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  • By Christopher Houck, PhD  

    Among high school students completing the Youth Risk Behavior Surveillance System, a nationally representative survey of adolescent health and risk, 7% stated that they had sex for the first time before they were 13 years old. These rates tend to be much higher in urban areas. By tenth grade, 44% of teens nationwide report having had sex, highlighting the importance of the early adolescent years in sexual risk decision making.

    July 2010 Vol. 26, No. 7  

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    This article was published in the  Brown University Child and Adolescent Behavior Letter
    in cooperation with Bradley Hospital.
     

    Teens who have sex earlier in life are more likely to continue to be risky into young adulthood, including more sexual partners and less condom use. This, in turn, puts them at more risk of unwanted outcomes of sexual activity, including unintended pregnancy or sexually transmitted diseases.

    Clinical and familial interventions are needed to reduce this risk. A recent randomized-controlled study of African American sixth and seventh graders found promising results for an abstinence-focused intervention, as well as an intervention that discussed both abstinence and safer sex information (Jemmott, Jemmott, & Fong, 2010). Over the span of 2 years, the authors found less sexual risk behavior among students who received these interventions, suggesting that programs targeting adolescents when they are young can have a long-term impact.

    Risk behavior is even more prevalent among adolescents with mental health concerns. Teens experiencing emotional problems, broadly defined by distress and affect dysregulation, have greater rates of sexual risk behaviors than their peers. Behavior problems of any severity, whether subclinical symptoms, diagnosable disorders, or involving legal infractions, are also associated with risk during adolescence, including early sexual activity. Furthermore, research suggests that these risks persist into adulthood for many, making early intervention critical.

    What Can Clinicians Do?

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    Recognizing the importance of sexuality in teens’ lives and the relative dearth of adult resources for accurate information makes it incumbent on mental health professionals to create opportunities to address sexual risk with all teens. Clinicians are sometimes reluctant to ask adolescents about sexual risk behavior. This can inadvertently convey the message that sexual risk is less important than other areas of concern, like substance use (which is more frequently assessed). Clinicians have opportunities to discuss activities that teens might be reluctant to discuss with other adults. The confidentiality afforded by mental health or medical visits can provide the ideal backdrop to talk about sexual behaviors, values, and risk prevention.

    In addition, providers can facilitate dialogue between parents and teens by helping to start conversations about values or discussing family members’ comfort with sensitive topics. To make it easier to introduce the topic when assessing sexual risk behavior with an adolescent, a clinician should normalize both the topic and the assessment. Let teens know that you raise the issue because you are aware that sex is a part of adolescent life, whether it is dealing with sexual feelings, hearing people talk about sex at school, or being sexually active with a partner. Normalize that you do this assessment with all teens, because it is an important part of life and because you know that some kids don’t have adults to whom they can ask questions or get good information about safety. The more parents and clinicians address sexual risk in an open, honest fashion, the more prepared early teens will be to make decisions that will protect their health.

    How Clinicians Can Assist Parents

    Sex can be a difficult topic for many parents, and once parents have the “birds and the bees” talk, it can be tempting for them to consider the job done. However, particularly with teens with mental health concerns, keeping an open dialogue is critical to addressing the developmental changes that are inherent in discussions about sexual behavior.

    Clinicians can play a key role in encouraging parents to have a series of conversations about sex that can begin when a child is young and continue through their teens. While they may not be the focus of treatment, these conversations can often be a barometer for family communication that can be useful to clinicians.

    1. Clinicians can help parents with these discussions by providing the rationale for their importance and giving tips to make these conversations easier for parents, such as the following: Help parents to recognize that sex is a normal human behavior and that people begin having sexual feelings at early ages. Managing those feelings — particularly in the absence of adults who will discuss them — can be challenging, making discussions with parents all the more valuable. People are bombarded with subtle (or not so subtle) sexual messages all the time, which can prompt confusion.

    2. Help parents to identify their message. If they are planning a conversation with their teen, help them consider the main idea that they want to get across. It may be that they want their teen to be aware of their values, or that they want them to have information to make safe decisions, or that they want to establish that they are someone their teen can talk to about difficult decisions. Knowing where they are headed with the conversation before they begin can make it go smoother.

    3. Practice some key phrases with parents to make sure they feel comfortable with them. Be a model that they can listen to and hear that discussing sex doesn’t have to feel embarrassing. Encouraging parents to practice when they’re alone in the car or in front of the mirror, listening for whether the way they’ve phrased something sounds judgmental or suspicious or just plain awkward, can prepare them well. Hearing themselves say the words is great practice for feeling comfortable, and having a couple of key phrases related to the main message ready can be helpful if they are feeling nervous. If parents are uncomfortable with terms they might need to use (like “penis” or “oral sex”), encourage them to practice saying them out loud ahead of time to make it easier.

    4. Reassure parents that if they don’t know something asked, it’s okay to say so. Embarrassment is a common barrier to having conversations about sex, sometimes because parents worry that their kids will ask things they aren’t prepared to answer. “You know, I’m not 100% sure about that, and I don’t want to tell you the wrong thing” is a great answer that conveys that the question is important and that the parent is invested in giving good information. Parents can use this as a natural entry point to having a follow-up conversation later, or they can use it as an opportunity to research the answer together to show their teens how to get accurate
      information about sex.

    5. Remind parents to be prepared to hear things that might surprise them. Encourage them to listen and consider that early teens (and younger) talk about sex, even if they aren’t yet sexually active. This means that they are probably getting “information” from their peers, who may or may not be accurate. Parents who talk about sexuality with their children can correct misconceptions they learn from peers. If parents express that they don’t think their child will come to them with questions or problems, encourage them to suggest an adult whom they trust as a source of accurate information for their teen.

    6. Encourage parents to communicate their values. Teens are often interested in what their parents think about things like sex, even if they don’t ask directly, and studies show that the more parents discuss their values with their children, the more teens’ values converge with those of their parents. Conveying values while recognizing that the point of view that their child has might not be exactly the same as their own since they have different life experiences, is important.

    7. Help parents identify naturally occurring moments to start discussions. Scenes in movies, lyrics in music, celebrity scandals reported on TV, or pictures in magazines are great conversation starters. They can be opportunities to ask teens’ opinions as well as chances for parents to express some of their values.

    8. Remind parents to avoid judgment. Coaching parents to give teens room to express their opinions can facilitate the kind of two-way conversation that is desired. Parents can use facts about risk as a way to express concern (e.g., “yes, some people do that, but it’s important to remember that they can catch diseases that way”), rather than judging the people who are doing those things (“well, your friends who do that are stupid sluts”).

    9. Encourage parents to start early. Even the best conversations can have limited impact if the timing is wrong. The best time for parents to talk to children is before their child needs the information, not after.


    Christopher Houck, PhD, is a staff psychologist at Rhode Island Hospital in the department of child and adolescent psychiatry and an assistant professor in the department of psychiatry and human behavior at the Warren Alpert Medical School.


    Reference

    Jemmott JB, Jemmott LS, Fong GT: Efficacy of a theory-based abstinence-only intervention over 24 months. Arch Ped Adol Med 2010; 164:152–159.