The investigators analyzed and compared themes in 268 qualitative studies on sexual behavior of primarily unmarried, heterosexual people under age 25, covering behaviors in the United Kingdom, Australia, Mexico, and South Africa.
The results are "surprisingly similar in different settings, with variations of the extent to which each theme is present rather than of kinds of themes," said Cicely Marston, Ph.D., of the London School of Hygiene and Tropical Medicine, and Eleanor King, of the Medical Research Council, in the Nov. 4 issue of The Lancet.
These studies were published in English over the past 15 years. Each study was classified as high or low quality depending on whether it contained empirical data and provided evidence for statements made.
The researchers identified five key themes related to general sexual behavior and two specifically regarding condom use. They found:
- Young people assess the risks from sexual partners on the basis of whether they judge the partner "clean" or "unclean," assessed primarily by how well they know their partner socially, the partner's appearance, and "other unreliable indicators." The researchers said this may help explain why some young people are inconsistent condom users even with high levels of knowledge and access to condoms.
- Sexual partners exert an important influence on sexual behavior in general. For example, sex may be used to strengthen a relationship or please a partner, pregnancy may be sought as a means of holding onto a boyfriend, and fear of violence or retribution from the partner may induce consent to sex.
- Condoms can be stigmatizing, such that carrying or buying condoms can imply sexual experience for good or ill, and be associated with lack of trust or imply that the partner is diseased.
- Gender stereotypes are an essential factor in social expectations and behavior. Worldwide, men are expected to be highly sexually active, but women chaste. "Paradoxically, despite the stigmatizing effect for women in carrying condoms or using other contraception, women, not men, are generally considered responsible for pregnancy prevention."
- Society offers both penalties and rewards for sex. Complying with gender expectations can raise social status, but sex may be a way to obtain money and gifts. Pregnancy can be both penalized by stigma and reward women with an escape route from the parental home.
- Reputations and social displays of sexual activity, or inactivity, are important in all societies. They can lead to social isolation, damaged reputations, or worse.
- Social expectations hamper communication about sex. This can result in deliberate miscommunication and ambiguity to avoid loss of face, hurt feelings, or damaged reputations or to keep open the option of refusing intercourse.
Although qualitative studies have been done on sexual behaviors in many nations, the researchers observed that the information seldom reaches those who need it.
"Because this is a comparatively new field and qualitative work is usually published in specialist journals, such research tends not to be read by other researchers, clinicians, or policymakers," they wrote.
The investigators said the findings help explain why many HIV prevention programs have not been effective.
"Programmes that merely provide information and condoms without addressing the crucial social factors identified are only tackling part of the problem," they wrote. "With nearly half of new HIV infections worldwide occurring in young people ages 15 to 24 years, changing sexual behaviour in this group will be crucial in tackling the growing pandemic."
Recognizing these underlying influences may help policymakers improve local safe sex and disease prevention efforts, Dr. Marston and King said. "The challenge now is to design locally tailored programs that take all seven themes into account and address the important factors for each setting."
However, Edward O. Laumann, Ph.D., of the University of Chicago, cautioned in a commentary that the findings need to be integrated with local quantitative data on sexual behavior. The systematic review included no information on how participants in the studies were recruited or how representative the samples were, he said.
"There's a sense in which they may have gone overboard underscoring the commonalities and not the differences," Dr. Laumann said. He emphasized that the findings should be understood as a context in which sexual behaviors play out locally.
The investigators acknowledged that one limitation of the study was the exclusion of homosexual behavior due to the rarity of such studies in young people. However, "our analysis of the few that do exist suggests similar themes to those identified for heterosexual behavior," they wrote.
They suggested that future research should focus on the causes of deviance from stereotypical behavior, asking more detailed questions, and the forces that drive changes in behavior.
- Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco