Emerging Issues in Male Adolescent Sexual and Reproductive Health Care

During adolescence, several transitions occur for boys, including the physical, psychological, and social changes associated with puberty, with most male adolescents reporting the initiation of sexual behavior.^1,2  Many emerging behaviors, including sexual initiation, are associated with preventable negative health consequences such as sexually transmitted infections (STIs), unintended pregnancies, and nonconsensual sexual activity.²  During this developmental period, the number of health encounters typically declines, particularly among older male adolescents, and there is a shift from routine to more time-limited acute visits.³  Pediatricians and other physicians who care for natal male adolescents (cisgender or transgender female adolescents) or those who identify as male (transgender male adolescents or gender nonconforming) have unique opportunities to incorporate anticipatory guidance around issues such as puberty and sexuality not only at any health maintenance visits but also at sick and/or injury visits with adolescents and their families. For the purposes of this report, the term “male” refers to cisgender adolescents and young adults, unless otherwise specified.⁴ 

Even after the release of the American Medical Association’s Guidelines for Adolescent Preventive Services (GAPS)⁵  and the American Academy of Pediatrics (AAP) Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,⁶  which recommend preventive health services for adolescents, there have been few improvements in the counseling of male teenagers regarding the prevention of STIs or HIV infection.^7,8  Furthermore, data from outpatient medical records reveal that pediatricians are 3 times more likely to take sexual health histories from female than male patients and twice as likely to counsel female patients on the use of barrier methods.^7,9  Thus, it is important for pediatricians to have an understanding of what sexual and reproductive health care means for the male adolescent. Although boys and young men comprise approximately half of the adolescent population in the United States, standards for addressing their reproductive and sexual health needs lag behind those for adolescent girls and young women, and male adolescents continue to be a particularly vulnerable patient population.^7,8  Pediatricians are encouraged to address male adolescent sexual and reproductive health on a routine basis, including boys and young men with developmental or physical disabilities,^10,11  by taking a sexual history, discussing healthy sexuality, performing an appropriate examination, providing patient-centered and age-appropriate anticipatory guidance, performing appropriate screening, and administering vaccinations.¹² 

The 2011 AAP clinical report on male adolescent sexual and reproductive health care discusses specific issues related to male adolescents’ sexual and reproductive health care in the context of primary care, including pubertal and sexual development, sexual behavior, masturbation, consequences of sexual behavior, and methods of preventing STIs (including HIV) and pregnancy.¹³  This revision provides updated information and recommendations since the 2011 clinical report, including the following:

• updated information concerning male adolescent sexual behavior;

• emerging issues in health confidentiality;

• data on the patterns of social media use in male sexual health;

• discussion of consent for sexual acts among adolescents;

• recommendations for counseling of male adolescents on their roles in contraception decision-making;

• updated data on STIs and treatment among male patients aged 15 to 24 years with updates on STI screening and treatment;

• recommendations on human papillomavirus (HPV) vaccine for boys;

• information on sexual dysfunction among adolescent and young adult males and recommendations for addressing in practice; and

• updated sexual and reproductive health resources (Supplemental Table 2) for pediatricians specifically for male adolescent patients.

According to the 2017 Youth Risk Behavioral Surveillance System (YRBSS), 41% of male teenagers of high school age reported they had sexual intercourse, defined as opposite-sex vaginal-penile contact, by the 12^th grade.²  In another study, male adolescents were significantly more likely to engage in oral sex compared with sexual intercourse and more likely to have significantly greater numbers of oral sex partners than sexual intercourse partners and indicated that during oral sex, they had never used STI protection.¹⁴  A substantial number of young men report engaging in concerning sexual behaviors, including an earlier age of sexual debut and having more sexual partners than female adolescents.²  YRBSS data from 2017 indicated that among surveyed male high school students, 22% reported using alcohol or drugs before last sexual intercourse, 12% reported ≥4 lifetime partners, 39% did not use a condom at last sexual intercourse, and 5% reported initiating sex at 13 years or younger.² 

Adolescents with intellectual disabilities (IDs) and physical disabilities are an overlooked group in terms of sexual behavior, but they have similar rates of sexual behaviors when compared with their peers without disabilities.¹⁵  These youth receive limited sexual education from their parents and pediatricians, who may assume they will not engage in sexual behaviors.¹⁵  Much of the research on IDs and sexuality among adolescents and young adults is focused on contraception choices and pregnancy prevention among females, with little focus on male adolescents. Jahoda and Pownall¹⁶  evaluated sexual knowledge and social networks among adolescents with IDs compared with adolescents without IDs. Results revealed that male adolescents with IDs scored higher in knowledge of sexual topics compared with female adolescents with IDs and discussed sexual topics more frequently in their social networks compared with female adolescents; however, male adolescents with IDs were less likely to have received information about sex from their pediatricians when compared with their peers without IDs.¹⁶  Current research is now being focused on the importance of sexuality counseling with these adolescents and young adults so that they develop healthy sexual behaviors.¹⁰  The AAP clinical report “Sexuality of Children and Adolescents With Developmental Disabilities” provides additional guidance and information.¹¹ 

As the national dialogue shifts toward openness and acceptance of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals, adolescents are increasingly expressing sexual fluidity and flexibility. Discordance between sexual attraction and orientation and behavior is also possible because one’s sexual attraction and sexual identity do not always predict sexual behavior.^17–19  In the 2017 YRBSS, youth were asked questions to ascertain sexual identity and gender of sexual contacts. Among male students, 92% identified as heterosexual or straight, 2% identified as gay, 3% identified as bisexual, and 3% identified as not sure. Of male youth who ever had sexual intercourse, 80% reported having sexual contact with the opposite sex only and 76% reported having sexual contact with the same sex only or both sexes. Fifty-nine percent of high school students denied any history of sexual contact.² 

Although most LGBTQ youth are resilient and emerge from adolescence as healthy adults, the effects of homophobia and heterosexism can contribute to concerning health issues for sexual minority youth (those who identify as gay, lesbian, or bisexual; those who are not sure about their sexual identity; or those who have sexual contact with only the same sex or with both sexes). Sexual minority youth, in comparison with heterosexual adolescents, have higher rates of depression and suicidal ideation, higher rates of substance abuse, and riskier sexual behaviors.²⁰  Sexual minority boys and young men reported significantly higher rates of violence-related behaviors, including being forced to have sex, school bullying, and being victims of physical and/or sexual dating violence.²¹  Sexual minority boys and young men also reported higher rates of earlier sexual debut, ≥4 sexual partners, less barrier-method use, less contraceptive use when engaged in intercourse with female partners, and higher use of drugs or alcohol before sexual intercourse compared with their non–sexual minority counterparts.²¹ 

Pediatricians rarely discuss high-risk sexual behaviors during routine adolescent visits, and they discuss same-sex sexual behaviors even less frequently. Studies have revealed that pediatricians often do not discuss sensitive topics, such as sexual orientation, sexual identity, gender identity, violence prevention, or sexual or physical abuse, as part of their routine practice.^7,9,22–24  These studies reveal that pediatricians who care for adolescents are not routinely asking about sexual practices and the sexual orientation of their patients, preventing them from adequately addressing sexual health concerns and sexual risk. LGBTQ teenagers and young adults are an underserved population, many of whom struggle with acceptance of their sexuality while they are managing the other rigors of adolescence. It is important that pediatricians and other physicians obtain the skills needed to provide culturally effective, developmentally appropriate care for sexual minority youth. The 2013 AAP policy statement “Office-Based Care for Lesbian, Gay, Bisexual, Transgender, and Questioning Youth” provides additional guidance.²⁰ 

Adolescents’ right to consent and confidentiality and health care are intertwined. Providing confidentiality supports adolescents in their development of autonomy and plays a significant role in their willingness to access necessary health care or disclose important information to pediatricians. There is no federal law that explicitly protects adolescents’ right to confidential health care. There are individual state laws, and numerous international and national organizations have outlined the importance of confidentiality protections, including the United Nations, American Public Health Association, AAP, Society for Adolescent Health and Medicine, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists.^25–29  The 2017 AAP clinical report “Sexual and Reproductive Health Care Services in the Pediatric Setting” provides specific guidance on the provision of confidential sexual health services.¹²  The Guttmacher Institute provides updated summaries of states’ consent and confidentiality laws for minors on its Web site.³⁰ 

The expansion of electronic health records and the increased coverage of young adults (up to age 26) through their parents’ insurance plans have presented additional challenges to confidentiality. Although the Health Insurance Portability and Accountability Act of 1996³¹  provides protection of private health information from some disclosures, it also allows disclosure of information for the purpose of treatment, payment, or health care operations with consent.³²  Adolescents are at risk for confidentiality breaches when insurers send explanations of benefits or denials of claims to policyholders after anyone covered under their policy obtains care. These insurance documents may identify the individual who received care, the health care provider, and the type of care obtained. In 2014, the AAP, American College of Obstetricians and Gynecologists, and Society for Adolescent Health and Medicine released a policy statement on the importance of confidentiality protections in the insurance billing process.³³  The AAP also recommended confidentiality protections in its 2012 policy statement “Standards for Health Information Technology to Ensure Adolescent Privacy.”³⁴  This guidance provides pediatricians with a framework to provide confidentiality while delivering important adolescent services.

Adolescents use a variety of media to socialize and learn about and engage in sexual activity. Media uses include television, video games, social media, texting, smart phone applications, Web sites, and online pornography. Boys are more likely than girls to make online friends and communicate with them online rather than in person.³⁵  Recent studies of adolescents revealed that male participants were statistically more likely to receive sexually explicit texts and be sexually active and that sexual minority male youth were more likely to send sexually explicit texts than female adolescents.^36,37  In a recent study examining “sextortion” (the threatened dissemination of explicit, intimate, or embarrassing images of a sexual nature without consent, usually for the purpose of procuring additional images, sexual acts, money, or something else) of US middle and high school students, researchers found that boys and sexual minority youth were more likely to be targeted and that boys were more likely to target other youth.³⁸ 

Of concern to pediatricians is frequent adolescent exposure to pornography. In one study, more than half of male youth Internet users 14 to 15 years of age had been exposed to either unwanted or wanted online pornography in the past year, as had more than two-thirds of those 16 to 17 years of age. Thirty-eight percent of male Internet users aged 16 to 17 intentionally visited pornographic sites in the past year.³⁹  There are conflicting data concerning the effects of pornography. Some studies reveal that users report positive effects on sexual health whereas others report negative effects, and there is no conclusive information concerning sexual function or dysfunction. Pornography frequently portrays male and female inequalities, specific body types (thin women with surgically enhanced breasts), normalization of aggressive or violent sexual acts and violence, and a lack of emotional intimacy between actors.⁴⁰  During the social history, pediatricians can screen for social media use, pornography viewing, patients’ perceptions of such material, and any adverse effects and provide guidance on safe and sensible Internet and social media use to parents and patients. The AAP provides policies, information, advice, and resources about families’ and children’s interactions with various forms of media on its Web site.^41,42 

Sexual assault is a prevalent issue that can affect many adolescents, regardless of gender. Until 2012, published US Federal Bureau of Investigation annual crime data defined “forcible rape” as “the carnal knowledge of a female forcibly and against her will.”⁴³  As a result of this definition, there are limited data concerning sexual assault of male victims and even less information for male adolescents.⁴⁴  In the 2017 YRBSS report, 3.5% of male high school students disclosed ever being physically forced to have sexual intercourse, of whom 3% identified themselves as heterosexual, 16% as LGBTQ, and 12% as unsure of their sexual orientation. Male victims who experienced sexual violence reported the sex of their sexual contacts as the following: 4% opposite sex only, 26% same sex only or both sexes, and 1% no sexual contact. In the same report, 4.3% of male high school students reported experiencing any sexual violence.² 

For male victims of sexual assault, there are significant stigmas to reporting the assault, including the misperceptions that males in noninstitutionalized settings are rarely sexually assaulted, that male victims are responsible for their assaults, that male sexual assault victims experience less trauma than their female counterparts, and that ejaculation is an indicator of a positive experience. As a result of these misbeliefs, there is an underreporting of sexual assaults by male victims, a lack of appropriate services for male victims, and less legal redress for male sexual assault victims. By comparison, male sexual assault victims have fewer resources and greater stigma than do female sexual assault victims.⁴⁵  Pediatricians are encouraged to ask male patients about exposure to sexual assault (and other types of victimization) during the social history of routine health supervision visits. When exploring alcohol or substance use, it is important to discuss the link between impairment and vulnerability to sexual assault. It is advised that adolescents who disclose a previous assault be asked about the dynamics of their relationships (eg, exploitative, controlling, nonconsensual). The 2017 AAP clinical report “Care of the Adolescent After an Acute Sexual Assault” provides additional guidance.⁴⁶  In addition to being victims of sexual assault, there have been many high-profile founded and unfounded cases of sexual assault by boys and young men resulting in significant disruption in the victims and alleged perpetrators’ lives and futures. In the United States, of people arrested or convicted of sexual assault, 96% to 99% are male. Overall, an estimated 9% of the victims of rape and sexual assault were cisgender male. Nearly 99% of the offenders described in single-victim incidents were male. In the United States, per capita rates of rape/sexual assault were found to be highest among residents aged 16 to 19 years, demonstrating tha youth are particularly vulnerable.⁴⁷ 

Each state has its own statutes regarding consent, rape, and sex crimes, and each college or institution may have its own set of policies concerning sexual consent.⁴⁸  The US Department of Justice provides the following definitions: “Rape - Forced sexual intercourse including both psychological coercion as well as physical force. Forced sexual intercourse means penetration by the offender(s). Includes attempted rapes, male as well as female victims, and both heterosexual and same sex rape. Attempted rape includes verbal threats of rape. Sexual assault - A wide range of victimizations, separate from rape or attempted rape. These crimes include attacks or attempted attacks generally involving unwanted sexual contact between victim and offender. Sexual assaults may or may not involve force and include such things as grabbing or fondling. It also includes verbal threats.”⁴⁹  There is no standard definition of consent, and many institutions have attempted to define and implement policies concerning sexual consent. The Department of Justice of the Government of Canada defines sexual consent for the purposes of sexual assault offenses as “the voluntary agreement of the complainant to engage in the sexual activity in question. Conduct short of a voluntary agreement to engage in sexual activity does not constitute consent as a matter of law.”⁵⁰ 

When discussing sexuality, pediatricians can address issues of consent during anticipatory guidance if sexual screening warrants concern. Additionally, pediatricians can encourage patients to communicate with partners concerning sexual activity before engagement by respecting verbal and nonverbal boundaries and cues, emphasizing that consent should occur with each activity every time and that parties may change their minds. Pediatricians can educate male youth that the following situations do not involve consent: refusing to acknowledge “no”; assuming that wearing certain clothes, flirting, or kissing is an invitation for anything more; someone being younger than the legal age of consent (as defined by the state); someone being incapacitated because of drugs or alcohol; pressuring someone into sexual activity by using fear or intimidation; and assuming permission to engage in a sexual act because it has occurred in the past. Pediatricians are encouraged to include discussions of definitions and understandings of sexual consent, dispel myths concerning consent, and provide anticipatory guidance concerning consensual sexual activity to facilitate safe and healthy relationships between male adolescents and their partners.

According to the 2011–2015 National Survey of Family Growth, 84% of sexually experienced cisgender male teenagers reported using contraception at first sexual intercourse.¹  These rates varied by the age of the male at first sex: boys who were 14 years and younger had lower rates of contraception use at first sex than did males who were 17 to 19 years of age (71% and 95%, respectively).¹  Ninety percent of male teenagers used some method of contraception, including withdrawal at last sex, with 61% reporting using condoms at last sex, 19% reporting some contraceptive pill use, and 35% reporting a dual method (hormonal and barriers).² 

The male adolescent can play an important role in the couple’s contraception decision-making. In many cases, male adolescents prefer their partners to involve them in discussions of contraception methods.⁵¹  Over the past decade, there has been a growing body of evidence regarding young men’s knowledge of various forms of contraception and the association with shared decision-making.⁵²  Richards et al⁵²  recruited 93 ethnically diverse adolescent men to study their knowledge of emergency contraception (EC). Their findings revealed that fewer than half of the young men had ever heard of EC. Those who were aware of EC were more likely to be older (median 19.7 years), have knowledge of other contraceptive methods, and participate in shared contraceptive decision-making with their partners. The most recent literature review regarding EC-related knowledge, attitudes, and behaviors among men revealed that male adolescents have lower knowledge of EC than their adult male counterparts and are less likely to have had a partner use this form of contraception.⁵³  This study reveals the importance of counseling young men on all contraceptive methods to promote increased usage.

Once it is determined that an adolescent is at risk for pregnancy, the pediatrician may take the opportunity to provide counseling regarding all forms of contraception and each method’s effectiveness in pregnancy prevention. If there is not time during a routine or sick appointment, the pediatrician can schedule follow-up appointments specifically to discuss pregnancy prevention and contraception options. Contraception counseling is relevant for heterosexual and sexual minority youth because LGBTQ youth are at a higher risk for unintended pregnancies than their heterosexual peers.⁵⁴  Transgender men or transmasculine people can themselves be at risk for pregnancy (and require contraceptive counseling if appropriate), and transgender women or transfeminine people may have male genitalia and require appropriate counseling about their risk of causing pregnancy.

Male adolescents can play a vital role in pregnancy prevention and contraceptive decision-making in their female partners. Pediatricians can encourage male adolescents to attend contraceptive visits with their partners. During these visits, there is a great opportunity to elicit pregnancy desires and/or intentions of the couple and to educate them on a variety of contraceptive methods and the importance of shared decision-making. Additionally, the provider can encourage the male partner to commit to consistent condom use as a way to have personal control over unplanned pregnancy. If the male adolescent becomes a father, either through intended or unintended pregnancy with his partner, he will require unique social supports during the journey of fatherhood. These needs are the focus of the AAP clinical report “Care of Adolescent Parents and Their Children.”⁵⁵ 

Adolescents continue to face the greatest risk of acquiring STIs and not receiving appropriate care for STIs because of insufficient screening, confidentiality concerns, lack of access to health care, and multiple sexual partners. Most cases continue to go undiagnosed and untreated, putting individuals at risk for severe and often irreversible health consequences, including infertility, chronic pain, and increased risk for HIV as well as the propagation of STIs in the population. Youth aged 15 to 24 years comprise 27% of the sexually active population in the United States but account for more than 50% of new cases of STIs each year.⁵⁶  According to the Centers for Disease Control and Prevention (CDC), youth account for the majority of new cases of gonorrhea, chlamydia, HPV, and genital herpes and nearly one-quarter of new cases of HIV and syphilis annually. In this section, CDC data refer to cisgender male patients, unless otherwise stated. From 2016 to 2017, the CDC reported substantially large increases for syphilis, gonorrhea, and chlamydia for both men and boys aged 15 to 24 years.⁵⁶ 

In 2017, males aged 13 to 24 years accounted for 17.5% of all new HIV diagnoses in the United States and 87% of all diagnoses among young people aged 13 to 24 years. Most of those new HIV diagnoses among youth (81%) were attributed to male-to-male sexual contact.⁵⁷  Young people (aged 13–24 years) accounted for an estimated 21% of all new HIV diagnoses in the United States in 2017, totaling 8164 people, of which 87% were in natal males and 13% were in natal females.²  Also, the study revealed that 25% of transgender women were living with HIV, and the percentage of transgender people who received a new HIV diagnosis was more than 3 times the national average in 2015.⁵⁸  In 2017, 1122 youth received a diagnosis of AIDS, representing 8% of total AIDS diagnoses that year.² 

There has been an increase in the incidence of Neisseria gonorrhoeae infections among male adolescents, particularly among males who have sex with other males.⁵⁹  During 2013 to 2017, the rate of N gonorrhoeae infection among male patients increased 86.3%, compared with the rate increase among female patients of 39.4%.⁵⁹  The 2016 Gonococcal Isolate Surveillance Project revealed significant antibiotic resistance to gonococcal infections, and isolates from males who have sex with males are more likely to exhibit antimicrobial resistance than isolates from males who have sex with females.⁶⁰  With increasing cephalosporin-resistant gonorrhea, the CDC recommended in 2012 exclusive parental high-dose ceftriaxone treatment (250 mg, intramuscular) and a second antibiotic (azithromycin, 1 g) for uncomplicated gonococcal infections.⁶¹ 

There continues to remain significant underscreening of youth for STIs in the pediatric setting.^62,63  This underscores the need for pediatricians to offer screening based on risk assessment, appropriate treatment, and review strategies for prevention of transmission to reduce STI incidence and morbidity among all adolescents. The CDC recommends that clinicians consider screening for chlamydia in clinical settings serving populations of young male patients with a high prevalence of chlamydia (eg, adolescent clinics, correctional facilities, and STI clinics). The CDC does not recommend the routine screening of adolescents who are asymptomatic for certain STIs (eg, syphilis, trichomoniasis, bacterial vaginosis, herpes simplex virus, HPV, hepatitis A, and hepatitis B) but does recommend screening for syphilis in males who have sex with males.⁶¹  The US Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening for chlamydia and gonorrhea in boys and men.⁶⁴  For males who have had sex with males, the CDC recommends at least annual screening for HIV, syphilis, gonorrhea at all sites of contact (by using urine, rectal, and pharyngeal sampling), and chlamydia on urine and rectal sampling (testing for chlamydia pharyngeal infection is not recommended) regardless of barrier-method use. More frequent STI screening (ie, for syphilis, gonorrhea, and chlamydia) at 3- to 6-month intervals is indicated for males who have sex with males if risk behaviors persist or if they or their sexual partners have multiple partners.⁶¹  Given the significant increases in all STIs among male patients in the past 5 years, it is reasonable for pediatricians to maintain a high index of suspicion for STIs and consider testing for male patients who are sexually active. Bright Futures provides a risk assessment to assist with screening decisions (Fig 1).⁶⁵ 

Only 10% of high school students have been tested for HIV, and among male students who have had sexual contact with other males, only 21% have ever been tested.⁵⁷  The AAP, in Bright Futures,⁷  the Red Book,⁶⁶  and a policy statement,⁶⁷  recommends that routine screening be offered to all adolescents at least once by 16 to 18 years of age in health care settings when the prevalence of HIV in the patient population is more than 0.1%. In areas of lower community HIV prevalence, routine HIV testing is encouraged for all sexually active adolescents and those with other risk factors for HIV.⁶⁸  Additionally, the CDC recommends routine HIV screening for all patients seeking treatment of STIs, including all patients attending STI clinics, during each visit for a new complaint regardless of whether the patient is known or suspected to have specific behavior risks for HIV infection.⁶⁹  For individuals at increased risk for HIV acquisition (sexually active males who have had sex with males, individuals with an HIV-positive partner, individuals participating in anal intercourse, individuals having frequent sex without a condom, and individuals with a high number of sexual partners), the CDC recommends preexposure prophylaxis (PrEP) to reduce HIV acquisition and transmission.⁶⁹  As of this publication, the US Food and Drug Administration has approved 2 medications, emtricitabine (200 mg)/tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg)/tenofovir alafenamide (25 mg), for PrEP in adolescents and adolescents who weigh at least 35 kg.^70,71  The CDC Web site provides an HIV risk behavior assessment, PrEP clinical practice guidelines, patient and provider education, and tool kits.⁷² 

The CDC publishes treatment guidelines for STIs, including recommendations for special populations such as adolescents, people in correctional facilities, males who have sex with males, and transgender men and women.⁵⁷  Effective clinical management of patients with treatable STIs includes treatment of the patients’ current sex partners to prevent reinfection and reduce further transmission. Expedited partner therapy (EPT) can be a particularly useful option to facilitate partner management for adolescents who are diagnosed with chlamydia or gonorrhea. The CDC’s Web site provides guidance, a provider tool kit, and a summary of states’ EPT laws.⁷³ 

HPV is the most common STI in the United States, with almost every person acquiring an HPV infection at some time in their life.⁷⁴  The most common clinical manifestation of HPV is warts, and the most prevalent high-risk (oncogenic) types are HPV-16 and HPV-18. Persistent infections with high-risk HPV types can cause cervical, vaginal, and vulvar cancers in natal women, penile cancers in natal men, and oropharyngeal and anal cancers in both men and women.⁷⁵  Approximately 9100 US men each year receive a diagnosis of oropharyngeal cancer caused by HPV infection.⁷⁵  During 2013 to 2014, oral and genital HPV prevalence among adults 18 to 59 years of age was significantly higher for men than women. There are no data currently available for boys younger than 18 years. Males who have sex with males are at particularly high risk for HPV-mediated anal cancers.⁷⁶ 

In 2006, the CDC Advisory Committee on Immunization Practices first recommended the HPV vaccine in the United States.⁷⁷  Beginning in December 2014, after US Food and Drug Administration approval of the 9-valent HPV vaccine (which provides additional protection against HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58), use of the quadrivalent HPV vaccine has been slowly phased out.⁷⁸  In October 2016, the Advisory Committee on Immunization Practices updated its recommended dosing schedule for routine HPV vaccination to a 2-dose series for adolescents initiating vaccination before their 15th birthday on the basis of available immunogenicity evidence indicating that a 2-dose schedule (0 and 6–12 months) has an efficacy equivalent to a 3-dose schedule (0, 1–2, and 6 months) if the HPV vaccination series is initiated before 15 years of age.⁷⁸  In a 2-dose schedule of the HPV vaccine, the minimum interval between the first and second doses is 5 months.⁷⁸  In clinical trials for male subjects, the most common adverse events were injection-site reactions (most of which were mild or moderate in intensity), headache, and fever. Still, male adolescent HPV vaccination rates continue to be low compared with other adolescent vaccination rates or female HPV vaccination rates. In the United States, male HPV vaccination coverage with at least 1 dose was 63%, and 53% of boys ages 13 to 17 years were up to date with the recommended HPV vaccination series.⁷⁹  The modified schedule for younger adolescents may improve rates, and pediatricians are uniquely situated to address the lag in HPV vaccination rates among adolescent boys and young men.

Healthy sexual function has an important role in the well-being and development of adolescents and young adults.^80,81  A 2016 study of sexually active males aged 16 to 21 years revealed that 79% reported a sexual problem, using the validated surveys the International Index of Erectile Function and the Premature Ejaculation Diagnostic Tool. On the International Index of Erectile Function, respondents indicate agreement with 15 items used to assess erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction.⁸²  These problems are more prevalent than previously believed and cause significant distress to young men. The most common sexual problems among young men include premature ejaculation (PE) (20%) and erectile disorder (ED) (45%). Other common problems included low sexual satisfaction (48%) and low desire (46%).^80,81 

PE is a persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute after penetration and before the person wishes it.⁸³  In a Swiss study of men aged 18 to 25 years, 11% reported PE.⁸⁴  This and another study revealed an association between PE and poor physical health, alcohol consumption, illegal drug use, tobacco use, and less sexual experience.^84,85 

ED is marked difficulty in obtaining an erection during sexual activity, marked difficulty in maintaining an erection until the completion of a sexual activity, or marked decrease in erectile rigidity.⁸³  ED prevalence among young men 18 to 25 years old approaches 30%.⁸⁴  Poor mental health, depression, and consumption of medication without prescription were predictive factors for ED. ED persistence was also associated with having multiple sexual partners.⁸⁵ 

When pediatricians identify health issues such as mental health problems, physical inactivity, substance use, or multiple sexual partners, they may consider these an indication to screen for sexual dysfunction. Pediatricians have an opportunity to screen for problems with sexual functioning, to offer reassurance or treatment, or to appropriately assess for an underlying medical condition. Young patients often will not spontaneously discuss these topics because of embarrassment, pride, or masculinity or confidentiality concerns, so the onus is on the pediatrician to screen for sexual problems.^85,86  In screening for sexual problems, pediatricians may want to explore whether male patients have unrealistic expectations or misinformation concerning sex and sexual activity. When discussing medications with patients, pediatricians should discuss sexual dysfunction as an adverse effect and screen for sexual dysfunction in patients taking medications routinely or on a long-term basis. Conversely, identification of sexual dysfunction is an indicator to screen for other health problems (Table 1).

Even when patients do not initiate this conversation, they may still be receptive to screening from their pediatricians, who may use standardized tools such as the International Index of Erectile Function 5 and the Premature Ejaculation Diagnostic Tool, which were validated to screen men 18 years and older.^87,88  When male patients are identified as having sexual dysfunction, a complete medical and psychosocial history and physical examination, including genital examination with sexual maturity rating, are essential to evaluation to assess for any medical issues that can be worked up and addressed (Table 1).^89,90  Pediatricians may also screen patients concerning illicit use of any medications or supplements (prescription as well as over the counter), including pharmacologic agents for ED and performance-enhancing substances (ie, 3,4-methylenedioxymethamphetamine or supplements) because unmonitored use may pose health risks and has been associated with increased risky sexual behavior.⁹¹ 

Several studies in men older than 18 years revealed statistically significant improved self-esteem, mood, sexual function, sexual relationship health, orgasmic function, sexual desire, and intercourse satisfaction among those, including young men, who received short-term (maximum 8 attempts with medication) pharmacotherapy for ED.^80,92,93  In treating sexual dysfunction, having an established and ongoing provider-patient relationship and addressing mental health concerns, including substance use, may be crucial therapeutic measures. Follow-up therapy may need to include mental health services, relaxation techniques, and a discussion of the skills needed to assist the adolescent in achieving some degree of voluntary control of sexual function.

It is important that pediatricians familiarize themselves with available counseling services within their communities for adolescents and young adults. This clinical report does not contain explicit recommendations for mental health services, but pediatricians can consult AAP resources for more direction, such as the Key Resources of the Mental Health Initiative (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/Key-Resources.aspx).

Pediatricians are in the best position to deliver high-quality sexual and reproductive health care services to male adolescents and can view even follow-up, acute care, and immunization visits as opportunities to address these health issues. Although time constraints at most adolescent visits may preclude a full exploration of many issues surrounding sexuality in adolescents, additional visits can be scheduled to address identified issues.

Pediatricians can also use “clinical hooks,” such as preparticipation physical evaluations or acne follow-up, to keep male adolescents engaged in care and to deliver sexual and reproductive health care services. Staying informed on different issues of sexuality and sexual behaviors, initiating these conversations with male patients, and being prepared to provide appropriate anticipatory guidance are best practices when taking care of male adolescents.¹²  The AAP publications “Sexual and Reproductive Health Care Services in the Pediatric Setting” and “Targeted Reforms in Health Care Financing to Improve the Care of Adolescents and Young Adults”⁹⁴  provide a framework to assist pediatricians in incorporating various aspects of sexual and reproductive health care into their practices and to provide guidance on overcoming barriers to providing this care routinely while maximizing opportunities for confidential health services delivery in their office.⁵  The AAP has issued a policy statement on refusal to provide information or treatment on the basis of conscience. According to the policy, pediatricians have a duty to inform their patients about relevant, legally available treatment options to which they object, and they have a moral obligation to refer patients to other physicians who will provide and educate about those services. Failure to inform and educate about availability and access to these services violates this duty to their adolescent and young adult patients.⁹⁵ 

• 1. Discuss sex and sexuality with all male adolescents during routine visits and more frequently, as appropriate, and screen for sexual activity and high-risk sexual activity at routine visits and other appropriate opportunities;

• 2. screen adolescents for social media use (especially sexually explicit material), pornography viewing, perceptions of such material, and any adverse effects and provide guidance on safe and sensible Internet and social media use to parents and patients during the social history of well visits;

• 3. screen for nonconsensual sexual activity and discuss principles of sexual consent and nonconsent during well visits as well as other visits, as appropriate;

• 4. coach male adolescents on how to talk with their partners about sex and family planning, encourage joint decision-making between partners about sexual and reproductive health matters, and encourage use of both contraception and barrier methods, as appropriate;

• 5. provide routine STI risk assessment screening for all male patients and appropriate testing for STIs, including HIV, syphilis, chlamydia, and gonorrhea, when warranted and on request and provide appropriate STI treatment, including prevention therapy and EPT;

• 6. consider HPV vaccination for boys starting at age 9 years, provide routine vaccination for all adolescent boys at age 11 years, and aim for complete HPV vaccination for all male patients, and emphasize the importance of complete HPV vaccination for male patients who participate in high-risk behaviors; and

• 7. provide screening for sexual problems with all sexually active male patients as part of the well visit sexual history and at other appropriate visits, consider the use of standardized screening tools for sexual dysfunction, investigate further for other health or mental health issues in male patients with sexual dysfunction, screen male patients with health and mental health issues for sexual problems, and follow-up with patients who report sexual problems and consider therapies such as counseling or pharmacotherapy, as appropriate.

AAP

American Academy of Pediatrics

CDC

Centers for Disease Control and Prevention

EC

emergency contraception

ED

erectile disorder

EPT

expedited partner therapy

HPV

human papillomavirus

ID

intellectual disability

LGBTQ

lesbian, gay, bisexual, transgender, and questioning

PE

premature ejaculation

PrEP

preexposure prophylaxis

STI

sexually transmitted infection

YRBSS

Youth Risk Behavioral Surveillance System

Laura K. Grubb, MD, MPH, FAAP

Makia E. Powers, MD, MPH, FAAP

Elizabeth M. Alderman, MD, FSAHM, FAAP, Chairperson

Richard J. Chung, MD, FAAP

Laura K. Grubb, MD, MPH, FAAP

Janet Lee, MD, FAAP

Makia E. Powers, MD, MPH, FAAP

Krishna K. Upadhya, MD, FAAP

Stephenie B. Wallace, MD, MSPH, FAAP

Cora C. Breuner, MD, MPH, FAAP, Former Chairperson

Laurie L. Hornberger, MD, FAAP

Liwei L. Hua, MD, PhD - American Academy of Child and Adolescent Psychiatry

Ellie Vyver, MD - Canadian Pediatric Society

Geri Hewitt, MD - American College of Obstetricians and Gynecologists

Seema Menon, MD - North American Society of Pediatric and Adolescent Gynecology

Lauren B. Zapata, PhD, MSPH - Centers for Disease Control and Prevention

Karen Smith

James Baumberger, MPP