Version May 2024
INTRODUCTION — This topic will provide an overview of sexual development and sexuality, including discussions of adolescent development, sexual behavior, and how to discuss sexuality with adolescents. Related content is presented in more detail separately:
●(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care" and "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns".)
●(See "Gender development and clinical presentation of gender diversity in children and adolescents" and "Management of transgender and gender-diverse children and adolescents".)
●(See "Pregnancy in adolescents".)
●(See "Contraception: Issues specific to adolescents".)
●(See "Sexually transmitted infections: Issues specific to adolescents" and "The adolescent with HIV infection".)
●(See "Adolescent relationship abuse including physical and sexual teen dating violence" and "Date rape: Risk factors and prevention" and "Date rape: Identification and management".)
●(See "Confidentiality in adolescent health care" and "Consent in adolescent health care".)
TERMINOLOGY — Human gender and sexuality are broad and intersecting concepts (figure 1).
Cultural and descriptive terms that may be used to describe various aspects of gender and sexuality are described below [1,2]:
●Assigned gender or assigned sex at birth – Typically designated according to genetic, hormonal, and anatomic characteristics.
●Gender identity – An individual's innate sense of feeling male, female, androgynous, some combination of both, or neither [1].
Gender identity is generally established during early childhood but may evolve across the lifespan. Gender development and the continuum of gender are discussed separately. (See "Gender development and clinical presentation of gender diversity in children and adolescents", section on 'Terminology'.)
●Gender expression – How gender is presented to the outside world (does not necessarily correlate with internal gender identity).
●Sexual orientation or identity – An individual's pattern of physical and emotional arousal (including fantasies, activities, and behaviors) and the gender(s) of persons to whom an individual is physically or sexually attracted [3].
People may use various terms to describe their affiliation with a particular sexual identity, such as straight, gay, lesbian, asexual, pansexual, queer, and others.
●Sexual and/or romantic attraction – Involves internal feelings of desire which may or may not be acted upon or may not be included in a person's identified sexual orientation.
Sexual and romantic attraction may differ. As an example, an asexual/panromantic person may not have sexual attraction but have romantic interests in all genders.
●Sexual behavior – Specific behaviors involving sexual activities that are useful for sexually transmitted infection screening and risk assessment.
Sexual behaviors are described by and evaluated by the body parts involved. Different behaviors are associated with different levels of risk.
Sexual behavior does not determine adolescent gender identity or sexual orientation/identity. Formation of sexual identify among youth often is fluid; some youth experiment with same-gender sexual contacts as part of healthy adolescent development. Heterosexual youth may experiment with same-gender sexual partners. Gay or lesbian youth may have different-gender sexual partners. Either group may abstain from sexual activity altogether. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Developmental perspective'.)
PARADIGM OF SEXUALITY — Human sexuality is an essential part of human development and the human experience. Developing sexuality encompasses complex interactions between gender and sexuality (figure 1). It involves interactions between chromosomes, anatomy, hormones, and physiology; psychology; interpersonal relationships; and sociocultural influences [4]. Sexuality can be a personal and internal experience and/or involve external social interactions.
ADOLESCENT DEVELOPMENT
General adolescent development — General adolescent development is frequently divided into three stages based loosely on chronologic age and level of functioning (table 1):
●Early adolescence (ages 10 to 14) – Early adolescence coincides with the onset of puberty and typically involves concrete thinking, preoccupations and insecurities surrounding the physical changes of the body, and an egocentric approach to sexuality. Sexual curiosity and exploration may lead to initiating sexual experimentation with masturbation or early sexual activity with same- or different-gender sexual partners.
●Middle adolescence (ages 15 to 18) – Middle adolescents complete the physical changes of puberty. Middle and late adolescents might have patterns of romantic relationships characterized by serial monogamy or having several partners at once and over brief periods of time. Middle adolescents can begin to imagine the consequences of their actions but still may not fully understand them and, because of this, engage in risk-taking behaviors such as substance use and unprotected sexual activity.
●Late adolescence (ages 18 and up) – Late adolescents have more mature social skills, empathy, and an understanding of risks and consequences that help them develop more intimate and serious relationships. They have a more mature understanding and enjoyment of their physical self, gender role, sexual orientation, and sexual behaviors. They can participate in a variety of intimate and social relationships (romantic partners, friends, family, professional colleagues) with a broader sense of connection and purpose in the community.
Development of sexuality — Sexual development occurs in the context of many other aspects of identity formation and human development. One of the tasks for healthy adolescent development is the acquisition of a mature and responsible sexual identity including:
●An understanding of their particular interests and behaviors.
●An understanding of which activities promote positive sexual experiences for themselves and others.
●Active expression of sexual behaviors with themselves and others.
●The capacity for meaningful intimate (romantic, sexual, other) relationships (eg, choosing caring and respectful partners, understanding the role of consent and body autonomy, informed decision-making about prevention of sexually transmitted infections and pregnancy, and engaging in sex that is pleasurable and life affirming).
Adolescents or young adults who are mature and healthy in their sexuality are able to [5,6]:
●Identify and live according to their values; take responsibility for their behavior.
●Practice effective decision-making; develop critical-thinking skills.
●Affirm that human development includes sexual development, which may or may not include sexual experience or reproduction.
●Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.
●Interact with all genders in respectful and appropriate ways.
●Affirm their gender identity and sexual orientation and respect the gender identities and sexual orientations of others.
●Appreciate their body and enjoy their sexuality throughout life, expressing their sexuality in ways that are congruent with their values.
●Express love and intimacy in appropriate ways.
●Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.
●Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.
Development of sexuality may be more complicated for sexual minoritized persons (eg, lesbian, gay, bisexual) and gender-diverse youth. The individual youth is the best person to describe and define their sexual and gender identity and behaviors. Many youth refuse categorization, self-identifying with more diffuse terminology regarding gender and sexuality (eg, gender queer, queer, pansexual, fluid). What matters for most youth is that the provider asks about their personal perspective, experience, and what terminology best suits their needs.
Problems may arise for adolescents who encounter conflict between their emerging sexuality and the approach to sexuality that is imposed by families, peers, culture, and society as a whole. Role modeling, sex education, and other information for developing adolescents often has a heterosexual and cisgender focus; being gay, lesbian, bisexual, or gender diverse may be considered a social or religious taboo. These issues are discussed separately. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Potential psychosocial and health concerns'.)
ADOLESCENT SEXUAL BEHAVIOR — Among adolescents in the United States:
●Persons with ovaries and assigned as female at birth reach puberty and sexual maturity (eg, breast development, menarche) at earlier ages than ever before. (See "Normal puberty", section on 'Trends in pubertal timing' and "Definition, etiology, and evaluation of precocious puberty".)
●Approximately 38 percent of high school youth report having had sexual intercourse, and 27 percent report being currently sexually active [7]. Prevalence of current sexual activity increases with age, rising from 12 percent in 9th graders to 42 percent in 12th graders. In large cross-sectional surveys, 7.6 percent of male high school students and 3.6 percent of males age 15 to 24 years reported having their first sexual intercourse before age 13 years; 8.5 percent of those with sexual initiation before age 13 years described their first episode of sexual intercourse as unwanted [8]. In another national cross-sectional survey, 6.5 percent of surveyed females age 18 to 44 years reported forced sexual initiation at an average age of 15.6 years (versus 17.4 years for those with voluntary sexual initiation) [9].
●In a large national survey, more than 50 percent of adolescents and young adults (age 15 to 24 years) reported ever having engaged in oral sex with a different-sex partner; <10 percent reported using a condom or dental dam at the last episode of oral sex [10].
●Trends (from 1991 to 2019) in the Youth Risk Behavior Survey indicate that [7]:
•Rates of sexual intercourse have decreased (54 to 38 percent)
•Rates of sex with more than four persons have decreased (19 to 9 percent)
●Many adolescents have sex without using effective contraception and are at risk for unintended pregnancy [11,12]. (See "Contraception: Issues specific to adolescents", section on 'Epidemiology'.)
●Female youth ages 15 to 24 years predominantly rely on the least effective methods of contraception, such as condoms and short-acting methods, such as pills, patch, and depot medroxyprogesterone, although their use of more effective, long-acting reversible contraceptives, such as implants and intrauterine devices, is increasing. (See "Contraception: Issues specific to adolescents", section on 'Epidemiology'.)
●Youth 15 to 24 years of age account for a disproportionate number of new sexually transmitted infections. (See "Sexually transmitted infections: Issues specific to adolescents", section on 'Epidemiology'.)
●Many high school youth report same-sex attractions or behaviors, and increasing numbers of youth are gender diverse. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Epidemiology' and "Gender development and clinical presentation of gender diversity in children and adolescents", section on 'Epidemiology'.)
DISCUSSING SEXUALITY
Setting up the visit
Preparing the office and office staff — Health care facilities and individual providers must have respect for the diversity and differences inherent in adolescents and young adults, including gender, race/ethnicity, sexual orientation, and physical appearance [13,14]. Respect begins with front desk staff and the set-up of the clinic and waiting areas. It is demonstrated by:
●Staff who are interested in seeing adolescents and skilled in the basics of providing adolescent health care
●Clinic materials (brochures, pamphlets, other information), administrative intake, bathrooms, and nursing triage that are inclusive of the spectrum of gender and sexual diversity
●Clinical providers using open, nonjudgmental terminology and questions
•Introducing themselves with pronouns and/or wearing pronoun badges.
•Asking about and using the youth's identified name and pronouns.
•Using terms that are not pejorative (eg, use "sexual relationships" rather than "casual sex;" use "one or more sexual partners" instead of "multiple sexual partners") and including trauma-informed references for persons with negative sexual experiences in their past creates an open and accepting space for a wider variety of sexual experiences.
•Avoiding assumptions about families and family structure (eg, that patients have opposite gender parents, that parents are married) [15]
●Clinicians who incorporate the additional time and attention necessary for sensitive and responsive screening and counseling
In a convenience sample of adolescents, factors that were associated with improved recall of anticipatory guidance provided to adolescents included having private time with clinicians, completion of previsit screening, the perception that the visit offered benefit, and visits lasting more than 10 minutes [16].
Removing barriers — Many health care providers miss opportunities to discuss sexuality [17]. Barriers to discussions of sexuality include [18]:
●Clinic and service accessibility (hours of operation, transportation, insurance, billing, or self-pay costs)
●Lack of or perceived lack of privacy and/or confidentiality (see "Confidentiality in adolescent health care")
●Mandatory parental consent laws or practices related to contraception, sexually transmitted infections (STIs), etc (see "Consent in adolescent health care")
●Provider- or system-level political, religious, and ethical beliefs and biases
●Provider-, caregiver-, or patient-perceived stigma and discomfort associated with various aspects of sexuality, including specific sexual behaviors, gender and sexual diversity, and early sexual activity
●Practical and financial constraints of clinic time and resources
Permission, privacy, and confidentiality — Most adolescents require absolute privacy to talk candidly about their sexuality. Always ask partners, friends, or caregivers to leave the examination room at some point during the visit and before beginning these discussions.
Obtaining permission to discuss sexuality and reviewing privacy and confidentiality help to establish basic trust between the medical provider and the adolescent patient. Privacy and confidentiality are crucial when discussing potentially sensitive information with adolescents [14,19,20], particularly sexual minoritized (eg, lesbian, gay, bisexual) and gender-diverse youth. Concerns about confidentiality are cited frequently as a reason to avoid seeking health care.
Understanding legal requirements, institutional policies, and local laws can help providers educate adolescents about the difference between privacy and confidentiality and make responsible plans to protect sensitive health information [21].
●Privacy refers to an individual's ability to control the timing, amount, and circumstances under which information about oneself is disclosed [22].
●Confidentiality pertains to the treatment of information once it has been disclosed.
To illustrate with an example, a youth may have an explicit conversation with their medical provider about their sexual orientation and behaviors that can be kept private (ie, between the provider and the patient). However, information recorded in the medical record is available upon request by parent(s). Although most states provide adolescents with some measure of consent and confidentiality for testing and treatment of STIs, many states do not protect other reproductive health information (including sexual orientation and activity, pregnancy testing, contraception). Explicit assurance of privacy and confidentiality (and exceptions to privacy and confidentiality) regarding discussions and details of emerging sexuality helps adolescents understand what to expect and what types of sensitive information they may safely disclose or is recorded by their health care provider [3]. Adolescent consent, examples of how to discuss confidentiality (and limits to confidentiality), and documentation of confidential information in the medical record is discussed separately. (See "Consent in adolescent health care" and "Confidentiality in adolescent health care".)
How to discuss
Normalize sexuality — Sexuality is an important component of childhood, adolescent, and young adult development and an appropriate topic of discussion during health maintenance visits. Health care professionals who provide developmental screening and anticipatory guidance can integrate conversations around gender and sexuality into their education and counseling. Aspects of sexuality, including body autonomy, can be discussed in developmentally appropriate ways in early childhood.
●Including questions about gender play and preferences, body image and esteem, and expression of femininity and masculinity in routine health care visits from the toddler (table 2) through the teenage years (table 3 and table 4) normalizes the youth's ongoing and evolving understanding of gender as a universal developmental experience.
Asking such questions provides a developmentally appropriate introduction to upcoming discussions about puberty and adolescence and can be helpful for both the parents and the child to practice open communication about these sensitive issues within the medical setting. It also allows parents, children, and adolescents, including those who are sexual minoritized or have experienced sexual prejudice, to realize that the medical visit can be a safe place to explore questions and concerns about sexual health.
●The health care provider's asking parents about their child's activities and preferences in the prepubertal years demonstrates that adults should be interested in their child's development of identity and provides appropriate models for communication and support about these issues.
●The provider's open and curious approach to understanding the ways children embrace their gender and sexual selves can guide parents in approaching their child's developing sexuality.
●Safe and respectful conversations about sexuality with adolescents and young adults may help them to better understand sex and its role in their present and future lives. The goal is for adolescents to have a better understanding of their body, to have and communicate ideas about what is pleasurable to them, and to feel free to ask questions about sexual health and satisfaction. When persons engaging in sexual activities are in emotionally and/or physically satisfying relationships, prevention and pleasure can go hand in hand.
Ongoing conversations about gender and sexuality may allow earlier identification and support for sexual minoritized and gender-diverse youth and their families. Using sex-positive paradigms, providers can help adolescents embrace the diversity of sexual identities, choices, and activities based on individual consent. Combined with appropriate screening, education, and support, sex-positive approaches can empower and encourage adolescents to make safer sexual decisions [23].
Use appropriate language — Use the appropriate terminology (table 5) and speak about sexuality and sexual behavior in terms that are professional yet familiar and comfortable for the youth. Developmentally appropriate terminology and focus is important for patients across the lifespan, and particularly important for youth with neurodiversity or developmental delay. As examples:
●Questions about fellatio or cunnilingus may be replaced with more colloquial terms, such as "oral sex."
●For young males having sex with males, questions about anal insertive or anal receptive sex may be replaced with more familiar terms, such as "top" or "bottom," respectively.
●Gender-diverse persons may be uncomfortable with terms for various gendered and sexual body parts. Providers can ask patients how they would like providers to refer to these parts or activities.
In discussions of sexuality, youth invariably use terminology or phrases that are not understood easily by the health care provider. In these cases, ask for clarification by stating, "I am not familiar with that term. Can you tell me what you mean?" Youth usually welcome the opportunity to talk about themselves and may see this request as an expression of interest on the part of the provider.
Avoid assumptions — Avoid making assumptions about the sexuality of adolescent patients. In particular, do not assume:
●That all patients are heterosexual. Gay, lesbian, asexual, and bi- or pansexual youth exist in all communities and in all pediatric practices.
Ask questions that are gender and sexuality neutral (eg, ask about "crushes" or "romantic or sexual partners" rather than "boyfriends" or "girlfriends"). Asking open-ended and gender-neutral questions allows the adolescent to reveal the gender of their partners and begin a conversation about sexual identity and sexual behaviors.
●That adolescents who self-identify as heterosexual do not also have same-gender sexual partners [23,24] or that adolescents who self-identify as gay or lesbian do not have different-gender partners.
●That a self-identified lesbian or transmasculine person does not require birth control [25-28]. Transmasculine people can and do get pregnant. Young females who have sex with females may experiment with different-gender sexual partners and are at risk of becoming pregnant and acquiring STIs. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Unplanned pregnancy'.)
●That psychosocially or medically complex patients such as youth with significant neurodiversity or developmental delays, ongoing chronic illnesses, or gender dysphoria or diversity are not involved in romantic or sexual relationships [29-31].
Incorporating specific discussions about burgeoning sexuality with neuro- and able-diverse youth is an integral component of anticipatory guidance. (See "Children and youth with special health care needs", section on 'Routine health care maintenance'.)
●That youth are not curious and open, including exploring alternative sexual interests or activities (eg, kink or bondage).
●That female adolescents do not engage in anal sex. Adolescent females may engage in anal sex as a pregnancy-prevention strategy and may not be aware of the need to use condoms for protection against human immunodeficiency virus (HIV) and STIs.
●That patients have all the understanding and information they need about safer sexual practices. Providers and patients may have different ideas and priorities for what constitutes "safer sex" practices.
RISK AND RESILIENCY-BASED ANTICIPATORY GUIDANCE — Comprehensive sexual health education is an essential component of preventive health guidance for all youth. Aspects of sexuality, including body autonomy, can be discussed in developmentally appropriate ways in early childhood. As children mature, more fully exploring their concepts and values about sexuality may permit earlier support and guidance.
Risk and resiliency-based anticipatory guidance considers sexual behavior in the context of the adolescent's social support, quality of sexual experience, and autonomy and self-esteem in making sexual decisions. By promoting sexuality as normative, healthy, respectful, and meaningful in the larger context of adolescent development, providers can foster empowerment, strength, and resiliency for all youth exploring their gender and sexual identities [32].
Sexuality education — As adolescents struggle to understand their emerging sexualities within their complex social environments, appropriate anticipatory guidance can foster optimal sexual health and help adolescents avoid behaviors and expressions that increase the risk of negative consequences (table 6) [3,6,14,23].
Successful sexuality education includes risk and resiliency, disease prevention and treatment, and the message that sexuality can enhance well-being.
Health care providers are a valued and trusted source of information and advice about sexuality (table 6). Clinicians with expertise in adolescent sexual health care use an interview style that includes motivational interviewing (table 7), harm reduction, trauma-informed care (table 8), and social marketing (ie, using marketing approaches and techniques to change behavior for the benefit of the patient or greater society). These approaches create an open dialogue that invites honest answers, focuses on individual strengths and goals, increases knowledge, builds skills, and promotes personal responsibility. They incorporate discussions of personal autonomy, consent, and communication among partners, and they focus on psychosocial and pleasure aspects of sexuality as well as risk and disease prevention [33].
Education and interventions that promote responsible and healthy sexuality also can and should be delivered in homes, schools, and community settings [6]. A systematic review of studies of school-based sex education programs found strong support for comprehensive sex education that occurs across a range of grade levels, addresses a range of topics, and takes a positive, inclusive approach [34]. Comprehensive sexuality education programs can improve knowledge and reduce risk behaviors [35,36]. Comprehensive information with motivational and skills-based content is successful in reducing penetrative sexual behaviors and improving condom negotiation and use [37-39]. State-specific sex education policies appear to affect youth sexual behavior; states that require sexuality education and contraceptive content have lower rates of sexually active youth and higher rates of contraception among sexually active youth than states that require abstinence content [40].Given the importance of media and technology in youth culture, additional frameworks of health education may include interactive computer modules, text messaging, and other social media networks (eg, Advocates for Youth, Amaze) [41-44]. (See 'Provide additional support and resources' below.)
Ask specific questions to assess risks and strengths — Detailed and specific information about sexual behaviors and partners (table 4) determines risks and strengths to target screening and anticipatory guidance. Ask the youth about specific sexual behaviors, use of condoms and contraception, and victimization.
●Specific sexual behaviors – The detailed sexual history can be introduced by saying something like: "I am going to ask you about intimate and personal details of your sexual behaviors, partners, and other activities so I can know what to suggest for screening, testing, and healthy sex decisions."
An explicit acknowledgement that the provider's "need to know" is for the purpose of screening, testing, and counseling rather than to make judgements lets the adolescent know that all topics are open for discussion and may open the door to more candid discussions.
In addition to information about partners (same- or different-gender, number of lifetime partners, and recent partners), the sexual history should include [45]:
•The date of last sexual activity
•The type of sexual activity (eg, digital, oral, vaginal, anal, other)
•History of sexually transmitted infections (STIs) or pregnancies
•Age at sexual debut
•Use of substances with sex
•Feeling threatened or coerced into sex
As part of normal sexual development, adolescents may explore/experiment with a variety of sexual behaviors. Leaving an open-ended time for an adolescent to reflect and report on their sexual experiences elicit additional important information including: open relationships, substance use with sex, sexual enhancing medicines or devices, auto-eroticism, and other sexual alternatives. Elicitation of such information permits more specific risk reduction counseling (eg, the safety measure of having a flared base for prosthetics or sex items that are used for anal penetration).
Going through a list of specific body parts (eg, "Does your penis go in your partner's mouth, vagina, rectum?"; "Does your partner's penis go inside your mouth, vagina, rectum?") can help educate youth about sexual behaviors that increase their risk of STI. While youth may initially be uncomfortable discussing body parts and activities, direct and explicit conversation about behaviors can help to normalize the conversation.
Sexual behaviors that may be associated with acquisition of STIs, regardless of sexual orientation, include:
•Digital penetration – Digital penetration or fingering (touching or penetrating the vagina or anus with fingers) is less risky than penile vaginal or anal penetration but is not entirely risk free.
•Oral sex – Oral sex includes kissing, licking, or sucking on the penis, scrotum, vagina, or anus (rimming). Adolescents may underestimate the risk of disease with oral sex, thinking it is entirely risk free [46]. STI transmission via oral routes is less likely than with anal or vaginal penetration, particularly for HIV [47,48], but gonorrhea, chlamydia, syphilis, herpes simplex virus type 1 and 2, and human papillomavirus can be transmitted orally.
•Anal sex – Unprotected penile-anal sex is associated with increased risk of HIV and STI transmission [49].
•Vaginal sex – Unprotected vaginal sex (whether insertive or receptive, with a penis or prosthetic [eg, hand-held or strap-on]) is associated with increased risk of STI transmission. The risk varies with the disease and sexual practice (eg, penile penetration or penetration with sex items).
Counseling for risk reduction (ie, "safer sex") is discussed below. (See 'Prevention of sexually transmitted infections and HIV' below.)
●Use of condoms and contraception
•How often and with whom they use a condom and date of last sexual activity without a condom
Separating condom use for STI prevention from condom use for contraception or family planning can be conceptually helpful and promotes use of dual methods for safer sex.
•Type of contraception for themselves and their partner and date of last sexual activity without contraception
Asking about current use of contraception and problems with previous methods (eg, difficulty with adherence or continuation, concern about side effects) may generate further discussion about contraceptive options. Including young heterosexual males in the screening and education process improves their ability to contribute to family planning decisions [50]. (See "Contraception: Issues specific to adolescents", section on 'Choosing a method'.)
●Victimization – Coerced sex is common in adolescence and may be associated with other health issues, including suicidal thoughts, substance use, and concerns about personal safety. Questions that explore victimization include:
•"Have you ever had unwanted sex?"
•"Have you ever felt pressured to have sex even though you did not want to?"
•"Have you ever been in a position where the sex went further than you wanted it to?"
•"Have you needed to trade sex for money, food, or a place to stay, or for drugs?" (particularly appropriate for youth who are homeless and disadvantaged)
Develop risk-reduction strategies — Helping youth make connections between their sexuality and other aspects of their lives is an important step in developing a comprehensive risk-reduction strategy. As an example, many youth engage in unsafe sexual practices while under the influence of drugs or alcohol. Recognizing this association permits incorporation of substance use services as well as safer sex practices. Exploring other potential associations (eg, domestic violence, exchanging sex for money or drugs, sexual assault) may provide additional opportunities for counseling, support, and referral.
Pregnancy prevention — The majority of adolescent pregnancies are unplanned. Any person may become pregnant if sperm and oocytes are involved. Although abstinence is the single most effective means to avoid pregnancy and we support adolescents who decide to abstain from sexual activity, we discuss contraception with all adolescents [50,51]. This engages male adolescents in family planning decision-making and acknowledges that adolescent females who have sex with females may also have sex with male partners. Choosing a method of contraception is discussed separately. (See "Contraception: Counseling and selection" and "Contraception: Issues specific to adolescents", section on 'Choosing a method'.)
Prevention of sexually transmitted infections and HIV — A disproportionate number of STIs occur in adolescents and young adults. Several aspects of adolescence contribute to the increased risk (eg, sequential sexual partnerships of inconsistent duration). These issues are discussed separately. (See "Prevention of sexually transmitted infections", section on 'Disproportionately affected populations' and "Sexually transmitted infections: Issues specific to adolescents", section on 'Risk factors'.)
STI prevention counseling for adolescents must be developmentally appropriate (table 6) and balance the importance of adolescent sexual development in achieving mature relationships with risk avoidance and harm reduction. Open-ended questions and nonjudgmental counseling is crucial for youth who may not report all of their risks and sexual behaviors.
Aspects of STI prevention that are particularly important for adolescents include:
●Support for abstinence and delaying sexual debut because early age of first intercourse is a risk factor for pregnancy and acquisition of STIs.
●Demonstrating appropriate techniques for condom use and recommending consistent and correct use of condoms as the most effective strategy to prevent STIs [52].
●Discussion of HIV-pre-exposure prophylaxis (PrEP) for adolescents who are not able or willing to use condoms or who engage in sexual behaviors with others who are at high risk for HIV infection; patient selection for HIV PrEP, including adolescents and young adults, is discussed separately. (See "HIV pre-exposure prophylaxis".)
●Modeling effective communication and partner negotiation skills.
Prevention of and screening for STIs are discussed in detail separately. (See "Prevention of sexually transmitted infections" and "Screening for sexually transmitted infections".)
Issues related to consent and confidentiality for services related to STIs and HIV are also discussed separately. (See "Consent in adolescent health care", section on 'Sexually transmitted infections' and "Confidentiality in adolescent health care", section on 'Sexually transmitted infections'.)
Teen dating violence — Teen dating violence (TDV) includes psychological, physical, and sexual aggression. It is common in adolescent dating relationships. TDV is more common in sexual minoritized and gender-diverse adolescents and adolescents engaging in other risk activities (eg, drug and alcohol use).
Routine discussion of TDV with adolescents opens opportunities for education and intervention. Discussing TDV with adolescents is discussed separately. (See "Adolescent relationship abuse including physical and sexual teen dating violence".)
Sexual minoritized and gender-diverse youth — There is substantial research documenting increased risk behaviors, victimization, and adverse health outcomes among sexual minoritized (eg, gay, lesbian, bisexual) and gender-diverse youth. Health risks and adverse outcomes include child abuse, bullying, sexual harassment, TDV, mental health problems (depression, anxiety, suicide, disordered eating and body image), substance use, and unprotected sex with risks for STIs and pregnancy. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Potential psychosocial and health concerns'.)
Prevention strategies for these youth are discussed in detail separately. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care", section on 'Anticipatory guidance/counseling' and "Management of transgender and gender-diverse children and adolescents".)
Provide additional support and resources — Some youth require or desire educational resources or other services that are beyond the scope of the individual practice setting. Know what resources exist for youth in your community, state, and nationally.
A variety of trustworthy online resources are available to provide relevant information and education about issues related to adolescent sexuality.
•Adolescent Health Care Resources for Teens
•Amaze is a partnership between Advocates, Answer and Youth Tech Health that harnesses the power of animation and social media to provide young adolescents with age-appropriate, comprehensive, and affirming sexuality education through short animated videos, in addition to resources for parents and educators
•American Social Health Association "I wanna know"
•National Youth Advocacy Coalition
•Sex Information and Education Council of the United States
•Resources for Adolescent Health
Resources for sexual minoritized (eg, gay, lesbian, bisexual) and gender-diverse youth are provided separately. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care" and "Management of transgender and gender-diverse children and adolescents".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Adolescent sexual health and pregnancy" and "Society guideline links: Health care for lesbian, gay, and other sexual minority populations" and "Society guideline links: Sexually transmitted infections".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they 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. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword[s] of interest.)
●Basics topics (see "Patient education: Teen sexuality (The Basics)" and "Patient education: Normal puberty (The Basics)")
●Beyond the Basics topic (see "Patient education: Adolescent sexuality (Beyond the Basics)")
SUMMARY
●Terminology and paradigm of sexuality – Human sexuality is a broad concept that encompasses various aspects of gender and sexuality (figure 1). It is an essential part of human development and the human experience. Developing sexuality involves interactions between chromosomes, anatomy, hormones, and physiology; psychology; interpersonal relationships; and sociocultural influences. (See 'Terminology' above and 'Paradigm of sexuality' above.)
●Development of sexuality – Sexual development occurs in the context of many other aspects of identity formation and human development (table 1). One of the tasks for healthy adolescent development is the acquisition of a mature and responsible sexuality including expression of sexual behaviors and the capacity for meaningful intimate relationships (eg, choosing caring and respectful partners, understanding the role of consent and body autonomy, informed decision-making about methods of sexually transmitted infection prevention and or contraception, and engaging in sex that is pleasurable and life affirming). (See 'Development of sexuality' above.)
●Discussing sexuality – Guidance for setting up the visit and how to discuss sexuality is summarized in the table (table 9). (See 'Discussing sexuality' above.)
●Sexuality education and resiliency-based anticipatory guidance
•Clinicians with expertise in adolescent sexual health care use resiliency-based anticipatory guidance, motivational interviewing (table 7), and trauma-informed care (table 8) to provide a sex-positive framework appropriate for adolescents as the adolescents develop and explore their sexuality. (See 'Sexuality education' above.)
•Resiliency-based anticipatory guidance considers individual goals, strengths, and needs; builds on consent and communication to promote autonomy and desired sexual behaviors; and integrates an understanding of the context of the adolescent's social support, past history and quality of sexual experiences, and autonomy and self-esteem in making sexual decisions.
It requires asking specific questions about sexual behaviors to target risks and strengths, developing targeted risk reduction strategies, and providing additional support and resources (table 6). (See 'Risk and resiliency-based anticipatory guidance' above.)
ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Robert Garofalo, MD, MPH, who contributed to an earlier version of this topic review.
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