The Social Context of Sexual Health and Sexual Risk for Urban Adolescent Girls in the United States

Abstract

Sexually transmitted infections including HIV and teenage pregnancy have resulted in considerable morbidity and mortality among girls in the United States. There is a need to further strengthen prevention efforts against these persistent epidemics. In order to promote girls' sexual health and most effectively reduce sexual risk, it is important to understand the social factors that influence the development of a girl's sexuality. The purpose of this study was to begin to fill a void in the literature by exploring girls' perspectives about the social context in which they learn about sex, sexuality, and relationships. Coding and content analysis was used to identify patterns and themes in 33 individual interviews with African American and Euro-American girls.

Participants identified family, friends/peers, partners, school, and the media as the most common sources for learning about sexual health. Girls sought out different types of information from each source. Many girls experienced conflicting messages about their sexual health and struggled to integrate the disparate cultural references to sex, sexuality, and relationships that emerged from these different spheres of social life. Girls often had to navigate the journey of their sexual development with little room for reflection about their own thoughts, feelings, desires, and decisions. Health care providers, especially those in mental health, are in an optimal position to promote girls' physical, developmental, and emotional sexual health.

The Centers for Disease Control and Prevention (CDC; 2008a) have identified risky sexual behaviors as one of the leading causes of morbidity and mortality among youth in the United States. In 2007, risky sexual behavior in adolescents resulted in 9.1 million cases of sexually transmitted infections (STIs), more than 5,000 cases of HIV/AIDs and 757,000 pregnancies among girls between the ages of 15–19. Much of the research shows that intervention programs with adolescents have been effective in reducing risky sexual behaviors, but there is a need to further strengthen prevention efforts against these persistent epidemics. More recently, researchers have begun to develop programs that focus on adolescents' sexual health in addition to sexual risk. Intervention programs that promote abstinence, delay of initiation of intercourse, and increased contraception or condom use and that also encompass broader developmental issues, such as puberty, dating, or family relationships, need to be further evaluated (Graber & Brooks-Gunn, 2002). In order to promote sexual health and most effectively reduce sexual risk, it is of great importance to understand the social factors that influence the development of a girl's sexuality.

Throughout previous research, the term “sexual health” has been given multiple definitions and its meaning varies when viewed from different perspectives. While some consider sexual health primarily through a medical lens as the prevention of physical conditions such as STIs, HIV, and unintended pregnancy, others refer to sexual health through a developmental and contextual lens as a state of sexual well-being throughout one's lifetime (Wingood, Sionean, & McCree, 2002). This study embraces the latter concept of sexual health in order to examine the facets of social context that impact girls' sexual health during the developmental transition of adolescence. Such a perspective facilitates more comprehensive sexual health promotion in addition to disease and pregnancy prevention.

Brooks-Gunn and Paikoff, early proponents of this approach, called for a reorientation in research regarding adolescent sexuality toward a focus on sexual health during developmental transitions (1997). They underscored the need for more research aimed at understanding adolescent sexuality in the contexts of self and of relationships and the meaning of sexuality in the adolescent's life. More specifically, they identified four areas of concern that merit further investigation: “(1) sexual well-being and developmental transitions, (2) the gendered nature of sexuality, (3) decision making and sexuality, and (4) the meaning of sexuality to youth” (Brooks-Gunn & Paikoff, 1997, p. 194).

By examining adolescent sexuality within a social context framework, sexual health takes on a definition that includes well-being rather than merely the absence of disease. The World Health Organization (WHO) suggests that one way to view sexual health encompasses “physical, emotional, mental and social well-being in relation to sexuality” and “requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” (2002). The U.S. Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior expands on this concept, adding that sexual health “includes the ability to understand and weigh the risks, responsibilities, outcomes and impacts of sexual actions and to practice abstinence when appropriate” (Satcher, 2001). These descriptions of sexual health lay the groundwork for a multifaceted and contextualized approach to the study of adolescent sexuality.

Defining sexual health in this way helps us to better understand how social and developmental factors influence sexual health and link to sexual risk. For example, recent findings indicate that “many sexually active young women perceive that they do not have the right to communicate about or control aspects of their sexual behavior” (Rickert, Sanghvi, & Wiemann, 2002, p. 178). These perceptions could augment sexual risk since limited sexual communication with partners has been linked with less condom use (Crosby et al., 2000) and fear in relation to condom negotiation (Crosby et al., 2002). In another example of this line of research, Wingood et al. (2002, p. 433) found that “women who are more dissatisfied with their body image may be at a greater risk for unintended pregnancy, sexually transmitted infections (STIs), and HIV infection.” Identifying such links between sexual health and sexual risk opens new avenues for prevention opportunities. However, more research is needed that reflects the diversity of young people's experiences and incorporates their perspectives (Baldo, 1996; Fullilove, Barksdale, & Fullilove, 1996; Guthrie et al., 1996; Hoffman & Futterman, 1996; Richey, Gillmore, Balassone, Gutierrez, & Hartway, 1997).

The purpose of this study is to begin to fill a void in the literature by exploring girls' perspectives about social influences on their sexual health. This study draws from a racially and economically diverse sample of adolescent girls with a goal of understanding their experiences dealing with sources of influence. Therefore, this study used qualitative methods to understand girls' perceptions of learning about sex, sexuality, and relationships in the context of their social experiences in order to inform interventions to promote sexual health and reduce sexual risk. The main research questions of this study are: (1) From what sources do girls learn about sex, sexuality, and relationships? 2) What types of information do girls learn about sex, sexuality, and relationships from each of these sources? 3) What are girls' reactions, conflicts, and challenges as they navigate this diverse set of experiences regarding their sexual health?

Design

Study Population and Eligibility

The population for this study consisted of urban adolescent females living in southeastern Michigan. The region in which the study took place was ethnically and economically diverse. In order to be eligible for this study, girls needed to be between the ages of 14 and 18 years old and agree to be interviewed (assent). All teens under 18 also needed to allow the researcher to obtain parental consent. Also, it was necessary that participants could speak and read English.

Sampling and Recruitment

In keeping with the purpose of the study, selective sampling was used to ensure there was near even representation by household income within the two major population groups living in the study locale. The goal for sampling was to interview both African-American and European-American female teens with approximately half of each group coming from lower income households and the other half from higher income households. Girls were classified into racial categories by self-identification.

Recruitment took place primarily in an adolescent health center. Approximately 60% of the teens who visited the health center were Euro-American and 40% were African-American. Most came from lower-income households. Teens came to the health center for general health care, family planning, and prenatal care. Flyers were placed in the waiting room and posted in the exam rooms. Other teens in the community learned about the study through word of mouth and were screened for eligibility when they called the number on the flyer.

Data Collection

The study was approved by the University of Michigan Institutional Review Board. All of the interviews took place in a mutually agreed upon location that allowed for private conversation without interruption. After the signed consent/assent forms were obtained, the individual interview was conducted. The primary author conducted all the interviews. All interviews were audiotaped. The tapes were transcribed verbatim and were reviewed for accuracy.

The interview questions were open-ended in order to foster participants' descriptions of their own experiences and perspectives. The interview guide was semi-structured in order to make sure several general areas were covered in the interview. The framework was organized topically and included sections on: the self; family and support network; friends; school and activities; body changes and body image; sexual feelings; relationships; and learning about sex, sexuality, and relationships. Girls were asked to describe their learning experiences and probed for their personal reactions or interpretations. In the final portion of the interview, girls were asked to provide some demographic and health information and to select a pseudonym. The stories that resulted from the interview process represent a “snapshot” of the teens' perspective at one particular point in time, created in the context of a research interview.

Data Analysis

Content analysis was the primary approach used to examine the data. In the initial reading of the transcripts the aim was to understand the overall story of the participant. Contradictions, repeated words or images, metaphors, and inconsistencies as well as absences and revisions were noted in memos in addition to the researcher's ideas, questions, and emerging themes.

In addition, a coding scheme was developed that allowed for content analysis and a way to retrieve common segments across interviews. NUDIST qualitative data analysis software was used to systematically link transcript segments to the codes. Four broad areas to code were identified: Source of Message; Type of Message; Experiences; and Other Codes, for example, missing messages. For the most part, these codes described broad categories that emerged from the teens' own words.

From the cross-case content analysis in the coding, patterns and themes were identified. Conceptually clustered matrices were developed to explore these patterns and themes across the sample. These matrices had a simple respondent by topic (or variable) format. All the topics in a matrix were conceptually related to each other. Theme-specific qualities were identified and compared to other themes to determine the qualities that distinguished one theme from another. Data analysis proceeded concurrently with data collection; when saturation was reached, data collection ended.

Finally, a demographic and health history summary form was developed based upon the questions that were asked in the final portion of the interview. This data sheet included variables that could more easily be classified with numbers or simple categorical values. All of the demographic and health history data were summarized in this way.

Results

The final sample consisted of 33 participants. Girls ranged in age from 14–18 years of age, with a larger proportion of 15 year olds and relatively fewer 18 year olds. There were 15 African-Americans, 15 European-Americans, and 3 biracial participants in the study. The two major groups included similar numbers of lower income teens (n = 17) and higher income teens (n = 16). Most of the teens attended high school, grades 9–12. One teen was in eighth grade and three teens had dropped out of school. Thirteen of the participants lived with a single parent, nine lived with both parents, and four were living with a parent and stepparent. The remaining participants had alternative arrangements including living with grandparents, foster parents, or guardians.

Participants were also asked about their sexual orientation in an open-ended format. Responses were categorized as the following: heterosexual (24); lesbian (0); bi-sexual (1); open to possibilities (6); questioning (1); missing (1). The most common sources for learning about sex, sexuality, and relationships identified by girls in this study were family, friends/peers, partners, school, and the media. This paper focuses on the different types of information girls took in and/or sought out about sex, sexuality, and relationships from the variety of sources they identified as well as their reactions.

Family/Parents/Guardians

All girls described family as the initial point of reference for information on sex, sexuality, and relationships, and many continued to find this source important. Four types of family scripts pertaining to sex, sexuality, and relationships were identified and described by the participants: danger and protection; waiting to have sex or to date; abuse; and taking charge. For example, many parents actively encouraged protection by taking their daughter to a clinic to acquire contraception. Sometimes multiple scripts were intermingled in the participants' narratives.

For many girls in the study, their parents' perspective on sex, sexuality and relationships was important to them; the teens struggled, however, with their parents' responses and with the amount parents could influence their decisions.

I still go to her for advice. And I still tell her what's going on in my life. But, we don't agree on everything. If there's something I want to do and she does not think that it's a good idea, then she knows that she can't stop me. She knows that I'm going to do it. Even if I don't have her approval, she knows that I'm still going to. But, if there's something, like, she said, “Nora I really don't want you to do that. I really don't think that it's a good idea,” then I wouldn't do it. (Nora)

The participant quoted above struggled with parental influence in her discussion of sexuality issues. Others did not talk about their own concerns with parents because they did not want to solicit parental opinions or elicit parental concern or restrictions.

And my mom, she say that I can tell her everything, but, I don't think so. Because I think that the things that I do, she would probably get mad. Like, I don't like to talk to her about sex or smoking, none of that. I just feel uncomfortable. Like, I can talk to you about it but, her, I don't think that I could. (Lois)

The family was a contested site as far as who was in control of the girl's sexuality. To some extent this varied by the girl's age. Some families provided varying levels of support in the service of helping the girls have control over their own sexuality and girls utilized this support in varying degrees. Other families employed various levels of social control over the girls' sexuality to which girls complied in varying degrees. Some families utilized a mixture of support and control.

Many of the teens in the study, however, made references to just their mothers regarding discussions of sexuality. This was common in households headed by mothers because the father was often absent. Even in households in which fathers were present, some participants described how they did not talk with their fathers about sexuality or that it was difficult. For example, “My dad like doesn't talk about anything. We don't talk about that. That's my dad. It's kind of like I'm his little girl” (Brandy).

A few of the teens in the study said that their mothers would talk to them like they were friends or sisters some or all of the time when talking about sex, sexuality, and relationships. They expressed mixed feelings about talking with their mothers in this way. For one participant, in these sister-like discussions, her mother talked about her own sex life, which the daughter referred to as telling her crazy stuff: “She'd be telling me how it feel good and stuff” (Kim). Another participant said when she wants to be understood, she likes a friend-like conversation, but when she is seeking guidance, she prefers her mother take on the parental role. Sometimes her mother gets confused and jokes around when she wants her to be serious and she has to remind her mother to be “parental” at those times (Nora).

Aunts, uncles, grandparents, older siblings, and older cousins were sometimes mentioned by the girls as providing some additional information or advice. Kim said her uncle cautioned her and her sister Barbara to avoid getting pregnant, Lois said her older cousin told her to use condoms, and Julia said her older brother warned her that boys “just want to have sex.” Maya was told by her older sister, “If I do start having sex, don't be trying to have more than one partner. At least have one.” When confiding their own experiences with relatives, however, there was always the possibility that information would later be passed on to other family members. So while many girls did confide in various relatives, some did so with caution and some felt their confidences were betrayed.

One participant described how her mother had started a girls' discussion group for her and her friends beginning when she was ten years old. She described this group as extremely beneficial as she negotiated her bodily changes and her sexual thoughts, feelings, and decisions.

Friends/Peers

Friends were a source of a different kind of knowledge. Several participants said they learned about slang terms and learned about non-intercourse sex (e.g., foreplay, oral sex, etc.) from friends.

Most stuff I got from my friends, I think, were just hearing wise cracks or jokes or whatever. Like me finding out what a BJ meant, or what a blow job meant. I'd end up asking my friends what that meant when they'd crack jokes or something, like “oh, okay.” (Shari)

Some talked about their own experiences while others participated by listening to others talk about their experiences. “Yeah, my friends. I was just telling them [that she had sex]. We all were talking about how we got it on and stuff. You know, girl talk” (Lois). From hearing about experiences of friends and peers, the girls learned that teen sex is common in high school.

Two girls who listened at the periphery mentioned how their difference was noticed by peers. According to Pat, some of her friends said she was a lesbian, and she said she just wasn't into boys. Jen's friends “joked” about her being a prude because she was the only one in her circle of friends who had not had sex. Several participants stated that they were teased, encouraged, or advised by friends to have sex. For example: “I always wondered what it was like, to have sex 'cause people used to always laugh at me and say stuff to me 'cause I was a virgin 'cause most of my friends weren't” (Linda). Several teens talked about resisting this norm. For example, Linda continued, “The most important thing, I think, is that it's all right to wait. 'Cause most girls get peer-pressured and they think that, “Well, if I do this, everybody will like me better.”

Frequently, relationships were the topic of discussion among peers. For example, “Sometimes we might talk about the boys that we're interested in. Somehow we think the same about the kind of guy we want to marry and stuff like that. And how he'll act” (Maya). One participant described how she and her friends would talk about “just how far we each are planning to go … Sometimes we talk about what we think the guy expects from us” (Lisa). Another participant said she was told by friends, “In order for my boyfriend to be happy, I have to have sex with him” (Jade). One younger participant was intrigued about sexual intercourse because of what she saw and heard from friends and peers.

Among friends, the teens in this study said they could talk about sexual feelings such as attraction and sexual pleasure. One girl said she and her friends discuss sexual preference. Two participants tried to understand their own disappointments given how others talked about sexual pleasure. Jade could not understand why her friends likened (heterosexual) sex to an amusement park after her own disappointing first experience. After hearing her friends' stories, however, Nicole now knows:

People more and more, as I get older as they get into more relationships where they consistently have sex, they find that it's better because, obviously, anything gets better with time and you practice. So everybody is getting practice now and sex is getting better. But, now I don't expect it—that sex is going to be all that much the very first time. (Nicole)

Many participants talked about how peer groups would apply social labels to other teens on the basis of sexual activity or presumed sexual activity. For example, one participant (Pat) talked about a friend who had a “bad reputation” and was labeled a “freak” for having sex with a basketball player she didn't know very well and then bragging about it.

Many participants said that they also exchanged information about physical dangers and consequences as well as protection measures with peers. A few participants said they talked with peers about AIDS and using condoms. One teen said she heard from several friends about the negative side effects of the contraceptive Depo Provera and therefore continued to use the pill. A few participants became aware of intimate partner violence when they saw peers abused by boyfriends at school. One teen (Toni) gave her friend advice to leave her abusive boyfriend. A few talked about the lack of social support (from the father of the baby and his family) for teens who did not know their baby's father. Some teens mentioned they learned about some of the consequences of teen pregnancy when friends with babies couldn't participate in social activities. “She really don't get to do nothing. She stays at home 24/7 with her baby. She don't get to hang out like most teens do” (Janice).

Sexual Partners, Boyfriends, and Girlfriends

Defining and describing relationships that were something other than friendship was complicated. One participant who tried said:

I guess it starts off as a friendship, obviously. I don't think you could have a relationship without being friends. That would be kind of hard. I guess you couldn't just be like, “Hey. You wanna come sleep with me?” But that wouldn't really be a relationship, either. That would just be having sex. I guess it's sort of a deeper friendship, almost, but not quite. Yeah. Yeah, I guess it is. Not necessarily a deeper friendship but a different form of it. I guess it almost moves faster than a friendship would 'cause with friends, you start off and you're just acquaintances. With a relationship, all of a sudden you're sharing such deep feelings. (Gayle)

When asked the question: “When someone uses the word relationship, what comes to mind?”, these were two of the answers:

Love, commitment, faithfulness. (Tete)

Relationship is when two people decide to be together, don't be doing everybody else, be with your one partner, don't be going out with other people while that person is with you. … For instance, I'm dating a boy and I go out with another guy, that's playing my boyfriend, in other words, I'm playing with his emotions. Relationship is when you get into something, but you ain't trying to play with their emotions. You trying to really be with them. That's how I look at a relationship. Relationship is built on trust and respect and love. (Diamond)

Another term used for expressing some commitment to a relationship was referred to as being “hooked up.” Degree of commitment was often signified by qualifying terms such as a slight relationship, or a little fling, versus a deep or serious relationship. Sexual partners were not always considered a boyfriend or girlfriend. Among the teens that were interviewed, there was usually some kind of physical aspect, but not necessarily intercourse, with those whom they called boyfriends or girlfriends. The meanings of some terms such as “relationship” or “girlfriend” varied depending on the context in which it was used.

A few participants stated that having a boyfriend clearly earned teens greater popularity. “But you know, by saying that I have a boyfriend and stuff, I felt like, you know, I was special, everybody treated me different, they included me in more events, and stuff like that” (Amber). This participant was pleased that she had been invited to a couples party.

What the participants learned from partners, boyfriends, and girlfriends they learned mostly by their experiences. Many of the teens in this study talked about sexual feelings they experienced in relation to others, including feelings of attraction, desire, and pleasure.

Um … like, he's really beautiful. Um … I want … like, I didn't just wanna be with him, like, I wanted to be with him. Like in a relationship. Like he's the kind of guy who would be a great boyfriend. … When I'm really attracted to someone or when we're just about to kiss or something like that, I get this feeling like in the pit of my stomach. It's all like tingly and like flip-floppy. (Susan)

Despite their own sexual interest, many participants described a common atmosphere of sexual pressure regarding relationships. The most considerable pressure for sexual activity, especially intercourse, came from male partners and boyfriends (many of whom were not peers in that they were considerably older). One participant (Janice) explained that if you had a boyfriend in high school for more than two months and if he knew you had already had sex, then he would usually expect to have sexual intercourse. “The pressure probably comes from the guys, mostly. Most girls, if they really like the guy, they don't want to tell them, “No.” They think, “If I don't do it, he may not talk to me no more.” However, a few participants in this study also described some male partners and boyfriends and all female partners and girlfriends, as not pressuring them toward sexual activity. “He wants to have sex really. But I don't think that's okay, and he says, ‘Fine.’ Yeah. We talk about that a lot. Yeah” (Sylvia).

The teens in the study struggled with the pressure they felt. A few participants recounted stories in which they were repeatedly asked to have intercourse. One participant describes being asked to have intercourse by one boy for four years. Initially she told him “no,” then “I don't know.” “And he just kept asking me. … I just said alright” (Kim). At that time she had intercourse she was 13 years old and she said she had become curious about having sex.

Sexuality Education in School

Most participants talked about a class in fifth or sixth grade that covered puberty and reproduction. Often the teens had another class in seventh or eighth grade and another class in high school. One girl mentioned that she had received some information over the course of several years. “Actually, in private school they used to do really basic sex education up through all the grades. Which is really good, I think” (Brandy). Some girls missed a lot of school or had dropped out and therefore received little sexuality education at school.

Many participants said their school sexuality education focused on the “mechanical” aspects. Some admitted, albeit somewhat reluctantly, they learned something. Usually the teen had some foreknowledge of the topics that were covered, but they said they gained more specific information.

I think I learned a little bit more. It wasn't all of the sudden this huge awakening. I had known pretty much a lot of it before. I think I learned more of the technical details. I learned about the details in slang terms from my friends and then I learned the technical stuff about the details from the class. (Gayle)

Topics usually included: pregnancy and reproduction; STDs including HIV; abstinence; contraception; safe sex; and condoms. Several participants said that they found this information helpful.

I pretty much knew about what sex was and everything. I mean, they did teach me about a lot of contraceptives I didn't know about. 'Cause, like, the only thing I knew about was the condom. And the rest of 'em I was like, “Oh wow, what's this?” But I think they did a pretty good job on letting me know of more different ways on how to protect yourself. (Shari)

A couple participants noted the information provided about STDs was too graphic and scary.

I don't know. Some of the stuff was, like, ok, like, good to know. But, like, some of the pictures was really out of control. I don't know how to say it. It was, like, good to show, if you have the sexual transmitted disease, how it would look on you and stuff like that … So it was like you're showing people how you would look or your body would look if you get this disease. So it would change their mind about doing it, because they don't want to walk around like that. [What do you mean by out of control?] Like, this one picture showed this sore on this male penis and it was, like, it was busted open. (Maya)

Several participants noted how others acted in sexuality education classes. Some boys acted immature and made jokes, but this usually happened back in middle-school classes. A few teens described their high school classes in which few questions were asked.

And, like, I'd be the only one asking questions, too. In our class, I think I was the only one that asked questions all the time. ‘Cause I was interested in, like, the birth control thing and like how it's not one hundred percent accurate and all this, I used to ask all the questions and everybody else was not saying nothing. That's just how I was, I had to ask questions. (Kim)

A few participants commented about what was missing from the sexuality education curriculum. Some topics mentioned as missing in school sexuality education were discussions about relationships, issues related to sexual desire, and homosexuality.

It's all more mechanical, what you learn in school. And sex is more not as mechanical as it is emotional. And the mechanics, they're necessary to know because it's better for people's sexual health that they know those kinds of things, but, it doesn't really teach you about a sexual relationship. It doesn't teach you a mature relationship and what that entails. That's the things that it leaves out. (Nicole)

I think that their main focus is on you don't feel pressured to have sex and things like that. I think that they depict it was the guy wants to have sex and the girl doesn't. And the guy is like, “Oh it will feel good.” They don't realize that a lot of girls want to have sex, too. And so I don't think that they focus on that enough at all. (Natalie)

I would also include stuff on homosexuality. They have a rule now that only health teachers can talk about it, and they can only talk about it in STD discussions. I think that that's really bad and really unfair. I think that it should be talked about 'cause I know that if you didn't come from a family who was okay with that sort of thing, you wouldn't even necessarily know what to call it. And it would probably be really weird for you. (Carola)

Media

Several participants described TV and movies as magnifying positive messages about sex, although the reactions to these messages varied. One teen described her reaction to the programming this way:

They be making it look like the best thing in the world, like you should try it. … Like, HBO or something, like, if you're watching TV at night, you look, like, what is this, and they be all into it, like, it's the world … [How has this influenced you?] Like, you should do it but then it's always the real world's telling you don't do it. You gone get pregnant, you gone get a STD. But they don't show that on TV. (Julia)

Many interviewees described relationships portrayed unrealistically as “a perfect couple,” “utopia,” and “love at first sight” and added comments like “that's so untrue.” Several participants noted that some shows and infomercials covered such topics as sexually transmitted diseases and abuse in relationships. For a few teens in the study, the topic of abuse seemed especially realistic. “I love Lifetime because it shows how women get abused, sex, and stuff. It shows a lot of stuff about women. And I can relate to that” (Janice). When some participants talked about what they thought was “good” programming, they would often provide examples of specific shows, describing plots that seemed to parallel their own concerns.

She's a virgin and she's getting into, like, her first real relationship. And she, you know, she really wants to have sex. There was just an episode about that. And how, you know, she was like, I think that we should have sex. And she was really eager about it. And then she took the time to think about it and, like, I think that it shows all the different levels, you know, like, your body is totally ready to have sex, but you're really not emotionally ready or you realize … You know what I'm saying? And I think that it shows that really well. (Susan)

Susan was exploring similar issues in her own life. Other examples of “good” shows covered topics such as women taking charge of their sexuality (Becca), gay and lesbian relationships (Joan and Susan), and a “roller coaster relationship with this boy” (Lisa).

The participants in this study listened to a variety of popular musical genres such as rap, jazz, gospel, country, rock, and folk. Several participants said the lyrics of the popular music they listened to conveyed romantic portrayals of relationships. Some interviewees said sex was a common topic in songs. “All my favorite songs, the messages glorified sex as being just as, oh, we have to have sex right now. All my favorite songs. They all say have sex right then and there” (Nicole). A few participants mentioned male non-monogamy was a common topic in songs.

Like Tupac. He … he keep all his stuff real. He … like, when he talk about how … cuz he's a scandalist. He'd talk about how he be having sex with other people's girls and all that. And I think that he really telling the truth ‘cause he ain’t got no reason to lie. (Kim)

Some participants said the lyrics sung by some male rap artists conveyed degrading images of women. “Yeah, because rap disrespect women. Like call them bitches and whores, and sluts and hoochie and stuff like that, excuse my French” (Janice).

Even so, they listened to the music. One teen stated that she tried to screen out the words. “Like as far as rap music sometimes it's not all the right messages. But I don't really too much focus on that 'cause I know it's not right. So, I don't pay any attention to it. … Like in this song, a man is calling his girlfriend a bitch” (Toni)

The teens often mentioned the names of the magazines they read or “looked at” such as, Seventeen, Ebony, Teen, Jet, YM, Ms. Rolling Stone, New Moon, Essence, and The Source. A few participants said magazines provided them with useful information. “About the use of the condoms, you can get pregnant if you don't put this condom on right. Like is there a right way to put on a condom? You just put it on. It taught me how to do all that” (Tete). Another teen described learning more about her body.

I guess I do remember learning some stuff from the Sex and Body columns from the teen magazines that was good. I remember first learning what discharge … I didn't know what it was, coming from me. When people talked about discharge, I didn't know what that was, and I remember I learned that. I learned it specifically from a specific Sex and Body column. (Gayle)

A few participants mentioned they liked the discussions of relationship problems in the advice columns. However, some also noted that advertisements often conveyed stringent beauty standards, “like when every woman is suppose to be a certain shape, like skinny, big boobs, or whatever. And every guy is supposed to be like built and everything. And every time it's shown like you're not going to have a good sexual experience or anything if you're not this way” (Jess). One teen said the advertisements make her “want to buy.”

Missing Messages

Eighteen participants discussed messages about sex, sexuality, and relationships that they had identified as lacking or that they wished they had received from any source, yet few identified the family as a likely source for providing these. Some felt there was not enough discussion about how to have mature relationships. Several noted a lack of discussion about sexual desire, for example:

I think that it would be good for them to know that they shouldn't feel like they are different or something if they want to do stuff. But, I think that they should also realize that the way society is when they do stuff, they are considered whorish and they're considered, like, easy or something like that. When a guy does stuff, he gets props. (Natalie)

One noted the importance of sexuality education in schools for those who could not comfortably discuss sex-related topics in their families.

I think they should have it.’Cause it's in this, it's, like, in this … in education. Because if you don't feel comfortable talking to your parents about it, or whatever, then you'll always have someone else to talk to, too. They won't run back and, like, try and tell your parents that you'd get in trouble or anything. (Alice)

Lisa talks about missing messages that she sees in other families.

A whole lot of kids don't feel comfortable having it and talking about it. And there are so many kids that learn so much about it because their parents wouldn't talk to them about it. I think that at whatever age you think your kids are ready, but not too late, is when a parent should inform their kids about sex. Like, I know my best friend's family, she has little sisters and, you know, she has a nine year old little sister who doesn't know yet and it's like the longer you wait it's like the longer she's going to find out about the wrong people and the wrong sources. So I think, in that sense, that we should have an established time and age in school when you learn it, kind of to give parents another option. Tell them to tell your kids before this class or after the class. My parents told me before and I was glad they did. (Lisa)

Discussion

The girls identified family, friends/peers, partners, school, and the media as the most common sources for learning about sex, sexuality, and relationships. The girls in the study learned different types of information about sexual issues and relationships from the different sources. Health care providers were generally not viewed as a resource for discussing sexual health issues other than contraception or reproductive tract infections.

From family, girls learned about waiting to have sex or to date, sexual risk and protection, abuse, and taking charge of their lives or their relationships. Their learning took place through conversations, observation, and other experiences. Most participants described family scripts regarding sex, sexuality, and relationships that involved their parents, especially their mother (or primary female caretaker). Some girls who generally felt comfortable talking with their mothers, however, felt that there should be boundaries for these discussions and that certain topics such as sexual pleasure and sexual feelings were not appropriate. In their interactions with parents, girls often struggled with their parents' responses to their behavior and the amount their parents could influence their decisions. This dynamic was less apparent when girls described scripts involving extended family. Relatives who were closer in age to the teen than the parents (older siblings and cousins, younger aunts and uncles) were sometimes able to provide information or guidance that seemed more relevant.

The girls in this study acknowledged that although sex-related discussions with their parents were informative, these discussions were often limited to topics related to reproductive health dangers. These findings are consistent with other studies on sex and parental communication. DiIorio, Kelley, and Hockenberry-Eaton (1999) reported that teens' discussions with parents were often focused on the negative consequences of sex and sexuality and many parents did not focus on helping the teens understand and come to terms with their sexual identity.

Parents are the most influential socializing force in a child's life. As a result, parents are in a unique position to shape their teen's values and behavior. DiIorio et al. (1999) reported that teens who did engage in conversations with their parents were more likely to delay sexual initiation than teens who primarily discussed these issues with their peers. Similarly, Whitaker and Miller (2000) reported that parental communication reduced the extent to which peer norms influenced a teen's initiation of sex and condom use. Hutchinson and colleagues (2003) also reported that higher levels of mother-daughter communication resulted in fewer incidents of sexual intercourse and unprotected sexual intercourse (Hutchinson, Jemmott, Jemmott, Braverman, & Fong, 2003). Having a positive impact on teens' sexual behaviors requires open and honest conversations that provide accurate information about the risks, consequences, and responsibilities surrounding sex. Parents can help promote a teen's sexual health and development by having these discussions with their teen throughout adolescence (Crosby & Miller, 2002). In order to facilitate conversations between parents and teens that promote the development of sexual health, more research on the content of sex-related conversations and how these conversations take place is needed (Crosby & Miller, 2002). Furthermore, process-related factors such as the timing of the communication, parental responsiveness during the conversation, and the actual message that is communicated to the teen need further investigation (Crosby & Miller, 2002).

In this study, the participants talked with friends about specific and real issues, for instance, slang terms, non-intercourse sex, relationships, and sexual safety as well as sexual feelings. The depth of these discussions varied but, for some girls, close friendships provided a safe place to have meaningful interchanges. However, for many girls, the wider peer network was characterized by competition, lack of trust, or social pressures to conform to social norms pertaining to relationships and sexual experiences.

Most of the literature on peers and teens has explored the relationship between peer norms and sexual behavior. Similarly, Kinsman and colleagues (1998) reported that the strongest predictor of sexual initiation in a group of sixth graders was having a high intention to engage in sexual activity. They found that the strongest predictor of intention was a belief that most of their friends had already engaged in sexual activity (Kinsman, Romer, Furstenberg, & Schwarz, 1998). Although the literature has described the role that peer norms have on sexual behavior, few studies have described the exact content of these discussions (DiIorio et al., 1999). A greater understanding of the sex-related peer pressures that are experienced by teen girls in addition to understanding what teens gain through these conversations is needed. These insights will help researchers and health care providers provide a safe space for girls to engage in sex-related discussions with their peers with support from a trusted adult source.

In the social sphere of sexual partners, boyfriends, and girlfriends, participants described strong pressures to conform to the norms of heterosexuality while trying to sort out their own desires. Many girls talked about sexual feelings such as attraction, desire, or pleasure. However, these feelings seemed to fade into the background when girls described the social pressures to have a boyfriend or to have sex. For those girls with boyfriends, the expectations and meanings of these relationships varied. For some, having a boyfriend helped maintain the appearance of being attractive and popular. Martin (1996) highlights the importance that boyfriend-girlfriend relationships play in a teen's life. “It is important not to underestimate the role and power of ideal love in adolescent girls' lives … it is about ideal love and fear of losing that love, if one refuses sex” (Martin, 1996, p. 77). It is important to recognize that teenage relationships are a complicated emotional issue for teenage girls. More discussion with teens on dating and relationships could help girls process their emotions and come to terms with the pressures that surround teenage relationships.

Some girls were influenced by strong pressures from peers or boyfriends to “do more” or “go further.” These pressures led many to experience inner conflicts as they tried to maintain their values and social standing in multiple social spheres. According to Martin (1996), typically girls are pressured into sex by boys and teen girls often succumb to these pressures. Sionean et al. (2002) suggested that negotiating for safer sex practices is an important skill for teenage girls to develop in order to help them stand up to sex-related pressures. Interventions that focus on developing teens' sexual agency and teaching adolescent girls how to refuse unwanted sex and negotiate for safe sex need to be incorporated into sex education programs.

Sex education in schools was often described by participants in this study as too technical. Some participants also found graphic descriptions of sexually transmitted diseases in sex education programs to be frightening. For several girls, sex education lacked emotional context and failed to provide practical guidelines for applying technical information to their own lives. In addition to the limited curriculum of sex education classes, the very setting in which these classes took place may have inhibited discussion.

According the literature on sexual education programs, the most widely evaluated school-based programs have targeted risky sexual behaviors and have been focused on outcomes— promoting abstinence, delaying sexual intercourse, and increasing the use of contraceptives (CDC, 2008b; Sociometrics, 2008). Intervention programs that include developmental issues, such as teen dating and relationships, need to be developed and evaluated to determine their effectiveness. Graber and Brooks-Gunn (2002) argue for school-based programs that include information on developmental issues and challenges as well as skill-building to enhance behavioral outcomes.

According to many participants, television and movies magnified and glorified sex. Many noted that relationships were portrayed in superficial or unrealistic ways. Programs and movies depicted relationships without any conflict or difficulties and sex as the ultimate experience that was always pleasurable and mutually satisfying. Some types of popular music, notably rap music, commonly used derogatory slang terms for women. Martino and colleagues (2006) found that teens, regardless of sex or gender, when exposed to degrading music lyrics— especially those that portrayed women as, primarily, sexual objects—were more likely to engage in sexual activity. These findings highlight the impact that cultural messages related to sexual practices and relationships have on adolescent girls.

A few participants noted that advertisements often conveyed rigid standards for physical beauty that only some could attain. These ads also insinuated that if women did not measure up to these standards, they were less likely to have satisfying relationships. Similarly, in a literature review of sexual media content in magazines, Brown and Stern (2002) found that girls reported that unrealistic images in women's magazines made them feel bad about themselves and can produce feelings of dissatisfaction with one's body. Our findings also indicated that some girls found solace and support in other aspects of the media that conveyed useful information, for example, pragmatic aspects of condom use, or more realistic portrayals of experience that explore the subtle complexities of topics such as relationships, abuse, or sexual feelings. This is consistent with the findings of Sutton, Brown, Wilson, and Klein (2001) that high school students reported learning about sex-related issues from media sources and some reported intentionally going to these sources for information that they could not obtain elsewhere. However, these finding suggest that teens are not able to access sufficient information about sex from non-media sources such as parents, peers, and sex education programs.

In conclusion, the girls in this study found some comfort and support within their families, either with their primary care givers or extended family members. Other families, however, were unable to achieve a balance between respecting teenage girls' autonomy and need to make independent decisions about sexuality and relationships on the one hand and the girls' need for parental support and guidance on the other. In the other social spheres outside of the family (friends/peers, partners, school, media), information was often limited, guidance was minimal, and pressures to adhere to narrow standards of behavior and appearance were strong. Given this social context, many girls experienced conflicting messages about their sexual health and struggled to integrate the disparate cultural references to sex, sexuality, and relationships that emerged from these different spheres of social life.

Implications

This study explored the various sources from which girls learn about sex, sexuality, and relationships. By doing so, it fills a gap in previous literature by assembling a more comprehensive view of the many social contexts that affect girls' perceptions and experiences relating to sex, sexuality, and relationships and, ultimately, their sexual health. By looking at the information most girls in this study gained from parents, peers, school, and media, it is apparent that girls were receiving conflicting messages about their bodies and sex-related issues. Furthermore, there was no social location where girls could feel safe to process these disparate messages about sex, sexuality, and relationships. Each site held promise to offer some guidance, but had the potential to increase the girls' social, emotional, or physical vulnerability as well. Girls often had to navigate the journey of their sexual development with little room for reflection about their own thoughts, feelings, desires, and decisions.

Health care providers, especially those in mental health, are in an optimal position to fill a void and promote girls' physical, developmental, and emotional sexual health. One of the most striking findings of this study is that the teenage girls did not view health care providers as a significant source of information or support. However, providers can play a number of roles both with the girls and with their parents. First, they can provide girls with a neutral place for either individual discussions or a facilitated group discussion with a supportive and knowledgeable adult. In these settings, they can help girls process the multiple, and often conflicting, messages they are receiving about their bodies, sexual behavior, and relationships. This would enable the girls to better distinguish between media hype, peer pressure, pressure from a partner or potential partner, and their own sexual feelings. Second, providers can help girls develop skills and strategies for resisting the pressures they encounter. This is important for negotiating safer sex and condom use, as well as helping girls be in charge of their sexuality. Third, providers can facilitate parent-adolescent communication in supportive families and assist girls in finding the resources they need if families are unable to provide this guidance. Health care providers can work with individual girls, their families, and communities to help create and evaluate comprehensive programs that foster sexual health for all adolescent girls. This additional support for girls and families and the provision of evidence-based programs from health care providers has the potential to enhance girls' sexual health—and thereby enable them to more effectively reduce their sexual risks.