Introduction

Recent literature confirms disparities in the risky sexual behavior of African American adolescents as compared with peers from other ethnic groups and the need to better understand these differences. A national longitudinal study of 8984 individuals between 12 and 16 years of age found that after adjusting for control variables such as SES, African American adolescents have a lower mean age of first sexual intercourse and are more likely to have first intercourse during adolescence, as compared with their White peers [1•]. Pflieger and associates [2] studied patterns of sexual behavior and associated rates of sexually transmitted infections (STIs) for Black, White, and Hispanic female teens. They examined condom use and a range of sexual activity, including oral, anal, and vaginal sex. They found that participants in all three groups were most commonly classified as being of moderate risk for contracting STIs, but that each group had its own distinct pattern of sexual risk behaviors. As compared with their White and Latino peers, participating African American adolescents’ risky behavior was characterized by more inconsistent rates of condom use with “risky” partners who have had multiple partners or have had an STI. Moreover, 29.3 % of African American study participants tested positive for an STI, as compared with 10.2 and 6.1 % of their White and Latino peers, respectively. This study found that African American youth had lower rates of oral/anal sex. Negative correlates and descriptions of African American sexuality have historically led to pathological emphases; therefore, this review attempts to present a balanced understanding of the factors that contribute to adolescent sexuality within this group [3•, 4].

The purpose of this review is to show that sexual scripts underlie sexual behavior and that both are influenced by ecological contexts ranging from media influences to the influences of individual mental health. We examine recent basic research and its implications for intervention and present a model for future research to better understand these influences on sexual scripts and sexual behavior. Given that evidence-based interventions (EBIs) have been developed on predominately White samples, we help readers to identify relevant EBIs and present preliminary findings on how to adapt them to fit the unique racial, gender, and class factors faced by African American youth. Moreover, we present data regarding the incorporation of technology and data regarding the controversy over abstinence-based versus comprehensive sex education programs. Together, these data provide clinicians and researchers with the best current options to address African American sexual risk behavior while attending to their contexts and utilizing their strengths.

Theory and Research: Sexual Scripts

The concept of sexual scripting has been applied to sexual behaviors for many years, and recent literature has used sexual scripts to contextualize and understand African American adolescents’ risky sexual behavior [5]. Sexual scripting is the process of developing schemas that individuals use to organize and process sexual experiences. These scripts contribute to a system of norms and beliefs that influence individuals’ evaluation of their sexual behavior and of others’ perceptions. Scripts develop through exposure to sexual messages conveyed socially on cultural, interpersonal, and personal levels, which all interact with each other [6]. The most prominent examples of the cultural level of sexual scripting are images of African American sexuality in the media, which have developed from a unique sociohistorical context in the USA. Interpersonal sexual scripts can be derived from one’s community, peers, and family. Individual level sexual scripts develop when African American adolescents identify with and internalize the messages that they receive at the other levels.

A Sexual Scripting Model for African American Youth

Below, we detail a comprehensive model of the theory and related data regarding sexual scripts, presented in Fig. 1. The model shows how the three levels of sexual scripts converge to increase our understanding of African American sexuality, and we also elaborate upon its implications for treatment. While the data supporting the elements of the model range in their degree of robustness, the model is useful in identifying key factors to examine in future research, toward a more contextual understanding of African American youths’ sexual risk behavior.

Fig. 1
figure 1

Model of key factors influencing the sexual scripts and behavior of African American youth. This figure illustrates a theoretical model of the factors that may affect African American youth’s sexual risk behavior, with attention to both challenges and strengths, as well as race, gender, and class factors

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Cultural Level: Media Factors

The sexual scripts that shape African American adolescents’ sexual behavior find their origins in the negative stereotypes of African Americans that developed to legitimize slavery [7]. The abuse of slaves was accepted in part because African slaves were dehumanized through the perpetuation of widespread and overwhelmingly negative stereotypes about them, many of which centered on sexual themes [3•]. For example, slave women were forced to satisfy their masters’ sexual appetites, but slave masters used myths of African American women’s hypersexuality to justify these abuses [3•]. Thus, current stereotypes of African American females parallel historical notions of exaggerated and exoticized African American female sexuality. African American males were also portrayed as hypersexual and violent, in addition to immoral and lazy, which legitimized the violence done to them by White men for alleged sex with White women [8].

The highly sexualized racial stereotypes that mirror those generated during slavery remain pervasive throughout the media, are recognized by African American youth, and sometimes become their scripts for sexual behavior. Researchers theorize that mass media overall, and hip hop music in particular, can influence adolescent sexuality by increasing youth exposure to racially stereotypic and highly sexualized portrayals of African Americans. These images can become the ideal scripts with which they identify and try to emulate [5, 9]. For example, one of the foundational images for framing African American female sexuality was the “Jezebel,” a promiscuous and oversexed woman who uses sexuality to get attention and material goods. Further, Stephens and Phillip’s [7] analysis of hip hop culture identified eight current sexual scripts of African American females, such as the “freak,” an aggressive woman who wants sex without emotional attachment, or the “gold digger” who provides sex for financial gain. A newer sexual script is the “video girl,” who exploits her sexuality to ensure success within the music industry [5]. Notably, across several small studies, African American youth report clear ideas of these scripts across conceptions of appearance, attitudes, desires, and interactions with others [5, 10].

Consistent with theory, these negative sexualized portrayals of African Americans can adversely affect their attitudes and behavior when adolescents self-identify with the scripts. Across African American and White youth in a sample of 967 adolescents from 14 middle schools across the southeastern USA, adolescents exposed to sexually explicit media had more permissive sexual norms and less progressive gender role attitudes. In addition, adolescents who had engaged in oral sex and sexual intercourse were much more likely to be using sexually explicit media, including television, Internet use, or magazines [11]. The issue may be more pronounced for African American youth, as their use of sexually explicit media is more frequent as compared to their White counterparts [11]. Also, in one prospective study of 522 African American adolescent females, greater exposure to hip hop music videos independently was associated with two times greater odds of having multiple sexual partners and 1.5 times greater odds of reporting a sexually transmitted disease in the ensuing year, as compared with lesser exposure to hip hop music videos [12]. With respect to gender ideals, within a sample of 152 African American high school students in the Midwest, adolescents who viewed videos with more stereotypical gender representations expressed more traditional views about gender and sexual relationships. Also, their viewing of music videos was positively associated with listening to popular music and holding more stereotypical gender role attitudes [13].

Evidence suggests that these scripts that are encouraged by media portrayals persist into adulthood. For example, within a sample of 221 African American adult males, nearly half of the men endorsed that African American women fit the “Jezebel” stereotype that represents sexually aggressive and promiscuous women. Also, close to three quarters of these men endorsed that African American women fit the “matriarch” stereotype of being unfeminine and emasculating. Those men who subscribed more to negative stereotypes about African American women also were less likely to have successful long-term relationships [14].

African Americans may critically assess the images and sexual scripts of themselves that appear in the media rather than blindly accepting them. Indeed, based on qualitative examination of the dominant messages in the media as perceived by a sample of 63 African American adolescents, these adolescents endorsed perceptions of a large imbalance between positive and negative images of Black women in the media, with negative portrayals as the dominant images [15•]. Despite the preponderance of negative images, some African American adolescents may use critical thinking to recognize, contest, and oppose stereotypes that they believe demean themselves and other members of the Black community [15•]. Similarly, the vast majority of Gillum’s [14] sample of African American men also endorsed positive characteristics of African American women, providing further evidence that negative sexual scripts may be viewed critically or tempered with positive views, rather than blindly accepted. In sum, as shown in our model in Fig. 1, sexually explicit and racially stereotypic media, which comprise the cultural level of sexual socialization, appear to have adverse effects on African American adolescents’ sexual scripts, although these adolescents are often able to view these sources critically.

Interpersonal Level: Community Factors

Adolescents’ neighborhood community also influences sexual scripts and behaviors [1•, 16, 17]. To examine how neighborhood environment affects adolescent sexual risk, Lang and associates [18] analyzed cross-sectional data from 384 sexually active adolescents in three urban areas. Results indicated that adolescents living in high-risk neighborhoods in which they reported characteristics such as people who were drunk or high, abandoned buildings, neighbors stealing or damaging property, and many homeless or poor people were significantly more likely to have a sexually transmitted infection (STI) such as chlamydia, and to have had casual sex partners. Further, several studies find correlations between community violence and sexual risk behaviors [19–21]. Voisin and associates’ [21] review of the empirical literature led to their model suggesting that the relationship between community violence and HIV risk among adolescents is mediated by psychological problem behaviors, low school success, and negative peer influences. This model provides further evidence that the various levels of sexual scripts influence each other in adolescents’ path toward sexual risk behaviors. Racial neighborhood segregation is another key community influence for African Americans. One study has shown that African American adolescents in areas of high segregation have a higher likelihood than Whites of first intercourse in adolescence [16], which the authors attribute to the concentration of economic and social disadvantage in areas of racial concentration.

To determine if changes in overarching neighborhood contexts can reduce adolescent sexual risk behaviors, recent studies have examined the impact of housing relocation programs [22•, 23]. For example, Byck and associates [22•] found that relocation from a high-poverty to a lower poverty neighborhood as part of the HOPE VI federal housing relocation program did not decrease adolescents’ sexual risk behaviors. The authors suggest that the continued effects of having grown up in a high-poverty neighborhood, the meager improvements in the new neighborhood, and the stress of moving all may hinder better outcomes for the relocated youth. Together, these data suggest that community influences may have long-term adverse effects on African American youth’s sexual scripts and behavior that may not be remedied quickly.

Akers and associates [16] examined the perspectives of 93 members of two rural African American communities about how their neighborhood context influences sexual risk. They examined structural factors, including socioeconomic status and racial composition, and social organization factors such as availability of community resources and collective social norms regarding issues like early sexual behavior. Findings suggested that both structural and organizational factors interact to create sexual opportunity for African American adolescents. Specific examples of the way that factors in the community operate synergistically to generate these sexual opportunities include the cost and limited availability of recreational options and poor community monitoring. Per one study participant,

if you’re 14, 15 years old you have nothing to preoccupy your time. So you just basically sit around and talk about sex. And if you talk about it long enough you’re going to end up doing it…you don’t care who you’re doing it with ([16], p. 95–96)

Clearly, the lack of community resources can contribute to a sexual script conveying the message that sexual behavior is a worthwhile activity for adolescents when there is nothing else to do. This study also identified institutional resources in the community as protective factors for low SES adolescents, such as parks and recreation, libraries, and family planning services that could provide them with other worthwhile alternatives to risky sexual behavior. In sum, as shown in our Fig. 1 model, the structural and organizational aspects of concentrated disadvantage within communities [16] may have adverse effects on sexual scripts and behavior, while resources may have positive effects.

Interpersonal Level: Peer Factors

African American adolescent’s sexual scripts are expressed openly in the peer culture, which becomes a socialization agent for sexual scripts [7]. Within an inner city sample of 15 African American adolescents, Harper and associates [24] found that common themes across peer conversations include how adolescents define the dating or sexual partner and their role, the meaning of the interactions with dating and sexual partners, partners’ expectations about fidelity, and friends’ beliefs about condom use. Friends also played a large role in adolescents’ acquisition of new partners, including reliance on peers for gathering information about potential partners, and during the active pursuit of a desired romantic partner. Data from 208 minority middle school students, 34.8 % of whom self-identified as African American, show that adolescents within peer groups that encourage premarital sex and who approve of sexual behaviors are more likely to initiate sexual activity in their early teens [25]. In a sample of 425 African Americans 12- to 15-year olds, adolescents who discussed sexual topics more frequently with peers were also more likely to engage in sexual behaviors [26].

Peer groups also may include scripts containing gendered sexual double standards regarding appropriate sexual behavior. Kreager and Staff [27] examined sociometric status data from a nationally representative sample and found that increased numbers of sexual partners were associated positively with boys’ status but negatively associated with girls’ status among peers. The authors interpret these findings to indicate that these adolescents’ discussions with peers influence the meanings attached to sex roles and behaviors. They also assert that adolescents’ ideas about appropriate sexual behavior in the peer group influence sexual scripts and risk-taking behaviors, and they learn by observing and imitating each other.

Adolescent peer influence regarding sexuality may operate in a negative fashion more than a positive one. Examining a sample of 159 sexually active, inner city African American adolescents, Brady and associates [28] found that supportive friendships did not appear to prevent adolescents from engaging in risky sexual behavior; adolescents with supportive friendships engaged in high to moderate risk taking regardless of stress level. These findings suggest that peers influence scripts in ways that increase sexual risk behavior. They also fit a model of peer socialization [29] postulating that adolescents who are highly integrated into peer networks may take advantage of increased opportunities to engage in risk behaviors. In sum, as illustrated in our model in Fig. 1, African American adolescents’ high integration with one’s peer networks [29] may have adverse effects, due to their developmentally appropriate interest in learning about and starting romantic relationships and concomitant developmentally appropriate lack of expertise and lack of a full understanding of the impact of their behavior [30].

Interpersonal Level: Family Factors

In addition to messages derived from the peer group, socialization from the family has an important influence on adolescent identity development, and sexual scripting is heavily influenced by the parental socialization process [9]. Research findings indicate that mothers are more likely than fathers to act as a sexuality educator [31, 32]. Data also shows that maternal influences on adolescents’ sexual behaviors interact with peer influence [31, 33•]. DiIorio and associates [31] examined how discussions between mothers and African American adolescents moderated the relationship between discussions with peers and sexual behaviors. For intimate behaviors and sexual intercourse, the association between friends’ discussions and involvement in sexual behaviors differed based on different levels of mother-daughter discussion. Specifically, conversations with mothers operated as a protective factor for females who had more sexual discussions with peers. These females were less likely to be involved in sexual behaviors if they spoke about these topics more with their mothers. These data are corroborated by findings from a sample of 176 Black (147) and Hispanic (29) mother-daughter dyads in the northeastern USA that show how maternal influences, including parental monitoring, relationship satisfaction, and sexual risk communication, are mediated through peer influence. Specifically, daughters who were monitored more by their mothers were less likely to exhibit susceptibility to peer influence and thus less likely to report intentions to engage in sexual behaviors [33•]. Therefore, maternal influence may serve as a protective factor to influence sexual scripts for adolescent females who believe that their peers are engaging in sexual risk behaviors.

Because the family, and specifically mothers, serve as one of the primary sites for socialization of gender identity, it is necessary to explore the messages that mothers are conveying about gender roles and the sexual double standard. African American mothers have been found to take a more proactive approach to sexual socialization with sons and a more prohibitive approach with daughters [34]. Specifically, mothers encouraged sons to use condoms and sometimes provided them, whereas mothers did not provide condoms to daughters and sometimes discouraged sexual preparedness. This approach may adversely impact African American females’ ability to protect themselves from sexual risk; sexually promiscuous girls may develop scripts viewing condoms as “dirty,” adding sexual stigma and shame to the socialization process. Carrying condoms also can be viewed as dirty, because they are associated with promiscuity. These messages of being “dirty” can create dilemmas for female youth in making sexual health decisions [34].

In addition to mothers’ prominent role in sexual socialization, paternal presence may play a role in the sexual debut of African American adolescents. For example, Langley [35] examined a community-based sample of 5900 African American adolescents living in economically and socially disadvantaged communities and found that adolescents who reported the presence of a father figure were less likely to report the debut of sexual intercourse than adolescents with a father figure absent. This relationship was partially accounted for by curfews and family rules. Based on these findings, it is likely that paternal presence and structure have a protective impact on African American adolescents’ sexual behaviors by supporting scripts about the issues with or infeasibility of sexual risk behavior, and thus, fathers should be included in parent-focused interventions when possible. Our model in Fig. 1 shows how for these youth, the presence of parental figures, their positive socialization, and structure all may have positive buffering effects.

Individual Level Factors

The sexual messages derived from the cultural and interpersonal levels only will translate into sexual behaviors when adolescents identify with these messages and incorporate them into their scripts at the individual level. For African American adolescents, the process of sexual identity development includes racial identity. For example, a less mature racial identity status was related to increased psychological distress in a sample of 255 African American males and females [36], and adolescents’ positive or negative views of their own racial group impact how they receive sexual messages and incorporate them into their own scripts [37, 38•]. Willis and associates [37] conducted a study with a community sample of 670 African American youth and found that racial socialization was related to ethnic pride, and ethnic pride was shown to be prominent as a protective factor against sexual risk behaviors. Further, African Americans’ positive racial or ethnic identity may provide some protection against racism and discrimination, as these attitudes are associated with greater well-being, higher self-esteem, and less psychological distress [36, 37, 38•].

For African American girls, both gender and a positive racial identity matter regarding their endorsement of sexual scripts. In a sample of 249 African American females from the Midwest region, those who reported that they felt good about being African American and expressed positive personal views of African Americans as a group were less likely to endorse the negative Jezebel script [38•]. Messages about gender also may impact sexual decision-making. For instance, African American women often lament the limited pool of “quality” Black males, with a much lower ratio of young adult males to females [9]. These demographics convey the message that African American women should compete or take greater sexual risks. These messages intersect with the sexual double standards previously discussed, such that African American female youth’s resulting sexual scripts may include ideas that their choices are limited to not having a partner at all, or having multiple partners and risking harm to their reputations.

Perceived discrimination also can decrease adolescents’ sense of personal efficacy and lead to psychological distress, which in turn can affect sexual risk behaviors, at least for males [40]. For example, in a 2-year longitudinal study of 221 African American male adolescents, self-reported racial discrimination at age 16, such as having been treated rudely because of race, or having been watched or followed in public, predicted psychological distress at age 18. The resultant psychological distress was found to increase these adolescents’ attitudes supporting multiple sexual partners and affiliations with peers who endorse those same sexual attitudes. These attitudes and peer affiliations were in turn a predictor of multiple sexual partnerships [40].

The authors tie these findings to the idea of racial discrimination as a masculinity threat, which can be buffered by protective parenting. They assert that racial discrimination increases men’s engagement in behaviors to enhance their masculine status, such as involvement with multiple sexual partners. However, for the youth who received protective parenting, the relationship between discrimination and risky sexual behavior was less than for the youth who did not receive protective parenting [40]. Again, these findings show the interconnection between individual and interpersonal factors. The importance of protective parenting to address individual level challenges becomes even more obvious when we consider that these challenges persist into adulthood. Data and clinical observations converge to suggest that some African American male adults who cannot meet societal standards of masculinity through the provider role may hold scripts that consider meeting masculine standards though sexual behavior. Such scripts can lead to infidelity when these men are in committed relationships [3•].

Individual level factors also include adolescents’ stress and psychological symptoms, as well as how they impact sexual behavior. Brady and associates [28] found that adolescents often engage in sexual risk taking in response to uncontrollable life stressors. Also, in a sample of 265 African American female adolescents seeking psychiatric care, Starr and associates [39] found a bidirectional relationship of romantic and sexual activities with psychological symptoms. Specifically, the authors found that self-reported sexual activities categorized as both “light” such as handholding, hugging, or kissing and “heavy,” such as heavy petting and intercourse, were positively associated with self-reported internalizing and externalizing symptoms. Their longitudinal analyses showed that internalizing symptoms were predicted by “light” activities and internalizing symptoms in turn predicted increases in “heavy” activities. Although these findings cannot account for causal pathways, these authors interpreted the results to suggest that light activities in this age group present psychological challenges that can trigger depressive vulnerabilities in the form of internalizing symptoms for African American females, and lead them to seek out heavy sexual activity to compensate for their distress. Thus, it is possible that internalizing symptoms may lead African American female youth to develop scripts that sexual behavior is a suitable way to address distress. Moreover, given the sequence of their findings, these authors assert that African American female youth who experience early internalizing symptoms prior to any sexual behavior may be at a higher risk for increased sexual behavior than their nondepressed counterparts [39]. Overall, at the individual level, African American youth’s racial identities and experiences of discrimination, negative gender-related messages, and their psychological symptoms all may have effects on their sexual scripts, as presented in our Fig. 1 model.

Clinical Implications of the Model

The influence of the cultural, interpersonal, and individual factors on African American adolescents’ sexual behavior has many implications for what to assess and understand when they enter treatment. Figure 2 presents the data from the foregoing empirical literature presented in this review. The use of these findings can facilitate open discussion and psychoeducation with African American youth and their families about the consequences of the challenges that they may face at all ecological levels. The foregoing data suggest that there may be many negative impacts of racially stereotypic and highly sexualized portrayals of African Americans and widely accessible sexually explicit media on youth’s sexual scripts. Also, the community disadvantage that can lead to disorder and violence, lack of recreational options, and lack of community monitoring may affect the sexual scripts and sexual risk behavior of many African American youth. In the peer realm, the data we reviewed suggests that all teens have some degree of peer integration that may impact sexual risk; it is developmentally appropriate, normal, and not completely avoidable for teens to have peers who discuss sex. The importance of parental presence, positive socialization, and structure also may help youth to develop positive scripts and decrease youth sexual risk behavior. For the teens themselves, identity factors such as racial identity and gender, their own mental health, and experiences of discrimination appear to play a prominent role in the development of sexual scripts and behavior. Thus, it is important for clinicians who work with these youth and their families to assess the role of each ecological context, in addition to understanding the individual teens that they treat.

Fig. 2
figure 2

African American youth and risky sexual behavior: ecological fact sheet [2, 15•, 12, 13, 18, 16, 25, 31, 32, 34, 35, 39, 40, 37]

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The model and associated data provide many implications regarding treatment for African American youth and their families. Clinicians can advise parents that some risks can be countered with community resources that they may help the families to access. Clinicians can encourage and guide mothers to have the kinds of protective socialization conversations implicated in the foregoing data, including the discussion of sexuality with their girls. For example, clinicians can educate families that conversations should aim to reduce sexual stigma for African American female youth who do initiate sexual behavior, which may help encourage the use of condoms for these females. Clinicians also may encourage African American parents to socialize their youth with a positive racial identity that can promote self-efficacy and decrease distress and gender-based risks for these youth, such as with confronting and counteracting stereotypes with positive examples within the community. Specifically, for some African American females, this socialization may prevent the internalization of stereotypical negative Black female scripts that can promote risky sexual behavior and instead promote the development of a positive self-image. In addition, the data detailing the influence of family and community contexts suggests that it is important for interventions addressing sexual behavior to facilitate the development of positive models of race and gender through these contexts in adolescents’ lives. Given that discrimination and other uncontrollable life stressors lead to more sexual behavior and that light sexual behavior may breed depressive symptoms that these teens may try to ameliorate with heavy sexual behavior, it is important for clinicians to empower these youth to manage their stress levels. Again, the information contained in Fig. 2 can be useful for the clinician in providing a rationale for these kinds of interventions.

Limitations of the Sexual Scripting Model and Potential for Future Research

As presented above, our model illustrates the connections between the factors across multiple levels that contribute to sexual risk behaviors for African American adolescents. However, much research needs to be done to test the model and its racial, gendered, and class-related aspects. While every factor in the model is at minimum consistent with existing correlational data, much needs to be done to test many links in the model across nationally representative samples of African American youth across varying geographic, age, race, gender, and class groups. Thus far, the model and data from the literature reviewed suggest that these factors matter for African American youth’s sexual scripts and behavior. Moreover, they suggest that race in particular plays a role culturally in terms of stereotypic media exposure, interpersonally in terms of the racially segregated neighborhoods, and individually in terms of racial identity and experiences of discrimination. Also, gender in particular appears to play a role at the cultural level in terms of gender-specific harmful stereotypes like the Jezebel stereotype and at the interpersonal level in terms of sexual double standards regarding status among peers and regarding socialization around sex and condom use with parents. The role of class appears to be particularly impactful at the interpersonal level in the form of concentrated disadvantage within the community. Yet class also may play an indirect role at the interpersonal level within the family and at the individual level through low parental monitoring and uncontrollable stress, respectively, which can be affected by socioeconomic status [22•, 41].

The data supporting these factors appear to be both scant and relatively consistent across studies and theories, and thus, the many specific variables encompassed by these broad factors need to be tested to strengthen the model. Future study can therefore achieve a greater contextualized understanding of every level of influence on sexual scripts and sexual risk behavior for African American youth, with consideration of the mechanisms by which race, gender, and class have an impact. Moreover, qualitative studies may be useful in fleshing out the specifics of these youth’s scripts in their own words.

The Alternative of Adapting Evidence-Based Interventions

The foregoing clinical implications of basic research are intended to help the everyday clinician focus treatment upon the ecological factors most relevant to African American youths’ sexual scripts and behavior, but also there are alternatives for those seeking to use evidence-based interventions. Effective prevention programs to reduce HIV risk behaviors serve as one of the most powerful tools in controlling the HIV epidemic. Yet consistent with the foregoing review, Wingood and DiClemente [42] discuss how evidence-based interventions may lack relevance, sustainability, and acceptability with diverse groups without attention to the group’s HIV-related risk factors and cultural context of the population. Moreover, few theoretically oriented frameworks exist to guide the adaptation of EBIs.

DiClemente and associates [43] provide data on one example of attending to risk factors and cultural context. They conducted a randomized controlled trial to assess the efficacy of an HIV prevention program to reduce sexual risk behaviors, STIs, and pregnancy among 522 African American adolescent females in the southern USA. The intervention also sought to enhance psychosocial mediators of HIV-preventive behaviors, including HIV knowledge, condom use attitudes, and self-efficacy. Participants were assigned to an HIV prevention intervention or a general health promotion condition emphasizing exercise and nutrition, which represented a dose-equivalent control condition. The program was designed in collaboration with African American adolescent girls in the community and was based on the theories of social cognition and of gender and power to specifically speak to the needs of the population [44, 45]. For example, the first session emphasized ethnic and gender pride and incorporated materials about the challenges and joys of being an African American female. To address the aforementioned peer socialization processes that often influence sexual scripts and behavior, two African American female peer educators helped to implement the intervention toward facilitating positive group norms, and modeled skills such as those involved in condom use. After 12 months, outcome measures showed that the participants in the HIV prevention condition were significantly more likely than the controls to use a condom at last intercourse, less likely to have a new vaginal sex partner in the past 30 days, more likely to apply condoms to sex partners, had better condom application skills, a higher percentage of condom-protected sex acts, and fewer unprotected vaginal sex acts. These data suggest that positive peer programs are helpful, and thus, research on the development and efficacy of such programs is needed.

Clinicians now have opportunities to adapt an EBI without contradicting its core elements or internal logic [42]. In one examination of six effective intervention programs with African American youth, effective factors included HIV/STI and sexual behavior education, emphasis on gender roles and peer influences, emphasis on substance avoidance or limited substance use, increased parental involvement, and integration of cultural teaching components [46•], many of which are consistent with our model derived from basic research (see Figs. 1 and 2). Alternatively, Wingood and DiClemente [42] propose an eight-phase framework for adapting HIV-related EBIs, called the ADAPT-ITT model, which includes assessment of the population, the decision of which EBI to select and whether to fully adopt or adapt the EBI, adaptation if the decision is made not to adopt a pre-existing EBI, production of a first draft, inclusion of topical experts, training, and testing of the adapted program. This framework has been implemented successfully with African American adolescent populations and may be aided by the existence of a compendium of evidence-based interventions and best practices for HIV prevention available on the CDC website [47•]. Clinicians interested in exploring available interventions can sort the compendium by intervention level, risk category, race/ethnicity, and sex of participants. Table 1 provides a sample of the information that can be obtained from the compendium and a link to access it.

Table 1 Evidence-based interventions with African American adolescent samples
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Considerations for Adapting EBIs at the Cultural, Interpersonal, and Individual Levels

Using Technology to Adapt EBIs

When adapting interventions for this population, the use of technology can increase the feasibility of the interventions. Because media consumption at the cultural level has been shown to strongly influence sexual scripts, Jones [48] implemented a cross-sectional study to examine the impact of a soap opera video designed to communicate HIV risk reduction themes with a sample of young African American females. Jones found that the soap opera video led to a statistically significant decrease in the teens’ expectations to engage in unprotected sex. Because of the preliminary success of the soap opera concept, Jones and associates [49] conducted a randomized controlled study with a sample of 238 high-risk young women, of whom 90.1 % were African American. The young women were provided with either a streamed soap opera video series or a smartphone with weekly risk reduction text messages to assess the comparative effect on unprotected sex with high-risk partners. Both interventions resulted in a significant decrease in unprotected sex with a high-risk partner. There was 18 % greater reduction in the video condition, although this difference was nonsignificant. Further, Guilamo-Ramos and associates [50] found that African American and Latino adolescents and their parents, recruited from six US cities (N = 168), reported in focus groups that they were motivated to obtain information about sexual health through the Internet and cell phones. These findings show the potential benefits of using media to convey positive messages to adolescents and to counteract negative scripts seen in other mass media. Moreover, these interventions may increase feasibility gained from using technology in line with adolescent preferences and behaviors.

At the interpersonal level, parents play an important role in sexual socialization and may buffer negative peer influences [33•], and thus, a structured didactic and multimedia risk reduction program has been developed to teach parents how to effectively discuss sex-related issues with their adolescents. Weekes and associates [51] conducted a mixed methods pilot study with 61 African American parents of adolescent males to test the effectiveness of a multimedia intervention to train parents in the role of sex educators. This intervention included an audio CD and provided parents with three in-home lessons with activities to be completed by parent and son based on information on the CD, a guidebook designed for parents of children age 8–13, and a handout with helpful hints about talking with children about sex. The CD included information on many factors, including puberty and reproductive anatomy and physiology, risky sexual behaviors, sexually transmitted infections, sexual responsibility, and expressing caring and love without intercourse. Although the study included no control group, the implementation of this intervention increased parental self-efficacy and outcome expectations with respect to communication about sex.

Issues with Abstinence and Comprehensive Sex Education Programs

When examining effective interventions at the individual level, it is important to consider the relative efficacy and appropriateness of comprehensive sex education compared to abstinence-only programs, particularly given the federal funding that historically has been dedicated to abstinence-focused programming. Comprehensive interventions are defined as those that discuss abstinence as the most effective method for avoiding STIs and unintended pregnancy, but also teach about condoms and contraception to reduce the risk of unintended pregnancy and of infection with STIs for those that are sexually active. Kohler et al. [52] used a nationally representative mixed-race sample of 1719 heterosexual adolescents (241 African American) to compare the sexual health risks of adolescents who received abstinence-only and comprehensive sex education to those with no formal sex education. This examination found that adolescents who received comprehensive sex education were significantly less likely to report teen pregnancy compared to those with no sex education, while abstinence-only programs had no significant effect. In addition, abstinence-only education did not reduce the chance of engaging in sexual intercourse, but comprehensive sex education was marginally associated with a lower likelihood. Neither intervention significantly reduced the likelihood of having an STI.

Data specific to African American adolescents is scant, though the disparate rates of STIs and pregnancy have led to some examination of this population. In a randomized controlled trial, Jemmott et al. [53] compared abstinence-only, comprehensive, or no sexual education in a sample of 659 African American 6th and 7th graders and found that at 12 months, the abstinence intervention did not reduce sexual behavior, while those receiving the comprehensive intervention reported more consistent condom use. Jemmott et al. [54] noted that some argue that abstinence interventions may not be shown to work because they contain inaccurate condom-related information and portray sex in a negative light. Thus, they then examined the efficacy of a theory-based abstinence intervention in a sample of 662 African American students in 6th and 7th grade designed to counter the weaknesses of studies of prior abstinence-based programs. This intervention was based on social cognitive theory, the theory of reasoned action, and the theory of planned behavior and was designed to increase HIV/STI knowledge, strengthen beliefs supporting abstinence, including the belief that abstinence can prevent pregnancy, and increase skills to negotiate abstinence. This abstinence-only condition was compared to an 8-h safer sex intervention promoting condom use, 8- and 12-h comprehensive interventions, and an 8-h health promotion control condition.

The authors’ abstinence intervention performed better than in the foregoing studies. Only the abstinence intervention reduced self-reported sexual involvement at 24-month follow-up relative to the control group, and the other intervention conditions did not differ from the control group on this outcome measure. The comprehensive interventions each reduced the incidence of multiple sexual partners compared with the control group, and none of the interventions had significant effects on condom use. Notably, this theory-based abstinence-focused intervention would not meet federal criteria for abstinence programs in that it increased knowledge about HIV/STD, emphasized the delay of sexual activity, but not necessarily until marriage, and did not put sex into a negative light.

Two studies have examined findings relevant to widespread perceptions about comprehensive and abstinence-based interventions for sexual risk behavior. One issue of contention is whether comprehensive sexuality education increases frequency of sexual intercourse among adolescents. To address this question, Milhausen et al. [55] examined the effects of an HIV prevention intervention group and a health promotion control group on the frequency of vaginal sexual intercourse at 6 and 12 months following a baseline assessment, in a sample of 522 sexually experienced African American adolescent females between the ages of 14 and 18. They found no significant differences in the frequency of sex between the intervention and control groups. Because it is also important to examine community perspectives about the sexual education provided to African American adolescents, Lloyd et al. [56] conducted 11 focus groups with 93 African American adults and youth in a rural community in North Carolina with high rates of HIV infection and marked racial disparities comprised of high rates of STIs and HIV/AIDS for African Americans as compared to the general population. Participants consistently identified the public schools’ sex education policies and practices, which were primarily abstinence-focused, as major barriers toward preventing HIV infection among youth in their community.

Overall, these studies yielded mixed findings in comparing the efficacy of abstinence-only programs to comprehensive sex education, as well as mixed findings regarding the efficacy of each type of program. Given the foregoing issues with each of these treatments with African American youth, more rigorous intervention research is necessary to determine fully the risks and benefits of each these interventions for African American adolescents.

Conclusions

To address the significant health implications of early sexual behavior for African American adolescents, it is necessary to understand the racial and gendered socialization process that leads to these behaviors. This socialization process is complex, and occurs at multiple levels. Pervasive negative stereotypes in the media interact with peer, family, and neighborhood contexts, which stimulate the development of African American adolescent sexual scripts. Specifically, peer discussions strongly influence sexual and dating choices, and parental influence and positive institutional resources can serve as protective factors to mitigate peer influence on sexual choices. Individual level factors, such as the racial identity and mental health of each youth, also play a significant role in how an adolescent will incorporate these socialization messages into their sexual scripts, and how sexual scripts translate into sexual risk behaviors. These findings yield important implications for clinicians working with these youth and a model for the future research that is needed to replicate and extend these findings with nationally representative samples of African American adolescents. Future research will illuminate the mechanisms behind the gender, class, and racial factors influencing African American adolescents’ sexual scripts and sexual risk behavior, and how these factors can translate most effectively to treatment.

For those who want to use EBIs to address sexual risk behaviors, these programs can only be successful if they are adapted to the population, and frameworks and factors that may lead to successful adaptation of EBIs are presented. Notably, the relevant considerations for adapting EBIs reveal that it is important to address the foregoing cultural, interpersonal, and individual levels of our model when adapting EBIs. Consistent with the three ecological levels in our model, clinicians are encouraged to use technology to transmit preventative media information, such as soap opera videos and smartphones, and include parents as key socialization figures. Because of the controversy regarding abstinence and comprehensive sex education programs, and the issue of which programs will receive federal funding, the mixed data regarding their efficacy with the adolescents themselves is presented, which highlights the importance of further research to determine choices of which types of programs to disseminate. Despite the numerous risk factors relevant to African American adolescents’ sexuality, an ecologically driven strengths-based approach to conceptualization and treatment has been shown to promote positive outcomes for this group. Such an approach is implicated both in basic research and research on the adaptation of EBIs for African American youth.