Abstract
Purpose:
To examine the lifetime and pre-18 sexual partnering patterns of populations with physical disabilities from adolescence to early adulthood, and how these patterns further vary by biological sex, race/ethnicity, and sexual orientation.
Methods:
Data were from 13,458 respondents to Waves I and IV of the National Longitudinal Study of Adolescent to Adult Health. Poisson regression models were used to assess differences in pre-18 and lifetime sexual partner counts among populations with physical disabilities compared to those without disabilities. Moderation analyses by biological sex, race/ethnicity, and sexual orientation were used to consider further differences among minority subgroups.
Results:
Results indicated more similarities than differences in sexual partnering patterns across disability severity groups. Specifically, populations with disabilities had just as many pre-18 and lifetime sexual partners as peers without disabilities. There was variation by biological sex, race/ethnicity, and sexual orientation, though this was not tied to disability status.
Conclusions:
These results fill an important gap in the literature by considering the sexual partnering behaviors of populations with physical disabilities in the United States over the life course. Future research should continue to include populations with disabilities and other minority groups to ensure that their experiences are represented in sexual health policies and programs.
Implications and Contribution:
Findings show that the sexual partnering behaviors of populations with and without disabilities are more similar than they are different, providing valuable evidence for the provision of age- and developmentally-appropriate sex education to populations with physical disabilities.
Introduction
Beyond timing of first sex, sexual partner accumulation is an important predictor of sexual health outcomes among adolescents and early adults in the United States.1 Unfortunately, most adolescent sexuality research has only focused on the relationship between timing of first sex and later health outcomes, which has influenced sex education programs that encourage abstinence only until marriage.2,3 More recent research suggests that sexual partnering may have more proximal implications for later sexual health, and thus deserves increased attention in the literature and in the design and implementation of sex education programs.1 While there is a relatively strong body of literature characterizing sexual partnering behaviors of the general population, no research has sought to understand variations in sexual partnering among populations with physical disabilities. Given that populations with disabilities have been found to be at greater risk for various negative health outcomes,4–7 it is important to understand their sexual behavior patterns, including sexual partnering, to identify their specific sex education needs.8
Past literature on sexual partnering patterns in population-based samples shows important variations in sexual partnering from adolescence to early adulthood. In particular, previous research using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) indicates that adolescents (12-18) and emerging adults (18-24) report higher partner accumulation rates than early adults (24-32); however, there are differences by biological sex and race/ethinicity.9 In terms of biological sex, Kan and colleagues15 found that adolescent females in the Add Health study reported more sexual partners over time than did males. In contrast, data from the national Youth Risk Behavior Survey (YRBS) consistently indicate that adolescent males are more likely than adolescent females to report having had four or more sexual partners.10 Such conflicting results may be related to differences in the datasets or the type of outcome variable (count vs. categorical). Regarding race/ethnicity, YRBS data show that Black adolescents are significantly more likely than Whites and Hispanics to report four or more sexual partners.10 Finally, sexual minorities (e.g., homosexual, bisexual), particularly male adults (18-39), and female adolescents and emerging adults (15-20), have been shown to have greater numbers of lifetime partners compared to their heterosexual, same sex peers.11,12
Limited research has focused on the sexual development of adolescents with physical disabilities, as this population has traditionally been excluded from such studies.13 Research to date consistently shows that adolescents with physical disabilities have less sexual education, are at increased risk for pregnancy and STI/STDs, and are more vulnerable to sexual violence and abuse, all of which may affect their sexual patterns over the life course.4–7 More recent research has examined normative sexual development and behavior patterns in populations with physical disabilities in the United States from adolescence to early adulthood, considering both the experiences and timing of various sexual acts.14,15 In particular, these studies show that populations with the most severe physical disabilities are less likely to have experienced vaginal sex, oral sex, and to have had any sexual experience, while those with mild or moderate disabilities are not significantly different in their sexual experiences compared to peers without disabilities.14 This research also shows differences by biological sex, such that males with severe disabilities were less likely to have had any sexual experience, and females with moderate and severe disabilities were less likely to have experienced vaginal sex compared to same sex peers without disabilities.14 Regarding the timing of these experiences, this research shows that populations with the most severe physical disabilities progress more slowly to first vaginal sex, oral sex, and first sexual experience compared to those without disabilities, but that these relationships further vary by biological sex, race/ethnicity, and sexual orientation.15 To our knowledge, no studies have examined normative partner accumulation patterns among populations with physical disabilities which, as mentioned earlier, is an important component of sexual patterns with implications for later sexual health.
Current Study
Our study draws upon the life course perspective, which explores the statuses and roles that people assume throughout life and how these are embedded in structural and social contexts.16 The life course perspective is often applied to sexual development because departures from normative sexual behavior patterns have important implications over time.17–19 In the context of disability and sexual experiences, the life course perspective suggests if individuals with disabilities have different sexual experiences,20 these experiences could have different implications over time.
One particularly important life course concept is transitions, which are the changes in statuses and roles that make up long-term trajectories, both within an individual and in historical time. For example, the transition to adulthood is often studied because it represents an important stage when young people reach a certain level of developmental and social maturity.21 This transition is particularly important when studying sexual partnering behaviors, because sexual experiences in adolescence (i.e., before age 18) may introduce different health risks compared to experiences in adulthood due to developmental and social differences in sexual risk-taking behavior over time.17,22
Also related to the life course perspective are cumulative advantage/disadvantage, which suggests that combinations of life experiences may exacerbate or mitigate negative health outcomes over time,23,24 and intersectionality, which similarly proposes that people with multiple marginalized identities may experience even greater disadvantage than individuals who identify with one or no minority groups.25 Consistent with these concepts, populations with physical disabilities who also identify with another marginalized group(s) (e.g., female, Black race, sexual minority) could experience additive or interactive adverse effects of sexual behaviors compared to individuals who do not share these statuses.26–28
Therefore, the goals of this paper are to examine 1) the lifetime and pre-18 sexual partner patterns of populations with physical disabilities from adolescence to early adulthood, and 2) how these sexual partnering outcomes further vary by biological sex, race/ethnicity, and sexual orientation. We hypothesize that individuals with physical disabilities will report fewer lifetime and pre-18 sexual partners compared to those without physical disabilities, but the degree to which they differ will depend on disability severity. Consistent with the concepts of cumulative advantage/disadvantage and intersectionality, we also hypothesize that the associations between physical disability and sexual partner accumulation will be moderated by biological sex, race/ethnicity, and sexual orientation.
Methods
Study Sample
We use data from Add Health, a large, nationally representative, longitudinal study of over 20,000 U.S. in-school adolescents who were in 7th-12th grade (ages 12-18) during the 1994-1995 school year.29 Five waves of data are available thus far, consisting of one in-school and one parent interview at study entry and five in-home interviews spanning from adolescence into adulthood.a This study uses data from the Wave I and IV interviews, which capture the important life course transitions from adolescence to early adulthood. Specifically, Wave I includes the original 20,745 respondents aged 12-18 in 1994-1995 (adolescence), and Wave IV includes 15,701 of the original respondents who were ages 24-34 in 2008-2009 (early adulthood; response rate=80.3%).30 This analysis only includes respondents with valid sampling weights (n=14,800) and complete data on all variables of interest. To decrease the amount of missing data, we completed 15 imputations using multiple imputation by chained equations (MICE),31 yielding a final sample of 13,458.
Measures
Physical disability.
We used Cheng and Udry’s32 Physical Disability Index (PDI), which integrates information from the adolescent interviews, interviewer reports, and the parent interview at Wave I. Adolescent respondents were identified for an extended interview using screening questions regarding limb difficulties during the in-school interview (n=989). For those identified, the adolescent and parent answered questions regarding the adolescent’s disabilities, functional limitations, and assistive care needs. Responses were coded independently, and the higher of the two scores defined the adolescent’s PDI score. In both the adolescent and parent surveys, scores started at zero and increased by one point for each of the following:
Having limb difficulties
Using medical equipment
Needing assistive care
If the respondent perceived, or believed others perceived, the adolescent to have a disability
Difficulty in walking, standing, extending, grasping, or holding things
More than three body parts affected (parent interview only)
After selecting the higher of the two scores, interviewer reports of blindness and deafness were incorporated as follows:
If deaf or blind in one eye/ear and had an initial score <3, the adolescent was given a final score of 3.
If blind in one eye and deaf and had an initial score <4, the adolescent was given a final score of 4.
If blind in both eyes and had an initial score <5, the adolescent was given a final score of 5.
Due to the infrequency of scores ≥4, scores of 4 and 5 were grouped into the “3” category, creating the final 0-3 scale, indicating no (0), mild (1), moderate (2), and severe (3) physical disability.
Partner accumulation.
At Wave IV, respondents were asked to report numbers of male and female sexual partners with whom they had ever engaged in any type of sexual activity, both in their lifetimes and before age 18 (pre-18). Given the range of responses and right skew of the distribution, lifetime partner counts were capped at 100 and pre-18 partner counts were capped at 60.
Controls and moderators.
For main effect analyses, we controlled for biological sex, race/ethnicity, age of the respondent at the time of the Wave IV interview, socioeconomic status (SES) of the family of origin, sexual orientation, cognitive ability, history of sexual violence and abuse, and years sexually active. In moderation analyses, biological sex, race/ethnicity and sexual orientation served as moderators, and age, SES, cognitive ability, history of sexual violence and abuse, and years sexually active served as controls.
Biological sex was indicated by the interviewer at Wave IV. Race/ethnicity was self-reported and verified by interviewers at Wave I.b Age at the time of the interview was calculated by finding the difference between the Wave IV interview date and birth date. SES was measured using the highest education level achieved by either parent at Wave I. For sexual orientation, the sexual minority group included those who endorsed an identity of fully or mostly homosexual, bisexual, mostly heterosexual, or asexual, and the heterosexual group included those who identified as fully heterosexual at Wave IV.
Since past research shows that populations with low cognitive abilities are less sexually experienced than peers of average cognitive abilities33 and because physical and cognitive disabilities are often comorbid, we controlled for cognitive ability using the Add Health Picture Vocabulary Test (AHPVT) from Wave I.34 The AHPVT is an abridged version of the Peabody Picture Vocabulary Test,35 which is moderately correlated with other intelligence measures including the Stanford-Binet Intelligence Scale36 and the Wechsler Intelligence Scale for Children.37 AHPVT scores were standardized to a mean of 100 and standard deviation of 15, resulting in four categories (<85, 85– 99, 100–114, >114).
Past research also shows that populations with disabilities are more susceptible to sexual violence and abuse.4 We therefore measured history of non-parental coerced sex, non-parental forced sex, and sexual abuse by a parent/caregiver using retrospective reports from Wave IV. Finally, because respondents had been sexually active for different periods of time, we also controlled for total years sexually active at the time of the Wave IV interview for lifetime partner analyses and years sexually active before age 18 for pre-18 analyses. This was calculated by subtracting the age at earliest sexual experience from the respondent’s age at Wave IV.
Analyses
After examining descriptive statistics, we used Poisson regression models to compare lifetime and pre-18 partner accumulation among disability severity groups to those without disabilities. For each partnering outcome, the first model only included disability and years sexually active, and the second model included disability, years sexually active, and all covariates. In moderation analyses, we repeated analyses after interacting disability with the moderator of interest (biological sex, race/ethnicity, sexual orientation). We used the Holm-Bonferroni method52 to report only statistically significant differences at the 0.05 level after correction for multiple tests. All analyses used sampling weights and adjusted variance estimates for the Add Health complex survey design and were completed using Stata 15.0.38
Results
Sample Characteristics
Table 1 provides descriptive statistics for all variables by disability severity. Most respondents had no physical disability (94.4%), with an additional 3.4% having mild, 1.2% having moderate, and 1.0% having severe disabilities. The sample was almost evenly split by biological sex, and the mean age at Wave IV was 28.3 years. Seventy percent were NH White, 12.8% were Hispanic, and 17.1% were NH Black. Almost 60% of parents completed at least some college, and 86.6% of respondents identified as heterosexual. Respondents had been sexually active for an average 2.1 years before age 18 and for 12.7 years in their lifetimes. Finally, respondents reported an average of 3.1 pre-18 and 12.9 lifetime partners. Comparisons of the confidence intervals suggested significant differences in the mean number of lifetime partners for respondents without disabilities (12.8, 95% CI: 12.3-13.4) and those with the most severe disabilities (9.5, 95% CI: 7.3-11.8).
Table 1.
Descriptive statistics by physical disability severity
| None | Mild | Moderate | Severe | Total | |
|---|---|---|---|---|---|
| weighted % (95% CI) | 94.4 (93.8-95.0) | 3.4 (2.9-3.9) | 1.2 (0.9-1.5) | 1.0 (0.8-1.3) | 100.0 |
| Biological Sex | |||||
| Male | 50.5 (49.2-51.9) | 50.2 (43.4-57.0) | 50.5 (40.0-61.1) | 49.2 (38.4-59.9) | 50.5 (49.2-51.8) |
| Female | 49.5 (48.1-50.8) | 49.8 (43.0-56.6) | 49.5 (38.9-60.0) | 50.8 (40.1-61.6) | 49.5 (48.2-50.8) |
| Race/Ethnicity | |||||
| Hispanic | 13.0 (9.3-16.7) | 9.3 (5.1-13.5) | 9.6 (2.7-16.6) | 10.1 (3.4-16.8) | 12.8 (9.2-16.5) |
| NH Black | 17.2 (12.7-21.7) | 13.4 (8.5-18.3) | 23.3 (12.4-34.3) | 16.2 (7.7-24.7) | 17.1 (12.7-21.6) |
| NH White | 69.8 (64.0-75.5) | 77.3 (71.1-83.6) | 67.0 (55.5-78.6) | 73.7 (62.7-84.6) | 70.0 (64.4-75.7) |
| Parent Education (SES) | |||||
| <HS | 12.4 (10.0-14.9) | 12.3 (7.1-17.5) | 20.0 (9.0-31.0) | 15.7 (7.1-24.3) | 12.6 (10.1-15.0) |
| HS/GED | 28.0 (25.7-30.3) | 24.1 (18.5-29.7) | 15.1 (8.2-22.1) | 33.3 (22.8-43.7) | 27.7 (25.5-30.0) |
| Some College | 29.8 (28.1-31.6) | 29.3 (22.6-36.0) | 32.6 (23.1-42.0) | 29.7 (20.1-39.4) | 29.9 (28.1-31.6) |
| College Grad | 29.7 (26.2-33.2) | 34.3 (26.6-41.9) | 32.3 (22.0-42.6) | 21.3 (13.7-28.8) | 29.8 (26.4-33.3) |
| Sexual Orientation | |||||
| Heterosexual | 86.7 (85.7-87.7) | 87.1 (83.2-91.0) | 81.8 (73.8-89.8) | 79.6 (70.2-89.1) | 86.6 (85.6-87.6) |
| Sexual Minority | 13.3 (12.3-14.3) | 12.9 (9.0-16.8) | 18.2 (10.2-26.2) | 20.4 (10.9-29.8) | 13.4 (12.4-14.4) |
| Cognitive Ability Score | |||||
| <85 | 13.9 (11.2-16.5) | 11.3 (6.8-15.8) | 14.7 (4.6-24.9) | 20.1 (11.2-29.0) | 13.9 (11.2-16.5) |
| 85-99 | 33.5 (31.5-35.5) | 38.9 (32.2-45.5) | 33.5 (24.1-43.0) | 31.4 (21.1-41.7) | 33.6 (31.6-35.7) |
| 100-114 | 35.6 (33.3-37.8) | 34.4 (28.2-40.7) | 29.8 (20.6-38.9) | 31.2 (20.9-41.5) | 35.4 (33.2-37.6) |
| >114 | 17.1 (14.9-19.3) | 15.4 (11.1-19.7) | 21.9 (12.8-31.1) | 17.3 (9.6-25.0) | 17.1 (14.9-19.2) |
| Coerced Sex | |||||
| No | 87.8 (87.0-88.6) | 83.3 (78.2-88.3) | 74.4 (64.5-84.2) | 83.8 (76.0-91.6) | 87.4 (86.6-88.3) |
| Yes | 12.2 (11.4-13.0) | 16.7 (11.7-21.8) | 25.6 (15.8-35.5) | 16.2 (8.4-24.0) | 12.6 (11.7-13.4) |
| Forced Sex | |||||
| No | 92.2 (91.5-92.9) | 87.2 (82.9-91.5) | 83.7 (76.8-90.7) | 87.5 (80.8-94.2) | 91.9 (91.2-92.5) |
| Yes | 7.8 (7.1-8.5) | 12.8 (8.5-17.1) | 16.3 (9.3-23.2) | 12.5 (5.8-19.2) | 8.1 (7.5-8.8) |
| Sexual Abuse | |||||
| No | 95.2 (94.6-95.8) | 92.4 (88.9-95.9) | 91.8 (86.9-96.8) | 91.5 (84.8-98.2) | 95.0 (94.4-95.6) |
| Yes | 4.8 (4.2-5.4) | 7.6 (4.1-11.1) | 8.2 (3.2-13.1) | 8.5 (1.8-15.2) | 5.0 (4.4-5.6) |
| MEANS | |||||
| Age at Wave IV | 28.3 (28.1-28.6) | 28.4 (28.0-28.8) | 28.7 (28.3-29.1) | 28.7 (28.3-29.2) | 28.3 (28.1-28.6) |
| Pre-18 Years Sexually Active | 2.1 (2.0-2.2) | 2.4 (2.1-2.7) | 2.0 (1.5-2.5) | 1.8 (1.4-2.2) | 2.1 (2.0-2.2) |
| Years Sexually Active | 12.7 (12.4-12.9) | 12.9 (12.3-13.5) | 12.5 (11.6-13.5) | 11.9 (10.9-12.9) | 12.7 (12.4-12.9) |
| Pre-18 Sexual Partners | 3.1 (2.9-3.3) | 3.8 (2.9-4.8) | 4.2 (2.7-5.7) | 2.8 (1.7-3.9) | 3.1 (2.9-3.3) |
| Lifetime Sexual Partners | 12.8 (12.3-13.4) | 14.1 (11.8-16.4) | 14.5 (10.6-18.4) | 9.5 (7.3-11.8) | 12.9 (12.3-13.4) |
Notes: Referent groups for categorical variables are in parentheses next to the variable names; CI = confidence interval; NH = Non-Hispanic; SES = socioeconomic status; HS = high school; GED = General Educational Development;
p<0.05
Poisson Regression Models
Table 2 presents adjusted rate ratios from analyses comparing numbers of pre-18 and lifetime partners among disability severity groups, showing no statistically significant differences at the 0.05 level after adjusting for covariates.
Table 2.
Adjusted rate ratios (and 95% confidence intervals) from Poisson regression models comparing numbers of pre-18 and lifetime sexual partners by physical disability
| aRR (95% CI) | Pre-18 Partners | Lifetime Partners | ||
|---|---|---|---|---|
| Disability Only | Full Model | Disability Only | Full Model | |
| Physical Disability (None) | ||||
| Mild | 1.13 (0.91-1.41) | 1.13 (0.92-1.40) | 1.06 (0.90-1.24) | 1.07 (0.92-1.24) |
| Moderate | 1.35 (0.96-1.89) | 1.26 (0.91-1.74) | 1.10 (0.88-1.38) | 1.04 (0.84-1.29) |
| Severe | 1.00 (0.73-1.36) | 0.98 (0.73-1.30) | 0.78 (0.62-0.98)* | 0.81 (0.66-1.00) |
| Years Sexually Active† | 1.15 (1.14-1.17)* | 1.13 (1.12-1.14)* | 1.41 (1.38-1.43)* | 1.44 (1.42-1.47)* |
| Biological Sex (Male) | ||||
| Female | 0.75 (0.69-0.81)* | 0.53 (0.50-0.56)* | ||
| Race/Ethnicity (NH White) | ||||
| Hispanic | 0.90 (0.78-1.04) | 1.01 (0.93-1.11) | ||
| NH Black | 1.01 (0.91-1.13) | 1.20 (1.12-1.27)* | ||
| Parent Education (SES; College Grad) | ||||
| <HS | 0.96 (0.82-1.13) | 0.73 (0.66-0.82)* | ||
| HS/GED | 1.04 (0.92-1.17) | 0.85 (0.79-0.92)* | ||
| Some College | 1.05 (0.94-1.17) | 0.92 (0.86-0.99) | ||
| Sexual Orientation (Heterosexual) | ||||
| Sexual Minority | 1.18 (1.06-1.31)* | 1.47 (1.36-1.59)* | ||
| Age at Wave IV | 0.98 (0.96-1.01) | 0.89 (0.88-0.91)* | ||
| Cognitive Ability Score (100-114) | ||||
| <85 | 0.97 (0.82-1.15) | 0.85 (0.76-0.96)* | ||
| 85-99 | 1.10 (0.99-1.22) | 0.96 (0.90-1.02) | ||
| >114 | 0.87 (0.78-0.98)* | 0.99 (0.92-1.08) | ||
| Coerced Sex (No) | ||||
| Yes | 1.32 (1.17-1.48)* | 1.33 (1.20-1.47)* | ||
| Forced Sex (No) | ||||
| Yes | 1.17 (1.02-1.34)* | 1.25 (1.11-1.42)* | ||
| Sexual Abuse (No) | ||||
| Yes | 1.12 (0.95-1.33) | 1.12 (1.00-1.26) | ||
Notes: Referent groups for categorical variables are in parentheses next to the variable names;
Pre-18 partners analyses are adjusted for years sexually active before age 18 and lifetime partners analyses are adjusted for total years sexually active;
aRR = adjusted rate ratio; CI = confidence interval; NH = Non-Hispanic; SES = socioeconomic status; HS = high school; GED = General Educational Development;
p<0.05;
Table 3 includes results of moderation analyses by biological sex, race/ethnicity, and sexual orientation (ref: males without disabilities).c In biological sex analyses, males without disabilities are the referent group. For pre-18 partners, only females without disabilities were significantly different from the referent, with a ratio of 0.75 pre-18 partners. All females at every disability severity level had significantly fewer lifetime sexual partners compared to males. In particular, the ratio for females without disabilities was 0.53, with mild disabilities was 0.55, with moderate disabilities was 0.60, and with severe disabilities was 0.40 compared to males without disabilities. Males with disabilities were not significantly different from males without disabilities for either outcome. Comparisons of the confidence intervals also indicated differences in lifetime partnering within disability groups. Specifically, females with mild disabilities and severe disabilities had fewer lifetime sexual partners than their male peers. No other differences emerged within biological sex or disability groups.
Table 3.
Adjusted rate ratios (and 95% confidence intervals) from three sets of Poisson regression models testing moderation in the numbers of pre-18 and lifetime sexual partners among disability severity groups by biological sex, race/ethnicity, and sexual orientation
| aRR (95% CI) | Pre-18 Partners | Lifetime Partners | ||
|---|---|---|---|---|
| Moderator Only | Full Model | Moderator Only | Full Model | |
| Physical Disability/Biological Sex (None/Male) | ||||
| None/Female | 0.88 (0.81-0.95)* | 0.75 (0.69-0.81)* | 0.64 (0.60-0.68)* | 0.53 (0.50-0.56)* |
| Mild/Male | 1.10 (0.80-1.51) | 1.12 (0.82-1.53) | 1.02 (0.81-1.27) | 1.09 (0.88-1.35) |
| Mild/Female | 1.04 (0.78-1.38) | 0.86 (0.65-1.14) | 0.72 (0.57-0.90)* | 0.55 (0.44-0.68)* |
| Moderate/Male | 1.36 (0.92-2.01) | 1.37 (0.92-2.04) | 0.91 (0.70-1.18) | 0.97 (0.76-1.24) |
| Moderate/Female | 1.18 (0.65-2.16) | 0.85 (0.49-1.48) | 0.91 (0.60-1.39) | 0.60 (0.42-0.86)* |
| Severe/Male | 0.93 (0.66-1.31) | 0.88 (0.63-1.24) | 0.86 (0.62-1.18) | 0.85 (0.62-1.16) |
| Severe/Female | 0.95 (0.60-1.50) | 0.79 (0.52-1.20) | 0.46 (0.36-0.60)* | 0.40 (0.32-0.51)* |
| Physical Disability/Race (None/NH White) | ||||
| None/Hispanic | 0.88 (0.76-1.03) | 0.90 (0.77-1.04) | 0.92 (0.82-1.03) | 1.03 (0.93-1.12) |
| None/NH Black | 1.00 (0.90-1.12) | 1.02 (0.91-1.14) | 1.10 (1.01-1.19) | 1.20 (1.13-1.28)* |
| Mild/Hispanic | 0.76 (0.56-1.02) | 0.76 (0.52-1.09) | 0.72 (0.52-1.00) | 0.74 (0.51-1.08) |
| Mild/NH Black | 0.95 (0.61-1.49) | 0.93 (0.61-1.42) | 1.11 (0.83-1.49) | 1.19 (0.92-1.54) |
| Mild/NH White | 1.19 (0.92-1.54) | 1.21 (0.95-1.55) | 1.10 (0.90-1.34) | 1.13 (0.94-1.35) |
| Moderate/Hispanic | 1.06 (0.60-1.90) | 1.08 (0.63-1.87) | 0.84 (0.65-1.07) | 0.86 (0.62-1.20) |
| Moderate/NH Black | 1.44 (0.64-3.23) | 1.33 (0.65-2.71) | 1.08 (0.52-2.26) | 1.17 (0.61-2.26) |
| Moderate/NH White | 1.32 (0.92-1.89) | 1.24 (0.85-1.81) | 1.17 (0.95-1.44) | 1.10 (0.89-1.37) |
| Severe/Hispanic | 1.73 (0.68-4.37) | 1.63 (0.67-3.97) | 1.05 (0.62-1.78) | 1.16 (0.72-1.87) |
| Severe/NH Black | 1.17 (0.72-1.90) | 1.19 (0.79-1.81) | 1.08 (0.57-2.03) | 1.02 (0.49-2.12) |
| Severe/NH White | 0.81 (0.54-1.21) | 0.79 (0.54-1.15) | 0.68 (0.53-0.87)* | 0.75 (0.61-0.92)* |
| Physical Disability/Sexual Orientation (None/Heterosexual) | ||||
| None/Sexual Minority | 1.11 (1.00-1.25) | 1.15 (1.03-1.28) | 1.36 (1.24-1.49)* | 1.46 (1.34-1.59)* |
| Mild/Heterosexual | 1.06 (0.83-1.35) | 1.05 (0.83-1.34) | 1.04 (0.87-1.25) | 1.04 (0.87-1.23) |
| Mild/Sexual Minority | 1.72 (1.04-2.83) | 1.78 (1.13-2.81) | 1.57 (1.09-2.26) | 1.80 (1.27-2.56)* |
| Moderate/Heterosexual | 1.33 (0.97-1.83) | 1.29 (0.94-1.78) | 1.05 (0.87-1.27) | 1.01 (0.83-1.22) |
| Moderate/Sexual Minority | 1.49 (0.62-3.55) | 1.37 (0.61-3.04) | 1.57 (0.80-3.05) | 1.67 (0.91-3.07) |
| Severe/Heterosexual | 0.84 (0.65-1.10) | 0.82 (0.64-1.06) | 0.80 (0.62-1.05) | 0.84 (0.65-1.07) |
| Severe/Sexual Minority | 1.72 (0.94-3.14) | 1.80 (0.99-3.27) | 0.89 (0.58-1.37) | 1.05 (0.69-1.59) |
Notes: Because estimates for covariates in moderation analyses were consistent with those from main effects, we excluded these from the moderation results table; Pre-18 partners analyses are adjusted for years sexually active before age 18 and lifetime partners analyses are adjusted for total years sexually active; Each full moderation model is adjusted for parent education, age at the Wave IV interview, cognitive ability score, coerced sex, forced sex, sexual abuse, and untested moderators; Referent groups for categorical variables are in parentheses next to the variable names; aRR = adjusted rate ratio; CI = confidence interval; NH = Non-Hispanic;
p<0.05 with Holm-Bonferroni correction for multiple comparisons
Moderation analyses by race/ethnicity are also shown in Table 3 (ref: NH Whites without disabilities). Two statistically significant differences in lifetime partnering emerged. Specifically, NH Blacks without disabilities had 1.09 times, and NH Whites with severe disabilities had 0.40 times as many lifetime partners as the referent. Comparisons of the confidence intervals also showed within group differences, such that NH Blacks without disabilities had more lifetime partners than Hispanics without disabilities, and NH White respondents with severe disabilities had fewer lifetime sexual partners than NH Whites with mild disabilities. No such differences existed for other racial/ethnic and disability groups, nor were there differences among groups for the pre-18 outcome.
Table 3 also includes moderation analyses by sexual orientation (ref: heterosexuals without disabilities). Sexual minorities with no disabilities had 1.46 times and sexual minorities with mild disabilities had 1.80 times as many lifetime sexual partners as the referent. Comparing confidence intervals, we also found that within the mild disability group, sexual minorities had more lifetime partners than did heterosexuals. There were no such differences for other groups and no significant differences in pre-18 partners by sexual orientation.
Discussion
The purpose of this paper was to understand differences in sexual partnering among populations with physical disabilities in the United States from adolescence to early adulthood, and to examine how these differences further vary by biological sex, race/ethnicity and sexual orientation. Overall, we found no differences in numbers of pre-18 or lifetime sexual partners across disability severity groups. However, our results did indicate important differences by biological sex, race/ethnicity, and sexual orientation, regardless of disability status. This study represents an important contribution to the literature by examining normative partner accumulation patterns of this vulnerable group, which can be used to inform future research, policies, and programs focused on sexual health among populations with physical disabilities.
Our first hypothesis was that individuals with physical disabilities would exhibit fewer pre-18 and lifetime sexual partners compared to those without physical disabilities, but that the degree to which they differed would depend on disability severity. This hypothesis was not supported. We did not find differences in numbers of pre-18 and lifetime sexual partners across disability severity groups in adjusted models. Although not statistically significant, these results do have important implications for sexual health and education. Populations with disabilities were once perceived to be less sexual than peers without disabilities, which has affected the timing and content of their sexuality education.5,6 In contrast, our results and those of past research on the timing of first sex15 indicate more similarities than differences in sexual behavior patterns across disability groups, further suggesting similar sex education needs for students with and without disabilities.
Our second hypothesis was that the relationships between physical disability and sexual partner accumulation would be moderated by biological sex, race/ethnicity, and sexual orientation. This hypothesis was partially supported. Main effect analyses showed that for lifetime partners, females had fewer than males, NH Blacks had more than NH Whites and Hispanics, and sexual minorities had more than did heterosexual peers, all of which is consistent with previous research.10–12 For the pre-18 partner outcome, only females without disabilities had fewer sexual partners before age 18 than did males without disabilities. This may be attributable to the narrower range of values, as most respondents reported four or fewer partners during adolescence.
We did, however, observe several instances of moderation for the lifetime partnering outcome. For biological sex, we found that females at every disability level had significantly fewer sexual partners than did males without disabilities. We also found within disability group differences, such that females with mild disabilities and severe disabilities had fewer lifetime partners than did male peers. These results are very similar to the patterns found in the general population,10 suggesting similar experiences and thus similar sex education needs, regardless of disability status.
Our findings were also consistent with previous research for race/ethnicity.10 Non-Hispanic Blacks without disabilities had significantly more lifetime partners than did NH White and Hispanic peers. We also found that NH Whites with severe disabilities had significantly fewer lifetime partners compared to NH Whites without and with mild disabilities. The fact that we did not observe similar trends for other racial/ethnic groups may reflect no differences in these groups, or may reflect a lack of statistical power due to small cell sizes. Future research should continue to include diverse populations with disabilities to better understand variations in sexual partnering and how these behaviors may have differential effects on later health outcomes.
Findings were also consistent with previous research for sexual orientation.11,12 We found that sexual minorities with mild disabilities and without disabilities both had more lifetime partners than did heterosexuals without disabilities. Within the mild disability group, we also found that sexual minorities exhibited significantly more lifetime partners than heterosexual peers. Such results further stress the importance of providing developmentally appropriate and inclusive sex education,3 as sexual minorities may be at even greater risk for negative health outcomes.
Strengths and limitations
Populations with disabilities have been historically excluded from sexual health research, limiting our ability to understand their experiences and needs.39 A particular strength of these analyses was our ability to study disability using the Add Health study, as these respondents were deliberately oversampled at study entry.30 Therefore, this paper makes a significant contribution to the sexual health literature by providing important information about the sexual behavior of this understudied group at a population level.
Although this dataset represents a unique opportunity to study sexual health among people with disabilities in a large, nationally representative sample, sample size and statistical power are still an important issue. Despite our best efforts to retain as much statistical power as possible by using MICE for missing data, it is still possible that we were unable to detect significant differences in the moderation analyses when the sample sizes for the comparison groups were particularly small. Unfortunately, such power issues are often due to a lack of representation of persons with disabilities from diverse backgrounds in population research. Disability researchers have recommended ways to involve such special populations in survey research, including using in-home surveys and computer assisted technologies.40 Add Health’s sampling design and follow-up procedures represent many of the identified recommendations30,40 and thus is an important strength of this study. However, future research should continue to make concerted efforts to include populations with disabilities to ensure that sexual health policies and programs are inclusive of their experiences.
In addition, we were unable to determine if sexual partners were accumulated before or after disability onset based on the items that are available in the Add Health dataset. Specifically, since Add Health does not ask for age at disability onset, we could not identify whether the disability existed prior to sexual debut. Although we assume that the disabilities predated sexual activity based on the average age of respondents at Wave I and their reported age at first sex, these results, particularly those for pre-18 partner accumulation, should be interpreted with caution.
Finally, we were unable to identify whether all sexual encounters, and thus partners, were consensual due to data limitations. This is important given the documented vulnerability of populations with disabilities to sexual violence and abuse.4 Although we did include experiences of sexual violence as covariates in our models, this represents a limitation of our analyses and a major consideration for future research with this population.
Conclusion
This paper represents an important contribution to the literature by presenting variations in sexual partnering behaviors among members of an understudied and vulnerable population. In particular, we find that the sexual partnering behaviors of populations with and without disabilities are more similar than they are different. Since sexual partnering during adolescence and across the life course has significant implications for later sexual health,1 this study provides valuable evidence for the provision of age- and developmentally-appropriate sex education to populations with physical disabilities.8 Future research should continue to include these and other minority groups to ensure that their experiences are represented in sexual health policies and programs.
Acknowledgements
This research was funded by the Jessie Ball DuPont Dissertation Fellowship for Adolescent Studies and the Royster Society of Fellows at the University of North Carolina.
This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Information on how to obtain the Add Health data files is available on the Add Health website (http://www.cpc.unc.edu/addhealth). No direct support was received from grant P01-HD31921 for this analysis.
We are grateful to the Carolina Population Center for general support (P2C HD050924).
Footnotes
Wave V data are now available, but were not at the time of this writing.
We initially collapsed smaller non-Hispanic (NH) race groups (i.e., NH Asian, NH Native American) into one group to yield a larger sample for analysis. However, estimates were unstable and difficult to interpret given the diversity of this group. We therefore limited our analyses in this paper to Hispanics, NH Blacks and NH Whites.
Based on our hypotheses, the referent group for the interaction models was identified as the “most advantaged” group (e.g., males without disabilities). While we use comparisons of the confidence intervals to evaluate within group differences (e.g., between females with severe and without disabilities), these comparisons were only used to assess general trends and directions of these associations, and do not necessarily indicate statistical significance.
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