Adolescent mental health and risky sexual behaviour

Risk taking among adolescents is of great concern to health professionals. Most of the morbidity among young people is related to behaviours that result in unintentional or intentional injuries, drug and alcohol misuse, tobacco use, sexual behaviour, diet, and physical inactivity.¹ Mental health problems in young people are common, with an overall prevalence of around 15%.²

Against this background, the observation in the paper by Ramrakha and colleagues (p 263) of the strong correlation between psychiatric disorders, substance misuse, and risky sexual behaviour in a birth cohort of 21 year olds is important.³ This finding has been observed previously,⁴ although in another study Bardone found risky sexual behaviour associated only with conduct disorders, and not with depression or anxiety, in a cohort of girls followed from ages 15 to 21.⁵ Many studies have reported associations between mental health and the risk of HIV infection.⁶

Ramrakha et al's work is part of the Dunedin study, a multidisciplinary, population based study of a birth cohort that uses a diverse range of measures, including those for diagnosing mental health disorders. The study has reported comorbid psychiatric conditions in children and adolescents and has explored aspects of adolescent risk taking and delinquency.⁷ Questions about mental health and behaviour were added initially at the assessment at age 11, and questions about sexual behaviour were added at the 18 year assessment. In this latter assessment 37% of the sample had one or more mental health disorders, while 58% of the men and 68% of the women reported having had sexual intercourse.

Risky sex may be an expression of anger

Ramrakha et al identified an increased probability of risky sex across a range of mental health diagnoses.³ Even the most prevalent, clinical depression, was associated with increased rates of risky sex, sexually transmitted diseases, and early sexual experience. With regard to sexual initiation, other questions arise, such as the role of sexual abuse (also a major precursor to mental health disorder). With the addition of histories of sexual abuse at the recently completed assessment at 26 years of age in the Dunedin study, important new information is likely to emerge.

Many researchers have documented a high prevalence of risky sexual behaviour in association with substance misuse.⁸ Stanton et al showed that increased use of alcohol and marijuana at younger ages was related to subsequent riskier sexual activity and increased drug misuse.⁹ Alcohol and drug consumption may increase the likelihood that young people will engage in high risk sexual behaviour, as a result of impaired decision making, mood elevation, and the reduction of inhibitions.

Similar mechanisms may apply in the context of psychiatric impairment, a circumstance that can severely interfere with the ability to assess risk or to adopt risk reduction strategies. Risk taking, including risky sex, may also represent an indirect expression of anger or a mechanism, albeit dangerous, to exert some control over one's life. For a seriously disturbed young person, sexual activity might also be used for diversion, to relieve tension, and as a salve of affection seeking—a sort of self medication with sex.

Youths who drop out of school have complex needs

The public health and policy implications of this study relate to the identification of high risk groups and the need to understand the frequent clustering of risk among adolescents. Those with health risks often have multiple problems by the end of their high school education.¹⁰ Youths who drop out of school have special and complex needs, with extremely high rates of sexual behaviour, mental health problems, and drug misuse.¹¹ The causal relations and direction remain to be elucidated, but the coexistence of drugs, risky sex, and mental health problems remains a consistent observation in epidemiological studies.⁵,¹⁰

In terms of prevention, we have learnt a great deal about adolescent risk and resilience and the importance of promoting healthy youth development and of fostering connections with family and school.¹² For clinicians, the challenge is to address the health issues of young people in a sensitive and comprehensive manner. One helpful intervention is the HEADSS exam, a mnemonic for home, education, peer activities, drugs, sexuality, and suicide.¹³ This reminds clinicians of the importance of taking a “psychosocial biopsy” at each encounter with a young person and of focusing on concerns, feelings, and behaviours whatever the presenting complaint.

The determinants of mental health disorders and the associations between chronic conditions and risky behaviours in general are complex matters. Ramrakha's paper highlights the necessity of exploring sexual behaviour in young people with depression, anxiety, and other mental health disorders. The need for coordinated health care for adolescents and young people—covering psychological, sexual, and social aspects—is perhaps the most important point that should be made.¹⁴

Papers p 263