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Original article| Volume 24, ISSUE 5, P567-574, September 2014

Association between Sexual Behaviors, Bullying Victimization and Suicidal Ideation in a National Sample of High School Students: Implications of a Sexual Double Standard

DOI:https://doi.org/10.1016/j.whi.2014.06.008
Association between Sexual Behaviors, Bullying Victimization and Suicidal Ideation in a National Sample of High School Students: Implications of a Sexual Double Standard
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      Abstract

      Purpose

      The sexual double standard is the notion that women are more harshly judged for their sexual behaviors than men. The purpose of this study was to investigate if the sexual double standard could explain gender differences in bullying victimization among adolescents and the extent to which that relationship correlated with depression and suicidal ideation.

      Methods

      Analyses were conducted using a sample of high school students (n = 13,065) from the 2011 Youth Risk Behavior Survey, a cross-sectional and national school-based survey conducted by the Centers for Disease Control and Prevention. Data were assessed using multiple logistic regression, gender-stratified analyses, and interaction terms.

      Findings

      Students who engaged in sexual intercourse (sexually active) had higher odds of being bullied. When this association was stratified by gender, odds of being bullying increased for girls (odds ratio [OR], 1.83; 95% CI, 1.58–2.13) and decreased for boys (OR, 0.94; 95% CI, 0.77–1.16). Sexually active students who were bullied also displayed more than five times (OR, 5.65; 95% CI, 4.71–6.78) the adjusted odds of depression and three times (adjusted OR, 3.38; 95% CI, 2.65–4.32) the adjusted odds of suicidal ideation compared with students who reported neither of those behavioral characteristics. When stratified by gender, girls had slightly higher odds of depression and suicidal ideation but overall, the odds remained strong for both genders.

      Conclusions

      Results provide some evidence that a sexual double standard exists and may play a prominent role in bullying victimization among girls. Therefore, addressing the sexual double may be important to consider when tailoring school bullying intervention programs.
      Bullying remains a serious and widespread public health problem in the United States (
      • Hertz M.F.
      • Donato I.
      • Wright J.
      Bullying and suicide: A public health approach.
      Journal of Adolescent Health,. 2013; 53: S1-S3https://doi.org/10.1016/j.jadohealth.2013.05.002
      ,
      • Stuart-Cassel V.
      • Bell A.
      • Springer J.F.
      Analysis of state bullying laws and policies.
      U.S. Department of Education, Washington, DC2011
      ). Since 1999, school shootings and youth suicides linked to chronic bullying have ignited a wave of bullying legislation and research. Consequently, almost all 50 states now have laws directing school districts to adopt bullying policies (
      • Stuart-Cassel V.
      • Bell A.
      • Springer J.F.
      Analysis of state bullying laws and policies.
      U.S. Department of Education, Washington, DC2011
      ), and there have been a number of school-based bullying interventions that have successfully reduced bullying by as much as 28% to 45% in the United States (
      • Olweus D.
      • Limber S.P.
      Bullying in school: Evaluation and dissemination of the Olweus Bullying Prevention Program.
      American Journal of Orthopsychiatry. 2010; 80: 124-134https://doi.org/10.1111/j.1939-0025.2010.01015.x
      ). However, despite the influx of these efforts, the prevalence of bullying remains high, suggesting there is more to be learned about its multifaceted nature.
      In 2011, one in five high school students in the United States reported being bullied on school property in the last 12 months and approximately one in six reported being cyber bullied (
      • Eaton D.K.
      • Kann L.
      • Kinchen S.
      • Shanklin S.
      • Flint K.H.
      • Hawkins J.
      • et al.
      Youth risk behavior surveillance - United States, 2011.
      MMWR Surveillance Summaries. 2012; 61: 1-162
      ). Of particular concern is that these recent findings were higher among girls. According to the 2011 Youth Risk Behavior Surveillance Survey, girls were more likely than boys to be bullied on school property (22% vs. 18.2%) and to be cyber bullied (22.1% vs. 10.8%;
      • Eaton D.K.
      • Kann L.
      • Kinchen S.
      • Shanklin S.
      • Flint K.H.
      • Hawkins J.
      • et al.
      Youth risk behavior surveillance - United States, 2011.
      MMWR Surveillance Summaries. 2012; 61: 1-162
      ). Other forms of bullying have also varied by gender (
      • Espelage
      • De La Rue L.
      School bullying: Its nature and ecology.
      International Journal of Adolescent Medicine and Health. 2012; 24: 3-10https://doi.org/10.1515/ijamh.2012.002
      ,
      • Young J.
      Bullying and victimization: Prevalence and relationship to gender, grade level, ethnicity, self-esteem, and depression.
      Adolescence. 2003; 38: 13
      ). Girls are more likely to experience indirect (e.g., social exclusion) and verbal (e.g., name calling) bullying victimization (
      • Espelage
      • De La Rue L.
      School bullying: Its nature and ecology.
      International Journal of Adolescent Medicine and Health. 2012; 24: 3-10https://doi.org/10.1515/ijamh.2012.002
      ,
      • Young J.
      Bullying and victimization: Prevalence and relationship to gender, grade level, ethnicity, self-esteem, and depression.
      Adolescence. 2003; 38: 13
      ). Although previous studies have successfully identified and described gender differences with respect to bullying victimization, few studies have been able to explain why (the root causes) gender differences exist.
      Bully perpetration has been shown to be largely influenced by peer norms and socialization (
      • Espelage
      • De La Rue L.
      School bullying: Its nature and ecology.
      International Journal of Adolescent Medicine and Health. 2012; 24: 3-10https://doi.org/10.1515/ijamh.2012.002
      ). One commonly known peer/societal norm that may explain why gender differences exist with respect to bullying is the sexual double standard. The belief that women and men should be held to different standards of sexual conduct is widespread in the United States (
      • Kreager D.A.
      • Staff J.
      The sexual double standard and adolescent peer acceptance.
      Social Psychology Quarterly. 2009; 72: 143-164
      ,
      • Marks M.
      • Fraley R.C.
      The sexual double standard: Fact or fiction?.
      Sex Roles. 2005; 52: 175-186https://doi.org/10.1007/s11199-005-1293-5
      ). More specifically, men are socially rewarded whereas women are socially criticized for their sexual behaviors (
      • Crawford M.
      • Popp D.
      Sexual double standards: A review and methodological critique of two decades of research.
      Journal of Sex Research. 2003; 40: 13
      ,
      • Marks M.
      • Fraley R.C.
      The sexual double standard: Fact or fiction?.
      Sex Roles. 2005; 52: 175-186https://doi.org/10.1007/s11199-005-1293-5
      ,
      • Milhausen R.R.
      • Herold E.S.
      Reconceptualizing the sexual double standard.
      Journal of Psychology & Human Sexuality. 2001; 13: 63
      ). Previous research on the existence of the sexual double standard among youth and young adults has yielded mixed results (
      • Crawford M.
      • Popp D.
      Sexual double standards: A review and methodological critique of two decades of research.
      Journal of Sex Research. 2003; 40: 13
      ,
      • Marks M.
      • Fraley R.C.
      The sexual double standard: Fact or fiction?.
      Sex Roles. 2005; 52: 175-186https://doi.org/10.1007/s11199-005-1293-5
      ,
      • Milhausen R.R.
      • Herold E.S.
      Does the sexual double standard still exist? Perceptions of university women.
      Journal of Sex Research. 1999; 36: 361-368
      ,
      • Milhausen R.R.
      • Herold E.S.
      Reconceptualizing the sexual double standard.
      Journal of Psychology & Human Sexuality. 2001; 13: 63
      ). A major limitation of previous studies is that the majority of studies were conducted with college-aged students (
      • Crawford M.
      • Popp D.
      Sexual double standards: A review and methodological critique of two decades of research.
      Journal of Sex Research. 2003; 40: 13
      ). The sexual double standard may be more difficult to detect at the college level because sexual behaviors may not be as harshly judged compared with high school, where sexually active students may be considered more deviant. Findings among the limited studies of adolescents demonstrate some evidence of a sexual double standard among middle and high school students (
      • Kreager D.A.
      • Staff J.
      The sexual double standard and adolescent peer acceptance.
      Social Psychology Quarterly. 2009; 72: 143-164
      ,
      • Lyons H.
      • Giordano P.C.
      • Manning W.D.
      • Longmore M.A.
      Identity, peer relationships, and adolescent girls' sexual behavior: An exploration of the contemporary double standard.
      Journal of Sex Research. 2011; 48: 437-449https://doi.org/10.1080/00224499.2010.506679
      ).
      • Kreager D.A.
      • Staff J.
      The sexual double standard and adolescent peer acceptance.
      Social Psychology Quarterly. 2009; 72: 143-164
      found that an increased number of sexual partners was negatively associated with peer acceptance among girls and positively associated with peer acceptance among boys. Lyons and co-workers (2011) found girls often recognized the sexual double standard on a school or societal level, but did not endorse it among their immediate networks of friends.
      Bullying has been consistently linked to peer acceptance in early and late adolescence (
      • de Bruyn E.H.
      • Cillessen A.H.N.
      • Wissink I.B.
      Associations of peer acceptance and perceived popularity with bullying and victimization in early adolescence.
      Journal of Early Adolescence. 2010; 30: 543-566https://doi.org/10.1177/0272431609340517
      ,
      • Espelage D.
      • Holt M.
      Bullying and victimization during early adolescence: Peer influences and psychosocial correlates.
      Journal of Emotional Abuse. 2001; 2: 123-142
      ,
      • Reijntjes A.
      • Vermande M.
      • Olthof T.
      • Goossens F.A.
      • van de Schoot R.
      • Aleva L.
      • et al.
      Costs and benefits of bullying in the context of the peer group: A three wave longitudinal analysis.
      Journal of Abnormal Child Psychology. 2013; 41: 1217-1229https://doi.org/10.1007/s10802-013-9759-3
      ). Lower levels of peer acceptance have been associated with bullying victimization (
      • de Bruyn E.H.
      • Cillessen A.H.N.
      • Wissink I.B.
      Associations of peer acceptance and perceived popularity with bullying and victimization in early adolescence.
      Journal of Early Adolescence. 2010; 30: 543-566https://doi.org/10.1177/0272431609340517
      ). If the sexual double standard exists among adolescents, girls who demonstrate sexual permissiveness may be more likely to experience bullying victimization than their male counterparts. In other words, girls who fail to conform to “sexual scripts” (social norms dictating appropriate versus inappropriate sexual behaviors), as defined by the sexual double standard, may experience peer rejection manifested in the form of bullying (
      • Sprecher S.
      • McKinney K.
      • Orbuch T.L.
      The effect of current sexual behavior on friendship, dating, and marriage desirability.
      Journal of Sex Research. 1991; 28: 387-408https://doi.org/10.1080/00224499109551615
      ).
      The purpose of this study was to determine whether an association exists between the sexual double standard and bullying victimization in a national sample of high school youth. First, we hypothesized that sexually active girls (engaged in sexual intercourse) would be more likely to be bullied than sexually active boys. Second, we hypothesized that girls who engaged in risky sexual behaviors would be more likely to be bullied than girls who engaged in non-risky sexual behaviors and that an opposite relationship would exist for boys. Finally, because bullying victimization and sexual behaviors have been linked with a number of poor health outcomes, including depression (
      • Espelage D.
      • Holt M.
      Bullying and victimization during early adolescence: Peer influences and psychosocial correlates.
      Journal of Emotional Abuse. 2001; 2: 123-142
      ,
      • Waller M.W.
      • Hallfors D.D.
      • Halpern C.T.
      • Iritani B.J.
      • Ford C.A.
      • Guo G.
      Gender differences in associations between depressive symptoms and patterns of substance use and risky sexual behavior among a nationally representative sample of U.S. adolescents.
      Archives of Women’s Mental Health. 2006; 9: 139-150https://doi.org/10.1007/s00737-006-0121-4
      ,
      • Wang J.
      • Nansel T.R.
      • Iannotti R.J.
      Cyber and traditional bullying: differential association with depression.
      Journal of Adolescent Health. 2011; 48: 415-417https://doi.org/10.1016/j.jadohealth.2010.07.012
      ,
      • Young J.
      Bullying and victimization: Prevalence and relationship to gender, grade level, ethnicity, self-esteem, and depression.
      Adolescence. 2003; 38: 13
      ) and suicidal behaviors (
      • Klomek A.B.
      • Sourander A.
      • Niemela S.
      • Kumpulainen K.
      • Piha J.
      • Tamminen T.
      • et al.
      Childhood bullying behaviors as a risk for suicide attempts and completed suicides: A population-based birth cohort study.
      Journal of the American Academy of Child and Adolescent Psychiatry. 2009; 48: 254-261https://doi.org/10.1097/CHI.0b013e318196b91f
      ), we hypothesized that students who were bullied and who also engaged in sexual intercourse would be more likely to report depression and/or suicidal ideation than students who were neither bullied nor engaged in sexual intercourse. We subsequently hypothesized that this relationship would be stronger among girls.

      Methods

      Setting and Sample

      We analyzed data using the 2011 Youth Risk Behavior Survey (YRBS). The YRBS is a cross-sectional and national school-based survey conducted by the Centers for Disease Control and Prevention and state and local education and health agencies. The survey is publicly available containing, deidentified data that qualified for exemption of institutional review board human subjects approval under 45 CFR 46.101 (b) (4). The YRBS uses a three-stage cluster sample design to produce a nationally representative sample of students in grades 9 through 12 who attend public and private schools (n = 15,425). Students completed a self-administered questionnaire during one class period. Students who were absent the day of testing were given the option to make it up on another day (
      • Brener N.
      • Kann L.
      • Shanklin S.
      • Kinchen S.
      • Eaton D.
      • Hawkins J.
      • Flint K.
      Methodology of the Youth risk behavior surveillance system – 2013. 62. MMWR, 2013: 13
      ). The school response rate was 81%, the student response rate was 87%, and the overall response rate was 71% (
      • Eaton D.K.
      • Kann L.
      • Kinchen S.
      • Shanklin S.
      • Flint K.H.
      • Hawkins J.
      • et al.
      Youth risk behavior surveillance - United States, 2011.
      MMWR Surveillance Summaries. 2012; 61: 1-162
      ).

      Measures

      Bullying victimization

      Students were asked two questions about bullying: “During the past 12 months, have you ever been bullied on school property?” and “During the past 12 months, have you ever been electronically bullied?” Students who answered “yes” to one or both of the questions were classified as having been bullied.

      Sexual intercourse and risky sexual behaviors

      Sexual intercourse was measured using the question, “Have you ever had sexual intercourse?” Regardless of sexual status, all students were subsequently asked six additional questions about risky sexual behaviors: “How old were you when you had sexual intercourse for the first time?” (first time ever had sex); “During your life, with how many people have you had sexual intercourse?” (lifetime sexual partners); “During the last 3 months, with how many people did you have sexual intercourse?” (past 3 month sexual partners); “Did you drink alcohol or use drugs before you had sexual intercourse the last time?” (drug/alcohol use before sexual intercourse); “The last time you had sexual intercourse, did you or your partner use a condom? (condom use); and “The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy? (contraceptive use). Categories for each variable were created based on frequency distributions. If students responded “no” to “ever having sexual intercourse,” they had the option to mark, “I have never had sexual intercourse” for all subsequent questions.

      Depression and suicidal ideation

      Depression was measured using the question, “During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?” Suicidal ideation was measured with the question, “During the last 6 months, did you ever seriously consider attempting suicide?”

      Demographic and other descriptive variables

      A final set of measures captured students' demographic characteristics and health behaviors. We included gender, grade level, race/ethnicity, weight status, and alcohol use. Students' age was excluded from analyses because it was highly correlated with grade level (r = 0.855). Race and ethnicity were measured using a computed variable that combined the two questions. Weight status was also measured by combining two YRBS computed variables: Overweight (at or above the 85th percentile but below the 95th percentile for body mass index by age and sex) and obese (at or above the 95th percentile for body mass index by age and sex). Alcohol use was based on the number of drinks consumed in a row on one or more of the past 30 days and was coded as “less than five drinks” or “five or more drinks.”

      Statistical Analyses

      We used STATA Version 11 to conduct all statistical, complete case analyses. Given the complex sampling design, weighting was applied accordingly (
      • Centers for Disease Control and Prevention
      2011 YRBS data user's guide.
      Centers for Disease Control and Prevention, Atlanta2011
      ). To test our first hypothesis, the relationship between sexual intercourse status and bullying victimization was examined using descriptive statistics and multivariable logistic regression analysis, controlling for demographic and behavioral characteristics of high school students, first for the full sample and then stratified by gender. The analytic sample for these analyses (n = 13,065) only included students who gave valid responses for the two questions related to bullying victimization and to the question related to sexual intercourse. Missing data for bullying victimization and sexual intercourse was 10% and 7%, respectively. We created two separate adjusted models. The first adjusted model only included sexual intercourse and demographic characteristics. The second adjusted model also included weight status and alcohol consumption, which have both been associated with bullying victimization in previous literature (
      • Litwiller B.J.
      • Brausch A.M.
      Cyber bullying and physical bullying in adolescent suicide: The role of violent behavior and substance use.
      Journal of Youth and Adolescence. 2013; 42: 675-684https://doi.org/10.1007/s10964-013-9925-5
      ,
      • Puhl R.M.
      • Peterson J.L.
      • Luedicke J.
      Weight-based victimization: Bullying experiences of weight loss treatment-seeking youth.
      Pediatrics. 2013; 131: e1-e9https://doi.org/10.1542/peds.2012-1106
      ). Differences between the two models were minimal; however, the second model containing all descriptive variables appeared to be a slightly better fit and was stratified by gender (6,644 girls and 6,376 boys).
      Next, we compared bullying victimization among sexually active girls with sexually active boys using an interaction term. Sexually active boys were chosen as the reference group because we hypothesized their odds of bullying victimization would be lowest. We also tested for the relative excess risk (RERI) due to interaction, attributable proportion, and synergy on the additive scale (
      • Andersson T.
      • Alfredsson L.
      • Kallberg H.
      • Zdravkovic S.
      • Ahlbom A.
      Calculating measures of biological interaction.
      European Journal of Epidemiology. 2005; 20: 575-579
      ). For our second hypothesis, the association between risky sexual behaviors and bullying victimization was tested in the subpopulation of sexually active students (n = 6,537). Separate adjusted models were run for each of the six risky sexual behaviors.
      Last, we examined the association between sexual intercourse and bullying victimization on depression and suicidal ideation. The model for depression adjusted for sexual intercourse, bullying victimization, demographic characteristics, weight status, and alcohol consumption (n = 4,215). The same covariates were retained in the model for suicidal ideation; however, we also included depression, a risk factor for suicidal ideation (n = 2,251;
      • Klomek A.B.
      • Sourander A.
      • Niemela S.
      • Kumpulainen K.
      • Piha J.
      • Tamminen T.
      • et al.
      Childhood bullying behaviors as a risk for suicide attempts and completed suicides: A population-based birth cohort study.
      Journal of the American Academy of Child and Adolescent Psychiatry. 2009; 48: 254-261https://doi.org/10.1097/CHI.0b013e318196b91f
      ). Each model was then stratified by gender. We subsequently ran separate models for depression and suicidal ideation using an interaction term to test the joint effect of sexual intercourse and bullying victimization on each of the outcomes. Again, results were stratified by gender.

      Results

      Table 1 describes our study sample. Slightly more than 50% of U.S. high school students reported that they had engaged in sexual intercourse. Bullying victimization was reported in 28% of high school students who had engaged in sexual intercourse compared with 25% of those who had not. Among those who engaged in sexual intercourse, 47% were girls.
      Table 1Bullying, Demographic and Behavioral Characteristics of High School Students by Sexual Intercourse Status
      CharacteristicsNo Sexual Intercourse (n = 6,500)Sexual Intercourse (n = 6,565)p Value
      n%n%
      Victim of bullying<.01
       No4,98174.584,86871.55
       Yes1,51925.421,69728.45
      Gender<.001
       Male2,97849.363,39853.05
       Female3,50550.643,13946.95
      Grade<.001
       12th1,09616.032,05530.69
       11th1,59921.701,91119.11
       10th1,66326.981,43814.38
       9th2,10335.281,11118.90
      Race/ethnicity<.001
       Black, non-Hispanic8209.861,35916.76
       White, non-Hispanic3,03162.752,51054.97
       Hispanic/Latino9028.488838.61
       Hispanic/Latino multiple
      Includes Hispanic/Latino persons of multiple races.
      		9509.911,06110.96
       Other
      Includes non-Hispanic/Latino persons of other races or multiples races, American Indian/Alaskan Native, Asian, Native Hawaiian or other Pacific Islander.
      		6779.006328.70
      Weight.4394
       Not overweight/obese4,24571.274,35772.85
       Overweight96215.5094414.49
       Obese83613.2382312.66
      Alcohol use in the past 30 days<.001
       <5 drinks5,82590.554,16663.30
       ≥5 drinks6209.452,21036.70
      ∗ Includes Hispanic/Latino persons of multiple races.
      † Includes non-Hispanic/Latino persons of other races or multiples races, American Indian/Alaskan Native, Asian, Native Hawaiian or other Pacific Islander.
      Table 2 compares the crude and adjusted odds of being bullied by sexual intercourse status among all high school students and stratified by gender. After controlling for confounders, students who engaged in sexual intercourse were more likely to be bullied (adjusted odds ratio [aOR], 1.34; 95% CI, 1.15–1.56) compared with students who did not engage in sexual intercourse. When students who engaged in sexual intercourse were stratified by gender, the odds of being bullied increased for girls (aOR, 1.83; 95% CI, 1.58–2.13) and decreased for boys (aOR, 0.94; 95% CI, 0.77–1.16).
      Table 2Crude and Adjusted Odds of Being Bullied among High School Students by Sexual Intercourse Status
      CharacteristicAll Respondents (n = 13,065)
      Larger than the sum of the stratified samples (girls and boys) owing to missing values for gender.
      		Girls (n = 6,644)Boys (n = 6,376)
      ORaORORaORORaOR
      Sexual intercourse
       No1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)
       Yes1.67 (1.04–1.31)1.34 (1.15–1.56)1.54 (1.37–1.73)1.83 (1.58–2.13)0.86 (0.72–1.06)0.94 (0.77–1.16)
      Gender
       Male1.00 (ref)1.00 (ref)
       Female1.54 (1.40–1.70)1.63 (1.45–1.83)
      Grade
       12th1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)
       11th1.14 (0.92–1.39)1.23 (0.99–1.52)0.97 (0.78–1.22)1.08 (0.86–1.36)1.37 (1.04–1.80)1.45 (1.08–1.95)
       10th1.41 (1.20–1.65)1.63 (1.39–1.91)1.33 (1.09–1.62)1.61 (1.32–1.95)1.54 (1.19–1.97)1.69 (1.30–2.19)
       9th1.48 (1.27–1.73)1.83 (1.55–2.16)1.46 (1.20–1.77)2.09 (1.69–2.58)1.53 (1.24–1.89)1.67 (1.32–2.12)
      Race/ethnicity
       Black, non-Hispanic1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)
       White, non-Hispanic2.29 (1.90–2.76)2.48 (2.03–3.03)2.44 (1.97–3.03)2.59 (2.07–3.26)2.20 (1.68–2.87)2.30 (1.71–3.10)
       Hispanic/Latino1.45 (1.07–1.94)1.53 (1.11–2.10)1.60 (1.18–2.18)1.67 (1.20–2.32)1.33 (0.93–1.91)1.40 (0.93–2.09)
       Hispanic/Latino Multiple
      Includes Hispanic/Latino persons of multiple races.
      		1.81 (1.45–2.25)1.79 (1.41–2.27)1.80 (1.44–2.25)1.76 (1.38–2.25)1.84 (1.31–2.57)1.81 (1.26–2.60)
       Other
      Includes non-Hispanic/Latino persons of other races or multiples races, American Indian/Alaskan Native, Asian, Native Hawaiian or other Pacific Islander.
      		2.16 (1.67–2.79)2.25 (1.71–2.97)2.40 (1.83–3.15)2.54 (1.87–3.44)1.96 (1.35–2.85)1.93 (1.28–2.90)
      Weight
       Not overweight/obese1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)
       Overweight1.02 (0.90–1.16)1.06 (0.91–1.24)1.11 (0.92–1.34)1.20 (0.97–1.49)0.94 (0.81–1.10)0.92 (0.77–1.09)
       Obese0.95 (0.80–1.13)1.07 (0.91–1.27)1.00 (0.78–1.30)1.13 (0.88–1.45)1.02 (0.82–1.25)1.00 (0.81–1.23)
      Alcohol use in past 30 days
       <5 drinks1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)
       ≥5 drinks1.27 (1.12–1.46)1.21 (1.07–1.37)1.55 (1.27–1.90)1.31 (1.06–1.61)1.11 (0.91–1.35)1.14 (0.96–1.36)
      Abbreviations: aOR, adjusted odds ratio; OR, odds ratio.
      ∗ Includes Hispanic/Latino persons of multiple races.
      † Includes non-Hispanic/Latino persons of other races or multiples races, American Indian/Alaskan Native, Asian, Native Hawaiian or other Pacific Islander.
      ‡ Larger than the sum of the stratified samples (girls and boys) owing to missing values for gender.
      Table 3 describes the interaction between sexual intercourse status and gender on bullying victimization. After adjusting for confounders, girls who engaged in sexual intercourse were more likely to be bullied (aOR, 2.27; 95% CI, 1.99–2.58) than boys who engaged in sexual intercourse. There was relative excess risk due to interaction that was greater than zero (0.95; 95% CI, 0.61–1.29), which suggests that engaging in sexual intercourse was a greater risk factor for bullying victimization among girls than boys. These results imply a synergistic association as defined in the sufficient component cause model (
      • Knol M.J.
      • VanderWeele T.J.
      Recommendations for presenting analyses of effect modification and interaction.
      International Journal of Epidemiology. 2012; 41: 514-520https://doi.org/10.1093/ije/dyr218
      ). Bullying victimization is most likely to occur when both risk factors (being female and engaging in sexual intercourse) are present, but not when only one or the other is present.
      Table 3Interaction between Sexual Intercourse and Gender on Bullying Victimization
      Sexual IntercourseNo Sexual IntercourseORs (95% CI) for Being Bullied Within Strata of Gender
      N Bullied/Not BulliedaOR
      aOR indicates odds adjusted for grade, race/ethnicity, weight, alcohol consumption.
      (95% CI)      		N Bullied/Not BulliedaOR
      aOR indicates odds adjusted for grade, race/ethnicity, weight, alcohol consumption.
      (95% CI)
      Boys672/2,7261.00 (ref)644/2,3341.05 (0.84–1.31)1.05 (0.85–1.31)
       p.652.640
      Girls1,018/2,1212.27 (1.99–2.58)872/2,6331.27 (1.09–1.47)1.62 (1.45–1.81)
       p≤.001≤.01≤.001
      ORs (95% CI) for being bullied within strata of sexual intercourse1.33 (1.15–1.53)1.27 (1.09–1.47)
       p<.001<.01
      Abbreviations: aOR, adjusted odds ratio; OR, odds ratio.
      Measure of interaction on the additive scale: Relative excess risk (RERI) due to interaction = 0.95 (0.61–1.29); attributable proportion = 0.42 (0.28–0.56); synergy = 4.00 (1.35–11.85).
      ∗ aOR indicates odds adjusted for grade, race/ethnicity, weight, alcohol consumption.
      Table 4 presents the gender-stratified adjusted odds of being bullied among sexually active students who engaged in risky sexual behaviors. Overall, girls who engaged in risky sexual behaviors were more likely to be bullied than girls who did not engage in risky sexual behaviors. More specifically, girls who started engaging in sexual intercourse at a younger age (14 years old) were more likely to be bullied (aOR, 1.71; 95% CI, 1.21–2.43) than girls who began engaging in sexual intercourse at older ages (≥17 years old). Girls were also more likely to be bullied if they had a greater number of sexual partners during their lifetime (aOR, 1.97; 95% CI, 1.46–2.65), and did not use condoms (aOR, 1.31; 95% CI, 1.10–1.56) or contraceptives (aOR, 1.59; 95% CI, 1.25–2.01). Boys who engaged in risky sexual behaviors also displayed higher odds of being bullied, but only with respect to having a high number of sexual partners in the last 3 months (aOR, 2.12; 95% CI, 1.37–3.30) and not using condoms and contraceptives (aOR, 1.68; 95% CI, 1.19–2.38).
      Table 4Adjusted Odds of Being Bullied among High School Students Who Engage in Risky Sexual Behaviors
      Girls (n = 3,139)
      Odds adjusted for grade, race/ethnicity, weight, alcohol consumption.
      		Boys (n = 3,398)
      Odds adjusted for grade, race/ethnicity, weight, alcohol consumption.
      Age (y) at first sexual intercourse
       ≥171.00 (ref)1.00 (ref)
       161.37 (0.95–1.99)0.94 (0.57–1.56)
       151.68 (1.12–2.53)0.76 (0.41–1.41)
       141.56 (1.09–2.25)0.92 (0.51–1.66)
       <141.71 (1.21–2.43)0.80 (0.43–1.49)
      No. of partners in lifetime
       11.00 (ref)1.00 (ref)
       21.34 (1.01–1.78)0.84 (0.62–1.14)
       3–51.28 (1.00–1.64)0.76 (0.58–0.99)
       ≥61.97 (1.46–2.65)0.86 (0.65–1.15)
      No. partners in last 3 months
       11.00 (ref)1.00 (ref)
       2–51.38 (0.99–1.92)1.08 (0.81–1.42)
       ≥62.61 (0.81–8.41)2.12 (1.37–3.30)
      Used drugs/alcohol before intercourse
       No1.00 (ref)1.00 (ref)
       Yes1.03 (0.77–1.39)0.97 (0.74–1.28)
      Used condom before intercourse
       Yes1.00 (ref)1.00 (ref)
       No1.31 (1.10–1.56)1.56 (1.25–1.95)
      Used contraception
       Yes1.00 (ref)1.00 (ref)
       No1.59 (1.25–2.01)1.68 (1.19–2.38)
      Reference group: Students who engaged in sexual intercourse but did not engage in risky sexual behaviors.
      ∗ Odds adjusted for grade, race/ethnicity, weight, alcohol consumption.
      As shown in Table 5, students who were bullied and who also engaged in sexual intercourse (n = 1,697) had more than five times (aOR, 5.65; 95% CI, 4.71–6.78) the adjusted odds of depression and three times (aOR, 3.38; 95% CI, 2.65–4.32) the adjusted odds of suicidal ideation compared with students who reported neither of those exposures. After stratifying by gender, girls who were bullied and also engaged in sexual intercourse (n = 1,018) displayed slightly higher odds of depression (aOR, 6.14; 95% CI, 4.82–7.83) and suicidal ideation (3.56; 95% CI, 2.66–4.77) than boys (aOR, 5.22 [95% CI, 3.94–6.91] and aOR, 3.20 [95% CI, 2.20–4.66], respectively). However, the joint effect of bullying and sexual intercourse on depression and suicidal ideation was strong for both genders.
      Table 5Adjusted Odds of Depression and Suicidal Ideation among High School Students Who Engage in Sexual Intercourse, Are Targets of Bullying, or Both (Sexually Active and Bullied)
      CharacteristicDepressionSuicidal Ideation
      All aOR
      aOR indicates odds adjusted for sex, grade, race/ethnicity, weight, and alcohol consumption.
      (n = 4,215)
      Larger than the sum of the stratified samples (girls and boys) owing to missing values for gender.
      		Girls aOR
      aOR indicates odds adjusted for grade, race/ethnicity, weight, and alcohol consumption.
      (n = 2,656)      		Boys aOR
      aOR indicates odds adjusted for grade, race/ethnicity, weight, and alcohol consumption.
      (n = 1,545)      		All aOR
      aOR indicates odds adjusted for sex, grade, race/ethnicity, weight, alcohol consumption, and depression status.
      (n = 2,251)
      Larger than the sum of the stratified samples (girls and boys) owing to missing values for gender.
      		Girls aOR
      aOR indicates odds adjusted for grade, race/ethnicity, weight, alcohol consumption, and depression status.
      (n = 1,395)      		Boys aOR
      aOR indicates odds adjusted for grade, race/ethnicity, weight, alcohol consumption, and depression status.
      (n = 848)
      Step 1
       Sexual intercourse
      No1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)
      Yes1.76 (1.57–1.97)1.93 (1.66–2.24)1.61 (1.33–1.97)1.49 (1.21–1.83)1.50 (1.20–1.87)1.49 (1.11–2.02)
       Victim of bullying
      No1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)
      Yes3.27 (2.88–3.70)3.32 (2.75–4.02)3.15 (2.61–3.81)2.27 (1.95–2.66)2.38 (1.93–2.94)2.15 (1.67–2.76)
      Step 2
       Sexual intercourse
      Larger than the sum of the stratified samples (girls and boys) owing to missing values for gender.
      bullying
      No intercourse–not bullied1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)1.00 (ref)
      Intercourse–bullied5.65 (4.71–6.78)6.14 (4.82–7.83)5.22 (3.94–6.91)3.38 (2.65–4.32)3.56 (2.66–4.77)3.20 (2.20–4.66)
      Abbreviation: aOR, adjusted odds ratio.
      ∗ Larger than the sum of the stratified samples (girls and boys) owing to missing values for gender.
      † aOR indicates odds adjusted for sex, grade, race/ethnicity, weight, and alcohol consumption.
      ‡ aOR indicates odds adjusted for grade, race/ethnicity, weight, and alcohol consumption.
      § aOR indicates odds adjusted for sex, grade, race/ethnicity, weight, alcohol consumption, and depression status.
      ‖ aOR indicates odds adjusted for grade, race/ethnicity, weight, alcohol consumption, and depression status.

      Discussion

      To our knowledge, this is the first study to examine the association between the sexual double standard and bullying victimization in a national sample of high school students. Our results demonstrate an association between sexual intercourse and bullying victimization with a more pronounced association for girls. These findings provide some evidence that girls are held to different sexual standards than boys. Previous studies have examined associations between sexual behaviors and bullying victimization but have yielded somewhat mixed results, which may be owing to small sample sizes and retrospective study designs (
      • Gallup A.C.
      • O’Brien D.T.
      • White D.D.
      • Wilson D.S.
      Peer victimization in adolescence has different effects on the sexual behavior of male and female college students.
      Personality & Individual Differences. 2009; 46: 611-615https://doi.org/10.1016/j.paid.2008.12.018
      ,
      • White D.D.
      • Gallup A.C.
      • Gallup G.G.
      Indirect peer aggression in adolescence and reproductive behavior.
      Evolutionary Psychology. 2010; 8: 49-65
      ).
      Prior research has also found that peer attitudes and norms play an influential role in adolescent sexual behavior (
      • Kinsman S.B.
      • Romer D.
      Early sexual initiation: The role of peer norms.
      Pediatrics. 1998; 102: 1185
      ,
      • Potard C.
      • Courtois R.
      • Rusch E.
      The influence of peers on risky sexual behaviour during adolescence.
      European Journal of Contraception and Reproductive Health Care. 2008; 13: 264-270https://doi.org/10.1080/13625180802273530
      ,
      • Prinstein M.J.
      • Meade C.S.
      • Cohen G.L.
      Adolescent oral sex, peer popularity, and perceptions of best friends' sexual behavior.
      Journal of Pediatric Psychology. 2003; 28: 243-249
      ), and that these beliefs differ by gender (
      • Kinsman S.B.
      • Romer D.
      Early sexual initiation: The role of peer norms.
      Pediatrics. 1998; 102: 1185
      ,
      • Potard C.
      • Courtois R.
      • Rusch E.
      The influence of peers on risky sexual behaviour during adolescence.
      European Journal of Contraception and Reproductive Health Care. 2008; 13: 264-270https://doi.org/10.1080/13625180802273530
      ). Adolescents are more likely to engage in sexual behaviors if they think their friends are sexually active (
      • Potard C.
      • Courtois R.
      • Rusch E.
      The influence of peers on risky sexual behaviour during adolescence.
      European Journal of Contraception and Reproductive Health Care. 2008; 13: 264-270https://doi.org/10.1080/13625180802273530
      ,
      • Prinstein M.J.
      • Meade C.S.
      • Cohen G.L.
      Adolescent oral sex, peer popularity, and perceptions of best friends' sexual behavior.
      Journal of Pediatric Psychology. 2003; 28: 243-249
      ), but less likely to engage in sexual behaviors if they think they might be stigmatized (
      • Kinsman S.B.
      • Romer D.
      Early sexual initiation: The role of peer norms.
      Pediatrics. 1998; 102: 1185
      ). Sexually experienced boys are more often perceived as gaining peer respect for their sexual encounters than sexually experienced girls (
      • Kinsman S.B.
      • Romer D.
      Early sexual initiation: The role of peer norms.
      Pediatrics. 1998; 102: 1185
      ). Boys are also more likely to believe that their peers endorse one-night stands (
      • Potard C.
      • Courtois R.
      • Rusch E.
      The influence of peers on risky sexual behaviour during adolescence.
      European Journal of Contraception and Reproductive Health Care. 2008; 13: 264-270https://doi.org/10.1080/13625180802273530
      ). Therefore, boys may pressure girls to engage in sexual behaviors as a means to increase their social status.
      Our results also add to existing literature on the relationship between risky sexual behaviors and bullying victimization (
      • Litwiller B.J.
      • Brausch A.M.
      Cyber bullying and physical bullying in adolescent suicide: The role of violent behavior and substance use.
      Journal of Youth and Adolescence. 2013; 42: 675-684https://doi.org/10.1007/s10964-013-9925-5
      ). A cross-sectional study by
      • Litwiller B.J.
      • Brausch A.M.
      Cyber bullying and physical bullying in adolescent suicide: The role of violent behavior and substance use.
      Journal of Youth and Adolescence. 2013; 42: 675-684https://doi.org/10.1007/s10964-013-9925-5
      found bullying victimization among high school students was associated with multiple risky sexual behaviors, including unprotected sex and number of sexual partners. Whether these behaviors varied with respect to gender was not explored. Consistent with Litwiller and Brausch, our results demonstrate a positive association between risky sexual behaviors and bullying victimization; however, we found that gender modified these associations. A greater number of risky sexual behaviors were associated with bullying victimization among girls. More specifically, engaging in sexual intercourse at a younger age and reporting a greater number of lifetime sexual partners increased the odds of bullying victimization among girls but not boys. Girls who begin having sexual intercourse at a younger age or who report more lifetime sexual partners may have a reputation of being promiscuous, consequently making them targets for bullying. Conversely, boys with many recent sexual partners may have a more positive reputation of being “sexually experienced” (
      • Kinsman S.B.
      • Romer D.
      Early sexual initiation: The role of peer norms.
      Pediatrics. 1998; 102: 1185
      ) and thus are safeguarded from bullying.
      Gender differences with respect to sexual behaviors and bullying victimization may also be explained by evolutionary theory, which posits that peer aggression occurs out of intrasexual competition for attention from the opposite sex (
      • Arnocky S.
      • Vaillancourt T.
      A multi-informant longitudinal study on the relationship between aggression, peer victimization, and dating status in adolescence.
      Evolutionary Psychology. 2012; 10: 253-270
      ,
      • Gallup A.C.
      • O'Brien D.T.
      • Wilson D.S.
      Intrasexual peer aggression and dating behavior during adolescence: An evolutionary perspective.
      Aggressive Behavior. 2011; 37: 258-267https://doi.org/10.1002/ab.20384
      ,
      • Gallup A.C.
      • O’Brien D.T.
      • White D.D.
      • Wilson D.S.
      Peer victimization in adolescence has different effects on the sexual behavior of male and female college students.
      Personality & Individual Differences. 2009; 46: 611-615https://doi.org/10.1016/j.paid.2008.12.018
      ). White and associates (2010) found that 73% of girls victimized by peers were victimized by other girls in an attempt to diminish the reputation and appeal of victimized girls (calling a girl a slut or a whore). Victims reported having more total dating partners and shorter relationships than nonvictims. On the other hand, girls who were involved in physical aggression and victimization of other girls often engaged in sexual activity that could be considered promiscuous. The findings by White and colleagues (2010) provide evidence that girls use aggressive behaviors (i.e., nonphysical or indirect) with explicit sexualized innuendoes toward other girls to diminish dating opportunities for victims and increase dating opportunities for bullies, whether or not the victim and bully are sexually active. These findings highlight the complex nature of the sexual double standard.
      We also found that some risky sexual behaviors associated with bullying victimization did not differ by gender. Girls and boys who failed to use condoms or contraceptives were both more likely to report bullying victimization. Engaging in sexual behaviors may be associated with greater levels of popularity, but not if the behaviors are considered risky or dangerous to one's health (
      • Prinstein M.J.
      • Meade C.S.
      • Cohen G.L.
      Adolescent oral sex, peer popularity, and perceptions of best friends' sexual behavior.
      Journal of Pediatric Psychology. 2003; 28: 243-249
      ). We found that 64% of sexually active high school students reported using a condom during last sexual intercourse. Condom and contraceptive use has increased among U.S. adolescents since the 1990s to prevent pregnancies and sexually transmitted diseases (
      • Abma J.C.
      • Martinez G.M.
      • Copen C.E.
      Teenagers in the United States: sexual activity, contraceptive use, and childbearing, national survey of family growth 2006-2008.
      Vital Health Statistics. 2010; 23: 1-47
      ). A growing number of adolescents may believe condoms are effective in preventing sexually transmitted diseases and pregnancies (Committee on
      • Committee on Adolescence
      Condom use by adolescents.
      Pediatrics. 2001; 107: 1463-1469https://doi.org/10.1542/peds.107.6.1463
      ) so that a lack of condom and/or contraceptive use may be viewed as particularly risky or dangerous to one's health. Therefore, the sexual double standard may not play a significant role in defining gender expectations for sexual conduct during adolescence when it comes to practicing safe sex.
      Consistent with previous studies (
      • Klomek A.B.
      • Sourander A.
      • Niemela S.
      • Kumpulainen K.
      • Piha J.
      • Tamminen T.
      • et al.
      Childhood bullying behaviors as a risk for suicide attempts and completed suicides: A population-based birth cohort study.
      Journal of the American Academy of Child and Adolescent Psychiatry. 2009; 48: 254-261https://doi.org/10.1097/CHI.0b013e318196b91f
      ,
      • Wade T.J.
      • Cairney J.
      • Pevalin D.J.
      Emergence of gender differences in depression during adolescence: National panel results from three countries.
      Journal of the American Academy of Child & Adolescent Psychiatry. 2002; 41: 190-198https://doi.org/10.1097/00004583-200202000-00013
      ), our results also demonstrate that the joint effect of engaging in sexual intercourse and being bullied on depression and suicidal ideation was significant for both genders, but the effect was slightly stronger for girls. These findings may explain why girls currently account for almost 60% of bullying-related suicides among youth (

      LeBlanc, J. C. (2012). Cyberbullying and suicide: A retrospective analysis of 41 cases. Paper presented at the American Academy of Pediatrics (AAP) National Conference & Exhibition. Available at: https://aap.confex.com/aap/2012/webprogram/Paper18782.html

      ). Future research should explore gender differences in how sexual activity among adolescents relates to different forms of bullying (i.e. physical, relational, indirect) and how those interactions may elicit depression and/or suicidality (
      • Espelage D.
      • Holt M.
      Suicidal ideation and school bullying experiences after controlling for depression and delinquency.
      Journal of Adolescent Health. 2013; 53: S27-S31https://doi.org/10.1016/j.jadohealth.2012.09.017
      ).
      Although our results demonstrated that engaging in sexual intercourse did not increase odds of bullying victimization among boys, it is possible this association may have only been true for socially dominant and popular heterosexual boys (
      • de Bruyn E.H.
      • Cillessen A.H.
      • Weisfeld G.E.
      Dominance-popularity status, behavior, and the emergence of sexual activity in young adolescents.
      Evolutionary Psychology. 2012; 10: 296-319
      ). Boys who are less socially dominate or who identify as homosexual or bisexual and engage in sexual intercourse may be at a particular risk for bullying victimization and subsequent depression and suicidal ideation. We were unable to test this hypothesis with our data, but past work has indicated that non-heterosexually identified youths are particularly susceptible to bullying victimization compared with heterosexually identified youths (
      • Schneider S.K.
      • O'Donnell L.
      • Stueve A.
      • Coulter R.W.
      Cyberbullying, school bullying, and psychological distress: A regional census of high school students.
      American Journal of Public Health. 2012; 102: 171-177https://doi.org/10.2105/ajph.2011.300308
      ).

      Limitations

      Although we found evidence of the sexual double standard with respect to bullying victimization, several limitations of the study deserve mention. This study is based on a cross-sectional design and causality cannot be inferred. A second limitation is our use of engaging in sexual intercourse as a measure of the sexual double standard. Because this question is based on self-report, the true prevalence of sexual intercourse may be underreported. This study also assumes that peers know about each other's sexual activity status when, in reality, some students, and particularly girls, may be reluctant to share this type of information for fear of damaging their reputation. However, if sexual behaviors have the potential to enhance boys' social status, boys may be more likely to share this information contributing to peer knowledge. A third limitation is our inability to control for sexual orientation, which may have altered our results. Homosexuality may be perceived as nonadherence to sexual scripts, putting sexual minority youth at increased risk for being bullied (
      • Berlan E.D.
      • Corliss H.L.
      • Field A.E.
      • Goodman E.
      • Bryn Austin S.
      Sexual orientation and bullying among adolescents in the growing up today study.
      Journal of Adolescent Health. 2010; 46: 366-371https://doi.org/10.1016/j.jadohealth.2009.10.015
      ).

      Implications for Practice and/or Policy

      In 2013, the Centers for Disease Control and Prevention identified a need for more research examining the intersection between bulling and sexual violence (“

      Connection between bullying and sexual violence perpetration. (2013) Available at: http://www.cdc.gov/violenceprevention/youthviolence/bullying_sv.html. Accessed March 8, 2013.

      ). This study provides an important step in understanding the association between sexual behaviors and bullying victimization among U.S. adolescents in the context of prescribed gender norms and has important implications for future interventions and research. Although past research has considered sexual harassment separate from bullying (
      • Charmaraman L.
      • Jones A.E.
      • Stein N.
      • Espelage D.L.
      Is it bullying or sexual harassment? Knowledge, attitudes, and professional development experiences of middle school staff.
      Journal of School Health. 2013; 83: 438-444https://doi.org/10.1111/josh.12048
      ,
      • Meyer E.J.
      Gender, bullying, and harassment: Strategies to end sexism and homophobia in schools.
      Teachers College Press, New York2009: 2510
      ,
      • Stuart-Cassel V.
      • Bell A.
      • Springer J.F.
      Analysis of state bullying laws and policies.
      U.S. Department of Education, Washington, DC2011
      ), more recent work has found significant overlap in behaviors often making it difficult for individuals to distinguish between the two forms of violence (
      • Charmaraman L.
      • Jones A.E.
      • Stein N.
      • Espelage D.L.
      Is it bullying or sexual harassment? Knowledge, attitudes, and professional development experiences of middle school staff.
      Journal of School Health. 2013; 83: 438-444https://doi.org/10.1111/josh.12048
      ). In a qualitative analysis of middle school teachers, differentiating bullying from sexual harassment was described as a “gray area” (
      • Charmaraman L.
      • Jones A.E.
      • Stein N.
      • Espelage D.L.
      Is it bullying or sexual harassment? Knowledge, attitudes, and professional development experiences of middle school staff.
      Journal of School Health. 2013; 83: 438-444https://doi.org/10.1111/josh.12048
      ). If teachers are having difficulty recognizing these differences, we posit that these ambiguities are likely to occur among students. Some forms of sexual harassment, such as name calling, may be classified as bullying. School-based bullying interventions should improve and expand teacher and student knowledge of bullying and sexual harassment, and the interrelationship between the two. Doing so can help to improve the enforcement of legal sanctions that have been more effective in responding to sexual harassment because it is characterized as a violation of civil rights as opposed to bullying, which is more broadly defined (
      • Stuart-Cassel V.
      • Bell A.
      • Springer J.F.
      Analysis of state bullying laws and policies.
      U.S. Department of Education, Washington, DC2011
      ).
      Furthermore, our study identifies sexually active girls as a specific student population that should be carefully considered when tailoring school-based bullying interventions. Girls may be particularly susceptible to sexual peer pressure and the negative reputational consequences that may follow. Therefore, school-based bullying interventions should address peer norms regarding sexual behaviors, attitudes toward the sexual double standard and more broadly, attitudes and norms regarding traditional gender roles held in U.S. culture (
      • Charmaraman L.
      • Jones A.E.
      • Stein N.
      • Espelage D.L.
      Is it bullying or sexual harassment? Knowledge, attitudes, and professional development experiences of middle school staff.
      Journal of School Health. 2013; 83: 438-444https://doi.org/10.1111/josh.12048
      ,
      • Poteat P.
      • DiGiovanni C.
      • Scheer J.
      Predicting homophobic behavior among heterosexual youth: Domain general and sexual orientation-specific factors at the individual and contextual level.
      Journal of Youth & Adolescence. 2013; 42: 351-362https://doi.org/10.1007/s10964-012-9813-4
      ). Previous research has consistently found students to be highly influenced by their peers with respect to bullying perpetration (
      • de Bruyn E.H.
      • Cillessen A.H.N.
      • Wissink I.B.
      Associations of peer acceptance and perceived popularity with bullying and victimization in early adolescence.
      Journal of Early Adolescence. 2010; 30: 543-566https://doi.org/10.1177/0272431609340517
      ,
      • Espelage D.
      • Holt M.
      Bullying and victimization during early adolescence: Peer influences and psychosocial correlates.
      Journal of Emotional Abuse. 2001; 2: 123-142
      ,
      • Reijntjes A.
      • Vermande M.
      • Olthof T.
      • Goossens F.A.
      • van de Schoot R.
      • Aleva L.
      • et al.
      Costs and benefits of bullying in the context of the peer group: A three wave longitudinal analysis.
      Journal of Abnormal Child Psychology. 2013; 41: 1217-1229https://doi.org/10.1007/s10802-013-9759-3
      ) and sexual activity (
      • Kinsman S.B.
      • Romer D.
      Early sexual initiation: The role of peer norms.
      Pediatrics. 1998; 102: 1185
      ,
      • Potard C.
      • Courtois R.
      • Rusch E.
      The influence of peers on risky sexual behaviour during adolescence.
      European Journal of Contraception and Reproductive Health Care. 2008; 13: 264-270https://doi.org/10.1080/13625180802273530
      ,
      • Prinstein M.J.
      • Meade C.S.
      • Cohen G.L.
      Adolescent oral sex, peer popularity, and perceptions of best friends' sexual behavior.
      Journal of Pediatric Psychology. 2003; 28: 243-249
      ). From a public health perspective, recruiting popular, highly regarded students to help facilitate bullying and sexual harassment prevention programs may be an effective approach for teaching other students how to effectively resist social prejudices and navigate away from negative and risky behaviors (
      • Prinstein M.J.
      • Meade C.S.
      • Cohen G.L.
      Adolescent oral sex, peer popularity, and perceptions of best friends' sexual behavior.
      Journal of Pediatric Psychology. 2003; 28: 243-249
      ). Moreover, creating programs that encourage students to be more empathetic and build perspective-taking skills may also help to reduce explicit and implicit sexual biases and prejudices that facilitate sexually based forms of bullying commonly linked with depression and suicidal ideation among adolescent girls and young women (
      • Fine C.
      Delusions of gender – How our minds, society and neurosexism create difference.
      W.W. Norton, New York2010
      ).

      Acknowledgments

      Conflicts of Interest/Disclosures: The authors disclose no conflicts.

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      Biography

      Hailee K. Dunn, MPH, holds a MPH from Brown University and is pursuing a PhD in Clinical Psychology at the University of Rhode Island. Her research interests include a synthesis of psychology, public health and women's studies with a focus on adolescents.
      Annie Gjelsvik, PhD, is an Assistant Professor of Epidemiology in Brown University's School of Public Health. Her research interests include the effects of incarceration on chronic disease health among incarcerated individuals, their families and their communities.
      Deborah N. Pearlman, PhD, is an Assistant Professor of Epidemiology at Brown University's School of Public Health. Her research interests include health disparities and inequalities across a wide range of chronic diseases with a substantive focus on women's health.
      Melissa A. Clark, PhD, is Professor of Epidemiology and Obstetrics & Gynecology at Brown University. She is a survey methodologist whose research interests integrate methodological issues associated with sampling and data collection with substantive areas of women's health.

      Article info

      Publication history

      Accepted: June 19, 2014
      Received in revised form: April 24, 2014
      Received: November 5, 2013

      Identification

      DOI: https://doi.org/10.1016/j.whi.2014.06.008

      Copyright

      © 2014 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.

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