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Male adolescents’ sexual and reproductive health needs often go unmet in the primary care setting. Especially the specific issues related to male adolescents’ sexual and reproductive health care in the context of primary care, including pubertal and sexual development, sexual behavior, consequences of sexual behavior, and methods of preventing sexually transmitted infections (including HIV) and pregnancy. 

During adolescence, a number of changes occur for boys, including the physical, psychological, and social changes associated with puberty, and the majority of male adolescents report the initiation of sexual behavior. Many of these events, including sexual initiation, are associated with preventable consequences that can lead to significant morbidity and mortality.

CORE MALE ADOLESCENT SEXUAL/REPRODUCTIVE HEALTH KNOWLEDGE AREAS

A. Puberty

  • With pubertal changes and the development of reproductive capacity come questions and concerns. Puberty for male adolescents follows a predictable sequence, but clinicians need to be aware that its timing is variable because of a variety of factors, including heredity and race/ethnicity. 
  • For boys, the first visible sign of puberty and the hallmark of the second sexual maturity rating (SMR) stage (SMR2) is testicular enlargement, followed by penile growth (the hallmark of SMR3). During SMR4, a male’s testicular volume has reached approximately 9 to 10 cm3 and his peak height growth typically occurs.

B. Alterations in Growth Associated With Puberty

  • Early and delayed pubertal timing, including short stature, can result in negative consequences for the developing male. Consequences can include higher mean levels of aggression and delinquency. 
  • Earlier-maturing boys might have more frequent involvement in risk-taking behaviors, and later-maturing boys might have lower levels of confidence and self-efficacy and increased experiences of teasing, bullying, mental health issues, and substance abuse.
  • Even a common issue such as acne, which affects 95% of male adolescents, can be related to self-reported embarrassment, lower self-esteem, depression, and anxiety.

C. Sexuality

  • Sexuality, as defined by the World Health Organization in 2002, is a central aspect of the human life course and encompasses sex, gender identities and roles, sexual orientation, intimacy, and reproduction.
  • Although sexuality can be experienced and expressed in thoughts, fantasies, desires, beliefs, values, behaviors, roles, and relationships, not all sexuality dimensions are experienced or expressed. 
  • One’s sexuality is also influenced by a variety of factors including biological, psychological, familial, societal, political, cultural, and religious factors. Before adolescence even begins, boys might be curious and ask questions about sex, body parts, differences between boys and girls, and where babies come from. However, not all parents talk about sex with their children. 
  • Male adolescents should be encouraged to talk with their health care provider about general health and, in particular, sex, relationships, and prevention of STIs/HIV and pregnancy.

D. Sexual Development

  • During adolescence, teenagers begin the process of developing a sexual self-concept, which involves the combination of physical sexual maturation, age-appropriate sexual behaviors, and formation of a positive sexual identity and sense of well-being.
  • In early adolescence, boys might become preoccupied with body changes, become interested in sexual anatomy and sex, compare changes in their body with others, and explore touching and mutual masturbation.
  • Along with the experience of spontaneous erections, ejaculation related to masturbation, and the onset of nocturnal ejaculatory events during sleep (ie, “wet dreams”), there are many reasons why preadolescent and older boys might have questions and anxieties about their emerging sexuality. 
  • It is not uncommon for a male to have anxieties and questions about genital size and function, especially when comparing himself to others and after initiating sexual behavior.

E. Masturbation and Spermarche

  • On average, the age of first male masturbation occurs between 12 and 14 years of age; most boys learn about masturbation through self-discovery. 
  • There is no evidence that masturbation is harmful in general or to one’s sexual development or later adult sexual adjustment. However, myths related to negative consequences of masturbation persist and can result in inappropriate anxiety and/or guilt.
  • Before puberty, boys might masturbate to orgasm; however, no ejaculation will occur until pubertal changes commence. Sperm in the ejaculate, or spermarche, typically appears during SMR3, approximately 12 to 18 months after the testes begin to enlarge. Although mature sperm production begins after the first ejaculate, a young man should be considered fertile from the time of his first ejaculation.
  • Health care providers can reassure male adolescents that self-masturbation is a normal behavior and can be a positive expression of sexuality and a way to delay having sex and its associated risks. Health care providers can also assist male adolescents with information and resources about normal sexual physiology and function that might not otherwise be available at home or school.

F. Sexual Behavior and Its Consequences

  • Sexual behavior is a normal part of development.
  • Discordance between sexual attraction/orientation and behavior is also possible, because one’s sexual attraction and identity do not always predict sexual behavior. 

G. Unwanted Sex

H. Dating Violence

Violence in adolescent relationships can include bullying, threatening, sexual harassment, dating violence, and/or coercion. Within the context of intimate relationships among romantic and sexual partners, such violence can be verbal, emotional, physical, or sexual. Male adolescents can be perpetrators, victims, or both. 

I. Sexual Function and Dysfunction

  • Healthy sexual function has an important role in adolescents’ and young adults’ well-being and development. Few studies, however, have examined sexual health and/or problems with sexual dysfunction among adolescents. 
  • Common causes of sexual dysfunction among young adult men include anxiety about performance, premature ejaculation, worries about attractiveness during sex, decreased pleasure associated with condom use, and organic performance-related issues attributable to comorbid medical conditions (eg, diabetes, cardiac disease, neurologic deficits) or adverse effects from medication (eg, selective serotonin-reuptake inhibitors or alcohol).

J. STIs/HIV, Pregnancy, and Adolescent Fatherhood

Involvement in sexual behaviors places young men and their partners at risk of negative sexual/reproductive health outcomes that are preventable, such as STIs, HIV infection, unintended pregnancy, and reproductive health-related cancers such as anal cancer attributable to human papillomavirus (HPV).

K. Preventing STIs/HIV Infection and Pregnancy

The male adolescent and his partner, family, school, and health care provider all have important roles in preventing the negative consequences of sexual behavior.

For health care providers, goals for male adolescents’ sexual/reproductive health beyond the prevention of STIs, HIV infection, unwanted pregnancy, and reproductive health-related cancers. They should include promoting sexual health and adolescent development, healthy intimate relationships and responsible behavior, and responsible fatherhood as well as reducing problems related to sexual dysfunction and infertility.