Beyond Abstinence and Risk: A New Paradigm for Adolescent Sexuality

Beyond Abstinence and Risk: A New Paradigm for Adolescent Sexuality

Objectives Identify limitations of the “Abstinence-Only” and “Sex-as-Risk-Taking” paradigms Discuss ways that dramatization may affect approaches to adolescent sexuality and teen health outcomes Describe the alternative ABCD paradigm of adolescent sexuality Explore practical applications of ABCD paradigm in working with adolescents, parents, and health professionals

Sexual Orientation Sexual Attraction Relationships Paradigm of Sexuality Biological Sex Sexual Behavior Gender Identity/ Expression

Two Narrow Approaches to Adolescent Sexual Development Over past three decades, two approaches have predominated in U.S. sexual health policy and practice: Abstinence-only Sex as risk taking

Sexual development and growth is a natural part of human development What Is Healthy Sexuality? Healthy sexual expression is different than sexual risk Same-sex sexual behavior is included in the realm of healthy sexuality

The Abstinence-Only (No-Sex) Paradigm Provides a code, not empowerment Gives limited tools for navigating relationships other than marriage Makes sex between teens hard to discuss when it does happen Despite investment of federal funds, not shown to be effective

Sex-as-Risk-Taking Paradigm Makes sex a disease rather than part of development Does not distinguish healthy sexual expression from sexual risk Instills fear, not sense of mastery/control Leaves out the pleasurable and relational contexts of sexuality

“Sex as Risk” in Current Practice Medically-derived risk-assessment/prevention, screening, and treatment approach Results in discussions that are based on: Narrow definitions of sexual health Focus on specific sexual behaviors as part of riskassessment strategy instead of personal development and interpersonal relationships

Shared Experiences in Adolescence Across developed nations adolescents go through similar developmental processes Schooling extends into the twenties Marriage in mid to late twenties/early thirties First sex typically happens during teen years What do you think the average age of first sex is in the U.S. and the Netherlands? www.guttmacher.org/pubs/FB-ATSRH.html www.rutgerswpf.nll

The U.S. vs. the Netherlands

Why Compare the U.S. and the Netherlands? Similarities Developed countries Went through a sexual revolution Reproductive health technologies Differences Approaches to adolescent sexuality Adolescent sexual health outcomes Socioeconomic, racial, and ethnic diversity in populations

2016 US Teen Birth Rate 20.3 vs Netherlands Birth Rate 4.5 Teen Birth Rate by Country, Age 15-19, 2008 www.TheNationalCampaign.org

US Birth rates per 1,000 females ages 15-19, by race/ethnicity, 1990-2016 Source: Martin, J.A., Hamilton, B.E., Osterman, M.J., Driscoll, A.K., & Drake, P. (2018). Births: Final data for 2016. Hyattsville, MD: National Center for Health Statistics.

Teen Pregnancy, Birth, and Abortion Rates Are Declining (15- to 19-yearolds), 1973-2013 Kost K, Maddow-Zimet I and Arpaia A, Pregnancies, Births and Abortions among Adolescents and Young Women in the United States, 2013: National and State Trends by Age, Race and Ethnicity, New York: Guttmacher Institute, 2017.

YRBS Question What Methods of Contraception are US High School Youth Using? % of students who used a condom before last sex % of students who used birth control pills before last sex US 53.8% 20.7% % of students who used IUD/Implant, pills, shot, patch, ring 29.4% % of students who used an IUD or Implant before last sex 4.1% National Youth Risk Behavior Survey, 2017

Contraceptive Use Among Dutch Youth is High Sex Under the Age of 25 Survey: Rutgers and Soa Aids Netherlands

The Question Why are there such large differences in sexual health outcomes between countries with so many similarities?

Explaining Differences in Health Outcomes Policies, economics, and culture play a role: U.S. teens are more likely to be poor and lack access to socioeconomic resources Dutch teens have better access to sexual health education and services Adults approach adolescent sexuality differently because of difference in culture

Turning to the Research Study: Examining Cultural Meanings of Adolescent Sexuality For information on this study, see Not Under My Roof: Parents, Teens and the Culture of Sex (University of Chicago Press) or visit works.bepress.com/amy schalet

Interviews with Dutch and U.S. Parents and Teens: 1991-2000 Subject demographics: white, secular, moderately religious, and middle class Interviews: 1-2 hours, taped, transcribed, and analyzed Interview type: Semi-structured, in-depth interviews 72 interviews with boys and girls, ages 15-18 58 parent interviews (mothers and fathers) Elliot S. Symbolic Interaction. 2010.

U.S. Culture and Adolescent Sexuality: Dramatization

Raging hormones United States: Dramatization Sex as risk taking Battle of the sexes Falling in love is extraordinary Secrecy between parents and teens

“Adolescents are completely hormonally driven” —American mother Dramatization —Raging Hormones The concept of “raging hormones” assumes: Teenagers are unable to control urges Disjunction between the onset of hormones and the development of the cognitive and emotional capacity to handle them Parents’ role is to contain Schalet, A. Medscape General Medicine. 2004

Dramatization —Sex as Risk Taking “Sex is a risk. If you’re not looking to have a baby, sex is definitely a risk . I have had a situation where condoms have broken and I was like, flippin’ out of my mind ready to puke. I was like ‘Jesus Christ, we’re dead. I’m screwed for the rest of my life.’” —16-year-old American boy

Dramatization —Battle of the Sexes Males want sex, females want love Consequences fall on females Parents must “protect” females, “rein in” males Schalet, A. Medscape General Medicine. 2004

Dramatization —Love Is Extraordinary Parents: “Teens just ‘think they are in love’; it is not real” Teens: “I want to be in love but other teens just want to have sex” Schalet, A. Medscape General Medicine. 2004

Dramatization —Sex Is a Secret [My mother] hasn’t asked me [whether I am having sex] and I haven’t told her I’d rather her not ask me straight out.” —16-year-old American girl Teens keep sex a secret Some parents prefer “not to know” Secrecy weighs especially on girls

Dutch Culture and Adolescent Sexuality Normalization

Readiness and self-regulation Sex is preparation Netherlands: Normalization Falling in love is common Relationships between the sexes “Normal” sexuality, not secretive

Normalization —Readiness and SelfRegulation “[My daughter] is 16, almost 17. I think she knows very well what matters, what can happen. If she is ready, I would let her be ready.” —Dutch father Teens are able to self-regulate Concept of “er aan toe zijn” or being ready Parents stress that sexual development should occur gradually Concept of “vrijen” A range of behavior, not limited to intercourse

Normalization —Sex as Preparation “It goes without saying that you use them [contraceptives].” —16-year-old Dutch boy Preparation is part of readiness for sex Contraception and condom use are expected preparations for sex

Normalization —Falling in Love Is Common Being in love is a common experience Including for teens In national survey, 63% of Dutch youth say they are “very much” in love with their current sexual partner deGraaf H, Meijer S, Poelman J, Vanwesenbeeck I. Seks onder je 25ste; Seksuele Gezondheid van Jongeren in Nederland Anno 2005

Normalization —Relationship Between the Sexes “If they really have something special with someone and then [sex] happens, well then who am I [to object]?” —Dutch mother Sex is part of a relationship Reflects mutual desires and interests Parents support relationships Not casual sex Schalet, A. Medscape General Medicine. 2004 De Graaf et al. 2005 CBS 2003

“It should be normal to talk about during dinner” —Dutch mother Normalization —“Normal” Sexuality Concept of “gewoon” or normal sexuality Sex should be normal, acceptable part of life Sex should not lead to secrets but be discussed openly between family members Sex should not cause conflict and alienation between parents and teenagers

Normalization —Sex Is Negotiation “I wanted to tell my mother. I don’t know. It was on my mind. So I told her regardless of the consequences.” —16-year-old Dutch girl An open subject is rendered negotiable Parents may not always be completely comfortable with teen sex, but they do not want it to lead to deception

Can Cultural Approaches to Adolescent Sexuality Change?

Conceptualizing a New Paradigm: ABCD2

ABCD ABCD2 HEALTHY SEXUALITY A New Paradigm AUTONOMY BUILD CONNECTEDNESS DIVERSITY/DISPARITIES 2

A New Paradigm Adolescent sexuality is a normal process of psychosocial and biological development Sexuality is a continuum along which youth move as maturity and relationships permit Adults play vital roles in providing resources and supporting the development of skills

FIRST: Provider Values Clarification Be aware of your own feelings about adolescent sexual behavior. How comfortable are you talking to adolescents? What are your feelings/beliefs about adolescent sexuality? Are you able to separate your own values to effectively counsel your patient?

Case: Janice 16-year-old female She has decided to have sex for the first time Wants to know where her boyfriend can get tested for STIs

A New Paradigm A Develop Autonomy of Sexual Self

Research has found that: Autonomy of Sexual Self Personal control and self-efficacy in sex negotiation are significantly associated with safer sex behavior Adolescents with a sense of control over their lives (in general and in sexual situations) more likely to abstain from sex or to use condoms when they engage in sexual intercourse

Research has found that: Autonomy of Sexual Self “Sexual subjectivity”—sexual body esteem, sense of entitlement to pleasure, sexual self-reflection—is associated with higher levels of self-efficacy in condom use in girls Girls who report more “sexual self-efficacy”—ability to act upon their own needs in a relationship—are more likely to have used condoms at first intercourse.

Case: Janice How would you respond to Janice and her service request? How could you assess her autonomy? How can you create positive communication about sexual decision-making?

Autonomy: Pearls for Practice Assess understanding of anatomy, reproduction, and contraception Identify sources of information Bridge gaps through education Assess self-efficacy in other domains and problem-solving abilities

Autonomy: Pearls for Practice Acknowledge the pleasurable and enjoyable aspects of sexual contact Normalize desire and arousal Emphasize owning and controlling one’s sexual decision-making Help youth examine readiness Promote preparation for sexual activity

A New Paradigm B Build Good Romantic Relationships

Building Healthy Relationships Research has found that: Communication with partners about contraception prior to first sex significantly increases contraception use in both genders Open communication in adolescent dating couples increases communication about contraception

Building Healthy Relationships Research has found that: Adolescent sexual activities are more likely to be safe, wanted, and pleasurable when: Partners are more equal (in age) Teens feel satisfied by their relationship Teens experience intimacy in their relationship

Building Relationship: Pearls for Practice Discuss peer relationships as lead-in to romantic relationships Acknowledge the value of relationship-building and the “virtues” of intimate relationships Encourage youth to discuss Defining a healthy relationship Communication with partners Sex-related communication Conflict resolution

What does a healthy relationship look like to you? Building Relationships: Pearls for Practice Disagreements and arguments are a normal part of any intimate relationship. What is it like when you and your partner get into an argument? How do you usually resolve it? How often are you and your partner together? How does your partner feel about you hanging out with other friends? (If sexually active) Who makes the decisions about when to have sex and what kind of contraceptives you should use?

A New Paradigm C Connectedness Between Adolescents

Case: Eric 15-year-old male His mother comes in concerned her son may be having sex She requests information on pregnancy and STIs she can give him to encourage abstinence

Research has found that: Connectedness Maintaining connectedness with parents/guardians and other trusted adults is important for many aspects of adolescent health, including sexual health

Research has found that: Connectedness Parent-teenager communication about sex has positive impacts on teen sexual health when: Parents and teenagers have a close relationship Communication about sex is frequent rather than one-time Teenagers feel their parents are open and comfortable in discussing the topic

Connectedness: Including Parents in the Discussion Adolescents aged 12 to 19 years report that parents are the greatest influence regarding sexual decision-making and values Nearly 87% of adolescents agree that “it would be easier to postpone sexual activity and avoid adolescent pregnancy if they were able to have more open, honest conversations about these topics.”

Case: Eric How do you respond to Eric’s mother and her service request? How can clinicians foster communication between adolescents and adults in regard to sex and sexual health? What other adults might be in Eric’s life to give Eric support around sexual decision-making?

Case: Eric How might this parent encounter have differed if this mother was concerned about her daughter rather than her son? How might you promote the concept of relationship between the sexes in this parent encounter?

Connectedness: The Caregiver Role in Education Parents usually not primary source of information Many parents feel unsure about how best to approach the topic Discussions about sexuality limited to one “Big Talk” Communication about sex not very extensive Parent-teen conversations about sex often one-way Based on the experiences and perception of the parent

Guiding Patients Towards Connectedness Parental Involvement vs. “Parentectomy”: Encourage honest and open communication if possible between caregiver and teen Encourage parents to communicate their values and beliefs but recognize that their children may have different perspectives and experiences

Connectedness: Pearls in Practice Talking to adolescents: Examine patient’s perspective of relationship with caregiver Examine barriers for conversation with caregiver about romantic/sexual relationships Offer to be a resource to both parents and teens

Connectedness: Pearls in Practice Talking to caregivers: Acknowledge to caregiver talking about relationships is difficult, but healthy Help caregiver understand the importance of modeling healthy relationships

A New Paradigm D 2 Recognize Diversity and Disparities

Research has found that: Diversity and Disparities Poverty and lack of access to socioeconomic and health resources negatively affect many aspects of adolescent sexual health, including STD/HIV rates Pregnancy rates Contraceptive use Teens’ feelings of self-efficacy

Cultural Humility Practicing “cultural humility” and patient-centered interviewing Recognizes interactions between A-B-C & D2 Avoid generalizing based on knowledge of some cultures/communities Patients communicate the role of culture in the encounter

Recognizing Diversity and Disparities in Practice How do we create best practices for diverse populations? How do we utilize knowledge about health disparities in communities without making assumptions about individual patients?

Diversity and Disparities: Pearls for Practice Where is the patient in his/her sexual development? How do cultural, religious beliefs play into patient values around sexuality? What barriers exist for patients to access health services and health information? How do socioeconomic forces shape patients experiences with clinicians?

NORMALIZE adolescent sexual development ABCD : Overall Practice Implications 2 Provide access to comprehensive and accurate reproductive and sexual health information and care Promote affirming discussions about sexual feelings and arousal, decision-making, responsibility, and relationships Change from “parentectomy” to parental involvement when appropriate/possible Reframe research focus—go beyond risk to help inform and support a paradigm shift

Conclusions Sexual development is a natural part of adolescence Cultural approaches to sexuality can affect clinical practice and patient outcomes Traditional clinical approach in the U.S. is primarily one of risk-assessment New paradigm needed to recognize healthy sexuality beyond abstinence and risk

Beyond Individual Practice Providers can advocate to normalize adolescent sexual development, and provide youth with necessary resources In schools In group practice In professional organizations In communities With policymakers

Exercise: Case Studies

Case: Shana 17-year-old female Comes to the clinic for emergency contraception Has received at the ED before Reports inconsistent condom use with her current boyfriend

Case: Shana How would you respond to Shana’s service request? How could you use a conversation about condom use to discuss healthy relationships?

Case: Maria 17-year-old female Scheduled visit for Depo-Provera shot and instead indicates desire for pregnancy Living with the same foster family since age 7 Foster family is part of a conservative DominicanAmerican community

How do you respond to Maria? Case: Maria What are some questions you would ask about family, community, and partner support to help her make decisions about childbearing? How can you recognize diversity of patients and cultural backgrounds in family planning discussions?

Case: Maria How can you recognize disparities in health education and access in a conversation about family planning? How can you help this patient access health and community resources?

www.advocatesforyouth.org—Advocates for Youth www.aap.org—American Academy of Pediatricians Provider Resources and Organizational Partners www.aclu.org/reproductive-freedom American Civil Liberties Union Reproductive Freedom Project www.acog.org—American College of Obstetricians and Gynecologists www.arhp.org—Association of Reproductive Health Professionals www.cahl.org—Center for Adolescent Health and the Law www.glma.org Gay and Lesbian Medical Association

www.guttmacher.org—Guttmacher Institute Provider Resources and Organizational Partners janefondacenter.emory.edu Jane Fonda Center at Emory University www.msm.edu Morehouse School of Medicine www.prochoiceny.org/projects-campaigns/torch.shtml NARAL Pro-Choice New York Teen Outreach Reproductive Challenge (TORCH) www.naspag.org North American Society of Pediatric and Adolescent Gynecology www.prh.org—Physicians for Reproductive Health

Provider Resources and Organizational Partners www.siecus.org—Sexuality Information and Education Council of the United States www.adolescenthealth.org—Society for Adolescent Health and Medicine www.plannedparenthood.org Planned Parenthood Federation of America www.reproductiveaccess.org Reproductive Health Access Project www.spence-chapin.org Spence-Chapin Adoption Services

Resources for Parents Additional Resources Advocates for Youth: Parents Sex Ed Center www.advocatesforyouth.org/parents-sex-ed-center-home Adolescent Health Working Group: Resources for Parents/Caregivers http://www.ahwg.net/resources-for-parents.html American Academy of Pediatrics Healthy Children www.healthychildren.org/English/Pages/default.aspx Planned Parenthood Tools for Parents www.plannedparenthood.org/parents/index.htm

Resources for Educators and Teens Additional Resources Healthy Children Radio: Adolescent Dating Violence, featuring Elizabeth Alderman, MD, FAAP www.futureswithoutviolence.org SexEdLibrary (a project of SIECUS with resources for providers of sexuality education) www.SexEdLibrary.org www.datingabusestopshere.com (DASH) Adolescent Health Working Group: Resources for Youth www.ahwg.net/resources-for-youth.html

Please Complete Your Evaluations Now