Toward a science of adolescent sexual health as an HIV/STI prevention strategy J. Dennis Fortenberry MD MS Indiana University School of Medicine Indianapolis IN USA

A definition of sexual health Sexual health encompasses sexual development and reproductive health, as well as such characteristics as the ability to develop and maintain meaningful interpersonal relationships; appreciate one’s own body; interact with both genders in respectful and appropriate ways; and express affection, love, and intimacy in ways consistent with one’s own values.” … “responsible adolescent intimate relationships” should be “consensual, non-exploitative, honest, pleasurable, and protected against unintended pregnancy and STD’s if any type of intercourse occurs.”

Why is a science of adolescent sexual health potentially useful? Definitions are difficult to operationalize Enduring belief in the value of empiricism Data as an anodyne to deception The nagging feeling that we’re talking about the wrong things

Adolescent sexual health as an oxymoron “Nearly exclusive focus on risk has created a limited research paradigm with uneasy correspondences to a social and political agenda that excludes sex from adolescent sexual health.” Adolescent Sex and the Rhetoric of Risk, 2003

Taboo words and adolescent sexual health Sexual rights Sexual choice Pleasure

Differences of adolescent and adult sexual health Sexual freedoms and rights typically restricted for people under age 18 Restricted access to sexual health information and sexual health services Restricted access to sexual health research, including clinical trials Developmental changes in organization and meaning of sexuality and sex

A contemporary public health model of adolescent sexual health Adolescent Sexual Un-Health What’s wrong with this picture? Abstinence Partnered Sexual Behaviors Masturbation

Adolescent Sexual Behaviors, Past 90 days - Men, by Age Fortenberry et al., J Sex Med, 2010

Adolescent Sexual Behaviors, Past 90 days - women, by Age Fortenberry et al., J Sex Med, 2010

A 21st century model of adolescent sexual health Abstinence Partnered Sexual Behaviors Masturbation

Abstinence as an adolescent sexual behavior Emergence of sexual thoughts and feelings associated with adrenarche/pubarche Cognitions about abstinence develop in concert with cognitions about sexual behavior Ability to frame abstinence as a choice Choice connects sexual health to sexual rights

Sexual desire is harder than most temptations Sexual desire is harder than most temptations - 16 yo (abstinent) adolescent women Abbot & Dalla, It’s a choice, simple as that: youth reasoning for sexual abstinence or activity. J. Youth Studies 2008.

Masturbation as a distinct expression of sexuality Masturbation as an adolescent sexual behavior why bother if there is no risk? Masturbation as a distinct expression of sexuality Masturbation as a prevalent sexual behavior Masturbation as a correlate of partnered sexual activity Why bother if

Masturbation and partnered sexual activity (past year), 14-17 year olds Robbins et al, Arch Pediatr Adolesc Med, 2011

Masturbation (past year) and condom use at last penile-vaginal sex, by gender NS Robbins et al, Arch Pediatr Adolesc Med, 2011

Pleasure and sexual function are the next frontiers of adolescent sexual health

Subjective Sexual Experience at last Penile-Vaginal Intercourse, by Condom Use – Men *Most recent event “extremely” ** Most recent event “any” Unpublished Data

Subjective Sexual Experience at last Penile-Vaginal Intercourse, by Condom Use – Women *Most recent event “extremely” ** Most recent event “any” Unpublished Data

A 21st century model of adolescent sexual health Adult Sexual Health Adolescent Sexual Health Abstinence Partnered Sexual Behaviors Masturbation

Measurement of sexual health – Adolescent Women Unpublished Data

Association of Sexual Health and Condom Use – Adolescent Women Unpublished Data

Association of Sexual Health and Lifetime Partners – Adolescent Women Unpublished Data

Sexual Health and STI – Adolescent Women Unpublished Data

A Research Framework for Health Sexual Development International Journal of Sexual Health, 2010 Freedom from unwanted sex Relationship skills Agency Competence in sexual media Understand of consent Understand boundaries Healthy Sexual Development Understand biology Understand parental values Lifelong learning Resilience Open Communi-cation Awareness of Pleasure Self-acceptance

A model for sexual health in adolescent men Partner Characteristics .14 Social Embededdness .31 .15 Physical Attraction .31 Relationship Quality .49 Male Sexual Health Relationship Feel .50 Satisfaction Desire .12 Condom Self-efficacy Sexual Communication .24 .27 .16

Principle of evolving capacity combines respect for children, their dignity and entitlement to protection Acknowledges the value of their own contribution towards their protection. Societies must create environments in which children can achieve their optimal capacities and where greater respect is given to their potential for participation in, and responsibility for, decision-making in their own lives.