Adolescent Sexuality

Introduction

Sexual development is a process that begins in utero and culminates in late adolescence with the solidification of one’s self-identity.¹ Sexuality, which is a component of sexual development, is defined by an individual’s expression of sexual interest, orientation, and preference.² This is influenced by gender identity, sexual knowledge, intimate relationship experiences, culture, and religious exposures.^2,29 Obstetricians and gynecologists are tasked with providing reproductive healthcare for the adolescent population; therefore, it is important for them to be aware of this developmental process to be able to support teens becoming healthy sexual adults (Table 1).² As a result, this review will focus on aspects that are involved in the healthy development of adolescent sexuality.

Table 1:

Life Behaviors of a Sexually Healthy Adult

Appreciate one’s own body.	Express one’s sexuality while respecting the rights of others.
Seek further information about reproduction as needed.	Seek new information to enhance one’s sexuality.
Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.	Discriminate between life-enhancing sexual behaviors and those that are harmful to self and/or others.
Interact with all genders in respectful and appropriate ways.	Use contraception effectively to avoid unintended pregnancy.
Affirm one’s own sexual orientation and respect the sexual orientations of others.	Engage in sexual relationships that are consensual, non-exploitative, honest, pleasurable, and protected.
Affirm one’s own gender identities and respect the gender identities of others.	Practice health-promoting behaviors, such as regular check-ups, breast and testicular selfexam, and early identification of potential problems.
Enjoy sexual feelings without necessarily acting on them.
Avoid contracting or transmitting a sexually transmitted disease, including HIV.	Act consistently with one’s own values when dealing with an unintended pregnancy.
Develop and maintain meaningful relationships.	Seek early prenatal care.
Avoid exploitative or manipulative relationships.	Help prevent sexual abuse.
Make informed choices about family options and relationships.	Identify and live according to one’s own values.
Exhibit skills that enhance personal relationships.	Demonstrate respect for people with different sexual values.
Assess the impact of family, cultural, media, and societal messages on one’s thoughts, feelings, values, and behaviors related to sexuality.	Exercise democratic responsibility to influence legislation dealing with sexual issues.
Take responsibility for one’s own behavior.	Express love and intimacy in appropriate ways.
Practice effective decision-making.	Promote the rights of all people to accurate sexuality information.
Develop critical-thinking skills.	Avoid behaviors that exhibit prejudice and bigotry.
Communicate effectively with family, peers, and romantic partners.	Reject stereotypes about the sexuality of different populations.
Enjoy and express one’s sexuality throughout life.	Educate others about sexuality.
Express one’s sexuality in ways that are congruent with one’s values.	Critically examine the world around them for biases based on gender, sexual orientation, culture, ethnicity, and race.

Outlines the life behaviors necessary for developing into a sexually healthy adult. From the Sexuality Information and Education Council of the United States – SIECUS. Life Behaviors of a Sexually Health Adult. In Guidelines for Comprehensive Sexuality Education’s (3rd edition). 2021. Available at https://npin.cdc.gov/publication/guidelines-comprehensive-sexuality-education-3rd-edition. Accessed April 27, 2023; with permission.

Adolescent Sexual Behavior and Development

Sexual development begins in utero with the interplay of hormones, anatomy, and genetics.^{3, 32} There is a progression of sexual curiosity rooted in self-exploration that begins in infancy with self-stimulation.⁴ Around ages 3–7 years, children become aware of genital differences between boys and girls and may participate in gender-based role-play influenced by observed familial relationships.³⁰ The preadolescent phase is characterized by a preoccupation with body and self-image. Some preadolescents may have same-gender relationships during this time, however this is often not indicative of future sexual orientation. The inverse is also true as some individuals that later identify as gay or lesbian had opposite-gender relationships as preadolescents.³³

Masturbation increases in frequency during adolescence with boys being more active than girls.³¹ Some of this may be related to biology, but it is also related to the social stigma associated with self-stimulation and pleasure.⁵ Yet, it has been noted that young women who masturbate have higher levels of self-awareness, seek to ensure sexual satisfaction in future relationships, resist sexual double standards, and have increased body positivity.^{3, 5} In spite of this finding, one study found that even those young women who were comfortable with masturbating and practiced it regularly, which resulted in feelings of reward and pleasure, still had some negative emotions related to the act of masturbation.⁵ Therefore, it is the role of parents and clinicians to help to destigmatize the act of self-exploration via masturbation as it can provide a foundation for healthy sexual relationships in the future.

Adolescent development is divided into three phases: early, middle, and late adolescence. Although adolescents develop on a continuum, each phase has distinct features. Early adolescence, or preadolescence, occurs between ages 10–14 years. It is characterized by continued concentration on body image and privacy. Preadolescents are starting to develop their sense of self and integrate into a peer group depending less on familial connections.^1—2 Middle adolescence occurs between 13–17 years old when there is increased independence. This is a period of increased risk taking despite further development of abstract thinking and understanding of consequences. Those in middle adolescence often engage in their first intimate relationships and are exploring the way sex plays a role in these partnerships.³² Lastly, late adolescence, which starts around 18-years-old and continues into young adulthood, is characterized by further development of the prefrontal cortex, which results in improved decision making. This age group can think more abstractly and consider more concretely the feelings of others. Their sexuality is well defined at this time, and they are taking on more responsibilities and considered to be adults.² Although adolescence is divided into three development phases, each youth acquires the skills to be a healthy adult over time and at their own pace (Figure 1).

Figure 1:

Outlines the development of gender and sexuality from childhood to young adulthood.

Data from multiple sources referenced throughout the review.

Sex and Gender

Sex is defined by a set of chromosomes and phenotypic characteristics that results from the expression of those genes.⁶ Gender is based on a social construct of attributes that society considers to be typically male or female. Gender identity is defined as an individual’s internal sense of self as male, female, or other. Gender identity is established between ages 2–3 years.^1,4 For some individuals, their gender identity may not correlate with their presumed gender based on their biological sex, appearance of their genitalia, or societal expectations of male and female roles. However, it is the role of the clinician to promote the self-expression of one’s identified gender and sexuality.⁶

Sexual Health Outcomes Among Adolescents

In 2023, the Center for Disease Control and Prevention (CDC) released updated data on the adolescent sexual trends from the Youth Risk Behaviors Survey. There was a decrease in the percentage of adolescents reporting ever having had sex from 47% to 30% between the years 2011 to 2021.⁷ There was also a decrease in percentage of adolescents reporting having four or more sexual partners from 15% to 6% during this same time frame.⁷ Unfortunately, there was also a decline in condom use from 60% to 52% of those surveyed.⁷ Decreased use of condoms puts teenagers at risk of contracting sexual transmitted infections. Adolescents account for 50% of all newly contracted sexually transmitted infection (STI) cases, despite representing only 25% of the sexually active population.² Some of the behaviors considered to be high risk for STI acquisition and unintended pregnancy are early sexual debut, using drugs or alcohol before sexual intercourse, having four or more partners, and smoking.^1,4,11

One of the most common STIs among adolescents is the human papilloma virus (HPV).² HPV can lead to dysplasia and cancer of the cervix, vagina, vulva, anus, and throat. The nine-valent HPV vaccination is approved in the US for people ages 9–45. It is recommended that all adolescents receive this vaccination, with the target age of 11–12 years, and preferably before sexual debut.¹²

Adolescents and Pregnancy

As there has been a decline in teen sexual activity, the teen pregnancy rate has declined in the United States as well. Most recently, in 2020, it was noted to be 15.4 births per 1000 females aged 15–19 years while in 2019, it was 16.7 births per 1000 females decreasing by 8%, but these rates are still much higher than other developed nations.^8,27 Seventy-five percent of adolescent pregnancies are unintended and there are wide disparities among racial groups in the United States.^9—10 For example, among females aged 15–19 years in the United States, the birth rates per 1,000 are 2.3 for those identifying as Asian, 10.4 for those identifying as White, 23.5 for those identifying as Hispanic, and 24.4 for those identifying as Black.⁸ The overall discrepancy between teen pregnancy rates in the U.S. versus other developed nations is thought to be due to a lack of standardized, comprehensive sex education programming for youth and inconsistent access to long acting reversible contraceptive (LARC) options.^9—10

The Development and Expression of Sexual Orientation

Sexual orientation is an individual’s expression of intimate interest or sexual attraction. This is influenced by physical and emotional arousal and is defined by the individual. It is not defined by one’s gender identity but develops like other aspects of the self over time and in relation to one’s personal identity.^2,6 There are a wide range of sexual orientations such as:

• Heterosexual: opposite sex attraction

• Gay / Lesbian: same sex attraction

• Bisexual: attraction to both sexes.²

The way an individual defines their sexual orientation may change over time, which is a normal developmental occurrence.² A survey of high school students completed in 2017 found that 85.4% identified as heterosexual, 2.4% identified as gay or lesbian, 8% identified as bisexual, while 4.2% were unsure of the sexual orientation.¹³

Sexual minorities are a targeted and at-risk community. During the coming out process, they may become victims of familial or peer group rejection, harassment, violence, and bullying. Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) identifying teens experience increased incidence of depression, suicidal ideation and attempts, substance use disorders, running away, participation in high risk sexual behaviors (i.e. exchanging sex for money, housing or goods) with increased exposure to STIs such as HIV, and dropping out of school.^1–2,13 This is often influenced by cultural norms within communities that may be less accepting or openly hostile towards LGBTQ identifying people. Therefore, it is important to help families and communities to create safe spaces for youth that identify as a sexual minority to come out and feel well supported in this process in addition to finding ways for families and communities who may not agree with the youth’s sexual orientation to develop a framework for acceptance and eventual celebration.

Adolescents with Special Healthcare Needs and Cognitive Delay

Individuals with physical and cognitive disabilities are often considered asexual and do not consistently receive the same education regarding their sexual health as others without these differences.¹⁴ However, they account for up to 15% of the adolescent population, they are known to have their first sexual encounter around the same time as other youth without these same challenges, and many of them are at risk of sexual coercion and abuse.² Therefore, it is vital to provide appropriate sexual health education for all adolescents regardless of disabilities. Vital information that should be reviewed include genital anatomy, public and private touch, consent and how to say “no”. Often, visual aids are used to supplement the information being taught to illustrate the content. When appropriate, these individuals should be afforded the opportunity to have a confidential conversation honoring their autonomy and helping them to develop the skills necessary to be independent in the medical landscape.^1–2,13

Sexual Health Education

Sexual health education varies widely in the United States. The American College of Obstetricians and Gynecologists (ACOG) currently recommends that a comprehensive sexual education model be used (Table 2).¹⁵ Educational programs and resources must portray age appropriate, medically accurate, and evidence-based information about sex, sexuality, physical anatomy, and reproductive biology. It is vital to incorporate information that is beneficial to sexual minorities such as the lesbian, gay, bisexual, questioning, and transgender youth. Emphasis should be placed on the benefits of delaying sexual intercourse. However, education should provide comprehensive information on methods to avoid STIs with proper use of barrier protection (i.e., male and female condoms, dental dams) as well as a complete review of contraceptive options from most efficacious to least.^2,13 These types of educational programs have been shown to significantly lower pregnancy and STI rates in high-risk communities.¹⁴

Table 2:

Components of Comprehensive Sexual Education

Key Components:
Accurate medically Evidence based Age appropriate	Ability appropriatea Culturally sensitive Participation based
Key Topics to Review:
Provides education on: Reproductive development Benefits of delayed onset of sexual activity Unintended pregnancy prevention, LARCb STIc prevention, barrier protection Gender and sexual minorities Providing, receiving consenting Consequences for teen sexual activity Safe online usage Support from intimate partner violence Provide diverse examples of healthy relationships

^a-accounting for those with intellectual and physical disabilities.

^b-long-acting reversible contraception; focus on implants and intrauterine devices.

^c-STI-sexually transmitted infection.

Data from multiple sources referenced throughout the review.

Parents and guardians play a vital role in supporting the educational curriculum schools provide by encouraging young people to engage in safe sexual activity. When surveyed about which sources of information are important to them as it pertains to sex and sexuality, adolescents have been found to value the views of their parents, peers, and media.² Parents can lead by example in their own relationship modeling and provide a safe space for open communication with their teenagers.^2,16 ACOG recommends that parents discuss sex with their adolescents, being flexible in their approach and honest in their conversations, and finding ways to connect and relate. Helping parents access resources to support their teenagers is important especially for those parents with children with special needs or other minority statuses.^2,16

Clinicians play a vital role in educating both adolescents and their parents about sex and sexuality. The initial reproductive health visit should occur between ages 13–15 years (Table 3).^2,17 This visit allows clinicians to start to support the teenager in functioning as an independent historian. In most cases, a genital exam is not needed for these visits. When necessary, a problem focused exam can be performed generally with an external genital exam with gentle labial traction.¹⁷

Table 3:

The Initial Gynecologic Health Visit

Occurs between ages 13–15 years

Provide preventive health care:

HPV vaccination Contraception administration Yearly GC/CT screeninga HIV screeningb

Health education regarding:

STIs prevention Pregnancy prevention Safe sex and healthy relationships Substance use

Confidential conversation

Genitourinary exam (as needed)

^a-GC/CT: Gonorrhea, chlamydia trachomatis If sexually active; trichomonas testing included based on symptoms and risk factors.

^b-at least once between ages 13—64 years.

Data from multiple sources referenced throughout the review.

It is imperative that the youth be provided alone time with the clinician to have a one-on-one conversation.^17—18 It is important to set a framework for the confidential portion of the visit including limitations of adolescent confidentiality (i.e., if the teenager expresses something that may bring harm to themselves or another person, this information will need to be shared with the parents and potentially other entities for the safety of the patient).¹⁸ This time allows the clinician to ask questions that are a part of the HEADSSS assessment (Home, Education, Activities, Drugs, Sexuality/Sexual Activity, Safety, and Suicide).² The confidential interview is an opportunity to discuss gender identity and pronouns as some youth may have not shared this information with their parents yet.¹⁷

Despite the importance of a confidential interview, many adolescents are not afforded this protected time with their clinician. A recent study found that at least 90% of adolescents had attended a healthcare visit in the previous year, but only 52.1% were questioned about sexual activity, 31.6% were counseled regarding safe sex practices, 12.6% were asked about sexual identity, 7.6% were asked about sexual difficulties, and 7.25% were offered STI testing.^17–20 In another study, one third of adolescents (n = 253) reported not having any discussions regarding sexual health during their annual visits and if they did, it was a short conversation lasting on average 36 seconds.²⁰ The confidential interview is an opportunity for the clinician to answer questions, clarify misconceptions, and help youth navigate potentially risky behaviors and avoid unwanted outcomes.

When discussing sexual practices with adolescents, clinicians should be aware and acknowledge that sex is not limited to penile-vaginal penetrative intercourse. Sex can include acts that are occurring virtually like sexting, phone sex, avatar intercourse, and chat room sex with and without a webcam. Additionally, sexual acts such as masturbation (e.g., solo, partnered), oral sex, sex using vibrators and other sex toys, sexual fantasy, non-penetrative sex such as petting or humping are all possible activities that adolescent may be engaging in.² Therefore, it is important to discuss these various sexual activities in a non-judgmental manner with open-ended questions so that the adolescent’s clinician can make an accurate risk assessment and provide counseling to mitigate risk.

All teens who are sexually active or considering sexual activity should be counseled about the contraceptive options available. In a study of sexual activity and contraceptive use among teens, 97% reported they had ever used condoms, 65% depended on withdrawal methods, and 53% utilized contraceptive pills. Only 20% were using LARC, which is considered a highly effective contraceptive method.²¹ There are many barriers to adolescents access to LARC: lack of familiarity and understanding of the method, financial constraints, parental resistance to implementation, misinformation, and clinician bias against use of LARC in teens.¹⁰ The findings from the Contraceptive CHOICE project, support presenting contraceptive methods from most to least effective by discussing LARCs first, followed by the other options (i.e., pills, patches, etc.).⁹ The American Academy of Pediatrics support these findings by providing the same recommendation to offer LARC as a first line contraceptive option to teens in their policy statement on Contraception in Adolescents.²⁸

It is important to highlight the risks and benefits of each method helping the adolescent to come to their own decision and even in these interactions, to exercise reproductive justice and if a teenager declines contraception, to respect their decision.⁹ Condom use with every sexual encounter should be encouraged to protect from STIs. Information about emergency contraception options should be shared as this method can be implemented up to 120 hours after unprotected intercourse.⁹ Due to some pharmacy restrictions around freely providing access to emergency contraceptive pills, it may be prudent to provide the adolescent with a prescription for use as needed in the future.

Media Influence

Social media platforms have gained increased use by teens over recent years. In the U.S., 74% of those aged 12—17 have access to a mobile device with 95% of them using the Internet. Additionally, 90% of adolescents endorse using social media sites multiple times per day.²² There are positive aspects associated with adolescents’ use of social media such as social connection especially for those with chronic or acute illnesses and expanded access to health information.²² Yet, much of the recent focus has been on the potential detrimental effects social media can have on adolescents. It can be a platform used to cyberbully, which can result in depression, anxiety, low self-esteem, and somatic symptoms such as sleep disturbances, bedwetting, fatigue, and appetite changes as their image is falsely portrayed leading to humiliation.^22—23 Some youth may suffer from an uncontrollable need to access the Internet and social media platforms, which is defined as Internet addiction. This can then lead to the mood related changes as well as self-harm, substance use, and obesity.²²

Adolescents have a natural shift in their sleep-wake cycles, being more apt to stay up late and the desire to sleep in the following day. This can be exacerbated by smart phone usage at night leading to sleep deprivation. It is recommended that teenagers get 9 hours of sleep a night and it is generally recommended as related to good sleep hygiene to avoid mobile devices before bed as the blue light can affect natural circadian rhythms.²² In general, the American Academy of Pediatrics recommend that screen time be limited to 2 hours per day, Internet connected devices such as computers and TVs be kept out of the bedroom, and there be established boundaries regarding the type of content that should be accessed online.²³

Other challenging aspects of social media and smartphone usage are access to inappropriate content and unsafe interactions with predators. Adolescents often lack the appropriate judgment for personal information to share with others online. Similar to the online chat rooms of the early 1990s, social media direct messaging, and the act of catfishing or a false portrayal of identity, can put teenagers in unsafe situations. Some youth, especially those from gender and sexual minority groups use social media and apps for dating and meeting others with similar experiences. Therefore, it is important to engage the youth in conversations regarding their digital footprint, the content that is appropriate to share with others, and the content that could potentially lead to legal action if shared (i.e., sexting with nude or partial nude photos).^22—23

Adolescents have easy access to sexualized imagery such as pornography online. Preadolescents as young as 11-years-old may have their first exposure to pornography. Early exposure to pornography has been noted to have adverse effects on adolescent development such as increased participation in risky sexual behaviors (i.e. unprotected sexual encounters, anal sex, multiple sexual partners, using drugs or alcohol during sex), relational views founded in stereotyped gender roles, and objectification of women.²⁵ When youth, especially boys, are exposed to violent pornography there is an increased risk of their involvement as actors of sexual harassment.²³ In one study, these adverse outcomes occurred more often as the amount of pornography viewed increased over an individual’s lifetime.²⁵ Youth that identify as LGBTQ may use pornography as a way of accessing information regarding the mechanics of non-heterosexual sex. Therefore, it is important that sexual education in the schools, the home, and the clinic focuses on helping these youth access age appropriate and accurate information from more reputable health platforms.²⁵

Sex Trafficking, Intimate Partner Violence, and Fostering Healthy Relationships

Adolescents that come from disadvantaged backgrounds are at greater risk of becoming victims of human trafficking.²⁴ Greater than 70% of trafficked individuals are women and girls and greater than 90% of those individuals end up in the sex industry.²⁴ Those at greatest risk are from vulnerable groups such as individuals smuggled into the country from politically, geographically or economically unstable regions who are often non-proficient English speakers, migrants, have experienced trauma or violence, have weak social support networks, and identify as gender or sexual minorities.²⁴ In the CDC 2023 Youth Risk Behavior Survey, those youth in grades 9—12 that identified as lesbian, gay, or bisexual were found to have a higher incidence of forced sexual intercourse (20% vs. 5%) as well as sexual violence in general (22% vs. 8%) compared to their heterosexual counterparts.⁷ Although these trends of violence are improving, they still warrant continued brainstorming on ways to address this inequity.

Adolescents at risk for human trafficking are often targeted in public places and are especially vulnerable in the first 48 hours of becoming displaced from their homes or running away.²⁴ If a clinician has concerns that an adolescent is involved in an unsafe situation and being exploited, it is important to investigate the issue, but it must be done in a calm and safe environment. It is important to build rapport with the patient and help them to become comfortable enough to share their truth. Often, they have been brainwashed by their trafficker to believe that this experience is their fault. Regarding minors, clinicians are mandated reporters of child abuse and neglect, and it is important to be aware of the laws in your state regarding the reporting process.^24—25

As adolescents explore romantic and intimate relationships, they may become involved in unhealthy relationships that are characterized by violence. Approximately one in ten female identifying high school students in the United States state that in the year prior they were victims of physical violence by their partners and one in five have been victims of dating violence.²⁷ The girls from this study were also at increased risk of having had an STI, becoming pregnant, using tobacco products, and suffered from mental health issues.²⁷ This is why it is imperative to screen for intimate partner violence at every visit with every patient especially those with special needs as they are often at the mercy of their caretakers and may not feel that they have the power to speak out about injustices that they may be experiencing. Early intervention may prevent future inappropriate relationship dynamics as those who were victims of intimate partner violence in their youth may also suffer in these types of relationships in adulthood.²⁷

Both parents and clinicians have an important role in helping teenagers develop skills necessary for healthy relationships. Parents have an opportunity to act as models for their children. This starts with respectful communication with the youth that includes conversations about sex and mutually beneficial physical intimacy. Clinicians are well positioned to provide anticipatory guidance, to ask open-ended questions, and provide age-appropriate education and guidance. Clinicians can help youth, in the context of familial, religious, and societal expectations, understand that there is a variety of normal as it pertains to interpersonal relationships.¹⁶ The goal is to help teens navigate the complex changes of adolescence so that they can become healthy sexual adults.

Summary

Adolescent sexual development is influenced by a complex interplay of biology and the social environment in which a teen exists. They are working to develop their sense of self while getting a better grasp on their sexual orientation and affirming their gender identity. This is all occurring under the influence of friends, family, and social media opinions. Therefore, it is important for clinicians to act as a place where factual information is shared and be able to provide guidance to help adolescents make healthy choices and have positive outcomes.

In summary, adolescence is a time of growth and exploration where individuals are on a journey to establish their self-identity. Both parents and clinicians are in a unique position to support the youth in a healthy passage through this period of their life. It is important to provide anticipatory guidance and support teens by providing safe spaces for inquiry and honest and developmentally appropriate answers.

Key Points.

• Understanding the phases of adolescent development is integral to understanding adolescent sexual development.

• Although there has been a decline in sexual activity among adolescents, they still require anticipatory guidance regarding contraception and barrier methods for future sexual encounters.

• Comprehensive sexual education is recommended that incorporates topics specific to sexual and gender minorities and information on pregnancy and sexually transmitted infection prevention.

• Parents are encouraged to monitor adolescents’ use of the Internet and social media.

• Clinicians should advocate for adolescents as they navigate the progression through adolescence so that they gain the necessary skills to have healthy relationships in the future.

• The confidential interview is a key component of teen medical visits.

Synopsis:

Adolescence is a unique time where there are many developmental changes occurring. Teenagers are striving to establish their personal identity as they are also developing a better understanding of their gender and sexual identity, while navigating social expectations both in person and online. Therefore, clinicians must continue to support adolescent patients and their families by providing accurate and timely information so that they can have the tools they need to avoid the pitfalls of an uninformed adolescent experience.

Clinical Care Points.

• Understanding the phases of adolescent development is integral to understanding adolescent sexual development.

• Although there has been a decline in sexual activity among adolescents, they still require anticipatory guidance regarding contraception and barrier methods for future sexual encounters.

• It is important to regularly include a confidential interview at most if not all medical visits with teens.

• Comprehensive sexual education is recommended that incorporates topics specific to sexual and gender minorities and information on pregnancy and STI prevention.

• Parents are encouraged to monitor adolescents’ use of the Internet and social media.

• Routinely screen for intimate partner violence.

• Be an advocate for adolescents as they navigate the progression through adolescence so that they gain the skills to have healthy relationships in the future.