Adolescent Sexuality/and Sexuality Education
Leslie M. Kantor
Maurice Melchiono
John S. Santelli
Sexuality is an integral part of being human and encompasses physical, psychological, social, and spiritual elements. According to the World Association of Sexual Health, “Sexuality is an integral part of the personality of every human being. Its full development depends upon the satisfaction of basic human needs such as the desire for contact, intimacy, emotional expression, pleasure, tenderness, and love” (1). Adolescence includes a number of important developmental tasks related to sexuality, which ideally culminate in sexually healthy adulthood. According to the Guidelines for Comprehensive Sexuality Education (2), a sexually healthy adult:
Appreciates one’s own body
Seeks further information about reproduction as needed
Affirms that human development includes sexual development, which may or may not include reproduction or sexual experience
Interacts with all genders in respectful and appropriate ways
Affirms one’s own sexual orientation and respects the sexual orientations of others
Affirms one’s own gender identities and respects the gender identities of others
Expresses love and intimacy in appropriate ways
Develops and maintains meaningful relationships
Avoids exploitative or manipulative relationships
Makes informed choices about family options and relationships
Exhibits skills that enhance personal relationships
Identifies and lives according to one’s own values
Takes responsibility for one’s own behavior
Practices effective decision making
Develops critical-thinking skills
Communicates effectively with family, peers, and romantic partners
Enjoys and expresses one’s sexuality throughout life
Expresses one’s sexuality in ways that are congruent with one’s values
Enjoys sexual feelings without necessarily acting on them
In order to become a sexually healthy adult, young people need comprehensive sexuality education, which provides information; opportunities to explore attitudes, beliefs, and values; and concrete skills such as communication and negotiation skills that are needed in relationships with peers, parents, and partners. In addition, young people need the support of many people and institutions—including parents, health care providers, schools, religious organizations, and the media—to support them in learning about issues related to sexuality.
Unfortunately, in the United States, sexuality is often defined as synonymous with sexual behavior and most of the available research on adolescent sexuality has focused almost exclusively on sexual behavior, mainly vaginal sexual intercourse. While there are important potential health sequelae from sexual intercourse such as pregnancy and sexually transmitted infections (STIs), young people need age-appropriate, medically accurate education and guidance that includes a broad range of topics. In this chapter, we examine adolescent sexuality and review the scientific evidence for the efficacy of sexuality education. In addition, we recommend ways that health care providers, policymakers, parents, and others concerned with the well-being of youth can contribute to helping young people develop into sexually healthy adults.
Adolescent Sexual Behaviors
Experimentation and exploration of sexual behavior often begin with masturbation. Although few U.S. data are available, the data that do exist show that among teens ages 14 to 17 years, 73.8% of males and 48.1% of females have masturbated. The likelihood of ever masturbating increases with age—at age 14, 62.6% of boys had masturbated compared to 79.8% at age 18. Among girls, 42.3% had masturbated at age 14 compared to 58% at age 17 (3).
Among adolescents ages 15 to 19, close to half (46%) have had vaginal intercourse (4). The likelihood that a teenager will have vaginal intercourse increases with age—13% have had vaginal intercourse before age 15, while before age 19, 70% have done so (5). The average age of first intercourse among U.S. teens is 17 years for males and 17.4 years for females, with some variation between racial and ethnic groups (6). The median age of first premarital sex among U.S. teens is 17.6 years for males and 17.2 years for females (7).
Although coital sexual behaviors are the primary behaviors focused upon in most studies of adolescent sexual behavior, some research exists about other sexual behavior. Oral sex is more common among adolescents ages 15 to 19 years than sexual intercourse. Among all adolescents, 54% of adolescent females and 55% of adolescent males have participated in oral sex (8). For most young people, the initiation of oral sex occurs close to the time of initiation of sexual intercourse. Within 6 months of a young person beginning to have sexual intercourse, 82% have engaged in oral sex, and oral sex is a much more common behavior among sexually experienced adolescents than among virgins (8). There is no difference between males and females in the percentage that report receiving oral sex from a partner. However, females are more likely than males to say that they had performed oral sex on a partner (44% compared to 39%) (8).
Anal sex is more common among young people who have been having sex longer. Among adolescents reporting the initiation of vaginal sexual intercourse within the past 6 months, only 11% reported having anal intercourse compared with 27% of adolescents who had initiated intercourse more than 3 years previously. Both oral sex and anal sex are more common among white adolescents and those from higher socioeconomic groups (8).
Negative Sequelae from Sexual Behavior
While many teens experience sexual behavior positively, for a subset of adolescents, early sexual experiences are coercive. Among all women whose first vaginal intercourse experience occurred before age 20, 13% report that they “didn’t really want it to happen at the time,” and 52% reported mixed feelings (5). For those who had sex for the first time before the age of 14, 27% reported that they really didn’t want it to happen compared with only 5% who delayed their first sex until ages 18 to 19 years (5). Among all females ages 15 to 19 years, more than 10% report ever being physically forced to have sexual intercourse when they did not want to (4).
Adolescent Pregnancy and Sexually Transmitted Infections
Pregnancy rates have declined from an all-time high in 1990 to a rate of 71.5 per 1000 in 2006 (9). However, there are still 750,000 pregnancies to teens annually in the United States (9). There are 9.1 million new cases of sexually transmitted infections among adolescents and young adults ages 15 to 24 years annually (10). The reasons for this are multifactorial and include social as well as biologic components. Adolescent pregnancy and sexually transmitted infections are explored further in Chapters 18 and 25.
Drugs and Alcohol
Almost a third of young adults report having “done more” sexually than they had planned while under the influence of drugs and/or alcohol (11). Alcohol use is associated with a larger number of sex partners and less likelihood of using condoms (12). Marijuana use is also associated with a larger number of partners and inconsistent condom use (12). Health care providers should ask both about alcohol and drug use and about their use in conjunction with sexual behavior to ascertain whether patients are at higher risk of engaging in unwanted or unprotected sexual behavior.
Issues for Gay, Lesbian, Bisexual, and Questioning Adolescents
Developing a clear sense of one’s sexual orientation is a key developmental task in adolescence for all adolescents whether heterosexual, homosexual, or bisexual. Sexual orientation includes components such as what gender one is attracted to, what gender one fantasizes about, and with which gender one engages in sexual behavior (13). Various estimates exist about the percentage of young people who consider themselves heterosexual, homosexual, or bisexual or are questioning their sexual orientation. In one study, 10.7% of students in high school were “unsure” of their sexual orientation, with 5.2% of males and 8.5% of females identifying as homosexual by the 12th grade (14). In the United States, homophobia and heterosexism contribute to a hostile environment for gay, lesbian, bisexual, and questioning youth, which may lead to a wide range of health problems. In comparison to their heterosexual peers, lesbian, gay, bisexual, and transgender (LGBT) youth are more likely to experience depression, substance abuse, social isolation, rejection by family and peers, harassment, violence, school dropout, suicidal ideation, running away, and sexual risks such as exposure to HIV infection (15,16). In addition, gay, lesbian, and bisexual youth are more likely to report a greater number of lifetime and recent sexual partners, earlier age at sexual debut, and higher pregnancy rates (16).
Adolescent Relationships
During adolescence, teens negotiate a wide range of relationships. During early adolescence, relationships with parents often shift as young people begin to form closer ties with their peers and rely more heavily on peers for signals as to socially acceptable norms. Parents may also pull away from children, perceiving that they should give their young teens additional opportunities for independence. Adolescents begin to form romantic relationships in early adolescence, though sexual behavior is rare in these partnerships. However, communication and negotiation skills as well as ideas about gender roles in relationships are practiced and encoded in these early relationships. Finally, when sexual behavior is initiated, many new relationship issues are introduced, including the need to protect oneself or one’s partner from pregnancy and STIs, and the psychological and social expectations that come with a sexual relationship.
The majority of teens are having relationships with partners of a similar age; 63% of sexually active females have partners within 2 years of their age but 28% have partners 3 to 5 years older (5). Girls are more likely than boys to have older partners, and the rates of intercourse for these younger females rise in conjunction with the age of their partners; 13% of relationships with same-age partners included intercourse, 26% when the partner was 2 years older, 33% when the partner was 3 years older, and 47% when the partner was 4 or more years older (5).
Sexuality education
Sexuality education is the lifelong process of acquiring information and developing values about one’s identity, relationships, and intimacy. It includes learning about sexual development, reproductive health, interpersonal relationships, affection, body image, and gender roles (2). As young children and adolescents grow and develop physically and cognitively, they are exposed to and receive sexuality education from multiple sources. More than three in four adolescents and young adults report a clear desire to learn more information pertaining to sexual health topics; specifically, one in four report the need for more information regarding how to use condoms, and two in five want more information about communicating effectively with partners about sensitive sexual concerns (11). Currently, youth list their top three sources of information as sex education through school, friends, and parents. Various media sources also play a clear role including the Internet, television, movies, videos, and magazines. Health care providers are not on many teens’ lists; however, health care providers can impact teen sexuality, sexual behaviors, and outcomes as providers, advocates, and sources of information for patients and their parents.
School-based Sexuality Education
The vast majority of parents and professionals serving youth support sexuality education in schools. More than 90% of both junior high and high school parents believe that it is very or somewhat important to have sexuality education as part of the school curriculum (17). Ninety-five percent of parents of junior high school students and 93% of parents of high school
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