Adolescent Sexuality: Introduction
Although nearly 90% of parents want their children to have it, 23 states require it, 13 other states encourage its teaching, and over 90 national organizations believe that all children should have it, only 5% of children in the United States receive sex education. Adolescence is a time of tremendous physical and emotional turmoil. Family and cultural values, as well as personal experiences, including fears, lead to different sex education needs, such as understanding their bodies and body functions, exploring personal values, and setting sexual limits with partners. Unfortunately, not only parents but many clinicians are ill prepared to discuss health issues related to sex with adolescents. Additionally, teens may be uncomfortable discussing sexual issues with their peers and adults. This leaves adults with the responsibility for facilitating the discussion.
Lack of comprehensive sex education programs as well as differences in cognitive and physical maturity put adolescents at increased risk for unwanted or unhealthy consequences of sexual activity. This includes increased susceptibility for contracting sexually transmitted diseases and increased risk for morbidity associated with sexual activity.
Scope of the Problem
About 50% of US adolescents begin having sexual intercourse between the ages of 15 and 18 years, over 50% of adolescent girls and nearly 75% of adolescent boys have had sexual intercourse by the time they graduate from high school, and nearly 90% have had sexual intercourse by age 22. About 40% of all 15- to 19-year-olds have had sexual intercourse in the past 3 months. For adolescents who want to have intercourse, the primary reasons given are sexual curiosity (50% of boys; 24% of girls) and affection for their partner (25% of boys; 48% of girls). For adolescents who agree to have intercourse but do not really want to, the primary reasons given are peer pressure (about 30%), curiosity (50% of boys; 25% of girls), and affection for their partner (>33%). With little sex education, adolescents are poorly prepared to openly discuss their need for contraception, negotiate safe sex, and negotiate the types of behavior in which they are willing to participate. Sexual behavior that contradicts personal values is associated with emotional distress and lower self-esteem. As adolescents are learning to develop appropriate interpersonal skills, damage to self-esteem can be significant when sexual activity is exchanged for attention, affection, peer approval, or reassurance about their physical appearance. Furthermore, early unsatisfactory sexual experiences can set up patterns for repeated unsatisfactory sexual experiences into adulthood.
Nearly 50% of all pregnancies in the United States are not planned, with the highest rates of unintended pregnancies occurring among adolescents, lower income women, and black women. About 10% of 15- to 19-year-olds become pregnant every year and more than 40% become pregnant before age 20. Despite similar rates of adolescent sexual activity, the United States has the highest rate of adolescent pregnancy among developed nations.
Unintended pregnancy is socially and economically costly. Medical costs include lost opportunity for preconception care and counseling, increased likelihood of late or no prenatal care, increased risk for a low-birth-weight infant, and increased risk for infant mortality. The social costs include reduced educational attainment and employment opportunity, increased welfare dependency, and increased risk of child abuse and neglect. In addition to being confronted with adult problems prematurely, adolescent parents’ ability to lead productive and healthy lives and to achieve academic and economic success is compromised.
Although abortion rates are higher for women in their twenties, accounting for 80% of total induced abortions, a greater proportion of adolescent pregnancies end in abortion (29%) than do pregnancies for women over 20 years of age (21%). Adolescents who terminate pregnancies are less likely to become pregnant over the next 2 years, more likely to graduate from high school, and more likely to show lower anxiety, higher self-esteem, and more internal control than adolescents who do not terminate pregnancies. For an adolescent, postponement of childbearing appears to improve social, psychological, academic, and economic outcomes of life (see Chapter 16).
Adolescents (10-19 years old) and young adults (20-24 years old) have the highest rate of sexually transmitted diseases, and rates of chlamydial and gonorrheal infection are highest among women aged 15-19 years. Additionally, one in five cases of AIDS in the United States is diagnosed in men and women aged 20–29 years, with the likelihood that HIV infection was acquired up to 10 years earlier. Education is key to preventing sexually transmitted diseases, and vaccination for hepatitis B and human papillomavirus—if not already done prior to adolescence—can reduce disease risk in this population (see Chapter 14).
More than 100,000 children are victims of sexual abuse each year. Sexual abuse contributes to sexual and mental health dysfunction as well as public health problems such as substance abuse. Victims of sexual abuse may have greater difficulty with identity formation as well as problems establishing and maintaining healthy relationships with others. Additionally, they may engage in premature sexual behavior, frequently seeking immediate release of sexual tension, and have poor sexual decision-making skills, attempting to create intimacy through sex.
Although only a relatively small proportion of rapes are reported, a major national study found that 22% of women and approximately 2% of men had been victims of a forced sexual act. Unfortunately, adolescent boys are more likely to believe that sexual coercion is justifiable.
Delinquency and homelessness are associated with a history of physical, emotional, and sexual abuse, as well as negative parental reactions to sexual orientation. Homelessness is associated with exchanging sex for money, food, or drugs. Additionally, homeless adolescents are at high risk for repeated episodes of sexual assault.
Development
Adolescence is a time of complex physical, psychosocial, sexual, and cognitive changes. With earlier onset of puberty, physical changes occur in advance of cognitive changes. Not until maturity is reached in all of these realms does the adolescent acquire mature decision-making skills and the ability to make healthy decisions regarding sexual activity. Sexuality involves more than just anatomic gender or physical sexual behavior; it incorporates how individuals view themselves as male or female, how they relate to others, and their ability to enter into and maintain an intimate relationship on a giving and trusting basis. Adolescents who are sexually active before having achieved the capacity for intimacy are at risk for unwanted or unhealthy consequences of sexual activity. Adolescent sexual development forms the basis for further adult sexuality and future intimate relationships. The child’s successful achievements during each stage have major implications for both physical and psychosocial development, positive self-concept, and, ultimately, healthy sexuality.
Adolescents often feel uncomfortable, clumsy, and self-conscious because of the rapid changes in their bodies. Disproportionate physical development among girls and boys contributes additionally to the awkwardness of adolescence. Adolescents must adapt to a new physical identity, which includes hormonal changes, menstruation (often irregular or unpredictable for the first 18-24 months), unpredictable spontaneous erections, nocturnal ejaculations (“wet dreams”), growth of pubic and axillary hair, and even the odors from maturing apocrine glands, necessitating deodorant use.
As adolescents are learning to adjust and grow comfortable with their changing bodies, questions concerning body image are common (eg, penis size, breast size and development, distribution of pubic hair, and changing physique in general). In addition to adapting to a new body, adolescents must develop social skills and learn to interact with peers and adults.
Adolescent psychosocial development necessitates that the adolescent develop a realistic and positive self-image and identity. Adolescent identity includes the development of physical, cognitive, and social skills; emotional and spiritual maturity; and sexual identity, including sexual orientation. Adolescents must develop the ability not only to view themselves realistically but also to relate to others. This necessitates successfully achieving independence from the family. Successful acquisition of a stable sense of self allows the adolescent to move on to face the task of the young adult: achieving intimacy by developing openness, mutual trust, sharing, self-abandon, and commitment to another. Core developmental tasks of adolescence include the following:
Becoming emotionally and behaviorally independent rather than dependent; in particular, developing independence from the family.
Acquiring educational and other experiences needed for adult work roles and developing a realistic vocational goal.
Learning to deal with emerging sexuality and to achieve a mature level of sexuality.
Resolving issues of identity (essentially being reborn) and achieving a realistic and positive self-image.
Developing interpersonal skills, including the capacity for intimacy, and preparing for intimate partnering with others.
This development includes both internal (introspective) and external forces. Peers, parents or guardians, teachers, and coaches have an important influence on adolescent expectations, evaluations, values, feedback, and social comparison. Failure to accomplish the developmental tasks necessary for adulthood results in identity or role diffusion: an uncertain self-concept, indecisiveness, and clinging to the more secure dependencies of childhood. With physical, cognitive, and social changes, it is natural for adolescents to explore sexual relationships and sexual roles in their social interactions, which contributes to self-identity. The adolescent’s task is to successfully manage the conflict between sexual drives and the recognition of the emotional, interpersonal, and biological results of sexual behavior.
Gender identity forms a foundation for sexual identity. Gender identity, the sense of maleness or femaleness, is established by age 2 years, solidifying as adolescents experience and integrate sexuality into their identity.
Sexual identity is the erotic expression of self as male or female and the awareness of self as a sexual being who can be in a sexual relationship with others. The task of adolescence is to integrate sexual orientation into sexual identity. Heterosexual orientation is taken for granted by society. For lesbian and gay individuals, this creates a clash between outside cultural expectations and their inner sense of self. Currently in US society, the primary developmental task of the gay adolescent is to adapt to a socially stigmatized sexual role. Same-sex orientation emerges during adolescence but is far more subtle and complex; it includes behavior, sexual attraction, erotic fantasy, emotional preference, social preference, and self-identification—felt to be a continuum from completely heterosexual to completely homosexual (see Chapter 62).
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