Case 1: This is a 17 year old male who has been in a year-long relationship with his 16 year old girlfriend. Their relationship includes sexual activity, including both vaginal intercourse and oral sex. They use condoms consistently, citing a wish to avoid pregnancy and sexually transmitted infections (STIs). They both say their relationship is mutually consensual and fulfilling. They are doing well at school, have good relationships with their family and peers, and have plans to attend college next year. Marriage has not been discussed although they see their relationship as a long-term commitment.
Case 2: This is a 14 year old female who was sexually assaulted by her uncle between ages 8 and 11. At age 12 she began to skip classes at school and "cruise" with friends at the beach. A year later she was introduced to "ice" (methamphetamines) and also used cocaine, alcohol and marijuana on a weekly basis at "hotel parties." She has met many of her sexual partners, usually older males, at these parties. She rarely uses condoms and has had chlamydia cervicitis once. She is not sure if she has ever been pregnant; but admits she would like to become a mother. She is not interested in learning more about contraception or STI prevention at this visit.
Case 3: This is a 16 year old female who is seeing you for her annual well-teen evaluation. In interviewing her about sexuality, she says she has never been sexually active. Although she has dated boys, she acknowledges a growing awareness of her sexual attraction to other girls and believes she may be a lesbian. She is hoping you can provide more information to help her better understand her feelings.
Sexuality is one of the most fundamental aspects of who we are as human beings. It is directly related both to an individual's physical as well as psychosocial well-being. It also is multidimensional in nature, referring not only to sexual behaviors but also to attractions, fantasies, affiliations, sexual orientation, and gender identity. Issues related to sexuality, particularly adolescent sexuality, are often controversial. In our pluralistic society, attitudes about adolescent sexuality differ not only by ethnicity, socioeconomic status, religion, and geographic region, but also can vary widely within individual families and communities. It is always a "hot topic" and one that health care providers will be required to address in their daily practice with adolescents and their families.
Human sexuality begins in infancy and continues through old age. However, with the beginning of puberty, there clearly is a quantitative change in the experience of sexuality by the developing child. The process has been described as a "sexual unfolding", that is the evolving expression of sexual feelings and experiences whose strongest roots are established in early infancy and childhood. This sexual "unfolding" is influenced by hormonal and physical changes, as well as psychosocial changes shaped by individual experiences and societal influences. Sexual development includes an adolescent's increasingly better understanding of who he/she is as a sexual being. This is accomplished in part through the acceleration of sexual exploration both with self and others. In general, pediatrics in the Western world feels that such experimentation is a normal and healthy part of adolescent development. However, there still remains some controversy, even within pediatrics, around what specific feelings and behaviors are developmentally appropriate.
Sexual development is intimately connected to the stages of adolescent development. In early adolescence (approximately 10 to13 years old) there is a significant increase in sexual feelings and preoccupations. These may be directed toward the same or opposite sex. There is often an increase in sexual self-exploration, including masturbation, which is considered a normal sexual behavior. Nocturnal emissions ("wet-dreams") occur in males and menarche in females, signifying the onset of reproductive capacity. Some early adolescents may engage in same or opposite-sex exploration. These do not necessarily reflect eventual sexual orientation. These sexual experiences are usually more experimental and self-focused than those of older adolescents.
Middle adolescence (approximately 14-16 years old) is often the hallmark of adolescent sexuality. Pubertal changes are nearly complete and there is significant increase in both same and opposite sex preoccupation and activity. With an increased understanding of their sexual selves, middle adolescents are more able to establish longer-term relationships and understand that intimacy involves more than simply sexual activity.
In late adolescence (approximately 17 to 19 years old), preoccupation with sexuality and the percentage of teenagers who are sexually active continue to increase but the older adolescent is, in general, able to bring a greater commitment and mutuality to his/her relationships. The late adolescent is also more future-oriented and often begins to consider what sorts of qualities, sexual and otherwise, he/she considers desirable in a potential spouse or life-partner. The "sexual unfolding" outlined above is a lifelong process and does not, of course, end at age 19. It is, in fact, a lifelong process.
While all adolescents address issues of sexual development, more than half abstain from sexual intercourse until age 17. However, research has demonstrated that some of these "abstinent" teenagers may engage in a variety of potentially risky sexual behaviors with others. These include mutual masturbation, fellatio, cunnilingus and anal intercourse. The Centers for Disease Control's (CDC) 2001 Youth Risk Behavior Survey, an anonymous survey of 9th to 12th graders in all 50 states, indicates that within this grade range, 46 percent acknowledge sexual intercourse, 14 percent have had four or more sexual partners, and 33 percent have had intercourse during the three months prior to the survey. Among those students who reported sexual intercourse, 33% had not used a condom and 82% of females had not used birth control pills during their most recent sexual intercourse. Despite this evidence of significant adolescent sexual activity, positive trends have appeared in the CDC data over the past decade. For example, the percentage of students reporting sexual intercourse has dropped from 54% to 46% between 1991 and 2001. The percentage reporting four or more partners has decreased from 19% to 14% and the use of condoms at most recent intercourse has increased from 46% to 58% during that ten-year period.
One of the reasons that health professionals are concerned about the high percentage of adolescents engaged in sexual behaviors is that these behaviors often entail significant risks to physical and psychosocial health. Early pregnancy and sexually transmitted infections are two of the primary risks inherent in adolescent sexual activity. Pregnancy occurs at a rate of 80 per 1,000 females aged 15 to 19. For the same age range, the birth rate is 50 per 1,000 and the abortion rate (intentional termination of pregnancy only) is 28 per 1,000 females. Adolescent pregnancy and birth rates have remained stable over the past decade. The rate of chlamydia infection is 1,132 per 100,000 adolescents aged 15 to 19. For the same age group, the rates for gonorrhea and syphilis infections are, respectively, 572 and 6 per 100,000 persons. The fact that these rates are far greater than those of Western European countries with similar rates of adolescent sexual activity most likely reflects U.S. adolescents' lower use of condoms and contraceptives. This may be due, in part, to cultural factors as well as health and educational policies at the federal and local levels that limit adolescents' access to information and services related to sexual and reproductive health.
Adolescent sexual decision-making is a very complex phenomenon. Research has demonstrated that the early onset of sexual activity with others is usually accompanied by other risk behaviors, such as substance use, school problems, and parent-teen conflict. It is also highly associated with a history of physical and sexual abuse, both inside and outside the family. In short, biological, social, familial, and experiential factors all play a part in each adolescent's decision to be sexually abstinent or become sexually active. If an adolescent does become sexually active, these factors also influence the ability to engage in "safer sex" practices. In general, the earlier the age of sexual initiation the more likely there are associated risk factors and a history of significant childhood abuse. The initiation of sexual activity during later adolescence is more likely to represent a normative process with fewer associated risks. The multitude of factors influencing an adolescent's decision to be abstinent or sexually active, likely is one of the reasons that "abstinence-only" sexuality curricula have been less effective in preventing adolescent sexual risk-taking than "comprehensive" sexuality curricula. The latter interventions encourage abstinence as the safest choice but recognize that some adolescents will choose to be sexually active and should be provided the information and skills they need to make that activity as safe as possible.
One of the most neglected areas related to adolescent sexuality has been that of sexual orientation. During puberty, approximately 3 to 10 percent of adolescents begin to recognize their lesbian or gay (homosexual) sexual orientation. An even greater percentage may be bisexual while a small minority is transgender, feeling as if they are one gender trapped in the body of the other gender. Sexual orientation and gender identity are not a choice and appear to be established by early childhood. They likely are shaped by both biological and environmental influences. Pediatrics now regards homosexuality and bisexuality as normal and healthy developmental outcomes. Transgenderism continues to be listed in the Diagnostic and Statistical Manual, 4th edition (DSM-IV) under the designation "Gender Identity Disorder," although the appropriateness of this continues to be debated. It is important to recognize that there are significant risks to growing up lesbian, gay, bisexual or transgender (LGBT) in American society. Certain segments of society regard a minority sexual orientation or transgender identity as pathologic or sinful. Many LGBT youth experience violence at school and in their own homes. Growing up with a stigmatized identity, or forced to hide one of the most important part of who they are, LGBT adolescents often encounter problems at home, at school, and in their communities. A small percentage run away from home, drop out of school, and turn to drugs, street-life, prostitution, or suicide as a means of escape. A larger percentage choose to postpone their sexual development or lead secret sexual lives that distort their sexual development and place them at high risk for depression, exploitation, violence, HIV/AIDS, and other sexually transmitted infections. Health providers have a special responsibility to these disenfranchised youths to make sure that they have access to accurate information, appropriate health care, and supportive community services so they may develop into healthy and productive adults. It is important to note that the American Academy of Pediatrics has taken a strong stand against "reparative therapies' and "transformational ministries" that seek to change sexual orientation from homosexual to heterosexual. These interventions are regarded as harmful and unethical.
A health provider has multiple roles in addressing issues of sexuality with adolescent patients, including those of screener, educator, counselor, and advocate. Research indicates, however, that many providers feel uncomfortable and unskilled in discussing sexuality with their adolescent patients. Therefore, providers must first examine their own comfort and attitudes about sexuality, particularly as these relate to adolescents, and reflect on how these attitudes affect their work with teenagers.
In their role as screeners, health providers should monitor their patients' sexual development by routinely asking questions related to sexual feelings and behaviors, preferably well before the onset of sexual activity. As educators, providers are in an excellent position to provide accurate information and anticipatory guidance to teenagers and their families, not only about pubertal development but also about normative sexual development during the adolescent years. It is especially important that they inform teenagers and their families about pediatrics' position on such controversial issues as contraception, masturbation and sexual orientation. As counselor, the provider should encourage postponement of sexual activity with others until the adolescent has the physical, emotional and cognitive maturity to enter into relationships that are consensual and non-exploitative. The provider should counsel adolescent patients that healthy sexual relationships should be both honest and pleasurable, and that steps should be taken to prevent sexually transmitted infections and unintended pregnancy. At a community level, health providers are in an excellent position to participate in the development and delivery of comprehensive sexuality curricula in the schools and other community forums. They also can be strong advocates for the development of confidential, accessible and affordable reproductive services for teenagers and for policies that nurture and support the healthy sexual development of all adolescents.
1. True/False: The incidence of U.S. adolescent sexual activity has increased over the past decade.
2. A 16-year-old boy reveals to you that he has become increasingly aware of his sexual attraction to other boys. Which is the most appropriate first response as a pediatrician to this revelation?
. . . . . a. Reassure the boy that such feelings are normal and may or may not be indicative of a homosexual or bisexual orientation.
. . . . . b. Report this revelation to the patient's parents.
. . . . . c. Refer the patient to a therapist trained in "reparative therapy."
. . . . . d. Discuss the dangers of anal intercourse, including HIV infection and other STIs.
. . . . . e. Suggest the boy spend more time with appropriate male role models and activities.
3. True/False: The onset of sexual activity in older adolescents may have different antecedents, predictors and consequences than that in younger adolescents.
4. True/False: Sexual experimentation is a normal part of adolescent development.
5. In the field of pediatrics which of the following is considered abnormal in adolescent sexual development.
. . . . . a. Masturbation
. . . . . b. Sexual coercion
. . . . . c. Homosexual orientation
. . . . . d. Sexual fantasies
. . . . . e. Sexual experimentation
1. American Academy of Pediatrics Committee on Adolescence. Homosexuality and adolescence. Pediatrics 1993;92(4):631-634.
2. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence. Sexuality education for children and adolescents. Pediatrics 2001;108(2):498-502.
3. Centers for Disease Control: 2001 Youth Risk Behavior Survey. Washington, DC, Centers for Disease Control. Available: http://cdc.gov/nccdphp/dash/yrbs/summary_results/usa.htm
4. Coupey SM, Klerman LV (eds). Adolescent Sexuality: Preventing Unhealthy Consequences. 1992, Philadelphia: Hanley & Belfus.
Answers to questions
1. False. The incidence of adolescent sexual activity, at least among in-school youth, appears to be declining. In addition, sexually active adolescents report fewer sexual partners and are more likely to use condoms than teenagers in the early 1990s.
2. a. Same-sex attraction is considered a normal part of adolescent and adult sexual experience. It may or may not reflect a bisexual or homosexual orientation, either of which, like heterosexuality, is believed to be established in early childhood and represents a normal developmental outcome.
3. True. The onset of sexual activity in younger adolescents is more likely to be associated with a history of negative life experiences and high-risk behaviors such as sexual abuse, substance use, parent-teen conflict and school problems. In older adolescents, the onset of sexual activity is often a more normative process.
4. True. Pediatrics as a discipline recognizes that sexual experimentation, with oneself and others, is a normal part of adolescent development. More controversial are the issues of age of initiation of sexual activity and the nature of those activities. There is a wide spectrum of viewpoints within pediatrics, reflecting broader societal views, on these latter issues.
5. b. Sexual coercion is a form of violence and, therefore, pathologic. Masturbation, homosexual orientation, and sexual fantasies and experimentation are considered a part of the spectrum of normal adolescent sexual development.