Talk with teens about sex: Unwanted sex common?

More effective communication cuts risks

In taking a sexual history from your next patient, a 15-year-old female tells you she is in a monogamous relationship with her boyfriend. She discloses that he often uses marijuana, and sometimes they have sex without a condom. When you ask further about the relationship, she tells you that sometimes she has unwanted sex with the boyfriend rather than risk an argument.

Many adolescent girls report being threatened or pressured by their partners into having sex, potentially increasing their risk for sexually transmitted diseases (STDs) and pregnancies, according to newly published research.1

Researchers at Indiana University Medical Center in Indianapolis conducted the new study, looking at 279 female adolescents ages 14-17 over 27 months. At each interview, the participants were tested for STDs and asked a series of questions about their sexual relationships. The teens talked about their sexual partners and provided details about their relationships. Investigators also asked about unwanted sex in the relationship, using such questions, "Would he break up with you unless you wanted to have sex?" and "Would he get mad if you didn't want to have sex?"

About 41% of the teens reported unwanted sex at least once, with about 10% reporting that they had been forced to have sex. Most said they had unwanted sex because they feared the partner would get angry if it was denied. Findings from the study indicate that unwanted sex appeared more likely to occur in longer-term relationships, among partners who had a baby together, when a female perceived less sexual control with a partner, when condoms were not frequently used, and when alcohol or marijuana were used by either partner.1

While the newly published paper reported on some 1,400 different sexual experiences in young women, it is important to note that 85% were without coercion, says Margaret Blythe, MD, the paper's lead author and professor of pediatrics at the Indiana University School of Medicine. However, the 15% of experiences that were coerced have significant impact, since they translate into negative effects on young women's self-esteem and their ability to feel confident in negotiating their feelings, she states.

Clinicians need to ascertain that a young woman is able to discourage sexual contact, whether it is an inappropriate touch, groping, or not allowing unwanted sexual intercourse, says Vaughn Rickert, PsyD, professor of clinical population & family health at Columbia University in New York City.

Rickert and fellow research associates spoke with 904 young women ages 14-26 at two Texas family planning clinics to analyze their feelings of sexual assertiveness. Almost 20% of the women believed they never had the right to make their own decisions about contraception, regardless of their partner's wishes, or to tell their partner that they did not want to have intercourse without birth control.2

The most important strategy for clinicians is to gauge whether the patient believes she has the ability or actually has the ability to talk to her partner about what she wants and doesn't want to have happen to her body, says Rickert. The problem for the clinician comes when the patient says she really can't say no, he states.

Check age of partner

When talking with a teen about their partners, be sure to ask about ages. Why? Research published in 2005 indicates that sexual activity between teens ages 15 and younger with individuals who are three or more years older correlates with risky health outcomes including unprotected sex and teenage childbearing.3 While most of these relationships are voluntary, they are more likely to be nonvoluntary than other teen sexual relationships, researchers note.

In the analysis, prepared by the Washington, DC-based Child Trends, researchers found that females ages 15 and younger whose first sexual experience was with an older individual were twice as likely as other sexually experienced females to report the experience was nonvoluntary — defined as the female did not choose to have sex of her own free will. An additional 9% of teens in the same group reported the sexual experience as voluntary, but they really didn't want it to happen.

Such activity is of concern for family planners. Young teens who have had sex with an older individual are less likely to use contraception at first sex than other sexually experienced teens.3 Teen childbearing is more common among females who had first sex at age 15 or younger with an older individual (44%) compared to 26% of other sexually experienced females.3

How can you help teens avoid unwanted sex? First, acknowledge the possibility, says Blythe. Family planning providers who see young women on a regular basis for pill refills or contraceptive injections have a perfect opportunity to open a line of discussion, she notes.

Lead off with a question or two, such as, "Last time we talked, you were in a relationship with this young man. What's your sense on how things are going?" suggests Blythe. This may be followed up with a statement, "There may be certain situations where you or your partner may not want to be involved in an intimate physical relationship. Some of those situations may be when either of you has been using alcohol or marijuana, and specifically when the partner has been using [drugs or alcohol] and you are not."

Drugs and alcohol can lead to loss of control, notes Blythe. A partner who is high may not be able to pick on the cues that an intimate physical relationship is not wanted, and a person who is inebriated may not have the willpower to resist sexual advances.

"There is a sense of loss of control of those situations," notes Blythe. "When there is loss of control, there are bad feelings that result, and that has a bad impact on relationships."

Don't be afraid to approach questions about sexual relationships, advocates Rickert. While providers face time constraints in busy clinic settings, such questions are an important facet of overall care, he notes. Rickert suggests such questions as:

  • How is your relationship going for you?
  • Can you talk to your partner?
  • Do you feel comfortable talking about your sexual wants and needs?
  • When you don't want to have sex, are you OK with telling your partner you don't want it?

If the patient says "yes" to these questions, providers can move on through the examination, says Rickert. However, clinicians should have fingertip resources for health educators, social workers, and other professionals for referral if needed.

"I think it is very difficult to learn how to communicate feelings, how to negotiate strategies, and situations where [teens] need to get themselves out," says Blythe. "I think as health care providers and health educators, those are the things we need to be able to anticipate with young people and give them ways to say, "This isn't the time where I feel comfortable or want to.'"


  1. Blythe MJ, Fortenberry JD, Temkit M, et al. Incidence and correlates of unwanted sex in relationships of middle and late adolescent women. Arch Pediatr Adolesc Med 2006; 160:591-595.
  2. Rickert VI, Sanghvi R, Wiemann CM. Is lack of sexual assertiveness among adolescent and young adult women a cause for concern? Perspect Sex Repro Health 2002; 34:178-183.
  3. Manlove J, Moore K, Liechty J, et al. Sex Between Young Teens and Older Individuals: A Demographic Portrait. Research brief. Washington, DC: Child Trends; 2005.