What About the Boys? The Importance of Including Boys and Young Men in Sexual and Reproductive Health Research

Throughout the past 50 years, when governments, researchers, and clinicians have discussed adolescent sexual and reproductive health, they have almost overwhelmingly focused on girls and young women. Even limiting to recent work, a perusal of the research literature since 2000 finds thousands of studies that focus only on girls and young women, compared with hundreds of studies that include both genders, but only tens of studies in sexual and reproductive health that focus exclusively on boys and young men. Within the Journal of Adolescent Health, such coverage is better, but still disproportionate; there are more studies in this journal that include both boys and girls, young women and young men, with several studies still exclusively focused on girls and young women, and relatively few studies that focus on populations of boys and young men. Most of the sexual health studies about male subjects are found in published abstracts in this journal, not in full articles or research briefs, and among the full-length articles, they have generally focused on subgroups of male subjects whose sexual health (although maybe not reproductive health) is considered problematic, for example, young men who have sex with men. Although there has been a recent review of sexual and reproductive clinical care for male adolescents in primary care settings [1], even this article acknowledged the relatively sparse literature focused on boys’ and young men’s sexual and reproductive health needs.

Why does most of our research and clinical practice conflate sexual and reproductive health with girls and young women, omitting half of the sexually active population? There are both sociocultural and pragmatic reasons for such limited coverage of the sexual health of boys and young men. Most societies’ dominant discourses about sexual behavior, fertility, and reproduction are highly gendered, with much of the discussion focused on controlling the sexual behavior (or its outcomes) among girls and young women [2]. When girls engage in sexual activity, it confers a different status, and different social sanctions or social rewards, than when boys do [3]. When the media talk about sexual violence, whether sexual assault, sexual abuse, or sexual exploitation, victims are most often identified as female, and except in rare cases, males are solely portrayed as perpetrators [4]. When governments focus on sexual health policy of adolescents, such as access to contraception, the policy is almost exclusively aimed at girls or young women, or the places where they receive sexual and reproductive health services [5]. As an example, one has only to look at the U.S. government policy around access to oral contraception, which requires a prescription for adolescent girls and, in some states, such as Texas, also requires parental notification or permission [6]. In contrast, there are no specific policies around access to condoms for adolescent boys, and as a result, condoms can be freely purchased in grocery stores and pharmacies throughout the U.S., including in Texas.

There are also some pragmatic reasons for focusing on female subjects when conducting sexual and reproductive health research and practice. For example, young women’s pregnancy involvement is a lot more obvious, and thus easier to identify and study than young men’s contributions. Government tracking of vital statistics for births, stillbirths, and abortions makes the health issues of young women visible because data about mothers are required on birth certificates, but data about fathers are not universally included. Additionally, much of the research on sexual and reproductive health of adolescents is clinic based, but girls and young women are far more likely to access sexual health clinics than boys and young men [7].

We miss important information when we focus sexual health research only on girls, however, and four articles in this journal illustrate some of what we miss. Sometimes we miss documenting similar issues among boys that have gone unnoticed. Sexual abuse, for example, is predominantly considered a female health issue, and the body of research has been extensive enough to generate several meta-analyses examining the link between sexual abuse and risky sexual behaviors among young women. The same could not be said for young men, until now. There are finally enough studies, although barely, for a meta-analysis by Homma et al [8], who focused on these same sequelae among sexually abused boys and young men. They find compelling evidence that boys’ sexual victimization drives similar risky sexual behaviors.

When we conflate sexual health and adolescent women’s health, we can also miss unique sexual health issues for adolescent boys. For example, the article by Mialon et al [9] documented the rates of sexual dysfunctions and their correlates among young men in Switzerland, providing important insight into an issue that few clinicians are assessing in primary care settings, but which affects one in three adolescent young men. With such a startlingly common health issue as mild erectile dysfunction, the effects it might have on sexual risk behaviors among young men are still unclear, but worth exploring in both research and clinical assessments.

Human papillomavirus (HPV) vaccination is another area where the practice and research have lagged for boys, but with immunization recommendations now including HPV for male adolescents as well, research about ways to increase vaccine uptake among them becomes increasingly important. An article by Reiter et al [10], with a National U.S. sample including both adolescent boys and their parents, provides some useful suggestions about sites of care where parents and sons would find HPV immunization acceptable. The challenge, of course, is that many adolescent boys and young men do not access health care in traditional sites, especially annual examinations, as opposed to acute care visits, and so identifying creative approaches to engaging young men in sexual health care will be important.

The invisibility of boys and young men in sexual and reproductive health research has consequences: if we miss boys and young men in research, we also miss them in health care practice, in health promotion, and in sexual health policies. Without the critical information about boys’ and young men’s realities and their needs, we do not design sexual health services for them, whether that is teen contraceptive care, sexual health education, sexually transmitted infection testing, prenatal care clinics, or even sexual violence support services. But what should be considered appropriate sexual and reproductive health care for male adolescents? There has been no published consensus to date, but a study by Marcell and Ellen [11] offers expert clinicians’ assessments of the key components of sexual and reproductive health for boys and young men in primary care settings, although where and how these services might be structured to effectively reach boys and young men is an ongoing challenge [12].

Effectively increasing our knowledge of sexual and reproductive health issues for boys and young men will require moving beyond clinical sampling, as these four studies have done. It will also require deliberately challenging common stereotypes about sexual health issues. We should consider fertility decisions, sexual function, contraception and pregnancy involvement, sexual abuse, and even sexual exploitation as young men’s health issues. Every adolescent, regardless of gender or sex, should be able to access high quality information and services to promote his or her sexual and reproductive health.