Adolescent Sexuality

Adolescent sexuality has undergone many changes, with adolescents now reaching physical maturity earlier, and a number of guidelines exist to help the clinician deal with adolescent sexuality.After completing this article, readers should be able to:Adolescence is a transitional stage of physical, emotional, and cognitive human development occurring before the onset of puberty and ending by adulthood. Sexuality, the expression of interest, orientation, and preference, is a normal part of adolescence. Adolescent sexuality encompasses multiple factors, such as developing intimate partnerships, gender identity, sexual orientation, religion, and culture.Adolescent sexuality has changed over the past 50 years, with adolescents now reaching physical maturity earlier and marrying later. Puberty marks the obvious physical development in early to middle adolescence and is seen as the time for potential onset of sexual thoughts and experimentation. On average, middle adolescence is a time when teens begin to be interested in more intimate relationships and experimentation. Parental and societal concerns regarding premature sexual activity include unplanned pregnancy, sexually transmitted infections (STIs), sexual abuse, and potential emotional consequences of sexual behaviors. These concerns underscore the importance of providing adolescents with preventive health services and comprehensive sexual health education.Approximately 10 years ago, new guidelines published in Pediatrics advised that girls who start to develop breasts and pubic hair at age 6 or 7 years are not necessarily abnormal. (1) The guidelines were based on a number of studies, the most important being the trial by Herman-Giddens et al (2) of 17,000 girls between the ages of 3 and 12 years who were patients in more than 200 pediatricians’ offices across the country. Published in 1997, the report was based on girls evaluated in 1992 and 1993. Previous norms for puberty were based on a study of fewer than 200 girls in a British orphanage in the 1960s. (3)The obesity epidemic has been postulated as the likely cause of earlier onset of puberty. However, a recent Danish study reported that Danish girls were developing breasts at an earlier age than they were 15 years ago. (4) The study found that the onset of puberty (as measured by breast development) dropped from a mean age of 10.9 years in 1991 to 9.9 years in 2006. This change was not due to obesity, because the girls’ BMI remained constant across the study periods. Other possible explanations for earlier puberty include environmental factors, socioeconomic conditions, nutrition, and access to preventive health care. Girls tend to move through adolescence earlier than boys. The stages for both sexes are the same and are divided into early, middle, and late adolescence.Earlier onset of puberty leads us to question whether adolescence starts with puberty, because the other aspects of adolescence often are not present before the age of 10 years. In general, the early adolescent experiences physical changes, attempts to adjust to the changes, and often wonders if they are normal. Children at this stage are self-preoccupied and concerned about body image and privacy. These privacy concerns evolve into some separation from family and an increased focus on relationships with peers and group activities. Concrete thinking continues from childhood, but abstract thinking starts to develop, especially in less personal areas, such as academics. (5)Although early adolescents may begin to experiment with their sexuality (particularly with sexual fantasy and masturbation), sexual intercourse is not common. Homosexual and heterosexual experimentation is common in early adolescence. If an adolescent has had sex with someone of the same sex, this experience does not mean that the teen is gay. It is important to note that many gay teens have never had a sexual experience with someone of the same sex, and that “teens who will eventually identify as gay, lesbian or bisexual do not always do so during adolescence.”(6)Attraction occurs in late childhood/early adolescence and can precede or occur concurrently with a first romance or first sexual experience. It is not uncommon for adolescents to experience same-sex attractions; in fact, most gay youth experience opposite-sex attractions, sometimes before same-sex attractions. Previous studies report that more than 80% of same-sex–attracted girls and 60% of the boys acknowledged opposite-sex attractions. Boys reported that the onset of heterosexual attractions happened around the same age as same-sex attractions and occurring on average 1 to 2 years earlier than girls. (7)This stage is marked by the full establishment of secondary sexual characteristics and growth deceleration. Feelings of omnipotence and invincibility peak (although this can also be a time of increased sense of vulnerability). These feelings favor the development of autonomy but can place the adolescent at increased risk of contracting an STI or becoming pregnant, because these individuals cannot weigh consequences appropriately. Abstract thinking and other executive functions continue to develop but still are not fully formed.During this stage, teens are moving toward forming a sexual orientation and identity. They become increasingly concerned with whether they are attractive and place more importance on their peer group. Many adolescents in this stage may “fall in love” for the first time. Sexual experimentation is common, and many will have intercourse during middle adolescence.It can be argued that late adolescence continues through the postsecondary education period. Brain development, particularly of the prefrontal cortex, can continue until age 22 years in female subjects and 25 years in male subjects. (8) Late adolescents tend to focus on autonomy and thinking beyond themselves. Most teens during this stage are able to think abstractly; they are future oriented and more insightful. They are secure with their body image and gender role; sexual orientation also is nearly secured. Teens in late adolescence work on transitioning to adult roles in relationships, school, and work. However, they may still act impulsively. (5) Becoming a sexually healthy adult is a developmental task of adolescence that requires integrating psychological, physical, cultural, spiritual, societal, and educational factors. It is particularly important to understand the adolescent in terms of his or her physical, emotional, and cognitive stage.Traditionally, we have thought of sexuality as including sexual fantasy, masturbation, nonpenetrative sexual acts, oral sex, vaginal intercourse, and anal intercourse. In the electronic age, other activities are included in the sexual lexicon, including phone sex, sexting, sex in chat rooms (with or without webcams), and virtual sex with the use of avatars. Most of the data available on adolescent sexual behavior are related to vaginal intercourse.In the United States, according to the 2009 Youth Risk Behavior Survey, students in grades 9 through 12 were less likely to report sexual intercourse with at least one person compared with students surveyed in 2003. (9) The percentage of students reporting condom use during the last sexual intercourse and use of birth control before last sexual intercourse remained unchanged. The survey indicated that 46% of students had sexual intercourse with at least one person, and 5.9% of students had sexual intercourse for the first time before age 13 years.The National Survey for Family Growth was conducted by the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics. Over the year before the survey, 13% of 15- to 17-year-old males and 11% of 15- to 17-year-old females had heterosexual oral sex but not vaginal intercourse. (10) Fourteen percent of students reported sexual intercourse with four or more persons during their lifetime.Sixty-one percent of students reported that either they or their partner had used a condom during their last sexual encounter. The prevalence of having used a condom during last sexual intercourse was higher among male (69%) than female (54%) students. Among the 46% of sexually active students, 20% reported that either they or their partner had used birth control pills to prevent pregnancy before their last sexual encounter. (9)The median age of first intercourse for male and female subjects in Canada is 16.5 years according to a Canadian study that included 1,171 participants age 14 to 17 years across the country. (11) The mean age of first oral sex in this study was 15 years. Five percent of boys and 1% of girls initiated intercourse before age 12 years. Approximately 30% of boys and 20% of girls had experienced sexual intercourse at least once by age 14 years. Among the teens who become sexually active, 68% reported oral sex and 85% reported vaginal intercourse. Seventy-six percent reported condom use the last time they had intercourse. Nine percent reported the use of the withdrawal method, and 1% used emergency contraception.In 2008, the British Columbia Adolescent Health Survey (a cluster-stratified weighted survey) obtained data from more than 280,000 students from grades 7 through 12. (12) Twenty-six percent of students reported ever having oral sex, and the percentages were similar for male and female students. The percentages increased from 3% among students 12 years or younger to 52% of students 18 years or older. The trend with condom use declined with age, and oral contraceptive pill use increased with age. Among the students who reported sexual activity, 32% reported that they drank alcohol or used drugs before their last sexual encounter.Rates of condom use among teens in the United States and Europe are similar; however, teens in Europe are much more likely to use hormonal methods of contraception. (13)(14) In 2006, 61% of 15-year-old sexually active females in the Netherlands reported using the birth control pill at their last sexual encounter. In the United States among sexually active females in grades 9 through 12, 10% reported using dual methods (eg, condoms with birth control pills or medroxyprogesterone injection). Among sexually active male students, 8% used dual methods in which they used a condom and their partner used birth control pills or medroxyprogesterone.It is estimated that adolescents age 15 to 19 years acquire 50% of all new STIs, yet they represent only approximately 25% of the sexually active individuals in the population as a whole. Sexually active adolescents are at higher risk for acquiring STIs due to behavioral, biological, and physiologic factors. (15)Human papillomavirus (HPV) is the most common STI acquired during adolescence. Surveillance for cervical infection with high-risk HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, or 68 was conducted in 26 STI, family planning, and primary care clinics in 6 US cities. (16) Testing was performed by using a commercially available test for high-risk HPV DNA. In all, 9,657 women ages 14 to 65 years were tested, and the prevalence of HPV was noted to be highest among women ages 14 to 19 years at 35% (confidence interval: 32–38).Chlamydia trachomatis infection is common among adolescents. The normal cervical ectopy present in this age group puts adolescent females at increased risk. (15) The higher prevalence also reflects the multiple barriers to accessing confidential STI prevention services and resources. Chlamydia remains the most common reportable STI in the United States. Girls age 15 to 19 years had the highest rate of Chlamydia compared with any other age or sex group, with African-American, American Indian/Alaska Native, and Hispanic females disproportionately affected. Increases in Chlamydia rates are likely a reflection of expansion of screening and an in is the most reported in the United States. (15) than were reported in The rate women age 15 to 19 years is similar to the rate reported for women age to years. 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