Abstract

PURPOSE Although a large proportion of males in the United States become sexually active during high school, condom use is decreasing and contributing to negative sexual health outcomes. Fathers are influential in promoting adolescent male sexual health; however, factors that shape fathers’ decisions about when to discuss condom use with their sons remain understudied. We examined paternal perceptions of adolescent males’ readiness for sex relative to fathers providing guidance for condom use in Latino and Black families.

METHODS We recruited 191 Latino and Black males aged 15-19 years and their fathers in the South Bronx, New York City. Dyads completed surveys, and a subset of fathers participated in audio-recorded sessions with a father coach, which included conversations about adolescent male condom use. A sequential explanatory mixed methods design identified adolescent male developmental predictors for paternal guidance for condom use and explored how fathers perceive their sons’ readiness for sex.

RESULTS The quantitative findings indicate that paternal perception of their sons’ readiness for sex is an important predictor of providing guidance for condom use, and that fathers consider other factors (beyond age and perceived sexual activity) in understanding their sons’ developmental readiness for sex. The qualitative findings provide insights into these additional factors, which should be considered when engaging fathers in primary care around issues of adolescent male condom use.

CONCLUSIONS Fathers’ perception of their sons’ readiness for sex is a predictor of providing condom guidance. We provide practical suggestions for engaging fathers in primary care to promote correct and consistent condom use by adolescent males.

Key words:INTRODUCTION

Despite overall reductions in sexual activity among adolescents over the past decade,1 a large proportion of young males in the United States report engaging in sexual activity before graduating high school.2 In 2021, 47% of males in the 12th grade reported having had sex, and more than 30% reported being sexually active.2 At the same time, the use of condoms—the only male-controlled contraceptive and multipurpose device offering protection against both unplanned pregnancies and sexually transmitted infections (STIs), including HIV—is decreasing. In 2021, only about one-half of all sexually active males in 12th grade reported using a condom the last time they had sex, compared with two-thirds in 2009.2

These trends contribute to negative sexual health outcomes among young males. For example, males aged 15-19 years account for more than 100,000 diagnoses of reportable STIs per year.3 In addition, the rate of new annual HIV diagnoses for males aged 15-24 years is higher than the national average among males overall, even though about one-half of all youth living with HIV are estimated to be unaware of their status.3 Moreover, the proportion of unplanned pregnancies among adolescents is well above that in older cohorts,4 and frequently results in adolescent parents, including fathers, that are inadequately prepared for the responsibilities of parenthood.5 It is also important to highlight that Latino and Black adolescent males experience inequitable and unequal availability, reach, and quality of health services6,7 relative to negative sexual health outcomes (STIs, HIV, and unplanned parenthood).3,8

The Society for Adolescent Health and Medicine and the American Academy of Pediatrics have identified male sexual health as a key adolescent health care priority,9,10 but there are few male-specific, evidence-based resources for promoting condom use among adolescents available to family health care clinicians today. Notably, fathers represent promising partners to help clinicians address this gap. Evidence supports the effectiveness of clinicians involving parents to reduce adolescent sexual risks,11,12 and the American Academy of Family Physicians’ policy statement on adolescent health care, sexuality, and contraception highlights family health care clinicians as ideally positioned to encourage parents or other trusted adults to be involved in sex education.13 In addition, parent-based sexual health interventions have been demonstrated to be effective for Latino and Black families,14 and represent powerful tools for addressing persistent sexual health inequities. Furthermore, research substantiates the influential role of both mothers and fathers in shaping adolescent sexual decision making and behavior,15-17 and shows that adolescent males desire guidance regarding the correct and consistent use of condoms, specifically from their fathers.18,19

Father-engaged approaches to promote sexual health for Latino and Black adolescent males would be congruent with the vision of the National Academies of Sciences, Engineering and Medicine’s 2021 consensus study regarding an increase in person- and family-centered, and community-oriented primary care delivered by interprofessional teams.20 These approaches may improve the reach of services among populations inadequately engaged in traditional models of care, such as Latino and Black fathers and sons. Minimal father-based and condom-focused communication resources, however, are currently available to care teams delivering family-centered health services.

To address this gap, this study expands on the existing body of research on father-based promotion of adolescent condom use. Research has substantiated the feasibility and acceptability of father-based condom use promotion, explored strategies for overcoming communication barriers on the topic, and examined preferences for teaching and learning about the use of condoms.18,19 The factors that influence fathers’ decisions about the appropriate timing to initiate discussion about condom use with their adolescent sons, however, remain insufficiently understood. This an important omission given the need to prepare adolescent males for the correct and consistent use of condoms before they become sexually active.21,22

Research has identified 3 factors that contribute to parents’ decisions to delay conversations about sex and sexual health with their adolescent children: (1) perceptions regarding their children’s readiness for sex (ie, “my child is not yet ready to have sex/talk about sex”); (2) the adolescent’s age (ie, “my child is too young to talk about sex”); and (3) perceptions of the onset of their children’s sexual activity (ie, “there is no need to talk about sex because my child is not yet having sex”).21-25 We investigated these 3 factors in relation to the fathers providing guidance for condom use to adolescent sons in Latino and Black families with 3 research questions: (1) Are paternal perceptions of Latino and Black adolescent males’ readiness for sex intercorrelated with or independent from adolescents’ chronological age and perceived sexual activity? (2) What degree of variability in paternal provision of condom guidance is explained by the 3 factors, independently and collectively? (3) What factors, beyond age and perceived sexual activity, are important in Latino and Black fathers’ conceptualization of their sons’ developmental readiness for sex? The research is designed to inform guidance for clinicians in family-focused health care to encourage fathers to initiate communication about readiness for sex and correct and consistent condom use with their adolescent sons.

METHODS

The study relied on a sequential explanatory mixed methods design.26 Quantitative data were used to identify adolescent male developmental predictors of the paternal provision of guidance for condom use. Qualitative data were used to explore how fathers evaluate their sons’ readiness for sex in greater detail.

Study Sample

Study participants were recruited from the South Bronx in New York City, a socially and medically underserved community with rates of STIs, HIV infection, and teen parenthood that are significantly higher than those at city and national levels.3,8,27-30 We used area sampling methods to recruit Latino and Black males aged 15-19 years and their fathers.31 Eligible father-son dyads were identified through door-to-door recruitment in public housing developments. Eligibility criteria required the adolescent male to (1) be aged 15-19 years at enrollment, (2) identify as Latino and/or Black race/ethnicity, (3) have regular contact with a resident or non-resident primary male adult caregiver (biologic or non-biologic), and (4) reside in the South Bronx. Adolescent males currently cohabitating with a partner or participating in a teen pregnancy prevention program were excluded. Eligible fathers and adolescents aged 18-19 years provided informed consent. For adolescents aged <18 years, we obtained both their assent and parental consent. The study was approved by the New York University and Duke University Institutional Review Boards.

Data Collection

Adolescent males and their fathers completed self-administered pen-and-paper surveys in their homes or at a mutually agreed-upon location in the community. Study staff separated fathers and sons while completing the surveys to ensure confidentiality of responses. The surveys contained psychometrically appropriate measurement scales that were adapted from large national surveys32 and that have been used effectively with the study population in our previous research.11,12,33 Adolescent surveys covered demographic measures, reports of paternal involvement and guidance regarding condom use, sexual behavior, and measures of social desirability response tendencies. Paternal surveys examined demographic measures, perceptions of son’s readiness for sex and sexual activity, and measures of social desirability response tendencies. Surveys were offered in English or Spanish, and the questionnaire was written at a 4th-grade reading level. To minimize social desirability response bias, the study staff reiterated that responses were confidential, that there were no correct or incorrect answers, and that it was important to provide truthful responses. To minimize measurement bias, the respondents completed a series of guided practice questions at the beginning of the survey to familiarize themselves with the 5-point response scales.

In addition, a random subsample of one-half the surveyed fathers was invited to participate in 2 face-to-face sessions with a father coach using the Fathers Raising Responsible Men curriculum.34 The sessions included guided conversations about the dangers of unprotected sex (eg, the consequences of unplanned teen fatherhood, the acquisition of STIs, or HIV), how to address common reasons why adolescent males engage in unprotected sex, how to overcome barriers to having conversations about sex and condoms, and how to demonstrate the 5 steps of correct and consistent condom use. Both sessions were 45 to 60 minutes long, offered in either English or Spanish, and were conducted in the participant’s home or at a mutually agreed-upon location in the community. Additional information about the father coaches and supplemental curriculum materials are available online.34 The conversations elicited a range of paternal perspectives about involvement and guidance for condom use. These conversations were recorded on digital audio recorders and transcribed verbatim by bilingual study staff. Participant names were replaced with subject identification numbers during transcription to ensure confidentiality.

Survey MeasuresPaternal Survey

Perceptions of readiness for sex and sexual activity. One item in the paternal survey assessed the perceptions of son’s readiness for sex. Fathers were asked to rate their agreement with the statement “I think my son is ready to have sexual intercourse at this time in his life” on a 5-point, Likert-type, disagree-to-agree scale. Subsequently, paternal perceptions of adolescent male readiness for sex were dichotomized: score of 1 for responses of strongly agree or agree, and score of 0 for responses of neither agree nor disagree, disagree, or strongly disagree.

We also asked, “Has your son ever had sexual intercourse?” and recorded the responses as ordinal numbers: no (coded as 1), I don’t know (coded as 2), and yes (coded as 3).

Adolescent Survey

Age in years was calculated from the adolescent’s birth date to the date of survey administration. The adolescent males were asked to report whether they had ever had sexual intercourse.

Paternal involvement and guidance regarding condom use. Four items, rated on a 5-point Likert-type scale, were used to capture distinct domains of paternal condom involvement and guidance: “My father is willing to provide condoms for me,” “My father has shown me how to use condoms correctly,” “My father has recommended that I use a new condom for each act of sexual intercourse,” and “My father has encouraged me to practice condom use regularly.” Given that the 4 items were significantly correlated, we created a composite measure of paternal condom guidance (ranging from 1-5) by calculating the mean score of the 4 independent items.

Analysis

In quantitative analyses, we explored the 3 factors of interest descriptively using frequency distributions, percentages, means, and variances, as well as bivariate and stratified cross-tabulations. Subsequently, we calculated the Pearson/point biserial correlation coefficients for paternal perceptions of adolescent son’s readiness for sex, adolescent age, and son’s sexual activity (both as perceived by fathers and as reported by the adolescent) to examine the degree to which the factors were associated with or independent from each other. Inferential analyses proceeded in 2 steps. First, we separately estimated bivariate associations of paternal condom guidance with each of the 3 factors of interest: paternal perceptions of adolescent male readiness for sex, adolescent age, and paternal perceptions of adolescent sexual activity. Second, we ran a combined multivariable model with all 3 factors to estimate the degree to which the observed bivariate associations could be accounted for by the other predictors included in the model. For inferential analyses, we used theoretically informed ordinary least squares regression models. We also adjusted the multivariable associations for adolescent race/ethnicity and adolescent and paternal social desirability tendencies. Quadratic and cubic relationships were assessed. The significance level was P = 0.05. SPSS software, version 2835 (IBM Corp) was used for the analysis.

Analysis of qualitative data included deductive coding of the intervention transcripts to contextualize the quantitative findings. Specifically, we elicited fathers’ perceptions regarding factors they consider important for gauging their sons’ developmental readiness to have sex. Qualitative analysis involved systematic textual coding by 3 researchers using a thematic codebook with code and sub-code definitions, inclusion and exclusion criteria, and code-specific narrative examples (intercoder reliability of >90%).36,37 We achieved a high level of coding consistency through deliberation to resolve any disagreement between coders.37 All data were coded using Dedoose (SocioCultural Research Consultants) software, which allows the coder to create a tree of codes that can be used to identify individual and overlapping thematic units in the data.36,37 We used vertical and horizontal analysis techniques to ensure in-depth analytical exploration. Vertical analyses involved examining the range of variation in individual codes across the sample to identify recurring themes. Horizontal analyses involved examining responses within the context of individual transcript narratives to understand how particular factors are related to an individual’s context of meaning and experience. Analysis continued until thematic saturation was achieved.38

RESULTS

There were 213 eligible father-son dyads identified during recruitment. Of these, 191 dyads consented or assented to participate, and 22 declined. Descriptive statistics for the 191 father-son dyads in the sample are presented in Table 1. The average age of the adolescent males was 16.6 years, with 76% identifying as Latino, and 56% reporting having had sex. The average age of the fathers was 44.0 years, with 38% having been born outside the United States, 40% perceiving their adolescent sons as ready to have sex, and 31% believing that their sons had ever had sex.

Table 1.

Sample Characteristics by Paternal Perception of Adolescent Male Readiness for Sex

Quantitative Results

Paternal perceptions of son’s readiness for sex were not significantly correlated with their age (r = 0.12, P = 0.13) and only modestly correlated with paternal perceptions of son’s sexual activity (r = 0.36, P <0.01) (Table 2). Given that adolescent age and paternal perceptions of son’s sexual activity were also only modestly correlated (r = 0.20, P <0.01), the data suggest that the 3 factors represent largely independent influences. To illustrate, more than one-half of the fathers in the study who had sons aged 19 years (the oldest eligible age) believed that their sons were not yet ready to have sex (53%, n = 11). Similarly, of all fathers who believed their sons had already had sex, more than 1 in 3 (37%, n = 22) thought their sons were not ready. These findings indicate that fathers consider factors beyond age and perceived sexual activity in evaluating their sons’ developmental readiness for sex.

Table 2.

Correlations of Paternal Perception of Son’s Readiness for Sex, Adolescent Age, and Paternal Perception of Son’s Sexual Activity

In addition, none of the 3 factors had strong associations with actual adolescent self-reported sexual activity. The correlations with adolescent age (r = 0.21, P <0.01) and with son’s readiness for sex as perceived by fathers (r = 0.25, P <0.01) were weak and the correlation with son’s sexual activity as perceived by fathers was moderate (r = 0.61, P <0.01).

In the bivariate regression analyses, paternal perceptions of son’s readiness for sex, adolescent age, and paternal perceptions of son’s sexual activity were associated with increased paternal provision of guidance for condom use (Table 3). Adolescent males whose fathers believed that their sons were ready for sex reported receiving paternal guidance for condom use that was 0.6 units higher on average than that reported by adolescent males whose fathers did not believe that their sons were ready for sex (95% CI, 0.28-0.89; P <0.01). A 1.0 unit increase in adolescent male age was also associated with increased paternal guidance for condom use; in addition, the estimate only marginally reached statistical significance (unstandardized beta coefficient (B) = 0.12, 95% CI, 0.00-0.24; P = 0.046). Furthermore, adolescent males whose fathers believed that their sons had already had sex reported paternal guidance for condom use that was 0.8 units higher on average than that reported by adolescent males whose fathers believed that their sons had never had sex (95% CI, 0.38-1.15; P <0.01). Adolescent males whose fathers were uncertain about their sons’ previous sexual activity reported paternal guidance for condom use that was 0.2 units higher on average than that of adolescent males whose fathers believed their sons had never had sex (95% CI, −0.19 to 0.54; P = 0.339), but the difference was not statistically significant.

Table 3.

Associations of Paternal Guidance for Condom Use With Paternal Perception of Son’s Readiness for Sex, Adolescent Age, and Paternal Perception of Son’s Sexual Activity

In the adjusted multivariable analyses, paternal perceptions of son’s readiness for sex remained significantly associated with paternal provision of guidance for condom use (ajusted unstandardized beta coeffiecient [aB]) = 0.41; 95% CI, 0.07-0.74; P = 0.018). Adolescent age, however, was no longer significantly associated with paternal condom use guidance (aB = 0.08; 95% CI, −0.04 to 0.20; P = 0.188). Paternal perceptions of son’s previous sexual activity also remained significantly associated with paternal condom use guidance (aB = 0.49; 95% CI, 0.07-0.74; P = 0.024), but adolescent males whose fathers were uncertain about their sons’ previous sexual activities did not report statistically significantly higher levels of paternal condom use guidance relative to adolescent males whose fathers believed that their sons had never had sex (aB = 0.10; 95% CI, −0.28 to 0.48; P = 0.596).

Qualitative Results

The qualitative interviews revealed 3 major themes governing how fathers evaluate adolescent male developmental readiness to have sex: (1) the completion of milestones related to adolescent males’ life opportunity trajectories; (2) cognitive-social-emotional maturity; and (3) preparedness to have sex safely and avoid negative health and social consequences. These themes emerged as salient for Latino and Black fathers of varying ages. We discuss each major theme and associated sub-themes in the subsequent section, along with relevant quotes from the interviewed fathers in Table 4.

Table 4.

Summary of Major Themes in Fathers’ Perceptions of Their Adolescent Sons’ Readiness for Sex

Life Opportunity Trajectory Milestones

Fathers exhibited significant emotional investment in maximizing their sons’ life opportunities and positive long-term social and economic trajectories. And, they frequently saw their son’s sexual activity as a possible barrier to realizing their potential. Fathers viewed sexual activity as a distraction from the pursuit of educational success and believed negative sexual health outcomes could interfere with son’s attainment of important developmental milestones. For example, one father expressed concerns over the disruptive consequences that unplanned parenthood could have for his son: “[Being a teen parent] drives the mother and father away from each other ’cause now you’re struggling financially, you can’t do what you dream to do, can’t go to college.”

Fathers identified 3 milestones related to sons’ life opportunity trajectories as important before initiating sexual activity. First, they emphasized the importance of their sons achieving educational success before starting to have sex to not jeopardize the benefits education can have on long-term life opportunities. Second, they expected their sons to wait to have sex until they were in a committed relationship with a romantic partner; this was regarded as an important milestone in social development. Third, the fathers expected their sons to wait to have unprotected sex until they had achieved financial independence, to avoid the economic burden of unplanned parenthood.

Cognitive-Social-Emotional Maturity

Fathers expressed wanting their sons to achieve maturity in 3 dimensions of cognitive-social-emotional development before starting to have sex. First, fathers asserted that their sons should make informed and carefully deliberated decisions about starting to have sex, rather than impulsive decisions. Fathers believed their sons should have sufficient information regarding the potential benefits and risks of sexual activity. Second, fathers wanted their sons to be mature enough to navigate the emotional elements of a sexual relationship, including the end of a potentially serious romantic relationship. Third, fathers hoped that their sons would wait until they were prepared to adopt the adult responsibilities associated with sex before beginning to have sex. In particular, fathers wanted their sons to “stay a child” for as long as possible to delay the emotional pressures that are part of life as an adult.

Preparedness for Safe Sex to Avoid Negative Consequences

Fathers expressed wanting their sons to wait to have sex until they were adequately prepared to take steps to avoid the potential negative health and social consequences of sex. Specifically, fathers indicated that they wanted their sons to have both a plan for safe sex and the requisite knowledge and skills to execute that plan. Regarding planning for protection, fathers emphasized the importance of their sons having a conversation with their partners about protection before starting to have sex. In addition, they expected their sons to use condoms if having sex and to consider additional birth control options. In terms of the requisite knowledge and skills, fathers wanted their sons to have received information and instruction regarding correct and consistent condom use. In addition, some fathers expressed wanting their sons to be sufficiently independent to acquire condoms for themselves before starting to have sex, while other fathers expressed a willingness to provide condoms to their sons.

DISCUSSION

Engaging families, both fathers and mothers, to promote adolescent sexual health is consistent with a recent National Academies consensus study advocating for family-centered and community-oriented primary care,20 especially for Latino and Black families who disproportionally reside in circumstances associated with greater sexual health inequities. The important role of fathers in promoting adolescent male sexual health, particularly with respect to guidance concerning correct and consistent condom use, has been highlighted by a growing body of research.15,16,18,19,39-41 Previous research has also established the feasibility and acceptability of paternal guidance regarding condom use among their adolescent sons19 and has identified strategies for fathers to overcome barriers to initiating conversations about condoms with their sons.18 The current study contributes to this body of work by examining the factors associated with timing of paternal guidance on condom use, which are important as adolescent males must be prepared to use condoms correctly and consistently before they begin engaging in sexual intercourse.

Our quantitative results suggest that paternal perceptions of their sons’ readiness for sex are an important predictor of when fathers provide guidance for condom use. Data from our sample indicate, however, there are commonly incongruities between paternal perceptions of readiness and actual adolescent male-reported sexual activity. Therefore, discussing paternal notions of adolescent male readiness for sex might be a key element of strategies for family-focused health care clinicians to encourage involvement of fathers in their adolescent sons’ sexual health, particularly for providing guidance about correct and consistent condom use.

Our qualitative findings suggest that fathers’ perception of their sons’ readiness for sex draws on considerations of their sons’ (1) completion of important milestones related to their long-term life opportunity trajectories, (2) cognitive-social-emotional maturity, and (3) preparedness to have sex safely. These insights can inform family health care clinician–initiated interactions with fathers regarding the provision of guidance for condom use to their sons. For example, discussions around adolescent male readiness for sex should remind fathers that providing guidance about correct and consistent condom use is not synonymous with encouraging their sons to have sex and that these conversations, as a protective measure, can and should occur before major developmental milestones and full cognitive-social-emotional maturity are reached. Furthermore, discussions can emphasize the role of fathers in ensuring their sons have the requisite knowledge and skills to engage in safe sex via the following means: (1) encouraging the use of condoms during every sexual encounter, (2) demonstrating correct condom use, (3) providing condoms to their sons, and (4) encouraging their sons to practice using a condom. Table 5 summarizes practical suggestions for family-focused health care clinicians and researchers.

Table 5.

Primary Care Strategies for Encouraging Paternal Provision of Condom Use Guidance

Some limitations warrant consideration when interpreting these results. Eligibility for the study was limited to Latino and Black adolescent males with an involved father that resided in a medically and socially underserved urban community. This should be considered when generalizing the study findings to more heterogeneous populations. Notably, previous research suggests that parents from all sociodemographic backgrounds can benefit from support and strategies to promote their adolescents’ sexual health.42 Furthermore, our quantitative results relied on cross-sectional data, and did not account for religiosity among fathers or sons. No causal attributions should be made on the basis of these data alone. Finally, our analyses relied on participant-reported quantitative and qualitative data, which may reflect social desirability response tendencies and recall bias. We relied on psychometrically sound measurement protocols and data collection procedures, however, that have been used effectively in our previous research with the study population,11,12,18,19,32,34 and we statistically controlled for both adolescents’ and fathers’ social desirability response tendencies in quantitative analyses.

CONCLUSIONS

Programming to encourage fathers to provide guidance regarding correct and consistent condom use to their adolescent sons represents a novel approach to increasing condom use and reducing negative sexual health outcomes among male adolescents. Fathers’ perceptions of their sons’ readiness for sex are an important predictor of paternal provision of condom use guidance and should be addressed in family primary care. This study provides practical suggestions for father-focused communication strategies for family health care clinicians.

Footnotes

Conflicts of interest: V.G-R. reports grants from ViiV Healthcare outside the submitted work. He also serves as a member of the US Presidential Advisory Council on HIV/AIDS; the CDC/HRSA Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment; and on the HHS Panel on Antiretroviral Guidelines for Adults and Adolescents. The other authors report none.

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Funding support: This work was supported by the William T. Grant Foundation, Reducing Inequality Initiative, grant 189030. The funder had no role in the design and conduct of the study.

Received for publication April 18, 2023.Revision received October 30, 2023.Accepted for publication November 22, 2023.© 2024 Annals of Family Medicine, Inc.