolescents were more likely to tell parents (X2 = 14.69, p = .0001) but telling one's parents was not significantly related to number of STD episodes. The m e a n age of respondents to each level of those questions with a significant age effect is presented in Table 2; the mean number of STD of respondents to each level of those questions showing a significant effect for this variable is shown in Table 3. Older adolescents were more likely to tell a partner (×2 = 5.00, p = .03) but there was no significant relationship to n u m b e r of STD episodes. H o w often the adolescent would feel embarrassed by the acquisition of an STD was significantly related to both the number of episodes of

an STD (X 2 = 10.69, p = .001) and age (X2 = 5.65, p = .02). Older adolescents reported feeling more embarrassed; those adolescents with a greater number of STD felt less embarrassed. Two of the statements (your friend would think you were a bad person (X2 = 7.97, p = .005) and n o b o d y would w a n t to have sex with y o u ever (×2 = 5.45, p -- .02)) were related to number of episodes of STD but not to age. For both of these statements, those with fewer episodes of an STD were more likely to endorse the statement. No other responses were related to either number of STD episodes or age of the subject. The next hypothesis related the adolescents' experiences with STD, to their perception of the prevalence of STD a m o n g their friends and among all adolescents in general. The modal response for the frequency of one's sexually active friends having an STD was "few," equivalent to "2-3 out of 10" friends. For the frequency of STD among sexually active teens in general, the modal response was "most," equivalent to "7-8 out of 10." Overall, the perceived prevalence among friends (40%) was significantly lower than the perceived prevalence a m o n g teens in general (74%) (p < .001). The results of a logistic regression indicated that those adolescents with more STD episodes perceived the prevalence of STD to be significantly greater (among friends: X2 = 23.66, p = .0001; among all adolescents: X2 = 14.23, p = .0002). There was no relationship of STD prevalence to the age of the subject.

Discussion These results aid our understanding of the perceptions of adolescent girls regarding parents' and peers' responses to STD acquisition and of the prevalence of STD. It suggests the potential impact of parents on adolescent girls" m a n a g e m e n t of STD. These girls expected to tell their parents about the acquisition, did not believe their parents would think they were bad, and perceived their parents as helpful. These views of parents were consistent re-

Table 2. Mean Age Years (SD) of Respondents For Each Level of Answer Question Tell partner Tell parents Embarrassed

Never 15.5 (2.5) n=16 17.6 (1.9) n=58 15.5 (0.6) n=4

Rarely 15.7 (2.3) n=10 17.1 (2.1) n=26 15.3 (1.5) n=7

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Sometimes 16.8 (2.1) n-23 17.3 (2.0) n=27 16.7 (2.1) n=44

Most of the Time

All of the Time

17.2 (2.2) n=24 16.8 (2.1) n=18 16.7 (2.1) n=31

17.0 (2.0) n=175 16.3 (2.0) n=119 17.0 (2.0) n=161

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Table 3. Mean Number of STD (SD) of Respondents For Each Level of Answer Question Embarrassed Friends think you are bad Nobody will have sex w/you

Never

Rarely

Sometimes

Most of the Time

All of the Time

2.5 (2.6) n =4 1.73 -4- 1.9 n= 161 2.0 (2.1) n = 48

1.14 (1.21) n =7 0.8 (.85) n=38 1.45 (1.7) n = 60

2.06 (2.2) n = 44 1.07 (1.0) n= 27 1.46 (1.7) n = 63

2.09 (2.3) (n--- 31) 1.46 (2.2) n= 13 1.32 (1.2) n = 37

1.20 (1.27) (n = 161) 1.11 (1.1) n=9 1.12 (1.3) n = 40

gardless of the number of STD episodes. The anticipated likelihood of telling one's parents decreased with age, consistent with an increase in perceptions of self-reliance a m o n g adolescent girls and the belief that "there are some things about me that m y parents don't know" (22). Our findings also support that the development of a u t o n o m y in adolescence is not associated with negative or severed relationships with parents. Several age-related findings such as that of older adolescents being more likely to expect to tell their partners and being more embarrassed, support changes in the qualities of the relationship such as communication and intimacy during adolescence. A history of multiple episodes of an STD was not related to the adolescent's belief that their partner could tell if they had had an STD. The most frequent response was that their partner w o u l d always be able to tell, and 42% of the overall sample believed that most of the time or always their partner could tell. This is consistent with other research suggesting that experience with an STD does not necessarily result in an understanding of asymptornatic infections (23). As hypothesized, a history of a greater number of episodes of an STD was significantly related to perceiving the acquisition of an STD as a less negative event. This finding has mixed implications. It m a y be that these girls are minimizing the negative perceptions of STD to cope with the event and reduce the psychological morbidity of the acquisition. Research on coping with herpes has indicated that those w h o use characterological self-blame are at a greater psychological risk (24). On the other hand, research on health care decision-making indicates that one's perception of negative consequences is related to the likelihood that one will implement a protective behavior. Thus, if a girl perceives the acquisition of an STD as negative then she is more likely to engage in risk reduction (25,26). Another important influence on adolescents' behavior is their perception of the norms among their

peers. The adolescents in this s t u d y perceived STD as less frequent among their friends than among sexually active adolescents in general. This is particularly interesting given the number of adolescents in this sample w h o had experienced at least one episode (74%) or multiple episodes of an STD (35%). Personal experience with an STD did lead to beliefs of greater frequency among both their friends and all adolescents. One possible explanation for the difference in perception of STD prevalence between friends and all adolescents is the personal fable (27), or the belief that they and their friends are unique and invulnerable. However, for those adolescents w h o have experienced STD, one might anticipate that their sense of invulnerability would have been challenged. The cross-sectional design limits analyses to the correlational analysis of variables examined at a single point in time, rather than the evaluation of multiple antecedent factors and subsequent behaviors. The exact relationship between the acquisition of multiple episodes with a less negative impact and greater perceived prevalence of STD is unclear. Perhaps these adolescents fail to protect themselves from subsequent episodes because they believe STD to be c o m m o n and have little negative impact, or perhaps it is the experience of repeated acquisitions that lead to those conclusions. This study is also limited by the use of age as an indirect measure of development. Future longitudinal studies could help separate the effects of age, time since initiation of sexual intercourse, and changes in the intimacy of one's dating relationships. This study focused on adolescent girl's relationships with parents and peers, and did not address these issues in adolescent boys. Research in adolescent health must focus on ways to involve families in STD prevention m a n a g e m e n t in adolescents, while preserving privacy. Some adolescents m a y have parents w h o are not perceived as supportive and, thus, the health care provider m a y need to help adolescents obtain health care and

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emotional support. However, many adolescents have parents who can be helpful and who could play a critical role in the adolescent's coping with the acquisition of an STD. Early involvement of parents and adolescents jointly by the health care provider may facilitate treatment and increase the likelihood that the parents and the health care providers work as a team. In addition, family supports may allow easier access to necessary health services and reduce the emotional stress associated with the STD for adolescent girls.

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The authors wish to express appreciation to Molly Bernard for data collection and transcription and Lynn McDermott for secretarial assistance. This study was supported, in part, by Project #MCJ-000964-15-0 from the Maternal and Child Health Program, Health Resources and Services Administration, U.S. Department of Health and H u m a n Services.

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