Design: Cross-sectional study using a computer-assisted self-administered survey and single-sex focus group discussions designed by a Young Mums’ Group operating on participatory action principles and acting as peer interviewers.
Results: 84/183 participants (45.9%) reported past sexual intercourse, with 56.1% commencing intercourse at age 13–14 years. The likelihood of having had sex increased with being male (P = 0.001), increasing age, increased perceived sexual activity of peer group (both P = 0.000), and drinking alcohol at least weekly (P = 0.015). Young women were more likely to report unwanted sexual touching (P = 0.031), and less likely to report enjoying sexual intercourse (P = 0.001). The main qualitative themes concerned females’ reputations, coercion, and denial of female desire. Only 49/80 participants (61.3%) reported always using condoms. The main reasons for not using contraception were “just not thinking about it”, shame, and problems with access. Despite having reasonable knowledge about contraception, most lacked the confidence and negotiation skills to communicate with partners about condom use.
Conclusions: Like teenagers elsewhere, Indigenous teenagers in Townsville are becoming sexually active at a young age, and not practising safe sex reliably. The need to protect their reputations puts young women at risk by not being prepared for safe sex by carrying condoms.
Adolescence is a time when many young people experiment and start to engage in sexual activity. Individual psychological factors,1,2 peer norms,3 family structure,4 neighbourhood factors,5 poverty, school engagement6 and cultural values about sexuality may all exert powerful influences on a teenager’s decisions (or absence of decisions) about sex.7
The high teenage fertility rate among Indigenous women of 69 per 1000 is more than four times the rate among all Australian teenage women;8 20.2% of pregnant women seen at the Mums and Babies section of Townsville Aboriginal and Islander Health Services are teenagers.9 Indigenous young people are considered a priority group for sexually transmitted infection (STI) strategies10 and teenage pregnancy programs,11 and have lower rates of contraceptive use than non-Indigenous young people.12 Indigenous adolescents deal with youth transitions and sexual maturation in a society that is often hostile,13 facing socioeconomic and educational disadvantage while working through tasks integral to forming their Indigenous cultural identity.14 Relations between males and females, and family and cultural norms for sexual behaviour may be different in Indigenous communities compared with non-Indigenous communities, and a pattern of earlier transitions and parenthood may be encouraged.15
Understanding the attitudes and behaviours of young people concerning relationships, contraception and safe sex, together with broader views about aspirations and parenthood, is integral to understanding factors around teenage pregnancy.
The Townsville region of Queensland has a large Indigenous population of 16 750 (5.2% of the population);16 70% of these are Aboriginal and 30% are Torres Strait Islander people. We aimed to gain a broad, contextual understanding of the attitudes of Indigenous teenagers in Townsville to pregnancy and parenthood, and the relationships between attitudes, behaviours and outcomes. We report data collected from non-pregnant Indigenous teenagers in three high schools and a homeless youth shelter.
We chose a mixed-methods study design with an inductive qualitative approach. Data collection involved a computer-assisted self-interview (CASI) and focus group interviews. The innovative consultative methods of the project are outlined in Box 1. Briefly, a Young Mums’ Group operating on a participatory action model17,18 served to design the project, and act as key participants and peer interviewers, and as a social support group.
Data were obtained between 27 April and 8 December 2004 from CASI surveys and focus group discussions with Indigenous Year 9–11 students at the three public high schools in Townsville with the highest enrolments of Indigenous students (although Year 12 students were included at one school at the request of students, staff and parents), and Indigenous residents of a homeless youth shelter. The laptop-based CASI, originally designed with input from other surveys,19-21 used appealing multimedia technology to ask questions about home, school, general health and substance use, relationships, sex and contraception, and attitudes towards childbearing. Participants completed the CASI in privacy, but with a peer interviewer ready to assist. Focus group discussions, facilitated by an Indigenous and a non-Indigenous researcher, covered similar areas. These were held with a subgroup of survey participants in single-sex friendship groups, chosen according to principles of theoretical sampling.22 Focus group sessions were audiotaped and transcribed in full. Consent was obtained from participants and their parents for high school students, and from participants alone for youth shelter residents.
The project received ethical approval from the James Cook University Human Research Ethics Committee, Education Queensland, and the Townsville Aboriginal and Islander Health Services Board of Directors.
Quantitative data were analysed with univariate descriptive measures and t tests or χ2 tests (with continuity correction) using SPSS version 11.0 for Windows (SPSS Inc, Chicago, Ill, USA). A two-tailed P value of less than 0.05 was considered significant. Qualitative data were managed within NVivo qualitative data analysis software (version 1.0; QSR International, Melbourne, Vic) and analysed thematically using inductive methods based on grounded theory.23 Triangulation, respondent validation and exploration of deviant cases were all used to strengthen our findings.22
Overall, 186 completed CASI surveys were received; 171 from the three high schools and 15 from the homeless youth shelter. There were few missing data for most variables. Uncertainty about the number of eligible Aboriginal or Torres Strait Islander students attending schools made it difficult to accurately calculate response rates. Estimated response rates for each school are listed in Box 2. We compared respondents with non-respondents at each school in terms of Year level and sex, and found no significant differences.
Eleven focus group discussions were held at the three schools; nine had between four and eight participants while two were small groups of two at the request of participants. Fifty-nine students participated in focus group discussions — 41 girls (in 8 groups) and 18 boys (in 3 groups). No focus group discussions were held at the youth shelter for logistical reasons.
One hundred survey participants (53.8%) were female, and 86 (46.2%) were male. The age range was 12–18 years (mean, 14.91 years; SD, 1.13). However, 66.3% were aged 14 or 15 years, reflecting lower Indigenous senior high school retention rates.24,25 Almost 56% of participants were identified as Aboriginal, with smaller groups identified as Torres Strait Islander (17.8%), Aboriginal and Torres Strait Islander (20.0%) and South Sea Islander (3.8%). South Sea Islanders were included at the request of students and parents, and did not differ significantly from other participants in terms of age or ethnicity by sex.
Although few in number, youth shelter participants were significantly younger (P = 0.004), more likely to use marijuana (9/15; P = 0.000) and to be unhappy with their lives (P = 0.000) than school students, and were disengaged from regular formal schooling. Despite their younger age, a larger proportion were sexually active (11/15; P = 0.051), with a tendency to have experienced more unwanted sexual touching (6/14), and fewer had used condoms at first sexual intercourse.
In survey responses, 84/183 participants (45.9%) reported having had sexual intercourse. Most commenced at 13–14 years of age (46/82; 56.1%), although 16 participants commenced at 12 years or younger. There were some differences between males and females in responses to the survey (Box 3). The likelihood of having had sex increased with being male (χ2, 11.667; df = 1; P = 0.001), increasing age (χ2 test for trend, 17.246; df = 2; P = 0.000; Box 4), increasing perceived sexual activity of the peer group (χ2 test for trend, 40.769; df = 2; P = 0.000), and drinking alcohol at least weekly (χ2, 5.865; df = 1; P = 0.015). A younger age of sexual initiation was associated with idealisation of parenthood (P = 0.003), while a later age at sexual initiation was associated with personal plans and reported parental expectation for tertiary education (P = 0.03 and 0.016, respectively).
Sixty-one of 83 participants (73.5%) reported having used a condom for their first sexual experience. For most (55/83; 66.3%), the first sexual experience was wanted, and most of the remainder “didn’t mind”, but for three young women (3.6%), it was unwanted. Thirty participants (36.1%) said their first sexual experience involved alcohol or drugs, and for 8/81 (9.9%), their first sexual partner was more than 5 years older than they were. Most respondents reported four or fewer sexual partners, but 17.1% (14/82; 11 male) had more than 12.
In the focus groups, sex was perceived as having a different role in relationships and different consequences for young women and young men (main themes summarised in Box 5). Older students were better able to resist coercion and negotiate the onset of a sexual relationship and the use of contraception. Some young people, especially the older ones, resisted the stereotypes about young women and desire, and the demonising of young men as sexual predators.
A lot of people make out as if girls never want sex, or whatever, it’s just the guys that always want sex, whereas most girls do, it’s just . . . A lot of people make out as if the guys are always the bad ones and stuff. They are in a way, because they’re boys . . . but a lot of chicks are, like, wanting it . . . (School 3, focus group 10 with 6 girls)
In survey responses, 73 sexually active participants reported on use of hormonal contraceptives, with 19 (26.0%) always using them and 32 (43.8%) never using them. Forty-nine of 80 respondents (61.3%) always used condoms when having sex, while three never did. Seven of the 84 sexually active participants reported only using unreliable methods such as withdrawal. Most participants obtained advice about contraception from family and friends. The most common reported reason for not using contraception was “I don’t think about it” (37/84 participants), although other reasons included “I don’t think she/I will get pregnant” (15), “having sex was unexpected” (19), and “I’m gay/lesbian” (10/84 participants; 11.9%; eight male; six of these always used condoms). Despite inconsistent condom use, only three participants (two female; two from the youth shelter) reported having had an STI. In comparison, 67.9% of female participants said that at least one of their friends had been pregnant, four girls had been pregnant themselves, and five boys reported impregnating a partner.
In the focus groups, discussions reflected inconsistent contraceptive use. Students expressed some understanding about safe sexual practices, but, in practice, did not use them, especially in the context of alcohol use at parties. Barriers to contraceptive use are summarised in Box 6. Older girls often felt able to insist on condom use, but, in practice, often did not.
I’ve been in the situation before where I’ve been under the influence of alcohol, and met up with a guy or whatever, but there has been no condom around, so, I have had unprotected sex before, I’ll admit . . . You get really worried after it, because, like, I was drunk at the time, I didn’t know what had happened or whatever . . . (School 3, focus group 10 with 6 girls)
For both boys and girls, avoiding pregnancy was a more salient reason for using a condom than fear of STIs, and this was related to the higher reported prevalence of pregnancies compared with known STIs in their peer groups. For girls, carrying condoms implied premeditation of sex, and thus rendered them “sluts”, so it was better for sex to “just happen” in the absence of protection. Thus they preferred risking their health to protect their reputations.
School-based sex education gave some students reasonable information about the mechanics of sexual relationships, but many students missed this education altogether because of “shame” (embarrassment from talking about sensitive issues or being singled out), timetabling issues or absenteeism. Many students’ main sources of information were friends and magazines, and their knowledge about STIs was incomplete. Some families were good sources of information, but in others, issues to do with sex were not discussed.
Interviewer: So it sounds like it [sex education] might have been a bit hit and miss, some got it and some didn’t . . . [Participants: yeah] . . . What about talking with family about things like that?
Participants: Ah, shame . . . my mum talks with us about it . . . gross, nah . . . I didn’t even talk to mum when I went to get the pill, I took my auntie and told her to never tell mum . . . (School 3, focus group 9 with 8 girls)
We present a “snapshot” of the attitudes and behaviours of young Indigenous people in Townsville concerning relationships, sex and contraceptive use, providing a contextual understanding of the transition to sexual adulthood for this population.
The 46% of our sample reporting sexual intercourse and inconsistent condom use is comparable to studies involving other groups of Australian young people.26-28 For example, a national survey of 2388 students found that 25% reported having had sexual intercourse by Year 10, and just over half by Year 12.26 Less information is available about the sexual behaviour of Indigenous young people. The large Western Australian Aboriginal Child Health Survey found that 74.5% of Aboriginal 17-year-olds reported having had sexual intercourse, and for 48.6% this occurred before the age of 16 years. Independent associations with having had sex were age, having left school, drinking alcohol and using marijuana.12 The slightly lower rates of sexual activity we found probably reflect our largely school-based, urban sample.
Young women were mostly concerned by unwanted pregnancy and damage to their reputations as consequences of sexual activity. The low salience of the risk of STIs for participants may represent underdiagnosis, or may be an accurate representation of prevalence in this population,29 but both this and the relatively large proportion of Indigenous adolescents reporting a gay or lesbian orientation warrant further exploration.
Young people’s knowledge about safe sex and birth control was variable, and 60% of sexually active participants reported always using condoms. The limiting factor in condom use seemed to be shame, in terms of bringing up the issue and negotiating condom use at the onset of a sexual relationship. That young womens’ reputations were at risk if they carried a condom or suggested its use encouraged sexual risk behaviour. This finding has been previously reported30,31 and poses challenges for sex education.
A strength of our project was that it was designed by a group of young Indigenous people within an Aboriginal medical service, ensuring that it was relevant to young peoples’ needs and well accepted by the community. Information was gathered through innovative, youth-friendly methods with peer interviewers. A disadvantage was that, like all cross-sectional descriptive studies, we report self-reported rather than actual behaviours of young people. We were also not able to measure changes in their self-reported behaviour over time. High student absenteeism meant that our response rates may be underestimates. This sample is not representative, and our findings are not generalisable, but our study does offer a unique insight into the attitudes and behaviours of a group of understudied regional Indigenous teenagers, and is likely to be relevant in work with similar groups elsewhere.
Indigenous teenagers, like other teenagers, are experimenting with sex, but not practising safe sex reliably. They need access to comprehensive information about sex, relationships, contraception and infections in a safe, shame-free environment.11,15
Poverty, family dysfunction and educational disadvantage for young Indigenous people may combine to make the consequences of early sexual initiation or pregnancy less cogent, especially for those disengaged from schooling. We cannot assume that early parenthood is “natural” for Indigenous young people, and they must have access to the same opportunities and reproductive rights as other young Australians.15
Targeted school-based programs in small, single-sex groups might be a good way to reach Indigenous students, but alternative approaches must be found to reach those who have disengaged from the education system. Programs must focus broadly on communication, relations between males and females, and healthy sexual relationships, in addition to diseases and pregnancy, to help young Indigenous people create more egalitarian and thus safer sexual relationships.
1 “U Mob Yarn Up*” project structure
2 Estimated survey response rates
3 Differences between males and females in self-reported sexual behaviour and attitudes
4 Respondents reporting sexual intercourse by age and sex
5 Main themes from focus groups about sexual relationships
Mostly the logical next step in ongoing relationships, but frequent casual encounters in some groups, often related to alcohol use
Participant 1: It’s like when you have sex, it’s not like you’re just looking for something to do . . .
Participant 2: The girls will more likely want to get to know them, like, first . . .
Participant 1: But the boys just like to have sex, cos it’s just the thing you do . . . (School 1, focus group 2 with 6 girls)
Participant 1: Pregnancy, illnesses, AIDS, name calls, reputation . . .
Participant 2: Yeah, see there’s a whole heap of them negatives, but there’s not much positives . . . (School 2, focus group 7 with 4 girls)
Boys listed the advantages of pleasure and the build-up of trust in relationships, and few disadvantages, but girls were not able to talk about desire
Boys gained positive reputations, especially among male peers, while girls were “dissed” (disrespected) and labelled as promiscuous by boys and other girls
. . . It’s different for the boys, cos they get called a stud, and all the boys praise up to them cos they slept with all these girls, but if it’s a girl they get called a slut or a ‘ho [whore] . . . (School 2, focus group 7 with 4 girls)
Interviewer: So are the boys prepared to wait, even if they want it more?
Participant 1: Only if they like you enough . . .
Participant 2: Like, if they’re going to hook you up for a one-night stand then, yeah, they’re going to put it on you . . . (School 1, focus group 2 with 6 girls)
6 Barriers to contraceptive use from focus group discussions
Limited skills for negotiating condom use, and embarrassed by discussions about sexual relationships (including standard school sex education)
. . . cos if you started talking before, and then you started doing anything it’s, like, just be embarrassing . . . it’s better just to go on . . . cos then you don’t have to, like, talk about it . . . (School 3, focus group 9 with 8 girls)
Guys think it’s the girl’s choice . . . but within truth, we sometimes sleep without a franger, cos you find more girls want guys to use them, but then you find girls that are too scared to confront guys to use it . . . then you find the guys that don’t want to use it because they feel comfortable without using it . . . (School 2, focus group 7 with 4 girls)