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  [email protected] AJN ▼June 2013 ▼ Vol. 113, No. 6 67 EVIDENCE FOR EXCELLENCE Promoting Healthy Sexual Behavior in Adolescents What the research says. A dolescents who engage in early sexual rela- tions have a high risk of sexually transmitted infections (STIs), pregnancy, and emotional pain.1 The Centers for Disease Control and Preven- tion estimates that youths account for more than half of the 20 million new STIs that occur each year in the United States.2 In 2010, 367,678 infants were born to girls 15 to 19 years of age.3 The individual and social costs of STIs and teen pregnancy indicate a need to help adolescents learn strategies for mak- ing better decisions about sex. Sex education, one intervention used to provide guidance, has been the source of heated debate for over a decade.4 This de- bate primarily focuses on whether or not sex edu- cation influences adolescents to engage in early and risky sexual behavior (such as having multiple part- ners or unprotected intercourse). The two most common sex education curricula in the United States are abstinence-only and compre- hensive sex education. Studies have compared and contrasted the outcomes of both,4 but few have exam- ined how peer groups and families influence adoles- cent decisions about sex.5 Even fewer studies have investigated the role of adolescent development on behavioral outcomes.6 This article will examine sev- eral studies exploring sex education programs and adolescent decision making within the context of cognitive development. It will also offer recommen- dations for evidence-based interventions that may re- duce risky adolescent sexual behavior. STAGES OF COGNITIVE DEVELOPMENT To better understand adolescent sexual behavior, a brief summary of cognitive development provides in- sight into how adolescents make decisions. Research- ers divide adolescence into three stages: • Early: 10 to 14 years6 ; 11 to 13 years7 • Middle: 15 to 17 years6 ; 14 to 16 years7 • Late: 18 to 21+ years6 ; 17 to 21 years7 Cognitive skill is required to link consequences to behavior. In early adolescence, thinking is predomi- nately concrete (only the here and now is relevant, for example) and long-term consequences are not consid- ered. In middle adolescence, abstract thinking starts (although in times of stress, the middle adolescent often reverts to concrete thinking) and consequences of behavior begin to be considered. In late adoles- cence, abstract thinking begins to mature and con- sequences of behavior are considered.6, 7 ADOLESCENT SEXUAL DECISION MAKING:A REVIEW OF THE LITERATURE Research often provides quantitative data addressing the “who, what, when, and where” of adolescent sex- uality. But it’s equally important to understand the “why”—why do adolescents make certain sexual de- cisions? To better answer this question, Fantasia con- ducted a comprehensive literature review of adolescent decision making, selecting for review 17 studies pub- lished in peer-reviewed journals from 1998 to 2009.8 She found that adolescents who decided to pursue sex- ual relations fell into one or more of three categories. • They minimized the risks of sexual activity. • They had specific risk factors for engaging in unsafe sexual behavior. • They believed that sexual activity was “safe” in relationships. By Deborah M. Wisnieski, PhD, APRN, and Marianne Matzo, PhD, APRN, FPCN, FAAN Photo©Camerique/ClassicStock/TheImageWorks. AJN0613.Matzo.EvidenceforExcellence.4th.indd 67 5/9/13 2:11 AM
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  68 AJN ▼June 2013 ▼ Vol. 113, No. 6 ajnonline.com EVIDENCE FOR EXCELLENCE The following is a review of some of the evidence Fantasia found to support these categories. Minimizing the risks of sexual activity. Kershaw and colleagues studied a group of 411 urban female adolescents ages 14 to 19 who engaged in unprotected sex with multiple partners.9 Over half believed their behavior was only “slightly risky” or “not at all risky.” Chapin studied 180 black male and female adolescents ages 10 to 17; he found that while condom use was inconsistent, the students exhibited “optimistic bias,” the misperception that they were less at risk than their peers of causing or experiencing pregnancy.10 They also overestimated the amount of sexual activity their peers engaged in, which is potentially risky because of adolescents’ desire to imitate peer behavior. Risk factors. In a study by Zwane and colleagues, female adolescents said they engaged in sexual activ- ity to be accepted by their peers and to avoid the label of being “old fashioned.”11 Sexual activity was also reported in another study as filling the adolescents’ need to feel important and cared about.12 Factors con- tributing to risky sexual behavior also include lack of close maternal supervision,13 use of drugs and al- cohol, and sensation seeking.14 Believing in the safety of relationships. Adoles- cents may believe they are in a safe relationship be- cause they experience a sense of familiarity with their partner.8 In a large sample of more than 1,000 early and middle adolescents, 40% reported initiating sex- ual activity within one month of establishing a dating relationship.15 Reported condom use in dating rela- tionships was low; 47% used condoms with a casual partner, while only 37% used them with a primary partner.16 Unfortunately, monogamy was also unusual; Lenoir and colleagues found that 42% of male ado- lescents reported sexual contact with someone out- side of the dating relationship.17 Once an adolescent establishes a relationship of mutual liking and trust, the use of condoms is often short lived.18 One study revealed that, on average, many adolescents stop using condoms after 21 days into the relationship.19 Fear of rejection and anxiety about discussing intimate sexual issues tends to lead adolescents to prioritize the maintenance of the rela- tionship over safety. The misperception of low health risk combined with the false sense of invulnerability (an aspect of early and middle adolescent develop- ment) can compound the risk of poor decision mak- ing.16 Recognizing a partner’s motives and setting high expectations within a relationship were two factors found to support consistent condom use among sexu- ally active 13-to-17-year-old girls.12 THE INFLUENCE OF SEX EDUCATION ON SEXUAL ACTIVITY Sex education can help adolescents make more in- formed decisions and is most effective among early adolescents, who have shown a documented decrease in risky sexual behavior after completing instruction.4 In the United States, there are two types of sex edu- cation curricula: comprehensive and abstinence only. Comprehensivesex education includes messages about abstinence but also teaches methods of contraception and the use of condoms to avoid STIs.4 Comprehen- sive sex education programs are designed to provide information about safe sexual practices to both sex- ually active adolescents and those who may need this information in the future. Abstinence-only education teaches that there are social and psychological advan- tages to remaining sexually abstinent. These programs are required to teach that abstinence from sexual ac- tivity until marriage is the “expected standard” and that condoms are ineffective in protecting against STIs and pregnancy.4 Because abstinence is the only accept- able option, other forms of contraception are not ad- dressed. Abstinence-only supporters often believe that pro- viding information about contraception and condoms encourages adolescents to engage in sexual activity— despite evidence to the contrary.20-22 Government funding for abstinence-only programs has decreased significantly since the George W. Bush administration. However, despite the paucity of data indicating that this curriculum reduces teen pregnancy or rates of sexually transmitted disease, the federal government has continued to support it, allocating $50 million to abstinence-only education in both 2010 and 2011.23 Abstinence-only vs. comprehensive sex educa- tion. The National Survey of Family Growth collected data from approximately 1,719 male and female het- erosexual adolescents (ages 15 to 19) to compare the effectiveness of abstinence-only, comprehensive, and no formal sex education.4 Adolescents from nonintact or low-income families were less likely to have re- ceived any formal sex education. Comprehensive sex education was marginally associated with reduced rates of sexual intercourse, whereas adolescents who received no sex education reported a higher incidence of intercourse. The inci- dence of pregnancy was no different in the abstinence- only and no-sex-education groups; only the group that Female adolescents said they engaged in sexual activity to avoid the label of being ‘old fashioned.’ AJN0613.Matzo.EvidenceforExcellence.4th.indd 68 5/9/13 2:11 AM
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  [email protected] AJN ▼June 2013 ▼ Vol. 113, No. 6 69 received comprehensive sex education had a decreased likelihood of pregnancy. Neither sex education pro- gram reduced the incidence of STIs when compared with no sex education.4 Low income and nonintact family structures were found to be predictors for early intercourse, pregnancy, and STIs.4 Jemmott and colleagues conducted a randomized controlled trial of sixth and seventhgraders to evaluate interventions to prevent sexual activity.24 Participants in this study received one of four types of instruction: abstinence only, comprehensive sex education, safer sex (which encouraged condom use to reduce the risk of pregnancy and STIs), and general health promotion (the control group). The findings suggest that students placed in the abstinence-only group had significantly less intercourse than those in the control group at three, six, 12, 18, and 24 months of follow-up (21% versus 29%, respectively; P = 0.02). However, findings were similar for the comprehensive sex education group compared with the control group (21% versus 29%, respectively; P = 0.06), an important point that was not widely reported in media coverage of this study. The authors acknowledged that the abstinence-only instruction did not meet the criteria needed to qualify for abstinence-only federal funding. As explained in a New York Times article on the study, “Unlike the fed- erally supported abstinence programs now in use, [this program] did not advocate abstinence until mar- riage. The classes also did not portray sex negatively or suggest that condoms are ineffective, and contained only medically accurate information.”25 Thus, these findings cannot be compared with those of most other abstinence-only research studies. The age of the study participants was another im- portant issue. The mean age was 12.2 (range, 10 to 15 years), placing the majority of the subjects in the early adolescent stage of development, where they remained throughout the two-year study. In this stage, cognitive development is only beginning and long-term conse- quences of behavior are not yet considered.7 The in- terventions were specifically tailored to this cohort. Participants were taught to wait for sex until they were ready, helped to build skills they needed to say “no,” and instructed in tactics to avoid peer pressure. While appropriate for early adolescents, these same interventions may not be appropriate for older teens, who respond to different kinds of instruction. RECOMMENDATIONS FOR BEST PRACTICES Nurses can help adolescents and their families by teaching them about sexual development and the process for choosing to engage in healthy, age- appropriate sexual behavior. These discussions should • incorporate interventions that match the adoles- cent’s level of cognitive development. • describe the effects of peer pressure and com- mon misperceived beliefs. • emphasize the importance of family, friends, and extended family in building relationships and monitoring adolescent behavior. Cognitive development. Understanding the developmental aspects of behaviors—for example, early adolescents make spur-of-the-moment deci- sions and are limited in their ability to consider the consequences—can be beneficial for nurses and parents alike. The amount of freedom and respon- sibility given to teens should match their develop- mental level. A 13-year-old, for example, may not know how to avoid sexual advances or how to con- trol her or his feelings. Impulse control is poorly developed, necessitating adult supervision. Con- versely, 17-year-olds may have experience with friends of both sexes in supervised social groups. Such experience can increase confidence and cogni- tive skills in potentially sexual situations, ultimately enabling older teens to manage their feelings and actions in ways that support their values and be- liefs. Parents can promote healthy group interac- tions by hosting mixed-sex group activities, such as listening to music or watching movies; activities like this can help build the social skills that form the foundation for decision making in older adoles- cence. Peer groups can encourage or reinforce adolescents’ decisions about whether to engage in sexual activity. Instruct parents to ask their chil- dren how they spend time with their friends and to inquire about their friends’ sexual activities. In some groups, engaging in sexual activity confers higher status and reinforces a sense of belonging. Adolescents may overestimate their peers’ sexual exploits, which can encourage them to become ac- tive as well.26 Parents who are aware of the real and perceived activities of their adolescent’s peers can be proactive in discussing the risks and benefits of sexual relationships. Forty-two percent of male adolescents reported sexual contact with someone outside of the dating relationship. AJN0613.Matzo.EvidenceforExcellence.4th.indd 69 5/9/13 2:11 AM
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  70 AJN ▼June 2013 ▼ Vol. 113, No. 6 ajnonline.com EVIDENCE FOR EXCELLENCE Parental support. When it comes to making de- cisions about sex, teenagers consider their parents’ in- fluence to be more important than that of their peers or popular culture.27 In fact, 87% of teens said that “it would be much easier to delay sexual activity and avoid teen pregnancy if they were able to have open, honest conversations about these topics with their par- ents.”27 Yet while most parents want to be involved and welcome dialogue about romantic relationships,5 few initiate timely discussions or provide information that meets their adolescents’ needs.28 Single parents and those who work long hours may benefit from building support systems of extended family and friends. Finally, comprehensive sex education can positively influence decisions about sexual behavior. However, parental supervision remains vital, especially for early adolescents who may be unable to adequately con- sider the consequences of their behaviors. Late ado- lescents have the cognitive skill to decide to engage in safe sex if they are armed with information about protection (such as condoms and birth control pills), how to use it, and where it can be obtained. Sexual education can result in closer family relationships and improved adolescent sexual health. RESOURCES Curriculum components for comprehensive sex ed- ucation programs can be obtained from the National Campaign to Prevent Teen and Unplanned Pregnancy (www.thenationalcampaign.org) or the Sexuality In- formation and Education Council of the United States (www.siecus.org). ▼ Deborah M. Wisnieski is an associate professor and Marianne Matzo is professor and Frances E. and A. Earl Ziegler Chair in Palliative Care Nursing at the University of Oklahoma, Oklahoma City. Matzo also coordinates Evidence for Excellence: mmatzo@ ouhsc.edu. Contact author: Deborah M. Wisnieski, deborah- [email protected]. The authors have disclosed no potential conflicts of interest, financial or otherwise. REFERENCES 1. Aspy CB, et al. Youth assets and delayed coitarche across de- velopmental age groups. J Early Adolesc 2010;30(2):277-304. 2. Centers for Disease Control and Prevention. CDC fact sheet: incidence, prevalence, and cost of sexually transmitted infec- tions in the United States. Atlanta; 2013. 3. Martin JA, et al. Births: final data for 2010. Hyattsville, MD; 2012 Aug 28. National Vital Statistics Reports; http:// www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf. 4. Kohler PK, et al. Abstinence-only and comprehensive sex ed- ucation and the initiation of sexual activity and teen pregnancy. J Adolesc Health 2008;42(4):344-51. 5. Lagus KA, et al. Parental perspectives on sources of sex infor- mation for young people. J Adolesc Health 2011;49(1):87-9. 6. Fonseca H, Greydanus DE. Sexuality in the child, teen, and young adult: concepts for the clinician. Prim Care 2007; 34(2):275-92; abstract vii. 7. Shafii T, Burstein GR. The adolescent sexual health visit. Obstet Gynecol Clin North Am 2009;36(1):99-117. 8. Fantasia HC. Adolescent sexual decision-making: a review of the literature. J Nurse Pract 2009;13(11/12):22-30. 9. Kershaw TS, et al. Misperceived risk among female adoles- cents: social and psychological factors associated with sexual risk accuracy. Health Psychol 2003;22(5):523-32. 10. Chapin J. It won’t happen to me: the role of optimistic bias in African American teens’ risky sexual practices. Howard Journal of Communications 2001;12(1):49-59. 11. Zwane IT, et al. Adolescents’ views on decision-making regard- ing risky sexual behaviour. Int Nurs Rev 2004;51(1):15-22. 12. Garwick A, et al. Risk and protective factors for sexual risk taking among adolescents involved in Prime Time. J Pediatr Nurs 2004;19(5):340-50. 13. Sieving RE, et al. Maternal expectations, mother-child con- nectedness, and adolescent sexual debut. Arch Pediatr Ado- lesc Med 2000;154(8):809-16. 14. Donohew L, et al. Sensation seeking, impulsive decision- making, and risky sex: implications for risk-taking and de- sign of interventions. Pers Individ Dif 2000;28(6):1079-91. 15. Manning WD, et al. Hooking up: the relationship contexts of “nonrelational” sex. J Adolesc Res 2006;21(5):459-83. 16. Lescano CM, et al. Condom use with “casual” and “main” partners: what’s in a name? J Adolesc Health 2006;39(3): 443,e1-e7. 17. Lenoir CD, et al. What you don’t know can hurt you: per- ceptions of sex-partner concurrency and partner-reported behavior. J Adolesc Health 2006;38(3):179-85. 18. Metts S, Fitzpatrick MA. Thinking about safer sex: the risky business of “know your partner” advice. In: Edgar T, et al., editors. AIDS: a communication perspective. Hillsdale, NJ: Lawrence Erlbaum Associates; 1992. p. 1-19. 19. Niccolai LM, et al. New sex partner acquisition and sexu- ally transmitted disease risk among adolescent females. J Ad- olesc Health 2004;34(3):216-23. 20. Bennett SE, Assefi NP. School-based teenage pregnancy pre- vention programs: a systematic review of randomized con- trolled trials. J Adolesc Health 2005;36(1):72-81. 21. Lindberg LD, Maddow-Zimet I. Consequences of sex edu- cation on teen and young adult sexual behaviors and out- comes. J Adolesc Health 2012;51(4):332-8. 22. Underhill K, et al. Abstinence-only programs for HIV infec- tion prevention in high-income countries. Cochrane Data- base Syst Rev 2007(4):CD005421. 23. SIECUS: Sexuality Information and Education Council of the United States. A history of federal funding for absti- nence-only-until-marriage programs. New York; 2011 Oct 19. http://www.siecus.org/index.cfm?fuseaction=page. viewPage&pageID=1340&nodeID=1. 24. Jemmott JB, 3rd, et al. Efficacy of a theory-based abstinence- only intervention over 24 months: a randomized controlled trial with young adolescents. Arch Pediatr Adolesc Med 2010;164(2):152-9. 25. Lewin T. Quick response to study of abstinence education. New York Times 2010 Feb 2. http://www.nytimes. com/2010/02/03/education/03abstinence.html. 26. Baumgartner SE, et al. Assessing causality in the relationship between adolescents’ risky sexual online behavior and their perceptions of this behavior. J Youth Adolesc 2010;39(10): 1226-39. 27. Albert B. With one voice: America’s adults and teens sound off about teen pregnancy. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy; 2012 Aug. http://www.thenationalcampaign.org/resources/pdf/ pubs/WOV_2012.pdf. 28. Beckett MK, et al. Timing of parent and child communica- tion about sexuality relative to children’s sexual behaviors. Pediatrics 2010;125(1):34-42. Keywords: abstinence, adolescents, sex educa- tion, sexual behavior, sexual health, sexuality, sexually transmitted infections AJN0613.Matzo.EvidenceforExcellence.4th.indd 70 5/9/13 2:11 AM