Sexuality and Well-being: a Developmental Snapshot of Adolescents in Italy

Sexuality and Well-being: a Developmental Snapshot of Adolescents in Italy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Sexuality and Well-being: a Developmental Snapshot of Adolescents in Italy Michela Bersia, Silvia Ciardullo, Paola Dalmasso, Giacomo Lazzeri, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7046152/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Evidence on well-being correlates of adolescent sexuality balancing risks and opportunities remains limited and discordant. This study evaluates associations between adolescent sexuality and multidimensional well-being through a developmental lens. Data referred to a nationally representative sample of 17-year-olds (N = 22,568) from the 2022 Italian Health Behaviour in School-Aged Children study. Measures included sexual activity (inactivity, early initiation < 16, on-time initiation ≥ 16), emotional (high life satisfaction), psychophysical (psychosomatic health complaints, PHC), social well-being (loneliness), and condom use. Early initiation (vs. inactivity) was associated with PHC in boys (OR: 1.26; 95% CI: 1.06–1.51) and girls (OR: 1.56; 95% CI: 1.23–1.99). Among boys, it was linked to life satisfaction (OR: 1.49; 95% CI: 1.14–1.94) and lower loneliness (OR: 0.77; 95% CI: 0.59–1.00). Boys and girls with on-time initiation presented lower loneliness (OR: 0.69; 95% CI: 0.52–0.88; OR: 0.78; 95% CI 0.64–0.94, respectively). Exclusively girls with on-time initiation showed higher PHC (OR: 1.47; 95% CI: 1.20–1.81). Halved condom use appeared among adolescents with early (vs. on-time) initiation. A developmental shift, earlier among boys, emerged from predominantly risk to more protective well-being associations of sexuality. The mixed well-being findings associated with adolescent sexuality underscore the need for gender-sensitive, developmentally informed sexual health education. Health sciences/Health care Health sciences/Medical research Biological sciences/Psychology Social science/Psychology Health sciences/Risk factors sexuality well-being adolescence HBSC condom Figures Figure 1 Figure 2 1. Introduction During adolescence, young people engage in romantic relationships and sexual experimentation, which represent a crucial developmental stage for navigating adult social interactions and sexuality 1 , 2 . Literature related to sexuality in adolescence traditionally adopted a risk perspective, focusing on the negative correlates of early sexual initiation 3 , 4 . In particular, it has been associated with early puberty and might depend on individual and environmental factors, such as ethnic background, low peer support, and parental monitoring 5 – 7 . Furthermore, early sexual initiation was related to physical and emotional immaturity that increases the risk of unprotected and non-consensual intercourse, unintended pregnancy, and sexually transmitted infections (STIs), with health and social consequences (e.g., emotional trauma, depressive symptoms, academic problems) 8 , 9 . On the other hand, from a positive youth development (PYD) perspective, sexuality in adolescence responds to an increasing demand for intimacy, love, and identity exploration 9 and leads to competence development. Several studies emphasize that a romantic or sexual relationship, especially during late adolescence, provides valuable opportunities to develop interpersonal, coping, and critical reflection skills 9 , 10 . These include learning assertive communication, effectively negotiating conflict resolution, and managing the end of an unwanted relationship 10 , 11 . From this viewpoint, a fine line may divide exploratory sexual activity that significantly increases the risk of harm and sexual experiences that ultimately contribute to positive sexual identity and competence 3 . In particular, adequate education, access to reproductive health care services, as well as open communication with adults can move the needle, allowing adolescents to face sexual experiences and empower competencies for their adult life, minimizing the adverse consequences 9 , 11 . The current literature still lacks sufficient evidence at the interface between risks and opportunities, particularly from a life-course PYD perspective. Existing research has yet to integrate both negative and positive well-being correlates into a comprehensive framework that encompasses the emotional, psychophysical, and social health outcomes of sexually related experiences 9 , 11 . The present study aims to evaluate the relationship between sexual activity and the multifaceted dimensions of well-being—social, emotional, and psychophysical— among adolescents by adopting a nationally representative sample of Italian youths aged 17. A focus on age at sexual initiation in adolescence was employed to provide a developmental picture of the phenomenon at the interface between risks and benefits. 2. Methods The work is based on data from the 2022 Italian Health Behaviour in School-Aged Children (HBSC) study 12 . The Italian survey adheres to the international HBSC study, a multicenter cross-sectional survey that runs every four years in more than 50 countries using a standardized research protocol to investigate health-related behaviours in adolescents 13 . The international target population consisted of students aged 11, 13, and 15 years, attending the first and third grades of lower secondary school and the second grade of upper secondary school. The Italian HSBC study represents the first Italian population-based survey on adolescent behaviours, adopting a larger sample size (N>65,000) than the one requested by the HBSC International Protocol to ensure the national and regional representativeness of the sample 12 . Furthermore, in 2022, the Italian study was extended to students aged 17 years attending the fourth grade of upper secondary school. The school class was the primary sampling unit, drawn by a stratified systematic cluster sampling from a list of all public and private schools obtained from the Ministry of Education. Data were collected in classroom settings through standardized, self-filled online questionnaires. Data analyzed in this study referred to 17-year-old adolescents from the 2022 Italian survey. Institutional Review Board Statement. The study was conducted according to the guidelines of the Declaration of Helsinki. In 2022, the Italian HBSC study protocol and questionnaire were formally approved by the Ethics Committee of the Italian National Institute of Health (Ref. PRE BIO CE01.00, 22 November 2021). 2.1. Measures Sexual activity. The information about sexual initiation was obtained through the questions “Have you ever had sexual intercourse (sometimes this is called “making love”, “having sex”, or “going all the way)?” and “How old were you when you had sexual intercourse for the first time?”. Adolescents were classified based on their sexual activity distinguishing inactivity, early initiation (at <16 years), and on-time initiation (at ≥16 years) 13 . Alternatively, a more detailed measure, i.e., sexual activity per age of initiation, was obtained distinguishing the age of sexual initiation: non-active, initiation at <14 years, initiation at 14, at 15, and at ≥16 years 13 . Well-being. It was evaluated according to Keyes' Model of Mental Health, which conceptualized a complete state of mental health as an integration of emotional, psychophysical, and social well-being dimensions 14 . In particular, the present study assessed high life satisfaction (High LS), multiple psychosomatic health complaints (PHC), and loneliness as proxies for emotional, psychophysical, and social well-being, respectively, in line with previous literature on the topic 15 . In particular, High LS represented a positive indicator of well-being, while PHC and loneliness were considered negative measures. High life satisfaction (High LS) . High LS was assessed using the Cantril ladder 16 . Participants were asked to rate their life satisfaction using a visual scale (range 0–10): the higher the score, the greater the feeling of life satisfaction. Respondents were asked to indicate the ladder step at which they would place their lives at present. The findings were categorized as high (≥9) vs. lower (≤8) life satisfaction, as recommended elsewhere 13 . Multiple psychosomatic health complaints (PHC). PHC were evaluated through the HBSC Symptom Checklist (HBSC-SCL), a non-clinical measure consisting of eight items (headache, stomachache, backache, feeling low, irritability or bad-tempered, feeling nervous, sleeping difficulties, and dizziness) 13 . Adolescents indicated how often they had experienced each complaint over the last six months. Response options for each symptom ranged from about every day to rarely or never. According to the international HBSC documentation 13 , a binary PHC variable was created to identify participants with multiple (two or more) health complaints more than once a week/other (reference category). The 8-item scale showed good internal consistency in our sample (α = 0.85). Loneliness. Information about loneliness was obtained by asking adolescents how often they had felt lonely during the last 12 months. Response options were “never”, “rarely”, “sometimes”, “most of the time”, and “always”. A dichotomous indicator was created based on reporting loneliness “most of the time” or “always” vs. all the others (“sometimes”, “rarely”, “never”) 13,17 . The measurement has been adopted from the Global Student Health Survey (GSHS). Previous studies confirmed the construct validity of the single-item measure and its similar validity and reliability with multiple-item scales 18 . Condom use. Those who reported early sexual intercourse were also asked about the contraceptive methods used at last sexual intercourse: “The last time you had sexual intercourse, did you or your partner use”: “a condom”, “birth control pill”, “withdrawal”, and “other methods”. Response options for each contraceptive method were “yes”, “no”, and “not sure”; the latter two options were grouped 19 . Contextual variables. Contextual variables included socioeconomic status (SES) (high, medium, low) through the Family Affluence Scale (FAS) 13,20 , high family and peer support (vs. medium-low) 13,20 , non-intact family structure (i.e., other condition than living with both parents) 21 , social media use profiles (non-active, active, intense, problematic) 22 , high school pressure (vs. low) 13,21 , migrant status (i.e., at least one parent born abroad vs. other) 21 , Italian geographic area (Northern, Central, and Southern Italy) 21 . Menarcheal status information distinguished adolescents who did not have menarche yet, with early menarche, defined as menarche onset at <11 years, and on-time menarche (i.e., onset at ≥ 12 years) 23 . Further details regarding the adopted measures are provided elsewhere 13 . 2.2. Statistical analyses Descriptive characteristics of the sample were reported by gender and sexual activity. Differences were tested with the corrected weighted Pearson Chi-square test. Multivariable quasibinomial regression models were performed to test the association between sexual activity and well-being (i.e., High LS, PHC, and loneliness) and condom use. All the models were adjusted by socioeconomic status, family support, peer support, family structure, social media use, school pressure, migrant status, geographic area, and stratified by gender. Models among girls were also adjusted by menarcheal status. In parallel, the regression analysis was replicated by considering the sexual activity variable with a categorization per year of sexual initiation. All the analyses were conducted by adjusting for the survey design. In all the analyses, a p-value < 0.05 was considered statistically significant. All the analyses were performed in the R version 4.2.1 24 . 3. Results The sample included 22,568 adolescents aged 17 years, equally distributed by gender (48.9% girls), with a response rate higher than 95%. Table 1 shows rates of sociodemographic and contextual characteristics, sexual activity, well-being, and condom use by gender. Overall, most of the sample was declared to belong to the medium socioeconomic status (52.4%), and 45.8% of the adolescents were from Southern regions. Most students were still sexually inactive (57.2%), followed by those with on-time sexual initiation (24.2%) and early sexual initiation (18.6%). About 2 out of 3 sexually active participants (62.3%) used a condom in their last intercourse. Regarding the mental panel, 9.0% declared High LS, about 2 out of 3 respondents showed PHC (67.3%), and 1 out of 5 felt lonely (18.6%). Some gender differences were found. The gender groups showed similar patterns of sexual activity (p=0.451), while girls reported significantly lower rates of condom use (p<0.001). Moreover, girls reported lower rates of high LS (6.8% vs. 11.1%; p<0.001), a significantly higher percentage of PHC (82.8% vs. 52.4%; p<0.001) and loneliness (25.2% vs. 12.3%; p<0.001) than boys. The distribution of sexual activity by age at first intercourse among boys and girls is shown in Figure 1 . As reported in Table S1 (Supplementary file), girls and boys with early sexual initiation showed a lower rate of condom use than those with on-time initiation. Statistically significant higher rates of PHC (p=0.028 among boys; p<0.001 among girls) and lower levels of loneliness (p<0.001 among boys; p=0.013 among girls) were found in the sexually active groups than in the inactive ones. Table 2 and Table S2 (Supplementary file) present the results of the regression models exploring the association between sexual activity and well-being measures. Overall, a nuanced well-being picture is suggested among boys and girls based on the timing of sexual initiation. Early sexual activity was positively associated with High LS among boys (OR: 1.49; 95% CI: 1.14-1.94). Regarding psychophysical well-being, early sexual initiation was significantly associated with a higher probability of presenting PHC. Such a pattern is more evident among girls (OR: 1.56; 95% CI: 1.23-1.99) than boys (OR: 1.26; 95% CI: 1.06-1.51). The association with PHC persisted among girls with on-time sexual initiation (OR: 1.47; 95% CI: 1.20-1.81), while among boys, it disappeared. Third, on-time sexual initiation was associated with a lower probability of loneliness among boys (OR: 0.67; 95% CI: 0.52-0.88) and girls (OR: 0.78; 95% CI: 0.64-0.94). The analysis performed considering sexual activity per age of initiation globally confirmed the results ( Figure 1 and Table S3, Supplementary file). Such analysis substantially corroborated the previous results among girls. However, while the analysis on sexual initiation at <14 and at 14 substantially confirmed findings related to early sexual initiation among boys, insights associated with sexual initiation at 15 provided a more nuanced picture of the phenomenon. In particular, the association between sexual initiation at 15 and PHC disappeared among boys (OR: 1.06; 95% CI: 0.84-1.34), anticipating the pattern observed for on-time sexual initiation (OR: 1.06; 95% CI: 0.90-1.26). Furthermore, among boys, the protective relationship between early sexual initiation and loneliness (OR: 0.59; 95% CI: 0.40-0.88) substantially overlapped findings regarding on-time sexual initiation (OR: 0.67; 95% CI: 0.52-0.88). Table 3 and Table S3 (Supplementary file) present findings related to the association between sexual activity and condom use in the last intercourse. Halved mean probabilities of condom use were registered among early sexually active adolescents compared to those with on-time sexual initiation among boys and girls (respectively, OR 0.49; 95% CI: 0.40-0.61; OR: 0.55; 95% CI: 0.46-0.66). In particular, adolescents with earlier age at sexual initiation presented a lower probability of condom use ( Figure 2 and Table S5, Supplementary file). The strongest pattern was found among adolescents with sexual initiation before the age of 14, especially among boys (OR: 0.25; 95% CI: 0.16-0.38). 4. Discussion The present work focuses on well-being correlates of sexual activity among 17-year-olds in Italy using a developmental lens on sexual initiation. Globally, the present study provided evidence suggesting mixed results on well-being correlates of sexual activity in adolescence on the line between risks and benefits. In particular, patterns suggested a shift from prevailing risk to emerging benefits of adolescents' sexuality depending on their early or on-time age at sexual debut, respectively. Prevalence of sexual activity and well-being The registered prevalence of sexual activity (42.8%) among Italian 17-year-olds can be contextualized in a progressive decrease in age at first intercourse over time in Italy, aligning with existing national and cross-national literature 25,26 . Similar prevalences of sexual activity per year of initiation were registered by gender, confirming the progressive decrease of the gender gap in sexual initiation over time 25 . Conversely, 2 out of 3 adolescents declared the condom use in their last intercourse. Such evidence could be the result of an educational gap leading to inadequate prevention against sexually transmitted infections 27 . Furthermore, girls seemed to use condoms less frequently than boys, aligning with previous literature 27,28 . Some authors hypothesized that it could represent a consequence of girls’ perception of having less power in decision-making on condom use in heterosexual intercourse than their partner, but also the result of the feeling that asking to use condoms could ruin their reputation 27,29,30 . Other gender differences were highlighted in terms of well-being. Girls presented significantly lower well-being than boys, accounting for lower degrees of high LS, higher rates of PHC, and doubled levels of loneliness. Such evidence highlights the peculiar well-being condition of adolescent girls in Italy, who were found to present the highest levels of PHC in Europe 17 . Furthermore, the gender gap in life satisfaction in Italy is higher than the average in Europe 17 . Conversely, the registered prevalence of loneliness among girls is below the mean European levels 17 , presumably indicating the protective role of meaningful social bonds within and outside the family 21 . Sexual activity and emotional well-being This study registered a positive association between early sexual activity and life satisfaction among boys, while it observed unclear patterns regarding early activity among girls and concerning on-time sexual initiation among boys and girls. Literature on the topic is mixed: some authors registered a risk association between lifetime sexual activity and life dissatisfaction 31 , while others found a protective relationship between early sexual debut and very high life satisfaction among boys 32 . Our findings can be partially explained by supposing the persistence of pervasive gender stereotypes and traditional roles. Presumably, early sexual activity responds to stereotypical expectations of masculinity 32 , elevating boys' status, whereas girls tend to be shamed for such activity 32–34 . Sexual activity and psychophysical well-being Boys and girls with early sexual activity were more likely to present PHC compared with sexually inactive peers at 17. While the association between on-time sexual initiation and PHC persists among girls, no association was found among boys. Findings concerning early sexual initiation align with previous international literature, revealing an association between early sexual initiation and internalizing symptoms, such as anxiety and depression 6,33 . Such evidence might corroborate the traditional conception that sexual intercourse in adolescence causes psychological harm 3,4 . Conversely, findings related to on-time sexual initiation among boys, confirmed by Wesche and authors 35 , partially challenged such a view, highlighting gender differences in the association between on-time sexual initiation and PHC in adolescence. Indeed, girls seemed to present stronger adverse mental consequences of experiencing sexual intercourse 35,36 , as a result of stronger intrinsic susceptibility to internalizing symptomatology 37 . Another possible explanation could concern the still existing gender norms regarding the internalized sexual stigma 29,38 , i.e., the process by which individuals internalize societal negative perceptions and stereotypes about their sexual identity. Overall, such elements could potentially contribute to determining the particularly high negative psychosomatic effects of on-time sexual initiation among girls, which is not evident among boys 35,36 . Sexual activity and social well-being Overall, we found that early and on-time sexually active boys and girls perceived lower levels of loneliness compared with the inactive ones, addressing the important positive social meanings of sex since early adolescence 34 . Patterns were stronger regarding on-time adolescents compared to patterns on early active ones, suggesting the increasing need for intimacy and a higher level of emotional competency in experiences made in the transition between early to mid-late adolescence 33 . More specifically, the effects of sexual experience on loneliness seemed to be stronger among boys than girls 34 . In particular, boys could be more likely to have sex to cope with needs (personal meanings), to rebel from social norms (transgressional meanings), and imitate peers (negative social meanings), but also to express their emotional bonds (positive social meanings) compared to girls 32,34 . Furthermore, girls' greater ability to develop emotional ties with friends independently of family closeness may mitigate their inclination to pursue connection through sexual activity 39 . As a result, the sexual experience could protect especially boys from feeling lonely. Sexual activity and condom use In the present work, early sexual initiation was associated with a halved likelihood of condom use in the last intercourse compared to those with on-time sexual debut. This finding aligns with the previous literature on the topic, which underlined that early sexual debut is associated with less condom use both at sexual initiation and subsequent sexual intercourse 40 . In regard, a possible educational gap related to age at early sexual initiation was suggested 28 . Sexual activity from risk to need: gender matters In this study, the analysis exploring well-being correlates of sexual initiation by age of first intercourse registered gender differences regarding age of transition in which sex as a risk-behavior gradually turns into a meaningful life experience. In particular, patterns radically changed from 14 to 15 among boys and from 15 to 16 among girls. In this transition, the association between first sexual debut and PHC disappeared, and the protective pattern between sexual initiation and loneliness strengthened among boys. Conversely, the association between sexual activity and lower loneliness became evident among girls experiencing their first sexual intercourse at 16 or later. Such evidence confirms previous results according to which sex could begin to represent a core life experience earlier among boys than girls 32–34 . Public health implications Overall, the produced knowledge supports the development of comprehensive school-based educational programs promoting sexual health and emotional maturation on the line between risks and opportunities 1 . Since the first sexual intercourse experience was found to determine the consequent sexual and emotional health, the effective introduction of such educational programs might be introduced before sexual initiation, i.e., since primary school 28,40 . As previously stated, the findings of this study directly support the adoption of a developmental and gender-specific approach to sexuality in adolescence. The last goal might be equipping adolescents navigating this uncharted territory with the appropriate educational skills to live positive sexually related experiences. Strengths and limitations The main strength of this study was the use of a large and representative national sample to investigate the well-being correlates of sexual activity and the use of condoms among 17-year-olds using a developmental lens on sexual initiation. Moreover, the low percentage of missing values allowed us to perform a robust analysis, providing highly reliable results. The strengths and limitations of the HBSC methodology have been described elsewhere 20 . Some limitations are inherent in the cross-sectional design, which does not allow for determining the directionality of emerging associations. Moreover, the present work was limited to exploring sexual activity, condom use, and well-being through available data from the 2021/2022 HBSC Italian survey, lacking information about other potentially involved elements such as gender identity, sexual partners' gender, and sexual orientation 27 . The introduction of a broader focus on sexual adolescents’ health in the 2025/2026 HBSC Italian questionnaires will be considered to explore the phenomenon in such subpopulations. 5. Conclusions The present work shed light on well-being correlates of sexual activity among 17-year-olds in Italy using a developmental lens on sexual initiation. Globally, the study provided evidence suggesting mixed results on well-being correlates of sexual activity in adolescence on the line between risks and benefits. Based on the age of sexual initiation, a transition was supposed from a prevailing risk role of sexual activity among adolescents with early sexual initiation to a prevailing protective association of such experience among youths with on-time sexual debut. Relevant gender differences in the age at such transition were observed, constituting fertile soil for further research and educational preventive programs adopting gender-specific and developmental approaches. Declarations Acknowledgments: We thank all students who completed the questionnaires. Special thanks go to the school head teachers, class teachers, and other school staff who actively participated in implementing the HBSC survey. We thank all the Regional and Local Health Unit coordinators and the health workers for their fundamental contribution to the HBSC. We further thank all the members of the 2022 HBSC-Italia Group. Author Contributions. MB, SC, and PN conceptualized and designed the study; MB analyzed the data; MB, SC, and PN wrote the first draft; MB, SC, PD, GL, PN, and AV contributed to the interpretation of data, critically reviewed the manuscript and approved the final version. All authors have read and agreed to the published version of the manuscript. Funding: The Italian HBSC survey was promoted and funded by the Ministry of Health and the Italian National Institute of Health. Conflicts of Interest: All authors declare no conflicts of interest. Informed Consent Statement. Informed consent was obtained from all the included subjects. Students’ parents received an information note describing the purpose of the survey before the data collection. Families could refuse participation by filling in the note returned to the involved classes' teachers. The anonymity and confidentiality of collected data were ensured. Data Availability Statement. The data presented in this study are available in accordance with the 2022 Italian HBSC data access policy. Requests should be directed to the Italy Principal Investigator, Dr. Paola Nardone: [email protected] . Implications and Contributions statement This study advances understanding of adolescent sexuality by exploring multifaceted well-being correlates through a developmental lens. Depending on the age at sexual debut, mixed patterns emerged regarding the well-being dimensions, revealing gender differences and a developmental transition from prevailing risks to benefits of sexuality. 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Dating, Sexual Activity, and Well-Being in Italian Adolescents. Journal of Clinical Child & Adolescent Psychology 35 , 275–282 (2006). Rudolph, K. D. Gender differences in emotional responses to interpersonal stress during adolescence. Journal of Adolescent Health 30 , 3–13 (2002). Fisher, T. D., Moore, Z. T. & Pittenger, M.-J. Sex on the Brain?: An Examination of Frequency of Sexual Cognitions as a Function of Gender, Erotophilia, and Social Desirability. Journal of Sex Research 49 , 69–77 (2012). Majumdar, D. Social Support and Risky Sexual Behavior among Adolescents: The Protective Role of Parents and Best Friends. Journal of Applied Sociology 23 , 28–43 (2006). Shafii, T., Stovel, K. & Holmes, K. Association Between Condom Use at Sexual Debut and Subsequent Sexual Trajectories: A Longitudinal Study Using Biomarkers. Am J Public Health 97 , 1090–1095 (2007). Tables Table 1. Sociodemographic and contextual characteristics, sexual activity, condom use, and well-being by gender at 17 years old. Overall N=22,568 Boys N=11,252 Girls N=11,316 p Gender (%) Boys 51.1 Girls 48.9 Socioeconomic status (FAS) (%) 0.006 Low 32.2 30.6 33.9 Medium 52.4 53.0 51.9 High 15.4 16.5 14.2 Geographical area (%) 0.159 Northern 31.7 29.8 33.7 Centre 22.5 22.6 22.3 Southern 45.8 47.6 44.0 Migrant status (%) 14.6 14.0 15.2 0.131 Non-intact family structure (%) 19.1 17.9 20.3 0.005 High family support (%) 59.6 63.5 55.6 <0.001 High peer support (%) 60.5 61.0 60.0 0.386 Social media use (%) <0.001 Inactive 6.3 7.7 4.9 Active 58.2 64.0 52.2 Intense 25.9 21.5 30.4 Problematic 9.6 6.8 12.5 High school pressure (%) 72.4 62.6 82.6 <0.001 Menarcheal status (%) NaN No menarche 1.6 Early menarche 12.6 On-time menarche 85.8 Sexual activity (%) 0.451 Sexual inactivity 57.2 57.8 56.7 Early sexual activity (≤15) 18.6 18.1 19.1 On-time sexual activity (≥16) 24.2 24.2 24.2 Condom use (%) 62.3 66.9 57.4 <0.001 High LS (%) 9.0 11.1 6.8 <0.001 PHC (%) 67.3 52.4 82.8 <0.001 Loneliness (%) 18.6 12.3 25.2 <0.001 Abbreviations. FAS, Family Affluence Scale; LS, life satisfaction; PHC, psychosomatic health complaints. Table 2. Association between sexual activity and High LS, PHC, and loneliness among 17-year-old boys and girls. Odds ratio (OR) and 95% confidence intervals (95%CI) are shown. Boys Girls High LS PHC Loneliness High LS PHC Loneliness Sexual activity Sexual inactivity Ref. Ref. Ref. Ref. Ref. Ref. Early sexual activity (≤15) 1.49 (1.14; 1.94) 1.26 (1.06; 1.51) 0.77 (0.59; 1.00) 1.20 (0.84; 1.71) 1.56 (1.23; 1.99) 0.87 (0.71; 1.06) On-time sexual activity (≥16) 1.08 (0.84; 1.39) 1.06 (0.90; 1.26) 0.67 (0.52; 0.88) 0.99 (0.73; 1.35) 1.47 (1.20; 1.81) 0.78 (0.64; 0.94) Note. Bold values indicate statistically significant associations (p<0.05). Abbreviations. LS, life satisfaction; PHC, psychosomatic health complaints. Table 3. Association between sexual activity and condom use among boys and girls at 17. Odds ratio (OR) and 95% confidence intervals (95%CI) are shown. Condom use Boys Girls Sexual activity Early sexual activity (≤15 yrs.) 0.49 (0.40; 0.61) 0.55 (0.46; 0.66) On-time sexual activity (≥16 yrs.) Ref. Ref. Note. Bold values indicate statistically significant associations (p<0.05). Additional Declarations No competing interests reported. Supplementary Files bersiaetalsupplementaryfilerep.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7046152","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":488688740,"identity":"cb0f7572-85a5-4441-9790-9d4861e8c8ad","order_by":0,"name":"Michela Bersia","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIie3Ov2rCUBTH8R9cOFkCrreIvoFwSiBBEJ/lXoTMjoUKHQp1STv3MdyKm3JBN7MWHIwUMqeLOARpAq20Q/6MHe53Owc+nAPYbP8xAQKmAJeDwqjc4HusI3wlYbEpDdeZ3wQwaDwzmIs0yXiMwHn+yJJZrN+czjrBNK8kvqHg9pUnGEZbX6rNXi8fheC6x3zjUtdlAX4PCYr2emEEyUaS8wP4kIpMXXYtCdgUVwhSP63aEPJvIt66wygkqV8mXkE8VuxVk9ik8nx33w+cjfg8n8a9Rbw+JlneryQ/uX9H1QhsNpvNVtcXKbxJm5bYzgoAAAAASUVORK5CYII=","orcid":"","institution":"University of Torino","correspondingAuthor":true,"prefix":"","firstName":"Michela","middleName":"","lastName":"Bersia","suffix":""},{"id":488688741,"identity":"df6477c2-22fc-4a44-b328-a0251281b38e","order_by":1,"name":"Silvia Ciardullo","email":"","orcid":"","institution":"Italian National Institute of Health","correspondingAuthor":false,"prefix":"","firstName":"Silvia","middleName":"","lastName":"Ciardullo","suffix":""},{"id":488688742,"identity":"a4f2ebc8-059e-45b2-887c-2f4dbfb1c100","order_by":2,"name":"Paola Dalmasso","email":"","orcid":"","institution":"University of Torino","correspondingAuthor":false,"prefix":"","firstName":"Paola","middleName":"","lastName":"Dalmasso","suffix":""},{"id":488688743,"identity":"5d9dd66b-fa77-4f57-84a1-d1708607de45","order_by":3,"name":"Giacomo Lazzeri","email":"","orcid":"","institution":"University of Siena","correspondingAuthor":false,"prefix":"","firstName":"Giacomo","middleName":"","lastName":"Lazzeri","suffix":""},{"id":488688744,"identity":"0b65eab7-a753-49d7-b1fc-036dd59ce047","order_by":4,"name":"Alessio Vieno","email":"","orcid":"","institution":"University of Padova","correspondingAuthor":false,"prefix":"","firstName":"Alessio","middleName":"","lastName":"Vieno","suffix":""},{"id":488688745,"identity":"fdfbb9fe-60cb-4d13-81ce-5c1f03617b6f","order_by":5,"name":"Paola Nardone","email":"","orcid":"","institution":"Italian National Institute of Health","correspondingAuthor":false,"prefix":"","firstName":"Paola","middleName":"","lastName":"Nardone","suffix":""}],"badges":[],"createdAt":"2025-07-04 11:08:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7046152/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7046152/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87344444,"identity":"e0132979-27a8-453e-8adc-4bded85dc96d","added_by":"auto","created_at":"2025-07-23 02:02:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1103823,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAssociation between sexual activity per age of sexual initiation and well-being (High LS, PHC, loneliness) among boys and girls. Odds ratio (OR) and 95% confidence intervals (95%CI) are shown. Abbreviations: LS, life satisfaction; PHC, psychosomatic health complaints.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"bersiaetalfig1.png","url":"https://assets-eu.researchsquare.com/files/rs-7046152/v1/d4a607f058c5ab1f82e4f373.png"},{"id":87344447,"identity":"469fb141-7a0c-44b7-b5ce-4465e43e27e7","added_by":"auto","created_at":"2025-07-23 02:02:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1163992,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAssociation between sexual activity per age of sexual initiation and use of condoms among boys and girls. Odds ratio (OR) and 95% confidence intervals (95%CI) are shown.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"bersiaetalfig2.png","url":"https://assets-eu.researchsquare.com/files/rs-7046152/v1/a2d984b1c947a5154fbcf39d.png"},{"id":100369817,"identity":"cdd9cabb-5408-47c1-90fd-79ed64e46e98","added_by":"auto","created_at":"2026-01-16 07:59:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4165785,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7046152/v1/76855740-8afc-4078-bf0a-66aede72cc55.pdf"},{"id":87345687,"identity":"b5ec8303-3753-48b6-a30a-fd2f49bdd7ec","added_by":"auto","created_at":"2025-07-23 02:18:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":331373,"visible":true,"origin":"","legend":"","description":"","filename":"bersiaetalsupplementaryfilerep.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7046152/v1/48b1ad615f8a541b3c311df9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sexuality and Well-being: a Developmental Snapshot of Adolescents in Italy","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eDuring adolescence, young people engage in romantic relationships and sexual experimentation, which represent a crucial developmental stage for navigating adult social interactions and sexuality \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Literature related to sexuality in adolescence traditionally adopted a risk perspective, focusing on the negative correlates of early sexual initiation \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. In particular, it has been associated with early puberty and might depend on individual and environmental factors, such as ethnic background, low peer support, and parental monitoring \u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Furthermore, early sexual initiation was related to physical and emotional immaturity that increases the risk of unprotected and non-consensual intercourse, unintended pregnancy, and sexually transmitted infections (STIs), with health and social consequences (e.g., emotional trauma, depressive symptoms, academic problems) \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOn the other hand, from a positive youth development (PYD) perspective, sexuality in adolescence responds to an increasing demand for intimacy, love, and identity exploration \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e and leads to competence development. Several studies emphasize that a romantic or sexual relationship, especially during late adolescence, provides valuable opportunities to develop interpersonal, coping, and critical reflection skills \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. These include learning assertive communication, effectively negotiating conflict resolution, and managing the end of an unwanted relationship \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. From this viewpoint, a fine line may divide exploratory sexual activity that significantly increases the risk of harm and sexual experiences that ultimately contribute to positive sexual identity and competence \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In particular, adequate education, access to reproductive health care services, as well as open communication with adults can move the needle, allowing adolescents to face sexual experiences and empower competencies for their adult life, minimizing the adverse consequences \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe current literature still lacks sufficient evidence at the interface between risks and opportunities, particularly from a life-course PYD perspective. Existing research has yet to integrate both negative and positive well-being correlates into a comprehensive framework that encompasses the emotional, psychophysical, and social health outcomes of sexually related experiences \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. The present study aims to evaluate the relationship between sexual activity and the multifaceted dimensions of well-being\u0026mdash;social, emotional, and psychophysical\u0026mdash; among adolescents by adopting a nationally representative sample of Italian youths aged 17. A focus on age at sexual initiation in adolescence was employed to provide a developmental picture of the phenomenon at the interface between risks and benefits.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThe work is based on data from the 2022 Italian Health Behaviour in School-Aged Children (HBSC) study\u0026nbsp;\u003csup\u003e12\u003c/sup\u003e. The Italian survey adheres to the international HBSC study, a multicenter cross-sectional survey that runs every four years in more than 50 countries using a standardized research protocol to investigate health-related behaviours in adolescents\u0026nbsp;\u003csup\u003e13\u003c/sup\u003e. The international target population consisted of students aged 11, 13, and 15 years, attending the first and third grades of lower secondary school and the second grade of upper secondary school. The Italian HSBC study represents the first Italian population-based survey on adolescent behaviours, adopting a larger sample size (N\u0026gt;65,000) than the one requested by the HBSC International Protocol to ensure the national and regional representativeness of the sample\u0026nbsp;\u003csup\u003e12\u003c/sup\u003e. Furthermore, in 2022, the Italian study was extended to students aged 17 years attending the fourth grade of upper secondary school. The school class was the primary sampling unit, drawn by a stratified systematic cluster sampling from a list of all public and private schools obtained from the Ministry of Education. Data were collected in classroom settings through standardized, self-filled online questionnaires. Data analyzed in this study referred to 17-year-old adolescents from the 2022 Italian survey.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement.\u0026nbsp;\u003c/strong\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki. In 2022, the Italian HBSC study protocol and questionnaire were formally approved by the Ethics Committee of the Italian National Institute of Health (Ref. PRE BIO CE01.00, 22 November 2021).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1. Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSexual activity.\u003c/strong\u003e The information about sexual initiation was obtained through the questions \u0026ldquo;Have you ever had sexual intercourse (sometimes this is called \u0026ldquo;making love\u0026rdquo;, \u0026ldquo;having sex\u0026rdquo;, or \u0026ldquo;going all the way)?\u0026rdquo; and \u0026ldquo;How old were you when you had sexual intercourse for the first time?\u0026rdquo;. Adolescents were classified based on their sexual activity distinguishing inactivity, early initiation (at \u0026lt;16 years), and on-time initiation (at \u0026ge;16 years)\u0026nbsp;\u003csup\u003e13\u003c/sup\u003e. Alternatively, a more detailed measure, i.e., sexual activity per age of initiation, was obtained distinguishing the age of sexual initiation: non-active, initiation at \u0026lt;14 years, initiation at 14, at 15, and at \u0026ge;16 years\u0026nbsp;\u003csup\u003e13\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWell-being.\u0026nbsp;\u003c/strong\u003eIt was evaluated according to Keyes\u0026apos; Model of Mental Health, which conceptualized a complete state of mental health as an integration of emotional, psychophysical, and social well-being dimensions\u0026nbsp;\u003csup\u003e14\u003c/sup\u003e.\u0026nbsp;In particular, the present study assessed high life satisfaction (High LS), multiple psychosomatic health complaints (PHC), and loneliness as proxies for emotional, psychophysical, and social well-being, respectively, in line with previous literature on the topic\u0026nbsp;\u003csup\u003e15\u003c/sup\u003e.\u0026nbsp;In particular, High LS represented a positive indicator of well-being, while PHC and loneliness were considered negative measures.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eHigh life satisfaction (High LS)\u003c/strong\u003e\u003cem\u003e.\u0026nbsp;\u003c/em\u003eHigh LS was assessed using the Cantril ladder\u0026nbsp;\u003csup\u003e16\u003c/sup\u003e. Participants were asked to rate their life satisfaction using a visual scale (range 0\u0026ndash;10): the higher the score, the greater the feeling of life satisfaction. Respondents were asked to indicate the ladder step at which they would place their lives at present. The findings were categorized as high (\u0026ge;9) vs. lower (\u0026le;8) life satisfaction, as recommended elsewhere\u0026nbsp;\u003csup\u003e13\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMultiple psychosomatic health complaints (PHC).\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003ePHC were evaluated through the HBSC Symptom Checklist (HBSC-SCL), a non-clinical measure consisting of eight items (headache, stomachache, backache, feeling low, irritability or bad-tempered, feeling nervous, sleeping difficulties, and dizziness)\u0026nbsp;\u003csup\u003e13\u003c/sup\u003e. Adolescents indicated how often they had experienced each complaint over the last six months. Response options for each symptom ranged from about every day to rarely or never. According to the international HBSC documentation\u0026nbsp;\u003csup\u003e13\u003c/sup\u003e, a binary PHC variable was created to identify participants with multiple (two or more) health complaints more than once a week/other (reference category). The 8-item scale showed good internal consistency in our sample (\u0026alpha; = 0.85).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLoneliness.\u0026nbsp;\u003c/strong\u003eInformation about loneliness was obtained by asking adolescents how often they had felt lonely during the last 12 months. Response options were \u0026ldquo;never\u0026rdquo;, \u0026ldquo;rarely\u0026rdquo;, \u0026ldquo;sometimes\u0026rdquo;, \u0026ldquo;most of the time\u0026rdquo;, and \u0026ldquo;always\u0026rdquo;. A dichotomous indicator was created based on reporting loneliness \u0026ldquo;most of the time\u0026rdquo; or \u0026ldquo;always\u0026rdquo; vs. all the others (\u0026ldquo;sometimes\u0026rdquo;, \u0026ldquo;rarely\u0026rdquo;, \u0026ldquo;never\u0026rdquo;)\u0026nbsp;\u003csup\u003e13,17\u003c/sup\u003e. The measurement has been adopted from the Global Student Health Survey (GSHS). Previous studies confirmed the construct validity of the single-item measure and its similar validity and reliability with multiple-item scales\u0026nbsp;\u003csup\u003e18\u003c/sup\u003e.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eCondom use.\u003c/strong\u003e Those who reported early sexual intercourse were also asked about the contraceptive methods used at last sexual intercourse: \u0026ldquo;The last time you had sexual intercourse, did you or your partner use\u0026rdquo;: \u0026ldquo;a condom\u0026rdquo;, \u0026ldquo;birth control pill\u0026rdquo;, \u0026ldquo;withdrawal\u0026rdquo;, and \u0026ldquo;other methods\u0026rdquo;. Response options for each contraceptive method were \u0026ldquo;yes\u0026rdquo;, \u0026ldquo;no\u0026rdquo;, and \u0026ldquo;not sure\u0026rdquo;; the latter two options were grouped \u003csup\u003e19\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContextual variables.\u0026nbsp;\u003c/strong\u003eContextual variables included socioeconomic status (SES) \u0026nbsp;(high, medium, low) through the Family Affluence Scale (FAS) \u003csup\u003e13,20\u003c/sup\u003e, high family and peer support (vs. medium-low) \u003csup\u003e13,20\u003c/sup\u003e, non-intact family structure (i.e., other condition than living with both parents) \u003csup\u003e21\u003c/sup\u003e, social media use profiles (non-active, active, intense, problematic) \u003csup\u003e22\u003c/sup\u003e, high school pressure (vs. low) \u003csup\u003e13,21\u003c/sup\u003e, migrant status (i.e., at least one parent born abroad vs. other) \u003csup\u003e21\u003c/sup\u003e, Italian geographic area (Northern, Central, and Southern Italy) \u003csup\u003e21\u003c/sup\u003e. Menarcheal status information distinguished adolescents who did not have menarche yet, with early menarche, defined as menarche onset at \u0026lt;11 years, and on-time menarche (i.e., onset at \u0026ge; 12 years) \u003csup\u003e23\u003c/sup\u003e. Further details regarding the adopted measures are provided elsewhere \u003csup\u003e13\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Statistical analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive characteristics of the sample were reported by gender and sexual activity. Differences were tested with the corrected weighted Pearson Chi-square test. Multivariable quasibinomial regression models were performed to test the association between sexual activity and well-being (i.e., High LS, PHC, and loneliness) and condom use. All the models were adjusted by socioeconomic status, family support, peer support, family structure, social media use, school pressure, migrant status, geographic area, and stratified by gender. Models among girls were also adjusted by menarcheal status. In parallel, the regression analysis was replicated by considering the sexual activity variable with a categorization per year of sexual initiation. All the analyses were conducted by adjusting for the survey design. In all the analyses, a p-value \u0026lt; 0.05 was considered statistically significant. All the analyses were performed in the R version 4.2.1\u0026nbsp;\u003csup\u003e24\u003c/sup\u003e.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe sample included 22,568 adolescents aged 17 years, equally distributed by gender (48.9% girls), with a response rate higher than 95%. \u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eshows rates of sociodemographic and contextual characteristics, sexual activity, well-being, and condom use by gender. Overall, most of the sample was declared to belong to the medium socioeconomic status (52.4%), and 45.8% of the adolescents were from Southern regions. Most students were still sexually inactive (57.2%), followed by those with on-time sexual initiation (24.2%) and early sexual initiation (18.6%). About 2 out of 3 sexually active participants (62.3%) used a condom in their last intercourse. Regarding the mental panel, 9.0% declared High LS, about 2 out of 3 respondents showed PHC (67.3%), and 1 out of 5 felt lonely (18.6%). Some gender differences were found. The gender groups showed similar patterns of sexual activity (p=0.451), while girls reported significantly lower rates of condom use (p\u0026lt;0.001). Moreover, girls reported lower rates of high LS (6.8% vs. 11.1%; p\u0026lt;0.001), a significantly higher percentage of PHC (82.8% vs. 52.4%; p\u0026lt;0.001) and loneliness (25.2% vs. 12.3%; p\u0026lt;0.001) than boys. The distribution of sexual activity by age at first intercourse among boys and girls is shown in \u003cstrong\u003eFigure 1\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs reported in \u003cstrong\u003eTable S1\u0026nbsp;\u003c/strong\u003e(Supplementary file), girls and boys with early sexual initiation showed a lower rate of condom use than those with on-time initiation. Statistically significant higher rates of PHC (p=0.028 among boys; p\u0026lt;0.001 among girls) and lower levels of loneliness (p\u0026lt;0.001 among boys; p=0.013 among girls) were found in the sexually active groups than in the inactive ones.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 and Table S2\u0026nbsp;\u003c/strong\u003e(Supplementary file) present the results of the regression models exploring the association between sexual activity and well-being measures. Overall, a nuanced well-being picture is suggested among boys and girls based on the timing of sexual initiation. Early sexual activity was positively associated with High LS among boys (OR: 1.49; 95% CI: 1.14-1.94). Regarding psychophysical well-being, early sexual initiation was significantly associated with a higher probability of presenting PHC. Such a pattern is more evident among girls (OR: 1.56; 95% CI: 1.23-1.99) than boys (OR: 1.26; 95% CI: 1.06-1.51). The association with PHC persisted among girls with on-time sexual initiation (OR: 1.47; 95% CI: 1.20-1.81), while among boys, it disappeared. Third, on-time sexual initiation was associated with a lower probability of loneliness among boys (OR: 0.67; 95% CI: 0.52-0.88) and girls (OR: 0.78; 95% CI: 0.64-0.94).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe analysis performed considering sexual activity per age of initiation globally confirmed the results (\u003cstrong\u003eFigure 1 and Table S3,\u0026nbsp;\u003c/strong\u003eSupplementary file). Such analysis substantially corroborated the previous results among girls. However, while the analysis on sexual initiation at \u0026lt;14 and at 14 substantially confirmed findings related to early sexual initiation among boys, insights associated with sexual initiation at 15 provided a more nuanced picture of the phenomenon. In particular, the association between sexual initiation at 15 and PHC disappeared among boys (OR: 1.06; 95% CI: 0.84-1.34), anticipating the pattern observed for on-time sexual initiation (OR: 1.06; 95% CI: 0.90-1.26). Furthermore, among boys, the protective relationship between early sexual initiation and loneliness (OR: 0.59; 95% CI: 0.40-0.88) substantially overlapped findings regarding on-time sexual initiation (OR: 0.67; 95% CI: 0.52-0.88).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 and Table S3\u0026nbsp;\u003c/strong\u003e(Supplementary file)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003epresent findings related to the association between sexual activity and condom use in the last intercourse. Halved mean probabilities of condom use were registered among early sexually active adolescents compared to those with on-time sexual initiation among boys and girls (respectively, OR 0.49; 95% CI: 0.40-0.61; OR: 0.55; 95% CI: 0.46-0.66). In particular, adolescents with earlier age at sexual initiation presented a lower probability of condom use (\u003cstrong\u003eFigure 2 and Table S5,\u0026nbsp;\u003c/strong\u003eSupplementary file). The strongest pattern was found among adolescents with sexual initiation before the age of 14, especially among boys (OR: 0.25; 95% CI: 0.16-0.38).\u0026nbsp;\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe present work focuses on well-being correlates of sexual activity among 17-year-olds in Italy using a developmental lens on sexual initiation. Globally, the present study provided evidence suggesting mixed results on well-being correlates of sexual activity in adolescence on the line between risks and benefits. In particular, patterns suggested a shift from prevailing risk to emerging benefits of adolescents\u0026apos; sexuality depending on their early or on-time age at sexual debut, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrevalence of sexual activity and well-being\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe registered prevalence of sexual activity (42.8%) among Italian 17-year-olds can be contextualized in a progressive decrease in age at first intercourse over time in Italy, aligning with existing national and cross-national literature\u0026nbsp;\u003csup\u003e25,26\u003c/sup\u003e. Similar prevalences of sexual activity per year of initiation were registered by gender, confirming the progressive decrease of the gender gap in sexual initiation over time\u0026nbsp;\u003csup\u003e25\u003c/sup\u003e. Conversely, 2 out of 3 adolescents declared the condom use in their last intercourse. Such evidence could be the result of an educational gap leading to inadequate prevention against sexually transmitted infections\u0026nbsp;\u003csup\u003e27\u003c/sup\u003e. Furthermore, girls seemed to use condoms less frequently than boys, aligning with previous literature\u0026nbsp;\u003csup\u003e27,28\u003c/sup\u003e. Some authors hypothesized that it could represent a consequence of girls\u0026rsquo; perception of having less power in decision-making on condom use in heterosexual intercourse than their partner, but also the result of the feeling that asking to use condoms could ruin their reputation\u0026nbsp;\u003csup\u003e27,29,30\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther gender differences were highlighted in terms of well-being. Girls presented significantly lower well-being than boys, accounting for lower degrees of high LS, higher rates of PHC, and doubled levels of loneliness. Such evidence highlights the peculiar well-being condition of adolescent girls in Italy, who were found to present the highest levels of PHC in Europe\u0026nbsp;\u003csup\u003e17\u003c/sup\u003e. Furthermore, the gender gap in life satisfaction in Italy is higher than the average in Europe\u0026nbsp;\u003csup\u003e17\u003c/sup\u003e.\u0026nbsp;Conversely, the registered prevalence of loneliness among girls is below the mean European levels\u0026nbsp;\u003csup\u003e17\u003c/sup\u003e, presumably indicating the protective role of meaningful social bonds within and outside the family\u0026nbsp;\u003csup\u003e21\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSexual activity and emotional well-being\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study registered a positive association between early sexual activity and life satisfaction among boys, while it observed unclear patterns regarding early activity among girls and concerning on-time sexual initiation among boys and girls. Literature on the topic is mixed: some authors registered a risk association between lifetime sexual activity and life dissatisfaction \u003csup\u003e31\u003c/sup\u003e, while others found a protective relationship between early sexual debut and very high life satisfaction among boys \u003csup\u003e32\u003c/sup\u003e. Our findings can be partially explained by supposing the persistence of pervasive gender stereotypes and traditional roles. Presumably, early sexual activity responds to stereotypical expectations of masculinity \u003csup\u003e32\u003c/sup\u003e, elevating boys\u0026apos; status, whereas girls tend to be shamed for such activity \u003csup\u003e32\u0026ndash;34\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSexual activity and psychophysical well-being\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoys and girls with early sexual activity were more likely to present PHC compared with sexually inactive peers at 17. While the association between on-time sexual initiation and PHC persists among girls, no association was found among boys. Findings concerning early sexual initiation align with previous international literature, revealing an association between early sexual initiation and internalizing symptoms, such as anxiety and depression\u0026nbsp;\u003csup\u003e6,33\u003c/sup\u003e. Such evidence might corroborate the traditional conception that sexual intercourse in adolescence causes psychological harm\u0026nbsp;\u003csup\u003e3,4\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConversely, findings related to on-time sexual initiation among boys, confirmed by Wesche and authors\u0026nbsp;\u003csup\u003e35\u003c/sup\u003e, partially challenged such a view, highlighting gender differences in the association between on-time sexual initiation and PHC in adolescence. Indeed, girls seemed to present stronger adverse mental consequences of experiencing sexual intercourse\u0026nbsp;\u003csup\u003e35,36\u003c/sup\u003e, as a result of stronger intrinsic susceptibility to internalizing symptomatology \u0026nbsp;\u003csup\u003e37\u003c/sup\u003e. Another possible explanation could concern the still existing gender norms regarding the internalized sexual stigma\u0026nbsp;\u003csup\u003e29,38\u003c/sup\u003e,\u0026nbsp;i.e., the process by which individuals internalize societal negative perceptions and stereotypes about their sexual identity. Overall, such elements could potentially contribute to determining the particularly high negative psychosomatic effects of on-time sexual initiation among girls, which is not evident among boys\u0026nbsp;\u003csup\u003e35,36\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSexual activity and social well-being\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, we found that early and on-time sexually active boys and girls perceived lower levels of loneliness compared with the inactive ones, addressing the important positive social meanings of sex since early adolescence\u0026nbsp;\u003csup\u003e34\u003c/sup\u003e. Patterns were stronger regarding on-time adolescents compared to patterns on early active ones, suggesting the increasing need for intimacy and a higher level of emotional competency in experiences made in the transition between early to mid-late adolescence\u0026nbsp;\u003csup\u003e33\u003c/sup\u003e. More specifically, the effects of sexual experience on loneliness seemed to be stronger among boys than girls\u0026nbsp;\u003csup\u003e34\u003c/sup\u003e. In particular, boys could be more likely to have sex to cope with needs (personal meanings), to rebel from social norms (transgressional meanings), and imitate peers (negative social meanings), but also to express their emotional bonds (positive social meanings) compared to girls\u0026nbsp;\u003csup\u003e32,34\u003c/sup\u003e. Furthermore, girls\u0026apos; greater ability to develop emotional ties with friends independently of family closeness may mitigate their inclination to pursue connection through sexual activity\u0026nbsp;\u003csup\u003e39\u003c/sup\u003e. As a result, the sexual experience could protect especially boys from feeling lonely.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSexual activity and condom use \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the present work, early sexual initiation\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewas associated with a halved likelihood of \u003cstrong\u003econdom use\u003c/strong\u003e in the last intercourse compared to those with on-time sexual debut. This finding aligns with the previous literature on the topic, which underlined that early sexual debut is associated with less condom use both at sexual initiation and subsequent sexual intercourse\u0026nbsp;\u003csup\u003e40\u003c/sup\u003e. In regard, a possible educational gap related to age at early sexual initiation was suggested\u0026nbsp;\u003csup\u003e28\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSexual activity from risk to need: gender matters\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, the analysis exploring well-being correlates of sexual initiation by age of first intercourse registered gender differences regarding age of transition in which sex as a risk-behavior gradually turns into a meaningful life experience. In particular, patterns radically changed from 14 to 15 among boys and from 15 to 16 among girls. In this transition, the association between first sexual debut and PHC disappeared, and the protective pattern between sexual initiation and loneliness strengthened among boys. Conversely, the association between sexual activity and lower loneliness became evident among girls experiencing their first sexual intercourse at 16 or later. Such evidence confirms previous results according to which sex could begin to represent a core life experience earlier among boys than girls\u0026nbsp;\u003csup\u003e32\u0026ndash;34\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublic health implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, the produced knowledge supports the development of comprehensive school-based educational programs promoting sexual health and emotional maturation on the line between risks and opportunities\u0026nbsp;\u003csup\u003e1\u003c/sup\u003e. Since the first sexual intercourse experience was found to determine the consequent sexual and emotional health, the effective introduction of such educational programs might be introduced before sexual initiation, i.e., since primary school \u003csup\u003e28,40\u003c/sup\u003e. As previously stated, the findings of this study directly support the adoption of a developmental and gender-specific approach to sexuality in adolescence. The last goal might be equipping adolescents navigating this uncharted territory with the appropriate educational skills to live positive sexually related experiences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main strength of this study was the use of a large and representative national sample to investigate the well-being correlates of sexual activity and the use of condoms among 17-year-olds using a developmental lens on sexual initiation. Moreover, the low percentage of missing values allowed us to perform a robust analysis, providing highly reliable results. The strengths and limitations of the HBSC methodology have been described elsewhere\u0026nbsp;\u003csup\u003e20\u003c/sup\u003e.\u0026nbsp;Some limitations are inherent in the cross-sectional design, which does not allow for determining the directionality of emerging associations. Moreover, the present work was limited to exploring sexual activity, condom use, and well-being through available data from the 2021/2022 HBSC Italian survey, lacking information about other potentially involved elements such as gender identity, sexual partners\u0026apos; gender, and sexual orientation\u0026nbsp;\u003csup\u003e27\u003c/sup\u003e. The introduction of a broader focus on sexual adolescents\u0026rsquo; health in the 2025/2026 HBSC Italian questionnaires will be considered to explore the phenomenon in such subpopulations.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThe present work shed light on well-being correlates of sexual activity among 17-year-olds in Italy using a developmental lens on sexual initiation. Globally, the study provided evidence suggesting mixed results on well-being correlates of sexual activity in adolescence on the line between risks and benefits. Based on the age of sexual initiation, a transition was supposed from a prevailing risk role of sexual activity among adolescents with early sexual initiation to a prevailing protective association of such experience among youths with on-time sexual debut. Relevant gender differences in the age at such transition were observed, constituting fertile soil for further research and educational preventive programs adopting gender-specific and developmental approaches.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eWe thank all students who completed the questionnaires. Special thanks go to the school head teachers, class teachers, and other school staff who actively participated in implementing the HBSC survey. We thank all the Regional and Local Health Unit coordinators and the health workers for their fundamental contribution to the HBSC. We further thank all the members of the 2022 HBSC-Italia Group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions.\u0026nbsp;\u003c/strong\u003eMB, SC, and PN conceptualized and designed the study; MB analyzed the data; MB, SC, and PN wrote the first draft; MB, SC, PD, GL, PN, and AV contributed to the interpretation of data, critically reviewed the manuscript and approved the final version. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe Italian HBSC survey was promoted and funded by the Ministry of Health and the Italian National Institute of Health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u0026nbsp;\u003c/strong\u003eAll authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement.\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from all the included subjects. Students\u0026rsquo; parents received an information note describing the purpose of the survey before the data collection. Families could refuse participation by filling in the note returned to the involved classes\u0026apos; teachers. The anonymity and confidentiality of collected data were ensured.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement.\u0026nbsp;\u003c/strong\u003eThe data presented in this study are available in accordance with the 2022 Italian HBSC data access policy. Requests should be directed to the Italy Principal Investigator, Dr. Paola Nardone: [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications and Contributions statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study advances understanding of adolescent sexuality by exploring multifaceted well-being correlates through a developmental lens. Depending on the age at sexual debut, mixed patterns emerged regarding the well-being dimensions, revealing gender differences and a developmental transition from prevailing risks to benefits of sexuality. Findings support the implementation of gender-sensitive sexual health education recognizing the evolving nature of adolescent experiences.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOrganization, W. H. \u0026amp; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, D. and R. T. in H. R. \u003cem\u003eSexual Health and Its Linkages to Reproductive Health: An Operational Approach\u003c/em\u003e. (World Health Organization, 2017).\u003c/li\u003e\n\u003cli\u003eArnett, J. J. Emerging adulthood. A theory of development from the late teens through the twenties. \u003cem\u003eAm Psychol\u003c/em\u003e \u003cstrong\u003e55\u003c/strong\u003e, 469\u0026ndash;480 (2000).\u003c/li\u003e\n\u003cli\u003eHalpern, C. T. 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Health\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, 379 (2014).\u003c/li\u003e\n\u003cli\u003eK\u0026ouml;ltő, A. \u003cem\u003eet al.\u003c/em\u003e \u003cem\u003eA Focus on Adolescent Sexual Health in Europe, Central Asia and Canada: Health Behaviour in School-Aged Children International Report from the 2021/2022 Survey\u003c/em\u003e. (World Health Organization. Regional Office for Europe, 2024).\u003c/li\u003e\n\u003cli\u003eOliveira-Campos, M., Giatti, L., Malta, D. \u0026amp; Barreto, S. M. Contextual factors associated with sexual behavior among Brazilian adolescents. \u003cem\u003eAnnals of Epidemiology\u003c/em\u003e \u003cstrong\u003e23\u003c/strong\u003e, 629\u0026ndash;635 (2013).\u003c/li\u003e\n\u003cli\u003eAgu, C. \u003cem\u003eet al.\u003c/em\u003e Gender differences in adolescents\u0026rsquo; perceptions of condom use in Ebonyi State, Southeast Nigeria. \u003cem\u003eAJRH\u003c/em\u003e \u003cstrong\u003e28\u003c/strong\u003e, 74\u0026ndash;82 (2024).\u003c/li\u003e\n\u003cli\u003eAbel, G. \u0026amp; Fitzgerald, L. \u0026lsquo;When you come to it you feel like a dork asking a guy to put a condom on\u0026rsquo;: is sex education addressing young people\u0026rsquo;s understandings of risk? \u003cem\u003eSex Education\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, 105\u0026ndash;119 (2006).\u003c/li\u003e\n\u003cli\u003eValois, R. F., Zullig, K. J., Huebner, E. S., Kammermann, S. K. \u0026amp; Drane, J. W. Association Between Life Satisfaction and Sexual Risk-Taking Behaviors Among Adolescents. \u003cem\u003eJournal of Child and Family Studies\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, 427\u0026ndash;440 (2002).\u003c/li\u003e\n\u003cli\u003eGazendam, N., Cleverley, K., King, N., Pickett, W. \u0026amp; Phillips, S. P. Individual and social determinants of early sexual activity: A study of gender-based differences using the 2018 Canadian Health Behaviour in School-aged Children Study (HBSC). \u003cem\u003ePLoS ONE\u003c/em\u003e \u003cstrong\u003e15\u003c/strong\u003e, e0238515 (2020).\u003c/li\u003e\n\u003cli\u003eSavioja, H., Helminen, M., Fr\u0026ouml;jd, S., Marttunen, M. \u0026amp; Kaltiala-Heino, R. Sexual experience and self-reported depression across the adolescent years. \u003cem\u003eHealth Psychology and Behavioral Medicine\u003c/em\u003e \u003cstrong\u003e3\u003c/strong\u003e, 337\u0026ndash;347 (2015).\u003c/li\u003e\n\u003cli\u003eGiannotta, F., Ciairano, S., Spruijt, R. \u0026amp; Spruijt‐Metz, D. Meanings of sexual intercourse for Italian adolescents. \u003cem\u003eJournal of Adolescence\u003c/em\u003e \u003cstrong\u003e32\u003c/strong\u003e, 157\u0026ndash;169 (2009).\u003c/li\u003e\n\u003cli\u003eWesche, R., Kreager, D. A., Lefkowitz, E. S. \u0026amp; Siennick, S. E. Early Sexual Initiation and Mental Health: A Fleeting Association or Enduring Change? \u003cem\u003eJ of Research on Adolesc\u003c/em\u003e \u003cstrong\u003e27\u003c/strong\u003e, 611\u0026ndash;627 (2017).\u003c/li\u003e\n\u003cli\u003eCiairano, S., Bonino, S., Kliewer, W., Miceli, R. \u0026amp; Jackson, S. Dating, Sexual Activity, and Well-Being in Italian Adolescents. \u003cem\u003eJournal of Clinical Child \u0026amp; Adolescent Psychology\u003c/em\u003e \u003cstrong\u003e35\u003c/strong\u003e, 275\u0026ndash;282 (2006).\u003c/li\u003e\n\u003cli\u003eRudolph, K. D. Gender differences in emotional responses to interpersonal stress during adolescence. \u003cem\u003eJournal of Adolescent Health\u003c/em\u003e \u003cstrong\u003e30\u003c/strong\u003e, 3\u0026ndash;13 (2002).\u003c/li\u003e\n\u003cli\u003eFisher, T. D., Moore, Z. T. \u0026amp; Pittenger, M.-J. Sex on the Brain?: An Examination of Frequency of Sexual Cognitions as a Function of Gender, Erotophilia, and Social Desirability. \u003cem\u003eJournal of Sex Research\u003c/em\u003e \u003cstrong\u003e49\u003c/strong\u003e, 69\u0026ndash;77 (2012).\u003c/li\u003e\n\u003cli\u003eMajumdar, D. Social Support and Risky Sexual Behavior among Adolescents: The Protective Role of Parents and Best Friends. \u003cem\u003eJournal of Applied Sociology\u003c/em\u003e \u003cstrong\u003e23\u003c/strong\u003e, 28\u0026ndash;43 (2006).\u003c/li\u003e\n\u003cli\u003eShafii, T., Stovel, K. \u0026amp; Holmes, K. Association Between Condom Use at Sexual Debut and Subsequent Sexual Trajectories: A Longitudinal Study Using Biomarkers. \u003cem\u003eAm J Public Health\u003c/em\u003e \u003cstrong\u003e97\u003c/strong\u003e, 1090\u0026ndash;1095 (2007).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Sociodemographic and contextual characteristics, sexual activity, condom use, and well-being by gender\u003c/strong\u003e \u003cstrong\u003eat 17 years old.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"665\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003cp\u003eN=22,568\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003eBoys\u003c/p\u003e\n \u003cp\u003eN=11,252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eGirls\u003c/p\u003e\n \u003cp\u003eN=11,316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eBoys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e51.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eGirls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e48.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocioeconomic status (FAS) (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e32.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e30.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e33.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e52.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e53.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e51.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e16.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeographical area (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eNorthern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e31.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e29.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e33.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eCentre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e22.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e22.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eSouthern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e45.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e47.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e44.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMigrant status (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-intact family structure (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e19.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e20.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh family support (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e59.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e63.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e55.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh peer support (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e60.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e61.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e60.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.386\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial media use (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eInactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eActive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e58.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e64.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e52.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eIntense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e25.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e30.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eProblematic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e9.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh school pressure (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e72.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e62.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e82.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMenarcheal status (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eNaN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eNo menarche\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eEarly menarche\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eOn-time menarche\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e85.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual activity (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.451\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eSexual inactivity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e57.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e57.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e56.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eEarly sexual activity (\u0026le;15)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e18.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e19.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eOn-time sexual activity (\u0026ge;16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e24.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e24.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e24.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCondom use (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e62.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e66.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;57.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh LS (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHC (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e67.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e52.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e82.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLoneliness (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e12.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e25.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations. FAS, Family Affluence Scale; LS, life satisfaction; PHC, psychosomatic health complaints.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Association between sexual activity and High LS, PHC, and loneliness among 17-year-old boys and girls. Odds ratio (OR) and 95% confidence intervals (95%CI) are shown.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"665\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBoys\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGirls\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh LS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLoneliness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh LS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLoneliness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual activity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eSexual inactivity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eEarly sexual activity (\u0026le;15)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.49\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(1.14; 1.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.26\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1.06; 1.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(0.59; 1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e1.20\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.84; 1.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.56\u003c/strong\u003e (1.23; 1.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(0.71; 1.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eOn-time sexual activity (\u0026ge;16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e1.08\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.84; 1.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e1.06\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.90; 1.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.67\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.52; 0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(0.73; 1.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.47\u003c/strong\u003e (1.20; 1.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.78\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(0.64; 0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote. Bold values indicate statistically significant associations (p\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003eAbbreviations. LS, life satisfaction; PHC, psychosomatic health complaints.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Association between sexual activity and condom use among boys and girls at 17. Odds ratio (OR) and 95% confidence intervals (95%CI) are shown.\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 390px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCondom use\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBoys\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGirls\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual activity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eEarly sexual activity \u0026nbsp; \u0026nbsp; \u0026nbsp;(\u0026le;15 yrs.)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.49\u003c/strong\u003e (0.40; 0.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.55\u003c/strong\u003e (0.46; 0.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eOn-time sexual activity (\u0026ge;16 yrs.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote. Bold values indicate statistically significant associations (p\u0026lt;0.05).\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"sexuality, well-being, adolescence, HBSC, condom","lastPublishedDoi":"10.21203/rs.3.rs-7046152/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7046152/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEvidence on well-being correlates of adolescent sexuality balancing risks and opportunities remains limited and discordant. This study evaluates associations between adolescent sexuality and multidimensional well-being through a developmental lens. Data referred to a nationally representative sample of 17-year-olds (N\u0026thinsp;=\u0026thinsp;22,568) from the 2022 Italian Health Behaviour in School-Aged Children study. Measures included sexual activity (inactivity, early initiation\u0026thinsp;\u0026lt;\u0026thinsp;16, on-time initiation\u0026thinsp;\u0026ge;\u0026thinsp;16), emotional (high life satisfaction), psychophysical (psychosomatic health complaints, PHC), social well-being (loneliness), and condom use. Early initiation (vs. inactivity) was associated with PHC in boys (OR: 1.26; 95% CI: 1.06\u0026ndash;1.51) and girls (OR: 1.56; 95% CI: 1.23\u0026ndash;1.99). Among boys, it was linked to life satisfaction (OR: 1.49; 95% CI: 1.14\u0026ndash;1.94) and lower loneliness (OR: 0.77; 95% CI: 0.59\u0026ndash;1.00). Boys and girls with on-time initiation presented lower loneliness (OR: 0.69; 95% CI: 0.52\u0026ndash;0.88; OR: 0.78; 95% CI 0.64\u0026ndash;0.94, respectively). Exclusively girls with on-time initiation showed higher PHC (OR: 1.47; 95% CI: 1.20\u0026ndash;1.81). Halved condom use appeared among adolescents with early (vs. on-time) initiation. A developmental shift, earlier among boys, emerged from predominantly risk to more protective well-being associations of sexuality. The mixed well-being findings associated with adolescent sexuality underscore the need for gender-sensitive, developmentally informed sexual health education.\u003c/p\u003e","manuscriptTitle":"Sexuality and Well-being: a Developmental Snapshot of Adolescents in Italy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 02:02:13","doi":"10.21203/rs.3.rs-7046152/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f559b9ee-9efe-4545-9f7c-c03757e1215d","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":51876328,"name":"Health sciences/Health care"},{"id":51876329,"name":"Health sciences/Medical research"},{"id":51876330,"name":"Biological sciences/Psychology"},{"id":51876331,"name":"Social science/Psychology"},{"id":51876332,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2026-01-14T06:25:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-23 02:02:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7046152","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7046152","identity":"rs-7046152","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}