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. Author manuscript; available in PMC: 2021 Jul 1.
Published in final edited form as: J Acquir Immune Defic Syndr. 2020 Jul 1;84(3):280–284. doi: 10.1097/QAI.0000000000002342

Sexual debut among 14-17-year-old sexual minority males: A preliminary investigation of early HIV risk and sexual health needs

Kimberly M Nelson a, Nicholas S Perry b,c, Claire D Stout a, Michael P Carey b,c,d
PMCID: PMC7293558  NIHMSID: NIHMS1594472  PMID: 32149857

Abstract

Background:

Adolescent sexual minority males (ASMM) are disproportionately at risk for HIV.

Purpose:

This study documents the sexual debut behaviors of ASMM, tests whether sexual debut and sexual behavior differed by race/ethnicity, and explores the association between early anal sex debut and engaging in condomless anal sex.

Methods:

Sexually active ASMM (N = 118; ages 14–17) in the United States completed an online sexual health survey. We used Fisher’s exact tests to explore differences by race/ethnicity in sexual debut characteristics and hypothesized relationships between sexual debut and risk behavior.

Results:

The average age of sexual debut with a male partner was 14 years old (SD = 2.4). Approximately one-third (31%) reported anal sex at their sexual debut, with non-Latino Black/African American ASMM more likely to report anal sex at debut (63%) compared to non-Latino White (28%), Latino (21%), or mixed race/other identified youth (19%; χ2 = 12.1, p = 0.01). All participants (100%) who reported an anal sex debut < 14 years old reported engaging in condomless anal sex in their lifetime, compared to 60% of those who reported an anal sex debut ≥ 14 years old (χ2 = 5.6, p = 0.03). Participants wanted information about how to safely and comfortably have anal sex (59%) and skills around partner communication (>50%) prior to debut.

Conclusion:

Sexually active ASMM begin engaging in sexual behavior with other males early and with incomplete knowledge and skills regarding sexual health and safety.

Keywords: adolescent, HIV, sexual debut, sexual risk, sexual minority

INTRODUCTION

Nearly all (93%) new HIV diagnoses among male adolescents (ages 13–19) in 2018 in the United States (US) resulted from male-male sexual contact, with racial and ethnic minority males disproportionately affected.1 Anal sex debut with another male among adolescent sexual minority males (ASMM) occurs early, with most studies reporting debut when youth were 14 to 18 years old.2–6 Age of anal sex debut with a male partner among ASMM has decreased over time.5,7,8 Among ASMM, early anal sex debut (defined variably in the literature) is associated with an increased likelihood of condomless sex and increased risk of acquiring HIV and other sexually transmitted infections (STIs).8–11 Some evidence indicates that age of anal sex debut and its relation with increased sexual risk differs by race/ethnicity among ASMM and contributes to racial/ethnic HIV disparities among ASMM.6,12

Most of the research documenting the associations between early anal sex debut and HIV/STI risk among ASMM has been conducted with older adolescents (>16 years old) and adults (>18 years old). Although valuable, this research has several methodological limitations. First, sampling older participants increases the retrospective nature of the research (i.e., details of their sexual debut are reported after a considerable passage of time). Second, most studies have assessed only anal sex debut, neglecting other sexual behaviors that also confer risk for STIs (e.g., oral sex). Third, no study has asked youth to identify the sexual health information and skills that they wished they had had prior to their sexual debut.

To address these limitations and knowledge gaps, we recruited a younger sample of ASMM (i.e., 14–17 years of age) and assessed their sexual debut behaviors as well as their perceived knowledge and skills before debut. We also inquired about the knowledge and skills youth wish they had prior to debut. These data allowed us to test differences by race/ethnicity, and to explore associations between early age of anal sex debut and condomless anal sex with male partners. Understanding ASMM sexual debut, as well as gaps in their knowledge at the time of debut, can inform HIV prevention efforts, including how to help youth establish healthy sexual behaviors from the start, which will help decrease HIV/STI incidence.

METHOD

Study Design

Data for this study were obtained from a larger sexual health study (described in detail in a previous publication13). Briefly, participants were recruited in June-July 2017 via advertisements and posts on social media (e.g., Instagram, Facebook). Eligibility criteria included: (1) age 14 to 17; (2) cisgender male (i.e., male sex at birth and male gender identity); (3) self-identify as gay/bisexual, report being sexually attracted to males, and/or report voluntary past year sexual contact with a male partner; (4) reside in the US; and (5) have a personal email address. Potential participants were directed to the study website, hosted using REDCap,14 for screening and consent. Capacity to consent was assessed using four questions that evaluated respondents’ understanding of study procedures, risks, and benefits. Respondents who were unable to answer all four questions accurately after three tries were deemed ineligible. Those who consented received an email containing a unique survey link. The survey took 30 minutes (SD = 12) on average. Completers were emailed a $15 Amazon.com gift code. To protect against fraudulent entries and multiple enrollments, screening and survey responses were cross-referenced using date of birth, location, sexual activity, and email address. All procedures, including a waiver of parental/guardian consent, were approved by the hospital IRB.

Measures

Socio-demographics.

Characteristics included age, race/ethnicity (Non-Latino White, Non-Latino Black/African American, Latino, Mixed Race/Other), sexual orientation (gay-identified, other), age participant realized he was sexually attracted to male partners, and census region of the US (Northeast, Midwest, South, West; recoded from state of residence).

Sexual debut and behavior.

Participants were asked about ever having voluntary sexual contact (i.e., kissing, mutual masturbation, oral sex, vaginal sex, and/or anal sex) with another person (yes, no). Participants who answered “yes” were asked the gender of their sexual partner(s) (male, female, transgender; check all that apply). Participants who reported male partners were asked about the sexual behaviors they engaged in at sexual debut with a male partner (kissing, mutual masturbation, oral sex, anal sex; check all that apply), what information or skills they believed they already had prior to sexual debut with a male partner (e.g., how to say no to sex, how to prevent HIV/AIDS, how to use a condom; check all that apply), what information they wish they had known prior to debut (e.g., how to say no to sex, how to prevent HIV/AIDS, how to use a condom; check all that apply), and their age at the time of their debut with a male partner.

Participants were also asked to report on the sexual behaviors they generally (i.e., not only at debut) engaged in with male partners (kissing, mutual masturbation, oral sex, anal sex; check all that apply). Those who reported ever having male–male anal sex were asked their age of male-male anal sex debut and to report the number of total and condom-protected times they had anal sex with a male partner. Using this information, a calculated field established the number of condomless anal sex acts, which was presented to participants for confirmation. A variable capturing ever having male–male condomless anal sex was created (yes, no).

Analyses

Analyses were limited to participants who reported their race/ethnicity and having voluntary sexual contact with a male partner (N = 118). Socio-demographic, sexual debut, and sexual behavior differences by race/ethnicity were assessed using Fisher’s exact tests and analysis of variance. Association between early male-male anal sex debut and ever engaging in male-male condomless anal sex was assessed using Fisher’s exact test. Early male-male anal sex debut was defined as debuting < 14 years old to conform to the middle of the range of definitions in prior literature8–11 and to be less than the average age of anal sex debut (m = 14.5, SD = 1.8, see Figure 1 for distribution) in our sample. Multivariable analyses were not conducted due to small cell sizes. Analyses were conducted using Stata 16.15

Figure 1.

Figure 1.

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Age of first sexual contact with a male partner (N = 118) and age of anal sex debut with a male partner (N =35) among sexually active 14 to 17-year-old sexual minority males who participated in an online survey in June – July, 2017 in the United States.

RESULTS

Participants

The average age was 16 years old (SD = 0.9). Fifty-four (46%) participants identified as non-Latino White, 19 (16%) as non-Latino Black/African American, 29 (25%) as Latino, and 16 (13%) as mixed race/other. The average age of realizing sexual attraction to male partners was 12 years (SD = 0.9). Participants lived in 32 states (West: 33%, South: 30%, Midwest: 20%; Northeast: 17%). Most (64%) self-identified as gay. Participants who identified as Latino (m = 16.2, SD = 0.7) or mixed race/other (m = 16.1, SD = 0.8) were slightly older than those who identified as non-Latino White (m = 15.7, SD = 0.9) or non-Latino Black/African American (m = 15.7, SD = 1.1; F = 2.8, p = 0.04). There were no other socio-demographic differences by race/ethnicity.

Sexual Debut

Most participants reported kissing (86%), mutual masturbation (60%), and/or oral sex (55%) at their sexual debut with a male partner (Table 1). Approximately one-third (31%) reported anal sex at their sexual debut, with non-Latino Black/African American youth more likely to report anal sex at debut (63%) compared to non-Latino White (28%), Latino (21%), or mixed race/other identified youth (19%; χ2 = 12.1, p = 0.01). The average age of first voluntary sexual contact with a male partner was 14 years (SD = 1.7; see Figure 1 for distribution). Age of debut did not differ by race/ethnicity.

Table 1.

Sexual debut characteristics by race/ethnicity among sexually active 14 to 17-year-old sexual minority males who participated in an online survey in June – July, 2017 in the United States.

Total Non-Latino White Non-Latino Black/ African American Latino Mixed Race/ Other
N = 118 n = 54 n = 19 n = 29 n = 16
Debut with a male partner n (%) n (%) n (%) n (%) n (%) Χ2
 Types of Sexual Behaviors at Debut
  Kissing 102 (86) 45 (83) 18 (95) 23 (79) 16 (100) 5.3
  Mutual masturbation 71 (60) 33 (61) 13 (68) 16 (55) 9 (56) 1.0
  Oral sex 65 (55) 30 (56) 12 (63) 17 (59) 6 (38) 2.7
  Anal sex 36 (31) 15 (28) 12 (63) 6 (21) 3 (19) 12.1**
 Information/skills known prior to sexual debut with a male partner
  How to say no to sex 93 (79) 46 (85) 13 (68) 21 (72) 13 (81) 3.3
  How to use a condom 85 (72) 40 (74) 12 (63) 20 (69) 13 (81) 1.7
  How to prevent STIs 82 (69) 38 (70) 11 (58) 21 (72) 12 (75) 1.6
  How to prevent HIV/AIDS 77 (65) 33 (61) 11 (58) 20 (69) 13 (81) 2.8
  How to talk with sexual partners about what you would like to do sexually 60 (51) 30 (56) 5 (26) 15 (52) 10 (63) 5.9
  How to use lubrication or lube 59 (50) 24 (44) 7 (37) 18 (62) 10 (63) 4.7
  How to talk with sexual partners about what you would NOT like to do sexually 58 (49) 28 (52) 5 (26) 14 (48) 11 (69) 6.6
  The types of sex you can have with a male partner 51 (43) 26 (48) 6 (32) 13 (45) 6 (38) 1.8
  How to talk with sexual partners about STIs/HIV 37 (31) 14 (26) 3 (16) 11 (38) 9 (56) 8.1*
  How to safely and comfortably have anal sex 30 (25) 15 (28) 2 (11) 6 (21) 7 (44) 5.6
 Information/skills they wish they had known prior to sexual debut with a male partner
  How to safely and comfortably have anal sex 69 (59) 32 (59) 11 (58) 17 (59) 9 (56) 0.1
  How to talk with sexual partners about what you would like to do sexually 62 (53) 30 (56) 11 (58) 14 (48) 7 (44) 1.1
  How to talk with sexual partners about what you would NOT like to do sexually 61 (52) 30 (56) 12 (63) 13 (45) 6 (38) 3.2
  How to use lubrication or lube 58 (49) 29 (54) 8 (42) 14 (48) 7 (44) 1.0
  How to talk with sexual partners about STIs/HIV 56 (48) 25 (46) 11 (58) 13 (45) 7 (44) 1.0
  How to use a condom 52 (44) 25 (46) 6 (32) 14 (48) 7 (44) 1.5
  The types of sex you can have with a male partner 50 (42) 27 (50) 7 (37) 8 (28) 8 (50) 4.5
  How to say no to sex 46 (39) 19 (35) 6 (32) 13 (45) 8 (50) 2.0
  How to prevent STIs 41 (35) 20 (37) 5 (26) 10 (35) 6 (38) 0.8
  How to prevent HIV/AIDS 43 (36) 22 (41) 5 (26) 10 (35) 6 (38) 1.3
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*

p<0.05;

**

p<0.01

At the time of their debut with a male partner, most participants believed that they knew how to say no to sex (79%), use a condom (72%), prevent STIs (69%), prevent HIV (65%), and talk with partners about what they would like to do sexually (51%). Only a quarter (25%) reported knowing how to safely and comfortably have anal sex. When asked what information participants wish they had known prior to their sexual debut, the majority reported wanting information about how to safely and comfortably have anal sex (59%) and skills around talking with partners about what they would (53%) and would not (52%) like to do sexually.

Early Anal Sex Debut and Engagement in Condomless Anal Sex

One participant who reported male-male anal sex at debut did not report their age of anal sex debut; therefore, analyses of the relation between early anal sex debut and condomless anal sex were limited to n = 35. Among participants who reported anal sex at debut, 10 (29%) reported an age of anal sex debut < 14 years old and 25 (71%) reported an anal sex debut ≥ 14 years old. Age of anal sex debut did not differ by race/ethnicity. In total, 25 (71%) participants reported engaging in condomless anal sex in their lifetime. Engagement in condomless anal sex did not differ by race/ethnicity. All participants (10/10) who reported an anal sex debut < 14 years old reported engaging in condomless anal sex in their lifetime, compared to 60% (15/25) of those who reported an anal sex debut ≥ 14 years old (χ2 = 5.6, p = 0.03).

DISCUSSION

Results from this study suggest that (a) sexually active ASMM begin engaging in sexual behavior with other males at a young age and (b) sexual debut encompasses a range of sexual activities, including anal intercourse. Notably, non-Latino Black/African American youth were more likely to report anal sex at sexual debut. Our data do not provide an explanation for why this disparity may be occurring and indicate the need for further study given higher HIV prevalence among Black/African American ASMM.1 Our finding that 100% of youth who reported anal sex debut before the age of 14 engaged in condomless anal sex either at debut or subsequently is concerning. HIV prevention efforts for ASMM need to equip youth with appropriate prevention skills early in order to reduce the spread of HIV in this population.

Findings also indicate that ASMM lack sexual health knowledge and skills needed to prevent HIV and STIs. Specifically, youth identified key areas of information they wish they had before debut, particularly related to sexual communication and how to have anal sex safely and comfortably. HIV preventive interventions and other educational efforts will be strengthened if they address these unmet sexual health needs; such efforts need to provide more comprehensive sexual health education that includes information relevant to male-male sex.16 Notably, the majority of participants reported they did have some important sexual health knowledge, including how to use a condom and how to prevent HIV/STIs. This suggests that ASMM benefit from the general (i.e., heterosexually-focused) sexual health information they receive.16

Despite most participants believing that they knew how to use a condom to prevent HIV/STIs, many ASMM reported not using condoms during anal sex; this was particularly true the younger participants were at their first anal sex experience. These contradictory results suggest that ASMM may not be aware of their skills deficits. They may know what to do (knowledge), but not how (skills). Prevention interventions for youth that are interactive and provide modeling, practice, and feedback may help ASMM to develop sexual health skills, along with knowledge to engage in safe, pleasurable sex.17–19

These results are limited by the small sample; we encourage replication with larger samples of racially and ethnically diverse youth. Further, this study was conducted prior to approval of pre-exposure prophylaxis (PrEP) for adolescents20 and the CDC’s public acceptance that people living with HIV who have undetectable viral loads are unable to sexually transmit HIV (i.e., U=U).21 Thus, future research might investigate how these newer prevention options relate to sexual risk among youth.

In summary, this study’s findings suggest that some ASMM begin engaging in sexual behavior with other males early and with potentially incomplete knowledge and skills regarding sexual health and safety. An association between early sexual debut and adult sexual risk behaviors has been previously established among sexual minority men.5,6 Thus, early prevention efforts for ASMM are critical to prevent future sexual risk behavior and continued HIV transmission in this young and vulnerable group.

Acknowledgements

We would like to thank our participants, youth advisory board, and research assistants.

Conflicts of Interest and Source of Funding:

All authors declare no conflict of interest. This work and the first author are supported by the National Institute of Mental Health (K23MH109346). The second author is also supported by the National Institute of Mental Health (T32MH078788). The content of this publication is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

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