Patient education: Adolescent sexuality (Beyond the Basics)
- Paul AS Benson, MD, MPH
Paul AS Benson, MD, MPH
- Associate Professor of Pediatrics
- OU-Tulsa School of Community Medicine
Most teens and preteens have a lot of questions about sex and sexuality. This is normal and natural. It also is normal to feel shy or embarrassed about raising these issues with adults or health care clinicians.
Sexual development is an important part of health, similar to other measures of physical growth, such as height and weight. Sexual behavior, which is related to sexual development, has important health implications for everyone and especially for teens. It is particularly important that teens be well informed about all aspects of sex and sexual health.
Some basic information on sex and sexuality is provided in this review, which may answer some questions and raise others. Find an adult with whom you feel comfortable – perhaps a clinician, parent, or teacher – to discuss any questions or concerns you may have.
SEXUALITY: WHAT IS IT?
Human sexuality is more than just whether you are male or female, and it is more than just the act of sex. It is a complex idea that involves your physical make-up, how you think about yourself, and how you feel about others and the society you live in.
Here are some of the things that contribute to sexuality:
Anatomic sex — Anatomic sex refers to the sex organs with which you were born. That is, you are either a boy (with a penis and testicles) or a girl (with breasts, a uterus, vagina, and ovaries). Occasionally, a baby is born with sex organs that are not normally developed and/or may appear to resemble both sexes; these individuals are said to have ambiguous genitalia or to be intersex. Anatomic sex is only one component of sexuality.
Gender identity — Gender identity relates to how you feel inside, and whether you "feel" like a boy or a girl. Most people have a combination of feelings, including some that are thought of as "male" or "masculine" and some that are thought of as "female" or "feminine." In most cases, someone feels mostly like a boy or mostly like a girl.
Gender identity and anatomic sex sometimes do not match. For example, a person can be born as a boy but feel like a girl, or can feel somewhere in between a boy and a girl. This is sometimes referred to as transgender.
Sexual orientation — Once you begin puberty, you are likely to begin to have strong physical and emotional attractions to others. Sexual orientation refers to whether you are primarily attracted to people of the opposite sex (heterosexual or straight), the same sex as you (homosexual, gay, or lesbian), or both (bisexual). Sexual orientation is influenced by many factors, including your anatomic sex, your gender identity, the society you live in, and other factors, some of which are not completely understood.
Sexual orientation exists on a continuum. That is, you may feel mostly attracted to people of the same sex as you but still have some feelings for people of the opposite sex, or vice versa. It is very common for young people to feel confused about their sexual orientation and that is entirely normal. How you may or may not choose to label your sexual orientation is not so important as how you feel about yourself as a person. You should understand that while there is still significant social stigma toward people of certain sexual orientations, there are people just like you who lead normal, happy lives. Regardless of to whom you feel attracted you should know that these feelings are entirely normal and sometimes change throughout life.
ADOLESCENT SEXUAL DEVELOPMENT
Sexual development begins in the preteen years and continues into adulthood. The body produces hormones that cause outward changes, including breast development in girls, growth in size of the penis and testicles and the appearance of facial hair in boys, and growth of hair under the arms and in the genital area of both boys and girls.
However, puberty is more than physical changes. As your body grows into adulthood, your way of thinking, emotions, and wants and needs will change as well. The factors discussed above (your anatomic sex, your gender identity, and your sexual orientation) will all become a part of how these changes affect you as a person.
You will probably start to feel strong attractions toward others. Sometimes these feelings include developing friendships with other teenagers. Other feelings include wanting to be physically close to another person. You may find yourself attracted to someone of the opposite sex, someone of the same sex, or both.
It's important to remember that these physical attractions can shift and change and that they develop at different times in different people. You may find you are attracted to someone of the same sex for a time, then find stronger attractions to someone of the opposite sex. Alternately, the reverse often occurs.
Over time, most teens will come to identify themselves as primarily heterosexual, homosexual, or bisexual. However, you should not be surprised if you feel confused about some of these issues during your teen years. This time of life may be troubling for teens who begin to identify themselves as gay, lesbian, or bisexual, especially if these ideas are not openly accepted by family members, friends, or the society in which they live. In this case, it is especially important for the teen to find a trusted adult and friends with whom he or she can talk openly. Several of the online resources listed below can also be of benefit. (See 'Where to get more information' below.)
It also is important to know that in the early years of puberty, it's normal to want to experiment with sexual activity. This often happens before a teenager is fully aware of how this activity might affect his or herself or others. As teens continue to grow and mature, they are better able to make choices about intimacy and physical relationships that will enhance their lives, rather than making choices that will cause problems for themselves or others. Adults generally recommend that teens not rush into sexual activity too soon, but rather wait until they are more mature. (See 'Health issues related to sex' below.)
When you are sexually mature, you'll have a more developed sense of your preferences and desires. You will understand the possible consequences of having sexual relationships with others, and you will be ready to take responsibility for whatever occurs. You will be more ready to engage in the satisfying, intimate relationships that are an important part of life.
SEXUAL ACTIVITY: THE FACTS
There are many ways to express intimacy. Spending time with another person, holding hands, and kissing are all ways to show affection and begin to explore physical intimacy. As you develop attractions toward others, you will probably want to explore these and other types of physical intimacy.
What might this involve? Most teens have questions about sex and sex acts. Here are some basic facts and definitions, including some important information about sexual boundaries; that is, what is and what is not OK as part of a sexual relationship.
Genitals — Genitals are the external sex organs that are sensitive to and stimulated by being touched, which typically occurs during sexual activity. The male external organs are the penis and scrotum, which holds the testicles (figure 1). The female external organs are the vulva, clitoris, and the opening to the vagina (figure 2).
Petting — Petting is feeling parts of another person's body. This usually refers to touching the genitals or other sexually sensitive areas, such as breasts.
Orgasm — Orgasm is an intensely pleasurable release of tension felt in the genital area and elsewhere in the body. It usually results from stimulation of the genitals. In girls and women, orgasm is associated with rhythmic contractions of the perineal muscles and reproductive organs. In men and boys, orgasm is associated with the release of semen (called ejaculation), which contains sperm. The term "come" is a slang word for orgasm.
Sexual intercourse — In general, this refers to sex involving a man's penis being placed inside a woman's vagina. When the man ejaculates during sexual intercourse, his semen is released into the woman's vagina. Pregnancy occurs if sperm, contained in the semen, are able to fertilize the egg released by a woman's ovary. However, semen can be released even if the man does not have an orgasm.
Oral sex — Oral sex involves using the mouth and/or tongue to stimulate the genitals. Oral sex can occur between a man and a woman, between two men, or between two women.
Anal sex — Anal sex is sexual activity involving penetration of the anus (the opening where bowel movements leave the body). A penis or another object is inserted into the anus during anal sex. Both men and women are able to engage in anal sex.
Masturbation — Masturbation involves using the hands, or sometimes a device such as a vibrator or other sex toy, to stimulate one's own or someone else's genitals.
Some people believe "having sex" only means sexual intercourse. But other activities, including oral sex, anal sex, or masturbation can also be considered as "having sex." Even things like kissing or petting are considered to be sexual activity because they are part of how one person responds sexually to another person.
Sexual boundaries — The only kind of sexual activity that is OK is activity that occurs between people who want to have sex with each other. Activity that occurs when a person is alone, such as masturbation, is also OK. If two people are having sex, both of them must be old enough and mature enough to participate without feeling pressured to prove something or try something new.
If a sex act is forced upon a person who does not want to participate, this is called rape. Rape is a serious crime that can result in being arrested, spending time in jail, and having a permanent criminal record. Having sex with someone who is not sure they want to have sex can also be called rape.
For teens, feelings about sex can be new and confusing. For example, sometimes a person begins kissing or petting but then changes his or her mind and wants to stop. The other person must always listen, even if it is very difficult to stop. It is not harmful to stop sex before orgasm occurs.
Teens sometimes get into difficult situations if they are drinking or using drugs and having sex. In these cases, someone may seem to want sex, but they may be too drunk or high to know what they are doing. Later, the sex can be called rape.
Teens may be lured into having sex with an adult. It is never OK for an adult to behave in this way. If an adult wants to engage in any type of sexual activity (kissing, petting, oral sex, intercourse), the teen should talk to a parent, health care clinician, law officer, or other trusted adult at once. Even if you feel like you have done something to cause the adult to be attracted or have sexual feelings, the adult is responsible for controlling his or her behavior, regardless of the circumstances.
Certain state laws, which vary from state to state, impose certain regulations or rules on sexual activity, even among teens. As discussed above, it is always a crime for anyone to force or coerce you into having sex against your wishes, no matter if it is an adult or someone around your own age. However, in some states, sex between teens below a certain age may also be illegal, even if both people want to have sex. Rules may depend upon the age of both partners and upon the sex of your other partner(s). Before deciding to have sex, speak to a trusted adult about these important issues.
HEALTH ISSUES RELATED TO SEX
The main reason it is important to postpone sexual activity until you are mature is that sexual activity affects both the physical and emotional health of the people involved. Here are some facts.
Sexually transmitted infections (STIs) — There are a number of infections that can be spread during sexual activity. Infections can be spread through sexual intercourse, anal sex, oral sex, and using fingers, other body parts, or sex toys that have come in contact with another person's genitals or body fluids. These diseases are called sexually transmitted infections, or STIs (often called sexually transmitted diseases, or STDs). Common places STIs can occur are the genital organs, anus, and throat.
Research has shown that young people are at an increased risk of catching STIs. The reasons for this are not completely understood. However, the younger you are when you start having sex, the more likely it is that you will get an STI. Also, having one STI can make it easier to acquire other STIs at the same time.
In many cases, you can get an STI and not know it. This is because STIs often do not have any noticeable signs or symptoms. All of the STIs can have serious consequences for future health, even when there are no symptoms. For example, a woman who gets an STI may have difficulty becoming pregnant later in life or may be more prone to developing certain types of cancer, such as cervical cancer.
Some of the most important STIs are:
Human papillomavirus — Human papillomavirus (HPV) is the most common STI in adolescents. Most people who get HPV do not know they have it. Some types of HPV cause genital warts. Other types of HPV cause cervical cancer in women, penile cancer in men, and anal or oropharyngeal cancer in either sex. A Pap smear is one important way your health care clinician can screen for cervical cancer associated with HPV. (See "Patient education: Genital warts in women (Beyond the Basics)" and "Patient education: Cervical cancer screening (Beyond the Basics)".)
In addition, there are vaccines to protect against common types of HPV. The vaccine is recommended for both males and females. Speak to your health care clinician about this important vaccine, even if you are not currently sexually active or thinking about becoming sexually active. The ideal time to receive this vaccine is before you have engaged in any type of sexual activity. That is when it is most effective at prevention. (See "Patient education: Human papillomavirus (HPV) vaccine (Beyond the Basics)".)
HIV — HIV (human immunodeficiency virus) is the virus that causes AIDS (acquired immune deficiency syndrome). HIV is a serious, incurable disease of the immune system. In the past, everyone who developed AIDS died. Although there is no cure for HIV and no vaccine to prevent it, there are treatments that help many people with HIV infection live longer. However, many people still die each year from AIDS.
Treatment of HIV-positive persons until the HIV virus is no longer detectable in their blood has the added benefit of significantly reducing the risk of transmission of HIV to HIV-negative partners. This is known as treatment as prevention (TasP). There also is a medication that can be taken daily by HIV-negative persons who are at risk of HIV to reduce their risk of acquiring the infection. This is known as PrEP (pre-exposure prophylaxis).
Each year in the United States, approximately 50,000 people are newly infected with HIV. Approximately 25 percent of these new infections are in young people 13 to 24 years old. Recommendations call for those who have been sexually active to be tested routinely for HIV infection. The earlier HIV is detected, the sooner a person can obtain treatment and the better the chances are of survival. Treatments for HIV have come a long way since HIV was first recognized, and people with HIV may now lead normal, full lives, provided they seek health care soon enough and take all of the medicine prescribed to them. Speak to your health care clinician about HIV testing. (See "Patient education: Testing for HIV (Beyond the Basics)".)
Gonorrhea and chlamydia — These are serious bacterial infections of the genital tract. They can lead to pelvic inflammatory disease (PID) in females, which can cause severe pain, lead to infertility (inability to become pregnant), and/or increase the risk of ectopic pregnancy (pregnancy implanting in a Fallopian tube or elsewhere than the uterus, or womb). Gonorrhea and chlamydia also can cause epididymitis in males. Both gonorrhea and chlamydia can be cured with antibiotics. It is important to be screened for these infections if you have had sex because most people do not have any symptoms. (See "Patient education: Gonorrhea (Beyond the Basics)" and "Patient education: Chlamydia (Beyond the Basics)".)
Herpes simplex virus — This is a viral infection that causes painful or itchy sores or blisters in the genital area. The sores heal but can reappear at any point later in life. There is no cure. The virus can be spread even when there are no sores present. Most people with herpes do not have symptoms so they do not know that they might infect a sexual partner. Medications are available from your health care clinician to shorten the length of time the sores last and decrease your risk of repeat outbreaks. If you have been diagnosed with herpes, discuss with your doctor the option of daily prophylactic medication that can reduce your risk of repeat outbreaks and spread of herpes to sex partners. (See "Patient education: Genital herpes (Beyond the Basics)".)
Hepatitis B virus — This is a viral infection that can cause liver disease. In most cases, the disease goes away after the initial illness. But in some people, serious liver damage or liver failure can occur. Most children and adolescents are being vaccinated against this infection with a series of three shots. You should speak to your health care clinician if you are not sure if you have had this vaccine. (See "Patient education: Hepatitis B (Beyond the Basics)".)
Hepatitis C virus — Hepatitis C virus is a viral infection that can cause serious liver damage or liver failure. Liver disease can occur even in people without symptoms. Hepatitis C is diagnosed with a blood test. Hepatitis C infection can usually be treated with medications, and with newer treatments, many patients can be cured. (See "Patient education: Hepatitis C (Beyond the Basics)".)
Syphilis — This is an infection caused by a small organism called a spirochete (/SPY-ro-keet/), which can cause an ulcer on a person's genitals or anus. It has become more common in teens and young adults, especially in certain cities and areas of the United States. Sometimes you may not notice the ulcer because it does not usually cause pain or may be on the inside of the vagina (in females) or anus (in either sex). It is important to see your health care clinician right away if you notice any sores or ulcers. The sore usually heals but can cause serious long-term problems if untreated. Syphilis can usually be cured with antibiotics.
Trichomonas — Trichomonas ("trich") is a common infection caused by a tiny parasite that can cause itching and/or a discharge from a female's vagina or a male's penis. Females notice symptoms far more often than males, although both sexes can be infected without having any symptoms. Due to the types of testing available, trich is most often diagnosed in females, but an infection in either sex requires treatment by a health care clinician. If a sex partner informs you she or he has been diagnosed with trich, you should seek treatment for this infection right away even if you have no symptoms. Trich can be cured with antibiotics.
PREVENTION AND SCREENING FOR STIS
The only way to be sure you will not get an STI is to not have sex. STIs can be transmitted through sexual intercourse, oral sex, anal sex, and using fingers, other body parts, or sex toys that have come in contact with another person's genitals or body fluids. STIs can be transmitted between a male and a female, between two females, and between two males who have sex.
It is not possible to tell by looking at someone whether he or she has an STI. Even if the other person tells you he or she does not have an STI or says he or she is "clean," you cannot be sure this is true. That is because the person may not know if he or she is infected. Also, it is common for teens to not be completely truthful about many things in relationships, including whether they may have been exposed to an STI.
Condom and dental dam use — People who are sexually active can reduce their risk of getting an STI by using a latex or polyurethane condom every time they have sex. Male condoms are worn on the penis, helping to prevent body fluids from passing to another person. Unlubricated condoms can be used for oral sex. Female condoms are also available and can be placed in the vagina to help prevent fluids from passing from one person to another. (If a male and female are having sex, only one should wear a condom. If both the male and female wear a condom, the condoms could rub together and move out of place.)
Dental dams (ie, squares of latex) are another barrier device that can be used when performing oral-vaginal sex on a female or oral-anal sex on a partner of either sex. A dental dam can be made by cutting an unlubricated condom lengthwise so it forms a square. (See "Patient education: Barrier methods of birth control (Beyond the Basics)".)
Condoms and dental dams reduce the risk of getting an STI, but they do not take away the risk completely. Condoms can break or leak, allowing passage of body fluids and transmission of infection. In addition, condoms do not completely cover all of the skin that is exposed during sex; herpes and HPV can be passed by skin-to-skin contact. Other birth control methods do not reduce the risk of STIs.
You can reduce the risk that a male condom will break or slip off in two ways. First, make sure the penis is completely hard before putting on the condom. Also, be sure to squeeze and hold the tip of the condom as you roll the rest of it down the penis, making sure there is no air pocket (like a small balloon) at the end of the penis. After ejaculation (male orgasm) during penile-vaginal sex, the penis should be pulled out of the vagina while it is still a little hard. It is important to hold the condom around the base of the penis when pulling out to prevent leakage of semen into the vagina. Similar precautions should be taken before and after penile-anal sex, whether with male or female partners.
Immunizations — Another way to reduce the risk of two specific STIs (HPV and hepatitis B) is to talk to a health care clinician about immunizations. As previously mentioned, most children and adolescents are routinely immunized against hepatitis B in the United States. The HPV vaccine is now available to males and females aged nine years and older.
Check-ups — Regular check-ups by your health care clinician are important to all adolescents, but it is particularly important to speak with a health care clinician if you decide to have sex. This talk should include ways to prevent pregnancy and STIs, as well as the need for regular testing for STIs, including HIV. Since STIs can occur in different body sites (genital organs, anus, and throat) and may have no symptoms, it is important to speak honestly with the clinician about sexual behavior to get appropriate testing. If your health care clinician is not comfortable or able to screen you for STIs, ask for a referral to a clinician who can. Your local health department should also be able to provide STI and HIV screening at low or no cost to you.
Pregnancy and birth control — Pregnancy is a serious consequence of sexual activity between males and females. Teen birth rates have declined since 1991, and especially since 2007, in large part due to increased use of birth control methods.
Pregnancy in teens has serious health consequences. Pregnant teens are more likely to have babies who are premature or sick. A pregnant adolescent is more likely to drop out of school and live in poverty. Although some teens who become pregnant choose to have an abortion, this choice also carries some risk.
As with STIs, the only way a young woman can be sure she will not become pregnant is to not have sexual intercourse. There is no reliable way to determine a "safe" time when she will not become pregnant; menstrual cycles at this age can be irregular. Teens should know that pregnancy is possible each time they have sexual intercourse, including the first time, during the menstrual period, and anytime between menstrual periods.
Birth control methods are available that can reduce the risk of pregnancy to near zero. However, birth control methods other than condoms do not reduce the risk of STIs. The best, most effective methods of birth control are the long-acting reversible contraceptive (LARC) methods. These include the subdermal implant (brand name: Nexplanon) and the intrauterine device (IUD; sample brand names: Skyla, Mirena, ParaGard). The implant is a small hormone-containing rod inserted just under the skin in the arm. The IUD is a small T-shaped device inserted into the uterus. Both methods must be placed and removed by a trained health care professional. LARC methods are available to females and provide up to 3, 5, or 10 years of continuous contraceptive benefit, depending on the method. LARC methods are approximately as effective in preventing pregnancy as female sterilization, but they are completely reversible, with rapid return to fertility after removal. (See "Patient education: Long-acting methods of birth control (Beyond the Basics)".)
Other birth control methods include birth control pills, patches, injections, and the vaginal ring. These are considered to be good methods of preventing pregnancy, but they require more effort on the part of the young woman using them. For example, she must remember to take a pill every day, change a patch once a week, or come in for a shot every three months. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)
Some methods, such as condoms and contraceptive foam, can be purchased without a prescription. A condom should be used every time you have sex, even if another method is used to prevent pregnancy. Using condoms with contraceptive foam can be as effective as birth control pills if both condoms and foam are used every time. Just using contraceptive foam is less effective than just using condoms. (See "Patient education: Barrier methods of birth control (Beyond the Basics)".)
If you use birth control but have an accident (the condom breaks, you forget a pill) or had sex without any form of birth control, you can take emergency contraception, also known as the "morning after pill," to reduce the risk of pregnancy. Note that emergency contraception is NOT the same as medical abortion, as it will not harm a pregnancy that already exists. The "morning after pill" can be offered within five days of having unprotected sex but is more effective the sooner it is taken after unprotected sex. In many states it is available over the counter at pharmacies, but depending on your age, you may need a prescription from your doctor. Some pharmacies choose not to carry emergency contraception or other forms of birth control, so you may need to seek one that does. (See "Patient education: Emergency contraception (morning after pill) (Beyond the Basics)".)
Teens who engage in sexual activity must be sure they have accurate information about the available birth control options. The best time to decide on a method of birth control is before you start having sex. If you are sexually active or thinking about becoming sexually active and do not desire pregnancy, speak to your health care professional about starting birth control.
Adolescent sexuality is influenced by many factors, including your gender identity, sexual orientation, the culture you live in, and how your body develops. During the teen years, you will develop a sense of your own sexuality, one that will lead to satisfying, mature sexual relationships later in life.
Although it is normal for teens to want to begin to experiment with physical intimacy, many teens are not able to understand the consequences of sexual activity for themselves and their partner. By taking it slowly, getting reliable information, and delaying sex until you are sure you are ready, you can help make sure that your sexuality is a healthy, positive aspect of your life.
WHERE TO GET MORE INFORMATION
Your health care clinician is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Teen sexuality (The Basics)
Patient education: Screening for sexually transmitted infections (The Basics)
Patient education: Normal sexual development (puberty) (The Basics)
Patient education: Early puberty (The Basics)
Patient education: Epididymitis (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Testing for HIV (Beyond the Basics)
Patient education: Genital warts in women (Beyond the Basics)
Patient education: Cervical cancer screening (Beyond the Basics)
Patient education: Human papillomavirus (HPV) vaccine (Beyond the Basics)
Patient education: Gonorrhea (Beyond the Basics)
Patient education: Chlamydia (Beyond the Basics)
Patient education: Genital herpes (Beyond the Basics)
Patient education: Hepatitis B (Beyond the Basics)
Patient education: Barrier methods of birth control (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Emergency contraception (morning after pill) (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
The following organizations also provide reliable health information.
●American Social Health Association
●Coalition for Positive Sexuality
●Centers for Disease Control and Prevention
- Committee On Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics 2013; 132:198.
- Kirby D. Sexuality and sex education at home and school. Adolesc Med 1999; 10:195.
- Brown RT, Brown JD. Adolescent sexuality. Prim Care 2006; 33:373.
- World Professional Association for Transgender Health (WPATH). WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th Version. Available at: www.wpath.org/documents/Standards%20of%20Care_FullBook_1g-1.pdf (Accessed on November 27, 2012).
- COMMITTEE ON ADOLESCENCE. Condom Use by Adolescents. Pediatrics 2013; 132:973.
- Breuner CC, Mattson G, COMMITTEE ON ADOLESCENCE, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH. Sexuality Education for Children and Adolescents. Pediatrics 2016; 138.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.