A R T I C L E S
Is Lack of Sexual Assertiveness Among Adolescent
And Young Adult Women a Cause for Concern?
By Vaughn I. Rickert,
Rupal Sanghvi
and Constance M.
Wiemann
CONTEXT: Understanding young women’s sexual assertiveness is critical to developing effective interventions to promote sexual health and reduce sexual risk-taking and violence. Young women’s perception of their sexual rights may
vary according to demographic characteristics, sexual health behaviors and victimization history.
METHODS: Data were collected from 904 sexually active 14–26-year-old clients of two family planning clinics in Texas,
Vaughn I. Rickert is
director of research
and evaluation,
Center for Community
Health and Education, Mailman School
of Public Health,
Columbia University,
New York. Rupal
Sanghvi is evaluation
officer, International
Planned Parenthood
Federation, Western
Hemisphere Region,
New York. Constance
M. Wiemann is
associate professor,
Department of
Pediatrics, Baylor
College of Medicine,
Houston.
178
reflecting their perceptions of their right to communicate expectations about or control aspects of their sexual encounters. Logistic regression analysis was used to assess which characteristics were independently associated with believing that one never has each specified sexual right.
RESULTS: Almost 20% of women believed that they never have the right to make their own decisions about contracep-
tion, regardless of their partner’s wishes; to tell their partner that they do not want to have intercourse without birth
control, that they want to make love differently or that their partner is being too rough; and to stop foreplay at any
time, including at the point of intercourse. Poor grades in school, sexual inexperience, inconsistent contraceptive use
and minority ethnicity were independently associated with lacking sexual assertiveness.
CONCLUSIONS: Many sexually active young women perceive that they do not have the right to communicate about or
control aspects of their sexual behavior. Interventions to prevent sexually transmitted diseases, unwanted pregnancy
and coercive sexual behaviors should include strategies to evaluate and address these perceptions.
Perspectives on Sexual and Reproductive Health, 2002, 34(4):178–183
An important part of adolescence is the development of sexuality and the achievement of good sexual health. Sexual
development is characterized by the acquisition of skills
used to control feelings of sexual arousal and to manage
the consequences of sexual behavior, as well as by the development of new forms of sexual intimacy.1 Despite the
complexity of this process, researchers and others concerned
with adolescent sexuality tend to focus only on whether
teenagers have had sexual intercourse and on whether they
have been involved in an unintended pregnancy.2 Consequently, research has examined outcomes of sexual behavior,
such as precocious sexual activity or unintended pregnancy, and little is known about the social interactions that accompany these behaviors.3 An important component of intimate social interactions is one’s repertoire of strategies for
promoting or discouraging sexual contact.4 Given the elevated risk of dating violence among adolescents5 and the
concomitant threats of unintended pregnancy and sexually transmitted diseases (STDs), increased understanding
of factors that promote effective communication about sexual contact is of considerable value.
A young woman’s ability to effectively communicate her
sexual beliefs and desires is a necessary step toward her
development of healthy sexual intimacy, and is critical if
she is to adequately protect herself against unwanted or
unsafe sexual activities.6 In the current cultural context,
where traditional gender roles establish the expectation
that men will initiate sexual activity and women will respond
with permission or denial,7 it is critical that young women
be able to clearly communicate their sexual beliefs and desires. Failure to do so may place them at risk for unintended
pregnancy, STDs, sexual coercion, violence and other negative sexual experiences.8
The construct of sexual assertiveness has been developed
to further the understanding of women’s communication
strategies to protect their sexual health and autonomy, and
is predicated on the assumption that women have rights
over their bodies and to behavioral expressions of their sexuality.9 For example, a young woman’s ability to engage in
safe sexual practices is dependent on her partner’s willingness to take measures to avoid unintended pregnancy
and STDs. If a young woman does not believe that she has
the right to assert her desire for effective protection, she increases her risk of pregnancy and infection, regardless of
whether she experiences any overt sexual coercion. Another
adolescent may not feel that she has the right to refuse sexual intercourse once she has had sex with a partner. Thus,
cognitive-behavioral interventions to promote sexual health,
as well as to reduce sexual risk-taking and unwanted sexual experiences, should be grounded in an understanding
of adolescent and young adult women’s perceived sexual
assertiveness.
Research examining beliefs and attitudes about sexual
behaviors among adolescent females is limited. However,
Perspectives on Sexual and Reproductive Health
a study conducted among a large sample of young adult
women found that the anticipation of negative reactions from
male partners was significantly associated with decreased
abilities to refuse unwanted sex and to effectively engage in
pregnancy and STD prevention; another important finding
was that previous sexual experience was associated with
an increased ability to initiate intimate behavior.10 It is less
clear, however, if beliefs about sexuality vary by demographic
characteristics, such as race and ethnicity, or by sexual behaviors, such as having multiple sexual partners. This article examines how perceived sexual assertiveness varies according to women’s demographic characteristics, sexual
health behaviors and history of violence.
DATA AND METHODS
Sample
Female clients of two Title X–funded, community-based
family planning clinics operated by the University of Texas
Medical Branch at Galveston were recruited by a bilingual
research assistant between April and November of 1997.
All sexually active women aged 14–26 who identified themselves as being white, black or Hispanic, who were not currently pregnant or were less than six weeks postpartum,
and who did not demonstrate any obvious cognitive or mental impairment were eligible to participate in the study. (Although we attempted to consecutively recruit participants,
it is likely that we missed some eligible women because of
clinic traffic patterns or scheduling.) The research assistant outlined study requirements and eligibility criteria in
Spanish or in English. After giving oral informed consent,
each woman completed an anonymous self-administered
questionnaire in English or Spanish; participants received
five dollars as compensation for their time and effort. The
methods used to recruit participants and the study procedures, including the questionnaire, have been described
in more detail elsewhere.11
Of 990 potential participants, 904 agreed to take part
in the study and completed the questionnaire. (Fifty-four
women refused to participate because of time constraints;
32 agreed to participate but did not complete the questionnaire.) The only difference noted between those who
completed the questionnaire and those who refused or did
not finish was that women who refused or did not finish
were more likely than those who completed the questionnaire to speak only Spanish. Therefore, our results may not
be representative of young women attending these family
planning clinics who speak only Spanish.
Questionnaire
We pilot-tested the questionnaire on a sample of 25 women
to ensure readability, ease of understanding and reasonable completion time. The final 12-page instrument contained five sections: demographic characteristics (e.g., age,
race and ethnicity), reproductive characteristics (e.g., parity, gravidity and age at menarche), contraceptive use and
high-risk sexual behaviors (e.g., number of sexual partners,
use of drugs prior to sex), lifetime history of physical or
Volume 34, Number 4, July/August 2002
sexual violence, and perceived sexual assertiveness. The
last section consisted of 13 items starting with the phrase
“I have the right to”; participants indicated whether they
felt that they never, sometimes or always have the right to
engage in each behavior.12
Statistical Analyses
Participants were categorized as being in one of three age
groups: 14–17, 18–21, or 22 or older. Each women was asked
what letter grades she typically received in her last year of
school; answers were coded into three categories: B average or higher, C average, or less than a C average. Sexual
experience was based on the participants’ lifetime number
of sexual partners: 1–2, 3–5, or six or more. Participants
who reported using birth control sometimes, about half of
the time or most of time in the last year were defined as inconsistent contraceptive users; women who reported using
some form of contraception at each act of intercourse were
defined as consistent users. We classified a woman as having a history of physical violence if she affirmed that someone (a parent, sibling, boyfriend, friend or stranger) had
ever hit, slapped, kicked or otherwise physically hurt her
enough to cause bruising or bleeding; we considered a
woman to have experienced sexual assault if she indicated that she had ever been touched without her permission,
forced to touch someone or forced to have intercourse.
We conducted logistic regression analyses to assess which
characteristics were independently associated with believing
that one never has each specified sexual right. All analyses
controlled for the effects of age, race and ethnicity, sexual
experience, academic grade average, parity, consistent contraceptive use in the last year and lifetime history of physical and sexual assault.
RESULTS
Overall, 27% of respondents were aged 14–17 years, 43%
were 18–21 and 30% were 22–26. The sample was almost
equally divided among white, black and Hispanic women.
Approximately half (54%) of respondents reported using
birth control at every sexual encounter in the last year; 44%
had one or more children. Of the total sample, 13% reported
early menarche (age 10 or younger), 32% had had six or
more sexual partners, 34% had a history of physical assault
and 21% had a history of sexual assault.
The proportion of respondents who reported believing
that they never have specific sexual rights ranged from 8%
to 49% (Table 1, page 180). Specifically, 8–9% believed that
they never have the right to make their own decisions about
sexual activity, regardless of their partners’ wishes, or to
tell their partners when they are or are not interested in sex,
or when they want to be hugged or cuddled without having sex. Larger proportions (15–19%) believed that they
never have the right to make decisions about contraception regardless of their partners’ wishes; to tell their partner that they do not want to have intercourse without birth
control, that they want to make love differently or that he
is being too rough; to ask their partner if he has been ex-
179
Lack of Sexual Assertiveness Among Young Women
TABLE 1. Percentage distribution of family planning clinic
clients aged 14–26, by how frequently they believe they can
assert various sexual rights
Sexual right and perceived frequency
of assertiveness
%
(N=904)
To make own decisions about sexual activity,
regardless of partner’s wishes
Never
Sometimes
Always
9
13
78
To make own decision about birth control,
regardless of partner’s wishes
Never
Sometimes
Always
17
15
69
To tell partner “I want to make love”
Never
Sometimes
Always
9
30
61
To tell partner “I do not want to make love”
Never
Sometimes
Always
8
30
62
To tell partner “I won’t have sex without birth control”
Never
Sometimes
Always
16
18
66
To tell partner “I want to make love differently”
Never
Sometimes
Always
16
34
50
To masturbate to orgasm
Never
Sometimes
Always
49
18
33
To tell partner he is being too rough
Never
Sometimes
Always
19
28
53
To tell partner “I want to be hugged or
cuddled without sex”
Never
Sometimes
Always
8
30
62
To tell relative “I am not comfortable being
hugged or kissed in certain ways”
Never
Sometimes
Always
27
15
57
To ask partner if he has been examined for STDs
Never
Sometimes
Always
15
13
72
To stop foreplay at any time, including at
the point of intercourse
Never
Sometimes
Always
18
27
55
To refuse to have sex even if she has enjoyed it
with this partner before
Never
Sometimes
Always
17
28
55
Total
180
100
amined for STDs; to stop foreplay at anytime, including at
the point of intercourse; and to refuse to have intercourse,
even though they may have had sex with that partner before and enjoyed it. However, 27% felt that they never have
the right to tell a relative that they are uncomfortable being
hugged or kissed in certain ways, and 49% reported that
they never have the right to masturbate to orgasm.
On the other hand, roughly 50–60% of women believed
that they always have the right to tell their partner that they
want to make love differently and that he is being too rough;
to tell a relative that they are not comfortable being hugged
or kissed in certain ways; to stop foreplay at anytime; and
to refuse to have sex even though they may have had sex
with that partner before and enjoyed it. More than 60% reported that they always have the right to make their own
decisions about sex and contraception regardless of their
partner’s wishes; to tell their partner when they are interested or not interested in sex, that they refuse to have sex
without birth control or that they want to hug or cuddle
without sex; and to ask their partner is he has been examined for STDs
Results of the logistic regression analyses show that a
young woman’s background characteristics, sexual and reproductive history, and history of abuse are important predictors of her level of sexual assertiveness (Table 2). In comparison with white women, black and Hispanic women have
significantly higher odds of perceiving that they never have
11 of the 13 sexual rights studied (odds ratios, 1.6–3.1),
including rights that would help them prevent acquiring
an STD or becoming pregnant unintentionally. Women with
poor grades in school had elevated odds of sharing seven
of these perceptions; for example, those with less than a C
average were more likely than those with better grades to
indicate that they can never stop foreplay or deny intercourse to a familiar partner (1.8 for each). Age has few effects on sexual assertiveness; most important, perhaps,
women aged 18–21 had higher odds than older women of
considering themselves unable to ask a partner if he has
had an STD test (1.7)
Of the factors related to a woman’s sexual and reproductive history, lifetime number of sexual partners emerged
as the most consistent predictor of her sexual assertiveness:
Women who had had only one or two partners were more
likely than those who had had six or more to believe that
they never have 10 of the 13 rights (odds ratios, 1.7–3.3).
Inconsistent contraceptive use was associated with about
half of the rights examined (1.5–1.9), and most of these
can affect a woman’s risk of having an unintended pregnancy. Women who had had one or more births were more
likely than those who had never given birth to feel that they
never have the right to masturbate to orgasm or to stop foreplay at any time (1.6–1.7).
Finally, physical or sexual victimization was associated
with four beliefs about sexual rights. For example, women
who had never been physically assaulted had elevated odds
of never feeling they have the right to refuse intercourse
with a familiar partner (odds ratio, 1.7), and those who rePerspectives on Sexual and Reproductive Health
TABLE 2. Adjusted odds ratios (and 95% confidence intervals) from logistic regression analyses assessing the effects of selected
characteristics on women’s belief that they never have certain sexual rights
Characteristic
To make own decisions about sexual activity,
regardless of partner’s wishes
1–2 lifetime partners*
History of sexual assault
Odds ratio
2.48 (1.33–4.62)
1.96 (1.07–3.57)
To make own decision about birth control,
regardless of partner’s wishes
1–2 lifetime partners*
1.96 (1.01–2.57)
To tell partner "I want to make love"
Black†
Hispanic†
1–2 lifetime partners*
2.14 (1.10–4.16)
2.04 (1.07–4.04)
3.26 (1.64–6.68)
To tell partner "I do not want to make love"
Black†
C average‡
<C average‡
1–2 lifetime partners*
Inconsistent contraceptive use
No history of physical assault
2.18 (1.12–4.25)
2.09 (1.18–3.72)
2.81 (1.28–6.14)
2.63 (1.31–5.26)
1.72 (1.03–2.87)
2.05 (1.08–3.89)
Characteristic
Odds ratio
To masturbate to orgasm (cont’d.)
1–2 lifetime partners*
≥1 birth
1.66 (1.15–2.40)
1.59 (1.17–2.16)
To tell partner he is being too rough
Black†
Hispanic†
1–2 lifetime partners*
No history of physical assault
1.71 (1.08–2.70)
1.90 (1.19–3.05)
1.81 (1.14–2.89)
1.60 (1.05–2.41)
To tell partner “I want to be hugged or
cuddled without sex”
Black†
Hispanic†
<C average‡
1–2 lifetime partners*
Inconsistent contraceptive use
3.09 (1.46–6.54)
2.58 (1.20–5.63)
2.06 (1.01–4.23)
2.85 (1.36–5.99)
1.85 (1.10–3.12)
To tell relative "I am not comfortable being
hugged or kissed in certain ways"
Hispanic†
1.58 (1.07–2.33)
To ask partner if he has been examined
for STDs
18–21§
Hispanic†
Inconsistent contraceptive use
1.66 (1.02–2.71)
1.67 (1.02–2.72)
1.50 (1.02–2.21)
1.75 (1.10–2.79)
1.65 (1.02–2.68)
1.75 (1.01–3.07)
1.98 (1.22–3.21)
1.49 (1.04–2.14)
1.66 (1.13–2.45)
1.91 (1.18–3.07)
1.81 (1.03–3.19)
1.88 (1.16–3.04)
1.52 (1.05–2.19)
1.65 (1.08–2.53)
To tell partner "I won’t have sex without
birth control"
Black†
Hispanic†
<C average‡
Inconsistent contraceptive use
1.97 (1.22–3.17)
1.82 (1.10–2.99)
1.86 (1.06–3.27)
1.93 (1.32–2.81)
To tell partner "I want to make love differently"
14–17§
Black†
Hispanic†
<C average‡
1–2 lifetime partners*
2.25 (1.31–2.87)
2.45 (1.48–4.07)
2.58 (1.54–4.25)
1.85 (1.05–3.27)
2.46 (1.50–4.03)
To stop foreplay at any time, including at
the point of intercourse
Black†
Hispanic†
<C average‡
1–2 lifetime partners*
Inconsistent contraceptive use
≥1 birth
To masturbate to orgasm
14–17§
18–21§
Black†
Hispanic†
C average‡
<C average‡
2.06 (1.37–3.11)
1.43 (1.01–2.01)
1.69 (1.20–2.37)
2.48 (1.73–3.57)
1.36 (1.01–1.85)
2.34 (1.43–3.83)
To refuse to have sex even if she has enjoyed it
with this partner before
Hispanic†
<C average‡
1–2 lifetime partners*
Inconsistent contraceptive use
No history of physical assault
*Reference group is six or more lifetime partners. †Reference group is white. ‡Reference group is B average or higher. §Reference group is is 22–26-year-olds. Notes:
Consistency of contraceptive use reflects clients’ use in the past year. Results are presented only for associations that are significant at p<.05.
ported a history of sexual assault had a higher likelihood
than others of feeling that they can never make their own
decisions about sexual activity (2.0).
DISCUSSION
Sexually assertive beliefs, behaviors and practices—including
acquiring knowledge about preventing pregnancy and STDs;
adopting health-promoting values, attitudes and norms;
and building proficiency in risk-reduction skills—are important components in the development of sexual health
during adolescence.13 Although we found that many adolescent and young adult women reported having sexually
assertive beliefs, almost 20% perceived that they never have
the right to refuse to have sexual intercourse, to ask their
partner if he has been examined for STDs or to say when
their partner is being too rough. These data are of concern,
as they represent the beliefs of a sexually experienced group
who may be vulnerable to unsafe sexual practices. Thus, it
is erroneous to assume that young women who attend Title
Volume 34, Number 4, July/August 2002
X clinics are more assertive about their own sexuality because they are seeking reproductive health care. Our findings highlight the importance of understanding how adolescents develop strategies and skills to negotiate sexual
behaviors within the context of romantic relationships, so
that effective programs for preventing STDs, pregnancy and
relationship violence may be developed.
Self-reported minority race or ethnicity and younger age
were associated with a relatively low level of sexual assertiveness. Black and Hispanic women were more likely than
white women to report believing that they never have most
of the sexual rights examined, including the right to tell a
partner “I won’t have intercourse without birth control.”
Younger women were more likely than older women to report believing that they never have the right to ask a partner if he has been examined for STDs. These findings may
help to explain why adolescents are more likely than adults
to acquire STDs,14 and why minority adolescents are at greatest risk.15 Previous research among young adult women has
181
Lack of Sexual Assertiveness Among Young Women
found that peers, the social culture and the interaction of
peers and the culture are important influences on managing sexual relationships and behaviors.16 Thus, effective programs to promote safer sexual behaviors among minority
young women need to assess the specific subculture’s beliefs and attitudes before addressing skill development.
Another important variable that contributed to young
women’s belief that they never have various sexual rights
was academic performance. Of critical concern is the finding that young women with poor grades often felt that they
could not stop foreplay or refuse to have intercourse with
a familiar partner. Thus, in addition to encouraging adolescents to stay in school, it is equally important to focus
on their school performance to facilitate sexual health
among this vulnerable population. Teenagers who achieve
better grades may feel more connected to school, which
may in turn be protective against a broad range of risky behaviors.17 Alternatively, youth who have greater sexual assertiveness may have a higher level of self-confidence, which
enables them to perform well in a variety of settings, including school.
Young women who reported having had one or two lifetime sexual partners held fewer sexually assertive beliefs
than those who were more sexually experienced. In addition, women who reported inconsistent contraceptive use
in the last year believed that they did not have many sexual rights. These data are consistent with prior research associating sexual assertiveness with sexual experience18 and
with contraceptive use.19 In contrast, few differences
emerged between the beliefs of young women who had and
had not borne children; the differences found suggest that
parous women may be more sexually passive and more concerned about their partner’s feelings and desires than about
their own.20
A young woman’s physical and sexual victimization history is also relevant to her sexual assertiveness. In a previous study, black adolescent females with a history of dating violence were almost three times more likely than others
to have an STD; these young women were also more likely to fear the perceived consequences of negotiating condom use, to fear talking with their partner about pregnancy prevention, to believe that they were at risk of acquiring
an STD, to believe that they have little control over their
sexuality and to have peer norms that were not supportive
of using condoms and of having a healthy relationship.21
Our data suggest that young women without a history of
physical assault were more likely than those who had been
physically assaulted to believe that they could never tell
their partner that he was being too rough or that they could
never deny intercourse to a familiar partner. These findings
are inconsistent with other work that has found victimization related to sexual assertiveness,22 which perhaps is
a function of resilience, and should be further studied. Our
data suggest that among women who have been assaulted,
sexual assertiveness, particularly in regard to refusal of intercourse, is increased, perhaps as a function of this victimization. Thus, a greater understanding of the process182
es that occur after assault may help improve programs designed to prevent sexual assault.
Three important limitations of our study deserve comment. First, responses to our survey questions do not necessarily represent young women’s behavior or their ability to engage in requisite behaviors to prevent unintended
pregnancy, disease or victimization; rather, they reflect young
women’s perception of their sexual rights. Further research
exploring sexual assertiveness needs to illuminate the relationships among perceived beliefs, intended behavior and
actual behavior. Second, we examined the beliefs only of
sexually active adolescents and young adult women; the
perceptions of women who are not sexually active may be
quite different. Finally, we surveyed women seeking reproductive health care from a federally funded program,
who were predominately from lower socioeconomic levels. It is unclear whether these results are generalizable to
women of higher socioeconomic levels or to those who live
in other locations.
Our data suggest that a significant proportion of young
women who are seeking reproductive health care have limited beliefs that they can control their own sexuality. Providing sexual health promotion programs within the school
setting represents an effective public health strategy to enhance the sexual assertiveness of young women.23 Although
many adolescents report obtaining information on sexual
health through schools, the content of these interventions
is not uniform24 and may lack important features to enhance
skill acquisition. Thus, sexual health programs should not
be confined to schools. Interventions to improve sexual
health (including sexual assertiveness) should be extended to other community settings, such as reproductive health
clinics; ideally, such programs should be tailored to targeted
groups to increase their relevance and effectiveness.
Interventions that target clients of Title X–supported clinics provide services to a high-risk population and, thus, may
have widespread benefits. For example, offering assertiveness counseling to young women with newly diagnosed
STDs may help reduce the likelihood of reinfection. Brief
individual counseling programs within clinics have been
shown to reduce sexual risk behaviors and decrease rates
of STD reinfection.25 In addition, clinic programs provide
care to mothers of female children and adolescents, and
mothers are important in reducing adolescents’ sexual risktaking, since they are generally the primary communicators on sex-related topics.26 Furthermore, adolescent females’ confidence in their ability to negotiate condom use
or to refuse sex rises as the frequency with which they discuss sexual topics with their mother rises.27
Clinic staff can encourage and support parent-adolescent communication about sexuality, including by providing
information on the importance of sexual beliefs that lead
to safer-sex practices. For example, clinicians could ask parents if they talk with their daughters about sex-related topics, and when dealing with adolescents, clinicians could
inquire about their ability to discuss sexuality with their
parents, especially their mother. Sexual health programs,
Perspectives on Sexual and Reproductive Health
especially those in a clinical setting, can teach and facilitate parental skills, so that mothers and daughters are able
to communicate about these issues; this, in turn, increases the ability of young women to carry on these conversations with their partners.28
To date, research examining adolescent sexual behavior
has been motivated largely by the health and social problems that result when young people engage in intercourse,
such as sexual assault, unwanted pregnancy and STDs.29
Previous research has focused mainly on examining the correlates of early sexual initiation and condom use, rather
than on understanding the sexual health and the antecedents of sexual behavior.30 Secrecy that continues to
surround sexual behavior in our society has hindered open
communication about sexuality. In addition, sexuality is
conceptualized in a negative and problematic context.31
Thus, our understanding of the development of adolescent
sexuality is limited and must improve to speed progress
toward meeting the nation’s public health objectives of decreasing unintended pregnancy, STDs and sexual violence.32
13. DiClemente RJ, Development of programmes for enhancing sexual health, Lancet, 2001, 358(9296):1828–1829.
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9. Ibid.
10. Ibid.
11. Rickert VI, Wiemann CM and Berenson AB, Prevalence, patterns,
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active adolescents and young adults, Pediatrics, 1999, <http://www.
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12. Counseling Center, State University of New York at Buffalo,
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Volume 34, Number 4, July/August 2002
23. DiClemente RJ, 2001, op. cit. (see reference 13).
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adolescents: the relation of parent and partner communication to adolescent condom use, Journal of Adolescence, 1994, 17(2):137–148.
29. Whitaker DJ et al., Teenage partners’ communication about sexual risk and condom use: the implications of parent-teenage discussions,
Family Planning Perspectives, 1999, 31(3):117–121.
30. Ibid.
31. DiMauro D, Sexuality Research in the United States: An Assessment of
the Social and Behavioral Sciences, New York: Social Science Research
Council, 1996, p. 17; and Eng TR and Butler WT, 1997, op. cit. (see reference 15).
32. Whitaker DJ, Miller KS and Clark LF, 2000, op. cit. (see reference
3).
Acknowledgment
The research on which this article is based was funded in part by
the Hogg Foundation for Mental Health.
Author contact: vir2002@columbia.edu
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