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Raquel Nogueira Avelar e Silva, Daphne van de Bongardt, Petra van de Looij-Jansen, Anne Wijtzes and Hein Raat
Pediatrics December 2016, 138 (6) e20160782; DOI: https://doi.org/10.1542/peds.2016-0782
OBJECTIVES: To assess the prospective associations between mother-adolescent and father-adolescent relationship quality and early sexual intercourse initiation (ie, ≤16 years) among a large sample of Dutch adolescents.
METHODS: Two waves of data from the Rotterdam Youth Monitor, a longitudinal study in the Netherlands, were used. The analysis sample consisted of 2931 adolescents aged 12 to 16 years (Meanage@T1 = 12.5 years, SD = 0.61; Meanage@T2 = 14.3 years, SD = 0.60). Variables were assessed by means of self-report questionnaires. Prospective associations between mother-adolescent and father-adolescent relationships and early sexual initiation were assessed by logistic regression analyses, stratified by gender, controlling for various potential confounders.
RESULTS: We found that only girls (not boys) having a higher-quality relationship with mothers were significantly less likely to have initiated early sexual intercourse between T1 and T2. Bivariate findings showed that both girls and boys having a higher-quality relationship with their father at T1 were significantly less likely to have engaged in early sexual intercourse between T1 and T2, but when assessed multivariately, these associations were no longer significant, neither for boys nor for girls.
CONCLUSIONS: Our findings suggest that a higher-quality relationship between adolescents and their parents, especially between mothers and daughters, may help to protect against early sexual initiation. Pediatricians and other health care professionals should be able to explain to parents that early sexual intercourse initiation can be associated with negative health outcomes, but that parents can play an important role in promoting healthy sexual behaviors.
A poor parent-adolescent relationship has been associated with early sexual intercourse in adolescence; however, most studies have focused only on the role of mothers. Hence, only a little is known about the role of fathers.
Using a prospective design, this study assessed the role of fathers additionally to the role of mothers in the associations between mother-adolescent and father-adolescent relationship quality and early sexual intercourse initiation in a large population of Dutch adolescents.
Adolescence is a period in which many adolescents start exploring intimate relationships and sexual behaviors, including intercourse.1,2 Although the initiation of sexual intercourse is a normative step in adolescents’ sexual development,1,2 early sexual intercourse initiation (ie, before the average age) may be problematic.3–12 Early sexual intercourse has been associated with risky sexual behaviors (eg, unprotected sex),3–6 sexually transmitted infections (STIs),7–10 and unwanted pregnancy.7,11 Early sexual starters tend to lack social, emotional, and cognitive skills that are normally gained with general life experiences, including experiences with romantic and sexual partnerships.13–15 In addition, early sexual starters have limited knowledge about the risks involved in unprotected sexual intercourse, such as the possibility of contracting STIs.16 These specificities of young adolescents may partly explain why early sexual intercourse is associated with negative outcomes.13–16 Understanding the determinants of early sexual intercourse may contribute to promote effective preventive strategies to improve adolescents’ sexual health.
According to the ecological systems theory, both the social environment (eg, family) and the quality of the relationships within the social environment (eg, parent-adolescent relationships), play a role in adolescents’ sexual development.17 The literature consistently shows that a poor parent-adolescent relationship quality, defined as adolescents’ perception of little warmth, support, and closeness in the relationship with their parents,18 is associated with a higher likelihood of engaging in sexual intercourse at an early age.19–23 However, most studies on the parent-adolescent relationship quality and adolescents’ sexual behavior have focused only on the role of mothers.19–21 This can be partly explained by a cultural aspect; in many societies mothers are the primary caregivers of children, and the primary providers of education on sexuality, for both boys and girls.24–26 Recently, studies have begun to look at the role of fathers in adolescents’ sexual development, showing that, for instance, fathers’ involvement may positively affect their children’s sexual development.27–29 To the authors’ knowledge, 2 studies have investigated the association between the quality of the father-adolescent relationship and adolescents’ sexual intercourse initiation.27,28 These 2 studies found that adolescents who reported higher-quality relationships with their fathers at baseline (age = 15–19 years) were less likely to report sexual intercourse experience at follow-up (age = 16–19 years).27,28 However, 1 study included girls only,28 and both studies were conducted in the United States.27,28 As mother-adolescent and father-adolescent relationships may differ for boys and girls,19,30–33 and vary across cultures,34 results from these studies may not be generalizable to all adolescents or other countries.
In the current study, we assessed prospective associations between mother-adolescent and father-adolescent relationship quality and early sexual intercourse initiation among Dutch adolescents, defined as first sexual intercourse experience before the age of 16 years, which is the average age at which Dutch adolescents initiate sexual intercourse (ie 16.7 years). Firstly, based on previous studies’ findings,19–23,35,36 we hypothesized that adolescents who would report a higher-quality relationship with their mother and/or father would be less likely to initiate early sexual intercourse at ≤16 years. Second, as the literature also shows that the associations between parent-adolescent relationship quality and the timing of sexual intercourse are stronger for girls than for boys,19,30–33 we hypothesized that a higher-quality relationship with their mother and/or father would be more strongly associated with a lower likelihood of engaging in early sexual intercourse for girls than for boys.
We used data that were collected as part of the Rotterdam Youth Monitor (RYM), a longitudinal youth health surveillance system that is incorporated into the preventive youth health care system of Rotterdam, 1 of the 4 largest cities in the Netherlands.37 Data were collected among a community sample of adolescents who were enrolled in secondary schools located in Rotterdam and surroundings. For the current study, data from 2 waves were used, with a 2-year interval between measurements. At T1 (2008–2009), 76 schools and 8272 students in the first year of secondary school participated in the measurement (ie, 100% school and 95% student participation rate). At T2 (2010–2011), 45 schools and 3184 students participated in the follow-up measurement (ie, 59% school and 38% student participation rate). The main reason for nonresponse at follow-up was that some schools were no longer able to participate.37 Administration of the questionnaires at schools was guided by trained researchers, school nurses from the Municipal Public Health Service, and teachers.
For our analyses, we selected only students who participated in both measurements (n = 3184). In addition, to be able to predict the initiation of early sexual intercourse (ie, ≤16 years), we selected only participants who never had sexual intercourse at T1 (n = 70 excluded) and who were ≤16 years old at both T1 and T2 (n = 3 excluded). Furthermore, we excluded participants with missing information on the following variables: age at T1 and/or at T2 (n = 3), mother-adolescent or father-adolescent relationship quality at T1 (n = 167), and sexual intercourse at T1 and/or at T2 (n = 10). Results from χ2 tests and 1-way analyses of variance (ANOVAs) showed that adolescents who were included in the final analysis sample (n = 2931) were more often younger (P < .01), enrolled in higher educational levels (P < .001), non-native Dutch (P < .001), more often lived with both biological parents (P < .001), and also reported a higher-quality relationship with their mother (P < .001) than adolescents who were excluded from the analyses (n = 4808).
Activities of the preventive youth health care system of Rotterdam, of which the RYM is part, have been approved by the Dutch government. The data of the RYM are protected by the Municipal Health Service of Rotterdam, which follows the Code of Conduct Health Research of the Netherlands. Adolescents received verbal information about the questionnaires each time they were applied, and their parents received written information regarding every assessment. Adolescents and their parents were free to decline participation. The questionnaires were completed on a voluntary basis, and confidentiality of responses was guaranteed.38 Observational research (ie, not experimental) with confidential data gathered in routine health care does not fall within the ambit of the Dutch Act on research involving human subjects, and therefore does not require the approval of an ethics review board; separate informed consent was therefore not required.37 Data were de-identified before the analyses.
Early sexual intercourse was measured using 1 item: “Have you ever had sexual intercourse? (With sexual intercourse we mean penile-vaginal intercourse)” (1 = never; 2 = once; 3 = a couple of times; 4 = regularly). For the present analyses, the item was dichotomized (0 = never; 1 = ever).39
The quality of the mother-adolescent relationship was measured at baseline by using the Family Attachment Scale of The Communities That Care Youth Survey, for which a good validity and reliability have been reported.18,40,41 This scale included 3 items (ie, “Do you feel close to your mother?” “Do you share your thoughts and feelings with your mother?” “Do you enjoy spending time with your mother?”), which were scored on a 4-point scale (0 = NO!; 1 = no; 2 = yes; 3 = YES!). A total score was calculated by averaging the scores on the 3 items (α = 0.72), where higher scores mean higher-quality mother-adolescent relationship (Mean = 2.60).
The quality of the father-adolescent relationship was operationalized in the same way as the mother-adolescent relationship quality, but “mother” was replaced by “father” in the 3 items (α = 0.78; Mean = 2.44).
Parental monitoring was included as a potential confounder, and was assessed as the level at which parents monitored adolescents’ behaviors.41 This variable was also measured at baseline by using the Family Attachment Scale,40 by 5 items (ie, “When I am not at home, one of my parents knows where I am and who I am with”; “My parents ask if I’ve gotten my homework done”; “Would your parents know if you did not come home on time?”; “My family has clear rules about alcohol and drug use”; “Would your parents find out if you were using drugs?”), which were scored on a 4-point scale (0 = NO!; 1 = no; 2 = yes; 3 = YES!). A total score was calculated by averaging the scores on the 5 items (α = 0.71), where higher scores mean a higher level of parental monitoring (Mean = 2.42).
Descriptive statistics were used to portray the analysis sample characteristics at baseline. One-way ANOVA tests were applied to compare differences in T1 variables between adolescents who did and did not engage in early sexual intercourse between T1 and T2. Prospective associations between mother-adolescent and father-adolescent relationship quality and early sexual intercourse initiation were assessed by a series of logistic regression analyses, stratified by gender. In the first 2 regression models, mother-adolescent relationship quality and father-adolescent relationship quality were included in the models separately. In the third model, mother-adolescent and father-adolescent relationship quality were added to the model simultaneously, to adjust for each other’s independent contribution. We also tested gender-interaction effects (ie, gender × mother-adolescent relationships, gender × father-adolescent relationships), to assess whether the found effects from the stratified analyses were indeed really statistically different for boys and girls. All regression models included the following potential confounders: gender,39 age,39 educational level,19, ethnic background,42 family structure,42–44 and parental monitoring.45–47 A significance level of P < .05 was used to indicate significant effects.
The final sample for the prospective analyses included 2931 adolescents aged 12 to 16 years (Meanage@T1 = 12.5 years, SD = 0.61; Meanage@T2 = 14.3 years, SD = 0.60). Table 1 presents participants’ descriptive characteristics at T1. A total of 233 adolescents (8.0%), including 77 girls (2.6%) and 156 boys (5.4%), had initiated sexual intercourse between T1 and T2.
Descriptive Characteristics of the Analysis Sample at T1
Table 2 shows the bivariate differences in T1 parenting variables between early and later sexual initiators. Girls who had initiated sexual intercourse between T1 and T2 scored significantly lower on parental monitoring and on relationship quality with their mothers and fathers than girls who had not initiated sex. Boys who had initiated sexual intercourse between T1 and T2 scored significantly lower on parental monitoring and on relationship quality with their fathers than boys who had not initiated sex.
One-Way ANOVA Results of Bivariate Differences in T1 Parenting Variables Between Early and Later Sexual Initiators
Results from the logistic regression analyses stratified by gender (Table 3) show that for girls, higher-quality relationship with mothers (Crude Model Mothers) and with fathers (Crude Model Fathers) were significantly associated with a lower likelihood of early sexual intercourse initiation. However, when mothers and fathers were combined in 1 model simultaneously (Full Model), only higher-quality relationship with mothers remained a significant protective factor against early sexual intercourse initiation, whereas the relationship with fathers became nonsignificant (Table 3).
Logistic Regression Analyses Results for Associations Between Mother-Adolescent and Father-Adolescent Attachment Relationship at T1 and Early Sexual Intercourse Between T1 and T2, Stratified by Sex
For boys, neither relationship (with mothers or fathers) was significantly associated with early sexual initiation, neither in the Crude models, nor in the Full Model.
In the full model for the total analysis sample (Table 4), we found 1 significant gender-interaction effect, indicating that only for girls (not for boys) having a higher-quality relationship with mothers was linked to a lower likelihood to initiate early sexual intercourse between T1 and T2 (odds ratio [OR] 0.66; 95% confidence interval [CI] 0.50–0.88, = P.01).
Logistic Regression Analysis Results for Associations Between Mother-Adolescent and Father-Adolescent Attachment Relationship at T1 and Early Sexual Intercourse Between T1 and T2
In the current study, we assessed prospective associations between mother-adolescent and father-adolescent relationship quality and early sexual intercourse initiation (ie, ≤16 years) among a large sample of Dutch adolescents. The results of both bivariate and multivariate analyses showed that only for girls (not for boys) having a higher-quality relationship with mothers was prospectively linked to a lower likelihood to initiate early sexual intercourse. Furthermore, bivariate findings showed that both girls and boys who reported a higher-quality relationship with their father at T1 were significantly less likely to have engaged in early sexual intercourse between T1 and T2. However, when assessed multivariately, the associations between father-adolescent relationship quality and early sexual initiation were no longer significant, neither for boys nor for girls. Overall, our results are partially in line with our hypotheses and consistent with previous studies. Yet our findings also expand the existing literature in several ways.
First, our finding that a higher-quality relationship with mothers is a protective factor against early sexual initiation for girls, but not for boys, is in line with previous studies.19,30–33 This may be related to the fact that mothers are still the primary providers of sexuality education within families, and also that mothers talk more often about sexuality with daughters than with sons.48–52 According to social learning theory,53 girls tend to learn more from and behave more according to their mothers’ role modeling, whereas boys tend to learn more from and behave more according to their fathers’ role modeling.53–55 Thus, having a high-quality relationship with mothers may contribute to more frequent parent-adolescent sexual communication,48–50 which in turn has been associated with a lower likelihood of early sexual intercourse initiation, particularly for girls.48,51 Future studies should further examine the exact mechanisms underlying the protective effects of a high-quality relationship with mothers.
Second, although our bivariate findings suggested that a higher-quality relationship with fathers may protect both girls and boys against early sexual initiation, the multivariate analysis results indicated no significant protective effect from fathers, neither for boys nor for girls. This finding differed from findings of previous studies.27,28 It may be that in our multivariate regression models, we have accounted for variables that have been consistently associated with adolescents’ sexual initiation, such as family structure,42–44 and parental monitoring,45–47 which in turn may have reduced the unique predictive value of father-adolescent relationship quality. Also, our study included younger adolescents (ie, 12–15 years at T1 and 12–16 years at T2) than previous studies, which included older adolesc
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