Premarital Sexual Intercourse Among Adolescents in

an Asian Country: Multilevel Ecological Factors

WHAT’S KNOWN ON THIS SUBJECT: Sexual initiation among
adolescents is associated with divorced parents; less education;
low income; dropping out of school; permissive attitudes; lack of
confidence to avoid sex; peer pressure; drinking; drug use; previous
sexual abuse; and exposure to sexual content of media.
WHAT THIS STUDY ADDS: The strongest factor associated with
sexual initiation was pornography viewing for boys but previous
sexual abuse for girls. Sexual initiation was not associated with
factual AIDS-related information, but viewing of HIV/AIDS/STI-infected
persons in the media showed a strong protective association.
CONTRIBUTORS: Mee-Lian Wong, MBBS, MPH, MD,a Roy Kum-Wah
Chan, MBBS, MRCP, FRCP,a,b David Koh, MBBS, MSc, PhD,a Hiok-
Hee Tan, MBBS, MRCP, FRCP,b Fong-Seng Lim, MBBS, MMed,c
Shanta Emmanuel, MBBS, MPH,d and George Bishop, MS, PhDe
aDepartment of Epidemiology and Public Health, Yong Loo Lin
School of Medicine and eDepartment of Psychology, Faculty of
Arts and Social Sciences, National University of Singapore,
Singapore; bDepartment of Sexually Transmitted Infection
Control, National Skin Centre, Ministry of Health, Singapore;
cNational Health Group Polyclinics, Singapore; dResearch and
Epidemiology Department, Singapore General Hospital,
Singapore
KEY WORDS
premarital sexual intercourse, adolescents, pornography, sexual
abuse, media
ABBREVIATIONS

abstract STI—sexually transmitted infection

OBJECTIVE: The goal was to assess personal and environmental fac-
tors associated with premarital sex among adolescents.
METHODS: We conducted a case-control study. Between 2006 and 2008,
we recruited 500 adolescents who reported having engaged in volun-
tary sex for most recent sex. Five hundred control subjects were
matched for age, gender, and ethnicity.
RESULTS: Independently significant factors for premarital sex among
boys were pornography viewing (adjusted odds ratio [OR]: 5.82 [95%
CI— confidence interval
OR— odds ratio
www.pediatrics.org/cgi/doi/10.1542/peds.2008-2954
doi:10.1542/peds.2008-2954
Accepted for publication Mar 6, 2009
Address correspondence to Mee-Lian Wong, MBBS, MPH, MD,
Department of Epidemiology and Public Health (MD 3), Yong Loo
Lin School of Medicine, National University of Singapore, 16
Medical Dr, Singapore 117597. E-mail: ephwml@nus.edu.sg
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

confidence interval [CI]: 2.34 –14.43]), lack of confidence to resist peer Copyright © 2009 by the American Academy of Pediatrics

pressure (OR: 3.84 [95% CI: 2.27– 6.50]), perception that more than one FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
half of their friends had engaged in sex (OR: 3.37 [95% CI: 1.92–5.92]),
permissiveness regarding premarital sex (OR: 3.41 [95% CI:
2.10 –5.55]), involvement in gang activities (OR: 3.45 [95% CI: 1.66 –
7.15]), drinking (OR: 1.77 [95% CI: 1.07–2.94]), smoking (OR: 1.91 [95%
CI: 1.14 –3.20]), and living in low-cost housing (OR: 3.25 [95% CI: 1.64 –
6.43]). For girls, additional factors were previous sexual abuse (OR:
7.81 [95% CI: 2.50 –24.41]) and dropping out of school (OR: 2.72 [95% CI:
1.32–5.61]), and stronger associations were found for lack of confi-
dence to resist peer pressure (OR: 5.56 [95% CI: 2.94 –10.53]) and per-
missiveness regarding premarital sex (OR: 6.25 [95% CI: 3.30 –11.83]).
Exposure to persons with HIV/AIDS or sexually transmitted infections in
the media was negatively associated with sex for boys (OR: 0.27 [95% CI:
0.16 – 0.45]) and girls (OR: 0.24 [95% CI: 0.13– 0.47]).
CONCLUSION: Sex education programs for adolescents must address
social, media, and pornographic influences and incorporate skills to
negotiate sexual abstinence. Pediatrics 2009;124:e44–e52

e44 WONG et al
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Approximately one half of new HIV in-
fections and one third of new sexually
transmitted infections (STIs) world-
wide occur among youths 15 to 24
years of age.1 Although programs ad-
vocating sexual abstinence only
among adolescents found no evidence
of impact,2–4 programs promoting sex-
ual abstinence as the best means of
preventing HIV but also encouraging
condom use and partner reduction
generally were found to reduce sexual
initiation and unprotected sex among
youths in high-income5 and develop-
ing6 countries.
Presently, adolescents have easy ac-
cess not only to sexual content in mov-
ies, television, and music videos but
also to Internet-based pornography.
Longitudinal studies among US adoles-
cents found that exposure to sexual
content in television7 and degrading
music lyrics8 predicted sexual initia-
tion. In another longitudinal survey,
Brown et al9 combined sexual content
across television, movies, music, and
magazines and found it to be associ-
ated with sexual initiation among
white but not black adolescents. Signif-
icantly associated factors among the
latter were parental disapproval of
teen sex and permissive peer sexual
normative behavior. Few studies10–12
have assessed the risk of pornogra-
phy, particularly Internet-based por-
nography, on teens’ sexual initiation.
Therefore, we aimed to determine the
extent to which pornography, media,
and other parental, school, peer, and
personal factors are associated with
sexual initiation among adolescents.
METHODS
We conducted a case-control study,
comparing characteristics of sexually
active adolescents (case subjects) at-
tending the only public Department of
STI Control clinic in Singapore for
screening or treatment of STIs with
those of non–sexually active adoles-
PEDIATRICS Volume 124, Number 1, July 2009
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FIGURE 1
Selection of case subjects and control subjects.
cents (control subjects) attending a
primary care clinic. Approximately
80% of adolescents with notified STIs
attend this public clinic in Singapore.
Singapore has a small population of
3.6 million citizens, with the majority
(75.2%) being Chinese, 13.6% Malay-
sian, and 8.8% Indian.13
Case subjects were local, never-mar-
ried, new clinic attendees 14 to 19
years of age who responded yes to the
following question: “Did you have sex
voluntarily for most recent sex? Sex in-
cludes any of these: penis entering the
vagina; another person’s mouth touch-
ing your genitals or your mouth touch-
ing another person’s genitals; or an-
other person’s penis entering your
anus or your penis entering another
person’s anus.” We excluded subjects
who reported forced sex and those
who were ⬍14 years of age, because
sex among the latter was considered
statutory rape.
Control subjects were same-aged ado-
lescents who had never engaged in
sexual intercourse. Because it is unac-
ceptable in Singapore’s conservative
society to ask adolescents about sex,
ARTICLES
we asked the following questions as
nonsensitive proxy indicators of sexual
intercourse: “Have you ever gone out
alone with a boyfriend/girlfriend/
other person for some romance or on
a date? Have you had close physical
contact such as kissing and fondling,
beyond just holding hands with him/
her?” Adolescents who responded no
to one or both of the aforementioned
questions were considered non–sexu-
ally active.
Between August 2006 and April 2008,
we recruited 544 case subjects, of
whom 91.9% (n ⫽ 500) responded
(Fig 1). Nonrespondents were younger
(14 –16-year-old subjects: 56.8% among
nonrespondents vs 13.8% among re-
spondents; P ⬍ .001). Five hundred
control subjects, matched according
to age, gender, and ethnicity (response
rate: 97.8%), were selected randomly
from a public primary health care
clinic with comparable ethnic distribu-
tion, located ⬃20 km from the Depart-
ment of STI Control clinic.
This study was approved by the institu-
tional review board of the National Uni-
versity of Singapore. We conducted
e45
face-to-face interviews, with self-ad-
ministered questions on sensitive data
placed at the end. Before the interview
began, adolescents signed the consent
form (age of consent: ⱖ16 years) after
receiving an explanation of the study
and the patient information sheet. For
subjects who were ⬍16 years of age,
accompanying parents, guardians, or
juvenile home officers signed the con-
sent form and the adolescents signed
the assent form. Only 3 subjects ⬍16
years of age were unaccompanied; be-
cause they could understand the na-
ture of the study and treatment, we fol-
lowed the Fraser guidelines and took
informed consent from them. Free lab-
oratory tests (worth $50) were offered
as incentives.
We adapted the multilevel ecological
model14 to assess the following factors
potentially associated with premarital
sexual intercourse: sociodemographic
variables for parents; family influ-
ences, including parental relation-
ships, parenting styles,15 and parent-
TABLE 1 Measures of Personality, Peer Connectedness, and Parenting Styles
Variables
Peer connectednessa
Authoritative Parenting Index (how do
you feel about your mother or
main caregiver?)a
a There were 4 responses, as follows: 1 ⫽ not like me, 2 ⫽ sort of like me, 3 ⫽ a lot like me, 4 ⫽ Just like me.
e46 WONG et al
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child communication regarding sex;
peer influences, including peer norms
and peer connectedness16; school in-
fluences, including self-reported
school performance, participation in
extracurricular activities, and holding
of leadership positions; influences of
media; and personal factors such as
previous sexual abuse, smoking, drink-
ing, drug abuse, gang activities, knowl-
edge about HIV/AIDS/STIs, permissive
attitudes toward sex, and confidence
in resisting peer pressure to engage in
sex. Table 1 lists the composite item
measures for assessment of peer con-
nectedness and authoritative parent-
ing style, with their reliability indices
(Cronbach ␣ values).
To develop measures of sexual content
in the mass media, we considered the
local context, policy implications, and
“legality” of the sexual content/materi-
als and the availability of harmful and
educational messages on sex for ado-
lescents. We classified the sexual con-
tent of media into 3 categories,
No. of Items Sample Question and Source
6 I get along very well with my peers/
friends.
I hang out a lot with my peers/friends.
I tend to follow what my peers/friends
do, even if other people disapprove
of it.
My peers’/friends’ opinion of me is
very important.
I enjoy spending time with my peers/
friends.
I am accepted by my peers/friends.
8 She/he makes me feel better when I
am upset.
She/he listens to what I have to say.
She/he wants to hear about my
problems.
She/he is too busy to talk to me
(reverse coding).
She/he has rules that I must follow.
She/he asks me what I do with
friends.
She/he knows where I am after
school.
She/he tells me times when I must
come home.
namely, public-access/free-to-air me-
dia approved by the local media au-
thority, “illegal” media, and educa-
tional media. Questions in the first
category assessed the frequency of ex-
posure (on a 4-point scale, ranging
from hardly to almost every time) to
talk about sex or portrayal of behavior
suggesting sexual intercourse from
public-access television, movies, mag-
azines, books, and popular music. An
example of a question is as follows:
“Based on the movies you have
watched, how often do you (1) hear
people talking about having sex and (2)
see people who are kissing passion-
ately, touching intimately, or undress-
ing themselves or see a couple half-
naked?”
Illegal media are pornographic materi-
als depicting explicit sexual inter-
course. These are banned, and use
was measured with 2 questions, as fol-
lows. “How often do you read or watch
pornography (⬘blue’ films, porn, or
movies, videos, or magazines that
show naked people having sex)? Where
do you mainly watch them (Internet,
magazines or comics, video CDs/DVDs/
Cronbach’s ␣ videos, mobile telephone, or other
sources)?”
.72
Questions on educational media per-
tained to attendance at talks on STIs or
exposure to media portraying persons
with STIs/HIV/AIDS or dying as a result
of AIDS. An example was a yes/no re-
sponse to the statement, “I have
watched television programs, movies,
or videos on people infected with sex-
ually transmitted diseases.”
.70
History of sexual abuse was defined as
a yes response to the question, “Did
anyone abuse you sexually (had sexual
contact with you or made you do sex-
ual things to them that you did not
want to) before your first voluntary
sex?” A school dropout was defined as
having dropped out before completing
secondary school (equivalent to 10
years of schooling).
 ARTICLES

TABLE 2 Sociodemographic, Personal, Parental, Peer, School, and Media Characteristics of Case and Control Male Adolescents in 2006 –2008
n (%) or Median (Range) Crude OR (95% CI) P
Case Control
(N ⫽ 264) (N ⫽ 264)
Sociodemographic features
Low-cost housing (1–3-room apartments), n (%) 73 (27.7) 25 (9.5) 3.65 (2.23–5.98) ⬍.001
Dropped out of school, n (%) 102 (38.8) 48 (18.2) 2.85 (1.91–4.25) ⬍.001
Parents divorced, n (%) 53 (20.1) 16 (6.1) 3.89 (2.16–7.01) ⬍.001
Personal factors
History of sexual abuse, n (%) 11 (4.2) 5 (1.9) 2.25 (0.77–6.57) .128
Other risk behaviors, n (%)
Smoking 150 (56.8) 66 (25.0) 3.95 (2.73–5.72) ⬍.001
Alcohol use 207 (78.4) 131 (49.6) 3.69 (2.52–5.39) ⬍.001
Drug abuse 48 (18.2) 14 (5.3) 3.97 (2.13–7.40) ⬍.001
Involved in gang activities 83 (31.6) 22 (8.3) 5.07 (3.05–8.43) ⬍.001
Knowledge, attitudes, and skills, n (%)
AIDS is curable 16 (6.1) 18 (6.8) 0.88 (0.44–1.77) .720
I can tell that a person has AIDS/HIV just by looking at him 64 (24.2) 51 (19.3) 1.34 (0.88–2.03) .206
One can have sex before marriage 172 (65.4) 75 (28.4) 4.76 (3.29–6.89) ⬍.001
Not confident in resisting peer pressure to engage in sex 221 (83.7) 131 (49.6) 5.22 (3.48–7.83) ⬍.001
Parental relationships
Not having mother as confidant, n (%) 236 (85.6) 210 (79.5) 1.53 (0.97–2.41) .067
Parent never discussed STIs or consequences of sex, n (%) 153 (58.0) 150 (57.0) 1.05 (0.74–1.48) .86
Authoritative Parenting Index score (parent or guardian), median 36 (16–54) 38 (17–54) .100
(range)
Peer characteristics
Peer connectedness score, median (range) 17 (7–24) 17 (6–24) .984
Perceived that one half or more of friends already had sex, n (%) 121 (45.8) 35 (13.3) 5.54 (3.60–8.51) ⬍.001
School environment/characteristics
Self-reported below average grades, n (%) 48 (18.2) 36 (13.6) 1.41 (0.88–2.25) .153
Have not represented school in sports/competitions or held 170 (64.4) 140 (53.0) 1.60 (1.13–2.27) ⬍.01
leadership positions in school, n (%)
Media exposure/characteristics
Have read or watched television/movies/videos about persons with 43 (16.3) 122 (46.2) 0.23 (0.15–0.34) ⬍.001
STIs/HIV/AIDS, n (%)
Heard or seen quite often/almost always talk about having sex or 112 (42.4) 123 (46.6) 0.85 (0.59–1.19) .335
portrayal of behavior suggesting sexual intercourse (eg,
kissing, touching, or half-naked couple) in public-access
television, video movies, or music, n (%)
Sexual media scorea
Median 7 7 .861
Low (1–4), n (%) 25 (9.5) 26 (9.8)
Medium (5–8), n (%) 198 (75.0) 190 (72.0)
High (9–12), n (%) 41 (15.5) 48 (18.2) .692
Ever read or watched pornography, n (%) 251 (95.1) 209 (79.2) 5.08 (2.70–9.56) ⬍.001
a Sum of frequency scores (scores of 1– 4) from the following 3 questions on exposure to public-access media depicting talk on sex or portrayal of behavior suggesting sexual intercourse.

(1) Based on television programs and movies you have watched, how often do you hear people talking about having sex (1 ⫽ hardly, 2 ⫽ once in a while, 3 ⫽ quite often, 4 ⫽ almost always)?
(2) Based on television programs and movies you have watched, how often do you see people kissing, touching, or undressing themselves? (3) Based on popular songs you have listened to,
how often do you hear people talking about having sex?

To identify independent factors signifi-
cantly associated with sexual inter-
course, we used unconditional binary
logistic regression analysis to esti-
mate the adjusted odds ratio (OR) and
95% confidence interval (CI). Although
individual matching was used in this
case-control study, we used uncondi-
tional logistic regression analysis (the
approach for unmatched analysis) be-
cause the analysis had already been
stratified according to the matching
factor of gender, and age and ethnicity
were not found to confound the rela-
tionship between the factors studied
and sexual initiation.
Independent variables with a statisti-
cal significance of ⱕ.1 in univariate
analyses were entered simultaneously
into the logistic regression model with
sexual intercourse (yes/no) as the de-
pendent variable. Variables were then
removed from the equation one at a
time, by using stepwise backward
elimination, until removal did not lead
to a significant decrease in the
strength of the equation. Pearson cor-
relation coefficients were ⬍0.30 for all
bivariate relationships tested for the

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TABLE 3 Sociodemographic, Personal, Parental, Peer, School, and Media Characteristics of Case variables dichotomized as yes or no.
and Control Female Adolescents in 2006 –2008
The significance level was set at P ⬍
n (%) or Median Crude OR (95% CI) P
(Range)
.05. All data analyses were performed
with SPSS 16.0 (SPSS, Chicago, IL).
Case Control
(N ⫽ 236) (N ⫽ 236)
Sociodemographic features
RESULTS
Low-cost housing (1–3-room apartments), n (%) 62 (26.3) 14 (5.9) 5.65 (3.06–10.43) ⬍.001 Of the 500 sexually active teens (52.8%
Dropped out of school, n (%) 105 (44.5) 30 (12.7) 5.50 (3.47–8.73) ⬍.001
Parents divorced, n (%) 51 (21.6) 15 (6.4) 4.06 (2.21–7.46) ⬍.001
boys and 47.2% girls), almost all were
Personal factors heterosexual, with 16 (3.2%) being ho-
History of sexual abuse, n (%) 53 (22.5) 7 (3.0) 9.48 (4.21–21.34) ⬍.001 mosexual (boys: 5.3%; girls: 0.8%) and
Other risk behaviors, n (%)
Smoking 94 (39.8) 26 (11.0) 5.35 (3.30–8.67) ⬍.001
7% bisexual (boys: 6.4%; girls: 7.6%).
Alcohol use 167 (70.8) 82 (34.7) 4.55 (3.08–6.70) ⬍.001 All except 24 had engaged in vaginal
Drug abuse 31 (13.1) 7 (3.0) 4.95 (2.13–11.48) ⬍.001 intercourse. Of those 24 adolescents,
Involved in gang activities 27 (11.4) 7 (3.0) 4.23 (1.80–9.91) ⬍.005
23 had engaged in oral intercourse
Knowledge, attitudes, and skills, n (%)
AIDS is curable 13 (5.5) 13 (5.5) 1.0 (0.45–2.21) 1.0 only and 1 had engaged in anal inter-
I can tell that a person has AIDS/HIV just by 45 (19.1) 35 (14.8) 1.35 (0.83–2.20) .269 course only. The median age of first
looking at him sexual intercourse was 16 years
One can have sex before marriage 157 (67.1) 35 (14.8) 11.71 (7.46–18.38) ⬍.001
Not confident in resisting peer pressure to 190 (80.9) 82 (34.7) 7.93 (5.20–12.08) ⬍.001 (range: 11–19 years), and the median
engage in sex number of partners was 4 (range:
Parental relationships and communication 1–11 partners). Approximately two
Not having mother as confidant, n (%) 199 (84.3) 177 (75.0) 1.79 (1.13–2.84) ⬍.05
Parent never discussed STIs or consequences of 123 (52.3) 95 (40.3) 1.62 (1.12–2.33) .01 thirds (60.7%) of the last sexual inter-
sex, n (%) course episodes were ⬍1 month ago,
Authoritative Parenting Index score (parent or 36 (20–53) 38 (20–53) ⬍.001 and only 8% were ⬎6 months ago.
guardian), median (range)
Peer characteristics Sexual intercourse among male ado-
Peer connectedness score, median (range) 16 (6–24) 17 (6–24) ⬍.005 lescents showed significant associa-
Perceived that one half or more of friends 123 (52.1) 34 (14.4) 6.47 (4.15–10.08) ⬍.001
already had sex, n (%)
tions with living in low-cost housing,
School environment/characteristics dropping out of school, having di-
Self-reported below average grades, n (%) 41 (17.4) 29 (12.3) 1.50 (0.90–2.51) .119 vorced parents, substance (tobacco,
Have not represented school in 152 (64.4) 125 (53.0) 1.61 (1.11–2.32) ⬍.05
alcohol, or drug) use, involvement in
sports/competitions or held leadership
positions in school, n (%) gang activities, permissive attitudes
Media exposure/characteristics regarding premarital sex, lack of con-
Have read or watched television/movies/videos 37 (15.7) 120 (52.8) 0.18 (0.12–0.28) ⬍.001
fidence in resisting peer pressure to
about persons with STIs/HIV/AIDS, n (%)
Heard or seen quite often/almost always talk 98 (41.5) 112 (47.4) 0.79 (0.55–1.13) .195 engage in sex, perception that one half
about having sex or portrayal of behavior or more of their friends were sexually
suggesting sexual intercourse (eg, kissing, active, and not holding leadership po-
touching, or half-naked couple) in public-
access television, videos, movies, or music, sitions or participating in competi-
n (%) tions in schools (Table 2). It showed
Sexual media scorea significant negative association with
Median 7 7 .904
Low (1–4), n (%) 24 (10.2) 25 (10.6) exposure to persons with STIs or HIV or
Medium (5–8), n (%) 156 (66.1) 163 (69.1) persons dying as a result of AIDS in
High (9–12), n (%) 56 (23.7) 48 (20.3 .674 magazines, newspapers, television, or
Ever read or watched pornography, n (%) 171 (72.5) 87 (36.9) 4.51 (3.05–6.65) ⬍.001
a Sum of frequency scores (scores of 1– 4) from the following 3 questions on exposure to public-access media depicting talk
movies. Female adolescents showed
on sex or portrayal of behavior suggesting sexual intercourse. (1) Based on television programs and movies you have similar findings, with the following dif-
watched, how often do you hear people talking about having sex (1 ⫽ hardly, 2 ⫽ once in a while, 3 ⫽ quite often, 4 ⫽ almost ferences: a history of sexual abuse was
always)? (2) Based on television programs and movies you have watched, how often do you see people kissing, touching, or
undressing themselves? (3) Based on popular songs you have listened to, how often do you hear people talking about having significantly associated with sexual
sex? initiation, and the median score for au-
thoritative parenting was significantly
independent variables, which demon- peer connectedness scores were en- lower among sexually active adoles-
strated no colinearity between inde- tered as continuous variables. Other cents than among non–sexually active
pendent variables. Parenting style and variables were entered as categorical adolescents (Table 3).

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For both genders, premarital inter-
course was not significantly associ-
ated with the wrong knowledge that
AIDS was curable and that it was
not possible to tell whether a person
had HIV/AIDS on the basis of appear-
ance alone; academic performance in
school; or exposure to sexual content
in public-access music, movies, or tele-
vision. Stratification according to age
(14 –16 years or ⱖ17 years) and eth-
nicity indicated no discernible differ-
ences in factors associated with sex-
ual intercourse (data not shown).
In multivariate analysis, the strongest
factor associated with sexual inter-
course among male adolescents was
viewing of pornography (Table 4).
Those who viewed pornography were
⬃6 times more likely than those who
did not do so to engage in sexual inter-
course. Other independent, signifi-
cantly associated factors were living in
low-cost housing, alcohol and tobacco
TABLE 4 Backward, Stepwise, Multivariate, Logistic Regression Model Indicating Significant ORs
for Premarital Intercourse Among 528 Male and 472 Female Adolescents in 2006 –2008
Variable
Male subjects (N ⫽ 528)
Lived in low-cost housing (1–3-room apartments)
Alcohol use
Smoker
Involved in gang activities
Thought that one can have sex before marriage
Perceived that one half or more of friends already
had sex
Not confident in resisting peer pressure to
engage in sex
Read or watched television/movies about persons
with STIs/HIV/AIDS
Ever read or watched pornography
Female subjects (N ⫽ 472)
Lived in low-cost housing (1–3-room apartments)
Dropped out of school
History of sexual abuse
Alcohol use
Thought that one can have sex before marriage
Lacking mother as confidant
Perceived that one half or more of friends already
had sex
Not confident in resisting peer pressure to
engage in sex
Read or watched television/movies about persons
with STIs/HIV/AIDS
Ever read or watched pornography
Only significantly associated factors (P ⬍ .05) and those close to statistical significance (P ⬍ .07) are shown.
PEDIATRICS Volume 124, Number 1, July 2009
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use, involvement in gang activities,
permissive attitudes about premarital
sex, perception that more than one
half of their friends were having sex,
and lack of confidence to resist peer
pressure to engage in sex. Having read
about or watched people with HIV/AIDS
or STIs demonstrated a strong protec-
tive association with sexual inter-
course. Adolescents who had read
about or watched characters or per-
sons with these diseases were 0.27
times as likely to engage in sex as were
those not exposed to them.
For girls, the strongest risk factor for
premarital intercourse was a history
of sexual abuse. Girls who had been
sexually abused were ⬃8 times more
likely to engage in voluntary sexual in-
tercourse. They also reported more
partners than non–sexually abused
girls (age-adjusted mean number of
partners: 7.3 vs 4.4; P ⬍ .001). Other
independent factors similar to those
Adjusted OR
(95.0% CI)
3.25 (1.64–6.43)
1.77 (1.07–2.94)
1.91 (1.14–3.20)
3.45 (1.66–7.15)
3.41 (2.10–5.55)
3.37 (1.92–5.92)
3.84 (2.27–6.50)
0.27 (0.16–0.45)
5.82 (2.34–14.43)
4.52 (1.78–11.50)
2.72 (1.32–5.61)
7.81 (2.50–24.41)
2.26 (1.20–4.26)
6.25 (3.30–11.83)
2.15 (0.95–4.87)
3.22 (1.65–6.28)
5.56 (2.94–10.53)
0.24 (0.13–0.47)
2.05 (1.11–3.78)
ARTICLES
for boys but with stronger associa-
tions were permissive attitudes re-
garding premarital sex and lack of
confidence to resist peer pressure to
engage in sex. Like adolescent boys,
girls who had viewed or read about
persons with HIV/AIDS/STIs were much
less likely to engage in sex. Other asso-
ciations similar to those for boys were
living in low-cost housing, alcohol use,
and perception that more than one
half of their friends were having sex.
Viewing of pornography was also a sig-
nificant but less strong risk factor,
compared with boys. A significant pre-
dictor of premarital intercourse for
girls (P ⫽ .007) but not boys (P ⫽ .243)
was having dropped out of school. Not
having a mother to confide in when
troubled showed an association that
was close to statistical significance for
girls (P ⫽ .068) but not boys (P ⫽ .16).
Most sexually active adolescents
(⬎70%) had viewed pornography, with
the Internet (59%) being the main
source, followed by videos (19%), mo-
bile telephones (14%), and magazines
P (8.1%). Primary self-reported reasons
for first sexual intercourse among
.001 boys were curiosity (58.7%), love
.027 (37.1%), and inability to control them-
.015 selves (21.2%). For girls, the reasons
.001
⬍.001
were love (49.2%), curiosity (38.6%),
⬍.001 and not knowing how to say no
(20.3%). Almost one half (43.6%) of the
⬍.001
girls and approximately one third
⬍.001 (29.5%) of the boys did not intend to
have sex in the first place but engaged
⬍.001
in sex subsequently because they
.002 could not control themselves, lacked
.007 the skills to say no, or were under the
.001
influence of alcohol or drugs.
.012
⬍.001
.068 DISCUSSION
⬍.001
The strongest factor associated with
⬍.001 sexual intercourse was viewing of por-
nography for male adolescents but a
⬍.001
history of sexual abuse for female ad-
.021 olescents. For both genders, a modifi-
able factor for sexual intercourse was
e49
lack of confidence to resist peer pres-
sure, whereas exposure to persons or
portrayal of characters with HIV or
STIs in the media showed a strong pro-
tective association. Other predictors
of sexual intercourse were having
dropped out of school, having a per-
missive attitude toward premarital
sex, consuming alcohol, smoking, and
living in low-cost housing.
Our study in a clinic-based setting lim-
its the generalizability of the findings.
However, our primary aim was not to
extrapolate our findings but to identify
predictors of sexual initiation, for plan-
ning of STI/HIV preventive interven-
tions targeting high-risk adolescents
who attend this clinic. Our study’s
strength is that the privacy and longer
time available at the clinic allowed the
use of a more-comprehensive ques-
tionnaire. In addition, we could study
school dropouts, who were reported to
be at higher risk for engaging in sexual
intercourse.17,18 Other study limita-
tions included possible bias from self-
reports of behavior and the difficulty
of demonstrating causality. We at-
tempted to reduce self-reporting bias
by ensuring anonymity and explaining
to the patients that the survey was con-
ducted to help us plan better pro-
grams to support them.
We identified 2 noteworthy findings
of public health significance. First, sex-
ual intercourse among adolescents
showed a significant independent as-
sociation with viewing of pornography,
which agrees with the results of a
study with high school boys (17–21
years of age) in Sweden.12 However,
the lack of association of sexual initia-
tion with exposure to sexual content in
television programs, movies, or music
in our study did not concur with the
results of the study by Brown et al9
among US adolescents. This might be
explained by differences in the classi-
fication of sexual content. Portrayals of
sexual intercourse and pornographic
e50 WONG et al
Downloaded from http://pediatrics.aappublications.org/ by guest on December 19, 2017
magazines such Playboy were classi-
fied under sexual content in media in
the study by Brown et al9 but were clas-
sified separately as pornography in
our study. Other explanations could in-
volve the difference in the availability
of explicit scenes of sexual intercourse
in publicly screened movies or televi-
sion in Singapore, compared with the
United States. Airing of explicit sexual
intercourse in public-access movies
and television is banned, and persons
⬍21 years of age are not permitted to
watch movies portraying sexual inter-
course and full nudity.
The second noteworthy finding was the
lack of association of knowledge of the
incurable nature of AIDS with sexual
initiation but the strong protective as-
sociation of having heard or seen peo-
ple or portrayal of characters with
HIV/AIDS/STIs in the media. The latter
finding concurs with the results of a
study in the United States8 that found
that black youths who were exposed to
depictions of sexual risks in the media
were less likely to initiate sexual inter-
course. Sexual risk depiction in the
media for teens is low in the United
States19 but high in Singapore, proba-
bly because of its school sex education
programs. However, there is no stan-
dardized curriculum for sex education.
The variations in levels of sex educa-
tion and the lack of access to sex edu-
cation among school dropouts could
explain the difference in exposure to
sexual risk depiction between case
subjects and control subjects in our
study.
A history of sexual abuse was strongly
associated with voluntary intercourse
for girls. Our finding of sexually abused
girls reporting more partners than
non–sexually abused girls was similar
to the results of a study in the United
States.20 The lack of association of sex-
ual abuse with sexual initiation among
boys might be attributable to the small
numbers, which limited the statistical
power. The association of sexual inter-
course with dropping out of school
among girls but not boys might be ex-
plained by girls’ greater vulnerability
to adverse environmental factors.
Consistent with results of studies in
the United States21 and Asia,22,23 we
found associations of sexual initiation
with gang activities, drinking, and
smoking, with a protective role of close
maternal relationships.24 Unlike other
studies,21 we did not find peer connect-
edness to be associated with sexual in-
tercourse. Previous research showed
that teens can influence their peers
not only in initiating sex but also posi-
tively in adopting more-conservative
sexual norms25 and delaying sexual ac-
tivity.26 This could explain the similar
high scores for sexually active and
non–sexually active teens and thus the
lack of association of peer connected-
ness with sexual intercourse. Finally,
our finding on the nonintention to have
sex reported by a large proportion (ap-
proximately one half) of adolescents
who subsequently engaged in it helps
us better understand why it is not
practical to promote sexual absti-
nence alone.
Given our finding on the strong associ-
ation of pornography with adolescent
sexual initiation and similar evidence
of explicit sexual media from previous
prospective studies,7–9 initiatives are
needed to monitor, to reduce, or to re-
strict access to explicit sexual media
and pornography for adolescents, by
working with Internet service provid-
ers, parents, and the entertainment in-
dustry. Parents and health care per-
sonnel should communicate openly
with adolescents regarding sexuality,
to help the adolescents develop a
more-critical attitude toward pornog-
raphy.
Because our study shows a lack of as-
sociation of sexual initiation with fac-
tual information on the incurable na-
ture of AIDS but a strong protective
 ARTICLES

association with exposure in the me-
dia to people who have HIV/STIs or are
dying as a result of AIDS, factual infor-
mation about HIV and STIs, coupled
with life-skills education, should be
woven into television dramas to con-
textualize sexual risk, so that teens can
relate to it. Teens also should be taught
how to resist peer pressure to engage
in sex.
Young school dropouts, particularly fe-
male school dropouts, should be pro-
vided with out-of-school care and sex
education. High-risk groups such as
those with a history of sexual abuse
and those involved in smoking, drink-
ing, and gang activities should be iden-
tified early, for interventions on life
skills and sex education.
Future research should include a lon-
gitudinal study to examine over time
the effects of Internet pornography
and educational media on adoles-
cents’ sexual initiation. Composite
measures combining sexual media
content from the study by Brown et al9
and media measures on sexual risk
and sexual behavior from the study by
Collins et al7 should be developed to
assess the effects of harmful and edu-
cational sexual contents on adolescent
sexual behavior.
ACKNOWLEDGMENTS
This nonclinical trial was funded by the
National Medical Research Council of
Singapore.
We thank Karen Ho Kar Woon and Amy
Chan Yoke Sim for their painstaking ef-
forts in conducting the interviews and
coordinating the survey.

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 Premarital Sexual Intercourse Among Adolescents in an Asian Country:
Multilevel Ecological Factors
Mee-Lian Wong, Roy Kum-Wah Chan, David Koh, Hiok-Hee Tan, Fong-Seng Lim,
Shanta Emmanuel and George Bishop
Pediatrics 2009;124;e44
DOI: 10.1542/peds.2008-2954

Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/124/1/e44
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
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 Premarital Sexual Intercourse Among Adolescents in an Asian Country:
Multilevel Ecological Factors
Mee-Lian Wong, Roy Kum-Wah Chan, David Koh, Hiok-Hee Tan, Fong-Seng Lim,
Shanta Emmanuel and George Bishop
Pediatrics 2009;124;e44
DOI: 10.1542/peds.2008-2954

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/124/1/e44

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2009 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
.

Downloaded from http://pediatrics.aappublications.org/ by guest on December 19, 2017