Journal of Adolescent Health 70 (2022) 607e616

www.jahonline.org

Original article

Regional and Sex Differences in the Prevalence and Correlates of

Early Sexual Initiation Among Adolescents Aged 12e15 Years in
50 Countries
Sayedul Ashraf Kushal, M.D. a, Yahia Md Amin, M.Sc. a, Shusama Reza, M.D. a,
Fariha Binte Hossain, M.Sc. b, and Md Shajedur Rahman Shawon, D.Phil. c, *
a
Research Division, Lifespring, Panthapath, Dhaka, Bangladesh
b
School of Population Health, UNSW Sydney, New South Wales, Australia
c
Centre for Big Data Research in Health, UNSW Sydney, New South Wales, Australia

Article history: Received May 28, 2021; Accepted October 20, 2021
Keywords: Early sex; Early sexual initiation; Early sexual debut; Adolescents; Young adults; Regional; Sex differences; Correlates;
Factors associated

See Related Editorial on p.523

A B S T R A C T
IMPLICATIONS AND
CONTRIBUTION
Purpose: This study aimed to investigate the regional and sex differences in the prevalence of early
sexual initiation and its correlates among school-going adolescents in 50 countries.
This study provides sex-
Methods: We used data from the Global School-based Health Survey from 50 countries in 2009e2015 specific estimates for early
for 124,091 adolescents (53.5% girls) aged 12e15 years. Using meta-analysis with random effects, we sexual initiation among
estimated the prevalence of early sexual initiation (i.e., having first sexual intercourse at
14 years) by adolescents in accordance
sex, region, and country income classification. Multilevel mixed-effect logistic regressions including a with country, WHO
random intercept for countries were used to investigate the correlates of early sexual initiation. regions, and the World
Results: Overall, 14.2% (95% confidence interval: 12.1e16.2) of adolescents aged 12e15 years had Bank country income
early sexual initiation, with boys reporting much higher than girls (19.7%, 16.9e22.5 vs. 8.9%, 7.6 groups. Findings will help
e10.3). The prevalence of early sexual initiation was the highest in the region of the Americas shaping strategies for
(18.4%, 15.2e21.5) and the lowest in the South-east Asia region (5.3%, 2.6e8.0). Adolescents from reducing early sexual
high-income and lower middle-income countries had the highest (19.5%, 13.5e25.5) and the initiation and
lowest (7.3%, 5.5e9.0) prevalence, respectively. Older age, anxiety, loneliness, suicidal ideation, subsequently other risky
being bullied, physical fight, school truancy, smoking, drinking alcohol, illicit drug use, physical sexual behaviors among
activity, and being overweight were associated with higher odds of early sexual initiation, whereas adolescents from different
female sex, parental monitoring, and peer support were protective. There was little or no evidence regions.
of heterogeneity by sex and across regions for these associations.
Conclusions: Substantial differences in the prevalence are observed by sex and across regions for
early sexual initiation among adolescents, whereas its correlates remain relatively similar when
examined separately by these characteristics.
Ó 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Conflicts of interest: The authors have no conflicts of interest to disclose. First sexual intercourse before 15 years of age is often
* Address correspondence to: Md Shajedur Rahman Shawon, D.Phil., Centre
considered as early sexual initiation [1,2]. Early sexual initiation
for Big Data Research in Health, UNSW Medicine, Level 2, AGSM Building (G27),
UNSW Sydney, NSW 2052 Australia. among adolescents is an important aspect of adolescent sexual
E-mail address: s.shawon@unsw.edu.au (M.S.R. Shawon). and reproductive health, particularly due to its downstream

1054-139X/Ó 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jadohealth.2021.10.027
608 S.A. Kushal et al. / Journal of Adolescent Health 70 (2022) 607e616

negative impacts on physical and mental health during adoles- either absent or collected using different questions in the ques-
cence and in later life. Many previous studies have reported that tionnaire. For countries where more than one surveys were
early sexual debut is associated with sexually transmitted in- conducted in the period of 2009e2015, the latest survey was
fections, HIV/AIDS, inconsistent contraception use, sexual included for analysis.
violence, unplanned and early pregnancies, and unsafe abortion The details about GSHS data have been described elsewhere
[3e7]. Early sexual initiation can also give rise to mental health [18] and summarized here. The GSHS is a population-based
problems, poor academic performance, and possible gateway to survey for school-going adolescents conducted in many coun-
nonsexual risk behaviors such as alcohol and illicit drug use [8e tries around the world with the support of WHO and the U.S.
11]. Despite all these negative consequences, a significant pro- Centers for Disease Control and Prevention (CDC) and in collab-
portion of adolescents engage in sexual intercourse in quite early oration with UNICEF, UNESCO, and UNAIDS. The main objectives
ages. Recent reports from the U.S. and other countries showed of the GSHS are to help countries develop appropriate in-
that the proportion of adolescents who experienced sexual in- terventions and policies for promoting adolescent health and to
tercourse before their 15th birthday ranged between 5% and 27% facilitate cross-country comparisons for various aspects of ado-
[2,12e15]. However, we observed wide variability in the under- lescents’ behaviors and protective factors.
lying age distribution of the study sample, and sexual activity is The GSHS uses the same methodology for sampling. Partici-
generally lower in younger adolescents than that in older ado- pants in the GSHS were selected using a standardized two-stage
lescents [12]. For these reasons, it is difficult to compare the rates cluster sampling process. At the first stage, schools were selected
of early sexual initiation across studies or over time from the using a probability-proportionate-to-size sampling method. At
existing evidence. the second stage, classrooms with students of the target age
The current evidence base for early sexual initiation among group were randomly selected from these schools, and all
adolescents is limited by several factors. First, although most students in the selected classrooms were asked to participate in
studies investigating early sexual initiation among adolescents the survey [18]. The age range of participating students varied
come from developed countries, a nascent body of evidence has across countries. We restricted our analysis to adolescents aged
been emerging from developing countries, particularly from 12e15 years because all countries had data for this age range.
using data from demographic and health surveys. However, The GSHS used a validated questionnaire which was self-
these surveys have limited information on factors that might be administered during one regular class period. Where necessary,
associated with early sexual initiation. Second, sexual and the questionnaire was translated into an appropriate language
reproductive health risks and outcomes are heavily influenced by using standard protocols, and country-specific examples, options,
complex interactions between social and cultural norms and and phrases were used to incorporate sociocultural adaptation [18].
gender scripts, which can translate into different sets of pre- In each participating country, the ethics approval for the GSHS
dictors and consequences of early sexual activity between boys was taken from a national government administrative body or an
and girls [2,16,17]. Therefore, it is important to explore correlates institutional ethics review committee, or both. Informed written
of early sexual initiation separately among boys and girls. Third, or verbal consent was taken from students’ parents or guardians,
differences in variable definitions, study populations, and and assent for participation was obtained from students. We
analytical approaches in the existing studies have made used publicly available data from the GSHS, so no separate ethics
cross-country and cross-region comparisons quite difficult. In approval was required for this study.
addition, no study thus far has compared the prevalence and
correlates of early sexual debut among adolescents across Variable definitions
various regions. To address these limitations and to help shaping
global adolescent sexual and reproductive health, a large-scale Our outcome variable of interest was participants’ age at first
epidemiological investigation into early sexual initiation among sexual intercourse. Participants were asked “How old were you
adolescents from different regions is needed. when you had sexual intercourse for the first time?” with the
The Global School-based Health Survey (GSHS) provides useful following responses: “I have never had sexual intercourse”,
data on sexual behaviors and a wide range of sociodemographic, “11 years old or younger”, “12 years old”, “13 years old”, “14 years
psychosocial, lifestyle, and protective factors among adolescents old”, “15 years old”, and “16 years old or older”. Early sexual
from many countries across various regions [18]. Using country- initiation was defined as having the first sexual intercourse
representative samples from the GSHS in 50 countries, in this before 15 years of age (i.e.,
14 years) [1,2].
study, we aimed to (1) estimate country-specific prevalence of We used 20 explanatory variables in our study: sex, age
early sexual initiation among adolescents aged 12e15 years; (2) group, proxy for below average socioeconomic status, anxiety,
compare the prevalence by sex, World Health Organization (WHO) loneliness, suicidal ideation, being bullied, parental support,
regions, and World Bank country income classifications; and (3) parental monitoring, parental supervision, parental respect of
investigate the sociodemographic, psychosocial, parental and privacy, physical fight, truancy, peer support, having close friend,
peer, and lifestyle correlates of early sexual initiation and their smoking, alcohol drinking, illicit drug use, physical activity, and
differences in accordance with sex and regions. overweight. Detailed descriptions of these variables and their
coding are presented in Supplementary Table S1. We grouped
Methods these variables into sociodemographic factors, psychosocial fac-
tors, parental and peer factors, and lifestyle factors.
Data sources
Statistical analysis
We used data from the GSHS surveys conducted between
2009 and 2015 in 50 countries. We did not include surveys We followed the instructions for GSHS data analysis provided
conducted before 2009 because the variables of our interest were by the CDC [18]. We computed country-specific weighted
 S.A. Kushal et al. / Journal of Adolescent Health 70 (2022) 607e616 609

prevalence estimates of early sexual initiation in accordance with Prevalence of early sexual initiation among adolescents
sex by using the sampling weights provided by the CDC. The
sampling weights accounted for nonresponse and the varying Overall, 14.2% (95% CI: 12.1e16.2) of adolescents aged
probability of selection of schools, classrooms, and students in 12e15 years had early sexual initiation, with boys reporting
the survey. The country-specific prevalence of early sexual much higher than girls (19.7%, 16.9e22.5 vs. 8.9%, 7.6e10.3)
initiation can be influenced by the underlying age distribution of (Figure 1). The prevalence of early sexual initiation was the
the survey sample. For fairer comparison across countries, we highest in the region of the Americas (18.4%, 15.2e21.5) and the
estimated the prevalence adjusted for age distribution in the lowest in the South-east Asia region (5.3%, 2.6e8.0). Adolescent
sample. We used the exact method to compute 95% confidence boys and girls in high-income countries reported the highest
intervals (CIs) for prevalence estimates. We then conducted (19.5%, 13.5e25.5) prevalence of early sexual initiation, whereas
meta-analysis using the ‘metaprop’ program in Stata 16.0 to those in lower middle-income countries reported the lowest
calculate pooled prevalence estimates in accordance with WHO (7.3%, 5.5e9.0). Across all WHO regions and country income
regions, World Bank country income groups [19], and overall. groups, we observed much lower prevalence of early sexual
Because there was substantial heterogeneity in prevalence esti- initiation among girls than boys (Figure 1). Adolescents in
mates among countries (as indicated by I2 > 95%), we used Vietnam had the lowest prevalence of early sexual initiation
random-effect models for meta-analysis. (1.2%, .7e1.8), and adolescents in Samoa had the highest
To investigate the correlates of early sexual initiation, we used prevalence (33.2%, 30.9e35.5) (Table 2). The country-specific
multilevel mixed-effect logistic regressions including a random prevalence estimates varied the most in the Western Pacific
intercept for countries to deal with common cluster-level region (cross-country range: 1.2%e33.2%) and the least in the
random effects within countries and with adjustments of South-east Asia region (1.6%e8.0%). In all 50 countries, girls had
various individual-, country-, and WHO region-level variables. lower prevalence of early sexual initiation than boys. The
Regression models were adjusted for survey year, WHO region, country-specific prevalence of early sexual initiation exceeded
sex, age group, socioeconomic status, anxiety, loneliness, suicidal the overall pooled estimate of 14.1% in 24 of 50 countries (48%).
ideation, being bullied, parental support, parental monitoring, The prevalence estimates in all five countries from the South-east
parental supervision, parental respect of privacy, physical fight, Asia region were lower than the overall pooled estimate (Table 2).
truancy, peer support, having close friend, smoking, alcohol
drinking, illicit drug use, physical activity, and overweight, as Correlates of early sexual initiation among adolescents
appropriate. To explore whether there were any sex-specific
differences in the associations of these factors with early sexual We examined the correlates of early sexual initiation from
initiation, we also examined the associations separately among fully adjusted multilevel logistic regression models, by sex and
boys and girls. To explore any potential heterogeneity across overall (Table 3). Girls were less likely to have early sexual debut
regions, we also looked at the associations stratified in accor- than boys (adjusted odds ratio [aOR] .43, 95% CI .41e.44). Ado-
dance with WHO regions and World Bank country income lescents aged 14e15 years had much higher odds of having early
groups [19]. sexual initiation than adolescents aged 12e13 years (aOR 1.72,
Participants who had valid information on age at the first 1.64e1.80). Among the psychosocial factors, anxiety (aOR 1.16,
sexual intercourse were included in the analysis. Missing or 1.08e1.24), loneliness (aOR 1.10, 1.03e1.17), suicidal ideation
nonapplicable values for covariates were treated as a separate (aOR 1.57, 1.49e1.66), and being bullied (aOR 1.11, 1.06e1.17)
category. We did sensitivity analysis restricting to participants were significantly correlated with early sexual initiation. Parental
who had valid information for all variables and found no sub- monitoring was significantly associated with lower odds of early
stantial differences (data not shown). Where we present results sexual initiation (aOR .78, .75e.82), whereas we did not observe
in figures, the prevalence estimates are represented by squares, significant associations for parental support, parental supervi-
and their corresponding 95% CIs are represented by lines. Sta- sion, and parental respect of privacy. Adolescents who were
tistical significance was set at a two tailed p < .05. involved in physical fight (aOR 1.69, 1.62e1.76) and truancy (aOR
1.49, 1.42e1.56) had higher odds ratios of early sexual initiation
Results than their counterparts. Peer support offered some protective
effect on early sexual initiation, particularly among girls. Lifestyle
We included GSHS data sets from 50 countries with 124,091 risk behaviors such as smoking (aOR 1.93, 1.82e2.04), drinking
adolescents (54.5% girls) aged 12e15 years in this analysis. alcohol (aOR 2.28, 2.17e2.38), and illicit drug use (aOR 3.58,
Table 1 shows the characteristics of the included surveys and the 3.34e3.84) were the strongest correlates of early sexual initia-
participants. We included surveys from four WHO regions: nine tion. Those who were physically active and overweight were also
from the African region, 21 from the regions of the Americas, five likely to report early sexual debut. We did not observe any sig-
from the South-east Asia region, and 15 from the Western Pacific nificant differences between boys and girls for these correlates
region. No survey from the Eastern Mediterranean region had (Table 3).
information on sexual intercourse. In accordance with the World When examined separately across WHO regions, we found
Bank country income classification, included surveys were from that suicidal ideation, drinking alcohol, and illicit drug use were
five low-income countries, 14 lower middle-income countries, 17 more strongly associated with early sexual initiation among
upper middle-income countries, 12 high-income countries, and adolescents in the South-east Asia region than other regions
two countries with no classification information. The range of (Table 4). Parental supervision had also some protective effect
sample size per country was from 77 in Tokelau to 20,129 in among adolescents in this region. The associations for physical
Argentina. We included 95.2% of the total sample in our analysis. fight, physical activity, and overweight with early sexual debut
The mean (standard deviation) age of all included adolescents were stronger for adolescents living in the region of the Americas
was 13.9 (.9) years (Table 1). than other regions. For other correlates, there was weak evidence
610 S.A. Kushal et al. / Journal of Adolescent Health 70 (2022) 607e616

Table 1
Survey characteristics, by country

Country Income group Survey year n/N Analysis sample (%) Boys, n (%) Girls, n (%) Mean age (SD)

African region
Benin L 2016 686/717 95.7 304 (44.3) 382 (55.7) 14.2 (.9)
Ghana LM 2012 1005/1110 90.5 512 (50.9) 493 (49.1) 13.8 (1.0)
Malawi L 2009 2076/2224 93.3 954 (46.0) 1122 (54.0) 13.9 (.8)
Mauritania LM 2010 1177/1285 91.6 533 (45.3) 644 (54.7) 14.2 (.9)
Mauritius UM 2011 2064/2074 99.5 955 (46.3) 1109 (53.7) 13.8 (1.0)
Mozambique L 2015 587/668 87.9 288 (49.1) 299 (50.9) 14.3 (.9)
Namibia UM 2013 1770/1936 91.4 711 (40.2) 1059 (59.8) 14.0 (.9)
Seychelles H 2015 1877/2061 91.1 844 (45.0) 1033 (55.0) 13.4 (1.1)
Tanzania L 2014 2496/2615 95.4 1110 (44.5) 1386 (55.5) 13.7 (1.1)
Regions of the Americas
Anguilla NA 2009 632/701 90.2 291 (46.0) 341 (54.0) 13.7 (1.0)
Antigua and Barbuda H 2009 1124/1235 91.0 518 (46.1) 606 (53.9) 13.9 (.9)
Argentina UM 2012 20,129/21,528 93.5 9309 (46.2) 10,820 (53.8) 14.1 (.8)
Bahamas H 2013 1254/1308 95.9 571 (45.5) 683 (54.5) 13.4 (.9)
Barbados H 2011 1426/1504 94.8 646 (45.3) 780 (54.7) 14.1 (.8)
Belize UM 2011 1486/1600 92.9 709 (47.7) 777 (52.3) 13.5 (1.1)
Bolivia LM 2012 2669/2804 95.2 1299 (48.7) 1370 (51.3) 14.0 (.9)
British Virgin Islands H 2009 1162/1195 97.2 508 (43.7) 654 (56.3) 13.5 (1.1)
Chile H 2013 1312/1353 97.0 640 (48.8) 672 (51.2) 13.6 (1.0)
Costa Rica UM 2009 2215/2265 97.8 1046 (47.2) 1169 (52.8) 13.9 (.8)
Curacao H 2015 1406/1498 93.9 651 (46.3) 755 (53.7) 13.8 (1.0)
Dominica UM 2009 1223/1310 93.4 515 (42.1) 708 (57.9) 13.5 (1.1)
El Salvador LM 2013 1565/1615 96.9 817 (52.2) 748 (47.8) 14.1 (.8)
Guatemala UM 2015 3349/3611 92.7 1583 (47.3) 1766 (52.7) 14.0 (.9)
Guyana UM 2010 1847/1973 93.6 811 (43.9) 1036 (56.1) 14.1 (.8)
Honduras LM 2012 1427/1486 96.0 669 (46.9) 758 (53.1) 13.6 (1.0)
Peru UM 2010 2324/2359 98.5 1119 (48.1) 1205 (51.9) 14.2 (.8)
Saint Kitts Nevis H 2011 1386/1471 94.2 586 (42.3) 800 (57.7) 14.1 (.8)
Suriname UM 2009 1014/1046 96.9 472 (46.5) 542 (53.5) 13.9 (1.0)
Trinidad and Tobago H 2011 2282/2363 96.6 1244 (54.5) 1038 (45.5) 13.5 (1.1)
Uruguay H 2012 2781/2869 96.9 1306 (47.0) 1475 (53.0) 14.1 (.8)
South-east Asia region
Bangladesh LM 2014 2697/2753 98.0 1028 (38.1) 1669 (61.9) 14.1 (.8)
Indonesia LM 2015 8606/8806 97.7 3943 (45.8) 4663 (54.2) 13.5 (1.0)
Nepal L 2015 4335/4616 93.9 1950 (45.0) 2385 (55.0) 13.9 (1.0)
Thailand UM 2015 3985/4132 96.4 1839 (46.1) 2146 (53.9) 13.6 (1.0)
Timor-Leste LM 2015 1419/1631 87.0 571 (40.2) 848 (59.8) 14.0 (1.0)
Western Pacific region
Brunei H 2014 1794/1824 98.4 832 (46.4) 962 (53.6) 13.9 (.9)
Cambodia LM 2013 1768/1812 97.6 775 (43.8) 993 (56.2) 14.0 (.9)
Fiji UM 2016 1441/1537 93.8 696 (48.3) 745 (51.7) 14.4 (.7)
French Polynesia H 2015 1843/1902 96.9 890 (48.3) 953 (51.7) 13.9 (1.0)
Kiribati LM 2011 1304/1340 97.3 538 (41.3) 766 (58.7) 14.1 (.9)
Laos LM 2015 1616/1644 98.3 673 (41.6) 943 (58.4) 14.5 (.7)
Malaysia UM 2012 16,003/16,273 98.3 8142 (50.9) 7861 (49.1) 14.0 (.8)
Mongolia LM 2013 3648/3707 98.4 1736 (47.6) 1912 (52.4) 13.7 (1.0)
Nauru UM 2011 310/367 84.5 123 (39.7) 187 (60.3) 13.7 (1.0)
Samoa UM 2011 1638/2200 74.5 634 (38.7) 1004 (61.3) 14.0 (.8)
Tokelau UM 2014 77/85 90.6 42 (54.5) 35 (45.5) 13.5 (1.2)
Tuvalu UM 2013 647/679 95.3 308 (47.6) 339 (52.4) 13.3 (1.1)
Vanuatu LM 2011 825/852 96.8 340 (41.2) 485 (58.8) 13.6 (1.0)
Vietnam LM 2013 1719/1743 98.6 796 (46.3) 923 (53.7) 14.5 (.5)
Wallis Futuna NA 2015 665/718 92.6 311 (46.8) 354 (53.2) 13.7 (1.1)
Total 124,091/130,405 95.2 57,688 (46.5) 66,403 (53.5) 13.9 (.9)

Country income classification was based on 2018 gross national income (GNI) per capita in accordance with the World Bank list of economies by income group.
H ¼ high income; L ¼ low income; LM ¼ lower middle income; N ¼ total number of participants aged 12e15 years included in the GSHS; n ¼ number of participants who
had valid response on age at the first sexual intercourse and included in this analysis; NA ¼ not available; SD ¼ standard deviation; UM ¼ upper middle income.

of heterogeneity across four WHO regions. When examined whereas effects of physical fight, truancy, physical activity, and
separately among boys and girls, we observed no substantial sex overweight were much stronger among adolescents in high-
differences in correlates across regions (Supplementary Tables S2 income countries.
and S3).
We did additional analyses examining correlates of early Discussion
sexual initiation separately for country income groups
(Supplementary Table S4). The observed associations for smok- In this multicountry study based on nationally representative
ing, illicit drug use, and suicidal ideation were much stronger samples of adolescents aged 12e15 years, we found that nearly
among adolescents from low- and middle-income countries, one in seven adolescents had early sexual initiation. Boys were
 S.A. Kushal et al. / Journal of Adolescent Health 70 (2022) 607e616 611

Figure 1. Prevalence of early sexual initiation among adolescents (boys, girls, and overall) aged 12e15 years, by WHO regions and country income groups. Country-
specific sampling weights were used to yield country representative estimates. Estimates were also adjusted for underlying age distribution in each country’s sample.
Random-effect meta-analysis was used to calculate the pooled estimates. Country income groups are based on the 2018 gross national income (GNI) per capita in
accordance with the World Bank list of economies by income.

more likely to report early sexual initiation than girls. There were and in the Caribbean also reported similar sex differences in the
substantial variations in the prevalence of early sexual debut prevalence of early sexual initiation [2,4,7,13,25]. One way of
across WHO regions and country income groups. Older age, explaining this sex difference could be that the cultural scripts on
anxiety, loneliness, suicidal ideation, being bullied, engaged in masculinity encouraging men to have sex early are widespread
physical fight, truancy, smoking, alcohol drinking, illicit drug use, across culture, region, and ethnicity [17]. Furthermore, the impact
physical activity, and being overweight were significantly asso- of cultural double standard which rewards boys for engaging in
ciated with early sexual initiation. On the other hand, adoles- sexual activity while shaming girls for doing so cannot be ignored
cents who were girls, had parental monitoring, and had peer [30]. However, the relationship between gender and early sexual
support were less likely to report early sexual initiation. debut is more complex in communities with unequal power dy-
Although many previous studies investigated early sexual namics between genders as it limits women’s ability to negotiate
initiation among adolescents in a specific country [7,15,20e24] or sexual activities, and a significant portion of early sexual initiation
in several countries within a specific region [2,4,6,25], our study might be forced or coerced [31].
is the first to examine the prevalence of early sexual initiation We found that the correlates of early sexual initiation are
among adolescent boys and girls across four WHO regions. Data rather homogenous across regions, when examined overall and
from prior global research on the prevalence rates of early sexual stratified in accordance with sex. Our study showed that early
initiation support our findings on substantial differences in early sexual debut is correlated with clusters of psychosocial factors
sexual initiation across regions. For example, a recent study (internalization problems) and risk-taking behaviors (external-
based on eight African countries reported that 27.3% adolescents izing problems). Previous studies also reported that adolescents
had experienced sexual intercourse before the age of 15 years [6]. with anormal internalizing and externalizing symptoms were
Another study based on Violence Against Children Surveys from more likely to engage in early sexual activities [5,32,33]. We
Kenya, Malawi, Nigeria, Tanzania, and Uganda found that the found that psychosocial factors such as anxiety, loneliness, sui-
prevalence of early sexual debut ranged between 8.6% and 17.7%, cidal ideation, and being bullied are strongly correlated with
with boys having significantly higher prevalence than girls [2]. early sexual initiation. There were also stronger associations for
Nearly one in five adolescents aged younger than 15 years in the loneliness, suicidal ideation, and being bullied among girls than
U.S. have had sex [12]. However, it is important to remember that boys. Many previous studies reported associations between early
cross-country and cross-region comparisons based on these sexual debut and negative mental health outcomes, with stron-
prior studies might not be appropriate because of various ger effects among adolescent girls [14,25,34,35]. However, it is
methodological differences. The observed striking regional dif- unclear whether mental health factors are predictors or out-
ferences in early sexual initiation among adolescents in our study comes of early sexual initiation. Some researchers argue that the
may be partly due to religious, social, and cultural differences relationship between early sexual intercourse and psychological
between countries [2,7,26,27]. The rate of early sexual initiation distress is bidirectional, particularly among girls [11,36]. Those
is generally lower in communities practicing religious and cul- struggling with various forms of psychosocial distress can be
tural norms to be remaining sexually abstinent before marriage more likely to engage in early sexual activity to alleviate their
[28]. On the other hand, the rate of early sexual initiation is emotional sufferings [36], whereas early sexual debut can also
higher in societies where child marriage and coercion of younger contribute to internal guilt, low self-esteem, bullying, and social
girls into sexual activities are common [29]. It is important to shaming, which, in turn, can lead to symptoms such as anxiety,
note that although we found substantial differences in early depression, and suicidal thoughts [11,16,37]. Coerced or
sexual debut across WHO regions and country income groups, nonconsensual sexual initiation has strong negative impacts on
there might be major country differences within these regions adolescents’ mental health [5], but we could not investigate
which deserve further exploration to reduce rates of early sexual these issues in this study. Adolescents with externalizing prob-
initiation. lems often engage in impulsive and overt risk-taking behaviors
In our study, boys were more likely to report early sexual debut [38], and we found that early sexual debut was correlated with
than girls in all regions and country income groups. Previous risky behaviors such as school truancy, physical fight, smoking,
studies conducted across multiple countries in sub-Saharan Africa alcohol consumption, and illicit drug use, both in adolescent boys
612 S.A. Kushal et al. / Journal of Adolescent Health 70 (2022) 607e616

Table 2
Country-specific, pooled-regional, and pooled-overall proportions of adolescents who had early sexual debut (i.e., before 15 years), by sex and overall

Country % (95% CI)a

Boys Girls Overall

African region
Benin 23.0 (18.4e28.2) 7.6 (5.1e10.7) 17.6 (14.9e20.7)
Ghana 14.1 (11.2e17.4) 9.9 (7.4e12.9) 12.0 (10.1e14.2)
Malawi 14.8 (12.6e17.2) 6.1 (4.7e7.6) 10.4 (9.1e11.8)
Mauritania 15.2 (12.3e18.5) 11.3 (9.0e14.0) 13.4 (11.5e15.5)
Mauritius 27.0 (24.2e30.0) 14.0 (12.0e16.2) 20.4 (18.7e22.2)
Mozambique 32.6 (27.3e38.4) 9.7 (6.6e13.6) 20.4 (17.3e23.9)
Namibia 35.0 (31.5e38.7) 11.5 (9.7e13.6) 21.2 (19.4e23.2)
Seychelles 28.7 (25.6e31.9) 24.7 (22.1e27.4) 26.6 (24.6e28.6)
Tanzania 11.5 (9.7e13.6) 4.0 (3.0e5.1) 7.5 (6.5e8.6)
Pooled estimatesb 22.3 (16.6e28.0) 10.9 (7.1e14.7) 16.6 (12.1e21.1)
Region of the Americas
Anguilla 32.0 (26.6e37.7) 15.0 (11.3e19.2) 22.9 (19.7e26.4)
Antigua and Barbuda 40.3 (36.1e44.7) 19.1 (16.1e22.5) 29.6 (27.0e32.4)
Argentina 31.0 (30.0e31.9) 21.0 (20.2e21.7) 25.7 (25.1e26.3)
Bahamas 30.3 (26.6e34.2) 10.0 (7.8e12.5) 19.5 (17.3e21.8)
Barbados 34.1 (30.4e37.9) 15.4 (12.9e18.1) 24.8 (22.5e27.1)
Belize 21.9 (18.9e25.1) 7.9 (6.1e10.0) 14.7 (13.0e16.6)
Bolivia 14.9 (13.0e17.0) 7.2 (5.8e8.6) 11.0 (9.8e12.2)
British Virgin Islands 34.8 (30.7e39.2) 15.6 (12.9e18.6) 24.5 (22.1e27.1)
Chile 19.5 (16.5e22.8) 12.8 (10.4e15.6) 16.2 (14.2e18.3)
Costa Rica 14.9 (12.8e17.2) 7.7 (6.2e9.4) 11.2 (9.9e12.5)
Curacao 14.0 (11.4e16.9) 9.4 (7.4e11.7) 11.7 (10.0e13.5)
Dominica 42.1 (37.8e46.5) 22.7 (19.7e26.0) 32.3 (29.7e35.0)
El Salvador 18.1 (15.5e20.9) 7.2 (5.5e9.3) 12.5 (10.9e14.2)
Guatemala 13.7 (12.1e15.5) 3.1 (2.3e4.0) 8.4 (7.5e9.4)
Guyana 32.7 (29.5e36.0) 10.2 (8.5e12.2) 21.0 (19.2e22.9)
Honduras 22.0 (18.9e25.3) 5.3 (3.8e7.1) 13.0 (11.3e14.8)
Peru 18.9 (16.7e21.4) 6.1 (4.8e7.6) 12.4 (11.1e13.8)
Saint Kitts Nevis 38.1 (34.1e42.1) 12.7 (10.5e15.3) 25.1 (22.8e27.5)
Suriname 22.0 (18.4e26.0) 10.3 (7.9e13.2) 15.1 (12.9e17.4)
Trinidad and Tobago 22.3 (20.0e24.7) 9.6 (7.9e11.6) 15.9 (14.4e17.4)
Uruguay 24.9 (22.6e27.3) 14.6 (12.8e16.5) 19.3 (17.9e20.8)
Pooled estimatesb 25.7 (22.0e29.3) 11.5 (8.5e14.5) 18.4 (15.2e21.5)
South-east Asia region
Bangladesh 6.0 (4.7e7.7) 3.1 (2.3e4.0) 5.0 (4.2e5.9)
Indonesia 2.3 (1.9e2.9) .9 (.6e1.2) 1.6 (1.3e1.9)
Nepal 6.1 (5.0e7.2) 4.1 (3.3e5.0) 5.0 (4.4e5.7)
Thailand 10.7 (9.3e12.2) 5.5 (4.6e6.5) 8.0 (7.2e8.9)
Timor-Leste 7.7 (5.7e10.2) 6.1 (4.6e8.0) 6.8 (5.6e8.3)
Pooled estimatesb 6.5 (3.3e9.7) 3.9 (1.7e6.0) 5.3 (2.6e8.0)
Western Pacific region
Brunei 2.6 (1.7e4.0) 1.9 (1.1e2.9) 2.2 (1.6e3.0)
Cambodia 2.1 (1.2e3.3) 1.3 (.7e2.2) 1.6 (1.1e2.3)
Fiji 12.8 (10.4e15.5) 3.9 (2.6e5.5) 8.0 (6.6e9.5)
French Polynesia 23.8 (21.1e26.8) 14.2 (12.0e16.5) 18.9 (17.1e20.7)
Kiribati 23.4 (19.9e27.2) 3.8 (2.5e5.4) 12.7 (10.9e14.6)
Laos 2.4 (1.4e3.8) .8 (.4e1.7) 1.5 (1.0e2.3)
Malaysia 2.8 (2.4e3.1) 1.0 (.8e1.3) 1.9 (1.7e2.1)
Mongolia 5.6 (4.6e6.8) 2.0 (1.5e2.8) 3.8 (3.2e4.5)
Nauru 23.6 (16.4e32.1) 13.9 (9.3e19.7) 18.4 (14.2e23.2)
Samoa 44.6 (40.7e48.6) 23.5 (20.9e26.3) 33.2 (30.9e35.5)
Tokelau 21.4 (10.3e36.8) 11.4 (3.2e26.7) 16.9 (9.3e27.1)
Tuvalu 13.3 (9.7e17.6) 2.9 (1.4e5.4) 7.6 (5.7e9.9)
Vanuatu 9.7 (6.8e13.4) 5.4 (3.5e7.8) 7.5 (5.8e9.5)
Vietnam 1.8 (1.0e2.9) .7 (.2e1.4) 1.2 (.7e1.8)
Wallis Futuna 24.4 (19.8e29.6) 8.2 (5.6e11.6) 15.9 (13.2e18.9)
Pooled estimatesb 13.4 (10.4e16.4) 5.3 (4.0e6.7) 9.5 (7.4e11.6)
Overall estimateb 19.7 (16.9e22.5) 8.9 (7.6e10.3) 14.2 (12.1e16.2)

CI ¼ confidence interval.
a
Country-specific sampling weights were used to yield country representative estimates. Estimates were also adjusted for underlying age distribution in each
country’s sample.
b
Random-effect meta-analysis was used to calculate the pooled estimates.

and girls. Previous studies also reported that early sexual debut school environments can deal with adolescents’ internalization
co-occurred with smoking, substance use, alcohol, and low and externalization problems which, in turn, can reduce risky
school attachment [6,38]. It is possible that positive family and sexual behaviors among them. In addition, it might be an
 S.A. Kushal et al. / Journal of Adolescent Health 70 (2022) 607e616 613

Table 3
Correlates of early sexual initiation among adolescents aged 12e15 years, by sex and overall

Variables ORs (95% CIs)a

Boys Girls Overall

Sociodemographic factors
Sex
Boys 1.00 (Ref)
Girls .43 (.41e.44)
Age group
12e13 years 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
14e15 years 1.66 (1.57e1.77) 1.80 (1.67e1.94) 1.72 (1.64e1.80)
Socioeconomic status
Average 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Below average 1.04 (.94e1.15) .98 (.86e1.11) 1.01 (.93e1.09)
Psychosocial factors
Anxiety
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.14 (1.03e1.25) 1.17 (1.07e1.29) 1.16 (1.08e1.24)
Loneliness
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.08 (.98e1.19) 1.11 (1.01e1.21) 1.10 (1.03e1.17)
Suicidal ideation
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.51 (1.40e1.63) 1.67 (1.55e1.80) 1.57 (1.49e1.66)
Bullied
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.08 (1.02e1.15) 1.17 (1.09e1.26) 1.11 (1.06e1.17)
Parental and peer factors
Parental support
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.02 (.96e1.08) 1.00 (.92e1.08) 1.01 (.96e1.06)
Parental monitoring
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes .77 (.72e.82) .80 (.74e.87) .78 (.75e.82)
Parental supervision
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.04 (.98e1.11) .91 (.85e.99) .99 (.94e1.04)
Parental respect of privacy
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes .96 (.90e1.02) .95 (.88e1.02) .95 (.91e1.00)
Physical fight
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.77 (1.68e1.87) 1.56 (1.46e1.67) 1.69 (1.62e1.76)
Truancy
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.42 (1.34e1.51) 1.59 (1.48e1.71) 1.49 (1.42e1.56)
Peer support
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes .95 (.89e1.01) .91 (.85e.98) .93 (.89e.98)
Close friend
Yes 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
No 1.00 (.90e1.10) 1.14 (1.00e1.29) 1.05 (.97e1.14)
Lifestyle factors
Smoking
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.90 (1.77e2.05) 2.00 (1.83e2.18) 1.93 (1.82e2.04)
Alcohol drinking
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 2.25 (2.12e2.39) 2.35 (2.18e2.53) 2.28 (2.17e2.38)
Illicit drug use
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 3.62 (3.30e3.97) 3.64 (3.26e4.07) 3.58 (3.34e3.84)
Physical activity
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.23 (1.16e1.31) 1.15 (1.05e1.25) 1.20 (1.14e1.26)
Overweight
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.06 (.99e1.13) 1.13 (1.05e1.23) 1.08 (1.03e1.14)

CI ¼ confidence interval; OR ¼ odds ratio.

a
Multilevel mixed-effect logistic regressions were used accounting for clustering of adolescents within countries with a random intercept. Models were adjusted for
survey year, WHO region, and all variables listed in the table, as appropriate.
614 S.A. Kushal et al. / Journal of Adolescent Health 70 (2022) 607e616

Table 4
Correlates of early sexual initiation among adolescents aged 12e15 years, by WHO regions

Variables ORs (95% CIs)a

African region Region of the Americans South-east Asia region Western Pacific region

Sociodemographic factors
Sex
Boys 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Girls .47 (.42e.52) .40 (.38e.42) .83 (.70e.98) .44 (.39e.49)
Age group
12e13 years 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
14e15 years 1.64 (1.47e1.84) 1.95 (1.84e2.07) 1.37 (1.15e1.63) 1.36 (1.20e1.55)
Socioeconomic status
Average 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Below average .97 (.82e1.15) 1.00 (.89e1.12) 1.22 (.92e1.62) 1.06 (.89e1.25)
Psychosocial factors
Anxiety
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes .86 (.72e1.03) 1.07 (.98e1.16) 1.20 (.92e1.56) 1.17 (1.00e1.38)
Loneliness
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes .92 (.78e1.10) .97 (.90e1.05) 1.27 (1.00e1.62) 1.14 (.97e1.34)
Suicidal ideation
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.49 (1.29e1.71) 1.26 (1.18e1.34) 2.47 (2.00e3.04) 1.49 (1.30e1.71)
Bullied
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.21 (1.08e1.35) 1.05 (1.00e1.12) .99 (.82e1.19) 1.49 (1.31e1.70)
Parental and peer factors
Parental support
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.05 (.91e1.21) 1.01 (.95e1.07) 1.00 (.81e1.23) 1.01 (.88e1.16)
Parental monitoring
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes .74 (.64e.86) .74 (.70e.78) .79 (.65e.96) .83 (.73e.95)
Parental supervision
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.05 (.91e1.20) 1.04 (.98e1.10) .72 (.59e.87) 1.09 (.95e1.24)
Parental respect of privacy
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.02 (.89e1.16) .97 (.92e1.03) .94 (.79e1.13) .93 (.82e1.05)
Physical fight
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.64 (1.47e1.82) 2.10 (2.00e2.21) 1.47 (1.24e1.75) 1.98 (1.75e2.23)
Truancy
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.47 (1.28e1.68) 1.52 (1.44e1.60) 1.58 (1.33e1.88) 1.34 (1.19e1.52)
Peer support
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes .88 (.76e1.02) .93 (.88e.98) .67 (.56e.82) .93 (.82e1.06)
Close friend
Yes 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
No .95 (.79e1.15) 1.08 (.98e1.19) 1.24 (.92e1.67) 1.26 (1.02e1.56)
Lifestyle factors
Smoking
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 2.48 (2.12e2.90) 1.77 (1.66e1.90) 1.96 (1.57e2.44) 2.22 (1.94e2.55)
Alcohol drinking
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 2.33 (2.05e2.65) 2.09 (1.98e2.21) 2.62 (2.10e3.28) 2.22 (1.94e2.54)
Illicit drug use
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 3.37 (2.74e4.13) 2.89 (2.64e3.15) 8.18 (6.40e10.45) 6.15 (5.20e7.28)
Physical activity
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes 1.19 (1.03e1.38) 1.44 (1.36e1.53) .81 (.63e1.05) 1.19 (1.02e1.38)
Overweight
No 1.00 (Ref) 1.00 (Ref) 1.00 (Ref) 1.00 (Ref)
Yes .99 (.84e1.16) 1.14 (1.08e1.21) .92 (.71e1.20) 1.12 (.99e1.27)

CI ¼ confidence interval; OR ¼ odds ratio.

a
Multilevel mixed-effect logistic regressions were used accounting for clustering of adolescents within countries with a random intercept. Models were adjusted for
survey year and all variables listed in the table, as appropriate.
 S.A. Kushal et al. / Journal of Adolescent Health 70 (2022) 607e616 615

effective approach to integrate programs for sexual health pro- access data from other sources to look at multilevel factors that
motion and mental health promotion in schools. may be driving these differences between countries or regions in
Parental and family factors have significant influence on ad- the future.
olescents’ age of sexual initiation. Family factors that are asso- In conclusion, our study using a large global sample of ad-
ciated with early sexual initiation in previous studies include olescents shows that there are substantial regional differences
single-parent family structure, poor parent-adolescent relation- in the proportion of adolescent boys and girls who engage in
ship, lower level of parental monitoring, and parents’ permissive early sexual activities, with boys reporting much higher than
attitude toward sexual activities [39e42]. In our study, we found girls. We also found that clusters of psychosocial factors (e.g.,
that parental monitoring rather than parental support had strong anxiety, loneliness, suicidal ideation, bullying victimization)
influence on decreasing the odds of having early sexual debut and risky lifestyle factors (e.g., smoking, alcohol drinking, illicit
among adolescents. Although some previous studies reported drug use, school truancy) are significantly correlated with early
that parental monitoring was significant only among girls [42,43] sexual initiation, with little or no variation across regions. In
or among boys [16], we did not observe significant heterogeneity contrast, adolescents with parental monitoring and peer sup-
in such association by sex. The influence of peers on risky sexual port are less likely to engage in early sexual activities. Our
behaviors is not clear yet, but we found that peer support findings will help shaping strategies for promoting sexual and
reduced the odds of having early sexual debut, especially among reproductive health among adolescents in different regions
girls. Previous evidence suggests that family and school micro- through reducing early sexual debut and subsequently other
system factors can be independently and mutually related to risky sexual behaviors.
early sexual initiation and risky sexual behaviors among ado-
lescents [44]. Acknowledgments
Our study is the first study to examine the prevalence of early
sexual initiation among adolescents from four WHO regions. We The authors thank the U.S. Centers for Disease Control and
also explored the correlates of early sexual initiation in a large WHO for making Global School-based Student Health Survey
multicountry sample. Although these are clear strengths of our (GSHS) data publicly available for analysis. They thank the GSHS
study, there are also several limitations. First, the GSHS only country coordinators and other staff members and the partici-
recruited adolescents who had attended school at the time of pating students and their parents.
survey. School-going adolescents might not be representative of This article uses data from the Global School-based Student
all adolescents in a country, particularly because there are pos- Health Survey (GSHS). The GSHS is supported by the World
sibilities that sexual activities might vary between these two Health Organization and the U.S. Centers for Disease Control and
groups. Second, because of the cross-sectional nature of the Prevention.
study, we cannot establish the temporal direction of associations
between early sexual debut and various factors. Third, informa-
Funding Sources
tion about sexual behaviors was collected using self-reported
measures, which can introduce reporting bias. Because of the
This research did not receive any specific grant from funding
sensitive nature of the questions asked, it is possible that ado-
agencies in the public, commercial, or not-for-profit sectors.
lescents under-reported and/or provided answers that are
considered as “socially desirable/acceptable”. Definition of sexual
Supplementary Data
intercourse was not provided in the questionnaire which can
lead to misinterpretations, and some adolescents might include
Supplementary data related to this article can be found at
activities like mutual masturbation as sexual intercourse. In
https://10.1016/j.jadohealth.2021.10.027.
addition, response to questions about sexual intercourse can be
heavily influenced by the age of the adolescents. Although we
adjusted for underlying age distribution in our analyses, age References
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