Risky sexual behavior in adolescent survivors of childhood cancer: A report from the Childhood Cancer Survivor Study.

Adolescents commonly engage in risky health behaviors (e.g., tobacco, drug and alcohol use, unprotected sex), which are associated with a variety of adverse outcomes including substance abuse and dependence, academic and vocational underachievement, and poor physical and mental health (Nebbit et al., 2010; Park et al., 2010; Staton et al., 1999; Vaughn et al., 2009). As such, it is important to identify factors associated with risky behavior, particularly among adolescent survivors of childhood cancer, a population at high risk for late health-related complications (Bhatia et al., 2003; Hudson et al., 2003; Oeffinger et al., 2006). Engagement in risky behavior exacerbates health risk among survivors, resulting in vulnerabilities to both acute and chronic adverse health outcomes (Emmons, 2008; Emmons et al., 2002; Van Leeuwen et al., 1995). Thus, survivors of childhood cancer should abstain from or limit risky health behavior as a mechanism for remaining healthy. One behavior receiving increased attention is risky sexual behavior, which is defined as the engagement of sexual behavior that increases one’s risk of negative health outcomes including transmission/contraction of infection or disease, or unintended pregnancy (CDC, 2013). Examples of risky sexual behavior include unprotected oral, vaginal, or anal contact/intercourse, early sexual debut, multiple sexual partners, and engagement in sexual encounters with high risk individuals. Genital human papillomavirus (HPV), the most common sexually transmitted infection, has been identified as causing cervical and other HPV-related cancers (Sauvageau et al., 2007; Weinstock et al., 2004). HPV is transmitted skin-to-skin and is spread via genital/genital, oral/genital, or digital/genital contact. Infection rates are highest among sexually active adolescents and rise sharply soon after the median age of sexual debut (16 years; Wulf, 2002). The prevalence of HPV is 30–49% among sexually active males and females 14 to 25 years of age (Dunne et al., 2007; Guiliano et al., 2008), with a lifetime prevalence approaching 80% among those who are sexually active. Survivors of childhood cancer have significantly increased risks of developing subsequent HPV-associated malignancies in adulthood relative to their peers (150% excess risk for males, 40% for females overall), and these risks increase to 1200% for penile and 760% for tonsillar cancers among males and females previously treated with radiation therapy (Ojha et al., 2013). Treatment-related immunocompromise has been suggested as a potential mechanism explaining this increased risk (Barzon, Pizzighella, Corti, Mengoli, & Palu, 2002; Bhatia et al., 2001; Sasadeusz et al., 2001). Despite these potential consequences, adolescent survivors of childhood cancer continue to engage in risky sexual behavior at rates equivalent to their siblings (Klosky et al., 2012). With these potential risks in mind, the current investigation utilized problem behavior theory (PBT; Jessor, 1993; Jessor, et al., 1995) as the theoretical framework for understanding risky sexual behavior in adolescent survivors. By recognizing the interplay between social (i.e., controls, models, and support), psychological (i.e., beliefs, attitudes, orientation), developmental (i.e., age-related norms and expectations, transition-marking behaviors), and environmental risk/protective factors, the consideration of PBT in the survivorship context may be particularly useful for understanding risky sexual behavior in this vulnerable group (Scaraella et al., 1998, Vazsonyi et al., 2008). For example, survivors may encounter unique life experiences such as an atypical developmental trajectory secondary to treatment, engagement in risky behavior as a mechanism for rejoining peer groups post treatment, and needing to balance cognitive dissonance and social desirablity when engaging in cancer-linked behaviors. All of these factors may associate with risky sexual behavior. Although testing the full PBT model is outside of the scope of this study, previous research has identified PBT-consistent factors such as peer influence, school performance, socioeconomic status, and psychological health as contributing to risky health behavior in survivors (Stolley et al., 2010; Thompson et al., 2009; Krull et al., 2010). These relationships have not yet been examined in relation to sexual risk-taking among adolescent survivors, but it is hypothesized that these described factors also differentiate engagement in risky sexual behavior in this group as well. Finally, cancer-specific factors have also been associated with academic performance, quality of social interactions, and alcohol use (Dolson et al., 2009; Ris & Noll, 2000), factors that have also been linked to risky sexual behavior in adolescents without a history of cancer. Therefore, the influence of factors within and between social, enviromental, biological, developmental, and psychological domains may be magnifed by the biological vulnerability observed in survivors of childhood cancer and should be considered in this high risk population. Despite their increased health risks secondary to cancer treatment, no current studies have considered factors contributing to risky sexual behavior among adolescent survivors of childhood cancer. As such, the purpose of this study was to examine the relationship between potential risk/protective factors and sexual risk taking in this compromised group.