Risky Adolescent Sexual Behavior: A Psychological Perspective for Primary Care Clinicians

Peter A. Hall, PhD; Maxine Holmqvist, BA; Simon B. Sherry, MA

Disclosures

Topics in Advanced Practice Nursing eJournal. 2004;4(1) 

In This Article

Abstract and Introduction

The majority of older adolescents in North America are sexually active, yet many do not take appropriate precautions to prevent pregnancy or the spread of sexually transmitted infections. This article discusses several ways to conceptualize, assess, and manage risky sexual behavior in adolescents from a psychological perspective. Adolescents, like adults, may be prone to engaging in risky sexual behavior due to perceptions of personal invulnerability and their tendency to focus on the immediate, rather than long-term, consequences of their behavior. Mentally ill adolescents may be particularly at risk and warrant special consideration. Specific clinical recommendations for assessing and managing risky sexual behavior are discussed. These include maintaining an empathic stance toward the adolescent, supporting the autonomy of the adolescent, identifying and owning one's own values, familiarizing oneself with available resources, and referring to mental health practitioners when appropriate.

Adolescents routinely engage in behaviors that put their health at risk. Risky sexual behaviors are of particular concern to advanced practice nurses (APNs) and other primary care clinicians in that they can lead to serious consequences both for the adolescent involved and for any number of unseen partners. Clinicians are faced with 3 challenges: (1) how to understand this behavior, (2) how to identify risky sexual behavior in the adolescent patient, and (3) what to do about it. This article will review some ways of conceptualizing adolescent risk behavior and some tips for assessment and change.

The majority of adolescents aged 15 to19 years in Canada and the United States report having had sexual intercourse at least once. In addition, 23.9% and 45.5% of adolescent females from Canada and the United States, respectively, report having had 2 or more sexual partners in the past year. Likewise, 32.1% of Canadian males in this age group report having had 2 or more partners, while 50.8% of American males report the same.[1]

Why should clinicians care about risky sexual behaviors in adolescents? Issues of morality and religion aside (which are important but beyond the scope of this paper), one good medical reason why this issue is important is that risky sexual behaviors increase the likelihood of contracting a sexually transmitted infection (STI). In the United States, for example, approximately 15 million new STIs occur annually,[2] and many of these new infections are among adolescents. Even nonfatal STIs, such as chlamydia, are associated with adverse outcomes including ectopic pregnancies and infertility.[3] Human papilloma virus, the virus that causes genital warts, has been associated with the development of cervical cancer.[3] The mere presence of an STI directly increases the likelihood of transmission of HIV infection,[4] an infection that adolescents and young adults are at increased risk for contracting.[5]

In Canada and the United States, the rate of syphilis among 15 to 19 year olds is 0.6 and 6.4 per 100,000, respectively.[6] More recent surveillance data suggest that there has been a rise in the rate of syphilis in this age group.[2] In this same age group, gonorrhea rates are 59.4 and 571.8 per 100,000 for Canada and the United States, respectively; chlamydia rates are 563.3 and 1131.6 per 100,000, respectively.[6]

In addition to the risk of STIs, the risk of unplanned pregnancy increases with frequency of unprotected sexual intercourse. Estimates have suggested that approximately 40% of adolescent American women (aged 15 to 19 years) become pregnant before age 20 years,[7] and most of these pregnancies are unintended.[8] Although more recent estimates suggest that rates have dropped to 35%,[9] the rates of teen pregnancy are still substantially higher in Canada and the United States than in other Western industrialized countries like France, Germany, and Sweden.[10]

It is clear that sexual activity (including sexual intercourse) is common among adolescents, and many of the behaviors that they engage in put them at risk for contracting STIs and experiencing unwanted pregnancy.

Risky sexual behavior can be defined in a number of ways. The most obvious way is according to the behavior itself: unprotected vaginal, oral, or anal intercourse. A second way would be to refer to the nature of the partner: HIV-positive individual, intravenous drug user, or nonexclusive partner.

Risky sexual behavior can take several forms, ranging from a large number of sexual partners, or engaging in risky sexual activities, to sexual intercourse under the influence of substances such as alcohol or cocaine. However, it may be difficult for the clinician to discern that these activities are occurring, especially since the adolescent is unlikely to volunteer this information. Instead, this behavior is often identified through the diagnosis of an STI or pregnancy.

Treating STIs can be frustrating for the clinician. It is not uncommon for adolescents to be treated on multiple occasions for STIs, even after they have been counseled to use protection or to abstain from sexual activity completely. It is easy, at this point, for the clinician to assume that the adolescent is unmotivated to change their behavior. However, there are other ways of understanding their behavior.

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