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Early Sexual Initiation among Malaysian Adolescents in Welfare Institutions: A Qualitative Study

Nik Farid ND1*, Dahlui M2, Che’ Rus S3, Aziz NA1 and Al-Sadat N4

1Faculty of Medicine, Department of Social and Preventive Medicine, University of Malaya-50603, Kuala Lumpur, Malaysia

2Faculty of Medicine, Julius Centre, University of Malaya, 50603, Kuala Lumpur, Malaysia

3Institute for Health Behavioural Research, Ministry of Health Malaysia, Jalan Rumah Sakit Bangsar, 50590, Kuala Lumpur, Malaysia

4Faculty of Medicine, Centre for Population Health, University of Malaya, 50603, Kuala Lumpur, Malaysia

*Corresponding Author:
Nik Farid ND
Faculty of Medicine
Department of Social and Preventive Medicine
University of Malaya 50603, Kuala Lumpur, Malaysia
Tel: +60-3-79677022
E-mail: [email protected]

Received date: September 17, 2015 Accepted date: October 08, 2015 Published date: October 14, 2015

Citation: Nik Farid ND, Dahlui M, Che’ Rus S, Aziz NA, Al-Sadat N (2015) Early Sexual Initiation among Malaysian Adolescents in Welfare Institutions: A Qualitative Study. Arts Social Sci J 6:129. doi:10.4172/2151-6200.1000129

Copyright: © 2015 Nik Farid ND. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: In recent years, more adolescents have been engaging in early sexual intercourse in Malaysia. This has become a public health concern due to its implications regarding sexually transmitted infections and teenage pregnancy. The objective of this study was to better understand the factors that influence early sexual initiation among adolescents and the circumstances in which this occurs. Methods: Criterion samples of adolescents aged 13–19 who admitted to consensual sexual intercourse before age 18 were recruited from four welfare institutions in Kuala Lumpur and Selangor. Data were collected using indepth interviews and essay writing. This study was guided by a grounded thematic theory methodology. Results: Adolescents identified proximal factors such as curiosity, stress relief, partner acquiescence and peer pressure to be directly associated with their early sexual initiation. Other factors, such as poor religiosity, domestic violence, poor interest in school and loitering with friends, were factors in some way related to early sexual initiation. Conclusion: The explorative approach used in this current study found that adolescents’ experiences of early sexual initiation were strongly bound to factors within their social world.

Keywords

Early sexual initiation; Adolescents; Empirical studies; family; Peer

Introduction

Adolescentsare at risk of negative health outcomes from early sexual initiation [1-3]. Early sexual initiation is associated with increased lifetime prevalence of sexual partners [1,3], thereby increasing the risk of exposure to sexually transmitted infections (STIs), including HIV/AIDS [3]. Additionally, the behaviour also increases the risk of human papillomavirus (HPV) infection and thus increased risk of cervical cancer [1] and [4-6]. Apart from these issues, adolescent pregnancy is another significant outcome of engaging in early sexual intercourse [7].

Worldwide, almost 50% of all new STIs and approximately 60% of new HIV infections occur in young people [8]. In the United States, for example, 8,300 young people were reported to have been infected with HIV in 2009, and nearly half of the 19 million new STIs each year occur among young people [9,10]. The percentage of HIV infections among adolescents in Malaysia has recently increased. The 2008 statistics from the Ministry of Health revealed an increase in new HIV infections among 13–19 year olds compared to 2004 (0.85% to 2.0%) [11]. However, information on STIs among Malaysian adolescents is very limited as they tend to avoid public hospitals [12]. In terms of adolescent pregnancy, worldwide, approximately 16 million girls aged 15 to 19 and some one million girls under 15 give birth every year, mostly from low and middle income countries [13]. In Malaysia, more than 18,000 cases of pregnancies were recorded among adolescents in 2012, of whom 22% were unmarried. In the first half of the subsequent year, statistics showed there were over 8,000 cases, with 25% not married [14].

Empirical studies, primarily from developing and Asian countries, indicate that early sexual initiation among adolescents is influenced by a wide range of factors, such as smoking, drug/alcohol abuse, negative peer culture, deviant friends, family structure, lack of parental or guardian bonding, domestic violence, out-of-school physical and/or sexual abuse, the viewing of pornography and dropping out of school [15-18]. The socio-ecological model proposes that individual, interpersonal, community, organizational and societal factors have direct and indirect influences on lifestyle, behaviour choices and health [19]. Individual factors such as attitudes have been shown to relate to sexual behaviour. One study carried out among adolescents attending urban public schools in the United States found that males who engaged in sex were found to hold more permissive sexual attitudes than females [20]. Interpersonal factors, including family and peers, play a very significant role in influencing adolescents’ early sexual initiation. Changes in family structure, declining religious values, cross-cultural communication facilitated by modern technology and increasing female participation in the labour force causing maternal deprivation of children also play a vital role in adolescents’ sexual behaviour [21]. Recent studies have demonstrated that young persons’ relationships with parents and peers are associated with their involvement in sexual risk behaviours. A study conducted in Western Ethiopia found that youths who had high levels of family connectedness were less likely to commence sexual activity (AOR = 1.98; 95% CI: 0.63–0.94) [22]. A literature review on the health behaviour of adolescents in the Caribbean showed that higher levels of sexual activity were reported if there was little adult supervision, whereas having good family connectedness delayed sexual activity [23]. In addition, a qualitative study conducted among Australian adolescent females found that conforming to norms was one of the reasons for premature experiences of sexual intercourse [24].

Despite the associated outcomes relating to early sexual initiation, to date there have been very few qualitative studies that have explored in-depth the factors that contribute to early sexual initiation among adolescents in Malaysia. Where they do exist, the studies have focused on the general population and involved focus group discussions [25]. The current study aims to address this research gap. Specifically, the aim of the study is to explore the factors associated with early sexual initiation and how these factors are related to lifestyle, values and the home environment among a sample of high risk Malaysian adolescents using qualitative methods, specifically in-depth interviews (IDIs) and essay writing.

Methodology

Sample

A sample of 29 adolescents took part in the study. They were recruited via purposive (criterion) sampling from four welfare institutions located within the central region of Peninsular Malaysia. Adolescents in welfare institutions were chosen because they conveniently met certain criteria: (1) adolescents who had experienced sexual intercourse and (2) those who had experienced early sexual initiation (i.e. <18 years of age). Moreover, they were able to offer more information on their sexual experiences compared to adolescents in the general population. The sample size was not fixed prior to data collection. Purposive sample sizes were determined on the basis of theoretical saturation – that is, the point in data collection when new data no longer bring additional insights to the research questions [26].

Data collection methods

A screening interview was first held to select adolescents who had experienced early sexual initiation. Then, the selected adolescents were interviewed by the researcher on a single occasion for between 45 to 60 minutes using an interview guide. All interviews were recorded with the permission of the adolescents being interviewed. Essay writing was offered to subjects only if they fulfilled the following criteria: (1) the subject was not comfortable talking about his/her sexual experience and hence incomplete information was gathered during the IDI and (2) during the screening interview the subject opted to write an essay instead of being interviewed. In both the IDIs and essay writing, the individual, family, peer and school domains were primarily explored. In addition, concepts related to sexual initiation were explored through the questions: ‘Tell me about the first time you had sex’ and ‘Why did you first have sex when you did?’

Data analysis methods

After the interviews and essay writing, the recordings as well as the essays were transcribed verbatim. Transcription was kept in the original language, Malay, in Microsoft Office Word 2007. Then, using Nvivo 8 software, detailed coding and analysis were completed. Using grounded theory, the analysis of the data was conducted concurrently with data collection. This concurrent collection and analysis of data continued until, in the investigator’s judgment, new data no longer brought additional insights to the research questions [27]. It is at this point that the themes were declared ‘saturated’ [27]. As a result, the total number of participants was 29. Data were divided according to two general codes: distal and proximal factors. Distal factors included factors that were indirectly related to sexual initiation. In contrast, proximal factors included factors that were directly related to sexual initiation.

Ethical considerations

This study was submitted to the University Malaya Medical Centre Ethics committee for review. In addition, permission and informed consent were granted by the Social Welfare Department of Malaysia after the study protocol was reconsidered.

Findings

The findings revealed two general pathways of adolescents’ sexual initiation: distal and proximal. The distal pathways revealed four themes that offered insight into the circumstances that indirectly influenced adolescents’ early sexual initiation. The proximal pathways revealed four factors in relation to adolescents’ perceptions of their first sexual experience.

Distal pathways

1) Poor religiosity

Several Muslim adolescents did not believe in praying and seeking help from God:

‘I have never prayed. I don’t believe in prayers. Whatever I asked for was not granted, so I gave up’ (Female, 18).

‘I don’t ask anything from God. For me, I live by the day. If yesterday I had a bad day, I will hope for a better day today’ (Male, 18).

2) Domestic violence

Some of the participants described witnessing domestic violence. Two girls spoke of their mothers being beaten by their stepfathers:

‘Mama wanted to run away, and then my stepfather pulled her hair and stepped on her’ (Female, 16).

‘I was at a school camp for three days. When I came home, I saw my mum’s ear was swollen’ (Female, 15).

3) Poor interest in school

A few adolescents reported their lack of interest in school. These adolescents demonstrated a very poor understanding of the importance of schooling:

‘When I was in school last time, I could not concentrate. So, I just came for the sake of meeting my friends’ (Male, 16).

‘I stopped attending school because I lost interest in learning. Besides, for exams, I got a D in one subject and the rest were all Es’ (Male, 18).

4) Loitering

Loitering was cited by a number of adolescents. Many spoke of spending a great deal of time hanging out with their friends outside their homes. For instance, some adolescents stated:

‘Every night I would go out and spend time at my boyfriend’s place. We didn’t do anything, just hung out’ (Female, 14).

‘I liked to hang out with my friends at night. We did “wheelies” [perform crazy stunts on motorbikes], sang at karaoke clubs or played snooker’ (Male, 18).

Proximal pathways

On further exploration, four themes emerged with regards to adolescents’ perceptions of their first sexual experience.

1) Curiosity

It was observed that curiosity among the adolescents had an influence on their sexual initiation, particularly among males, for whom experience was the way to learn.

‘I had sex because I was curious about it. And when I did it, then I knew what sex was about’ (Male, 19).

Their inquisitiveness regarding what sex was all about drove them to give it a try.

‘In my whole life, I had never had sex. It was my first time, and I wanted to try it’ (Male, 17).

2) Stress reliever

The analysis also revealed that adolescents had sex to relieve stress. For instance, according to two adolescents:

‘When she is facing any sort of problem, she calls me for sex. I do the same’ (Male, 17).

‘Stress sometimes when I feel like getting into a fight with my friends…, I’ll go to her house for sex’ (Male, 15).

3) Partner acquiescence

A number of male adolescents reported that their partners willingly gave in to sex. For example:

‘She wanted it (sex) with me. At that time, I didn’t know anything’ (Male, 19).

‘The girl was sexually excited herself. So, we did it. I was quite casual about it’ (Male, 17).

4) Peer pressure

Adolescents also attributed their sexual initiation to their peers. It was generally believed that the sexual activities of their peers were very influential. Spending most of their time with friends who had had sex influenced them to do it as well.

‘I started having sex because I became very social and was influenced by my friends’ (Male, 15).

‘Many of my friends said that having sex makes you feel good. That is why I’m doing it. I was influenced by them’ (Male, 16).

Discussion

The analysis revealed several key findings which, when summed up, placed the initiation of intercourse more within their social world. Figure 1 shows a possible causal structure related to adolescents’ early sexual initiation. Distal and proximal factors within the individual, family and peer domains were found to be related to adolescents’ early sexual initiation.

arts-and-social-sciences-journal-possible-causal

Figure 1: A possible causal structure related to the risk factors affecting adolescents’ sexual initiation.

Adolescents spoke of their curiosity and wanting to know what it felt like as an important motivator at the time they had their first sexual experience. This finding is concurrent with a recent study in Nigeria [28]. In this study, was the most common major reason for initiation among adolescents [28]. Another study carried out among out-of-school female Nigerian adolescents also reported a similar finding [29]. For adolescents in the current study, curiosity was probably due to pressure from their peers to some extent. In these cases, the dynamic nature of peer interaction during adolescence and the growing frequency of conversations about sexual activity could have shaped their perceptions of normative attitudes and behaviours, rather than simply their own curiosity about sex. Additionally, this curiosity was also driven for some by wide access to pornographic materials.

In this study, stress relief was another factor that drove adolescents to have their first experience of sexual intercourse. This finding is similar to that of a study conducted among African American female adolescents aged 13–19 years [30]. In addition, the study also mentioned that the female participants viewed sex as a stress reliever [30], and one of the feelings that drove them to have sex was described as wanting somebody to comfort them [30]. Again, these factors were reported by adolescents in this study.

For adolescent males, in particular, their reason for having their first experience of sexual intercourse was due to their sexual partner’s willingness to give in. This was probably motivated by the partner’s mature age. One study found that having a sexual partner who was older played an important role in sexual initiation [31]. The maturity portrayed by the sexual partner may have attracted the vulnerable and naive adolescent. In addition, having someone who willingly showed their affection and care through the sexual act could have been interpreted as something that was acceptable. Nevertheless, this situation may also suggest unrecognized child abuse. For some adolescents, their partner’s sexual arousal during their date was the reason they had sex. Other factors, such as poor religiosity and reduced conscience also probably contributed to this decision.

Adolescents in this study indicated that peer pressure influenced their decision to have sex. A number of studies have indicated similar findings [17,32]. Additionally, several qualitative studies have also reported such findings [24,33]. For male adolescents, in particular, the likely explanation is that being able to inform their friends was sometimes more important than engaging in the act itself. In addition, in order to be accepted by their peer group or to gain a reputation, they felt the urge to conform.

Poor religiosity as a factor concurs with other studies which have reported the relationship between religiosity and sexual activity in adolescents [34-36]. For adolescents, poor religiosity has led to a lack of faith. The lack of faith increases their stress levels and this, in turn, reduces their psychological well-being [37]. Additionally, lack of faith lessens adolescents’ inner strength, making them vulnerable to negative influences, and thus increases their susceptibility to sex.

Involvement in sexual activity is one of the potential after-effects observed in children who witness violence. The link between these two variables was found in a 2011 study among Finnish adolescents. They found that witnessing domestic violence and being exposed to parental violence is associated with adolescents’ sexual activity [38]. One possible explanation lies in the emotional and behavioural responses experienced after witnessing such violence against someone they love. These emotional responses may include sadness and depression, both of which have been associated with sex among adolescents [39].

Many adolescents who have had an early sexual initiation have pointed to a lack of interest in school. This poor interest in school has often been associated with sex among youths [40-44]. One possible mechanism for explaining this relationship is the stress initiated by family problems. Family problems, such as parental divorce, have led to sadness and depression in some adolescents. For these depressed adolescents, using illicit drugs and being with their peer group are seen as their only escape. It allows them to temporarily relieve their feelings of hopelessness and stress, makes them feel better and helps them to survive. Thus, once they have chosen this alternative, school is no longer a priority. Moreover, the situation will worsen if adolescents feel that teachers are not showing concern and giving support but are simply continuing to blame them.

In Malaysia, loitering in public places is prevalent high risk behaviour among adolescents [45]. For adolescents in this study, the activity is carried out with a group of friends. Spending so much time with friends may expose them to peer pressure, which could eventually lead to high risk behaviour. One qualitative study conducted among 14–19 year old Australian female adolescents showed that peers might have some influence on their decision to begin having sex [24]. Additionally, using illicit drugs has been associated with the places youths loiter as well as the kinds of friends they hang out with. A study in Africa revealed that youths began smoking heroin in the places where they hung out with their friends [46]. This activity can eventually influence sexual initiation among adolescents, as indicated in one study in Thailand. In that study, the early sexual initiation of adolescents was associated with using methamphetamine [47].

There were several strengths and limitations to this study. First, the sample only represented the experiences of adolescents in welfare institutions. It did not capture the experiences of those in the general population. However, ensuring saturation of the concepts among higher risk adolescents was more important for the purposes of understanding early sexual initiation than could be provided with a representative sample. In addition, based on the existing theory and literature, the findings may be transferable to other settings. Secondly, due to the sensitive nature of the topic, some individuals were uncomfortable discussing their sexual behaviour during the IDIs. Thus, the information gathered was quite limited. However, the use of essay writing to supplement the interviews provided some freedom for participants to express their thoughts without having to be anxious about the interviewer’s reactions or judgments. Thirdly, this sample included only four non-Malays, and, although the experiences of this group were captured in the results, the number was too small to describe specific cultural experiences and to compare them with those of the majority ethnic group. Finally, the findings are based upon adolescents’ retrospective descriptions of their first experience of sexual intercourse and the meanings assigned to it, which may have been reconstructed differently over time and with subsequent sexual experiences.

Conclusion and Recommendations

The explorative approach used in this study expands the current understanding of the factors influencing early sexual initiation. It was found that adolescents’ first experiences of sexual intercourse were strongly bound to social factors within the individual, family and peer domains. Therefore, public health prevention incorporating all the factors discussed above should be applied at all levels of prevention. Primary-level prevention is proposed to assist all adolescents in the general population by striving to prevent or delay early sexual initiation, at least until they are mature enough to understand the importance of safe sex. Some examples of preventative measures include screening for at-risk adolescents who have the potential to engage in sex, and early sexual and reproductive health education in schools as well as for adolescents out of school. Furthermore, mental health programmes should include identifying at-risk individuals. The school setting affords an opportunity for school teachers and counsellors to provide a safety net for at-risk families through guidance and assistance. Family closeness, parental supervision and consistent discipline are factors that enable adolescents to resist peer pressure. In addition, the family provides a foundation for religious teaching. A child who experiences an adequate degree of connectedness in his or her family relationships as well as sound religiosity early in life will have better social relationships outside of the family when they reach the adolescent period.

Secondary-level prevention offers targeted interventions for individuals who are at risk – such as those living in welfare homes or on the streets as well as those who did not respond favourably to the initial level of prevention. At the secondary level, screening and examinations by health professionals may help to detect early STIs, including HIV, and provide prompt intervention to alleviate the disease. Moreover, counselling for individuals predisposed to early sexual initiation can be offered. Finally, tertiary-level interventions are recommended for adolescents who warrant individualized care. As the primary and secondary levels may not be effective for all, these individuals may require individual treatment and psychotherapy to reduce the disabilities associated with the disease.

Acknowledgement

We would like to thank the Department of Social Welfare Malaysia, Putrajaya, Malaysia who assisted us throughout the data collection process.

Funding

The study was funded by grants from Postgraduate Research Fund, University of Malaya, Kuala Lumpur, Malaysia (Number: PS166/2009B).

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