Recommendations and Conclusions
The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions:
- Interventions to promote healthy relationships and a strong sexual health framework are more effective when started early and can affect indicators of long-term individual health and public health.
- Because middle school is a time when some adolescents may develop their first romantic or sexual relationships, it is an ideal timeframe for obstetrician–gynecologists and other health care providers, parents, and guardians to play a role in anticipatory guidance.
- Obstetrician–gynecologists have the opportunity to promote healthy relationships by encouraging adolescents to discuss past and present relationships while educating them about respect for themselves and mutual respect for others.
- Creating a nonjudgmental environment and educating staff on the unique concerns of adolescents are helpful ways to provide effective and appropriate care to this group of patients.
- Obstetrician–gynecologists who treat adolescent patients should provide resources for parents and caregivers and encourage continued parental involvement.
Defining Healthy Relationships
Healthy relationships consist of sexual and nonsexual elements (Table 1). Key aspects of a healthy relationship include respect and communication, and healthy sexual elements include not only physical intimacy, but mutuality and pleasure as well. As stated by the American Academy of Pediatrics, “healthy sexuality includes the capacity to promote and preserve significant interpersonal relationships; value one’s body and personal health; interact with [others] in respectful and appropriate ways; and express affection, love, and intimacy in ways consistent with one’s own values, sexual preferences, and abilities” (1). Obstetrician–gynecologists have the opportunity to promote healthy relationships by encouraging adolescents to discuss past and present relationships while educating them about respect for themselves and mutual respect for others. It is important to discuss with adolescents that there is a wide range of “normal;” for example, some relationships will involve sexual intimacy and others will not.
Learning to develop healthy relationships is a lifelong process and is influenced by a variety of factors, including family, religion, social norms, media exposure, peers, and school, where most adolescents spend the majority of their time. The processes in which early family influences play a role in an adolescent’s future relationships, at least in the domain of romantic relationships, include parental modeling and deidentification from parents (2). As part of a medical visit, obstetrician–gynecologists may assess an adolescent’s knowledge of and experiences with parental and family relationships.
Defining Unhealthy Relationships
Although the primary focus of counseling should be helping an adolescent define a healthy relationship, there are clear elements that characterize an unhealthy one. Aspects of unhealthy relationships include disrespect, intimidation, dishonesty, and abuse (Table 1). Physical violence between dating partners (intimate partner violence) and sexual dating violence (sexual assault and reproductive and sexual coercion) are common events in adolescent relationships. In one study of young females in grades 9–12, 10.7% had been forced to engage in sexual activities they did not want to do, including kissing, touching, or sexual intercourse; 11.3% reported having been forced to have sexual intercourse when they did not want to; and 9.1% reported having been physically hurt on purpose by someone they were “going out with” or dating within the 12 months before being surveyed (3). Furthermore, misogyny and sexual harassment (eg, “catcalling,” touching without permission, insulting with sexualized words) are pervasive among adolescents and young adults. Of women aged 18–25 years, 87% reported experiencing at least one such event in their lifetime (4).
Understanding Adolescent Development
Adolescence is the time frame of psychosocial, cognitive, and physical development when young people make the transition from dependent child to independent adult. Although explorations of gender identity, sexuality, relationships, and intimacy occur throughout a lifespan, adolescence is a critical developmental period (5). The physical and cognitive developments are rarely synchronous; therefore, the obstetrician–gynecologist may encounter adolescents who have matured physically but not cognitively. Young adolescents (12–14 year olds) are typically concrete thinkers with poor or inconsistent abstract reasoning or problem-solving skills. Middle-aged adolescents (15–17 year-olds) often assume they are invulnerable. They may assume, for example, that risks apply to their friends but not to themselves. Generally, older females (18–21 year olds) have acquired problem-solving abilities and have relatively consistent abstract reasoning. Thus, the clinical approach to counseling a cognitively younger adolescent will differ from the approach taken with a cognitively older adolescent or an adult (6). Research in neuroscience demonstrates that adolescents may have limitations to their capacity for consequential thought and ability to imagine alternative outcomes (7); thus, judgement can lag, and adolescents may not always make wise or healthy decisions. Adolescence is a time to prepare for future relationships by learning healthy skills such as compromise, negotiation, conflict resolution, setting healthy boundaries, and other potentially protective behavior.
The Role of the Obstetrician–Gynecologist
The initial reproductive health visit recommended for girls ages 13–15 years provides the opportunity for obstetrician–gynecologists to educate the adolescent and accompanying parent or guardian on numerous age-appropriate health issues (8). Because middle school is a time when some adolescents may develop their first romantic or sexual relationships, it is an ideal time frame for obstetrician–gynecologists and other health care providers, parents, and guardians to play a role in anticipatory guidance. In addition to counseling about reproductive and general health, the visit also may include a discussion about healthy relationships. Creating a nonjudgmental environment and educating staff on the unique concerns of adolescents are helpful ways to provide effective and appropriate care to this group of patients. Resources on preparing medical practices for adolescent patients and talking with adolescents are available in the American College of Obstetricians and Gynecologists’ Adolescent Guide (9). Obstetrician–gynecologists and other health care providers caring for minors should be aware of federal and state laws that affect confidentiality (10). Statutes on the rights of minors to consent to health care services vary by state, and obstetrician–gynecologists should be familiar with the regulations that apply to their practice. Useful sources of information on state laws include the Guttmacher Institute (11) and the Center for Adolescent Health and the Law (12, 13).
Obstetrician–gynecologists may counsel adolescents and young women to define their current relationships as well as their expectations or hopes for future ones. Because current and future relationships may involve sexual intimacy, comprehensive sexuality education should begin in early childhood and continue through a person’s lifespan (14). Obstetrician–gynecologists should screen routinely for intimate partner violence along with reproductive and sexual coercion and be prepared to address positive responses (15, 16). Additionally, noncoital sexual behavior is a common expression of human sexuality for adolescents and adults, and obstetrician–gynecologists should actively engage patients in discussions about all sexual behavior to assess patient perceptions as well as risks (17). Romantic relationships without sexual intimacy or sexual elements also are important and should be discussed. In addition, obstetrician–gynecologists have the unique opportunity to act “bi-generationally” by asking their adult patients about their adolescents’ reproductive development and sexual education (18).
Multiple tools exist to assist obstetrician–gynecologists in their efforts to promote healthy relationships in adolescents. Counseling starts with the ability to ask age- and education-appropriate open-ended questions that allow an adolescent to express herself (Box 1). Because adolescents use a variety of media sources to fill in knowledge gaps, online communication and online sources of information should be addressed along with their benefits and potential dangers (18). For more information, see Committee Opinion No. 653, Concerns Regarding Social Media and Health Issues in Adolescents and Young Adults (19). Numerous reliable online resources exist and can be shared with patients and their families (see the For More Information section). Regardless of which tools are chosen, obstetrician–gynecologists have the potential to play a unique and important role in educating adolescent patients about healthy relationships as well as identifying troubled partnerships. Obstetrician–gynecologists should be aware of mandatory reporting laws in their state when intimate partner violence, adolescent dating violence (20), or statutory rape is suspected. Obstetrician–gynecologists also should be aware that adolescents who have recently experienced the breakup of a romantic relationship may be at greater risk of mental health issues, suicidal ideation, and self-harm. In a group of adolescents aged 10–18 years who sought counseling for a romantic concern, the most common concern was postrelationship issues, including breakups. Female adolescents were more concerned about the dissolution stage of relationships when compared with males, who showed greater concern about the establishment stage (21).
Involving Parents and Caretakers
Obstetrician–gynecologists may provide guidance for parents and families and suggest tools to help in their discussions with their adolescents (Box 2). When surveyed, a large proportion of young women expressed a desire to receive more information or guidance on some emotional aspect of romantic relationships either from a parent (70%) or in a health or sex education class at school (65%) (4). Important aspects to communicate include the following:
- Encourage good relationship modeling. The family unit plays an important role in a young person’s sexual health (22). Supportive relationships with parents or other caregivers enable adolescents to develop interpersonal skills that influence their choice of partners and views on relationships.
- Encourage parents to discuss sex. Adolescents who recall a parent talking with them about sex are more likely to report delaying sexual initiation and increasing condom and contraceptive use (23). Although mothers primarily communicate with adolescents about sex, fathers play a role in their adolescents’ sexual socialization (23); thus, it is important for obstetrician–gynecologists to encourage involvement by both parents when possible. Open communication should pertain to all children in the family, male and female. The benefits of parenting extend beyond helping adolescents avoid sexual risk. Parent discussion also enhances adolescents’ capacity to have positive sexual relationships (24). Parental involvement, knowledge of reproductive health, and effective communication can modify adolescents’ sexual behavior (22, 25).
- Encourage parents to monitor media. Parental monitoring to reduce exposure to a highly sexualized media environment (eg, television, the internet, social media) may offer protection against early sexual initiation (24, 26). In contrast to sometimes unreliable sources in the media or friends, parents are uniquely suited to engage and educate their children about sexual health; notably, many adolescents cite parents as preferred sources for accurate sex-related information (27). In some studies, interventions that engage parents and youth in sexual health communication and incorporate parental monitoring have been associated with increased comfort in discussing sex and content expertise for parents and decreased sexual risk behavior among youth (27).
- Encourage parents to be flexible in their approach. Because adolescents’ sexual knowledge and behavior change throughout adolescence, parental approach to discussing sex with their adolescents should change as well. Parents should be counseled that adolescent sexual behavior is a normal developmental milestone and parents should receive information about the profound neurocognitive, social, and emotional changes that occur during adolescence (7).
- Provide resources for parents and guardians. Obstetrician–gynecologists who treat adolescent patients should provide resources for parents and caregivers and encourage continued parental involvement. Resources to help parents talk to their adolescents are included in the For More Information section.
Pregnant and parenting adolescents; lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ) individuals; and adolescents with physical and mental disabilities are at particular risk of disparities in the health care system (28–30). Adolescents with physical and cognitive disabilities often are considered to be asexual and, thus, have been excluded from sexuality education (18). However, every adolescent has the capability to form relationships, and no group should be marginalized or omitted from receiving information about healthy sexual and nonsexual relationships. Needs of subgroups will vary and discussions should provide an open environment for patients to express their unique concerns. The promotion of healthy relationships in these groups requires the obstetrician–gynecologist to be aware of the unique barriers and hurdles to sexual and nonsexual expression, as well as to health care.
Effect of Interventions
Interventions to promote healthy relationships and a strong sexual health framework are more effective when started early and can affect indicators of long-term individual health and public health (31). Early intervention programs in middle schools have demonstrated sustained positive effects on female and male students’ attitudes toward issues of gender equality and adolescent dating violence (32). Brief interventions in an emergency department showed a reduction in moderate and severe dating victimization in patients aged 14–18 years (33). Continuing interventions, including sexual and reproductive health counseling, education, and contraceptive availability, have been effective in increasing adolescent knowledge about sexual health and contraception, resulting in increased use of contraception and a decrease in unintended pregnancy (34). In addition to effects on the individual adolescent, intervention programs have demonstrated effects on policy and practice (35). Obstetrician–gynecologists should support programs that encourage sexual health (14).
For More Information
The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/HealthyRelationships.
These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.
1. Breuner CC, Mattson G. Sexuality education for children and adolescents. Committee on Adolescence, Committee on Psychosocial Aspects of Child and Family Health. Pediatrics 2016;138:e20161348.
2. Kuo SI, Wheeler LA, Updegraff KA, McHale SM, Umana-Taylor AJ, Perez-Brena NJ. Parental modeling and deidentification in romantic relationships among Mexican-origin youth. J Marriage Fam 2017;79:1388–403.
3. Kann L, McManus T, Harris WA, Shanklin SL, Flint KH, Queen B, et al. Youth risk behavior surveillance—United States, 2017. MMWR Surveill Summ 2018;67(SS-8):1–114.
5. Miller E. Prevention of and interventions for dating and sexual violence in adolescence. Pediatr Clin North Am 2017;64:423–34.
6. American College of Obstetricians and Gynecologists. Guidelines for women’s health care: a resource manual. 4th ed. Washington, DC: American College of Obstetricians and Gynecologists; 2014.
7. Baird AA, Fugelsang JA. The emergence of consequential thought: evidence from neuroscience. Philos Trans R Soc Lond B Biol Sci 2004;359:1797–804.
8. The initial reproductive health visit. Committee Opinion No. 598. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:1143–7.
9. American College of Obstetricians and Gynecologists. Adolescent guide. Washington, DC: American College of Obstetricians and Gynecologists; 2017. Available at: https://www.acog.org/ayaguide
. Retrieved June 27, 2018.
10. Adolescent confidentiality and electronic health records. Committee Opinion No. 599. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:1148–50.
13. Counseling adolescents about contraception. Committee Opinion No. 710. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e74–80.
14. Sexual health. Committee Opinion No. 706. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e42–7.
15. Intimate partner violence. Committee Opinion No. 518. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:412–7.
16. Reproductive and sexual coercion. Committee Opinion No. 554. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:411–5.
17. Addressing health risks of noncoital sexual activity. Committee Opinion No. 582. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:1378–82.
18. Comprehensive sexuality education. Committee Opinion No. 678. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e227–30.
19. Concerns regarding social media and health issues in adolescents and young adults. Committee Opinion No. 653. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e62–5.
21. Price M, Hides L, Cockshaw W, Staneva AA, Stoyanov SR. Young love: romantic concerns and associated mental health issues among adolescent help-seekers. Behav Sci (Basel) 2016;6(2).
22. Wight D, Fullerton D. A review of interventions with parents to promote the sexual health of their children. J Adolesc Health 2013;52:4–27.
23. Akers AY, Holland CL, Bost J. Interventions to improve parental communication about sex: a systematic review. Pediatrics 2011;127:494–510.
24. Parkes A, Henderson M, Wight D, Nixon C. Is parenting associated with teenagers' early sexual risk-taking, autonomy and relationship with sexual partners? Perspect Sex Reprod Health 2011;43:30–40.
25. Gavin LE, Williams JR, Rivera MI, Lachance CR. Programs to strengthen parent-adolescent communication about reproductive health: a systematic review. Am J Prev Med 2015;49:S65–72.
26. Parkes A, Wight D, Hunt K, Henderson M, Sargent J. Are sexual media exposure, parental restrictions on media use and co-viewing TV and DVDs with parents and friends associated with teenagers’ early sexual behaviour? J Adolesc 2013;36:1121–33.
27. Sutton MY, Lasswell SM, Lanier Y, Miller KS. Impact of parent-child communication interventions on sex behaviors and cognitive outcomes for black/African-American and Hispanic/Latino youth: a systematic review, 1988–2012. J Adolesc Health 2014;54:369–84.
28. Care for transgender adolescents. Committee Opinion No. 685. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e11–6.
29. Health care for lesbians and bisexual women. Committee Opinion No. 525. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:1077–80.
30. Menstrual manipulation for adolescents with physical and developmental disabilities. Committee Opinion No. 668. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e20–5.
31. Satcher D, Hook EW III, Coleman E. Sexual health in America: improving patient care and public health. JAMA 2015;314:765–6.
33. Cunningham RM, Whiteside LK, Chermack ST, Zimmerman MA, Shope JT, Bingham CR, et al. Dating violence: outcomes following a brief motivational interviewing intervention among at-risk adolescents in an urban emergency department. Acad Emerg Med 2013;20:562–9.
34. Salam RA, Faqqah A, Sajjad N, Lassi ZS, Das JK, Kaufman M, et al. Improving adolescent sexual and reproductive health: a systematic review of potential interventions. J Adolesc Health 2016;59:S11–28.