In a fairly recent book on adolescent medicine the author states in his preface that "Adolescent life is a revolt against the rules of nature."1 1 would definitely question the truth of this statement with regard to adolescent sexual drive, the need for sociability and peer acceptance, the desire for superiority, and the breaking away from parental bonds. These are ruled by nature rather than by man made standards.
This is especially true of adolescent sexuality when it suddenly arises in inexperienced boys and girls. Unless restrained, directed and understood, these experiences may cause serious physical and emotional problems.
This issue of Pediatrie Annals is devoted to the problems and pathology of adolescent sexuality. Most of the subjects covered are related directly or indirectly to the sexual drive of boys and girls in their teenage years.
Adolescent pregnancy, sexual offenses, incest, prostitution, and venereal diseases are frequently the result of uncontrolled sexual drives. We still know too little of the causes of homosexuality (the sexual drive is there but is biologically misdirected).
As today's practicing pediatricians, we have fairly adequate backgrounds in dealing with the emotional and behavioral problems of childhood. Most of us feel quite capable of advising parents on such problems as shyness, aggressiveness, sibling rivalry and educational difficulties.
However, the average pediatrician is poorly prepared to handle the emotional and behavioral problems of adolescents. This is largely due to the fact that teenagers usually keep their thoughts and activities to themselves, only turning to the physician in times of severe stress or fear (such as pregnancy, venereal disease or anxiety over a feeling of homosexuality).
What are our attitudes and advice when adolescents are brought to us as sex offenders, prostitutes, or incest victims? How should we advise on sex activity for our mentally retarded teenagers or those who have cerebral palsy? These are not questions easily answered.
We have entitled this issue, "Adolescent Sexuality: Problems and Pathology" for lack of a better name. Certainly we know too little about homosexuality, and sexuality in the mentally retarded is not aberrant or abnormal but the result of normal sexual urges in adolescents who are mentally below average.
This issue of Pediatrie Annals is dedicated to the memory of Dr. Warren R. Johnson, a co-author of the article, "Sexuality and the Mentally Retarded Adolescent." Dr. Johnson was considered the outstanding authority on this subject. His books and anieles relating to this aspect of adolescent sexuality are recognized as authoritative by all involved with the care and education of the retarded teenager. We feel privileged to present his excellent discussion of the many relevant problems with which parents, pediatricians, educators and all concerned must contend in controlling the sexuality of this special group of adolescents.
In the September 1982 issue, we published a symposium on the normal aspects of adolescent sexuality. This present issue of Pediatrie Annals dealing with the problems of adolescent sexuality is under the same guest editorship of Dr. Tomas Silber, Director of the Department of Adolescent Medicine at the Children's Hospital National Medical Center in Washington, D. C.
This hospital was one of the first large pediatrie services to form a special unit to counteract child abuse. Called the "Child Protection Center," this was the first in the country to develop specialized sub-units dealing with incest and the sexual offender. Several of the contributors to the present symposium draw from their experiences as active participants in these special programs.
Dr. Silber introduces the symposium by describing the sexual urges of the developing teenager and the difficulties encountered in satisfying these urges. He points out that as a rule, peer pressure is much stronger than parental pressure. In boys this peer pressure for early sexual relations and experimentation frequently leads to sexual aggression. To prove their sense of masculinity or "machismo," some boys attempt to make girls pregnant. Then there are the adolescent girls, also with sexual urges and desires, many of whom accept intercourse as the price to pay for socialization. Frequently, they become pregnant.
Certainly the practicing pediatrician plays an important role when dealing with the problems of the adolescent boy or girl. Often teenagers bring their problems to the physician on whom they feel they can depend for advice. At other times concerned parents bring their adolescents* true or suspected problems to the pediatrician, and occasionally we are called in by the courts for opinions based on our knowledge of teenagers and their difficulties.
Frequently the problems are of a serious nature, and pediatricians must satisfy themselves that they are not forming judgments based on their own personal prejudices or moral concepts but on what they sincerely believe is best for the individual.
Judging from the experience of over 50 years of pediatrie practice, I would state without question that the problems of pregnancy in adolescents are those most frequently brought to the pediatrician. If a teenage girl comes to us for contraceptive advice, should we give it? If so, should it be kept confidential or should the parents be notified? If a teenage girl is pregnant, what decision should be made? These are all very important problems and our decisions and the outcome of our decisions may be decisive in our patients' lives,
I'm quite sure that most pediatricians are as baffled as I am by the subject of homosexuality. Just what is it and why? I have written previously that for years I was involved in the subject of sex education. My wife and I wrote several books on sex and reproduction for children and teenagers, and a booklet on sex identity. I mention the latter booklet for this subject has always been of interest to me.
Some years ago I was the pediatrician for two private children's schools in Greenwich Village in New York City. While in that area I rounded up a group of homosexual men who agreed to give me samples of their blood for sex hormones and samples of their semen for sperm count and sperm motility. I brought the plan of my approach to the Cornell Medical College only to learn that a controlled study had already been made with negative results. As a matter of fact, the sperm count was somewhat higher in the homosexual group than in the normal male group. To date, the reasons why human beings who are built biologically and physiologically to be heterosexual are at variance are unknown. In the few cases that I have followed through from childhood there always seemed to be emotional factors responsible. But future studies may be more definitive. At any rate, it should be the aim of the pediatrician to separate the occasional early homosexual practices from true homosexuality and in the latter case to help these boys and girls and their parents work through the situation.
Dr. Silber has also included for discussion in this symposium the subject of the juvenile sex offender. This has been written by Joyce N. Thomas, the Director of the Child Protection Center and refers especially to the information gained in a special "Juvenile Abuser Treatment Program" of the Children's Hospital National Medical Center of Washington, D.C.
Apparently the adolescent sex offenders are much more common than most pediatricians realize. In this article it is reported that of 1200 cases of child sexual victimization 48% involved a juvenile offender. Just what is the responsibility of the pediatrician in the prevention of such crimes and in treatment of the adolescent perpetrator? Obviously the problem requires mental health consultants, pediatricians, and at times, legal advice. But pediatricians with their knowledge of the child and family and relationships with them are often best equipped to gather information that will lead to an understanding of the family dynamics responsible for the adolescent's offenses. Knowledge of a child's upbringing and environment will often lead to an understanding of problems and eventual optimal treatment.
The paper on "Incest in Adolescence" also comes from the Special Unit of the Child Protection Center of the Children's Hospital National Medical Center and is written by Martha Conn Romney, a nurse specialist in that unit. Complete knowledge of this activity in adolescence is insufficient since so much of it is guarded by secrecy. This article presents not only an excellent review of the literature but also discusses the diagnosis plus the physical and emotional care of the individual as well as therapy including the entire family.
The article on adolescent female and male prostitutes comes from the University of Washington in Seattle, and is contributed by Dr. Robert Deisher, Professor of Pediatrics and Director of the Division of Adolescent Medicine, and Greg Robinson and Debra Boyer, both from the Department of Psychiatry and Behavioral Sciences. This is the most complete article on this subject to come to my attention. It deals with all aspects of the problem - social and economic aspects, abusive childhood experiences, boredom, and negative self image. It presents the implications of entering and becoming involved in a life of prostitution and the gradual emotional and sometimes physical breakdown.
Especially important is the section dealing with the role of physicians, an important role in caring for such adolescents who turn to them for help.
The final paper deals with sexually transmitted diseases in adolescence and has been written by Dr. Silberand Dr. Kathy Woodward, both from the Department of Adolescent Medicine at the Children's Hospital National Medical Center. This excellent review of the subject brings us up-to-date on all aspects of the subject. Gonorrhea, syphilis, chlamydial infections, and genital herpes are well covered, with salient points in screening, diagnosis, and treatment presented in outline form for quick and easy reference. The section on syphilis is of particular note for it presents fully the frequent difficulty in diagnosing the infection, the laboratory confirmation and the treatment.
I. K u gel mas s IN: Adolescent Medicine - Principles and Practice. Springfield. Illinois. Charles C Thomas Inc. 1975.