Sexual behavior is the result of many forces. Far from being animal instinct, it is a learned behavior. Gender identity is differentiated from the moment of birth1 and newborns demonstrate specific gender differences.2 The surrounding culture also impinges on the child's sexuality.3 With the arrival of puberty, the sexual drive is experienced as a qualitatively new phenomenon. During adolescence a simple truth becomes obvious: sexual excitement and mating behavior are not dependent on reproductive need, but instead are very specifically geared to the experience of pleasure and satisfaction of a need. However, the development of reason in adolescents makes it also possible "to elect, to perform, to remember, to anticipate whatever behavior, sexual and otherwise, is to be engaged in."4
With all of this in mind, we pediatricians, parents, and responsible adults have to realize that our job is not to suppress adolescent sexuality, but instead to educate and to provide reasonable behavioral standards. Our aim should be for all adolescents to acknowledge their sexuality, to value it as pan of their physical and intellectual as well as developmental endowment, and to express it wisely, safely and intelligently for a lifetime.4 This is indeed difficult in our society.
The process of becoming a young adult is seldom simple; gender identity, sexual role development, and acquiring a capacity for intimacy mark the tasks of adolescence.5 Sexual behavior relates clearly to how each of these tasks is fulfilled. Some behaviors, such as intercourse during adolescence and homosexuality have been scrutinized with attention, and opinions are divided whether to consider them pathological or alternative styles. Other behaviors such as sexual assault, are pathological beyond doubt.6 Several problems related to adolescent sexuality such as promiscuity,7 pregnancy,8 prostitution,9 incest,10 and venereal disease" have caught the attention of pediatricians and are being studied extensively.
In this article, I propose to look at our knowledge of child development as a model to understand adolescent sexual problems. This has been persuasively advocated by Noshpitz, who states: "As one leaves the initial unity of self and mother, and the later involvement between self and oedipal couple, a certain element of each is retained." Indeed, children incorporate the situations surrounding them as they develop. When they reach adolescence, they often find themselves torn between conflicting loyalties, contradictory impulses and confusing choices. Additional stress may be posed by decreased family support.
The biological events of puberty do not always encounter a child "ready and prepared." Puberty is a crisis. On occasion there might be a massive resistance to this change. When a child lacks integrative capacity to bridge the new pubertà! experiences, all physical transformations, aU sexual or aggressive stirrings are experienced beyond control. This is best shown in the extreme situation of anorexia nervosa, in which the capacity for sexual development is literally starved away.
To highlight the importance of developmental issues, it is worthwhile to look at an everyday experience, the disparity between the age of puberi al changes in girls and boys. This simple fact tends to place early adolescent boys into playing a sexual role prior to their physical, sexual and social maturity. At present there is widespread cultural support to the downward extension of heterosexual social activity. Early "dating" may intensify at a younger age a set of inner conflicts between the individual's true developmental need and his expected social role.
This is the time in which the peer group serves as a dramatic influence on adolescent mores. Sociological factors, such as frequent moves, suburbanization and disappearance of the extended family accentuate this normal developmental pattern and may at times give it a sinister connotation. A situation originates in which parents do not really know each other or each other's values. In turn, children perceive their parents as confused and less supportive. Indeed, this is often true; frequently the conditions under which the parents were reared were quite different from those under which they are now trying to rear their own children. To add to this disheartening scene comes the social expectation that all adolescents must go to college, with little tolerance for those who cannot.
The whole situation is made even worse when parents have a rather unrealistic view of the social life of their teenagers. Some believe they are fostering their children's independence, which is at complete variance with the real situation: utter dependency on the peer group.
The control of socialization conditions by peer group mores is associated with early sexual experimentation. Thus, pressure upon the adolescent male may lead him to an aggressive, and often brutal, demand for sexual relations. The adolescent girl often will accept this as the price of socialization. Other variants occur. At times an adolescent girl will select a boy to "go steady with" because he is less aggressive and more an object of sympathy. With the passing of time, however, the original motivation will come to the fore and pregnancy may occur almost as a way of forcing open the ambiguous issue.
Pregnancy may be an accident. However, it replaces the search for possible developmental solutions. Pregnancy often occurs when a girl's needs for nurture and protection have not been met:
Thus, one basis for adolescent pregnancy is formulated again and again by teenage girls who speak of the baby as the answer to all the pain of early privation. In fantasy, the infant becomes someone alt their own, to whom they can show all the love and care that they seek so urgently for themselves, someone who will need them, love them, and will not leave them.12
A more extreme form of the same pathology may be seen in the adolescent form of female promiscuity which frequently leads to recurrent episodes of venereal disease, pelvic inflammation, ectopìe pregnancy and other disturbing physical and mental health problems. Giant u reo studied a population of adolescent promiscuous girls and was able to verify that their sexual behavior was connected to disturbance in the mother-daughter relationship.7 He documented the mothers themselves to be unhappy, frustrated women who were unable to give affection to their daughters. The girls all lacked a sense of worth and were hungry for affection. They readily traded themselves for affection or a symbolic substitute (drugs, clothes, favors, etc.). In this situation, boys substituted for the mother in the girls' nurtural fantasies. This phase of adolescent rebellion often took on the character of an all-out "war" with mother.
An interesting clinical feature is that a large number of them are anorgasmic and uninterested in intercourse. They do enjoy skin-to-skin contact and holding, which seems to show that they are looking for a mother in their "boyfriend." It is remarkable that their promiscuous behavior decreases when a more positive relationship develops between mother and daughter.
The role of the adolescent male in the spreading of venereal disease and adolescent pregnancy deserves more attention. Again, a developmental model might help us understand. Perhaps there is some truth to the fact that in many adolescent males, sexual behavior is the result of the general hunger for sensation and the specific sexual exploratory yearnings that emerge at this age. However, there is definitely a subgroup of male teenagers who have grown up with serious doubts about their masculinity and who, therefore, also suffer from the pressing need to "prove themselves." They pride themselves by getting girls pregnant.
This often helps shore up a fragile sense of maleness forever tottering on the brink of effeminacy or infantilism, they need this overt, visible demonstration of the fact of their manliness to undo their hidden inner weakness.
This situation becomes more common when socioeconomic circumstances increase the level of teenage unemployment and make unlikely any possible advancement in the future. For some male teenagers, paternity is seen as the only imprint they can leave on the world.
Adolescents of both sexes are in quest of a personal identity, developing a new "adult-in-becoming" role. This means that many things will be new, inexperience will be the rule and pain frequently the consequence. A sense of helplessness may become part of the adolescent experience and this feeling is intensified by the high uncertainty of the world situation. At midadolescence teenagers often express the view that they are unable to affect the course of events. This is a faithful reflection of the decreased feeling of certainty and security within their own family and the families in their community as a whole.
The manner in which adolescent sexuality finds its expression relates to cultural changes in a rapidly changing world. In the 80s this leaves us with an obvious problem: the expectation of adolescent sexual performance is ill-defined. A confused peer group attempts to fill the vacuum. When this happens parents may react by pacification (essentially adapting to peer group control) or by retaliation (perpetuating a vicious circle of rebellion and punishment). All this may result in adolescent acting out and may end up bringing the adolescent to the pediatrician's attention. It is not unusual for the pediatrician to observe how these patients receive the emotional support, for which they are starving, from peers who are often sicker and even more confused than the patient seeking help.
The problem of disproportionate peer control of adolescent development and the simultaneous parental abdication relates to the large number of adolescents with sexual problems and sexual pathology. It is difficult to cope with these problems unless families in local communities can be brought together to give to their teenagers a well delineated set of expectations and support. The pediatrician may convey this during anticipatory guidance and counseling sessions. This is a legitimate pediatrie task, since, because of our familiarity with child development, we are in a unique position to understand, intervene and therefore break the cycle of adolescent sexual pathology, which may be viewed as the manifestation of a developmental cycle gone astray.
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