Sex and Sexuality

Sex and sexuality are important topics for many adolescents and young adults. Encouraging informative and sensitive discussion of sexuality is a great service to teens, even if they are not completely comfortable with the conversation.

Adolescents are bombarded by images, expectations, and messages about sex and sexuality, often with divergent views. At the same time, hormonal changes and sexual desires are surfacing, and many adolescents are beginning to explore sexual attractions and gender identities. By offering to have these conversations early and without stigma, medical providers demonstrate their willingness to provide a fact-based, judgment-free space to discuss sex, sexuality, and how to stay safe.

Such conversations can feel daunting to residents, and developing the language needed to talk about sex may not feel natural. Health care providers bring their own beliefs and judgments to this part of the clinical encounter, and the conversation can vary substantially throughout adolescence based on developmental stage. Typically, however, adolescents benefit from an acknowledgement that they may feel attracted to others and that they can talk about it with you. These discussions are nuanced. Striking the balance between being supportive but not permissive can be challenging. Our task as clinicians is to help adolescents understand the development of healthy sexuality.

Many individuals have their first experience of sexual pleasure in early childhood by exploring their own bodies. Over time, sexuality progresses to the desire to explore sexual pleasure with others. Although we may agree that we do not want 12-year-olds to be sexually active, we do want to help prepare adolescent patients to have safe and fulfilling sexual experiences in the future. How do we create a safe space for teens regardless of sexual preference or gender identity? How do we support a patient who reveals they are in an abusive relationship? What are best practices for providing gender-affirming care? What is the role of parents in these conversations, and what do parents have a “right” to know? How do we address the importance of consent with our patients?

Fortunately, a little information and practice go a long way toward developing skills and comfort and developing your own style. With the guiding principle of providing fact-based, judgment-free information, practitioners can help adolescent patients feel supported, stay safe, and make information-based decisions.

Data on Youth Sex and Sexuality in the United States

National surveys, including the Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Surveillance System (YRBSS) provide insight about sexual behavior among teens. The following statistics are from the Youth Risk Behavior Surveillance — United States, 2019 survey of high school students, Sexually Transmitted Disease Surveillance 2020 survey, and Diagnoses of HIV Infection in the United States and Dependent Areas 2020 surveillance report.

Risks associated with youth sex: Sexual risk behaviors put teens at risk for pregnancy, sexually transmitted infections (STIs), and HIV infection.

• In 2019, more than 170,000 babies were born to teens in the U.S. aged 15 to 19 years. Although rates of teen pregnancies have been trending downward since the early 1990s, the rate (16.7 births per 1000) is still substantially higher than rates in other developed nations.

• The average age of first sexual encounter is about 18 years.

• The average age of marriage is in the mid-20s.

• Young people accounted for 53% of more than 2.4 million new STIs reported each year.

• In 2020, more than 6,000 new diagnoses of HIV were reported among 13- to 26-year-olds, accounting for an estimated 20% of all new HIV diagnoses in the U.S. that year.

  • Among those diagnosed with HIV in 2020, 68% were gay and bisexual men.

  • Among women, 15% contracted HIV through heterosexual contact and 3% through intravenous drug use (4% in men).

Sexual activity in high school students:

• 39% of respondents had ever had sexual intercourse (rates increased from 9th to 12th grade)

• 27% had had sexual intercourse during the previous 3 months.

  • 46% did not use a condom the last time they had sex.

  • 12% did not use any method to prevent pregnancy.

  • 21% had drunk alcohol or used drugs before their last sexual intercourse.

  • 9% of high school students were ever tested for a sexually transmitted infection (STI).

Data on sexual-minority youth:

(Reference: Youth Risk Behavior Survey, United States, 2019. Overview and Methods for the Youth Risk Behavior Surveillance System — United States, 2019. Morb Mortal Wkly Rep MMWR Suppl 2020.)

• 11% of high school students report a sexual identity other than heterosexual.

• Sexual-minority youth are often at significantly higher risk for exposure to violence than their heterosexual peers.

  • 12% were threatened or injured with a weapon at school.

  • 32% were bullied at school.

  • 27% were victims of cyberbullying.

  • 16% of sexual-minority students who had dated or went out with someone during the 12 months before the survey had experienced sexual dating violence.

  • 13% of sexual-minority students had experienced physical dating violence.

  • 19% of sexual-minority students had been forced to have sexual intercourse at some point in their lives.

• During the Covid-19 pandemic, increased time at home exacerbated these risks for many sexual-minority youth, 60% of whom reported experiencing anxiety, depression, and psychological stress.

• Supportive schools, families, and positive friendships mitigate these risks. In a 2009 study, lesbian, gay, and bisexual young adults who experienced strong rejection from their families were compared with peers who had more-supportive families. Those who experienced stronger rejection were:

  • 8.4 times more likely to have tried to commit suicide

  • 5.9 times more likely to report high levels of depression

  • 3.4 times more likely to use illegal drugs

  • 3.4 times more likely to have risky sex

• Sexual-minority patients have markedly more negative interactions with health care providers than heterosexual peers, and these interactions prevent or delay seeking medical care.

Discussing Sex and Sexuality

A judgment-free provider can help minimize barriers to care by offering their own gender- or sexual-identity pronouns and eliciting patients’ pronouns, using transgender and gender nonconforming youths’ chosen names, educating families when needed, broadening reproductive and sexual health screening to include all genders and sexual practices and ensuring that your beliefs are not the focus of the visit.

Keys Principles for Discussing Sex and Sexuality

The following principles and sample phrasing can help put youth at ease when discussing sex and sexuality:

• Set the stage and make it clear that you are interested in keeping the patient safe.

  • “I ask all my patients a few questions about relationships and sex so that I can make sure they know what they need to keep themselves safe.”

• Use a “two-step” approach to query how a patient identifies.

  • “What sex were you assigned at birth, on your original birth certificate (male, female)?”

  • “How do you describe yourself? (male, female, transgender, do not identify as male/female/transgender)”

• Ensure you are using their correct pronouns and name.

  • “The chart says your name is ___, but what name do you use or prefer?”

  • “My pronouns are __; what are yours?”

• Don’t presume you know who they are attracted to.

  • “Are you attracted to males, females, both, neither, or unsure?”

• Provide information about contraception in a way that does not presume existing knowledge, recognizes that method utility and desirability varies between individuals, and promotes reproductive autonomy. Many patients are uncomfortable acknowledging that they don’t know much about contraception or do not know they are wrong about how to use contraception. See Contraception in this rotation guide for more information about reproductive autonomy.

  • “Have you been shown how to use a condom? You have? Great, so you already know that you need to put the condom on before entry and…”

• Be direct with questions about whether they have had sex.

  • “Have you ever had sex? Are you sexually active? Do you think that’s something you might be doing soon or much later in the future?”

  • “Have you ever had your penis inside someone else’s mouth? Vagina? Butt?”

• Share data about sexual norms in the conversation and reinforce decisions to delay sexual debut as appropriate.

  • “It’s great that you are holding off on having sex. When we do surveys of people your age, we find that most are also waiting until they are older.”

• For adolescents who are not sexually active, leave the door open to readdress safety at future visits.

  • “If you are thinking about becoming sexually active, you can always come talk to me about how to keep yourself safe, prevent sexually transmitted infections, and prevent pregnancy if desired.”

• Inform both male and female patients in heterosexual relationships about hormonal and emergency contraception.

  • “Many of my male patients don’t know much about emergency contraception. Is this something I can review with you?”

  • “Lots of my patients don’t know about all the available options to prevent pregnancy. Can we go over what’s out there to make sure you know all your options?”

• Talk about consensual sex, what it is, and how to obtain it. Remind youth that consent must be freely obtained, is for a specific act at a specific encounter, and is provided by individuals not under the influence of drugs or alcohol.

  • “How do you know someone wants to have sex? Who decides?”

  • “Particularly when people have had something to drink or used drugs, it’s not always clear what they want. Are you 100% sure they want to have sex?”

• Talk about healthy relationships.

  • “Who makes decisions in your relationship? What do friends/family think of your boyfriend/girlfriend?”

• Do not assume people with developmental or physical disabilities are not sexually active. Ensure they have access to the same information and screening as able-bodied youth.