Correlates of Heterosexual Anal Intercourse Among At-Risk Adolescents and Young Adults

Objectives. We sought to learn what factors are associated with anal intercourse among adolescents and young adults. We examined demographic, behavioral, relationship context, attitudinal, substance use, and mental health correlates of recent heterosexual anal intercourse among adolescents and young adults who reported engaging in recent unprotected sex.Methods. Among 1348 at-risk adolescents and young adults aged 15 to 21 years in 3 US cities, we assessed sexual risk behavior with each sexual partner in the past 90 days. Data were collected from 2000 to 2001.Results. Recent heterosexual anal intercourse was reported by 16% of respondents. Females who engaged in anal intercourse were more likely to be living with a sexual partner, to have had 2 or more partners, and to have experienced coerced intercourse. For males, only a sexual orientation other than heterosexual was a significant predictor of engaging in heterosexual anal intercourse.Conclusions. Our findings document the prevalence of heterosexual anal intercourse among adolescents and young adults who had recent unprotected sex. Among females, the variables associated with anal intercourse relate to the context and power balance of sexual relationships. Different influences for males and females suggest different foci for interventions.Unprotected anal intercourse is a significant HIV risk because the odds of contracting HIV are calculated as 5 times as risky for receptive anal intercourse than for receptive vaginal intercourse.¹ In addition, anal intercourse appears to be increasing: a survey of adults aged 18 to 39 years showed that the rate of anal sex had doubled from 1995 to 2004.² In the most recent National Survey of Family Growth, 35% of women and 40% of men reported engaging in heterosexual anal intercourse in their lifetime.³Many adolescents have engaged in anal intercourse, and the prevalence increases with age. In the National Survey of Family Growth, 8% of adolescent boys and 6% of adolescent girls aged 15 to 17 years reported having had heterosexual anal intercourse. Among those aged 20 to 24 years, 33% of men and 30% of women reported the experience. Data also show that anal intercourse among adolescents and young adults is often unprotected^4–6 and that condom use is less likely than during vaginal intercourse.^5,7 Most studies that have examined race as a factor have not found a significant correlation,^7–9 although some evidence exists that Whites engage in anal intercourse more frequently.⁴Despite the prevalence of anal intercourse among adolescents and young adults, little research exists about related factors. Among adults, substance use is often described as a precipitant or cofactor for heterosexual anal intercourse. In one study, adults who had engaged in anal intercourse were more likely than were those who had not to use alcohol once a week or more; to have used marijuana in the past year; to have used cocaine, crack, or LSD in the past year; or to have ever injected drugs.⁸ Among injection drug users, amphetamine use has been associated with heterosexual anal intercourse,¹⁰ and in a sample of adult women, drug use was significantly associated with engaging in anal intercourse.⁹ This relationship may reflect lowered inhibition during drug use or a common attitude that fosters experimentation with both substances and anal intercourse.A significant relationship exists between anal intercourse and other sexual behaviors. Heterosexual anal intercourse has been associated with a greater number of sexual partners for adults,⁸ college students,^11,12 and male injection drug users.¹⁰ Women who had engaged in anal intercourse also reported more episodes of unprotected vaginal intercourse than did women who had not.¹³ In addition, anal intercourse has been found to be related to other HIV risk behaviors, including injection drug use, having sex with an HIV-positive partner, having sex with a man who has sex with men, or exchanging drugs or money for sex.^4,6–8Halperin has suggested that power in relationships exerts a strong influence in the practice of anal intercourse.¹⁴ Indeed, having a main partner dictate sexual practices was associated with unprotected anal intercourse in a study of women aged 18 to 24 years.⁹ This may be particularly relevant for adolescents and young adults, who may be less sexually experienced and more likely to follow a partner''s lead in sexual activities.Because little is known about factors associated with anal intercourse among adolescents and young adults or their prevalence, we sought to identify demographic, behavioral, relationship context, attitudinal, substance use, and mental health correlates of recent (previous 90 days) experience with anal intercourse among adolescents and young adults. The scant adolescent literature, along with the adult literature, led us to hypothesize that older age, other risky sexual practices (e.g., multiple sexual partners, unprotected vaginal intercourse), and more substance use would be significantly associated with recently engaging in anal intercourse. We also hypothesized that those with a history of aggression (as a proxy for power) in relationships would be more likely to engage in anal intercourse. Because we identified no previous research on the association between anal intercourse and sexual attitudes or mental health, we formulated no hypotheses about these variables.