[The Call to Action - Contents]
The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior
IV. Risk and Protective Factors for Sexual Health
Human beings are sexual beings throughout their lives and human sexual
development involves many other aspects of development- physical, behavioral,
intellectual, emotional, and interpersonal. Human sexual development follows a
progression that, within certain ranges, applies to most persons. The challenge
of achieving sexual health begins early in life and continues throughout the
lifespan. The actions communities and health care professionals must take to
support healthy sexual development vary from one stage of development to the
next. Children need stable environments, parenting that promotes healthy social
and emotional development, and protection from abuse. Adolescents need
education, skills training, self-esteem promoting experiences, and appropriate
services related to sexuality, along with positive expectations and sound
preparation for their future roles as partners in committed relationships and as
parents. Adults need continuing education as they achieve sexual maturity--to
learn to communicate effectively with their children and partners and to accept
continued responsibility for their sexuality, as well as necessary sexual and
reproductive health care services.
There are also a number of more variable risk and protective factors that shape
human sexual behavior and can have an impact on sexual health and the practice
of responsible sexual behavior. These include biological factors, parents and
other family members, schools, friends, the community, the media, religion,
health care professionals, the law, and the availability of reproductive and
sexual health services.
Biological Factors
Although human sexuality has come to serve many functions in addition to
reproduction, its biological basis remains fundamental to the sexual experience.
Sexual response involves psychological processing of information, which is
influenced by learning, physiological responses and brain mechanisms which link
the information processing to the physiological response. Although there is much
that is not well understood about this complex sequence, it is understood that
individuals vary considerably in their capacity for physical sexual response.
This variability can be explained only in part by cultural factors. The role of
early learning or genetic factors, or an interaction between the two, remains to
be determined by further research.
Reproductive hormones are clearly important. However, their role is best
understood and most predictable for men-and much more complex for women. For
example, apart from the fact that women may experience a variety of
reproduction-related experiences--the menstrual cycle, pregnancy, lactation, the
menopause, and hormonal contraception-all of which can influence their sexual
lives, there does appear to be greater variability among women in the impact of
reproductive hormones on their sexuality (Bancroft, 1987). In addition,
variations in the onset of puberty and menstruation can represent special
challenges for girls in some populations.
Parents and Other Family Members
A number of family factors are known to be associated with adolescent sexual
behavior and the risk of pregnancy. Adolescents living with a single parent are
more likely to have had sexual intercourse than those living with both
biological parents (Miller, 1998). Having older siblings may also influence the
risk of adolescent pregnancy, particularly if the older siblings have had sexual
intercourse, and if an older sister has experienced an adolescent pregnancy or
birth (East, 1996; Widmer, 1997). For girls, the experience of sexual abuse in
the family as a child or adolescent is linked to increased risk of adolescent
pregnancy (Browning, 1997; Roosa, 1997; Miller, 1998). In addition, adolescents
whose parents have higher education and income are more likely both to postpone
sexual intercourse and to use contraception if they do engage in sexual
intercourse (Miller, 1998).
The quality of the parent-child relationship is also significant. Close, warm
parent-child relationships are associated with both postponement of sexual
intercourse and more consistent contraceptive use by sexually active adolescents
(Jaccard, 1996; Resnick, 1997). Parental supervision and monitoring of children
are also associated with adolescents postponing sexual activity or having fewer
sexual partners if they are sexually active (Hogan and Kitagawa, 1985; Miller,
1998; Upchurch et al, 1999). However, parental control can be associated with
negative effects if it is excessive or coercive (Miller, 1998).
Schools
Evidence suggests that school attendance reduces adolescent sexual risk-taking
behavior. Around the world, as the percentage of girls completing elementary
school has increased, adolescent birth rates have decreased. In the United
States, youth who have dropped out of school are more likely to initiate sexual
activity earlier, fail to use contraception, become pregnant, and give birth (Mauldon
and Luker, 1996; Brewster et al, 1998, Manlove, 1998; Darroch et al, 1999).
Among youth who are in school, greater involvement with school-including
athletics for girls--is related to less sexual risk-taking, including later age
of initiation of sex, and lower frequency of sex, pregnancy, and childbearing
(Holden et al, 1993; Billy et al, 1994; Resnick et al, 1997).
Schools may have these effects on sexual risk-taking behavior for any of several
reasons. Schools structure students' time; they create an environment which
discourages unhealthy risk-taking--particularly by increasing interactions
between youth and adults; and they affect selection of friends and larger peer
groups. Schools can increase belief in the future and help youth plan for higher
education and careers, and they can increase students' sense of competence, as
well as their communication and refusal skills (Manlove, 1998; Moore et al,
1998).
Schools often have access to training and communications technology that is
frequently not available to families or clergy. This is important because
parents vary widely in their own knowledge about sexuality, as well as their
emotional capacity to explain essential sexual health issues to their children.
Schools also provide an opportunity for the kind of positive peer learning that
can influence social norms.
The Community
Community can be defined in several ways: through its geographic boundaries;
through the predominant racial or ethnic makeup of its members; or through the
shared values and practices of its members. Most persons are part of several
communities, including neighborhood, school or work, religious affiliation,
social groups, or athletic teams. Whatever the definition, community influence
on the sexual health of those who comprise it is considerable, as is its role in
determining what responsible sexual behavior is, how it is practiced and how it
is enforced.
The measurable physical characteristics of neighborhoods and communities, such
as economic conditions, racial and ethnic composition, residential stability,
level of social disorganization, and service availability have demonstrated
associations with the sexual behavior of their residents-initiation of sexual
activity, contraceptive use, out-of-wedlock childbearing and risk of STD
infection (Billy and Moore, 1992; Brewster et al, 1993; Grady, 1993; Billy et
al, 1994; Grady et al, 1998; Tanfer et al, 1999). An understanding of these
characteristics and their impact on individuals is important in planning and
developing services and other interventions to improve the sexual health and
promote the responsible sexual behavior of community residents.
A shared culture, based either on heritage or on beliefs and practices, is
another form of community. Each of these communities possesses norms and values
about sexuality and these norms and values can influence the sexual health and
sexual behavior of community members. For example, strong prohibitions against
sex outside of marriage can have protective effects with respect to STD/HIV
infection and adolescent pregnancy (Comas-Diaz, 1987; Kulig, 1994; Savage and
Tchombe, 1994; Sudarkasa, 1997; Tiongson, 1997; Abraham, 1999; Amaro, 2001). On
the other hand, undue emphasis on sexual restraint and modesty can inhibit
family discussion about sexuality and perhaps contribute to reluctance to seek
sexual and reproductive health care (Hiatt et al, 1996; Schuster et al, 1996; He
et al, 1998; Tang et al, 1999). Gender roles that accord higher status and more
permissiveness for males and passivity for females can have a negative impact on
the sexual health of women if they are unable to protect themselves against
unintended pregnancy or STD/HIV infection (Amaro and Raj, 2000; Bowleg et al,
2000; Castaneda, 2000).
When a community--defined by its culture--also has minority status, its members
are potential objects of economic or social bias which can have a negative
impact on sexual health. Economic inequities, in the form of reduced educational
and employment opportunities, and the poverty that often results, has obvious
implications for accessing and receiving necessary health education and care. In
addition, a history of exploitation has, in some cases, led to distrust and
suspicion of public health efforts in some minority communities (Tafoya, 1989;
Thomas and Quinn, 1991; Wyatt, 1997).
The Media
The media--whether television, movies, music videos, video games, print, or the
Internet-are pervasive in today's world and sexual talk and behavior are
frequent and increasingly explicit. More than one-half of the programming on
television has sexual content (Cope and Kunkel, in press). Significant
proportions of music videos and Hollywood movies also portray sexuality or
eroticism (Greenberg et al, 1993; DuRant et al, 1997). Among young people, 10-17
years of age, who regularly use the Internet, one-quarter had encountered
unwanted pornography in the past year, and one-fifth had been exposed to
unwanted sexual solicitations or approaches through the Internet (Finkelhor et
al, 2000).
Media programming rarely depicts sexual behavior in the context of a long-term
relationship, use of contraceptives, or the potentially negative consequences of
sexual behavior. The media do, however, have the potential for providing
sexuality information and education to the public. For example, more than
one-half of the high school boys and girls in a national survey said they had
learned about birth control, contraception, or preventing pregnancy from
television; almost two-thirds of the girls and 40 percent of the boys said they
had learned about these topics from magazines (Sutton et al, in press).
While the available research evidence shows a connection between media and
information regarding sexuality, it is still inadequate to make the link between
media and sexual behavior.
Religion
Simply being affiliated with a religion does not appear to have great effect on
sexual behavior; however, the extent of an individual's commitment to a religion
or affiliation with certain religious denominations does (Brewster et al, 1998).
For example, an adolescent's frequent attendance at religious services is
associated with less permissive attitudes about premarital sexual activity and a
greater likelihood of abstinence (Ku et al, 1993; Billy et al, 1994;
Werner-Wilson, 1998). On the other hand, for adolescents who are sexually
active, frequency of attendance is also associated with decreased use of
contraceptive methods among girls and increased use by boys (DuRant and Sanders,
1989; Ku et al, 1993).
Health Care Professionals
Physicians, nurses, pharmacists and other health care professionals, often the
first point of contact for individuals with sexual health concerns or problems,
can have great influence on the sexual health and behavior of their patients.
Yet, both adolescents and adults frequently perceive that health care providers
are uncomfortable when discussing sexuality and often lack adequate
communication skills on this topic (Croft and Asmussen, 1993).
Health care providers typically do not receive adequate training in sexual
aspects of health and disease and in taking sexual histories. Ideally,
curriculum content should seek to decrease anxiety and personal difficulty with
the sexual aspects of health care, increase knowledge, increase awareness of
personal biases, and increase tolerance and understanding of the diversity of
sexual expression. Although such training for physicians has increased-95
percent of North American medical schools offer curriculum material in
sexuality-nearly one-third do not address important topics such as taking a
sexual history (Dunn and Alarie, 1997).
The Law
In the United States, the law regulates sexual behavior in complicated ways
through criminal, civil, and child welfare law and operates at local, state, and
federal levels. Criminal law imposes penalties for certain kinds of sexual
activities, considering factors such as age, consent of both parties, the actual
act performed, and the location in which it takes place. Civil law complements
criminal law and can extend the law's reach. Civil law, for example, provides
individuals with protection from sexual harassment and allows legal redress for
some victims of sexual violence (Levesque, 1998). It can also have an impact
through regulation of relationships such as marriage, divorce, and child custody
and support.
The law may also regulate some aspects of the community's influence on
sexuality, including the family, schools, and media. While it generally protects
parental rights (Levesque, 2000), the law also imposes limits. For example, it
protects children from sexual victimization by a family member. The law also
regulates access to sexual health services through mechanisms such as parental
notification and waiting period requirements. With respect to schools, although
states may set certain minimum standards, the law allows individual school
systems to determine the content of curriculum, including sexuality education
curriculum. In addition, the legal system provides schools with the power to
develop and implement programs to address the prevention of sexual harassment,
relationship violence, and rape.
Under protection of the First Amendment to the U.S. Constitution, the media have
great freedom in the choice of content they portray. At the same time, the law
can impose certain restrictions on the media; for example, it may limit minors'
access to sexually explicit materials.
Availability of Reproductive Health Services
In the United States, contraceptive and reproductive health services are
provided to women and men by a wide range of health care professionals. These
services are offered in a variety of settings-private practice offices, publicly
funded family planning clinics, private clinics, military clinics, school-based
health centers, college and university health centers, and private hospitals.
Often, contraceptive services are integrated with other basic preventive health
services such as pelvic examinations and pap tests, and screening for sexually
transmitted infections (Frost and Bolzan, 1997). In addition to medical care,
counseling or education related to sexual and reproductive health may be
provided.
Barriers to obtaining these services can exist if providers are not conveniently
located, are not available when needed, do not provide (or are thought not to
provide) confidential, respectful, culturally sensitive care, or are not
affordable (Forrest and Frost, 1996). Federally subsidized family planning
services have been an important factor in helping many persons overcome these
barriers and avoid an estimated 1.3 million unintended pregnancies per year
(Forrest and Samara, 1996).
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