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org The Prevention Researcher Volume 16(4) November 2009 3

B
Understanding how, why, and when an adolescent
decides to initiate sex, or abstain from sex, and why
a particular type of sexual behavior will be chosen,
is critical for the development of more effective
public health campaigns aimed at delaying or
preventing adolescent sexual behavior.
Bridging childhood and adulthood, adolescence is a fundamental
and exciting time of life. It describes a colorful and unique spectrum
of development that is marked by rapid and extreme biological,
social, cognitive, and emotional changes. One of the hallmarks
ofadolescent development is sexual maturation, as pubertal
development and hormonal changes result in the development
ofsecondary sexual characteristics, including breasts, pubic hair,
and menses. These newfound physical characteristics often result
in the adolescent looking more mature and occur around the
same time as the desire for more autonomy and decision-making
opportunities develop, including in the area of sexual behavior.
Adolescents physical development and increases in their need
for autonomy, coupled with new social influences, yield important
new attitudes toward sexual behavior and sexuality.
In this review, we will first briefly describe adolescent sexual
behavior, including the broad spectrum of sexual behaviors
experienced during adolescence, as well as both positive and
negative outcomes experienced after engaging in sexual behavior.
Then we discuss adolescent sexual attitudes, including definitions
of sexual attitudes and how such attitudes vary by gender, age,
race/ethnicity, and type of sexual behavior. Finally, we briefly
describe the multitude of social and environmental influences
that shape, either directly or indirectly, adolescent sexual attitudes.
ADOLESCENT SEXUAL BEHAVIOR
Adolescent sexual behaviors are broadly defined, typically beginning
with self-stimulation (masturbation) and then extending to
behaviors involving another person. These partnered sexual
behaviors include kissing, touching, mutual masturbation, oral
sex, anal sex, and vaginal sex. The timing of when these behaviors
emerge varies greatly by gender, race/ethnicity, and type of
sexual behavior.
Approximately 47% of all high school students reported having
had sexual intercourse at some point during high school, ranging
from 34% of 9th graders to 63% of 12th graders. A greater percentage
of males report onset of sexual intercourse during high school
than do female adolescents (NAHIC, 2007).
Evidence is mounting that adolescents are more likely to initiate
and engage in oral sex than vaginal sex. At least 20% of adolescents
have had oral sex by the end of ninth grade, and over 50% of high
school students report having had oral sex at some point. Among
adolescents between the ages of 15 and 19, 55% of males and 54%
of females have had oral sex with members of the opposite sex
(Mosher, Chandra, & Jones, 2005). Additionally, between 14%
and 50% of adolescents had oral sex prior to vaginal sex, and
both sexual behaviors are more prevalent than anal sex. As
discussed further below, it appears that the trend toward oral
rather than vaginal sex is based in part on sexual attitudes,
namely the desire to avoid risk while still experiencing pleasure
(Cornell & Halpern-Felsher, 2006; Halpern-Felsher et al., 2005).
Rates of sexual behavior vary by race and ethnicity. Data from
the 2007 Youth Risk Behavior Surveillance Survey (YRBS) showed
the overall prevalence rate of ever having had sexual intercourse
to be higher among black (67%) and Hispanic (52%) adolescents,
compared to white adolescents (44%) (Eaton et al., 2008). A pooled
analysis of four years of data from the YRBS found that Asian
adolescents were less likely than other adolescents to have
Adolescent
Sexual Attitudes
and Behaviors:
A Developmental Perspective
By Bonnie L. Halpern-Felsher, Ph.D., and Yana Reznik
4 November 2009 Volume 16(4) The Prevention Researcher www.TPRonline.org
engaged in sexual intercourse (Grunbaum et al., 2000). The
limited research available on racial/ethnic disparities in oral
sexbehaviors suggests that white adolescents are more likely to
engage in oral sex compared to black and Hispanic adolescents
(Lindberg, Jones, & Santelli, 2008), and that Asian adolescents
have the lowest rates of oral sex compared to other racial/ethnic
groups (Schuster et al., 1998).
Unfortunately, rates of sexual behavior among gay and lesbian
youth are much more difficult to find, in part because researchers
fail to ask the question, or more often the venues from which data
are being collected do not allow these questions to be posed to
adolescents. Further, there is debate over how one should define gay
and lesbian sexual behavior. Some argue it is important to determine
adolescents stated sexual identity, while others focus more on
whether and the extent to which an adolescent has engaged in
same-sex sexual behaviors. A recent national study of adolescents
showed that approximately 1.1% of males and 2% of females report
having same-sex relations (Knopf et al., 2007).
ADOLESCENTS SEXUAL EXPERIENCES
Understanding the outcomes adolescents experience following
sexual behavior is important. These outcomes are likely to be
shaped by previous sexual perceptions, and also help mold
subsequent sexual attitudes. As such, it is critical not only
toexplore negative consequences but positive outcomes that
adolescents experience during and following sexual engagement.
To our knowledge, however, no study has examined adolescents
experiences following kissing, touching, or masturbation. However,
one study did examine adolescents stated experiences following
initiation of oral and/or vaginal sex. Brady and Halpern-Felsher
(2007) found that adolescents report both positive and negative
outcomes associated with engagement in sexual behavior, with
61% of the adolescents reporting at least one positive outcome
from having oral sex, and 86% reporting at least one positive
experience from vaginal sex. Specific positive outcomes included
experiencing pleasure, becoming popular, having their relationship
improve, and feeling good about oneself. Interestingly, compared
to the reported positive outcomes, fewer adolescents reported
negative outcomes from oral sex (31%) or vaginal sex (58%). These
negative consequences included getting into trouble with parents,
having a bad reputation, relationship worsening, feeling guilty,
having regret, feeling used, becoming pregnant, or contracting a
sexually transmitted infection (STI).
ATTITUDES TOWARD SEXUAL BEHAVIOR
Understanding adolescents attitudes regarding sexual behavior
is key to understanding why they choose to engage or not engage
in sex, which sexual behavior(s) they initiate and continue, and
the outcomes experienced during and following sexual behavior.
There is no one definition of adolescent sexual attitudes. Most often,
sexual attitudes are measured by perceptions of the positive and
negative outcomes one experiences from engaging in or abstaining
from sex. Others have measured sexual attitudes in terms of the
perceptions of the prevalence of sexual behaviors (i.e., social norms).
We will review several areas of sexual attitudes, then follow with
a discussion of the origins of some of these attitudes.
Sexual behavior is also largely
influenced by positive motivations.
Many models explaining adolescent risk behavior, including
sexual behavior, propose that adolescents perceptions of potential
consequences (risks and benefits) play an important role in
adolescents behavioral decision making (e.g., Beyth-Marom
&Fischhoff, 1997; Fishbein & Ajzen, 1975; Reyna & Farley, 2006).
Research examining the relationship between sexual behavior
and sex-related positive and negative perceptions generally
support these models, showing that adolescents are more likely
to have sex if they believe sex will result in positive outcomes,
and they are less likely to have sex if they perceive great chance
ofrisk (Millstein & Halpern-Felsher, 2002). Data examining
onset of sexual intercourse among female adolescents found that
ambivalent (mixed positive and negative) perceptions of social
and emotional risks and benefits predicted delayed intercourse
among non-depressed females (Rink, Tricker, & Harvey, 2007).
Two other studies found that perceptions of greater social and
emotional risks and less social and emotional benefits predicted
less likelihood of sexual debut among adolescents (Meier, 2003;
Rostosky, Regnerus, & Wright, 2003). Some gender differences
have been noted, with studies typically showing that adolescent
females perceive higher sexual risks compared to their male
counterparts, and males perceiving greater benefits than do
adolescent females.
Sexual behavior is also largely influenced by positive motivations,
including desires for physical pleasure or excitement, intimate
personal relationships, peer approval or peer respect, and
self-confidence and exploration. Ott and colleagues (2006) went
a step beyond just examining perceptions of benefits to identify
attitudinal factors that actually explain why an adolescent
chooses to have sex. Specifically, they examined goals associated
with sexual behavior, whether adolescents believed these goals
would be met, and whether there were differences in goals and
expectations by gender and sexual experience. In this study,
adolescents first valued the goal of intimacy, followed by social
status, and then sexual pleasure, although they expected that sex
would most likely lead to pleasure, followed by intimacy, and
then social status. Significant and important gender differences
were found: adolescent females valued the goal of intimacy more
than did males, whereas males valued pleasure more.
Adolescents sexual attitudes clearly vary by the type of sexual
behavior. For example, comparing perceptions associated with
oral and vaginal sex, Halpern-Felsher and colleagues (2005)
showed that adolescents perceive oral sex as significantly less
risky than vaginal sex. These attitudinal differences were greater
among adolescents who reported intentions to have oral sex in
the next six months: for these adolescents, the differentiation
between perceived risk for oral sex and vaginal sex is even
greater. That is,they perceive that vaginal sex is much more
likely to result in negative outcomes than will oral sex. Other
attitudinal variables have also been explored. For example,
Halpern-Felsher and colleagues (2005) showed that adolescents
Adolescent Sexual Attitudes and Behaviors: A Developmental Perspective, continued
It is critical not only
to explore negative
consequences
butalso positive
outcomes that
adolescents
experience during
and following sexual
engagement.
www.TPRonline.org The Prevention Researcher Volume 16(4) November 2009 5
largely believed that it was not okay to have vaginal or oral sex
with someone they are not dating, but they did agree that it was
okay to have sex with someone they were dating or with whom
they were in love. These attitudes did vary by type of sexual
behavior, with adolescents believing it was more acceptable to
have oral than vaginal sex, and that oral sex was less against
their moral values than was vaginal sex.
Few studies have examined racial/ethnic differences in sex-related
perceptions, or whether such differences in perceptions might
account for observed racial/ethnic differences in rates of sexual
behavior. Cuffee et al. (2007) examined racial differences in
perceived sex-related social and emotional risks and benefits
among white and African American adolescents. This study
found that African American males perceived less sex-related
shame and guilt than white males. There were no racial/ethnic
differences in perceived benefits of sex. The authors also found
that higher perceived benefits of sex predicted higher likelihood
of sexual initiation among African American females, and higher
perceived risks decreased the likelihood of sexual initiation for
white males and females. Dzung and colleagues (2009) expanded
this line of research to examine differences in health-related risks
of vaginal sex, risk and benefit perceptions of oral sex, or differences
in perceptions between white, Latino, and Asian adolescents. They
found that, compared to white adolescents, Asian and to a lesser
extent Latino adolescents generally perceived a greater chance of
risks and a lower chance of benefits associated with either vaginal
or oral sex. In general, adolescents who had engaged in vaginal
and oral sex perceived lower risks and higher benefits from these
behaviors, compared to adolescents who had not engaged. However,
analyses did not reveal racial/ethnic differences in the relationship
between sex-related risk and benefit perceptions and sexual behaviors.
Adolescents perceive oral sex as
significantlyless risky than vaginal sex.
It is important to note that adolescents also develop attitudes
concerning not having sex. For example, Brady and Halpern-
Felsher (2008) reported that adolescents perceived consequences
from not having sex included positive consequences such as
having a good reputation, having friends proud, and feeling
responsible. Negative perceived outcomes from not having sex
included partner becoming angry, having a bad reputation,
feeling regret or left out, and feeling like you let your partner
down (Brady & Halpern-Felsher, 2008). In a recent article, Ott
and Pfeiffer (2009) conducted a qualitative study to examine
early adolescents views of abstinence. Adolescent participants
were between the ages of 11 and 14. Their answers fell into three
main categories. Younger adolescents, especially the 11 year olds,
viewed sex as nasty and not open for discussion with their
peers. They thus viewed abstinence positively. These nasty
attitudes were largely shaped by their beliefs that they would get
into trouble if they had sex. A second category was curiosity
about sex and the facts surrounding sexual behavior. These
youth felt that abstinence was good, believing that sex should be
limited until marriage or within the context of a monogamous
relationship. Finally, adolescents (all age 14) felt that sex was a
normative part of development and recognized that they too
would have sex at some point.
FACTORS INFLUENCING ADOLESCENTS SEXUAL ATTITUDES
While there are many studies identifying psychosocial and
environmental influences on adolescent sexual behavior, few
studies have examined factors that specifically inf luence
adolescents sexual attitudes. In this section, we review the limited
literature on the role of parents, school, media, and religiosity.
Although studies have not examined well the role of parental
sexual attitudes on adolescents sexual attitudes, a few studies
have examined the role of parental sexual attitudes on adolescents
sexual behavior. For example, Dittus and Jaccard (2000) found
that adolescents were less likely to have sexual intercourse if they
believed their mothers disapproved of adolescent sexual behavior.
Others have found that adolescents, especially younger adolescents,
have more negative attitudes toward sex in part because of fear
that they would get into trouble if they have sex (Ott & Pfeiffer,
2009), or if they believed their parents would disapprove of sex
(Jaccard & Dittus, 2000).
Adolescents are constantly exposed to mixed messages about
sexuality. On the one hand, adolescents see sex in the media
portrayed in a very positive light, with sexual behavior often
portrayed as a normal part of adolescent and adult life. It is not
surprising then that adolescents exposure to sex through various
media outlets (including television and the Internet) has also been
shown to shape adolescents sexual attitudes. Braun-Courville
and Rojas (2009), for example, found that adolescents exposed to
sexually explicit Web sites had more permissive sexual attitudes
than did youth with less exposure to these Web sites. It is thus not
surprising that messages aimed at reducing or delaying adolescent
sexuality are met with frustration, as the positive images of sex
often drown out the health risk warnings.
Religiosity is another important factor shaping adolescent sexual
attitudes and behavior, although again most studies examine the
extent to which religion reduces sexual behavior rather than its
impact on attitudes. As discussed by Uecker and colleagues (2008),
adolescents who describe themselves as more religious and
indicate that religion is an important part of their lives, are less
likely to engage in any form of sexual behavior. This pattern is
particularly strong among adolescents who actually attend
religious services on a frequent basis (deVisser et al., 2007; see
also Cotton et al., 2006; Rew & Wong, 2006).
Adolescents bonding with school and relationships with peers
also shapes their sexual attitudes. Bersamin and colleagues (2006)
showed that adolescents who were more bonded to school were
While studies do show that adolescents have
positive beliefs about delaying sexual activity, they
also recognize that abstinence entails some risk,
including both social and personal risk.
6 November 2009 Volume 16(4) The Prevention Researcher www.TPRonline.org
Identifying factors that shape adolescents sexual attitudes is more
challenging, as studies typically examine the role of psychosocial
and contextual variables directly on behavior and not necessarily
moderated through attitudes. However, studies do show that factors
such as parental attitudes toward adolescent sex, religiosity, the
media, school bonding, and perceived peer social norms influence
sexual attitudes.
The studies summarized within this article show the importance
of considering the broad array of sexual attitudes that adolescents
consider. Clearly it is not enough to deter adolescents away from
sexual behavior by simply encouraging negative sexual attitudes.
As adolescents develop and mature physically, cognitively, socially,
and emotionally, they need information that helps them shape
and weigh both positive and negative perceptions of having, as
well as abstaining from sex, so that they can make the best
decision possible.
Dr. Bonnie Halpern-Felsher (bonnie.halpernfelsher@ucsf.edu)
is an Associate Professor in the Division of Adolescent Medicine,
Department of Pediatrics, University of California, San Francisco.
Sheis also the Associate Director of the General Pediatrics Fellowships,
and is a faculty member at UCSFs Psychology and Medicine
Postdoctoral Program, The Center for Health and Community, the
Center for Tobacco Control Research and Education, the Comprehensive
Cancer Center, and the Robert Wood Johnson Scholars Program. Dr.
Halpern-Felsher is a developmental psychologist whose research has focused on
cognitive and psychosocial factors involved in health-related decision making,
perceptions of risk and vulnerability, health communication, and risk behavior; and
she has published in each of these areas.
Yana Reznik is a college student at the University of San Francisco. She is also a
Research Assistant for the University of San Francisco California Department of
Pediatrics, Division of Adolescent Medicine Research and Policy Center for Childhood
and Adolescence. She has also published in the Permanente Journal focusing on
Adolescent Sexual Health. Yana Reznik is an full-time undergraduate Pre-Medical
Student with a Biology and Neuroscience Major.
Copyright 2009, Integrated Research Services, Inc.
less likely to have vaginal or oral sex. Adolescents are also more
likely to have favorable attitudes toward sex if they believe their
friends are accepting of sexual behavior and if they believe more
of their friends are having sex.
SUMMARY
Adolescent sexual behavior varies greatly, ranging from kissing
and petting, to non-coital behaviors such as oral sex and anal
sex, to vaginal intercourse. Although rates of initiation and
patterns of engagement in sexual activity depends on age, gender,
race/ethnicity and type of sexual behavior, clearly the high
school years mark the onset of sexual behavior for many youth.
Understanding how, why, and when an adolescent decides to
initiate sex, or abstain from sex, and why a particular type of
sexual behavior will be chosen, is critical for the development
ofmore effective public health campaigns aimed at delaying
orpreventing adolescent sexual behavior. An understanding
ofadolescents sexual attitudes is likely to get us a step closer
tounderstanding sexual behavior.
Many studies examining adolescents sexual attitudes have been
within the context of decision-making models. These models posit
that engagement in any behavior, including sexual behavior, entails
the weighing of perceived positive and negative outcomes, both
of which are expected to predict behavior. These models have
been largely supported, with data showing that not only does fear
of risk reduce likelihood of engagement in sexual activity, but
perceptions of benefits predict greater engagement. Adolescents
attitudes toward not having sex (abstinence) are also important
to consider. While studies do show that adolescents have positive
beliefs about delaying sexual activity, they also believe that abstinence
entails some risk, including both social and personal risk.
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Bonnie
Halpern-Felsher