To describe sexual behaviors and acceptability of receiving sexual and reproductive health (SRH) services among hospitalized adolescent males.
We performed a cross-sectional survey of hospitalized adolescents. Eligible participants were males aged 14 to 20 years admitted at 2 academic medical centers. Outcome measures included reported healthcare utilization, sexual health behaviors (eg, sexual activity), contraception use, and acceptability of SRH discussions during a hospitalization.
Among 145 participants, 42% reported a history of vaginal sex, 27% current sexual activity, 12% early sexual debut, and 22% 4 or more prior sexual partners. At last sex, condom use was reported by 63% and use of reversible contraception by 36%. Nearly half (45%) agreed that hospital-based SRH discussions were acceptable, particularly among those with history of sexual activity (P < .01). Some (12%) reported they had not accessed care in the past year when they felt they should.
Hospitalized males in our study had similar rates of sexual activity as compared with the general population but had higher rates of early sexual debut and number of prior partners, which are independently linked with negative sexual health outcomes (eg, sexually transmitted infections). Our participants found SRH discussions to be generally acceptable. These findings reveal opportunities to screen for unmet SRH needs and provide SRH education and services for adolescent males in the hospital.
Adolescents face a unique set of health concerns for pediatricians to address, many specifically related to reproductive health care. Nearly half of male high school students have had sex, putting them at risk for sexually transmitted infections (STIs) and which may increase their female partners risk for unintended pregnancy.1 American Academy of Pediatrics guidelines highlight the importance of patient-centered sexual and reproductive health (SRH) care for adolescent males in all settings, including in the acute care setting.2,3 A majority of males are willing to discuss SRH topics with their primary care providers, including discussion of contraception for their female partners.4 However, adolescent male attendance to primary care and preventive health visits decline rapidly in late adolescence, with older teenage males representing only 6% of preventative healthcare visits.5 Among adolescents attending a primary care visit, adolescent males are half as likely to have a SRH discussion compared with their female counterparts. Barriers impacting SRH discussions include inadequate time, knowledge, and physician discomfort.6–11 In light of the recent Supreme Court decision in Dobbs versus Jackson removing women’s constitutional right to abortion, efforts to increase SRH access in all clinical settings are critically important, particularly for historically marginalized populations, such as adolescents who face significant barriers in accessing care.12
A hospitalization offers a unique opportunity to deliver SRH services as half of hospitalized adolescent males report no SRH counseling from their primary care physician.13 A small study of hospitalized adolescent males found that provision of STI testing and contraception education was acceptable.13 Adolescent males, however, are less likely to have sexual history documentation and STI testing in the acute care setting than females.14–18 Additionally, adolescent males who are knowledgeable about female contraception are more likely to discuss contraception with their partners, are more likely to have a partner that uses contraception, and are less likely to have partners who experience an unintended pregnancy.19–21 Therefore, SRH interventions for males that include STI screening, treatment, and prevention while also incorporating education about contraception may improve SRH outcomes in this population.
Patient-centered SRH interventions in the pediatric emergency department have been found to be feasible and effective in increasing SRH services (eg, STI testing, contraceptive use) in male and female adolescents.22,23 A computer-based SRH intervention for adolescents in the hospital was feasible and acceptable, however this study was limited to female adolescents.24 The only SRH intervention to our knowledge including hospitalized adolescent males was piloted in an inpatient psychiatric setting and found to improve SRH knowledge and general acceptability, although demonstrated lower acceptability among males as compared with females.25 To date, no interventions for adolescent males in the medical or surgical hospital setting have been developed or tested. Better understanding of the sexual health behaviors and needs of hospitalized adolescent males is important to inform hospital-based SRH interventions, yet little is known on this topic. To address this gap, we sought to describe the sexual health behaviors among hospitalized adolescent males.
Methods
Study Design and Survey Instrument
We performed a cross-sectional survey of a convenience sample of adolescent males (self-reported sex at birth) aged 14 to 20 years old who were hospitalized at 2 Midwestern tertiary care children’s hospitals from August 2019 to March 2020. Participants were enrolled at any point during their hospitalization. Inclusion criteria were admission to the general medical or surgical units, English fluency, and no severe illness, developmental delay, or current cancer diagnosis as determined by electronic health record (EHR) review or discussion with the medical or surgical team. The study took place in a state where sex education is not mandated in schools.26 The Institutional Review Board at each participating institution approved the study and waived parental consent for minors.
Our multidisciplinary team adapted previously validated survey instruments (ie, Youth Risk Behavioral Surveillance System, National Survey of Family Growth) to assess demographics, healthcare utilization, SRH behaviors (eg, sexual activity, contraception use), and acceptability of SRH discussions.27,28 Study data were collected and managed using Research Electronic Data Capture. We collected age, race and ethnicity, and insurance type from the EHR for potential participants who were approached and were consented or refused, though because of a procedural error, the enrollment log was incomplete at 1 study site (ie, completed on 48 of 63 enrollment days). The study team also collected select underlying medical conditions via EHR review.
Study Procedures
The research team reviewed the EHR to identify eligible adolescents, notified (ie, via pager, phone, or in person) the adolescent’s medical or surgical team (ie, nurses, physicians), and then approached the adolescent for study enrollment. Eligible adolescents provided verbal consent or assent. If a parent or guardian was present at enrollment, they were given brief information about the study and asked to leave the room for consent or assent and study procedures. After consent, participants completed the confidential, anonymous, self-administered, tablet-based survey which took ∼ 20 minutes to complete. Upon completion of the survey, each participant was given a $10 gift card and an adolescent SRH resource handout with local adolescent clinic sites and contact information as well as phone numbers for national support hotlines (eg, suicide, mental health hotline).
Outcome Measures
Our primary outcome was a history of sexual activity, defined as an affirmative response to questions regarding any past vaginal, oral, or anal sex. We also assessed the gender of past partners, age at first sex, number of lifetime partners, current sexual activity (sexual activity in the past 3 months), frequency of condom use, and emergency and/or reversible contraception use at last sex. Reversible contraception was defined as use of oral contraceptive pills, transdermal patch, intravaginal ring, Depo-Provera injection, subdermal implant, or intrauterine device. Specifically, participants were asked, “The last time you had vaginal intercourse, which method did you or your partner use to prevent pregnancy?” and could select from a list of contraceptive methods used. Dual contraception was defined as report of a male condom in addition to a reversible method of contraception. We assessed acceptability of sexual health discussions using a 5-point Likert scale to determine agreement (strongly agree or agree) with the benefit of health care providers discussing birth control and other sexual health practices with adolescents in general and during a hospital stay.
Statistical Analysis
We calculated means with standard deviations (SD) to summarize normally distributed data and proportions for categorical data. Because our data were normally distributed, χ2 tests were used to compare between categorical variables. We noted data missing in frequency calculations. Microsoft Excel 2016 for Windows and IBM SPSS Statistics for Windows (IBM Corp, Armonk, N.Y., USA) were used to conduct statistical analyses. Full methodology of this study has been previously described.29,30
Results
One hundred and forty-five males participated out of 170 approached (85% response rate) across the 2 sites with no differences in age, race and ethnicity, or insurance type between participants and those who declined. The mean age was 15.9 years (standard deviation 1.4). Most participants were non-Hispanic White (54%), cisgender (99%), straight or heterosexual (92%), had private health insurance (53%), and reported a prior medical visit in the past year (89%) (Table 1). Regarding healthcare access, 12% (18 of 145) reported a time in the prior 12 months when they thought they should get medical care but did not. The most common underlying conditions were mental health disorders (10%), sickle cell disease (9%), inflammatory bowel disease (6%), and diabetes (6%).
Participant Characteristics (n = 145)
| Characteristic . | . | |
|---|---|---|
| Age, mean (SD) | 15.9 (1.4) | |
| Race and ethnicity, n (%) | ||
| Non-Hispanic White | 79 (54) | |
| Non-Hispanic Black | 34 (23) | |
| Hispanic | 16 (11) | |
| Other (Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander) | 16 (11) | |
| Gender identity, n (%) | ||
| Male | 143 (99) | |
| Female | 1 (0.5) | |
| Nonbinary or third gender | 1 (0.5) | |
| Sexual identity,an (%) | ||
| Straight or heterosexual | 131 (92) | |
| Gay or lesbian | 3 (2) | |
| Bisexual | 7 (5) | |
| Asexual or self-described | 2 (1) | |
| Insurance type,bn (%) | ||
| Private or military | 76 (53) | |
| Public | 54 (37) | |
| None identified | 14 (10) | |
| Had at least 1 visit in a doctor’s office in the last year,cn (%) | 125 (89) | |
| Characteristic . | . | |
|---|---|---|
| Age, mean (SD) | 15.9 (1.4) | |
| Race and ethnicity, n (%) | ||
| Non-Hispanic White | 79 (54) | |
| Non-Hispanic Black | 34 (23) | |
| Hispanic | 16 (11) | |
| Other (Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander) | 16 (11) | |
| Gender identity, n (%) | ||
| Male | 143 (99) | |
| Female | 1 (0.5) | |
| Nonbinary or third gender | 1 (0.5) | |
| Sexual identity,an (%) | ||
| Straight or heterosexual | 131 (92) | |
| Gay or lesbian | 3 (2) | |
| Bisexual | 7 (5) | |
| Asexual or self-described | 2 (1) | |
| Insurance type,bn (%) | ||
| Private or military | 76 (53) | |
| Public | 54 (37) | |
| None identified | 14 (10) | |
| Had at least 1 visit in a doctor’s office in the last year,cn (%) | 125 (89) | |
Missing data included in % calculations.
Missing n = 2.
Missing n = 1.
Missing n = 5.
Sexual Health Behaviors, Contraceptive Use and Receipt of Contraceptive Counseling
Almost half (46%; 65 of 140) reported previous sexual activity; with 42% (59 of 140) reporting ever having vaginal sex, 27% (37 of 138) current sexual activity, 36% (50 of 140) oral sex, and 7% (10 of 140) anal sex (Table 2). Among those with a history of vaginal sex, 12% (7 of 57) reported early sexual debut (before age 13 years), and 22% (13 of 58) reported 4 or more prior partners.
Sexual Health Behaviors
| Reported Behavior (n, total no. of respondents) . | n (%) . |
|---|---|
| History of vaginal sex (n = 140) | 59 (42) |
| Among those with history of sexual activity | |
| Early sexual debut (<13 y) (n = 57) | 7 (12) |
| 4 or more lifetime partners (n = 58) | 13 (22) |
| Vaginal sex in past 3 months (n = 138) | 37 (27) |
| History of oral sex (n = 140) | 50 (36) |
| History of anal sex (n = 140) | 10 (7) |
| Acceptability of SRH services | |
| Agreement with services from a healthcare provider (n = 139) | 74 (53) |
| Agreement with services during a hospital stay (n = 138) | 62 (45) |
| Reported contraception use at last sex (n = 59) | |
| Condom | 37 (63) |
| Combined hormonal contraceptive | 14 (24) |
| Injectable | 2 (3) |
| LARC | 5 (8) |
| EC | 0 (0) |
| Reported Behavior (n, total no. of respondents) . | n (%) . |
|---|---|
| History of vaginal sex (n = 140) | 59 (42) |
| Among those with history of sexual activity | |
| Early sexual debut (<13 y) (n = 57) | 7 (12) |
| 4 or more lifetime partners (n = 58) | 13 (22) |
| Vaginal sex in past 3 months (n = 138) | 37 (27) |
| History of oral sex (n = 140) | 50 (36) |
| History of anal sex (n = 140) | 10 (7) |
| Acceptability of SRH services | |
| Agreement with services from a healthcare provider (n = 139) | 74 (53) |
| Agreement with services during a hospital stay (n = 138) | 62 (45) |
| Reported contraception use at last sex (n = 59) | |
| Condom | 37 (63) |
| Combined hormonal contraceptive | 14 (24) |
| Injectable | 2 (3) |
| LARC | 5 (8) |
| EC | 0 (0) |
Agreement was defined by selecting either “agree” or “strongly agree.” LARC, long-acting reversible contraception; EC emergency contraception.
Among sexually active participants, 63% (37 of 59) reported condom use with last vaginal sex, and 45% (26 of 58) reported always using condoms when having sex. At last vaginal sex, 36% reported reversible contraceptive use and 22% reported dual contraceptive use. Most of those reporting reversible contraception used a combined hormonal contraceptive (pill, patch, or ring) (24%; 14 of 59); a minority used injectable contraception (3%; 2 of 59) or a long acting reversible contraception (LARC) method (subdermal implant or intrauterine device) (8%; 5 of 59). Some (14%; 8 of 59) reported being “not sure” of the birth control method used; 10% (6 of 59) reported “I have never used a method of birth control.” No participants reported knowledge of their female partner using emergency contraception (EC) after last sex. Three sexually active participants reported a history of male sexual partners; among them, none reported condom use at last sex.
Acceptability of Hospital Interventions
More than half (53%; 74 of 139) of participants agreed it is helpful for healthcare providers to talk about birth control and other sexual health practices with adolescents. When asked if a hospital stay is a good opportunity to discuss birth control and other sexual health practices, 45% (62 of 138) reported they “agree” or “strongly agree,” 34% (47 of 138) reported they were “neutral,” and 21% (29 of 138) reported they “disagree” or “strongly disagree.” Participants who were sexually active were more likely to agree that a hospital stay is a good opportunity to discuss birth control (P < .01).
Discussion
This study is the first to describe sexual health behaviors among hospitalized male adolescents and reveals important opportunities to meet the SRH needs of this population. Our study participants demonstrated similar rates of ever having vaginal sex (42% vs 39%), current sexual activity (27% vs 26%), and condom use at last sex (63% vs 60%) when compared with the nationally representative population from the Youth Risk Behavioral Surveillance System.27 Encouragingly, our population reported higher rates of reversible contraceptive use at last sex (36% vs 26%). Our participants, however, reported higher rates of early sexual debut (12% vs 4%) and of having 4 or more prior sexual partners (22% vs 10%), both of which are independently linked with adverse sexual health outcomes (eg, STI).31–34 One third of our participants reported reversible contraceptive use at last sex with an even smaller minority reporting that their partner used more effective LARC and injectable contraceptive methods. Further, no males reported that their female partner had used EC at last sex. Nearly a quarter of our participants reported they were not sure of a method used or reported never having used a method to prevent pregnancy, which may be because of a lack of communication with partners about contraceptive use or may represent under-report of contraceptive use by males, as has been noted as a concern in prior literature.35 Additionally, none of the adolescent males in our study with male sexual partners reported use of condoms at last sex. We also found that 1 in 8 reported a time in the past year that they hadn’t accessed healthcare when they felt they should. Further study is needed to understand underlying drivers of contraception, EC, and condom use in hospitalized adolescent males, which can then inform interventions to improve contraception knowledge and use in this population.
Overall, our population was receptive to conversations about birth control, as nearly half agreed that a hospital stay is a good opportunity for SRH discussions, particularly among those with a history of sexual activity. Patient-centered delivery of SRH has been well-studied and is encouraged in outpatient settings among females receiving contraceptive counseling as well as in human immunodeficiency virus care and decisions related to pre-exposure prophylaxis for human immunodeficiency virus.36–41 Further work is needed to develop and test interventions using this framework to promote SRH education for hospitalized males regarding mutual consent, prevention of STIs and unintended pregnancy, including contraception.19–21
Our study was limited by sampling bias and social desirability bias, which may have increased reports of condom and contraception use. We did not collect full data on underlying medical conditions or reason for hospital admission, which may have differed between subgroups (ie, acceptability of SRH services in the hospital). Although our sample size was relatively small, particularly among subgroups such as men who have sex with men, our sample size was larger compared with other hospital-based studies regarding male adolescent SRH.13,25 Lastly, cisgender, White males comprised the majority of our sample, which may limit generalizability.
In conclusion, a hospitalization offers an important, and to date, underutilized opportunity to provide SRH education and care for adolescent males. Our findings highlight the need for future efforts to develop effective patient-centered SRH interventions, which may offset risk for unintended pregnancy, STIs, and other related adverse health outcomes in this population.
FUNDING: Research reported in this work was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (K23HD083405, PI Miller; K23HD098299, PI Randell). The funding source had no role in the design and conduct of the study, including collection, management, analysis, or interpretation of the data and preparation, review, or approval of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the views of the National Institutes of Health. Funded by the National Institutes of Health (NIH).
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest to disclose.
Dr Hunt conceptualized and designed the study, conducted data analysis, critically reviewed the study data, and drafted the initial manuscript; Drs Randell, Mermelstein, and Miller participated in study design and critically reviewed the study data; Dr Masonbrink conceptualized and designed the study and drafted sections of the initial manuscript; and all authors critically reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number K23DA055736 (Masonbrink). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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