Sexual risk behavior and pregnancy in detained adolescent females: a study in Dutch detention centers

At the time of this study, seven Juvenile Justice Institutions (JJIs; detention centers) provided closed placement for adolescent females, of which three participated in this study (covering 57% of all places nationwide). As this study covered the majority of the available places, and because females are placed in a JJI on a random basis (when a place is available), this study sample was considered representative for the population of detained girls in the Netherlands. Between September 2002 and April 2004, all newly admitted girls (N = 256) were approached for participation in their first month of detention, of whom 229 (89.5%) agreed to participate. Of the 27 non-participants, 19 (7.4%) refused participation, while another 8 (3.1%) were not able to participate because of an insufficient command of the Dutch language. Another 17 girls were excluded because they were released before or during the study, or because they had not completed the questions on pregnancy, bringing the final group included in the analyses to 212. Approximately equal numbers of participants were recruited from each of the three institutions. The age of the participants varied from 12 to 18 years (mean 15.6; SD 1.4), and ethnicity could be broken down as follows: 57.2% Dutch ethnicity, 14.6% Surinamese, 7.8% Moroccan, 3.9% Antillean, 1.5% Turkish, and 15.1% other. In 81.1% of cases, the girls had been placed in the institution under a civil law measure. Considering previous placements, 35.2% of the participants had previously been placed in a JJI, and more than 72.2% had previously undergone a residential placement of some kind (other than JJI). Considering previous care, 16.8% of the girls had a history of foster care and 74.2% had received some kind of outpatient care. In terms of the socio-economic backgrounds, about half of the mothers (48.6%) had a lower level of education and over half (57.5%) were unemployed, whereas over half of the fathers (61.3%) had a lower level of education and almost half (45.3%) were unemployed (see also table 1).

The project was approved by the review boards of the Ministry of Justice, which imposed strict conditions in terms of confidentiality, appropriate handling of information and the participants' assent for participation and for contacting the parents. Shortly after admission (within one week), all eligible girls were approached individually by the interviewers in order to explain the purpose of the study. It was explained and written on the consent form that participation was voluntary, that refusal would not affect their legal status and that confidentiality was guaranteed. Participants were by no means forced to participate. The participants signed a consent form before the study commenced. The parents or primary caregivers were informed by letter. Parents could object to their daughter's participation, which only occurred for one participant. The consent procedure was carried out at least one week before the assessment. The instruments were presented and completed in a fixed order. First, participants were asked to fill in self-report questionnaires in groups of 3 girls at a time, and subsequently, the interview was carried out individually, preferably on the same day. When administering self-report questionnaires, a researcher was present and available for questions.

The SPSS (Statistical Package for Social Sciences, version 11.0) statistical program has been used for analyzing the data. First, descriptive statistics were provided on pregnancy. Second, individuals from the pregnancy group and the non-pregnancy group were compared in terms of sexuality related factors and other risk factors (socio-demographic and mental health characteristics) using Chi-square tests (Fisher Exact when expected cell counts less than 5). The level of statistical significance (two sided) was set at .05. Third, all factors shown in tables 2 and 3 with a p-value < 0.1 (sexual risk behavior, sexual trauma, multiple sex partners and early maturity and drug use disorder, suicidality, and age) were incorporated as potential predictors in the multiple logistic regression analysis with pregnancy as the dependent variable. The forward method was used (adding variables one-by-one). The odds-ratios represented show how much more likely the presence of these factors is in the pregnancy group as compared to the non-pregnancy group, adjusted for the other variables in the model.

We divided our sample into two groups: a pregnancy group (N = 43, 20%) and a non-pregnancy group (N = 169, 80%). Twenty percent of the participants reported one or more pregnancies ever, while none of the girls had actually given birth to a child. No information was found on specific method of termination of pregnancy in the files. Medical files also hardly revealed miscarriages or abortions, abortions were mentioned only in 7 cases.

The ages of the total group ranged from 12 to 19, (mean age 15.57; SD = 1.39). The mean age of the girls in the pregnancy group (16.07; SD 1.39) was significantly higher than the girls in the non-pregnancy group (15.45; SD 1.31; p = 0.009). In table 1 other sociodemographic characteristics of the pregnancy and the non-pregnancy group are shown, such as judicial measure, level of education and employment of the parents, history of placements, history of foster care and outpatient care, and ethnicity. None of these characteristics differed significantly between the pregnancy and the non-pregnancy groups. Total IQ didn't differ either between both groups (pregnancy group:mean IQ: 88.5 SD 15.4;non-pregnancy group: mean IQ: 88.7 SD 15.6; p = 0.934).

Differences in sexuality related and mental health related characteristics between pregnancy and non-pregnancy groups are shown in tables 2 and 3. A number of sexuality related characteristics differed between the pregnancy group and the non-pregnancy group; sexual risk behavior, multiple sex partners and sexual trauma were more prevalent in the pregnancy group than in the non-pregnancy group. There was no difference between groups in (lack of) assertiveness in sexual issues. In the medical files only in 17 cases use of oral contraceptives was mentioned. By self-reports (N = 206) 25 girls (12.1%) mentioned no or insufficient use of contraception the last time they had sex, 7 (17.1%) were in the pregnancy group and 18 (10.9%) in the non-pregnancy group (p = 0.279). Early maturity showed a trend (p < 0.1) towards being significantly higher in the pregnancy group. As for the mental health characteristics, drug use disorder and suicidality showed a trend in the same direction. There were no significant differences between the groups in terms of conduct disorder and alcohol use disorder. In the medical files only in 13 cases use of methylfenidate was mentioned.

In table 4 the predictive value of risk factors for pregnancy are shown. Variables with p < 0.1 in tables 2 and 3 were included in the regression (i.e. suicidality, sexual risk, early maturity, age, drug use disorder, sexual trauma and multiple sex partners. It is shown that four variables, i.e. age, early maturity, sexual risk behavior and suicidality, predicted pregnancy group membership.

The lifetime prevalence of teenage pregnancy among detained girls is high and associated with both sexuality related characteristics and mental health characteristics. Therefore, the diagnostic assessment of detained adolescent females should be comprehensive and include adequate psychological and psychiatric assessment as well as a comprehensive assessment of sexual risk. Clinicians should realize that a history of teenage pregnancy could indicate a certain combination of risk factors. Future research should evaluate whether intervention programs will result in a reduction of teenage pregnancy in this sample.

Some limitations of this study should be mentioned. First, only self-report information was available for most participants. Sexuality is a sensitive topic and it is conceivable that subjects, consciously or unconsciously, have provided social desirable answers (e.g. regarding assertiveness in sexual matters). Secondly, the cross-sectional nature of the study did not allow us to investigate causal pathways between possible risk factors and pregnancy. For this purpose, longitudinal studies assessing adolescent females before and after detention should be conducted. Thirdly, we were not able to compare groups on education or time in residential care. We forwent comparisons on psychopathological comorbidity as this was described in another publication focusing on psychopathology and aggression (Hamerlynck et al, 2007, in press). A relevant finding in this respect was that 20.8% of the girls had a diagnosis of ADHD.

Finally, it is unknown whether these findings can be generalized to detained girls in other countries, as cross-cultural differences may exist. However, as mentioned above, many results approximate results reported in North American samples of detainees, so it is likely that, in these girls, risk factors for pregnancy are similar across Western countries.