Public health

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Young adults’ sexual health in the digital age: Perspectives of care providers

Laura E. Anderson1 ,2, Genevieve A. Dingle1, 2, Beth O'Gorman2, Matthew J. Gullo1, 2

1Centre for Youth Substance Abuse Research, The University of Queensland

2School of Psychology, The University of Queensland

Corresponding author - Laura E. Anderson, [email protected]

This is the preprint version of a published journal article. The published version can be found at doi:10.1016/j.srhc.2020.100534. Please cite as:

Anderson, L. E., Dingle, G. A., O’Gorman, B., & Gullo, M. J. (2020). Young adults’ sexual health in the digital age: Perspectives of care providers. Sexual & Reproductive Healthcare, 100534. doi:10.1016/j. srhc.2020.100534

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Abstract

Objectives. This study examined care providers’ views on young people’s sexual

health in the digital age. Young people have high rates of sexually transmitted infections

(STIs), indicating sexual risk-taking behaviours. Adolescents transitioning to adulthood may

be particularly at risk due to increased sexual behaviour and exposure to risk factors for

unsafe sex, such as less parental monitoring. These risks may be accentuated in the digital

age, where the availability of dating apps and pornography have potentially influenced young

people’s sexual behaviours. Care providers give a unique insight into sexual health in the

digital age as they are able to identify changes over time.

Study design. Qualitative semi-structured interviews were conducted with general

practitioners, nurses, counsellors and university residential college staff (N = 15, six female)

who work with young people aged 17 and 18. Interviews took 20-40 minutes, and were

recorded and transcribed verbatim. Transcripts were coded by the primary researcher and

an independent coder using thematic analysis.

Results. We identified four themes depicting predictors for sexual risk-taking among

young people: media influence on norms (influence on sexual behaviours, relationships and

appearance), transition to adulthood (independence, social opportunity), communication

difficulties (gender and sexuality differences, greater fear of pregnancy than STIs), and

impulsive behaviour (disinhibition, substance use).

Conclusion. Findings highlight targets for prevention of sexual risk-taking among

adolescents, such as addressing changing norms depicted in media. Further, the complex

interplay of contextual and individual factors highlights the need for more comprehensive

theory and holistic approaches to STI prevention.

Keywords: adolescents; risky sexual behaviour; sexually transmitted infections; digital age;

provider perspectives.

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Young peoples’ sexual health in the digital age: Perspectives of care providers

Sexually transmitted infections (STIs) are a cause of major concern, particularly for

young people aged 15 to 24 years who have some of the highest rates of infection (Kirby

Institute, 2017). Many STIs are asymptomatic, and if left untreated, can cause infertility or

premature death (Gottlieb et al., 2014). Interventions targeting young people (or

‘adolescents’, as per revised definitions of adolescence to including those aged up to 24

years; S. M. Sawyer, Azzopardi, Wickremarathne, & Patton, 2018) have the potential to play

an important role in preventing and treating STIs, as the transition towards adulthood

typically coincides with an increase in sexual behaviour and risk factors for sexual risk-

taking. These factors include: less parental monitoring, greater exposure to peer influence,

greater alcohol and drug use, and changes in identity and peer group (Iyer, Jetten, Tsivrikos,

Postmes, & Haslam, 2009; Loxton, Bunker, Dingle, & Wong, 2015). This risk period is

particularly evident in university residential colleges, where a growing number of Australian

students live (McDonald, Hay, Gecan, Jack, & Hallett, 2015). Therefore, the university

campus provides an important context in which to investigate adolescent sexual risk-taking.

Rates of STIs such as chlamydia, gonorrhea and syphilis have increased in many

Western countries, including Australia (Kirby Institute, 2017). For example, from 2001 to

2011, the rate of chlamydia diagnoses (the most common STI) tripled among women and

men in Australia (from 152 per 100,000 in 2001, to 502 per 100,000 in 2011 in women; and

from 106 per 100,000 in 2001, to 366 per 100,000 in 2011 in men; ABS, 2012). Eighty-two

percent of these diagnoses were among 15 to 29 year-olds. More recently the increase has

slowed, with rates of chlamydia increasing by 42% from 2008 to 2017 among those aged 15-

24 years (Kirby Institute, 2017). This increase suggests a change in risk-taking behaviours

and in the nature of relationships more broadly. These changes may be due in part to the

‘digital age’ (internet access, including via mobile devices) in which young people have been

increasingly exposed to dating applications (“apps”), accessible pornography, and sexual

content in digital streaming platforms, television series and movies. There is an association

between the use of smartphone dating apps, such as Tinder (heterosexual focus) and Grindr

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(homosexual focus), and STI risk; however, the relationship complicated (Choi et al., 2017;

A. Sawyer, Smith, & Benotsch, 2017). For example, STI rates began to climb in 2007, while

dating apps became available later. Tinder was created in 2012, and is likely the most widely

used dating app among young people in Western societies, with approximately 57 million

users, and 15 million mutual matches per day (Iqbal, 2018).

There are several theoretical perspectives on risky sexual behaviour among

adolescents (see Buhi & Goodson, 2007 for a review). For example, the Theory of Planned

Behaviour predicts that attitudes, norms and perceived behavioural control will determine

engagement in health behaviours (Ajzen, 1991). Social-Cognitive Theory predicts that self-

efficacy will influence outcome expectancies which in turn influences engagement in health

behaviours (Bandura, 2001). An integration of five health behaviour models showed that

self-efficacy (from Social-Cognitive Theory) and partner norms (from the Theory of Planned

Behaviour) were key in predicting condom use in young women (Reid & Aiken, 2011).

Both individual and contextual levels of analysis are important to gain an accurate

understanding of the factors that may influence young people’s sexual behaviour, yet few

theories link individual and contextual factors (Edelman, 2018). The contextual risk factors

may have changed in recent years due to rapid technological developments that have

increased the availability of sexual content (i.e., internet access on mobile devices). Early

research suggests that dating app use is a key risk factor for engaging in risky sexual

behaviours among young people (Choi et al., 2017; A. Sawyer et al., 2017). Therefore, it is

important to investigate the influence of digital media on risky sexual behaviour, and

integrate this new environmental context with existing research and theory on individual

factors, particularly those which are modifiable in interventions.

Known individual predictors of risky sexual behaviour include low self-efficacy (one’s

belief in their own ability; Bandura, 1982) for safe sex, personality traits such as high

impulsivity (heightened propensity to approach rewards and reduced capacity to inhibit

behaviour despite negative consequences; Gullo, Loxton, & Dawe, 2014), and lack of

knowledge about risks and prevention of STIs (Allen & Walter, 2018; Chariyeva, Golin, Earp,

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& Suchindran, 2012). Other predictors include norms against condom use, sexual coercion

and substance use by individuals and/or partners (Barriger & Velez-Blasini, 2013; de Visser

et al., 2014). Theoretically, greater exposure to online media with sexual content (e.g.,

dating apps, pornography) should influence these individual-level factors (e.g., self-efficacy,

norm perceptions). For example, media observations of sexual behaviour without condom

use (e.g., television shows aimed at young people such as Gossip Girl and Skins) will inform

norms for unsafe sexual behaviour and the expectation that people do not use condoms.

Unlike social group behaviours (e.g., alcohol consumption, eating), sexual behaviour is

normally private, involving only those engaging in the behaviour. Therefore, adolescents –

particularly those who are poorly informed about human sexuality - are likely to be prone to

the influence of media norms. The current cohort of adolescents are beginning to engage in

sexual behaviour during a digital age which includes more sexual references and scenes

than at any other time in history (Strasburger, Jordan, & Donnerstein, 2010). Therefore, the

current study sought to investigate the role of digital media on sexual risk-taking.

While adolescent perspectives on sexual risk-taking have been documented (e.g.,

perspectives on alcohol use and sex, multiple partners, condom useLivingston, Bay-Cheng,

Hequembourg, Testa, & Downs, 2013; Smith, Fenwick, Skinner, Merriman, & Hallett, 2011;

Teitelman, Tennille, Bohinski, Jemmott, & Jemmott, 2013), there is a lack of research from

health practitioners’ perspectives. Health practitioners play a key role in general health care

of adolescents, and the diagnosis and treatment of STIs. Clinicians are identified as a

preferred source of sexual information among adolescents, and a key driver for getting

sexual health testing (Denison, Bromhead, Grainger, Dennison, & Jutel, 2018; Rajapaksa-

Hewageegana, Piercy, Salway, & Samarage, 2015). Similarly, university residential college

staff and student counsellors are providers of student sexual and personal support.

Importantly, unlike adolescents themselves, health practitioners bring experience across

interactions with multiple young people, and can identify changes in trends over time.

Therefore, we interviewed nurses, general practitioners, counsellors, and residential college

staff who work with first year university students, typically aged 17 and 18. The interviews

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were designed to gain a broad perspective of sexual health among adolescents in the digital

age.

Method

Participants

Participants included 15 key informants (six female) who provide sexual health

information and/or health care in a university (see Table 1). This included seven university

health staff (general practitioners and registered nurses); a university gender and sexuality

counsellor; and seven residential college staff (heads of colleges, deans of students and

resident advisors). Given interviews were in-depth, the aim was specific, and the numbers of

university staff who work in adolescent sexual health are relatively small, a sample size of 15

was sufficient according to published guidelines (Braun & Clarke, 2013; Malterud, Siersma,

& Guassora, 2015) and is consistent with sample sizes in similar research (e.g., Leickly,

Nelson, & Simoni, 2017; Tarzia, Wellington, Marino, & Hegarty, 2018). Informants had

between one and 32 years (mean = 13.5, median = 9.5) experience working with adolescent

sexual health.

< INSERT TABLE 1 HERE >

Procedure

Informants were recruited via email and snowball sampling around a large university

campus in a metropolitan city in Australia. Prior to the interview, informants were emailed an

information sheet, consent form, and a list of interview questions (see Table 2) to give them

a sense of the topics covered. For example, ‘How often do you work with young people in

relation to sexual health?’. Informants were briefed before each interview about the broader

topic (i.e., efforts to reduce STIs among students), which was narrowed for the scope of this

article to risk factors for STIs among adolescents. The semi-structured interviews were

conducted face-to-face by the first author in a quiet room without other people (e.g., care

provider’s office or meeting room) and ran for approximately 20-40 minutes. The interviews

were recorded and transcribed verbatim. Ethical approval for the study was obtained from

the relevant university ethics committee.

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< INSERT TABLE 2 HERE >

Analysis

Data were coded in line with thematic analysis guidelines by Braun and Clarke

(2006). There are a range of qualitative analysis methods, including theory-informed

(deductive) methods and grounded approaches which entirely data driven (inductive; Braun

& Clarke, 2012). For this study were working with well-established social-cognitive and

health behaviour theories, so a deductive approach was most appropriate. The first stages

of the analysis including data familarisation and coding were undertaken by the first and third

authors (female, clinical PhD students). Two coders were used to ensure coding was

comprehensive, representative of the data, and to reduce the risk of bias (Tong, Sainsbury,

& Craig, 2007). Both coders were of equivalent status which facilitated independent coding

without a power differential. The codes for analysis were chosen based on risk factors for

unsafe sex in relation to social-cognitive theories. Theme development included reviewing,

defining and naming themes and was led by the first author in consultation with all authors

(second and last authors were clinical psychologists and researchers).

Results

Care providers indicated contextual and individual risk factors for adolescent sexual

risk-taking. Contextual themes included: media influence on norms (influence on sexual

behaviour, relationships, and appearance), and the transition to adulthood (independence,

social opportunity; see Table 3 for a list of themes and subthemes). Individual themes

included: communication difficulties (gender and sexuality differences, greater fear of

pregnancy than STIs) and impulsive behaviour (disinhibition, substance use; see Figure 1).

< INSERT FIGURE 1 HERE >

< INSERT TABLE 3 HERE >

Contextual Factors

Media influence on norms

Media influence on norms was noted by many care providers as a key factor

impacting sexual risk-taking. “Media” was discussed in terms of television shows, movies,

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pornography, music, social media (facebook, instagram, snapchat) and dating apps (e.g.,

Tinder and Grindr). When asked specifically about their view of dating apps and social

media (see Table 1), many informants spontaneously mentioned the role of pornography,

movies and other media. Three sub-themes were identified: the impact of media on norms

about: sexual behaviours, sexual relationships, and sexual appearance.

Media influence on sexual behaviour norms. Informants described how media

influence norms about sexual behaviour in ways which may increase STI risk. For example,

movies rarely show characters engaged in sexual health communication. A counsellor

highlighted how this makes it difficult for adolescents to initiate discussion about sexual

health.

“... think about the last movie you watched where two people got together for the first

time. There was no talk about it. There’s no even real hint or anything at sexual

health history talks, about negotiating consent, what is happening, what’s not

happening, negotiating protection.” - Counsellor

Informants also discussed the media portrayal of sex as something that has to be ‘seen

through from start to finish’ without interruptions. This linear sexual script omits

communication, which is important for sexual health (i.e., negotiating sexual behaviours,

barrier protection).

“It’s sort of like with sex ... once you’ve started you have to see it through, but there’s

no start line. They sort of go, “Oh, we’re now doing this. Okay, I have to see it

through,” because there’s no communication at the start of, “Is this going to happen?”

and how it’s going to happen.” - Counsellor

Media influence on sexual behaviour was also discussed in terms of gender roles. For

example, an informant noted the differential influence of pornography on men and women,

where heterosexual pornography may be particularly detrimental for women, who are

frequently depicted as submissive and with low agency.

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“... especially for women too because porn is often targeted at men and so it’s

designed to make men feel powerful, aroused, excited. It’s more often another man

being very domineering over another woman and a lot of young women will watch

porn to learn more about it and they will see that this is the role that they’re expected

to take as a subservient sort of person who is almost used in sex and they don’t

realise that, no, it’s a two-way street and you have a right to play a very active role in

that if that’s what you’re interested in.” - Counsellor

Informants also described the wide accessibility of pornography, which (like movies) rarely

depicts communication about sexual health or barrier protection.

“I think pornography is a bigger issue today than it probably was. Because, quite

simply, it’s there and it seems everybody is able to access ….people are guided by

what they view or observe into thinking that’s normal, and it’s not...” College staff

member

Media influence on sexual relationship norms. Informants noticed that media

influence the nature of relationships, particularly dating apps, where casual sex is more

accessible and normalised. Dating apps like Tinder may enable greater ‘access’ and

frequency of casual sex and sexual risk-taking.

“... people are feeling the expectation to have more sex than maybe they’re

comfortable with. I think there’s this expectation, especially dating apps, that

everybody has a really high sex drive, which is not correct. … And naturally, with

people feeling that pressure of using online apps to have more sex with more people

more frequently, there’s higher risk of spreading of STIs..” - Counsellor

Further, these apps may discourage deep, emotional relationships, and instead reflect a

culture of short term pleasure-seeking.

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“I think Tinder and Grindr in particular have taken the romance away from sex. Tinder

and Grindr have been great in giving people the ability to connect easier, but it’s

turned meeting people into online shopping.” - Counsellor

Dating apps may also increase the number of casual sexual relationships by facilitating

transient connections and normalising ‘hook up’ culture.

“I guess the thing that I’ve noticed is that there’s a higher degree of transience in

terms of relationships. .... definitely social media has changed the way people

interact and it makes complete sense that it would have changed the way in which

young people interact with respect to sexual activity.” - College staff member

These quotes show a convergence of perspectives from university-based informants that an

increase in dating app use has led to more casual sex among young people.

Media influence on sexual appearance norms. Although not directly related to

sexual risk, another sign that pornography is influencing adolescents’ sexual behaviour is on

their appearance preferences, specifically pubic hair removal among adolescents and

labiaplasties (female genital cosmetic surgery to trim the labia), among women.

“...you don’t see pubic hair very often anymore. So that’s probably based on social

media and pornography” - Nurse

“We know there’s been a rise in labiaplasties because girls are not wanting to look

too unusual and are getting all this cosmetic stuff so they look like the models in the

porn” - General Practitioner

Overall, the impact of media norms on sexual behaviours, relationships and sexual

appearance was consistently identified as a key factor to address regarding young people’s

sexual health.

Transition to adulthood

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Many informants highlighted the elevated level of risk for adolescents when they

leave high school, usually aged 17 (in Queensland) or 18 years (other parts of Australia).

Greater independence. Leaving high school and transitioning to work, traineeships

or university was identified as a time of increased independence, with less family influence

and parental monitoring. This heightened independence is particularly evident for

adolescents who have moved away from home and are living with peers. As one informant

described the residential college experience:

“…they’ve just been given the keys to freedom and there are no parents. … they’re

handed alcohol and members of the opposite sex ‘on tap’” - College staff member

Social opportunity. Another informant described the increased number of social

opportunities, particularly at the residential colleges:

“They’ve got all the sporting activities, cultural activities, and then they do all their

celebrations after all of those events and then each of the colleges has their own

parties and then there’s just little get-togethers and dinners and then all of the

birthdays, just uni classes ...they are socialising with a lot of people.” - College staff

member

Informants highlighted that young people’s sexual health is influenced by this developmental

period of independence and social opportunity, particularly in university and residential

college contexts.

Individual-level factors

Communication difficulties

Poor communication was a key individual-level risk factor for sexual risk-taking

identified by informants, which may mirror the lack of sexual health communication in

portrayed media. Informants frequently noted that adolescents reported being motivated to

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engage in protective behaviours, but did not effectively communicate this to their sexual

partner, and thus did not engage in the protective behaviour.

Gender and sexuality differences. Communication difficulties appeared to be more

prevalent among heterosexual women and those in the LGBTQI+ community. There was

concern about women’s ability to negotiate condom use with men.

“Condoms, it’s a tricky one because females tend to be a little bit more obliging if

their partners don’t like to use condoms” - General Practitioner

Care providers also spoke of their belief that dating apps had contributed to communication

difficulties within sexual relationships, particularly in terms of expectations for casual sex.

For example, dating apps can expose vulnerable people (e.g., marginalised groups) to

exploitation. This highlights the need for good communication skills and an ability to be

assertive.

“... a fellow … who finds partners on, I think it’s Grindr... He had a recent experience

where I think it started out consensual, but then he wanted to pull back. He ... tried to

voice some concerns in some form or other. ….. So it’s really been difficult for him. ...

it worries me that it [Grindr] does expose some very vulnerable people who are

seeking a relationship of some form or other and they can just be made use of.” -

General Practitioner

Some informants also emphasised that communication is required for both safe sex (i.e.,

using barrier protection), and for consensual sex. Particularly for heterosexual women, this

can be challenging once sexual behaviour is initiated, due to fear of retaliation.

“For a few women that I’ve spoken to there’s a fear of violence and aggression if they

say “no” once it’s started. There’s that fear of retaliation, of, “What will happen to

me?” and so it’s almost like that freeze instinct kicks in where it’s just like, “I’m just

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going to freeze and just get through this and hope for the best,” rather than say, “This

is hurting,” or, “I don’t like the fact that you’re not wearing a condom.” - Counsellor

Greater fear of pregnancy than STIs. Another reason why communication about

barrier protection may be difficult is that there is a greater concern for pregnancy prevention

(which can be achieved with non-barrier methods) than STI prevention. Hormonal

contraception was seen as sufficient due to protection against pregnancy, which was a more

salient concern that STIs.

“...So in my conversations, especially with young men, often the question is asking

women, “Are you on the pill?” That’s as far as any sort of sexual health history, any

sort of consent talk, any sort of negotiating of what they will or won’t be doing if

they’re engaging in sex together goes. ... You can’t have safe sex with someone if

you’re not able to communicate.” – Counsellor

Communication was described by care providers as crucial for safe and health sexual

relationships, and that this was most likely to be difficult for people in relationships with men.

Impulsive behaviour

Many informants talked about adolescents acting impulsively, linked to factors such

as disinhibition and substance use, despite having a fair knowledge of sexual health (i.e., the

need for STI checks, risks of unprotected sex, risks of multiple partners). Disinhibition and

substance use both involve increasing the attraction of pursing immediate short-term reward

in spite of potential negative consequences.

Disinhibition. Informants discussed frustrations with adolescents did not follow

through on their knowledge of sexual health risks due to momentary disregard, or to a loss

of judgement and inhibition.

“...this generation has had more education on sexual things than any generation in

the past and yet they do still seem to have that young, “It’s not going to happen to

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me.” ... And you talk to them and they go, “I know. I know. I shouldn’t do that.” But it’s

almost like, “It was in the moment.”” - Nurse

Further, informants noted that adolescents who engage in impulsive sexual behaviour often

justify it in terms of how trustworthy/ nice their partner appeared.

“ “No, that person’s a nice girl,” or, “a nice boy,” it doesn’t really matter, “then I just

don’t worry about it [STI risk].”” - Nurse

Substance use. Informants also discussed the role of substance use in increasing

the likelihood of sexual risk-taking. Substance use was described as impacting decision

making.

“Because I think a lot of the problem is, quite often, it’s those decisions are made

when intoxicated or making decisions about sexual health aren’t the same decisions

you would make in a classroom when you’re learning about it in Grade 10 versus

those decisions you’re making at 3:00 am in the morning when you’ve been drinking

for an extended period or [taking] drugs or whatever. Sometimes those things can

get lost, lost along the way.” – Nurse

Informants indicated that impulsive behaviour was often the reason for unsafe sexual

behaviours, and that this lack of impulse control and greater desire is heightened with

substance use.

Discussion

We investigated predictors of sexual risk-taking among older adolescents from the

perspective of care providers. Analysis of interviews with general practitioners, nurses,

counsellors and residential college staff members shows a range of important contextual

factors (media influence on norms, transition to adulthood) and individual factors

(communication difficulties, impulsive behaviour). A hypothesised depiction of relationships

between these factors, based on the data, is presented in Figure 2. Care providers

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consistently observed that young peoples’ sexual risk-taking is influenced by digital media.

Informants’ reported that the digital age of unprecedented access to sexual content and

dating apps has impacted sexual norms, which in turn has increased sexual risk-taking. This

relationship may be largely mediated by communication difficulties. Informants also

discussed that greater social opportunity and independence during the transition to

adulthood increases risk for young people, particularly for those who are impulsive.

< INSERT FIGURE 2 HERE>

Our findings on media norms and communication difficulties align with the

conclusions of a recent review: that social networking sites have the capacity to convey risk

through compromised interpersonal skills and the promotion of risky norms around sexual

behaviour (Holloway et al., 2014). Informants reported that app use and subsequent casual

relationships undermines sexual communication, increasing STI risk. Given that vulnerability

and honesty are required to communicate about sexual health, communication is likely to be

more difficult in a casual sex context, as opposed to in an existing relationship. Meeting

sexual partners through dating apps in itself may increase the spread of STIs as

transmission can occur between people who would not otherwise meet. In a recent study,

finding sexual partners online was correlated with condomless sex with greater than two

partners (Cabecinha et al., 2017). Similarly, the finding that greater fear of pregnancy than

STIs inhibits communication is supported by research from young people’s perspectives. A

study of young males’ perspectives showed that when a partner was using birth control this

failed to motivate continued use of condoms (Smith et al., 2011).

Pornography and sexually explicit content were seen as detrimental to sexual health

by portraying a linear sexual script (i.e., a model of a behavioural sequence involving

different characters; for an introduction to sexual scripting theory see Simon & Gagnon,

1986) where sexual acts do not include conversations about sexual health and barrier

protection. Further, this sexual script depicted in media is often highly gendered and

heteronormative, whereby men are agents (actors) and women are passive (acted upon;

Charles & Meyrick, 2018). Informants highlighted how this portrayal is detrimental to sexual

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communication, particularly for heterosexual women, because such norms discourage

assertive communication. Both norms and communication have been shown to play a

central role in sexual behaviour. A systematic review showed that perceived norms are one

of the most stable predictors of adolescent sexual behaviour (Buhi & Goodson, 2007).

Similarly, a meta-analysis concluded that communication is a strong predictor of condom

use (Carlyle & Cole, 2006).

Theoretical implications

The risk factors identified were both contextual (e.g., media norms) and individual

(e.g., communication difficulties), which highlights the need for a holistic approach to

research and prevention. For example, media norms (e.g., not communicating about sexual

health, linear, gendered, and heteronormative sexual script) may undermine confidence in

communicating about sexual health and barrier protection, because it is perceived as norm-

inconsistent or abnormal, thus leading to sexual risk-taking behaviours, see Figure 2.

Importantly, risky sexual behaviour depends on opportunity for sexual behaviour, which is

influenced by factors inherent to the transition to university (less parental monitoring, more

socialising). The combination of opportunity for sexual behaviour and impulsivity (substance

use, disinhibition) is likely to increase risky sexual behaviour (Johnson, Albery, Frings, &

Moss, 2018), particularly when communication about safe sex preferences is poor. Carefully

controlled studies are needed to test health behaviour change theories such as the Theory

of Planned Behaviour and the Health Action Process Approach (Ajzen, 1991; Schwarzer &

Luszczynska, 2008) to determine the complex interactions between factors.

Practical implications

Given this study was conducted in an applied context, there are a number of practical

implications for those working with young people to reduce sexual risk-taking.

Media influence on norms. Informants believe media including pornography,

movies and dating apps had a negative impact on adolescents’ sexual behaviour,

relationships and appearance. This suggests that interventions should acknowledge and

address media representations, and identify the ways in which they are unrealistic and

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unhealthy to reduce inaccurate norm formation. Interventions could help adolescents to

engage in critical reflection on the accuracy or limitations of media portrays of sex. Further,

producers of sexual media content could also design it in such a way that helps viewers to

challenge unhealthy sexual portrayals. Technology may even be used to increase safe sex

practices. For example, it may be easier to negotiate STI testing and condom use via text

messages rather than face-to-face. Similarly, app developers could include an option in

dating apps to indicate whether one practices safe sex.

Transition to adulthood. Leaving high school was regarded as a risky period for

adolescence due to increased independence and social opportunity. This was particularly

highlighted for students who move to the residential colleges, as they are usually living out of

their family home for the first time, and are surrounded by peers. Subsequently, students

moving into colleges may benefit from extra support in this area from college staff members,

university general practitioners, nurses and counsellors. For example, residential colleges

could facilitate workshops to enhance adolescent skills and knowledge about safe sex

practices. A recent systematic review found that college interventions with motivational

interviewing or reminder cues were most effective in increasing condom use (Kilwein, Kern,

& Looby, 2017).

Communication difficulties. Interventions should help to teach adolescents sexual

communication skills, and particularly address inequality and discrimination. For example,

gendered challenges for women negotiating condom use with men, and challenges for

people who do not identify as part of the heteronormative population (i.e., people who

identify as LGBTQIA+) should be discussed (Thitasan, Aytar, Annerback, & Velandia, 2019).

Young people who are not hetero or cis-gendered may have greater difficulty due to stigma

and ignorance from sexual partners. Among female undergraduate students, the greater

one’s perception that women are subordinate to men, the lower the frequency of discussing

sexual history or condom use (Bui et al., 2012). Therefore, norms and beliefs impact

communication self-efficacy. Further, frameworks for discussing sexual health and behaviour

may be useful to increase communication self-efficacy. As one informant highlighted, the

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use of a ‘traffic light system’ can help. This system may have been adapted from the ‘Traffic

lights framework’ for sexual behaviours in children (True Relationships and Reproductive

Health, 2015). Before initiating sexual behaviour with a new partner, adolescents are

encouraged to chat about what they are keen for (green), what they are not sure about -

they might like or might not (orange), and what they do not want to do (red). These states

are dynamic and important to chat about before, during and after sexual behaviour. This

portrayal of a ‘healthy’ sexual script that is easy to remember may help to increase self-

efficacy (‘I know how to communicate about this now’), particularly if intoxicated. It may be

useful to address the linear, heteronormative script portrayed in media, and provide this

alternative script.

Interestingly, research on sexually risky behaviour such as drinking alcohol before

sex from the perspective of young women shows the complexity of sexual communication in

this gendered context. Young women described the risks of drinking before sex (risk of

regret and coercion), but also perceived advantages regarding social and sexual interactions

(facilitating social and sexual interactions, excusing unsanctioned sexual behaviour;

Livingston et al., 2013). The authors suggest prevention efforts need to address social

needs and the larger cultural context. This is particularly crucial when the heterosexual norm

is for women to be acted upon.

Impulsive behaviour. Informants indicated that young people often engaged in risk-

taking behaviour despite sufficient sexual health knowledge. A recent meta-analytic review

supports the notion that risky sexual behaviours are associated with trait impulsivity (Dir,

Coskunpinar, & Cyders, 2014). While it is not possible or necessarily desirable to reduce

trait impulsivity, it may be beneficial to help adolescents manage their impulses in the

context of sexual health. Also, the discrepancy between knowledge and behaviour indicates

that interventions need to focus on motivational factors (e.g., wanting to avoid condoms

because they reduce sensation, or to please a partner) rather than knowledge and skills

alone. Cooper, Agocha, and Sheldon (2000) demonstrated that motives (i.e., specific

reasons for choosing a behaviour) mediate the link between impulsivity and sexual risk-

19

taking. Motivational enhancement may include non-judgmental, value-independent

education about sexual health and discussion of one’s sexual health goals. This discussion

could include the benefits and costs of different choices, and how easy it is to get regularly

tested for STIs. Interventions addressing impulsive behaviour could also address the role of

alcohol, thinking through consequences, and having an awareness of one’s own desires

regarding sexual health before initiating sexual activity.

There are a few limitations of this study that give rise to future directions. The nature

of this study meant it had an individual focus as opposed to a dyadic focus. A future study

could involve sexual partners and relational factors. Also, data were collected across one

university, albeit the largest in the state, therefore it may not be generalisable to different

contexts. Further, the diversity of informant job positions has some limitations. For example,

only nurses are in a position to notice changes in pubic hair (sexual appearance norms),

whereas counsellors and college staff are more likely to notice changes in relationship

norms. Also, three of the 15 informant had less than 6 years of experience, meaning that

their ability to comment on changes over time was limited. Future studies could investigate

different populations of care providers (e.g., rural locations, younger adolescent care

providers), and other study designs (focus groups, surveys, experiments) to enhance our

understanding of sexual health in the digital age. It is important to note that while care

providers give valuable insight, these perspectives may differ to young peoples'

perspectives, particularly in regards to relationship with digital media.

Strengths include that the care providers are very close to the sexual practices and

health of young people (working only with this population), and have experienced this work

over time (in contrast to young people themselves who are less able to notice changes over

time). Also the diversity of care providers interviewed helped to gain medical, social and

psychological perspectives on overall sexual wellbeing.

In conclusion, this qualitative study provided new insights into the changing nature of

adolescent sexual risk-taking by investigating the perspective of health practitioners. Health

practitioners bring a depth of experience and knowledge about adolescents, their behaviour

20

and STI risk. These findings contribute to our understanding of the complex interplay of

contextual and individual factors, which requires more comprehensive theory, such as

understanding the interplay between impulsive behaviours, motivational factors and

communication skills. This could expand existing theoretical constructs in the Theory of

Planned Behaviour and Health Action Process Approach such as self-efficacy and

expectancies (Ajzen, 1991; Schwarzer & Luszczynska, 2008). Further, the important role of

digital media highlights the need for more holistic approaches to STI prevention, which

address unhealthy norms depicted in media.

21

Acknowledgments

Thank you to all the informants in this study.

Declaration of interest statement

No financial interest or benefits.

22

Tables

Table 1: Care provider details (names have been changed)

Name Job Title Years of experience

Rani College staff member 8 Julie General Practitioner 9.5

George General Practitioner 24

Robert General Practitioner 32

Lucy General Practitioner 30

James College staff member 2.5

Anthony College staff member 9

Nicole Nurse 6

Sarah Nurse 16

Rebecca Nurse 10

Oscar College staff member 5.5

Michael College staff member 24

Samuel College staff member 1

Andrew Counsellor 4

23

Table 2: Semi-structured interview questions.

Topic Interview questions

Your role How long have you been working in this area? How often do you work with young people in relation to sexual health? Follow up:

● When working with young people about sexual health, what brings up this topic?

● Do you usually see the same young person more than once regarding sexual health?

● When do you refer out to a sexual health service? How do you find the interactions with young people regarding safe sex? Follow up:

● How do think young people find these interactions?

The problem Have young people’s sexual behaviour and views changed in the age of social media and dating apps?

● If so, how?

The solution Have you seen prevention efforts in this area? Follow up:

● What is it about those programs that enables them to work well, or not so well?

How could you be more supported as a health practitioner/professional working with young people’s sexual health?

24

Table 3. Themes and Subthemes

Theme Subtheme

Contextual

Media influence on norms

Sexual behaviours

Sexual relationships

Sexual appearance

Transition to university Independence

Social opportunity

Individual

Communication difficulties Gender and sexuality differences

Greater fear of pregnancy than STIs

Impulsive behaviours Disinhibition

Substance use

25

Figures

Figure 1

Transition to university

Media influence on norms

Impulsivity

Communication difficulties

Contextual factors Individual factors

Sexual risk-taking

Figure 2

Media Norms

Impulsive behaviours

Communication difficulties Risky sexual

behaviour

Transition to university

Contextual Individual

26

Figure captions

Figure 1. Thematic map describing university informants’ perspectives on predictors of

sexual risk-taking behaviours.

Figure 2. Diagrammatic summary of hypothesized relationships between themes predicting

risky sexual behaviour among university-based adolescents.

27

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