The Science of Adolescent Sexual Health: Moving Beyond a Risk Framework

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Analysis Sexual Health

The Science of Adolescent Sexual Health: Moving Beyond a Risk Framework

J. Dennis Fortenberry MD MS

For years, research on adolescent sex was so entrenched in a risk perspective that “adolescent sexual health” was an oxymoron. Today, a new science of adolescent sexual heath is emerging that may help us look beyond risk.

Almost 20 years ago, the remarkable Consensus Statement of the National Commission on Adolescent Sexual Health, endorsed by more than 50 national medical and policy organizations, defined adolescent sexual health: “Sexual health encompasses sexual development and reproductive health, as well as such characteristics as the ability to develop and maintain meaningful interpersonal relationships; appreciate one’s own body; interact with both genders in respectful and appropriate ways; and express affection, love, and intimacy in ways consistent with one’s own values.” The Consensus Statement additionally noted that “responsible adolescent intimate relationships” should be “consensual, non-exploitative, honest, pleasurable, and protected against unintended pregnancy and STDs if any type of intercourse occurs.”

The Consensus Statement is remarkable for its vision, its affirmation of the developmental importance of sexuality, and its recognition that sex itself could be healthy for adolescents. Pursuit and affirmation of its vision could have avoided the subsequent decades-long waste of public funds on abstinence-only-until-marriage programs, and the still-felt chill these programs caused to sexuality research in general.

Looking back the boldness of the statement is even more remarkable when you take into account that most of the empirical evidence available to those crafting it was based only on wide-spread concern about sexually transmitted infections (including HIV) and unintended pregnancies among adolescents. The sexual science that would allow us to understand and aid “responsible adolescent intimate relationships” did not exist in the 1990s. Instead, what we had was a largely uniform set of studies focused on “risk” and “risk behavior.” Sex for adolescents was so entrenched in this “risk” perspective that “adolescent sexual health” was an oxymoron.

In fact, even as we moved into the first decade of the 21st century, there was very little science on which to base understanding of adolescent sexual health within the larger concept of healthy sexual development. However, that has begun to change, and there is evidence of an emerging science of adolescent sexual health that can support and hopefully advance the perspectives of the Consensus Statement. I will highlight four areas here but others are likely to emerge.

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Role of Parents
First, some research has begun to highlight the role of parents in healthy sexual development. For a long time, parents have been viewed as agents whose role was to restrain adolescent sexual activity. Parents’ communication about sex, and parental monitoring were both seen as elements that would increase the likelihood that teens would postpone first sex until some older age, or until marriage. While some attention was given to parents’ role in contraceptive use for those teens who became sexually active, no attention was given to the role of parents in their children’s overall healthy sexual functioning.

New studies are now drawing attention to the idea that parental support and parental monitoring are both associated with increased feelings of sexual agency, satisfaction with sex, and self-reported sexual pleasure. We have also seen data that lack of parental support is part of the many struggles faced by sexual minority youth as they move from adolescence into young adulthood.

Sexual Self-Concept and Self-Efficacy
A second emerging area has to do with the role of sexual self-concept and self-efficacy in adolescent sexual health. These studies suggest that higher levels of sexual self-efficacy are associated with more active sexual decision-making, higher levels of contraceptive use, and lower levels of unwanted sex.

Some of these studies demonstrate that sexual self-concept—at least in adolescent women—tends to improve over time. These studies suggest that adolescents’ sexual health may be best achieved by helping adolescents become more comfortable with their sexuality rather than simply teaching its mechanics and giving warnings about its dangers.

Sexual Dysfunction
A third emerging area has to do with the possibility that sexual dysfunction has a role in adolescents’ sexual health. These studies suggest that a substantial proportion of adolescents and young adults experience sexual difficulties that interfere to at least some degree with their sexual relationships. Young men report erectile difficulties, some of which are persistent, and such difficulties are more frequent during condom use. In addition, a substantial proportion of young women report lubrication difficulties, and, again, these are more frequent in association with condom use.

As adults, we have come to expect that health professionals are attentive to and knowledgeable about such issues, but I suspect few of those professionals could claim knowledge about the sources and solutions for erectile and lubrication difficulties among sexually active adolescents.

Finally, attention to the subjective experiences of sex—arousal, pleasure, and orgasm— has begun to emerge. For many years, one could read literally hundreds of research-based papers on adolescent sexual behavior and find no mention of these topics. More recently, data has begun to demonstrate the consistency with which sexual arousal is associated with sexual activity, and the levels of satisfaction adolescents and young adults have about their sexual lives and sexual relationships.

Taken together, these diverse but still relatively uncommon studies suggest the opening of a new era in our understanding of sexual health. This understanding is focused on adolescents but it is important to remember that adolescent sexuality is not qualitatively distinct from adult sexuality. As part of each person’s sexual life course, adolescence makes a key contribution to a life-long sexuality.

These emerging areas of sexual science suggest that we will be able to approach issues related to sexuality and sexual behavior among adolescents in ways that secure their sexual health as both adolescents and adults.