Sexual & Reproductive Healthcare 25 (2020) 100534

Contents lists available at ScienceDirect

Sexual & Reproductive Healthcare

journal homepage: www.elsevier.com/locate/srhc

Young adults’ sexual health in the digital age: Perspectives of care providers T
a,b,⁎ a,b b a,b
Laura E. Anderson , Genevieve A. Dingle , Beth O'Gorman , Matthew J. Gullo
a
Centre for Youth Substance Abuse Research, The University of Queensland, Australia
b
School of Psychology, The University of Queensland, Australia

A R T I C LE I N FO A B S T R A C T

Keywords: Objectives: This study examined care providers’ views on young people’s sexual health in the digital age. Young
Adolescents people have high rates of sexually transmitted infections (STIs), indicating sexual risk-taking behaviours.
Risky sexual behaviour Adolescents transitioning to adulthood may be particularly at risk due to increased sexual behaviour and ex-
Sexually transmitted infections posure to risk factors for unsafe sex, such as less parental monitoring. These risks may be accentuated in the
Digital age
digital age, where the availability of dating apps and pornography have potentially influenced young people’s
Provider perspectives
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, coun-
sellors and university residential college staff (N = 15, six female) who work with young people aged 17 and 18.
Interviews took 20–40 min, 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 in-
fluence on norms (influence on sexual behaviours, relationships and appearance), transition to adulthood (in-
dependence, 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.

Introduction increased in many Western countries, including Australia [28]. For

Sexually transmitted infections (STIs) are a cause of major concern,
particularly for young people aged 15–24 years who have some of the
highest rates of infection [28]. Many STIs are asymptomatic, and if left
untreated, can cause infertility or premature death [21]. Interventions
targeting young people (or ‘adolescents’, as per revised definitions of
adolescence including those aged up to 24 years [37]) have the po-
tential 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
[25,31]. This risk period is particularly evident in university residential
colleges, where a growing number of Australian students live [33].
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
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 in-
creasing by 42% from 2008 to 2017 among those aged 15–24 years
[28]. 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 appli-
cations (“apps”), accessible pornography, and sexual content in digital
streaming platforms, television series and movies. There is an associa-
tion between the use of smartphone dating apps, such as Tinder (het-
erosexual focus) and Grindr (homosexual focus), and STI risk; however,
the relationship complicated [15,36]. For example, STI rates began to
climb in 2007, while dating apps became available later. Tinder was

⁎
Corresponding author at: Centre for Youth Substance Abuse Research, The University of Queensland, Australia.
E-mail address: laura.anderson@uqconnect.edu.au (L.E. Anderson).

https://doi.org/10.1016/j.srhc.2020.100534
Received 1 October 2019; Received in revised form 27 April 2020; Accepted 18 May 2020
1877-5756/ © 2020 Published by Elsevier B.V.

Descargado para Jose Fernando Díez Concha (jose.diez@correounivalle.edu.co) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en junio 20,
2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
L.E. Anderson, et al. Sexual & Reproductive Healthcare 25 (2020) 100534

created in 2012, and is likely the most widely used dating app among Table 1
young people in Western societies, with approximately 57 million users, Care provider details (names have been changed).
and 15 million mutual matches per day [24]. Name Job Title Years of experience
There are several theoretical perspectives on risky sexual behaviour
among adolescents (see [9] for a review). For example, the Theory of Rani College staff member 8
Julie General Practitioner 9.5
Planned Behaviour predicts that attitudes, norms and perceived beha-
George General Practitioner 24
vioural control will determine engagement in health behaviours [1]. Robert General Practitioner 32
Social-Cognitive Theory predicts that self-efficacy will influence out- Lucy General Practitioner 30
come expectancies which in turn influences engagement in health be- James College staff member 2.5
haviours [5]. An integration of five health behaviour models showed Anthony College staff member 9
Nicole Nurse 6
that self-efficacy (from Social-Cognitive Theory) and partner norms
Sarah Nurse 16
(from the Theory of Planned Behaviour) were key in predicting condom Rebecca Nurse 10
use in young women [35]. Oscar College staff member 5.5
Both individual and contextual levels of analysis are important to Michael College staff member 24
Samuel College staff member 1
gain an accurate understanding of the factors that may influence young
Andrew Counsellor 4
people’s sexual behaviour, yet few theories link individual and con-
textual factors [20]. The contextual risk factors may have changed in
recent years due to rapid technological developments that have in- Method
creased the availability of sexual content (i.e., internet access on mobile
devices). Early research suggests that dating app use is a key risk factor Participants
for engaging in risky sexual behaviours among young people [15,36].
Therefore, it is important to investigate the influence of digital media Participants included 15 key informants (six female) who provide
on risky sexual behaviour, and integrate this new environmental con- sexual health information and/or health care in a university (see
text with existing research and theory on individual factors, particularly Table 1). This included seven university health staff (general practi-
those which are modifiable in interventions. tioners and registered nurses); a university gender and sexuality
Known individual predictors of risky sexual behaviour include low counsellor; and seven residential college staff (heads of colleges, deans
self-efficacy (one’s belief in their own ability; [4]) for safe sex, per- of students and resident advisors). Given interviews were in-depth, the
sonality traits such as high impulsivity (heightened propensity to ap- aim was specific, and the numbers of university staff who work in
proach rewards and reduced capacity to inhibit behaviour despite ne- adolescent sexual health are relatively small, a sample size of 15 was
gative consequences; [22]), and lack of knowledge about risks and sufficient according to published guidelines [8,32] and is consistent
prevention of STIs [2,13]. Other predictors include norms against with sample sizes in similar research (e.g., [29,42]). Informants had
condom use, sexual coercion and substance use by individuals and/or between one and 32 years (mean = 13.5, median = 9.5) experience
partners [3,17]. Theoretically, greater exposure to online media with working with adolescent sexual health.
sexual content (e.g., dating apps, pornography) should influence these
individual-level factors (e.g., self-efficacy, norm perceptions). For ex-
ample, media observations of sexual behaviour without condom use Procedure
(e.g., television shows aimed at young people such as Gossip Girl and
Skins) will inform norms for unsafe sexual behaviour and the expecta- Informants were recruited via email and snowball sampling around
tion that people do not use condoms. Unlike social group behaviours a large university campus in a metropolitan city in Australia. Prior to
(e.g., alcohol consumption, eating), sexual behaviour is normally pri- the interview, informants were emailed an information sheet, consent
vate, involving only those engaging in the behaviour. Therefore, ado- form, and a list of interview questions (see Table 2) to give them a sense
lescents – particularly those who are poorly informed about human of the topics covered. For example, ‘How often do you work with young
sexuality - are likely to be prone to the influence of media norms. The people in relation to sexual health?’. Informants were briefed before
current cohort of adolescents are beginning to engage in sexual beha- each interview about the broader topic (i.e., efforts to reduce STIs
viour during a digital age which includes more sexual references and among students), which was narrowed for the scope of this article to
scenes than at any other time in history [41]. Therefore, the current risk factors for STIs among adolescents. The semi-structured interviews
study sought to investigate the role of digital media on sexual risk- were conducted face-to-face by the first author in a quiet room without
taking. other people (e.g., care provider’s office or meeting room) and ran for
While adolescent perspectives on sexual risk-taking have been approximately 20–40 min. The interviews were recorded and tran-
documented (e.g., perspectives on alcohol use and sex, multiple part- scribed verbatim. Ethical approval for the study was obtained from the
ners, condom use [30,40,43]), there is a lack of research from health relevant university ethics committee.
practitioners’ perspectives. Health practitioners play a key role in
general health care of adolescents, and the diagnosis and treatment of Analysis
STIs. Clinicians are identified as a preferred source of sexual informa-
tion among adolescents, and a key driver for getting sexual health Data were coded in line with thematic analysis guidelines by Braun
testing [18,34]. Similarly, university residential college staff and stu- and Clarke [6]. There are a range of qualitative analysis methods, in-
dent counsellors are providers of student sexual and personal support. cluding theory-informed (deductive) methods and grounded ap-
Importantly, unlike adolescents themselves, health practitioners bring proaches which entirely data driven (inductive; [7]). For this study
experience across interactions with multiple young people, and can were working with well-established social-cognitive and health beha-
identify changes in trends over time. Therefore, we interviewed nurses, viour theories, so a deductive approach was most appropriate. The first
general practitioners, counsellors, and residential college staff who stages of the analysis including data familarisation and coding were
work with first year university students, typically aged 17 and 18. The undertaken by the first and third authors (female, clinical PhD stu-
interviews were designed to gain a broad perspective of sexual health dents). Two coders were used to ensure coding was comprehensive,
among adolescents in the digital age. representative of the data, and to reduce the risk of bias [45]. Both
coders were of equivalent status which facilitated independent coding
without a power differential. The codes for analysis were chosen based

Descargado para Jose Fernando Díez Concha (jose.diez@correounivalle.edu.co) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en junio 20,
2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
L.E. Anderson, et al. Sexual & Reproductive Healthcare 25 (2020) 100534

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?

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 in-
fluence 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 beha-
viour (disinhibition, substance use; see Fig. 1). Fig. 1. Thematic map describing university informants’ perspectives on pre-
dictors of sexual risk-taking behaviours.

Contextual factors
“… think about the last movie you watched where two people got
Media influence on norms together for the first time. There was no talk about it. There’s no
Media influence on norms was noted by many care providers as a even real hint or anything at sexual health history talks, about ne-
key factor impacting sexual risk-taking. “Media” was discussed in terms gotiating consent, what is happening, what’s not happening, nego-
of television shows, movies, pornography, music, social media tiating protection.” - Counsellor
(Facebook, Instagram, Snapchat) and dating apps (e.g., Tinder and
Grindr). When asked specifically about their view of dating apps and Informants also discussed the media portrayal of sex as something
social media (see Table 1), many informants spontaneously mentioned that has to be ‘seen through from start to finish’ without interruptions.
the role of pornography, movies and other media. Three sub-themes This linear sexual script omits communication, which is important for
were identified: the impact of media on norms about: sexual beha- sexual health (i.e., negotiating sexual behaviours, barrier protection).
viours, sexual relationships, and sexual appearance. “It’s sort of like with sex … once you’ve started you have to see it
Media influence on sexual behaviour norms. Informants de- through, but there’s no start line. They sort of go, “Oh, we’re now
scribed how media influence norms about sexual behaviour in ways doing this. Okay, I have to see it through,” because there’s no
which may increase STI risk. For example, movies rarely show char- communication at the start of, “Is this going to happen?” and how
acters engaged in sexual health communication. A counsellor high- it’s going to happen.” - Counsellor
lighted how this makes it difficult for adolescents to initiate discussion
about sexual health. Media influence on sexual behaviour was also discussed in terms of
gender roles. For example, an informant noted the differential influence
Table 3 of pornography on men and women, where heterosexual pornography
Themes and subthemes. may be particularly detrimental for women, who are frequently de-
picted as submissive and with low agency.
Theme Subtheme
“… especially for women too because porn is often targeted at men
Contextual Media influence on norms Sexual behaviours
and so it’s designed to make men feel powerful, aroused, excited. It’s
Sexual relationships
Sexual appearance more often another man being very domineering over another
Transition to university Independence woman and a lot of young women will watch porn to learn more
Social opportunity about it and they will see that this is the role that they’re expected to
Individual Communication difficulties Gender and sexuality differences take as a subservient sort of person who is almost used in sex and
Greater fear of pregnancy than STIs
they don’t realise that, no, it’s a two-way street and you have a right
Impulsive behaviours Disinhibition
Substance use to play a very active role in that if that’s what you’re interested in.” -

Descargado para Jose Fernando Díez Concha (jose.diez@correounivalle.edu.co) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en junio 20,
2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
L.E. Anderson, et al.
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 no-
ticed 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.
“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 re-
lationships 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 di-
rectly related to sexual risk, another sign that pornography is influen-
cing 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, re-
lationships and sexual appearance was consistently identified as a key
factor to address regarding young people’s sexual health.
Transition to adulthood
Many informants highlighted the elevated level of risk for adoles-
cents 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
Descargado para Jose Fernando Díez Concha (jose.diez@correounivalle.edu.co) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en junio 20,
2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Sexual & Reproductive Healthcare 25 (2020) 100534
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 influ-
enced by this developmental period of independence and social op-
portunity, 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 fre-
quently noted that adolescents reported being motivated to 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 con-
tributed 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 ex-
ploitation. 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 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 com-
munication 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.
L.E. Anderson, et al.
“…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 healthy 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 rewards in spite of potential negative consequences.
Disinhibition. Informants discussed their frustrations with adoles-
cents who did not follow through on their knowledge of sexual health
risks due to momentary disregard, or to a loss of judgement and in-
hibition.
“…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 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 de-
cisions 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 ado-
lescents 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 de-
piction of relationships between these factors, based on the data, is
presented in Fig. 2. Care providers 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 com-
munication difficulties. Informants also discussed that greater social
opportunity and independence during the transition to adulthood
Descargado para Jose Fernando Díez Concha (jose.diez@correounivalle.edu.co) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en junio 20,
2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Sexual & Reproductive Healthcare 25 (2020) 100534
Fig. 2. Diagrammatic summary of hypothesized relationships between themes
predicting risky sexual behaviour among university-based adolescents.
increases risk for young people, particularly for those who are im-
pulsive.
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 behavior [23].
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 [11]. 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 [40].
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 introduc-
tion to sexual scripting theory see [39] 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 hetero-
normative, whereby men are agents (actors) and women are passive
(acted upon; [14]). Informants highlighted how this portrayal is detri-
mental to sexual 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 [9]. Similarly,
a meta-analysis concluded that communication is a strong predictor of
condom use [12].
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 con-
fidence 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 Fig. 2. Importantly, risky sexual
behaviour depends on opportunity for sexual behaviour, which is in-
fluenced by factors inherent to the transition to university (less parental
monitoring, more socialising). The combination of opportunity for
L.E. Anderson, et al.
sexual behaviour and impulsivity (substance use, disinhibition) is likely
to increase risky sexual behaviour [26], particularly when commu-
nication 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 [1,38] 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 ado-
lescents’ sexual behaviour, relationships and appearance. This suggests
that interventions should acknowledge and address media representa-
tions, and identify the ways in which they are unrealistic and unhealthy
to reduce inaccurate norm formation. Interventions could help adoles-
cents 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 facil-
itate workshops to enhance adolescent skills and knowledge about safe
sex practices. A recent systematic review found that college interven-
tions with motivational interviewing or reminder cues were most ef-
fective in increasing condom use [27].
Communication difficulties. Interventions should help to teach
adolescents sexual communication skills, and particularly address in-
equality and power. For example, gendered challenges for women ne-
gotiating 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 [44]. 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 [10]. Therefore, norms and beliefs impact communication self-ef-
ficacy. Further, frameworks for discussing sexual health and behaviour
may be useful to increase communication self-efficacy. As one in-
formant highlighted, the use of a ‘traffic light system’ can help. This
system may have been adapted from the ‘Traffic lights framework’ for
sexual behaviours in children and young people [46]. 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
Descargado para Jose Fernando Díez Concha (jose.diez@correounivalle.edu.co) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en junio 20,
2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Sexual & Reproductive Healthcare 25 (2020) 100534
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 un-
sanctioned sexual behaviour; [30]). 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 [19].
While it is not possible or necessarily desirable to reduce trait im-
pulsivity, it may be beneficial to help adolescents manage their im-
pulses 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 re-
duce sensation, or to please a partner) rather than knowledge and skills
alone. Cooper, Agocha, and Sheldon [16] demonstrated that motives
(i.e., specific reasons for choosing a behaviour) mediate the link be-
tween impulsivity and sexual risk-taking. Motivational enhancement
may include non-judgmental, value-independent education about
sexual health and discussion of one’s sexual health goals. This discus-
sion could include the benefits and costs of different choices, and access
to regularly STI testing. 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 ex-
perience, 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 en-
hance our understanding of sexual health in the digital age. It is im-
portant 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 popula-
tion), 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 and STI
risk. These findings contribute to our understanding of contextual and
individual factors, which requires more comprehensive theory, such as
understanding the interplay between impulsive behaviours, motiva-
tional 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 [1,38].
Further, the important role of digital media highlights the need for
more holistic approaches to STI prevention, which address unhealthy
norms depicted in media.
L.E. Anderson, et al.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
Acknowledgments
Thank you to all the informants in this study. The first author was
supported by a Research Training Program stipend and a Children’s
Hospital Foundation PhD Scholarship Top-Up (RPCPHD0152017). The
last author was supported by a Medical Research Future Fund
Translating Research into Practice (TRIP) Fellowship (1167986).
References
[1] Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process
1991;50(2):179–211. https://doi.org/10.1016/0749-5978(91)90020-t.
[2] Allen MS, Walter EE. Linking big five personality traits to sexuality and sexual
health: a meta-analytic review. Psychol Bull 2018. https://doi.org/10.1037/
bul0000157.
[3] Barriger M, Velez-Blasini CJ. Descriptive and injunctive social norm overestimation
in hooking up and their role as predictors of hook-up activity in a college student
sample. J Sex Res 2013;50(1):84–94. https://doi.org/10.1080/00224499.2011.
607928.
[4] Bandura A. Self-efficacy mechanism in human agency. Am Psychol
1982;37(2):122–47. https://doi.org/10.1037/0003-066x.37.2.122.
[5] Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol
2001;52:1–26. https://doi.org/10.1146/annurev.psych.52.1.1.
[6] Braun V, Clarke V. Using thematic analysis in psychology. Qualit Res Psychol
2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa.
[7] Braun V, Clarke V. Thematic analysis. In: APA handbook of research methods in
psychology, vol. 2; 2012. p. 57–71. doi:10.1037/13620-004.
[8] Braun V, Clarke V. Successful qualitative research: a practical guide for beginners.
SAGE Publications; 2013.
[9] Buhi ER, Goodson P. Predictors of adolescent sexual behavior and intention: a
theory-guided systematic review. J Adolesc Health 2007;40(1):4–21. https://doi.
org/10.1016/j.jadohealth.2006.09.027.
[10] Bui TC, Markham CM, Ross MW, Williams ML, Beasley RP, Tran LTH, et al.
Perceived gender inequality, sexual communication self-efficacy, and sexual beha-
viour among female undergraduate students in the Mekong Delta of Vietnam.
Sexual Health 2012;9(4):314–22. https://doi.org/10.1071/SH11067.
[11] Cabecinha M, Mercer CH, Gravningen K, Aicken C, Jones KG, Tanton C, et al.
Finding sexual partners online: prevalence and associations with sexual behaviour,
STI diagnoses and other sexual health outcomes in the British population. Sexually
Transmitted Infect 2017;93(8):572–1282. https://doi.org/10.1136/sextrans-2016-
052994.
[12] Carlyle K, Cole C. Why communication is crucial: meta-analysis of the relationship
between safer sexual communication and condom use AU – Noar, Seth M. J Health
Commun 2006;11(4):365–90. https://doi.org/10.1080/10810730600671862.
[13] Chariyeva Z, Golin CE, Earp JA, Suchindran C. Does motivational interviewing
counseling time influence HIV-positive persons' self-efficacy to practice safer sex?
Patient Educ Couns 2012;87(1):101–7. https://doi.org/10.1016/j.pec.2011.07.021.
[14] Charles P, Meyrick J. Exploring the way sexually explicit material informs sexual
beliefs, understanding and practices of young men: a qualitative survey.
1359105318788736 J Health Psychol2018. https://doi.org/10.1177/
1359105318788736.
[15] Choi EPH, Wong JYH, Lo HHM, Wong W, Chio JHM, Fong DYT. Association be-
tween using smartphone dating applications and alcohol and recreational drug use
in conjunction with sexual activities in college students. Subst Use Misuse
2017;52(4):422–8. https://doi.org/10.1080/10826084.2016.1233566.
[16] Cooper ML, Agocha VB, Sheldon MS. A motivational perspective on risky behaviors:
the role of personality and affect regulatory processes. J Pers 2000;68(6):1059–88.
https://doi.org/10.1111/1467-6494.00126.
[17] de Visser RO, Badcock PB, Rissel C, Richters J, Smith AMA, Grulich AE, et al.
Experiences of sexual coercion in a representative sample of adults: the Second
Australian Study of Health and Relationships. Sexual Health 2014;11(5):472–80.
https://doi.org/10.1071/sh14103.
[18] Denison HJ, Bromhead C, Grainger R, Dennison EM, Jutel A. What influences
university students to seek sexually transmitted infection testing?: a qualitative
study in New Zealand. Sexual Reprod Healthcare 2018;16:56–60. https://doi.org/
10.1016/j.srhc.2018.01.004.
[19] Dir AL, Coskunpinar A, Cyders MA. A meta-analytic review of the relationship
between adolescent risky sexual behavior and impulsivity across gender, age, and
race. Clin Psychol Rev 2014;34(7):551–62. https://doi.org/10.1016/j.cpr.2014.08.
004.
[20] Edelman N. Towards a critical epidemiology approach for applied sexual health
research. J Health Psychol 2018;23(2):161–74. https://doi.org/10.1177/
1359105317743768.
[21] Gottlieb SL, Low N, Newman LM, Bolan G, Kamb M, Broutet N. Toward global
prevention of sexually transmitted infections (STIs): the need for STI vaccines.
Descargado para Jose Fernando Díez Concha (jose.diez@correounivalle.edu.co) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en junio 20,
2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Sexual & Reproductive Healthcare 25 (2020) 100534
Vaccine 2014;32(14):1527–35. https://doi.org/10.1016/j.vaccine.2013.07.087.
[22] Gullo MJ, Loxton NJ, Dawe S. Impulsivity: four ways five factors are not basic to
addiction. Addict Behav 2014;39(11):1547–56. https://doi.org/10.1016/j.addbeh.
2014.01.002.
[23] Holloway IW, Dunlap S, del Pino HE, Hermanstyne K, Pulsipher C, Landovitz RJ.
Online social networking, sexual risk and protective behaviors: considerations for
clinicians and researchers. Curr Addict Rep 2014;1(3):220–8. https://doi.org/10.
1007/s40429-014-0029-4.
[24] Iqbal M. Tinder Revenue and Usage Statistics; 2018. Retrieved from http://www.
businessofapps.com/data/tinder-statistics/.
[25] Iyer A, Jetten J, Tsivrikos D, Postmes T, Haslam SA. The more (and the more
compatible) the merrier: multiple group memberships and identity compatibility as
predictors of adjustment after life transitions. Br J Soc Psychol 2009;48(4):707–33.
https://doi.org/10.1348/014466608X397628.
[26] Johnson HL, Albery IP, Frings D, Moss AC. STI-protective self-efficacy and binge
drinking in a sample of university students in the United Kingdom. Sexual Reprod
Healthcare 2018;17:19–25. https://doi.org/10.1016/j.srhc.2018.05.004.
[27] Kilwein TM, Kern SM, Looby A. Interventions for alcohol-related risky sexual be-
haviors among college students: a systematic review. Psychol Addict Behav 2017.
https://doi.org/10.1037/adb0000294.
[28] Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in
Australia: Annual surveillance report 2017; 2017. Retrieved from Sydney: https://
kirby.unsw.edu.au/sites/default/files/kirby/report/SERP_Annual-Surveillance-
Report-2017_compressed.pdf.
[29] Leickly E, Nelson K, Simoni J. Sexually explicit online media, body satisfaction, and
partner expectations among men who have sex with men: a qualitative study.
Sexuality Res Social Policy 2017;14(3):270–4. https://doi.org/10.1007/s13178-
016-0248-7.
[30] Livingston JA, Bay-Cheng LY, Hequembourg AL, Testa M, Downs JS. Mixed drinks
and mixed messages: adolescent girls' perspectives on alcohol and sexuality.
Psychol Women Quart 2013;37(1):38–50. https://doi.org/10.1177/
0361684312464202.
[31] Loxton NJ, Bunker RJ, Dingle GA, Wong V. Drinking not thinking: a prospective
study of personality traits and drinking motives on alcohol consumption across the
first year of university. Personality Individ Differ 2015;79(C):134–9. https://doi.
org/10.1016/j.paid.2015.02.010.
[32] Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies:
guided by information power. Qual Health Res 2015;26(13):1753–60. https://doi.
org/10.1177/1049732315617444.
[33] McDonald P, Hay D, Gecan I, Jack M, Hallett S. National Census of University
Student Accommodation Providers 2014; 2015. Retrieved from Subiaco, Western
Australia: http://universitycollegesaustralia.edu.au/wp-content/uploads/2015/
06/2015-05-27_uca_census_2014_report_final_lowres_sec.pdf.
[34] Rajapaksa-Hewageegana N, Piercy H, Salway S, Samarage S. Sexual and re-
productive knowledge, attitudes and behaviours in a school going population of Sri
Lankan adolescents. Sexual Reprod Healthcare 2015;6(1):3–8. https://doi.org/10.
1016/j.srhc.2014.08.001.
[35] Reid AE, Aiken LS. Integration of five health behaviour models: common strengths
and unique contributions to understanding condom use. Psychol Health
2011;26(11):1499–520. https://doi.org/10.1080/08870446.2011.572259.
[36] Sawyer A, Smith ER, Benotsch EG. Dating application use and sexual risk behavior
among young adults. Sexuality Res Social Policy 2017;15(2):183–91. https://doi.
org/10.1007/s13178-017-0297-6.
[37] Sawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence.
Lancet Child Adolescent Health 2018;2(3):223–8. https://doi.org/10.1016/S2352-
4642(18)30022-1.
[38] Schwarzer R, Luszczynska A. How to overcome health-compromising behaviors -
the health action process approach. Eur Psychol 2008;13(2):141–51. https://doi.
org/10.1027/1016-9040.13.2.141.
[39] Simon W, Gagnon JH. Sexual scripts - permanence and change. Arch Sex Behav
1986;15(2):97–120. https://doi.org/10.1007/bf01542219.
[40] Smith JL, Fenwick J, Skinner R, Merriman G, Hallett J. Young males' perspectives
on pregnancy, fatherhood and condom use: where does responsibility for birth
control lie? Sexual Reprod Healthcare 2011;2(1):37–42. https://doi.org/10.1016/j.
srhc.2010.10.002.
[41] Strasburger VC, Jordan AB, Donnerstein E. Health effects of media on children and
adolescents. Pediatrics 2010;125(4):756–67. https://doi.org/10.1542/peds.2009-
2563.
[42] Tarzia L, Wellington M, Marino J, Hegarty K. “A huge, hidden problem”: Australian
Health Practitioners' views and understandings of reproductive coercion.
1049732318819839 Qual Health Res2018. https://doi.org/10.1177/
1049732318819839.
[43] Teitelman AM, Tennille J, Bohinski J, Jemmott LS, Jemmott 3rd. JB. Urban ado-
lescent girls' perspectives on multiple partners in the context of the sexual double
standard and intimate partner violence. J Assoc Nurses AIDS Care
2013;24(4):308–21. https://doi.org/10.1016/j.jana.2013.04.001.
[44] Thitasan A, Aytar O, Annerback EM, Velandia M. Young people's health and risk
behaviours in relation to their sexual orientation: a cross-sectional study of
Thailand and Sweden. Sexual Reprod Healthcare 2019;21:67–74. https://doi.org/
10.1016/j.srhc.2019.05.004.
[45] Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative re-
search (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual
Health Care 2007;19(6):356. https://doi.org/10.1093/intqhc/mzm042.
[46] True Relationships and Reproductive Health. Traffic Lights Framework Retrieved
from https://www.true.org.au/ArticleDocuments/337/Traffic%20LightsBrochure.
pdf.aspx?Embed=Y; 2015.