Adolescent Sexual and Reproductive Health 

Adolescents have unique needs when it comes to their sexual and reproductive health care. They are at an age where they are beginning to explore their bodies and their sexuality but they might not have much knowledge or experience with it. They wish to learn more about sex from their parents, but their parents are ill-equipped to discuss much with them. They are gaining agency and independence, but they are still minors subject to laws and regulations. Most of the emphasis on sexual and reproductive health care is aimed towards women, and men tend to ignore their health and not seek services. And these teens live in a society that is highly ambivalent about their sexuality. How do health care providers, schools, and parents provide effective, integrative sexual health care for their teenagers? Let’s first explore what is sexual and reproductive health care and some of the barriers that teens face.

What is sexual and reproductive health care?

According to the World Health Organization’s Millennium Development Goal Target 5B: Universal Access to Reproductive Health (2009),

“Reproductive health is a broad and comprehensive concept, which is defined by the International Conference on Population and Development (ICPD) as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes.”

The WHO noted that universal access also includes a “wider context” of the rights of individuals and disadvantaged populations, and those needs may vary by individual and during different times for each person.

Specific services for sexual and reproductive health include sexual education, pregnancy education (birth control, emergency contraception, abstinence education), sexually transmitted infection (STI) screening and treatment, treatment of other diseases and infections of the reproductive organs (like urinary tract infections), pre-natal care, safe abortion, and obstetrics services (including safe childbearing and reducing maternal and child mortality).

The United States has over 42 million adolescents between the ages of 10 and 18 in 2005 (MacKay & Duran, 2007, p. 8). This represents approximately 14% of the US population. Per Abma, Martinez, Mosher, and Dawson (2004), “in 2002, about 47 percent of female teenagers (4.6 million), and about 46 percent of male teenagers (4.7 million) had had sexual intercourse at least once.” A study by Finer (2007) observed that premarital sex is now normative behavior; 95% of United States residents have had premarital sex. Mackay and Duran (2007) wrote in their report that “contraceptive use among sexually active teenagers increased between 1995 and 2002, and contracepting teenagers chose more effective contraceptive methods.” They also observed that 83% of never-married female adolescents who had intercourse used at least one form of contraception in the last three months.

Senanayake and Faulkner (2003) observed, “adolescent sexuality and sexual development is commonly viewed as a problematic and negative phase in life, rather than a common and normal bridge to adulthood.” They also pointed out that teens are viewed in a contradictory way, both as “irresponsible risk-takers” and also as “innocent and dependent” (Ibid.).

Laws that limit sexual and reproductive health care

As unemancipated minors, teenagers are subject to additional laws, rules, and regulations that affect their sexual and reproductive health. Senanayake and Faulkner (2003) wrote “without accepting adolescents as sexual beings, whether they are sexually active or not, societies treat adolescent sexuality as something that must be restrained or controlled (p. 118).” Brindis (2002) concurred, stating that

“Teenage pregnancy, the human immunodeficiency virus (HIV) epidemic, sexually transmitted infections (STIs), and other consequences of adolescent sexuality, combined with moral and religious values, often lead well-intentioned policymakers and other stakeholders to attempt to mandate and socially regulate adolescent behavior, usually with mixed results (p. 296).”

As of this writing, 35 states in the US have parental consent or notification laws that affect minor girls seeking abortions. This ranges from no notification at all, as in California, to needing both parents to consent to the abortion as in Mississippi and North Dakota (Coalition for positive sexuality, 2009). Some girls will travel over state lines to avoid telling her parents. According to Brindis (2002), “research has shown that parental consent and notification laws, which are required to include judicial bypass or similar provisions, have no effect on the percentage of teens who involve their parents in abortion decisions” (p. 300). She contended that sixty-one percent of girls do involve at least one parent in the decision to have an abortion. Notification laws serve to delay an abortion, and earlier abortions are less expensive, safer, and have a lesser emotional and physical impact than a later abortion.

Access to Health Care Services

Adolescents face many barriers to accessing sexual and reproductive health care. Some of these barriers may include:

· Accessibility: The health care services may have inconvenient hours and/or a location that is difficult to access. The farther away the clinic is, the more difficult it is for teens to access services without informing their parents. Teens may also justify not seeking health services if the location is accessible and they are frightened or ashamed (Reeves et al, 2006, p. 376).

· Attitudes: Some health care providers may be insensitive to the teen’s concerns. Teens may be intimidated by service providers in authority.

· Legal: HIPPA privacy rules are confusing. In general, parents have access to their unemancipated minor child’s personal health records (English & Ford, 2004, 80).

· Publicity: Teens may not know what health care services are available to them and where they are.

· Privacy and Confidentiality: Teens are concerned that that will not have privacy and confidentiality in their visit. They are also concerned that their parents will be told that they visited a clinic and what the results were.

· Education: Teens may lack knowledge to discuss their health issue or understand medical terminology.

· Finances: Some teens may not have access to free or low-cost clinics and may not have the money to pay for a visit. They also may be reluctant to use their parent’s health insurance for confidentiality reasons or even know how to use their parent’s insurance.

Teens may feel judged and ashamed when it comes to their sexuality. And some teens do not seek sexual health care for “reasons of ignorance, fear, or a perception that they do not need such services” (Nwokolo et al, 2002, p. 342).

Teen Males

Most political targeting is aimed at reducing pregnancy; therefore this prioritization focuses the accessibility of health services for girls. Teen males, however, have specific factors that should be addressed. Marcell, Ford, Pleck, and Sonenstein (2007) wrote that “male adolescents frequently become disconnected from health care, especially as they get older” (p. e967) and they are at higher risk for health problems due to riskier behavior and less likely to seek medical care (p. e973). The authors go on to note that three modifiable factors influence male’s health care utilization: masculine beliefs, parent-teen communication, and insurance status (p. e972). The male’s role in birth control and STI prevention has shifted, with more emphasis being placed on the man in recent years.

Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Intersex Teens

According to the Healthy Teen Network, approximately 5% of adolescents aged 13–18 identify as lesbian, gay, bisexual, transgender, and queer. Health care providers often equate sexual orientation with sexual behavior and that can lead to inadequate information for the teen (2007, p. 2). The LGBTQQI adolescent population “appear[s] to be at higher risk for certain adverse health outcomes, and to have several personal, cultural and structural barriers to accessing healthcare” (Hoffman, Freeman, & Swann, 2009, p. 222). LGBTQQI teens face structural heterosexism that pervades how their family, peers, and health care providers treat them.

Integrative Sexual Education

Comprehensive sexual education programs should “use a variety of teaching methods, focus on personalizing the information, present basic and accurate information about the risks of and avoidance of unprotected intercourse, and provide opportunities to practice communication, negotiation, and refusal skills” (Brindis, 2002, p. 298). Brindis added that punitive approaches or scare tactics are not effective and accurate information is a better route. Sex education can be held in schools, teen health clinics, by family pediatricians, by family, and even by the media.

Cowan (2002) noted a few best practices. The first is that positive behaviors should be modeled and that teens should get a chance to develop and practice strategies for safer sexual behaviors. This will help increase their self-efficacy (p. 316). Programs should also allow teens to reflect upon their personal and cultural assumptions about sexual issues, ideally before they become sexually active (ibid.). Topics that should be taught include all of the subjects defined in the beginning of this paper, plus skills on communication, relationships (with partners, friends, and family), self-esteem, self-efficacy, medical terminology, and overall wellness for the teen. Programs should have clear health goals (preventing pregnancy, increasing safer sex practices) and also address psychosocial issues.

In his 2006 survey, Reeves et al. found that young people wanted to be taught by experts in the field and not by teachers. He also found that the mean age for most sexual topics was 13; the mean age for the topic “how to say ‘no’ to sex” was 12.1 (p. 375). Peer-led programs also show promise (Cowan, 2002, p. 317). The teachers of sex education should be warm and friendly, develop a genuine rapport with the teen, listen to the teen’s concerns with respect, and treat the teens as individuals with the right to this knowledge.

An ideal integrative teen clinic would first take into account what benefits the teen may get from having sex. Koyama, Corliss and Santelli (2009) observed

“An important, yet overlooked, component of adolescent sexuality is a young person’s motivation for engaging in sexual activity. A survey of ninth graders in the United States found that participants rated intimacy as the ‘most important’ goal of a romantic relationship, followed by social status and then sexual pleasure (p. 445).”

We should not forget that sexuality is a normal aspect of growing up and sexual activity should include pleasurable and safe sexual activities. Since this is an area that society is most ambivalent about, this ideal teen clinic would have a sex-positive approach.

With this sex-positivity does come responsibility. A better teen clinic would have classes to model healthy sexual behaviors, for situations such as having sex for the first time, choosing a partner, selecting and using birth control and safer sex protection, interpersonal communication of sexual likes and dislikes, and conflict resolution. We could offer the normal array of sexual and reproductive services -- birth control, annual exams, STI screening and treatment, infection checks, pregnancy testing and counseling, and abortion services. Ideally our clinic would also accept the teen parent’s insurance confidentially, without the parent’s knowledge. Otherwise, the clinic would offer services for free. Hours would be convenient to the adolescent’s schedule, such as after school and on the weekends. Drop-in hours would be offered as much as possible. The location of the clinic would be easily accessible by public transportation.

A better clinic might also address other aspects of teen life, such as peer relationships, bullying, issues with authority, drug use, stress management, relationship violence, family issues, LGBTQQI, and topics specific to males and females. We would have after-school programs that discuss these topics with trained facilitators and ideally we would have peer-led groups to encourage leadership development among teens. We would offer classes and workshops for parents and guardians to understand the teen experience, to communicate effectively with your teen, and to discuss sex with their teen.

We need to remember that sex is not all about accidental pregnancies, lethal STIs, and non-consensual sex. In order to promote healthy sexuality, health care professionals, families, and communities must take a whole-person approach to this complex topic. In order to promote healthy sexuality for adolescents to bring into adulthood, we need to set aside our ambivalence and put our kids on the right track.

 Bio: Jennifer Yee is a wellness coach and owner of Enliven Wellness. She has a 
M.A. in Integrative Health Studies from the California Institute of Integral 
Studies and training in Reiki, massage therapy, motivational interviewing, and 
women’s sexual and reproductive health. She wishes to promote health and 
wellness and help people solve their health issues by coaching, education, and 
promotion. In exploring all options – ranging from western medicine to complementary and alternative 
medicine -- the right solution can be found for each individual. Please 
contact her at enlivenwellness.com or enlivenwellness@gmail.com.