TEEN SEX DECISIONS

Helping teenaged girls make wise sexual decisions

By Mary B. Short, PhD, and Susan L. Rosenthal, PhD

Rational decision-making and raging adolescent hormones do sound like strange bedfellows. But research reveals some ways ob/gyns can help teens make wiser choices—and grow into healthy sexual adults.

Each year approximately 3 million new cases of sexually transmitted diseases occur in adolescents, and one in four sexually active teens will get an STD before they're old enough to vote.¹ As daunting as that statistic may be, ob/gyns can make a difference during adolescence—a time marked by the onset of puberty and sexual maturation. They can help teens to develop healthy sexual decision-making skills, while steering them away from health-compromising behaviors linked with acquiring STDs or becoming unintentionally pregnant.

The sobering pregnancy statistics (approximately 800,000 to 900,000 adolescent pregnancies each year) have further repercussions.² Saddled with these responsibilities at such a young age, many teen parents face an uphill battle completing high school, becoming financially secure adults, and coping with the demands of caring for a baby—both emotionally and cognitively.³

Understanding developmental processes can aid both clinicians and parents alike in their efforts to help adolescents. Adolescents are qualitatively different at each stage, and even teens of identical age may be at different stages of biological, cognitive, and/or emotional development. For example, while one 16-year-old may already be dating and having sexually intimate relationships, another may be spending her time with groups of peers playing sports. Therefore, consider your adolescent patient's development across time and within context, including individual characteristics, family environment, social milieu, and relationship context.

The research on adolescent sexual behavior has concentrated on coital behaviors, and contraceptive and STD-protective behaviors. Sexual behaviors include kissing, masturbation by self or other, genital-oral contact, and genital-anal contact. Despite growing interest in the prevalence of oral sex, little attention has been paid to identifying the influences for engaging in any of these other sexual behaviors outside of intercourse. Therefore, in this article we'll focus on identifying influences on decision-making about sexual intercourse, but that doesn't diminish the importance of understanding factors influencing other sexual behaviors.

How individual characteristics influence sexual decision-making

The timing of puberty, cognitive development, and the level of psychological functioning are characteristics impacting sexual decision-making that are specific to each individual. These three variables influence not only sexual decision-making, but also STD acquisition and unintended pregnancies. To understand just how difficult it can be to sort out these influences, consider that earlier puberty may be linked with more problem-behavior only in girls who were having difficulties even before puberty.^4,5

The relationship between earlier puberty and sexual risk-taking has both biological and environmental causes. For example, others may respond to girls who mature early as if they were older, which can propel them into dating and sexual situations.⁶ Moreover, perhaps girls who mature early may show more interest in sex due to higher hormones levels.

Young teens are "concrete thinkers." At about 14 years, adolescents begin to develop the ability to think hypothetically, abstractly, to imagine possibilities not yet experienced, although some individuals never develop these skills. Some researchers hypothesize that concrete thinking makes it tough for teens to protect themselves against STDs and pregnancy.^6,7 Regardless of the level of cognitive functioning, adolescents are inexperienced sexual decision-makers. In general, people tend to function at their highest problem-solving level in familiar and unemotionally laden situations.

Another aspect of cognitive functioning is intellectual functioning. A higher degree of intelligence seems to be protective against early initiation of sexual intercourse.⁸ Teens who are doing poorly academically or having other problems in school are more likely to start having sex at younger ages.^8-11 On the other hand, involvement in school activities, attachment to school, and good attendance are associated with a later onset of sexual intercourse.^12,13

What is the impact of psychological functioning—such as low self-esteem, depression, and other risk-taking behavior—on sexual decision-making? Research findings have been mixed—for several reasons.^14-17 First, researchers have used different assessment measures, so they're not always measuring the exact same parameter. Although some reports suggest causal links between substance use and high-risk sexual behaviors (for example, the decision not to use a condom or choice of partner), distinguishing between causality and association is no easy task.¹⁸ To conclude that substance use is causal, you'd need to show that an adolescent does not use a condom when using substances, but does use one when sober.¹⁸

Another difficulty is the ability to assess the true underlying reason for behavioral associations. For example, using substances during a sexual encounter is different from viewing alcohol as the reason for sexual intercourse.¹⁹ Alcohol and drugs may serve as social cues for sexual activity, rather than prompting the decision.²⁰ It's been proposed that high-risk behaviors (sexual and otherwise) and substance use are related to underlying psychosocial functioning (e.g., impulsivity) or cultural values that accept a lifestyle characterized by health-compromising behavior.^17,18,21 For example, Santelli and colleagues found that lifetime substance use and non-use of condoms were associated (reflecting a behavioral style), but that substance use and condom use at last intercourse were not correlated.²¹

How family environment influences sexual behavior

A teen's family environment influences her sexual behaviors in many ways (Table 1). Girls whose mothers or sisters had a teen pregnancy also have first intercourse at earlier ages.^10,22,23 On the other hand, authoritative parenting—exemplified by parents who set developmentally appropriate standards for behavior, provide structure, and set limits within a warm and caring environment—is associated with a child's general psychosocial competence, including less sexual risk-taking.^23-29 Greater parental supervision and involvement is related to girls being more sexually assertive,³⁰ delaying sexual initiation,^31,32 using dual contraception,²³ and being less likely to become pregnant or acquire an STD.^33,34

TABLE 1
How adults can positively influence a teen's sexual development

Encourage and educate teens about general healthy behaviors; discourage risk-taking behaviors.

Provide opportunities for success in school and work.

Send positive messages about her body and sexuality.

Encourage her to delay becoming sexually active.

Foster positive parental-adolescent relationships by promoting authoritative parenting skills, providing guidelines about teen supervision, and encouraging communication.

Have parents send clear messages regarding values and expectations.

Encourage parents to make every attempt to get to know a teenager's friends and boyfriends.

Another important aspect of effective parenting is communication about sexuality. Parent-adolescent discussions on this topic are related to less risky behavior, less conformity to peer norms, and teens' stronger belief that parents are the best source of information about sex.^32,35-38 Parents should not shy away from expressing their views. For example, adolescents who perceive that their mothers disapprove of them having sex are more likely to delay becoming sexually active.^13,37,39,40 Sexually experienced teens, whose parents communicate their approval of birth control measures, are more likely to use birth control.⁴¹

In addition, the frequency of conversations makes a difference. Teens who've had more sex-based discussions with parents are more likely to hold conservative attitudes towards teen intercourse in general.^36,38 Furthermore, adolescents who talk more often with their parents about sex-based issues are more likely to consistently refuse unwanted sex.⁴² Merely communicating with the adolescent isn't sufficient, however; the context in which communication occurs is crucial. Parent-adolescent communication is effective when the parents are skilled communicators and when the adolescent-parent relationship is positive.^39,43,44

How social milieu influences sexual behavior

The social context of an adolescent's life, including peer and societal norms, influences the adolescent's decision-making choices. As adolescents age, they spend a greater amount of time with their peers. Not surprisingly, there is a relationship between adolescents' perceptions of their peers' behaviors and their own sexual behavior. Adolescents who perceived that their friends had an early sexual initiation, engaged in unprotected sexual intercourse, and/or had multiple partners were found to engage in those same behaviors and view those behaviors positively (i.e., being sexually experienced was associated with social gains.)^45-48 However, again, it is difficult to ascertain whether adolescents who engage in risky sexual behavior choose friends who are engaging in similar behaviors or whether the social context of their peers leads to riskier sexual behaviors. As noted above, it is important to remember that adolescents whose parents communicate with them about sexuality are less likely to conform to peer norms.³⁵

In general, American teens, particularly girls, are given confusing and mixed messages about sexuality (Table 2). Girls are not encouraged to express or acknowledge emerging feelings of sexual desire and arousal, and may even be taught to perceive such feelings as inappropriate.^6,49,50 Discouraging females from acknowledging their sexual feelings can be potentially damaging by leaving them unprepared for the challenges involved in sexual situations. For example, girls may let intercourse "just happen" so that they do not need to acknowledge their desire.

TABLE 2
Important messages for teens*

Sexual feelings are a normal part of life, but acting on them has consequences and you're not invulnerable.

Wait to do anything until you feel comfortable with the person and the activity.

Do not place yourself at risk for unintended pregnancy, sexually transmitted diseases, or physical harm. Multiple partners raise the risk.

Just because you're symptom-free doesn't mean you don't have an STD.

Gravitate towards places where there are enough people to turn to, in case a situation becomes uncomfortable.

You never have to do something that you do not want to do.

Adults can help you if you are feeling confused about what the right thing is to do.

Health-care providers can answer your questions confidentially.

If you do decide to have intercourse, use a condom and a back-up method and talk to your health-care provider. Birth control only works if it's used consistently.

*Spell them out in terms a teen can grasp at what you judge to be her stage of cognitive development.

An additional difficulty is the different societal messages given to girls and boys about the other gender's views. For example, girls may assume that boys would not want to use a condom and would respond negatively to being asked, whereas boys may assume that girls will ask.⁵¹

The media is a powerful source of the messages adolescents receive about sexuality. Although sexual content in the media can influence any age group, adolescents seem to be particularly vulnerable because their cognitive skills can prevent them from critically analyzing the messages given to them. These messages often contain unrealistic, inaccurate, and misleading information that young people accept as fact. As a result, the media may function as a "norm-setter" for sexual behavior in teens, which may lower their sense of risk of potential consequences. ^52,53

How relationship context affects sexual behavior

During adolescence, interactions become more collaborative; friendships become more significant; and romantic relationships develop. Within each partnership, decisions about specific sexual behaviors are made. Aspects of a relationship that influence sexual decision-making include opportunity, degree of closeness, and perception of the relationship (ranging from casual encounter to steady boyfriend).

Our research found that sexually experienced girls spent more time outside of school with their boyfriends and believed that their relationship would last longer than did girls who were sexually inexperienced.⁵⁴ Furthermore, the sexually experienced girls were more likely to share unique information with their boyfriends. However, we don't know whether these qualities led to sexual experience or resulted from being sexually intimate.⁵⁴

Although in general, adolescents believe that intercourse should happen in a committed relationship, sometimes teens do find themselves having sex with people they don't know well.⁵⁵ The type of relationship impacts whether or not condoms are used. For example, adolescents were more likely to use condoms in "one-night stands" than in steady relationships.⁵⁶ Condoms also were more likely to be used with older partners, when sexual intercourse is less frequent, and when the partner was perceived as supportive or was asked consistently to use condoms.^46,57-60

Implications for practice

As we've seen, the psychosocial influences affecting a teen's sexual decision-making are many. The goal is for adolescents to make choices that are based on and lead to the following four goals:

(1) viewing one's body and its physical changes positively; (2) accepting and feeling comfortable about sexual feelings, arousal, and desire; (3) feeling comfortable about sexual behavior; and (4) for sexually experienced adolescents, practicing safer-sex behaviors.⁷

You can promote the development of healthy sexuality in adolescents directly through your interventions and indirectly by supporting other positive influences in adolescents' lives. As you take a comprehensive sexual history, don't hesitate to take the lead in discussing sensitive issues, since adolescents may be interested but not able to initiate the conversation.⁶¹ Adolescents appreciate an ob/gyn who is interested in "all of them," so as you interview a teen (with no one else in the room), try to slip in sensitive questions between asking about friends, school, and extra- curricular activities. (You can also imbed sensitive questions in questionnaires.) In addition, have brochures on hand, such as those produced by the American Academy of Pediatrics, for adolescents to take home. But be discreet. Adolescents need to be able to take the brochure privately and not under the watchful eyes of parents.

Indirectly, clinicians can influence choices by fostering authoritative parenting skills and parent-adolescent conversations about sexuality, while maintaining adolescents' right to confidential care. You can provide parents with guidelines about the supervision that adolescents need and what constitutes developmentally appropriate limit-setting. In addition, encourage parents to get to know their adolescents' friends and boyfriends.⁶² You can support parents in developing their own skills at discussing sexuality comfortably with their teens or advise them to find other family members with similar values with whom the adolescent feels comfortable.

Finally, you can work with your communities to ensure that school and community interventions incorporate programs that demonstrate evidence-based effectiveness. Reviews of successful programs find that they share the nine qualities listed in Table 3.⁶³

TABLE 3
Nine criteria for successful community intervention programs for teens

(1) Reduction in one or more sexual behaviors that lead to HIV/STD risk

(2) Appropriateness to age, sexual experience, and culture of participants

(3) Basis in theoretical approaches

(4) Duration of sufficient length to complete activities

(5) Variation in teaching methods that allows fthe participants to personalize the information

(6) Provision of basic and accurate information

(7) Attention to social pressures.

(8) Modeling and practice of communication, negotiation, and refusal skills

(9) Leadership (i.e., teachers or peers) that believes in the program's effectiveness⁶³

Conclusions

As we've discussed, many influences affect the development of behaviors associated with health versus those linked with risk. Because these influences are interrelated, consider them together to accurately understand an adolescent's risks and strengths. Keep in mind that because each adolescent is an individual product of his or her own culture, no one strategy will work for all teens. By guiding teens to make wiser choices, ob/gyns and other health-care providers are in a unique position to help them grow up to be healthy sexual adults.

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Dr. Short is a Postdoctoral Fellow, and Dr. Rosenthal is Director, Division of Adolescent and Behavioral Health, and Professor, Department of Pediatrics, at University of Texas Medical Branch, Children's Hospital, Galveston, Tex.

Acknowledgments
Supported by a grant from the National Institutes of Health, Grant # HD40151. The authors would like to acknowledge Jasmine Majkowski and Stephanie Ramos for clerical and resource management support.

Key points

• Each adolescent's ability to make good decisions about becoming sexually active and avoiding sexually transmitted diseases and unintended pregnancy varies. Timing of puberty, progress in developing the ability to think like an adult, and level of psychological functioning all play a part.

• Ob/gyns can help a teen directly by bringing up sensitive issues—and indirectly by fostering authoritative but caring parenting skills that provide structure, limit-setting, supervision, and parental involvement.

• Teens whose parents communicate with them about sexuality are less likely to succumb to pressure by peers who engage in risky sexual behavior.

• Ideally, a teen's choices should be directed by: (1) a positive view of her body and its physical changes; (2) acceptance of and comfortableness with sexual feelings, arousal, and desire; (3) comfortableness about sexual behavior; and (4) practicing safer-sex behavior.

Mary Short, Susan Rosenthal. Helping teenaged girls make wise sexual decisions.

Contemporary Ob/Gyn

May 1, 2003;48:84-95.