Adolescent Sexuality

Robert Wm. Blum, MD, MPH, PhD
William H. Gates, Sr. Professor and Chair of the Department of Population and Family Health Sciences, Johns Hopkins Bloomberg School of Public Health
Tuesday, May 16, 2006; 11:00 AM

Dr. Robert Wm. Blum was online Tuesday, May 16, at 11 a.m. ET to field questions and comments about risk and protective factors associated with sexually active teenagers. He also took medical questions relating to adolescent sexuality.

Blum is the William H. Gates, Sr. Professor and Chair of the Department of Population and Family Health Sciences, Johns Hopkins Bloomberg School of Public Health. He has edited two books, and has written more than 220 journal articles, book chapters and special reports.

Blum is a Past-President of the Society for Adolescent Medicine; has served on the American Board of Pediatrics; was a charter member of the Sub-Board of Adolescent Medicine, is a past chair of the Alan Guttmacher Institute Board of Directors and served as chair of the National Academy of Sciences Committee on Adolescent Health and Development. He is a consultant to The World Bank and UNICEF as well as the World Health Organization where he has served on the Technical Advisory Group of the Child and Adolescent Health Department as well as the Scientific and Technical Advisory Group of the Human Reproductive Program.

The transcript follows.


Dr. Robert Wm. Blum: Welcome to this chat on adolescent sexuality. I will respond to questions as they come in. am a professor at Johns Hopkins University School of Public Health ands have worked in adolescent health for the past 25 years as a physician and researcher.


Cambridge, Mass.: Why is it generally assumed that it is bad for adolescents to have sex? Of course, there is the risk of STDs; but this risk can be managed, and doesn't seem to be what really bothers people about adolescent sexuality. There is also the argument that adolescents are something like too "emotionally immature" for sexual relations; but this is a mushy argument that doesn't explain why emotional maturity is needed, what it is, and whether or not adolescents generally, or can ever, have it. So if we leave aside the specter of STDs and avoid mushy generalities: should adolescents ever be sexually active, and, if so, under what conditions?

Dr. Robert Wm. Blum: The question is complicated since "adolescence" spans an 8 to 10 year period depending on how you define it and there is a lot of development that occurs during that time. The issues: when there is a wide difference in age between 2 adolescents (often defined as more than 3 years) it may very well be an unequal power relationship; 2. developmentally, some young adolescents may not really understand what they are consenting to when they have consensual sex. There is little data, however, that shows that young people who willingly engage in mutually consenting, non-abusive sexual relations are harmed by it.


Washington, D.C.: My daughter is 15 and claims that she is bi-sexual. She claims that she had not had sex yet but finds both boys and girls attractive. How can this be? Is this normal or is this is just her way of rebelling? I am not sure what to say or do.

Dr. Robert Wm. Blum: It depends on how you define "normal". Most young people define themselves as predominantly attracted to the opposite sex. Perhaps one in about 20 young women are like your daughter attracted to both. It is adolescent rebellion? NO. It is probably an honest reflection of how she feels and that she can discuss it with you is very good. She needs help to feel comfortable with who she is and her sexual orientation. When young people are confused by their sexuality they are at greater risk for "proving" that they are heterosexual by getting pregnant. What is critical is that your daughter feel comfortable with both attractions. Having an attraction does not mean that you have to act on it; you have to learn to live with it.


Guangzhou City, China: Dear Dr. Robert Wm. Blum,

After reading the articles, I find that in the American society, almost all the parents and teaching institutions give a double message towards young people at the same time, just as some experts like Michaud mentioned---On one hand, parents and teachers teach the adolescents to be abstinent until marriage. While, on the other hand, they give guidance on having sex to the children at the same time. This way of guiding is strongly opposed by Western Europeans who support premarital sexual activities with appropriate contraceptives. Well, since the rates of premarital pregnancy, STDs and abortions in US are evidently much higher than those in European Countries such as Sweden. I am wondering that what you think of the popular teaching of abstinent in US nowadays. Is it suitable for American teenagers? Do you agree that sex is a normal part of adolescent development? Will American society achieve successful result in preventing premarital pregnancy, STDs and abortion of adolescents by using the European way of guiding? Thank you very much!

Dr. Robert Wm. Blum: Your question has many questions in it. In the United States we are very ambivalent about sexuality--witness what we teach in school and what young people witness on music videos. There is no evidence that abstinence education devoid of contraceptive information makes much of an impact. Can kids understand complex messages? Yes. The message is not so complex: Not now but if you have sex contracept.

I would suggest that that is essentially the message that many European parents give their kids.


Boston, Mass.: Isn't it unrealistic to expect adolescents to wait until marriage? Unless we advocate very early marriage, which I don't want to see. As I understand it, 200 years ago girls went through puberty (defined as the first period) mostly between 17 and 19, and got married around the same age. Nowadays, girls go through puberty between 12 and 14, and don't get married until 25 or later. I'm not sure about male puberty, but it's probably similar.

Dr. Robert Wm. Blum: Between 1860 and 1960 female puberty declined by about 3 months per decade to about 12.5 years for females and about 14 years (plus or minus) for males. Marriage is delayed and so you are correct that the period between onset of reproductive capability and marriage is longer now than ever b4. Is it reasonable for young people to wait until marriage? You decide but it appears that approximately 85% of young people believe that it is not.


Arlington, Va.: Usually, none of the articles or studies cited on this topic include the impact of religious teachings on teens decisions to engage/not engage in premarital sex. Why is that?

Dr. Robert Wm. Blum: Sadly, as much as we would like to believe, religious teachings have little or no impact on adolescent sexual behavior. My colleagues and I did an analysis (recently published in Social Science and Medicine) where we looked at the impact of religion and while it has an impact on smoking and drinking it has no impact on sexual behavior. In 1984 we looked at you people who got abortion in Wisconsin and Minnesota and we analyzed it by religion. What we found was that the distribution of those who were getting abortions was exactly the same as the distribution by religion of the population in those 2 mid-western states. I know that we would like to believe that a religion's prohibitions have an impact; the data do not support it.


Fort Washington, Md.: Now that the prom weekends are among us, what are the statistics that many of the young adolescent females loose their virginity during this time of their lives? What kind of parental advice is suggested?

Dr. Robert Wm. Blum: I don't know the data between proms and pregnancy. My advise to my daughters was: 1. if you have sex with someone make sure it is you who want it as much as him-- if not tell him to buzz off;

2. if you do have sex, contracept.

Having sex is not an accident-- don't make it one.


Washington , D.C.: It seems to me that abstinence-only education is incredibly short-sighted. Most people don't get married at 19 these days! Do we really expect these kids to be virgins on their wedding nights when they're 25 or 35?

Isn't it disingenuous to tell kids to abstain until marriage when really we only expect them to do so until they hit 20 or so? And then what? They don't know anything about birth control or STDs or anything else because all you taught them was to say no!

Dr. Robert Wm. Blum: I think that I have addressed this in a prior comment.


Washington, D.C.: I am noticing that a lot more young people, especially teen girls seem to be claiming to be bisexual or gay. Is there a growth in teen homosexuality or is it just more acceptable to come out today than in the past?

Dr. Robert Wm. Blum: I do not know the data historically. Today about 3% of girls (and about double that for boys) say that they are homosexual; and about 5% of girls identify as bisexual. Is it a fad? Probably not; rather, it probably reflects actual sexual orientation. My hunch (without data) is that it probably hasn't changed much over the years.


Rockville, Md.: I'm not sure why this seems so hard for so many people. My folks were pretty basic about sex: You should probably wait, but if you don't use a condom so you don't get her pregnant or catch a disease. I'm 25, but my wife is pregnant now, and these seem to be simple rules I'll use for my own kids one day.

Dr. Robert Wm. Blum: I agree... not so complicated.


Arlington, Va.: To what extent is sexuality in adolescence biological and to what extent cultural? I had always assumed it was a biological "fact of life" that at a certain age boys and girls start experiencing sexual feelings, but after talking to friends and partners who grew up in societies with fewer sexual images and opportunities, I'm amazed at the different responses I've received to questions about first recalled sexual attraction, experience, crush, all of these things.

Dr. Robert Wm. Blum: Complicated question. When you look around the world there is wide variance culturally in sexual behaviors. In Vietnam and Japan, for example, less than 5% of girls and probably no more than about 10% of boys have sex as adolescents. Prevalence rates of sexual onset in adolescence varies widely in sub-Saharan Africa. That having been said, there is a strong biologic basis for a sex drive that has a lot to do with testosterone.


New York, N.Y.: What roles do you feel educators and parents should play in terms of sex education for adolescents? It seems in the US, there is a tendency for educators to want that responsibility to belong to parents, often parents often want their personal ethics to be reflected in the general literature. Are there any studies that evaluate the effectiveness of sex education from each source?

Dr. Robert Wm. Blum: There is a lot of data on effective sex education in schools--I'd refer you to the work of Doug Kirby available on the web-site of the National Campaign to Prevent Teen Pregnancy. We do know quite a bit about what works (why we don't use it is a different story). Parents are not keen on being their kids sex educator. That having been said, parents are key. We are our kids sex educator in how we role model talking to our spouses. We role model sex education if we are in dating relationships with others and how we behave. we are our kids sex educator when we turn off the TV and avoid discussing some sexual message that we and they saw and pretend that we didn't see it. We are our kids sex educators in everything that we do even if we never discuss sex with them directly.

Which do I think is more important? The indirect sex education that our kids get from birth by watching their parents.


Arlington, Va.: I guess the problem I have with all this is that it seems to communicate the message that it is not normal to want to wait to have sex. For teens who do choose not to have sex, whether out of fear of pregnancy or religious upbringing, are they getting a message that they are abnormal and out of the mainstream? That's certainly what I hear in the attacks on the abstinence programs.

Dr. Robert Wm. Blum: The fact that there is no data to support abstinence programs in no way is meant to suggest that delaying sex is abnormal. To the contrary. For me the best abstinence program is to give kids a meaningful future. Kids who do better in school delay first sex. Kids who have an adult in their lives who is "crazy about them" delay first sex. As Marion Wright Edelman said a generation ago: "The best contraception is a meaningful future."

That's what the data support.


Washington, D.C.: How do teen pregnancy rates in Western Europe compare to those in the United States and across what types of demographics do you see adolescent pregnancies in Western Europe? Additionally, how do abortion rates compare? Finally, do you see any connection between the lower rates of marriage in Western Europe to the more liberal attitudes toward teen sex and unwed parents?

Dr. Robert Wm. Blum: Pregnancy rates in ALL of Europe is much lower than in the United States. Even when you control for demographic variability, the US is still way ahead of every country in Europe. US has higher abortion rates than every country in Europe (with perhaps the exception of Russia. You ask if delayed marriage reflects more liberal attitudes; I think not. Most people delay marriage because they have competing options such as employment and school. Without those options early pregnancy might look pretty good.


Washington, D.C.: Can you speak about the influence government has on adolescent health with regards to this topic? It seems that we are devolving into a position in which science is being replaced by unsupported belief. Is my belief accurate?

Dr. Robert Wm. Blum: Your belief is quite accurate. For example in the name of "balance" a recent scientific meeting of the international STD association was forced to add to a panel of those who represent an unsubstantiated pseudo-scientific perspective while a peer-reviewed presentation was bumped to accommodate that change. That was done by the CDC. The FDA web-site touts the association between abortion and breast cancer where the association is spurious at best. The CDC web-site speaks about the limitations of condoms. The federal government prohibits the use of federal funds to teach the efficacy of contraception. Enough?


Washington, D.C.: You've mentioned statistical variance of sexual activity in different countries. Do you have data on the sexual activity rates between the ethnicities in the US? I ask this in general but specifically because I know that the rate of STD infection including HIV is significantly higher for African-Americans, at least in DC. I was wondering if you can comment on why that may be.

Dr. Robert Wm. Blum: There is substantial variation by race and gender. For example while the rate of teen pregnancy has declined in the US since 1991 the decline has been steepest for African Americans and least steep for Latinos (and steepest decline has been among African American males. There are variations in STD and HIV rates as well. But when you look at adolescents (as we did in a paper published 4 years ago in the American Journal of Public Health) race is a very poor predictor of outcomes. Rather, school, parent supports and "connectedness", peer relationships, meaningful activities, academic performance, whether your parents know your friends and their parents, connectedness with a teacher or other adult in the school are much more powerful predictors than race of outcomes. Their parents


Arlington, Va.: I don't understand how parents can be so outraged by the current perceived lack of morals of today's teens when they themselves want to push the responsibility of sex education to the school system. Do you really want to trust something as sensitive as your child's sexuality to a one size fits all agenda created by the schools? Why are parents so afraid to talk to their children about sex? Is it just a case of having their heads in the sand? Trying to avoid embarrassment? They would rather deal with the embarrassment of a pregnant teenaged daughter instead?

Dr. Robert Wm. Blum: As I mentioned earlier, whether we choose to be explicit or not, we are our kids sex educators. They are watching us all the time.


Seattle, Wash.: We talk a lot about the roles of parents in sexuality in terms of things like sex education and talking to kids about sex, but isn't it true that by just being highly involved parents can make a big difference in their kids' lives. One study in TX showed daughters with highly involved dads abstaining from early sex.

Dr. Robert Wm. Blum: Yes, Yes, Yes.


Tampa, Fla.: Are there key differences in adolescent sexuality between young men and women. Theoretically, a male sex drive is highest at 18, whereas a female's is highest at 35.

Dr. Robert Wm. Blum: There are vast gender differences from the age of puberty to hormonal influences to socialization... but variations within gender are equally great.


Fairfax, Va.: In regards to the religious aspect, is the data broken down in that regard? I have heard that some religions hold hard and fast with no pre-marital sex. Is there any data that by taking "vows" to not have pre-marital sex that it works? Does heavy religious pressure help? Thanks.

Dr. Robert Wm. Blum: We have looked at 43 religions and see no difference as to age of first sex. Regarding chastity vows, there is a cohort effect short term (see, for example the work of Peter Bearman) but the evidence that is emerging is that it does not have long term staying power.


Chicago, Ill.: What role does the media play in shaping attitudes/beliefs in teens regarding sexuality? Does the heavily sex-soaked film/TV show environment make it more tempting for young people to enter sexual relationships?

Dr. Robert Wm. Blum: The data are not in like it is with media violence but it does suggest that sexually provocative media may have an impact on behavior especially where sexual intercourse is uncoupled from the risks of pregnancy and STDs/HIV and the need to contracept.


Falls Church, Va.: Based on the supporting articles and information from Western European countries, it appears that the strategy used in the US pertaining to teen sexuality is not effective. Do you think the US government and various religious groups play too much of a role in teaching children about sexuality and that parents are possibly involved too little? And do you have any recommendations on books parents can read to better prepare for discussions with children?

Dr. Robert Wm. Blum: I don't think that the government is playing too much of a role; rather, it is compelling unproven interventions while avoiding interventions where there is an evidence-base.

As for book, I have been out of this for a while but when my kids were little I always had Peter Masyle's books lying around so that they could pick them up. look at them and when they were older start to read them (but I may be dating myself with this suggestion).


Gaithersburg, Md.: Hello Dr. Blum -

Would you please address HPV and it's relationship to cervical cancer. How is it diagnosed and can one contract the virus by other means than sexual transmission? Thank you for your time.

Dr. Robert Wm. Blum: HPV is a sexually transmitted disease and early cervical cancer is diagnosed by Pap smear and culposcopy. The evidence is mounting that the 2 primary strains of HPV that cause cervical cancer can be prevented with the new vaccines.


Dr. Robert Wm. Blum: Thank you for joining me for this discussion. It is noon EDT and we need to conclude.


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