Ch. 6- Sexuality

Why are adolescent pregnancy rates in other countries lower than they are in the United States? Three reasons identified in cross-cultural studies are described below (Boonstra, 2002, pp. 9-10):

"Childbearing regarded as adult activity." European countries and Canada share a strong consensus that childbearing belongs in adulthood "when young people have completed their education, have become employed and independent from their parents and are living in stable relationships. ... In the United States, this attitude is much less strong and much more variable across groups and areas of the country." "Clear messages about sexual behavior." Although adults in other countries strongly encourage teens to wait until they have established themselves before having children, they are generally more accepting than American adults of teens having sex. In France and Sweden, in particular, teen sexual expression is seen as normal and positive, but there is also widespread expectation that sexual intercourse will take place within committed relationships. (In fact, relationships among U.S. teens tend to be more sporadic and of shorter duration.) Equally strong is the expectation that young people who are having sex will take precautions to protect themselves and their partners from pregnancy and sexually transmitted infections, an expectation that is much stronger in Europe than in the United States. "In keeping with this view, ... schools in Great Britain, France, Sweden, and most of Canada" have sex education programs that provide more comprehensive information about prevention than do U.S. schools. In addition, these countries use the media more often in "government-sponsored campaigns for promoting responsible sexual behavior." "Access to family planning services." In countries that are more accepting of teenage sexual relationships, teenagers also have easier access to reproductive health services. "In Canada, France, Great Britain, and Sweden, contraceptive services are integrated into other types of primary health care and are available free or at low cost for all teenagers. Generally, teens (in these countries) know where to obtain information and services and receive confidential and nonjudgmental care. ... In the United States, where attitudes about teenage sexual relationships are more conflicted, teens have a harder time obtaining contraceptive services. Many do not have health insurance or cannot get birth control as part of their basic health care."

Sexual Literacy

A recent study assessed sixth-grade students' knowledge and curiosity about sex-related topics (Charmaraman, Lee, & Erkut, 2012). The questions most frequently asked by the sixth-graders involved sexual activity, female anatomy, reproduction, and puberty, while questions about sexually transmitted infections, sexual violence, and drug/alcohol use were less frequent. Questions asked in lower-risk schools tended to avoid sexual topics, whereas those asked in higher-risk schools focused more on sexual topics such as sexual initiation, contraception, and vaginal and anal sex.

Date rape (acquaintance)

A form of rape that went unacknowledged until recent decades is date rape, or acquaintance rape, which is coercive sexual activity directed at someone whom the perpetrator knows. Acquaintance rape is an increasing problem in high schools and on college campuses (Angelone, Mitchell, & Grossi, 2015; Sabina & Ho, 2014; Turchik & Hassija, 2014). A major study that focused on campus sexual assault involved a phone survey of 4,446 women attending two- or four-year colleges (Fisher, Cullen, & Turner, 2000). In this study, slightly less than 3 percent said that they had experienced either rape or an attempted rape during the academic year. About one of ten college women said that they had experienced rape in their lifetime. Unwanted or uninvited sexual contacts were widespread, with more than one-third of the college women reporting such incidents. As shown in Figure 8, in this study most women (about nine of ten) knew the person who sexually victimized them. Most of the women attempted to take protective actions against their assailants but were then reluctant to report the victimization to the police. Several factors were associated with sexual victimization: living on campus, being unmarried, getting drunk frequently, and having been sexually victimized on a prior occasion. A number of colleges and universities have identified a "red zone"—a period of time early in the first year of college when women are at especially high risk for unwanted sexual experiences (Cranney, 2015). A recent study revealed that first-year college women were more at risk for unwanted sexual experiences, especially early in the fall term, than were second-year women (Kimble & others, 2008).

Sex Education in Schools

A survey revealed that 89 percent of parents in Minnesota recommended teaching adolescents about abstinence and also providing them with comprehensive sex education that includes contraception information (Eisenberg & others, 2008, 2013). The parents said that most sex education topics should first be introduced in middle schools. Other surveys also indicate that a large percentage of U.S. parents want schools to provide adolescents with comprehensive sex education (Constantine, Jerman, & Juang, 2007; Ito & others, 2006). One study indicated that parents think adolescents too often get their information about sex from friends and the media (Lagus & others, 2011). A recent study in Minnesota of what more than 350 middle and high school sex educators can or cannot teach found that almost two-thirds faced structural barriers, one-half were concerned about parent, student, or administrators' responses, and one-fourth reported having restrictions on what they could teach (Eisenberg & others, 2013). Structural barriers were reported related to teaching about communication, teen parenting, and abortion; concerns about responses were linked to teaching about sexual violence; and restrictive policies were associated with teaching about abortion and sexual orientation.

Factors Associated with Sexual Minority Behavior

A very early critical period might influence sexual orientation (Hines, 2013, 2015). In the second to fifth months after conception, exposure of the fetus to hormone levels characteristic of females might cause the individual (female or male) to become attracted to males (Ellis & Ames, 1987). If this critical-period hypothesis turns out to be correct, it would explain why clinicians have found that sexual orientation is difficult, if not impossible, to modify (Meyer-Bahlburg & others, 1995). Researchers have also examined genetic influences on sexual orientation by studying twins. A recent Swedish study of almost 4,000 twins found that only about 35 percent of the variation in homosexual behavior in men and 19 percent in women were explained by genetic differences (Langstrom & others, 2010). This result suggests that although genes likely play a role in sexual orientation, they are not the only factor (King, 2014).

Incidence of Adolescent Pregnancy

Adolescent girls who become pregnant are from different ethnic groups and from different places, but their circumstances have the same stressfulness. To many adults, adolescent pregnancy represents a flaw in America's social fabric. Each year more than 200,000 females in the United States have a child before their eighteenth birthday. Like Angela, far too many become pregnant in their early or middle adolescent years. As one 17-year-old Los Angeles mother of a 1-year-old son said, "We are children having children." In cross-cultural comparisons, the United States continues to have one of the highest adolescent pregnancy and childbearing rates in the industrialized world, despite a considerable decline since the 1980s (Cooksey, 2009). The adolescent pregnancy rate is six times as high in the United States as it is in the Netherlands. This dramatic difference exists in spite of the fact that U.S. adolescents are no more sexually active than their counterparts in the Netherlands. A recent cross-cultural comparison found that among 21 countries, the United States had the highest adolescent pregnancy rate among 15- to 19-year-olds and Switzerland the lowest (Sedgh & others, 2015).

Sources of Sex Information

Adolescents can get information about sex from many sources, including parents, siblings, other relatives, schools, peers, magazines, television, and the Internet. A special concern is the accuracy of sexual information adolescents can view on the Internet. One study revealed that adolescents' most frequently consulted sources of information about sexuality were friends, teachers, mothers, and the media (Bleakley & others, 2009). In this study, learning about sex from parents, grandparents, and religious leaders was linked with adolescent beliefs that were likely to delay having sexual intercourse, whereas learning about sex from friends, cousins, and the media was related to beliefs that were likely to increase the likelihood of having sexual intercourse earlier. Many parents feel uncomfortable talking about sex with adolescents, and many adolescents feel uncomfortable with such conversations as well (Guilamo-Ramos & others, 2008; Tanton & others, 2015). One study revealed that 94 percent of fathers and 76 percent of mothers had never discussed sexual desire with their daughters (Feldman & Rosenthal, 1999). Many adolescents say that they cannot talk freely with their parents about sexual matters, but those who can talk with their parents openly and freely about sex are less likely to be sexually active (Chia-Chen & Thompson, 2007). Contraceptive use by female adolescents also increases when adolescents report that they can communicate about sex with their parents (Fisher, 1987). Also, a recent study found that first-semester college women who felt more comfortable talking openly about sex with their mothers were more likely to have positive beliefs about condoms and confidence in using them (Lefkowitz & Espinosa-Hernandez, 2006). Adolescents are far more likely to have conversations about sex with their mothers than with their fathers (Kirkman, Rosenthal, & Feldman, 2002). This tendency is true for both female and male adolescents, although female adolescents report having more frequent conversations about sex with their mothers than their male counterparts do (Feldman & Rosenthal, 2002).

A normal part of adolescent. development

Although we will discuss a number of problems that can occur in the area of adolescent sexuality, it is important to keep in mind that the majority of adolescents have healthy sexual attitudes and engage in sexual behaviors that will not compromise their journey to adulthood.

Sexual Scripts

As adolescents and emerging adults explore their sexual identities, they are guided by sexual scripts (Lefkowitz & others, 2014). A sexual script is a stereotyped pattern of role prescriptions for how individuals should behave sexually (Morrison & others, 2015). By the time individuals reach adolescence, girls and boys have been socialized to follow different sexual scripts. Differences in female and male sexual scripting can cause problems and confusion for adolescents as they work out their sexual identities. Female adolescents learn to link sexual intercourse with love (Michael & others, 1994). They often rationalize their sexual behavior by telling themselves that they were swept away by the passion of the moment. A number of studies have found that adolescent girls are more likely than their male counterparts to report being in love as the main reason they are sexually active (Crooks & Baur, 2014; Hyde & DeLamater, 2014). Other reasons that girls give for being sexually active include giving in to male pressure, gambling that sex is a way to get a boyfriend, curiosity, and sexual desire unrelated to loving and caring. As one adolescent remarked, "I feel a lot of pressure from my buddies to go for the score." Deborah Tolman (2002) interviewed a number of girls about their sexuality and was struck by how extensively a double standard still restricts girls from experiencing and talking about sexuality but allows boys more free rein with their sexuality. In movies, magazines, and music, girls are often depicted as the object of someone else's desire but rarely as someone who has acceptable sexual feelings of her own. Tolman says that girls face a difficult challenge related to their sexual selves: to be the perfect sexual object, they are supposed to be sexy but control their desire. A recent study indicated that adolescent girls often recognized the existence of a sexual double standard on a societal or school level, but support or acceptance in their close friend network served as a buffer against the double standard (Lyons & others, 2010).

Obtaining Research Information about Adolescent Sexuality

Assessing sexual attitudes and behavior is not always a straightforward matter (Saewyc, 2011). Consider how you would respond if someone asked you, "How often do you have intercourse?" or "How many different sexual partners have you had?" The individuals most likely to respond to sexual surveys are those with liberal sexual attitudes who engage in liberal sexual behaviors. Thus, research is limited by the reluctance of some individuals to provide candid answers to questions about extremely personal matters, and by researchers' inability to get any answer, candid or otherwise, from individuals who simply refuse to talk to strangers about sex. In addition, when asked about their sexual activity, individuals may respond truthfully or they may give socially desirable answers. For example, a ninth-grade boy might report that he has had sexual intercourse even if he has not, because he is afraid someone will find out that he is sexually inexperienced. One study of high school students revealed that 8 percent of the girls understated their sexual experience, while 14 percent of the boys overstated their sexual experience (Siegel, Aten, & Roghmann, 1998). Thus, boys tend to exaggerate their sexual experiences to increase perceptions of their sexual prowess, while girls tend to downplay their sexual experience so they won't be perceived as irresponsible or promiscuous (Diamond & Savin-Williams, 2015).

Adolescents as Parents

Children of adolescent parents face problems even before they are born (Jeha & others, 2015). Only one of every five pregnant adolescent girls receives any prenatal care at all during the important first three months of pregnancy. Pregnant adolescents are more likely to have anemia and complications related to preterm delivery than are mothers aged 20 to 24. The problems of adolescent pregnancy double the normal risk of delivering a low birth weight baby (one that weighs under 5.5 pounds), a category that places the infant at risk for physical and mental deficits (Dryfoos & Barkin, 2006). In some cases, infant problems may be due to poverty rather than the mother's age. Infants who escape the medical hazards of having an adolescent mother might not escape the psychological and social perils. Adolescent mothers are less competent at child rearing and have less realistic expectations for their infants' development than do older mothers (Osofsky, 1990). Children born to adolescent mothers do not perform as well on intelligence tests and have more behavioral problems than children born to mothers in their twenties (Silver, 1988). One longitudinal study found that the children of women who had their first birth during their teens had lower achievement test scores and more behavioral problems than did children whose mothers had their first birth as adults (Hofferth & Reid, 2002). And a recent study assessed the reading and math achievement trajectories of children born to adolescent and non-adolescent mothers with different levels of education (Tang & others, 2015). In this study, higher levels of maternal education were linked to growth in achievement through the eighth grade. Nonetheless, the achievement of children born to adolescent mothers never reached the levels of children born to adult mothers. Adolescent fathers have lower incomes, less education, and more children than do men who delay having children until their twenties. One reason for these difficulties is that the adolescent father often compounds the problem of becoming a parent at a young age by dropping out of school (Resnick, Wattenberg, & Brewer, 1992).

Chylamydia

Chlamydia, one of the most common of all STIs, is named for Chlamydia trachomatis, an organism that spreads by sexual contact and infects the genital organs of both sexes. Although fewer individuals have heard of chlamydia than have heard of gonorrhea and syphilis, its incidence is much higher. Many of the new cases of chlamydia reported each year are in 15- to 25-year-old females. A recent large-scale survey found that adolescents who screened positive for chlamydia were more likely to be female, African American, and 16 years of age and older (Han & others, 2011). About 10 percent of all college students have chlamydia. This STI is highly infectious; women run a 70 percent risk of contracting it in a single sexual encounter with an infected partner. The male risk is estimated at between 25 and 50 percent. The estimated annual incidence of chlamydia in the 15- to 24-year-old age group is 1 million individuals (Weinstock, Berman, & Cates, 2004). Many females with chlamydia have few or no symptoms. When symptoms do appear, they include disrupted menstrual periods, pelvic pain, elevated temperature, nausea, vomiting, and headache. Possible symptoms of chlamydia in males are a discharge from the penis and burning during urination. Because many females with chlamydia are asymptomatic, the infection often goes untreated and the chlamydia spreads to the upper reproductive tract, where it can cause pelvic inflammatory disease (PID). The resultant scarring of tissue in the fallopian tubes can produce infertility or ectopic pregnancies (tubal pregnancies)—that is, a pregnancy in which the fertilized egg is implanted outside the uterus. One-quarter of females who have PID become infertile; multiple cases of PID increase the rate of infertility to half. Some researchers suggest that chlamydia is the number one preventable cause of female infertility.

Health

Concern has been voiced about the possible sexual health risks for sexual minority youth. A recent national survey revealed that the prevalence of health-risk behaviors was higher for sexual minority youth than for heterosexual youth in 7 of 10 risk-behavior categories: behaviors that contribute to violence, behaviors related to attempted suicide, tobacco use, alcohol use, other drug use, sexual behaviors, and weight management (Kann & others, 2011). However, a research review concluded that there are mixed results as to whether sexual minority adolescents are more likely to attempt suicide (Saewyc, 2011). A recent research review of more than 300 studies concluded that bisexual youth had a higher rate of suicide ideation and attempts than their gay, lesbian, and heterosexual counterparts (Pompili & others, 2014). And a recent study of more than 72,000 adolescents, more than 6,200 of whom were sexuality minority adolescents, revealed that the sexual minority adolescents had a higher incidence of suicide ideation, planning, and attempts than the heterosexual adolescents (Bostwick & others, 2014). A recent study also found that family support was linked to a decreased risk of suicide attempts in sexual minority youth (Reisner & others, 2014). Recent research also indicates that sexual minority adolescents are more likely to develop substance abuse problems and engage in sexual risk taking (Rosario & others, 2014; Saewyc, 2011). A longitudinal study revealed that sexual minority adolescents were more likely to begin drinking earlier than their heterosexual counterparts and that most sexual minority groups had higher levels of drinking, including binge drinking in late adolescence (Coker, Austin, & Schuster, 2010). Another recent study also found a higher rate of substance use and suicide ideation and attempts in sexual minority youth, especially when they lacked connections with adults at their school (Seil, Desai, & Smith, 2014). Sexual minority adolescents are more likely to have an early sexual debut (before age 13 in some studies, prior to age 14 in others), report a higher number of lifetime or recent sexual partners, and have more sexually transmitted infections than do heterosexual adolescents, although mixed findings have been found for condom use across these groups (Parkes & others, 2011; Saewyc, 2011). A special concern is the higher rate of sexually transmitted infections, especially HIV, in males who have sex with males (Morgan, 2014). Also, researchers recently found a higher incidence of sexually transmitted infections in adolescent girls with same-sex partners (especially when they have sexual relations with male partners as well) (Morgan, 2014). Further, a recent national study of 15- to 20-year-olds found that bisexual and lesbian young women experienced a younger sexual debut and had more male and female sexual partners than did their heterosexual counterparts (Tornello, Riskind, & Patterson, 2014). In this study, bisexual women reported the earliest sexual debut, highest numbers of sexual partners, greatest usage of emergency contraception, and highest frequency of pregnancy termination. Other research has found more extensive sexual health risks for bisexual adolescent females and males than for members of other groups (Morgan, 2014).

Developing a Sexual Identity

Dealing with emerging sexual feelings and forming a sense of sexual identity is a multifaceted process (Diamond & Savin-Williams, 2015). This lengthy process involves learning to manage sexual feelings such as sexual arousal and attraction, developing new forms of intimacy, and learning the skills required to regulate sexual behavior so as to avoid undesirable consequences. Developing a sexual identity also involves more than just sexual behavior. Sexual identities emerge in the context of physical factors, social factors, and cultural factors, with most societies placing constraints on the sexual behavior of adolescents. An adolescent's sexual identity is strongly influenced by social norms related to sex—the extent to which adolescents perceive that their peers are having sex, using protection, and so on. These social norms have important influences on adolescents' sexual behavior. For example, one study revealed that when adolescents perceived that their peers were sexually permissive, the adolescents had a higher rate of initiating sexual intercourse and engaging in risky sexual practices (Potard, Courtois, & Rusch, 2008). An adolescent's sexual identity involves an indication of sexual orientation (whether an individual has same-sex or other-sex attractions), and it also involves activities, interests, and styles of behavior. A study of 470 tenth- to twelfth-grade Australian youth found considerable variation in their sexual attitudes and practices (Buzwell & Rosenthal, 1996). Some were virgins and sexually naive. Some had high anxiety about sex and perceived their bodies as underdeveloped and unappealing, whereas others had low anxiety about sex and an interest in exploring sexual options. Yet others felt sexually attractive, were sexually experienced, and had confidence in their ability to manage sexual situations.

Trends in US adolescent pregnancy rates

Despite the negative comparisons of the United States with many other developed countries, there have been some encouraging trends in U.S. adolescent pregnancy rates. In 2013, the U.S. birth rate for 15- to 19-year-olds was 26.5 births per 1,000 females, the lowest rate ever recorded, which represents a dramatic decrease from the 61.8 births for the same age range in 1991 (Martin & others, 2015) (see Figure 4). As can be seen in Figure 4, the 2013 figures reflect a substantial decrease in adolescent pregnancies across ethnic groups. Reasons for the decline include school/community health classes, increased contraceptive use, and fear of sexually transmitted infections such as AIDS. Ethnic variations characterize adolescent pregnancy (Bartlett & others, 2014; Centers for Disease Control and Prevention, 2015a; Kappeler & Farb, 2014) (see Figure 5). Latina adolescents are more likely than African American and non-Latina White adolescents to become pregnant (Martin & others, 2015). For 15- to 19-year-old U.S. females in 2013, per 1,000 females the birth rate for Latinas was 41.7, for African Americans 39.0, and for non-Latina Whites 18.6 (Martin & others, 2015). Latina and African American adolescent girls who have a child are also more likely to have a second child than are non-Latina White adolescent girls (Rosengard, 2009). And daughters of teenage mothers are at risk for teenage childbearing, thus perpetuating an intergenerational cycle. A study using data from the National Longitudinal Survey of Youth revealed that daughters of teenage mothers were 66 percent more likely to become teenage mothers themselves (Meade, Kershaw, & Ickovics, 2008). In this study, risks that increased the likelihood that daughters of the teenage mothers would become pregnant included low parental monitoring and poverty.

Genital Herpes

Genital herpes genital herpes A sexually transmitted infection caused by a large family of viruses of different strains. These strains also produce nonsexually transmitted diseases such as chicken pox and mononucleosis. is a sexually transmitted infection caused by a large family of viruses with many different strains, some of which produce nonsexually transmitted diseases such as cold sores, chicken pox, and mononucleosis. Three to five days after contact, itching and tingling can occur, followed by an eruption of painful sores and blisters. The attacks can last up to three weeks and can recur as frequently as every few weeks or as infrequently as every few years. The virus can also pass through nonlatex condoms as well as contraceptive foams and creams. It is estimated that approximately 20 percent of adolescents have genital herpes (Centers for Disease Control and Prevention, 2015b). It also is estimated that more than 600,000 new genital herpes infections are appearing in the 15- to 24-year-old age group in the United States each year. Although drugs such as acyclovir can alleviate symptoms, there is no known cure for herpes. Thus, individuals infected with herpes often experience severe emotional distress in addition to the considerable physical discomfort. They may feel conflicted or reluctant about sex, angry about the unpredictability of the infection, and fearful that they won't be able to cope with the pain of the next attack. For these reasons, many communities have established support groups for victims of herpes.

Genital warts

Genital warts are caused by the human papillomavirus (HPV), which is difficult to test for and does not always produce symptoms but is very contagious nonetheless. Genital warts usually appear as small, hard, painless bumps on the penis, in the vaginal area, or around the anus. More than 9 million individuals in the United States in the 15- to 24-year-old age group are estimated to have an HPV infection, making HPV the most commonly acquired STI in this age group. Treatment involves the use of a topical drug, freezing, or surgery. Unfortunately, genital warts may return despite treatment, and in some cases they are linked to cervical cancer and other genital cancers. Condoms afford some protection against HPV infection. In 2010, the Centers for Disease Control and Prevention recommended that all 11- and 12-year-old girls as well as females 13 to 26 years of age be given a three-dose HPV vaccine, which helps to fight off HPV and cervical cancer (Friedman & others, 2011). Females as young as 9 years of age can be given the HPV vaccine.

Sexual Harassment

Girls and women encounter sexual harassment in many different forms—ranging from sexist remarks and covert physical contact (patting, brushing against bodies) to blatant propositions and sexual assaults. Literally millions of girls and women experience such sexual harassment each year in educational and work settings (Cantalupo, 2014). One study of adolescent girls indicated that most (90 percent) of the girls said they had experienced sexual harassment at least once (Leaper & Brown, 2008). In this study, 52 percent of the girls reported that they had experienced academic sexism (involving science, math, and computer technology) and 76 percent said that they had encountered athletic sexism. In a survey of 2,000 college women by the American Association of University Women (2006), 62 percent of the respondents reported that they had experienced sexual harassment while attending college. Most of the college women said that the sexual harassment involved noncontact forms such as crude jokes, remarks, and gestures. However, almost one-third said that the sexual harassment was physical in nature. A recent study of almost 1,500 college women revealed that when they had been sexually harassed they reported an increase in psychological distress, greater physical illness, and an increase in disordered eating (Huerta & others, 2006).

Gonorrhea

Gonorrhea is an STI that is commonly called the "drip" or the "clap." It is caused by a bacterium called Neisseria gonorrhoeae, which thrives in the moist mucous membranes lining the mouth, throat, vagina, cervix, urethra, and anal tract. The bacterium is spread by contact between the infected moist membranes of one individual and the membranes of another. Although the incidence of gonorrhea has declined, it is estimated that more than 400,000 new cases appear each year in the 15- to 24-year-old age group (Weinstock, Berman, & Cates, 2004). A recent large-scale study revealed that adolescents who were most likely to screen positive for gonorrhea were female, African American, and 16 years of age or older (Han & others, 2011).

Discrimination, Bias, and Violence

Having irrational negative feelings against individuals who have same-sex attractions is called homophobia. One of the harmful aspects of the stigmatization of same-sex attraction is the self-devaluation engaged in by sexual minority individuals (Diamond & Savin-Williams, 2015). One common form of self-devaluation is called passing, the process of hiding one's real social identity. Without adequate support, and with fear of stigmatization, many gay and lesbian youth retreat to the closet and then emerge at a safer time later, often in college. Sexual minority youth are more likely to be targeted for violence than heterosexual youth in a number of contexts, including forced sex and dating violence, and verbal and physical harassment at school and in the community (Coker, Austin, & Schuster, 2010; Ryan & others, 2009). Many sexual minority adolescents also experience discrimination and rejection in interactions with their families, peers, schools, and communities (Diamond & Savin-Williams, 2015; Savin-Williams, 2015). Sexual minority youths' exposure to stigma and discrimination has been cited as the main reason they are more likely to develop problems (Saewyc, 2011). For example, one study found that family rejection of coming out by sexual minority adolescents was linked to their higher rates of depression, substance use, and unprotected sex (Ryan & others, 2009). A recent study of 15-year-olds found that sexual minority status was linked to depression mainly via peer harassment (Martin-Storey & Crosnoe, 2012). Despite these negative circumstances, many sexual minority adolescents successfully cope with the challenges they face and develop levels of health and well-being that are similar to those of their heterosexual peers (Saewyc, 2011).

Following are several of the questions asked by the sixth-graders that reflect a lack of sexual knowledge:

If you have had sex the night before your period you're not going to get pregnant, right? If a guy puts his penis in a girl's mouth, will she get pregnant? If you have anal sex, is it still considered sex? If you are trying to have abstinence and you have sex more than once, is that abstinence?

Abortion

Impassioned debate surrounds the topic of abortion in the United States today, and this debate is likely to continue in the foreseeable future (Coleman & Rosoff, 2013). The experiences of U.S. adolescents who want to have an abortion vary by state and region. Thirty-eight states prohibit abortions after a specified point in pregnancy, most often fetal viability (Alan Guttmacher Institute, 2010). Thirty-four states require some form of parental involvement in a minor's decision to have an abortion. Abortion is easier to obtain in some countries, most notably the Scandinavian countries, than in the United States, where abortion and adolescent sexual activity are more stigmatized. In many developing countries, such as Nigeria, abortion is far more unsafe than in the United States. A recent cross-cultural comparison of 21 countries found the highest abortion rate for 15- to 19-year-olds in England and Sweden, the lowest in Switzerland (Sedgh & others, 2015). In 2006, 27 percent of teen pregnancies ended in abortion (Alan Guttmacher Institute, 2010). A recent analysis found that the percentage of abortions that were performed on 15- to 19-year-olds in the United States decreased 21 percent between 2002 and 2011 and the abortion rate for this age group decreased by 34 percent (Pazol & others, 2014). Adolescent girls are more likely than older women to delay having an abortion until after 15 weeks of pregnancy, when medical risks associated with abortion increase significantly.

Premarital Sex in America: How Young Americans Meet, Mate, and Think About Marrying

In a recent provocative book, Premarital Sex in America: How Young Americans Meet, Mate, and Think About Marrying, sociologists Mark Regenerus and Jeremy Uecker (2011) described the free, temporary, and self-rewarding sexual "benefits" of emerging adulthood as superficial and incompatible with long-term, secure relationships such as marriage. They conclude that the sexual life of emerging adults is often characterized by serial monogamy: one partner at a time. Regenerus and Uecker also state that these patterns of emerging adults' sexual behavior are more likely to produce sexual regrets and diminished emotional well-being in emerging adult women than men because the emotional connection of a relationship is so important to women. They further argue that many emerging adult women are not aware of how damaging such short-term, serial monogamous relationships can be to their emotional health. Critics have asserted that Regenerus and Uecker's analysis is male-biased and devalues women (Katz & Smith, 2012).

Cognitive Factors

Informing adolescents about contraceptives is not enough—what seems to predict whether or not they will use contraceptives is their acceptance of themselves and their sexuality. This acceptance requires not only emotional maturity but cognitive maturity.

Developmental Pathways

It is commonly perceived that most gays and lesbians quietly struggle with same-sex attractions in childhood, do not engage in heterosexual dating, and gradually recognize that they are gay or lesbian in mid- to late adolescence (Diamond & Savin-Williams, 2015). However, there is much more fluidity in sexual orientation than this developmental milestone approach suggests (Saewyc, 2011). Many youth do follow this developmental pathway, but others do not. For example, many youth have no recollection of same-sex attractions and experience a more abrupt sense of their same-sex attraction in late adolescence (Savin-Williams & Cohen, 2015). Researchers also have found that the majority of adolescents with same-sex attractions also experience some degree of other-sex attractions (Garofalo & others, 1999). And, although some adolescents who are attracted to same-sex individuals fall in love with these individuals, others claim that their same-sex attractions are purely physical (Savin-Williams, 2015). In sum, sexual minority youth have diverse patterns of initial attraction, often have bisexual attractions, and may have physical or emotional attraction to same-sex individuals but do not always fall in love with them (Savin-Williams & Cohen, 2015).

The Sexual Culture

It is important to put adolescent sexuality into the broader context of sexuality in the American culture (Herdt & Polen-Petit, 2014). Whereas 50 years ago sex was reserved for married couples, today adult sex is openly acknowledged among both married and single adults. Sex among unmarried teenagers is an extension of this general trend toward greater sexual permissiveness in the adult culture. In the United States, society sends mixed messages about sex to youth—on the one hand, adolescents (especially girls) are told not to have sex—but on the other hand, they see sex portrayed in the media as positive (especially for boys). Thus, it is no wonder that adolescents find sexual development and choices so confusing.

Reducing Adolescent Pregnancy

John Conger (1988) offered the following four recommendations for reducing the high rate of adolescent pregnancy: (1) sex education and family planning, (2) access to contraceptive methods, (3) the life options approach, and (4) broad community involvement and support. We will consider each of these recommendations in turn. n the United States. an organization called Girls Inc. offers four programs that are intended to increase adolescent girls' motivation to avoid pregnancy until they are mature enough to make responsible decisions about motherhood (Roth & others, 1998). "Growing Together," a series of five two-hour workshops for mothers and adolescents, and "Will Power/Won't Power," a series of six two-hour sessions that focus on assertiveness training, are for 12- to 14-year-old girls. For older adolescent girls, "Taking Care of Business" provides nine sessions that emphasize career planning as well as information about sexuality, reproduction, and contraception. "Health Bridge" coordinates health and education services—girls can participate in this program as one of their club activities. Research on girls' participation in these programs revealed a significant drop in their likelihood of getting pregnant compared with girls who had not participated (Girls Inc., 1991).

Patterns of heterosexual behavior for males and females in emerging adulthood include the following (Lefkowitz & Gillen, 2006):

Males have more casual sexual partners, and females report being more selective about their choice of a sexual partner. Approximately 60 percent of emerging adults have had sexual intercourse with only one individual in the past year, but compared with young adults in their late twenties and thirties, emerging adults are more likely to have had sexual intercourse with two or more individuals. Although emerging adults have sexual intercourse with more individuals than do young adults, they have sex less frequently. Approximately 25 percent of emerging adults report having sexual intercourse only a couple of times a year or not at all (Michael & others, 1994). Uncertainty characterizes many emerging adults' sexual relationships. Consider a recent study of emerging adult daters and cohabitors that found nearly half reported a reconciliation (a breakup followed by a reunion) (Halpern-Meekin & others, 2013). A recent study found that sexual risk factors increase in emerging adulthood, with males engaging in more of these risk factors than females (Mahalik & others, 2013).

Risk Factors in Adolescent Sexuality

Many adolescents are not emotionally prepared to handle sexual experiences, especially in early adolescence. Early sexual activity is linked with risky behaviors such as drug use, delinquency, and school-related problems (Chan & others, 2015; Coley & others, 2013; Skinner & others, 2015). A recent study confirmed that early engagement in sexual intercourse (prior to 14 years of age) is associated with high-risk sexual factors (forced sex using drugs/alcohol at last sex, not using a condom at last sex, having multiple partners in last month, and becoming pregnant or causing a pregnancy), as well as experiencing dating violence (Kaplan & others, 2013). Also, a recent study of more than 3,000 Swedish adolescents revealed that sexual intercourse before age 14 was linked to risky behaviors such as an increased number of sexual partners, experience of oral and anal sex, negative health behaviors (smoking, drug and alcohol use), and antisocial behavior (being violent, stealing, running away from home) at 18 years of age (Kastbom & others, 2015). And a study of adolescents in five countries, including the United States, found that substance use was related to early sexual intercourse (Madkour & others, 2010). n addition to having sex in early adolescence, other risk factors for sexual problems in adolescence include contextual factors such as socioeconomic status (SES) and poverty, immigration/ethnic minority status, family/parenting and peer factors, and school-related influences (Van Ryzin & others, 2011). The percentage of sexually active young adolescents is higher in low-income areas of inner cities (Morrison-Beedy & others, 2013). A recent study revealed that neighborhood poverty concentrations predicted 15- to 17-year-old girls' and boys' sexual initiation (Cubbin & others, 2010). And a recent study in low-income neighborhoods found that caregiver hostility was linked to early sexual activity and sex with multiple partners while caregiver warmth was related to later sexual initiation and a lower incidence of sex with multiple partners (Gardner, Martin, & Brooks-Gunn, 2012). Also, a recent national survey of 15- to 20-year-olds found that Spanish-speaking immigrant youth were more likely to have a sexual partner age difference of 6 or more years and less likely to use contraception at first sexual intercourse than their native Latino, non-Latino White, and English-speaking Latino immigrant counterparts (Haderxhanaj & others, 2014). A number of family factors are associated with sexual risk-taking (de Looze & others, 2015; Widman & others, 2014). A recent study found that family strengths (family closeness, support, and responsiveness to health needs, for example) in childhood were protective against early initiation of sexual activity and adolescent pregnancy (Hillis & others, 2010). Another recent study revealed that sexual risk-taking behavior was more likely to occur in girls living in single-parent homes (Hipwell & others, 2011). Further, a recent study found that difficulties and disagreements between Latino adolescents and their parents were linked to the adolescents' early sex initiation (Cordova & others, 2014). Also, having older sexually active siblings or pregnant/parenting teenage sisters placed adolescent girls at higher risk for pregnancy (Miller, Benson, & Galbraith, 2001). Cognitive and personality factors are increasingly implicated in sexual risk taking in adolescence (Fantasia, 2008). Two such factors are attention problems and weak self-regulation (difficulty controlling one's emotions and behavior). A longitudinal study revealed that attention problems and high rates of aggressive disruptive behavior at school entry increased the risk of multiple problem behaviors (school maladjustment, antisocial behavior, and substance use) in middle school, which in turn was linked to early initiation of sexual activity (Schofield & others, 2008). Another longitudinal study found that weak self-regulation at 8 to 9 years of age and risk proneness (tendency to seek sensation and make poor decisions) at 12 to 13 years of age set the stage for sexual risk taking at 16 to 17 years of age (Crockett, Raffaelli, & Shen, 2006). And a recent study also found that a high level of impulsiveness was linked to early adolescent sexual risk taking (Khurana & others, 2012). Also, a recent meta-analysis indicated that the link between impulsivity and risky sexual behavior was likely to be more characteristic of adolescent females than males (Dir, Coskunpinar, & Cyders, 2014).

Adolescents' character traits and spirituality

Might adolescents' character traits and spirituality protect them from negative sexual outcomes? A research review concluded that prosocial norms (providing youth with information about norms of risk behaviors; having youth make public commitments to behave in a prosocial manner, such as avoiding risk behaviors; and having peers and older youth communicate positive aspects of prosocial behavior) and spirituality (being spiritual, religious, or believing in a higher power, for example) were linked to positive sexual outcomes for adolescents: being less likely to intend to have sex, not likely to engage in early sex, having sex less frequently, and not becoming pregnant (House & others, 2010). A recent study also found that parents' religiosity was linked to a lower level of adolescents' risky sexual behavior, in part resulting from adolescents hanging out with less sexually permissive peers (Landor & others, 2011).

Forcible Sexual Behavior and Sexual Harassment

Most people choose whether they will engage in sexual intercourse or other sexual activities—but, unfortunately, some people force others to engage in sex. Too many adolescent girls and young women report that they believe they don't have adequate sexual rights (East & Adams, 2002). These include the right not to have sexual intercourse when they don't wish to, the right to tell a partner that he is being too rough, or the right to use any form of birth control during intercourse. One study found that almost 20 percent of sexually active 14- to 26-year-old females believed that they never have the right to make decisions about contraception; to tell their partner that they don't want to have intercourse without birth control, that they want to make love differently, or that their partner is being too rough; or to stop foreplay at any time, including at the point of intercourse (Rickert, Sanghvi, & Wiemann, 2002). In this study, poor grades in school and sexual inexperience were linked to a lack of sexual assertiveness in females.

HIV and AIDS

No single STI has caused more deaths, had a greater impact on sexual behavior, or created more public fear in recent decades than HIV (Carroll, 2016). We explore here its nature and incidence, how it is transmitted, and how to prevent it from spreading. AIDS stands for acquired immune deficiency syndrome, a sexually transmitted infection that is caused by the human immunodeficiency virus (HIV), which destroys the body's immune system. Following exposure to HIV, an individual is vulnerable to germs that a normal immune system could destroy. Through December 2012, there were 62,400 cumulative cases of AIDS among 13- to 24-year-olds in the United States (Centers for Disease Control and Prevention, 2015b). Of these youth, 32,000 were living with an undiagnosed HIV infection. Worldwide, the greatest concern about AIDS is in sub-Saharan Africa, where it has reached epidemic proportions (UNICEF, 2015). Adolescent girls in many African countries are especially vulnerable to becoming infected with the HIV virus through sexual contact with adult men (Cherutich & others, 2008). Approximately six times as many adolescent girls as boys have AIDS in these countries. In Kenya, 25 percent of 15- to 19-year-old girls are HIV-positive, compared with only 4 percent of boys in the same age group. In Botswana, more than 30 percent of the adolescent girls who are pregnant are infected with HIV. In some sub-Saharan countries, less than 20 percent of women and 40 percent of 15- to 19-year-olds reported having used a condom the last time they had sexual intercourse (Bankole & others, 2004). There are some differences in AIDS cases in U.S. adolescents, compared with AIDS cases in U.S. adults: A higher percentage of adolescent AIDS cases are acquired by heterosexual transmission. A higher percentage of adolescents are asymptomatic individuals (but will become symptomatic in adulthood—that is, they are HIV-positive, but do not yet have AIDS). A higher percentage of African American and Latino AIDS cases occur among adolescents. A special set of ethical and legal issues is involved in testing and informing partners and parents of adolescents. Adolescents have less access to contraceptives and are less likely to use them than are adults.

The Office for Civil Rights in the U.S. Department of Education published a 40-page policy guide on sexual harassment. In this guide, a distinction is made between quid pro quo and hostile environment sexual harassment (Chmielewski, 1997):

Quid pro quo sexual harassment occurs when a school employee (such as a teacher) threatens to base an educational decision (such as a grade) on a student's submission to unwelcome sexual conduct. For example, a teacher gives a student an A for allowing the teacher's sexual advances, or the teacher gives the student an F for resisting the teacher's approaches. Hostile environment sexual harassment occurs when students are subjected to unwelcome sexual conduct that is so severe, persistent, or pervasive that it limits the students' ability to benefit from their education. Such a hostile environment is usually created by a series of incidents, such as repeated sexual overtures.

Oral sex

Recent research indicates that oral sex is now a common occurrence for U.S. adolescents (Fava & Bay-Cheng, 2012; Halpern & Haydon, 2012). In a national survey, 55 percent of U.S. 15- to 19-year-old boys and 54 percent of girls of the same age said they had engaged in oral sex (National Center for Health Statistics, 2002).Oral sex negates the risk of pregnancy and is linked to fewer negative outcomes than is vaginal sex. However, oral sex is not risk-free, being related to such negative health outcomes as sexually transmitted infections (herpes, chlamydia, and gonorrhea, for example). In recent research, Halpern-Felsher and her colleagues have examined the merits of engaging in oral versus vaginal sex (Brady & Halpern-Felsher, 2007; Song & Halpern-Felsher, 2010). In one study, the temporal order between oral and vaginal sex in sexually active adolescents was examined (Song & Halpern-Felsher, 2010). In this study, most of the adolescents initiated vaginal sex after or within the same 6-month period of starting to have oral sex. Those who initiated oral sex at the end of the ninth grade had a 50 percent chance of having vaginal sex by the end of the eleventh grade, but those who delayed having oral sex until the end of the eleventh grade had less than a 20 percent chance of initiating vaginal sex by the end of the eleventh grade.

Self-Stimulation

Regardless of whether adolescents have a heterosexual or same-sex attraction, they will experience increasing feelings of sexual arousal. One way in which many youths who are not dating or who consciously choose not to engage in sexual intercourse or sexual explorations deal with these insistent feelings of sexual arousal is through self-stimulation, or masturbation. Masturbation is the most frequent sexual outlet for many adolescents, especially male adolescents. A recent study of 14- to 17-year-olds found that 74 percent of the males and 48 percent of the females reported that they had masturbated at some point (Robbins & others, 2012).

Portrayal of sex in the media

Sex is explicitly portrayed in movies, TV shows, videos, lyrics of popular music, MTV, and Web sites (Doornwaard & others, 2015; Ybarra, Strasburger, & Mitchell, 2014). A study of 1,762 12- to 17-year-olds found that those who watched more sexually explicit TV shows were more likely than their counterparts who watched fewer of these shows to initiate sexual intercourse in the next 12 months (Collins & others, 2004). Adolescents in the highest 10 percent of viewing sexually explicit TV shows were twice as likely to engage in sexual intercourse as those in the lowest 10 percent. The results held regardless of whether the exposure to explicit sex involved sexual behavior or just talk about sex. In another study, U.S. high school students who frequently viewed talk shows and "sexy" prime-time programs were more likely to endorse sexual stereotypes than their counterparts who viewed these shows infrequently (Ward & Friedman, 2006). Also in this study, more frequent viewing and stronger identification with popular TV characters were linked with higher levels of sexual experience in adolescents. And a research review concluded that adolescents who view more sexual content on TV are likely to initiate sexual intercourse earlier than their peers who view less sexual content on TV (Brown & Strasburger, 2007). Further, a study of adolescents across a three-year period revealed a link between watching sex on TV and subsequent higher risk of pregnancy (Chandra & others, 2009). And a recent study revealed that adolescents' music video viewing was linked to asking someone for a sexting message and having received a sexting message (Van Ouytsel, Ponnet, & Walrave, 2014). Adolescents increasingly have had access to sexually explicit Web sites (Doornwaard & others, 2015). One study revealed that adolescents who reported ever visiting a sexually explicit Web site were more sexually permissive and were more likely to have multiple lifetime sexual partners, to have had more than one sexual partner in the last three months, to have used alcohol or other substances at their last sexual encounter, and to engage in anal sex more than their counterparts who reported that they had never visited a sexually explicit Web site (Braun-Courville & Rojas, 2009). A recent study of Korean boys found that a higher risk of Internet addiction was linked to sexual intercourse experience (Sung & others, 2013).

Contraceptive Use

Sexual activity is a normal behavior that is necessary for procreation, but if appropriate safeguards are not taken it brings the risk of unintended, unwanted pregnancy and sexually transmitted infections (Crooks & Baur, 2014; Jaccard & Levitz, 2013). Both of these risks can be reduced significantly by using barrier methods of contraception, such as condoms. Are adolescents increasingly using condoms? A recent national study revealed a substantial increase in the use of a contraceptive (59 percent in 2013 compared with 46 percent in 1991) by U.S. high school students the last time they had sexual intercourse (Kann & others, 2014). Also, a recent study in 20 European countries found that condom use increased from 2002 to 2010 (Ramiro & others, 2015). Many sexually active adolescents do not use contraceptives, or they use them inconsistently (Amialchuk & Gerhardinger, 2015; Finer & Philbin, 2013; Tschann & others, 2010; Yen & Martin, 2013; Vasilenko, Kreager, & Lefkowitz, 2015). In 2013, 34 percent of sexually active adolescents had not used a condom the last time they had sexual intercourse (Kann & others, 2014). In the recent national U.S. survey (2014), among sexually active adolescents, ninth-graders (63 percent), tenth-graders (62 percent), and eleventh graders (62 percent) reported that they had used a condom during their last sexual intercourse more than did twelfth-graders (53 percent) (Kann & others, 2014). A recent study also found that 50 percent of U.S. 15- to 19-year-old girls with unintended pregnancies ending in live births were not using any birth control method when they got pregnant, and 34 percent believed they could not get pregnant at the time (Centers for Disease Control and Prevention, 2015a). Also, a recent study found that a greater age difference between sexual partners in adolescence is associated with less consistent condom use (Volpe & others, 2013). Researchers also have found that U.S. adolescents use condoms less than their counterparts in Europe (Jorgensen & others, 2015). Studies of 15-year-olds revealed that in Europe 72 percent of the girls and 81 percent of the boys had used condoms during their last intercourse (Currie & others, 2008). Use of birth control pills also continues to be higher in European countries (Santelli, Sandfort, & Orr, 2009). Such comparisons provide insight into why adolescent pregnancy rates are much higher in the United States than in European countries.

Sexually transmitted infections (STIs)

Sexually transmitted infections (STIs) are infections that are contracted primarily through sexual contact. This contact is not limited to vaginal intercourse but includes oral-genital and anal-genital contact as well. STIs are an increasing health problem. Every year more than 3 million American adolescents (about one-fourth of those who are sexually experienced) acquire an STI (Centers for Disease Control and Prevention, 2015b). Recent estimates indicate that while 15- to 24-year-olds represent only 25 percent of the sexually experienced U.S. population, they acquire nearly 50 percent of all new STIs (Centers for Disease Control and Prevention, 2015b).

Syphillis

Syphilis is an STI caused by the bacterium Treponema pallidum, a member of the spirochaeta family. The spirochete needs a warm, moist environment to survive, and it is transmitted by penile-vaginal, oral-genital, or anal contact. It can also be transmitted from a pregnant woman to her fetus after the fourth month of pregnancy; if she is treated before this time with penicillin, the syphilis will not be transmitted to the fetus. If left untreated, syphilis may progress through four phases: primary (chancre sores appear), secondary (general skin rash occurs), latent (a period that can last for several years during which no overt symptoms are present), and tertiary (cardiovascular disease, blindness, paralysis, skin ulcers, liver damage, mental problems, and even death may occur) (Crooks & Baur, 2014). In its early phases, syphilis can be effectively treated with penicillin.

Consequences of Adolescent Pregnancy

The consequences of America's high adolescent pregnancy rate are cause for great concern (Lau, Lin, & Flores, 2015; Siegel & Brandon, 2014). Adolescent pregnancy creates health risks for both the baby and the mother (Bartlett & others, 2014; Kappeler & Farb, 2014). Infants born to adolescent mothers are more likely to be born preterm and have low birth weights—a prominent factor in infant mortality—as well as neurological problems and childhood illness (Khashan, Baker, & Kenny, 2010). Adolescent mothers often drop out of school (Siegel & Brandon, 2014). Although many adolescent mothers resume their education later in life, they generally do not catch up economically with women who postpone childbearing until their twenties. A longitudinal study revealed that several characteristics of adolescent mothers were related to their likelihood of having problems as emerging adults: a history of school problems, delinquency, hard substance use, and mental health problems (Oxford & others, 2006). Also, a recent study of African American urban youth found that at 32 years of age, women who had been teenage mothers were more likely than women who had not been teenage mothers to be unemployed, live in poverty, depend on welfare, and not have completed college (Assini-Meytin & Green, 2015). In this study, at 32 years of age, men who had been teenage fathers were more likely to be unemployed than were men who had not been teenage fathers.

SEXUAL MINORITY YOUTHS' ATTITUDES AND BEHAVIOR

The majority of sexual minority individuals experience their first same-sex attraction, sexual behavior, and self-labeling as a gay or lesbian during adolescence (Diamond & Savin-Williams, 2015; Savin-Williams, 2015). However, some sexual minority individuals have these experiences for the first time during emerging adulthood. Also, while most gays and lesbians have their first same-sex experience in adolescence, they often have their first extended same-sex relationship in emerging adulthood. Until the middle of the twentieth century, it was generally thought that people were either heterosexual or homosexual. However, there has been a move away from using the term "homosexual" because the term has negative historical connotations (Crooks & Baur, 2014). Also, the use of the term "homosexual" as a clear-cut sexual type is often oversimplified. For example, many more individuals report having same-sex attractions and behavior than ever identify themselves as members of a sexual minority—individuals who self-identify as lesbian, gay, or bisexual. The term bisexual refers to someone who is attracted to people of both sexes. Researchers have gravitated toward more descriptive and limited terms than "homosexual," preferring such terms as "individuals with same-sex attractions," or "individuals who have engaged in same-sex behavior." National surveys reveal that 2.3 to 2.7 percent of U.S. individuals identify with being a gay male, and 1.1 to 1.3 percent identify with being a lesbian (Alan Guttmacher Institute, 1995; Michael & others, 1994). Although some estimates of same-sex sexual activity (intercourse or oral sex) are in the 2 to 3 percent range for adults (Remafedi & others, 1992), others are higher (Mosher, Chandra, & Jones, 2005).

Christine's Thoughts About Sexual Relationships

The next day or the day after that. And after college, you're probably going to get into a routine of going to work, coming back home, feeding your dog, feeding your boyfriend, you know? It's going to feel like you have more of a stable life with this person, and think that they're going to be more intimate.

Cross-cultural Comparisons

The timing of teenage sexual initiation varies widely by culture and gender, and in most instances is linked to the culture's values and customs (Carroll, 2016). In one study, among females, the proportion having first intercourse by age 17 ranged from 72 percent in Mali to 47 percent in the United States and 45 percent in Tanzania (Singh & others, 2000). The proportion of males who had their first intercourse by age 17 ranged from 76 percent in Jamaica to 64 percent in the United States and 63 percent in Brazil. Not all countries were represented in this study, and it is generally agreed that in some Asian countries, such as China and Japan, first intercourse occurs much later than in the United States. Sexual activity patterns for 15- to 19-year-olds differ greatly for males and females in almost every geographic region of the world (Singh & others, 2000). In developing countries, the vast majority of sexually experienced males in this age group are unmarried, whereas two-thirds or more of the sexually experienced females at these ages are married. However, in the United States and in other developed nations such as the Netherlands, Sweden, and Australia, the overwhelming majority of 15- to 19-year-old females are unmarried.

The question of what information should be provided in sex education courses in U.S. schools today is a controversial topic

Three ways this controversial topic is dealt with are to focus on: (1) abstinence; (2) sex education that includes information about contraceptive use; and (3) abstinence-plus programs that promote abstinence as well as contraceptive use

What Is the Most Effective Sex Education?

Two research reviews found that abstinence-only programs do not delay the initiation of sexual intercourse and do not reduce HIV risk behaviors (Kirby, Laris, & Rolleri, 2007; Underhill, Montgomery, & Operario, 2007). Further, a recent study revealed that adolescents who experienced comprehensive sex education were less likely to report adolescent pregnancies than those who were given abstinence-only sex education or no sex education (Kohler, Manhart, & Lafferty, 2008). A number of leading experts on adolescent sexuality now conclude that sex education programs that emphasize contraceptive knowledge do not increase the incidence of sexual intercourse and are more likely to reduce the risk of adolescent pregnancy and sexually transmitted infections than are abstinence-only programs (Constantine, 2008; Eisenberg & others, 2008; Hampton, 2008; Hyde & DeLamater, 2014).

Development of Sexual Activities in Adolescents

What is the current profile of sexual activity of adolescents? In a U.S. national survey conducted in 2013, 64 percent of twelfth-graders reported having experienced sexual intercourse, compared with 30 percent of ninth-graders (Kann & others, 2014). By age 20, 77 percent of U.S. youth report having engaged in sexual intercourse (Dworkin & Santelli, 2007). Nationally, in 2013, 49 percent of twelfth-graders, 40 percent of eleventh-graders, 29 percent of tenth-graders, and 20 percent of ninth-graders recently reported that they were currently sexually active (Kann & others, 2014). A recent analysis of more than 12,000 adolescents in the Longitudinal Study of Adolescent Health found a predominant overall pattern of vaginal sex first, average age of sexual initiation of 16 years, and spacing of more than 1 year between initiation of first and second sexual behaviors (Haydon & others, 2012). In this study, about a third of the adolescents initiated sex slightly later but initiated oral-genital and vaginal sex within the same year. Further, compared with non-Latino adolescents, African American adolescents were more likely to engage in vaginal sex first. Also, adolescents from low-SES backgrounds were characterized by earlier sexual initiation. Sexual initiation varies by ethnic group in the United States (Kann & others, 2014). African Americans are likely to engage in sexual behaviors earlier than other ethnic groups, whereas Asian Americans are likely to engage in them later (Feldman, Turner, & Araujo, 1999) (see Figure 2). In a more recent national U.S. survey (2014) of ninth- to twelfth-graders, 61 percent of African Americans, 49 percent of Latinos, and 44 percent of non-Latino Whites said they had experienced sexual intercourse (Kann & others, 2014). In this study, 14 percent of African Americans (compared with 6 percent of Latinos and 3 percent of non-Latino Whites) said they had their first sexual experience before 13 years of age.

Forcible Sexual Behavior

Why is rape so pervasive in the American culture? Feminist writers assert that males are socialized to be sexually aggressive, to regard females as inferior beings, and to view their own pleasure as the most important objective (Davies, Gilston, & Rogers, 2012). Researchers have found that the following characteristics are common among rapists: aggression enhances their sense of power or masculinity; they are angry at females generally; and they want to hurt their victims (Yarber, Sayad, & Strong, 2013). Research indicates that rape is more likely to occur when alcohol and marijuana are being used (Fair & Vanyur, 2011). A recent study revealed that regardless of whether or not the victim was using substances, sexual assault was more likely to occur when the offender was using substances (Brecklin & Ullman, 2010).