Detained youth 1

Running head: SEXUAL HEALTH RISKS

A Review: Ecological Factors associated with Sexual Risk Behaviors among Detained
Adolescents
Dexter R. Voisin1,2, Jun Sung Hong3, Kelly King1,2

University of Chicago, School of Social Service Administration

STI/HIV Intervention Network

School of Social Work, Children and Family Research Center, University of Illinois at

Urbana-Champaign

Correspondence/Reprints:
Dexter R. Voisin, PhD, LCSW,
Associate Professor,
University of Chicago, School of Social Service Administration
969 East 60th Street Chicago, IL 60636
Email: d-voisin@uchicago.edu

Abstract
Adolescents who have a history of being detained report rates of STI that are 8 to 10 times
higher than peers without such histories. Consequently, this group represents a highly
vulnerable population warranting greater attention. Over the last decade, an increasing
number of studies have identified multiple factors that are associated with STI risk behaviors
and acquisition among detained youth. This paper utilizes a socio-ecological model to

Detained youth 2
identify risk and protective factors related to STIs among this population. We discuss
mechanisms that may account for such relationships and conclude with recommendations for
advancing future research with this population.

Introduction
Sexually transmitted infections (STIs) are a significant public health concern
resulting in billions of dollars yearly in direct and indirect health care costs (Centers for
Disease Control and Prevention, 2009). Left untreated, STI may lead to serious physical
complications, such as infertility, chronic pain, cancer, or even death (DiClemente, Salazar,
& Crosby, 2007).
Adolescents account for considerable numbers of STIs in the United States (U.S.).
Over 19 million STI cases (e.g., Chlamydia, Gonorrhea, and Trichomoniasis) are reported
annually among adolescents, ages 15 to 24 (Centers for Disease Control, 2009). Among all
adolescents, those with a history of juvenile detention report disproportionately higher rates
of risky sexual behaviors and STI infections compared to peers without such histories.
Detained youth refers to those with a history of being detained, who may or may not have

Detained youth 3
been officially adjudicated. In 2009 it was estimated that over 300,000 juveniles are
incarcerated within detention centers and another 100,000 return to those facilities as they
await legal action. Youth may be detained for any number of offences such as truancy, theft,
aggravated assault, to murder (REFERENCE).
Behaviors such as having a high number of sexual partners, engaging in group sex,
and inconsistent condom use are some of the behavioral factors associated with the
acquisition of STIs (Centers for Disease Control, 2009). Youth with detention histories report
many of these risk behaviors (Altaf et al., 2009; Du Plessis et al., 2009; Grimley et al., 2000;
Haller et al., 2011; Pack et al., 2000; Romero et al., 2007; Salazar, Crosby, & DiClemente,
2009; Valera et al., 2008; Voisin et al., 2006). For instance, Haller et al. (2011) found that
68% of adolescents in a correctional facility had two or more sexual partners within the past
year, prior to arrest, while Valera et al. (2009) reported that 63% had sex with more than one
partner, and 81% did not use condoms consistently. Not surprising incidence of STIs are
extremely high among this group. Surveillance and study data shows that detained youth
report rates of STIs that are up to ten times higher than peers without having such histories
(Centers for Disease Control, 2009; Crosby et al., 2004; Dembo et al., 2009a; Elkington et al.,
2008; Fialho et al., 2008; McDonnell, Levy, & Morton, 2008; Odgers, Robins, & Russell,
2010).
During the last decade, there have been an increasing number of studies examining
correlates of STI-related behaviors among youth. However, no studies to date have reviewed
these correlates in the context of detained youth. Many youth who come to the attention of
juvenile detention authorities may live within certain ecological niches and have several
unmet health and psychosocial needs (Harrington et al., 2004; Matson, Bretl, & Wolf, 2000).
Consequently, they represent a distinct subpopulation of adolescents and warrant a special
focus.

Detained youth 4
Risky sex is one of the most immediate threats to the health and well-being of
detained adolescents. Risky sex can infer a higher risk for unplanned pregnancies and/or
contracting STIs such as Chlamydia, Gonorrhea, and Trichomoniasis. In turn, the presence of
an existing STI can increase vulnerabilities to contracting human immunodeficiency virus
(HIV) (Centers for Disease Control and Prevention, 2009). Unplanned pregnancies and STIs
during adolescence often disrupt the educational completion and subsequent upward mobility
of many youth, resulting in cycles of poverty and marginalization. Applying an ecological
framework to such a review provides a useful analysis given that adolescents interact across a
number of social strata that are likely to promote or restrain such risk behaviors. Moreover,
an ecological framework may suggest promising entry points for future prevention initiatives.
The primary aim of this paper is to utilize a socio-ecological model to identify risk
and protective factors related to STIs among this population. We discuss mechanisms that
may account for such relationships and conclude with recommendations for advancing future
research with this population.
Method
We conducted a review of the published literature to identify correlates of STIs
among detained youth. PsycINFO, PubMed, MEDLINE and Googlescholar were searched
for English-language publications from 1999. The period from 1999-2011 represents the time
period when the majority of research was conducted among this population. Variations in the
following terms were used in the search: juvenile youth, detained youth, incarcerated youth,
and youth with detention histories. Additional studies were identified through bibliographic
referencing. Criteria for inclusion were detained youth as a population focus. According to
the World Health Organization (1977), adolescence refers to a person between 10 and 19
years of age. Thus, research examined in this review includes samples where the majority of
participants were between the this age range. In order to be included in our review, studies

Detained youth 5
must report quantitative findings, and the assessment at least one of the following core
outcome variables: early sexual dbut (i.e., prior to the age of 13), unprotected vaginal sex,
sex without condoms, inconsistent condom use, sex with multiple partners, sex with an STI
infected partner, and having sex with a partner who uses drugs during sex. These variables
were selected given that they are the primary sexual risk behaviors that have been identified
as contributing to STIs among adolescents (Centers for Disease Control, 2009). All potential
articles were evaluated by two independent reviewers to ensure that they met eligibility
criteria. In total, XX articles met eligibility criteria and were included in this review.
Ecological Framework
An ecological framework provides a useful organizing paradigm for examining the
correlates of sexual risks behaviors among detained adolescents. According to
Bronfenbrenners (1977) application of ecological systems theory, sexual behaviors and STIs
are ecological phenomena, maintained over time as a result of the complex interactions
among multiple spheres. Bronfenbrenner originally identified four system of influences: 1)
microsystems refers to direct interpersonal interactions an individual has with their
environment (e.g., the individual interacting with school); 2) mesosystems are interactions
between two or more microsystems (e.g., interactions between home and school that involves
the individual); 3) exosystems are settings that do not include the individual but affect them
nevertheless (e.g., parents working conditions or work schedules which may affect the
quality of parental monitoring); and 4) macrosystems which reflect societys broader societal
norms and practices. Conceptually this model, posits that individuals are not only influenced
by the interaction among these systems but also exert influence on these spheres. Therefore,
interactions are synergistic and bi-directional. This approach has been previously applied in
prevention research among non-detained youth (DiClemente et al., 2005).

Detained youth 6
Historically, the majority of research in prevention science has focused on individual
characteristics associated with sexual risks and STIs. Consequently, the primary targets of
STI prevention and intervention have been on the individual level (DiClemente, Salazar, &
Crosby, 2007). Utilizing an ecological framework, acknowledges individual agency in risky
sexual decision-making, but also identifies important contextual factors at the family, peer
network, community and larger societal levels that influence such risks. This is consistent
with increasing calls to examine health disparities within a social framework (DiClemente et
al., 2005; Organista, 2007; Rhodes et al., 2005). Consistent with the ecological model, we
begin the review with individual-level factors, and then describe factors at the mico, meso
and macro levels that have been identified as significant correlates of STI-risk behaviors. Exo
level factors are not included given that research is under developed in this area
(see Figure 1).
Individual-Level Factors
Individual-level characteristics, such as age, gender, substance use and mental health
problems have been identified as major risk and protective factors with regards to risky sex
and STI acquisition among detained adolescents. Gender expression could be considered a
socially and culturally constructed factor and could be examined at the societal level.
However, given that several gender differences have been noted with regards to individuallevel constructs we discuss such distinctions here.
Age
Age is frequently identified as a significant correlate of risky sex. Older detained
adolescents are more likely to engage in risky sexual practices (Dembo et al., 2009b; Dembo
et al., 2010); and to be diagnosed with an STI (Belenko et al., 2008; Templeton et al., 2010)
than their younger counterparts. Although a few studies have documented that being older is
not a significant risk factor for unsafe sex (Broussard et al., 2002) or STIs (Schmiege, Levin,

Detained youth 7
& Bryan, 2009). For instance, results from a study of 1,236 detained youth found that those
who were older were 1.4 times more likely to test positive for an STI than younger peers
(Dembo et al., 2009b). In contrast, Shmiege et al. (2009) investigated the association
between alcohol use and risky sexual behavior among detained adolescents (ages 14-17) in
Denver using latent class analyses. Results showed that for a majority of participants alcohol
use negatively predicted condom use and positively predicted frequency of sex, with age
being insignificant for risky sex.
Gender
Findings related to age and STI risk and infections, also suggest that gender matters.
Biological factors imply greater STI acquisition risk for females compared to males given
that higher levels of viral loads are present in semen than vaginal fluids (Bolan, Ehrhardt, &
Wasserheit, 1999). Additionally, females are more likely than males to come into contact
with health professionals both within and outside detention facilities (e.g., related to
pregnancy and prenatal care) and may be tested for STIs more readily than their male
counterparts.
Typically, girls report lower risky sexual behaviors (Romero et al., 2007; Teplin et
al., 2003; Voisin et al., 2011) but bear a higher STI burden that is approximately two times
higher than their male counterparts (Barry et al., 2007; (Broussard et al., 2002; Chartier et al.,
2004; Joseof et al., 2009; Kelly et al., 2000; Kingree, Braithwaite, & Woodring, 2000;
Matson, Bretl, & Wolf, 2000; Robertson et al., 2005). For instance, Teplin et al. (2003) found
that more than 90% of detained males were sexually active, and that males engaged in more
risky sex than females. In contrast, one study found that the rate of sexual risk taking was
higher among girls than boys (Dembo et al., 2010). However, the ability of girls to use
condoms and practice safer sex can be comprised by other factors such as sexual violence.
Studies have also shown that females were also less likely than males to report condom use

Detained youth 8
(Broaddus & Bryan, 2008; Richardson et al., 2010). However, being a victim of sexual abuse
may compromise the ability of girls to negotiate condom use which may result in higher rates
of risky sex (Ohene et al., 2005).
It is difficult to disentangle age from gender and some studies have attempted to
examine how these factors may interact to influence STI risk. For instance, Dembo et al.
(2010) reported from a sample of 948 newly arrested adolescents (ages 12-18) in Florida that
being older was a significant STI risk factor for females but not for males. Older adolescent
girls had higher level of sexual risk and STI than did younger girls. Some older girls may not
only be more sexually active than their younger peers but might be having sex with older
partners who themselves might have higher STI-risk profiles.
Collectively, several of the above findings can be explained by gender and power
concepts (Wingood & DiClemente, 2000). According to these concepts, males have more
power than females in sexual situations and typically drive condom use during sex.
Additionally, females in general are more physically susceptible to sexual abuse than males
which may compromise their capacity to effectively negotiate condom use (Briere & Elliott,
2003; Dembo, Schmeidler, & Childs, 2007; May-Chahal & Cawson, 2005; Ohene et al.,
2005).
Taken together, findings on age and combined findings on age and gender suggest
that age operates as a potential risk factor based on the presence or absence of other risk
dimensions (e.g., gender, alcohol use, sexual abuse, etc) many of which are not routinely
assessed across single studies. This strengthens the argument for adopting an ecological
approach to STI risk behaviors examining multiple risk factors and contexts.
Substance Use
Substance use and misuse are known correlates of risky sexual behavior, which can
culminate in STI acquisition and transmission (SAMSA, 2007). Similar findings have been

Detained youth 9
reported among samples of detained youth (Belenko et al., 2008; Childs et al., 2011;
Lederman et al., 2004; Matson et al., 2000; McDonnell et al., 2008; Salazar et al., 2009;
Teplin et al., 2003; Voisin et al., 2006; Voisin et al., 2007b). Detained adolescents who tested
positive for alcohol (Du Plessis et al., 2009; Malow et al., 2006; Richardson et al., 2010;
Robertson et al., 2005; Schmiege et al., 2009; Steinberg et al., 2011; Valera et al., 2009),
marijuana (Dembo et al., 2009b, c; Hendershot et al., 2010a; Kingree & Betz, 2003; Kingree
& Phan, 2001, 2002; Kingree et al., 2000; Richardson et al., 2010; Rosengard et al., 2006;
Valera et al., 2009), cocaine (Dembo et al., 2009a), injected drugs (Kelly et al., 2000; Teplin
et al., 2010), or were diagnosed with a substance use disorder (Elkington et al., 2008)
reported an elevated risk for unprotected sexual activity and STIs. No gender differences
have been noted with regards to this relationship in a detained population (Dembo et al.,
2010; Kingree & Phan, 2002). This is not surprising, given that drug use may be extremely
high among detained youth regardless of gender, and in fact may be one of the precipitating
reasons for these youth coming to the attention of juvenile justice authorities.
With regards to mechanisms linking drug use and risky sex, several pathways may
exist. It is well documented that alcohol and other drugs impair functional decision-making
(see Dom et al., 2005, for a review). In addition, drugs may desensitize individuals to the
fear of contracting STIs and may also lead to poor impulse control (Allen et al., 1998).
Additionally, poor impulse control has been found to be associated with a higher number of
riskier sexual acts (Stanford & Barratt, 1992). Researchers have also posited that positive
expectations about the benefits of alcohol and other drugs connects youth to other peers who
may adhere to similar beliefs (Stanford & Barratt, 1992). Youth who come to the attention of
juvenile justice authorities may live in peer milieus that are characterized by positive norms
or attitudes towards riskier practices and higher positive expectations about the benefits of
drug use (Eng & Butler, 2000). Consequently, such peer networks may be characterized by

Detained youth 10
members with high risk sexual profiles, where the incidence of STIs is greater inferring
higher STI transmission and acquisition probabilities (Lopez et al. (2011).
Mental Health
Depression and other mental health symptoms have also been identified as a
significant correlate of STIs among detained youth (Elkington et al., 2008; Lederman et al.,
2004; Lopez et al., 2011). However, such relationships may be direct, mediated, or have
differential outcomes based on the type of psychological problems noted. For instance,
Voisin et al. (2011) investigated whether psychotropic medication (PM) use was related to
STI diagnosis among 550 youth detainees (ages 14-18). Findings provided evidence that
non-PM users were more likely to test positive, compared to PM users. In contrast,
Elkington et al. (2008) found from a sample of 689 arrested youth in Cook County, Illinois
that adolescents diagnosed with major mental disorder (e.g., major depressive episode) at
baseline were less likely to have unprotected sex than adolescents diagnosed with substance
use disorder or those with neither disorders.
Lopez et al. (2011) examined the pathways leading to sexual risk taking among 329
White and 484 African American female adolescent detainees. Findings showed that child
abuse and/or maltreatment were associated with higher levels of depression, which mediated
alcohol-based expectancies for sexual pleasure and higher rates of non-condom use. Taken
together, these findings suggest that various types of mental health problems may lead to
differential outcomes. For instance, depressed youth may be more isolated and have fewer
possibilities for, or interest in having sex. Whereas, youth displaying aggressive
symptomology may experience higher levels of poor impulsivity which is a known predictor
for unsafe sex (see Zuckerman & Kuhlman, 2000). In general, mental health problems may
be more pronounced among detained populations than those without such histories. For
instance, mental health problems resulting in poor impulsivity and aggressive behaviors may

Detained youth 11
attribute to detention arrests (REFERENCE). In addition, the experience of detention may be
a traumatic event by itself and may exaggerate existing mental health problems. However,
existing studies have not allowed us to differentiate between differ types of mental health
problems and differential STI-risk behaviors.
Micosystem-Level Factors
Intimate relationships with parents and peers have also been identified as significant
correlates of STI risks among detained youth. Dynamics with the home and the nature and
norms of social networks are all associated with risky sex.
Parental Monitoring
Family is an important micro context and one family factor that has emerged as an
important protective factor against risky sex is parental monitoring. Perceived parental
monitoring refers to youth believing that they parents know where they are at all times
(DiClemente, Salazar, & Crosby, 2007). Similar relationships have also been observed with
detained adolescents. Youth who perceived that that their parents knew where they were
reported lower rates of STI-related risk behaviors than peers reporting lower perceived
parental monitoring (Voisin et al., 2006). Advancing this line of inquiry, researchers have
also attempted to differentiate between the relative significance of parental monitoring,
communication and support as they may be related to STI risks. When assessed collectively,
findings indicated that for detained youth, parental monitoring was associated with decrease
in diagnosis of STI in 45.1% of the cases, whereas parental social support and parent-youth
communication about sex were not statistically associated with such diagnoses (Crosby et
al., 2006). These findings may suggest that parental monitoring may be an umbrella
construct that incorporates parental communication or support.
Social control theory provides some theoretical support for linkages between parental
monitoring and STI risks. According to one application of this theory (Hirschi, 1969),

Detained youth 12
adolescents who have strong bonds to positive adults such as parent figures are more likely
to adhere to their positive norms. Therefore, parental monitoring may not only mitigate the
influences of negative peer pressure but also reduce the possibilities for unsupervised
situations where sexual activity and risky sex may occur.
Family Violence
Family violence may disrupt protective parental monitoring and may advance
conditions which can lead to youth engaging in risky sex (Lederman et al., 2004; Odgers et
al., 2010). For instance, Lederman et al. (2004) documented a high prevalence of violence in
the homes of a sample of 493 female detainees (ages 10-17). Researchers found that
antecedents to risky sex were correlated with stressful life events, such as exposure to family
violence (Odgers et al., 2010). The Risky Families Model (Repetti et al, 2002) might provide
insight into processes that might account for such outcomes. According to this model, family
violence can create poorer positive peer relations linking youth to negative peer networks
which may advance and endorse risky sex. Additionally, youth exposed to family violence
may develop poor emotional coping skills which may further mental health problems which
heightens likelihood of engaging in risky sex.
Peer Influences
Peer influences have also been shown to be a significant correlate of STI risk behaviors
(Lederman et al., 2004; Voisin et al., 2004; Voisin et al., 2006). Research has shown that
adolescents who affiliate with friends and peers that endorse risk norms such as unsafe sexual
practices, are more likely to adopt such behaviors themselves. For instance, Voisin et al.
(2004) reported that adolescent males with prior gang affiliation were significantly more
likely than those not involved in gangs to be sexually active, use condoms inconsistently,
have caused a pregnancy, be high on drugs during sexual activity, have sex with a partner
who was high, or engage in group sex. Negative peer influences may also mediate the

Detained youth 13
relationship between larger structural factors such as community violence exposures and STIrisk behaviors (Voisin, Neilands, Salazar, Crosby, DiClemente, 2008). Social learning
perspectives (Bandura, 1977) provide a logical explanation for such linkages. Youth are more
likely to adopt the negative norms of their peer negative networks. This is especially the case
when individuals are centrally embedded within those networks; there is a high degree of
reciprocal relationships; and networks are isolated.
Mesosystem-Level Factors
Social contexts such as community and school factors have been identified as
significant correlates of STI risks. During adolescence, these factors are more likely to have
stronger influences as risk outcomes as parental monitoring functions may decrease as youth
age (REFERENCE).
School Enrollment
School enrollment has been identified as an important protective factor against
unsafe sexual behavior among detained youth (Broaddus & Bryan, 2008). Researchers
documented that among a racially diverse sample of mostly males, that participants who were
enrolled in school reported a rate of consistent condom use that was almost three times higher
than peers not enrolled in school (Broaddus & Bryan, 2008).
Student-Teacher Connectedness
Consistent with the finding on school enrollment, researchers also documented that
positive relationships with teachers was a protective factor against risky sex for detained
youth. Voisin et al. (2005) found among a sample of 550 detained adolescents (ages 14-18)
that even after controlling for potential confounders (e.g., demographics, socioeconomic
status, truancy, number of days in the detention, and family factors), youth with low teacher
connectedness, in the two months prior to being detained, were twice as likely to use
substances, to be sexually active, engage in sexual activities while high on substances, have

Detained youth 14
sex with a partner who was high on a substance, and have multiple sex partners that peers
who reported poorer relationships with teachers.
Collectively, the findings on school enrollment and positive student-teacher
connections as protective factors against sexual risk behavior can be explained using social
control (LeBlanc, Vallieres, & McDuff, 1992) and social learning (Bandura, 1986)
perspectives. Youth who are connected to positive norms and institutions are more apt to
adopt such positive values, which tend to result in fewer risk behaviors and more positive
health outcomes. Additionally, attending school may limit adolescents time to pursue
multiple sex partners, or serve to restrict their sexual networks to a safer population of
peers also in school.
Community Violence Exposure
Community violence exposure (CVE) consists of violent incidents (e.g., witnessing or
being a victim of robberies, muggings, gang-related deaths, or homicides) taking place
outside the home, between individuals who are unrelated and who may or may not know each
other (Krug et al., 2002). Findings have shown, controlling for race, gender, socioeconomic
and family factors, that among a multiethnic detained youth sample, participants who
witnessed violence in the year prior to being detained were twice as likely to report having
been high on alcohol or other drugs during sexual intercourse and to have had sex with a
partner who was high on alcohol or other drugs than peers not exposed to community
violence (Voisin et al., 2007b). Youth who reside in neighborhood with high rates of violence
are significantly more likely to have low attachment to positive institutions that oppose risk
behaviors, which may increase their likelihood of engaging in these behaviors (Voisin et al.,
2007b). However indirect pathways may account for the relationship between community
violence exposures and risky sex. One study of 550 detained adolescents documented that
when controlling for demographics and family variables, there were positive associations

Detained youth 15
between witnessing community violence and drug and sexual risk behaviors. Witnessing
community violence was directly related to sexual risk behaviors and indirectly associated
with these risk behaviors and substance use through gang membership and perceived risky
peer norms (Voisin, Neilands, Salazar, Crosby, DiClemente, 2008).
Social control theory (Hirschi, 1969) provides a framework for better understanding
the relationship between community violence exposure and increased sexual risk behavior.
According to one application of this theory, high and recurring rates of community violence
result in social disorganization in the community, weakening the bonds to positive agents.
These agents often are parents and teachers who might also be threatened by loss of safety
and consequently less able to adequately monitor and supervise their youth (Hirschi, 1969).
Weak social attachment to positive figures lessens young peoples ability to make sense of the
violence around them, which heightens their vulnerability to succumbing to negative peer
involvement. Negative peer involvement, in turn, has been consistently shown to advance
youth risk behaviors (Bachanas et al., 2002; Boyer et al., 2000; Crosby et al., 2000).
Macrosystem Factors
Race/Ethnicity
Race and ethnic identity are conceptualized as societal factors because they often
imply structural disadvantage with regards to employment, heath care access, admission to
well resourced schools, access broader neighborhood and societal social capital, and rates of
juvenile arrests and incarceration. Many of these can influence sexual knowledge and health
among adolescents (Voisin, Jenkins, & Takahashi, 2011). Although, some studies among
racial minorities have failed to demonstrate ethnic differences with regards to sexual risk
(Crosby et al., 2004; Dembo et al., 2010; Romero et al., 2007), the majority of surveillance
and study data shows that racial and ethnic minority youth who have been detained are more
likely than their non-Hispanic White counterparts to test positive for STIs (Lofy et al., 2006;

Detained youth 16
Risser et al., 2001). This is especially the case with minority youth who are African
American (Aalsma et al., 2011; Belenko et al., 2008; Dembo et al., 2009b; Joseof et al.,
2009; Matson et al., 2000; Richardson et al., 2010; Robertson et al., 2005; Teplin et al.,
2003). Specifically, Broussard et al. (2002) found that African American males appear to be
at increased risk for reporting Chlamydia and Gonorrhea infections compared to other racial
groups, while several studies demonstrated increased risk of STIs among African America
women (Chartier et al., 2004; Dembo et al., 2009c).
Structural Disadvantage
The disproportionate risk for STIs among racial minorities, especially those who are
African American and Hispanic, may reflect a number of environmental factors such as
poverty, low educational attainment, compromised family structures, and a greater clustering
of STIs in those communities (Fullilove, 1998). For example, some findings have shown that
detained Hispanic adolescents compared to peers from all other ethnic groups (e.g., African
Americans, Asians, whites) are least prone to use condoms (Broaddus & Bryan, 2008). In
addition, detained white youth reported higher rates of unprotected sex compared to peers
from other ethnic groups (Kingree, Braithwaite, & Woodring, 2000). Lower rates of STIs
among white youth despite the high rates of unprotected and risky sex may partly reflect the
lower prevalence of STIs among potential sex partners, compared to African Americans and
Hispanic populations.
Cultural Norms and Gender Violence
Cultural norms may allow for a greater acceptance of gender-based violence
(Salazar et al., 2009) and gender norms that favor male dominance in sexual situations
(Voisin et al., 2006) may advance risky sex and STI acquisition. For instance, Salazar et al.
(2009) reported that female detainees who experienced gender-based violence had high rates
of STIs, such as Chlamydia. Additionally, researchers found that holding gender role norms

Detained youth 17
supporting male dominance was a significant factor for self-reported STI risk behaviors
among a sample of 280 detained female adolescents (Voisin et al., 2006).
Health Care Policies
Policies and laws that effectively address sexual risk behavior and STI acquisition
can promote increased structural accessibility to prevention and intervention programs for
youth in correctional facilities, which could have a profound effect on their sexual health. For
example, thirty-nine states currently have policies regarding the administration of the human
papillomavirus (HPV) vaccine to female detainees in juvenile justice facilities (Hendershot,
Rich, & Lally, 2010). However, in many of these states, the HPV vaccine is only offered to
committed youth (i.e., those held by court orders) and is either not offered or inconsistently
offered to detained youth (i.e., those awaiting adjudication, disposition, or placement
elsewhere). Nevertheless, the enactment of such laws is likely to have some impact on the
acquisition of STIs for adolescents who are involved in the juvenile justice system.
Discussion and Future Directions
This paper utilized a socio-ecological model as a framework to identify risk and
protective factors related to sexual risk and STI acquisition among detained adolescents, a
highly vulnerable youth population. It is clear from our review of the literature that there are
several individual, mico, meso and macro-level factors that coalesce to create unique culture
of risk for adolescents that have come in contact with the juvenile justice system. As
evidenced by the review the majority of studies have focuses on individual levels factors,
with fewer studies examining community and societal levels factors. Additionally, although
researchers evoke ecological frameworks in their studies of sexual health disparities, virtually
none evaluate exosystem level factors given that they are complicated to access (DiClemente
et al., 2007; Salazar et al., 2010; Voisn et al., 2007; Voisin et al., 2011). Moreover, few of the
studies reviewed, have multiple system correlates across the same sample. Therefore, we do

Detained youth 18
not have a clear sense of how risk or protective factors may function when assessed
simultaneously. One study which did test an ecological approach to STI risk behaviors among
detained females examined various ecological factors an independent predictors but failed to
explore interactions among variables (Voisn et al., 2007). Researchers posited that those distal
factors may influence more proximal factors (Voisn et al., 2007). However future studies
would need to empirically test this assumption. Another study documented that witnessing
community violence was directly related to sexual risk behaviors and indirectly associated
with these risk behaviors and substance use through gang membership and perceived risky
peer norms (Voisin, Neilands, Salazar, Crosby, DiClemente, 2008). Along similar lines were
need more conceptual models that help us to better understand how many of these valuables
interrelate to influence or restrain STI risk behaviors and outcomes (Voisin et al., 2011). One
shows that community level factors such as study indicated that the
It is also important to note that the majority of the studies reviewed were crosssectional in design. Therefore, we are unable to infer causality and it is possible that some
relationships are bidirectional. Further, we do not know whether such observed relationships
persist across time. Moving forward more longitudinal studies are necessary to better
understand and clarify the temporal ordering between key variables. Elucidating the
relationships between various ecological factors longitudinally will provide new avenues for
intervention. Future research should employ the use of advanced methodological techniques,
such as structural equation modeling, to better understand how these variables interact with
one another both directly and indirectly. Additionally, prior studies have not always
controlled for length of time in detention or previous detention histories. Detention itself can
be a stress event that may infer an additional level of risk by exacerbating underlying mental
health problems. Furthermore, youth who are detained for minor offences and are socialized
with chronic violent offenders may be recruited into risky peer and sexual networks upon

Detained youth 19
release. Many existing studies have not assessed these factors as they may influences STI
risks.
It is clear from this review that detained adolescents may be particularly vulnerable
to individual level risk factors such as substance use (Belenko et al., 2008; Childs et al., 2011;
Lederman et al., 2004; Matson et al., 2000; McDonnell et al., 2008; Salazar et al., 2009;
Teplin et al., 2003; Voisin et al., 2006; Voisin et al., 2007b) and poor mental health (Elkington
et al., 2008; Lederman et al., 2004; Lopez et al., 2011). There are also higher-level factors
that may serve to increase sexual risk in this population. For example, detained adolescents
report a high prevalence of family violence (Lederman et al., 2004), higher levels of
association with deviant peers or gang involvement (Lederman et al., 2004; Voisin et al.,
2004) and increased exposure to community violence (Voisin et al., 2007b), all of which have
been found to influence sexual risk behavior. As a result protective factors such as parental
monitoring, school enrollment and student-teacher connectedness may especially important in
preventing against poor sexual health outcomes in this population.
Unfortunately, detained adolescents most often exist in community or family milieus
that might infer a greater level of risk. They may have weak ties to primary caregivers,
associate with peer groups that endorse risky norms, or exist within sexual networks with
higher rates of STIs. While some of these factors are not easily amenable to change,
addressing unmet mental health needs and trying to foster alternative protective elements are
crucial to reducing sexual risk behavior. Moreover, given the syndemic relationships between
many of these factors, effecting change in one dimension may also have positive spill over
into others. For example, increasing levels of student teacher connectedness may reduce risky
sex and STI outcomes in itself but may also protect against other correlates of risk. If youth
feel a strong connection to their teachers, this may result in increased levels of school
involvement, lower levels of truancy and therefore reduced gang involvement and exposure

Detained youth 20
to community violence. Future research should seek to test this assumption, as well as
attempt to identify other empirically generated moderators that may be amenable to change
It is clear from our present review that research and interventions must move beyond
individual level factors to address family, community and structural level factors such as
parental relationships, community violence, and social policy in order to reduce sexual risk
behavior and STI acquisition in this population. Moreover, societal level factors such as race
and ethnicity, structural disadvantage and cultural gender norms must be acknowledged
through the integration of culturally competent prevention and interventions designed to
address many of these significant correlates.
Ultimately, experiences of detainment among youth present periods of opportunity to
intervene and help reduce sexual risk behaviors, with implications for individuals and their
communities. Future research can draw from this review to better understand pathways that
lead to or mediate sexual risk in this vulnerable population in an attempt to integrate bestpractices into HIV/STI interventions and policy surrounding their administration in
adolescent criminal justice settings.

Detained youth 21
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