Adolescent Health Care: A Practical Guide

Chapter 39

Adolescent Sexuality

Martin M. Anderson

Lawrence S. Neinstein

Adolescents are sexual beings, a reality that many parents, health care providers, and adolescents themselves may not be comfortable addressing. Focusing solely on negative outcomes related to vaginal sexual intercourse such as pregnancy, human immunodeficiency virus (HIV), and other sexually transmitted diseases (STDs) ignores the fact that (a) all teenagers are sexual beings whether or not they are sexually active and (b) teens engage in sexual activities other than vaginal intercourse. Sexual behavior does not start during adolescence or adulthood, but with childhood sexual curiosity. There is a sudden upsurge of curiosity and interest in one's own body and that of peers during adolescence. Even very young adolescents are interested in “how things work” and are exposed to a wide range of sexual language and images through friends, family, school, and the media (television, movies, radio, videos, Internet). Understanding the sexual nature of adolescence is essential to developing the skills needed to answer teenagers' questions and to address their sexual feelings and problems. This chapter provides an overview of heterosexual adolescent sexuality and methods by which the professional can better assist adolescents in negotiating sexually related issues (see Chapter 40 for information relevant to gay, lesbian, bisexual, and transgender [GLBT] youth).

Adolescent Sexual Development

Preadolescence

Physical gender is established in utero and is based on chromosomes, gonads, and hormones. Gender identity (masculine, feminine) and sexual preference is established by early childhood. The exact timing is unknown. Characteristics of preadolescent sexual development include the following:

1. A low physical and mental investment in sexuality
2. Information gathering on the topic of sexuality (including facts and myths) from the media, friends, school, and family
3. Prepubertal appearance
4. Masturbation occurs as a normal behavior and provides a feeling of pleasure as opposed to being a response to a sexual feeling or urge.

Early Adolescence

Characteristics of sexual development in early adolescence include the following:

1. Initiation of puberty.
2. Extreme concern and curiosity exists about one's own body and that of peers.
3. Sexual fantasies are common and may serve as a source of guilt.
4. Masturbation in response to sexual feelings begins and may be accompanied by guilt.
5. Sexual activities are most often nonphysical. Early adolescents may be content with nonsexual interactions at school, during group activities, or at home (by telephone, e-mail, instant messaging, or chat rooms).

Middle Adolescence

Sexual development in middle adolescence is characterized by the following:

1. Full pubertal maturation is attained and menstruation has begun in females.
2. Sexual energy is at a high level, with more emphasis on physical contact.
3. Sexual behavior is of an exploratory, experimental nature.
4. Dating and noncoital sexual activities are common; casual relationships with noncoital contacts are prevalent.
5. Attention to the adverse consequences of sexual behavior is not fully developed.

Late Adolescence

Sexual development in late adolescence is characterized by the following:

1. Completion of puberty.
2. Sexual behavior becomes more expressive.
3. Intimate sharing relationships may develop.

As already outlined, sexuality is an important aspect of adolescent development. An understanding of issues related to adolescent identity and sexual development include:

1. How do I know I'm ready for sex?
2. What is important in a relationship?

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3. How do I say no? Do I want to?
4. How do I deal with anger, rejection, and loneliness?
5. What is safe sex?
6. Am I gay or straight?

Adolescents are involved in sexual activity for a variety of reasons including:

1. Peer pressure
2. Experimentation
3. To experience feelings of pleasure, affection, and closeness
4. The expression of being grown up

Noncoital Sexual Behaviors

There are more than 40 million adolescents between 10 and 19 years living in the United States. Data on rates of vaginal intercourse, pregnancy, and STDs are readily available. Data on noncoital sexual activities are more difficult to find. In 1996, Schuster et al. published one of the first papers on the sexual activity of virgins (no vaginal intercourse) (Schuster et al., 1996). This group studied male and female virgins attending an urban California high school. Thirty percent of males and females had engaged in mutual masturbation. Eleven percent of male virgins and 8% of female virgins had engaged in fellatio to the point of ejaculation. Cunnilingus was a sexual activity of 9% of males and 12% of female virgins (Table39.1). This study compared nonsexual risk-taking behaviors of virgins with nonvirgins. The virgins who engaged in sexual activities had risk-taking behaviors that were closer to nonvirgins than to non–sexually active virgins. This data is supportive of the importance of asking about all sexual behaviors and not just focusing on vaginal intercourse (Table 39.2). Subsequently, there have been additional studies that have investigated sexual behaviors other than vaginal intercourse (Gates and Sonenstein, 2000; Mosher et al., 2005).

TABLE 39.1 Percentage of High School Virgins in Each Demographic Group who Engaged in Each Heterosexual Genital Sexual Activity during the Prior Year

Activity % Demographic Group Numbera Masturbation of Partner Masturbation by Partner Fellatio with Ejaculation Cunnilingus Anal Intercourse a Covers the range of virgins in each demographic group who responded to each item. Demographic groups differed significantly by chi-square test: b p < 0.001;c p < 0.01;d p < 0.05. From Schuster MA, Bell RM, Kanouse DE. The sexual practices of adolescent virgins: genital sexual activities of high school students who have never had vaginal intercourse. Am J Public Health 1996;86:1570, with permission. Gender              Male 385–387 30 31 11 9 1  Female 432–434 29 31  8 12 <0.5 Grade              9th 255–260 25 27  7  7 1  10th 242–244 33 36 12 11 1  11th 176–178 30 30  8 10 0  12th 135–136 31 33 10 15 1 Race/ethnicity              African-American 45–46 30 33  2 11 0  Asian and Pacific islander 104–106 16 16  4 10 0  Latino 190–192 24 24  7  7 1  White 403–407 36 39 13 12 1  Other/mixed 52  29b  37b  10c 13 2 Total number Males and Females 817–821 29 31   9d 10 1

Oral Sex

Over the past several years there has been increased media attention regarding the prevalence of oral sex, giving the impression that it is of epidemic proportions. However, between 1988 and 2002 there did not appear to be any significant increase in males receiving oral sex from females (Gates and Sonenstein, 2000; Mosher et al., 2005). There are no comparable data for females over this time. The most recent data that includes both males and females is from the National Survey of Family Growth (NSFG) (Mosher et al., 2005) (Tables 39.3 and 39.4). This survey explored the sexual activities of 15- to 19-year olds. Forty-six percent of 15- to 17-year-old males were not sexually experienced whereas 36% had vaginal intercourse and 44% had oral sex. Twenty-one percent of 15- to 17-year-old male virgins (no vaginal intercourse) and 85% of nonvirgins had engaged in oral sex. The data for 15- to 17-year-old females indicated that 48.6% were not sexually experienced whereas 39% have had vaginal sex, 47% oral sex with a male, and 8% oral sex with a female. The

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percentage of females engaging in oral sex differed between virgins and nonvirgins. Eighteen percent of virginal women between 15 and 17 years of age had oral sex with a male and 4.8% had oral sex with a female. Eighty percent of nonvirgin 15- to 17-year-old females reported oral sex with a male and 14% had oral sex with a female.

TABLE 39.2 Percentage of High School Students Who Used Illicit Substances and Engaged in Other Problem Behaviors during the Prior Year, by Category of Sexual Experience

Virgins             All Students   No Sexual Activitya (n = 496–502) Masturbation with Partnera (n = 167–169) Oral Sex (n = 110–113) Virgins (n = 805–815) Nonvirgins (n = 856–874) The sample sizes reported in parentheses cover the range of respondents for each item in the left-hand column. The values for the three virgin categories do not add up to the values for all virgins because the response rate for the individual sexual acts was lower than that for virginity. a The ‘No Sexual Activity’ category includes virgins who did not report engaging in heterosexual masturbation with a partner or oral sex during the previous year. The ‘Masturbation with Partner’ category includes virgins who reported engaging in heterosexual masturbation with a partner but not heterosexual oral sex during the previous year. The ‘Oral Sex’ category includes virgins who reported engaging in heterosexual fellatio with ejaculation or cunnilingus regardless of whether they had also engaged in heterosexual masturbation with a partner during the previous year. Sexual experience groups differed significantly by chi-square test: b p < 0.001; c p < 0.05. From Schuster MA, Bell RM, Kanouse DE. The sexual practices of adolescent virgins: genital sexual activities of high school students who have never had vaginal intercourse. Am J Public Health 1996;86:1570, with permission. Illicit substances            Drank beer, wine, liquor, or other alcoholic beverages (not counting religious ceremonies) 56 77 87b 64 88b  Smoked cigarettes 24 41 56b 32 59b  Used marijuana (pot, grass) 10 30 45b 19 57b Other problem behaviors            Skipped class or school without a good excuse 48 67 80b 56 78b  Stayed out late at night without parents' permission 35 58 63b 44 58b  Took something not belonging to you worth more than $50  8 17 27b 13 31b  Ran away from home for overnight or longer  3  8 9c  5 17b

Adolescents believe that oral sex is significantly less risky than vaginal sex when considering health, social, and emotional consequences. It is less of a threat to their values and beliefs. However, oral sex is still more acceptable in dating than nondating relationships (Halpern-Felsher et al., 2005). The 2002 NSFG (Mosher et al., 2005) reported that 16.2% of males and 22% of females (Table 39.5) between 15 and 24 years of age who engaged in oral sex abstained from vaginal sex for moral or religious reasons; oral sex has a different religious or moral value than vaginal sex in their belief system.

Anal Sex

The 2002 NSFG reported that 8.1% of males had anal sex with a female and 3.9% had anal or oral sex with a male. In virgin males, the rate of anal sex with a female was 1% and oral or anal sex with a male was 2.6%. For nonvirgin males, the rate of anal sex with a female was 20.7% and oral or anal sex with a male was 6.4%. In addition, 5.6% of females had anal sex with a male. For virgin females, the data did not reach statistical significance and for nonvirgins it was 28.6%.

Sexual Pressures

There is still much to learn about the full range of noncoital sexual behaviors of adolescents. The role that noncoital sexual behavior plays in the areas of pregnancy, STDs, and avoidance or protection of virginity is not completely understood.

Coital Sexual Behaviors

There are several sources of data on the rates of sexual intercourse in American adolescents. The four major surveys currently available are the following (see the Web sites for full data):

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TABLE 39.3 Types of Sexual Contact for Males 15 to 19 Years Old Including Anal and Oral Sex

Opposite-Sex Sexual Contact             Oral         Characteristic Number (in Thousands) Any Opposite- Sex Sexual Contact Vaginal Any Oral Gave Received Anal Female Touched Penis Any Oral or Anal Sex with a Male No Sexual Contact with Another Person a Figure does not meet standards of reliability or precision. Adapted from Mosher WD, Chandra A, Jones J. Centers for Disease Control and Prevention. Sexual behavior and selected health measures: men and women 15–44 years of age, United States, 2002. Adv Data Vital Health Stat 2005;362:1. Age                     15–19 years 10,208 63.9 49.1 55.2 38.8 51.5 11.2 52.4 4.5 35.4 15–17 years 5,748 53.2 36.3 44.0 28.2 40.3 8.1 42.7 3.9 46.1   15 years 1,930 43.2 25.1 35.1 15.5 30.3 4.6 35.4 2.2 55.9   16 years 1,998 53.3 37.5 42.0 27.0 39.4 7.3 43.2 3.1 46.3   17 years 1,820 63.5 46.9 55.7 43.2 51.9 12.9 50.1 6.6 35.6 18–19 years 4,460 77.7 65.5 69.5 52.4 66.0 15.2 65.0 5.1 21.6   18 years 2,392 74.4 62.4 65.4 50.5 61.7 15.1 59.2 4.3 24.6   19 years 2,067 81.6 68.9 74.2 54.6 70.9 15.3 71.6 6.0 18.0 Ever had vaginal intercourse with a female and age Yes 13,624 100.0 100.0 88.8 75.1 85.9 31.3 81.3 5.3 —  15–17 years 2,069 100.0 100.0 84.8 60.5 79.3 20.7 80.0 6.4 —  18–19 years 2,912 100.0 100.0 90.2 69.9 86.9 21.9 82.1 6.0 — No 6,393 30.0 — 25.2 13.5 22.2 1.3 24.8 4.4 67.9  15–17 years 3,629 27.1 — 20.7 10.0 18.1 1.0 21.7 2.6 71.8  18–19 years 1,537 35.7 — 30.6 19.6 26.8 a 33.0 3.3 62.4

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TABLE 39.4 Types of Sexual Contact for Women 15 to 19 Years Old Including Anal and Oral Sex

Opposite-Sex Sexual Contact             Oral       Characteristic Number (in Thousands) Any Opposite-Sex Sexual Contact Vaginal Any Oral Gave Received Anal Any Oral or Anal Sex with a Male No Sexual Contact with Another Person a Figure does not meet standards of reliability or precision. Adapted from Mosher WD, Chandra A, Jones J. Centers for Disease Control and Prevention. Sexual behavior and selected health measures: men and women 15–44 years of age, United States, 2002. Adv Data Vital Health Stat 2005;362:1. Age                   15–19 years 9,834 63.3 53.0 54.3 43.6 49.6 10.9 10.6 35.5 15–17 years 5,819 49.8 38.7 42.0 30.4 38.0 5.6 8.4 48.6   15 years 1,819 33.8 26.0 26.0 18.3 23.9 2.4 7.2 63.7   16 years 1,927 49.6 39.6 42.4 30.4 39.3 6.9 13.1 48.8   17 years 2,073 64.0 49.0 55.5 41.1 49.1 7.3 5.1 35.2 18–19 years 4,015 82.9 73.8 72.3 62.0 66.7 18.7 13.8 16.5   18 years 2,035 78.2 70.3 70.2 61.3 62.4 18.8 13.7 21.2   19 years 1,980 87.8 77.4 74.4 64.2 71.1 18.6 13.9 11.7 Ever had vaginal intercourse with a male and age Yes 13,782 100.0 100.0 87.4 77.6 83.4 28.6 15.6 —  15–17 years 2,251 100.0 100.0 80.1 60.6 74.5 13.9 14.1 —  18–19 years 2,953 100.0 100.0 85.6 75.8 78.7 25.2 17.4 — No 5,858 24.1 — 24.3 17.9 21.1 0.8 4.8 73.0  15–17 years 3,563 18.1 — 18.0 11.4 14.9 a 4.8 79.2  18–19 years 1,049 35.3 — 35.3 26.2 33.0 a 3.7 62.5

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TABLE 39.5 Main Reason for No Vaginal Intercourse among Males and Females 15 to 24 Years of Age

Type of Sexual Contact Characteristic Number in Thousands Total Vaginal Intercourse Oral Sex, but No Vaginal Intercourse No Vaginal Intercourse or Oral Sex, but Other Sexual Contact No Opposite-Sex Sexual Contact STD, sexually transmitted disease. a Category not applicable. b Figure does not meet standards of reliability or precision. c Quantity zero. Adapted from Mosher WD, Chandra A, Jones J. Centers for Disease Control and Prevention. Sexual behavior and selected health measures: men and women 15–44 years of age, United States, 2002. Adv Data Vital Health Stat 2005;362:1. Male              Against religion or morals 2,116 100 a 16.2 (2.8) 2.3 (0.9) 81.5 (2.8)  Don't want to get a female pregnant 1,178 100 a 30.2 (4.8) 11.9 (3.6) 58.0 (4.5)  Don't want to get an STD 569 100 a 23.4 (7.3) 6.4 (2.8) 70.2 (7.7)  Haven't found the right person yet 1,501 100 a 31.0 (4.7) b 67.6 (4.7)  In a relationship, waiting for the right time 360 100 a 30.7 (10.4) b 65.3 (10.8)  Other 492 100 a 13.7 (4.9) b 83.7 (5.2) Females              Against religion or morals 2,497 100 a 21.8 (2.8) c 78.2 (2.8)  Don't want to get pregnant 851 100 a 25.3 (4.8) 0 74.0 (4.8)  Don't want to get an STD 298 100 a 19.1 (6.6) c 80.9 (6.6)  Haven't found the right person yet 1,100 100 a 26.5 (4.3) c 73.5 (4.3)  In a relationship, waiting for the right time 357 100 a 37.0 (8.7) c 63.0 (8.7)  Other 685 100 a 20.3 (7.6) c 79.7 (7.6)

• Youth Risk Behavior Survey (YRBS), http://www.cdc.gov/HealthyYouth/yrbs/index.htm;
• National Survey of Family Growth (NSFG), http://www.cdc.gov/nchs/nsfg.htm;
• National Longitudinal Study of Adolescent Health (Add Health), http://www.cpc.unc.edu/projects/addhealth;
• National Survey of Adolescent Males (NSAM), http://www.nichd.nih.gov/about/cpr/dbs/res national3.htm.

Although all four surveys collect information about sexual behavior, they differ in purpose, design, and implementation (Tables 39.3, 39.4, 39.5, 39.6, 39.7; Figs. 39.2, 39.3, 39.4,39.5).

The 2005 YRBS (http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5505a1.htm) that surveyed “in-school” youth (Fig. 39.2) found that 47% of students in grades 9 to 12 had vaginal intercourse (48% male, 46% female). This increased from 34% (29% female, 39% male) in 9th grade to approximately 63% by their senior year (62% female, 64% male). Four percent of females and 9% of males in grades 9 to 12 started having sex before 13 years of age (Fig. 39.3). More than 20% of high school seniors had four or more partners (Fig. 39.4). The pregnancy rate for seniors (2003 survey, data not available in 2005) was 8%; 5% of male seniors revealed that they had fathered a pregnancy (Fig. 39.5).

The 2002 NSFG (http://www.cdc.gov/nchs/datawh/statab/pubd.htm-Sexual Activity) (Tables 39.3 and 39.4) surveyed both “in- and out-of school” youth and found that 39% of 15- to 17-year-old females and 36% of 15- to 17-year-old males had engaged in vaginal intercourse. By the time adolescents reached 17 years of age, 46.9% of males and 49% of females had vaginal intercourse and by 18 years, this increased to 62% for males and 70% for females.

Trends in Sexual Intercourse

To put adolescents' current sexual behavior into perspective, it helps to look at trends over time. Rates for sexual intercourse and its sequelae have been decreasing (Table 39.6). From 1991 to 2005, there has been a decrease in teens who had sexual intercourse and those who had four or more partners (Table 39.6). There was no change

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in the percentage that had been sexually active within 3 months before the survey but there was a downward trend. Table 39.7 tabulates data from the 1997 and 2005 YRBS, the 1995 and 2002 NSFG, and the 1995 NSAM for males and females by ethnicity. It is important to note that each survey has different rates for sexual intercourse due to the different sampling methods and populations surveyed.

TABLE 39.6 Trends in the Prevalence of Sexual Behaviors

1991 1993 1995 1997 1999 2001 2003 2005 Changes from 1991–2005a Changes from 2003–2005b a Based on linear and quadratic trend analyses using a logistic regression model controlling for sex, race/ethnicity, and grade. b Based on T-test analyses. c 95% confidence interval. Adapted from National Youth Risk Behavior Survey (YRBSS), 1991–2005. (http://www.cdc.gov/yrbs/pdf/trends/2005_YRBS_sexual_behaviors.pdf) Ever had sexual intercourse                   54.1 (±3.5)c 53 (±2.7) 53.1 (±4.5) 48.4 (±3.1) 49.9 (±3.7) 45.6 (±2.3) 46.7 (±2.6) 46.8 (±3.3) Decreased, 1991–2005 No change                   Had four or more sex partners during lifetime                   18.7 (±2.1) 18.7 (±2.0) 17.8 (±2.7) 16 (±1.4) 16.2 (±2.6) 14.2 (±1.2) 14.4 (±1.6) 14.3 (±1.5) Decreased, 1991–2005 No change                   Currently sexually active                   37.5 (±3.1) 37.5 (±2.1) 37.9 (±3.5) 34.8 (±2.2) 36.3 (±3.5) 33.4 (±2.0) 34.3 (±2.1) 33.9 (±2.5) No change, 1991–2005 No change

Protective and Risk-Promoting Factors

The Henry J. Kaiser Family Foundation and Seventeen magazine formed a public information partnership to provide young people with information and resources on sexual health issues. As part of this partnership, they regularly survey teens on their sexual lives. The Kaiser Family Foundation published the National Survey of Adolescents and Young Adults: Sexual Health Knowledge, Attitudes and Experiences in 2003 (Kaiser Family Foundation, 2003).

Oral sex was viewed by 24% (18% males, 31% females) of 15- to 17-year olds as a way to avoid vaginal intercourse.

Many of these teens agreed with the statement that “oral sex is not as big of a deal as sexual intercourse” (46% of all teens, 54% of males, and 38% of females). In fact, almost 40% (47% males, 30% females) of youth viewed oral sex as safer sex.

Kaiser Family Foundation also partnered with the Seventeen magazine and issued several reports under the heading of Sex Smarts (Web site www.kff.org). In October 2002, they released a report (http://www.kff.org/youthhivstds/3257-index.cfm) entitled “Relationships” (Fig. 39.1). In this report, both casual and dating relationships were common in 15- to 17-year olds. Twenty-six percent of the teens reported that oral sex was part of a dating relationship “almost always” or “most of the time;” 23% of teens surveyed reported that oral sex was part of a casual relationship.

FIGURE 39.1 Defining relationships. Activities identified to be part of a relationship “almost always” or “most of the time.” (From Kaiser Family Foundation. Relationships: a series of national surveys of teens about sex. www.kff.org/youthhivstds/3257.index.cfm. 2003.)

Adolescents reported a number of reasons that influenced their decision not to have sex including worries about pregnancy (94%), concern about HIV/acquired immunodeficiency syndrome (AIDS) (92%), concerns about STDs (92%), feeling of being too young (91%), concerns about what their parents would think (91%), what they learned in sex education (89%), moral or religious values (84%), had not met the right person (83%), concerns about reputation (77%), partner is not ready (66%), and do not have access to birth control (59%) (Fig.39.6). The major reasons that influenced their decision to have sex included curiosity (85%), partner wanted to (84%), felt like it was the right time (82%), ready to lose their virginity (80%), met the right person (76%), been with their partner for a long time (74%), hoped it would make relationship closer (70%), in love with their partner (69%), many of their friends had

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already done it (62%), wanted to get it over with (58%), ready to marry their partner (53%), and they were drinking or using drugs at the time (18%) (Fig. 39.7). In this survey, 29% (33% males, 23% females) of 15- to 17-year olds felt pressure to have sex. Sixty-three percent (66% males, 60% females) felt that waiting to have sex was nice but nobody really did. Almost 60% (59% males, 58% females) responded in the affirmative that there was pressure to have sex by a certain age and 39% (50% males, 27% females) agreed that “If you have been seeing someone for a while, it is expected that you will have sex.”

TABLE 39.7 Percentage of High School Adolescents Aged 15 to 19 Years or Grade 9 to 12, Who Reported Ever Having Had Sexual Intercourse, by Gender and Survey, According to Race and Ethnicity

Survey, Year, and Comparison Total White Black Hispanic YRBS, Youth Risk Behavior Survey; NSFG, National Survey of Family Growth; NSAM, National Survey of Adolescent Males. Adapted from Mosher WD, Chandra A, Jones J. Centers for Disease Control and Prevention. Sexual behavior and selected health measures: men and women 15–44 years of age, United States, 2002. Adv Data Vital Health Stat 2005;362:1. Santelli JS, Lindberg LD, Abma J, et al. Adolescent sexual behavior: estimates and trends from four nationally represented surveys. Fam Plann Perspect 2000;32:156. Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2005. MMWR 2006;55:SS-5. FEMALE          YRBS (9–12th grade)           1997 48.4 44.7 67.2 48.1   2005 45.7 43.7 61.2 44.4  NSFG (15–19 years old)           1995 36.5 34.3 45.4 47.8   2002 53.0 51.7 61.7 48.8 MALE          YRBS           1997 46.9 41.0 78.9 56.8   2005 47.9 42.2 74.6 57.6  NSAM           1995 41.3 32.8 76.8 47.4  NSFG           2002 48.9 44.5 65.6 56.0

Youth as young as 13 to 14 years old felt pressure to have sex. Forty-seven percent (40% males, 54% females) of 13- to 14-year olds felt pressure to have sex. Almost a one fourth (27% males, 18% females) agreed with the statement, “If you have been seeing someone for a while, it is expected that you will have sex.” NSFG reported on the main reasons for not having sex among adolescents (both females and males) who had never had sexual intercourse (Fig. 39.8). The main reasons included it was against morals and religion beliefs, did not want to get pregnant (or partner pregnant), and had not found the right person. All of these were in the 20% to 35% range. Fear of STDs was given by <10% of adolescent males and females.

Some of the major protective factors associated with whether a teen had sexual intercourse included making a “virginity pledge” (especially for black and Hispanic males and white and black females), perceived personal and social costs to sex, and perceived costs of getting/making someone pregnant (Table 39.8). Virginity pledges are a commitment made by teenagers to refrain from sexual intercourse until marriage. Recent studies have raised questions about the effectiveness of virginity pledges in preventing adolescent sexual behavior. Bersamin et al. (2005) found that private rather than public pledges reduced the likelihood of sexual intercourse. Bruckner and Bearman (2005) found that teens who make virginity pledges start having sex at a later age, but have the same rates of STDs and are less likely to use condoms when they become sexually active. In addition, those who made a virginity pledge were more likely to substitute anal or oral sex for vaginal sex.

Social and Demographic Factors Associated with Sexual Activity

Sexual activity in teens is often described in terms of the traditional demographic factors of gender, race, socioeconomic status, and family structure. The richness of the Add Health study has allowed researchers to explore social factors beyond simple demographics. Blum et al. (2000a) analyzed the Add Health data, looking at several traditional as well as nontraditional variables in an attempt to predict sexual activity.

Race/ethnicity, income, and family structure explained only 9.7% of the difference between younger teens who have or have not had sexual intercourse and 2.9% of the difference for older teens. A more comprehensive picture of the social and demographic factors that affect a teen's choice of being or not being sexually active is described in Table 39.8. Considered jointly, these factors explain 25% to 34% of the difference between males who have and males who have not had sexual intercourse and 35% to 49% of the difference for females.

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FIGURE 39.2 Percentage of high school students who had sexual intercourse, by sex and grade, 2005. Nationwide in 2005, 46.8% of high school students had had sexual intercourse during their life. Overall, the prevalence of having had sexual intercourse was higher among black than white and Hispanic students and higher among Hispanic than white students. (From the Centers for Disease Control and Prevention. Youth risk behavior surveillance–United States, 2005. MMWR 2006;55:SS-5.)

FIGURE 39.3 Percentage of high school students who engaged in their first sexual intercourse before age 13 years, by sex and grade, 2005. (From the Centers for Disease Control and Prevention. Youth risk behavior surveillance–United States, 2005. MMWR 2006;55:SS-5.)

FIGURE 39.4 Percentage of high school students who have had four or more sex partners during their lifetime, by sex and grade, 2005. (From the Centers for Disease Control and Prevention. Youth risk behavior surveillance–United States, 2005. MMWR 2006;55:SS-5.)

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Health Care Provider and Teen Communication about Sex

In a 2000 survey of 15,000 American high school students, only 43% of teenage females and 26% of teenage males discussed pregnancy or STDs with their physicians during routine examinations (Marchione, 2000).

FIGURE 39.5 Percentage of high school students who have been pregnant or who have gotten someone pregnant, by sex and grade, 2003. (From the Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2004. MMWR 2004;53(2):1.)

The Commonwealth Fund (Schoen et al., 1997) published a survey that identified a gap between what adolescents believed doctors should discuss and what doctors actually discuss. Between 35% and 65% of boys thought doctors should discuss issues of physical or sexual abuse, pregnancy prevention, STD prevention, drinking and drugs, whereas <one third of doctors actually discussed these issues. More than 50% of girls wanted to discuss alcohol, drugs, STDs, and eating disorders. However, <30% of doctors discussed these issues (Figs.39.9 and 39.10).

Age Difference Between Sexual Partners

Several states have enacted or started to enforce statutory rape laws because of a concern about adult men fathering babies of teenage females (Darroch et al., 1999; Donovan, 1997; Males and Chew, 1996).

FIGURE 39.6 Reasons that have influenced teens (15 to 17 years old) regarding their decision not to have sex. HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome; STD, sexually transmitted disease. (From Henry J. Kaiser Family Foundation and Seventeen. Sex smarts: decision making about sex. Henry J. Kaiser Family Foundation and Seventeen, http://www.kff.org/entpartnerships/3368-index.cfm. October, 2003.)

The 2002 NSFG reported that 13% of females and 5% of males had a first sexual experience at 15 years or younger with an individual who was 3 or more years older (Fig. 39.11). The younger the teen was at first sexual intercourse, the more likely their partner was at least 3 years older (Fig. 39.12) (Manlove et al., 2005).

Although many teens have their first sexual intercourse with an older partner, 77% of these older male and female partners were still in their teens. Few relationships occur

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when the adult partner is significantly older than the teen. The distribution of age differences between younger teens and older partners is shown in Figure 39.13.

FIGURE 39.7 Reasons that have influenced teens (15 to 17 years old) regarding their decision to have sex. (From Henry J. Kaiser Family Foundation and Seventeen. Sex smarts: decision making about sex. Henry J. Kaiser Family Foundation and Seventeen, http://www.kff.org/entpartnerships/3368-index.cfm. October, 2003.)

FIGURE 39.8 Main reasons for not having sex among adolescents who have never had sex: National Survey of Family Growth, 2002. (From Blum RW, Beuhring T, Rinehart PM. Protecting teens: beyond race, income and family structure, Center for Adolescent health, University of Minnesota, 200 Oaks Street SE, Suite 260, Minneapolis, MN., University of Minnesota Printing Services, Minneapolis, MN, 2000 with permission.)

TABLE 39.8 Factors Associated with Whether Youth had Sexual Intercoursea

Males Females   Whiteb Black Hispanic Whiteb Black Hispanic aThe following risk and protective factors were not associated with ever having had intercourse in any gender/ethnic subgroup: whether would keep child if became pregnant; frequency of religious activities or physical recreation; youth has bad temper; believes successes were earned; self-esteem; parent presence after school; parent presence at dinner; sets own curfew; frequency of parent drinking; family member suicide or attempt; joint decision making; whether Spanish was the primary language at home (Hispanic). b The following were not consistently related to ever having had intercourse among white youths when their sample size was matched to the Hispanic and black sample sizes: ever dated; virginity pledge; ever repeated a grade; hobbies; college plans; parent-family relationship; extended family in the home (adults); friend's suicide or attempt; number of best friends who drink; worked 20+ hr/wk. c Dichotomous (yes/no) variable. History of rape was asked only of girls. d Extent of perceived knowledge of birth control was only weakly related to extent of actual knowledge regardless of grade or sexual experience. e Risk is enhanced if the youth sees a benefit to sex. f Risk is enhanced if the youth repeated a year. g Risk is enhanced if the youth feels knowledgeable about birth control. h Risk is enhanced if the youth sees few social costs. i Risk is enhanced if the youth had a romantic relationship. j Protection is enhanced if the youth sees risk of pregnancy. k Protection is enhanced if the youth has strong religious belief. l Protection is enhanced if the youth has good school attendance. m Protection is enhanced if the youth sees many social costs. ▴ = Risk;○= Protection. From Blum RW, Beuhring T, Rinehart PM. Protecting teens: beyond race, income, and family structure, Center for Adolescent Health, University of Minnesota, 200 Oaks Street SE, Suite 260, Minneapolis, MN, University of Minnesota Printing Services, Minneapolis, MN 2000. Individual sexual experience              Opportunity               Ever datedc         ▴     Ever kissed or neckedc ▴ ▴ ▴     ▴   Romantic relationship in 18 months before surveyc ▴ ▴ ▴e,f ▴ ▴ ▴  Motivation               Made public or written virginity pledge   ○ ○ ○ ○     Perceived personal and social benefits to sex ▴g ▴h ▴I ▴   ▴   Perceived personal and social costs to sex ○ ○j ○j ○   ○k   Perceived costs of getting/making someone pregnant ○l ○l   ○l ○l ○l   Perceived (not actual) knowledge of birth controld ▴ ▴   ▴ ▴ ▴  Individual               Ever repeated a gradec     ▴i         Frequent problems with school work           ▴   Wants and expects to attend college     ○     ○   Religious beliefs           ○m   Physical maturity           ▴  Peer context               Number of best friends who drink       ▴ ▴     Prejudice among teens at school           ▴  Family context               Parents disapprove of youth having sex at this time in their life         ○ ○   Positive parent/family relationships         ○     Number of siblings         ○

Most young females who had sex with older males viewed these relationships as “going steady,” whereas most young males having sexual intercourse with older females viewed these relationships as casual (Fig. 39.14).

FIGURE 39.9 Boys' beliefs about what doctors should discuss and what doctors actually discuss. STD, sexually transmitted disease. Schoen C, Davis K, Collins KS, et al. The commonwealth fund survey of the health of adolescent girls. The Commonwealth Fund. Louis Harris and Associates, www.cmwf.org/publications/publications_show.htm?doc_id=221230. 1997.

FIGURE 39.10 Girls' beliefs about what doctors should discuss and what doctors actually discuss. STD, sexually transmitted disease. (From Schoen C, Davis K, Collins KS, et al.The commonwealth fund survey of the health of adolescent girls. www.cmwf.org/publications/publications show.htm?doc_id=221230. 1997.)

Unwanted Sexual Experiences

Unfortunately, unwanted sexual experiences are very common. The earlier a woman has sex, the more likely it is unwanted (Fig. 39.15 and Table 39.9). During adolescence, intercourse was involuntary in 61% of females who were 13 years old and younger at the time of first intercourse (Table 39.9). Sex with an older male partner increases the likelihood it was forced (Fig. 39.15). In the NSFG, 15- year olds who had their first sexual intercourse with a male at least 3 years older were twice as likely to be forced to have intercourse as compared to other females who are younger than 18 years. One in five females who were 15 years or younger and having sex with a male at least 3 years older reported this experience as “voluntary and wanted” compared to one in three of all sexually active females who were younger than 18 years. Although not commonly reported, males do experience unwanted sexual intercourse. Of males younger than 15 years who had sex with an older woman (more than 3 years older), 22% stated it was unwanted as opposed to 8% of all sexually active males younger than 18 years (Fig. 39.16).

Why is Adolescent Sexuality a Concern

Despite the fact that adolescent sexuality is part of normal development, it remains the focus of much attention and concern. The following are some explanations for this dichotomy:

1. Opposing views of sexuality: Inherent in the problem of adolescent sexuality are the often divergent attitudes expressed by adolescents, their parents, and the community. Predominant views among adolescents are that sex is justified as physical pleasure or as a new experience; it is an index of maturity; it reflects peer-group conformity; it represents a challenge to parents or to society; and it offers an escape from pressures. On the other hand, the adolescent's parents or the community often view sex among teenagers as ill advised, premature, risky, immoral, and frightening.
2. Menarche versus marriage: The age at menarche has decreased significantly over time with improved health and nutrition. In the 1400s, the age at menarche was close to the age at marriage, both of which were approximately 18 years of age. The current average age at menarche is approximately 12.6 years and marriage is put off until after education is completed or a career path is well established. This leaves a significant gap between the time from when teens are reproductively capable and when intercourse occurs within the bounds of marriage. It is no wonder that many teens and young adults find it difficult to delay sex until marriage. This, of course, excludes the GLBT youth who often do not have the legal option of marriage.
3. Difficulties in communication with parents: Numerous studies reveal that approximately two thirds or more of adolescents feel that they cannot communicate with their parents about se Many parents assume that their teenagers do not want to talk about sex. However, many adolescents wish they could talk with their parents about sex. This lack of communication or miscommunication perpetuates misunderstandings and lack of trust. Several studies have demonstrated a positive effect on sexual behavior secondary to parent–teen discussions (DiIorio et al., 1999; Whitaker et al., 1999; Parera and Suris, 2004).

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4. Media: The media (radio, printed media, movies, television, and the Internet) often depict unrealistic views of sexual behavior and its consequences. This can lead to confusion about what sexual behaviors are acceptable.
5. Peer pressure: Adolescents find increasing pressure from their peers to be sexual; a pressure that represents a formidable struggle for many adolescents.
6. Developmental stage: A typical characteristic of early and middle adolescent development (see Chapter 2) is a sense of immortality, with resultant risk-taking behavior. Adolescents often react without a full sense of the potential consequences of their actions. They are caught between the images of sex portrayed by the media, peer values, parental values, and their own developing values. Youth may therefore act impulsively, engaging in sexual activities without being psychologically and emotionally prepared for them. The resultant guilt that many adolescents feel might become a barrier to the development of healthy attitudes toward sex.

FIGURE 39.11 Prevalence of sex between young teens and older individuals. (Source: National Survey of Family Growth, 2002.)

FIGURE 39.12 Percentage of young teens whose first sex was with an individual 3+ years older, by age at first sex. (Source: National Survey of Family Growth, 2002.)

7. Sex education: Many sex education courses, if available, stress upon reproductive function and menstruation. More recently, sex education has focused federally funded abstinence-only education. Although it is important for teenagers to be informed about the mechanics of sexual relationships, they also need help in decision-making skills and in dealing with their feelings, fears, and relationships. Unfortunately, many abstinence-only programs contain medically inaccurate information to frighten teens into not having sex.

American Medical Association, American Public Health Association, Institute of Medicine, Society for Adolescent Medicine and SIECUS, among others, support comprehensive sex education including education about abstinence and different methods of contraception (Klein, 2005; Committee on HIV Prevention Strategies, 2000; Society for Adolescent Medicine, 2006; SIECUS, 2004; Boostra, 2002).

Recommendations

Several suggestions to help adolescents deal better with their sexuality include the following:

1. Parent education
2. Many parents are surprised (and even shocked) to learn that their teenagers are sexually active. Conversely, most adolescents do not think their parents actually have sex. Children need to learn and recognize their parents as sexual beings. It is not unusual for young children or adolescents to interrupt their parents during sex. Although this can be embarrassing for both parties, it can be an opportunity for parents and their children to have a conversation about sex and privacy. The preceding data on frequency and onset of early sexual activity raises the question of when parents should discuss sex with their children. If parents wait until adolescence, it may be too late. Sex is a topic that is often relegated to a one-time “birds and the bees” lecture. Rather than one big talk, parents should talk about sex throughout childhood and adolescence as they would about other aspects of life. These discussions may be hampered by a parent's discomfort with the subject or their personal experience of similar awkward discussions with their own parents. Most parents did not get adequate information about sexuality from their own parents and therefore have few role models to help them teach their own children about sex.

• Infants and toddlers

During this period, a child begins to comprehend gender differences. A first step in a child's sex education is using accurate anatomical terms to

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name the parts of the body. Penises and vaginas should be named in the same matter-of-fact manner as ears, toes, elbows, or noses. It is important for parents to acknowledge that it is normal for toddlers to touch their own genitals. They can be taught that their genitals are private and not to be touched in public. Children can be taught this information in the same way they are educated to cover their mouths when they cough or not pick their noses in public.

FIGURE 39.13 Distribution of age difference among young teens whose first sex was with an individual 3+ years older. (Source: National Survey of Family Growth, 2002.)

FIGURE 39.14 Self-reported relationship type at first sex among young teens whose first sex was with an individual 3+ years older. (Source: National Survey of Family Growth, 2002.)

TABLE 39.9 Percentage of Sexually Experienced U.S. Females Aged 19 Years and Younger with History of Involuntary Intercourse

Age at First Intercourse Involuntary Intercourse Only (%) Both Voluntary and Involuntary Intercourse (%) Voluntary Intercourse Only (%) From Alan Guttmacher Institute. Sex and America's teenagers. New York: Alan Guttmacher Institute, 1994, using data from Moore KA, Nord CW, Peterson JL. 1987 National survey of children. Fam Plann Perspect 1989;21:110, with permission. 13 and younger 61 13 26 14 and younger 42 17 40 15 and younger 26 14 60 16 and younger 10 14 76 17 and younger  5 13 82 18 and younger  3 12 85 19 and younger  1 14 85

FIGURE 39.15 Wantedness of first sex among females who had sex before age 18. (Source: National Survey of Family Growth, 2002.)

FIGURE 39.16 Percentage ever forced to have sexual intercourse among teens who had sex before age 18. (Source: National Survey of Family Growth, 2002.)FIGURE39.16 Percentage ever forced to have sexual intercourse among teens who had sex before age 18. (Source: National Survey of Family Growth, 2002.)

• Preschoolers

At this age, children want to know where babies come from. The best approach is to answer questions with simple and honest answers as they arise. It is not advisable to put children off with “I'll tell you when you are older.” Parents should take advantage of a child's environment which often presents common examples of sex and procreation—a family pet has a litter of puppies; a teacher is pregnant; a younger sibling is born. Children should feel that it is acceptable to ask questions about sex. Children should also feel that sex is something natural that can be talked about within the family.

Sexual abuse of children is present in all societies. Children should be taught the difference between “good” and “bad” touches. A “good” touch is one that feels comfortable and safe. A “bad” touch is one that makes the child feel “uncomfortable” or “confused.” It should be explained to a child that their body is their own and they have the right to say “no” to any touch that makes them feel uncomfortable. A child should also be encouraged to tell a trusted adult if they find themselves in an uncomfortable situation. Regardless, appropriate supervision is always needed.

• Elementary school–aged children

Children at this age are able to comprehend more complex explanations. They will often have questions about what they see on television or hear at school. In American households the television is on for an average of 7 hours a day; teenagers watch approximately 24 hours of television per week. In a year of prime television, there are more than 20,000 scenes of a sexual nature. Television watching and computer use should be supervised at this age. Screen time should be minimized. Parents can use television programs as the impetus for a discussion about sex.

School-aged children can begin to understand about germs, infections, and hygiene. This is an appropriate time to share information about AIDS (what it is, how it is transmitted, how to prevent). School-aged children need to understand that AIDS is not something you get from holding hands, sitting on a public toilet seat, or donating blood.

• Preteens

Onset of puberty is a time when parents should begin frank and open discussions with their adolescents about STDs and pregnancy. Masturbation occurs at all ages and in both males and females. During adolescence, it can be a source of guilt. There is no medical reason to proscribe this normal behavior. Parents should discuss masturbation, wet dreams, and menstruation. Children should be familiar with common terminology about sexuality such as “sexual intercourse” and “homosexuality.” They should understand that feelings of physical attraction toward a member of the same sex are normal during puberty. They should know what intercourse is and that vaginal intercourse can result in pregnancy. They should also understand why preteens are not emotionally ready to have sexual intercourse. Sex can be discussed as a natural and wonderful experience to be shared with someone in a loving relationship. In many Western European countries sexuality is openly discussed from the early stages in a child's education. In these countries, the abortion and adolescent pregnancy rates are significantly lower than in the United States. There is no evidence that discussing sex makes children more likely to engage in it. At this age, pre-teens should have a good understanding of AIDS and STDs and should be taught that safe sex may help prevent their transmission.

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• Teens

In talking with a teenager, parents should openly express their opinions concerning the appropriate time for their child to become sexually active. Parents who believe that their teenager should delay initiation of sexual activities should do so in the context of their religious, moral, or ethical belief system. A teenager can begin to grasp the long-term consequences of their actions. Rules about dating and curfews should be openly discussed. Contraception and disease prevention should be reviewed.

1. Parents can help by walking their teens through various scenarios and role playing with them. For example, a parent might present their daughter with the following scenario:
2. “Your boyfriend invites you to come over and listen to a new CD with friends after school. When you arrive at his house, no one else is home. He sits on the couch with you and tells you how much he loves you. He becomes more “physical” than you are ready for. He wants to have sexual intercourse but you say “no.” He becomes more forceful and angry.”
3. Such a scenario allows the teenager to know that the parent understands the pressures the teen may be experiencing. It also reinforces that the parents are aware that there are situations in which saying “no” can be very difficult. Parents can help their adolescents negotiate difficult situations by building their child's confidence and self-esteem. This will help the teen to resist pressure from others.
4. Teens who are more physically developed or develop earlier than their peers may experience added pressure to engage in sexual behaviors before they are ready as their physical development may exceed their cognitive and emotional development.
5. Teenagers need to be somewhat rebellious in order to forge their own identities separate from that of their parents. Despite this, they usually assume a value system that is similar to their parents. Teenagers often admit that they really do want to know what their parents think. They long for appropriate guidance and limit setting. Sexual values should be taught along with other values. Sexually responsible behavior is part of the overall assumption of adult responsibility.
6. When asked, many adolescents would prefer their parents as counselors and sources of information about sex. If parents feel uncomfortable in this role, it is probably best to acknowledge this discomfort. Parents can admit that they are embarrassed to discuss these issues because of the way their parents talked to them about sex and that they do not want to make the same mistakes. The most important thing that teenagers need to know is that regardless of their “mistakes,” their parents will still love them and try to help them.
7. Timing: Because sexuality begins in childhood, it is important to treat sexuality as a natural part of life from birth onward. Given this perspective, it is much less awkward to have discussions about sexuality as children grow up.
8. Education: Adolescents should be informed and knowledgeable with the help of parents, school, or community resources in the following areas:

• Basic reproductive anatomy and physiology
• Basic sexual functioning and alternatives to intercourse
• Discussion of common myths about sex and contraception; myths should be replaced by medically accurate information
• The consequences of sexual activities including pregnancy, STD, HIV, and parenthood
• Contraception
• The range of human relationships
• The components of decision making
• The importance of self-esteem and respecting one's choices
• Available resources to answer concerns, address questions, or tackle problems

1. Admit personal discomfort: Adolescents respect honesty and this approach will often allow for additional trust between the adolescent and the parent or counselor.
2. Resources: Be informed about available books, pamphlets, and other resources regarding adolescent sexuality. Some valuable references and organizations are listed at the end of the chapter and in Appendix II to this book.
3. Privacy: It is important to respect an adolescent's privacy and at the same time allow them the opportunity to comfortably discuss issues of sexuality without prying into details.
4. Community resources
5. Sex education: Schools need to incorporate a curriculum on sex education that, in addition to including facts, stresses concepts of sexual responsibility and sexual decision making.
6. Family-planning clinics: Increased availability of family-planning clinics that serve and are sensitive to the needs of adolescents is essential.
7. Professional education: It is crucial that health care providers continue to be educated regarding adolescent sexuality, resultant problems, and helpful resources.
8. Contraceptive technology: Development of continued safe, effective, easy-to-use contraception that would complement the adolescent's active lifestyle is needed. The birth control patch and ring are examples of this.
9. Sexual history: A sexual history should be taken of all patients. Providers should become comfortable obtaining a comprehensive sexual history. Chapter 3 includes a description of the HEADSS approach to psychosocial history taking. When taking a sexual history, confidentiality must be clearly stated with an explanation of the limits of confidential health care (e.g., sexual abuse and in some states, statutory rape). Teenagers should be informed that questions about sexual activity are asked of allpatients. Acknowledge that the questions might be embarrassing but need to be asked in order to provide them with good health care. Make no assumptions about sexuality or sexual practices. Teens should be asked if they are “now having” or “have ever had” sexual contact, both noncoital and coital. Adolescents should also be asked if they have ever been forced to have sex. A brief sexual history should be obtained even during episodic care. A teen's symptom of abdominal pain or headaches could be the result of a prior history of sexual abuse or current relationship abuse (see Chapter 3 for more details).

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5. Sexual health of adolescent with chronic illness: The sexual health of adolescents with chronic illness is often neglected. A study of teens with physical disabilities in the Add Health data reports that teens with disabilities have rates of sexual activity similar to teens without physical disabilities. They also found that adolescent females with physical disabilities consistently have higher odds of experiencing forced sex (Cheng and Udry, 2002). A review of studies on risk behaviors in teens with chronic illnesses found a substantial prevalence of sexual activity, but low level of knowledge and low prevalence of contraceptive use (Valencia and Cromer, 2000). The reader is referred to review articles by Gittes and Strickland (2005) for a discussion of the contraception options and dangers of pregnancy for chronically ill adolescents. The clinician should determine the patient's knowledge about sexuality and encourage discussion of sexual relationships, concerns about sexual performance, and ability to reproduce. Zeltzer et al. found that patients with cardiac disease were concerned about sexual activity and had fears of dying during intercourse (Zeltzer, 1980). Openly discussing sexual issues will make teenagers more comfortable about asking questions. Siecus has published a report on sexual education for teens with disabilities (Tepper, 2001).

Web Sites

For Teenagers and Parents

www.noah-health.org/. Ask NOAH. New York Online Access to Health (NOAH). City University of New York, the Metropolitan New York Library Council, the New York Academy of Medicine, and the New York Public Library.

www.goaskalice.columbia.edu. Go Ask Alice is a source of general health and sex information maintained by Columbia University health educators. Most questions answered are submitted by high school and college-aged people.

www.itsyoursexlife.com. It's Your (Sex) Life is sponsored by the Kaiser Family Foundation. Provides sexual health information to young adults.

www.iwannaknow.org. This Web page is specifically designed for teenagers to find answers to their questions about their bodies, sex, and sexual feelings, and to provide them with “responsible educational information in a relaxed, safe, and fun environment.”

http://healthfinder.gov/justforyou/. Just for You: Teens. healthfinderKIDS. HealthFinders Teen Page has multiple links to government-sponsored information for teens and providers.

http://www.ippfwhr.org/. International Planned Parenthood Federation (IPPF). An on-line guide about love and relationships developed by and for young people worldwide. Offers viewpoints on issues including sexual decision making, contraception, and relationships.

http://sxetc.org. Sex etc. is a teen-oriented newsletter from Rutgers University's Network for Family Life Education, produced by a teen editorial board with professional supervision. Topics include dating, relationships, sexuality, communication, and sexual health.

www.chebucto.ns.ca/Health/TeenHealth/. Teen Health, Dalhousie University. This site provides information to teens on a wide variety of reproductive health topics including healthy sexuality, sexual orientation, STDs, pregnancy, women's health, men's health, and sexual assault.

www.advocatesforyouth.org/CORNER.HTM. Teen Scene. Advocates for Youth. Provides a place for youth, particularly those involved in educating others about adolescent reproductive health issues, to connect with each other, share information, and describe experiences.

http://teensexuality.studentcenter.org. Teen Sexuality. The Student Center Network, 2000

www.scarleteen.com. Advice, help and information about teen sexuality. This is a very sex positive site.

www.teenwire.com/index.asp. TeenWire is sponsored by the Planned Parenthood Federation of America. Provides teens with unbiased, uncensored sexuality and sexual health information.

www.unicef.org/voy. Voices of Youth. United Nations Children's Fund. Designed for youth worldwide as a venue to share ideas.

www.butyoudontlooksick.com/2006/03/breaking_the_ice_on_sex_intima.php

www.enablelink.org/abilities/archive.html?article=1663. Sexual Development in Teens with Disabilities

For Health Professionals

http://education.indiana.edu/cas/adol/adol.html. Adolescence Directory On-Line. Center for Adolescent Studies, Indiana University, 1996. Electronic guide to information on adolescent health issues.

http://www.ippfwhr.org. Adolescent Forum Listserv. IPPF/Western Hemisphere Region (WHR) hosts an on-line newsletter that highlights adolescent sexual and reproductive health programs of IPPF/WHR affiliates and other organizations in the region.

http://www.nutrition.uio.no/ARHNe/. Adolescent Reproductive Health Network is a research network including several ongoing research programs and projects. It consists of 18 partner institutions in southern and eastern Africa, as well as in Europe involved in research and/or implementation of programs that target adolescent reproductive health and risk behaviors.

http://www.rho.org/html/adol_links.htm. Adolescent Reproductive Health Outlook. The reproductive health Web site produced by the Program for Appropriate Technology in Health is designed for reproductive health program managers and decision makers working in developing countries and low-resource settings.

http://www.agnr.umd.edu/users/nnfr/adolsex/home.html. Adolescent Sexuality. National Network for Family Resiliency (NNFR). The Adolescent Sexuality Special Interest Group of the NNFR seeks to promote research-based, educational programs that address adolescent sexuality.

http://www.advocatesforyouth.org/. Advocates for Youth provides information, training, and advocacy to youthserving organizations. Advocates for Youth creates programs and promotes policies to help young people make informed and responsible decisions about their sexual and reproductive health.

http://www.agi-usa.org/index.html. The Alan Guttmacher Institute home page. The Alan Guttmacher Institute is a research, policy analysis, and public education organization dedicated to protecting the reproductive choices of men and women in the United States and throughout the world.

http://www.ashastd.org/and www.iwannaknow.org/. American Social Health Association.

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http://www.engenderhealth.org. Engender Health works to improve reproductive health services worldwide.

http://www.cedpa.org. Center for Development and Population Activities includes the following programs:
1. http://www.cedpa.org/trainprog/betterlife/betlife.htm. Better Life Options for Girls and Young Women. A global initiative to empower girls and young women to set goals, build skills, and improve self-esteem.
2. http://www.cedpa.org/trainprog/ppgyw.htm. Partnership Projects for Girls and Young Women, which focuses on community projects conducted by Egyptian nongovernmental organizations to help girls in upper Egypt strengthen their vocational and literacy skills and increase understanding of family life issues.
3. http://www.cedpa.org/trainprog/saharan/subsahaf.htm. Adolescent and Gender Project in sub-Saharan Africa. A multicountry initiative to protect and promote the rights of adolescents to reproductive health information and services, with shared responsibility among young women and young men.

http://www.positive.org/. Coalition for Positive Sexuality.

http://www.socio.com/data_arc/daappp_0.htm. The Data Archive on Adolescent Pregnancy and Pregnancy Prevention of the U.S. Office of Population Affairs is a repository for data on teenage sexual behavior including pregnancy, contraception, behavioral factors, and STDs. Data sets from more than 130 studies published since the late 1970s (many of them longitudinal) were selected as being among the best in the field by a national panel of experts. These data sets are briefly described and may be ordered on-line in several different formats.

http://ec.princeton.edu. Emergency Contraception Web site, a site maintained by the Office of Population Research at Princeton University, provides accurate information based on the medical literature about emergency contraception.

http://www.etr.org. ETR Associates develops health promotion products and services that emphasize sexuality and health education. Currently, they also have an adolescent pregnancy prevention Web site, called the Resource Center for Adolescent Pregnancy Prevention.

http://www.etr.org/recapp. Designed to provide health educators and program coordinators with practical tools and research on reducing sexual risk-taking behaviors among teens.

http://www.europeer.lu.se. Europeer: AIDS Peer Education is a collaborative effort of the department of community medicine, Lund University, Sweden and policy makers, professionals, and youth in 14 European Union countries, focusing on peer education. The site provides knowledge and guidance about the use of AIDS-peer-education with young people.

http://www.familycareintl.org. Family Care International is dedicated to improving women's sexual and reproductive health and rights in developing countries. Site includes publications and working papers, including case studies on adolescent reproductive health in eastern and southern Africa, and information on how to purchase video and text resources.

http://www.jsi.com/intl/seats. Family Planning Service Expansion and Technical Support Project is a program developing and expanding high quality, client-centered, sustainable family planning and reproductive health services in developing countries and enhancing access to these services. SEATS' Youth Initiative information (www.jsi.com/intl/seats/spcint/YOUTH.html) includes descriptions of eastern European and African programs.

http://www.pathfind.org/focus.htm. FOCUS on Young Adults. FOCUS is a Pathfinder International program in partnership with the Futures Groups International and Tulane University School of Public Health and Tropical Medicine. Its goal is to improve the health and well-being of young adults in developing countries.

http://www.kff.org/. The Henry J. Kaiser Family Foundation home page. You can sign up for daily e-mails regarding reproductive health. Has a wealth of information on teen behavior.

http://www.ippf.org. International Planned Parenthood Federation links family planning associations in more than 150 countries worldwide and provides information to a number of other sites.

http://www.jhuccp.org. Johns Hopkins University Center for Communications Programs is a rich source for family planning and reproductive health information. Includes a Media/Materials Clearinghouse; NetLinks, a showcase of on-line resources; PHOTOSHARE, an online database of international photos related to reproductive health; the full text of Population Reports (www.jhuccp.org/pr/index.stm); and Jim Shelton's Pearls (www.jhuccp.org/pearls/), which address various reproductive health issues.

http://healthfinder.gov/justforyou/. Just for You: Teens. HealthfinderKIDS. HealthFinders Teen Page has multiple links to government-sponsored information for teens and providers.

http://www.ppnyc.org/services/msci.html. Margaret Santer Center International. The international arm of Planned Parenthood of New York City aims at developing multimedia education programs relating to sexual health in emerging democracies and expanding adolescent reproductive health services in clinics and community-based programs.

http://www.teenpregnancy.org. National Campaign to Prevent Teen Pregnancy. Information on organization's research, conferences, publications, and resources for parents, teens, and leaders of faith organizations.

http://www.cpc.unc.edu/. The National Longitudinal Study of Adolescent Health (1998) Web site regarding the Add Health Study data available and using the data.

http://www.girlshealth.gov/. The National Women's Health Information Center, Adolescent Health page. The Department of Health and Human Services Office on Women's Health. The page on adolescent health includes brief overviews of HIV/AIDS, STDs, eating disorders, nutrition, exercise, stress, and teen pregnancy in question-answer format.

http://www.piwh.org. Pacific Institute for Women's Health works to improve women's health through applied research, advocacy, community involvement, consultation and training. Information about their adolescent health programs in Africa at www.piwh.org/adolhlth_f.html.

http://www.paho.org. Pan American Health Organization (PAHO) addresses the health of adolescents and youth within the context of their social and economic environment, developing mechanisms to meet their needs. The adolescent health materials section (www.paho.org/english/hpp/hppadol.htm) includes an overview of general health and reproductive health issues. PAHO's Plan of Action for Health and Development of Adolescents and Youth in the Americas 1998–2001 is found at www.paho.org/english/hpp/downloads/planact.pdf

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http://www.plannedparenthood.org. Planned Parenthood Federation of America.

http://www.populationaction.org. Population Action International Web site includes policies and programs to slow population growth; advocates expansion of voluntary family planning and other reproductive health services; and includes search engine to find documents related to adolescent reproductive health.

http://www.popcouncil.org. The Population Council Organization conducts reproductive health research and policy work worldwide. Publications cover a range of reproductive health topics, including adolescent health. Abstracts of “Studies in Family Planning” are available on-line at www.popcouncil.org/publications/sfp/sfpabs.html

http://www.arhp.org/rap/. Resources for Adolescent Providers. Information sharing network provides information on current clinical and social issues that affect adolescents and young adults. Links to sites for adolescents are provided on this site.

http://www.sxetc.org. Rutgers University's Network for Family Life Education. “Sex etc. Newsletter.” Web site for teens.

http://www.siecus.org/index.html. Sexuality Information and Education Council of the United States develops, collects, and disseminates information, promotes comprehensive education about sexuality, and advocates the right of individuals to make responsible sexual choices.

http://www.who.int/dsa/cat98/adol8.htm. World Health Organization Publications. Adolescent Health (1991–2000).

References and Additional Readings

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Alan Guttmacher Institute. Sex and America's teenagers. New York: Alan Guttmacher Institute, 1994.

American Academy of Pediatrics, Committee on Communications. Sexuality, contraception, and the media. Pediatrics 1995;95:298.

Bersamin MM, Walker S, Waiters ED, et al. Promising to wait: virginity pledges and adolescent sexual behavior. J Adolesc Health 2005;36:428.

Blum RW, Beuhring T, Rinehart PM. Protecting teens: beyond race, income, and family structure. Minnesota, Minneapolis: Center for Adolescent Health, University of Minnesota, Minneapolis, University of Minnesota Printing Service, 2000a.

Blum RW, Beuhring T, Shew M, et al. The effects of race/ethnicity, income, and family structure on adolescent risk behaviors. Am J Public Health 2000;90:1879.

Blum RW, Kelly A, Ireland M. Health-risk behaviors and protective factors among adolescents with mobility impairments and learning and emotional disabilities. J Adolesc Health2001;28:48190.

Boostra H. Legislators craft alternative vision of sex education to counter abstinence-only drive. Guttmacher Rep Public Policy 2002;2:1.

Braverman PK, Strasburger VC. Adolescent sexuality: part 4. The practitioner's role. Clin Pediatr (Phila) 1994;33:100.

Britto MT, Garrett JM, Dugliss MA, et al. Risky behavior in teens with cystic fibrosis or sickle cell disease: a multicenter study. Pediatrics 1998;101:2506.

Brown RT. Adolescent sexuality at the dawn of the 21st century. Adolesc Med 2000;11:19.

Bruckner H, Bearman P. After the promise: the STD consequences of adolescent virginity pledges. J Adolescent Health 2006;36:271.

Butler N, Gilby R, McIntyre J, Rowntree C. Introducing sexuality. A guide for presenting sexual issues to adolescent and young adults with developmental disabilities. London, Ontario, Canada: 1995. Available from: Child and Parent Resource Institute, 600 Sanatorium Rd., London, OH N6H 3W7.

Caldirola D, Gemperle M, Guzinski G. Chronic pelvic pain as related to abdominal pain in childhood and to psychosocial disturbance in the family. In: Rizzi R, Visentini M, eds.Pain: proceedings of the joint meeting of the european chapters of the international association for the study of pain. Padua, Italy: Piccin/Butterworth, 1994:291.

Carroll G, Massarelli E, Opzoomer A. Adolescents with chronic disease–are they receiving comprehensive health care? J Adolesc Health Care 1983;4:261.

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Centers for Disease Control and Prevention. Youth risk behavior surveillance–United States, 2005. Morb Mortal Wkly Rep CDC Surveill Summ 2006;55(SS05);1.

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Darroch JE, Landry DJ, Oslak S. Age differences between sexual partners in the United States. Fam Plann Perspect 1999;31: 160.

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Elstein SG, Davis N. Sexual relationships between adult males and young teen girls: exploring the legal and social issues. Chicago: American Bar Association, 1997.

Enright R. Caution: do not open until puberty! An introduction to sexuality for young adults with disabilities. Ontario, Canada: Devinjer House, 1995.

Eyre SL, Read NW, Millstein SG. Adolescent sexual strategies. J Adolescent Health 1997;20:286.

Forrest JD, Singh S. The sexual and reproductive behavior of American women 1982–1988. Fam Plann Perspect 1990;22:206.

Frey MA, Guthrue B, Loveland-Cherry C, et al. Risky behavior and risk in adolescents with IDDM. J Adolesc Health 1997;20: 3845.

Gates GJ, Sonenstein FL. Heterosexual genital sexual activity among adolescent males: 1988 and 1995. Fam Plann Perspect 2000;32:295.

Gittes EB, Strickland JL. Contraceptive choices for chronically ill adolescents. Adolesc Med Clin 2005;16(3):635.

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Gordon S, Scales P, Everly K. The sexual adolescent: communicating with teenagers about sex. Belmont, MA: Duxbury Press, 1979.

Grunbaum JA, Kann L, Kinchen S, et al. Youth risk behavior surveillance–United States, 2003. MMWR Surveill Summ 2004;53(2):1.

Haka-Ikse K, Mian M. Sexuality in children. Pediatr Rev 1993; 14:401.

Halpern-Flesher BL, Corell JL, Kropp RY, et al. Oral versus vaginal sex among adolescents: perceptions, attitudes and behavior. Pediatrics 2005;115:845.

Holt T, Greene L, Davis J. Kaiser Family Foundation. National survey of adolescents and young adults: sexual health knowledge, attitudes and experiences. Menlo Park, C, Henry J. Kaiser Family Foundation, 2003.

Kaufman M. Easy for you to say: Q & A's for teens living with chronic illness or disability. Toronto, Ontario, Canada: Key Porter Books, 1995.

Klein JD. Committee on Adolescence. Adolescent pregnancy: current trends and issues. Pediatrics 2005;116(1):281.

Ku L, Sonenstein FL, Lindberg LD, et al. Understanding changes in sexual activity among young metropolitan men: 1979–1995. Fam Plann Perspect 1998;30:256.

Landry DJ, Forrest JD. How old are U.S. fathers? Fam Plann Perspect 1995;27:159.

Langdell JI. Adolescent sexual preoccupations. Med Aspects Hum Sex 1980;14:90.

Leitenberg H, Detzer MJ, Srebnik D. Gender differences in masturbation and the relation of masturbation experience in preadolescence and/or early adolescence to sexual behavior and sexual adjustment in young adulthood. Arch Sex Behav 1993;22:87.

Males M, Chew KSY. The ages of fathers in California adolescent births, 1993. Am J Public Health 1996;86:565.

Manlove J, Moore K, Liechty J, et al. Sex between young teens and older individuals: a demographic portrait. Child Trends Research Brief, September 2005.

Marchione M. Centers for Disease Control and Prevention National Center for HIV, STD, and TB Prevention. HIV/AIDS Information Center. Teens don't talk sex with physicians.JAMA Available at www.ama-assn.org/special/hiv/newsline/edc/120800g2.htm. Daily News Update: December 8, 2000.

Miller KS, Kotchick BA, Dorsey S, et al. Family communication about sex: what are parents saying and are their adolescents listening? Fam Plann Perspect 1998;30:218.

Miller KS, Levin ML, Whitaker DJ, et al. Patterns of condom use among adolescents: the impact of mother-adolescent communication. Am J Public Health 1998;88:1542.

Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: men and women 15–44 years of age, United States, 2002. Adv Data from Vital Health Stat2005;362:1.

National Adolescent Health Information Center. Fact sheet on adolescent demographics. San Francisco: National Adolescent Health Information Center, University of California, 2000.

Neinstein LS, Katz B. Contraceptive use in the chronically ill adolescent female. Part I. J Adolesc Health Care 1986;7:123.

Neinstein LS, Katz B. Contraceptive use in the chronically ill adolescent female. Part II. J Adolesc Health Care 1986;7:350.

Parera N, Suris JC. Having a good relationship with their mother: a protective factor against sexual risk behavior among adolescent females? J Pediatr Adolesc Gynecol 2004; 17:267.

Remafedi G. Sexually transmitted diseases in homosexual youth. In: Strasburger VC, Greydanus DE, eds. The at-risk adolescent. adolescent medicine: state of the art reviews, Vol.1. 1990:565.

Remez L. Oral sex among adolescents: is it sex or is it abstinence? Fam Plann Perspect 2000;32(6):298–304.

Rew L. Sexual health promotion in adolescents with chronic health conditions. Fam Community Health 2006;29(1 Suppl): 61S.

Santelli JS, Brener ND, Lowry R, et al. Multiple sexual partners among U.S. adolescents and young adults. Fam Plann Perspect 1998;30:271.

Santelli JS, Lindberg LD, Abma J, et al. Adolescent sexual behavior: estimates and trends from four nationally represented surveys. Fam Plann Perspect 2000;32:156.

Schoen C, Davis K, Collins KS, et al. The commonwealth fund survey of the health of adolescent girls. The commonwealth fund. Louis Harris and Associates, Available at www.cmwf.org/publications/publications_show.htm?doc id=221230. 1997.

Schoen C, Davis K, DesRoches C, et al. The health of adolescent boys: commonwealth fund survey findings. The Commonwealth Fund. Available at www.cmwf.org/publications/publications_show.htm?doc id=221410. April 1998.

Schuster MA, Bell RM, Gberry SH, et al. Impact of a high school condom availability program on sexual attitudes and behaviors. Fam Plann Perspect 1998;30:67.

Schuster MA, Bell RM, Kanouse DE. The sexual practices of adolescent virgins: genital sexual activities of high school students who have never had vaginal intercourse. Am J Public Health 1996;86(11):1570.

Schuster MA, Bell RM, Petersen LP, et al. Communication between adolescents and physicians about sexual behavior and risk prevention. Arch Pediatr Adolesc Med 1996b; 150:906.

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Stout JW, Kirby D. The effects of sexuality education on adolescent sexual activity. Pediatr Ann 1993;22:120.

Suris JC, Parera N. Sex, drugs and chronic illness: health behaviours among chronically ill youth. Eur J Public Health 2005;15(5):484.

Suris JC, Resnick MD, Cassuto N, et al. Sexual behavior of adolescents with chronic disease and disability. J Adolesc Health 1996;19:12431.

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Whitaker DJ, Miller KS, May DC, et al. Teenage partners' communication about sexual risk and condom use: the importance of parent-teenager discussions. Fam Plann Perspect1999;31:117.

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