This document summarizes two studies on heterosexual anal intercourse among urban female adolescents. The first study found that over 1/3 of participants reported engaging in anal intercourse, with little condom use. Those who engaged in anal intercourse were less likely to use condoms during vaginal sex. The second study found a quadratic relationship between relationship power and anal intercourse, with those having low or high power more likely to engage in it. Education is needed to increase awareness of risk associated with anal intercourse.

1. Heterosexual Anal Intercourse
Among Urban Female Adolescents:
Prevalence and Associated Factors
Carol F. Roye, EdD, CPNP
Beatrice J. Krauss, PhD
Paula Perlmutter Silverman, MPH
Hunter College

2. Background
 Heterosexual contact is
the primary mode of
HIV transmission in
women.
 But it’s not just who one’s
sexual partner is
 It is also what behaviors
one is engaging in

3. The risks vary
 Vaginal Intercourse
 Oral Intercourse
 Anal Intercourse

4. Anal Intercourse
Background Information
 Anal intercourse confers a very high risk
of HIV transmission.
 Researchers estimate that the probability of
HIV transmission from receptive anal sex
is between 5 to 10 times higher than for
receptive vaginal intercourse.

5. Anal Intercourse
 The unique morphology of the large intestine is
one reason for this.
 The intestinal mucosa contains most of the
body's lymphocyte population and therefore
likely represents the largest reservoir of human
immunodeficiency virus type 1 (HIV-1) and site
of viral replication

6. Risks Associated with
Anal Intercourse
 Researchers inundated punch biopsies of healthy
vaginal and cervical tissue with HIV for 6-24
hours. During that time, the virus was unable
to infect intact, healthy tissue.
 Conversely, when healthy intestinal tissue was
subjected to the same treatment, it was rapidly
infected (Greenhead P, Hayes P, Watts PS, Laing KG, Griffin GE,
Shattock RJ. Parameters of Human Immunofdeficiency Virus infection of
human cervical tissue and inhibition by vaginal virucides. J Virol
2000;74:5577-5586.)

7. My Concern
Are teens who use hormonal
contraceptives at elevated risk for
HIV because they are less likely to
use condoms??

8. Background
 A study of 600 Black and Hispanic teenage girls
in New York City found that those who used
hormonal contraceptives were significantly less
likely to use condoms than those who used
condoms only, even though they all identified
AIDS risk as an important concern in their
choice of contraceptive method.
(Roye, 1998)

9. Background
 Qualitative studies were then done to
understand the context of condom use and
nonuse.

10. “The last time you had vaginal intercourse, and did not use a
condom, what were the reasons you did not use a condom?”
 The NUMBER 1 REASON FOR NOT USING
CONDOMS:
They were using other protection - OCs or
Depo - to protect them from pregnancy
“Cause I was on the pill and can’t get pregnant.”

11. “The last time you had vaginal intercourse, and did not use a
condom, what were the reasons you did not use a condom?”
 Monogamy is another reason that teens do not
use condoms
 Even though many questioned their partners'
fidelity, and many engage in serial monogamy.
 “Because I feel that I can trust my partner, or at least I
hope I can.”

12. We asked teens how we can help
other teens use condoms
Personalizing the message.
“I am going to say it but there are a lot of
teenagers that have AIDS. And, if they come
out on TV and do like little conventions and
stuff like that, [teens] can see that it can happen
to teenagers also. Suppose it being someone
my age, it would scare me. . . . It would make
me think and I would use condoms.”

13. Therefore
 A video tailored to
this population
makes a lot of
sense.

14. And
 We implemented a
brief counseling
protocol as well,
which was an
adaptation of the
CDC’s Project
RESPECT.

15. Purpose
 To develop and test  Specifically,
brief interventions to interventions which
promote condom use are low- or no-cost,
in this vulnerable and can be
population. implemented in any
clinical setting.

16. Intervention
 Randomized Clinical Trial of:
1. Brief interactive patient counseling
2. Video education
3. Video and then brief patient counseling
4. Usual care
See: Roye, C., Silverman, P., & Krauss, B. (2007). A brief, low-
cost, theory-based intervention to promote dual method use by
Black and Latina female adolescents: A randomized clinical trial.
Health Education and Behavior, 34, 608-621.

17.  Teens who saw the video and then got
counseling were significantly more likely to use a
condom at last intercourse with main partner.

18. Sites
 Planned
Parenthood in the
Bronx and
Brooklyn

19. Data Collection
 Data were collected at baseline and 3
month and 1-year follow-up
 Eligibility criteria included: Black or
Latina females, aged 15-21, who had
engaged in vaginal intercourse, and
who use or were starting use of a
hormonal contraceptive.

20. Data
 Data include:
 ACASI computer-based questionnaire
with detailed questions about sexual
behaviors including oral, anal and vaginal
intercourse

21. Results
 N = 326
 Age
 range 15 - 21
 mean age is 18.15
 Ethnicity
 50% Black/African American
 44% Latina
 6% Both

22. Sexual Behaviors
Vaginal Intercourse
 Age at first vaginal
intercourse
 Range 12-21
 Mean = 15.3
 47% reported
condom use for last
vaginal sex with
main partner

23. Sexual Behaviors
Oral Sex
 78 % of the sample had performed oral sex on a
partner
 90% had had oral sex performed on them
 Age at first oral sex ranged from 11-21years

24. Anal Intercourse In Our Sample
 More than 1/3 (41%) of the teens had
engaged in anal intercourse.
 Significantly more Latina than Black teens
had had anal intercourse (Z=3.59 [p<.001).
 The reported age at first anal intercourse
ranged from 12 – 21 years, with a mean of
16.8.

25. Anal Intercourse In Our Sample
 Only 30% of those who reported anal
intercourse reported using a condom during
their last anal intercourse.
 Young women who had ever had anal
intercourse were significantly less likely than
other teens to use condoms during vaginal
intercourse.

26. Condom Use
 Of the young women
who had engaged in
anal intercourse, 36%
reported condom use
at last vaginal
intercourse with their
main partner, and 30%
reported condom use
at anal intercourse.

27. SURPRISING!
 Heterosexual anal intercourse has
traditionally been looked on either:
 As a way to protect vaginal virginity
OR
 As a form of birth control

28. HOWEVER
 The young women in our sample had
all lost their vaginal virginity
AND
 Were using a hormonal method of
contraception

29. Additional correlates of AI
 High-risk sexual history
 younger at first vaginal intercourse
 more likely to have had an STI
 more likely to have been abused by a
partner or by someone close to them.

30. Data by Age
 Significant correlation between older age and
history of AI (r=.336, p=.001).
 However, there was no correlation between age and
having had AI in the last 2 months .
 May be explained by the fact that older teens may
have been sexually active for a longer period of time

31. Why do young women engage in AI?
 We need research to gain an
understanding of the context of
heterosexual anal intercourse.

32. Sexual Relationship Power
 Recently, research has highlighted the
importance of the construct of “sexual
relationship power” (SRP) for understanding
heterosexual relationships and behaviors

33.  Women with low SRP believe that their sexual
partner is dominant (has power over them) and
have little input into sexual decision-making
 Women with high SRP have significantly more
input into their sexual behaviors.

34.  We wanted to understand whether SRP plays a
role in teens’ decisions to engage in AI
 Hypothesized that teens with more SRP would
have less AI
 Literature shows that teens with greater SRP are
more likely to use condoms during vaginal
intercourse.

35. Second Study
 A subsequent study was conducted on a
different sample of young women
 Same criteria as first study except:
 1) use of a hormonal method was not an eligibility
criterion
 2) the questionnaire was supplemented with the
Sexual Relationship Power Scale (Pulerwitz).

36. Sample
 N = 101
 Aged 14 – 22 (mean = 17.4)
 30% of the sample self-identified as Black or
African American
 70% identified as Latina.

37. Results
 23 young women had engaged in AI
 2 Blacks, and 21 Latinas, a difference which was
significant (p=.009).

38.  None of the young women reported
using a condom during anal
intercourse with their main partner!
 43% reported using a condom at last vaginal
intercourse with their main partner.

39. Why??
 Perhaps condom use in general was primarily for
disease, rather than for pregnancy prevention.
 Young women may not recognize that AI presents a
risk for HIV and other STIs.
 We have data suggesting that teens are not
aware of the risk, and may even think that
AI is less risky than vaginal intercourse.
 One study found that 1/5 of college students
don’t consider AI to be sex at all!

40. Was there a correlation between AI
and SRP Score?
 There was no significant linear correlation
between SRP score and AI

41. SRP and Anal Intercourse
 But there was a significant quadratic relationship
between AI and SRP (R square = .122; p = .003)

42.  Relationship power scores
were divided into tertiles
(low, medium and high).
 Chi-square revealed that 54%
of the women with low
relationship power scores
(RPS) had engaged in AI, as
had 24% of those with high
RPS.
 Only 4% of those with mid-
level scores had had AI.

43. Data by Ethnicity
 78% of Latinas with low scores had had AI
 33% of those with high scores had had AI.
 Only one young woman in the middle had had
AI (chi square = 13.955; p = .001).
 Chi-squares could not be run on Black teens
because there were too few who had engaged in
AI.

44. SRP and Condom Use for
Vaginal Intercourse
 There was a significant linear relationship
between SRP and condom use during vaginal
intercourse in the expected direction.

45.  Why did SRP operate in the expected direction
for condom use during vaginal intercourse, but
an unexpected quadratic relationship was found
between SRP and anal intercourse??

46.  The researchers hypothesize that young women
with low SRP scores may be exploited by their
partners perhaps explaining why they engage in
AI.
 Teens with high scores may be in more loving
relationships and thus willing to engage in this
behavior to please their partners.
 And/or more interested in engaging in sexual
exploration.

47.  Perhaps teens have been taught that they should
use condoms during vaginal intercourse
 Without having been taught about condom use
for AI, they may not realize that it is necessary.
 Or………………

48. Limitations
 Self-report data
 Sample limited to sexually active Black and
Latina teenage girls
 No data on partner age

49.  Research is needed to contextualize heterosexual
adolescent AI, in order to develop effective
HIV/AIDS prevention programs that address
this high risk behavior

50.  More women engage in receptive
AI than men
 We must educate them about risk
reduction for AI

51. Funded by
 Study 1
 NINR 5RO1NR007962-03
 Study 2
 American Nurses Foundation

52. THANK YOU
croye@hunter.cuny.edu
www.carolroye.org
Please email me if you
would like a copy of our
DVD