Thoughts about Sexual Difficulties and Related Anxiety among a Predominantly Female Sample of Adolescents

Abstract

This qualitative data analysis examined adolescents’ thoughts and feelings about difficulties that can emerge during sexual experiences. The sample consisted of 53 sexually experienced, ethnically diverse, predominantly female, non-pregnant adolescents participating in a web-based sexual health intervention. As part of a message board discussion, adolescents described anxiety-enhancing attitudes and beliefs (e.g., men should be skilled sexually, women should express satisfaction even if they do not feel it). Several adolescents advocated for condom use despite potential difficulties when attempting to use them. Health professionals should equip adolescents with skills to communicate with partners about sexual difficulties and cope with related anxiety.

Sexuality education for adolescents has traditionally focused on prevention of negative health outcomes, such as unwanted pregnancy and sexually transmitted infections (Schmidt, Wandersman, & Hills, 2015). The extent to which education has focused on developmentally normative, positive facets of sexuality, such as desire, pleasure, and intimacy with one’s partner, varies greatly. One developmentally normative facet of sexuality that can impede pleasure and intimacy and has received little attention in education programs for adolescents is the experience of sexual difficulties and related anxiety. Learning how to cope with sexual difficulties is an important task with respect to the development of sexual health and the cultivation of mutually satisfying sexual relationships (McCarthy & Fucito, 2015). Adolescents have expressed a strong desire to discuss aspects of sex other than pregnancy and STI prevention (Allen, 2005, Pound, Langford, & Campbell, 2016). Several professional organizations have called for a more holistic focus when educating adolescents about sexuality (American Public Health Association, n.d., Future of Sex Education Initiative, 2011). Information and skills to address sexual difficulties and related anxiety would aid in the continued refinement of comprehensive, holistic sexuality education programs.

Sexual difficulties are normal and are increasingly being recognized as such in public discourse, highlighting opportunities for sexuality education to include this topic. In the United States, advertisements for products designed to ameliorate sexual difficulties (e.g., erectile dysfunction, vaginal dryness) have proliferated. Medications to treat erectile dysfunction are now among the most advertised prescription drugs on television (Millman, 2015). In 2014, the pharmaceutical company Pfizer spent over $210 million dollars to advertise one erectile dysfunction drug (Koons, 2015). Such advertisements have largely contributed to an increased cultural understanding of sexual difficulties as normal (McCarthy & Fucito, 2005, Millman, 2015; Allen, 2014). However, with the exception of lubrication for young couples (e.g., KY Yours + Mine), the majority of products are targeted and marketed towards older adults, with direct to consumer advertising that airs during programs that older males view (Koons, 2015; McCarthy & Fucito, 2005). This may lead adolescents and young adults to believe that sexual difficulties should only occur later in life, or that difficulties should only become problematic at this time.

The terms “sexual difficulty” and “sexual dysfunction” are often used interchangeably in the literature; however, the term “sexual difficulty” may more accurately capture normative challenges to pleasure and intimacy that individuals may encounter across the life span. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), sexual dysfunctions are “a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure” (American Psychiatric Association, 2013). Inclusion of personal distress is a key aspect of different definitions of female sexual dysfunction developed by one group of interdisciplinary experts (Basson et al., 2000). However, personal distress is not a key aspect of different definitions of male sexual dysfunction developed by another group of interdisciplinary experts (Rösing et al., 2009). It is possible for individuals to experience a sexual desire or response issue without experiencing distress; by some definitions, these individuals would not be considered to experience sexual dysfunction (Rowland & Kolba, 2016). Hendrickx and colleagues (2014) suggest that a “sexual difficulty” differs from “sexual dysfunction” in that an individual experiencing a “difficulty” does not necessarily experience distress. However, this distinction is not widely observed in the literature (e.g., Rösing et al., 2009). The term “sexual difficulty” encompasses sexual desire and response issues regardless of degree of distress. This term is used below unless a literature source explicitly uses the term “sexual dysfunction.”

A small, but consistent empirical literature suggests that sexual difficulties are common among adolescents and young adults as well as older adults. In one study of Canadian adolescents aged 16 to 21 years, 50% of youth experienced sexual problems; of those who experienced sexual problems, 50% reported significant levels of distress (O’Sullivan et al., 2014). In this study, low desire and orgasm difficulty were the most commonly reported sexual problems among women, while low desire and erectile dysfunction were the most commonly reported sexual problems among men. A national study of French youth aged 15–24 years found that 48% of women and 23% of men reported at least one sexual dysfunction (Moreau, Kågesten, & Blum, 2016). Of those reporting at least one dysfunction, 31% of women reported that the dysfunction negatively impacted their sexuality compared to 9% of male respondents. Similarly, a national study of Swiss men aged 18 to 25 years found that one third experienced at least one sexual dysfunction (e.g., erectile dysfunction, premature ejaculation) (Mialon, Berchtold, Michaud, Gmel, & Suris, 2012). After conducting a review of the literature, Hayes and Dennerstein (2005) concluded that sexual functioning (e.g., desire, frequency of orgasm) decreases with age among women. Hendrickx and colleagues (2014) conducted an online survey of heterosexual Dutch women between the ages of 16 and 74; while many sexual difficulties and dysfunctions were more common in older women than younger women, sexual distress was more common in younger women. Collectively, this research highlights the importance of helping adolescents to understand that sexual difficulties are normal and to cope with any accompanying sexual anxiety or distress.

Comfortably talking about sex with partners seems important to the amelioration of sexual anxiety among young people. In one cross-sectional study of heterosexual couples aged 21 to 65 years, open self-disclosure of sexual likes and dislikes with one’s partner was associated with greater sexual satisfaction and sexual functioning (Rehman, Rellini, & Fallis, 2011). Communication about sexual difficulties among young people is important not only because it may impact the quality of sexual experiences, but also because it may impact the likelihood of engaging in safe sexual behavior. Widman and colleagues (2014) conducted a meta-analytic review of 41 studies and found that adolescents who engaged in more sexual communication with their dating partners reported more condom use during their sexual encounters. Research suggests that communication about sex should not only include topics such as past sexual experience and safer sexual behavior, but also worries about the sexual encounter itself (Graham, Crosby, Sanders, Milhausen, & Yarber, 2016; Graham et al., 2006). Anxiety about sexual performance, in particular, may pose an obstacle to safer sexual behavior. In support of this idea, condom-associated erection loss was associated with inconsistent condom use in a sample of young men aged 18–35 years (Graham et al., 2006).

Qualitative data can provide a nuanced perspective of how adolescents think and feel about sexual difficulties. For the present study, adolescents in the Midwestern United States were asked to identify difficulties that can emerge during a sexual encounter and to describe their thoughts and feelings about sexual difficulties. To facilitate this process, adolescents were shown a brief video vignette, No Worries. This video featured a male adolescent who experienced difficulty maintaining an erection while putting on a condom within the context of a heterosexual encounter. Adolescents were invited to talk about other types of difficulties that male and female adolescents may experience in the context of a sexual encounter. Information provided by adolescents may be used to develop and refine content for sexuality education programs designed to promote health and well-being across the life course.

Two overarching research questions guided the present analysis:

1. What are adolescents’ thoughts about and experiences with sexual difficulties, particularly inability to maintain an erection while putting on a condom?

2. To what extent do adolescents feel confident that they can set boundaries between sexually pleasurable experiences designed to enhance comfort and reduce anxiety, and unplanned or unwanted penetrative sex?

The recruited sample was predominantly comprised of female, non-pregnant adolescents with recent heterosexual experiences. Findings from the present study may be integrated with other literature to understand what is similar and dissimilar across the experiences of young people who vary with respect to gender, sexual orientation, geography, and culture.

Methods

Procedure and Participants.

Data were collected from 53 adolescents who participated in the intervention arm of a pilot randomized controlled trial of TeensTalkHealth, an interactive, web-based intervention to promote condom use and other healthy decision-making in the context of romantic and sexual relationships. The intervention was guided by the Information-Motivation-Behavioral-skills (IMB) model of HIV-risk reduction (Fisher, Fisher, Bryan, & Misovich, 2002) and communication theory (Fishbein & Cappella, 2006) to provide sexual health and risk reduction knowledge, motivation to engage in health protective behaviors, and skills to negotiate condom use and remove barriers to healthy decision-making. The TeensTalkHealth study was approved by the University of Minnesota Institutional Review Board (IRB) and a federal certificate of confidentiality was obtained.

Participants were recruited from three community clinics specializing in adolescent sexual health and three small schools in Minnesota between January and October, 2011 (Brady et al., 2015). Adolescents were eligible to participate in the study if they were aged 14–18 years at the time of enrollment, had engaged in vaginal or anal sex at least once in the past three months, and typically used the Internet at least twice a week for a total of two hours or more. Adolescents who graduated from high school prior to spring 2011 or who were pregnant at the time of screening were ineligible for study participation. Pregnant adolescents were excluded from the study because their relationship concerns are likely to differ in important ways from their non-pregnant peers (e.g., maintaining a relationship with the father; potentially navigating a new romantic relationship when one has an infant child); it was also anticipated that they would represent a small proportion of adolescents on the website.

In-person enrollment meetings were scheduled to obtain parental consent and the assent of adolescents under 18 years. Adolescents aged 18 years provided consent and did not need to be accompanied by a parent. As part of the enrollment meeting, participants chose a non-identifying username and password to use on the website. Study involvement included a pre-intervention period, 4-month intervention period, and 2-month follow-up. All study participants were asked to complete seven monthly surveys online; these surveys are not the focus of the present study and are not discussed further.

A total of 147 adolescents participated in the pilot randomized controlled trial; the TeensTalkHealth intervention group consisted of 92 adolescents. The present study’s purposive sample of 53 adolescents consists of intervention group participants who commented on the message board topic analyzed in the present study (see Figure 1).

Figure 1.

Phases of recruitment, enrollment, and data collection.

TeensTalkHealth Intervention.

Adolescents in the intervention condition accessed website content for a 4-month period. Although intervention participants were free to access any content that was available from the time they joined, health educators assigned standard weekly content through a section of the website, My Required Tasks. Participants were instructed to watch video vignettes 3–5 minutes in length, read teen-friendly articles, and participate in discussion topics posted by health educators. These materials served as conversation catalysts on message boards visible to all adolescents participating in the intervention. Topics addressed planning for condom-protected sex, advocacy for condom-protected sex, and handling consequences of unprotected sex. Topics also addressed an array of factors that may impact condom use and other healthy decision-making in the context of romantic and sexual relationships, including sexual anxiety. Each unique topic (video vignette, adolescent-friendly article, discussion topic) was associated with its own message board discussion. Message boards functioned as a forum for asynchronous focus groups (Wilkerson, Iantaffi, Grey, Bockting, & Rosser, 2014).

During the intervention period, all submitted comments by adolescents were read at least daily and approved by health educators before they appeared publicly. When enrolled, adolescents were told that identifying information and abusive language directed towards other website users would be removed. Potentially identifying information was rarely submitted; abusive language was never submitted. No other censorship of adolescents’ comments was made.

Data Analyzed in the Present Study.

Comments on one message board provided an opportunity to examine sexually experienced adolescents’ thoughts about and experiences with sexual difficulties and related anxiety, as well as their communication with partners about these topics. Prior to commenting on the message board, participants were asked to view the video vignette, No Worries. In No Worries, a heterosexual couple talked with one another after the male partner was unable to maintain an erection while attempting to put on a condom. (No sexually explicit content was depicted in the video.) After the male partner expressed his sexual anxiety, his female partner provided reassurance and explained that sometimes her body did not work the way she wanted it to, as well. These disclosures led to a discussion of how the partners could feel close to one another and feel pleasure without feeling sexual anxiety. At one point, the female partner suggested, “Let’s make it about feeling close instead of having sex. Why don’t we just try messing around?”

Immediately following the No Worries video vignette, adolescents were prompted to complete a brief, private survey. Items administered as part of the No Worries survey (Table 1) were developed by the study authors to align with learning objectives of the No Worries video vignette (Table 2). Constructs that were assessed as part of the No Worries survey are common in sexual health research and include motivation to use condoms, self-efficacy to engage in specific health protective behaviors, and health protective attitudes (i.e., acceptance items). Table 1 contains survey questions that had close-ended responses. In addition to these questions, adolescents were asked two open-ended questions: (1) In your opinion, what messages is the video trying to get across? (2) In your opinion, what does “messing around” mean? After submitting their responses, adolescents were asked to add at least one comment to the corresponding message board, which could be viewed by other adolescents on the website. The discussion questions posed to participants after the No Worries video vignette and survey are shown in Table 2. Adolescents were asked to answer one of the questions posed by health educators, respond to another adolescent’s comment, or express any other thought about the topic. Health educators moderated the discussion by providing health promoting information, motivation, and behavioral skills in response to adolescents’ comments and questions.

Table 1.

Distributions of and correlations between variables assessed after viewing No Worries and before commenting on the message board.

Construct	Item	Mean	SD	Correlations
				1	2	3	4	5	6	7	8	9
1. Attention a	How much did this video interest you?	2.98	1.11
2. Relevance - Difficulty Using a Condom in Past Year b	In this video, Marcus didn’t stay hard when he tried to put on a condom. In the past year, how often did you or your partner(s) experience this?	1.91	1.06	−.03
For the next set of questions, imagine that you don’t or a male partner doesn’t stay hard when you put a condom on.
3. Motivation - Desire to Use a Condom a	How much would you still want to use a condom?	3.28	1.38	.25 +	−.13
4. Skill - Self-Efficacy to Insist on Condom Use c	How confident are you that you could insist on not having vaginal or anal sex unless you and your partner used a condom?	3.67	1.35	.04	−.15	.60 ***
5. Low Barrier - Positive Partner Response d	How do you think this partner would respond?	2.78	.50	.18	−.26 +	.43 **	.44 **
6. Skill - Self-Efficacy to Suggest Alternatives to Penetrative Sex c	How confident are you that you could say, “Let’s make it about feeling close instead of having sex. Why don’t we just try messing around?”	3.78	1.20	−.06	.06	.26 +	.41 **	.34 *
7. Low Barrier - Positive Partner Response e	How do you think this partner would respond?	2.73	.57	.02	.08	.28 *	.19	.56 ***	.44 **
How much do you agree with the following statements?
8. Acceptance - I Can Please Partner Without Sex f	“There are ways to make my partner feel good physically, without having sex.”	4.55	.63	−.04	.05	.08	.17	.15	.36 **	.59 ***
9. Acceptance - My Partner Can Please Me Without Sex f	“There are ways my partner can make me feel good physically, without having sex.”	4.56	.69	.01	.05	.13	.18	.01	.29 *	.47 **	.60 ***
10. Acceptance - Commitment to Condom Use f	“It’s ok to have sex without a condom if my partner or I are having difficulties using one.” (lower scores indicate greater commitment)	2.46	.98	−.14	.11	−.53 ***	−.62 ***	−.21	−.01	−.06	−.04	−.19

^aResponse options: 1- Not at all; 2- A little; 3- Somewhat; 4- Pretty much; 5- Very much

^bResponse options: 1- Never; 2- Almost never; 3- Sometimes; 4- Fairly often; 5- Very often

^cResponse options: 1- Not at all; 2- A little; 3- Somewhat; 4- Pretty confident; 5- Very confident

^dResponse options: 1- Refuse to wait until a condom could be used; 2- Agree in a way that makes me feel bad; 3- Agree in a way that makes me feel good

^eResponse options: 1- Refuse to do anything other than having sex; 2- Agree in a way that makes me feel bad; 3- Agree in a way that makes me feel good

^fResponse options: 1- Strongly disagree; 2- Disagree; 3- Undecided; 4- Agree; 5- Strongly agree

⁺p<.10

^*p<.05

^**p<.01

^***p<.001

Table 2.

No Worries synopsis, learning objectives, and discussion questions.

Video Synopsis

Marcus and Isabella have some troubles when trying to use a condom.

Learning Objectives (not shown to participants)

1. Remain committed to condom use even if a partner is having difficulty using one.

2. Show that acceptance of a partner should not be conditioned on his or her sexual performance in the moment.

Discussion Questions

1. Why do you think a guy might be embarrassed to talk about not staying hard when he tried to put a condom on? Are there other things than can happen to a guy during sex that might make him embarrassed or frustrated? What are some benefits of talking about this with a partner? Are there drawbacks?

2. Girls’ bodies don’t always work the way they want. What are some things that can happen to a girl during sex that might make her embarrassed or frustrated? What are some benefits of talking about this with a partner? Are there drawbacks?

3. If a teen suggested “messing around” to a partner instead of having sex, what would messing around involve? How could somebody keep “messing around” from turning into unplanned or unwanted sex?

4. What would make someone change their ideas to believe that condoms can be pleasurable? (Or at least believe that condoms don’t decrease pleasure.)

Analytic Approach.

Distributions of and correlations between survey items were examined. Responses to the two survey questions that were open-ended were categorized into themes. Following this preliminary analysis, an in-depth qualitative analysis of participants’ comments on the No Worries message board was conducted. Participant responses to open-ended survey questions and message board discussion questions are best viewed as “articulated data,” which Massey (2011) defines as “data that arises in direct response to the questions and prompts provided”; Massey observes that this type of data “offers, in the participants’ own words, their descriptions, interpretations, and commentary on the topics of interest.” Themes were generated through a general inductive analytic approach (Thomas, 2006), which involved the identification of core meanings relevant to open-ended survey and message board discussion questions.

Comments made by adolescents were coded using thematic analysis (Braun & Clarke, 2008). Comments were organized according to theme under the research question that appeared to elicit the theme. The process for rigorous thematic analysis as described by Braun and Clarke (2008) was followed, including the collation of codes into potential themes and iterative review of how themes related to each other in the construction of a cohesive story. Analysis consisted of a series of inductive and deductive open coding grounded in the responses to a priori questions from health educators, as well as emergent data generated organically by participants (Massey, 2011). An entire comment by a participant was treated as the unit of analysis with respect to assignment of codes. Comments were categorized under major themes and subthemes using N-Vivo, specialized software for organizing qualitative data. Selected quotes from participants’ comments were identified to illustrate themes and subthemes. Participants were quoted verbatim without editing of spelling or grammatical mistakes.

The first author addressed the trustworthiness of data through maintaining a methodological journal, maintaining faithfulness to participants’ words, and discussion with the Principal Investigator of the TeensTalkHealth intervention throughout the coding process (Shenton, 2004). Reflexivity was addressed by reflecting upon any biases or assumptions in a separate section of the methodological journal (Berger, 2013).

Results

Sample Demographics and Characteristics

The study sample consisted of 53 adolescents who commented on the No Worries video vignette (see Table 3). The average age of participants at baseline was 17.5 years (SD=1). A majority of study participants were female (n=51; 96%). Among females, 21% reported attraction to both male and female partners, and 79% reported attraction to male partners only. Of reported sexual partners in the past month, all but one was male. Participants’ self-reported race and ethnicity were coded into the following categories: Caucasian (53%), African American (11%), Asian American (8%), Hispanic (2%), and Multi-racial (26%). No significant differences were found between individuals who commented on the topic under study (n=53) and those who did not (n=39) in terms of age and race/ethnicity. There was a significant difference in terms of sex (p<0.01), with fewer males in the study sample than in the overall TeensTalkHealth intervention sample. Of note, the overall TeensTalkHealth study sample was primarily comprised of female adolescents (90%).

Table 3.

Comparison of demographics and other characteristics between TeensTalkHealth participants who did and did not contribute to the No Worries survey and message board.

	Analytic Sample Contributed to No Worries (n=53)	Non-Analytic Sample Did Not Contribute to No Worries (n=39)
Age (Mean, SD)	M=17.5, SD=1	M=17.7, SD=1
Gender (%)
Female	96% *	72% *
Attraction to both male and female partners (%)	21%	23%
Attraction to male partners only (%)	79%	69%
Attraction to female partners only (%)	0%	8%
Exclusively male partners in past month (%)	98%	92%
Male a	4% *	28% *
Race/Ethnicity (%)
Caucasian	53%	69%
African American	11%	15%
Asian American	8%	5%
Hispanic	2%	3%
Native American	0%	3%
Multi-racial	26%	5%

^aAttraction to same sex and opposite sex partners and gender of sexual partners is not reported for male participants due to small sample size.

^*Significant difference between analytic and non-analytic sample at p<.05.

No Worries Brief Survey

Table 1 contains distributions of variables assessed just after adolescents viewed No Worries and before they commented on the message board. On average, interest in the video (attention) was at the scale’s center point (M=2.98). Remaining questions focused on sexual difficulties related to condom use and the ability to experience physical pleasure without penetrative sex. To assess relevance of the video vignette, adolescents were asked how often they or their partners had difficulty staying hard when trying to put on a condom in the past year. Although the mean response to this question corresponded to “almost never” (M=1.91), frequencies showed that half of adolescents reported this difficulty; nearly a quarter of adolescents reported this difficulty “sometimes,” and over 5% reported this difficulty “fairly often” or “very often” (not shown in Table 1). Given a hypothetical scenario in which they or a male partner had difficulty staying hard while putting on a condom, adolescents varied in their motivation to still use a condom (M=3.28); only a quarter of adolescents would be “very much” motivated to still use a condom (not shown in Table 1). Mean confidence in one’s ability to insist on condom use (M=3.67) or suggest non-penetrative sex by “making it about feeling close instead of having sex” (M=3.78) corresponded to values between “somewhat” and “pretty confident.” When adolescents imagined engaging in these persuasive behaviors, roughly 80% anticipated their partners would agree in a way that would made them feel good, roughly 15% anticipated their partners would agree in a way that would make them feel bad, and a few adolescents anticipated their partners would refuse (frequencies and counts not shown in Table 1). The majority of adolescents “agreed” or “strongly agreed” that they (M=4.55) and their partners (M=4.56) could make one another feel good physically without having sex. Adolescents varied in their belief about the acceptability of not using a condom because they or their partner were having difficulty using one (M=2.46); no adolescents strongly agreed that this was acceptable, however.

Table 1 also contains correlations between variables assessed after adolescents viewed No Worries. Correlations revealed that adolescents who perceived greater self-efficacy to negotiate condom use in the event of a difficulty (i.e., not staying hard) and fewer barriers to continued attempts to use a condom (i.e., positive partner response) were more motivated to use condoms in the event of a difficulty. Adolescents who perceived lower self-efficacy to negotiate condom use in the event of a difficulty and who were less motivated to use condoms in this scenario tended to agree with the statement that it was okay not to use condoms in the scenario. Adolescents who believed that they and their partners could make one another feel good physically without having sex reported greater self-efficacy to suggest alternatives to penetrative sex and anticipated a more positive partner response to this suggestion. Perceptions of self-efficacy and positive partner response were correlated across the behaviors of insisting on condom use and suggesting alternatives to penetrative sexual behavior (see inter-correlations between constructs 4–7 in Table 1).

Of the adolescents who completed the No Worries survey, 50 answered an open-ended question assessing understanding of the video’s messages. Responses focused on six non-mutually exclusive themes: importance of communication, acceptance and normalization of sexual difficulties, relationship closeness without having sex, importance of condom use, importance of respecting sexual boundaries, and relationship quality. Fifteen respondents (30%) mentioned communication as a message from the video. These respondents emphasized the importance and necessity of communication with a sexual partner. Twelve respondents (24%) mentioned acceptance and normalization of sexual difficulties. Half of these respondents stated that sometimes sex does not go as planned, and half stated that experiencing a sexual difficulty was not something about which one should feel negatively. Eleven respondents (22%) mentioned relationship closeness without having sex and observed that engaging in sexual activity is not the only way to feel close to a partner. Nine respondents (18%) stated that the importance of condom use was the focus of the video. The majority of these respondents stated that condoms can have a positive impact on a sexual experience. Five respondents (10%) mentioned the importance of respecting sexual boundaries. These respondents emphasized that one should not compromise on their boundaries or pressure a partner. Three respondents (6%) mentioned relationship quality, highlighting that comfort and closeness is important in sexual situations.

Of the adolescents who completed the No Worries survey, 49 answered an open-ended question assessing what “messing around” would entail. The majority of respondents defined messing around as one or more behaviors other than penetrative sex. Identified behaviors included manual sex (mutual masturbation), kissing or “making out,” oral sex, non-genital touching, “foreplay,” non-sexual activities, communication, and “everything/anything but…” sex. Manual sex was the most frequently mentioned activity with twenty-three respondents (46%) identifying “using hands,” “fingering,” and “hand jobs” as a type of messing around. Nineteen respondents (38%) mentioned kissing or “making out.” Fifteen respondents (30%) mentioned oral sex, with several naming oral sex on a penis or “blowjobs,” specifically. Eight respondents (16%) mentioned non-genital touching such as cuddling or “feeling each other up.” Six respondents (12%) mentioned “foreplay” without definition. Two respondents (4%) mentioned nonsexual activities including wrestling and being comfortable with each other, and three respondents (6%) mentioned communication such as “being flirty” or teasing. Twelve respondents (24%) described “messing around” as “everything/anything but…” sex. Several of these respondents did not define the type of sex that was excluded, while others specified that “messing around” was everything/anything but penetrative sex (e.g., vaginal sex, anal sex). One respondent included oral sex as an activity that could not be defined as “messing around.” Four responses contained themes that were not mentioned by other respondents; according to these responses, “messing around” meant using sex toys, “getting freaky,” engaging in activities “further than making out,” and seeing other people.

After completing the No Worries survey, respondents could view and contribute to the corresponding message board.

No Worries Message Board Themes and Subthemes

Data are organized by No Worries discussion question to show how comments may have been elicited by specific questions posed by TeensTalkHealth health educators. Illustrative quotes to represent themes are presented in Table 4.

Table 4.

Illustrative quotes addressing selected themes.

Major Theme or Sub-theme	Participant Description	Illustrative Quote (portions that best illustrate the theme or sub-theme are italicized)
Sexual Difficulties among Males and Females
Emotional Response to a Sexual Difficulty	White female, 18 years	My old boyfriend had this problem. It wasn’t when we would put on a condom but it was a little bit into the sex when he would loose his erection. He got so frustrated and embarrassed. Then he would begin to worry about it and it would happen more frequently during sex.
	Multi-race female, 17 years	…I know that I’ve felt embarrassed when, for some random reason, I can’t get wet. It’s very frustrating because you want to make the experience good for both of you, and you feel turned on, but your body just isn’t agreeing with your mind.
Anxiety Enhancing Attitudes and Beliefs	White female, 16 years	I think guys get embarrassed because they want to keep that manly type thing going for them. If they cant stay hard they don’t want the girl to think something is wrong with them. In my opinion its pretty much just a confidence thing
	Multi-race female, 17 years	… it’s embarrassing when I don’t feel satisfied but sometimes have to act like it hah.
Communication about Sexual Anxieties and Sexual Difficulties
Barriers to communication	Multi-race female, 14 years	…when it came time for him to actually put it in I wasn’t wet enough so it wasn’t enjoyable at all for me. I never had the guts to say anything about it because I never knew how to approach the situation.
	White female, 18 years	Sometimes when a girl is having sex one may be in an awkward position that makes sex uncomfortable and she may be embarrassed to say anything in the event she may ruin the moment.
	Multi-race female, 17 years	I think it is definitely a pride issue with most guys… guys don’t usually like talking about feelings unfortunately
Benefits to communication	White female, 18 years	I think that it does help a lot to be open with your partner. It helps you learn from each other on what things you like and what things you don’t like. It also helped my boyfriend become more comfortable in the situation when I talked to him about him not being able to keep hard the first couple of times we tried to have sex. Now we are able to talk freely about it without having to feel like we are going to judge each other and I love that. It really does help a lot.
	White female, 16 years	…i have been in that kind of a situation where my partner could not get it up and i felt like i was doing something wrong and didn’t know what to do about it but we talked about it and he reassured me that it wasn’t my fault and that he was just stressed
Relationship Strengthening Attitudes and Beliefs
Our relationship is more important than sex	White female, 16 years	This [losing an erection] happened to my last boyfriend. I always insisted we used a condom and he was completely okay with that. Once we were going to have sex but he wasn’t hard once he put it on. It was really great how he was able to laugh it off because he and I both knew that sex isn’t the most important thing. Things happen, and if someone gets mad that their partner can’t keep it up, I think that’s stupid.
	Multi-race female, 15 years	I agree that they think it [losing an erection] makes them feel less manly. This happened with my current boyfriend once and he felt so bad he wanted to try again but then we talked and I told him how its not that important and that what was important was that we were together and having fun. So I also think it is a great idea to talk it out with your partner and to make sure he knows that it is okayy and not to feel embarrassed about it
Sexual difficulties are normal	White female, 17 years	Many guys, especially teens, don’t like to talk about not staying hard when trying to put a condom on because they usually think they’re too cool and tough to have something like that happen to them, even though it’s a normal thing. Another thing that embarrasses guys, and I know from experience, is when they don’t last long. They think that if they don’t last long than they’re not manly enough, but in my eyes it shows how much the guy loves me and how happy I make him feel just when we touch.
Boundary Setting
I won’t have sex without a condom	White female, 18 years	My ex boyfriend actually struggled with this [difficulty maintaining an erection while using a condom] a lot. If he did it himself, he couldn’t stay hard but I wouldn’t have sex without a condom. Once I started to do it for him, they worked just fine.
Follow through on boundaries	White female, 17 years	The first time setting boundaries is the most important because if you dont follow through- you lose all your legitimacy. and if you do- they respect your choices!
Improving the Condom Use Experience
Research and try different condoms	White female, 18 years	…For condoms to be pleasurable, they need to be researched and tried out.. if that takes buying a different kind everytime to have sex then it is worth it.
Recognize that condoms can make sex last longer	Multi-race female, 16 years	Condoms make sex last longer, which can make that big moment even more pleasurable. I think that as soon as people realize that, then they’ll enjoy condoms.

Discussion Questions: Why do you think a guy might be embarrassed to talk about not staying hard when he tried to put a condom on? Are there other things than can happen to a guy during sex that might make him embarrassed or frustrated?

Prompted by the health educators’ questions, participants described several sexual difficulties that men may experience, including losing an erection, not lasting long enough for one’s partner, and being unable to orgasm. Due to the predominantly female sample, comments often described a partner’s experience and the potential impact of the sexual difficulty on the partner and relationship. Two subthemes emerged with respect to sexual difficulties that men may experience: emotional responses to the difficulty and anxiety-enhancing attitudes and beliefs (see Table 4). Participants linked sexual difficulties to negative emotional responses, including embarrassment, frustration, worry, upset, fear, and loss of self-confidence. Embarrassment was by far the most commonly identified emotional response, followed by frustration; of note, both of these emotions were highlighted in health educators’ discussion questions. Negative emotional responses often appeared to be linked to specific attitudes and beliefs that served to enhance anxiety, including expectations about sexual performance for men. The most commonly expressed anxiety-enhancing belief that could be held by young men was that they are “not a man” if they are unable to meet expectations for sexual performance. Other anxiety-enhancing beliefs that could be held by young men were that “cool and tough guys” do not lose erections, men should be good at sex, men need to make female partners feel satisfied, men are doing something wrong, men are letting their girlfriends down, and men are a failure if they cannot provide pleasure to a woman. Many participants linked sexual anxiety among young men to feeling pressured by gendered stereotypes of male sexual performance.

Discussion Question: Girls’ bodies don’t always work the way they want. What are some things that can happen to a girl during sex that might make her embarrassed or frustrated?

Similar to their discussion of men’s sexual difficulties, participants described several sexual difficulties that women may experience during a sexual encounter, including not getting wet, worrying that a partner would feel like the young woman was not being turned on, being in an uncomfortable sexual position, queefing (audible expulsion of air from the vagina), being unable to orgasm, and menstruating. Also mirroring their discussion of men’s sexual difficulties, participants described emotional responses to sexual difficulties and anxiety-enhancing attitudes and beliefs among women (see Table 4).

Many participants discussed their personal embarrassment and frustration over not being well lubricated during sexual encounters. Participants articulated fewer expectations regarding sexual performance for young women in comparison to young men. Instead, participants focused on how women’s attitudes and beliefs about the sexual desire and satisfaction that they “should” experience – but often do not experience – could produce negative emotions. Anxiety-enhancing attitudes and beliefs included thoughts that women should always want to have sex to please a male partner, moan despite feeling embarrassed to do so, and express satisfaction even if they do not feel it. Thinking that “I’m doing something wrong” also appeared to enhance anxiety among young women.

Participants identified seven contexts or situations that might contribute to sexual difficulties and related anxiety among both men and women. These contexts included timing of sex in a relationship (e.g., having sex at the start of a relationship), not feeling comfortable around one’s partner, not feeling comfortable using condoms, when one’s body “isn’t agreeing” with one’s mind, feeling stressed, and health problems. A few participants attributed the experience of a sexual difficulty to being distracted. For example, one participant attributed her boyfriend’s loss of an erection to thinking about other things besides the sexual encounter.

Discussion Questions: What are some benefits of talking about [sexual difficulties] with a partner? Are there drawbacks?

Communication with partners about sexual difficulties and related anxiety was addressed by many participants. Mirroring the health educator’s questions, comments described both barriers and benefits to communication (see Table 4).

Several adolescents identified barriers to communication about a personal sexual difficulty, including lack of knowledge about how to approach the situation; awkwardness, discomfort, and embarrassment; lack of self-confidence; disappointment in one’s inability to perform, feel desire, or feel satisfaction; fear of ruining the moment; fear of hurting a partner’s feelings; fear that a partner would make one feel badly about oneself; fear that a partner would talk to others about the difficulty; lack of connection to one’s partner; and thinking the difficulty was because one’s partner was not attractive enough. Some comments illustrated the potential for adolescents to tolerate rather than communicate about uncomfortable sexual experiences and difficulties with partners.

Several gender-based barriers to communication were described by participants, including that male partners want to appear cool and tough, have egos, are too proud to talk, and do not want to admit that they are wrong or did something wrong. Comments illustrated the potential for both heterosexual women and men to lack empathy for their partners. One adolescent commented that women can sometimes misunderstand nature and blame a male partner for losing an erection. Another participant observed that a partner may not support one’s efforts to improve the quality of the sexual experience.

While many participants emphasized barriers to communication about sexual anxiety, participants also emphasized benefits. Several adolescents described communication as useful and helpful. Specific benefits of communication included reframing a sexual difficulty as normal; obtaining reassurance that the difficulty is not one’s fault; obtaining help to solve problems; resolving tension; being able to laugh about the difficulty with one’s partner; making sex less embarrassing; understanding the other person’s feelings; learning about different things to do during sex; enhancing comfort with a partner; affirming that sex is not the most important part of a relationship; and enhancing relationship quality. These benefits were often viewed as not only alleviating sexual anxiety in the moment, but also strengthening the overall relationship (see Table 4).

A couple of participants expressed the belief that sexual difficulties are normal. Several participants stated that partners should support each other when there is a difficulty.

In addition to advocating for communication about sexual anxiety in the moment, participants identified several strategies to prevent future sexual difficulties. These strategies included communication prior to sex, not having sex until one was comfortable and relaxed, “messing around,” and improving the condom use experience. The latter two strategies were likely elicited by health educators’ questions and are discussed in turn below.

Discussion Questions: If a teen suggested “messing around” to a partner instead of having sex, what would messing around involve? How could somebody keep “messing around” from turning into unplanned or unwanted sex?

The TeensTalkHealth website was designed to promote condom use as well as other healthy decision-making in the context of romantic and sexual relationships. For this reason, adolescents were asked how they could prevent “messing around,” a potential alternative to sexual activities that cause anxiety, from turning into unplanned or unwanted sex. Through message board comments, “messing around” was defined by participants as involving one or more of the following activities: engaging in activities less serious than sex; being playful; being flirtatious; teasing; kissing; making out; using your hands; engaging in oral sex; and doing anything other than penetration without a condom. These activities were suggested as alternatives to having unprotected sex if a partner loses an erection. Participants highlighted two benefits of “messing around” – it is arousing and it is a good alternative to having penetrative sex.

Participants suggested setting boundaries as a strategy for preventing “messing around” from turning into unplanned and unwanted sex. Participants commented that one could set boundaries prior to initiating sexual activity, state that one does not plan to go any farther, follow through on set boundaries, and stop before it goes too far. Boundary setting included insistence on condom use, particularly in situations where condom use appeared to cause sexual difficulties (see Table 4).

Discussion Question: What would make someone change their ideas to believe that condoms can be pleasurable? (Or at least believe that condoms don’t decrease pleasure?)

In response to the health educator’s discussion questions, a few participants highlighted the importance of making condom use a more positive experience. These adolescents highlighted the importance of advocating for condom use, despite a partner’s potential difficulty in using one. Participants suggested several ways to make condom use positive and prevent future sexual difficulties, including “fooling around” for a bit before putting the condom on, having the female partner put the condom on, using a vibrating ring with a condom, researching and trying out different types of condoms, using thin condoms, and using female condoms. While several participants shared ways that condom use could be more enjoyable, one adolescent expressed the opinion that it would not be possible to improve the condom use experience. A couple of participants asserted that condoms, instead of decreasing pleasure, may actually make sex better (see Table 4).

Discussion

Adolescents’ comments on the No Worries message board support the idea that sexual difficulties and related anxiety are common and developmentally normative. Adolescents in the present study were predominantly female. Perhaps due to the male/female pairing of actors in the video vignette, No Worries, they described heterosexual experiences. Consistent with the video vignette, many female adolescents stated that their male partners had experienced difficulties maintaining an erection, particularly when using a condom. In response to the post-video survey, roughly 50% of respondents reported that they or their male partner had experienced difficulty maintaining an erection while trying to put on a condom in the past year.

Condom-related difficulties with maintaining an erection is consistent with other literature on young men’s experiences of erection difficulties (Graham, Crosby, Sanders, Milhausen, & Yarber, 2016; Sanders, Hill, Janssen, Graham, Crosby, Milhausen, & Yarber, 2015). Such difficulties may be linked to problems with how the condom fits and feels, attempting to use the condom before having a full erection, and having low motivation to use condoms (Graham et al., 2016). Difficulty maintaining an erection while using a condom may be one indicator of sexual difficulties, more broadly. In one study, young heterosexual men who reported condom-associated erection problems were more likely to experience other erection difficulties when not using condoms (Sanders et al., 2015). Men may experience a range of sexual difficulties and sexual dysfunction, with premature ejaculation being the most common form of sexual dysfunction (Rösing et al., 2009). The No Worries video vignette may have concentrated discussion on condom-related difficulties with maintaining an erection and limited discussion about other types of sexual difficulties that men may experience.

On the No Worries message board, female adolescents described personal difficulties with being well-lubricated or “wet” and experiencing orgasm. These difficulties are consistent with the broader literature on female sexual difficulties and dysfunction (O’Sullivan et al., 2014; Hays & Dennerstein, 2005). In Hendrickx and colleagues’ (2014) survey of heterosexual Dutch women, sexual distress was more common in younger than older women. In the present study, sexual difficulties were discussed along with negative emotional reactions, such as uncertainty, awkwardness, embarrassment, frustration, discomfort, and stress.

Several anxiety-enhancing attitudes and beliefs appeared to worsen the experience of a sexual difficulty. These attitudes and beliefs linked masculinity to sexual performance and also revealed expectations for how women should receive a man’s attentions (e.g., always being willing to have sex, readily becoming wet and having an orgasm, expressing satisfaction despite not feeling it). It is conceivable that emotional reactions, distress, and anxiety-enhancing attitudes and beliefs may impact young people’s satisfaction with their relationships. Rowland and Kolba (2016) conducted an online survey of women between the ages of 18 and 60 and found that women who were distressed by orgasmic difficulties were less satisfied with their sexual relationship than women who were not distressed by orgasmic difficulties.

Adolescents in the present study identified several contexts or situations that might contribute to the experience of sexual difficulties, such as engaging in sexual activity at the onset of a new relationship and feeling stressed. Attributions for sexual difficulties, if discussed with a partner, might serve to reduce sexual anxiety and prompt a different approach to sexual behavior. In addition to acknowledging potential benefits of communication, such as improved relationship quality, adolescents referenced several barriers to communicating, such as embarrassment or uncertainty about how to initiate the conversation. Communication was thus acknowledged as an important, but often difficult way for an individual to share personal experiences with a partner and prevent future sexual difficulties.

Participants’ discussion of the benefits and barriers to communication is consistent with the Interpersonal Exchange Model of Sexual Satisfaction (Byers, 1999). In this model, communication comes with rewards and costs. Rewards are defined as conversational exchanges that are enjoyable and beneficial to a partner, whereas costs are defined as conversational exchanges that demand unpleasant effort or cause negative emotions such as pain, embarrassment, or anxiety. Communication may be comprised of both costs and rewards. As one adolescent in the present study stated, conversation about sexual anxiety, “though uncomfortable, can get down to the bottom of the problem.” Based on comments offered by adolescents in the present study, however, it seems unlikely that communication will occur unless young people know how to approach the subject and feel comfortable talking with their partners. Given feelings of anxiety and vulnerability associated with experiencing a sexual difficulty, the costs to communication may simply be viewed as too high by some adolescents.

The No Worries video vignette modeled how to have a tactful conversation with a partner. When a female adolescent’s male partner had difficulty maintaining an erection while using a condom, she explained that her body did not always work the way she wanted it to. She also demonstrated that her positive regard for her partner was not conditioned on his sexual performance in the moment. While adolescents in the present study appeared to appreciate the video vignette, many doubted their ability to initiate and navigate a similar conversation. Quantitative data collected just after adolescents viewed the No Worries video demonstrate the importance of improving adolescents’ self-efficacy (confidence in their ability) to have difficult conversations with partners. Greater self-efficacy to insist on condom use was associated with greater commitment to condom use in the context of having difficulty using condoms and greater agreement that partners would respond positively to one’s insistence on using condoms. Greater self-efficacy to suggest alternatives to penetrative sex was associated with greater agreement that partners could make one another feel good physically without having sex and greater agreement that partners would respond positively to the suggestion of alternatives.

Implications for sexuality education.

A recent review of evidence-based sexuality education programs found that few programs addressed topics other than abstinence, contraception, and prevention of sexually transmitted infections (Schmidt, Wandersman, & Hills, 2015). This can leave adolescents ill-prepared to navigate the challenges and rewards of developing intimate relationships. Several professional organizations have called for a more holistic focus when educating adolescents about sexuality (American Public Health Association, n.d., Future of Sex Education Initiative, 2011).

Findings from the present study can inform the manner in which sexuality educators, health care providers, caregivers, and other family members address sexual health with adolescents. First, adults should normalize the experience of sexual difficulties for both male and female adolescents and correct any misperceptions that may be fostered by societal messages. The proliferation of advertisements for pharmaceuticals to enhance erectile function (Millman, 2015) may normalize erectile difficulties among older men while simultaneously stigmatizing erectile difficulties among younger men. Such advertisements may also suggest that erectile difficulties are best remedied through medication instead of communication with one’s partner. Treatment of sexual dysfunctions for men of all ages must include therapeutic techniques to address potential psychosocial needs and frustrations that may be contributing to experiences of sexual dysfunction and difficulties (Rösing et al., 2009). Conversations between adults and adolescents should acknowledge the normativeness of sexual difficulties across the life course and address concerns about sexual performance (e.g., maintaining an erection). Encouraging young men who experience difficulties maintaining an erection while trying to use a condom to be patient and allow sufficient time for sexual arousal may ameliorate their issues (Graham et al., 2016). Adults can also challenge attitudes that link the sexual functioning of young men to masculinity, as well as the belief that a male partner’s sexual performance is an indication of how attracted he is to a partner.

Lack of “wetness” was the most commonly discussed sexual difficulty experienced by young women. Female adolescents appeared to view lack of wetness as a personal failing. Such views may be cultivated by societal messages. For example, in the 2007 film Superbad (Apatow & Mottola), a male teen ridiculed his friend for bringing both condoms and lubrication to a party because the young woman he liked was not a “dried-up, old hag.” Associating lack of wetness with old age and unattractiveness may lead adolescents to view use of lubrication negatively. Indeed, some female adolescents in the present study tolerated uncomfortable intercourse rather than voicing a need for better lubrication. Negative attitudes towards the use of lubrication may be countered by recent trends in marketing (e.g., KY Yours+Mine). However, not all adolescents may view products that enhance the quality of sexual experiences as applicable to them. Sexuality education is an opportunity for knowledgeable adults to provide adolescents with useful and accurate information about resolving sexual difficulties.

A second way in which sexuality educators, health care providers, and caregivers can improve the sexual health of adolescents is by helping them to understand that many sexual behaviors besides penetrative sex can provide mutual pleasure. A qualitative study of British youth aged 18 to 26 years found that orgasm was viewed as the primary goal of sexual intercourse; in addition, many youth, regardless of gender, felt responsible for ensuring that their partners experienced orgasm (Opperman, Braun, Clarke, & Rogers, 2014). An exclusive focus on penetrative sex and orgasm in a sexual relationship may prevent adolescents from experiencing and appreciating a range of pleasurable sensations. In the present study, an open-ended survey question assessing the meaning of “messing around” elicited a wide range of activities, ranging from non-sexual to sexual activities that pose less risk for pregnancy or transmission of sexually transmitted infections. Adults can help adolescents understand that penetrative sex and orgasm are not the only ways to experience intimacy and pleasure in the context of a relationship. Such an understanding may also prevent unsafe sexual behavior (e.g., having penetrative sex without a condom when a male partner cannot maintain an erection with the condom). Although adolescents in the present study distinguished “messing around” from penetrative sex, they may nonetheless benefit from skill building activities to assist in setting and maintaining boundaries with partners.

A third way in which adults can aid adolescents is by providing guidance on how to communicate with partners about sexual difficulties and related anxiety. Knowing how to approach this type of communication requires both an understanding of one’s sexual functioning and the skills to initiate a potentially awkward conversation. In conversations with adolescents, adults should emphasize the time required to understand how one’s own body and a partner’s body work. This may lead adolescents to become more patient with themselves and their partners and to potentially delay having sex until they feel more comfortable with their own body, a relationship, or the idea of communicating about difficult topics. If adolescents have a clear vision of what they expect from a sexual partner (e.g., feelings of comfort, intimacy, and shared pleasure) and place high value on having their expectations met, they may be more likely to abstain from or delay sexual activity in situations where their expectations are not being fulfilled. Such conversations, particularly from parents and caregivers, may also lead many adolescents to be more selective about partners, which may in turn enhance relationship quality and overall well-being (McGee, n.d., Planned Parenthood, n.d.). Although the processes outlined above are plausible from a clinical perspective, research is needed to confirm that communication with partners about sexual functioning may impact the timing, trajectory, and quality of romantic and sexual relationships.

Participants’ comments demonstrated that they have motivation to communicate with partners about sexual difficulties and anxiety, but often lack the skills to initiate and navigate candid conversations. Communication with a sexual partner requires specialized skills that individuals must learn and practice (Robinson et al., 2002). Sexuality education in schools does not typically include instruction on skills for communicating about sexual difficulties and related anxiety. The majority of evidence-based sexuality education programs provide opportunities for the development of delay, refusal, and condom-negotiation skills, leaving out all other forms of communication with partners (Schmidt, Wandersman, & Hills, 2015). Compounding this deficit in skills is an overarching societal myth that sex should be spontaneous, occurring with little to no conversation (Dune & Shuttleworth, 2009). By discussing sexual difficulties and anxiety with adolescents and providing communication skills, adults may reduce barriers to communication with partners. Adolescents may also accept communication about difficult topics as an essential part of a healthy relationship.

The recommendations above are consistent with best practices. In the Guidelines for Comprehensive Sexuality Education published by the Sexuality Information and Education Council of the United States (SIECUS), sexual dysfunction is included in the Key Concept of Sexual Behavior (2004). Recommended developmental messages for adolescents ages 12–18 include normalizing sexual dysfunction (e.g., “At one time or another, nearly everyone will experience a sexual concern or dysfunction”), causes of sexual dysfunction (e.g., “Sexual dysfunctions may result from guilt, anger, stress, anxiety, depression, medical problems, medication, or relationship difficulties”), and how to address sexual dysfunction (e.g., “For some couples, honest communication can solve sexual problems”) (SIECUS, 2004). The present manuscript provides insights about the types of sexual dysfunctions and difficulties that adolescents may experience, anxiety-enhancing attitudes and beliefs that may contribute to distress, and areas in which adolescents may benefit from skill-building conversations with caring adults.

Strengths and limitations.

Strengths of the present study include its innovative approach to collecting qualitative data through a message board, which functioned as an asynchronous online focus group (Wilkerson et al., 2014). Adolescents engaged in moderated conversation with one another and health educators on a secure website. By using non-identifying screen names, participants may have perceived fewer barriers to disclosing their experiences with sexual anxiety and communication with partners about this topic. Additionally, participants may have had more time to formulate thoughtful responses to health educators’ questions, as data collection occurred flexibly across a 4-month period. It is also a strength of the present study that quantitative data was collected from participants before they were able to view discussion questions and respond on the TeensTalkHealth message board.

Limitations of the present study must also be acknowledged. Asynchronous focus groups can be susceptible to uneven participation (Wilkerson et al., 2014). TeensTalkHealth participants were a convenience sample comprised primarily of female, non-pregnant adolescents in one geographic region; this reflected the clientele of our primary recruitment partners, community clinics who specialize in adolescent sexual health services. Pregnant adolescents were excluded from the present study because their relationship concerns were likely to differ in important ways from their non-pregnant peers (e.g., maintaining a relationship with the father, potentially navigating a new romantic relationship when one has an infant child). Sexual and gender minority person’s concerns were not examined in the present analysis because participants discussed heterosexual encounters. Although 1/5 of female participants expressed sexual interest in women, comments on the No Worries message board described solely heterosexual encounters; this message board discussion was likely elicited by the corresponding video vignette, in which a male/female couple experienced difficulty using a condom. Transgender or gender nonconforming identity was not assessed. Participants were not asked about other personal and social factors that may influence experiences of sexual difficulties and anxiety, such as religious affiliation or experiences of sexual violence. Items administered as part of the No Worries survey were developed by the study authors to align with learning objectives of the No Worries video vignette. They have not been validated because they were piloted during the study. Despite these limitations, data collected in the present study provide insight into a relatively understudied and novel area of research. Further research is needed to determine the prevalence of sexual difficulties and related anxiety among adolescents.

Conclusion.

Sexually experienced adolescents struggle with sexual difficulties that cause embarrassment, discomfort, and stress. While adolescents understand the benefits of communication with partners about sexual difficulties and anxiety, they sometimes lack the behavioral skills to initiate and navigate these conversations with partners. It is likely that adolescents’ experiences with sexual anxiety will influence their quality of relationships and sexual health into adulthood. Therefore, sexuality education for adolescents should normalize the experience of sexual difficulties. Education should also provide behavioral skills to openly communicate with partners and strategies to prevent sexual difficulties (e.g., use of lubrication). Discussions about sexual difficulties and related anxiety can emphasize that it takes time to understand one’s body and feel comfortable communicating with one’s sexual partner. Such discussions may lead to healthier, happier relationships over time.