SEXUALITY OVERVIEW

Most teens and pre-teens 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 healthcare providers.

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 you feel comfortable with — perhaps a healthcare provider, 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. 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), 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 is believed to exist 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. These feelings are normal and may change throughout life.

ADOLESCENT SEXUAL DEVELOPMENT

Sexual development begins in the pre-teen years and continues into adulthood. The body produces hormones that cause outward changes, including breast development in girls, 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 could occur.

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 homosexual 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 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 their 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, healthcare provider, 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 developing 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. 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:

HIV — HIV (Human Immunodeficiency Virus) is the virus that causes AIDS (Acquired Immune Deficiency Syndrome). AIDS is a serious, incurable disease of the immune system. Until recently, everyone who developed AIDS died. Although new treatments are now helping many people with HIV infection live longer, there is still no cure for this serious disease or vaccine to prevent it. Many people still die each year from AIDS.

Each year, between 40,000 and 80,000 people are newly infected with HIV. Half of these new infections are in people younger than 25 years old. New 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 their chances are of survival. Speak to your healthcare provider about HIV testing. (See "Patient information: Testing for HIV (Beyond the Basics)".)

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 cancer in either sex. A Pap smear is one important way your healthcare provider can screen for cervical cancer associated with HPV. (See "Patient information: Genital warts in women (Beyond the Basics)" and "Patient information: 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 healthcare provider about this important vaccine, even if you are not currently sexually active or thinking about becoming sexually active. (See "Patient information: Human papillomavirus (HPV) vaccine (Beyond the Basics)".)

Gonorrhea and chlamydia — These are serious bacterial infections of the genital tract. They can lead to pelvic inflammatory disease (PID) in women, which can cause severe pain, can 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). Both gonorrhea and chlamydia can be cured with antibiotics. It is important to be screened for these infections if you have had sex, because you may not always have symptoms. (See "Patient information: Gonorrhea (Beyond the Basics)" and "Patient information: 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 blisters present. Medications are available from your healthcare provider to shorten the length of time the blisters 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 information: Genital herpes (Beyond the Basics)".)

Hepatitis B virus — This is a viral infection that can cause liver disease. In most cases, the disease resolves 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 healthcare provider if you are not sure if you have had this vaccine. (See "Patient information: Hepatitis B (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 healthcare provider right away if you notice any sores or ulcers. The sore usually heals but can cause important long-term problems if untreated.

Trichomonas — Trichomonas ("trich") is a common infection caused by a tiny parasite that can cause itching and/or a discharge from a person's genital organs. Females notice symptoms far more often than males, although both sexes can be affected and require treatment by a healthcare provider. There is no available clinical test for Trichomonas infection in males, so 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. Trichomonas can be cured with antibiotics.

PREVENTING 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 they do not have an STI or says they are "clean", you cannot be sure this is true. That is because the person may not know if they are 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 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. 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 are another barrier device that can be used when performing oral sex on a female. (See "Patient information: 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.

Immunizations — Another way to reduce the risk of two specific STIs (HPV and hepatitis B) is to talk to a healthcare provider 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 healthcare provider are important to all adolescents, but it is particularly important to speak with a healthcare provider 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 provider about sexual behavior to get appropriate testing. If your healthcare provider is not comfortable or able to screen you for STIs, ask for a referral to a provider who can.

Pregnancy and birth control — Pregnancy is a serious consequence of sexual activity between males and females. Each year in the United States, about 1 million adolescents become pregnant.

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 risks.

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 and during the menstrual period.

Birth control methods are available that can reduce the risk of pregnancy. However, birth control methods other than condoms do not reduce the risk of STIs. The most reliable methods (other than abstinence) must be prescribed by a doctor or nurse practitioner. These include birth control pills, patches, injections, and the vaginal ring. Other longer term (3 to 5 year) birth control options for females include a small hormone-containing implantable rod inserted just under the skin in the armor an intrauterine device (IUD). Both of these longer term birth control options must be placed by a qualified physician. (See "Patient information: 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. (See "Patient information: 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 information: 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.

SUMMARY

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, most teens are not able understand the consequences of sexual activity for themselves and their partner. By taking it slowly, getting reliable information, and delaying sex until you are mature, you can help make sure that your sexuality is a healthy, positive aspect of your life.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare 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 information: Teen sexuality (The Basics)
Patient information: Screening for sexually transmitted diseases (The Basics)
Patient information: Normal sexual development (puberty) (The Basics)
Patient information: Early puberty (The Basics)
Patient information: 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 information: Testing for HIV (Beyond the Basics)
Patient information: Genital warts in women (Beyond the Basics)
Patient information: Cervical cancer screening (Beyond the Basics)
Patient information: Human papillomavirus (HPV) vaccine (Beyond the Basics)
Patient information: Gonorrhea (Beyond the Basics)
Patient information: Chlamydia (Beyond the Basics)
Patient information: Genital herpes (Beyond the Basics)
Patient information: Hepatitis B (Beyond the Basics)
Patient information: Barrier methods of birth control (Beyond the Basics)
Patient information: Hormonal methods of birth control (Beyond the Basics)
Patient information: 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.

Adolescent sexuality
Contraception: Overview of issues specific to adolescents
Pregnancy in adolescents
Sexually transmitted diseases: Overview of issues specific to adolescents

The following organizations also provide reliable health information.

• American Social Health Association

      (www.iwannaknow.org)

• Teen Sexuality

      (www.teensexuality.org)

• Nemours Foundation

      (www.teenshealth.org)

• Planned Parenthood

      (www.teenwire.com)

• Coalition for Positive Sexuality

      (www.positive.org)

• Centers for Disease Control and Prevention

       (www.cdc.gov)

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