Sexual & Reproductive Health| Volume 29, ISSUE 6, P489-498, November 2019

Download started.


Female Age at First Sexual Intercourse by Rural–Urban Residence and Birth Cohort

Published:August 20, 2019DOI:



      Previous studies have examined timing of sexual initiation in the United States, but little is known about rural–urban differences in age at first sex.


      We used female respondent data from the National Survey of Family Growth (n = 29,133; 2006–2010 and 2011–2017) to examine age at first vaginal sex with a male partner. We used the Kaplan-Meier estimator and Cox proportional hazard analyses to assess differences in age at first sex by rural–urban residence, overall and stratified by 5-year birth cohorts (1968–1997). Models were adjusted for respondent characteristics and accounted for complex survey design.


      Overall, rural women experienced first sex earlier compared with urban women (hazard ratio [HR], 1.20; 95% confidence interval [CI], 1.12–1.29). By age 18, 62% of rural women had experienced first sex, compared with 54% of urban women. After adjustment for respondent characteristics, HRs were attenuated, but rural women were still more likely to have experienced first sex compared with urban women (HR, 1.07; 95% CI, 1.01–1.13). In unadjusted models, rural women were more likely to have experienced first sex compared with urban women for most birth cohorts (HRs ranged from 1.14 to 1.32); for only one cohort (1988–1992) was this association found in the adjusted analysis (HR, 1.23; 95% CI, 1.09–1.39).


      Women living in rural areas were generally more likely to report first sex at an earlier age compared with urban women, suggesting that delivery of sexual education and reproductive health services for women in the United States may need to take into account rural–urban residence.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Women's Health Issues
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Abma J.C.
        • Martinez G.M.
        Sexual activity and contraceptive use among teenagers in the United States, 2011-2015.
        National Health Statistics Report. 2017; : 1-23
        • 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 and Health Statistics. Series 23: Data from the National Survey of Family Growth. 2010; : 1-47
        • Bennett K.J.
        • Lopes J.E.
        • Spencer K.
        • van Hecke S.
        Rural women's health. National Rural Health Association National Policy Brief.
        • Bennett T.
        Reproductive health care in the rural United States.
        JAMA. 2002; 287: 112
        • Biello K.B.
        • Ickovics J.
        • Niccolai L.
        • Lin H.
        • Kershaw T.
        Racial differences in age at first sexual intercourse: Residential racial segregation and the black-white disparity among U.S. adolescents.
        Public Health Reports. 2013; 128: 23-32
        • Cavazos-Rehg P.A.
        • Krauss M.J.
        • Spitznagel E.L.
        • Schootman M.
        • Bucholz K.K.
        • Peipert J.F.
        • Bierut L.J.
        Age of sexual debut among US adolescents.
        Contraception. 2009; 80: 158-162
        • Committee on Healthcare for Underserved Women
        ACOG Committee Opinion No. 586: Health disparities in rural women.
        Obstetrics and Gynecology. 2014; 123: 384-388
        • Daniels K.
        • Martinez G.M.
        • Nugent C.N.
        Urban and rural variation in fertility-related behavior among U.S. women, 2011-2015.
        Date: 2018
        Date accessed: February 8, 2019
        • Dunne M.P.
        • Martin N.G.
        • Statham D.J.
        • Pangan T.
        • Madden P.A.
        • Heath A.C.
        The consistency of recalled age at first sexual intercourse.
        Journal of Biosocial Science. 1997; 29: 1-7
        • Ely D.M.
        • Hamilton B.E.
        Trends in fertility and mother's age at first birth among rural and metropolitan counties: United States, 2007-2017.
        NCHS Data Brief. 2018; (Available:): 1-8
        • Ethier K.A.
        • Kann L.
        • McManus T.
        Sexual intercourse among high school students - 29 states and United States overall, 2005-2015.
        Morbidity and Mortality Weekly Report. 2018; 66: 1393-1397
        • Finer L.B.
        • Philbin J.M.
        Sexual initiation, contraceptive use, and pregnancy among young adolescents.
        Pediatrics. 2013; 131: 886-891
        • Finer L.B.
        • Philbin J.M.
        Trends in ages at key reproductive transitions in the United States, 1951–2010.
        Women's Health Issues. 2014; 24: e271-e279
        • Future of Sex Education Initiative
        National sexuality education standards: Core content and skills, K-12 [a special publication of the Journal of School Health].
        • Gavin L.
        • Moskosky S.
        • Carter M.
        • Curtis K.
        • Glass E.
        • Godfrey E.
        • Zapata L.
        Providing quality family planning services: Recommendations of CDC and the US Office of Population Affairs.
        MMWR Recommendations and Reports. 2014; 63: 1-54
        • Geske S.
        • Quevillon R.
        • Struckman-Johnson C.
        • Hansen K.
        Comparisons of contraceptive use between rural and urban teens.
        Journal of Pediatric and Adolescent Gynecology. 2016; 29: 33-41
        • Guttmacher Institute
        Fact sheet: American adolescents' sources of sexual health information.
        • Hamilton B.E.
        • Rossen L.M.
        • Branum A.M.
        Teen birth rates for urban and rural areas in the United States, 2007-2015.
        NCHS Data Brief. 2016; : 1-8
        • Haydon A.A.
        • Herring A.H.
        • Prinstein M.J.
        • Halpern C.T.
        Beyond age at first sex: Patterns of emerging sexual behavior in adolescence and young adulthood.
        Journal of Adolescent Health. 2012; 50: 456-463
        • Heywood W.
        • Patrick K.
        • Smith A.M.
        • Pitts M.K.
        Associations between early first sexual intercourse and later sexual and reproductive outcomes: A systematic review of population-based data.
        Archives of Sexual Behavior. 2015; 44: 531-569
        • Jones J.
        • Mosher W.
        • Daniels K.
        Current contraceptive use in the United States, 2006-2010, and changes in patterns of use since 1995.
        National Health Statistics Report. 2012; : 1-25
        • Liang W.
        • Chikritzhs T.
        Errors in recall of age at first sex.
        PLoS One. 2013; 8: e72947
        • Lindberg L.D.
        • Maddow-Zimet I.
        • Boonstra H.
        Changes in adolescents' receipt of sex education, 2006-2013.
        Journal of Adolescent Health. 2016; 58: 621-627
        • Liu G.
        • Hariri S.
        • Bradley H.
        • Gottlieb S.L.
        • Leichliter J.S.
        • Markowitz L.E.
        Trends and patterns of sexual behaviors among adolescents and adults aged 14 to 59 years, United States.
        Sexually Transmitted Diseases. 2015; 42: 20-26
        • Manlove J.
        • Ikramullah E.
        • Mincieli L.
        • Holcombe E.
        • Danish S.
        Trends in sexual experience, contraceptive use, and teenage childbearing: 1992-2002.
        Journal of Adolescent Health. 2009; 44: 413-423
        • Marcell A.V.
        • Raine T.
        • Eyre S.L.
        Where does reproductive health fit into the lives of adolescent males?.
        Perspectives on Sexual and Reproductive Health. 2003; 35: 180-186
        • Martinez G.M.
        • Abma J.C.
        Sexual activity, contraceptive use, and childbearing of teenagers aged 15-19 in the United States.
        NCHS Data Brief. 2015; : 1-8
        • Mohammed K.A.
        • Subramaniam D.S.
        • Geneus C.J.
        • Henderson E.R.
        • Dean C.A.
        • Subramaniam D.P.
        • Burroughs T.E.
        Rural-urban differences in human papillomavirus knowledge and awareness among US adults.
        Preventive Medicine. 2018; 109: 39-43
        • Murray Horwitz M.E.
        • Ross-Degnan D.
        • Pace L.E.
        Contraceptive initiation among women in the United States: Timing, methods used, and pregnancy outcomes.
        Pediatrics. 2019; 143: e20182463
        • National Center for Health Statistics
        2006-2010 NSFG: Public use data files, codebooks, and documentation.
        Date: 2010
        Date accessed: February 8, 2019
        • National Center for Health Statistics
        2011-2013 NSFG: Public use data files, codebooks, and documentation.
        Date: 2013
        Date accessed: February 8, 2019
        • National Center for Health Statistics
        2013-2015 NSFG: Public use data files, codebooks, and documentation.
        Date: 2015
        Date accessed: February 8, 2019
        • National Center for Health Statistics
        2015-2017 NSFG: Public use data files, codebooks, and documentation.
        Date: 2017
        Date accessed: February 8, 2019
        • Petrosky E.Y.
        • Liu G.
        • Hariri S.
        • Markowitz L.E.
        Human papillomavirus vaccination and age at first sexual activity, National Health and Nutrition Examination Survey.
        Clinical Pediatrics. 2016; 56: 363-370
        • Thompson E.L.
        • Mahony H.
        • Noble C.
        • Wang W.
        • Ziemba R.
        • Malmi M.
        • Daley E.M.
        Rural and urban differences in sexual behaviors among adolescents in Florida.
        Journal of Community Health. 2018; 43: 268-272
        • U.S. Department of Agriculture
        Rural America at a glance: 2017 edition.
        • Zahnd W.E.
        • Rodriguez C.
        • Jenkins W.D.
        Rural-urban differences in human papillomavirus-associated cancer trends and rates.
        Journal of Rural Health. 2019; 35: 202-215


      Jaclyn A. Janis, BSN, RN, is an MPH candidate at the University of Southern Maine, Muskie School of Public Service. Her research interests include reproductive health, health disparities, and health services use.


      Katherine A. Ahrens, MPH, PhD, is an epidemiologist and assistant research professor in the Public Health Program at the University of Southern Maine, Muskie School of Public Service. Her research interests include maternal and child health, with a focus on family planning.


      Erika C. Ziller, PhD, is director, Maine Rural Health Research Center, and assistant professor and chair of Public Health at the University of Southern Maine, Muskie School of Public Service. Her research interests include rural health care access and health insurance coverage.