Henrietta Szold Hadassah Hebrew University School of Nursing, Jerusalem
Adolescent Sexuality:
Growing up healthy
Anna Woloski-Wruble, EdD, RN
sections adapted from: Carol E. Peterson, MS, RN, Nurse Consultant, Wyoming Health Council
SIECUS
4UPARENTS
Order of the Day
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Sexual development
Assessment
Behavior
Decision making
Primary Coitus
Safe sex
Romantic relationships
Challenges
Curriculum
Education
Teen Sexual Development
• 1955 Dr. J.M. Tanner developed in-depth
description of development of the reproductive
system during puberty.
(Growth at adolescence, Blackwell Scientific Publications, Oxford)
• Tanner Stages 1-5 for female breast, male
genitalia, and pattern/ distribution of male and
female pubic hair.
– Stage 1 / pre-puberty through Stage 5 /
sexual development complete.
• Some variation in speed of progression normal;
can go from Stage 1 to 5 in two to five years.
• Body odor - an early sign that puberty is about to
begin!
Teen Sexual Development
Estrogen and testosterone cause the physical sexual
changes noted during puberty.
• Male Development:
– Average age of onset of puberty in males
(Stage 2) is 9 to 9 ½.
– First sign of male puberty in usually onset of
testicular enlargement.
– Ejaculation usually begins in Stage 3 with
fertility (sperm production) in Stage 4 (ranges
from age 12 to 16).
– Stage 4 voice deepens; Stage 5 facial hair
thickens.
Teen Sexual Development: Females
• Average age of onset of puberty in females
(Stage 2) is 11.2 (range 9 -13 ½ ), however 7 is
the accepted lower level of normal timing of start
of breast development.
• First signs of female puberty – downy pubic hair
and development of breast bud (glandular tissue
can be palpated).
• Average age of menarche (menstruation and
egg production) in the U.S. has declined.
Usually occurs at end of Stage 3/start of Stage
4. Has been decreasing over the years: late
1800s = age 16/17, 1954 = age 13 ½, now
average age is 12 ½ with normal range of 12 to
16.
Stage 1 :
May begin as early as age 9 and continue until 14.
• No sign of physical development but hormone production is beginning.
Stage 2 :
May begin anywhere from ages 11 to 13.
• Height and weight increase rapidly .
• Testicles become larger and scrotum hangs lower .
• Scrotum becomes darker in color .
• Fine hair growth begins at the base of the penis .
• Hair growth may begin on the legs and underarms.
Stage 3 :
May begin anywhere from ages 12 to 14.
• The penis, scrotum, and testicles grow .
• Pubic hair becomes darker, thicker, and curlier .
• Muscles become larger and shoulders become broader .
• Sweat and oil glands become more active, which can result in acne .
• Sperm production may begin .
• Temporary swelling and tenderness may occur around nipples .
• Height and weight continue to increase .
• Hair growth on the legs and underarms continues.
Stage 4:
May begin anywhere from ages 13 to 16.
• Sperm production has usually begun .
• The larynx (Adam's apple) increases in size. Vocal chords become
longer and thicker, and the voice begins to break or crack, then
becomes low .
• Height and weight continue to increase .
• Penis and testicles continue to grow .
• Pubic hair increases in amount and becomes darker, coarser, and curly.
Stage 5 :
May begin anywhere from ages 14 to 18.
• Growth of facial hair begins .
• Chest hair growth may begin
• Adult height is reached .
• Penis and testicles have reached full adult size .
• Pubic, underarm, and leg hair are adult color, texture, and distribution .
• Overall look is that of a young adult man.
Stage 1 :
Between ages 8 to 12.
• No visible signs of physical development. But the ovaries
are enlarging and hormone production is beginning.
Stage 2 :
May begin anywhere from ages 8 to 14.
• Height and weight increase rapidly .
• Fine hair growth begins close to the pubic area and underarms .
• Breast buds appear; nipples become raised and this area may be
tender .
• Sweat and oil glands become more active which can result in acne.
Stage 3 :
• May begin anywhere from ages 9 to 15.
• Breasts become rounder and fuller .
• Hips may start to widen in relation to waist .
• Vagina begins secreting a clear or whitish discharge
• Pubic hair becomes darker, thicker, and curlier .
• Height and weight continue to increase .
• For some girls, ovulation and menstruation (periods) begin, but may
be irregular.
Stage 4 :
May begin anywhere from ages 10 to 16.
• Underarm hair becomes darker .
• Pubic hair starts to form a triangular patch in front and around
sides of genital area .
• The nipple and the dark area around the breast (areola) may
stick out from the rest of the breast .
• For many girls, ovulation and menstruation (periods) begin, but
may be irregular.
Stage 5 :
May begin anywhere from ages 12 to 19.
• Adult height is probably reached .
• Breast development is complete .
• Pubic hair forms a thick, curly, triangular patch .
• Ovulation and menstruation (periods) usually occur regularly .
• Overall look is that of a young adult woman.
Teens: Our future
Psychosocial Assessment - HEADSSS
• Home
• Education/Employment
• Activities
• Drugs/Alcohol/Tobacco
• Sexuality
• Suicide/Depression
• Safety
[Review Confidentiality & Limitations]
Culture and Sexuality
Hormones & Brain Activity
• Parts of the brain responsible for sensation
seeking & excitement are “turned on” at the
same time as the parts for exercising judgment
are still “under construction.”
– Like turning on the engine of a car and putting
a unskilled driver at the wheel!
• Dopamine - hormone involved with motivation
and reinforcing behavior is abundant & active in
teen years; may influence experimentation & risk
taking.
• Melatonin – signals body to begin shutting down
for sleep; daily levels take longer to rise in teens
(so they want to go to bed later and get up later).
Sexual Behavior
Normal progression of behavior relates
to age/developmental stage:
– Early adolescence (9-14):
postponement & abstinence,
experimentation with nonintercourse sexual behavior is
common
– Middle adolescence (13-17): more
frequent experimentation and first
intercourse for some
– Late adolescence (17 and older):
initiation of sexual
activity/intercourse; sexuality
often associated with commitment
and future goals
Sexual Behavior
• Sexual Debut – most people become
sexually active before adulthood;
debut rarely planned in advance;
median age for first intercourse in
U.S. is 16 ½.
• Sexual Desire & Sexual Response
– Females: discussion often in context
of “ruining reputation” or “staying
pure” or “getting it over with”
– Males: Discussion in context of
sexual appetite, “being a man”
– Teens often frightened by “desire”
and “sexual response”; shrouded in
misinformation; adults rarely engage
in honest conversations with teens
about these normal responses.
But its not sex ….
• Young people have redefined sexual behavior –
in large part because of media messages!
• Consider themselves “virgins” even if they are
sexually active and engaging in mutual
masturbation, oral sex, or anal intercourse.
• Risk of pregnancy may be reduced, but not the
risk of HIV (with anal sex) and STIs (oral and
anal); teens need to know this!
• 12 & 13 year olds do not truly understand the
implications of oral sex; may see it as less
intimate than intercourse.
But its not sex …
• Girls agreeing for short term reasons (e.g. so
boys will “like” them).
• Often don’t see forced oral sex as “rape”
• Most information about incidence is anecdotal,
from school nurses and other clinicians (linked
to increases in stomach aches & sore throats).
• One national study reported that as many as
50% of students will have tried oral sex by the
time they graduate from high school.
• Other risky behaviors: “hooking-up”, ”friends with
benefits”
Factors Influencing
Adolescent Sexuality
• Parental involvement/discussion
– Youth who discuss sex with their parents are
less likely to engage in risky behavior (O’Donnell,
2005)
– Youth who discuss sex with their parents are
more likely to take precautions and have fewer
sexual partners (Camp, 2005)
More factors influencing
teenage sexuality
• Alcohol use
• Having a boyfriend/girlfriend
• Poor parental monitoring/permissive
parental attitudes
• Low SES
Peer Influences
• Peers often share misinformation about
sexuality
• Youth tend to overestimate the number of
peers engaging in sex
• Role of peer pressure
Media
• Media: one of the primary sources for
sexual information
Speculations on Teen Sexual
Behavior
Current Trends, Pennsylvania 2001
• Increase in oral sex
• Intercourse occurs quickly in a
relationship.
• Much of teen sex does not occur in the
context of a relationship, but at parties
under the influence of alcohol or other
drugs.
• Partners seldom communicate about sex,
setting limits, or using contraception.
Age of First Intercourse
• Changes after the sexual revolution of the
1960s
• Sex before marriage and at a younger age
became more prevalent
First Intercourse
• Changes again during the turn of the 21st
century
• Declines in the number of youth having
sex
– Increase in condom use and use of
contraceptives
Stages in the Sexual Development and Predictors
of Coitus Initiation among Israeli High School
Starkshall, Carmel, Woloski-Wruble, 2007, Archives of Sexual Behavior
• 475 classes, randomly sampled
• The overall proportion of those experiencing
coitus among male and female adolescents in
our sample was 29.2% and 15.8% for boys and
girls, respectively.
• The strongest associative variable with coitus
initiation was the perception of the proportion of
their peers that already practiced intercourse.
Males
(% practicing activity)
Females
(% practicing activity)
9th
10th
11th
12th
9th
10th
11th
12th
Kissing
406
(70.9)
439
(79.5)
468
(83.7)
341
(85.3)
377
(63.6)
433
(74.0)
545
(81.6)
384
(86.9)
Petting over the clothes
345
(58.3)
381
(68.0)
412
(73.6)
320
(79.8)
272
(46.3)
350
(59.8)
487
(74.1)
342
(78.6)
Petting under the
clothes
236
(40.3)
298
(53.0)
339
(60.5)
276
(69.5)
143
(24.7)
254
(44.3)
383
(58.6)
293
(67.8)
Genital Touching
182
(30.7)
246
(43.7)
285
(50.9)
245
(61.9)
88
(14.8)
153
(26.2)
290
(43.5)
237
(54.2)
Initiated coitus
87
(14.6)
152
(26.9)
197
(34.7)
186
(45.9)
33
(5.6)
64
(10.7)
137
(18.8)
139
(31.62)
Grade
Sexual behavior- developmental
concerns
• 13% of teen girls and 6% of teen boys felt
uncomfortable/did not want their first
sexual experience to happen when it did
• Emotional maturity and developmental
level
- US teens wait an average of one
year after intercourse begins before
visiting a birth control clinic.
Current Trends, Pennsylvania 2001
- Many teens are exposed
to contraception during
their first coitus
Reasons for delaying visit to clinic:
• “I just didn’t get around to it.”
• “I was afraid my parents would find out.”
• “I was waiting for a closer relationship with
my partner.”
• “I was afraid of the exam.”
Current Trends, Pennsylvania 2001
Safe Sex Practices
http://www.revolutionhealth.com/sexualhealth/safe-sex/basics/safe-sex-practices
Safe Sex Questions: Are you
mature enough to ask??
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How many people have you had sex with?
Have you had sex without a condom?
Have you ever had unprotected oral sex?
Have you had more than one sex partner at a
time?
• Do you inject illegal drugs or have you had sex
with someone who injects drugs?
• Have you ever had unprotected sex with a
prostitute?
• Have you ever had an STD, including Hepatitis
B or Hepatitis C Was it treated and cured?
• Watch for symptoms of STD’s, such as unusual discharge,
sores, redness, or growths in your and your partner's genital
area, or pain while urinating.
• Don't have more than one sex partner at a time. The safest sex is
with one partner who has sex only with you. Every time you add a
new sex partner, you are being exposed to all of the diseases that
all of their partners may have. Your risk for an STD increases if you
have several sex partners at the same time.
• Use a condom every time you have sex. Latex and
polyurethane condoms do not let STD viruses pass through, so
they offer good protection from STDs. Condoms made from
sheep intestines do not protect against STDs.
• Use a water-based lubricant such as K-Y Jelly or Astroglide to help
prevent tearing of the skin if there is a lack of lubrication during
sexual intercourse. Small tears in the vagina during vaginal sex or in
the rectum during anal sex allow STDs to get into your blood.
• Avoid douching if you are a woman, because it can change the
normal balance of organisms in the vagina and increases the
risk of getting an STD.
• Be responsible. Avoid sexual contact if you have symptoms of an
infection or if you are being treated for an STD or HIV. If you or your
partner has herpes, avoid sexual contact when a blister is present
and use condoms at all other times.
Safety during Oral Sex
- http://wso.williams.edu/orgs/peerh/sex/safesex/oralsex.html
- http://www.guttmacher.org/pubs/journals/3229800.html
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“It has become increasingly clear, however, that the narrow
focus on sexual intercourse in research that does get funded is
missing a major component of early sexual activity. There is
growing evidence, although still anecdotal and amassed largely
by journalists, not researchers, that adolescents might be
turning to behaviors-noncoital behaviors—that is, mutual
masturbation, oral sex and anal intercourse—that are not linked
to pregnancy but involve the risk of STDs? that avoid
pregnancy risk but leave them vulnerable to acquisition of many
STDs, including HIV."
Romantic Relationships/Attachments
• Early interactions among opposite sex occur in
the context/safety of larger peer groups.
• Romantic Relationships (RRs) are often
superficial and short lived.
• RRs may be crucial to identity formation,
transformation of family relationships, ability to
develop close relationships with peers, sexual
identity and academic success.
• However, they can become the focal point of an
early adolescent’s daily life.
• They imagine an “ideal partner/ideal romance”
and real life relationships may pale in
comparison; confusing media representations
can lead to inevitable disappointment.
Romantic Relationships/Attachments
• RRs can impact mental health, school and family
life and other aspects of teen life such as college
and career plans.
• Adults should not take RRs lightly! If they
dismiss these relationships as minor they may
alienate teen and block communications, also
occasionally a teen may take this so seriously
that they might become suicidal when it does not
work out.
• Teens may spend great deal of time with
partners and distance self from other friends and
family: need adults help them to keep a balance!
• Positive RRS can offer needed positive support
and healthy companionship.
Sexual Decision Making
• Adolescent decision making differs from adult
decision making; depends on the stage of
cognitive, emotional and social development –
However, for the most part emotions rule!
• Decisions regarding initiation of sexual
intercourse, use of birth control, and “consent”
issues can have a significant impact on the
health and well-being of an adolescent.
• Situations concerning sexual decisions
(consenting to have sex or using contraceptives)
are flooded with passionate emotions; important
decisions often made in the heat of the moment.
Sexual Decision Making
• Teens will state that it is important for them to
wait for the right person or until they reach a
certain age, but during the passion of the
moment they may make a different decision
• They need to develop skills and have a plan so
they can be prepared, in advance, for the
moment.
• Psychological changes (personality type/traits,
self-esteem, internal or external locus of control,
etc.); social factors (religious & moral beliefs,
influence of media, etc.); developing sex drive;
developing autonomy; knowledge and skills; all
play roles in the sexual decisions teens make.
Sexual Decision Making
• Elements of Decision Making
– Cognitive Development – may not be refined
enough to allow for realistic cost-benefit
analysis. Dependant on:
• Capacity (ability to use cognitive resources)
• Knowledge (acquisition of information),
• Skills (assessment of odds, confidence, etc.).
– Emotional Development – Hot Emotions
(strong undercurrents dependant on the
situation) vs. Cold Emotions (rely on basic
values and cognitive skills).
Sexual Decision Making
Social Development – includes learning the
norms, attitudes, and values of one’s
group and observing others and learning
from experience.
• Knowledge alone does not change behavior.
• Peer influence is very powerful (i.e. teens whose
friends rarely used condoms 3x more likely to
engage in risky behaviors).
• Difficult situation because teens have a
biological/psychological urge for sexual activity
accompanied by a sense of invulnerability to
harm from STI’s, pregnancy, etc.
LGBT
• LGBT (or GLBT) refers collectively to lesbian , gay, bisexual,
and transgender/transsexual people
• Identifying or being perceived as LGBT or “queer” is commonly
associated with internalized and externalized stigmatization,
victimization and resultant negative mental and physical
outcomes.
• LGBT Identity Development
– LGBT youth must accomplish the same
developmental milestones and processes as
other youth but also are trying to come to terms
with their “difference” as LGBT.
– LGBT adolescents are commonly left isolated
without healthy, socially acceptable venues for
exploring their sexual feelings.
Process of “Self Identifying”
Four Stages:
1. Acknowledges being or feeling “different”
as child/early teen;
2. Identity confusion (non-heterosexual but
not sure if LGBT);
3. Identity assumption (self identifies &
comes out);
4. Commitment stage (identifies as LGBT in
all aspects of life)
LGBT Teens
• Common Safety/Health Care Concerns with
LGBT Adolescents
– Involved in fights; increased injuries;
increased skipping school because of feeling
unsafe; increased rates of attempted suicide.
– HIV/AIDS & Hepatitis, substance abuse,
emotional stress/depression/anxiety disorder
– Need for harm reduction counseling.
• Establish Safe Settings for LGBT Youth
– gender neutral language.
• Need information and resources to reduce risks.
Teen Relationships and Danger
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Unprotected first time sex
Fatal attraction
Coercion
Multiple partners
Violence and Teen Sexuality
Wood, K. , Maforah,F., & Jewkes, R. (1998). “He forced me
to love him”: Putting Violence on Adolescent Sexual
Health Agendas. Social Science & Medicine, 2, 233242.
EXPLORATORY QUALITATIVE STUDY IN SOUTH AFRICA
1. Is there negotiation and decision making in teen
sexual practices?
2. If you want to be popular, belong to that group, you
have to do IT!
3. Male violent and coercive behavior
4. Beating vs. gifts and money
5. Sign of love
SIECUS
http://www.siecus.org/
Types of Sexual Health Education Curricula
– Abstinence-Only: can help to delay initiation of
sexual activity in young teens (Jr. High) for up to 18
months – however after that STI rates are equal to
those who have never had any sex ed.; they need
more information as they get older.
– Abstinence-Based: teaches facts about HIV/STI’s
and unintended pregnancy and teaches valuable
communication and refusal skills that can be
transferable to other situations (e.g. when offered
drugs); appropriate for Jr. & Sr. High
– Comprehensive Sexuality Education: best for Sr.
High; a must for high risk and sexually active teens,
incarcerated youth and college students.
LIFE VALUES AND INTIMACY EDUCATION
FOR THE JEWISH DAY SCHOOL
Yocheved Debow MA
Dr. Anna C. Woloski-Wruble EdD, RN
Key Concepts
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Values and personal skills
Relationships
Human development
Sexual behavior
Sexual health
Society and culture
The Leading Subjects by Gender
Stages in the Sexual Development and Predictors of Coitus Initiation among Israeli High School
Starkshall, Carmel, Woloski-Wruble, 2007, Archives of Sexual Behavior
2.5
2.3
2.3
2.2
2.0
1.9
1
2
3
4
5
6
16
Physical
Development
Contraception
Sex in
Adolesc.
Communication
STIs and
HIV/AIDS And Relationships
Between genders
Psychological
Development
Sexual
Violence
1
2
3
4
5
6
2.9
2.8
2.8
2.5
2.2
2.0
16
‫ביה"ס לסעוד ע"ש הנרייטה סאלד של הדסה והאוניברסיטה העברית‬
‫‪Pre‬‬‫‪Pre-Marital‬‬
‫‪Education‬‬
Special needs :Sexuality Education
Advice for Nurse Educator
– Provide an environment where open discussion is
allowed
– Encourage teens to share their ideas & thoughts.
– Allow them to think independently.
– Teach them skills that allow them to become
comfortable with this own bodies: self breast
exams, testicular self exams.
– Recognize and praise teens for well-thought-out,
responsible decisions
– Assist adolescents in reevaluating decisions that
have negative consequences. (How might you do
this differently next time?)
Confidentiality and Consent –
What’s the Big Deal?
Adolescents are going through tremendous
physical, cognitive, emotional, sexual changes.
Teens strive for autonomy and independence.
Privacy is a key issue.
Confidentiality is the cornerstone of alliance.
Five Core Needs of
Teens*
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Affirmation
Information giving
Values clarification
Limit setting
Anticipatory guidance
*Roffman D. Sex and Sensibility: The Thinking Parent’s Guide to
Talking about Sex. Perseus Publishing, USA. 2001.
Parents: Keeping them in the picture
Burgess, V., Dziegielewski, S.F., & Green, C.E. (2005).
Improving comfort about sex communication
between parents and their adolescents:
Practice based- research within a teen
sexuality group
Brief Treatment and Crisis Intervention, 5, 379-390.
Characteristics of Sexually Healthy Teens
• Appreciates and values own body.
• Takes responsibility for own behaviors.
• Is knowledgeable about sexuality issues.
• Communicates effectively with family about
many issues, including sexuality.
• Seeks and understands information about
parent’s values and considers them when
forming own values.
• Interacts with both genders in appropriate and
respectful ways.
• Expresses love and intimacy in developmentally
appropriate ways.
• Able to evaluate personal readiness for mature
sexual relationships.
In Conclusion….
• In order to effectively assist teens with their own
sexuality, health providers must first:
– Identify their own sexual views and values.
– Support teens autonomy when possible.
– Show empathy and be good listeners.
– Familiarize themselves with available
programs and resources for teens.
– Know when, how, and where to make
referrals for teens who are already sexually
active, high risk teens, teens in abusive
situations, teens with mental health issues,
substance abuse issues, etc.
Teen SexualityA Multicultural and Mulltidimensional Approach