Sex education discussions should start early and continue for young patients

What is the best approach when a young patient asks about or a family requests assistance in answering questions or in contributing to the education of a child about human sexuality?

Reply: Generally, pediatricians should be immensely gratified when a family requests assistance in educating a child about human sexuality. That request reflects confidence and trust in the pediatrician. When the adolescent asks for help, however, we might balance that gratification with a sense of chagrin about the missed opportunities to help the teen and family develop the lifelong communication about sexuality that might have been most valuable.

Educating a child about human sexuality is as fundamental as teaching a child to walk and talk, to be safe when crossing the street, to respect his or her elders, to know right from wrong. Although the content of the education about human sexuality will appropriately reflect the values specific to a given family, the importance of the education is universal.

Pediatricians are in an excellent position to help families with this critical communication, empowering them with knowledge, resources, anticipatory guidance and encouragement as they raise healthy and competent children.

Somewhere, however, we are missing the boat. A 2010 article in Pediatrics noted that more than 40% of children have sexual intercourse before talking with their parents about issues as important as condom use, choice of birth control and symptoms of sexually transmitted illnesses. Parents who think they are communicating with their children about sex may be overestimating their effectiveness. A Kaiser Family Foundation report noted that while 85% of parents surveyed thought they talked with their teens about sex "often or very often," 58% of teens in the survey said they talked with parents about sex "never or not often."

Whether or not parents are talking, messages about sexuality and sexual behavior surround children in the U.S. Seventy-seven percent of prime-time TV shows include sexual content; those with sexual content show an average of six sexual scenes per hour, according to the Kaiser report. Forty-percent of lyrics in popular music are about sex, and degrading, sexually violent lyrics are common. One important message pediatricians should be giving to parents: "Talk with your children about sex -- everyone else is."

What happens if the parents want the pediatrician to teach the child about sexuality? It is important for pediatricians to recognize their limits in this setting. The medical aspects of human sexuality are only the tip of the iceberg. The values content of family discussions about human sexuality is not for the pediatrician to direct.

Pediatricians can be most helpful in using their particular expertise to help families develop strategies for presenting developmentally appropriate information. Parents can be reminded that the most important lessons about sexuality are not the facts, but the values.

Going beyond "The Talk"

One of our biggest sexual health blunders as a society is the myth of "The Talk" -- a single comprehensive discussion about sexual behavior and sexual health that is a rite of adolescence. The cartoonish image of an embarrassed parent making an awkward presentation to a mortified teen has become a powerful archetype, with negative consequences for families.

Education about sexuality should start early in the child's life and flow along with physical and cognitive development. Pediatricians should be adept in offering anticipatory guidance to families, both about the questions children may raise and developmentally appropriate responses.

Pediatricians can engage parents about sexuality education when they open discussion of toilet training. As early as 18 months to 2 years, parents can start by using correct terms for body parts and body functions. By age 4 or 5, children may notice gender differences and wonder where babies come from. By age 8, children may notice sexual taboos, develop interest in "playing doctor" and look for information about sex. Preteens are likely to feel conscious about their sexual identity, worry about puberty and become self-conscious about asking questions about sex.

Each of these developmental stages should be accompanied by direct and open communication about relevant sexuality issues. Pediatricians can help families identify the teachable moments to help these discussions develop naturally. The media, so full of sexual content, offer excellent openings for parents to initiate discussion about specific sexual references with their children. The American Academy of Pediatrics provides several resources for parents that identify developmentally appropriate topics and methods to address key points about sexuality: ParentsMatter and HealthyChildren.org are two helpful examples. ChildrenNow's website Talking with Kids offers parents some easy steps to open difficult conversations.

The good news is that parents make a big difference when they talk with their children about sex. Teens who talk with parents about sex are less likely to initiate sexual activity early. Preteens whose parents communicate openly about sex are more likely to ask parents for help with other tough issues.

What about the adolescent who seeks confidential information and advice about sexuality from the pediatrician? While pediatricians ought to be ready to help a teen navigate the informational side of sexuality, the importance of family and the natural limits on a pediatrician's ability to replace parental support should form a framework for this discussion. Pediatricians should explore the adolescent's home-based education about sexuality and the values it implies. Ethics concerns may arise when it is clear that a teen is challenging his or her family's values. While pediatricians have a duty to support and encourage the developing autonomy of a teenager, the fact remains that most teens live and thrive within a family structure. Pediatricians seeking to promote and protect the well-being of teenagers should strive to offer advice that will strengthen the bonds between teen and family while protecting health and the teen's developing sexual identity.

Information about sexuality and safe sexual practices has to meet the needs and limits presented by the teen's physical and emotional/cognitive development. Asynchrony between physical and emotional or cognitive development can create significant risks for adolescents. Pediatricians should be careful to assess the teen's developmental state and use that assessment to direct the delivery of information and advice. Early, middle and late adolescence are characterized by distinct phases of cognitive and moral development.

Generally, younger adolescents are still concrete thinkers with limited capacity to see long-term consequences of behavior. Morality tends to be conventional and less likely to challenge family values. Adolescents in the middle years are developing capacity for abstract thought, but may have a hard time applying that capacity to actual decisions. They are more likely to start challenging family morality but may not have any useful framework for doing so. Asynchrony between physical and cognitive development may be at its peak and with it the propensity for high-risk sexual behavior. In the later stages of adolescence, teens become able to organize abstract ideas about goals and strategies and apply them to immediate behavior. Sexual identity and physical characteristics are stable.

The key point is that pediatricians facing teens whose moral and cognitive capacities are consistent with the middle phase of adolescence should be very aware of the context for decision-making about sex in particular. Family ties may be frayed during this period but are never more important.

The goal of pediatrics is to promote healthy families. Considering sexuality, the specific objectives ought to include first helping families develop a lifelong discussion about sexuality and then, as needs arise, helping an adolescent make informed and healthy choices while reconnecting that teen to family strengths and supports. Therein are long-lasting benefits to the whole family.

Margaret Moon, MD, MPH, assistant professor of pediatrics in the Johns Hopkins University School of Medicine, baltimore, Division of General Pediatrics and Adolescent Medicine. She also is the Freeman Family Scholar in Clinical Ethics at the Johns Hopkins Berman Institute of Bioethics