Teenage Sexuality: A Doctor's Thoughts

If you have no memories of high school that make you blush, you are an exception to the rule. For most of us, adolescence is an intense and tumultuous time, and can leave us years later with the question, 'What happened back there?"

Dr. Jennifer Johnson wondered this herself. "I'm sure that I chose to work with teenagers for reasons that relate to my own adolescence, and probably some unresolved issues about that time. Adolescents are fascinating people. They're going through one of the most important and active developmental periods in their lives."

As the Chairperson of the Section on Adolescent Health of the American Academy of Pediatrics, and a practicing physician, Dr. Johnson knows more than most about American teenagers today. Below, Dr. Johnson shares some of what she's learned about teenage sexuality, risky behavior, and growing up.

When adults use the words 'teenager' and 'sexuality' together, they're usually describing a problem. But are there healthy ways for teenagers to express themselves sexually?

Sexuality is a very important part of who we are, and adolescents who have gone through puberty have the same hormones and the same hormonal drive as adults. And our society reinforces those drives. We do all kinds of direct and indirect things to encourage sexual intercourse and sexual behavior -- everything but talk about sexuality. So we're giving our kids a double message.

On the one hand, we're exposing them to people who have sex, for example, on TV, but on TV they don't talk about contraception and don't use condoms. We tell our teenagers, "No, you shouldn't do that," but we don't talk with them about how they might express their sexuality in a healthy way.

What are the current trends in teenage pregnancy?

The good news is that in the last five years or so, teen pregnancy rates in the United States have been declining. And there's a lot more condom use than there was in the mid-'80s, early '90s, which also helps protect teenagers from STDs.

But the United States has still got, by far, the highest teen pregnancy rate of any developed country in the world. The reason for that is not because our kids have sex at a younger age than in other cultures. It's because they're less likely to use contraception.

And because our pregnancy rate is so high, our abortion rate is also much higher than in other developed countries. About a third of adolescent girls who became pregnant have had abortions. And that's across the socioeconomic board, from poor kids to rich kids.

How well do kids understand sexual risks?

In general, early adolescents are not ready to understand the consequences of having sex. A lot of them don't really understand how babies are made, even in this day and age, and they have tons of misconceptions about pregnancy. There are still beliefs among teenagers that a girl can't get pregnant if she's on her period, or she can't get pregnant if it's her first time, or that pulling out is a reliable contraceptive method. There's a lot of misinformation.

Doesn't cognitive development have something to do with what teenagers understand about sex? The teenage brain is still growing...

Yes. Once they reach middle adolescence - 14 to 16 years old -- they can generally think abstractly, which makes it a lot easier for them to understand the implications of sex. Even though you can't see the egg and the sperm coming together, you can imagine how they might. And it appears that abstract thinking isn't really fully mature until people are around 17 to 19 years of age.

Are teenagers then inherently bigger risk takers than adults?

Yes and no. Adults do take risks, but often within a different context than adolescents. For example, the majority of pregnancies in adult American women, as in American teenagers, are unplanned. But adults are more likely to have completed their education, to be economically stable, and to have a stable relationship with the baby's father. Many experts believe that some degree of risk-taking is a normal part of adolescence. This is called "exploratory behavior," and it is part of finding out who you are, and what life is like.

But adolescents usually can't incorporate experience into risky situations. They don't have as much experience in solving problems -- they don't have the background. For instance, it's probably easier to avoid an accident when driving at night if you have hundreds of hours of daytime driving under your belt.

And when teenagers are in situations that are new and/or stressful, they tend to revert back from abstract thinking to concrete thinking.

So kids tend to steer their way through tricky situations using this less conceptual, or developed, thinking?

Yes, and that's one reason why a lot of prevention programs -- for sexual activity or pregnancy prevention or substance abuse prevention -- focus on teaching kids the skills that they need in new situations, sometimes even rehearsing the situations. They imagine scenarios they could find themselves in, and practice handling them.

Can you give an example?

So, "Okay, this guy that you've gone out with is pressuring you to have sex. What do you say?" And they actually practice. They have skill-building exercises. "How do you get home if things are uncomfortable, and you don't feel safe with this guy? What do you do?"

That goes back to my mother telling me to always take a dime in the heel of my shoe on a date so I'd be able to call home for a ride if I needed to.

The story's always the same.

Yes, it is. And you know, that was a wise thing that she did.

But getting back to taking risks, we do know that certain risk behaviors imply other risk behaviors, right?

Yes. Risk behaviors tend to cluster. If a kid is smoking cigarettes, now or within a short period of time that kid is more likely to become sexually active, more likely to drink alcohol, and probably more likely to experiment with other drugs, et cetera.

As a doctor, what sorts of information are you looking for from teenagers about their sex lives?

We're in a time-limited situation, so if the teenager has had sex, we usually focus on when they first had sex, and who their first partner was. If a girl had sex when she was 12, that raises red flags for me, because she's much more likely to have been sexually abused than a girl who didn't have sex until she was 16. And I ask how old the partner is. A girl whose partner is considerably older may feel pressure to have a baby. And of course there are many other ramifications if an adult is having sex with a minor.

I also want to know what kinds of protection they have used, among other things.

Do they share this information openly?

I find that kids are very willing to share information with me that can be critically important in their medical care as long as they know that confidentiality is going to be maintained and they can trust that confidence.

Do you find it difficult not be openly critical of teenagers when they tell you about their sexual experience?

I think in our society we are fairly judgmental, and as a physician, I feel I need to step back from that. There are sound medical reasons for delaying age at first sexual intercourse, limiting the number of sexual partners, and, of course, using protection against pregnancy and sexually transmitted infections.

But if I see a 13-year-old and talk with her about sexual intercourse, and she says, "I've decided I'm not going to have sex until I'm married," I reinforce to her the value of holding off on having intercourse. And if a kid is 15 or 16 and having sexual intercourse, I don't think it is helpful to say, "Don't do it anymore," but I'll try to make sure that she or he is adequately protected from pregnancy and STDs. And I talk with them about these as potential consequences of sex. But I try to do it in a nonjudgmental way.

Doctors who care for teenagers should encourage them to behave in ways that are physically and emotionally healthy and respectful of themselves and others. I don't think that telling a sexually active teenager that what he or she is doing is "wrong," is helpful or productive. On the other hand, this doesn't mean I can't ask a 15-year-old girl who is thinking about having sexual intercourse whether she would like my opinion about it.

What I tell our residents is that you need to learn how to provide medical service to these kids, and in your practice, if you feel that you can't provide nonjudgmental care for them, then you should refer them to another physician. I think it's critical that doctors who are providing care for teenagers be nonjudgmental. It's just an absolute prerequisite.