At a time where issues of consent are being publicly discussed in the media and pop culture, supporting youths’ sexual health and well-being should be a priority. Yet, the primary means Americans use to educate youth about sexual health relies on fear-based tactics that highlight potential negative outcomes rather than health. In this article, we will discuss the potential for sexual health and well-being despite experiences of trauma and adversity. We will also highlight the importance of trauma-informed approaches to sexuality education and increasing adolescents’ access to helping professionals capable of addressing sexual health issues that reinforce respect and well-being.
In general, health is often viewed as the absence of disease. However, the reality is that health encompasses a person’s entire well-being. Thus, sexual health is best conceptualized as “a state of physical, emotional, mental, and social well-being in relation to sexuality… (that) 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” (WHO, 2006). Further, healthy sexual experiences and relationships are critical to healthy development. Positive sexual experiences and relationships are associated with positive outcomes, such as more sexual esteem, more sexual enjoyment, and better communication and negotiation skills (e.g., Horne & Zimmer-Gembeck, 2005; Vasilenko et al., 2014). Regrettably, for youth, sexual health is typically defined and measured as abstinence, absence of sexually transmitted infections (STIs), and absence of pregnancy. Sex education programs focus on reducing risks based on this very narrow definition of sexual health. In doing so, these programs miss the critical opportunity to introduce life-long knowledge and skills to youth that focus on healthy relationships, self-image, pleasure, consent, and sexuality.
A holistic definition of sexual health is critical if we are to support everyone’s right to sexual well-being, especially those who have experienced trauma or adversity. Trauma is defined as “exposure to actual or threatened death, serious injury, or sexual violence” by the American Psychiatric Association (2013). Unfortunately, trauma is not an uncommon experience; about 4.1 million reports involving 7.4 million children were made to CPS agencies in 2016 (USDHHS, 2018), more than 60% of youth are victims of violence each year (Finkelhor et al., 2009), and in 2016, 45% of youth have been exposed to at least one adverse childhood experience (Sacks & Murphy, 2018). The impact of trauma reaches across various domains of development, including sexuality. Those with trauma histories tend to initiate sexual intercourse earlier, have more sexual partners, contract more STIs, become pregnant during adolescence (Noll et al., 2018), experience intimate partner violence (Hamby, Finkelhor, & Turner, 2012), hold critical views of the self and their sexuality, and have difficulty building fulfilling relationships (DiLillo et al., 2009; Lassri et al., 2018). They may also choose sexual partners who are older or who mimic the characteristics of their abusers, they may form attachment to sex traffickers, they may be more likely to use alcohol or drugs during sexual experiences, or they may avoid sexual experiences altogether (Putnam, 2003).
Although not often studied, sexual health is still possible among individuals who have experienced childhood trauma and adversity. Based in resilience theory (i.e., people can bounce back after adversity and achieve healthy outcomes), there is evidence to support that individuals with histories of childhood trauma can be healthy sexual beings. For example, using the National Longitudinal Study of Adolescent to Adult Health dataset, Fava and colleagues (2018) examined trajectories of sexual health among individuals with histories of childhood maltreatment, and found that youth with histories of maltreatment often had comparable levels of sexual health to peers without such adversity. Research also finds that strong social supports are key to health and well-being among those with trauma histories. Therefore, it is important that adults/professionals can effectively counteract early negative childhood experiences by supporting youth from a trauma-informed perspective. Rather than asking youth “what’s wrong with you?”, a trauma-informed question becomes “what’s happened to you?” Accordingly, the focus is on understanding behavior from the developmental and trauma history of the adolescent, rather than a focus on deficits.
We assert that a trauma-informed perspective promotes relationship building whereby an adult provides shame-free, accurate, and inclusive information that emphasizes self-efficacy, pleasure, mutuality, and consent in intimate relationships. Sexual health educators and those in helping professions (e.g., therapists, child welfare workers, juvenile justice workers, etc.) must operate from a trauma-informed perspective to best support the sexual health of youth who have experienced adversity and trauma. Creating safe spaces for relationship building with trusted adults who can provide information means all adults must be prepared to think about sexual health from a trauma-informed perspective. Existing sexual education curricula may need to be adapted or changed so that shame- and fear-based messaging and exercises are not utilized that may act as triggers for youth with trauma histories. Many evidence-based curricula contain condom demonstrations that are not optional, even if the curriculum is being implemented in a setting where youth have likely experienced sexual abuse. For example, to an adolescent who has been forced to touch a penis, this can be triggering, or bring forth traumatic memories and unpleasant emotions. Trauma-informed sexuality education (Fava & Bay-Cheng, 2013; Faulkner, 2018) is one way to offer accurate information about sexuality, but in ways that are not retraumatizing and that offer health as a possibility for all youth.
Oftentimes, adults may feel ill-equipped to discuss sexual health, but we contend that explicit knowledge about sexual health is not as important as providing a trusting relationship. Adults can provide positive messages about the capacity of every person to develop healthy relationships, discuss sexual health as more than pure avoidance of negative health outcomes, and refer youth to experts on sexuality when necessary. Positive sexual health is possible for everyone when we move past definitions that constrain us to only thinking about risk and negative outcomes. A trauma-informed perspective of sexual health rejects the notion that trauma victimization denies one the right to future sexual pleasure and fulfillment.
Cite This Article
Fava, N. (2019, May). Resilient sexualities: Sexual health & well-being despite childhood adversity. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/resilient-sexualities/
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Faulkner, M. (2018, October). Brave Conversations: Utilizing trauma-informed approaches to talk to youth about sexual health. Texas Alliance for Child and Family Services Annual Conference.
Fava, N.M., Bay-Cheng, L.Y., Nochajski, T.H., Bowker, J.C., & Hayes, T. (2018) A resilience framework: Sexual health trajectories of youth with maltreatment histories, Journal of Trauma & Dissociation, 19:4, 444-460, DOI: 10.1080/15299732.2018.1451974
Fava, N.M. & Bay-Cheng, L.Y. (2013). Trauma-informed sexuality education: Recognizing the rights and resilience of youth. Sex Education: Sexuality, Society and Learning, 13, doi:10.1080/14681811.2012.745808.
Finkelhor, D., Turner, H., Ormrod, R., Hamby, S., & Kracke, K. (2009). Children’s exposure to violence: A comprehensive national survey. US Department of Justice. https://www.ncjrs.gov/pdffiles1/ojjdp/227744.pdf
Hamby, S., Finkelhor, D., & Turner, H. (2012). Teen dating violence: Co-occurrence with other victimizations in the National Survey of Children’s Exposure to Violence (NatSCEV). Psychology of Violence, 2(2), 111-124. http://dx.doi.org/10.1037/a0027191
Horne, S. & Zimmer-Gembeck, M. J. (2005). Female sexual subjectivity and well-being: Comparing late adolescents with different sexual experiences. Sexuality Research and Social Policy, 2, 25–40. doi:10.1525/srsp.2005.2.3.25
Lassri, D., Luyten, P., Fonagy, P., & Shahar, G. (2018). Undetected scars? Self-criticism, attachment, and romantic relationships among otherwise well-functioning childhood sexual abuse survivors. Psychological Trauma: Theory, Research, Practice, and Policy, 10(1), 121-129. http://dx.doi.org/10.1037/tra0000271
Putnam, F. (2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child & Adolescent Psychiatry, 42 (3), 269-278. https://doi.org/10.1097/00004583-200303000-00006
Sacks, V. Murphey, D. (2018). The prevalence of adverse childhood experiences, nationally, by state, and by race or ethnicity. Child Trends. https://www.childtrends.org/publications/prevalence-adverse-childhood-experiences-nationally-state-race-ethnicity
U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2018). Child maltreatment 2016. Available from https://www.acf.hhs.gov/cb/research-data-technology/statistics-research/child-maltreatment.
Vasilenko, S. A., Lefkowitz, E. S., & Welsh, D. P. (2014). Is sexual behavior healthy for adolescents? A conceptual framework for research on adolescent sexual behavior and physical, mental, and social health. New Directions for Child and Adolescent Development, 144, 3–19.
World Health Organization (WHO). (2006). Defining sexual health: Report of a technical consultation on sexual health. http://www.who.int/reproductivehealth/publications/sexualhealth/defining_sexual_health.pdf.