Adolescent Sexuality

Puberty and Sexuality

The process of puberty encourages the release of specific hormones that are primarily responsible for the development of secondary sex characteristics and for the emergence of reproductive capabilities. The relationship between pubertal change and adolescent sexuality may not only be hormonal but may also include how the teen and others respond to changes in secondary sex characteristics. For example, researchers have found that adolescent boys who demonstrated higher levels of testosterone also reported higher levels of sexual activity (i.e., coitus) (Udry, 1985; Halpern, Udry, & Suchindran, 1998; Finkelstein et al., 1998).

Researchers have also linked hormonal changes at puberty and increased sexual/emotional arousal (Brooks-Gunn et al., 1994). However, higher levels of androgens in adolescent females were not related to higher rates of sexual behavior, but rather were predictive of their anticipation of future sexual involvement. The best predictor of coital behavior in these girls was whether their friends were sexually active or at least supportive of sexual experimentation (Udry, Talbert, & Morris, 1986). More recent research continues to support a mediated model between puberty and sexual behavior (Udry & Campbell, 1994; Halpern et al., 1997). In other words, hormones may enhance feelings of sexual arousal in adolescents but how they act on those feelings is very much determined by multiple internal and external variables.

Noncoital Sexual Behavior

These increased “feelings of arousal” or “desire” manifest themselves in a variety of noncoital and coital thoughts and behaviors (Halpern et al., 1993).

Fantasy.
Having erotic fantasies was acknowledged by 72% of 13- to 18-year-olds (Coles & Stokes, 1985). Sexual fantasies may allow for a safe and nonthreatening way to experience sexual arousal and provide insight into sexual desires and preferences (Katchadourian, 1990).

Masturbation.
When surveyed, 81% of males and 45% of females report masturbating, or bringing themselves to orgasm, by age 18. Adolescent males masturbate three times as often as females, and it is usually their earliest sexual experience. Females usually experience sexual contact with another person before they masturbate. The high prevalence rate suggests that it is a “normative” adolescent sexual experience. However, masturbation is still perceived as “taboo” in the United States and other countries, such as Finland, Sweden, Estonia, and Russia (Kontula & Haavio-Mannila, 2002). It appears that parents rarely talk to their teens about masturbation as a normal sexual outlet and that it is perceived by teens to be less desirable than sex with a partner. As the result of a study comparing young adult males’ reports of their own adolescent masturbation practices to self-reports collected when they were teens, researchers suggested that most studies underestimate the percentage who masturbate by as much as one-third (Halpern et al., 2000).

Petting and oral sex.
When asked about sexual activity, most White adolescents report a continuum of noncoital activity that begins with kissing and French kissing and proceeds to fondling genitalia over and then under clothing, followed by oral sex, and then intercourse (Boyce, Doherty, Fortin, & MacKinnon, 2003). This sexual continuum may not represent the noncoital sexual experiences of all adolescents (Smith & Udry, 1985).

Survey data suggest that overall rates of reported oral sex have increased over the past decade. In a study of over 11,000 students in grades 7, 9, and 11, 32% of grade 9 males and 28% of grade 9 females, as well as 53% of grade 11 males and 52% of Grade 11 females reported that they had engaged in oral sex at least once (Boyce et al., 2003). Another study found that girls are more likely to give rather than to receive from their partner (Gates & Sonenstein, 2000). Adolescents report that oral sex has become a more “normative” aspect of their sexuality and is perceived as a “safe” method of sexual pleasure (McKay, 2004).

Sexual Intercourse

Sexual intercourse is the behavior used most often to report on the status of adolescents’ sexual behavior. It is only one behavior along the sexual continuum, but because of the potential long-term consequences of intercourse it is the most often-reported index. The latest figures show that more than one-half of high school seniors (61.1%) have had sexual intercourse at least once, an approximately 5% decrease since 1991 (CDC, 2003d). These data vary according to gender, race, and ethnicity. Approximately 7.4% of young adolescents had sex prior to age 13 (a figure which is on the decline). This percentage is significantly different from the 19% reported by young Black adolescent males, who, as a whole, engage in intercourse at a much higher rate at a significantly younger age. Also, 28.8% of young African American males report intercourse with a greater number of partners (four or more) than Caucasian (10.8%), Hispanic (15.7%), or other (16.0%) males report (CDC, 2003).

Why do some adolescents initiate sexual intercourse earlier than others? Who delays their sexual debut, or first-time intercourse, and who abstains? These questions are of interest to parents, teachers, practitioners, and health care professionals who want to understand the individual and contextual variables that promote sexual debuts. The answer is determined by the complex interaction of biological, psychological, and sociocultural factors that exert both direct and indirect pressure on the adolescent (Crockett, Raffaelli, & Moilanen, date). Variables such as early maturation,  substance use, having a history of sexual abuse, and having friends who view sexual behavior as acceptable are linked to the initiation of sexual intercourse. Having educational plans, good grades, high religiosity, family support, and parental supervision are linked to the delay of sexual intercourse (Kirby, 2001; Miller et al. 2001). It is unlikely, however, that any single variable can be identified as the sole cause of sexual behavior. Rather, these variables are most likely to aggregate into a profile that is predictive of sexual debut or delay.

Gay, Lesbian, and Bisexual Orientations

The incidence rates discussed above assumed heterosexual behavior. What is not known is how many same-sex experiences were included in the data. In fact, very little is known about the sexual experiences of lesbian, gay, and bisexual youth. Recent research has helped shape our understanding of how sexual orientation and sexual identity provide a context of development for adolescents (D’Augelli & Patterson, 2001; Savin-Williams, 2001).

Now we will focus on same-sex sexual orientation, defined as “a consistent pattern of sexual arousal toward persons of the same gender encompassing fantasy, conscious attractions, emotional and romantic feelings, and sexual behaviors” (Remafedi, 1987, p. 331). Sexual identity is an “organized set of self-perceptions and attached feelings that an individual holds about self with regard to some social category” (Cass, 1984, p. 110). Although some scholars are concerned that this distinction is too simplistic, it clarifies some of the following survey results. For example, when the sexual orientation of 35,000 students in grades 7 through 12 was assessed, only a very small percentage of students defined themselves as lesbian/gay (1.1%) or bisexual (0.9%). However, 11% admitted to being “unsure” of their sexual orientation; this percentage was highest in the lower grades.

In the higher grades, adolescents reported more homosexual activity. The number who self-defined themselves as exclusively gay, lesbian, or bisexual increased from 1 to 3% by age 18, although a larger percentage reported same-sex attractions: 2% at age 12, and 6% at age 18, while 3% reported same-sex fantasies (Remafedi et al., 1992). Consistent with these findings, in a study carried out in Australia, a significant minority of adolescents, between 8 and 11%, did not define themselves as exclusively heterosexual (Hillier, Warr, & Haste, 1996).

Most of this research has been carried out in high schools and most likely has underrepresented sexual-minority youth because they do not always identify themselves. It has been suggested that researchers may be missing at least half if not three-quarters of youth with same-sex attractions (Savin-Williams, 2001).

It may also be the case that youth who self-identify early in adolescence as lesbian, gay, or bisexual are significantly different from those who self-identify in late adolescence or early adulthood. Taking into account the limitations of the methodology and sampling techniques, the following is a summary of research findings on sexual-minority youth:

• Gay adolescents experience the same pubertal transitions as heterosexual adolescents at approximately the same time (Savin-Williams, 1994a).
• Gay adolescents experience similar physiological arousal and seem to be aroused by the same tactile stimulations (Savin-Williams, 1995).
• Studies show a range in the age of initiation of sexual behavior by bisexual and gay males, 12.5 to 16 years, and a higher number of sexual partners than heterosexual adolescents (median age = 8) at age 15 (Remafedi, 1994; Rotheram-Boris et al., 1992).
• When heterosexual, bisexual, and gay males are recruited from similar settings, such as homeless shelters, the number of high-risk sexual acts is similar across groups (Rotheram-Borus et al., 1999).
• Sexual-minority youth are more likely to engage in heterosexual sex than heterosexual teens (Meininger, Cohen, Neinstein, & Remafedi, 2002).

Some research shows that sexual-minority youth have higher incidences of homelessness, substance abuse, eating disorders, isolation, runaway behaviors, domestic violence, risky sexual behaviors, depression, suicide attempts, and pregnancy (Garofalo & Katz, 2001). Although this profile suggests that bisexual, gay, and lesbian youth engage in more high-risk behavior than heterosexual youth, it is inappropriate and inaccurate to overgeneralize this negative trajectory to all sexual-minority youth (Savin-Williams, 2001). Recent longitudinal research shows that the incidence rates of substance abuse, progress at school, feelings of anxiety and depression, conduct problems, and delinquency match the rates of adolescent ethnic minorities and adolescent females, thereby making their experiences far more “normative” than thought previously (Rotheram-Borus & Langabeer, 2001). The focus of future research should be on the identification of moderator variables (e.g., supportive parents) that make some gay, lesbian, and bisexual youth more resilient and on comprehending the diverse developmental pathways within sexual minority groups.

Contraceptive Use

Adolescents’ understanding of contraception as well as their motivation to use it is determined not only by individual characteristics (e.g., gender, race, cognitive level) but also by how their friends, families, teachers, and society at large perceive its use and effectiveness (Lagana, 1999). Condoms and birth control pills are the two most commonly used methods of contraception. The Youth Risk Behavior Survey (CDC, 2003) reports that 63% of adolescents said they used condoms during their last sexual intercourse, up from 46.2% who reported condom use in 1991. The reported use of condoms, however, is highest in the 9th and 10th grades (69%) and then drops to 57.4% in 12th grade. In addition, males report higher use (68.8%) than females (57.4%), and 81.2% of African American males reported condom use during their most recent sexual intercourse experience.

When asked about using birth control pills during last intercourse, 22.6% of all adolescents responded affirmatively. Such use increases from 9th to 12th grade, and females report higher use (27.2%) than males (17.5%). White American females report the highest use of birth control pills (26.5%), with African American females reporting the lowest use (11.7%). Other contraceptive methods used included injectable contraception (10%), withdrawal (4%), and implants (3%) (Alan Guttmacher Institute (AGI), 1998).

Although the use of contraceptives is increasing, many adolescents (37%) do not use any, use them inconsistently, or do not use them during first-time intercourse. An adolescent who does not use effective contraception consistently has a 90% chance of pregnancy within a year (AGI, 1998). Because unsafe sexual practices, such as not using a condom, may result in an unplanned pregnancy or a life-threatening sexually transmitted disease, researchers have tried to understand which adolescents are least likely to use contraceptives and why. Adolescents under 13 are less likely to use contraceptives or use them consistently (Kirby, 2001). Adolescent females are particularly vulnerable to the contraceptive preferences of a partner with whom they would like to stay emotionally connected (Tschann, Adler, Millstein, Gurvey, & Ellen, 2002). Adolescents who have a positive and warm relationship with their parents and are able to talk about sexual behavior and contraceptive use are more likely to use protection (Kirby, 2002a, 2002b).

Focus groups with Latina and African American youth ages 14 to 19 were conducted to try to understand their knowledge of and attitudes toward contraception. The most frequently mentioned barrier to consistent and effective use of contraception was misinformation provided by friends, relatives, and neighbors about current contraceptive practices (Aaron & Jenkins, 2002).

African American Participant 1:  This girl, she got Norplant in her arm. And some other girls told me it don’t work, but she got pregnant when she had hers.
Moderator:  Somebody got pregnant with Norplant?
African American Participant 1:  That’s what she told me.
African American Participant 2:  They say it’s not for everybody to get Norplant.
African American Participant 1:  Well, it won’t be for me.
Moderator:  And what do you think is the best [contraceptive] method?
Latina Participant 1:  None.
Moderator:  No method?
Latina Participant 1:  Maybe condoms or injections, and the pill.
Latina Participant 2:  But they say that condoms break sometimes.
Latina Participant 1:  Yes they break. (from Aarons & Jenkins, 2002, pp. 17–18)

The teens in this study conveyed a sense that no single contraceptive was infallible and might even cause side effects (e.g., cancer from implants). Therefore, using contraceptives was perceived as equally risky as not using them and pregnancy was perceived as somewhat inevitable. Other reasons for noncontraceptive use are

• Unavailability (i.e., they were unprepared)
• Being prepared (i.e., carrying a condom) might send the wrong message (e.g., slut versus good girl)
• Too costly
• Uncomfortable (i.e., condoms reduced sensation and feelings of pleasure)
• No use of contraception is a sign of trust and fidelity in a sexual relationship
• Teens feel ambivalent or positively predisposed towards pregnancy

Aspects of contraceptive education programs that successfully increase use include

• Increased contraceptive availability and affordability
• The building of psychosocial skills that teach proactive contraceptive practices and conversational strategies
• The changing of the subculture so that contraceptive use becomes the norm rather than the exception

Contraceptive education programs are usually incorporated into sex education classes of school- or community-based pregnancy prevention programs. Several consistent findings among studies that evaluate components of contraceptive education are that making condoms more available to adolescents does not increase sexual activity but does increase the percentage of youth who report using condoms (Schuster, Bell, Berry, & Kanouse, 1998; Sellers, McGraw, & McKinlay, 1994). Another finding is that education/prevention programs are more effective with those adolescents who have not yet had intercourse. For some populations (e.g., Black urban youth), this means providing contraceptive information or making condoms available sooner (fifth or sixth grade) rather than later (Johnson, 2002).

Sexually Transmitted Diseases (STDs) and HIV/AIDS

A possible consequence of not using effective contraception is contracting a sexually transmitted disease (STD). STDs are bacterial or viral infections that are passed from one person to another through sexual contact. Approximately 25%, or 3 out of 12 million, of sexually active youth (ages 15–19) contract an STD each year (CDC, 2003e). Sexually active adolescents are at high risk for STDs because they are more likely to have multiple sex partners in shorter-term relationships, engage in unprotected sex, and have partners who are also at higher risk for STDs.

Chlamydia and gonorrhea are the most common bacterial, and therefore curable, STDs among teens, and genital herpes is the most common viral STD contracted by adolescents.

Human immunodeficiency virus, or HIV, is the virus that causes AIDS. AIDS stands for Acquired Immunodeficiency Syndrome. Adolescents are disproportionately affected by the HIV/AIDS epidemic—they have higher infection rates than any other population group in the United States. The group with the highest infection rates is 20- to 24-year-olds. Given the 10-year incubation period for HIV, these young adults were most likely infected during adolescence. Reported rates for adolescents in other countries, particularly sub-Saharan Africa, are alarmingly high (UNAIDS/ WHO, 2002). Adolescent subgroups in the United States are not equally at risk for contracting HIV/AIDS. African American youth, other minorities, and females are particularly susceptible.  Homosexual male youth, urban youth, pregnant adolescents, and adolescent mothers are also at higher risk (Koniak-Griffin, Lesser, Uman, & Nyamathi, 2003). Although there is a decline in the national incidence of HIV/AIDS, it has not been accompanied by a decline in the number of new HIV cases among adolescents (CDC, 2003e).

Information about STDs is usually incorporated into sex education programs and, more recently, AIDS awareness programs. However, a recent study showed that being more knowledgeable about STDs or contracting an STD does not necessarily lead to an increase in condom use (AGI, 2003).

Adolescent Pregnancy

Another possible outcome from not using contraceptives is pregnancy. A total of 4.2% of adolescents reported being pregnant or had gotten someone pregnant one or more times (CDC, 2003d). This percent age marks a significant decline in pregnancy rates over the last decade,  but the United States still has the third-highest adolescent pregnancy rate in the world, behind only the Russian Federation and Bulgaria (Singh & Darroch, 2000). The pregnancy rate of African American teens in 2003 (9.1%) was almost four times higher than that of Caucasians who reported pregnancy during the same year (2.3%) (CDC, 2003d). The proportion of older adolescent females who become pregnant is twice as high (15.3% for ages 18–19) as the proportion of middle adolescents (6.2% for ages 15–17) (AGI, 1999).

An adolescent pregnancy may have several outcomes. The first is miscarriage, or a spontaneous abortion, in which the nonviable embryo or fetus is naturally expelled from the body. Approximately 14% of teen pregnancies end in miscarriage. A second outcome of pregnancy may be an induced abortion, in which the pregnancy is deliberately terminated. Abortion terminates approximately 30% of all adolescent pregnancies and involves a disproportionate number of Caucasian and higher-income teens (Donovan, 1995). Rates of adolescent abortion appear to be heavily underreported in national surveys, especially for non-White females (Jones & Forest, 1992). The number of reported adolescent abortions also has declined over the past decade.

A third pregnancy outcome is giving birth. The 2000 teen birthrate of 48.7 births per 1,000 15- to 19-year-old females is at a historic low for all racial/ethnic groups (Moore, Papillo, Williams, Jager, & Jones, 1999). Approximately one quarter of these births are to females under 15 years, and about three quarters are to 18- and 19-year-olds.

The recent trends in reduced adolescent pregnancies and births have been attributed to a decline in sexual activity and an increase in contraceptive use. The decline in sexual activity has been linked to greater HIV/AIDS awareness, more cautious attitudes towards casual sex, the heightened impact of abstinence education programs, and increased communication between parents and youth about sex. The increase in contraceptive use has also been attributed to HIV/AIDS awareness and to increased parent-teen communication. In addition, the higher availability of effective contraceptives and their correct use may have contributed to the reduction in pregnancies. From an analysis of available data the Alan Guttmacher Institute (2001) estimated that one quarter of the decline in teen pregnancies was due to delayed onset of sexual activity (abstinence) and three quarters to improved contraceptive use. A more recent study estimated that among single 15- to 19-year-old females, the delay of sexual activity (abstinence) accounts for 67% of the decline in pregnancy rates and 100% of the decline in birthrates (Mohn, Tingle, & Finger, 2003).

Consequences of adolescent pregnancy.
Despite these recent declines in adolescent pregnancies and birthrates, approximately 900,000 adolescent females give birth each year in the United States. Our society believes that teenage mothers put themselves and their offspring “at risk.” Past research has shown that mothers under 19 exhibit poorer educational achievement and are more likely to drop out of school (Hotz, McElroy, & Sanders, 1997; Woodward & Fergusson, 2002). They are also more likely to experience high stress and to suffer from depression (O’Callaghan, 2001), are less involved with peers and families, less effective in problem solving, and less cognitively prepared to assume parenting roles (Sommer, Whitman, Borkowski, Schellenbach, Maxwell, & Keogh, 1993). Adolescent mothers followed 3 to 5 years after the birth of their first child by the Notre Dame Parenting Project still tended to be undereducated, underemployed, and give birth to additional children (Whitman, Borkowski, Keogh, & Weed, 2001). Adolescent fathers typically complete less schooling, earn less income, and appear to engage in more delinquent behaviors and drug use than older fathers (Brien & Willis, 1997; Thornberry, Smith, & Howard, 1997; Thornberry et al., 2000).

Children of adolescent mothers weigh less at birth, have more health problems, suffer more physical abuse and neglect, and perform at a lower level in school (Wolfe & Perozek, 1997; Maynard, 1997; Moore, Morrison, & Greene, 1997). Children of adolescent mothers are also more likely to drop out of high school, run away from home, spend time in prison, and have their own children before the age of 19 (Haveman, Wolfe, & Peterson, 1997; Grogger, 1997).

In addition to the less-than-desirable individual outcomes associated with teenage parenting, Maynard (1997) estimated the financial cost to society of adolescent childbearing to be approximately $21 billion per year. As a result of a range of negative and costly consequences, countless pregnancy prevention programs have been designed and implemented, as illustrated in (Kirby, 2001). The following recommendations for middle and high school pregnancy prevention programs are based on existing programs that have had proven success:

• Use instructional techniques that encourage youth engagement in and attachment to school
• Address both pregnancy and STDs/HIV in sex education programs
• Develop service-learning programs that incorporate community service and ongoing small group discussions
• Have school-based or school-linked clinics that focus upon reproductive health and give clear messages about abstinence and use of contraception
• Make condoms available through school programs

Although teenage pregnancy is viewed in the United States largely as a “problem” with negative short- and long-term outcomes for mothers, fathers, and children, recent research based on comprehensive and longitudinal data suggests that this profile does not apply to all adolescent families (Whitman, Borkowski, Keogh, & Weed, 2001). For some adolescent girls, becoming mothers makes them vulnerable to the stress associated with single parenting, including higher rates of depression, child abuse, unemployment, and poverty. However, there are teen mothers who, with sufficient cognitive skills and educational and economic support, show a resiliency that encourages competent parenting and more favorable developmental outcomes for themselves and their children. By examining individual trajectories, we get a better and more accurate sense of the complexity of the factors that determine the outcomes of teenage pregnancy. In addition, we see more clearly how the “interwoven lives” of mothers and children influence the direction of these trajectories.