TALKING TO TEENS ABOUT SEXUAL PLEASURE

1. TALKING TO TEENS ABOUT SEXUAL PLEASURE BY KYLE RAGINS, YALE SCHOOL OF MEDICINE AND ISABEL CHEN, YALE SCHOOL OF PUBLIC HEALTH

2. DISCLAIMER • This guide is designed by a medical student, with the education of other medical students in mind. It is not intended to provide any medical or legal advice specific to any given patient. • This presentation is intended for informational purposes only. How those who view this presentation choose to use this information is solely their responsibility. Kyle Ragins, Isabel Chen, the American Medical Student Association, the AMSA National Sexual Health Scholars Program, and anyone who uses the slides of this presentation, relinquish all legal responsibility for your actions in using what you learned in this presentation. • Be smart. Be safe.

3. THE PURPOSE OF THIS PRESENTATION • Traditional emphasis for doctors or sexual health educators in addressing sex with teens is focused on safety (i.e. pregnancy and STI control); doctors, parents, and schools have been shown to rarely, if ever, comment on the issue of pleasure (Elliott 2010) • Don’t forget, safety is important! Teens are the most likely demographic to use inadequate contraception or STI protection during sex (Isley et al. 2010) and 15 to 24 year olds are the most likely to become infected with common STIs (Reznik and Tebb 2008) • But, when it comes to sexual pleasure, teens are left in a VACUUM!

4. WE CAN FILL THAT VACUUM • Studies show that 40-50 percent of teens already cite their health care providers as a source of informationabout sex (Bleakley et al. 2010) • However, the number 1 source of info for teens about sex is their friends (Reznik and Tebb 2008); one reason for this may be that doctors, parents, and schools don’t normally offer teens advice about PLEASURE

5. IS THIS OUR PLACE? • YES! • The WHO defines sexual health as “a state of physical, mental and social well-being … [with] the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.” • There is much to be gained by talking about sexual pleasure • Teens will have better, more pleasurable sex • They will be more aware of their own bodies and needs • They will be more likely to consider you a trusted source for safety-related issues, as well as other health issues END RESULT = MORE SAFETY, MORE PLEASURE, MORE HEALTH

6. HOW YOUNG IS TOO YOUNG? • Age, maturity, and cultural factors should always be considered when broaching the topic of sex • Be a smart clinician and use your own judgment, addressing sex in pre-pubescent patients may be appropriate in some cases and inappropriate in others • In pre-pubescent patients it may be best to broach the topic in the context of a genital exam (i.e. “Do you have any questions about your penis/vulva/vagina?”) • Building a dialogue with patients early about sex as they are moving into sexual maturity will help patients come to trust you as a source for information about sex as they move into engaging in sexual acts • Be careful! Talking about sex with minors can be a prosecutable form of sexual abuse

7. 6 STEPS FOR TALKING TO TEENS ABOUT SEX • Address the issue of sex • Enquire about questions • Stress safety – physical and emotional (the “4 rights”) • Introduce the issue of pleasure • Give advice about pleasure based on CLEWS model • Summarize and wrap up with emphasis on safety • *Steps 1-3 should be completed with any post-pubescent patient, while the clinician should read the situation carefully and decide to continue into steps 4-6 only when appropriate

8. INITIATING CONVERSATION • ASK ABOUT SEX! Research shows that the single most important variable that will determine whether teens consider their clinicians a primary source of information on sex is whether their doctor asked them about sex (Reznik and Tebb 2008) • Confidentiality has also been shown to be key in adolescent decisions to seek the attention of health professionals on sensitive issues (Rosenthal 1999) • Always start a conversation about sex when the patient is alone

9. STEP 1: ADDRESS SEX • “As your doctor, I want you to know that you can tell me about anything including sex. You don’t need to worry about me telling anyone, because I will keep anything you say completely confidential.”* • “A lot people your age start to become interested in kissing, hugging, or sexual contact with other boys and girls. Have you or your friends done this at all?” • “Are you having sex? What kind?“ • “Have you had any kind of sex?” • “Do you have a boyfriend/girlfriend? What do you do together?” • “Are you interested in having sex of any kind?” • “Have you had any sex ed classes at school? What did you think of them?” • *In the United States, you are legally required to report sexual abuse in anyone under 18. Different states have different laws about the specifics of this, so do your research, avoid lying to your patient, and clarify this with your patients if and when necessary.

10. STEP 2: ENQUIRE ABOUT QUESTIONS • “What questions do you have about sex?” • “What questions have you or your friends had about sex?” • “Do you have any questions about your vagina/vulva/clitoris/penis/foreskin?” • “Is there something you want to ask me about sex?” • “What questions do you have about kissing, hugging, touching, or any kind sexual contact?” • “What questions do you have about sexual orientation?” • “What questions do you have about sexual safety?” Remember: Sex is a topic many teens are curious about and don’t have a lot of reliable sources to go to for information, because frank discussion of sex can be so taboo in our society. Don’t add to that taboo! This is your chance to answer questions teens might not have another chance to get a good, honest and accurate answer to.

11. STEP 3: STRESS SAFETY • Regardless of whether you address safety in your answers to patient questions you NEED to give a short sex safety talk when talking to any teen about sex (remember the statistics about teens, protection, pregnancy, and STIs from before) • Safety should be addressed BROADLY in PHYSICAL and EMOTIONAL terms • A good way to open up this topic is with a permission question • “Is it okay if I tell you some information about sex safety?”

12. PHYSICAL SAFETY • Pregnancy and infection protection • This should be the one part of this talk EVERYONE is already VERY familiar with • Remember to emphasize with patients, penis-in-vagina sex is not the be all and end all, many other “safer” sex options • Does anyone have any questions about any birth control methods or STI protection techniques?

13. EMOTIONAL SAFETY • Often neglected by clinicians but is almost as important as physical safety, patients should be warned to protect themselves emotionally, sex can be an emotional event • Encourage 4 “rights”: • Right person – have sex with someone you trust (and maybe even love) • Right reason – have sex because you want to, not because a partner or friends are pushing, or you desire changes in your relationship or social status; avoid ulterior motives • Right time – do you feel ready to have sex? Are you prepared to discuss with your partner what you would do if you got pregnant, what kind of protection to use, what feels good, etc? • Right state – avoid any first-time sexual activity or first-time sexual partner while not sober, that is a recipe for emotional hurt

14. INTIMATE PARTNER VIOLENCE AND SEXUAL ABUSE • There are very real safety concerns at the intersection of emotional and physical safety when it comes to intimate partner violence and sexual abuse • In the US, you are legally required as a medical professional to report abuse to anyone who is under the age of 18 • Be prepared when broaching the topic of sex with a teen that this may be the first time they have had a concrete opportunity to talk about sexual misconduct and report this kind of behavior • Keep an eye out for warning signs of sexual abuse and intimate partner violence and have deeper screening questions ready if need be

15. STEP 4: INTRODUCE PLEASURE • If your patient asked a pleasure-related question during Step 2, you’re set on this and you can sail right in to the CLEWS model (Step 5) in answering their question • Chances are patients won’t ask about pleasure because many do not see physicians as providers of this kind of information, so you have to introduce it • Is everything feeling good when you and your partner engage in sexual activity? Would you want some advice about how make sure things feel the best they can? • I know you said you haven’t had any kind of sex yet, but you’re thinking about starting soon. Would you want to hear some advice about how to make things feel best once you start? • Many people your age are worried about sexual activities hurting or not feeling good, would you want to hear about how to avoid that?

16. STEP 5: THE CLEWS MODEL • C ommunication – communicate with your partner about likes and dislikes, if this feels too uncomfortable, it might mean the patient is not “ready” for sex • L ubrication – any kind of sex from masturbation to penis-in-vagina can feel better with lubrication • E xperimentation – experiment with yourself (masturbate) and with your partner, find out what feels good, you can try anything as long as there is consent; remember penis-in-vagina isn’t everything • W ant – desire is an important part of sexual pleasure, if you wait until both parties truly want it, as opposed to there just being an opportunity, it is more likely to be pleasurable • Safety – the emotional and physical safety emphasized in Step 3 are not only important from a protection perspective, but emotional safety lends another level of intimate pleasure Make sure your patient has a clue when it comes to sex!

17. STEP 6: WRAP UP WITH EMPHASIS ON SAFETY • Pleasure is fun (and important!) but safety with teens is REALLY important • Any conversation about sex with a teen, especially a conversation that dives into sexual pleasure, should wrap up with an emphasis on safety • Remember this isn’t just a condom lecture, emotional safety is important too! • A simple reiteration of a plan to prevent pregnancy and infection while preserving emotional safety is good, or ask a patient to repeat back to you what you talked about to check for understanding

18. LET’S REVIEW THE 6 STEPS! • Address the issue of sex • Enquire about questions • Stress safety – physical and emotional (the “4 rights”) • Introduce the issue of pleasure • Give advice about pleasure based on CLEWS model • Summarize and wrap up with emphasis on safety

19. REFERENCES • Bleakley, Amy, Michael Hennessy Martin Fishbein Harry C Coles Jr, and Amy Jordan. 2009. “How Sources of Sexual Information Relate to Adolescents’ Beliefs about Sex.” American journal of health behavior 33 (1): 37. • Elliott, Sinikka. 2010. “Talking to Teens about Sex: Mothers Negotiate Resistance, Discomfort, and Ambivalence.” Sexuality Research and Social Policy 7 (4) (July 3): 310-322. • Isley, Michelle M, Alison Edelman, Bliss Kaneshiro, Dawn Peters, Mark D Nichols, and Jeffrey T Jensen. 2010. “Sex education and contraceptive use at coital debut in the United States: results from Cycle 6 of the National Survey of Family Growth.” Contraception 82 (3) (September 1): 236-242. • Reznik, Y. 2008. “Where Do Teens Go to Get the 411 on Sexual Health? A Teen Intern in Clinical Research with Teens.” TPJ. • “WHO | Sexual health.” WHO. www.who.int/topics/sexual_health/en/

20. ANY QUESTIONS? • The creators of this presentation can be contacted at kyleragins@gmail.com with any questions, comments, or concerns related to this presentation or other issues of sexual health. We want to hear your thoughts and feedback so feel free to check in!