Transcript Sexual Behavior and Teens: Laying a Healthy Foundation It

Teen Sexual Development,
Sexual Behavior and
Decision Making
It’s more than just plumbing
Carol E. Peterson, MS, RN
Nurse Consultant
Wyoming Health Council
Why should adults discuss teens & sex?
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Human beings are sexual beings.
Most people become “sexually active” at some
point in their lives.
Sexual development and some sexual
exploration are normal parts of adolescence.
Adolescents need to be allowed opportunities to
understand what is happening with their bodies,
minds and emotions.
They need to be provided with useful
information and skills so that they can be
prepared to make healthy decisions as teens
and so that they can become sexually healthy,
sexually responsible adults.
Presentation Overview
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Teens & Sex: Complex Factors At Play
Sexual Development
Adolescent Brain and Cognitive Development
Stages of Cognitive Development
Psychological/Emotional Development
Romantic Attachments
Sexual Decision Making, Sexual Behavior
But it’s not sex….
LGBTQ Youth
Other Factors to Consider
Characteristics of Sexually Healthy Adolescents
Implications for Adults
Teens & Sex: Complex Factors At Play
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No clear age at which adolescence begins or
ends (as early as 7/9 to maturity at 19/23).
Age at which puberty begins has been getting
earlier.
Early puberty is associated with early initial
sexual intercourse.
Adolescents experience a strong drive for
intimacy.
Tobacco, alcohol, drug and sexual
experimentation is common.
Sexual activity among teens increases when
they perceive that their peers are also sexually
active.
Teens & Sex: Complex Factors At Play
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During adolescence teens attempt to separate
from their parents and identify more closely with
their peers; become self centered.
Discussion of sensitive subjects with teens is
difficult and there is often lack of communication
between parents and teens.
Media plays a very strong role in adolescents’
concept and view of sexuality (TV, music, music
videos, radio, the internet, movies, magazines,
etc.). Sex is used to sell almost everything in our
society!
Parents can play a role in prohibiting or
promoting sexual activity.
Teen Sexual Development
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1955 Dr. J.M. Tanner developed in-depth
description of development of the reproductive
system during puberty.
Tanner Stages 1-5 for female breast, male
genitalia, and pattern/ distribution of male and
female pubic hair.
 Stage 1 / pre-puberty through Stage 5 /
sexual development complete.
Some variation in speed of progression normal;
can go from Stage 1 to 5 in two to five years.
Body odor - an early sign that puberty is about to
begin!
See www.4parents.gov for detailed information
on normal teen physical sexual development.
Teen Sexual Development
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Growth spurt accounts for 20-25% of adult
height. Begins 1 ½ to 2 years earlier in females
than males, but females peak at end of Stage 3
while in males it continues through Stage 5.
Arms and legs grow more rapidly than the trunk
= spindly look. Feet grow first; sudden increase
in shoe size often first sign child is about to enter
puberty.
Weight gain accounts for half of adult ideal body
weight.
Females experience a greater increase in
adipose mass while males experience a
significant increase in lean mass.
Teen Sexual Development
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Estrogen and testosterone cause the physical
sexual changes noted during puberty.
Male Development:
 Average age of onset of puberty in males
(Stage 2) is 9 to 9 ½.
 First sign of male puberty in usually onset of
testicular enlargement.
 Ejaculation usually begins in Stage 3 with
fertility (sperm production) in Stage 4 (ranges
from age 12 to 16).
 Stage 4 voice deepens; Stage 5 facial hair
thickens.
Teen Sexual Development: Females
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Average age of onset of puberty in females
(Stage 2) is 11.2 (range 9 -13 ½ ), however 7 is
the accepted lower level of normal timing of start
of breast development.
First signs of female puberty – downy pubic hair
and development of breast bud (glandular tissue
can be palpated).
Average age of menarche (menstruation and
egg production) in the U.S. has declined.
Usually occurs at end of Stage 3/start of Stage
4. Has been decreasing over the years: late
1800s = age 16/17, 1954 = age 13 ½, now
average age is 12 ½ with normal range of 12 to
16.
The Brain and Cognitive Development
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Until recent years scientists believed the brain
was largely a finished product by age 12.
According to Piaget the highest rung on the
ladder of cognitive development was achieved at
12 with “formal operations.”
Use of the MRI has paved the way in attempting
to answer questions about brain development
and in providing new insights into patterns of
brain activity.
Not only is the adolescent brain not mature, but
both gray and white matter undergo extensive
structural changes well past puberty, even into
the late 20s!
The Brain and Cognitive Development
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Brain development follows a set plan; cues are
pre-programmed into the genes while other
subtler changes (in gray matter) reflect
experience and environment.
These structural brain changes and the
accompanying psychological changes account
for typical teen behaviors: emotional outbursts,
risk taking, rule breaking, impassioned pursuit of
“sex, drugs, rock & roll.”
Brain overproduces neurons in utero to first 18
months of life, followed by a period of pruning.
The Brain and Cognitive Development
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Second surge in neuron development - bushier
neurons/thickening of gray matter (ages 6-12)
followed by severe pruning at start of puberty;
gray matter is thinned at rate of 0.7% a year &
tapers off in early 20s. At same time white matter
thickens (fatty myelin sheath) - makes neuron’s
signal transmission faster & more efficient.
Development proceeds from back of brain to
front:
 Cerebellum – Back/base of the brain:
coordinates both physical & mental activities –
is particularly responsive to environment &
experience – grows into early 20s.
The Brain and Cognitive Development
– Center of the brain: “emotional”
center of the brain
 Frontal lobe – Front of the brain: center of
cognitive skills, planning, impulse control and
reasoning.
Because of this pattern of brain development
teens will appear more mature in one area of
behavior while seem to be lagging behind in
other areas.
 For example, while older teens do gain
mature language and spatial functions, the
area of brain that controls the executive
functions of decision making and risk
management are not fully developed until
early adulthood (age 25-30).
 Amygdala
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Hormones & Brain Activity
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At the same time as the brain switches from
proliferation to pruning - the hormones kick in!
The intense emotional changes seen in teens
are often attributed to “hormones” - however this
is probably due to a combination of hormones
and structural brain changes.
Hormone production by the adrenal glands also
increases and these are extremely active on the
brain; attach to receptors and directly influence
neurochemicals that regulate mood and
excitability.
Hormones & Brain Activity
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Parts of the brain responsible for sensation
seeking & excitement are “turned on” at the
same time as the parts for exercising judgment
are still “under construction.”
 Like turning on the engine of a car and putting
a unskilled driver at the wheel!
Dopamine - hormone involved with motivation
and reinforcing behavior is abundant & active in
teen years; may influence experimentation & risk
taking.
Melatonin – signals body to begin shutting down
for sleep; daily levels take longer to rise in teens
(so they want to go to bed later and get up later).
Stages of Cognitive Development
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Early Adolescence (ages10/12 to 14)
 Begins use of formal logic operations in
school work.
 They are egocentric, concrete thinkers.
 Begin to form and verbalize own thoughts and
views on many topics.
 Opinions, choices and decisions about home,
school, peers, and intimate relationships
begin to surface.
Stages of Cognitive Development
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Middle Adolescence (ages 14 to 17)
 Surge in complex thinking processes; many
changes occurring.
 Focus on expanding beyond individual
concerns – becomes more philosophical and
futuristic.
 Increased challenging of authority and
analysis of issues and concerns.
 Develops individual code of ethical behavior.
 Thinks in the long term, but often makes
choices and decisions based on urgency and
impulsivity!
 Demonstrates ability to engage in in-depth
discussions.
Stages of Cognitive Development
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Late Adolescence (ages 17 to 19/23):
 Complex thinking processes.
 Focus less on self-centered concepts.
 Increased personal decision making.
 Interest in more global concepts such as
justice, history, politics, patriotism, etc.
 Engages in debate with peers and parents;
often intolerant of opposing views
 Focused on making career decisions.
Stages of Cognitive Development
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Cognitive development is:
1. Linked to brain (structural) development,
2. Reflected in psychological/emotional
development and sexual decision making,
3. Observable in age related sexual
behaviors,
4. Ongoing until the late 20s.
Psychological/Emotional Development
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Critical psychological task is “development of
identity” (Erickson); period when they “define”
themselves.
Time of “storm & stress” for teens and parents.
In general, adolescents have lots of doubts;
about their body image and appearance, who
they are, their sexual identity, goals in life, etc.
Moodiness, conflict and distancing occur within
the family.
Psychological/Emotional Development
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They over identify with those around them.
“Love” at this stage is an attempt to further
define the self.
Important period in life as it is the transition from
childhood to adulthood and is the testing ground
for much of what we come to believe as adults!
Early Adolescence (12-14)
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Independence – initial movement toward
independence.
Emotions & Affect – mood swings; return to
childish behaviors at times (e.g. want to sit on
parent’s lap, play with dolls, etc.) often express
emotions with actions; lots of risk taking.
Relationships - close friendships become
important; less attention shown to parents; lots
of conflict; same sex friends and group activities;
travel in groups.
Early Adolescence (12-14)
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Physical Appearance & Body – group influences
clothing, makeup, hair. Pre-occupied with their
physical appearance.
School, Work & Career Interests – not important;
focus on present & near future (here & now).
Middle Adolescence (14-17)
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Sexuality & Romantic Attachments – girls and
boys enter puberty; shyness, blushing, modesty,
interest in privacy; masturbation; concerns about
“normal” development; sexual curiosity.
Independence – self-involvement; alternate
between unrealistically high expectations and
poor self-concept.
Emotions & Affect – periods of sadness and
emotional withdrawal from parents; use diaries.
Relationships – protest parental involvement;
lowered opinion of parents; high degree of
conflict; parents “don’t know anything”; peer
“group” and youth culture very important.
Middle Adolescence (14-17)
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Physical Appearance & Body – extremely
focused and concerned with own appearance;
sense of being a “stranger in their own body.”
School, Work & Career Interests – intellectual
interests gain importance; greater capacity for
setting goals.
Sexuality & Romantic Attachments – concerns
about sexuality and sexual attractiveness;
increased interest in opposite sex; frequently
changing short-term relationships; emotional
connections expressed as “love and passion.”
Late Adolescence (17-19/23)
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Independence – ability to make independent
decisions; self-reliant.
Emotions & Affect – ability to delay gratification
is a key developmental milestone; more
developed sense of humor; ability to gain insight
into own emotions and behaviors.
Relationships – greater concern for others;
recognition of parents as a resource.
Physical Appearance and Body – sexual
development complete – comfortable in own
skin.
Late Adolescence (17-19/23)
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School, Work & Career Interests – ability to
process ideas and express them in words; ability
to compromise; increased level of concern for
the future; ability to set goals and follow through.
Sexuality & Romantic Attachments – concern
with developing serious relationships; capacity
for sensitivity, caring and sensual love.
Romantic Relationships/Attachments
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Early interactions among opposite sex occur in
the context/safety of larger peer groups.
Romantic Relationships (RRs) are often
superficial and short lived.
RRs may be crucial to identity formation,
transformation of family relationships, ability to
develop close relationships with peers, sexual
identity and academic success.
However, they can become the focal point of an
early adolescent’s daily life.
They imagine an “ideal partner/ideal romance”
and real life relationships may pale in
comparison; confusing media representations
can lead to inevitable disappointment.
Romantic Relationships/Attachments
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RRs can impact mental health, school and family
life and other aspects of teen life such as college
and career plans.
Adults should not take RRs lightly! If they
dismiss these relationships as minor they may
alienate teen and block communications, also
occasionally a teen may take this so seriously
that they might become suicidal when it does not
work out.
Teens may spend great deal of time with
partners and distance self from other friends and
family: need adults help them to keep a balance!
Positive RRS can offer needed positive support
and healthy companionship.
Sexual Decision Making
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Adolescent decision making differs from adult
decision making; depends on the stage of
cognitive, emotional and social development –
However, for the most part emotions rule!
Decisions regarding initiation of sexual
intercourse, use of birth control, and “consent”
issues can have a significant impact on the
health and well-being of an adolescent.
Situations concerning sexual decisions
(consenting to have sex or using contraceptives)
are flooded with passionate emotions; important
decisions often made in the heat of the moment.
Sexual Decision Making
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Teens will state that it is important for them to
wait for the right person or until they reach a
certain age, but during the passion of the
moment they may make a different decision;
they need to develop skills and have a plan so
they can be prepared, in advance, for the
moment.
Psychological changes (personality type/traits,
self-esteem, internal or external locus of control,
etc.); social factors (religious & moral beliefs,
influence of media, etc.); developing sex drive;
developing autonomy; knowledge and skills; all
play roles in the sexual decisions teens make.
Sexual Decision Making
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Elements of Decision Making
 Cognitive Development – may not be refined
enough to allow for realistic cost-benefit
analysis. Dependant on:
Capacity (ability to use cognitive resources)
 Knowledge (acquisition of information),
 Skills (assessment of odds, confidence, etc.).
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Development – Hot Emotions
(strong undercurrents dependant on the
situation) vs. Cold Emotions (rely on basic
values and cognitive skills).
 Emotional
Sexual Decision Making
Development – includes learning the
norms, attitudes, and values of one’s group
and observing others and learning from
experience.
Knowledge alone does not change behavior.
Peer influence is very powerful (i.e. teens whose
friends rarely used condoms 3x more likely to
engage in risky behaviors).
Difficult situation because teens have a
biological/psychological urge for sexual activity
accompanied by a sense of invulnerability to
harm from STI’s, pregnancy, etc.
 Social
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Sexual Behavior
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Normal progression of behavior relates to
age/developmental stage:
 Early adolescence (9-14): postponement &
abstinence, experimentation with nonintercourse sexual behavior is common
 Middle adolescence (13-17): more frequent
experimentation and first intercourse for some
 Late adolescence (17 and older): initiation of
sexual activity/intercourse; sexuality often
associated with commitment and future goals
Sexual Behavior
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2005 Wyoming Youth Risk Behavior Survey
(YRBS): valuable data about teen sexual activity
(as well as many other health related behaviors
such as substance abuse and depression also
some local/district level data is also available):
15.5% or middle school students (6th-8th grade)
report ever having sexual intercourse.
47.1% of high school students (9th -12th grade)
report ever having had sexual intercourse;
increases to 61% for all 12th graders.
Of those high school students who report having
sexual intercourse in the past three months,
64.9% reported using a condom.
Sexual Behavior
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Sexual Debut – most people become sexually
active before adulthood; debut rarely planned in
advance; median age for first intercourse in U.S.
is 16 ½.
Sexual Desire & Sexual Response
 Females: discussion often in context of
“ruining reputation” or “staying pure”
 Males: Discussion in context of sexual
appetite as the underlying “evil” that gets
them (and girls) into trouble
 Teens often frightened and ashamed by
“desire” and “sexual response”; shrouded in
misinformation; adults rarely engage in honest
conversations with teens about these normal
responses.
But its not sex ….
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Young people have redefined sexual behavior –
in large part because of media messages!
Consider themselves “virgins” even if they are
sexually active and engaging in mutual
masturbation, oral sex, or anal intercourse.
Risk of pregnancy may be reduced, but not the
risk of HIV (with anal sex) and STIs (oral and
anal); teens need to know this!
12 & 13 year olds do not truly understand the
implications of oral sex; may see it as less
intimate than intercourse.
But its not sex …
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Girls agreeing for ridiculous reasons (e.g. so
boys will “like” them).
Often don’t see forced oral sex as “rape”
Most information about incidence is anecdotal,
from school nurses and other clinicians (linked
to increases in stomach aches & sore throats).
One national study reported that as many as
50% of students will have tried oral sex by the
time they graduate from high school.
Other risky behaviors: “hooking-up”, ”friends with
benefits”
LGBTQ Teens
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Identifying or being perceived as LGBT or
“queer” is commonly associated with internalized
and externalized stigmatization, victimization
and resultant negative mental and physical
outcomes.
LGBT Identity Development
 LGBT youth must accomplish the same
developmental milestones and processes as
other youth but also are trying to come to
terms with their “difference” as LGBT.
 LGBT adolescents are commonly left isolated
without healthy, socially acceptable venues for
exploring their sexual feelings.
LGBTQ Teens
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Process of “Self Identifying” Has Four
Stages:
1. Acknowledges being or feeling “different”
as child/early teen;
2. Identity confusion (non-heterosexual but
not sure if LGBT);
3. Identity assumption (self identifies &
comes out);
4. Commitment stage (identifies as LGBT in
all aspects of life)
LGBTQ Teens
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Common Safety/Health Care Concerns with
LGBT Adolescents
 Involved in fights; increased injuries;
increased skipping school because of feeling
unsafe; increased rates of attempted suicide.
 HIV/AIDS & Hepatitis, substance abuse,
emotional stress/depression/anxiety disorder
 Need for harm reduction counseling.
Establish Safe Settings for LGBT Youth – pink
triangles, rainbow flags, items with pictures of
same sex couples, use gender neutral language.
They are our children and they need information
and resources to help them reduce their risks.
Many Other Factors/Issues to Consider
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Lots of other factors to consider!
Environmental Factors - single parent home,
lack of healthy adult male or female role models,
too much unstructured/unsupervised time, etc.
Legal Issues: Confidentiality/Right to Privacy,
Minors and Consent/ Right to Access
Reproductive Health Care without Parental
Consent
Access to and availability of reproductive health
care; not always there or may not know how to
access it.
No health insurance (Kidcare/SCHIP covers till
age 19)
Many Other Factors/Issues to Consider
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Previous STI or pregnancy.
Non-Consensual Sex: coercion, abuse, rape
Mental Illness – may engage in more risky
behaviors; may be a significant factor if there is
promiscuity, behavior that is out of character;
teens who report they feel “out of control” with
respect to their sexual behavior.
Chronic Illnesses – sex education and
reproductive health needs are often overlooked.
Physical & Developmental Disabilities – often
are victimized; need sensitive, developmentally
appropriate sex ed; they encounter unique
barriers to obtaining reproductive health care.
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Characteristics of Sexually Healthy Teens
Appreciates and values own body.
Takes responsibility for own behaviors.
Is knowledgeable about sexuality issues.
Communicates effectively with family about
many issues, including sexuality.
Seeks and understands information about
parent’s values and considers them when
forming own values.
Interacts with both genders in appropriate and
respectful ways.
Expresses love and intimacy in developmentally
appropriate ways.
Able to evaluate personal readiness for mature
sexual relationships.
Implications for Adults
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Talk with teens about the many factors that
contribute to early sexual activity
Research shows that if teens think that most
other teens are having sex, they may be more
likely to be sexually active.
Many teens regret becoming sexually active at a
young age.
Teens often lack honest and accurate
information about contraceptives and the long
term consequences of STIs.
Teens have an unrealistic idea of what it is like to
“parent” a child.
Implications for Adults
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Teens can have an unrealistic idea of what the
future might hold for their child.
Teens may be unclear about the financial
responsibilities that come with pregnancy and
raising a child.
Teens need help to plan their future and need
opportunities to discuss birth control options.
Teens need to have hope for the future – a real
problem in parts of WY because of limited
opportunities for good jobs!
Teens thrive when involved in the world around
them; they need healthy outlets such as music,
art, drama, sports, debate team, etc.
Implications for Adults
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Assisting teens to meet their sexual/reproductive
health needs provides an excellent opportunity
to help them begin to develop health literacy –
the ability to understand, gain access to and use
health information and services – a skill many
adults lack!
 Teens are usually healthy so there are limited
opportunities to help them gain this skill –
sexual/reproductive health is something they
are already interested in!
 Clinicians should allow teens opportunities for
decision making and assist them to “plan
ahead” at routine health care visits.
Implications for Adults
 Provide
an environment where open
discussion is allowed
 Encourage teens to share their ideas &
thoughts.
 Allow them to think independently.
 Teach them skills that allow them to become
comfortable with this own bodies: self breast
exams, testicular self exams.
 Recognize and praise teens for well-thoughtout, responsible decisions
 Assist adolescents in reevaluating decisions
that have negative consequences. (How might
you do this differently next time?)
Implications for Adults
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It is crucial to address reproductive anatomy and
physiology, human sexuality, and sexual
decision making throughout adolescence – once
is not enough!
 Different programs, approaches needed at
different stages of adolescence – one two
week class in 7th or 8th grade is not sufficient!
 Programs must be appropriate for teens’
developmental levels and based on their
individual needs (e.g. non-sexually active 13
year olds vs. sexually active 17 year olds
need different programs and services).
Implications for Adults
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Support age/developmentally appropriate sex
education in their communities:
 Abstinence-Only:
can help to delay initiation of
sexual activity in young teens (Jr. High) for up to 18
months – however after that STI rates are equal to
those who have never had any sex ed.; they need
more information as they get older.
 Abstinence-Based: teaches facts about HIV/STI’s
and unintended pregnancy and teaches valuable
communication and refusal skills that can be
transferable to other situations (e.g. when offered
drugs); appropriate for Jr. & Sr. High
 Comprehensive Sexuality Education: best for Sr.
High; a must for high risk and sexually active teens,
incarcerated youth and college students.
In Conclusion….
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In order to effectively assist teens with their own
sexuality adults must first:
 Identify their own sexual views and values.
 Support teens autonomy when possible.
 Show empathy and be good listeners.
 Familiarize themselves with available
programs and resources for teens.
 Know when, how, and where to make
referrals for teens who are already sexually
active, high risk teens, teens in abusive
situations, teens with mental health issues,
substance abuse issues, etc.
In Conclusion….
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Parents, youth serving organizations, churches,
educators, public health and family planning
entities may have different opinions about teen
sexuality but we can and must work together
because we do have a common goal:
 To assist all teens to avoid unintended
pregnancy and STIs and to help them to
become sexually healthy /sexually
responsible adults.
References
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California Family Health Council. (2002).
Reducing Teen Pregnancy: Helping Teens Make
Healthy Decisions. Campbell, CA.
Erickson, E.H. (1968). Identity, youth and crisis.
New York: Norton
Gaffney, D.A. and Roye, C. (2003). Adolescent
sexual development and sexuality: Assessment
and interventions. Kingston, NJ: Civic Research
Institute
Hall, P.A., Holmquest, M., Sherry, S.B., (2004).
Risky adolescent sexual behavior: A
psychological perspective. Topics in Advance
Practice eJournal 4(1).
References
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Neistein, L.S. (1996). Adolescent health care: A
practical guide. Baltimore, MD: Williams &
Wilkerson.
Piaget, J. (1972). Intellectual evolution from
adolescence to adulthood. Human
Development, (15).
Time Magazine. (2004). Secrets of the teen
brain. Pg. 56-65. Issue: 5/10/2004.
www.time.com
Federal web site for parents: www.4parents.gov
Youth Risk Behavior Survey (2005). Wyoming
Department of Education, Health and Safety
Unit. www.K12.wy.us/HS/yrbs/yrbs.asp
Contact Information
Carol E. Peterson, MS, RN
Nurse Consultant
Wyoming Health Council
2120 O’Neil Ave.
Cheyenne, WY 82001
E-mail: [email protected]
Phone: 307-632-3640
Fax: 307-632-3611
Web: www.wyhc.org