Abstract
We explored psychosocial correlates of sexual risk among heterosexual and sexual minority youths (SMYs) in Johannesburg, South Africa. Young people 16 to 18 years old (n = 822) were administered surveys assessing demographic characteristics, sexual behaviors, mental health, and parent–child communication. Adjusted multivariate regressions examining correlates of sexual risk revealed that SMYs had more sexual partners than heterosexual youths (B = 3.90; SE = 0.95; P < .001) and were more likely to engage in sex trading (OR = 3.11; CI = 1.12-8.62; P < .05). South African SMYs are at increased risk relative to their heterosexual peers.
South Africa has the highest burden of HIV in the world; 9.2% of young persons aged 15 to 19 years living in the country are infected with HIV.1,2 Few studies have examined multilevel sexual risk factors (e.g., individual, partner, family) among sexual minority youths (SMYs)3 in South Africa, despite their increased vulnerability.4–8 Research has shown that rates of sexual risk behavior are high among adult men who have sex with men (MSM) in sub-Saharan Africa,5,9 and South African SMYs may be especially vulnerable given the transitional nature of adolescence, fear of discrimination, and lack of cultural acceptance of homosexuality.4,7,10
Our analyses were guided by theories of syndemics (i.e., collective risk or co-occurring epidemics)11–13 and minority group stress.14 These theories posit that young MSM experience psychosocial disparities in numerous areas (substance use, abuse and victimization, mental health problems, risk taking)15–18 and that SMYs are at increased risk for poor mental health, sexual vulnerability, substance use, and violence.19,20 Moreover, stigma creates stressful environments, another cause of mental health problems among SMYs.14 This situation is especially salient in South Africa, where same-sex behavior is so highly stigmatized that even normative adolescent sexual exploration would likely be denounced.7
We hypothesized that South African SMYs would be at increased sexual risk relative to heterosexual youths. To our knowledge, this is one of the first investigations to examine risk and protective factors associated with sexual risk in this population.
METHODS
We recruited a stratified convenience sample of youths from Johannesburg, South Africa, between October 2008 and November 2009. Black, “colored” (a South African term for individuals of mixed race), Indian, and White adolescents were stratified according to area of residence within the city (Soweto, Eldorado Park, Lenasia, and Brixton, respectively). Approximately 1184 young people were approached (157 were not interested in taking part in the study, 208 expressed interest but did not show up for their scheduled interview, and 1 was removed from the analysis owing to an extensive amount of missing data) by bilingual fieldworkers near schools, youth organizations, and shops. Youths completed 90-minute, interviewer-administered questionnaires at a private venue and were reimbursed ZAR50 (approximately US $7).
Data were gathered on participants’ sociodemographic characteristics, sexual behaviors,21 condom use,22 and substance use,21 as well as partner-perpetrated violence.23 Also, participants completing instruments measuring depression,24,25 traumatic stress,2,26 self-esteem,27 and parent–child communication.28
RESULTS
Our final sample comprised 822 youths aged 16 to 18 years (mean = 17.02 years; SD = 0.83; 57% female). Of the 818 youths who responded to the sexual behavior questions, 8% (n = 65) self-identified as lesbian, gay, bisexual, or undecided; 3% (n = 23) had same-sex sexual partners; and 6% (n = 49) reported having a same-sex boyfriend or girlfriend (some of the participants were grouped into more than one category). This resulted in a classification of 89 young people as SMYs (61 young women, 28 young men). Table 1 shows sample characteristics.
TABLE 1—
Sociodemographic Characteristics, Sexual Behaviors, and Psychosocial Characteristics of Heterosexual (n = 729) and Sexual Minority (n = 89) Youths: Johannesburg, South Africa; October 2008–November 2009
| Characteristic | Heterosexual Youths, No. (%) or Mean ±SD | Sexual Minority Youths, No. (%) or Mean ±SD | Total, No. (%) or Mean ±SD |
| Female | 56 (406) | 69 (61) | 57* (469) |
| Age, y | 17.04 ±0.83 | 16.93 ±0.81 | 17.02 ±0.83 |
| Race | |||
| Black | 62 (448) | 65 (58) | 62 (506) |
| Colored | 13 (96) | 12 (11) | 13 (107) |
| Indian | 13 (97) | 6 (5) | 13 (106) |
| White | 12 (88) | 17 (15) | 13 (103) |
| Language spoken | |||
| IsiZulu | 31 (221) | 36 (32) | 32 (253) |
| Afrikaans | 20 (143) | 26 (23) | 21 (166) |
| English | 18 (130) | 12 (11) | 18 (142) |
| Sesotho | 10 (73) | 11 (10) | 10 (83) |
| Other | 21 (146) | 15 (13) | 20 (159) |
| Parental status | |||
| Mother alive | 90 (653) | 88 (78) | 90 (735) |
| Father alive | 73 (529) | 65 (58) | 76 (591) |
| Both parents deceased | 4 (27) | 5 (4) | 4 (31) |
| Parent/guardian’s highest level of education | |||
| ≤ some high school | 35 (230) | 35 (29) | 35 (259) |
| High school | 48 (321) | 48 (39) | 49 (363) |
| > high school | 17 (112) | 17 (14) | 17 (127) |
| Parent/guardian’s employment status | |||
| Both unemployed | 11 (75) | 14 (11) | 11 (86) |
| One parent employed | 49 (342) | 55 (44) | 49 (386) |
| Both employed | 41 (288) | 31 (25) | 40 (317) |
| Marital status | |||
| Never married | 25 (180) | 38 (33) | 26 (213) |
| Married/living together | 47 (339) | 34 (30) | 46* (373) |
| Separated/widowed | 28 (197) | 28 (25) | 28 (222) |
| Resides in brick house/flata | 83 (597) | 81 (70) | 83 (670) |
| Sexual behaviorsb | |||
| Ever had vaginal sex | 48 (346) | 39 (35) | 47 (381) |
| Ever had anal sex | 3 (23) | 18 (16) | 5 (39) |
| Condom use (past 6 mo) | 5 (18) | 2 (1) | 5 (19) |
| Sex trading (ever) | 4 (30) | 10 (9) | 5 (39) |
| Age of sexual debut, y | 15.26 ±1.63 | 14.76 ±2.34 | 15.21 ±1.72 |
| Lifetime no. of partners | 3.55 ±4.69 | 7.42 ±11.31 | 4.25 ±5.96 |
| Psychosocial variables | |||
| Depressionc | 7 (52) | 19 (17) | 8 (69) |
| Traumatic stressd | 50 (308) | 51 (40) | 50 (348) |
| Substance use | 68 (494) | 74 (66) | 69 (560) |
| Partner-perpetrated violence | 18 (133) | 25 (22) | 19 (155) |
| Older partner (>21 y) | 9 (60) | 16 (13) | 10 (73) |
| Self-esteeme score | 21.73 ±4.16 | 20.97 ±4.33 | 21.66 ±4.19 |
| Parent–child communicationf score | 11.68 ±4.57 | 11.33 ±4.54 | 11.61 ±4.57 |
Note. As a result of missing values, totals may not match sample size. Sexual minority and heterosexual youths significantly differed with respect to gender and parents’ marital status.
As a gauge of socioeconomic status in low-resource settings, participants were asked about type of household structure, that is, whether they lived in a brick, flat, reconstruction or development program (low-income) housing, hostel, or shack (temporary housing).
Among sexually active heterosexual (n = 348) and sexual minority (n = 40) youths.
Assessed with the Children’s Depression Inventory; responses were dichotomized as depressed (score above 19) versus not depressed (α = 0.79).
The Trauma Events Questionnaire (α = 0.94) assessed lifetime trauma exposure, and the Impact of Event Scale examined the effects of the most difficult trauma experienced over the past month; the total traumatic stress score was dichotomized as high (score above 19) versus medium or low traumatic stress (α = 0.94).
Assessed with the Rosenberg Self-Esteem Scale (α = 0.75); scores ranged from 0–30.
Assessed with the Parent-Child Communication Scale (α = 0.84); scores ranged from 5–20.
P < .05.
Adjusted multivariate regression models were used to examine correlates of sexual risk. Results indicated that ever having sex was associated with being male, being older, being Black African, using substances, experiencing partner-perpetrated violence, and having an older partner (Table 2). Earlier age of sexual debut was related to being male and older. Being an SMY and male was associated with having a greater number of lifetime partners. Multivariate correlates of engaging in sex trading included being an SMY, being male, experiencing partner-perpetrated violence, and having lower self-esteem. Variables associated with a lower likelihood of condom use included being older, being Black African, having lower self-esteem, and reporting poor parent–adolescent communication.
TABLE 2—
Adjusted Multivariate Correlates of Sexual Risk: Heterosexual and Sexual Minority Youths (n = 822): Johannesburg, South Africa; October 2008–November 2009
| Variable | Ever Had Vaginal/Anal Sexa (n = 822), OR (95% CI) | Age at Sexual Debut (n = 366), B (SE) | Lifetime No. of Partners (n = 374), B (SE) | Sex Trading (n = 388), OR (95% CI) | Condom Useb (n = 360), OR (95% CI) |
| Sociodemographics | |||||
| Sexual minority orientationc | −0.52 (0.29) | 3.90*** (0.95) | 3.11* (1.12, 8.62) | ||
| Male | 2.61*** (1.87, 3.64) | −0.89*** (0.18) | 2.62*** (0.60) | 5.22** (2.04, 13.37) | |
| Age | 1.71*** (1.40, 2.08) | 0.72*** (0.11) | 0.51* (0.27, 0.96) | ||
| Black race | 1.41* (1.01, 1.97) | 0.23** (0.08, 0.65) | |||
| Parents unemployed | −0.40 (0.28) | ||||
| Psychosocial risk factorsd | |||||
| Depression | 2.42 (0.72, 8.14) | ||||
| Substance use | 2.00*** (1.38, 2.90) | −0.16 (0.22) | 1.36 (0.78) | 4.46 (0.95, 20.89) | |
| Partner-perpetrated violence | 1.66* (1.11, 2.49) | −0.30 (0.19) | 4.90*** (2.26, 10.63) | ||
| Older partner | 4.03*** (2.15, 7.57) | −0.06 (0.26) | |||
| Psychosocial protective factors | |||||
| Self-esteem | 0.89* (0.80, 0.99) | 0.88* (0.78, 0.99) | |||
| Parent–child communication | 0.02 (0.02) | 0.94 (0.85, 1.03) | 0.81** (0.70, 0.94) |
Note. CI = confidence interval; OR = odds ratio. We conducted bivariate analyses (not shown) in which each sociodemographic and psychosocial variable and each outcome variable were used. Only variables with P < .1 in the bivariate tests were included in each adjusted multivariate regression.
As a result of small sample sizes, we combined the vaginal sex and anal sex variables into this single variable.
Dichotomized as always versus sometimes/never.
We classified participants as sexual minority youths if they self-identified as homosexual, bisexual, or undecided; reported a history of same-sex sexual intercourse; or reported being involved in a same-sex relationship.
None of the traumatic stress bivariate analyses had a P < .1; thus, traumatic stress was excluded from the multivariate analyses.
*P < .05; **P < .01; ***P < .001.
DISCUSSION
SMYs were not more likely than heterosexual youths to have had sex; when they did have sex, however, they engaged in riskier sexual behaviors. Our results are consistent with syndemic studies conducted in South Africa29,30 and the United States.31,32 SMYs in South Africa are an increasingly vulnerable population at risk for mental health and psychosocial difficulties19,20 that stem from stressors at the individual, family, peer, and partner levels. We did not have ample power to examine interaction effects according to SMY status and gender. However, the observed higher rates of sexual risk behaviors among sexual minority and male youths indicate that male SMYs are a very vulnerable group. HIV prevention campaigns tailored for young South African MSM, including HIV testing initiatives and social media or direct marketing campaigns to decrease sexual risk and promote safer sex, are needed.8
The impact of syndemics was also evident among Black African youths, who were more likely than young people in other groups to have had sex and less likely to use condoms. These results are concerning given that Black Africans are disproportionately affected by HIV relative to other South African groups.33 In addition, our finding that lower rates of condom use were associated with lower self-esteem and poorer parent–adolescent communication among all youths indicates that a potential next step is the development of culturally tailored prevention interventions that incorporate parental involvement34–37 and address mental health functioning.38 Moreover, prevention efforts targeting SMYs should be promoted to curtail the spread of HIV.
Future work could begin with qualitative explorations of the factors contributing to increased risk and determination of prevalence rates among SMYs. This research should not only include youth-friendly materials that are developmentally and culturally appropriate, but also incorporate novel strategies for recruiting and retaining SMYs.
The limitations of our study include its small sample size and the fact that the sample was skewed toward young people whose parents had graduated from high school and were employed. Other limitations were potential self-reporting bias resulting from the use of interviewer-administered questionnaires and potential misclassification of SMYs. As noted, our study is one of the first to examine factors associated with sexual risk among SMYs in South Africa. There is a critical need for an even larger-scale study examining multilevel risk factors known to be associated with HIV acquisition and transmission among SMYs in South Africa.
Acknowledgments
This study was supported by the National Institute of Mental Health (grants R21MH083308 and R34MH090790-S1), the Medical Research Council of South Africa, and the National Research Foundation (NRF) of South Africa.
We thank the research staff at the Perinatal HIV Research Unit (University of the Witwatersrand) for their contributions to recruitment and data collection efforts.
Note. Any opinions, findings, conclusions, or recommendations expressed are those of the authors, and the NRF does not accept any liability in this regard.
Human Participant Protection
This study was approved by the institutional review boards of the University of the Witwatersrand and Duke University. Written participant consent and parental consent (in applicable cases) were obtained from all study participants.
References
- 1. World Health Organization. AIDS epidemic update. Available at: http://data.unaids.org/pub/Report/2009/JC1700_Epi_Update_2009_en.pdf. Accessed March 28, 2014.
- 2.Vrana S, Lauterbach D. Prevalence of traumatic events and post-traumatic psychological symptoms in a nonclinical sample of college students. J Trauma Stress. 1994;7(2):289–302. doi: 10.1007/BF02102949. [DOI] [PubMed] [Google Scholar]
- 3.Williams KA, Chapman MV. Comparing health and mental health needs, service use, and barriers to services among sexual minority youths and their peers. Health Soc Work. 2011;36(3):197–206. doi: 10.1093/hsw/36.3.197. [DOI] [PubMed] [Google Scholar]
- 4.Dietrich J, Khunwane M, Laher F, de Bruyn G, Sikkema K, Gray G. “Group sex” parties and other risk patterns: a qualitative study about the perceptions of sexual behaviours and attitudes of adolescents in Soweto, South Africa. Vulnerable Child Youth Stud. 2011;6(3):244–254. doi: 10.1080/17450128.2011.597796. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Lane T, Raymond HF, Dladla S et al. High HIV prevalence among men who have sex with men in Soweto, South Africa: results from the Soweto Men’s Study. AIDS Behav. 2011;15(3):626–634. doi: 10.1007/s10461-009-9598-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Miller CL, Dietrich J, Nkala B et al. Implications for HIV prevention: lesbian, gay, and bisexual adolescents in urban South Africa are at increased risk of living with HIV. Pediatr Infect Dis J. 2013;32(6):e263–e264. doi: 10.1097/INF.0b013e31828b28f1. [DOI] [PubMed] [Google Scholar]
- 7.Reddy V, Sandfort T, Rispel L. From Social Silence to Social Science: Same-Sex Sexuality, HIV & AIDS and Gender in South Africa. Cape Town, South Africa: HSRC Press; 2009. [Google Scholar]
- 8.Qian HZ, Vermund SH. Are Low- and Middle-Income Countries Repeating Mistakes Made by High-Income Countries in the Control of HIV for Men who have Sex with Men? J AIDS Clin Res. 2012;(suppl 4):e001. doi: 10.4172/2155-6113.S4-e001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Price MA, Rida W, Mwangome M et al. Identifying at-risk populations in Kenya and South Africa: HIV incidence in cohorts of men who report sex with men, sex workers, and youth. J Acquir Immune Defic Syndr. 2012;59(2):185–193. doi: 10.1097/QAI.0b013e31823d8693. [DOI] [PubMed] [Google Scholar]
- 10.Rispel LC, Metcalf CA, Cloete A, Moorman J, Reddy V. You become afraid to tell them that you are gay: health service utilization by men who have sex with men in South African cities. J Public Health Policy. 2011;32(suppl 1):S137–S151. doi: 10.1057/jphp.2011.29. [DOI] [PubMed] [Google Scholar]
- 11.Singer M. AIDS and the health crisis of the US urban poor: the perspective of critical medical anthropology. Soc Sci Med. 1994;39(7):931–948. doi: 10.1016/0277-9536(94)90205-4. [DOI] [PubMed] [Google Scholar]
- 12.Singer MC, Erickson PI, Badiane L et al. Syndemics, sex and the city: understanding sexually transmitted diseases in social and cultural context. Soc Sci Med. 2006;63(8):2010–2021. doi: 10.1016/j.socscimed.2006.05.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Dyer TP, Shoptaw S, Guadamuz TE et al. Application of syndemic theory to black men who have sex with men in the Multicenter AIDS Cohort Study. J Urban Health. 2012;89(4):697–708. doi: 10.1007/s11524-012-9674-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–697. doi: 10.1037/0033-2909.129.5.674. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Thiede H, Valleroy LA, MacKellar DA et al. Regional patterns and correlates of substance use among young men who have sex with men in 7 US urban areas. Am J Public Health. 2003;93(11):1915–1921. doi: 10.2105/ajph.93.11.1915. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Savin-Williams RC. Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: associations with school problems, running away, substance abuse, prostitution, and suicide. J Consult Clin Psychol. 1994;62(2):261–269. doi: 10.1037//0022-006x.62.2.261. [DOI] [PubMed] [Google Scholar]
- 17.Safren SA, Heimberg RG. Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. J Consult Clin Psychol. 1999;67(6):859–866. doi: 10.1037//0022-006x.67.6.859. [DOI] [PubMed] [Google Scholar]
- 18.Koblin BA, Torian L, Xu G et al. Violence and HIV-related risk among young men who have sex with men. AIDS Care. 2006;18(8):961–967. doi: 10.1080/09540120500467182. [DOI] [PubMed] [Google Scholar]
- 19.Kann L, Olsen EO, McManus T et al. Sexual identity, sex of sexual contacts, and health-risk behaviors among students in grades 9–12—youth risk behavior surveillance, selected sites, United States, 2001–2009. MMWR Surveill Summ. 2011;60(7):1–133. [PubMed] [Google Scholar]
- 20.Mustanski B, Newcomb M, Garofalo R. Mental health of lesbian, gay, and bisexual youth: a developmental resiliency perspective. J Gay Lesbian Soc Serv. 2011;23(2):204–225. doi: 10.1080/10538720.2011.561474. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Sikkema KJ, Brondino MJ, Anderson ES et al. HIV risk behavior among ethnically diverse adolescents living in low-income housing developments. J Adolesc Health. 2004;35(2):141–150. doi: 10.1016/j.jadohealth.2003.09.008. [DOI] [PubMed] [Google Scholar]
- 22.Noar SM, Cole C, Carlyle K. Condom use measurement in 56 studies of sexual risk behavior: review and recommendations. Arch Sex Behav. 2006;35(3):327–345. doi: 10.1007/s10508-006-9028-4. [DOI] [PubMed] [Google Scholar]
- 23.Hendriksen ES, Pettifor A, Lee S-J, Coates TJ, Rees HV. Predictors of condom use among young adults in South Africa: the Reproductive Health and HIV Research Unit National Youth Survey. Am J Public Health. 2007;97(7):1241–1248. doi: 10.2105/AJPH.2006.086009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Kovacs M. The Children’s Depression Inventory. New York, NY: Multi-Health Systems; 1992. [Google Scholar]
- 25.Matthey S, Petrovski P. The Children’s Depression Inventory: error in cutoff scores for screening purposes. Psychol Assess. 2002;14(2):146–149. doi: 10.1037//1040-3590.14.2.146. [DOI] [PubMed] [Google Scholar]
- 26.Horowitz M, Wilner N, Alvarez W. Impact of Event Scale: a measure of subjective stress. Psychosom Med. 1979;41(3):209–218. doi: 10.1097/00006842-197905000-00004. [DOI] [PubMed] [Google Scholar]
- 27.Rosenberg M. Society and the Adolescent Self-Image. Princeton, NJ: Princeton University Press; 1965. [Google Scholar]
- 28.DiClemente RJ, Wingood GM, Crosby R, Cobb BK, Harrington K, Davies SL. Parent-adolescent communication and sexual risk behaviors among African American adolescent females. J Pediatr. 2001;139(3):407–412. doi: 10.1067/mpd.2001.117075. [DOI] [PubMed] [Google Scholar]
- 29.Pitpitan EV, Kalichman SC, Eaton LA et al. Co-occurring psychosocial problems and HIV risk among women attending drinking venues in a South African township: a syndemic approach. Ann Behav Med. 2013;45(2):153–162. doi: 10.1007/s12160-012-9420-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Russell BS, Eaton LA, Petersen-Williams P. Intersecting epidemics among pregnant women: alcohol use, interpersonal violence, and HIV infection in South Africa. Curr HIV/AIDS Rep. 2013;10(1):103–110. doi: 10.1007/s11904-012-0145-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Mustanski B, Garofalo R, Herrick A, Donenberg G. Psychosocial health problems increase risk for HIV among urban young men who have sex with men: preliminary evidence of a syndemic in need of attention. Ann Behav Med. 2007;34(1):37–45. doi: 10.1080/08836610701495268. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Balaji AB, Bowles KE, Le BC, Paz-Bailey G, Oster AM. doi: 10.1097/QAD.0b013e32835ad489. High HIV incidence and prevalence and associated factors among young MSM, 2008. AIDS. 2013;27(2):269–278. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Shisana O, Rehle T, Simbayi LC . South African National HIV Prevalence, Incidence, Behaviour and Communication Survey 2008: A Turning Tide Among Teenagers? Cape Town, South Africa: HSRC Press; 2009. [Google Scholar]
- 34.Bastien S, Kajula LJ, Muhwezi WW. A review of studies of parent-child communication about sexuality and HIV/AIDS in sub-Saharan Africa. Reprod Health. 2011;8:25. doi: 10.1186/1742-4755-8-25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Biddlecom A, Awusabo-Asare K, Bankole A. Role of parents in adolescent sexual activity and contraceptive use in four African countries. Int Perspect Sex Reprod Health. 2009;35(2):72–81. doi: 10.1363/ipsrh.35.072.09. [DOI] [PubMed] [Google Scholar]
- 36.Peltzer K. Early sexual debut and associated factors among in-school adolescents in eight African countries. Acta Paediatr. 2010;99(8):1242–1247. doi: 10.1111/j.1651-2227.2010.01874.x. [DOI] [PubMed] [Google Scholar]
- 37.Bogart LM, Skinner D, Thurston IB et al. Let’s Talk! A South African worksite-based HIV prevention parenting program. J Adolesc Health. 2013;53(5):602–608. doi: 10.1016/j.jadohealth.2013.01.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Nduna M, Jewkes RK, Dunkle KL, Shai NP, Colman I. Associations between depressive symptoms, sexual behaviour and relationship characteristics: a prospective cohort study of young women and men in the Eastern Cape, South Africa. J Int AIDS Soc. 2010;13:44. doi: 10.1186/1758-2652-13-44. [DOI] [PMC free article] [PubMed] [Google Scholar]