Green E.

Sonenstein

Stout J.W.

Thickston P.

English

Joseph R. Zanga

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The Linacre Quarterly

The Adolescent Brain: Implications of Sexuality Education

Zanga, Joseph R.

epublications@Marquette

The Linacre QuarterlyVolume 74 | Number 1 Article 8February 2007The Adolescent Brain: Implications of SexualityEducationJoseph R. ZangaFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationZanga, Joseph R. (2007) "The Adolescent Brain: Implications of Sexuality Education," The Linacre Quarterly: Vol. 74: No. 1, Article 8.Available at: http://epublications.marquette.edu/lnq/vol74/iss1/8The Adolescent Brain: Implications of Sexuality Education by Joseph R. Zanga, M.D., FAAP The author is Jefferson-Pilot/Catherine and Max Ray Joyner Distinguished Professor in Primary Care and Assistant Dean, Office of Generalist Programs, Brody School of Medicine, Greenville, North Carolina. This paper was presented at a plenary session of the Catholic Medical Association's 74th Annual National Education Conference in Portland, Oregon on October 22,2005. When well-intentioned people consider the issues involved in adolescent sexual health today they quickly begin to focus on solutions based on time-honored, but somewhat outmoded, education theories. Viewed from the broad perspective of education's general success in modifying behavior, the approach still seems logical. Today, I ask that you set aside what you think you know and consider the issue from a slightly different perspective, including the development of the adolescent's cognitive and- intellectual capacity. Not long ago a colleague presented to me a hypothetical construct. It was a question and se1ies of observations in the context of a discussion of adolescent sexual development. Its conclusion pointed out that things are not always what they seem. The construct asked: What would you think if you encountered an adolescent with a condition leading to: 68 • Decreased likelihood of establishing a successful marriage • Lowered life expectancy. • Increased risk of potentially fatal liver disease • Increased incidence of infectious diseases • Low likelihood that the adverse effects can be eliminated unless the behavior is changed • Reluctance to change the behavior despite the destructive consequences • Denial of the problem and a negative attitude toward those who encourage change. Linacre Quarter! y In the context in which that construct was presented most people conclude that the condition is sexual promiscuity or perhaps promiscuous unprotected sex. In fact, the construct most closely illustrates the problems associated with alcohol abuse. Is this a significant problem for adolescents? In 2004, the American Academy of Pediatrics noted that 10.7 million adolescents consumed alcohol in a given month. By the 12th grade, 77% had consumed alcohol and 58% of them admitted to being drunk. The percentages were only slightly lower among lOth graders. Among 8th graders those numbers were 46% and 20% respectively1 These young people drink because of peer pressure and because it "feels" good. We take some comfort in the fact that the risk for dependence decreases with each increasing year of age of drinking onset. With that information before you, what approach would you take with your preadolescent or adolescent patient? Even more important to this discussion, I ask you to consider why you would take that approach. I'll speak later about our usual stance with respect to this issue in order to make more obvious its relationship to the subject of sexuality education. Before we proceed there, it is important to understand the milieu in which we must work. We need to understand more clearly the development of the human brain. Cognition, our ability to understand, relate to, and deal with the world around us, begins in utero. The pace of brain development increases from the time of conception and peaks early in the 2nd trimester. We know from a variety of studies that there are long -term effects, including such things as attention deficit hyperactivity disorder, which are more likely in the child whose brain had been exposed in utero to maternal smoking, alcohol, or drug use 2 Recent advances in imaging of the human brain, which demonstrate changes in its activity over time, have enabled us to advance beyond traditional concepts of brain maturation. Researchers at the National Institutes of Mental Health (NIMH) postulated that the brain is not fully mature in early adolescence, but rather at a much later time. To test this hypothesis, they screened by telephone 14,040 healthy individuals from age 4 to adolescence. Nine hundred and twenty-two were sent parent/ teacher questionnaires and 490 were brought to the NIMH for face-to-face examinations, with 325 accepted for the study. Of that group, 272 measurable scans were acquired to quantify and map total and regional brain volume. Study individuals were brought back every 2 years to catalog long -term brain development. In 2004, one of the principal investigators, Jay Giedd, M.D., presented the following summary finding. As a result of their studies, he concluded that "the brain of the adolescent is far from mature ... both gray February, 2007 69 and white matter undergo extensive structural changes well past puberty ... probably to age 25 .""3 Their findings also lead to the conclusion that cognitive maturation is poorly conelated with age. and furthermore. that the ability to weigh risks and benefits is not generally mature until adulthood. Finally, the extra-ordinary sculpting of the brain continues throughout adolescence, particularly in areas involved in "executive" decision-making abilities, the very abilities needed to make appropriate choices with respect to risky behaviors. While this is new science, most of us probably recall our parents, and elders in general, telling us that we were too young, too immature, too intellectually deficient to do all the things we wanted to do in those omnipotent and omniscient days of adolescence. In fact, science has probably simply verified what our parents and others have always known. I cannot tell you when we first decided that the adolescent brain was not yet mature, but in the 5th Century BC, in the Republic of Athens, Socrates noted the following, "Our youth love luxury. They have bad manners, contempt for authority; they show disrespect for their elders and love chatter in place of exercise; they no longer rise when elders enter the room; they contradict their parents; chatter before company; gobble up their food and tyrannize their teachers." William Shakespeare in The Winter's Tale, Act III, Scene 3, presented a somewhat different perspective, "I would that there were no age between lO and three-and-twenty, or that youth would sleep out the rest, for there is nothing in between, but getting wenches with child, wronging the ancestry, stealing, fighting ... " Present research then simply conflims that the time between what an adolescent might want to do and when he/she has the intellectnal and emotional maturity to choose conectly, has not significantly changed. By way of excnse, well intentioned "experts" have proposed a variety of explanations including the increasing length of adolescence, in part because of the steadily decreasing age at puberty (though Shakespeare spoke of age 10). While many of these postulates contain elements of truth, they are and will remain unrelated to the simple fact that until the early to mid-twenties people are simply not generally capable of ma..hng critical, often life and death, decisions. The American Bar Association admitted as much in 2003 when they noted that: "For social and biological reasons teens have increased difficulty making mature decisions and understanding the consequences of their actions." Even the oft-quoted Bette Midler noted to the popular press: "If sex is such a natnral phenomenon, how come there are so many books on how to do it?" 70 Linacre Quarterly With that background then, let's modity the ongmal nypomeucal construct and ask why are we so concerned about modern sex education? Is sexual activity a problem for our students?Yes, if you accept the fact that premature, premarital, promiscuous sexual activity is dangerous/harmfuL Then please recall that 77% of 12th graders drink- 61 %of them have had sex, Fifty-eight percent of them drink to excess (get drunk) while 21% have had 4 or more sexual partners (inaeasingly, we find that all of these data points are related), each and all se1iously risky behaviors, While it is clear that adolescent alcohol use and abuse is a concern, I believe that more concern should be placed on the issues related to adolescent sexual activity, We know, for example, that 3 million teenagers acquire a Sexually Transmitted Infection (STI) each year, 30% of female adolescents are positive for Chlamydia, 30% to 50% are infected with Human Papilloma Virus (HPV), and adolescents make up 25% of those newly infected with HIV It is clear to most that promiscuous sexual activity leads to the same set of problems we noted for alcohol- and morel Knowing that, what would you dory When child and adolescent health experts gather to consider solutions to the problem of alcohol use, and almost any other risky behavior, their recommendation is very simple, These experts advise us that we must tell the adolescent to "Just Say No!" There is no wavering in this case, no suggested use oflow-alcohol beer, or filter cigarettes, or even clean needles (though the latter are mentioned for the hopelessly addicted), On the other hand, when the issue is sexual activity, these same experts simply recommend that adolescents use condoms, Why is it that for almost every other risky behavior, the strategy of risk elimination is touted as the sole solution while for sexual activity many encourage only risk reduction, leaving adolescents (and others) vulnerable to an ever-expanding number of dangerous and often deadly consequences? It is said that those who do not know history are doomed to repeat it, Those who advocate condoms (risk reduction) are clearly not in touch with the history of that failed medical device, The condom in some form has been available since antiquity, In its present fonn, it has been available since at least the middle of the last century, Intensive education has always been part of the condom use philosophy, but though the device itself is structurally an excellent product, it is nonetheless a failed technology, If any other medical device in use today had such a high failure rate, it would long ago have been discarded, The experts, however, say that the failure is not intrinsic to the device, but rather to our lack of education of young people, in particular, about the need-to and the how-to of using a condom, Unfortunately, I'm old enough to differ, In the early 1970s, fresh out of residency, I knew it February, 2007 71 active wish they had waited. Ninety-four percent of 12 to 14-year-old and 87% of 15 to 19-year-old boys state that teens should be given a strong message not to have sex until they are at least out of high school.7 Just as we encourage abstinence from other 1isky behaviors. parents and teenagers themselves say that we should be encouraging abstinence from sexual activity during the teenage years. What do the studies say? Because abstinence education is so new and so relatively under-funded compared to condom education, there is a paucity of studies demonstrating its success. One of the earliest reviews was published in 1989 and was entitled Schools and Sex Education: Does it Work? 8 In that article it was reported that, "In one study, a somewhat lower prevalence of reported sexual activity in 15 to 16 year old teenagers was found" in an abstinence education program. No other (condom-based) program showed any success. A 2002 article entitled An Evaluation of an Abstinence Education Curriculum Series: Sex Can Wait9 concluded, "results are encouraging and should be considered by those interested in helping young people postpone sexual involvement." In 2004, a published study from a program in Zambia concluded, "A single session of school-based sexual health intervention resulted in the development of nonnative beliefs about abstinence that were sustained over a six month period." 10 Meanwhile, the CDC reported that 53% of the decline in pregnancy rates for 15 to 17 year olds is attributable to decreased sexual activity. 11 Perhaps the best modem example of the effectiveness of abstinence education comes from Uganda where, having adopted an abstinence education program in 1989 called ABC, the Public Health Ministry noted that by 1995 premarital sex among 15 to 24 year old males decreased from 60 % to 23%. Males with greater than one partner decreased from 41% to 21% and males with greater than 3 partners decreased from 15% to 3%.12 By 2000,95% of Ugandans had either zero or one sex partner.13 HIVrates were cut by two thirds within a decade of the roll-out of this education intervention. 14 The annual cost of the ABC Program is less than $1.00 per person age 15 and Up 15 Clearly, abstinence education works, but not as well as it might since we only currently spend $1.00 on abstinence for every $12.00 we spend on condom-based education. Abstinence education works because it targets the age appropriate, concrete thinking, developing intellectual capabilities of its adolescent audience. It works because it supports what most parents believe and what most adolescents want. It works because instead of targeting simply self-esteem, it targets self-control. As Strayhorn noted, "Self-control is a psychological skill whose development could potentialiy prevent, or aid in the treatment of, vast amounts ofpsychopathology." 16 February, 2007 73 So well does it work that an article in the Lancet in 2004, condensing the opinions of 150 contributing authors, concluded,",. when targeting young people ... who have not started sexual activity, the first priority should be to encourage abstinence ... after sexual debut, returning to abstinence ... (is) the most effective way of avoiding infection." 17 Finally, abstinence education works because it is risk elimination not just risk reduction. It provides a consistent and seamless message to adolescents that some activities engaged in by adults are not appropriate for adolescents or that they're appropriate for adults within a certain context (marriage), but not for adolescents absent that same context. I note that I now live and work in North Carolina. This state is one of the major cigarette tobacco producing areas in the nation. Tobacco is a mainstay of our economy, yet North Carolina has recognized that it is too risky a product, particularly for our youth, for the state to continue to hold that distinction. There are, therefore, education programs in virtually every school to make this and future generations tobacco-free. A recent newspaper headline noted that "Making North Carolina Schools Tobacco-Free is Proving to be a Long Process." 18 The article detailed the difficulty of the process, but noted that there would be no giving up or turning back. Children were at risk and though, like alcohol, tobacco is seductive, popular and easy to obtain, we must convince our young people to abstain from its use because of its inherent dangers. I say, and we must say, that we should not do less for our children with regard to the seductiveness of premature, premarital, promiscuous sexual behavior. We as a society are film with regard to other risky behaviors because we know adolescents do not have the cognitive ability to make appropriate decisions with regard to these behaviors. Neither can they make those decisions with regard to sexual activity and so, as with drugs, alcohol, and tobacco we must stand up, look our teenagers and society in the eye, and tell them to "Just Say No!" References 1. L.R. Wilson et al., "Are Clinical Impressions of Adolescent Substance Use Accurate?" Pediatrics, 2004; 114(5):e536-e540. 2. J. Girod, "Structural Magnetic Resonance Imaging of the Adolescent Brain," Ann NY Achd Sci. 2004; 1021:77-85. 3. "What Were You Thinking?: New Discoveries About the Teen Brain," The Medical Institute. 2005; brochure: http://www .medinstitute .org/products/college adult.html 74 Linacre Quarter] y 4. Youth Risk Behavior Surveillance-United States. MMWR. 1998:47: l-89. 5. Sonenstein, et al. "Involving Males in Preventing Teen Pregnancy: A Guide for Program Planners," Urban Institute [ online]. Posted: December 01, 1997. Available at: http://www.urban.org/url.cfm?ID-307327 6. Kaiser/Kennedy School Education Survey. NPR [online]. Posted: 1999. Available at: http://www .npr.org/programs/specials/ooH/education/education .front.html 7. National Campaign to Prevent Teen Pregnancy. Posted 2003. Available at: http://www.teenpregnancy.om 8: 1 .W. Stout and FP. Rivara, "Schools and Sex Education: Does It Work?" Pediatrics. 1989;83(3):375- 379. 9. G. Denny et al., "An Evaluation of An Abstinence Education Cuniculum Series: Sex Can Wait," Am J Hlth Behav 2002;26 (5):366-377. 10. S. Agha and V. Ronan, "Impact of a School-Based Peer Sexual Health Intervention on Normative Beliefs, Risk Perceptions, and Sexual Behavior of Zambian Adolescents," J Adolescent Hlth. 2004; 34(5):441-452. 11. F. Sonenstein, "\Vhat Teenagers are Doing Right: Changes in Sexual Behavior Over the Past Decade. J Adolescent Hlth. 2004; 35(2):77-78. 12. P. Thickston and K. Hendricks (eds), "Evidence that Demands Action," The Medica/Institute. 2005. l3.1bid. 14. E. Green, P. McDermott, et al., USAID/Uganda HlV/AIDS assessment. USAID. 1 an 2003. Available at: http:/ /pdf.dec .ore/pdf-docs!PNACU842.pdf 15. Op Cit. 16. J. Strayhorn, "Self-Control: Theory and Research," JAm A cad Child Adol Psych. 2002; 41(1):7-16. 17. D. Halperin et al., "The Time Has Come for Common Ground on Preventing Sexual Transmission ofi:ITV," Lancet. 2004; 364:1913-1915. 18. The Daily Reflector, "Survey Reveals Drinking on Rise in Pitt Middle Schools," July 2, 2005. Febmary, 2007 75 

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The Adolescent Brain: Implications of Sexuality Education

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