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Adolescent Brain Development and Sexual Decision Making

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1 Adolescent Brain Development and Sexual Decision Making
Freda McKissic Bush, MD, FACOG Clinical Instructor, University of Mississippi Jackson, MS May 14, 2010

2 The Questions What happens inside the brain when teens have sex?
How they can successfully handle the challenge for a lifetime of healthy living?

3 What Is Sex? Sexual activity is defined as any bodily contact meant to derive or give sexual gratification. Horan PF, et al J HIV/AIDS Prev and Educ for Adolescenc and Children Sexual activity defined: Any intimate contact between two individuals that involves arousal, stimulation, and/or a response by at least one of the two partners. It also applies to one person if self stimulation is used.

4 Teen Pregnancy 1 More than 700,000 teens become pregnant each year.
1 in 3 become pregnant at least once before age 20 . 8 out of 10 teen fathers don’t marry the teen mother of their baby. 7 out of 10 unwed mothers receive no financial support from the fathers of their children Less than 2 out of 3 teen mothers graduate from high school or earn a GED within two years of giving birth. 1 McIlhaney and Bush, Hooked, 2008 Both teenage mothers and fathers tend to have unrealistic expectations about parenthood and have difficulty adjusting to teen parenthood. Becoming a parent before age 18 significantly reduces the likelihood of graduation from high school for both boys and girls. Teen parents who obtain a GED have even lower lifetime earnings than those who graduate from high school. Teen parents who graduate from high school or earn a GED are less likely than their peers to go to college.2

5 Emotional Consequences of Sexual Activity
Pain and suffering from broken relationships Fear, confusion about romantic feelings Altered self-esteem Sense of betrayal and abandonment Guilt, depression and emotional rollercoaster Impaired ability to form healthy long-term relationships

6 Sexual activity involves more than just your physical body
Sexual activity involves more than just your physical body. It is an integral part of who you are not just what you do. When we separate the physical then sex becomes just a raw animal act. Like dogs: they do it and keep going to the next dog. Humans are not dogs.

7 How Neuroscience Has “Opened” the Brain for Study
MRI (Magnetic Resonance Imaging) Utilizes magnets instead of x-ray Can therefore be done repetitively on an individual without brain damage fMRI (Functional MRI) Functioning brain tissue utilizes oxygen. Increased blood flow to an area of the brain that has become active can be detected by fMRI. PET (Positron Emission Tomography) A patient is given a safe dose of a positron emitting radioisotope on a metabolically active molecule. For brain function study FDG (fluorodeoxyglucose), a modified glucose molecule is often used. PET detects active areas of the brain by identifying concentration of isotope in those areas. Fisher, et al. J. Comp Neural, 2005 Jer-Pogossian, et al. Radiology, 1975

8 The Brain Parietal Lobe Frontal Lobe Occipital Lobe Cerebellum
The brain has been called the largest sex organ in the body. Sexual excitement is actually centered in the brain. It is possible to be stimulated and even achieve orgasm without any physical contact with the sexual organs. Cerebellum Brain Stem

9 Sagittal View of the Human Brain
Frontal Lobe Parietal Lobe Occipital Lobe SLIDE 3: Introduce the parts of the brain: This is a mid-sagittal view or an image of the brain as if it were cut right down the middle of your head. The major parts of the brain (which is part of the central nervous system) are: Brainstem: The brain stem plays a vital role in basic attention, arousal, and consciousness. All information to and from our body passes through the brain stem on the way to or from the brain. (midbrain, pons, medulla oblongata) Cerebellum: Important for coordination, balance, and control of voluntary movements. Cerebrum: The cerebrum includes the cerebral hemispheres and the diencephalon (thalamus and hypothalamus). - Only three of the four lobes of the cerebral cortex are identified here. The frontal lobes are involved in motor function, problem solving, spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior. The frontal lobes are extremely vulnerable to injury due to their location at the front of the cranium (plug helmets!). The parietal lobes process sensory information (i.e. touch). They are also involved in spatial processing (i.e. forming mental map). The occipital lobe is involved in visual processing (i.e. color discrimination, movement processing, form processing). The lobe that cannot be viewed from this sagittal image is the temporal lobe (can be viewed on next slide). Cerebellum Brainstem

10 The Brain Three pounds 10 billion neurons 100 billion support cells
100 trillion connections (more than all of the internet connections in the world) THE BODY EXHIBIT at the Bellagio, Las Vegas Girl’s brains = 2.5% of their body weight; boy’s brains = 2% Dura mater “tough mother” Nervous system_ faster than world’s most powerful computer; regulates all body’s vital functions. Also, processes all thoughts & emotions Carrying signals over 270 mi/hr. Brain requires 20% of the body’s total blood supply

11 One Fundamental Understanding of Brain Development –
The prefrontal cortex is not fully mature until the mid-twenties1 EX: Rental car companies will not rent a car to young people under age 25 due to damage potential to their property from risk taking young people do. Giedd, et al. Nature Neuroscience, 1999 Weinberger, et al. The Adolescent Brain, 2005

12 The prefrontal cortex is the source of
Judgment Seeing into the future Seeing how behavior can affect the future Moral intelligence Abstract thinking Seeing what is not obvious Planning for the future Rational behavior and decision making Understanding rules of social conduct FAIR=Forward thinking; Assessing risk and abstract thinking; Impulsive behavior control and decision making; Rules of social conduct Giedd, et al. Neuroscience, 1999 Weinberger, et al. The Adolescent Brain, 2005.

13 Brain Development – Age 5
Images courtesy of Jay Giedd, MD, National Inst of Mental Health

14 Brain Development – Age 8
Images courtesy of Jay Giedd, MD, National Inst of Mental Health

15 Brain Development – Age 12
Images courtesy of Jay Giedd, MD, National Inst of Mental Health

16 Brain Development – Age 16
Images courtesy of Jay Giedd, MD, National Inst of Mental Health

17 Brain Development – Age 20
Images courtesy of Jay Giedd, MD, National Inst of Mental Health

18 What happens inside the brain
when teens have sex?

19 What The Anatomy Doesn’t Show- Neurochemicals
More than 100 have been identified Receptors must be present in the brain for these substances to be active – the more receptors, the more active. They have a powerful impact on our cognition and behavior and ultimate brain structure

20 Dopamine Dopamine is secreted into the brain in response to:
Excitement Pleasure New things Adventure Risk taking Addictive drugs Volkow (referenced in The Primal Teen, p. 94)

21 Dopamine Dopamine causes a person to feel good by producing intense energy, exhilaration, and focused attention. Dopamine is involved in the feeling of need or desire to repeat pleasurable acts. Therefore, dopamine presence is termed a “reward signal.” Strauch. The Primal Teen, 2003. Arias-Carrion, et al. Act Neurobiol Exp 2007

22 Dopamine – The Good and the Bad
Dopamine can be a reward signal for the excitement of learning, maturing, new relationships, and the possibility of a bright future. or Dopamine can be a reward signal for the excitement of drugs, sex, violence, and other risky behaviors that threaten the adolescent’s future, including the final structure of their brains.

23 Dopamine and “Addiction”
Addiction is defined by Dorland as “ the state of being given up to some habit, especially strong dependence on a drug”1 “Then there’s the addictive quality. For men and women alike, dopamine – the chemical that injects intense pleasure in activities as diverse as gambling and drug addictions rockets during sexual encounters.”2 Dorland. Medical Dictionary 27th Ed Goleman. Social Intelligence

24 Oxytocin and Vasopressin
Sexual intercourse releases large amounts of oxytocin into the female brain and vasopressin into the male brain Both hormones promote bonding with a sexual partner1 Lechman, 1999 Brizendine, 2007, p. 71

25 Oxytocin and Vasopressin
Even if you don’t particularly feel attracted to someone, if you have enough sexual stimulation with them, oxytocin and vasopressin may cause an “involuntary chemical commitment” or strong emotional attachments. (Morse, JR,, 2006.) “Bonding hormones help explain the remarkable propensity of battered women to return to the very men who abused them. Our hormonal response to touch, to sex, and to proximity is so powerful it can trump our better judgment about what is truly in our interests

26 Oxytocin Engenders Trust
Oxytocin is naturally released in the brain after a 20 second hug from a partner – sealing the bond between the huggers and triggering the brains trust circuits. WARNING: “Don’t let a guy hug you unless you plan to trust him.” The “trust” impact of oxytocin is so pronounced that Louann Brizendine, M.D., a neuropsychiatrist at the University of California states “from an experiment on hugging, we also know that oxytocin is naturally released in the brain after a 20 second hug from a partner – sealing the bond between the huggers and triggering the brains trust circuits, so don’t let a guy hug you unless you plan to trust him.” Brizendine. “The Female Brain”, 2006

27 Men and Vasopressin The male brain has many more receptors for vasopressin.1 Sexual intercourse releases large amounts of vasopressin into the male brain1 Vasopressin in the male brain promotes bonding with a sexual partner1 And bonding with their offspring according to studies with prairie voles. Lechman. Child Adolescent Psychiatry elin N Am, 1999 Brizendine. “The Female Brain” 2007

28 Pheromones Chemicals secreted from the skin and sweat glands of many animals and from human males and females1 These chemicals are unconsciously detected by the female nose (but not the male) 1 These chemicals can influence a woman’s attraction to a man and her sexual satisfaction with him 2 1. McClintock, et. al. Chem. Senses 30 (Supply 1) 2005

29 Serotonin Serotonin, among other actions, is a calming neurohormone that has been shown to decrease in people madly in love to levels similar to those found in individuals with obsessive-compulsive disorder. Therefore, people newly in love are less calm and may act somewhat obsessive-compulsive. OCD is characterised by low levels of a chemical called serotonin. Drugs such as Prozac work by keeping serotonin hanging around in the brain for longer than normal, so they might stave off romantic feelings. (This also means that people taking anti-depressants may be jeopardising their ability to fall in love.) But once romantic love begins in earnest, it is one of the strongest drives on Earth. Dr Fisher says it seems to be more powerful than hunger. A little serotonin would be unlikely to stifle it. Marazziti, D. The National Geographic, 2006

30 Lust, Infatuation and Mature Love
Each of these result in dynamic and visible brain activity Each of these produce activity in different areas of the brain Strauch. “The Primal Teen”, 2003 Leckman. Child Adolesc Psychiatry. elin N Am. 1999 30 30

31 Lust, Infatuation and Mature Love
One individual cannot tell if another person’s interest is a result of lust or love – only time and other behaviors can reveal the difference Lust is a powerful emotional state and can cause people to do things that they would not ordinarily do, often for self-gratification. “Early love” is also a powerful emotional state, but, in general, is oriented toward caring for the other person.

32 Connectedness and Sex When a person’s body is in intimate contact with another person, the entire person is “connected” with the other1,2 A person’s inborn need for and ability to connect with another person is a human characteristic that must be nurtured and protected for a person to prosper1,2 Sex can greatly benefit this connection or can greatly damage it Bonding occurs even with one act of intercourse. Repeated acts produce even stronger bonds through the neurohormones making impressions on the synapses in the brain. Light. Biol Psychol, 2005 Schore. “Affect Dysregulation and Disorders of the Self”, 2003 32

33 Sex, Is a Powerful Brain Experience- Two Powerful Brain Events Seem to
Sex, Is a Powerful Brain Experience- Two Powerful Brain Events Seem to Always Occur As A Result Attachment (bonding) to the sexual partner Desire for repetition of sex acts (“addiction”) Both teenage mothers and fathers tend to have unrealistic expectations about parenthood and have difficulty adjusting to teen parenthood. Becoming a parent before age 18 significantly reduces the likelihood of graduation from high school for both boys and girls. Teen parents who obtain a GED have even lower lifetime earnings than those who graduate from high school. Teen parents who graduate from high school or earn a GED are less likely than their peers to go to college.2 Young females who marry after becoming teen mothers are more likely to divorce and spend more years as single mothers than females who wait until marriage to become mothers. Teen mothers have more problems with pregnancy and delivery than older females and their babies are less healthy. Pregnant teens, especially unmarried teens, are less likely to receive adequate prenatal care.1 Emotional and intellectual development during the teen years, when adolescents should be developing a sense of identity and independence from their parents while growing and developing as individuals through normal teen activities such as peer relationships, dating, school, and career choices, is significantly disrupted by the demands and responsibilities of teen parenthood.1 Teens who follow the “ideal” pathway from adolescence to adulthood to parenthood have the best chance of a happy life. The first steps for teens to take in the transition from adolescence to adulthood are completing their education before leaving the family home, developing a career, and finding a permanent job. After achieving emotional and financial independence, a young adult finds a suitable partner, marries, and establishes an emotionally stable relationship and a financially stable household. The birth of the first child and the transition to parenthood is the final step in the transition to adulthood. Yet only a small number of teen parents complete their education before the birth of their first child, and may not ever achieve any of the other steps, such as finding a suitable partner, a permanent job, or establishing a financially stable household. Weinberger, et.al., The Adolescent Brain, 1999. References: Coley RL, Chase-Lansdale PL. Adolescent pregnancy and parenthood: recent evidence and future directions. Am Psychol. 1998;53(2): Available as “in press” publication at: uchicago.edu/About/publications/working-papers/pdf/wpsup_01.pdf. Accessed September 14, 2005. Alan Guttmacher Institute. Facts in Brief: Teen Sex and Pregnancy. New York, NY:Alan Guttmacher Institute; Available at: Accessed September 13, 2005.

34 Use It or Lose It Molds the Brain
SOURCES: Dr. Jay Giedd, Chief of Brain Imaging, Child Psychiatric Branch—NIMH; Paul Thompson; Andrew Lee; Kiralee Hayashi; Arthur Toga—UCLA Lab of Neuro Imaging and Nitin Gogtay; Judy Rapoport—NIMH Child Psychiatry Branch. TIME Diagram by J oe Lertola. TIME.com graphic by Garrett Rosso. The Image Bank—Getty Images from the May 10, 2003 issue of TIME MAGAZINE 34

35 Synapses

36 Brain Molding – The Unexpected Reality
A reciprocal pattern of brain function causes physical change (molding) of our brains We initiate an action or thought We repeat the action or thought The experience of the action or thought physically molds our brains to habitually repeat the action or thought Giedd et al 2005 36 36 36

37 What About Bonding And The Sexually Active Adolescent?
Bonding always occurs with sexual involvement as far as science can tell1 The cycle of sexual involvement – break up- sexual involvement – break up is the pattern many young people experience2 Young, et al, 2001 Independent Women’s Forum Survey, 2001

38 The Emotional Truths 50% of teen relationship break up within 6 months of beginning Depression and Suicide is higher in sexually active teens

39 Broken Bonding, Repetitively Experienced, Seems to Often Damage the Human Ability to “Bond” (to Connect) Individuals who have had multiple sexual partners prior to marriage are more likely to divorce when they do marry than individuals who did not have multiple partners prior to marriage1 Couples who cohabit before marriage are more likely to divorce when they do marry than couples who did not cohabit 2 Kahnetal. J of Marriage and Fam, 1991 Lee, et al. Demography, 1995

40 Young People are Crying Out for Help
90% of high school students think they all need a strong abstinence message from all society 2/3 of high school students think it is wrong for high schoolers to have sex even if they use condoms and contraceptives National Campaign to Prevent Teen and Unintended Pregnancy – Various Surveys

41 Young People are Crying Out for Help
2/3 of students who have had sex wish they had waited Since 2/3 of high school students have had sexual intercourse by graduation, we know many of these students were sexually active National Campaign to Prevent Teen and Unintended Pregnancy – Various Surveys00

42 Healthy Brain Molding The brain learns by trial and error, particularly from the age of 18 on Mistakes are supposed to be made by adolescents The role of parents and caring adults is to provide boundaries within which a young person can make decisions including mistakes, as safely as possible. The brain is plastic and can be remolded. Parents have a powerful influence on teens. Parents need to understand safe sex is not safe enough.

43 How can teens successfully handle
the challenge for a lifetime of healthy living?

44 Dopamine – The Good and the Bad
Dopamine can be a reward signal for the excitement of learning, maturing, new relationships, and the possibility of a bright future. or Dopamine can be a reward signal for the excitement of drugs, sex, violence, and other risky behaviors that threaten the adolescent’s future, including the final structure of their brains.

45 RISK TAKING Clothes: Immodest, Sexy/provocative Make-up: Mature
“Girls Gone Wild” Curiosity with Gay & Lesbian lifestyle Drugs Drag racing Dropping out of school

46 Spanning Tree Sexual Network (n=286)
In a period of 18 months more than 50% of students at this high school were chained together through romantic and sexual relationships that could have involved exchange of fluids. This is one of the most efficient ways of transmission of disease. There were almost 35% or 189 students who were part of isolated partnerships like the one shown in a box. In this case the partners had no other sex partners before or after the relationship. Diad Bearman, Moody, & Stovel. 2004

47 Delay of Intercourse Reduces Number of Partners
Average number of lifetime partners Age at sexual debut Source: The Heritage Foundation

48 The Solution Primary Prevention: Risk Avoidance
Secondary Prevention: Risk Reduction Tertiary Prevention: Immunzation

49 Risk Avoidance Abstinence is the calculated decision and deliberate action to refrain from sexual activity. The only truly effective and practical method to prevent sexually transmitted diseases (STIs) and nonmarital pregnancies. The method that increases the ability to form healthy long term emotional relationships. 49 49

50 Risk Reduction Condoms Contraception Alternative Behaviors
Sexual activity defined: Any intimate contact between two individuals that involves arousal, stimulation, and/or a response by at least one of the two partners. It also applies to one person if self stimulation is used.

51 Planned Parenthood “Safer Sex” is about protection and pleasure
Safe “Secure from danger, harm or evil” “Safer Sex” is about protection and pleasure Outercourse Mutual Masturbation Body Rubbing Sex Toys Oral Sex Anal Sex Planned Parenthood: “Sex-Safer and Satisfying”, 9/6/04 51

52 Condom Effectiveness in STD Prevention
CONDOM EFFICACY preventing HIV transmission – 85% risk reduction for gonorrhea in men approximately – 50% no evidence for risk reduction for HPV insufficient evidence for prevention of all other STDs A comprehensive study of all the research available on condom efficacy was conducted by the National Institute of Health (NIH) in The NIH study titled “Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease Prevention”, found strong evidence for condom effectiveness in preventing HIV transmission in both men and women with vaginal intercourse with the average efficacy rate being 85% ; risk reduction for gonorrhea in men at approximately 50% efficacy ; no evidence for risk reduction for HPV infection, though perhaps some for warts in men and cervical cancer in women; and insufficient evidence for syphilis, herpes, and chancroid. CHANGE – Bullet #4 last sentence to “All other STDs” Source: National Institute of Health, “Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease Prevention”, July 2001 Source: National Institute of Health, “Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease Prevention”, July 2001 52

53 New Studies Published After NIH Report
126,220 patients Only 16% always used a condom In “Always condom use” – risk reduction for gonorrhea and Chlamydia 34% Shlay, 2004 53

54 New England Journal of Medicine June 22, 2006
82 virgin women U. of Washington GYN exams every 4 months 100 % condom use Electronic diaries of daily sexual activity Number of instances of vaginal intercourse Frequency of male condom use Number of new partners 54

55 New England Journal of Medicine June 22, 2006
14 virgins had sex with virgins 40 did not know if partners were experienced Median # of intercourse 48/ year Median number new partners 1/ year 55

56 New England Journal of Medicine June 22, 2006
82 virgin women 54 partners not known to have ever had sex before Conclusion: Among newly sexually active women, consistent condom use by their partners appears to reduce the risk of cervical and vulvovaginal HPV infection 56

57 Contraception and Teen Pregnancy
20% of those aged using birth control pill get pregnant within six months. 20% of teens younger than 18 using condoms get pregnant within one year.

58 Immunization Gardasil HPV Vaccine Quadrivalent Vaccine
Types 6,11,16 and 18 100% effective against these serotypes Not effective once seropositive Proposed indications Routine - Girls 11-12 Catch up Three doses 0, 2 and 6 months ($360) CDC fact sheet June 2006

59 Adolescents Need Adult Guidance
Until the mid-twenties young people do not have the physical brain capacity to make fully mature decisions We abandon adolescents to the impossibility of mature decision making if we just give them information and then say “do what you think is best”. (This reality applies through the mid 20s.) Giedd, et al 1999

60 Sexual health comes from a positive self-image based on strong characteristics
Self control Personal responsibility Honesty Kindness Respect for yourself and others

61 What do teens say will help?
Ask questions. Encourage practical tips: “SET BOUNDARIES”” -Don’t go to parties where there is no parent. -Don’t go to private places to “make out”. -Role play helping them to avoid a situation. Come up with phrases that don’t sound cheesy. -Encourage them to hang out with groups.

62 The Planning for Sex The Promise of Sex
Decision Making= S T O P; DROP & ROLL State the decision; Write it down Talk about your feelings and needs Options are considered. Pick the best option and evaluate the results DROP the pretence: “Aim to abstain.” Be ready to ROLL. “Run, baby, run!” Make a Decision; Make it plain.

63 The Promise of Life & Love

64 Graduation Ask questions about their goals and dreams for the future.

65

66 Live out your values- model the behavior you desire of her; get rid of your guilty feelings from the past. Reinforce your love and concern “no matter what”.

67 Learn about them…their friends, their interest, what they do when their out.
Listen- see if you can learn why they are thinking that way

68 How to Avoid Getting Hooked on Sex
Know The Purpose of Sex: B’s Understand The Problem of Sex: D’s Choose The Protection of Sex: H’s

69 Important Points to Communicate
Sex within the right kind of relationship i.e. marriage, is healthy and good. Sexual desires are normal and healthy; a decision to act on these desires is controllable behavior Self control is healthy and necessary- for success in all areas of your life.


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