Adolescent and Young Adult Sexuality

Devon J. Hensel

Kimber L. Hendrix

Adolescence and young adulthood is recognized as an important period in the development of lifelong sexual health. Sexuality is a normal and primary developmental element of puberty and the several years that follow. Many key biologic, psychological, social, and behavioral aspects of adult sexuality begin to unfold during this period of time. Among many changes, adolescents and young adults (AYAs) develop new sexual feelings and interests, initiate close relationships, and explore a wide range of partnered and solo sexual behaviors.

Many AYAs can find it difficult to discuss sexuality in a direct and open manner. As a result, it is common for people to equate the emergence of sexuality with potential consequences of sexual behavior, such as sexually transmitted infections (STIs) or unintended pregnancy. Yet, it is important to remember that formative experiences with different aspects of sexuality provide AYAs with the skills they will need to be sexually independent and responsible adults.

Health care providers play an important role in the development of sexuality, as both AYAs and their parents value clinical guidance on a variety of sexuality-related topics. Clinicians are uniquely positioned to deliver AYA sexual and reproductive health services, such as taking a sexual history or prescribing contraception, and take a patient-centered approach to discussing the ancillary emotional or interpersonal issues associated with AYA sexuality, such as emerging readiness for sex or refusing any unwanted sex. Professionals need to be prepared to have informed, supportive, and nonjudgmental conversations with their adolescent and young adult patients and to facilitate similar conversation between them and their parents.

This chapter provides an overview of the key changes in heterosexual AYA sexuality (see Chapters 38 and 39 for additional information on sexuality issues for gay, lesbian, bisexual, and transgendered [GLBT] youth). Using data from several different nationally representative studies, we address the development of close relationships in adolescence and young adulthood and the association of these relationships to the emergence of partnered and nonpartnered sexual behaviors. This information is intended to improve physician’s and other health care provider’s ability to directly and regularly engage sexuality-related topics with their AYAs and families, to anticipate initiation of sexual health changes, and to proactively devise counseling strategies that may improve health outcomes.

CLOSE RELATIONSHIPS IN ADOLESCENCE AND YOUNG ADULTHOOD

Close relationships—both romantic and nonromantic—play an important role in the development of sexuality during adolescence and young adulthood. Each partnership’s emotional and behavioral characteristics provide a context for young people’s ongoing learning and organizing of sexuality. Different relationships can fulfill different needs, such as intimacy, companionship, or sexual behavior(s), at different points in time, with changes in these relationships helping AYAs transition from childhood to later adult sexuality.

Relationship Forms and Meaning

Several studies have articulated the trajectory of young men’s and women’s close relationships changes in industrialized countries from early adolescence to early adulthood.¹,²,³,⁴,⁵

Between pre- and early adolescence:

Relationship interests shift from same-gender friendship groups to mixed-gender friendship groups in early adolescence to opposite-gender dyadic friendships and some romantic interests.
Initial romantic partnerships are typically short lived (e.g., “going together”) and are usually arranged by intermediaries, such as peers or friends, rather than by the adolescent themselves.
Early relationships are limited in physical and emotional investment, and typically consist of interaction occurring at school, on the phone, or in groups.

During middle adolescence:

Young men and women become increasingly aware of their romantic feelings toward the specific members of the opposite gender.
The relationships associated with these feelings increase in both the importance adolescents ascribe to them and in the time adolescents spend with partners.
Interactions typically become “one-on-one,” and can become the venue for the emergence of “lighter” partnered sexual behaviors, such as kissing or hand-holding.

By late adolescence:

Most young people have had and/or are in a serious romantic relationship.
These dyads are associated with the emergence of learning more adult-like emotional and communication qualities, such as expressing feelings for one’s partner, negotiating conflict, or recognizing sexual satisfaction.
Young men and women may also make decisions about more involved types of partnered sexual behavior (e.g., genital touching, oral sex, or vaginal sex).

During young adulthood:

Relationships move into a period of increased degree of investment and confidence in the relationship.
AYAs further hone the characteristics found in earlier relationships. These characteristics can include better communication with one’s partner, greater comfort with one’s own sexuality, and increased sexual activity.
Young women may be more confident than young men in navigating these relationships, as the social dynamics contained in these relationships often mimic those in friendships.

Increasing attention has also been paid to “friends with benefits” (FWB) and “hook up” relationship typologies in adolescence and young adulthood.⁶,⁷ While sexual activity can occur in both, and these two forms are often used interchangeably in popular media, studies suggest important differences between the two.

FWB relationships typically:

Combine traits of friendships and romantic relationships.
Draw on psychological intimacy and trust afforded by a friendship with the sexual intimacy of a romantic relationship.
Avoid expectations of commitment or exclusivity often present in romantic relationships.
Often characterized in popular and medical literature as an early adult phenomenon (particularly among college students), but also endorsed by adolescents as distinctly different from romantic relationships and casual sex partners, but not different from friendship except for sexual activity.

“Hook Ups”:

Characterized as no-strings-attached sexual behaviors.
Typically occurs once, usually between people who are strangers or acquaintances.
Unlike traditional romantic relationships, they have no expectations.

Developmental Benefits in Relationships

Close partnerships in adolescence and young adulthood help individuals learn the emotional and behavioral skills they will need to manage sexual relationships during their lifetime.¹,²,³,⁴,⁵

Emotional skills include learning how to develop intimacy, building trust and fidelity, first expressing love and affection, how to negotiate conflict, how to resolve conflicting emotions, and how to successfully end relationships.
Behavioral skills include learning about a wide range of “lighter” (e.g., hugging, hand-holding, and kissing) and more involved (e.g., oral sex and penile-vaginal intercourse) partnered sexual acts, understanding and advocating for sexual pleasure, communicating likes and dislikes, or balancing power in relationships.
FWB and “hook up” relationships can also include opportunities for experiencing exploration, particularly because they are perceived to be low risk.

SEXUAL BEHAVIOR IN ADOLESCENCE AND YOUNG ADULTHOOD

Traditional discussions of AYA sexual behavior commonly center on three partnered behaviors: giving or receiving oral sex, penile-vaginal sex, and penile-anal sex. While these behaviors are important pieces in understanding AYA sexuality, it is also vital to consider the role of other intimate partnered contact (e.g., kissing, hugging, holding hands, genital touching), any nonpartnered behaviors (e.g., solo masturbation), and the absence of any “behavior” (e.g., sexual abstinence). Understanding specifically what AYAs are (or are not) participating in when they say they are “having sex” is key to a health care provider being prepared to assess ongoing levels of sexual risk as well as contraceptive and condom use needs.⁸,⁹,¹⁰,¹¹

Sexual “Abstinence”

Overview

Many cultural terms (e.g., “abstinence,” “virginity” or “celibacy”) are used to describe AYAs’ nonparticipation in sexual activity.
These terms make it challenging to accurately know how and when AYAs may voluntarily opt out of specific types of sexual activity.
A clinician should not assume no sexual contact is occurring if an adolescent or young adult says that he or she is “sexually abstinent.”
- Avoidance of any and all sexual activity that occurs by one’s self, or with partners.
- Avoiding a limited scope of behaviors, such as those that carry a risk of pregnancy or STIs, while still participating in other behaviors.

Prevalence

The National Survey of Family Growth (NSFG)¹² suggests that about three-quarters of 15- to 17-year-olds (females: 73%; males: 74%) and about one-third of 18- and 19-year-olds (females: 37.3%; males: 36.1%) have never had sex.
The Youth Risk Behavior Survey (YRBS)¹³ demonstrates that about half of all young people in high school have never had sex (females: 54%; males: 52.5%), with a decrease in reported abstinence between grade 9 (females: 71.9%; males: 68%) and grade 12 (females: 37.2%; males: 34.6%).
About one-third of college students (females: 30.0%; males: 34%) report not having any oral, vaginal, or anal sex in the past year.¹⁴
Young people sometimes differentiate between “primary” sexual abstinence (an absence of any lifetime sexual intercourse experience, usually penile-vaginal sex) and “secondary” sexual abstinence (first time sexual experience followed by periods without sexual activity).
Both “primary” and “secondary” abstainers participate in nonpenetrative partnered sexual behaviors (e.g., kissing, breast fondling, genital stimulation, and oral-genital sex), often because they believe these behaviors do not “count” as sexual experience.

Context

Choosing “primary” and “secondary” sexual abstinence could occur for a variety of reasons.
- Avoid perceived social or health risks
- Uphold moral or religious commitments
- Peer or parental pressure
- Saving sexual experience for one’s future spouse
Age wise:
- Younger AYAs typically see themselves as less “ready” for sex.
- Older AYAs balance their moral (e.g., “doing the right thing”) with their behavioral (e.g., avoiding specific activities) ideals in deciding.

Solo Masturbation

Overview

Solo masturbation is perhaps the most difficult of all sexual behaviors to study.¹⁵,¹⁶

Historically, participation in solo masturbation has been stigmatized.
Many social and gender norms still proscribe masturbation, particularly among women.
Very few nationally representative studies ask questions about masturbation.

Prevalence

The National Study of Sexual Health Behavior (NHSSB) suggests that:¹⁷,¹⁸
- The majority of adolescent males (62.6% to 80.0%) and adolescent females (43.3% to 58.0%)¹⁹ as well as among emerging adult men (e.g., over the age of 18) (86.1% to 94.3%) and women (66.0% to 84.6%) have ever masturbated in their lifetime.
- About half of adolescent men (42.9% to 58.0%), a quarter of adolescent women (24.1% to 25.5%), about 60% of young adult men (61.1% to 62.8%), and between a quarter and a half of young women (26.0% to 43.7%) have masturbated in the past month.
- About half of adolescent males (49.1%) and a fifth (22.1%) of adolescent women reported masturbating two or more times per week.

Context

Solo masturbation serves important functions in developing sexuality.¹⁵,¹⁶,²⁰,²¹
- Learning about the geography of one’s body
- Learning about sexual response
- Learning about one’s own personal sexual likes and dislikes, and communicating these preferences to partners
Solo masturbation may be used as a “safe sex” alternative to avoid STI or pregnancy.
Solo masturbation can be used to experience sexual pleasure in the absence of a partner, when one does not desire to have sex with a partner, or as a follow-up to partnered sexual activities that were not sexually fulfilling.

Partnered Masturbation

Overview

The term “partnered masturbation” can refer either to two individuals who self-masturbate in the presence of one another or to individuals stimulating the genitals of their partner.
Similarly to solo masturbation, very few nationally representative studies ask questions about partnered masturbation.

Prevalence