Experts in adolescent sexual health are concerned that the coronavirus pandemic will have serious effects on the sexual health and social behavior of young people.
“I would start from the fact that our young people are not OK,” said Laura Lindberg, a researcher at the Guttmacher Institute, who was the lead author of an article on the subject in June in the journal Perspectives on Sexual and Reproductive Health. Their developmental task, she said, is to separate from their parents, connect with their peers and build relationships, and “the pandemic has just put an enormous roadblock.”
High numbers of young adults are reporting suicidal thoughts, Dr. Lindberg said, and “the constraints on developing and sustaining intimacy in the pandemic are hitting young people hard.” Many are living at home with parents and other relatives when they didn’t expect to be, many are feeling the stress of working as essential workers, and perhaps taking on increased family responsibilities.
“Once they get in their parents’ home, obviously their autonomy and privacy changes,” said Dr. David Bell, a co-author on the article, and a professor of pediatrics and population and family health at Columbia University Irving Medical Center, where he is the medical director of the Young Men’s Clinic. For some, it means they’ve gotten closer to their families, he said, while for others it’s been much more stressful.
Over all, Dr. Bell said, young people’s sexual behavior has become more moderate in recent years. “Most of our young people aren’t having sex at the same frequency we used to think they were,” he said. In the pandemic, what he has seen in clinic is that “if they had had multiple partners in the past, they are definitely trying to pare it down to some degree.” And Dr. Lindberg pointed out, “Today’s teens have been training for this pandemic their whole adolescence — they’re the most comfortable in sustaining relationships online, in digital space.”
Many sexual health and reproductive health services shut down in the spring, Dr. Bell said, and though some have reopened, the difficulties of infection control during a pandemic and the exigencies of protecting patients and health care workers can make it harder or more intimidating for adolescents to get the care they need, or get their questions answered — especially in minority populations and underserved neighborhoods which have been hit disproportionately by the pandemic.
Dr. Tracey Wilkinson, an assistant professor of pediatrics at Indiana University School of Medicine, was the lead author on a commentary which ran last May in the journal JAMA Pediatrics, arguing that providing contraception for adolescents during the pandemic constituted essential health care, whether for birth control or other reasons. She and her colleagues offered an algorithm for contraceptive methods that can be safely started or refilled remotely, with appropriate follow up. The algorithm provided a set of questions to make sure the patient was not already pregnant, to make sure there were no contraindications to prescribing a hormone-based contraceptive method and to explore the personal preferences of the patient.
If appropriate, a doctor could prescribe short-acting contraception, such as pills, patches or rings, and a self-administered injection, with the recommendation of condoms and with a prescription for emergency contraception as backup. “Patients that start a new method, I either touch base or have them come back,” Dr. Wilkinson said, but she prescribes a 12-month supply. The long-acting methods will require a clinic visit, but patients can be offered a “bridge” method to get them through till then.
“It’s important to remember that what we find important in medicine is not necessarily what our patients find important,” Dr. Wilkinson said. Often, doctors focus only on the efficacy of a particular method, rather than how acceptable it is to a particular patient. When she talks to adolescents, “I ask them, does it matter to you to have your period every month,” she said, and “whether your partner can see the method or is aware that you’re on birth control.”
For some adolescents, it may be important that they can stop the method whenever they want. And the conversation has to include a discussion of what would happen if a method were not to be used, or were to fail, and about the importance of being able to discuss all these issues with your partner.
Pediatricians need to be comfortable having these conversations, Dr. Wilkinson said. “Data shows young people are transitioning into their sexual lives during the time we are taking care of them,” she said. The dialogue should include conversations about when they are ready for that transition, and how that reflects their personal values.
Even in medicine, some may have assumed that contraception would not be a priority during a pandemic, she said, but that is not necessarily true. And the topic is even more important this fall, with a whole cohort of young people either going back to universities under extraordinary conditions, or else not going back to their universities, where they might be accustomed to getting health care.
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As some college students do go back to campus, Dr. Lindberg said, “colleges’ and universities’ response and guidance around safe behaviors around Covid ignored the fact that young people are sexual beings.”
“Instead, what we see are guidelines that say, no guests allowed in your room,” she said. “Kids are going to break that rule, and then we’re going to be mad at them.” Guidance should emphasize careful decision making, she said, both with respect to sex and with respect to Covid, and guidelines should be cast in terms of risk reduction and consent. “It can’t be all or nothing, because that model fails,” she said.
“The themes repeat themselves again and again,” Dr. Lindberg said. “You need to have empowered them and given them the skills — how they make decisions, how they choose their actions wisely.” She pointed to the New York Department of Health guidelines for sexual behavior, which start with the advice that you are your own safest sexual partner, but move beyond that to address the specific risks of different kinds of behavior.
The message from parents, who have already discussed these issues with their children, who have communicated their own values, should be a message like, “This is the time for you to make good decisions,” Dr. Lindberg said. Parents should be discussing what a socially distanced date might look like, but also the possibility that relationships may progress. “We can’t approach all young people as asexual; sex and intimacy may be part of what they’re doing.”
Dr. Bell suggested, “maybe starting off the semester with a heart-to-heart about acknowledging this unique situation.”
Colleges and universities have struggled — and in many cases failed — to change student behavior around issues like hazing and sexual assault, she said, and the pandemic may provide new opportunities to help students make those good decisions: “When Covid is reduced or gone away, maybe there’s some takeaway for how we approach and promote healthy sexual behavior on campus.”
Dr. Perri Klass is the author of the forthcoming book “A Good Time to Be Born: How Science and Public Health Gave Children a Future,” on how our world has been transformed by the radical decline of infant and child mortality.
