Sex and the Adolescent
Linda Grant
I. Description of the problem. The expression of human sexuality is the result of a complex interplay of biologic, psychological, interpersonal, and social factors—each with varying importance as the child grows up. In adolescence, the newly discovered ability to engage in sexual activity implies neither the cognitive and emotional maturity to deal with intimacy nor an understanding of its negative consequences (such as premature pregnancy and sexually transmitted diseases). It is the role of the primary care clinician to: (1) prepare the family to guide their adolescent through puberty, and (2) guide the adolescent in responsible sexual decision-making.
A. Epidemiology.
1. Sexual experience.
There is no one profile of adolescent sexuality. Trends in coital initiation and continuation of sexual activity reflect differing ethnic, cultural, and sex-specific rates. There are also few methodically sound scientific investigations of teen sexuality, due to the controversial nature of interviewing adolescents about their sexual behavior.
In general, the majority of adolescents are virginal at the age of 15; by the senior year in high school, approximately 60% are coitally experienced.
Males consistently report earlier coital initiation than females.
Sixty percent of sexually active high school seniors report using a condom at the last intercourse.
Noncoital sexual behaviors are prevalent. Over half of adolescent males and females aged 15 to 19 report engaging in oral sex with someone of the opposite sex; 11% of 15- to 19-year-olds of both sexes had engaged in anal sex with the opposite sex.
Gay, lesbian, bisexual, and transgender (GLBT) adolescents have higher rates of attempted and completed suicide, violence victimization, substance abuse, and human immunodeficiency virus (HIV) risk. Most have an awareness of their orientation by the age of 9 or 10.
Drugs and alcohol were involved in 23% of high school students before their last intercourse.
Although the rate of negative sexual outcomes has been declining over the last decade, there is evidence that this trend may be slowing.
2. Teenage pregnancy.
The United States has one of the highest rates of teenage pregnancy of any industrialized country.
Of the 2.4 million pregnancies occurring in US females under 25 years of age, 30% are to 15- to 19-year-old adolescents. Of these adolescent pregnancies, 57% are carried to term; the other half is therapeutically or spontaneously terminated.
3. Sexually transmitted diseases.
The 15 to 24-year-old age group acquires half of all sexually transmitted diseases (STD’s) although they represent only 25% of the sexually active population, with Chlamydia the most frequently reported.
Each year approximately 14% of all newly reported AIDS diagnoses are of 13- to 24-year-olds.
Nearly a quarter of females aged 15 to 19 years had HPV infection in a one-year study
4. Sexual aggression.
About one in three high school students report that they have been hit, slapped, or physically hurt by someone they were dating. Dating violence includes psychological and emotional abuse, physical abuse, and sexual abuse.
Children with disabilities are sexually abused at a ratethat is 2.2 times higher than that for children without disabilities.
B. Developmental considerations.
1. Dealing with body changes. Adolescents must learn to be comfortable with their new physical identity. Puberty is a time when they come to terms with a changing body and bewildering emotions fueled by hormonal surges. The reproductive capacity, however, is present well before emotional and cognitive maturity have developed.
2. Developing a separate identity. The adolescent must develop an identity that is separate from the family. Sexual behavior is often viewed as a rite of passage into adulthood and as a way to become a distinct entity from the family. As adolescents separate from the family, they develop replacement relationships with their peers. Technology has contributed new venues for social networking, expanding risk-taking options such as “sexting,” the act of sending sexually explicit messages or photographs.
3. Developing intimate relationships. Another task of adolescence is to achieve the capacity to develop intimate and meaningful mutual relationships. Early relationships may involve physical intimacy as a means of comparison and experimentation. Later, with the addition of formal operational thinking, emotional intimacy and reciprocity can be incorporated into relationships.
4. Developing the ability to think abstractly. Concrete operational thinking dominates early and mid adolescence. Therefore, young adolescents are incapable of fully understanding the ramifications of their actions. This, coupled with a sense of infallibility and invulnerability, heightens the risk for sexual activity. Formal operational thinking, which develops around the age of 15, allows the adolescent to generate a more appropriate decision-making tree and to develop abstract thinking on moral values.
5. Personality characteristics. The degree of any risk-taking behavior in adolescence is mitigated by the individual’s personality profile. In general those with low self-esteem, a tolerance for deviant behavior, and a propensity for sensation seeking are at highest risk. Those who place a high value on achievement and future orientation and who have strong religious beliefs are generally in lower risk categories.
6. Sexual orientation. Children have a sense of their sexual orientation at an early age. Gay teens have the same developmental tasks as heterosexual teens but may not have access to positive support systems that allow for fine-tuning the learning tasks of dating and loving (see Chapter 46).
7. Special needs. Children with cognitive and physical disabilities have the same sexual feelings and sexual developmental needs as their nondisabled peers. Discussions and/or planning for these needs are an integral part of medical home management.
II. Making the diagnosis.
A. History. The key to engaging adolescents is providing a trusting, confidential, nonjudgmental, and honest atmosphere. In order for adolescents to talk about their risk behaviors and sexual orientation with the primary care clinician, they must be assured that disclosure will not compromise their relationships with their family, their friends, or the community. Adolescents often resist medical visits because they fear that the information will be shared with the parent. It is important to establish with them that what is said will be confidential and equally important is to inform them of any qualifying parameters. For example, when an adolescent’s or another’s safety is jeopardized (as in suicidal or homicidal ideation, physical or sexual abuse, and life-threatening illnesses), confidentiality may need to be breached. Informing the adolescent and his or her parent of these guidelines at the initial visit allows for a clarifying discussion of safety, communication, and trust. Clinicians should be aware of their state’s statutes regarding mature and emancipated minors.
The sexual history should be part of a larger sociologic history that screens for all risk behaviors. The goal of a sexual history is to determine if there has been sexual activity and if so, the degree of health or emotional risk involved. Questioning needs to be direct and comprehensive. The clinician should make no a priori assumptions about the sexual activity, practices, or sexual orientation of any adolescent.
B. Key clinical questions.
1. “Are you currently in a relationship?”
2. “Does this relationship include having sex?”
3. “What kind of protection do you use to avoid pregnancy and sexually transmitted diseases?”
4. “Have you ever had any sexually transmitted disease?”
5. “How many partners have you had?”
6. “How old were you when you first had intercourse?”
7. “What made you decide to have sex?”
8. “Has anyone ever forced you to have sex?”
9. “Have you ever been pregnant? What happened to the pregnancy?” or “Have you ever fathered a child?”
10. “Have you ever had sex with someone of the same sex?”
11. “Have you ever had rectal or oral sex?”
12. “Is sex an enjoyable experience for you?”
13. “Tell me what you know about AIDS.”
14. “What do you know about the different methods of birth control?”
15. “How do you feel about not being sexually active?”
16. “Have you ever ‘sexted’?”
C. Physical examination.
When the examiner is of the opposite sex from the patient, it is prudent to ask about the patient’s comfort level and request for a chaperone.
1. Pelvic examination. Sexually active adolescents should seek preventative healthcare to address risks and screen for STDs. However, new guidelines suggest that adolescents do not need cervical cancer screening until the age of 21. Before that time, the need to perform a pelvic exam will depend on the gynecological symptoms, history, and the availability of newer urine tests for STDs.
There continues to be some debate as to when to initiate a pelvic examination in an adolescent who is not sexually active. Variables to consider include the patient’s request, the nature of the gynecologic complaint, and the gynecologic versus chronologic age of the adolescent. For the young, virginal adolescent with a gynecologic complaint, external visualization and bimanual rectal palpation and/or pelvic ultrasound may be adequate.
The development of a positive attitude toward pelvic examinations begins with the first. It is helpful to have the adolescent as involved as possible so that she feels in control of the process. For example, she can be asked if she wants to look at her cervix and external genitalia in a hand-held mirror. She should also be told that the examination will be stopped if she feels pain and she should describe any discomfort. Each step should be anticipated so that there are no surprises.
As the examination proceeds, the clinician might continue a relaxing and empowering dialogue.
2. Male genitalia examination. The adolescent male examination may also be anxiety provoking. Explanations and demonstrations of testicular self-examination as well as reassurance of normality help to relieve the anxiety. The male should be examined while standing, and it is helpful and educational to describe anatomic findings as a diversion during the examination. It is not necessary to comment on an erection unless the adolescent seems particularly embarrassed by it. The normality of the examination should always be stressed.
D. Tests. If an adolescent is sexually active, there should be routine screening for STDs. In females this means at least yearly testing for gonorrhea and chlamydia. (However, screening intervals should take into account the epidemiology of the community.) Rectal and pharyngeal gonococcal cultures should be considered if there is a history of oral or rectal sex, and rectal chlamydia screening should be considered in males who have receptive intercourse. A pap smear is currently recommended starting at age 21. Women often think that the “pap smear” and “pelvic exam” are interchangeable, when a pap smear is just a test performed occasionally during a pelvic exam. It is important to stress the distinction. Males can be screened for asymptomatic STDs using urine dipstick testing for leukocyte esterase in areas of high STD prevalence. Both males and females should be offered syphilis and Hepatitis C serology testing if they have had unprotected sex. Adolescents should be aware of and have access to confidential and anonymous HIV testing.
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