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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.
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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.’
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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.
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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-
wisnieski@ouhsc.edu. The authors have disclosed no potential
conflicts of interest, financial or otherwise.
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Keywords: abstinence, adolescents, sex educa-
tion, sexual behavior, sexual health, sexuality,
sexually transmitted infections
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