FACING

FACTS:SEXUAL

HEALTH FOR

AMERICA’S

ADOLESCENTS

THE REPORT OF THE NATIONAL COMMISSION ON ADOLESCENT SEXUAL HEALTH

Eugene Beresin, M.D.Harvard Medical School

Robert Blum, M.D.University of Minnesota

Michael Carerra, Ed.D.Children’s Aid Society

Arthur B. Elster, M.D.American Medical Association

Jacqueline Darroch Forrest, Ph.D.The Alan Guttmacher Institute

Donald E. Greydanus, M.D.American Academy of Pediatrics

Debra W. Haffner, M.P.H.Sexuality Information and EducationCouncil of the United States

Karen Hein, M.D.Institute of Medicine

Robert L. Johnson, M.D.Commission ChairNew Jersey Medical School

Mariana Kastrinakis, M.D., M.P.H.U.S. Public Health Service

Douglas Kirby, Ph.D.ETR Associates

Lawrence Kutner, Ph.D. Kutner, Olson & Associates, Inc.

Carlos Molina, Ed.D.York College

Rhonda Nichols, M.D.Jersey City Medical Center

Marilyn Poland Laken, Ph.D.Wayne State University

Rt. Rev. David E. RichardsSIECUS Board of Directors

Peter Scales, Ph.D.Center for Early Adolescence

Pepper Schwartz, Ph.D.University of Washington

Isabel StewartGirls Incorporated

Ruby Takanishi, Ph.D.Carnegie Council on Adolescent Development

Elizabeth Winship“Dear Beth”

MEMBERS OF THE NATIONAL COMMISSION ON ADOLESCENT SEXUAL HEALTH

Note: Institutional affiliations are listed for identification purposes only.

FACING FACTS:

SEXUAL HEALTH FOR AMERICA’S ADOLESCENTS

Debra W. Haffner, editor

National Commission onAdolescent Sexual Health

Copyright 1995Sexuality Information and Education Council of the United States

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ACKNOWLEDGMENTS

This report is the result of the deliberations of the National Commission on AdolescentSexual Health. Commissioners volunteered their time to participate in meetings, contribute ideas, review documents, and offer feedback. The report emerged as a

consensus of the members of the Commission. It could not have been completed withouttheir assistance.

Dr. Robert Johnson, director, adolescent medicine, New Jersey Medical School, chaired theCommission. Dr. Johnson chaired the meetings, reviewed countless drafts of the report,and offered invaluable feedback and suggestions. This project could not have happenedwithout his commitment.

Ilene Wachs completed the extensive literature review for the project, including developingthe project bibliography.

Betsy Wacker coordinated the Commission project. She arranged the meetings, compiledthe literature for the review, compiled the briefing book for the Commission members, andworked diligently on the preparation of this report.

Daniel Daley, Dore Hollander, Leslie Kantor, and Valarie Morris, SIECUS staff members,also played important roles in the project. Erika Mathews compiled the references andreworked countless drafts.

The work of the Commission was supported by grants from the Ford Foundation, theHenry J. Kaiser Family Foundation, Menlo Park, California and the U.S. Public HealthService. The Commission is indebted to these sources for their commitment to the sexualhealth of young people. They are not responsible for the statements or views expressed inthis report.

Members of the National Commission on Adolescent Sexual Health ………Inside cover

Acknowledgments ……………………………………………………………………………v

Introduction ……………………………………………………………………………………1

Consensus Statement on Adolescent Sexual Health ………………………………………4

Consensus Statement Background …………………………………………………………6

Adolescent Development ……………………………………………………………6

Characteristics of a Sexuality Healthy Adolescent ………………………………14

Adolescent Sexual Behavior in the 1990s …………………………………………16

The Adult Role in Promoting Adolescent Sexual Health ………………………23

Summary of Recommendations For Policy Makers ………………………………………27

Additional Readings …………………………………………………………………………28

Commissioners’ Biographical Sketches ……………………………………………………29

References ………………………………………………………………………………………31

TABLE OF CONTENTS

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More than nine in ten American adoles-cents experiment with sexual behaviors.

By the time they turn age 20, more than three-quarters of American youngwomen and young men have had sexual intercourse.

Every year, one million U.S. teenagewomen become pregnant, more than half a million have a child, and three millionteenage men and women acquire a sexuallytransmitted disease.

Adolescent sexuality has changed dramatically during the past 40 years. Inthe 1950s, petting was the most commonintimate teenage sexual experience, adolescents reach physical maturity laterand married earlier, and teenage inter-course was uncommon except among the oldest and often engaged or marriedadolescents. Patterns of sexual behaviordiffer widely among young men andyoung women, as well as among youthfrom different backgrounds.

Today’s teenagers reach physical maturityearlier and marry later. There has been asteady increase in the percentage of youngpeople having sexual intercourse, and inthe percentage of doing so at younger andyounger ages. Almost all teenagers experi-ment with some type of sexual behavior.Patterns of sexual activity are now fairlysimilar among young men and women,and young people from different ethnic,socio-economic, and religious groups.

There is public and professional consensusabout what is sexually unhealthy for

teenagers. Professionals, politicians, andparents across the political spectrum sharea deep concern about unplanned adoles-cent pregnancy; out-of-wedlock child-bearing; sexually transmitted diseases(STDs) including AIDS; sexual abuse; date rape; and the potential negative emo-tional consequences of premature sexualbehaviors.

However, there is little public, profession-al, or political consensus about what is sexually healthy for teenagers. The publicdebate about adolescent sexuality has often focused on which sexual behaviorsare appropriate for adolescents, andignored the complex dimensions of sexuality.

Some groups support the “just say no”approach to adolescent sexuality. Theybelieve that the only healthy adolescentsexuality is abstinence from all sexualbehaviors until marriage, and that adultsshould work to eliminate teen sexualexperimentation.

Another approach could be described as “just say not now.” This philosophyencourages young people to abstain untilthey are more mature, but given the highrates of teenage sexual involvement intercourse, recommends that it is impor-tant to provide young people with accessto contraception and condoms whether or not adults approve of their behavior.This approach might also be labeled “ifyou can’t say no, protect yourself!”

Other adults adopt a “don’t ask, don’t tell”posture, and simply pretend that adolescentsexuality and sexual behavior do not exist.

INTRODUCTION

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“The world has changed. The word sex is not a bad word today. It’stalked about very openly. And that is a good thing.”

Mandy, H.S. Senior, WI

In 1994, SIECUS convened the NationalCommission on Adolescent SexualHealth. The Commission believes there is an urgent need for a new approach toadolescent sexual health. Society has aresponsibility to help adolescents under-stand and accept their evolving sexualityand to help them make responsible sexualchoices, now and in their future adultroles. The Commission believes thatadults must focus on helping young peo-ple avoid unprotected and unwanted sexual behaviors. Individual adults andsociety in general must help adolescentsdevelop the values, attitudes, maturity, andskills to become sexually healthy adults.

This report summarizes the deliberations,findings, and recommendations of the National Commission onAdolescent Sexual Health. The report is presented as a consensus and is notintended to represent the individualviews of Commissioners nor their institutional affiliations.

Audience: This report is designed to be aguide for policy makers. Although it mayprovide insights to health and educationpractitioners, as well as parents of adoles-cents, it is written primarily to helpnational, state, and local policy makersdevelop sound policies on adolescent sexual health. The Commission believesthat public policies on adolescent sexualhealth should be based on knowledge ofadolescent development, accurate data, anestablished theoretical basis for programeffectiveness, ongoing evaluation, and adequate funding and support.

Assumptions: The reader should keep inmind several assumptions that underliethis report:

Sexuality is a natural and healthy partof life. Sexuality encompasses the sexualknowledge, beliefs, attitudes, values, andbehaviors of individuals. It deals with theanatomy, physiology, and biochemistry of the sexual response system, as well aswith roles, identity, and personality.Sexuality encompasses thoughts, feelings,behaviors, and relationships.

All human beings are inherently sexual.Infants, children, adolescents, and adults at different stages experience their sexuality in distinct ways. Sexuality evolves during childhood andadolescence, laying the foundation foradult sexual health and intimacy.Adolescent sexual health is defined by a broad range of knowledge, attitudes,and behaviors, and cannot be definedsolely on the basis of abstinence or preventive behaviors.

Adolescent sexuality is a highlycharged emotional issue for manyadults. All adults are former adolescents,and one’s own personal biography oftencolors the understanding of this complexissue. Most of the members of theCommission—as well as many of thereaders of this reportare parents of preadolescents, adolescents, or youngadults. Commission deliberations oftenstarted with discussions about what individuals hoped for their own children.Policy makers are urged to understand the context of contemporary adolescentsas they read this report.

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Adolescents in the United States growup in a variety of contexts and communi-ties. The Commission struggled to defineadolescent sexual health in its broadestcontext while respecting the difficulty ofgeneralizing to our complex society.Young people who face special physical,mental, emotional, social, cultural, andeconomic challenges confront a widerange of barriers to sexual health andrequire priority attention.

“Sexual behavior,” as used in thereport, is not synonymous with hetero-sexual penilevaginal intercourse. TheCommission emphasizes that sexualbehavior can include a range of physicalacts, such as masturbation; kissing; holding hands; touching; caressing; massage; and oral, vaginal, or anal intercourse. In addition, the Commissionrecognizes that these behaviors may takeplace with a partner of the same or othergender. The term “sexual intercourse” isused explicitly in the report to refer to anytype of vaginal, oral, or anal intercourse.Unless specified, the discussion in thisreport includes youth of all sexual orientations.

The available research on healthy adolescent sexuality is extremely limited.Although data are presented in the sectionsthat follow, the Commission recognizes thatmost of the existing research has focused onadolescent women, particularly those whoattend family planning clinics, and on themorbidities associated with adolescent sex-ual behavior. Most studies have examinedheterosexual intercourse and contraceptivepractices. Few studies are available on thecontext of adolescent romantic relation-ships, noncoital behaviors, and healthy ado-lescent sexual relationships. Further,research is usually available only onEuropeanAmerican and AfricanAmericanadolescents, and information on educationor income is often unavailable.

The Commission recognizes the veryserious morbidities related to adolescentsexual behavior and their negativeimpact on adolescents. There are manyexcellent reports on adolescent pregnancyand sexually transmitted diseases, includ-ing AIDS. This report concentrates onwhat is sexually healthy for adolescents,and does not repeat the information thereader can find elsewhere. For a list of rec-ommended reading in this area, seeAdditional Readings on page 28.

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“Most adults think that just because you ask about it, it meansyouíre going to go out and do it.”

Teen male, 16, D.C.

This statement reflects the consensus of the NationalCommission on Adolescent Sexual Health. Each point is explored in greater depth in the ConsensusStatement: Background section of this report. The Consensus Statement has been endorsed by 48 national organizations.

Becoming a sexually healthy adult is akey developmental task of adoles-cence. Achieving sexual health

requires the integration of psychological,physical, societal, cultural, educational,economic and spiritual factors.

Sexual health encompasses sexual develop-ment and reproductive health, as well assuch characteristics as the ability to developand maintain meaningful interpersonalrelationships; appreciate one’s own body;interact with both genders in respectful andappropriate ways; and express affection,love and intimacy in ways consistent withone’s own values.

Adults can encourage adolescent sexualhealth by:

� Providing accurate informationand education about sexuality;

� Fostering responsible decision-making skills;

� Offering young people supportand guidance to explore andaffirm their own values; and

� Modeling healthy sexual attitudesand behaviors.

Society can enhance adolescent sexualhealth if it provides access to comprehen-sive sexuality education and affordable,sensitive, and confidential reproductivehealth care services, as well as educationand employment opportunities.

Families, schools, community agencies,religious institutions, media, businesses,health care providers, and government atall levels have important roles to play.

Society should encourage adolescents todelay sexual behaviors until they are readyphysically, cognitively, and emotionally for mature sexual relationships and theirconsequences.

This support should include educationabout:

� Intimacy;� Sexual limit setting;� Resisting social, media, peer and

partner pressure;� Benefits of abstinence from inter-

course; and� Pregnancy and sexually transmit-

ted disease prevention.

Society must also recognize that a majorityof adolescents will become involved insexual relationships during their teenageyears. Adolescents should receive supportand education for developing the skills toevaluate their readiness for mature sexualrelationships. Responsible adolescent inti-mate relationships, like those of adults,should be based on shared personal val-ues and should be:

� Consensual;� Nonexploitative;� Honest;� Pleasurable; and� Protected against unintended

pregnancies and sexually trans-mitted diseases; if any type ofintercourse occurs.

CONSENSUS STATEMENT ON ADOLESCENT SEXUAL HEALTH

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Advocates for YouthAIDS Action CouncilAmerican Association of Family

and Consumer Services American Association on Mental

RetardationAmerican Association of Sex Educators,

Counselors and TherapistsAmerican Association of University

WomenAmerican College of Obstetricians

and GynecologistsAmerican Counseling AssociationAmerican Medical AssociationAmerican Orthopsychiatric AssociationAmerican School Health AssociationAmerican Social Health AssociationAssociation for the Advancement of

Health EducationAssociation of Reproductive

Health ProfessionalsAVSC InternationalBlacks Educating Blacks about Sexual

Health IssuesCatholics for a Free ChoiceChild Welfare League of AmericaEducation Development Center,

IncorporatedETR AssociatesFederation of Behavioral, Psychological

and Cognitive SciencesGirls IncorporatedHetrick-Martin Institute Human Rights Campaign FundLatina Roundtable on Health and

Reproductive Rights

National Abortion FederationNational Abortion and Reproductive

Rights Action LeagueNational Asian Women’s Health

OrganizationNational Association of School

PsychologistsNational Center for Health EducationNational Coalition of Advocates

for StudentsNational Council of the Churches of

Christ, Commission on Family Ministriesand Human Sexuality

National Education Association HealthInformation Network

National Family Planning andReproductive Health Association

National Lesbian and Gay HealthAssociation

National Minority AIDS CouncilNational Native American AIDS

Prevention CenterParents, Families and Friends of

Lesbians and GaysPlanned Parenthood Federation of

AmericaReligious Coalition for Reproductive

ChoiceSexuality Information and Education

Council of the United StatesSociety for Adolescent MedicineSociety for the Scientific Study of SexThe Alan Guttmacher InstituteUnitarian Univeralist AssociationUnited Church Board for Homeland

MinistriesYWCA of the U.S.A.

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THE FOLLOWING NATIONAL ORGANIZATIONS HAVE ENDORSED THIS CONSENSUS STATEMENT.

Zero Population GrowthADOLESCENT DEVELOPMENT

Becoming a sexually healthy adult is a key developmental task of adolescence. Achieving sexual

health requires the integration of psycho-logical, physical, societal, cultural, educa-tional, economic, and spiritual factors.

Discussions about adolescent sexualityoften are predicated on an adult percep-tion of how “things should be;” rather than on an appreciation of the dynamicsand goals of adolescent development and maturation.

Adolescence is the time when young people develop the knowledge, attitudes,and skills that become the foundation forpsychologically healthy adulthood.Although it is beyond the scope of thisdocument to fully elaborate on adolescentdevelopment, this chapter will give policy makers a basic introduction to adolescence.

Adolescence is a period characterized byrapid changes and the need to achievemany significant developmental tasks.Nevertheless, far from being a time ofgreat conflict and distress, the majority ofadolescents pass through adolescence successfully. Children who enter adoles-cence with the most social or psychologicaldisadvantages are likely to experience thegreatest difficulties. Indeed, it may be thatthe greatest barrier to healthy developmentis a lack of education and economicopportunities. (Peterson and Leffert,1994)

THE THREE STAGES OE ADOLESCENCE

Developmental psychologists andhealth professionals have catego-rized adolescence into three devel-

opmental stages: early adolescence, middle adolescence, and late adolescence.These stages are key to understandingadolescents’ behavioral decisions and adolescent sexuality. TABLE I summarizesthese stages.

While reading this section, it is importantto remember that there is no such thing as an “average adolescent.” Individualadolescents vary widely in the pace oftheir development. For example, in anygroup of thirteenyearolds, some mightfunction as nineyearolds, and some as sixteenyearolds. There is also a highdegree of variation within each adoles-cent: for example, a physically maturefifteenyearold might function emotionally

as a twelveyearold in dealing with his parents, and yet cognitively as a late adolescent in dealing with math problems.

Adolescent growth and development—and adolescent sexuality—is not singularor stable. It is plural and dynamic. Formost young people, adolescence does notentail an absolutely predictable, consistentset of developmental tasks, nor does itunfold in a singular, universal fashion.Adolescent sexuality emerges from cultural identities mediated by ethnicity,gender, sexual orientation, class, andphysical and emotional capacity. (Carrera,1981; Irvine, 1994) Adolescent develop-ment is affected by parents, other familymembers, and other adults, as well asschools and the peer group.

CONSENSUS STATEMENT: BACKGROUND

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EARLY ADOLESCENCE

The young adolescent experiencesbody changes more rapidly than atany time since infancy—secondary

sexual characteristics begin to appear;growth accelerates; and physical changesrequire psychological and social adjust-ments on the part of the adolescent, family, and other adults. These young people are often concrete thinkers andtherefore have difficulty projecting them-selves into the future. This phenomenon is problematic when young people areasked to modify their behaviors and delaygratification to achieve a distant futuregoal. The young adolescent is beginningto separate from the family, but usuallyvalues parental guidance on importantissues. Conflicts with parents usually peak at the height of these pubertalchanges, yet only 15 percent of teenagersand their parents will experience a severedisruption in the parentchild relationship.(Peterson and Leffert,1994) Peer norms,especially identification with a particulargroup or set of groups, assume increasingimportance.

Experimenting with some sexual behaviorsis common, but sexual intercourse of anykind is usually limited. Males may initiateintercourse during this stage, but mostoften delay regular sexual activity untilmiddle or late adolescence. Adolescentgirls are much less likely to begin sexualintercourse at this age. Of those who do,many are in relationships with much oldermen. (See Box on page 19.)

Young adolescents seek to develop a senseof identity, connection, power, and joy. For

many adolescents from communities thatdo not support the development of per-sonal identity in other ways, drugs andsexual experimentation may be a short cutto provide these feelings. Early sexualinvolvement is one way that disadvan-taged youth may meet developmentalneeds for power, identity, connection, andpleasure. (Selverstone,1989) Involvementin sexual behaviors may not be about sexual pleasure, but rather may reflectpeer norms, boredom, conflicts withadults, low selfesteem, and poor ability tocontrol impulsivity. (Durban, DiClemente,and Siegel, 1993)

MIDDLE ADOLESCENCE

Middle adolescence is the stage thatmost typifies the stereotype of“teenagers.” The transitions in

this stage are so dramatic that they seemto occur overnight. The secondary sexualcharacteristics become fully established,and for girls, the growth rate decelerates.Abstract thought patterns begin to develop in significant proportions of middle adolescents.

Middle adolescents are sometimesdescribed as feeling omniscient, omnipo-tent, and invincible. These feelings provide young people with the support todevelop greater autonomy, but may alsoput them at risk. Although recent studiessuggest that adolescents feel no moreinvincible than adults who are risk takers(Quadrel, et a11993), a sense of invincibility,coupled with a developing ability to predict consequences, allows some adolescents to participate in risk takingbehaviors and believe that they cannot beharmed—for example, “I can drive a car 7

“Hanging with a tough crowd made me feel cool ...when I was withmy homegirls, I felt like I was the coolest person on Earth.”

Evelyn, 18, CA

even though I have never taken a drivinglesson”; “I can stop a bullet and not die”;“I can have unprotected sexual intercourseand not become pregnant or get HIV.”

As adolescents continue the process ofseparation from the family, they clingmore tightly to the peer group that theydefined for themselves in early adoles-cence. The peer group begins to define therules of behavior. Parents’ values onlonger term issues such as the importanceof education and career preparation aregenerally stronger than peer values on thesame issues. However, the desire to beaccepted by the peer group often influ-ences such issues as experimentation withdrugs or sexual behaviors. By its accep-tance or rejection, the peer group acts toaffirm the adolescent’s selfimage.

Sexuality and sexual expression are ofmajor importance in the lives of manymiddle adolescents. As they movethrough rapid developmental changes,adolescents at this stage often focus onthemselves and assume others will equal-ly focus on them. Many middle adoles-cents choose to show off their new bodieswith revealing clothes such as miniskirtsand muscle shirts. Although adults maydefine this as sexually provocative, thismay be more the adult’s perception thanthe intent of the middle adolescent.

Middle adolescents often fall in love forthe first time. Again, because they are self-centered, the love object may serve as amirror and reflect characteristics that theteenager admires, rather than seeing anindividual who is loved for him or herself.Sexual experimentation is common, andmany adolescents first have intercourse inmiddle adolescence.

LATE ADOLESCENCE

Teenagers in this stage are most explic-itly moving toward adult roles andresponsibilities. Some are beginning

fulltime jobs; others are beginning fami-lies. Many are preparing for these adultroles. The late adolescent completes theprocess of physical maturation. Manyachieve the ability to understand abstractconcepts, and they become more aware oftheir limitations and how their past willaffect their future. They understand theconsequences of their actions and behav-iors, and they grapple with the complexi-ties of identity, values, and ethical princi-ples. Within the family, they move to amore adult relationship with their parents.The peer group recedes in importance as adeterminant of behavior, and sexualitymay become closely tied to commitmentand planning for the future.

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TABLE 1: HIGHLIGHTS OF ADOLESCENT DEVELOPMENT STAGES

EARLY ADOLESCENCE

Females ages 9–13Males ages 11–15

� Puberty as hallmark

� Adjusting to pubertalchanges such as secondarysexual characteristics

� Concern with body image

� Beginning of separationfrom family, increased parent child conflict

� Presence of social group cliques

� Identification in reputation-based groups

� Concentration on relationships with peers

� Concrete thinking butbeginning of exploration ofnew ability to abstract

MIDDLE ADOLESCENCE

Females ages 13–16Males ages 14–17

� Increased independencefrom family

� Increased importance ofpeer group

� Experimentation with relationships and sexual behaviors

� Increased abstract thinking ability

LATE ADOLESCENCE

Females ages 16 and olderMales ages 17 and older

� Anatomy nearly secured

� Body image and gender roleidentification nearly secured

� Empathic Relationships

� Attainment of abstractthinking

� Defining of adult roles

� Transition to adult roles

� Greater intimacy skills

� Sexual orientation nearly secured

DEVELOPMENTAL TASKS

Developmental psychologists haveidentified six key developmentaltasks for adolescents. The

Commission affirms that becoming a sexually healthy adult is embedded inthese key developmental tasks. The six key tasks are:

Physical and Sexual Maturation:Adolescents mature biologically intoadults, a process that occurs at an earlierchronological age than it did in the past.

Independence: Adolescents developautonomy within the structure that gavethem nurture and support during theirchildhood. This is usually the family, but may include some similar surrogatestructure. The parentchild relationship is transformed during adolescence, as theyoung person develops autonomy whileobtaining the skills to maintain satisfyingrelationships within the home and with others.

Conceptual Identity: Adolescents estab-lish and place themselves within the reli-gious, cultural, ethnic, moral, and politicalconstructs of their environments.

Functional Identity: Adolescents begin toprepare themselves for adult roles in society. By identifying their competencies,they discover how they will supportthemselves and contribute to their ownfamilies and society.

Cognitive Development: Children andyoung adolescents are concrete thinkersand focus on real objects, present actions,and immediate benefits. They have

difficulty projecting themselves into thefuture. During adolescence, young people will develop a greater ability tothink abstractly, plan for their future, and understand the impact of their current actions on their future lives andother people.

Sexual Selfconcept: During adolescence,young people tend to experience their firstadult-like erotic feelings, experiment withsexual behaviors, and develop a strongsense of their own gender identity andsexual orientation.

The pursuit of these developmental tasksanswers three psychosocial questions that adolescents ask themselves: Am I normal? Am I competent? Am I lovableand loving? (Scales, 1991) Many adoles-cent behaviors can be attributed to the search for affirmative answers to these questions.

PHYSICAL AND SEXUAL MATURATION

Sexual maturation differs significantlyamong young men and youngwomen. On average, young girls

begin pubertal events one to two yearsbefore boys. The adolescent female com-pletes the process of puberty in three tofive years, whereas for males, the processtakes four to six years.

Although it is beyond the scope of thisdocument to provide indepth informationabout physical development, certain keypoints that relate to adolescent sexualityshould be emphasized.

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*Young people today are reaching sexualmaturity at much younger ages than theydid in the past. Today, most girls experi-ence menarche (first menstruation)between 12-12.5 years of age. Records from family Bibles around the time of theAmerican Revolution indicate an age ofmenarche of approximately 17 years. In1860, the average age of menarche wassomewhat more than 15 years in Europeand Northern America. During the pastcentury, the age at menarche declined anaverage of three months per decade until1960. Over the past three decades, theaverage age of menarche appears to haveremained constant at 12-12.5, with slightethnic and urbanrural differences in theUnited States. (Neinstein,1991)

*Early pubertal development is associat-ed with an increased likelihood for earlyexperimentation with sexual behaviors,in particular intercourse. Girls and boyswho mature early are more likely thanothers to have had sexual intercourse.(Chilman,1990; Paikoff and BrooksGunn, 1991)

*The discrepancy between maturationamong young women and young men isone factor that may contribute to someyoung women seeking partners olderthan themselves. This difference in ageplaces young women at considerable riskfor sexual exploitation. (See Box page 19)

*Adjusting to the biological changes ofpuberty is a major task of early adoles-cence, and society does not adequatelyprepare or support young people duringthese changes. A significant minority ofyoung women do not receive educationabout menstruation before menarche, and

few adult men can recall receiving infor-mation on pubertal maturation prior totheir first ejaculation or nocturnal emis-sion. Many adolescents are embarrassedby or ashamed of normal pubertal events.

Sexual health for adolescents includes anability to appreciate one’s own body andto view pubertal changes as normal.Achievement of these goals is dependenton parents’ and other trusted adults’preparing young people in advance ofpubertal events, as well as supportingthem during this important transition.

COGNITIVE DEVELOPMENT

During adolescence, young peopledevelop a range of intellectual char-acteristics that increase the probabil-

ity that they will be able to become sexu-ally healthy adults. Ideally, this includesdeveloping the ability to reason abstractly,to foresee consequences of actions, and tounderstand the social context of behav-iors. Adolescents develop an increasedability to control impulsivity, to identifythe future implications of their actions,and to obtain control of their future plans.

Decision-making abilities increase duringadolescence. Conformity with one’s peerspeaks in early adolescence. In middle ado-lescence, people develop the skills tostrengthen the capacity for autonomousdecision making. They begin to develop abetter understanding of personal risks,possible consequences, and the need toobtain more information. (Peterson andLeffert,1994)

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“The future ain’t what it used to be.”Teenage male, NY

Developmental age and general level ofcognitive and emotional developmentmay influence adolescent sexual decisionsand contraceptive use. An adolescent’sdegree of cognitive maturity may placelimits on his or her ability to plan for sexual relationships, clearly articulate personal values, negotiate with a partner,and obtain contraception and condoms.Further, the adolescent’s ability to formempathetic relationships is dependent on“social cognition”; being able to see a situation from another person’s perspec-tive is one aspect of cognitive develop-ment. Understanding one’s feelings andthe feelings of others is central to emotional growth.

SEXUAL SELFCONCEPT

Sexual selfconcept, an individual’sevaluation of his or her sexual feel-ings and actions, develops during

adolescence. Young people develop astronger sense of gender identity. Theyunderstand and more clearly identify asmen and women. An understanding ofone’s sexual orientation also develops during adolescence: Young people becomemore aware of their sexual attractions andlove interests, and adult-like erotic feelingsemerge. Sexual experimentation is com-mon among all groups of adolescents, aswill be discussed in depth in the section“Adolescent Sexual Behavior in the 1990s.”

During adolescence, young people solidifytheir gender identification by observingthe gender roles of their parents and otheradults. Gender identification includesunderstanding that one is male or femaleand the roles, values, duties, and

responsibilities of being a man or awoman. Most young people have a firmsense of their maleness or femalenessprior to adolescence, but in adolescence,clear identification with adult masculineand feminine models emerge. It is essential that adolescents have men andwomen in their environment who conveythe values, behaviors, and attitudes ofappropriate gender role models. By interacting with psychologically healthyadult men and women, adolescents learnwho they are and how to behave in appropriate ways.

Gender role stereotypes impede bothyoung men and young women in attain-ing sexual health. Young women maylearn that “it is better to be cute and popular than smart,” “girls have few sexual feelings;” and “girls who carry condoms are bad.” Boys may learn that“real men are always ready for sex;’ andthat “guys should never act like girls.”One study found that teenage males whoagree with traditional cultural messagesabout masculinity are more likely thanother young men to use condoms less consistently (or not at all), and to say thatif they made a partner pregnant, theywould feel like a “real man”; they are lesslikely to think men share the responsibilityfor preventing pregnancy. (Pleck,1991)

It is important to note that although patterns of sexual involvement areincreasingly similar for boys and girls,persistent gender stereotypes mean thatyoung women still experience their sexualbehaviors quite differently. (Thompson,1990) In a 1994 poll, young women reported that they were more likely toregret their sexual experiences, more likely

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to label the relationship “love,” less likelyto report their sexual experiences as pleasurable, and more likely to bear thebrunt of negative outcomes than theirmale counterparts. (Roper, 1994)

One’s sexual orientation often emerges inadolescence. In one study of students ingrades 7 12, 88 percent of teenagersdescribed themselves as predominantlyheterosexual, 1 percent described them-selves as bisexual or predominantlyhomosexual, and 11 percent were“unsure” of their sexual orientation.Uncertainty about sexual orientationdiminished with chronological age; 26 per-cent of the twelve-year-olds were “unsure”compared with only 5 percent of theeighteen-year-olds. (Remafedi et al.,1992)

In retrospective studies, many gay and lesbian adults identify adolescence as aperiod of confusion about their sexualidentity. Although a majority of adult gaymen recall feeling different as children(Bell, Weinberg, and Hammersmith, 1981),most did not selfidentify as gay until theirlate teenage years. Gay males begin to believe that they might be homosexualat an average age of seventeen years(Troiden,1980); lesbians at an average ofeighteen. Gay males act on their homosex-ual feelings at a mean age of fifteen yearswhile lesbians report an average age atfirst genital sexual experience at twenty.(Bell, Weinberg, and Hammersmith, 1981)

“Coming out,” or sharing one’s sexual orientation with others, generally does notoccur until adulthood.

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“You expect men to be experienced, it’s like a given. We’re sup-posed to be these perfect little flowers and the idea of saving our-selves for our perfect little marriage is expected.”

Kelly, H.S. Senior, IN

The Commission identified the charac-teristics and behaviors of a sexuallyhealthy adolescent in relationship to

self, parents and other family members,peers, and romantic partners. Sexuallyhealthy adolescents appreciate their bod-ies, take responsibility for their ownbehaviors, communicate effectively withintheir families, communicate effectivelywith both genders in appropriate andrespectful ways, and express love and intimacy in a developmentally appropriatemanner. Sexual health is not defined by which sexual behaviors a teenager hasor has not engaged in. The Commissionrecognizes that the majority of attributesand behaviors relevant to self, peers, andpartners also apply to a sexually healthyadult and, in many cases, represent anideal to strive toward.

SELFAPPRECIATES OWN BODY

� Understands pubertal change� Views pubertal changes as normal� Practices healthpromoting

behaviors, such as abstinence from alcohol and other drugs andundergoing regular checkups.

TAKES RESPONSIBILITY FOROWN BEHAVIORS

� Identifies own values� Decides what is personally “right”

and acts on these values� Understands consequences of

actions� Understands that media messages

can create unrealistic expectationsrelated to sexuality and intimaterelationships

� Is able to distinguish personaldesires from that of the peer group

� Understands how alcohol and otherdrugs can impair decision making

� Recognizes behavior that may beselfdestructive and can seek help

IS KNOWLEDGEABLE ABOUTSEXUALITY ISSUES

� Enjoys sexual feelings withoutnecessarily acting upon them

� Understands the consequences ofsexual behaviors

� Makes personal decisions aboutmasturbation consistent with personal values

� Makes personal decisions aboutsexual behaviors with a partner

� Understands own gender identity� Understands effect of gender role

stereotypes and makes choicesabout appropriate roles for oneself

� Understands own sexual orientation

� Seeks further information aboutsexuality as needed

� Understands peer and culturalpressure to become sexuallyinvolved

� Accepts people with different values and experiences

RELATIONSHIPS WITH PARENTS AND FAMILY MEMBERS

COMMUNICATES EFFECTIVELYWITH FAMILY ABOUT ISSUES,INCLUDING SEXUALITY

� Maintains appropriate balancebetween family roles and respon-sibilities and growing need forindependence

CHARACTERISTICS OF A SEXUALLY HEALTHY ADOLESCENT

14

� Is able to negotiate with family onboundaries

� Respects rights of others� Demonstrates respect for adults

UNDERSTANDS AND SEEKSINFORMATION ABOUT PARENTS’AND FAMILY’S VALUES, AND CONSIDERS THEM INDEVELOPING ONE’S OWN VALUES

� Asks questions of parents andother trusted adults about sexualissues

� Can accept trusted adults’ guidanceabout sexuality issues

� Tries to understand parental pointof view

PEERSINTERACTS WITH BOTH GENDERS IN APPROPRIATE AND RESPECTFUL WAYS

� Communicates effectively withfriends

� Has friendships with males andfemales

� Is able to form empathetic relationships

� Is able to identify and avoidexploitative relationships

� Understands and rejects sexuallyharassing behaviors

� Respects others’ rights to privacy� Respects others’ confidences

ACTS ON ONE’S OWN VALUESAND BELIEFS WHEN THEY CONFLICT WITH PEERS

� Understands pressures to be pop-ular and accepted and makes deci-sions consistent with own values

ROMANTIC PARTNERSEXPRESSES LOVE AND INTIMACYIN DEVELOPMENTALLY APPROPRIATE WAYS

� Believes that boys and girls haveequal rights and responsibilitiesfor love and sexual relationships

� Communicates desire not toengage in sexual behaviors and accepts refusals to engage in sexual behaviors

� Is able to distinguish love andsexual attraction

� Seeks to understand andempathize with partner

HAS THE SKILLS TO EVALUATEREADINESS FOR MATURE SEXUAL RELATIONSHIPS

� Talks with a partner about sexualbehaviors before they occur

� Is able to communicate and negotiate sexual limits

� Differentiates between low- andhigh-risk sexual behaviors

� Together with a partner, makes sex-ual decisions and plans behaviors

� If having intercourse, protectsself and partner from unintendedpregnancy and diseases througheffective use of contraceptionand condoms and other safer sex practices

� Knows how to use and access thehealth care system, communityagencies, religious institutions,and schools; and seeks advice,information, and services as needed

15

“I realize how important it is to take care of myself and think hardabout the sexual choices I make.”

Teenage Female

A lmost all American adolescentsengage in some type of sexualbehavior. Although policy debates

have tended to focus on sexual intercourseand its negative consequences, young peo-ple explore dating, relationships, and inti-macy from a much wider framework. Theinformation below is presented to givepolicy makers an accurate picture of ado-lescent sexual behavior in the 1990s.

Throughout time, adults have viewedadolescent sexuality and the developmen-tal tasks of youth as problematic. Overtwo thousand years ago, Socratesdescribed youth as disrespectful of theirelders: “They are also mannerless and failto rise when their elders enter the room.They chatter before company, gobble updainties at the table, cross their legs, andtyrannize over their teachers.”

Historically, young women and youngmen did not reach physical maturity untiltheir middle teenage years. Marriage andother adult responsibilities followedpuberty closely.

Today’s teenagers are different fromyoung people of generations ago. Theyreach puberty earlier, have intercourseearlier, and marry later. Women and menwho marry today do so three to four yearslater than young people did in the 1950s.

Sexual behavior is almost universalamong American adolescents.

Consider these statistics:� A majority of American teenagers date.

� 85 percent of American teenagers have had a boyfriend or girlfriend.

� 85-90 percent of American teenagers have kissed someone romantically.

� 79 percent have engaged in “deep kissing.” (Coles and Stokes, 1985;Roper, 1994)

The majority of adolescents move fromkissing to other more intimate sexualbehaviors during their teenage years.

� More than half of all teenagers haveengaged in “petting behaviors.” By theage of fourteen, more than half of allboys have touched a girl’s breasts, anda quarter have touched a girl’s vulva.(Coles and Stokes, 1985)

� By the age of eighteen, more than three-quarters have engaged in heavy pet-ting. (Roper, 1994)

� One-quarter to one-half of young peo-ple reporting experience with fellatioand/or cunnilingus. (Coles and Stokes,1985; Newcomer and Udry,1985)

� 2–5 percent of teenagers report sometype of same-gender sexual experience.(Coles and Stokes, 1985; Remafedi,1992;Roper 1994)

Some data suggest that the progressionfrom kissing to noncoital behaviors tointercourse differs among different groupsof adolescents. While many teenagersmove through a progression of intimatebehaviors, lower-income teenagers are lesslikely to follow this progression, movingmore rapidly from kissing directly to sexual intercourse. (Brooks-Gunn andFurstenberg,1990)

ADOLESCENT SEXUAL BEHAVIOR IN THE 1990s

16

MOST TEENAGERS WHO HAVE INTERCOURSE DO SO RESPONSIBLY.

More than 80 percent of Americansfirst have intercourse as teenagers. (AGI,1994) More than

half of women and almost threequarters ofmen aged 1519 have had sexual inter-course. However, despite the large num-bers of young people who experimentwith a variety of sexual behaviors, inter-course is generally less widespread andcertainly less frequent than manyteenagers and adults believe. The majorityof teenagers use contraceptives as con-sistently and effectively as most adults.

Teenagers have always engaged in sexualbehaviors. However, in the past, at least forteenage women, intercourse was reservedfor engaged or married couples. When anoutofwedlock pregnancy occurred, “shot-gun” marriages were frequently the answer,or girls were sent away to stay with a rela-tive until the baby was born and adopted. Itmay surprise readers to note that thebirthrate for adolescents peaked in 1957.

In fact, the adolescent birthrate is signifi-cantly lower than it was forty years ago.In 1955, 90 out of every 1,000 15-19 year-old women gave birth; by 1992, that num-ber had dropped to 61 in every 1,000.(Child Trends, 1995)

Nevertheless, in the last two decades,there has been a significant change in thenumbers of young people who have hadintercourse at young ages. At each age ofadolescence, higher proportions ofteenage men and women have had sexual

intercourse today than had done so twen-ty years ago. (AGI,1994)

Contraceptive use has also increased sub-stantially during this time. In 1979, fewerthan half of adolescents used a contracep-tive at first intercourse (Zelnik and Shah,1983; Forrest and Singh, 1990); in 1988,twothirds did so. By 1990, that proportionhad increased to more than 70 percent.(National Center for Health Statistics,1995) Recent surveys suggest that as manyas two-thirds of teenagers now use con-doms; these proportions are two to threetimes higher than those reported in the1970s. (CDC, 1992) However, in every sur-vey, fewer than half of the teenagers whorecently used condoms did so all of thetime. (Cates, 1991)

Consider these additional facts:� The majority of teenagers wait until

middle and late adolescence to haveintercourse. (AGI,1994; CDC, 1992) (See Table II)

� In the United States, the average age at first intercourse is sixteen for malesand seventeen for females. (AGI,1994;CDC, 1994)

� The majority of teenagers report theydo not feel peer or partner pressure tohave intercourse. (Roper 1994; Smith1988)

� The majority of teenagers who haveintercourse do so with someone whomthey love or seriously date. (Roper, 1994)

� Typically, teenage men and womenwho have sexual intercourse do so lessthan once a month. (AGI,1994;Sonenstein, Pleck, and Icon, 1991)

17

“Teenagers are portrayed as sex maniacs, when in fad this isn’t true.Teens show just as much responsibility or lack of responsibility as adults.”

Juan, 17, NY

� The majority of teenagers who haveintercourse use contraception. Two-thirds of adolescents use a method thefirst time they have intercourse (AGI,1994), and more than three-quarters doso on an ongoing basis. (AGI, 1994)Almost 60 percent used a condom atlast intercourse. (CDC, 1994)

TABLE II

PERCENTAGE OF TEENAGERS WHOHAVE HAD INTERCOURSE, BY AGE

AGES

Source: The Alan Guttmacher Institute, 1994

PERCENTAGE OF TEENAGERS WHOHAVE HAD INTERCOURSE, BY GRADE

GRADES

Source: CDC, 1992

FOR SOME ADOLESCENTS, PARTICULARY THE YOUNGEST, INTERCOURSE IS DEVELOPMENTALLYDISADVANTAGEOUS.

The Commission affirms that for manyadolescents, sexual involvement ispleasurable, safe, and normative.

However, for a significant minority ofyoung people, these behaviors can bequite risky and dangerous. In particular,young adolescents who become involvedin sexual behaviors prematurely face ahost of risks.

Although intercourse is relatively rarefor young adolescents, in some popula-tion groups, it is quite common.According to a national youth poll, in1990, 20 percent of females and 34 per-cent of males have intercourse beforethey are fifteen. (CDC, 1992)

The Commission believes that inter-course is developmentally disadvanta-geous for young adolescents as they donot have the cognitive or emotionalmaturity for involvement in intimate sexual behaviors, especially intercourse.The Commission had a lively debateabout whether to recommend a mini-mum chronological age for intercourse.The Commission agreed by consensusthat developmental age and readiness, as well as relationship context, are moreimportant than chronological age.

18

0%

9%16%

23%30%

42%

59%71%

82%

12 13 14 15 16 17 18 19

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

50

30%

9th 10th 11th 12th

40

60

70

80%

40%

47%

57%

71%

Consider these facts:� Teenage sexual behavior, particularly

among the youngest teenagers, is oftennot voluntary, and young people whohave been sexually abused often experience delays in cognitive, social,emotional, and psychological develop-ment. Further, compared with otheradolescents, they have first voluntaryintercourse at younger ages, a largernumber of partners, and a greater likeli-hood of adolescent pregnancy andchildbearing. (Boyer and Fine, 1992)

� Teenage women have male sexual part-ners on an average three years olderthan they are. The National Center forHealth Statistics reports that in almost70 percent of births to teenage girls, thefathers were aged 20 or older. (NationalCenter for Health Statistics, 1991). ACalifornia study found that theyounger the mother, the greater thepartner age gap. Among mothers aged11 and 12, the fathers’ age averagednearly 10 years older. (California VitalStatistics Section, 1992)

� The earlier a teenager begins havingintercourse, the more partners she or heis likely to have. Young people whosefirst intercourse occurred before agethirteen are nine times more likely toreport three or more partners thanthose adolescents whose first sexualintercourse was at fifteen or sixteen.(CDC, 1992). Among fifteen to twenty-four year-olds who had initiated inter-course before age eighteen, 75 percentreport having two or more partners,and 45 percent report having had fouror more partners. (MMWR, 1992).

19

SEXUAL ABUSENot all adolescent sexual behavior is vol-untary. Sexual assault is not uncommonamong adolescents. Six percent of boysand fifteen percent of girls are sexuallyassaulted prior to their sixteenth birthday.In a study of teenage girls in foster care,43 percent reported experiencing sometype of sexual abuse. One in six reportedthat they had been forced to have inter-course with an adult. One-third of theyoung women had been sexually abusedbefore their tenth birthday. (Polit, et al.,1990). Ten thousand young women underage eighteen were raped in 1992. (ChildWelfare League, 1994). In fact, one-quarterof rapes are to women 11-17 years of age.(National Victims Center and CrimeVictims Research and Treatment Center,1992). Nearly three-quarters of youngwomen who had intercourse before agefourteen report having had intercourseinvoluntarily. (AGI, 1994; Child WelfareLeague of American, 1994)

A disproportionate number of youngwomen who become pregnant during ado-lescence are victims of childhood sexualabuse. In one study of teenagers who werepregnant parents, 70 percent of whites, 42percent of the African-Americans, and 37percent of Hispanics had been sexuallyabused as a child. (Boyer and Fine, 1992). Inanother study, 64 percent of parenting andpregnant teens reported that they had hadat least one unwanted sexual experience.(Child Welfare League of America, 1994).

Gay, lesbian, and bisexual teenagers facean additional form of abuse related totheir sexuality. A study in New York Cityfound that of lesbian, gay and bisexualteenagers reporting an assault, almost halfreported the assault was related to theirsexual orientation, and for almost two-thirds, the assault happened within theirfamilies. (Hunter, 1990).

“People are talking to us after it’s already too late.”Melissa, 14, IN

ABSTINENCE AND SEXUAL INTERCOURSE

The Commission believes that toomuch of the public policy debateabout adolescent sexuality has

focused on whether adolescents shouldabstain from sexual behaviors, particularlyintercourse, or whether contraception andcondoms should be available. Some sexu-ally healthy adolescents abstain fromintercourse, some sexually healthy adoles-cents have intercourse.

The Commission affirms the following:Society should encourage adolescents to delaysexual behaviors until they are ready physical-ly, cognitively, and emotionally for maturesexual relationships and their consequences.This support should include education aboutintimacy; sexual limit setting; resisting socialmedia; peer, and partner pressure; benefits ofabstinence from intercourse; and pregnancyand STD prevention.

The Commission urges all adult sectors ofsociety (parents, schools, religious institu-tions, community youth programs, mediaand government) to give adolescents con-sistent and age-appropriate messagesabout abstinence.

All messages should clearly communicateto teenagers that abstinence from sexualintercourse is the most effective method ofpreventing pregnancies and sexual trans-mitted diseases. The Commission affirmsthat delaying first intercourse until lateadolescence is likely to result in lower ratesof pregnancy, STDs, and childbearing.

The Commission opposes education pro-grams that are designed to provoke fear

and shame in adolescents about sexualityin order to enforce abstinence from all sex-ual behaviors. The Commission believesthat young adolescents in particular needclear messages on the benefits of absti-nence, but that programs must also addressthe likelihood that many young people willhave intimate sexual relationships.

The Commission recommends that messages about abstinence include the following:� Young adolescents are not mature

enough for a sexual relationship thatincludes intercourse.

� Most young adolescents do not haveintercourse.

� Teenagers who date need to discusssexual limits with their romantic partner.

� People need to respect the sexual limitsset by their partners.

� There are many ways to give andreceive sexual pleasure and not haveintercourse.

� Teenagers considering sexual inter-course should talk to a parent or othertrusted adult.

� Most adults believe teenagers shouldnot have sexual intercourse.

� Many religions believe that sexualintercourse should occur only in marriage.

� Abstinence from intercourse has benefits for teenagers.

The Commission recommends that mes-sages about abstinence for older adoles-cents also include the following:� Many teenagers in the United States

have had sexual intercourse and manyhave not.

20

� Sexual intercourse is not a way toachieve adulthood.

� People in romantic relationships canexpress their sexual feelings withoutengaging in sexual intercourse.

� Many adults experience periods ofabstinence.

The Commission also affirms the following:Society must also recognize that a majority ofadolescents will become involved in sexualrelationships during their teenage years.Adolescents should receive support and educa-tion for developing the skills to evaluate theirreadiness for mature sexual relationships.Responsible adolescent intimate relationships,like those of adults, should be based on shared

personal values, and should be consensual,non-exploitative, honest, pleasurable, and pro-tected against unintended pregnancies andsexually transmitted diseases, if any type ofintercourse occurs.

The Commission adapted the followingchecklist to help young people assess theirreadiness for mature sexual relationships.(Winship, 1983).

The check list may be helpful for adoles-cents and adults to evaluate if they areready for a mature sexual relationshipwith a partner. Ideally, these criteriawould be met before a young person or an adult engages in intimate sexualbehaviors, including any type of intercourse.

21

READINESS FOR MATURE SEXUAL RELATIONSHIPS

“They have questions. They need to have those questions answeredhonestly and directly, no with, “Wait until you’re married kid.”

Meghan, H.S., IN

PERSONAL CHARACTERISTICSEach individual is:

Physically mature

Patient and understanding

Knowledgeable about sexuality and sexual response

Empathetic and able to be vulnerable

Committed to preventing unintendedpregnancies and STDs

Able to handle responsibility for positive consequences

Able to handle responsibility for potential negative consequences

Honestly approving the behavior

RELATIONSHIP CHARACTERISTICS

The relationship is committed, mutual-ly kind, and understanding.

Partners trust and admire each other.

Partners have experienced and foundpleasure in non-penetrative behaviors.

Partners have talked about sexualbehaviors before they occur.

Motivation for sexual relationship is pleasure and intimacy.

The setting for sexual relationship is safe and comfortable.

AN INTERNANTIONAL COMPARISON

Young people around the worldexperiment with sexual behaviors.Young people in Northern European

countries and the United States have simi-lar ages at first intercourse, but NorthernEuropean teenagers have much lowerpregnancy and STD rates. European coun-tries ten to be more open about sexuality,and their official governmental policiesfocus on reducing unprotected inter-course, rather than reducing sexual behav-iors. There is a greater availability of sexu-al information and reproductive healthservices for teenagers.

The United States has one of the highestadolescent birthrates in the world.Teenagers in Sweden, the Netherlands,Canada, Great Britain, France, and theUnited States experience similar levels of

sexual intercourse, but teenagers in othercountries are much more successful thatU.S. adolescents at avoiding sexual mor-bidities. For example, Sweden has one-third and the Netherlands has one-sixththe U.S. rate of teenage pregnancies,despite similar levels of teenage sexualintercourse. A 1985 study of thirty-sevenindustrialized countries found that amajor reason for the difference is thatEuropean teenagers use contraceptioneffectively. (Jones, et al., 1988)j.

According to the study’s authors:� Teenagers in these countries are not too

immature to use contraceptives consis-tently and effectively.

� Teenage pregnancy rates are lower incountries where there is greater avail-ability of confidential contraceptiveservices and comprehensive sexualityeducation. (Jones, et al., 1988).

22

Many adults have difficultyacknowledging teenagers’ emerg-ing sexuality. Adults’ denial and

disapproval of teenage sexual behaviormay actually increase teenagers’ risk ofpregnancy and sexually transmitted dis-eases. The majority of adults disapproveof teenagers having intimate sexual rela-tionships, and adolescents often perceivethis disapproval. Many teenagers are will-ing to risk pregnancy and disease ratherthan damage their “reputation” with theirparents or experience the disapproval ofadults with whom they must interact toobtain contraceptives and condoms.

The Commission urges policy makers toremember that adolescents grow up infamilies and communities, and that thesecommunities must be involved in promot-ing adolescent sexual health. TheCommission affirms that all sectors of thecommunity—parents, families, schools,community agencies, religious institu-tions, media, businesses, health careproviders, and government at all levels—have important roles to play.

PARENTS

Parents are the primary sexuality educators of their children. Theyeducate both by what they say and

by how they behave. It is important tobegin deliberate education at the earliestchildhood level; however, adolescenceposes new challenges for many parents.In homes where there is open communi-cation about contraception and sexuality,young people often behave more respon-sibly. At a minimum, such communicationmay help young people accept their ownsexual feelings and actions.

With open communication, young peopleare more likely to turn to their parents intimes of trouble, without it, they will not.(Blum, Resnick, and Stark, 1987).

Many parents have difficulty communicat-ing with their children about sexuality.Parents must receive education about sex-uality and how to provide this educationand information to their children.

Individual adults, especially parents andother trusted adult family members, canplay an important role in encouragingadolescent sexual health. Adults canassure that young people have access toaccurate information and education aboutsexuality issues by direct communicationand by providing books, pamphlets, andvideos. Adults need to foster responsiblesexual decision-making skills and need tomodel healthy sexual attitudes andresponsible behaviors in their own lives.

The Commission believes that parents andfamilies can play a major role in ensuringadolescent sexual health. The Commissiondeveloped the following list of behaviorsthat often characterize the parents of asexually healthy adolescent.

These parents:� Demonstrate value, respect, acceptance,

and trust in their adolescent children� Model sexually healthy attitudes in

their own relationships� Maintain nonpunitive stance toward

sexuality� Are knowledgeable about sexuality� Discuss sexuality with their children� Provide information on sexuality to

their children� Seek appropriate guidance and infor-

mation as needed

THE ADULT ROLE IN PROMOTING ADOLESCENT SEXUAL HEALTH

23

“I think our parents are trying to do a better job than their parentsdid when it comes to talking to their children.”

H.S. Student, CO

� Try to understand their adolescent’spoint of view

� Help adolescents gain understanding ofvalues

� Set and maintain limits for dating andother activities outside of school

� Stay actively involved in the youngperson’s life

� Ask questions about friends andromantic partners

� Provide a supportive and safe environ-ment for their children

� Offer to assist adolescents in accessinghealth care services

� Help them plan for their future

COMPREHENSIVE SEXUALITY EDUCATION

The Commission affirms that childrenand youth need age-appropriate com-prehensive sexuality education.

Further, the Commission recognized thatschools are only one site for sexuality edu-cation. Community agencies, religiousinstitutions and youth serving organiza-tions should develop sexuality educationprograms that are appropriate for theirsettings. In addition, education programsshould be available for parents of childrenand adolescents to help them provide sex-uality education within their homes.

The primary goal of sexuality education isthe promotion of sexual healthComprehensive sexuality education seeksto assist children in understanding a posi-tive view of sexuality, to provide themwith information and skills about takingcare of their sexual health, and to help

them acquire skills to make decisions nowand in the future. A comprehensive sexu-ality education program includes informa-tion as well as an opportunity to exploreattitudes and develop skills in such areasas human development, relationships, per-sonal skills, sexual behavior, sexual health,and society and culture. (NationalGuidelines Task Force, 1991)

The characteristics of effective compre-hensive sexuality education programsinclude the following:� Are experimental and skill-based;� Are taught by well-trained teachers and

leaders;� Discuss controversial issues;� Provide multiple sessions through mul-

tiple mediums;� Are relevant to all teenagers, regardless

of sexual orientation;� Are culturally specific and sensitive;� Are linguistically appropriate;� Discuss social influences and pressures;� Reinforce values and group norms

against unprotected sexual behaviors;� Provide age and experience appropriate

messages and lessons;� Teach skill-building, including refusal

skills;� Are integrated within comprehensive

health education; and � Use peer counseling and peer support

when appropriate.

HEALTH CARE

The Commission affirms the need forhealth providers, health care organi-zations, and communities to provide

young people with affordable, sensitive,24

and confidential sexual and reproductivehealth care services. This includes mentalhealth counseling; support services forgay and lesbian youth; family planning;abortion; STD screening; diagnosis, andtreatment; and prenatal care.

School-based and school-linked programs,special adolescent health care services,and private practitioners all have specialroles to play in reaching adolescents withthese important services. It is also impor-tant that there be formal linkages betweenhealth care delivery and education pro-grams.

The characteristics of effective healthand medical programs for adolescentsinclude the following:� All staff have both an interest and spe-

cial training in working with adoles-cents.

� The operating hours and location areconvenient for teenagers.

� The physical space is inviting to adoles-cents.

� Counseling is a routine part of each vis-its.

� Confidentiality is assured.� Parental involvement is encouraged.� The staff include the teen’s family when

appropriate and negotiate the balancebetween confidentiality and adult sup-port and involvement.

� The approach is multidisciplinary.� There is a focus on sexuality and sexual

health.� Services are affordable to teenagers.� Youth are involved in designing and

implementing the program.� Continuity from pediatric care to adult

care is assured.

� Bilingual and bicultural staff are avail-able, as needed.

COMMUNITY PROGRAMS

Community youth-serving programscan play a major role in ensuringadolescent sexual health. The

Commission urges such programs—including girls’ and boys’ clubs, scouts,sports organizations, public libraries,recreation departments, after-school pro-grams, worksites, camps, juvenile justicecenters, job training programs, and reli-gious organizations—to develop sexualityeducation programs as well as a variety ofopportunities to provide young peoplewith education and employment opportu-nities. (Carnegie Corporation of NewYork, 1992)

Community programs should worktogether to give young people a consistentset of messages regarding community val-ues about such issues as sexual behaviors,responsibility, and future planning.Programs should reinforce each other.

The characteristics of effective communi-ty programs include the following:� They are accessible to young people.� The setting is safe and inviting.� The program offers adolescents oppor-

tunities to contribute to the communityand feel competent.

� Mentoring programs are featured.� Staff integrate sexuality information

and referrals into other youth develop-ment programs.

� They offer an opportunity to developrelationships with both genders. 25

“Not everybody has parents they can talk to. Where are those kidssuppose to go? You’ve got to think about everybody.”

Nicole, H.S. Senior, WI

� They are run by well-trained leaders.� They have an established referral net-

work for health care services.� They encourage family involvement.� They are culturally specific and sensi-

tive, and linguistically appropriate.

MASS MEDIA

The Commission recognizes that themass media have become a majorsource of young people’s information

about sexuality. The Commission urgesthose who work in the mass media toexercise their influence by providing accu-rate information and modeling responsi-ble behaviors. The communication ofaccurate information adds realism andhelps adolescents gain insights into theirown sexuality, and to make more respon-sible decisions about their behavior.

The Commission strongly encourageswriters, producers, programming execu-tives, reporters, and others to incorporatethe following into their work wheneverpossible:� Provide diverse and positive views of a

range of body images and eliminatestereotypes about sexuality and sexualbehaviors; for example, eliminating theideas that only beautiful people havesexual relationships or that all adoles-cents have intercourse.

� When describing or portraying a sexualencounter, include steps that should betaken such as using a condom to pre-vent unwanted pregnancy and sexuallytransmitted diseases. Recognize andshow that the majority of sexualencounters are planned events, not

spur-of-the-moment responses to theheat of passion. Model communicationabout an upcoming sexual encounter. Ifthe sexual encounter includes unpro-tected intercourse, portray or refer tothe possible short- and long-term nega-tive consequences.

� Although the Commission recognizesthe need for dramatic tension and con-flict in some relationships, and for theaccurate portrayal of stressful relation-ships when they exist, typical interac-tions between men and women or boysand girls should be respect and non-exploitative.

� When possible and appropriate, includeinformation about or the portrayals ofeffective parent-child communicationabout sexuality and relationships.

� Lift barriers to contraceptive and con-dom product advertising.

� When feasible, promote responsibleadolescent behavior by using teenageidols to model appropriate actions,highlighting youth success stories, andinvolving articulate youth spokesper-sons.

� When possible and appropriate, pro-vide ways for young people to obtainadditional information about sexualityand related issues, such as by listingaddresses and telephone numbers ofappropriate public health organizationsand support groups.

26

The National Commission on Adolescent Sexual Health urges policy makers to:

For public policies consistent with research about adolescent develop-ment, adolescent sexuality, and program effectiveness.

Support parents and families as integral members of efforts to improveadolescent sexual health, while recognizing that adolescents are developing greater autonomy.

Recognize that sexual development is an essential part of adolescenceand that the majority of adolescents engage in sexual behaviors as partof their overall development.

Facilitate optimal adolescent development by ensuring high-qualityeducation and employment opportunities for all young people.

Support comprehensive sexuality education, which includes humandevelopment, relationships, personal skills, sexual behavior, sexualhealth, and sexuality and culture.

Provide a full range of confidential sexual and reproductive healthservices tailored for the adolescent.

Encourage cultural messages that support adolescent and adult sexual health and responsible sexual relationships.

Support research on adolescent sexuality and sexual behaviors.

Provide funding for coordinated and integrated adolescent programs.

Respond to the diverse sexual health needs of adolescents, includingaddressing the needs of disenfranchised, disabled, and gay and lesbian adolescents.

Involve youth in program planning and implementation.

Value and respect adolescents.12

11

10

9

8

7

6

5

4

3

2

1

SUMMARY OF RECOMMENDATIONS FOR POLICY MAKERS

27

ADDITIONAL READINGS

28

Adolescent Health: State of theNation. Atlanta: Centers for Disease Control, 1995.

AIDS Sexual Behavior andIntravenous Drug Use. Washington,DC: National Academy Press, 1989.

A Matter of Time: Risk andOpportuity In The Out-Of-SchoolHours. New York: CarnegieCorporation of New York, 1992.

Brindis, C. D. Adolescent Pregnancy Prevention: A GuidbookFor Communities. Palo Alto, CA:Health Promotion Resource Center,Stanford Center for Research inDisease Prevention, 1991.

Dryfoos, J. Adolescent At Risk. NewYork: Oxford University Press, 1990.

Greydanus D. E. (ed): Caring for Your Adolescent: Ages 12-21. New York: Bantam Books Inc., 1992.

Guidelines for ComprehensiveSexuality Education. New York:SIECUS, 1991.

Herdt, G. (ed.) Gay and LesbianYouth. New York: The HaworthPress, 1989.

Jones, E. F., et al. Teenage Pregnancyin Industrialized Countries. NewHaven: Yale University Press, 1986.

Hayes, C. D. Risking the Future:Adolescent Sexuality, Pregnancyand Childbearing. Washington:National Academy Press, 1987.

Millstein S., Petersen A., andNightingale, E. Promoting TheHealth of Adolescents. New York:Oxford University Press, 1993.

Lawson, A. and Rhode, D. L. (eds).The Politics of Pregnancy:Adolescent Sexuality and PublicPolicy. New Haven: Yale UniversityPress, 1993.

Sex and America’s Teenagers. New York: The Alan GuttmacherInstitute, 1994.

Eugene V. Beresin, M.D.Director, Consolidated Child and Adolescent Psychiatry Residency TrainingProgram, Massachusetts General Hospital and McLean Hospital

Dr. Beresin teaches on such topics as education and training, eating dis-orders, personality disorders, and child and adolescent development atHarvard Medical School, Massachusetts General Hospital, and McLeanHospital. He received recognition in 1991 as Teacher of the Year in thechild and adolescent residency program at Massachusetts GeneralHospital, and was awarded the Region I Teacher of the Year from theAssociation for Academic Psychiatry. Articles by Dr. Beresin haveappeared in the American Journal of Psychotherapy and AcademicMedicine, and he has contributed chapters to numerous book projects.Dr. Beresin serves as co-chair of the Training Committee of theAmerican Academy of Child and Adolescent Psychiatry, and chair ofthe Task Force on Recruitment for the American Academy of Child andAdolescent Psychiatry. He is the president-elect of the New EnglandCouncil of Child and Adolescent Psychiatry.

Robert W. Blum, M.D., M.P.H., Ph.D.Professor and Director, Adolescent Health Program, Department ofPediatrics, University of Minnesota

Dr. Blum serves on the board of directors and scientific advisoryboard of The Alan Guttmacher Institute. He is part present of theSociety for Adolescent Medicine and received the Society’s 1993Outstanding Achievement Award. In addition, Dr. Blum has servedon a multitude of editorial boards, peer review committees, and feder-al grant review committees. He has published over 125 articles, books,and chapters, focusing mainly on sexual decision making and preg-nancy outcomes among adolescents. Dr. Blum has consulted for theWorld Health Organization and the Pan American HealthOrganization, and has made innumerable presentations to nationaland international organizations.

Michael A. Carrera, Ed.D.Director, National Adolescent Sexuality Training Center, Children’s Aid Society

Dr. Carrera is Thomas Hunter Professor Emeritus of Health Sciencesat Hunter College of the City University of New York. He directs boththe National Adolescent Sexuality Training Center and the AdolescentSexuality and Pregnancy Prevention Programs of the Children’s AidSociety. Dr. Carrera has authored Sex, The Facts, The Acts and yourFeelings; Sexual Health for Men; Your A to Z Guide; Sexual Health forWomen; Your A to Z Guide; and most recently, The Language of Sex. Dr.Carrera has received awards from the American Association of SexEducators, Counselors, and Therapists (AASECT); Rutgers University,Advocates for Youth; and the Society for the Scientific Study of Sex.He has served as board president for both the Sexuality Informationand Education Council of the United States and AASECT.

Arthur B. Elster, M.D.Director, Department of Adolescent Health, American Medical Association

Dr. Elster has written extensively on adolescent health promotion andprevention services in such publications as Pediatrics, the Journal ofPediatrics, and the American Journal of Diseases of Children. He hasauthored books and book chapters, and done extensive public speak-ing on issues related to adolescent pregnancy and parenthood andadolescent clinical preventive services.

Jacqueline Darroch Forrest, Ph.D.Senior Vice President and Vice President for Research, The Alan Guttmacher Institute

Dr. Forrest has authored and coauthored over 100 articles and publi-cations on sexual behavior, fertility, family planning, maternal andchild health, teenage pregnancy, and abortion. Most recently, shecoauthored Sex and America’s Teenagers, an examination of the mythssurrounding the sexual and reproductive behavior of U.S. teenagers.With colleagues at the Institute, she has also recently conducted aninvestigation of the health benefits and risks of contraception, evalu-ating effects on fertility, and analyzing women’s sexual and reproduc-tive behavior and risk of sexually transmitted diseases. She serves onnumerous panels and boards, including the Program DevelopmentBoard of the American Public Health Association and the TechnicalAdvisory Committee of the Contraceptive Research and Developmentprogram (CONRAD).

Donald E. Greydanus, M.D.Adolescent Health Section, American Academy of Pediatrics

Dr. Greydanus serves on the American Academy of Pediatric’sCommittee on Scientific Meetings, the Academy’s Committee onAdolescence, and the National Medical Committee on the PlannedParenthood Federation of America. Dr. Greydanus serves in an edito-rial capacity for the Adolescent Health Section Newsletter and AdolescentMedicine State of the Art Review, and has published over 140 articles,chapters and books in adolescent health. He is the 1995 recipient ofthe Adele Dellenbaugh Hofmann Award from the American Academyof Pediatrics for excellence in the field of adolescent medicine. Dr.Greydanus is professor of pediatrics and human development atMichigan State University’s College of Human Medicine.

Debra W. Haffner, M.P.H.President, Sexuality Information and Education Council of the United States(SIECUS)

As one of the nation’s leading experts on sexuality and HIV/AIDSprevention education, Ms. Haffner has authored articles in a varietyof publications, such as Family Planning Perspectives, the Journal ofSchool Health, the School Administrator and newsletters of many nation-al organizations. She has offered keynote presentations and work-shops at the annual meetings of diverse national organizations, hasprovided training in sexuality eduction to over 13,000 professionals,and has presented to more than 30,000 professionals. She serves onthe board of directors of the National Leadership Coalition on AIDS,the National Committee for Responsive Philanthropy, and the Centerfor Sexuality and Religion and is the past chair of the Family Planningand Population Section Council of the American Public HealthAssociation. She is the recipient of the 1994 Public Service Award ofthe Society for Scientific Study of Sex.

Karen Hein, M.D.Executive Officer, Institute of Medicine, National Academy of Sciences

Dr. Hein is clinical professor of pediatrics, epidemiology, and socialmedicine at Albert Einstein College of Medicine. At the Institute ofMedicine, she oversees eight Divisions responsible for the productionof sixty reports each year in a variety of healthy policy issues. Dr. Heinhas been the principal investigator on over twenty grants, was thefounder and director of the nation’s first Adolescent AIDS Program(1987-93) and was the President of the Society for Adolescent Medicinein 1993. She has served on numerous boards and advisory panels, andis a frequent consultant and lecturer in issues related to health carereform, youth and HIV. Dr. Hein has written over 150 manuscripts andis on editorial boards of several journals. She worked in the U.S.Senate Finance Committee on Health Care Reform (1993-1994).

Robert L. Johnson, M.D.Commission Chair

Director of Adolescent and Young Adult Medicine, University of Medicine and Dentistry, New Jersey Medical School

Dr. Johnson is professor of clinical pediatrics and clinical psychiatry;and director of adolescent and young adult medicine at the NewJersey Medical School. He is associated with local, state and nationalorganizations, such as the American Academy of Pediatrics, theSociety for Adolescent Medicine, and the Governor’s Task Force onAdolescent Pregnancy. In addition, he has served on the board ofdirectors of Advocates for Youth, the Children’s Defense Fund, andthe Sexuality Information and Education Council of the United States(SIECUS). He addresses many national and international audienceseach year, and frequently is interviewed for television and radio. Dr.Johnson has published widely, and conducts research and a clinicalpractice at the New Jersey Medical School.

Mariana Kastrinakis, M.D., M.P.H.Senior Advisor on Adolescent Health, U.S. Public Health ServiceDepartment of Health and Human Services

Dr. Kastrinakis is an internist who specializes in adolescent medicine.For the past two years, she has been with the Department of Healthand Human Services, working on special assignments in adolescenthealth policy. She is an assistant clinical professor of internal and ado-lescent medicine at the George Washington University MedicalSchool. In addition, she has given multiple presentations and beeninvolved in research and publishing in her field of expertise.

COMMISSIONERS’ BIOGRAPHICAL SKETCHES

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Douglas B. Kirby, Ph.D.Director of Research, ETR Associates

Dr. Kirby conducts a variety of studies designed to reduce unprotect-ed intercourse among adolescents. He has directed nationwide studiesof adolescent sexual behavior; sexuality education programs, andschool-based clinics. Dr. Kirby has coauthored research on theReducing the Risk curriculum and published syntheses of otherresearch studies. He has authored numerous volumes, articles, andchapters both on school-based programs to reduce unprotected sexualintercourse and on methods of evaluating these programs. Dr. Kirbyhas frequently presented on these topics and provided consultation tomany groups designing and evaluating programs for youth.

Lawrence A. Kutner, Ph.D.Psychologist and Journalist

Dr. Kutner is a clinical psychologist and journalist who specializes inissues related to child development and parenting. He is contributingeditor of Parents magazine and the author of its “Ask The Expert” col-umn. From 1987 through 1994, he wrote the award-winning weeklyNew York Times “Parent & Child” column, which also appeared in sev-eral hundred newspapers across the United States and Canada. Dr.Kutner is on the faculty of the department of psychiatry at HarvardMedical School, and is the author of four books on child development.

Marilyn Pland Laken, Ph.D., R.N.Professor of Obstetrics and Gynecology, Division of Community HealthPrograms, Wayne State University School of Medicine

Dr. Laken received her doctorate in biological anthropology. She hasconducted research in and published on issues related to health deliv-ery for vulnerable populations of low-income women, adolescents,and children. She is professor of obstetrics and gynecology at WayneState University School of Medicine, teaching courses in maternal andchild health and alternative medicine. Dr. Laken has reviewed grantsfor the National Institute of child Health and Human Developmentand the Office of Population Affairs. She frequently gives presenta-tions to professional audiences and elected officials, and she serves onstate and national advisory groups that direct new programs andpolicies for women and children.

Carlos W. Molina, Ph.D.Associate Professor of Public Health Education, York College, CityUniversity of New York

Dr. Molina is a former acting vice president for academic affairs at theCity University of New York, and former chief executive officer forLincoln Medical and Mental Health Center in the Bronx, New York.Dr. Molina has served as a member of the American Public HealthAssociation’s executive board, as well as on the board of directors ofthe Planned Parenthood Federation of America and The AlanGuttmacher Institute. He has also served on advisory committees forthe Robert Wood Johnson Foundation, the surgeon general’s office,and the American Cancer Society. Dr. Molina has published research,presented papers, served on panels, and participated in national pressconferences focusing on Latino health concerns.

Rhonda R. Nichols, M.D.Director of Medical Education, Jersey City Medical Center

Dr. Nichols is a board-certified obstetrician and gynecologist servingas director of medical education in the department of obstetrics andgynecology at Jersey City Medical Center, as well as being in privatepractice. Dr. Nichols is a former assistant professor of obstetrics andgynecology at the University of Medicine and Dentistry of New Jersey(UMDNJ), where she was the medical director of maternity and infantcare in the hospital-based, state-funded Comprehensive AdolescentPregnancy Program, and administrative director of the HealthyMothers-Healthy Babies Outreach Team. She is also former director ofthe pediatric and adolescent gynecologic division at UMDNJ.

Rt. Rev. David E. RichardsBoard of Directors, Sexuality Information and Education Council of theUnited States (SIECUS)

Bishop Richards has served in the ministry of the Episcopal Churchsince 1945; he has been the bishop of Central America and was the

first director of the denomintation’s Office of Pastoral Development.Bishop Richards has provided training conferences in Africa, HongKong, the Philippines, and the West Indies. He was a senior fellow atthe Harvard Medical School in 1973-74, and received additional train-ing at the Family Center of Georgetown Medical School. BishopRichards is associated with Counseling Services in Coral Gables,Florida, and is cofounder of the Center for Sexuality and Religion.

Peter C. Scales, Ph.D.Director of National Initiatives, Center for Early Adolescence, School ofMedicine, University of North Carolina at Chapel Hill

Before serving as the director of national initiatives at the Center forEarly Adolescence, Dr. Scales was chair of the Alaska Governor’sCommission on Children and Youth, national director of education forthe Planned Parenthood Federation of America, and a senior socialscientist for Mathtech. At Mathtech, he coauthored An Analysis of U.S.Sexuality Education Programs and Evaluation Methods. He has authoredor coauthored more than 140 books and articles, including A Portraitof Young Adolescents in the 1990’s, The Front Lines of Sexuality Education,and The Sexual Adolescent: Communicating with Teenagers About Sex. Hereceived the 1988 U.S. Administration for Children, Youth, andFamilies’ Commissioner Award for exceptional service to youth, andwas a consultant for the 1992 PBS television program What Kids Wantto Know About Sex and Growing Up.

Pepper J. Schwartz, Ph.D.Professor of Sociology, University of Washington

Dr. Schwartz is past president of the Society for the Scientific Study ofSex. She coauthored A Student’s Guide to Sex On Campus, AmericanCouples, and Peer Marriage, and has written numerous academic arti-cles. She writes columns on human sexuality for American Baby andGlamour, and contributes to the New York Times “Parent & Child” col-umn. Dr. Schwartz has served on the board of directors of PlannedParenthood of Seattle-King County and the AIDS Foundation.

Isabel C. Stewart, M.Ed.National Executive Director, Girls Incorporated

Ms. Stewart began with Girls Incorporated as the deputy director in1991. She had previously served as director for program administra-tion at the National Academy Foundation. Ms. Stewart has been aneducator and administrator at the Brearley School in New York, theTrinity School in Atlanta, the American University in Cairo, theWilliam Penn High School in Philadelphia, and the African-AmericanInstitute in New York. Ms. Stewart serves on the board of directors atthe Brearley School, and has been a member of the board of directorsfor Hampshire College, the Lower East Side Tenement Museum, andthe Mary Reynolds Babcock Foundation.

Ruby Takanishi, Ph.D.Executive Director, Carnegie Council on Adolescent Development

Dr. Takanishi was the former director of the Office of Scientific Affairsat the American Psychological Association (APA), and administrativeofficer for children, youth, and family policy at the APA. Dr.Takanishi’s extensive background in child development and socialpolicy has informed her work as a professor, consultant, and memberof national advisory councils and review panels. Dr. Takanishi haswritten articles and reviews in such publications as AmericanPsychologist, the Journal of the American Medical Association, and theTeachers College Record. She has received professional honors from theAFA and the National Academy of Education.

Elizabeth C. WinshipAuthor, “Ask Beth”

Ms. Winship is a longtime columnist for the Boston Globe and TheL.A. Times syndicate, providing advice to teenagers on a wide range ofsexual health issues. Ms. Winship has written Ask Beth: You Can’t AskYour Mother; Reaching Your Teenager, and a high school sexuality edu-cation textbook, Perspectives on Health: Human Sexuality. Ms. Winshipreceived the 1978 Massachusetts Psychological AssociationHumanitarian Award, and was named the Massachusetts Associationof School Psychologists Journalist of the Year in 1982.30

Bell, A. and Weinberg, M. Sexual Preference: ItsDevelopment in Men and Women. (Indiana:Indiana University Press, 1981).

Blum, R., Resnick, M., and Stark, T., “The Impactof a Parental Notification Law on AdolescentAbortion Decision Marking,” American Journal ofPublic Health, 775 (1987): 619-20.

Boyer, D. and Fine, D., “Sexual Abuse as a Factorin Adolescent Pregnancy and ChildMaltreatment,” Family Planning Perspectives, 24:1(1992): 4-11.

Brooks-Gunn, J. and Furstenberg, FF, “Coming ofAge in the Era of AIDS; Puberty, Sexuality, andContraception,” The Millbank Quarterly, 68,Suppl. 1, (1990).

California Vital Statistics Section, “CaliforniaResident Live Births, 1990, by Age of Father, byAge of Mother,” Sacramento, California:California Vital Statistics Section Department ofHealth Services, 1992.

Carnegie Corporation of New York. A Matter ofTime: Risk and Opportunity in The Out-Of-SchoolHours. (NY: Carnegie Corporation of New York,1992).

Carrera, M. Sex, The Facts, The Acts, and YourFeelings. (New York: Crown Publishers, 1981).

Cates, W., “Teenagers and Sexual Risk Taking:The Best of Times and the Worst of Times,”Journal of Adolescent Health, 12:2 (1991): 84-94.

Centers for Disease Control and Prevention,“Selected Behaviors that Increase Risk for HIVInfection Among High School Students,”MMWR, 41 (1992): 237.

Centers for Disease Control and Prevention,“Sexual Behavior Among High School Students.United States, 1990,” MMWR, 40 (1992): 886.

Centers for Disease Control and Prevention,Pregnancy, Sexually Transmitted Diseases, andRelated Risk Behaviors Among US Adolescents.(Atlanta: CDC, 1994).

Child Welfare League of America. A Survey of 17Florence Crittenton Agencies Serving MinorMothers. (Washington, DC: CWLA, 1994).

Chilman, C., “Family Life Education: PromotingHealthy Adolescent Sexuality,” Family Relations,39:2 (1990): 123-31.

Child Trends. Facts At A Glance. (DC: ChildTrends, 1995).

Coles, R. and Stokes, F. Sex and the AmericanTeenager (New York: Harper and Row, 1985).

Durant, R., Jay S., and Seymore, C.,“Contraceptive and Sexual Behavior of BlackFemale Adolescents: A Test of a Social-Psychological Theoretical Model,” Journal ofAdolescent Health Care, 11:4 (1990): 326-34.

Durban, M., DiClemente, R., and Siegel, D.,“Factors Associated with Multiple Sex PartnersAmong Junior High School Students,” Journal ofAdolescent Health, 14:3 (1993): 202-7.

Forrest, J., and Singh, S., “The Sexual andReproductive Behavior of American Women,1982-1988,” Family Planning Perspectives, 22:5(1990): 206-14.

Hunter, J., “Violence Against Lesbian and GayMale Youths,” Journal of Interpersonal Violence, 5(1990): 295-300.

Irvine, J. Sexual Cultures and The Construction ofAdolescent Identities. (PA: Temple UniversityPress, 1994).

Jones, E., et al., “Teenage Pregnancy inDeveloped Countries: Determinants and PolicyImplications,” Family Planning Perspectives, 17:2(1985): 53-63.

Jones, E., et al., “Unintended Pregnancy,Contraceptive Practice and Family PlanningServices in Developed Countries,” FamilyPlanning Perspectives, 20:2 (1988): 53-67.

National Center for Health Statistics,“Contraceptive Use in the United States: 1982-1990,” Advance Data. February 14, 1995.

REFERENCES

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National Guidelines Task Force. Guidelines forComprehensive Sexuality Education:Kindergarten–12th Grade, (New York: SexualityInformation and Education Council of theUnited States, 1991).

National Victims Center. Rape In America.(Virginia: National Victims Center, 1992).

Neinstein, L.S. Adolescent Health Care: A PracticalGuide. (Maryland: Urban and Schwarzenberg,Inc., 1991).

Newcomer, S. and Udry, J., “Oral Sex in AnAdolescent Population” Archives of SexualBehavior, 14 (1985): 41-46.

Paikoff, R, and Brooks-Gunn, J., “Do Parent-Child Relationships Change During Puberty?,”Psychological Bulletin, 110 (1991): 47-66.

Peterson, A.C. and Leffert, N., “What is SpecialAbout Adolescence” in Rutter, M., editor,Psychosocial Disturbances In Young People:Challenges for Prevention. (Cambridge: CambridgeUniversity Press, 1994).

Pleck, J., Sonenstein, F., and Ku, L., “MasculinityIdealogy: Its Impact on Adolescent Males’Heterosexual Relationships.” Journal of SocialIssues, 49:3 (1993): 11-30.

Polit, D., Cozette, W., and Thomas, D., “ChildSexual Abuse and Premarital Intercourse AmongHigh Risk Adolescents,” Journal of AdolescentHealth Care, 11 (1990): 231-34.

Quadrel, M.J., Fischoff, B., and Doris, W.,“Adolescent (In) Vulnerability,” AmericanPsychologist, 48:2 (1993): 102-16.

Remafedi, G., et al., “Demography of SexualOrientation in Adolescents,” Pediatrics, 89:4(1992): 714-21.

Roper Starch Worldwide. Teens Talk About Sex:Adolescent Sexuality in the 90’s (New YorkSexuality Information and Education Council ofthe United States, 1994).

Scales, P. A Portrait of Young Adolescents in the1990’s: Implications for Healthy Growth andDevelopment, (North Carolina: Center for EarlyAdolescence, University of North Carolina atChapel Hill, 1991).

Selverston, R., “Adolescent Sexuality: DevelopingSelf Esteem and Mastering DevelopmentalTasks,” SIECUS Report, 18:1 (91989): 1-5.

Smith, P., National Adolescent Student HealthSurvey Results (Reston, VA: American SchoolHealth Association, 1988).

Sonenstein, F., Pleck, J., and Ku, L., “SexualActivity, Condom Use, and AIDS AwarenessAmong Adolescent Males,” Family PlanningPerspectives, 21:4 (1989): 152-58.

Sonenstein, F., Pleck, J., and Ku, L., “Levels ofSexual Activity Among Adolescent Males In TheUnited States,” Family Planning Perspectives, 23:4(1991): 162-67.

The Alan Guttmacher Institute, Sex and America’sTeenagers. (New York: The Alan GuttmacherInstitute, 1994).

Thompson, S., “Putting a Big Thing into a LittleHole: Teenage Girls’ Accounts of Sexual Initiation,”Journal of Sex Research, 27:3 (1990): 341-61.

Winship, E., Reaching Your Teenager. (N.Y.:Houghton Press, 1983).

Zelnik, M. and Shah, F.K., “First IntercourseAmong Young Americans,” Family PlanningPerspectives, 15:2 (1983): 64-68.

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