INTRODUCTION
The proportion of sexually experienced adolescents in South Korea increased from 5.7% in 2018 [1] to 6.4% in 2024 [2]. In the United States, the prevalence of vaginal intercourse with an opposite-sex partner was higher among adolescent girls (40.5%) compared adolescent boys (38.7%) [3]. Adolescence is a vulnerable period for engaging in various sexual behaviors. While curiosity about sexuality is a normal part of development [4], sexual experience during adolescence can negatively impact mental health factors, leading to suicidal ideation, behaviors, or attempts [4-6]. The prevalence of suicidal ideation among adolescents is significantly higher in those with frequent sexual activity, early initiation of sexual activity [5,6], and those using contraception [5].
Globally, suicide is the third leading cause of death among adolescents [7], but in South Korea, it has been the leading cause of death for adolescents since 2011 [8,9]. As of 2022, the suicide attempt rate among adolescents was significantly higher among females (3.4%) than males (2.0%) [5,10-12]. In the United States, suicidal ideation among adolescents has increased by 3.4% annually since 2009, with a more pronounced upward trend observed among adolescent girls [13]. Similarly, in South Korea, the prevalence of suicidal ideation was 1.34 times higher among adolescent girls than among their male counterparts [14], and adolescent girls were reported to be more vulnerable to mental health problems [10,14]. These findings indicate that adolescent girls are at greater risk for suicide, underscoring the need to identify factors influencing suicidal ideation specifically among adolescent girls. Adolescent girls' suicidal ideation is significantly associated with mental health factors such as depression, stress, and loneliness [11,14,15] as well as health risk behaviors, including smoking, alcohol consumption, and drug use [14,15]. Among adolescent girls, those with suicidal ideation are 1.28 times more likely to engage in sexual experiences [16]. Furthermore, sexually experienced adolescent girls were found to have a 1.60 times higher likelihood of depression compared to their sexually inexperienced peers [1]. These findings highlight the necessity of examining the factors influencing suicidal ideation among sexually experienced adolescent girls.
Sexually experienced adolescent girls are vulnerable to sexual health issues, such as contraception and pregnancy, as well as mental health problems. However, existing research on sexually experienced adolescent girls has predominantly focused on factors related to sexual intercourse and contraceptive practices [17] or analyzed the impact of sexual experiences and mental health factors among both male and adolescent girls [3,7,14]. Studies specifically investigating factors influencing suicidal ideation in adolescent girls, who are more vulnerable to depression and stress compared to their male counterparts, remain limited. Although prior research has examined the influence of sexual behavior and mental health factors on suicidal attempts among sexually experienced adolescent girls [18] it did not consider health risk behaviors and only included three variables—stress, happiness, and depression—with-in the mental health domain. Moreover, while the Korean Youth Risk Behavior Survey data uses a complex sampling design to ensure representativeness, requiring statistical analysis through complex sample analysis, the Park study [18] employed simple analysis, which limited the reliability of its findings. In addition, it included only stress, happiness, and depression within the mental health domain. To address these limitations, the present study is grounded in Jessor's Problem Behavior Theory [19], which posits that adolescent risk behaviors arise from the interaction of problem behaviors, such as alcohol use and sexual behavior, and health-compromising behaviors, including smoking and physical inactivity. Based on this theoretical framework, the present study incorporates additional mental health factors, such as anxiety disorders, loneliness, and sleep satisfaction, and considers both sexual behavior and health risk behavior domains. It employs a comprehensive analysis of influencing factors using complex sample analysis that accounts for stratification, clustering, and weighting. Adolescents' suicidal behaviors are characterized by impulsivity and their inability to recognize their own depression, often resulting in sudden suicide attempts [9]. Therefore, this study was designed to analyze the impact of mental health factors, health risk behaviors, and sexual behavior on suicidal ideation among sexually experienced adolescent girls. The findings aim to raise social awareness, serve as foundational data for effective prevention efforts, and inform policy development.
METHODS
1. Study Design
This descriptive survey study utilized secondary data analysis of the 19th Korean Youth Risk Behavior Survey, conducted in 2023, to identify the sexual behavior characteristics of sexually experienced adolescent girls and examine their influence on suicidal ideation.
2. Study Population
This study used raw data from the Korean Youth Risk Behavior Online Survey, provided and managed in 2024 under the guidelines of the Korea Disease Control and Prevention Agency. The survey targeted middle and high school students in South Korea as of April 2023. The sampling process included stratification, sample allocation, and sample extraction. The stratification process divided the population into 117 strata based on 39 regional groups and school levels. Regional groups were classified into metropolitan, mid-sized/small cities, and rural areas considering geographic accessibility, the number of schools, population, living environment, smoking rates, and drinking rates. During sample allocation, 400 middle schools and 400 high schools were selected. Five middle and five high schools were first allocated to each of the 17 regions. The stratified cluster sampling method was applied, with schools as the primary sampling unit and classes as the secondary sampling unit. For the first stage of sampling, schools were randomly selected within each stratum using permanent random number extraction. For the second stage, one class per grade was randomly chosen from the selected schools. All students in the selected classes participated in the survey, except for those absent long-term, unable to participate independently due to special needs, or with reading disabilities. A total of 56,935 students were sampled, of whom 52,880 completed the survey, resulting in a response rate of 92.9% and a non-response rate of 7.1%. Among the respondents, 49,531 adolescents (93.6%) who reported no sexual intercourse experience were excluded. Of the 3,349 adolescents (6.3%) who reported having sexual intercourse experience, 2,018 (3.8%) were male. Accordingly, the final sample consisted of 1,331 sexually experienced adolescent girls (2.5%) (Figure 1).
3. Research Variables
1) General characteristics
The general characteristics included grade, household income, living with family, academic achievement, father's education level, mother's education level, financial assistance, and diagnoses of allergic rhinitis and asthma. In the raw data, the original variables for household income and academic achievement, which consisted of five categories (high, upper-middle, middle, lower-middle, and low), were recategorized into three levels: high, middle, and low. Living with family was classified into two categories: living with family or not. Father's and mother's education levels were categorized into three groups: high school or below, university graduate or higher, and unknown. Financial assistance and diagnoses of allergic rhinitis and asthma were classified as either yes or no.
2) Sexual behavior
Sexual behavior included items on contraceptive use contraceptive methods, and sex education at school. The contraceptive experience item asked whether participants used contraception to prevent pregnancy during sexual intercourse. Responses of "always used contraception" were classified as practicing contraception, while responses of "mostly used contraception," "sometimes used contraception," or "never used contraception" were classified as not practicing contraception. Contraceptive methods were categorized as modern or non-modern. "Oral contraceptives," "condoms," "emergency contraceptive pills," and "intrauterine devices (IUDs)" were considered modern methods, while "withdrawal method" and "menstrual cycle method" were considered non-modern methods [17].
3) Mental health
Mental health was assessed using items on Generalized Anxiety Disorder (GAD), depressive symptoms, loneliness, stress, happiness, and sleep satisfaction. Depression was measured with a yes/no question, with "yes" responses indicating the presence of depression. GAD was assessed using the Seven-Item Generalized Anxiety Disorder Scale, which evaluates the participant's state over the past two weeks [20]. This scale uses a 4-point Likert scale, with a total score of 21 points. A score of 10 or above indicated the presence of anxiety, while a score below 10 indicated its absence [20]. Loneliness was classified based on the raw data guidelines: responses of "never felt lonely," "rarely," or "sometimes felt lonely" were classified as not lonely, while "often" or "always felt lonely" were classified as lonely. Stress levels were categorized as follows: "felt very much" and "felt much" were classified as having stress, while "felt a little," "felt barely," and "did not feel at all" were classified as not having stress. Subjective happiness was assessed by categorizing responses into two groups: "very happy" and "somewhat happy" were considered as feeling happy, while "neutral," "somewhat unhappy," and "very unhappy" were considered as not feeling happy. Sleep satisfaction was categorized as follows: "very suffi-cient" and "sufficient" were classified as satisfied, "average" as neutral, and "insufficient" and "very insufficient" as not satisfied. Suicidal ideation was assessed with the question, "Have you seriously thought about suicide in the past 12 months?" Participants who responded "yes" were classified as having suicidal ideation.
4) Health risk behaviors
Health risk behaviors included alcohol drinking, smoking, inadequate physical activity, insufficient breakfast consumption, experience of violence treatment, habitual and intentional drug use, smartphone usage time, and smartphone overdependence. Alcohol drinking smoking, inadequate physical activity and habitual and intentional drug use were assessed with yes/no (binomial) questions. Breakfast skipping was assessed with the question, "During the past 7 days, on how many days did you eat breakfast?" Responses of 0∼4 days were classified as irregular, while 5∼7 days were classified as regular. Experience of hospital treatment due to violence was categorized as "none" for 0 occurrences and "yes" for 1 or more occurrences. Smartphone usage time was measured for both average weekday and average weekend usage. Based on previous studies [21], smartphone usage time was categorized into "<2 hours," "2∼4 hours," and ">4 hours." Smartphone overdependence was measured using a 10-item scale with a total score of 40 points. Scores below 23 were classified as normal, 23∼30 as the potential risk group, and 31 or above as the high-risk group.
5) Covariates
Potential confounders that may influence suicidal ideation, including general characteristics, mental health, health risk behaviors, and sexual behavior, were selected based on previous literature. Covariates included school grade [22], living with family (no/yes) [21,22], household income (low, middle, high) [21,23], and academic achievement (low, middle, high) [15,21]. Additionally, lifetime diagnoses of allergic rhinitis [23,24] and asthma [24], as well as parental education level [21,23], were included as covariates.
4. Ethical Considerations
This study utilized raw data from the 19th Korean Youth Risk Behavior Online Survey (KYRBWS). The data were publicly accessible and anonymized, with no personally identifiable information. The data were downloaded after inputting the research purpose on the Korea Disease Control and Prevention Agency website. The dataset is a nationally approved statistic (approval number 117058), and this study was conducted after receiving an exemption from review by the Institutional Review Board (IRB) of Eulji University (IRB No: EUIRB2025-330).
5. Data Analysis Methods
Data analysis was conducted following the guidelines for the use of KYRBWS raw data, incorporating STRATA, CLUSTER, Weight, and finite population correction (FPC) information. Analyses were performed using SPSS version 30.0 with the complex sampling method. Differences in suicidal ideation according to adolescents' general characteristics, mental health, health risk behaviors, and sexual behavior were analyzed using the complex samples general linear model and the Rao-Scott x2 test. Factors influencing suicidal ideation among sexually experienced adolescent girls were analyzed using complex sample logistic regression analysis. In the complex sample logistic regression analysis, variables with p<.05 in the univariate analysis were included. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each factor.
RESULTS
1. Differences in Suicidal Ideation by General Characteristics among Sexually Experienced Adolescent Girls
Differences in suicidal ideation by general characteristics among sexually experienced adolescent girls were statistically significant for grade (x2=6.57, p<.001), household income (x2=7.67, p =.001), living with family (x2= 19.94, p<.001), academic achievement (x2=9.01, p<.001), financial assistance (x2=13.84, p<.001), and asthma diagnosis (x2=16.27, p<.001). However, there were no statistically significant differences for father's education level (x2=.057, p=.943), mother's education level (x2=1.18, p= .306), and allergic rhinitis diagnosis (x2=2.44, p =.119) (Table 1).
Table 1.
General Characteristics of the Study Population according to Suicidal Ideation (N=1,331)
2. Sexual Behavior Characteristics Among Sexually Experienced Adolescent Girls
In response to the question, "Did you use contraception to prevent pregnancy during sexual intercourse?" 45.1% reported "always used contraception," while 13.7% and 19.7% reported "sometimes" or "never" using contraception, respectively. The most commonly used contraceptive method was condoms (62.6%), followed by the withdrawal method (9.6%), menstrual cycle method (1.7%), emergency contraceptive pills (1.0%), and IUDs (0.6%). Additionally, 66.9% of participants reported having received sex education at school within the past year (Table 2).
Table 2.
Sexual Behavior Characteristics of Sexually Experienced Adolescent Girls (N=1,331)
3. Differences in Suicidal Ideation by Mental Health, Health Risk Behavior, and Sexual Behavior among Sexually Experienced Adolescent Girls
The analysis of differences in suicidal ideation by mental health, health risk behaviors, and sexual behavior among sexually experienced adolescent girls revealed statistically significant differences in the mental health domain. Suicidal ideation was significantly associated with Generalized Anxiety Disorder (x2=98.03, p<.001), depression (x2=182.41, p<.001), loneliness (x2=147.69, p<.001), stress (x2=85.40, p<.001), happiness (x2=90.00, p<.001), and sleep satisfaction (x2=5.50, p=.005). Adolescents with anxiety, depression, loneliness, and stress had higher rates of suicidal ideation compared to those without these conditions. Additionally, adolescents who were unhappy or had poor sleep satisfaction reported higher rates of suicidal ideation. In the health risk behavior domain, significant differences in suicidal ideation were observed for alcohol consumption (x2=7.64, p=.006), smoking (x2=29.54, p<.001), experience of violence treatment (x2=42.81, p< .001), habitual and intentional drug use (x2=41.06, p< .001), smartphone usage time (x2=6.94, p=.001), and smartphone overdependence (x2=12.02, p<.001). In the sexual behavior domain, there were no statistically significant differences in suicidal ideation by contraceptive practice (x2=1.33, p=.249), sex education experience (x2= .01, p =.961), or contraceptive methods (x2=.01, p =.940) (Table 3).
Table 3.
Mental Health, Health Risk Behaviors, and Sexual Behavior of the Study Population According to Suicidal Ideation (N=1,331)
4. Factors Influencing Suicidal Ideation among Sexually Experienced Adolescent Girls
To identify the factors influencing suicidal ideation among sexually experienced adolescents girls, complex sample logistic regression analysis was conducted. In Model 1, mental health, health risk behaviors, and sexual behavior variables were included as independent variables, and in Model 2, covariates were adjusted based on Model 1a for further analysis. The results showed that in the mental health domain, the presence of depressive symptoms, GAD, loneliness, and stress (ref: absence) was associated with higher suicidal ideation, while adolescents who reported feeling happy (ref: not happy) exhibited lower suicidal ideation. In the health risk behavior domain, smoking and experiencing violence treatment (ref: no experience) were associated with higher suicidal ideation. Adolescents who used smartphones for 4 hours or more (ref: less than 2 hours) had higher suicidal ideation, and those who always practiced contraception (ref: did not practice contraception) had lower suicidal ideation. In the final model (Model 2), the presence of GAD, depressive symptoms, loneliness, and stress (ref: absence) was still significantly associated with higher suicidal ideation, while adolescents who felt happy exhibited lower suicidal ideation. Specifically, adolescents with GAD were 2.30 times more likely to experience suicidal ideation (95% CI: 1.14∼4.62), and those with depressive symptoms were 3.32 times more likely to experience suicidal ideation (95% CI: 2.01∼5.49). Adolescents who felt lonely were 1.90 times more likely to experience suicidal ideation (95% CI: 1.23∼ 2.95), and those with stress were 1.67 times more likely to experience suicidal ideation (95% CI: 1.02∼2.71). Conversely, adolescents who felt happy were 0.51 times less likely to experience suicidal ideation (95% CI: 0.32∼0.81). Within the health risk behavior domain, experiencing violence treatment increased the likelihood of suicidal ideation by 2.44 times (95% CI: 1.03∼5.79), and using smartphones for 4 hours or more increased the likelihood of suicidal ideation by 4.83 times compared to those using smartphones for less than 2 hours (95% CI: 1.28∼18.23). However, in the sexual behavior domain, variables such as contraceptive practice, sex education, and contraceptive methods were not statistically significant predictors of suicidal ideation (Table 4).
Table 4.
A Logistic Regression Analysis of Factors Influencing Suicidal Ideation among Sexually Experienced Adolescent Girls (N=1,331)
| Variables | Categories | Model 1† | Model 2‡ | ||||
|---|---|---|---|---|---|---|---|
| OR | 95% CI | p | OR | 95% CI | p | ||
| GAD | No (ref) | 1.00 | 1.00 | ||||
| Yes | 2.41 | 1.37∼4.21 | .002 | 2.30 | 1.14∼4.62 | .019 | |
| Depressive symptoms | No (ref) | 1.00 | 1.00 | ||||
| Yes | 3.37 | 2.28∼4.99 | ＜.001 | 3.32 | 2.01∼5.49 | ＜.001 | |
| Loneliness | No (ref) | 1.00 | 1.00 | ||||
| Yes | 1.97 | 1.35∼2.88 | ＜.001 | 1.90 | 1.23∼2.95 | .004 | |
| Stress | No (ref) | 1.00 | 1.00 | ||||
| Yes | 1.71 | 1.17∼2.50 | .005 | 1.67 | 1.02∼2.71 | .038 | |
| Happiness | Yes | 0.54 | 0.36∼0.80 | .002 | 0.51 | 0.32∼0.81 | .005 |
| No (ref) | 1.00 | 1.00 | |||||
| Sleep satisfaction | Satisfied | 1.22 | 0.68∼2.17 | .491 | 0.86 | 0.43∼1.74 | .690 |
| Average | 1.05 | 0.67∼1.63 | .817 | 1.16 | 0.70∼1.92 | .543 | |
| Dissatisfied (ref) | 1.00 | 1.00 | |||||
| Alcohol drinking | No (ref) | 1.00 | 1.00 | ||||
| Yes | 1.05 | 0.68∼1.62 | .810 | 1.10 | 0.63∼1.91 | .736 | |
| Smoking | No (ref) | 1.00 | 1.00 | ||||
| Yes | 1.55 | 1.05∼2.30 | .027 | 1.29 | 0.78∼2.13 | .315 | |
| Inadequate physical activity | No (ref) | 1.00 | 1.00 | ||||
| Yes | 1.12 | 0.67∼1.85 | .659 | 1.83 | 0.88∼3.80 | .100 | |
| Insufficient breakfast consumption | Regular | 1.09 | 0.74∼1.59 | .657 | 1.20 | 0.78∼1.84 | .406 |
| Irregular (ref) | 1.00 | 1.00 | |||||
| Experience of violence treatment | No (ref) | 1.00 | 1.00 | ||||
| Yes | 4.92 | 2.46∼9.84 | ＜.001 | 2.44 | 1.03∼5.79 | .042 | |
| Habitual and intentional drug use | No (ref) | 1.00 | 1.00 | ||||
| Yes | 0.63 | 0.32∼1.23 | .632 | 1.44 | 0.23∼8.89 | .690 | |
| Smartphone overdependence | General risk group (ref) | 1.00 | 1.00 | ||||
| Potential risk group | 0.69 | 0.47∼1.00 | .056 | 0.07 | 0.42∼1.04 | .667 | |
| High risk group | 0.77 | 0.43∼1.37 | .777 | 0.51 | 0.32∼1.74 | .758 | |
| Smartphone usage time (per day) | ＞4 hrs | 4.66 | 1.17∼18.45 | .028 | 4.83 | 1.28∼18.23 | .020 |
| 2∼4 hrs | 1.22 | 0.63∼2.34 | .550 | 0.81 | 0.39∼1.70 | .586 | |
| ＜2 hrs (ref) | 1.00 | 1.00 | |||||
| Contraceptive practice | Yes | 0.61 | 0.41∼0.90 | .014 | 0.63 | 0.39∼1.00 | .052 |
| No (ref) | 1.00 | 1.00 | |||||
| Sex education | No | 0.86 | 0.56∼1.32 | .503 | 0.74 | 0.46∼1.20 | .230 |
| Yes (ref) | 1.00 | 1.00 | |||||
| Contraceptive methods | Modern | 1.41 | 0.53∼3.77 | .555 | 1.27 | 0.45∼3.58 | .646 |
| Non-modern (ref) | 1.00 | 1.00 | |||||
DISCUSSION
This study investigated the characteristics of sexual behavior and factors influencing suicidal ideation among sexually experienced adolescent girls. Among these adolescents, 19.7% reported not using contraception at all during sexual intercourse. This represents a 24.3% decrease compared to the 44.0% reported in a study analyzing 2015 Korean Youth Risk Behavior Survey data [18], indicating an increase in contraceptive practice among Korean adolescents. However, this rate is still lower than the 1.1% of sexually experienced adolescent girls in the United States who reported not using contraception [3]. Regarding contraceptive methods, condoms were the most commonly used method at 62.6%, followed by the withdrawal method at 9.6%. Similarly, among sexually experienced adolescent girls in the United States, condoms were also the most commonly used method at 95.4%, followed by the withdrawal method at 64.8%, showing a similar ranking of contraceptive methods between the two countries [3].
IUDs were the least used method in South Korea, with a usage rate of 0.6%. In contrast, in the United States, the usage of IUDs increased significantly from 0.4% in 2002 to 19.2% in 2019 [3]. These differences may be attributed to variations between countries in perceptions of contraception, cultural factors, and social factors, such as the content and scope of school-based sex education and requirements for parental consent during clinical care.
The investigation into differences in suicidal ideation among sexually experienced adolescent girls revealed that the rates of suicidal ideation were notably high among those with GAD and depressive symptoms, at 92.4% and 82.4%, respectively. Similarly, suicidal ideation rates were 75.7% for those experiencing stress and 64.5% for those feeling lonely. These findings indicate that the mental health of sexually experienced adolescent girls is more vulnerable compared to adolescents during the COVID-19 pandemic. A 2020 study on both male and adolescent girls during the COVID-19 period found that suicidal ideation rates were 31.2% for those with depression, 28.0% for those with stress, and 37.2% for those with loneliness [11]. The suicidal ideation rates among sexually experienced adolescent girls were more than twice as high as those reported in this COVID-19 study. Additionally, suicidal ideation rates were 90.0% among those who used smartphones for more than 4 hours a day and 87.0% among those who engaged in inadequate physical activity. These rates are significantly higher compared to a study on smartphone addiction among adolescent girls, which reported suicidal ideation rates of 20.0% for those using smartphones for more than 4 hours a day and 21.8% for those with inadequate physical activity [21]. The suicidal ideation rates among sexually experienced adolescent girls were approximately 3∼4 times higher than those of smartphone-addicted adolescent girls. These findings highlight the importance of recognizing the high rates of suicidal ideation among sexually experienced adolescent girls and understanding the influence of mental health and health risk behaviors on their suicidal ideation. It is crucial to develop tailored approaches to sexual education and establish policies that address these specific needs.
The factors influencing suicidal ideation among sexually experienced adolescent girls were analyzed across three domains: mental health, health risk behaviors, and sexual behavior. In the mental health domain, GAD, depression, loneliness, stress, and happiness levels were identified as significant factors influencing suicidal ideation. The results showed that adolescents with depression had a 3.32 times higher likelihood of suicidal ideation compared to those without depression, while those with GAD had a 2.30 times higher likelihood. This pattern is consistent with a previous study of male and adolescent girls, which reported that adolescents with depression had a 5.03 times higher risk of suicide attempts [25]. In addition, prior research has shown. These findings align with previous research indicating that sexually inexperienced adolescent girls with depression were 0.62 times less likely to have suicidal ideation compared to sexually experienced adolescent girls [26]. Together, these results indicate that depression and GAD are significant risk factors for suicidal ideation.
A study on adolescents with depression found that GAD was the most significant factor influencing suicide attempts, increasing the likelihood by 3.68 times [27]. Additionally, moderate anxiety was associated with a 2.87 times higher likelihood of suicidal ideation [12], further underscoring the critical role of depression and anxiety in suicidal ideation. Depression is also linked to sexual experiences, as adolescent girls with depressive symptoms were 2.47 times more likely to engage in sexual intercourse compared to those without such symptoms [1]. This highlights the close relationship between depression, sexual experiences, and suicidal ideation. Loneliness was identified as a major risk factor for both suicidal ideation and depression among adolescents [28]. In this study, adolescents who felt lonely were 1.90 times more likely to have suicidal ideation. Similar results were found in previous studies, where loneliness was associated with a 1.96 times higher likelihood of suicide planning and attempts [11]. Meta-analyses have also identified loneliness as a predictor of suicidal ideation and behaviors, with depression acting as a mediator [29]. These findings suggest that loneliness exacerbates the negative effects of depression on suicidal ideation, highlighting the need for psychological support systems that address both loneliness and depression. Stress and happiness also played significant roles in suicidal ideation among sexually experienced adolescent girls. Adolescents experiencing stress were 1.67 times more likely to have suicidal ideation, while those who reported feeling happy were 0.51 times less likely to have suicidal ideation. Previous studies have shown that happiness mitigates the negative effects of stress on anxiety [30], supporting the findings of this study. Research on male and adolescent girls indicated that those with high levels of stress were 1.77 times more likely to plan suicide [11], and the risk of suicide attempts was also found to increase by 3.08 times [27]. Among adolescent girls with severe depression affecting their daily lives for at least two weeks, stress increased the likelihood of suicidal ideation by 2.55 times [26]. The influence of stress on suicidal ideation among sexually experienced adolescent girls was found to be similar to the impact of stress on suicide planning among the general adolescent population.
Smoking also showed a close relationship with sexual experiences and suicidal ideation. A previous study of male and adolescent girls reported that those who smoked fewer than 20 cigarettes per day had a 1.86 times higher risk of suicide attempts, while those who smoked 20 or more cigarettes per day had a 2.76 times higher risk, indicating a dose-response relationship between smoking intensity and suicide risk [27]. In addition, adolescent girls with smoking experience were 5.61 times more likely to engage in sexual intercourse [16], and among this group, stress increased the likelihood of suicidal ideation by 1.64 times [21]. This similarity in suicidal ideation levels between sexually experienced adolescent girls and adolescent girls with smoking experience highlights the interplay of these factors. Therefore, improving happiness and reducing stress could be effective strategies to lower suicidal ideation among sexually experienced adolescent girls. Developing tailored support systems to enhance mental health and reduce stress could serve as a foundation for effective suicide prevention interventions.
Among the health risk behaviors of sexually experienced adolescent girls, smartphone usage of more than 4 hours per day was associated with a 4.83 times higher likelihood of suicidal ideation compared to those using smartphones for less than 2 hours per day. This finding aligns with a study on smartphone-dependent adolescent girls, where suicidal ideation decreased by 0.82 times among those using smartphones for 2 to 4 hours compared to those using smartphones for over 4 hours [25]. Another study on male and adolescent girls found that smartphone-dependent adolescents had a 1.50 times higher likelihood of suicidal ideation and a 1.87 times higher likelihood of suicide attempts [24]. Notably, among adolescents with high levels of smartphone use, the level of risk-taking behaviors was substantially higher in adolescent girls (4.17 times) than in adolescent boys (2.85 times), suggesting that adolescent girls may be a more vulnerable group to the risks associated with excessive smartphone use [22]. Previous research on adolescents showed that those with three or more lifestyle risk factors had a 1.96 times higher likelihood of suicidal ideation, and those with five to six risk factors had a 3.36 times higher likelihood [31]. The risk of suicidal ideation associated with excessive smartphone use exceeds that of having five to six lifestyle risk factors. Accordingly, to prevent suicidal ideation among adolescents, it is essential to recognize gender differences and implement school-level policies to limit smartphone use, provide continuous monitoring and counseling for students with smartphone overdependence, and offer parent-focused education programs that support the management of smartphone use both at home and in school settings.
Adolescents with experience of violence treatment were found to have a 2.44 times higher likelihood of suicidal ideation. This is higher than the 1.7 times increase reported in a U.S. study where adolescents with depression who had experienced violence were compared to those without such experiences [32]. However, it is lower than the 3.18 times increase reported in a study of Korean adolescents with experiences of violence [11]. The discrepancy with Wang's study may stem from the inclusion criteria, as only individuals with ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) diagnoses related to violence, such as child abuse or physical assault, were included, excluding those who had experienced violence but did not receive a formal diagnosis. In contrast, this study included all adolescents who reported experiencing violence and receiving treatment, regardless of formal diagnosis, providing broader representativeness. Suicidal ideation and attempts are closely linked to school bullying, victimization, and child abuse [33]. Therefore, when counseling adolescents, it is crucial to identify the perpetrators of violence—whether peers, seniors, or family members—and adopt differentiated approaches based on the sources and causes of violence. Notably, a study involving both male and adolescent girls found that the risk of suicidal ideation increased by 1.15 to 2.21 times as the number of health risk behaviors increased [34]. This finding suggests that, for the prevention of suicidal ideation, a comprehensive approach that assesses and manages overall health risk behaviors, rather than focusing on individual risk behaviors in isolation, is necessary.
Sexual behavior-related factors among sexually experienced adolescent girls were not identified as significant predictors of suicidal ideation. Similarly, a study conducted in Argentina reported that sexually experienced adolescents were 1.73 times more likely to attempt suicide; however, the use of contraception during sexual activity was not associated with suicide attempts [6]. This suggests that the primary factors influencing suicidal ideation among sexually experienced adolescent girls are more closely tied to psychosocial and health risk behaviors rather than sexual behavior itself.
Limitation
This study employed a cross-sectional design, which limits the ability to establish causal relationships and instead focuses on identifying associations between variables. To better understand these relationships, future longitudinal studies are needed. In addition, emotional variables were measured using binary nominal and ordinal indicators rather than validated and structured instruments, which represents a limitation in terms of the validity and reliability of the measurement tools. Additionally, as this study was conducted through school-based surveys targeting adolescents enrolled in schools, further research involving a broader population, including out-of-school adolescents, is required.
CONCLUSION
This study provides a comprehensive understanding of the factors influencing suicidal ideation among sexually experienced adolescent girls. The findings indicate that mental health factors, including GAD, depression, loneliness, stress, and happiness, as well as experiences of violence treatment and smartphone usage time, significantly impact suicidal ideation. Recognizing the characteristics and challenges of sexual behavior among sexually experienced adolescent girls requires ongoing efforts from families and society to prevent suicide. Pediatric nurses, in particular, should acknowledge the importance of mental health management for sexually experienced adolescent girls and ensure regular monitoring of their mental state. When experiences of violence treatment are identified, it is crucial to determine the perpetrator of the violence and thoroughly assess whether ongoing issues persist. Furthermore, recognizing smartphone usage time as a critical factor in suicide prevention, it is essential to develop policies that promote healthy smartphone usage among adolescents and establish management strategies to limit excessive usage.
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