Risky sexual behaviors among Malay adolescents: a comparison with Chinese adolescents in Singapore.

OBJECTIVE: Malays, with majority of the individuals being Muslim, form the largest ethnic group in Southeast Asia. This region is experiencing a rising incidence of HIV infections. Due to circumcision and prohibition of sex outside marriage, being Muslim was argued to be a protective factor against sexually transmitted infections (STI) and Human Immunodeficiency Virus (HIV). However, Malay adolescents were found to be more likely to contract chlamydia and gonorrhea than non-Malay adolescents in Singapore. DESIGN: Using a cross-sectional survey, we examined and compared safer sex knowledge, attitudes and self-efficacy, and sexual behaviors of 248 sexually active Malay adolescents with 384 Chinese adolescents aged 16-19 years in Singapore. Poisson regression, adjusted for socio-demographic characteristics, was used for modeling each dependent variable. Adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) were obtained. RESULTS: On multivariate analysis, Malay adolescents were more likely to report marginally unfavorable attitude towards condom use (aPR 1.21 CI 1.00-1.48) and significantly lower confidence in using condoms correctly (aPR 1.24 CI 1.05-1.47) than Chinese adolescents. They were also more likely to report significantly younger first sex age (aPR 0.98 CI 0.96-1.00), never use of condoms for vaginal sex (aPR 1.32 CI 1.16-1.49) and anal sex (aPR 1.75 CI 1.11-2.76) and non-use of contraceptives at last sex (aPR 1.30 CI 1.17-1.45) than Chinese respondents. Malay males were less likely to buy sex (aPR 0.56 CI 0.37-0.85), but they reported higher likelihood of inconsistent condom use with female sex workers (aPR 2.24 CI 1.30-3.87). CONCLUSION: Malay ethnicity was associated with unfavorable condom use attitude and lower self-efficacy in using condoms, which was consistent with risky sexual behaviors such as non-use of condoms. Future research should use mixed methods to explore and identify cultural influences to these behaviors.

Determinants of Heterosexual Adolescents Having Sex with Female Sex Workers in Singapore.

OBJECTIVES: We assessed the proportion of and socio-ecological factors associated with ever having had sex with female sex workers (FSWs) among heterosexual adolescents. We also described the characteristics of the adolescents who reported inconsistent condom use with FSWs. METHODS: This is a cross-sectional study (response rate: 73%) of 300 heterosexually active male adolescents of 16 to 19 years attending a national STI clinic in Singapore between 2009 and 2014. We assessed the ecological factors (individual, parental, peer, school and medial influences) and sexual risk behaviors using a self-reported questionnaire. Poisson regression was used to obtain the adjusted prevalence ratios (aPR) and confidence intervals (CI). RESULTS: The proportion of heterosexual male adolescents who had ever had sex with FSWs was 39%. Multivariate analysis showed that significant factors associated with ever having had sex with FSWs were sex initiation before 16 years old (aPR 1.79 CI: 1.30-2.46), never had a sexually active girlfriend (aPR 1.75 CI 1.28-2.38), reported lower self-esteem score (aPR 0.96 CI: 0.93-0.98), higher rebelliousness score (aPR 1.03 CI: 1.00-1.07) and more frequent viewing of pornography (aPR 1.47 CI: 1.04-2.09). Lifetime inconsistent condom use with FSWs was 30%. CONCLUSIONS: A significant proportion of heterosexual male adolescents attending the public STI clinic had ever had sex with FSWs. A targeted intervention that addresses different levels of influence to this behavior is needed. This is even more so because a considerable proportion of adolescents reported inconsistent condom use with FSWs, who may serve as a bridge of STI transmission to the community. National surveys on adolescent health should include the assessment of frequency of commercial sex visits and condom use with FSWs for long-term monitoring and surveillance.

Gender Differences in Factors Associated With Anal Intercourse Among Heterosexual Adolescents in Singapore.

Using a cross-sectional survey, we examined the gender differences in prevalence of and factors associated with anal sex among adolescents attending the only public STI clinic in Singapore. Data were collected from 1035 sexually active adolescents aged 14 to 19 and analyzed using Poisson regression. Prevalence of anal intercourse was 28%, with significantly more females (32%) than males (23%) ever engaged in it. On multivariate analysis, the factors associated with anal intercourse for both genders were oral sex and the nonuse of contraception at last sex. For males, anal intercourse was associated with younger age of sexual debut and greater perceived external control. Among females, it was associated with higher rebellious scores and lack of confidence to resist peer pressure to engage in sex. Consistent condom use for anal sex was 22% and 8% for males and females, respectively. STI prevention programs for adolescents should address anal sex, be gender-specific, and take into consideration individual personality characteristics.