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SEXUAL HEALTH AND SEXUAL BEHAVIOR AMONG
ROMANIAN ADOLESCENTS
va KLLAY
*
, Catrinel CRCIUN, Gabriel VONA, Adriana BBAN
Department of Psychology, Babes-Bolyai University, Cluj-Napoca, Romania

ABSTRACT

Adolescence is an extremely challenging period of life, when drastic physical and
psychological changes take place in relatively short time-frames, when most
adolescents start experiencing sexual feelings on which some will act upon or not.
Sometimes, these initiatives may prove highly maladaptive, which may negatively
impact both the adolescent, his/her immediate environment, and society as a whole.
The major aims of this study refer to the identification of gender specificities in
sexual behavior among Romanian adolescents. In the same time, we would also
like to investigate the trend in sexual behaviors specific to this age group between
the two assessments: 2006 and 2010. The investigation of sexual risk behaviors as
well as the attitudes and beliefs associated with these behaviors in the case of
Romanian adolescents is essential for the development of efficient programs
through which one may promote healthy sexual behaviors.

KEYWORDS: sexual health, sexual behavior, development, contraceptive use.

INTRODUCTION

Adolescence is probably the most challenging and complicated period of life to
describe, study, or experience. Between the ages of 10 and 20 more changes occur,
and greater individual variation is evident, than during any other period (Berger,
1986, p. 459). These are crucial times in life, in which drastic physical and
psychological changes take place in relatively short periods of time. Major and
visible transformations in the persons physical aspect and functioning may occur in
less than months, thinking styles and emotional life get increasingly more complex,
socializing starts to get more diversified (peers start to be favored instead of the
company of parents). Moreover, adolescence is a critical period where many

*
Corresponding author:
E-mail: evakallay@psychology.ro

Cognition, Brain, Behavior. An Interdisciplinary Journal
Copyright 2011 Romanian Association for Cognitive Science. All rights reserved.
ISSN: 1224-8398
Volume XV, No. 1 (March), 57-68

. Kllay , C. Crciun, G. Vona, A. Bban

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58
patterns of health and health behavior are formed (Levin, Torsheim, Volleberg,
Richter, Davies, Schnohr, Due, & Currie, in press). Thus, adolescence becomes a
time that may seriously influence the future functioning of the individual.
However, adolescence is not only a stage in the transition from childhood
to adulthood, but also a period when most adolescents start experiencing sexual
feelings on which some will act upon (by beginning different forms of sexual
intercourse) (Remez, 2000), while others will focus on non-sexual activities. One of
the key aspects that may further on significantly affect the persons life is the way
in which he/she modulates his/her personal relationships and sexual behavior in
adolescence (Kirby, van der Sluijs, & Currie, 2010a).
Sexual health has been defined in several slightly different ways, but a
comprising one is given by Berkeley and Ross (2003), as the complete physical,
emotional, mental and social well-being of individuals with regards to their sexual
behavior (as cited in Kirby et al., 2010a, p. 1). A healthy and harmonious sexual
life is an essential component of the general development of the person, at social,
physical and psychological levels. It does not only presume that one would try to
avoid unwanted pregnancies and getting infected with sexually transmitted
infections (STIs), but it also concentrates on the integration of physical, emotional,
intellectual, and social aspects of individual sexuality. The concept of healthy
sexual development refers to the accumulation of knowledge and development of
attitudes regarding sexuality (own and others), and sexual experiences and
relationships (WHO, 2004). Sexual maturation in adolescence includes besides
physical and physiological characteristics of puberty, also a series of psychological
changes at personal level and interpersonal relationships. Consequently, in order to
develop a healthy sexuality, adolescents have to learn to accept themselves, how to
deal efficiently with their newly developed sexuality, and how to establish a healthy
relationship with peers.
Adolescence is a period of opportunity and vulnerability (Currie,
Gabhainn, Godeau, Roberts, Smith, Currie, et al., 2008), in which new ideas and
possibilities are explored. However, this is also a period of time when adolescents
are exposed to different risks as: alcohol consumption, smoking and improper
sexual behaviors. Some of the specific behaviors of adolescence, as spontaneity,
social immaturity, sensation seeking, emotional instability, etc. may negatively
impact the pathways of harmonious sexual development. The most important socio-
cultural factors associated with adolescent sexual health are: self-worth, body
image, perception of control, perception of vulnerability, presence of other risk
behaviors, attitudes and relationship with parents and teachers, level of academic
implication and academic performance. Early physical maturation in the case of
girls and late in the case of boys may for instance induce problems associated with
body image and low self-esteem. On the other hand studies revealed that high levels
of self-esteem help adolescents to face group or partner pressure regarding the

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59
beginning of sexual activities, or to negotiate the use of contraception in order to
avoid unwanted pregnancies or STIs (Cheesbrough, Ingham, & Massey, 1999).
Attainment of sexual maturity was described as the moment in which the
person has developed a feeling of self-acceptance and the ability to have
relationships based on understanding and reciprocal trust (Strasburger &
Greydanus, 2000). Sexual maturation represents one of the greatest challenges both
at physical and psychological level it is not only a developmental phase, but it
presumes a long-lasting process that begins in late childhood and continues beyond
the attainment of adulthood.
However, attitudes towards sexuality have significantly changed across the
ages. If several decades ago life goals that influenced the initiation of sexual
activity and choice of sexual partners were quite clear (for girls for example,
usually, to start sexual life and have children after marriage), nowadays the
situation is less obvious (Moore & Rosnethal, 2006). Boundaries between proper
and improper sexual behaviors have become less clear, and there are many more
possible pathways for healthy (and unhealthy) sexual development for todays
adolescents than there were in the 1950s or even the 1990smore possibilities but
also more pitfalls (Moore & Rosenthal, 2006, p. 5).
The most problematic aspects are risky sexual behaviors that may have a
serious impact both at the individual and societal levels; age of initiation, use of no
or inadequate contraception methods, unwanted pregnancies, etc. Early, premature
beginning of sexual activities, occurring before reaching physical and psychological
maturity to deal with its implications may have a negative impact on adolescents
health and well-being (Godeau et al., 2008). For instance, initiation of early sexual
activity has been found to be strongly associated with: poor mental health (Sabia &
Rees, 2008), lower academic success (Sabia, 2007), not to mention the increased
risk of sexually transmitted infections (STIs), unwanted pregnancies (Godeau et al.,
2008), and unsafe abortions (Olukoya, Kaya, Ferguson, & Abou Zahr, 2001).
The number of adolescents getting infected with sexually transmitted
infections (STIs) continues to be high. This is due both to the fact that a
considerable number of adolescents do not use protection, and some of those who
are infected do not seek treatment (either because they do not realize that they have
a serious infection or because of embarrassment) (WHO, 2004). Another
aggravating aspect refers to the fact that most of the STIs are asymptomatic (both in
the case of male and female patients), thus remain untreated, which increases by 10
fold the risk of getting infected with AIDS (UNAIDS, 1998).
Unwanted pregnancies in adolescence have serious implications both for
the teen-age mother and the child. The rates of maternal and infant mortality and
morbidity (Phipps & Sowers, 2002; Treffers, Olukoya, Ferguson, & Liljestrand,
2001; Jolly, Sebire, Harris, Robinson, & Regan, 2000) are significantly higher both
due to deficient antenatal and intrapartum care, delivery problems, and due to
undeveloped physical abilities (Alan Guttmacher Institute, 2002a, b), preterm labor

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60
and stillbirth (WHO, 2004). The number of teenage mothers grows at a constant
rate. If this rate remains unchanged, according to the WHOs estimates, by 2025,
there will be approximately 16 million infants with very young mothers, aged
between 15 and 19 (WHO, 2004).
Unwanted pregnancies and STIs in adolescence imply serious social,
economical, and health problems. However, these may be prevented by the
concerted efforts on behalf of the adolescents families, schools, community, and
programs organized by the Ministry of Health and Public Health Organizations. The
development of different programs, that are to be implemented at the school level
and within the community, may be conducted only if they rely on solid data. Thus,
serious investigations regarding the adolescents sexual attitudes, beliefs, and
behaviors have to be conducted. The comprehension of individual underlying
mechanisms as well as social and cultural factors that may contribute to the
development of risky sexual behaviors is crucial in the development of efficient
interventions.
The investigation of sexual risk behaviors as well as the attitudes and
beliefs associated with these behaviors in the case of Romanian adolescents is
essential for the development of efficient programs through which one may promote
healthy sexual behaviors. On the other hand, it is important to investigate the
specific slopes in the trends regarding sexual behavior, thus tendencies at social
level may be evinced. In the same time, gender specific aspects of sexual behavior
in adolescence are also important in order to increase the efficiency of the programs
that are going to be implemented.

THE PRESENT STUDY

Aim of the study

The major aims of this study refer to the identification of gender specificities in
sexual behavior among Romanian adolescents. In the same time, we would also like
to investigate the trend in sexual behaviors specific to this age group between the
two assessments: 2006 and 2010.

Measures

The Health Behavior in School-aged Children (HBSC) is a collaborative cross
national study, with the participation of 41 countries/regions (Levin et al., in press).
These studies are carried out each 4 years, and the HBSC questionnaire assesses
children 11, 13, and 15 years of age, with school being the primary sampling unit
(Levin et al., in press). The HBSC questionnaire assesses several dimensions of
child and adolescent functioning, from relations with family, friends, school, family

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61
affluence, life satisfaction, physical activity, positive health, to sexual behaviors and
sexual activity, alcohol and drug consumption, and so on.
The HBSC (Health Behavior in School Aged Children) questionnaire has
been applied with two occasions: for the first time in 2006 in Romania, and the
second wave in 2010. The questionnaire assesses sexual behaviors and sexual
health through four items which aim to record the frequency of sexual intercourse in
15 year old adolescents, age at which the first intercourse occurred, degree to which
birth control is used (at the last sexual intercourse), and identification of most
frequently used contraceptive methods among adolescents. One of the major
limitations of such studies though, refers to the fact that these questionnaires are
self-report measures, however, their informative power is useful in the development
of an overall picture regarding the investigated issue.

Participants

The participants included in these studies are represented by 15 year old
adolescents. The 2006 HBSC study assessed 1605 adolescents, 606 boys and 999
girls. The 2010 HBSC study assessed 2055 adolescents, 1081 boys and 974 girls.
Both HBSC studies are nationally representative, participants being selected from
all social strata of the society.

RESULTS

Frequency of sexual intercourse in Romanian adolescents

Our results reveal that in 2006, 45.80% of the boys and 12.40% of the assessed girls
have already had some form of sexual intercourse, while in 2010 these percentages
were 47.90% for boys and 17.40% for girls. Figure 1 illustrates the percentages for
both assessments.
0%
10%
20%
30%
40%
50%
60%
2006 2010
%

w
h
o

h
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h
a
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s
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x
u
a
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i
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t
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o
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r
s
e
Boys Girls

Figure 1.
Percentages of sexual intercourse in 15 year old Romanian adolescents (boys - girls) in 2006 and
2010

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62

While the differences between the 2006 and 2010 assessments in the
number of 15 year old boys who have already had sex before the age of 16 has not
proven significant [
2
(1,N = 1555) = 0.63 p = .45], the slope of this trend is steeper
in the case of girls. Thus, compared to the assessment conducted in 2006, the 2010
study revealed that the percentage of 15 year old girls who had sexual intercourse is
significantly higher than four years before [
2
(1,N = 1912) = 9.26 p < .01].

Age of first sexual intercourse

Both HBSC studies have investigated the age at which adolescents begun their
sexual activities. Thus, the results show, for 2006 (see Figure 2), 9.96% boys vs.
8.11% girls reported to have started sexual intercourse at the age of 11; 11.26%
boys and 1.35% girls at age 12; 11.69% boys and 2.70% girls at age 13; 32.90%
boys and 24.32% girls at age 14, and 34.20% boys and 63.51% girls at age 15.
0%
10%
20%
30%
40%
50%
60%
70%
%

a
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f
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s
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x
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a
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i
n
t
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r
c
o
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r
s
e
Age 11 Age 12 Age 13 Age 14 Age 15
Boys Girls

Figure 2.
Results regarding age of first sexual intercourse in 2006

As one can see, the percentages are higher for boys than girls up till age 15,
when the percentage of girls becomes higher. Overall, our results show that the age
at which boys have the first sexual intercourse is significantly lower than that of the
girls [
2
(4,N = 305) = 24.17 p < .01].
Figure 3 comprises the results regarding age of first sexual intercourse in
2010.

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63
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
%

a
g
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o
f

i
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t
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a
t
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o
n

f
o
r

t
h
o
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h
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v
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h
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s
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i
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t
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r
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o
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r
s
e
11 12 13 14 15
Boys Girls

Figure 3.
Age of first sexual intercourse, 2010: boys-girls

As seen, the tendency by the age of 15 is usually higher for boys than for
girls (12.93% vs. 9.40%; 6.35% vs. 5.13%, 16.55% vs. 7.69%, 32.65% vs. 23.08%).
Though, the percentage of sexual initiation at the age of 15 is higher for girls than
for boys (31.52% vs. 54.70%). On average, the age at which boys start sexual
activity is significantly lower in their case than that of the girls [
2
(4,N = 558) =
22.54 p < .01].

Contraception use at last sexual intercourse

Use of contraceptives in 2006 are resented in Figure 4. Thus, results show that at
the last sexual intercourse 10% of the boys and 17.91% of the assessed girls used
birth control pills; 86.79% of the boys and 59.61% of the girls used condoms;
31.45% of the boys and 18.75% withdrawal; 8.77% of the boys and 3.39% of the
girls spermicide ovules, and 10.43% of the boys and 10.17% of the girls other
methods.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
%

u
s
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n
g

t
h
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c
o
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p
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l
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i
n
t
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c
o
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r
s
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Birth control
pills
Condoms Withdrawal Spermicide
ovules
Other method
Boys Girls

Figure 4.
Contraception use at last sexual intercourse, 2006

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64
Our results have evinced significant differences between boys and girls
regarding condom use, in the sense that boys rely significantly more frequently on
this method [
2
(1,N = 316) = 29.88 p < .01]. There have not been found significant
differences regarding birth control pills [
2
(1,N =187) = 2.41 p = .17]; withdrawal
[
2
(1,N = 188) = 3.45 p = .08]; spermicide ovules [
2
(1,N = 173) = 1.76 p = .22],
and other methods [
2
(1,N = 174) = .003 p = 1.00].
Percentages regarding the use of different forms of contraception specific
for 2010 also reveal differences between boys and girls (see Figure 5). During the
last sexual intercourse 18.08% of the boys and 31.62% of the assessed girls used
birth control pills; 73.24% of the boys and 56.15% of the girls used condoms;
33.46% of the boys and 27.08% withdrawal; 9.16% of the boys and 9.41% of the
girls spermicide ovules, and 5.58% of the boys and 3.70% of the girls other
methods.
If birth control pills are used by a significantly higher percentage of girls
[
2
(1,N = 377) = 8.55 p < .01], condom use is significantly more frequent among
boys [
2
(1,N = 541) = 13.51 p < .01]. Other contraceptive methods as, withdrawal
[
2
(1,N = 362) = 1.32 p = .30], spermicide ovules [
2
(1,N = 34) = 0.01 p = 1.00],
and other methods [
2
(1,N = 314) = 0.44 p = .77] are used at similar percentages in
both girls and boys.
0%
10%
20%
30%
40%
50%
60%
70%
80%
%

u
s
i
n
g

t
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p
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a
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n
t
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r
c
o
u
r
s
e
Birth control
pills
Condoms Withdrawal Spermicide
ovules
Other method
Boys Girls

Figure 5.
Contraception use at last sexual intercourse, 2010

Trends in condom and pill use 2006-2010

The tendency in the usage of contraceptive methods among boys and girls is
illustrated in Figure 6. Our results show a significant [Boys
2
(1,N = 727) = 15.66
p<.01] and alarming decrease in condom use among boys between 2006 and 2010.

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65
Even if in the case of girls there is an ascending slope in the use of condoms as
contraceptive methods, the differences are not significant [
2
(1,N = 258) = 0.46
p=.51] .
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
2006 2010
%

u
s
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n
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c
o
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d
o
m

a
t

l
a
s
t

i
n
t
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c
o
u
r
s
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Condom (Boys) Condom (Girls)

Figure 6.
Trends in condom and contraceptive pill use at last intercourse 2006-2010

CONCLUSIONS AND DISCUSSIONS

The major aim of this present paper was to offer a brief overview regarding sexual
behavior specific to 15 year old Romanian adolescents, based on data obtained at
two nation-wide HBSC assessments. We have presented the percentage of 15 year
old boys and girls who reported to have already been active. When data obtained at
the 2006 and 2010 HBSC assessments were compared regarding frequency of
sexually active adolescents, the tendency shows an increase since 2006
(insignificant increase in boys, but significant in girls). The results obtained in 2006
indicate that compared to other countries participating in the HBSC study, the
percentage of Romanian adolescents already having had sexual intercourse is lower
than in Greece (66% of girls and 55% of boys), Bulgaria (31% of girls and 47% o
boys), Denmark (40% of girls and 47% of boys), etc., but higher than in Italy (22%
girls and 27% of boys), Slovenia (17% girls and 30% boys), Hungary (21% of girls
and 25% ob boys), Slovakia (11% of girls and 13% of boys), etc. (for more see
Currie et al., 2008). Comparative, cross national results will be presented in the
2010-2011 International HBSC report in the near future.
Also, the age at which boys report to have had their first sexual intercourse
is overall lower in the case of boys than in the case of girls. An interesting aspect
that may be relevant for future investigation is that mentioned by Kirby et al.

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66
(2010a), regarding the identification of the first sexual intercourse (i.e., voluntary or
coerced), especially at such young ages as 11-14 years.
At both assessments there has been identified a predilection for the use of
condoms, with percentages being in both cases higher for boys. These results are
similar to the tendencies found in other countries (e.g., Scotland, see Kirby et al.,
2010a). As Kirby (2010b) underscores, gender differences in attitudes towards
condom use may be due to embarrassment at buying or carrying condoms.
Similarly, girls apparent preference for contraceptive pills based on the obtained
results may reflect the fact that boys are not aware that girls reside to such
contraceptive measures (Kirby et al., 2010a). Moreover, the trends resulted evince a
serious decline in condom use in boys from 2006 to 2010, however results show a
less abrupt increase in contraceptive pill use for girls.
The percentage of boys and girls using traditional as well as modern
contraceptive methods obtained at the 2006 HBSC study reveals alarmingly low
percentages compared to those of the other European countries, especially if we
consider the use of different contraceptive methods: condom use at the last sexual
intercourse in: Portugal (84% girls and 86% boys), Greece (69% girls and 91%
boys), Hungary (76% girls and 79% boys), and contraceptive pill use in
Netherlands (61% girls and 42% boys), Germany (55% girls and 41% boys),
Slovenia (25% girls and 19% boys), etc. (for more see Currie et al., 2008).
Thus, the discrepancies found in the age of first sexual intercourse and
preference towards specific contraceptive methods between 15 year old boys and
girls raises important questions regarding the relationship between sexual behavior
and cultural context, as well as gender roles Romanian adolescents assume in
interpersonal relationships.
Taking into account all these results, we think that the need for developing
educational programs and public policies that would target the amelioration of
adolescent maladaptive sexual behaviors is stringent. One of the most salient
aspects is represented by the introduction of the topic of sexual education into the
school curricula, as early as children understand the risks implied in premature
sexual activities and can talk about interrelated aspects and factors that may
influence sexual behavior at this age. Taking into consideration the factors
associated with maladaptive sexual behaviors, the main objectives of sexual
education should be try to develop attitudes, beliefs and values regarding sexual
identity, body image, efficient interpersonal relationships and responsible decisions.
In the same time, the development of assertive communication is also crucial,
because in this way adolescents can withstand group and intra-couple pressure.
Another aspect revealed by this survey suggests that self-efficacy at this age should
also be developed, thus, coupled with assertive communication styles, adolescents
may be able to negotiate their stand in a relationship or say NO.
In order to assure a harmonious sexual development and sexual health in
adolescents, it is also necessary to develop, in parallel with the fostering of

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67
responsible sexual behavior, family planning centers which would offer their
services (medical consultations, modern contraceptives, etc.) either for free or at
affordable rates especially targeting this high risk population (Gabhainn, Baban,
Boyce, Godeau, et al., 2009). Simultaneously, at the community level, the
development of alternative possibilities to enjoyably spend free time (youth
organizations, sport clubs and sport centers, artistic clubs, etc.) may indirectly
contribute to the promotion of sexual health among adolescents.

ACKNOWLEDGEMENTS

The collection of the data for the 2005 HBSC Study was possible due to a grant obtained
from Jacobs Foundation, Switzerland, while the collection of data for the 2010 HBSC study
was financed by a grants award by the Norwegian Government through the program of
Norway Innovation.

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