Article summary with Offline and Online Sexual Risk Behavior among Youth in the Netherlands: Findings from 'Sex under the Age of 25" by De Graaf et al. - 2018

What is this study about?

As children grow up, they naturally begin to explore and develop their sexuality. This process typically starts with less intimate behaviors like kissing and progresses to more intimate behaviors such as oral sex or intercourse. However, as these behaviors become more intimate, they also come with risks. Engaging in unprotected sex can lead to negative health outcomes such as sexually transmitted infections (STIs) or unwanted pregnancy. Additionally, in today's digital era, young people face new risks related to online sexual behaviors.

Sexual risk behavior refers to behaviors that increase the chances of unintended pregnancy or STI transmission, including HIV. However, measuring these behaviors is challenging due to survey constraints. Researchers often focus on limited indicators like condom use or number of partners, assuming they represent other risky behaviors. To understand the actual risk level, multiple factors like partner type, specific behaviors, and frequency of sex should be considered. It's important to explore risk reduction strategies, like monogamy, although there's still a risk of infection if a partner has an STI. Research on these strategies among young Europeans is limited, as most studies focus on high-risk groups. Studies on unplanned pregnancy risk primarily emphasize contraceptive use, neglecting other factors. Assessing risk requires considering multiple factors, including the "unmet need for family planning" indicator, which monitors conditions like being sexually active without contraception or a desire to delay future children. However, this indicator is mainly studied among married or partnered women and less among adolescents.

Studies examining the risk of unplanned pregnancy among young people typically focus on contraceptive use but often overlook these other conditions. It is assumed that young people are fertile and do not intend to get pregnant, without considering the desires and intentions of emerging adults (18-24 years old). Additionally, some adolescents may temporarily abstain from sex or only engage in same-sex relationships, eliminating the risk of pregnancy. Comprehensive measures of contraceptive use should include a range of methods, including intrauterine devices (IUDs), as their usage is increasing among women and girls in Europe. Contraceptive compliance, especially with short-acting contraceptives, should also be considered, as some users do not consistently use them.

In the digital age, sexual behaviors are not limited to offline interactions. Online sexual risk behavior typically refers to sexting (sending and receiving sexual images and messages) or seeking sexual partners online through dating applications. While these behaviors are not inherently risky, they can have negative emotional outcomes. Sexting, for instance, can lead to invasion of privacy, embarrassment, and negative emotional effects if private images are shared without consent. Meeting sexual partners online has been associated with risks such as non-consensual sex or increased STI transmission.

This paper analyzes data from a Dutch survey called "Sex under the age of 25" to examine sexual risk behaviors in three categories: STI/HIV-related behavior, unplanned pregnancy-related behavior, and online sexual risk behavior. The study focuses on boys and girls separately, as well as different age groups (adolescents and emerging adults). It investigates the association between these behaviors and negative health outcomes like STI/HIV infection, unplanned pregnancy, and non-consensual sex. The findings aim to inform professionals working in sex education and sexual health services about the prevalence of sexual risk behaviors among young people in the Netherlands and provide guidance on addressing the specific risks faced by Dutch youth.

What are the results of this study?

This study recruited participants from secondary schools and municipal population registers in the Netherlands to assess sexual behaviors and related risks. A total of 20,500 participants were included after exclusions. Measures included sexual experience, partner type, number of sexual partners, condom use, testing behavior, STI/HIV diagnosis, contraceptive use, risk of unplanned pregnancy, experience of unplanned pregnancy, sexting behavior, redistribution of sexts, online dating, and experience of non-consensual sex. Statistical analyses were conducted to examine associations between risk indicators and negative outcomes.

The results of the study can be summarized as follows:

1. Sexual Behavior:
   
   • 34.3% of adolescents and 68.8% of emerging adults had experience of oral sex.
   • 14.3% of adolescents and 73.2% of emerging adults had experience of vaginal intercourse.
   • 5.4% of adolescents and 28.0% of emerging adults had experience of anal intercourse.
2. Risk of STI/HIV:
   
   • Between 53.5% and 74.2% of sexually active participants did not always use condoms with their last sexual partner.
   • The proportion of participants reporting that their partner was a casual partner with whom they did not always use condoms was smaller.
   • About 11% of the participants had more than one partner in the last 6 months and did not use condoms consistently with their last partner.
   • 19.2% of adolescents and 33.1% of emerging adults in long-term relationships used condoms only at the start of the relationship.
   • A small percentage of young people who used this strategy reported that both partners were tested for STIs or HIV.
   • The prevalence of inconsistent condom use was higher among girls and emerging adults compared to boys and adolescents.
3. Risk of Unplanned Pregnancy:
   
   • 15.7% to 26.2% of participants sometimes or never used contraceptives with their last sexual partner.
   • Boys and adolescents reported contraceptive non-use more than girls and emerging adults.
   • Among girls, 87% reported using a contraceptive method at the time of the questionnaire, with the contraceptive pill being the most common method.
   • Some girls reported not using contraception because they were not currently sexually active or were planning to get pregnant.
   • 4% of girls were directly at risk of an unplanned pregnancy.
4. Online Sexual Risk Behavior:
   
   • 6.9% of adolescents and 21.2% of emerging adults reported engaging in at least one sexting activity in the past 6 months.
   • Sending nude pictures or sex videos of themselves was the most prevalent sexting behavior.
   • Some participants reported that someone had shared their nude pictures or sex videos with others.
   • Age differences were found, with higher prevalence among emerging adults.
   • A small percentage of participants had engaged in online dating behaviors, with more emerging adults than adolescents participating.
   • Associations were found between online sexual behaviors and negative outcomes, such as non-consensual sex.

The study aimed to examine sexual risk behaviors and their associations with negative outcomes, such as STIs, unplanned pregnancy, and non-consensual sex, both offline and online. The prevalence of negative outcomes was low in the Dutch sample. The Netherlands has a low rate of adolescent pregnancy and a high rate of contraceptive use. However, some risky behaviors were identified. About 13% of sexually active girls did not use contraceptives, putting them at risk of unplanned pregnancy. Inconsistent contraceptive use was associated with a higher likelihood of experiencing unplanned pregnancy. The use of other contraceptives, such as the contraceptive pill or IUD, was high, but it might adversely affect the prevention of STIs and HIV since condoms reduce the risk of both STIs and unplanned pregnancy. Sexting was found to have mixed outcomes, with some negative consequences, particularly among adolescents. Online dating was more prevalent among emerging adults, and engaging in sexting or online dating was associated with a higher likelihood of experiencing non-consensual sex. The study had limitations, such as the inability to establish causal relationships and a lack of detailed measures. Recommendations include promoting preparedness for unexpected sexual encounters, emphasizing the importance of consistent contraceptive use and condom use for STI prevention, and targeting prevention efforts for negative outcomes of sexting among young adolescents.