Psychosocial Factors Underlying Sexual Deviance Among Adolescents in ASEAN: a Systematic Review

Mohammad Rahim Kamaluddin (  rahimk@ukm.edu.my ) Universiti Kebangsaan Malaysia Karunaagaran Chendirasagaram Universiti Malaya Loy See Mey Monash University Malaysia Fauziah Ibrahim Universiti Kebangsaan Malaysia Balan Rathakrishnan Universiti Malaysia Sabah Soon Singh Bikar Singh Universiti Malaysia Sabah Norruzeyati Che Mohd Nasir Universiti Utara Malaysia Azlina Tengku Muda Universiti Kebangsaan Malaysia Zahrotur Rusyda Hinduan Padjadjaran University Daniella Maryam Mohamed Mokhtar Universiti Kebangsaan Malaysia Zaizul Ab Rahman Universiti Kebangsaan Malaysia Ibrahim Maclean Chong Ministry of Home Affairs


Background
Adolescents belong in an uncertain phase of life where biological and psychological changes occur transitioning them from childhood into early youth. The incipience of sexual and reproductive ability places them in a vulnerable position leading them to be involved in transgressions and high-risk sexual behaviours [1,2]. The World Health Organisation (WHO) de nes adolescents in a global age range of 10 -19 years old and they do not belong in a heterogenous population. Consistently, studies of sexual behaviour indicate salient cultural and social factors that shape sexual behaviour of adolescents in the examination of sexual behaviour among adolescents in the Southeast Asian context [3][4][5][6]. As a regional organisation, The Association Southeast Asian Nations (ASEAN) is a culturally, economically and politically diverse group of nation-states that comprise 11 countries namely the Philippines, Vietnam, Thailand, Singapore, Myanmar, Brunei, Cambodia, Timor Leste, Indonesia, Laos, Malaysia. The cases of illegal abortion, pre-marital sex, early sexual debut, teen pregnancy, sexually transmitted diseases such as HIV amongst adolescents are becoming more prevalent in these countries [7][8][9][10][11][12]. While a number of studies has explained the link between sexual attitudes and sexually risky behaviours with variables such as peer in uences, familial and extra-familial in uences system, exposure to media containing sexual content, gender scripts, gender equality of a country and social class [7][8][9][10][11][12], there exists a paucity in a systematic review of psycho-social association with sexual deviance of adolescent within the ASEAN context.
Past systematic reviews have focussed on treatment effects and scale of sexual aggression and protective factors but none on psychosocial determinants or factors that contribute to sexual deviance of adolescents speci cally [2][3][13][14][15]. This current systematic review intends to elucidates the occurrence of sexual deviance amongst ASEAN adolescents and the psychosocial antecedents that contribute to their intent of deviance through value as source of attitude.
Speci cally, what are the factors present and the types of deviances. Sexual values are moral guides to make decisions with regard to acceptable or unacceptable sexual behaviour on situational and cultural contexts [16][17][18][19]. Thus, this review intends to provide an insight into how adolescent sexual behaviours are construed as deviant from country to country within ASEAN and the psychosocial factors that contribute to such deviance.
This systematic review anchors on the three dimensions of sexual values which are Absolutism, Relativism and Hedonism [16][17][18][19]. Absolutism concerns values based on authoritative power of law, religion and tradition which favours abstinence until marriage. Relativism as the term indicates demonstrates distinct values that are socio-culturally determined. Hedonism ties in with intentions for behaviours that are pleasurable and as respite for sexual behaviours [16][17][18][19]. This trinity of dimensions, more notably relativism and hedonism provide us the gradient of nuances which underpins the acts of sexual behaviour of a particular age group (adolescent in this case) as sexual deviance. The dimensions will thus enable the review to answer how sexual deviances amongst adolescents and their associated psychosocial factors by mapping to the sociocultural complexities of ASEAN.
This bears the rationale of ASEAN as a regional choice in this review as it takes into account of the Southeast Asian context of regional belonging with commonality of shared cultural values yet diverse all the same in so far as adolescent sexual offences such as pre-marital sex, sexual violence, homosexuality, transgenderism, inter alia, are concerned. As WHO mentioned, the understanding of motivations behind adolescent sexual behaviours with its associated psychological factors are pertinent in forming educational sex programmes. It is consistent with ASEAN's formation of the Youth Development Index (YDI) to measure its youths progression across critical areas in education and employability as well as youth oriented initiatives as it can aid in overcoming deviant sexual behaviours which otherwise may impede their progression in life and well-being [20,21].

Operationalisation of Sexual Deviance and Psychosocial Factors
Indonesian Demographic and Health Survey Report (SDKI) de nes risky sexual practices as the liberal execution of activities with the encouragement of risky sexual desire, in-tentionally or unintentionally without deference to rules or norms. A continental split be-tween western and eastern blocs gives the relative ideation of how sexual deviance may be construed [22]. While sexual deviance is conventionally de ned in terms of paraphilia, zoophilia, voyeurism, exhibitionism, sadomasochism in a global, perhaps western context [23], the de nition of sexual deviance may denote other activities beyond just those mentioned. The major distinction can easily be attributed to through cultural norms and values. Chu [24] clari es that culture and society are determinants of how sexual deviance is construed beyond the consensus of generally accepted sexually deviant's behaviour such as molestation, rape and paraphilia.
In a study of sexual behaviours in Papuan cultures [25], high risk behaviours such as polygyny, promiscuity, early debut, extra marital affairs are evident in spite of normative ideals and consternations of such 'deviant sexuality'. Thus, high risk sexual behaviours can be subsumed under or categorically de ned as sexual deviance and the types mentioned are considered deviant behaviours for subsequent review. Further to this operationalisation of sexual deviance, past studies that concern regret and stigma post sexual behaviour are be presuppositions of a sexual deviant behaviour as such concepts renders a good indicator of shame of the personal vis-à-vis the societal management of expected behaviour [19,[26][27]. As per the sexual dimension of relativity, it is prudent to acknowledge however that within member states of ASEAN region, sexual deviance amongst adolescent may occur on a slope of difference with different gradients of contributing psychosocial factors owing to the heterogeneous social variables of religion, spirituality socio-economic status and cultural values.
Psychosocial aspect of behaviourism relates the personal (internal) to the society and culture (external), vice versa. A number of studies [28][29][30][31][32][33] has ascertained the roles of psychosocial as underlying factors towards deviant behaviour. In fact, a multitude of studies has touched upon psychosocial factors that contribute to the intentions of sexual deviance which in turn demonstrate the correlation of how environmental factors affect sexual deviance amongst individuals.
Psychosocial factors as mentioned prior is an interplay between the external and internal, such factors thus and be further de ned as having externalisation and internalisation factors respectively. Externalising factors in previous studies have been de ned with examples such as sexual violence and aggression as well as substance abuse (drugs and alcohol) while internalising factors were illustrated with mental health such as depression and suicidal thoughts, and self-deprecation [14,34]. Furthermore, psychosocial factors are seen as vital to human functioning and emergence of disease. This is wholly signi cant as high-risk sexual behaviours are almost inextricably linked to venereal dis-eases such as HIV and mental instability such as suicidal ideations. Such factors become especially relevant and signi cant to review in a continental setting as pre-indicated of the prevalence of sexual deviance in ASEAN. The delineation of psychosocial de nition further encapsulates the nuances of diverse psychosocial factors that contribute to the differences of sexually deviant behaviour.  [35]. Studies that were published from year 2010 to 2020 were included in the review. Electronic databases were used such as ScienceDirect, PubMed, Google Scholar, Emerald Insight and OVID to undertake the literature review.

Search Strategy
Only search strings in English were used with numerous keywords of (1) 'psychosocial factors' AND 'sexual deviance' OR 'high-risk sexual behaviour'; (2) 'psychosocial factors' AND 'sexual deviance' AND 'adolescents' AND 'Asia' OR 'Southeast Asia'; (3) 'psychosocial factors' AND 'sexual behaviour' AND 'adolescent' OR 'youth' AND 'ASEAN'. A ow chart of the selection of studies is presented in Fig. 1. The initial search and screening resulted in 44 studies that met the inclusion criteria as represented by Fig. 1. After further assessment, 24 articles were removed resulting in a nal 20 articles for assessment following the inclusion and exclusion criteria as indicated below: Inclusion Criteria 1) Articles that pertain to psychosocial factors as independent variable which include externalising and internalising factors.
2) Articles that only include respondents or informants or samples within the age range of 10 to 19 apropos the adolescent age bracket de ned by the WHO. In the instance of samples that include lower age limit as this review's upper limit (18-19 years old), the article(s) will be accepted with data extraction and inclusion derived from that upper limit sample.
3) Participants, subjects, respondents and informants from the Southeast Asian member states. If population sample is transnational, transregional or transcontinental, the article(s) will be accepted with data extraction and inclusion that is ASEAN-speci c. 4) Empirical quantitative and qualitative data and research modes are accepted or where measures of psychosocial factors of sexual deviance are discussed.
Exclusion Criteria 1) This paper excludes data of psychosocial consequences from sexual deviance. Psychosocial antecedents or determinants towards sexual deviance are the focal point. Article(s) that contributes to psychosocial effects will be rejected.
2) Sole mention of sexual deviance activities without mapping psychosocial factors to them are excluded. Additionally, articles that concern protective factors without discussion of psychosocial counterpart will be excluded.
3) Sample size that are statistically insigni cant (<20%) and age range that is be-low or beyond the adolescent age range will inde nitely be excluded. 4) Studies conducted before 2010 and after 2020 will be omitted.

Risk of bias
Risks of bias were consciously sought to be reduced by appointing two researchers to assess articles which are properly framed as sexually deviant by using semantic and pragmatic approximations as indicated in Table [3] in the column of 'Sexual Deviance Indicator'. It incorporates Geoffrey Leech's 'semantic representation and pragmatic in-terpretation' to strictly interpret high-risk sexual behaviour as sexual deviance through textual cues.  [47] each scored one. One study [4] was jointly set in both Thailand and Indonesia. 85% of the studies undertook a quantitative approach with 15 studies (75%) conducted cross-sectionally as seen in Table [1]. Two studies (10%) employed the triangulation method (quantitative and qualitative) while only one study was done using a qualitative approach. Since the respondents were adolescents who were mostly schooling, multi-staged random sampling was mostly employed since schools will have to be selected prior to students from classrooms. 95% of the studies focussed on an age range de ned as adolescent by the WHO. Nawi  In the articles centred in Malaysia [36-41], a majority of the respondents were Ma-lay/Muslim, as were the respondents in Indonesia in Susanto et al. [43]. Studies in Singapore [24,51] were Chinese and the Thai study of Pradubmook-Sherer's [49] were mostly Buddhists as well as the Cambodian adolescents in Lopez  65% of the literature reviewed did not specify the sexuality of the participants as indicated in Table [3]. Even though they may be inferred to concern heterosexuals, reducing the risk of bias exercise has hindered this review to make that inference. Other studies have clearly indicated that their respondents have had sexual relationships with the opposite sex [43,[48][49]. Smith et al [4] cite in the limitation of the study that the heteronormative structure of their study may have held non-hetero adolescents from responding to their questionnaire truthfully with respect to their sexual identity. Diarsvitri et al's [25] study is solely the one that is inclusive of all types of sexuality.
Parental support, attachment and monitoring is another prominent psychosocial feature reported in 20% of the articles [4,37,[41][42]. Parental as protective factor serves as mediating factor as well as a host to many psychosocial pathway coe cients as in Shahruddin et al. [41] and Suwarni et al. [42]. It is evident from In terms of sexual deviance, mainly oral sex and sexual intercourse are witnessed. Promiscuity is another dominant deviant behavioural pattern as seen in several studies in Table [3]. In Awaluddin et al. [40] it is explicated that determination of sexual behaviour among Malaysian adolescent was a limitation of the study. Nevertheless, the study showed sexual deviance of masturbation and pornography serving as factors, but they are also coupled with psychosocial factors of anti-social behaviour and low religiosity thus ful lling the inclusion criteria for this review. Only Chu et al. [24] and Zeng et al. [51] t into the conventional understanding of sexual deviance since the adolescents in their respective studies were involved in voyeurism, exhibitionism, molestation and rape.
Intentions for sexual activities are determined as deviant much in the way subject of sexual fantasies and fetishes are deemed as deviant. Fantasies and fetishes bear compatibility to terms like 'attitudes', 'intentions', 'willingness' and 'selfmotivation' as seen in Shahruddin  al. [41] further expound that adolescent sexual attitude begins with desires for extreme sexual relationship. Table [3] shows that 35% of studies were performed using self-reported or established questionnaires from existing reliable and validated ones to nd association between psychosocial factors and sexually deviant behaviours of adolescents. Where qualitative or triangulation methods are concerned, in-depth interviews and focus-group discussion were employed [50]. As self-esteem has been mentioned to be a prominent feature of psychosocial dimension, Rosenberg's Self-Esteem Scale was prominently used in three studies [37,41,49]. The measurement of substance abuse has not been measured by a speci c scale but as a subsection of larger surveys as in the case of Lopez Mukaire and Matay [46]. Parental factor was measured using Parent and Peer Attachment Scale and The Parental Monitoring Assessment in Shahruddin et al. [41] and Farid et al. [37] respectively.
Sexual deviance was measured using diverse scales such as Brief Sexual Attitudes Scale, The Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR), Sex Ed-ucation Inventory, Self-Reported Peer Sexual Norms Questionnaire, Love Style Inventory (LSI) and Sexual Risk Survey. Commonality was not reported in this review.
(2) Rosenberg Self-Esteem Scale by Morris Rosenberg, where Islam is the predominant religion of the respondents; demonstrate deviance as a result of poor religiosity. Religion in these studies is advocated as a protective factor as much as it is a psychosocial determinant. The daily religious observance of ve-times-a-day prayer as an oblation is deemed a forti cation against deviance [39].
The trajectory of these studies including a Cambodian study by Lopez,Mukaire and Mataya [46], seem to index towards an absolutist dimension of sexual values that places sanctity in deferment in sexual experiences post marriage as per custom and religions. Consistently, in Chu et al. [24] who examined primary human goods as factors to sexual offending among Singaporean individuals found spirituality (0%) to be a non-contributing factor but inner peace (17.3%) was a contributing factor, which incidentally is a desired outcome of spirituality or religiosity.
Additionally, the scope of deviance is presupposed through the concept regret and shame under the purview of religion in  [52]. Remarkably, the review exhibits a full-circle pattern of psychosocial antecedent to a sexual deviant succedent and psychosocial impact through negative appraisals of self-esteem. Parental monitoring appears to be another psychosocial protective factor that positively correlates with sexual deviance amongst adolescence in ASEAN. This may be attributed to the fact that ASEAN member states belong in a collectivistic culture as detected in a majority of the studies reviewed. Interestingly in two studies reviewed [41][42], many psychosocial subfactors such as self-esteem, attitude and locus of self-control act as pathway coe cients or intermediary factors between parental attachment to adolescents while in Smith et al. [4] parental support serves as one of the psychosocial linking factors between sedentary behaviour and risky sexual behaviour among Thai and Indonesians adolescents. Other mediating factors include substance abuse, parental, loneliness and depressive symptoms manifest in sexual intercourse with a report of sedentary behaviour of 3 hours/day. As such, future research may delve into 'physical activities' as a means towards mitigating psychosocial factors to reduce sexual deviance incidences among adolescents.
However, in Farid et al. [37] study, institutionalised adolescent (female) showed a negative correlation. High family connectedness increased sexually deviant behaviours. This could be attributed to the fact that welfare children's family dynamics differ from those belonging in a stable nuclear family unit. What is psychosocial protective factor for the latter is detrimental factor for the former which may explain their being institutionalised in the rst place.
In matters of sexual-orientation based deviances, the limited number of studies displayed in this review prompts for more research focus. Using non-hetero respondents poses a challenge as indicated by Smith et al. [4] a heteronormative setting may result in reticence among them to respond in order to elucidate psychosocial determinants to sexual deviance. Moreover, an examination on sexual minorities would be an interesting insight into the distinction of values between identity and behaviour. Sexual orientation as demographic datum in itself may be seen as sexual deviance in ASEAN member states. This is supported in two contrasting studies found beyond this review where transgenderism and homosexuality have been seen as socially permissible in Thailand [53] as opposed to Vietnam where it is deemed immoral [54].
Substance abuse as an externalising pattern of psychosocial factor appears in a majority of studies [4, 25-6, 37-39, 43, 46, 51]. However, in Rahman et al. study [39], there is not a signi cant relationship between substance abuse like alcohol among adolescents which could index to its consumption as non-permissible its among Muslim respondents. Lopez Mukaire and Mataya [46] and Pengpid and Peltzer [45] indicated that males were more prone to substance abuse leading to risky sexual behaviour such as sexual coercion, violence and aggression leading to female sexual victimisation and control [49]. A compounding factor is patriarchy in certain ASEAN member states which permits and justi es men's aggressive behaviour, even to the extent of females being pressured to accept certain deviant behaviours.
Hedonistic dimensions are linked to pleasure seeking and sensory heightening through the in uence of substance usage and abuse thereof. Farid et al. [37], Chu et al. [24] and Osorio et al. [26] demonstrate that sexual deviance as sexual satiation and pleasure seeking through alcohol, smoking and illicit drugs were factors towards promiscuity and oral sex.
Sexual satisfaction however appears less in uential as compared to other factors which make the hedonistic dimension of sexual values, though existing but comparatively benign.
It is evident from the review that a quantitative cross-sectional approach is the dominant mode of study. While quantitative study enables a demonstrable quanti cation measure of relationship between two distinct variables as parameters, a qualitative approach provides an in-depth probing into sexual deviance factors and intentions which may capture nuances that is hitherto unmeasured in validated questionnaires. As per Sychareun et al.
[48] qualitative study, it was determined from rst-hand account that pre-marital sex, adolescent marriage and pregnancy were not just the cultural norm in rural Laos, but there was an economic advantage in term of yoking adolescents into agricultural businesses which turns labour into pro table assets.
Research also tends to centre itself amongst the poor. Sexual deviance, though of course impulsed by lower socioeconomic standings, would potentially provide a contrasting realm among adolescents who are socioeconomically privileged as their psychosocial needs may differ. The level of digital pro ciency, arguably higher among privileged adolescent provide an exposure to other forms of sexual degradations. As per the study in Singapore [24], a higher income country, demonstrates performance of sexual deviance by adolescent sexual offenders similar to those enacted by Western adolescents such as voyeurism and exhibitionism.
In line with western ideation of sexual deviance, as sadomasochism is denoted as deviance that may be consensual, sexual violence however takes place in the ASEAN setting as a coercive, forceful act. The study on dating violence in Thailand shows the cultural norm of permissible male aggression towards female adolescent [49]. Moreover, the synthesis shows gender as a salient demographic data that links psychosocial factors to sexual deviance. Both Farid et al. [37]  consider them to be 'sexually deviant' but rather as an integral part of their sexual identity. While this may be seen as the strength for its interpretive rigour, however, it is a missed opportunity to review their psychosocial needs for the purpose of the ASEAN YDI. Another limitation of the present review is the fact that qualitative studies are lower than quantitative studies which impede the capturing of ner nuances of psychosocial motivations and intentions towards sexual deviance. Finally, authors would like emphasised that the detail explanation on absolutism, relativism and hedonism were not included in the review. Besides that, the articles were searched using various terms pertaining to sexual deviance. As such, those articles may not collected or measured using the same term (sexual deviance). Despite these limitations, this review has successfully offered some insights regarding psychosocial factors contributing sexual deviance among adolescents from ASEAN countries.

Conclusion
We can assign con dence in describing sexual deviance amongst adolescents in ASEAN along with the diverse psychosocial factors as uid. Just as adolescents are de ned to belong in a precarious transitionary state, so are the psychosocial factors and their sexual behaviours. Low religiosity, low self-esteem, high substance abuse and minimal parental monitoring are some of the reciprocal factors that abet sexual deviance among adolescents in ASEAN. In terms of sexual deviance, early sexual debut appears to be the dominant act. Sexual deviance in ASEAN appears to be wholly different (pornography, oral sex, dating) from their Western counterparts with the exception of Singapore [24]. This is largely due to cultural norms and how sexual permissibility is regarded.
Fluidity is also cognisant and discernible across the dimensions of absolutism, hedonism and relativism. It is evident from the synthesis of review that the triumvirate of sexual values and dimension hold true with respect the degrees of differences and nuances. By accounting this uidity, sexual and reproductive health strategies for adolescents are recommended to be more inclusive and culturally sensitive to achieve the goal of progress as per the ASEAN YDI.
This review recommends parental monitoring, religion/spirituality and self-esteem building as vital focal areas for policy makers and initiative strategists to consider to curb adolescent sexual deviance in order to achieve the goals of the 'Health and Wellbeing' domain of ASEAN YDI. More research studies are recommended to be conducted in Timor Leste and Vietnam as they were not reviewed in this study. Furthermore, researches pertaining to sexuality and sexual orientation need to be carefully undertaken to ensure their adolescents' psychosocial well-being regardless if their sexualities are deviant by taking into account another dominant psychosocial factor of religion/spirituality present in this review. Future studies in this topic would bene t policymakers, counsellors and researchers alike by opting for a longitudinal approach using qualitative designs as opposed to predominance in cross-sectional mode for an in-depth analysis of sexual deviance and its psychosocial factors among adolescents in ASEAN.  Figure 1