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Associations Between Health Risk Behaviors and Opposite-, Same-, and Both-Sex Sexual Partners in Representative Samples of Vermont and Massachusetts High School Students
Leah Robin, PhD;
Nancy D. Brener, PhD;
Shaun F. Donahue, MEd;
Tim Hack, MAEd;
Kelly Hale, MA;
Carol Goodenow, PhD
Arch Pediatr Adolesc Med. 2002;156:349-355.
ABSTRACT
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Objective To examine associations between health risk behaviors and sexual experience
with opposite-, same-, or both-sex partners in representative samples of high
school students.
Design We used 1995 and 1997 data from the Vermont and Massachusetts Youth
Risk Behavior Surveys. Logistic regression and multiple regression analyses
were used to compare health risk behaviors among students who reported sex
with opposite-sex partners only (opposite-sex students), with same-sex partners
only (same-sex students), and with both male and female sexual partners (both-sex
students).
Setting Public high schools in Vermont and Massachusetts.
Participants Representative, population-based samples of high school students. The
combined samples had 14 623 Vermont students and 8141 Massachusetts students.
Main Outcome Measure Violence, harassment, suicidal behavior, alcohol and other drug use,
and unhealthy weight control practices.
Results In both states, both-sex students were significantly more likely to
report health risk behaviors than were opposite-sex students. For example,
both-sex students had odds 3 to 6 times greater than opposite-sex students
of being threatened or injured with a weapon at school, making a suicide attempt
requiring medical attention, using cocaine, or vomiting or using laxatives
to control their weight. In both states, same-sex students were as likely
as opposite-sex students to report most health risk behaviors.
Conclusion Relative to opposite- and same-sex students, both-sex students may be
at elevated risk of injury, disease, and death by experiencing serious harassment
and engaging in violence, suicidal behavior, alcohol and other drug use, and
unhealthy weight control practices.
INTRODUCTION
SEXUAL MINORITY youth (ie, gay, lesbian, bisexual, or those still questioning
their sexual orientation) face a disproportionate number of health risks compared
with their heterosexual peers. Studies using community- and population-based
samples have found that these young people are more likely to experience violence
and harassment,1-4
suicidal ideation and behavior,5-8
alcohol and other substance use,1-3
unhealthy weight control practices and negative body image,3, 8-9
and forced sexual intercourse3, 8, 10
than are their heterosexual peers. Such health risks occur both in and out
of school and are accompanied by more academic problems.11
Studies documenting health risks among these youth have used a variety
of measures to identify those who are gay, lesbian, or bisexual. Self-reported
sexual identity, such as gay, lesbian, bisexual, heterosexual, or questioning,
allows all youth, not just those who are sexually active, to be classified.
As Russell et al11 point out, however, such
measures may misclassify youth who do not yet self-identify as gay, lesbian,
or bisexual but who do later. Another, broader measure is sexual orientation,
including fantasies, social and political affiliations, and reports of romantic
or sexual attraction to members of the same or opposite sex.12
Measures of sexual orientation vary, however, and some include behavior. Some
researchers treat orientation as synonymous with identity, but this seems
inappropriate, as being attracted to and fantasizing about particular sexual
partners may occur without adoption of an associated identity. Like sexual
identity, sexual orientation has the advantage of including youth who are
not sexually experienced. A third measure, sexual behavior, includes reports
of sexual activity with members of the same or opposite sex. This measure
is narrower than identity and orientation and can be used only among sexually
experienced youth. These 3 measures include different, but overlapping, groups
of youth and may not necessarily be highly associated with each other. Studies
have found that health risk behaviors are significantly more common among
youth whose sexual identities,3-6,8-9
orientations,7, 10-11
or behaviors1-2 include same-sex
sexuality.
To date, most studies examining health risk behaviors among sexual minority
youth have combined all youth reporting same-sex sexuality, but there may
be significant differences between these groups. These differences are critical
to public health and education professionals who want to target health risk
reduction programs and services toward youth who face the highest risk for
undesirable health outcomes. Among the few studies that have disaggregated
these groups of youth, one used a nationally representative sample in finding
that bisexual orientation was more associated than gay, lesbian, or heterosexual
orientation with school troubles such as not paying attention, or completing
homework, or getting along with other students, and, among male bisexuals,
feeling disliked and having lower grades.11
Another study used a convenience sample in finding that self-identified bisexual
youth were significantly more likely than their gay or lesbian peers to make
more than one suicide attempt during their lifetime.13
Using 1995 and 1997 data from the Vermont and Massachusetts Youth Risk
Behavior Surveys (YRBSs), we compared the frequency of selected health risk
behaviors among sexually experienced youth who reported experience with opposite-sex
partners only (opposite-sex students), those who reported experience with
same-sex partners only (same-sex students), and those who reported experience
with both same- and opposite-sex partners (both-sex students). We use these
terms to describe each group of students simply based on their reported sexual
behaviors. A behavioral measure of sexuality was used because it was included
in both the Vermont and Massachusetts YRBSs.
To our knowledge, this article is one of the first to differentiate
between same-sex and both-sex students in population-based samples. Two years
of data were combined for Vermont and for Massachusetts to provide enough
participants to explore differences among students with opposite-, same-,
and both-sex sexual partners. Combined data also allowed us to control for
age, gender, and whether students reported ever having been forced to have
sexual intercourse, one limitation of prior studies examining the links between
sexual identity or sexual behavior and risk behaviors among adolescents.1-3 We focused on behaviors
related to violence and harassment, alcohol and other drug use, and unhealthy
weight control practices because prior studies of these behaviors have not
disaggregated bisexual youth from gay and lesbian youth. A separate analysis
focuses on sexual risk behaviors among males in Masschusetts high schools
with opposite-, same-, and both-sex sexual partners.14
Based on the previous studies that distinguished between gay, lesbian, and
bisexual youth, we expected to find that both-sex students would report higher
levels of health risk behaviors than would same-sex or opposite-sex students.
PARTICIPANTS, MATERIALS, AND METHODS
To maximize the number of students who report engaging in same-sex and
both-sex sexual behavior, data for Vermont were obtained by combining data
from the 1995 and 1997 Vermont YRBSs. Similarly, data for Massachusetts were
obtained by combining the 1995 and 1997 Massachusetts YRBSs. Each state's
YRBS measures the prevalence of health risk behaviors among its public high
school students. Both states used a 2-stage cluster sample design to produce
a representative sample of 9th- to 12th-grade students.
Across the 4 cross-sectional surveys, sample sizes ranged from 3982
to 8636, and response rates ranged from 74% to 94% for schools, 77% to 85%
for students, and from 63% to 72% overall. Students completed the self-administered,
voluntary, anonymous questionnaire in classrooms. A more complete discussion
of the survey methods has been presented elsewhere.15-16
The questionnaires varied slightly across years and sites, but all included
items assessing demographic information, sexual behaviors, harassment, violence,
suicidal behaviors, alcohol and other drug use, and dietary behaviors. These
items demonstrated good test-retest reliability.17
In both Massachusetts surveys, students were asked, "The person(s) with whom
you have had sexual contact is (are): (a) I have not had sexual contact with
anyone, (b) Female(s), (c) Male(s), (d) Females and males." Sexual identity
was assessed by asking, "Which of the following best describes you? (a) Heterosexual
(straight), (b) Gay or lesbian, (c) Bisexual, (d) Not sure." In the 1995 Vermont
survey, all students were asked, "During your life, with how many males have
you had sexual intercourse?" and "During your life, with how many females
have you had sexual intercourse?" We combined these responses with the sex
of the respondent to determine opposite-sex, same-sex, and both-sex sexual
behavior. In the 1997 Vermont YRBS, students were asked, "The persons you
have had sexual activity with are: (a) I have not had sexual activity with
anyone, (b) Females, (c) Males, (d) Females and males." Each respondent was
classified as having had exclusively opposite-sex contact, exclusively same-sex
contact, sexual contact with both sexes, or no sexual contact. The Vermont
YRBS did not include a question on sexual identity in either survey.
Data were weighted to adjust for school and student nonresponse. Prevalence
estimates, odds ratios (ORs), and 95% confidence intervals (CIs) were calculated
using SUDAAN (Survey Data Analysis), which accounts for the complex sampling
design and weighting.18 Prevalence estimates
were considered to be significantly different if their 95% CIs did not overlap.
Logistic and multiple regression models that controlled for age, gender, and
forced sexual intercourse were used to identify statistically significant
differences in the prevalence of other health risk behaviors among students,
or the total number of health risk behaviors, comparing same-sex and both-sex
students to opposite-sex students. No interactions could be assessed in the
logistic or multiple regressions because of the small number of same-sex and
both-sex students, and we were unable to stratify the analyses by gender for
the same reason. Multiple risk behaviors were assessed by dichotomously coding
each risk behavior as 0 (if not occurring) or 1 (if it occurred 1 or more
times). A multiple risk variable index was constructed by summing the dichotomous
scores across health risk behaviors. Forced sex was controlled for in the
regression analyses because of the high prevalence of reports of this event
among same-sex and both-sex students. All variables were entered into the
equations simultaneously.
RESULTS
SAMPLE CHARACTERISTICS
Vermont's combined sample had 14 623 students; the combined Massachusetts
sample had 8141 students. In Vermont, 47.0 % (6873) of the sample reported
opposite-sex partners only, 1.7% (249) reported same-sex partners only, 2.3%
(336) reported both-sex partners, and 49.0% (7165) reported never having sexual
intercourse. In Massachusetts, these prevalences were 48.5% (3948), 1.3% (106),
1.5% (122), and 48.7% (3965), respectively. Age distributions were similar
in each state, and sexually experienced students were older than those who
were not experienced (Table 1).
In Vermont, the same-sex group was more than 70% male, but the other 3 groups
were relatively evenly divided between male and female respondents. In Massachusetts,
all groups were rather evenly divided between male and female respondents.
In Vermont, 16.7% of opposite-sex students, 27.1% of same-sex students, and
46.9% of both-sex students reported being forced to have sexual intercourse
during their lifetime. In Massachusetts, these prevalences were 17.4%, 18.4%,
and 60.7%, respectively.
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Table 1. Sample Variables by Opposite-, Same-, and Both-Sex Sexual
Partners: Vermont and Massachusetts 1995 and 1997 Youth Risk Behavior Surveys*
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In Massachusetts, of opposite-sex students, 96.0% identified themselves
as heterosexual, as did 81.1% of same-sex students. Among both-sex students,
27.2% identified themselves as heterosexual and 43.4% as bisexual. Finally,
among students who had never had sex, 94.3% identified themselves as heterosexual,
and 4.7% were not sure or identified with none of the groups.
VIOLENCE, HARASSMENT, AND SUICIDAL BEHAVIORS
The percentages and 95% CIs of sexually experienced youth in Vermont
and in Massachusetts engaging in violence and experiencing harassment and
suicidal behaviors are listed in Table 2. In both states, both-sex students were significantly more likely
to report all of these health risk behaviors than were their opposite-sex
peers. For example, in Vermont, 8.3% of opposite-sex students compared with
38.6% of both-sex students were threatened or injured with a weapon at school
in the 12 months preceding the YRBS. In Massachusetts, these prevalences were
9.1% and 45.3%, respectively. In Vermont, 4.5% of opposite-sex students reported
a suicide attempt requiring medical attention in the 12 months preceding the
YRBS compared with 26.8% of both-sex students. In Massachusetts the prevalences
were 4.5% and 31.6%, respectively. There was only 1 significant difference
between same- and opposite-sex students, with same-sex students in Vermont
more likely to have been threatened or injured with a weapon at school than
opposite-sex students (13.4% vs 8.3%, respectively).
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Table 2. Percentage of Sexually Experienced Students Engaging in Selected
Risk Behaviors by Opposite-, Same-, and Both-Sex Sexual Partners: Vermont
and Massachusetts, 1995 and 1997 Youth Risk Behavior Survey*
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To assess the strength of the association between opposite-, same-,
and both-sex sexual partners and violence, harassment, and suicidal behaviors,
we conducted logistic regressions controlling for age, gender, and whether
respondents had ever been forced to have sexual intercourse (Table 3). In both states, both-sex students had significantly greater
odds of engaging in all of these behaviors than their opposite-sex peers.
Odds ratios in Vermont and Massachusetts ranged from 1.82 (95% CI, 1.41-2.36)
and 1.63 (95% CI, 1.01-2.64) for being in a physical fight during the 12 months
preceding the YRBS, to 5.01 (95% CI, 3.58-7.01) and 5.36 (95% CI, 3.22-8.91)
for being threatened or injured with a weapon at school. In Vermont, same-sex
students were significantly less likely than their opposite-sex peers to carry
a weapon in the 30 days preceding the survey (OR, 0.54; 95% CI, 0.33-0.90)
and to have been in a physical fight (OR, 0.62; 95% CI, 0.42-0.90).
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Table 3. Logistic Regressions for Opposite-, Same-, and Both-Sex Sexual
Partner on Selected Health Risk Behaviors Among Sexually Experienced Adolescents
in Vermont and Massachusetts: 1995 and 1997 Youth Risk Behavior Surveys*
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ALCOHOL AND OTHER DRUG USE
Both-sex students in Vermont were significantly more likely than opposite-sex
students to binge drink and to use other drugs (Table 2). In contrast, Massachusetts both-sex students were as likely
as their opposite-sex peers to report binge drinking ( 5 drinks on 1 occasion)
in the 30 days preceding the YRBS but were significantly more likely to use
marijuana in the 30 days preceding the survey and to ever use cocaine. In
Vermont 14.3% of opposite-sex youth had used cocaine compared with 47.2% of
both-sex students. In Massachusetts, the prevalence was 11.6% and 44.1%, respectively.
In both states, same-sex students were as likely as opposite-sex students
to binge drink and to use marijuana. In Massachusetts, the prevalence of cocaine
use did not differ between same- and opposite-sex students but was significantly
higher for same-sex students in Vermont (23.2% vs 14.3%, respectively).
In logistic regression analyses, both-sex students in Vermont were significantly
more likely than their opposite-sex peers to binge drink (OR, 1.36; 95% CI,
1.09-1.68), but no such difference was seen in Massachusetts (Table 3). In both states, both-sex students had greater than twice
the odds of their opposite-sex peers of using marijuana. Both-sex students
in Vermont had over 4 times the odds of their opposite-sex peers of using
cocaine (OR, 4.43; 95% CI, 3.34-5.88) and over 3 times the odds in Massachusetts
(OR, 3.86; 95% CI, 2.56-5.83). Same-sex students in Vermont were as likely
as their opposite-sex peers to use cocaine but in Massachusetts were significantly
more likely to use cocaine.
UNHEALTHY WEIGHT CONTROL PRACTICES
In both states, both-sex students were significantly more likely than
opposite-sex students to engage in unhealthy weight control practices, defined
as vomiting and using laxatives to lose weight or to keep from gaining weight
in the 30 days preceding the YRBS (Table
2). In Vermont, 25.6% of same-sex students compared with 7.1% of
opposite-sex students engaged in unhealthy weight control practices. In Massachusetts,
the prevalences were 37.4% and 7.0%, respectively. Same-sex students in Vermont
were significantly more likely to engage in unhealthy weight control practices
than were opposite-sex students (12.3% vs 7.1%, respectively), but no significant
difference was seen in Massachusetts.
In a logistic regression analysis (Table 3), both-sex students were significantly more likely than
their opposite-sex peers to engage in unhealthy weight control practices in
both Vermont (OR, 3.46; 95% CI, 2.35-5.08), and Massachusetts (OR, 5.87; 95%
CI, 3.37-10.20). Same-sex students in Vermont were more than twice as likely
as their opposite-sex peers to engage in unhealthy weight control practices,
but there was no significant difference in Massachusetts.
MULTIPLE RISK BEHAVIORS
In multiple regression analyses that used the number of health risk
behaviors as the dependent variable (data not shown), Vermont and Massachusetts
both-sex students engaged in significantly more health risk behaviors than
opposite-sex students (ß = 1.83, P = <.001; ß
= 2.15, P<.001). In both states, same-sex students
did not differ from opposite-sex students.
COMMENT
In this analysis of Vermont and Massachusetts high school students,
we found that both-sex students must be considered at high risk for violence,
harassment, suicidal behavior, marijuana and cocaine use, and unhealthy weight
control practices. In both states, these students had odds 3 to 6 times greater
than opposite-sex students of being threatened or injured with a weapon at
school, making a suicide attempt requiring medical attention, using cocaine,
or vomiting or using laxatives to control their weight. Our findings raise
serious public health concerns as they mean that these youth bear increased
risk of injury, disease, and death.
In both Vermont and Massachusetts, both-sex students reported high rates
of forced sexual intercourse. We also found that forced sexual intercourse
independently predicted all health risk behaviors in both states except for
binge drinking in Vermont. Across all health risk behaviors, odds ratios for
forced sexual intercourse ranged from 1.29 to 3.74 in Vermont and from 1.32
to 3.59 in Massachusetts. The high rate of forced sexual intercourse among
both-sex youth likely contributes to their heightened levels of risk behaviors.
These findings of greater risk among both-sex students are consistent
with the few reports that have compared bisexual- and gay- or lesbian-identified
youth and found more frequent health risk behaviors among bisexuals. For example,
Hershberger et al13 reported that bisexual-identified
adolescents were 5 times more likely to attempt suicide than their gay and
lesbian peers. Research should continue that can replicate these findings,
especially using large, population-based samples like the ones in this analysis.
Researchers should differentiate subgroups of sexual minorities, as the present
study suggests that combining gay, lesbian, and bisexual students obscures
important differences in their health risk behaviors.
We found that same-sex students were not significantly more at risk
for most health risk behaviors than were opposite-sex students. Furthermore,
we found that Vermont same-sex youth were significantly less likely than their
opposite-sex peers to carry a weapon or to be in a physical fight. However,
Vermont same-sex youth were significantly more likely than opposite-sex youth
to vomit or use laxatives to control their weight, and Massachusetts same-sex
youth were more likely to use cocaine.
One possible explanation for the significantly greater risk behavior
among both-sex students than among same-sex students is that the latter were
much less likely to identify themselves as being in a sexual minority. In
Massachusetts, 73% of the both-sex students identified as gay, lesbian, bisexual,
or as unsure of their identities, but more than 80% of same-sex students identified
themselves as heterosexual. Thus, a much greater proportion of both-sex students
have adopted an identity that reflects their same-sex sexual behavior than
have same-sex students. There is no clear match between sexual behaviors and
sexual identities reported by students in Massachusetts.
Possibly, same-sex students reported a heterosexual identity because
that was socially desirable. Alternatively, same-sex students may not yet
have adopted identities consistent with their behaviors, or the same-sex behavior
they reported was anomalous and not salient to their identity development.
Because same-sex students in Massachusetts mostly identified as heterosexual
and may have been perceived as heterosexual by their peers, they may not have
experienced the stressors of sexual prejudice, victimization, and social marginalization
associated with increased health risk behaviors.6, 19-20
We might expect that a higher level of stressors associated with sexual minority
status would lead to engagement in more health risk behaviors, but no studies
to date have demonstrated a causal relationship between stress related to
sexual minority status and health risk behaviors. It is likely that some amount
of the heightened risk found among gay, lesbian, and bisexual youth compared
with their heterosexual peers in prior studies is accounted for by students
who have sex with both males and females, and among those who are bisexual-identified.
Researchers should examine disparities between sexual behaviors and
sexual identities in youth, and the associations of sexual behaviors and identities
with health risk behaviors. To date, researchers have studied sexual behavior,
identity, or orientation as isolated constructs when they analyze health risk
behaviors among sexual minority adolescents. Instead, researchers should measure
all 3 of these constructs and examine their interactions to determine the
implications of using these different measures. We would also expect these
health risk behaviors to vary by the gender of students within all of the
constructs, and researchers should explore the interaction of gender with
them. In addition, qualitative and longitudinal research should examine the
context and understandings of sexuality and sexual behavior among youth and
the role that peer, parental perceptions, and broader social norms play in
developing sexual identity and behavior.
Another explanation for these findings is that both-sex sexual behavior
may be part of a larger cluster of interrelated risk behaviors in which a
small group of highly at-risk students is engaged. Not only are both-sex students
more likely than opposite-sex students to engage in individual risk behaviors,
they also engage in a greater number of them. As Jessor21
suggests, multiple risk behaviors among adolescents are related to complex
sets of risk and protective determinants ranging from biological to social
factors. Understanding determinants that might underlie both-sex sexual behavior
and health risk behaviors requires careful investigation of a wide range of
risk and protective factors.
This study has several important limitations. First, some questions
were worded differently within and across sites. For example, in 1995, the
Vermont YRBS measured forced sex by asking: "Have you ever been forced or
pressured to have sexual intercourse against your will?" but in 1997, it asked:
"Have you ever been forced or pressured to have sexual intercourse?" In both
of its surveys, Massachusetts measured forced sex by asking: "During your
life, has anyone ever had sexual contact with you against your will?" Furthermore,
as described earlier, the 1995 and 1997 Vermont YRBS asked about whether students
had opposite-, same-, or both-sex partners in slightly different ways, questions
that were worded differently than on the Massachusetts YRBS. If these differently
worded questions were measuring significantly different subpopulations or
behaviors, we would expect to see weak and diffuse findings. On the contrary,
the pattern of results was strong and consistent across the 2 sites.
A second limitation is that measures were self-reported, and underreporting
or overreporting may have occurred, especially for sensitive questions such
as whether students had opposite-, same-, or both-sex sexual partners and
sexual identity. Although the reliability of many YRBS questions has been
studied, the validity and reliability of questions on whether students had
opposite-, same-, or both-sex sexual partners and sexual identity have not.
A third limitation is that the YRBS is cross-sectional, and, therefore,
the nature of the relationship between opposite-, same-, and both-sex sexual
partners and health risk behaviors cannot be determined, nor can the development
of sexual behaviors and identities be measured over time.
A fourth limitation is that the number of same-sex students in both
states' samples is small and the lack of difference between those students'
and opposite-sex students' health risk behaviors may reflect low statistical
power rather than true similarity in risk behaviors. However, the number of
both-sex students is also small, and unlike same-sex students, the findings
for both-sex students are consistently different from opposite-sex students.
This suggests that the findings for same-sex students are at least partially
reflective of behavior and not simply an artifact of statistical power. A
power analysis demonstrated that the sample sizes were sufficiently large
to detect differences among the groups at a power of 80%. A final limitation
is that although the data were representative of students in Vermont and Massachusetts,
the results cannot be generalized to all youth in the 2 states, or to students
throughout the United States.
CONCLUSIONS
The findings of this study can help public health agencies, school personnel,
health educators, and health service providers to understand and target youth
in sexual minorities who are at highest risk for multiple risk behaviors.
Increased understanding of the health needs of these youth is critical to
the goal of eliminating health disparities in the United States by sexual
orientation, as stated in Healthy People 2010.22 School- and community-based interventions should
be designed to help prevent and reduce risks among adolescents who have sex
with both male and female partners. Such interventions should be comprehensive
and address multiple health issues, including forced sex, sexual risk behaviors,
violence, harassment, suicidal behavior, alcohol and other drug use, and unhealthy
weight control practices. Sexual minority youth should receive timely interventions
that are sensitive to the cultural contexts of gay, lesbian, and bisexual
communities, that address the development of healthy sexual identities, and
that assist youth in navigating the process and consequences of disclosing
their sexual identities to adults and peers. In addition, health professionals
should anticipate that gay, lesbian, and bisexual youth may have both male
and female sexual partners and should provide relevant reproductive health
information accordingly. Service strategies for these youth should be comprehensive
and may need to involve physical and mental health, legal, and housing services
and to provide youth with the skills to make healthy decisions and to engage
in positive relationships with their sexual partners, peers, parents, and
other adults.
| What This Study Adds
Sexual minority youth (ie, gay, lesbian, bisexual, or questioning youth)
face a disproportionate number of health risks compared with their heterosexual
peers. Only a few studies have disaggregated bisexual from gay and lesbian
youth. Those that did found that bisexuality was associated with significantly
more troubles in school, and a greater likelihood of making a suicide attempt.
To our knowledge, this is the first population-based study to differentiate
between high school students who have experience only with opposite-sex students,
only with same-sex students, and with both male and female both-sex students
to compare the prevalence of a variety of health risk behaviors. Both-sex
students were significantly more at risk for violence, harassment, suicidality,
alcohol and other drug use, and unhealthy weight control than opposite-sex
students. Same-sex students were as likely to engage in most of these risk
behaviors as opposite-sex students. School- and community-based interventions
should be designed to help prevent and reduce health risks among adolescents
who have sex with both male and female partners.
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AUTHOR INFORMATION
Accepted for publication January 4, 2002.
Corresponding author and reprints: Leah Robin, PhD, MS K-33, Centers
for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341
(e-mail: ler7{at}cdc.gov).
From the Division of Adolescent and School Health, Centers for Disease
Control and Prevention, Atlanta, Ga (Drs Robin and Brener); Vermont Department
of Education, Montpelier (Mr Donahue); Massachusetts Department of Education,
Malden (Mr Hack and Dr Goodenow); and the Vermont Department of Health, Burlington
(Ms Hale).
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