Blackwell Science, LtdOxford, UKCCHDChild: Care, Health and Development1365-2214Blackwell Publishing Ltd, 20032003295337344Original ArticleRisk-

taking sexual behaviour and depressionE. Kosunen

et al.

Original Article

Risk-taking sexual behaviour and

self-reported depression in middle
adolescence – a school-based survey
E. Kosunen,* R. Kaltiala-Heino,†‡ M. Rimpelä§ and P. Laippala†¶
*Medical School, Department of General Practice, University of Tampere,
†School of Public Health, University of Tampere,
‡Department of Psychiatry, Tampere University Hospital,
§National Research and Development Centre for Welfare and Health (STAKES), Helsinki, and
¶Research Unit, Tampere University Hospital, Tampere, Finland

Accepted for publication 15 May 2003

Abstract
Background Early sexual activity has been widely studied in the context of pregnancies, substance
use and antisocial behaviour, but the aspects of psychosexual health have received less attention.
Aim To study the associations of early sexual activity and self-reported depression.
Setting A school survey in Finland in 1999 and 2000 in the eighth and ninth grades.
Methods Adolescents with experience of sexual intercourse were studied (11 793 girls and 10 443
boys, mean age 15.5 years). Scores of 8 or more in the Beck Depression Inventory were regarded as
indicative of self-reported depression. Associations with sexual behaviour variables were analysed
using logistic regression models.
Results In both genders, self-reported depression increased in proportion to the number of sexual
partners and with the non-use of contraception. A higher number of coital experiences correlated
with depression only among boys. Adjusting for age and age at menarche/oigarche did not affect
the associations detected. In stepwise logistic regression, an increasing number of partners increased
the risk for self-reported depression [for boys with at least five partners odds ratio (OR) 2.5, 95%
confidence intervals (CI) 2.2–3.0, and for girls OR 2.7, 95% CI 2.3–3.2]. Boys and girls who did not use
contraception showed roughly twice as high a risk as contraceptive users. However, girls with five or
more coital experiences had a significantly lower risk for depression compared to girls with only one
sexual intercourse.
Conclusions Multiple sexual partners and non-use of contraception may reflect a depressive
Keywords disorder in both genders. While adolescent health service providers should be aware of the risk for
adolescence, depression,
sexual behaviour,
depression among sexually active adolescents, the sexual health of depressed adolescents also
contraception warrants special attention.

Correspondence:
Elise Kosunen, Senior
Lecturer of General Practice,
Medical School, Department behaviour (Udry & Bearman 1998): early sexual
of General Practice, Introduction
activity is considered to reflect problems in adoles-
University of Tampere,
FIN-33 014, Finland Adolescent sexual behaviour is most often cent development rather than successful adolescent
E-mail:meelko@uta.fi described in terms of problem behaviour or risk passage. However, a remarkable proportion of
Original Article

© 2003 Blackwell Publishing Ltd 337

338 E. Kosunen et al.
teenagers in Western countries engage in sexual
intercourse at an age that can be called ‘early’. In
many European countries around 30% of adoles-
cents experience their first sexual intercourse
before the age of 16 (Ross & Wyatt 2000), and even
higher figures are reported from the USA, Canada
and Australia (Cheesbrough et al. 1999). Does this
mean that all these adolescents are at risk of
unfavourable development?
In Scandinavia, attitudes to adolescent sexuality
are quite permissive: sexual activity is considered
normative behaviour during the transition period
from adolescence to adulthood (Davis 1989). How-
ever, there is also evidence that at least some teen-
agers engage in sexual activity before they are
mature enough, with reasons ranging from peer
pressure and an unfavourable family background
to substance use (Goodson et al. 1997; Kinsman
et al. 1998). According to recent British studies, a
large proportion of adolescents who engaged in
sexual intercourse at age 16 or below regretted their
early initiation (Dickson et al. 1998; Wight et al.
2000).
Adolescent sexual health is most typically
described from the vantage point of physical
health, using such indicators as the incidence of
pregnancies, abortions and sexually transmitted
infections. The viewpoint of psychosexual health is
largely ignored. For instance, there are only very
few studies that have discussed the associations
between depressive disorders and sexual behaviour
(Rubin et al. 1992; Tubman et al. 1996), even
though depression is a common and increasing
problem in the population, including adolescents
(Leon et al. 1993; Prosser & McArdle 1996).
Our previous study based on a major school
survey was concerned with associations between
adolescents’ self-reported depression and sexual
events in the chain of advancing sexual experiences
(kissing, fondling, petting, sexual intercourse) in
the adolescent population aged 14–16 years. We
found an association between intimate sexual
experiences (petting, sexual intercourse) and
depression in girls (Kaltiala-Heino et al. 2003). In
boys, depression was associated with experiences of
sexual intercourse only. In this report, we focus on
adolescents who have experienced at least one sex-
ual intercourse and their psychosexual health. We
© 2003 Blackwell Publishing Ltd, Child: Care, Health & Development, 29, 5, 337–344
also elaborate on the association between self-
reported depression and indicators of sexual
behaviour: the total number of coital experiences,
the number of sexual partners and contraceptive
use.
Materials and methods
The School Health Promotion Study is an anony-
mous classroom survey concerned with the health,
health behaviour and school experiences of adoles-
cents in the eighth and ninth grades of secondary
school. The survey has been carried out annually
since 1995. The data for the present study were
derived from the surveys in 1999 (188 municipali-
ties mainly from western Finland) and 2000 (160
municipalities mainly from eastern Finland). A
total of 348 out of the country’s 448 municipalities
took part in the survey. Less than 1% of the forms
returned were rejected because of poor data qual-
ity, leaving us with 47 952 responses from the
eighth grade (mean age 14.8 years, SD ± 0.3 years)
and 47 214 from the ninth grade (mean age
15.8 years, SD ± 0.3 years). Pupils absent on the
survey day were not contacted. Earlier data collec-
tions have taught us that each day, 10–15% of all
pupils are absent.
The material for the present study comprises
those eighth and ninth grade pupils who reported
having experienced at least one sexual intercourse.
The number of girls was 11 793, the number of
boys 10 443. Their mean age was 15.5 (SD ± 0.58)
years. The majority had stable living conditions:
63.6% lived with both parents, 73.8% had lived in
the same municipality for 10 years or more, and
60.8% reported stable parental employment (nei-
ther father nor mother unemployed during the
past 12 months). One-quarter of the respondents
(28.1%) said that their parents (one or both) had
academic qualifications.
Self-reported depression was measured by the
13-item short form of the Beck Depression Inven-
tory (BDI) (Beck & Beck 1972; Beck et al. 1974;
Kaltiala-Heino et al. 1999a). The Finnish version of
the instrument has been shown to have good psy-
chometric properties among 14- to 16-year-old
adolescents (Kaltiala-Heino et al. 1999a). The 13-
item BDI measures the respondents’ own percep-

tion of their depressive symptoms, but it is not a
diagnostic instrument for depressive disorders.
The 13 items consist of statements which show an
increasing intensity of depressive emotions and
cognitions, scoring 0–3 each. The maximum score
is thus 39. Scores 0–4 are classified as no depres-
sion, 5–7 as mild, 8–15 as moderate and 16 + as
severe depression (Beck & Beck 1972).
Mood changes are part of normal adolescent
development, but severe depressive symptoms are
likely to be relatively persistent (Charman 1994).
To avoid bias, we did not take into account those
BDI scores that indicated mild depression, but
dichotomized the depression score (moderately to
severely depressed vs. no/mildly depressed). In this
study, we refer to high BDI scores (scores of 8 or
more, which signifies moderate to severe depres-
sion) as self-reported depression.
The first School Health Promotion Studies used
the 13-item BDI in full without any modifications,
but in 1998 the item concerning suicidal ideation
had to be removed because of concerns at the Min-
istry of Education that asking the question might
provoke suicidality in adolescents. We analysed a
previous sample (Kaltiala-Heino et al. 1999b;
2001) and noted that even with one item less in the
scale, the original cut-point between no/mild (0–7
points) and moderate/severe (8 or more) depres-
sion caused only a minimal transfer of cases from
one class to another: as few as 0.7% of the respon-
dents were transferred from being cases to being
non-symptomatic subjects. The psychometric
properties of the 12-item scale corresponded to
those of the original scale (Kaltiala-Heino et al.
1999a).
Onset of menstruation (ejaculations) was elicited
by asking, ‘How old were you when you had your
first menstruation (ejaculation)?’ [‘10 years or
younger/11 years/12 years/13 years/14 years/15 years
or older/I have not yet experienced menstruation
(ejaculation)’]. The two lowest classes (10 years or
younger and 11 years) were combined because of
the small number of cases in the lowest category.
Adolescents who had experienced sexual inter-
course were asked to provide more data on their
sexual behaviour. First, the number of intercourse
experiences was enquired by the question, ‘How
many times have you had intercourse?’ (once/2–4
© 2003 Blackwell Publishing Ltd, Child: Care, Health & Development, 29, 5, 337–344
Risk-taking sexual behaviour and depression 339
times/5–9 times/10 or more times). Second, the
number of sexual partners they had had was
inquired by asking, ‘With how many different part-
ners have you had intercourse?’ (one/two/three or
four/five or more). Finally, use of contraception
was evaluated by asking, ‘What kind of contracep-
tion did you use in the most recent intercourse?’
[none/condom/oral contraceptives/condom and
oral contraceptives/other method (please
describe)]. The responses in the category ‘other
methods’ virtually includes only methods of natu-
ral family planning (withdrawal, calendar method)
and the proportion of this category is from zero to
three percentages in the Finnish adolescent surveys
(Kosunen et al. 2000). For the analyses, the
response options ‘none’ and ‘other method’ were
grouped together to form the category ‘no contra-
ception’, compared to having used contraception
(condom, oral contraceptives or both)’.
Age was calculated from date of birth and the
survey date and used in bivariate analyses classified
into years (14/15/16) and in multivariate analyses
as a continuous variable.
Statistical analysis
Bivariate associations between sexual behaviour
variables and self-reported depression were studied
using the chi-square test. Multivariate analysis was
performed using stepwise logistic regression, where
self-reported depression (yes/no) was the depen-
dent variable. First, the bivariate odds ratios (OR)
were calculated for each sexual behaviour variable,
forcing age and age at menarche/oigarche into the
model in order to adjust for their confounding
effect. Then, the sexual behaviour variables were
tested as independent variables simultaneously,
again forcing age and age at menarche/oigarche into
the model. This final model was additionally tested
separately for those who were currently dating
(6823 girls and 4658 boys) and for those who were
not (4934 girls and 5726 boys).
Results
The proportion of girls having had at least 10 coital
experiences was 45% (of girls having experienced
at least one sexual intercourse). The figure was 37%
340 E. Kosunen et al.

in boys, respectively (Table 1). Around a half of Among boys, self-reported depression also
adolescents had had only one sexual partner, but increased in line with the number of reported coital
10% of girls and 17% of boys reported at least five experiences, but no such association was found
partners. Four out of five adolescents had used among girls (Table 2).
effective contraceptive methods (oral contracep- Adjusting for age and age at menarche/oigarche
tives or condoms) at the most recent intercourse. did not change the associations detected between
Among both girls and boys, self-reported the variables related to sexual behaviour and self-
depression increased in proportion to the number reported depression, when the sexual behaviour
of reported sexual partners. Furthermore, self- variables were tested independently in turn in the
reported depression was associated with the non- logistic regression models (Table 3).
use of contraception at the most recent intercourse. Next, the association between self-reported
depression and sexual behaviour variables was
tested by entering all the sexual behaviour variables
in one model (age and age at menarche/oigarche
Table 1. Total number of coital experiences, number of sex-
ual partners and contraceptive use (oral contraceptives or forced). When using the stepwise forward selection
condom) among 14- to 16-year-old adolescents who had procedure in logistic regression, all the sexual
experienced at least one sexual intercourse. Distributions behaviour variables studied as well as age and age
(%) by gender
at menarche emerged in the final model among girls
Girls Boys
(Table 4). A growing number of partners increased
(n = 11 793) (n = 10 443)
% % the risk for self-reported depression, and non-use
Total number of coital experiences
of contraception at the most recent intercourse was
1 18.1 23.2 likewise associated with a greater risk [OR 1.7, 95%
2–4 23.5 27.2 confidence intervals (CI) 1.6–1.9]. However, if a girl
5–9 13.4 12.5
had had five or more coital experiences, the risk of
10 or more 45.1 37.1
Number of sexual partners depression was significantly lower compared to girls
1 50.8 48.0 with only one sexual intercourse.
2 22.1 20.3
Among boys, OR for self-reported depression
3–4 17.4 14.4
5 or more 9.6 17.3 was 2.5 (95% CI 2.2–3.0) for those who had had at
Contraception at the most recent intercourse least five sexual partners compared to those with
Yes 82.3 79.4 only one partner. Boys who did not use any con-
No 17.7 20.6
traception at the most recent intercourse had twice

Table 2. Self-reported depression (%) by total number of coital experiences, number of sexual partners and contraceptive
use among 14- to 16-year-old adolescents who had experienced at least one sexual intercourse
Girls (n = 11 793) Boys (n = 10 443)
% P-value % P-value

Total number of coital experiences

1 23.6 0.134 9.2 <0.0001
2–4 23.4 10.8
5–9 23.4 12.5
10 or more 21.6 19.8
Number of sexual partners
1 19.0 <0.0001 9.6 <0.0001
2 22.2 11.4
3–4 26.3 14.0
5 or more 35.8 29.5
Contraception at the most recent intercourse
Yes 20.4 <0.0001 10.6 <0.0001
No 32.9 26.9

© 2003 Blackwell Publishing Ltd, Child: Care, Health & Development, 29, 5, 337–344
 Risk-taking sexual behaviour and depression 341

Table 3. Bivariate odd ratios [OR, 95% confidence intervals (CI)] for self-reported depression according to total number of
coital experiences (Model 1), number of sexual partners (Model 2), and use of contraception (Model 3) at the most recent
intercourse, controlled for age and age at menarche/oigarche, among 14- to 16-year-old adolescents
Girls Boys
OR (95% CI) OR (95% CI)

Model 1: total number of coital experiences

1 NS Ref
2–4 1.3 (1.0–1.6)
5–9 1.4 (1.1–1.8)
10 or more 2.2 (1.8–2.6)
Model 2: number of sexual partners
1 Ref Ref
2 1.2 (1.1–1.4) 1.2 (1.0–1.4)
3–4 1.6 (1.4–1.8) 1.5 (1.3–1.9)
5 or more 2.4 (2.1–2.8) 3.2 (2.7–3.7)
Model 3: use of contraception at the most recent intercourse
Yes Ref Ref
No 1.9 (1.7–2.1) 2.6 (2.3–2.9)
NS, not significant.

Table 4. Multivariate odds ratios [OR, 95% confidence intervals (CI)] for self-reported depression according to total number
of coital experiences, number of sexual partners, and use of contraception at the most recent intercourse, controlled for age
and age at menarche/oigarche, among 14- to 16-year-old adolescents (forward stepwise logistic regression)
Girls Boys
OR (95% CI) OR (95% CI)

Total number of coital experiences

1 Ref NS
2–4 0.8 (0.7–1.0)
5–9 0.7 (0.6–0.9)
10 or more 0.7 (0.6–0.8)
Number of sexual partners
1 Ref Ref
2 1.3 (1.2–1.5) 1.2 (1.1–1.4)
3–4 1.7 (1.5–2.0) 1.5 (1.3–1.8)
5 or more 2.7 (2.3–3.2) 2.5 (2.2–3.0)
Use of contraception at the most recent intercourse
Yes Ref Ref
No 1.7 (1.6–1.9) 2.1 (1.8–2.4)
NS, not significant.

as high a risk for depression as contraceptive users
(Table 4).
When stepwise modelling was carried out sepa-
rately for adolescents who were currently dating
and for those who were not, the results remained
almost the same as in Table 4, except that the total
number of coital experiences did not enter the
model among girls who were not dating.
Discussion
This study was carried out in Finnish secondary
schools, which cover more than 99% of adolescents
at this age. The samples collected in 2 years com-
prised around 80% of 1-year-birth cohorts in both
the eighth and the ninth grades. Almost all the
pupils present at school returned an acceptable
response. Pupils absent on the day were not con-
tacted, which may constitute a source of bias
because they probably have more health and psy-
chosocial problems, including depression. Then, it
is possible that our results for the prevalence of
depression are slight underestimates, but there is
no reason to suggest that this in any way affects the
associations between the phenomena studied.
Against the background of the high and growing
prevalence of depressive disorders in the popula-
tion (Leon et al. 1993; Prosser & McArdle 1996), it

© 2003 Blackwell Publishing Ltd, Child: Care, Health & Development, 29, 5, 337–344
342 E. Kosunen et al.
is surprising how little work has been done to
explore the associations of sexual behaviour and
depression among adults, let alone adolescents. In
the metropolitan New York area, Tubman et al.
(1996) found in a school sample of 10th and 11th
graders (aged 15–17 years) that depressive symp-
toms were common among sexually active adoles-
cents. Rubin et al. (1992) studied correlates of
depressive affect among high school students (9th-
12th grades, 13–19 years) and found that life events
related to sexuality were the prepotent stressor
among girls. For boys, sexuality-related events did
not emerge as a risk factor when other domains
were controlled for.
According to the present study, having had mul-
tiple partners increased the risk of depression in
both genders. Among boys, a high number of coital
experiences was also associated with an increased
risk of depression. A previous Finnish study
showed that boys with early sexual debut report
more sexual partners than girls of the same age
(Kosunen et al. 2000). This points at different gen-
der patterns in early sexual relationships: boys tend
more often to start with casual partners while girls
start with their dating partners. Another Finnish
study showed that boys start regular dating later
than girls, with the proportions of current dating
being lower for boys throughout adolescence, even
at the age of 18 (Rimpelä et al. 1992). In boys, this
way of commencing sexual activities does seem not
to be satisfactory from the point of view of sexual
health, but may be an expression of depressive
behaviour.
The association between the total number of
sexual intercourses and depression was more com-
plicated among girls: a high number of coital
experiences lowered the risk of self-reported
depression. We thought that this connection might
result from the fact that young girls more often
have sexual intercourse within a steady dating rela-
tionship rather than with a casual partner. This
dating relationship is probably more satisfying in
emotional respects as well. Therefore, we analysed
this association separately among currently dating
and non-dating adolescents. Among dating girls,
the association remained unchanged, but among
non-dating girls, the protective effect of sex disap-
peared. However, the risk of self-reported depres-
© 2003 Blackwell Publishing Ltd, Child: Care, Health & Development, 29, 5, 337–344
sion did not increase with a growing number of
coital experiences among non-dating girls, either.
The group of non-dating girls is more heteroge-
neous, including not only girls who had had sex
with casual partners, but also girls who had earlier
had a steady sexual partner, before the study was
carried out. Unfortunately, we were unable to pur-
sue this issue further because our questions only
covered current dating, not the number or length
of previous dating relationships.
Variables describing sexual behaviour, such as the
number of partners and the number of intercourse
experiences, are probably interwoven with one
another in complex ways, and they might also have
interactions regarding the risk for depression. We
considered the potential interactions between sex-
ual behaviour variables, age and age at menarche/
oigarche. However, the stepwise logistic regression
procedure did not support this assumption.
Sex education has been an integral part of the
curriculum in Finnish secondary schools since
1970. Earlier studies have shown that knowledge of
contraception is reasonably good (Kontula et al.
1992). Although there are undoubtedly areas that
are not adequately covered in sex education, con-
traception is certainly not among them in the
majority of the schools (Liinamo et al. 2000): at
least ignorance cannot be blamed for the non-use
of contraceptives. Despite high awareness and the
availability of birth control services, there are still
those who opt not to use contraceptive methods.
The literature on the psychology of contraception
suggests that neglecting contraceptive use reflects a
developmental stage in early or middle adoles-
cence: a teenager cannot yet plan ahead or antici-
pate the future consequences of his/her current
activities (DuRant et al. 1990). On the other hand,
some researches have suggested that neglecting to
use contraception is associated with low self-
esteem (DuRant et al. 1990) and could be a sign of
depressive disorders. This is indeed supported by
our findings, because the non-use of contraceptive
methods at the most recent intercourse was
strongly associated with self-reported depression
among both boys and girls.
We found in this study that risky sexual behav-
iour (non-use of contraception and multiple sex
partners) was associated with self-reported depres-

sion. It is noteworthy that these associations
remained when age at menarche/oigarche was con-
trolled for. This suggests that at this age, adolescents
with early physical maturation are not less prone
to emotional problems related to sexual activity,
probably because psychosocial maturation is
delayed compared to physical maturation. In both
genders, having multiple partners is associated with
poor psychosexual health, suggesting perhaps a lack
of social and emotional support that these individ-
uals are trying to compensate. On the other hand,
a large number of coital experiences was a protec-
tive factor among girls who had a steady dating
relationship, regardless of their young age. To sum-
marize these findings from the point of view of
health service providers for adolescents, it is clearly
important that each individual’s sexual behaviour
is carefully reviewed: psychosexual health cannot
be automatically inferred from age or the duration
of biological maturity.
Conclusion
In middle adolescence, having multiple sexual
partners and the non-use of contraception may
reflect a depressive disorder. Among boys of this
age, multiple experiences of intercourse is in itself
a risk factor. Adolescent health service providers
should be aware of the risk for depression among
teenagers with risk-taking sexual behaviour. On the
other hand, it is important to note that the sexual
health of depressed adolescents warrants special
attention.
Acknowledgements
We wish to dedicate this article to the memory of
our co-author, Professor Pekka Laippala, who
unexpectedly passed away during the process of
publishing this article.
This study was funded by the Ministry of Social
Affairs and Health.
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