Promoting Healthy Adolescent Sexual Choices
Mary S. Larew, MD, FAAP,
Assistant Professor of Pediatrics
    Fall 2000

Although talking to teens about their sexual behavior can be uncomfortable, information provided by parents and physicians can significantly affect the choices teens make. Our goal in influencing adolescent behavior is to promote physical and emotional health, including a healthy sexual identity. Sexual health in adolescence includes:

• Developing positive feelings about one's changing body
• Expressing sexual feelings in appropriate ways
• Discriminating between healthy and unhealthy sexual activity
• Preparing for responsible sexual relationships

Adults can play an important role in promoting healthy adolescent sexual behavior. For example, they can look for opportunities to discuss the facts and to explore misinformation. These discussions should neither lecture nor moralize, so that they encourage an ongoing dialog. Adults also need to observe what they communicate to adolescents through their use of humor, comments about the opposite sex, or about those with a different sexual orientation.

Adolescents often do not know how to gain access to health care. They may be embarrassed or fearful about their changing bodies and feelings. Teens are more likely to share questions and information about their relationships if they know the listener will be open to hearing what might be perceived by the teen as "weird" or inappropriate. If a teen is uncomfortable with discussing sexual issues with you or a parent, it is crucial to encourage them to seek out another responsible adult with whom to talk.

Communicating with teens about sexuality requires an understanding of the changes that occur as an individual moves from early puberty to full adulthood:

• In early adolescence, from age 10 to 14, teen experience newfound sexual urges and interests, and become intensely curious about sex. They become highly aware of their changing bodies, and are often highly egocentric and self-conscious.
   
• During middle adolescence, from 14 to 17 years, they grow more comfortable with their new bodies, and begin to experience adult-like sexual drives. They are more aware of sexual messages directed to and from them, and may participate in sexual experimentation and risk-taking. During this time, their sense of invulnerability puts them at especially high risk, because they may not appreciate the health implications of their choices.
   
• In late adolescence, teens become more aware of their sexual identity and the consequences of their actions, and they develop increasingly intimate relationships.

Issues in adolescent sexual health

Sexual identity. Not all adults who provide guidance to teens recognize that by the age of 19 years, 6% of females and 17% of males report they have had a homosexual experience. These activities do not define a person's sexual identity, and may be a part of teenage sexual experimentation. However, because an estimated 5 to 10% of the adult population is homosexual, one can assume a similar proportion of teens are homosexual -- many of whom are not aware of their sexual identity.

Although it is important to be nonjudgmental when communicating with any teenager about sex, it is especially important with those struggling with their sexual identity. Approximately a third of adolescent suicides, and a third of AIDS cases in middle adolescence, occur among teens who are homosexual. All youth are at risk for stress, sexual victimization, depression, suicidal behavior, substance abuse, sexually transmitted diseases, but gay and lesbian youth are particularly vulnerable. They especially need positive, responsible adult support.

Pregnancy. Frank discussion of the implications of sexual activity is necessary to assist teens in avoiding negative consequences. Annually, about one million teenage girls become pregnant in the United States. This represents over four times the teen pregnancy rate in France, Germany, or Japan. Only about half of U.S. teens used condoms the last time they had intercourse. On average, female adolescents consult a physician for birth control pills one year after beginning to be sexually active.

Most teens do not fully appreciate how parenthood will interfere with their social lives, may interrupt their education, limit their job opportunities, and potentially create a less than ideal life for their child. The abortion alternative, which carries substantial emotional and physical risk, is chosen by almost one third of pregnant 15 to19 year olds.

STDs. Three million American teens contract a sexually transmitted disease (STD) each year. Some of these diseases are not adequately treatable, and can be fatal. Nonfatal complications may include:

• Cancer
• Ectopic pregnancy
• Infertility
• Neonatal infection, which may lead to death
• Recurrent abdominal pain
• Recurrent ulcers
• Surgery

Rape. Parents and teens may feel that pregnancy and STDs are obvious negative consequences of premature sexual activity. However, young men and women often do not recognize the damage caused by acquaintance rape. Four out of five adolescents believe that forced sex is acceptable under some conditions. Many teens have the misperception that date rape is not "real" rape, due to the nature of the relationship. However, date rape victims suffer from the same symptoms as those who have been sexually assaulted by strangers.

Ninety-two percent of victimized adolescents were assaulted by someone they knew. Eighty percent of rapes on college campuses occur between dating partners. It may be helpful for teens to understand that alcohol use is one of the strongest predictors of date rape. The use of specific date rape drugs is also on the increase; these drugs are tasteless, odorless, and much stronger than alcohol.

Anticipatory guidance
We must provide teens with tools to protect themselves from unhealthy behaviors by listening to their concerns, by reassuring them that their confusion and fears are normal, and by guiding them to factual information that can help them make choices that are right for them. They can be encouraged to postpone sexual activity, maintain support systems, set limits, communicate with their partners, be assertive, and learn conflict resolution techniques. Some questions that may help open discussions involving these difficult issues include:

• Do you date or have a steady partner? Do they treat you well?
• Have they pressured you into going further than you wanted to? How did you deal with that situation?
• Has anyone ever physically hurt you or forced you to have sex?
• Have you had sex with a girl? Boy? Both?
• Do you use birth control? What kind? Do you know how a condom is used?
• Do you know what an STD is? How would you know if you had and STD?
• Many kids your age drink, or use drugs. Do any of your close friends? Have you? How much?
• Do your parents have rules about when to be home?
• Can you talk with them about sex?

Resources:
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, at www.BrightFutures.org.
Bluestein, J. Parents, Teens, and Boundaries (1993).
Bartle, N. Venus in Blue Jeans (1998).
Slap, G. Teenage Health Care (1994). Steinberg, L. You and Your Adolescent; A Parent's Guide for Ages 10 - 20 (1997).