Examining the Effect of Maternal Sexual Communication And

Journal of Adolescent Health xx (2012) xxx

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Original article Examining the Effect of Maternal Sexual Communication and Adolescents’ Perceptions of Maternal Disapproval on Adolescent Risky Sexual Involvement Atika Khurana, Ph.D.a,*, and Elizabeth C. Cooksey, Ph.D.b a Annenberg Center for Advanced Study in Communication, Annenberg Public Policy Center, University of Pennsylvania, Philadelphia, Pennsylvania b Department of Sociology and Center for Human Resource Research, The Ohio State University, Columbus, Ohio

Article history: Received September 10, 2011; Accepted March 6, 2012 Keywords: Adolescent risky sexual behaviors; Maternal sexual communication; Maternal disapproving attitudes; Add Health

ABSTRACT IMPLICATIONS AND CONTRIBUTION Purpose: To examine the influence of maternal sexual communication during early adolescence on three adolescent sexual risk behaviors (assessed 5–6 years later) in relation to adolescents’ percep- Maternal sexual communi- tions of maternal disapproval of [their] sexual involvement and contraceptive use. cation can have a significant Methods: Using data from waves 1 and 3 of the National Longitudinal Study of Adolescent Health influence on adolescent (Add Health), we distinguish between youth who reported being virgins from those who reported risky sexual involvement. having had sex by the time maternal sexual communication was assessed. However, its influence var- Results: Frequency of maternal sexual communication has a significant influence on adolescents’ ies based on adolescents’ lifetime number of sexual partners, but its effect is moderated by adolescents’ perceptions of perceptions of maternal maternal disapproval of contraceptive use. This relationship holds regardless of whether the disapproving attitudes as adolescent was a virgin or not at the time of the communication. When occurring in the context of well as the timing of such adolescent-perceived maternal nondisapproval, greater frequency of maternal sexual communica- communication in relation tion is associated with a higher likelihood of having multiple sexual partners. Greater frequency of to the adolescent’s sexual maternal sexual communication was also associated with inconsistent condom use and positive status. sexually transmitted infection diagnosis among adolescents who were sexually experienced at baseline and who perceived maternal disapproval of contraceptive use. Conclusions: These findings emphasize the need to evaluate the effect of maternal sexual communication on adolescent risky sexual behaviors in relation to the value context of these discussions as well as the sexual status of the adolescent. ᭧ 2012 Society for Adolescent Health and Medicine. All rights reserved.

Almost half of American adolescents have had sexual inter- of unintended pregnancies [5] reported annually. Aside from the course before they graduate from high school, with a mean age of steep treatment costs associated with these unwanted sexual sexual debut of approximately 16 years [1,2]. When compared health outcomes [6], involvement in unprotected sexual inter- with youth in other developed nations, American adolescents are course can have life-altering consequences for youth and their not only younger when they first have sex, but they also report families, making it especially important to identify ways in having more lifetime sexual partners and higher rates of unpro- which adolescents can be encouraged to practice responsible tected sexual intercourse [1,3]. Although American adolescents sexual behaviors. represent only a quarter of the nation’s sexually experienced Adolescence is a life stage when youth are exposed to multi- population, they account for Ͼ50% of all new sexually transmit- ple novel and potentially risky behaviors. On the edge of an adult ted infection (STI)/HIV cases [4] and an overwhelming majority world, but not yet equipped with the adult decision-making abilities that come with increasing maturity, many youth find adolescence to be a vulnerable time. Parents can play a critical role in this transition when aware of their child’s maturity level * Address correspondence to: Atika Khurana, Ph.D., Annenberg Public Policy Center, University of Pennsylvania, 202 S. 36th St., Philadelphia, PA 19104. and life experiences. Specifically, they can make informed deci- E-mail address: [email protected] (A. Khurana). sions regarding the optimum timing and content of sexual dis-

1054-139X/$ - see front matter ᭧ 2012 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2012.03.007 2 A. Khurana and E.C. Cooksey / Journal of Adolescent Health xx (2012) xxx cussions, tailoring their communication to fit within the context Methods of their own family beliefs and values [7]. Adolescents also report parents as their preferred source of sexual information [8], even Data and sample though they are often reluctant to discuss sexual topics with them [9]. We use data from waves 1 and 3 of the National Longitudinal Despite extensive research attention, the role of parental sex- Study of Adolescent Health (also known as Add Health), which ual communication in reducing adolescent sexual risk taking is a nationally representative, probability-based, longitudinal remains unclear [10]. Some studies have found parental (more study of adolescents that started in 1994–1995 [28]. Eighty U.S. commonly maternal) sexual communication to be associated high schools and their corresponding middle schools were se- with consistent condom use [11–13] and fewer lifetime sexual lected with a probability proportional to size. Approximately partners [14]. Others have reported a null effect [15,16]. Still 90,000 students in grades 7–12 completed in-school question- naires, of which a sample of 20,475 adolescents completed a others have documented risk-enhancing effects [8,17]. wave 1 home interview. A parent of each adolescent was also These mixed findings can be attributed to a variety of reasons. asked to participate. In total, 17,670 parents participated, Ͼ90% Most studies have been cross-sectional in design, making it dif- of whom were mothers. Adolescents interviewed for wave 1 ficult to ascertain whether maternal sexual communication oc- were then followed up in 1996 (wave 2), 2001–2002 (wave 3), curred before adolescent sexual debut, or if adolescent sexual and 2007–2008 (wave 4). activity resulted in more frequent sexual discussions by a con- Our study sample comprises those adolescents who com- cerned parent. When this conundrum was explored with longi- pleted interviews in both waves 1 and 3 and whose mothers tudinal data, researchers found parental sexual communication participated in the wave 1 parent survey (n ϭ 13,808). Sample to be associated with more responsible sexual behaviors, espe- adolescents additionally had to be aged Ͻ23 years at wave 3 (i.e., cially when communication occurs before adolescent sexual de- Յ15 years at wave 1) (n ϭ 7,547), report having been sexually but [18]. However, much of this work has been based on small active before wave 3 (n ϭ 6,161), and have valid sampling samples of youth who were at high risk for STIs/HIV. Whether weights (n ϭ 5,648). these findings can be generalized to the wider population remains less certain. Outcome variables Other factors like characteristics of the communication pro- cess, including openness [10], mutuality [19], and self-disclosure We used three variables from wave 3 to measure adolescent [9]; comfort level of participants [20]; quality of the parent–teen risky sexual involvement. Number of lifetime sexual partners relationship [21]; and the content and depth of topics covered was assessed using adolescents’ responses to the question “With [22], can modify the effect of parent–teen sexual communica- how many partners have you ever had vaginal intercourse, even tion, but have not been adequately accounted for in past re- if only once?” Responses ranged from 1 to 50, with a mean of 5.59 search. partners (standard deviation ϭ 5.95). A closer examination of the It is also important to consider the value context of parent– distribution of responses revealed positive skewness of 3.00 and teen sexual communication [7,23]. Previous research indicates kurtosis of 14.95. To correct for this, we conducted a natural log that when adolescents perceive maternal disapproval of their transformation of the data. sexual involvement, they are less likely to engage in frequent Adolescents were also asked “On how many occasions of sexual activity and inconsistent condom use [24] and conse- vaginal intercourse in the past 12 months, did you or your part- quently have lower odds of STIs [25] and unintended pregnan- ner use a condom?” We reverse coded the original response cies [21]. Conversely, perceptions of maternal approval of birth categories ranging from 0 (none) to 4 (all) for our measure of control are associated with not only a higher probability of sex- condom use inconsistency so that higher scores represented ual initiation but also greater odds of birth control use at most greater inconsistency, and created a “low risk” group that included both adolescents who reported consistent condom use in recent sex [26]. the past 12 months and those who had not had a sexual partner Parental attitudes can influence the timing, nature, and extent over this period. “Medium risk” adolescents were those who of parent–teen sexual communication as well as how communi- reported inconsistent condom use during the past 12 months, cation is perceived by the adolescent. Using cross-sectional data, and “high risk” respondents reported never having used a con- previous research has shown that when mothers disapprove of dom over the 12-month period. adolescent sexual behavior and explicitly communicate their Information on our third dependent variable of positive STI views to their adolescents, it helps reduce adolescent risky sex- diagnosis came from the following question: “In the past 12 ual involvement [24,27]. However, these findings warrant fur- months, have you been told by a doctor/nurse that you had the ther validation using a prospective study design with lagged following sexually transmitted diseases . . .?” Respondents an- measures of adolescent sexual behaviors. swered yes/no to 14 different STIs, including chlamydia, gonor- The purpose of our research is threefold. First, we use national rhea, and HIV. Adolescents who reported having been diagnosed longitudinal data to assess the impact of maternal sexual com- with one or more of these STIs were coded as 1; if not, they were munication on change in adolescent risky sexual behaviors and coded 0. STI outcomes. Second, we examine the synergistic impact of Each of these outcome variables was tested in separate mod- maternal sexual communication and adolescents’ perceptions of els. To assess the influence of maternal variables on change in maternal disapproving attitudes on adolescent risky sexual in- adolescent risky sexual behaviors, we included a proxy variable volvement. Third, we evaluate if these effects vary based on of adolescents’ reported risky sexual involvement at wave 1. This whether the adolescent was a virgin or sexually experienced at variable had three response categories: 0 ϭ never had sex; 1 ϭ the time of communication. used some form of birth control at the time of first sexual inter- A. Khurana and E.C. Cooksey / Journal of Adolescent Health xx (2012) xxx 3

Table 1 Table 1 Descriptive statistics (N ϭ 5,472) Continued

Variable names Mean (SD)/ Variable names Mean (SD)/ frequencies frequencies

Dependent variables (assessed at wave 3) How much do you think your mom cares about you Lifetime number of sexual partners 5.59 (5.95) Quite a bit or less 10% (range: 1–50)a Very much 90% Condom use inconsistency (past 12 months) Parental monitoring (adolescent reports) 4.83 (1.49) Low risk ([i] no sexual partners and [ii] condom used 30% (range:0–7) during all sexual encounters) a Range starts at 1 because only those adolescents who were sexually active at Medium risk (inconsistent condom use) 46% wave 3 were retained in the sample. High risk (never used condom during any sexual 24% b This variable comprises maternal reports of frequency of maternal commu- encounter) nication with adolescent about (a) sex (n ϭ 1), (b) birth control (n ϭ 1), and (c) Been diagnosed with an STI (past 12 months) negative consequences associated with sexual intercourse (n ϭ 4). Never 90% At least once 10% Independent variables (maternal–adolescent context; assessed at wave 1) course; and 2 ϭ used no birth control at the time of first inter- Frequency of maternal sexual communication (range: 2.87 (.85) course. As 60% of adolescents were sexually inexperienced at b 1–4) wave 1, we designated the “never had sex” category as the refer- Adolescents’ perceptions of maternal disapproval of ence category. For the STI diagnosis outcome, we included ado- sexual intercourse Approve or ambivalent 12% lescents’ self-reported STI histories from wave 1 as an additional Disapprove 88% control. Adolescents’ perceptions of maternal disapproval of birth control use Predictor and moderator variables Approve or ambivalent 49% Disapprove 51% Demographic control variables Our key predictor variable of maternal sexual communication Age (assessed at wave 3) (range: 18–22) 20.62 (1.11) frequency and the moderator variables of adolescent percep- Gender tions of maternal disapproval of sex and birth control were taken Male 47% from wave 1 assessments. Female 53% Race/ethnicity White 71% Frequency of maternal sexual communication. In Add Health, only African American 13% parents’ perceptions of parent–teen sexual communication were Hispanic 11% assessed. Given our focus on mother–adolescent dyads, we ana- Other (including Asians and Native Americans) 5% Parental education level (assessed at wave 1) lyzed maternal reports of mother–teen sexual communication Less than high school 10% using six items from the parent questionnaire to assess the fre- High school 54% quency with which each mother had discussions with her child College and beyond 36% about (a) sex, (b) birth control, and (c) negative consequences of Family income (in thousands, assessed at wave 1) 43 (31) sex. Following confirmatory factor analysis procedures, we aver- Family structure (assessed at wave 1) Both biological parents 59% aged the scores from these three variables to create a continuous Single biological parent 27% score of maternal sexual communication frequency that ranged Other (including step, adoptive, and foster parents) 14% from 1 (not at all) to 4 (a great deal). Adolescent-related control variables (assessed at wave 1) Risky sexual behaviors Adolescents’ perceptions of maternal disapproving attitudes. Past Not sexually active 74% Some form of birth control measure used at first 17% research has found adolescents’ perceptions of maternal disap- sexual intercourse proving attitudes to be better predictors of adolescent behaviors No birth control measure used at first sexual 9% than mothers’ own stated disapproval [21,24]. We used two intercourse items from the adolescent in-home questionnaire to measure Frequency of alcohol use in the past 12 months Never 56% adolescents’ perceptions of maternal disapproval of both sexual 1–2 days in past 12 months 18% intercourse and contraceptive use: “How would your mother feel Once a month or less 13% about your having sex at this time in your life?” and “How would 2–3 d/month 7% she feel about your using birth control at this time in your life?” 4ϩ d/month 6% Responses for each ranged from 1 (strongly disapprove) to 5 Ever taken a public or written pledge to remain a virgin until marriage (strongly approve). Given their skewed distributions, we col- No 87% lapsed each into a dummy variable, coded 0 if the adolescent Yes 13% perceived maternal approval/ambivalence and 1 if the adoles- Importance of religion for the adolescent cent perceived maternal disapproval. Not “very important” 57% Very important 43% How close do you feel to your mother Control variables Somewhat close 9% Quite a bit 21% All control variables in our models were from wave 1 and Very close 70% were included because they have been previously identified as having a significant influence on adolescent risky sexual involvement: age, gender, race/ethnicity, importance of religion [29], 4

Table 2 Regression analyses output for three outcome variables from separate models Variable names Sexual partners (N ϭ 5,472) Condom use inconsistency (N ϭ 5,472) Positive STI diagnosis (N ϭ 5,472) ␤ (95% CI) Odds ratio (95% CI) Odds ratio (95% CI) Main effects Two-way Three-way Main effects Two-way Three-way Main effects Two-way Three-way A interaction interaction D interaction interaction G interaction interaction B C E F H I

Independent variables (wave 1) *** **** Ϫ ** Frequency of maternal sexual .06 (.02, .10) .11 (.06, .17) .07 ( .04, .17) 1.10 (1.01, 1.20) 1.10* (.99, 1.22) .96 (.81, 1.14) .96 (.81, 1.14) .97 (.76, 1.24) .84 (.57, 1.23) communication Adolescents’ perceptions of Ϫ.01 (Ϫ.09, .06) .27** (.04, .49) .10 (Ϫ.25, .05) .81 *** (.70, .94) .79 (.47, 1.33) .94 (.68, 1.31) .76 ** (.59, .97) .78 (.30, 2.03) .72 (.45, 1.16) maternal disapproval of birth control use xxx (2012) xx Health Adolescent of Journal / Cooksey E.C. and Khurana A. Adolescents’ perceptions of Ϫ.12* (Ϫ.25, .02) Ϫ.11 (Ϫ.24, .03) Ϫ.10 (Ϫ.23, .03) .94 (.75, 1.18) .94 (.75, 1.18) .92 (.73, 1.16) 1.14 (.81, 1.61) 1.14 (.82, 1.60) 1.09 (.77, 1.54) maternal disapproval of sex *** Ϫ Ϫ Ϫ Ϫ **** *** Maternal sexual Ϫ.10( .17, .02) .09 ( .26, .09) 1.01 (.85, 1.20) 1.67 (1.23, 2.28) .99 (.72, 1.36) 2.25 (1.22, 4.15) communication ϫ maternal disapproval of birth control use (two-

way interaction) **** *** Maternal sexual Ϫ.02 (Ϫ.23, .18) .51 (.36, .74) .34 (.16, .72) communication ϫ maternal disapproval of birth control use ϫ virginity status (three- way interaction) Control variables (wave 1) Adolescent risky sexual a involvement Some form of birth control .46 **** .45**** (omitted) 1.21* 1.21* (omitted) 1.17 1.17 (omitted) used at ﬁrst intercourse No form of birth control used .42**** .42**** (omitted) 1.57 **** 1.57**** (omitted) 1.56 1.56 (omitted) at ﬁrst intercourse Age Ϫ.01 Ϫ.00 .002 1.06* 1.06* 1.06* .83 *** .83*** .83*** Gender (female ϭ 1, Ϫ.12 **** Ϫ.12**** Ϫ.12**** 1.52**** 1.52**** 1.51**** 3.94**** 3.94**** 3.93**** male ϭ 0) Race/ethnicity b African Americans .02 .03 .03 .55 **** .55**** .55**** 3.11**** 3.11**** 3.11**** Hispanics Ϫ.17 **** Ϫ.17**** Ϫ.16*** .86 .86 .88 1.15 1.15 1.18 Others Ϫ.09 Ϫ.09 Ϫ.10 .80 .80 .79 1.44 1.44 1.44 Frequency of alcohol use in .12**** .12**** .12**** 1.10*** 1.10*** 1.10*** 1.12*** 1.17*** 1.16*** past 12 months Abstinence pledge taken Ϫ.18 **** Ϫ.18**** Ϫ.18**** 1.19* 1.19* 1.19* .93 .93 .93 Religion very importantc Ϫ.05 Ϫ.04 Ϫ.05 1.07 1.07 1.07 .70 ** .70** .69** Positive STI diagnosis .75 .75 .77 history at wave 1

Nonsignificant control variables were removed from the final models. a Reference category ϭ not sexually experienced. b Reference category ϭ whites. c Reference category ϭ religion not “very important.” * p Ͻ .10, ** p Ͻ .05, *** p Ͻ .01, **** p Ͻ .001. A. Khurana and E.C. Cooksey / Journal of Adolescent Health xx (2012) xxx 5 having taken an abstinence pledge [30], frequency of alcohol use slightly overrepresented. Most respondents (59%) lived with in the past 12 months [31], family structure [32], family income both their biological parents at wave 1, and 27% lived with a and parental education [33], parental monitoring [34], and single biological parent, which was the mother in 95% of the mother–adolescent relationship quality [21], assessed using two cases, given our sample restrictions (Table 1). questions: How much do you think your mother cares about By wave 3, the 18- to 22-year-old sexually active adolescents you? and How close do you feel to your mother? The degree to reported having had six lifetime sexual partners, on average. which each control variable is correlated with our key predictors With regard to condom use, only 30% could be classified as “low ranges from r ϭ .08 to r ϭ .21. risk,” with either no sexual partners (8%) or having always used a condom during intercourse (22%) in the past 12 months. Twenty- Analytical procedures four percent never used a condom and were in the high-risk category. Ten percent reported having been diagnosed with an We conducted all analyses using the “svyset” command in STI during the 12-month period. STATA 11.0 (Stata Corporation, College Station, TX), with robust estimation procedures to account for survey design characteristics and to obtain unbiased and nationally representative esti- Multiple regression analysis mates [35]. We used ordinary least squares regression for our continuous outcome of number of lifetime sexual partners, and Number of sexual partners. In the main effects model, the effect logistic regression for both the three-category outcome of con- of maternal sexual communication was statistically significant at dom use inconsistency and the binary variable of STI diagnosis. the .01 level, such that for each unit increase in frequency of Independent variables were added in blocks, with control vari- communication at wave 1, there was a 6% increase in lifetime ables entered first, followed by our key predictor variables, and number of sexual partners, on average, by wave 3, holding all finally a series of interaction terms. Because Ͻ5% of cases had other variables constant (Table 2, column A). missing values on any of our independent variables, we used Of the two two-way interaction terms tested, only maternal ϫ listwise deletion to account for missing data [36]. Our final sam- communication maternal disapproval of birth control use was ple size totaled 5,472 adolescents. statistically significant (Table 2, column B). Among adolescents who did not perceive maternal disapproval of birth control, a Results higher frequency of maternal sexual communication was associated with a significant increase in number of lifetime sexual Descriptive characteristics partners, whereas among adolescents who did perceive maternal disapproval, higher frequency of maternal sexual communi- The mean age of our analytical sample at wave 3 was 20.62 Ϯ cation was not associated with such an increase. This is depicted 1.11 years. Female (53%) and white (71%) adolescents were graphically in Figure 1.

Figure 1. Interaction between maternal sexual communication and maternal disapproval of birth control use in predicting number of sexual partners. Note: The nature of interaction between maternal sexual communication and perceived maternal disapproval of birth control use did not vary based on the sexual status of the adolescent at the time of the communication. The separate graphs for virgins and nonvirgins show the same interaction pattern. Frequency of maternal sexual communication ranges from 1 (not at all) to 4 (a great deal). 6 A. Khurana and E.C. Cooksey / Journal of Adolescent Health xx (2012) xxx

Neither of the three-way interaction terms (maternal com- only among sexually experienced adolescents (Figure 2). These munication ϫ maternal disapproval of sex ϫ virginity status and results are presented in Table 2 (column F). maternal communication ϫ maternal disapproval of birth con- ϫ ϭ ϭ trol use virginity status) was significant, F(1,127) .71, p .40 STI diagnosis. The main effect of perceptions of maternal disap- ϭ ϭ and F(1,127) .11, p .75, respectively. proval of contraceptive use was significantly associated with reduced odds of STI diagnosis (see Table 2, column G). Neither of Condom use inconsistency. The main effects from our logistic the two-way interaction terms was significant, but the three- regression analyses of condom use inconsistency are pre- way interaction term involving maternal disapproval of birth sented in Table 2 (column D). A higher frequency of maternal ϭ Ͻ control use was statistically significant, F(1,127) 13.44, p .001. sexual communication was associated with greater odds of Again, the interaction between maternal communication and inconsistent condom use in the previous 12 months. Adoles- adolescent-perceived disapproval was significantly different cents who perceived maternal disapproval of contraceptive ϭ ϭ from zero for nonvirgins only: F(1,127) 6.89, p .01. As shown in use had significantly lower odds of reporting inconsistent Figure 3, among nonvirgin adolescents only, there was a higher condom use. likelihood of a positive STI diagnosis (at wave 3) if there was both Neither of the two-way interaction terms was significant. a high frequency of maternal sexual communication and per- However, one of the three-way interaction terms (maternal com- ceived maternal disapproval of contraceptive use at wave 1. munication ϫ maternal disapproval of birth control use ϫ virgin- ϭ Ͻ ity status) was statistically significant, F(1,127) 12.9, p .001. This implies that the nature of the two-way interaction between Discussion maternal communication and maternal disapproval of birth control use varied based on the adolescent’s virginity status. Decom- Empirical evidence concerning the role of maternal sexual posing this interaction further, we find that the interaction be- communication in affecting adolescent risky sexual behaviors is tween maternal communication and maternal disapproval of inconclusive [10,37]. Our study extends previous research by (1) birth control use was significantly different from zero for nonvir- using of a large sample of youth drawn from a national longitu- ϭ ϭ ϭ gins, F(1,127) 7.65, p .007, but not for virgins, F(1,127) 2.14, dinal data set rather than cross-sectional and/or convenience p ϭ .15. Put another way, a greater likelihood of inconsistent samples, (2) incorporating three different indicators of adoles- condom use existed 5–6 years later, if the frequency of maternal cent risky sexual involvement, (3) examining the interactional communication reported at wave 1 had been high and the ado- dynamics of maternal sexual communication frequency and ad- lescent perceived maternal disapproval of contraceptive use, but olescents’ perceptions of maternal disapproving attitudes, and

Figure 2. Interaction between maternal sexual communication, maternal disapproval of birth control use, and adolescent virginity status in predicting condom use inconsistency. Note: Condom use inconsistency ranges from 1 to 3, with higher values indicating greater inconsistency in condom use. Frequency of maternal sexual communication ranges from 1 (not at all) to 4 (a great deal). A. Khurana and E.C. Cooksey / Journal of Adolescent Health xx (2012) xxx 7

Figure 3. Interaction between maternal sexual communication, maternal disapproval of birth control use, and adolescent virginity status in predicting positive STI diagnosis. Note: Frequency of maternal sexual communication ranges from 1 (not at all) to 4 (a great deal).

(4) attending to youth’s sexual status (virgin/nonvirgin) at the proving attitudes, and found that adolescents tend to underesti- time of maternal sexual communication. mate maternal disapproval of their sexual involvement [21]. Our findings show that frequency of maternal sexual commu- They propose that this discrepancy between adolescents’ per- nication does significantly impact adolescents’ sexual behaviors. ceptions of maternal disapproval and mothers’ actual disap- However, the magnitude and nature of this effect varies based on proval might be reduced through greater parent–adolescent sex- adolescents’ perceptions of maternal disapproval and whether ual communication. We concur because our results indicate that the communication reported occurs before or after their sexual maternal sexual communication and perceptions of maternal debut. Our study is not the first to test these interactions. The disapproval when present together can effectively reduce num- moderating influence of parental disapproving attitudes on the ber of sexual partners. relationship between parent–teen sexual communication and Our findings also reveal that for sexually experienced adoles- adolescent risky sexual behaviors was first explored by Moore et cents, frequent maternal sexual communication that occurs in al in 1986 [38] and later investigated by Jaccard et al [24]. How- the context of perceived maternal disapproval of contraceptive ever, both these studies were based on cross-sectional data from use can do more harm than good, especially in regard to condom restricted samples. The present study is the first to use a longitu- use and STI risk. These results underscore the importance of dinal design with lagged measures of adolescent sexual risk tailoring the content of parent–teen sexual communication to behaviors and a nationally representative sample. the needs and sexual experiences of the adolescent. However, In the absence of perceived maternal disapproval, higher fre- parents often tend to underestimate their adolescent’s sexual quency of maternal sexual communication was associated with experiences [39]. In our sample, Ͼ60% of mothers of sexually an increased risk of having multiple sexual partners 5–6 years experienced adolescents inaccurately reported that their child later. The most plausible explanation for this effect seems to be was a virgin. It is possible that these mothers believed that their that when adolescents do not get a clear message of maternal adolescent was about to become sexually active, which is why disapproval, they are likely to misinterpret high frequency of they were engaging in frequent sexual discussions. However, maternal sexual communication as signifying maternal ap- given that the adolescent was already sexually experienced at proval. This finding suggests that by engaging in frequent sexual the time of the communication, we find that their frequent com- discussions while explicitly vocalizing their disapproval of ado- munication coupled with disapproval of contraceptive use had a lescents’ sexual involvement and contraceptive use until they risk-enhancing effect. For mother–teen sexual communication reach a mature age, mothers may be able to deter their adoles- to be effective in reducing adolescent sexual risk behaviors, cents from having multiple sexual partners. mothers need to be better informed about their teenager’s sexual Using data from the Add Health study, Dittus and Jaccard experiences. It is therefore important that characteristics of the compared mothers’ and adolescents’ reports of maternal disap- parent–teen relationship that can facilitate open, honest, and 8 A. Khurana and E.C. Cooksey / Journal of Adolescent Health xx (2012) xxx mutual exchange of sexual information between adolescents and Entwisle for assistance in the original design. Information on their parents be considered in future research. how to obtain the Add Health data files is available on the Add That adolescents’ perceptions of maternal disapproval of sex Health Web site (http://www.cpc.unc.edu/addhealth). No direct did not significantly influence either condom use or STI diagnosis support was received from grant P01-HD31921 for this analysis. is also interesting, although we did find a weak main effect (p Ͻ This work was part of the first author’s doctoral dissertation that .10) on the number of sexual partners. The correlation between was supported by a research fellowship from the College of the two maternal disapproval variables was .31 and their vari- Education and Human Ecology at the Ohio State University and a ance inflation factor score was Ͻ10, ruling out multicollinearity graduate student research award from the Criminal Justice Re- as an explanation. However, low variance might be a contribut- search Center at the Ohio State University. ing factor. Approximately 10% of our sample reported perceiving maternal approval or ambivalence toward their sexual involve- References ment, whereas almost 50% reported perceiving maternal ambivalence or approval of contraceptive use. 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Family relationships and adolescent degree of congruence between maternal and adolescent reports pregnancy risk: A research synthesis. Dev Rev 2001;21:1–38. [11] DiClemente RJ, Wingood GM, Crosby R, et al. Parent-adolescent communi- and how that might affect our findings. cation and sexual risk behaviors among African American adolescent fe- Further, as Add Health is primarily a school-based sample, our males. J Pediatr 2001;139:407–12. findings may or may not apply to adolescents who do not attend [12] Pick S, Palos PA. Impact of the family on the sex lives of adolescents. Adolescence 1995;30:667–75. school. Also, adolescents reporting inconsistent condom use may [13] Romer D, Stanton B, Galbraith J, et al. Parental influence on adolescent have been using alternative contraceptive measures, which we sexual behavior in high-poverty settings. Arch Pediatr Adolesc Med 1999; did not assess. Finally, we recognize that maternal influences are 153:1055–62. [14] Holtzman D, Rubinson R. Parent and peer communication effects on AIDS- likely to change as the adolescent grows older, but we were related behavior among U.S. high school students. Fam Plann Perspect unable to measure such change. 1995;27:235–68. To conclude, our study provides further evidence of the pro- [15] Bettinger JA, Celentano DD, Curriero FC, et al. Does parental involvement predict new sexually transmitted diseases in female adolescents? Arch tective role of maternal sexual communication and maternal Pediatr Adolesc Med 2004;158:666–70. disapproving attitudes and generates a more nuanced picture of [16] Santelli JS, Kaiser J, Hirsch L, et al. Initiation of sexual intercourse among the relationship between these variables and its impact on ado- middle school adolescents: The influence of psychosocial factors. J Adolesc lescent sexual behaviors. Future research would benefit from Health 2004;34:200–8. [17] Chen AC, Thompson EA. Preventing adolescent risky sexual behavior: Par- examining the influence of these variables in relation to the onset ents matter! J Spec Pediatr Nurs 2007;12:119–22. of sexual activity among adolescents. Besides being timely, sex- [18] Miller KS, Levin ML, Whitaker DJ, Xu X. Patterns of condom use among ual communication that is better tailored to the needs and expe- adolescents: The impact of mother-adolescent communication. Am J Public Health 1998;88:1542–4. riences of the adolescent is most likely to be effective. [19] Lefkowitz ES, Kahlbaugh PE, Sigman MD. Turn-taking in mother–adolescent conversations about sexuality and conflict. J Youth Adolesc 1996; 25:307–21. Acknowledgments [20] Whitaker DJ, Miller KS, May DC, Levin ML. Teenage partners’ communication about sexual risk and condom use: The importance of parent-teenager This research uses data from Add Health, a program project discussions. Fam Plann Perspect 1999;31:117–21. directed by Kathleen Mullan Harris and designed by J. Richard [21] Dittus PJ, Jaccard J. Adolescents’ perceptions of maternal disapproval of sex: Udry, Peter S. Bearman, and Kathleen Mullan Harris at the Uni- Relationship to sexual outcomes. J Adolesc Health 2000;26:268–78. [22] Eisenberg ME, Sieving RE, Bearinger LH, Swain C, Resnick MD. Parents’ versity of North Carolina at Chapel Hill, and funded by grant communication with adolescents about sexual behavior: A missed oppor- P01-HD31921 from the Eunice Kennedy Shriver National Insti- tunity for prevention? J Youth Adolesc 2006;35:893–902. tute of Child Health and Human Development, with cooperative [23] McNeely C, Shew ML, Beuhring T, et al. Mothers’ influence on the timing of first sex among 14- and 15-year-olds. J Adolesc Health 2002;31:256–65. funding from 23 other federal agencies and foundations. Special [24] Jaccard J, Dittus PJ, Gordon VV. Maternal correlates of adolescent sexual and acknowledgment is owed to Ronald R. Rindfuss and Barbara contraceptive behavior. Fam Plann Perspect 1996;28:159–65. A. Khurana and E.C. Cooksey / Journal of Adolescent Health xx (2012) xxx 9

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