Parent-Child Sex Communication

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J Sex Res. Author manuscript; available in PMC 2018 May 01.
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Published in final edited form as:

J Sex Res. 2017 May ; 54(4-5): 532–548. doi:10.1080/00224499.2016.1267693.
21st Century Parent-Child Sex Communication in the U.S.: A

Process Review
Dalmacio Flores, PhD ACRN1 and Julie Barroso, PhD, ANP, RN, FAAN2
1Postdoctoral Fellow at the University of Pennsylvania School of Nursing
2Professor and Department Chair at the Medical University of South Carolina College of Nursing
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Abstract
Parent-child sex communication results in the transmission of family expectations, societal values,
and role modeling of sexual health risk reduction strategies. Parent-child sex communication’s
potential to curb negative sexual health outcomes has sustained a multidisciplinary effort to better
understand the process and its impact on the development of healthy sexual attitudes and behaviors
among adolescents. This review advances what is known about the process of sex communication
in the U.S. by reviewing studies published from 2003 to 2015. We used CINAHL, PsycInfo and
Pubmed, the key-terms “parent child” AND “sex education” for the initial query; we included 116
original articles for analysis. Our review underscores long-established factors that prevent parents
from effectively broaching and sustaining talks about sex with their children and has also
identified emerging concerns unique to today’s parenting landscape. Parental factors salient to sex
communication are established long before individuals become parents and are acted upon by
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influences beyond the home. Child-focused communication factors likewise describe a maturing
audience that is far from captive. The identification of both enduring and emerging factors that
affect how sex communication occurs will inform subsequent work that will result in more
positive sexual health outcomes for adolescents.
Parent-child sex communication is the bi-directional communication between parents (or

parent figures) and their children about sex-related issues including sex, sexuality, and
sexual health outcomes. Parents, through communication about sex in the home, have been
identified as ideal sex educators because they are able to reach youth early to provide
sequential and time-sensitive information that is responsive to the adolescent’s questions and
anticipated needs (Krauss & Miller, 2012; Mustanski & Hunter, 2012). The sexual health of
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most adolescents and young adults is greatly influenced by the powerful role that parents
play in children’s sexual socialization; the messages conveyed are influential in shaping
adolescent sexual decision-making (DiIorio, Pluhar & Belcher, 2003).
Traditionally conceptualized as a verbal exchange between knowledgeable parents

bestowing wisdom about sex to their uninitiated children, parent-child sex communication
actually is a reciprocal process consisting of mothers, fathers and other caregivers interacting
with daughters and sons. Whereas previous research tended to focus on parental concerns
Corresponding Author: Dalmacio Flores, 318 Curie Blvd, Philadelphia PA 19103, Dalmacio@upenn.edu, Phone: 404.394.4593.
Flores and Barroso Page 2
related to sexual behavior surrounding mostly negative outcomes (e.g., unplanned

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pregnancies, sexual abuse), recent scholarship has begun to explore more inclusive topics
that children inquire about and deem pertinent (e.g., non-heterosexual identities, pleasure).
And while most sex communication studies still predominantly document normative sex
discussions performed along gender lines and role expectations, there has been a steady
increase in research that investigates nuanced sex communication and topics (e.g., sexuality
discussions around able-bodiedness, sexuality concerns of adolescents with chronic medical
concerns).
The purpose of this review is to update what is known about the process of sex
communication in the U.S. by reviewing studies published from 2003 to 2015. DiIorio,
Pluhar and Belcher (2003) reviewed sex communication literature from 1980 to 2002 and
identified three domains of research: 1) content and process, 2) predictors, and 3) behavioral
outcomes. In the 12 years since that 2003 review, more U.S.-based studies that include novel
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theoretical and empirical findings have been published and now require critical analysis and
synthesis.
Sex Communication and Adolescent Sexual Health Outcomes

The sustained research interest in sex communication is grounded in the relationship
between parental provision of guidance about sex and the sexual health outcomes of youth.
For example, parental warnings and discussions about sex were associated with condom use,
decreased unprotected sex and increased protection from HIV and other sexually transmitted
infections STIs (Harris, Sutherland, & Hutchinson, 2013; Hutchinson, 2007; Kapungu,
Baptiste, Holbeck, et al., 2010; Teitelman, Ratcliffe, & Cederbaum, 2008). Nadeem (2006)
found more explicit maternal conversations about condoms were associated with daughters’
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detailed and accurate explanations of contraceptive knowledge, and Hadley (2009) identified
that more discussions about condom use were associated with more protected sex acts.
Additionally, greater self-efficacy in discussing sex with parents has been associated with
greater condom use among adolescent males (Halpern-Felsher, Kropp, Boyer, Tschann, &
Ellen, 2004).
The association between sex communication and adolescent sexual attitudes and health
behaviors has also been well-documented. Sex communication with mothers was associated
with more conservative adolescent attitudes towards sex and less perceived difficulty talking
to partners about sexual topics (Hutchinson, 2007). Children who have been talked to by
their HIV-infected mothers reported greater comfort talking about sex compared to their
peers who had uninfected mothers (O’Sullivan, Dolezal, Brackis-Cott, Traeger, & Mellins,
2005). The more children perceived mothers talked about a topic, the more the adolescents
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endorsed that issue (Guilamo-Ramos et al., 2007). Furthermore, parental sex discussion
about pubertal changes, intercourse and STIs was associated with daughters’ feeling
prepared about bodily changes, availing human papillomavirus (HPV) vaccines and
adolescents testing for HIV (Clawson & Reese-Weber, 2003; Roberts, Gerrard, Reimer, &
Gibbons, 2010).

Parents talking about sex with youth does not lead to sexual debut. In fact, adolescents who
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rate their general communication with parents favorably are less likely to be sexually active
(Karofsky, Zeng & Kosorok, 2000). There is strong support that children who received
messages to wait for marriage before sex were not as sexually active compared to those who
were not given explicit instructions (Aspy et al., 2007; Sneed, 2008). Daughters were less
sexually active when sex communication involved discussions of sexual values, where
mothers related abstaining from sex for moral reasons to its potential effect on their
daughters’ lives (Teitelman & Loveland-Cherry, 2004; Usher-Seriki, Bynum, & Callands,
2008). Fathers who provided information about how to resist pressure increased girls’
abilities to avoid being forced into sex (Teitelman, et. al., 2008). Moreover, mothers who are
comfortable and responsive during sex communication were predictive of adolescents’ lesser
likelihood of being sexually active, being abstinent, and being older at first intercourse
(Fasula & Miller, 2006; Guzman et al., 2003). If youth were sexually active, they were more
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likely to use birth control (Aspy et al., 2006).
Despite the evidence linking sex communication with positive adolescent sexual behavior,
these discussions in U.S. homes are fraught with well-established challenges and persistent
concerns (DiIorio, Pluhar & Belcher, 2003). Our review will focus solely on the factors that
affect the sex communication process; since DiIorio’s review, Akers, Holland, and Bost
(2011) reviewed interventions that aimed to increase the frequency of sex communication;
Sutton, Lasswell, Lanier, and Miller (2014) described interventions that used sex
communication to impact sex and cognitive outcomes among minority youth; and Santa
Maria, Markham, Bluethmann, and Mullen (2015) conducted a meta-analysis of parent-
based adolescent sexual health interventions and its effects on communication outcomes. By
focusing on study findings from the last 12 years, we were able to identify enduring factors
that affect the process of sex communication and underscore areas of current and emerging
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research. The identification of both enduring and emerging factors that influence parents and
children during sex communication will inform subsequent work that will result in more
positive sexual health outcomes for adolescents.
Theoretical Framework
Urie Bronfenbrenner’s Bioecological Theory of Human Development (2006), henceforth
Bioecological Theory, provides an encompassing approach to the study of an individual’s
behavior, and in particular, a comprehensive lens to identify the multi-system factors that
give rise to sexual health outcomes. The major concepts of the Bioecological Theory include
process, person, context and time (the PPCT model).
First, process is the interaction between an individual and his or her immediate environment
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(Bronfenbrenner & Morris, 1998) over time and is posited as “the primary mechanisms
producing human development” (Bronfenbrenner & Morris, 2006). For example, these
reciprocal relationships include an adult explaining to a child where babies come from or
parents and a teenage daughter discussing contraception use after menarche. Through these
proximal processes individuals and the environment act on and shape each other (Tudge et
al., 2009). Second, person pertains to the biopsychosocial characteristics of developing
individuals that impact their capacity to influence proximal processes (Bronfenbrenner &

Morris, 2006). Inherent in the person is their capacity to initiate and sustain relationships;
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their abilities, knowledge and skills essential for effective functioning; and their
characteristics to invite or disrupt talks about sex. Next, context is the nested set of
environments for which the Bioecological Theory is most famous. Conceptualized as four
concentric circles centering on the developing person, context includes the microsystem,
such as one’s parents, siblings, teachers and peers, who participate in the life of the person
on a regular basis over an extended period of time; the mesosystem, the interrelations
between the other microsystems such as the interaction of the home with churches or
schools; the exosystem that includes societal institutions, such as media and local politics
that have an important distal influence on human development; and the macrosystem, or the
cultural context that encompasses groups whose members subscribe to shared beliefs, mores
and customs. Finally, time refers to ongoing episodes of proximal processes that are spread
across varying intervals such as days and weeks. This construct includes changing
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expectations and events in larger society, within and across generations over the life course
(Bronfenbrenner & Morris, 2006).
The Bioecological Theory will guide this literature review by examining sex communication
as a proximal process that simultaneously affects parent and child attitudes and behaviors
when talking about sex. The following research questions will be answered in this review: In
the past 12 years: 1) What are the bioecological factors that influence the occurrence of this
process? and 2) What are the enduring and emerging factors that affect sex communication?
Methodology
In order to systematically review the sex communication literature, we used a multi-step
approach that included an exhaustive search strategy guided by a defined inclusion and
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exclusion criteria. Afterwards, we inspected the initial search results, read the final articles,
abstracted the data from individual studies and synthesized the findings according to factors
that affect the process of sex communication. Tenets of the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed in this review
(i.e. identification, screening, eligibility, and inclusion) (Moher, et.al. 2009).
Literature search strategy

A search was undertaken for all published articles about sex communication using the
following electronic databases: Cumulative Index to Nursing and Allied Health Literature
(CINAHL), PubMed, PsycINFO and SocIndex. Key terms or controlled vocabulary (e.g.,
Medical Subject Headings [MeSH]) such as “parent-child relations,” “communication,” “sex
education,” and “sexual behavior” were used for each database. Search sets were combined
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using Boolean operators (and, or, not). We consulted a Duke Medical Library health
information specialist throughout the search of the online databases. A staged review was
conducted (Torraco, 2005) which began with an initial review of the titles and abstracts,
followed by an in-depth reading of each article that met the inclusion criteria.

Inclusion and exclusion criteria

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Articles identified through online databases had to meet the following conditions: 1) U.S.-
based and published in a peer-reviewed journal, 2) with publication delimiters from January
2003 to December 2015, 3) published in English language journals, and 4) contained
original findings from descriptive qualitative, quantitative or mixed method studies about the
sex communication process. Sex in this review pertains to topics that parents talk about with
their children, including developmental information about puberty, sexuality, and decision-
making about sexual behavior. The articles accepted for inclusion were informed by the
views of parent/s or children only or from parent-child dyads. Parents in these studies
included biological, adoptive, foster, or custodial parents who are the guardians of the child/
ren. Articles involving intervention research were excluded as these have been recently
reviewed. Grey literature, systematic reviews and metasyntheses were also excluded.
Articles that had a secondary finding or section on sex communication but whose main
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research questions were about other protective familial factors (e.g., parental monitoring,
parent-child connectedness, general support) that also impact adolescent sexual behavior
were excluded as were articles that measured sex communication frequency as one of many
factors, and concurrently reported other adolescent behaviors (e.g., alcohol abuse, cigarette
smoking, and delinquency).
Search result
Our initial electronic search yielded 1,044 citations. Two hundred and two duplicates were
removed and both authors screened the titles and abstracts to assess the relevance of the
studies to the project. Of the remaining 842 articles, 736 references were excluded, leaving
106 full-text articles from the electronic search (see Figure 1). All reference lists were
checked for pertinent citations that might not have been identified in the main online query
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of electronic databases. Through this ancestry method of cross-checking and back-

referencing we ensured comprehensiveness (Whittemore & Knafl, 2005). Ten additional
articles were identified from reference lists for a final count of 116 included studies. The
accepted articles were exported to an EndNote library (Thomson Reuters, 2014) for data
management. The authors individually conducted quality tests on the excluded articles, such
as by skimming every tenth article to validate that these were correctly excluded. Further, if
questions arose about an article’s ineligibility, the article was discussed until a consensus
decision was reached.
Data Abstraction
The 116 articles accepted after the comprehensive search were abstracted through the matrix
method (Garrard, 2013). An evidence table was created in Excel to organize information
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according to how it systematically informed the research findings. Column headings were
based on study characteristics such as study design, setting, sample and methodology. DF
independently abstracted findings from the eligible studies into the standardized matrices
and this allowed the examination of the literature for contextual patterns and themes across
studies.

Synthesis
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An adaptation of framework synthesis (Carroll, Booth, & Cooper, 2011) scaffolded by

Bronfenbrenner’s Bioecological Theory guided this review. This was accomplished by
organizing the abstracted findings under broad groupings based on the PPCT model and
informed by a priori themes from DiIorio and colleagues’ 2003 review. By using a relevant
pre-existing framework merged with themes from the most recent review of sex
communication, we were able to map and code data from the included studies. Throughout
the analysis, similar and contradictory findings were noted as newer sex communication
themes. Through this process, both the enduring and emergent bioecological factors that
affect the process of sex communication were identified. Research implications of our
findings are incorporated in the subsequent discussion section.
Findings
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Methodological approaches
Table 1 provides the details of the studies included in this review. There was a similar
number of qualitative (43%) and quantitative (45%) designs with the remaining using mixed
methods (12%). A majority of studies (84%) used convenience sampling to identify
participants. Most of the samples were Caucasian (22%), African American (23%), or came
from diverse racial backgrounds (36%). Most of the studies included both children and
parent samples (42%). There were more studies with mothers-only samples compared to
studies with fathers-only samples (44% and 7%). Similarly, there were more studies with
samples that only included daughters compared to studies with samples comprising of sons
only (40% and 4%). Most of the children were high school and college age (36% and 23%).
Process
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According to the Bioecological Theory, processes are the interactions in which the parent
and child are active participants who shape their environment, evoke responses and react to
one another (Bronfenbrenner & Morris, 2006; Bronfenbrenner & Morris, 1998; Darling,
2007). Parents and children engage in sex communication while riding in the family car,
when watching TV, when considering whether to allow children to attend events such as sex
education at school, and when discussing events involving family or friends (Eastman,
Corona, Ryan, Warsofsky, & Schuster, 2005; Hannan, Happ, & Charron-Prochownik, 2009;
Murray et al., 2014). During sex communication, numerous factors have been found as
influential in the process including parent and child gender, the specificity of topics
discussed, parents’ communication styles, tone, language, the focus on the consequences of
sex, and its implications for the future. Ultimately, these factors result in a lack of
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congruence among sex communication reports.
Gender dynamics
Parent and child gender dynamics interact most strongly to predict sex communication, with
most discussions occurring between mothers and daughters (Guilamo-Ramos et al., 2007;
Kapungu, Baptiste, Holbeck, et al., 2010; Marhefka, Mellins, Brackis-Cott, Dolezal, &
Ehrhardt, 2009; Miller et al., 2009; Pluhar, DiIorio, & McCarty, 2008; Sneed, 2008;

Wisnieski, Sieving, & Garwick, 2015). Across most of the literature, mothers figured more
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prominently than fathers in children’s sexuality education (Harris et al., 2013; Morgan,
Thorne, & Zurbriggen, 2010; Raffaelli & Green, 2003; Sneed, Somoza, Jones, & Alfaro,
2013; Wilson, Dalberth, & Koo, 2010). The number of topics discussed is highest between
same-gender dyads, where daughters receive significantly more sexual health discussions
from their mothers than fathers (Kapungu, Baptiste, Holbeck, et al., 2010; Raffaelli &
Green, 2003; Swain, Ackerman, & Ackerman, 2006), and sons received more from their
fathers than mothers (Tobey, Hillman, Anagurthi, & Somers, 2011). Still, some studies
contradict that general trend and found that sons reported an equal amount of information
about sex communication from both parents (Wyckoff et al., 2008) or in one case, more sons
than daughters discussed sex with mothers (Sneed et al, 2013).
General versus specific topics

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Parents emphasize general communication about sex rather than engaging in talks about
specific topics (Eisenberg, Sieving, Bearinger, Swain, & Resnick, 2006; Kapungu, Baptiste,
Holbeck, et al., 2010; LaSala, 2015; Sneed, 2008). For example, parents tended to focus
more on informational topics such as warnings about STIs and HIV protection rather than
discussing personal topics such as asking if children were having sex (Sneed et al., 2013).
Even mothers with HIV infection are more likely to discuss HIV prevention, but not sex or
birth control (Marhefka, Mellins, Brackis-Cott, Dolezal, & Ehrhardt, 2009). In a qualitative
study involving mother-child dyads in New York City, mothers expressed relative comfort
and willingness to discuss the consequences of sex, but not specific, fact-based information
regarding intercourse and birth control (Guilamo-Ramos et al., 2006).
Further, talks about sexual decision-making were supported more than discussions about
emotions, relationships and romance (Stiffler, Sims, & Stern, 2007; Wisnieski et al., 2015).
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Parental communication style

Although parental directness facilitates sex communication, the findings are mixed when it
comes to who engages in this communication style. In general, lack of parental
communication skills causes children to avoid and be anxious about sex discussions, while
parents who can communicate with their children share and discuss their life experiences
with minimal reservation (Afifi, Joseph, & Aldeis, 2008). The directive communication
style, which includes parents being forthright in the provision of clearly stated expectations
about sex and unambiguous about their preference for children’s behavior, are associated
with positive parent-child relationships and less risky sexual behavior (Peterson, 2007;
Sneed, 2008). However, another study found that directive parents who tend to have a more
authoritarian communication style do not invite open discussion and questions from children
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(Heller & Johnson, 2010). Few fathers provide explicit guidance (Solebello & Elliott, 2011);
those who were willing to have in-depth, open and honest conversations contributed to
daughters’ knowledge, ability to clarify, and knowledge that they could talk to fathers about
sex any time (Nielsen, Latty, & Angera, 2013). Many mothers were blunt about sex and
honest in their approach (Murray et al., 2014), while others were avoidant or reticent (Baier
& Wampler, 2008; Pluhar, Jennings, & DiIorio, 2006). Daughters agreed that mothers’
candidness contributed to communication about sexual risks (Cederbaum, 2012; Cox,

Mezulis, & Hyde, 2010). Interactive communication strategies include making sure
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adolescents’ voices are heard to encourage active exchange of questions and answers,
assessing current knowledge and leaving room for future discussions (Edwards & Reis,
2014).
Tone and language

Daughters discussed how a parent’s negative emotional tone affected their ability to talk
about sex, while a positive tone lead to further discussions about sex (Aronowitz &
Agbeshie, 2012). Fathers who are good sex educators were thorough and their tone
communicated clearly the seriousness of the topic, while fathers who are not as effective
broached sexuality in vague, nonspecific ways that left daughters wondering what parents
were trying to communicate (Nielsen et al., 2013). Parents sometimes used veiled language
(Aronowitz & Agbeshie, 2012) and discussions about sex often included the use of
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euphemisms (Meschke & Dettmer, 2012; Pluhar et al., 2006). In a study involving
grandparents as sex educators, their unfamiliarity with slang and sexual lingo used by
teenagers did not facilitate sex communication (Cornelius, LeGrand, & Jemmott, 2008).
Further, children as young as 4 years old preferred slang words over parents’ use of
anatomical terms (Martin & Torres, 2014).
Consequence-focused discussions
Studies indicate that parents framed the sex discussions in terms of consequences and
cautionary statements, with the underlying message often being sexually prohibitive (Afifi et
al., 2008; Akers, Schwarz, Borrero, & Corbie-Smith, 2010; Cox, Scharer, Baliko, & Clark,
2010; Eisenberg et al., 2006; Jerman & Constantine, 2010; Kim & Ward, 2007; Meschke &
Peter, 2014; Nappi, McBride, & Donenberg, 2007). Parents conveyed clear disapproval of
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their children engaging in sex (Jaccard, Dodge, & Dittus, 2003), and they underscored the
negative outcomes of sex (Heisler, 2005; Stauss, Murphy-Erby, Boyas, & Bivens, 2011),
which for them can ruin children’s lives (Guilamo-Ramos et al., 2006). Fear was regularly
employed to persuade daughters to be abstinent (Pluhar & Kuriloff, 2004) and parents
routinely talked about the repercussions of sex and the risks of pregnancy, disease, and
victimization (Elliott, 2010b; Gilliam, 2007; Teitelman, 2004). The threat of sexual abuse is
another topic often brought up that further discouraged any positive discussions about
sexuality (El-Shaieb & Wurtele, 2009). Pleasure or the positive aspects of sex was off limits;
sex positivity was not addressed (Aronowitz, Todd, Agbeshie, & Rennells, 2007b; Elliott,
2010a; Hertzog, 2008). From adolescents’ perspectives, sex communication was essential to
prevent risky sexual behavior (Cornelius, LeGrand, & Jemmott, 2009), but they dismissed
scare tactics as ineffective sex communication (Fitzharris & Werner-Wilson, 2004).
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Future orientation
For a lot of parents, conversations with children about abstinence, pregnancy and delaying
sex were related to future success. Sex communication in these households emphasized the
future in terms of prioritizing educational goals (McKee & Karasz, 2006) and attaining self-
sufficiency through gainful employment before supporting a family (Akers et al., 2010;
Meschke & Peter, 2014; Murray et al., 2014). In these talks about the future, sex and

unplanned pregnancies were depicted as a threat that forced children to grow up early (Afifi
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et al., 2008) and can be an impediment to achieving one’s dreams (Jaccard et al., 2003).
Incongruence of reports
There remains a marked incongruence between parent and adolescent reports of the
frequency of sex communication. Parents typically remembered more incidents of having
the sex talk while children reported fewer recollections (Chung et al., 2007; Fitzharris &
Werner-Wilson, 2004; Hadley et al., 2009; LaSala, 2015; Miller, Ruzek, Bass, Gordon, &
Ducette, 2013; Nappi, McBride, & Donenberg, 2007; O’Sullivan et al., 2005). Between
grandparents and grandchildren, there was a more pronounced incongruence about which
sex topics were discussed (Cornelius et al., 2008). However, preadolescents and their parents
agreed about the occurrence of sex communication (Wyckoff et al., 2008) and topics
discussed during childhood and into adolescence (Beckett et al., 2010). Similarly,
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incongruence was also reported among young men who have sex with men (YMSM) and sex
talks with their parents, where parents did not report any barriers to talking about health and
sexual orientation with their sons, while the opposite was reported by the YMSM (Rose,
Friedman, Annang, Spencer, & Lindley, 2014).
Reciprocal reluctance to initiate conversations

When mothers provided information and feedback, daughters were more engaged and
desired further conversations about sex (Mauras, Grolnick, & Friendly, 2013). However,
most mothers admitted they only discussed sex-related issues at their daughters’ initiation
and they did not talk about sex unless asked (Baier & Wampler, 2008; Elliott, 2010a).
Parents believed their children would approach them if they have questions, while children
reported they were unlikely to do so even if they had concerns (Collins, Angera, & Latty,
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2008; Fitzharris & Werner-Wilson, 2004). Daughters reported not knowing how to initiate
conversations about sex and looked to their mothers to start the sex communication process
(Dennis & Wood, 2012). Further, parents of gay and bisexual youth wished their sons would
bring up sex topics if they have any questions, but the youth reported being reticent and
wished parents would take the first step (LaSala, 2015). Similarly, most Muslim mothers did
not think it was necessary to initiate conversations and said they were available if daughters
need to talk (Orgocka, 2004). Additionally, some parents thought it was almost like an
assault if they were too forceful or too open about sex (McKee & Karasz, 2006).
Person
When viewing sex communication through the Bioecological Theory, children are
conceptualized as more than passive recipients of knowledge. Children bring with them
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developmental attributes, temperaments and predispositions that impact how parents broach
sex-related issues. Likewise, parents’ interactions with children involve their own
experiences, ideas and values that trigger specific reactions from children. The following
child and parent attributes have been identified as salient person centered factors that impact
sex communication.

Child Attributes
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A child’s age and their perception that initiating conversations about sex would elicit a
negative reaction from parents are the two main child-centered attributes that affect sex
communication.
Age—There is ample evidence that the child’s age is a significant predictor of sex
communication. Current age of the daughter predicted timing of first discussions about sex
(Askelson, Campo, & Smith, 2012; Miller et al., 2009b), and sex communication occurs
earlier with daughters than with sons (Beckett et al., 2010). Parents are less likely to talk
with younger teens about sex (Swain et al., 2006), and they reported discussions to be more
challenging with younger rather than older daughters (Coffelt, 2010). Parents are more
inclined to talk about sex when they deem their child as mature, which can explain why
older adolescents received more communication than younger children (Lefkowitz, Boone,
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Au, & Sigman, 2003; Pluhar et al., 2008; Tobey et al., 2011). Nevertheless, it has also been
reported that children’s age was not associated with sex communication between mothers
and daughters (O’Sullivan et al., 2005).
Anticipated disapproval—Generally, adolescents could not discuss topics of a sexual

nature with their parents out of fear that they may be viewed as sexually active and face
punishment (Fitzharris & Werner-Wilson, 2004; Guilamo-Ramos et al., 2006). Fear, based
on the assumption that parents would judge them – that mothers think, “if she’s talking
about it, she’s doing it” (Pluhar & Kuriloff, 2004) – keeps children from engaging in sex
communication about a variety of topics (Dennis & Wood, 2012; Eastman, Corona, Ryan,
Warsofsky, & Schuster, 2005a; Sisco, Martins, Kavanagh, & Gilliam, 2014). Daughters’
fears of relationship strain, anticipated loss of trust, and beliefs that mothers are not open to
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hearing information about their sex-related concerns, caused reluctance to ask about sex
(Cederbaum, 2012). Furthermore, among adolescents whose parents disclosed to them their
HIV-infected status, the fear of upsetting or reminding parents of their serostatus prevented
some children from talking about sex (Corona et al., 2009).
Parent Attributes
Factors identified from the literature that exclusively affect parents’ capacity to discuss sex
with children include their low levels of knowledge about sex, a commitment to become
better sex educators for their children than their parents were for them, leveraging traumatic
experiences as impetus to talk about sex, viewing sex talks as permission for children to
have sex, and a perception that their children are not old enough for sex communication.
Knowledge deficit—Parents have varying levels of knowledge about sex-related topics,

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with most of them having an inadequate base of information (Heller & Johnson, 2010;
Jerman & Constantine, 2010; Martin & Torres, 2014; Meschke & Dettmer, 2012; Pluhar et
al., 2006). For instance, in a study about family planning discussions, contraceptive
knowledge was low for parents and they had minimal information about risks and side
effects (Akers et al., 2010). Fathers in Atlanta supported the view that as sex educators they
did not have subject matter expertise (DiIorio et al., 2006). For mothers, many professed
inadequate knowledge about male sexuality (Cox et al., 2010), and they relied on male

figures to address those questions (Murray et al., 2014; Pluhar et al., 2006). Single mothers,
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for example, limited sex communication out of concern that they might impinge on their
son’s development of a normative masculine and heterosexual identity (Elliott, 2010a).
Adolescents concurred and attributed the lack of sex communication to parents not being
knowledgeable about sex-related topics (Fitzharris & Werner-Wilson, 2004; Gilliam, 2007).
Denes and Afifi (2014) found that for many gay, lesbian, bisexual and queer individuals,
disclosing their sexuality to parents a second time was necessary to share more information
about themselves and address parents’ lack of understanding about what being a sexual
minority was about. Further, parents’ lack of knowledge about the health issues that YMSM
contend with was reported to be a barrier to parent-child sex communication (Rose et al.,
2014).
Doing better than their parents—Due in part to the perceived parental lack of
knowledge about sex observed when they were growing up, the parents included in the
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review reported a need to be better sex educators for their own children. Parents viewed their
own parents as ineffective sexuality educators (Kenny & Wurtele, 2013); they did not have
parents who modeled how to have these conversations effectively (Eastman et al., 2005).
Parents attributed their lack of preparedness for sex communication to their own dismal
experiences with the process (Eastman et al., 2005; Lehr, Demi, DiIorio, & Facteau, 2005;
McKee & Karasz, 2006; McRee et al., 2012; Noone & Young, 2010). According to DiIorio
et al (2006), some parents’ negative feelings about their own experiences with sex
communication a generation earlier often serve as an impetus to provide better sex education
for their children. Parents want “to do better than their parents had done with them,” (p. 460)
(Ballard & Gross, 2009; LaSala, 2015) and they intended to discuss sex when their children
are younger compared to when they themselves were taught about it or when they were
forced to contend with sexual silence (Alcalde & Quelopana, 2013; El-Shaieb & Wurtele,
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2009; Kenny & Wurtele, 2013). Muslim mothers, for example, saw sex communication as an
important duty to offer moral and emotional support to daughters, based on their own
experiences lacking parental models (Orgocka, 2004).
Learning from traumatic experience—Parents’ own experiences with risky sexual

behavior when they were adolescents triggered discussions about sex-related issues with
their own children (Grossman, Tracy, Richer, & Erkut, 2015; Noone & Young, 2010;
Williams, Pichon, & Campbell, 2015). Broaching sex-related issues was motivated by
concerns over victimization of vulnerable children, such as those with autism spectrum
disorders (Ballan, 2012; Holmes & Himle, 2014), or stemming from their own personal
trauma such as experiences with sexual abuse or interpersonal violence (Akers, Yonas,
Burke, & Chang, 2011; Deblinger, Thakkar-Kolar, Berry, & Schroeder, 2009; Woody,
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Randal, & D’Souza, 2005). For HIV-infected mothers, sex communication involved taking a
negative experience and creating a positive teaching opportunity (Cederbaum, 2012; Corona
et al., 2009; Murphy, Roberts, & Herbeck, 2012). Mothers living with HIV were more
comfortable and more likely to report discussing HIV and related sexuality topics compared
to mothers without HIV (O’Sullivan et al., 2005).

Acknowledgement of parental responsibility—Parents acknowledged it is their

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responsibility to teach their children about sex (Ballan, 2012; Elliott, 2010a, 2010b;
Fitzharris & Werner-Wilson, 2004; Guilamo-Ramos, Jaccard, Dittus, & Collins, 2008;
Regnerus, 2005; Stiffler et al., 2007). Sex communication is viewed as an opportunity for
parents to educate not only about sexuality, but also the effects of children’s sexual behavior
on their overall health (Eisenberg et al., 2006; Hannan et al., 2009; Hutchinson &
Cederbaum, 2011). Fathers wanted to instill a sense of responsibility so that their sons can
learn from their stories and be trusted to make the right choices to protect themselves from
negative consequences such as STI (DiIorio et al., 2006; Ohalete, George & Doswell, 2010).
Despite fathers having lower self-efficacy and lower expectations that sex communication
would have positive outcomes (Wilson, Dalberth, & Koo, 2010), they believe sex
communication is an ongoing process that should start at a young age and continue
throughout adolescence (Lehr et al., 2005). In particular, some fathers provide the male
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perspective for their daughters (Solebello & Elliott, 2011). Nevertheless, parental
responsibility for children’s sex education was not shared by all parents. From a group of
parents who were in college, Heller and Johnson (2010) found that many of them did not
feel any urgency to cover discussions about condoms and HIV/AIDS due to public schools
discussing those topics with their children; also, some fathers view sex education as part of a
mother’s responsibility (Collins et al., 2008).
Sex communication as a green light to have sex—Parents are concerned about

sending mixed signals when discussing sex with children and fear that the information might
be misconstrued as permission to have sex and promote adolescent sexual activity (DiIorio
et al., 2006; Fitzharris & Werner-Wilson, 2004; Meschke & Dettmer, 2012; Wilson,
Dalberth, Koo, & Gard, 2010). For parents, including the positive aspects of a sexual
relationship during sex communication might lead to risky sexual behavior and be perceived
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as a “green light” to have sexual intercourse (Aronowitz et al., 2007; McKee & Karasz,
2006). In several studies, parents struggled to promote abstinence and feared sex discussions
might increase curiosity and encourage sexual experimentation (Aronowitz et al., 2007;
Elliott, 2010a; Ohalete, Georges & Doswell, 2010). However, contrary to these parents’
concerns, grandparents in another study believed that talking about sex does not encourage
sexual activity (Cornelius et al., 2008).
Children being too young—Many parents think children are too young for sex
information and have difficulty acknowledging their children’s sexuality (Deblinger et al.,
2009; Meschke & Dettmer, 2012; Noone & Young, 2010). For instance, mothers of
elementary age children often did not associate sexuality and sexual development with their
6-10 year olds, and therefore felt they would not be ready when asked about sex by their
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children (Pluhar et al., 2006). Additionally, according to daughters, fathers viewing them as
“Daddy’s little girl” inhibited sex communication (Hutchinson & Cederbaum, 2011).
Further, parents express ambivalence and disagree about when, what, and how much to say
to their children about sexual topics (Cornelius, Cornelius, & White, 2013; Elliott, 2010a).
However, not everyone is reticent about broaching sexuality. Parents can and do talk about
sexuality issues with young children and preadolescents (Miller et al., 2009; Wilson,
Dalberth, Koo, et al., 2010; Wyckoff et al., 2008).

Context
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Bronfenbrenner described context as the nested set of environments that affect the
developing individual. Distinct contextual patterns have been identified in the literature and
can be classified according to the four concentric circles of the Bioecological Theory (Table
2).
Time
Frequency and consistency of sex communication play a crucial role in how this proximal
process simultaneously affects parents and their children.
Frequency and consistency

Most discussions in the US about sex are episodic or one-time events that are punctuated by
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frustration and unease (Aronowitz & Agbeshie, 2012; Aronowitz et al., 2007; Averett et al.,
2008; Baier & Wampler, 2008; Coffelt, 2010; Cornelius et al., 2009; Cornelius et al., 2013;
Dennis & Wood, 2012; Meschke & Dettmer, 2012; Orgocka, 2004; Wilson & Donenberg,
2004). Fathers conducted ‘spot-checks’ and assumed their children received information
from other sources (Solebello & Elliott, 2011). However, other studies report that continuous
sex communication occurs in some households. For example, daughters reportedly received
more instructive information from fathers when they were younger, and over time these
conversations evolved into collaborative and open dialogues (Collins et al., 2008). Further, in
a longitudinal study with college-aged young adults, there was more open and comfortable
sex communication with parents noted during students’ senior years compared to when they
were freshman (Morgan et al., 2010). Finally, patterns across time showed that while sons
received the same number of talks about birth control methods from the 1980s to early
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2000s, the same was not the case for daughters (Robert & Sonenstein, 2010). Specifically,
longitudinal data from national surveys showed that fewer daughters had a conversation
about STDs or birth control in 2002 than they did in 1995 (Robert & Sonenstein, 2010).
Discussion and Recommendations

The parent-child relationship during adolescence shifts from unilateral parental authority to
one that is cooperative and negotiated (Steinberg, 2015). However, numerous individual
factors coupled with contextual influences act on parents and children to make sex
communication a complicated process that is far from cooperative and negotiated. A handful
of these bioecological factors are enduring issues related to the sex communication process
and have been previously identified by DiIorio et al. (2003). These include awkwardness and
discomfort, reciprocal reluctance, and gender dynamics and gendered content. Twelve years
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after the DiIorio review, several emergent issues have been identified and demand further
scrutiny. Among them is the role of a redefined family, nonverbal cues during sex
communication, a focus on specific adolescent subpopulations, and the ubiquity of new
media.

Enduring Sex Communication Issues

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Awkwardness and timing concerns

By and large, the perennial awkwardness and discomfort noted as a defining attribute of the
process is due to the reactive and one-time nature of these sex conversations. Often triggered
by developmental cues, conversations about sensitive topics – especially when no prior talks
precede it – can be perceived by adolescents as awkward, intrusive, or forced. Additionally,
at a time when they are simultaneously adapting to their changing bodies, labile emotions,
and asserting independence, ill-timed sex communication comes across as confrontational. It
is therefore crucial to understand the timing of sex communication. Morgan and colleagues
(2010) reported a change in conversations over time between parents and college-age
children from previously unilateral and restrictive talks about sex to more reciprocal
discussions characterized by mutuality. Longitudinal comparative studies that explore timing
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issues with pre-adolescents must be conducted to more fully understand how sequential and
developmentally appropriate conversations can be achieved. A better understanding of the
evolving parent-child relationship with regard to sex topics that are deemed age-appropriate
can counter the universal embarrassment felt by parents and adolescents that is a substantial
barrier when discussions about sex do occur.
Reciprocal reluctance
Many parents truly expect their children will approach them for guidance when they have
questions about sex, but children also expect parents to initiate these conversations. This
waiting game undercuts the potential of sex communication as a proximal process to
influence the sexual development of children and perpetuates the cycle of silence that is
observed from one generation to the next. Given that parental comfort in discussing general
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and specific topics increases over time, studies about broaching developmentally appropriate
sex communication at earlier ages are recommended. Investigating sex communication
starting at the pre sexual stage can yield a better understanding of the reciprocal and
evolving dynamics between parents and children and the contexts that determine adolescent
behavior and attitude at later sexual stages.
Gender dynamics and gendered content

The literature has affirmed that parent and child gender is an important factor during sex
communication. Findings also revealed the general pattern that when sex communication
happens, the marked differences in content conveyed to girls and boys reinforce gender
stereotypes. A battle of the sexes mentality is the prevailing approach perpetuated by parents
who both admonish sons against aggressive girls and daughters against opportunistic boys.
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The attempt to reduce adolescent sexual risks through sex communication in the last 12
years in many U.S. households, particularly in minority and low socioeconomic status
families, is therefore based on an adversarial approach that is founded on mistrust and that
does not encourage factual learning about potential sex partners. To address this, the
unanimity of parents’ desire to equip children with knowledge or skills for a successful
future can be leveraged and necessitates studies that will examine and challenge parents’
perpetuation of gender bias and sexual stereotypes. Gendered messages around sex must be

investigated to encourage meaningful re-conceptualizations of equal and consistent sex

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messages for daughters and sons.
Mothers as de facto sex educators

The findings that mothers are overwhelmingly cited in most studies as the primary sex
educator in U.S. homes is not a surprise. Mothers are consistently noted as more proactive in
broaching sex talks, they cover more topics, and they exhibit more comfort when discussing
sex compared to fathers. The finding that mothers are more comfortable engaging with
daughters than sons in sex communication also supports the gendered sex communication
noted above. This difference in comfort with sex communication based on parents’ gender
can be explained in part by a large survey of mothers with young children that found that
mothers do not care as much about daughters seeing them naked compared to sons, which
provides more early opportunities to talk about bodies and sexuality among mothers and
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daughters (Martin & Luke, 2010). While seemingly simplistic, these early dyadic exchanges
do set a pattern for more mother-daughter discussions that continue through adolescence and
beyond. Additionally, the comfort level in talking about sex with children that is associated
with mothers more than with fathers has resulted in the burden of sex education falling
mainly within mothers’ purview. Compounded by the fact that caregiving responsibilities are
still viewed as part of mothers’ domain, as evidenced by the fact that mothers usually are
heads of household for most single-parent families in the U.S., the responsibility for sex
education remains lopsided. Finally, when related to the findings that sex communication is
simultaneously future- and consequence-oriented, that engaging in sex early almost certainly
has ramifications, pressure on daughters to be gatekeepers of sex, and their mothers who
have to make sure that daughters are forewarned, are reinforced so as not to undermine their
future prospects.
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Paternal roles
Children view their fathers as having inherent authority regarding specific topics, such as
how males think, and children would prefer learning about such topics from their fathers.
However, only 7% of the studies reviewed here included father-only samples compared to
the 44% that involved mother-only participants. The study of fathers’ sex communication
support needs is paramount to improve paternal engagement in sex communication.
Specifically, the role of residential versus non residential fathers and the increasing number
of stay-at-home fathers (Rehel, 2014) merit further attention for paternal sex
communication. Despite parents favoring an ideal scenario where they present a united
parental front (Ballard & Gross, 2009), no information is available on how shared custody
affects the sexual socialization of children. Sex communication involving parents with
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strained relationships has not been studied to determine how topics and values are shared
with children who reside in dual homes (Collins et al., 2008). Similarly, fathers’ perceptions
of maternal gatekeeping, where mothers discredit fathers and portray them in a negative light
(Ohalete & Georges, 2010), can influence the receptiveness of their children to paternal sex
communication and would benefit from further research.

Emergent Issues
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Nonverbal sex communication

Directly related to cultural issues underlying communication about sensitive topics are the
non-verbal cues that can be as powerful as the overt information received by adolescents.
The few studies that have focused on these dimensions (e.g., affective style and direct vs.
indirect communication) report on a vital component in the sexual socialization of
adolescents. We recommend that more studies be conducted to further explore how non-
verbal communication impacts the process and transmits implicit messages that also shape
adolescent attitudes and behaviors. Further, the development of scales that measure implicit
or indirect communication cues and negative or positive modeling from parents can advance
this overlooked dimension of sex communication.
Beyond heteronormativity and able-bodiedness

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While children’s assumed heterosexuality continues to guide most sex communication

research, there are initial studies that have begun to examine sex talks between parents and
their lesbian, gay, bisexual or transgender (LGBT) children. Despite mothers reporting
concern about impinging on sons’ development of a normative heterosexual identity (Elliott,
2010a) and fathers placing a premium on making sure their sons are socialized into
becoming heterosexual (Solebello & Elliott, 2011), we have identified a growing interest in
this subpopulation. In light of the cultural shift in the acceptance of LGBT individuals in the
U.S. that has caused LGBT children to come out at earlier ages (Friedman et al., 2008),
more research on the sexual socialization needs of this population and how their parents can
assist with this process is warranted. Because adolescence is the dynamic stage that usually
involves sexual experimentation and risk-taking, the minimal attention to parents’ discussion
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about transitory or potentially permanent same-sex attraction or behavior during adolescence

might be missing significant risk factors that impact all adolescents. With LGBT teens at
higher risks for negative sexual health outcomes, there is an urgent need to consider how
parental guidance about sex, sex orientation and gender identity can affect this population.
Preliminary reports have begun to investigate the conundrum parents and children with
chronic conditions face when navigating adolescence (Ballan, 2012; Holmes & Himle,
2014). Aside from LGBT adolescents, children with cognitive issues such as autism; those
with chronic illness such as Type I diabetes or HIV infection; and those with other
congenital issues would also benefit from further research about how parents assist in their
transition to becoming sexually active adults. Because these adolescents are sexual beings
and are influenced by the ecological system, a concerted push to account for these
adolescents’ normative sexual development needs will improve not only their sexual health
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specifically, but also their overall psychosocial well-being.
The redefined American family

The changing American family structure that is now more blended and less nuclear
redistributes some of the responsibility for sexuality education to other members in the
microsystem. Sex communication studies must be inclusive of non-parental family members
who can also be influential purveyors of information. Grandparents, along with aunts and

uncles, are in unique positions to augment or even provide primary guidance for
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adolescents’ sex-related developmental needs. Similarly, due to the shift in U.S.

demographics, further studies on how to facilitate intergenerational conversations about sex
in minority and immigrant families is crucial to assist minority and second generation
immigrant youth to navigate sexual concerns in the U.S. Understanding the tension between
minority and majority culture or a country of origin’s sexuality values and expectations
versus the reality of U.S. acculturated youths’ lives may result in better assistance when they
start going through adolescence and early adulthood.
New media
The media’s facilitative role in sex communication noted in this review is not a surprising
finding. While the role of the media in general and the internet in particular has been
previously examined, further investigations into adolescent social media use and how
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parents mediate its impact on adolescent sexual health outcomes deserve further scrutiny.
Compounded by a technological divide between tech-savvy children and their
technologically-challenged parents that is more prominent in minority families and those
coming from a lower socioeconomic background, there is an urgency to assist parents to be
updated on the web-based influences their children access. A nascent movement to study the
relationship between social media use, adolescent outcomes, and parental supervision over
children’s presence online has begun. However, commensurate focus on how parents discuss
with their children issues about sexuality in the age of sexting, snapchatting and porous
Internet privacy is needed. Furthermore, an investigation of how communication between
parents and children occurs through varied technological media is necessary given the
numerous advancements in communication technology.
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Conclusion
As a proximal process that affects children’s sexual development, sex communication is a
function of bioecological factors that are complex and multi-dimensional. It is essential to
understand sex communication in the context of myriad, often competing, environmental
factors to glean how sexual health discussions between parents and children are supported or
undermined. Further, the consonance or disjunction of parental versus environmental
messages has to be examined to determine how children decide which to listen to and which
to disregard. This review has underscored long-established factors that prevent parents from
effectively broaching and sustaining talks about sex with their children and has also
identified emerging concerns unique to today’s parenting landscape.
Overall, parental factors salient to sex communication are established long before
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individuals become parents and are acted upon by influences beyond the home. Child-
focused communication factors likewise describe a maturing audience that is far from
captive. Revolving around parents and children are ecological factors that contribute to how
sex discussions occur. Our findings suggest that future work on sex communication must
always be sensitive to these contextual forces. The challenge of 21st century sex
communication then is to make clear these factors that affect sex communication as an
ongoing dialogue that addresses the sexuality-related concerns of all children, ideally

beginning at the pre-sexual stage, through adolescence and early adulthood. More than being
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focused solely on sharing knowledge with children about matters related to sex, parents can
assist them to develop the capacity to recognize salient influences on their attitudes and
behavior and how they can best respond to these factors.
Acknowledgments
The authors would like to acknowledge the assistance of Drs. Sharron Docherty, Michael Relf and Ross McKinney
for feedback on earlier version of the manuscript. The authors would also like to thank Ms. Adrianne Leonardelli
who, at the time of the study, was a health information specialist at the Duke University Medical Library. Mr. Flores
would like to acknowledge funding assistance from the Surgeon General C. Everett Koop HIV/AIDS Research
Grant and from the National Institute of Health’s Ruth Kirschstein National Research Service Award
(F31NR015013) and Research on Vulnerable Women, Children, and Families (T32NR007100).
References
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Figure 1.
Literature Review Flow Search
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Table 1
Design and Sample Characteristics Across Studies

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Number (N) Percentage (%)

General Approach
Qualitative 50 43%
Quantitative 52 45%
Mixed methods 14 12%
Total 116 100%
Sampling Strategy
Convenience 97 84%
Random within specific population 13 11%
Nationally representative 6 5%
Total 116 100%
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Race
>75% Caucasian 25 22%
>75% African American 26 23%
>75% Latino 13 11%
>75% Asian 6 5%
Racially Diverse/Multiethnic 42 36%
Unknown 4 3%
Total 116 100%
Overall Sample
Children Only 31 27%
Parents Only 36 31%
Children-Parent Dyads 49 42%
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Total 116 100%

Gender Composition of Parents
Mothers only 37 44%
Fathers Only 6 7%
Mothers and Fathers 40 47%
Others 2 2%
Total 85 100%
Gender Composition of Children
Females Only 32 40%
Males Only 4 5%
Females and Males 44 55%
Total 80 100%
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School Age Composition of Children

Pre-K to Grade 6 8 10%
Middle 20 25%
High School 29 36%
College 18 23%

Number (N) Percentage (%)

Not Specified 5 6%
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Total 80 100%
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Table 2
Ecological Factors that Impact PCSC Sex Communication

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Ecological Level Description References
Microsystem
Adolescent milestones as Parents use observable pubertal changes and children’s emerging sexual Askelson et al., 2011; Cox, Scharer,
cues or romantic interests during adolescence as cues to initiate conversations Baliko, & Clark, 2010; Eisenberg,
about sex. Parents wait until their children are physically mature, as Sieving, Bearinger, Swain, and
evidenced by breast development or menses, before initiating sex Resnick, 2006; Hannan, Happ, &
communication. For example, sex communication is triggered when Charron-Prochownik, 2009; Lehr,
daughters become more inquisitive about boys or after observing their Demi, Dilorio, & Facteau, 2005;
son’s physical development or only after parents believed their children Marhefka, et.al., 2009; McRee et al.,
were sexually or romantically involved. Moreover, parents are less likely 2012; Miller et al., 2009; Ohalete,
to talk with teens they believed are not romantically involved. Social 2007; Swain, Ackerman, &
milestones used as a reminder to discuss sex and developmental changes Ackerman, 2006a
include times when children begin having sex education classes in
school and when discussing preventive sexual health issues on general
such as HPV vaccines.
Closeness and comfort The closeness and comfort level adolescents have with parents is Boyas, Stauss, & Murphy-Erby,
level associated with sex communication. More sex communication is 2012; Corona et al., 2009; DiIorio et
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associated with greater parent-child closeness. Further, greater parent al., 2006; Fasula & Miller, 2006;
comfort with sex communication explains direct guidance, such as face- Guzman et al., 2003; Hutchinson &
to-face discussions, and a higher number of sex topics discussed. Montgomery, 2007; Jerman &
Additionally, parental comfort in discussing general and specific topics Constantine, 2010; Martin & Luke,
increases over time. Approachability and responsiveness also affects sex 2010; McRee et al., 2012; Miller et
communication. Mothers who are approachable foster trust and are able al., 2009; E. M. Morgan, A. Thorne,
to assess daughters’ readiness to talk. Mothers with the highest & E. L. Zurbriggen, 2010; Nielsen,
responsiveness had significantly increased odds of discussions about Latty, & Angera, 2013; Noone &
abstinence, puberty, and reproduction. Meanwhile, paternal discomfort Young, 2010; Pluhar, DiIorio, &
is interpreted as a lack of caring or being judgmental of children’s McCarty, 2008; Solebello & Elliott,
thoughts or actions, and keeps daughters away. 2011; Woody, Randal, & D’Souza,
2005
Embarrassment For a majority of parents, discussions about sex are associated with Afifi, Joseph, & Aldeis, 2008;
embarrassment. Despite being cognizant of the need to address sex with Ballard & Gross, 2009; Cox et al.,
their children, parents anticipate a conversation that will cause 2010; DiIorio et al., 2006; Eastman,
frustration and discomfort for both parties. Even among a group of Corona, Ryan, Warsofsky, &
urban-dwelling parents with advanced educational degrees, the Schuster, 2005; Elliott, 2010b;
embarrassing notion of someday discussing sex with their children is Fitzharris & Werner-Wilson, 2004;
identified as potentially getting in the way of sex communication. Guilamo-Ramos et al., 2006; Jerman
Adolescents too are generally dismissive of parents’ attempts to discuss & Constantine, 2010; McKee &
Author Manuscript
sex and are also embarrassed by the exchange. Sons joke and employ Karasz, 2006; Meneses, Orrell-
sarcasm with their parents during these talks while daughters admit that Valente, Guendelman, Oman, &
discussing sex with their parents is avoided. Overall, older adolescents Irwin, 2006; Noone & Young, 2010;
tend to display higher levels of negative affect than younger children Romo, Nadeem, Au, & Sigman,
when probed by their mothers about sexuality matters. 2004; Rose, Friedman, Annang,
Spencer, & Lindley, 2014; Wilson &
Koo, 2010
Extended family members Parental silence is a roadblock that results in other family members Cornelius, LeGrand, & Jemmott,
stepping in and becoming resources for sex. Children sometimes opt to 2008; Crohn, 2010; Guzman et al.,
talk to aunts and grandparents. Stepmothers are seen as less judgmental, 2003; Pluhar & Kuriloff, 2004;
more accepting, and less inclined to worry when compared to their own Wisnieski, Sieving, & Garwick,
mothers. Further, familismo among Latino families allow adolescents to 2015
discuss sexual issues with extended family members, including talks
about romance.
Mesosystem
Parental Education Parental education is positively associated with sex communication; Kim & Ward, 2007; Lefkowitz,
discussions are more likely to occur with mothers who have a college Boone, Au, & Sigman, 2003; Lehr
degree or parents with more formal schooling. More educated Latina et al., 2005; McRee et al., 2012;
mothers probe more about children’s sexuality-related activities and Raffaelli & Green, 2003; Romo et
Author Manuscript
questions, while paternal education predicted sex communication with al., 2004; Stidham-Hall, Moreau, &
both Latino sons and daughters. Nevertheless, fathers with less Trussell, 2012
education have also been reported to engage in more sex
communication.
Religiosity There are mixed results about the role religion plays in how Afifi et al., 2008; Baier & Wampler,
conversations about sex are framed. Several reports support the idea that 2008; Cornelius, Cornelius, &
religion impacts sex communication. In rural South Carolina, mothers White, 2013; Cox et al, 2010; El-


used faith-based messages with their children where “biblical instruction Shaieb & Wurtele, 2009; Hertzog,
should be sufficient to prevent the adolescent from engaging in sexual 2008; Lefkowitz et al., 2003;
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activity,” p. 189, (Cox et al., 2010). Less religious mothers initiate sex Nadeem, Romo, & Sigman, 2006;
communication earlier compared to their religious counterparts and Ohalete, Georges, & Doswell, 2010;
parents in the southern U.S. are receptive to faith-based and church-led Pluhar et al., 2008; Regnerus, 2005;
sex discussions with their children. Regnerus (2005) found that higher Romo, Bravo, Cruz, Rios, &
parental religiosity was linked to fewer discussions and greater unease Kouyoumdjian, 2010; Swain et al.,
in talking about sex. Further, religious affiliation and church attendance 2006; Williams, Pichon, &
contributed to less frequent conversations about birth control and were Campbell, 2015
associated with more discussions about the moral implications of
adolescent sexual activity. Adolescents who discussed safer sex with
their parents reported less church attendance compared to their peers
who did not discuss safer sex, but attended church more frequently.
However, there are a handful of studies that do not link religiosity and
parent-child sex communication where reports of religiosity did not
determine the amount of time Latina mothers talked both implicitly and
explicitly about abstinence and contraceptive use, despite being
Catholic.
Exosystem
Mass Media Mass media emerged as the most influential factor in the exosystem and Aronowitz, Todd, Agbeshie, &
its impact occurs in two distinct ways. First, the perceived negative Rennells, 2007; DiIorio et al., 2006;
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effects of highly sexualized media content on impressionable minds Eastman et al., 2005; Edwards &
compel parents to discuss sex-related issues with their children. Even Reis, 2014; Hannan et al., 2009;
among parents who found it challenging to verbalize their concerns Kim, 2009; McRee et al., 2012;
about sex, a form of indirect sex communication included restricting Noone & Young, 2010; Pluhar &
media use by Asian American children to convey disapproval of Kuriloff, 2004
Western sexuality. Second, many parents used examples from TV as
opportunities to broach sex-related issues. For example, in a study about
how mothers discuss sexuality with daughters born with Type 1
Diabetes, mothers recalled addressing reproductive health when
sexually explicit content appeared on TV. Similarly, the internet has
been used by parents to assist their children to find sexuality-related
resources to complement discussions they had about sex.
Macrosystem
Race/Ethnicity Race and ethnicity affects how sex communication occurs in various Chung et al., 2005; Chung et al.,
ways. In a diverse sample of adolescents from the Midwest, Caucasian 2007; González-López, 2004; Kim
children reported more sex communication when compared to African & Ward, 2007; McKee & Karasz,
American and Latino/Hispanic children. African American adolescents 2006; Meneses et al., 2006;
received significantly more paternal communication than Caucasians Meschke & Dettmer, 2012; Murphy-
did, and Caucasians received more sex communication from fathers than Erby, Stauss, Boyas, & Bivens,
Hispanic adolescents did. Data from a national study found that Asian 2011; Orgocka, 2004; Raffaelli &
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and Latina mothers reported the most infrequent amounts of sex Green, 2003; Romo, Bravo, Cruz,
communication. Among Asian families, mothers, more than fathers, are Rios, & Kouyoumdjian, 2010;
the sources of sexual information, but there is also a “don’t ask, don’t Sneed, 2008; Somers & Vollmar,
tell” policy in which both parties avoid communication about sex to 2006; Tobey, Hillman, Anagurthi, &
avoid tension. Somers, 2011
Parents of Latino children tend to use direct rather than indirect
communication about sexuality. Discussing sex as improper was
associated with less perceived openness in general communication by
both Latina mothers and daughters. On the contrary, tener confianza
(“instilling confidence”) observed among Latino parent-child dyads
underscores confiding in parents and seeking their advice, keeping
information confidential and having non-punitive responses to
children’s disclosures. Among Asian American children, indirect sex
communication included gossiping to convey sexual values along with
imposing rules that constrained how daughters dress and socialize.
Cultural differences between immigrant parents and their U.S.-born
children that impede sex communication are consistently noted, with
more adolescent acculturation predicting less frequent discussions about
sex. For example, the varying ability of parents to speak to their children
in English or the conservative upbringing of Latina mothers clash with
children’s sexual mores. In Asian American families, a cultural divide
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caused both groups to withdraw from family communication about sex

to avoid conflict and preserve harmony. Nonetheless, migrating to the
U.S. has also been pointed out by fathers as causing a transformation in
traditional views about children’s sexuality.
Gendered Content There are differences in what parents tell males compared to what they Akers, Schwarz, Borrero, & Corbie-
tell females during sex discussions. Females are held to a stricter moral Smith, 2010; Akers, Yonas, Burke,
standard compared to males. Daughters recalled discussing delaying sex & Chang, 2011; Aronowitz et al.,
until marriage while more males discussed condom use. Similarly, 2007; Averett, Benson, &


college-aged women remembered receiving restrictive sex messages, Vaillancourt, 2008; Brown, Rosnick,
including warnings about the opposite sex, while young men received Webb-Bradley, & Kirner, 2014;
Author Manuscript
positive sex messages, including the inevitability of sex before marriage. Dennis & Wood, 2012; Elliott,
According to parents, daughters have to value themselves in order to 2010a; Gilliam, 2007; González-
avoid being taken advantage of, while sex communication with sons are López, 2004; Guilamo-Ramos et al.,
more about taking responsibility for behaviors and treating women with 2006; Heisler, 2014; Kapungu et al.,
dignity and respect. Fathers wanted to teach their sons to grow up 2010; Kim & Ward, 2007; Martin &
heterosexual by modelling masculine behavior and giving tacit Luke, 2010; Morgan, Thorne, &
permission when sons are caught watching pornography. Among Asian Zurbriggen, 2010; Murphy-Erby et
and Latino families, parents are explicit about their expectations for al., 2011; Sneed, Somoza, Jones, &
their daughters’ dignified behaviors out of concern for family reputation Alfaro, 2013; Solebello & Elliott,
while sons do not receive the same messages. 2011; Stauss, Murphy-Erby, Boyas,
& Bivens, 2011; Wilson & Koo,
2010
Socioeconomic Status A family’s socioeconomic status influences the content of sexual Romo et al., 2010; Swain,
communication. Low income minority parents reported more discussion Ackerman, & Ackerman, 2006b;
about the negative consequences of sex and where to obtain birth Teitelman & Loveland-Cherry, 2004
control, compared to higher income Caucasian parents. Scripts explicitly
about postponing sexual intercourse or involvement in a relationship are
recalled mostly by low income girls, while girls from higher income
households have fewer explicit discussions about sexual risks, but more
conversations about good decision-making and life opportunities.
Author Manuscript
Similarly, Latina mothers from a lower socioeconomic background

talked more to their daughters about avoiding risky situations and
engaging in self-protective practices, while those with a higher
socioeconomic status had longer discussions about positive sexuality,
and contraceptive use.
Author Manuscript
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21st Century Parent-Child Sex Communication in the U.S.: A

Parent-child sex communication is the bi-directional communication between parents (or

Traditionally conceptualized as a verbal exchange between knowledgeable parents

related to sexual behavior surrounding mostly negative outcomes (e.g., unplanned

Sex Communication and Adolescent Sexual Health Outcomes

J Sex Res. Author manuscript; available in PMC 2018 May 01.

likely to use birth control (Aspy et al., 2006).

J Sex Res. Author manuscript; available in PMC 2018 May 01.

Literature search strategy

J Sex Res. Author manuscript; available in PMC 2018 May 01.

Inclusion and exclusion criteria

of electronic databases. Through this ancestry method of cross-checking and back-

J Sex Res. Author manuscript; available in PMC 2018 May 01.

An adaptation of framework synthesis (Carroll, Booth, & Cooper, 2011) scaffolded by

congruence among sex communication reports.

J Sex Res. Author manuscript; available in PMC 2018 May 01.

General versus specific topics

Parental communication style

J Sex Res. Author manuscript; available in PMC 2018 May 01.

Tone and language

J Sex Res. Author manuscript; available in PMC 2018 May 01.

Reciprocal reluctance to initiate conversations

J Sex Res. Author manuscript; available in PMC 2018 May 01.

Anticipated disapproval—Generally, adolescents could not discuss topics of a sexual

Knowledge deficit—Parents have varying levels of knowledge about sex-related topics,

J Sex Res. Author manuscript; available in PMC 2018 May 01.

Learning from traumatic experience—Parents’ own experiences with risky sexual

J Sex Res. Author manuscript; available in PMC 2018 May 01.

Acknowledgement of parental responsibility—Parents acknowledged it is their

Sex communication as a green light to have sex—Parents are concerned about

J Sex Res. Author manuscript; available in PMC 2018 May 01.

Frequency and consistency

Discussion and Recommendations

J Sex Res. Author manuscript; available in PMC 2018 May 01.

Enduring Sex Communication Issues

Awkwardness and timing concerns

Gender dynamics and gendered content

J Sex Res. Author manuscript; available in PMC 2018 May 01.

investigated to encourage meaningful re-conceptualizations of equal and consistent sex

messages for daughters and sons.

Mothers as de facto sex educators

J Sex Res. Author manuscript; available in PMC 2018 May 01.

Nonverbal sex communication

Beyond heteronormativity and able-bodiedness

While children’s assumed heterosexuality continues to guide most sex communication

about transitory or potentially permanent same-sex attraction or behavior during adolescence

specifically, but also their overall psychosocial well-being.

The redefined American family

J Sex Res. Author manuscript; available in PMC 2018 May 01.

adolescents’ sex-related developmental needs. Similarly, due to the shift in U.S.

J Sex Res. Author manuscript; available in PMC 2018 May 01.

Articles reviewed are denoted with an asterisk (*).

10.1177/0886260510383028 [PubMed: 20889536]

10.1080/10410236.2011.606526 [PubMed: 21978128]

J Sex Res. Author manuscript; available in PMC 2018 May 01.

participatory research. Ambulatory Pediatrics. 2005; 5(1):50–55. [PubMed: 15658886]