Patient education: Adolescent sexuality (Beyond the Basics)

INTRODUCTION — Most teens and preteens have a lot of questions about sex and sexuality. This is normal and natural. It also is normal to feel shy or embarrassed about raising these issues with adults or health care clinicians.

Sexual development (puberty) is an important part of health, similar to other measures of physical growth, such as height and weight. Sexual behavior, which is related to sexual development, has important health implications for everyone, especially teens. It is important to be well-informed about sex and sexual health, be able to separate fact from myth, and empower yourself with knowledge so you can make informed decisions in a responsible and positive way.

Some basic information on sex and sexuality is provided in this article, which may answer some questions but also raise others. If possible, find an adult you feel comfortable talking to – perhaps a parent, relative, teacher, doctor, or nurse – to discuss any questions or worries you may have.

WHAT IS SEXUALITY? — Human sexuality is more than just whether you are biologically male or female, and it is more than just the act of sex. It is a complex idea that involves your physical make-up, how you think about yourself, and how you feel about others and the society you live in.

Below are some of the factors that contribute to a person's sexuality.

Sex assigned at birth — Sex assigned at birth (also called "birth-assigned sex" or "birth-recorded sex") refers to the assignment that is made according to anatomic sex or the sex organs with which you were born. That is, you are either male (with a penis and testicles (figure 1)) or female (with breasts, a uterus, vagina, and ovaries (figure 2 and figure 3)).

Occasionally, a baby is born with sex organs that are not typically developed and/or may appear to resemble both sexes; the term "intersex" is sometimes used to describe this condition.

Sex assigned at birth is only one component of sexuality.

Gender identity — Gender identity relates to how you feel inside and whether you identify as a boy or a girl, both, or neither. A person's gender identity may or may not be the same as their sex assigned at birth. You might hear different words used to describe gender identity, such as:

●"Cisgender" – This describes a person whose gender identity is the same as their sex assigned at birth.

●"Transgender" – This describes a person whose gender identity is different from their sex assigned at birth.

●"Nonbinary" – This describes a person who does not identify with one gender. Some people prefer to use other terms for themselves, like "genderqueer," "gender fluid," or "gender nonconforming."

There are many other terms that people use to describe their gender identity, too.

Sexual orientation — This refers to your physical or sexual attraction to other people. "Straight" (heterosexual) means being attracted to people of the opposite gender. "Gay" or "lesbian" means being attracted to people of the same gender, while "bisexual" means being attracted to both genders. It is important to know that sexual orientation is not something you can choose or control.

Words like straight, gay, lesbian, and bisexual all assume that there are only two genders, male and female. Since some people do not identify with either of these, they might not feel that any of these terms describes them. This is normal. Some people use the term "pansexual," which means being attracted to people of any gender identity. "Asexual" means not feeling sexual attraction to other people at all.

Sexual orientation exists on a continuum. That is, you may feel mostly attracted to people of the same gender as you but still have some feelings for people of a different gender, or vice versa. It is common for young people to feel confused about their sexual orientation, and that is entirely normal. How you label your sexual orientation is less important than how you feel about yourself as a person. Although there may be social stigma toward people who are mostly attracted to people of the same gender, most people with same-gender attractions lead normal, happy lives. Regardless of to whom you feel attracted, you should know that these feelings are entirely normal and sometimes change throughout life.

SEXUAL DEVELOPMENT (PUBERTY) — Sexual development (puberty) usually begins in the preteen or teen years. The body produces hormones that cause outward changes. For example:

●In people whose sex assigned at birth is female, the breasts grow bigger. Hair grows under the arms and in the pubic area. Menstruation (monthly periods) begins.

●In people whose sex assigned at birth is male, the penis and testicles grow larger. The voice also begins to change, and hair grows on the face, under the arms, and in the pubic area.

However, puberty is more than just physical changes. As your body develops, your way of thinking, emotions, and wants and needs will change as well. The factors discussed above (your sex assigned at birth, your gender identity, and your sexual orientation) will all become a part of how these changes affect you as a person.

You will probably start to feel strong attractions toward other people. Sometimes these feelings include developing friendships with other teenagers. Other feelings include wanting to be physically close to another person. You may find yourself attracted to someone of a different sex, someone of the same sex, or both.

It is important to remember that attraction can shift and change, and this can happen at different times for different people (see 'Sexual orientation' above). You may find you are attracted to someone of the same sex for a time, then feel stronger attractions to someone of a different sex. Or, the opposite may happen. Regardless of your sexual orientation, if you do not feel supported by your family or friends, try to find a trusted adult or other person with whom you feel comfortable talking. There are also resources that can help. (See 'Where to get more information' below.)

It also is important to know that in the early years of puberty, it is normal to want to experiment with sexual activity. This often happens before a teenager is fully aware of how this activity might affect them or others. As you continue to grow and mature, you will develop a stronger sense of your desires and preferences and be better prepared to make sexual activity a healthy and positive part of your life. You will also be better able to make informed choices about intimacy and relationships while understanding the possible risks. (See 'Sexual activity' below.)

The body changes that happen during puberty can be difficult for teens who are transgender or nonbinary. They can be associated with anxiety or symptoms of depression. If you are struggling with this, try to find a trusted adult or other person with whom you feel comfortable talking. There are also resources that can help.

SEXUAL ACTIVITY — There are many ways to express intimacy. Spending time with another person, holding hands, and kissing are all ways to show affection and begin to explore physical intimacy. As you develop attractions toward others, you will probably want to explore these and other types of physical intimacy.

When people talk about sex, they are often talking about vaginal intercourse, but there are other types of sex, too:

●Vaginal intercourse – This is when a person puts their penis into their partner's vagina. During vaginal intercourse, pregnancy can occur if sperm (contained in semen) fertilizes an egg (released by the ovary). There are different methods of birth control that can be used to prevent pregnancy. (See 'Pregnancy and birth control' below.)

●Touching or "petting" your partner's body or genitals – The genitals are the external sex organs that can be stimulated by touch. They include the penis and scrotum, which holds the testicles (figure 1), and the vulva, clitoris, and opening to the vagina (figure 3). The breasts are also sensitive to stimulation.

●Oral sex – This involves using the mouth or tongue on another person's genitals.

●Anal sex – This involves putting the penis or another object into another person's anus.

●Masturbation – This is the word for touching your own genitals with your hand or another object (such as a vibrator or sex toy).

Sexual activity often, but not always, involves orgasm for one or both partners. Orgasm is an intensely pleasurable release of tension felt in the genital area and elsewhere in the body. It usually results from stimulation of the genitals. In females, orgasm is associated with rhythmic contractions of the muscles in the pelvic area. In males, orgasm is associated with the release of semen (called ejaculation), which contains sperm. The term "come" is a slang word for orgasm.

What is consent? — Before having any type of sex with another person, it is important to make sure they agree to what you are doing. This is called "giving consent." The only kind of sexual activity that is OK is activity that occurs by mutual consent.

Here are some things to know about consent:

●You have to ask someone for consent before doing anything to or with them. This means any type of sexual activity, not just intercourse.

●A person who is drunk or on drugs, passed out, or asleep cannot give consent.

●A person can change their mind and decide they do not want to do something, even if they gave consent before. Sometimes a person agrees to do something but then wants to stop. If this happens, the other person must respect their wishes. It is not harmful to stop sex before orgasm occurs.

●When a person forces sex on someone who does not consent, or who gives consent but then changes their mind, it is called sexual assault or rape. This is a serious crime that can lead to being arrested or put in jail.

●If someone does something without your consent, it is not your fault. If this happens, you can tell a trusted family member or friend, or your health care provider. You might need medical care. In the United States, you can also call the sexual assault hotline for advice (800-656-4673).

It is never OK for an adult to have any kind of sex with anyone who is a teen or younger. If an adult wants to engage in any type of sexual activity with you, tell a parent, health care clinician, law officer, or another adult you trust. Even if you feel like you did something to cause the adult to be attracted or have sexual feelings, it is not your fault. Adults are responsible for controlling their behavior, regardless of the circumstances.

Certain laws, which vary from state to state, impose regulations or rules on sexual activity, even among teens. As discussed above, it is always a crime for anyone to force or coerce you into any sexual activity against your wishes, no matter if it is an adult or someone around your own age. However, in some states, sex between teens under a certain age may also be illegal, even if both people want to have sex. Rules may depend upon the age of both partners and upon the sex of your other partner(s). If you are not sure if something is OK, consider talking to a trusted adult.

SEXUALLY TRANSMITTED INFECTIONS (STIs) — Sexual activity can affect both the physical and emotional health of the people involved. This is why it is important not to engage in sexual activity until you are emotionally ready as well as prepared to protect yourself and your partner(s).

There are a number of infections that can be spread through sexual activity. Infections can be spread through vaginal sex, anal sex, oral sex, and using fingers, other body parts, or sex toys that have come in contact with another person's genitals or body fluids. These diseases are called sexually transmitted infections or STIs (they are also often called sexually transmitted diseases, or STDs). Common places STIs can occur are the genital organs, anus, and throat.

Research has shown that young people are at an increased risk of catching STIs. The reasons for this are not completely understood. However, the younger you are when you start having sex, the more likely it is that you will get an STI. Also, having one STI can increase your risk of getting other STIs at the same time.

In many cases, you can get an STI and not know it. This is because STIs often do not have any noticeable signs or symptoms. All STIs can have serious consequences for future health, even when there are no symptoms. For example, a woman who gets an STI may have difficulty becoming pregnant later in life or may be more prone to developing certain types of cancer, such as cervical cancer. You can lower your risk of future complications by following your doctor's or nurse's instructions about treatment if you do get an STI.

Some of the most important STIs are:

●Human papillomavirus – Human papillomavirus (HPV) is the most common STI in teens. Most people who get HPV do not know they have it. Some types of HPV cause genital warts. Other types of HPV cause cervical, penile, and anal or oropharyngeal (mouth and throat) cancer. (See "Patient education: Genital warts in women (Beyond the Basics)".)

There are vaccines to protect against common types of HPV. Vaccination is recommended for everyone, regardless of their sex assigned at birth or gender identity, and can be given to people as young as nine years of age. Speak to your health care clinician about this important vaccine, even if you are not currently sexually active or thinking about becoming sexually active. The ideal time to receive this vaccine is before you have engaged in any type of sexual activity. That is when it is most effective at prevention. (See "Patient education: Human papillomavirus (HPV) vaccine (Beyond the Basics)".)

●HIV infection – HIV stands for human immunodeficiency virus; this is the virus that causes acquired immune deficiency syndrome (AIDS). HIV infection is a serious, incurable disease of the immune system. In the past, everyone who developed AIDS died. Although there is no cure for HIV and no vaccine to prevent it, there are treatments that help many people with HIV infection live longer (as well as lower the risk of transmitting it to their partners). However, many people still die each year from AIDS.

Experts recommend that everyone who has been sexually active be tested routinely for HIV infection. The earlier HIV is detected, the sooner a person can begin treatment and the better the chances are of survival. Treatments for HIV have come a long way since HIV was first recognized, and people with HIV may now lead normal, full lives, provided they seek health care soon enough and take all of the medicine prescribed to them. There also is a medication that can be taken daily by HIV-negative people who are at risk of HIV to reduce their risk of acquiring the infection. This is known as pre-exposure prophylaxis or "PrEP."

Your doctor or other health care clinician can talk to you more about HIV testing and your personal risk. (See "Patient education: Testing for HIV (Beyond the Basics)".)

●Gonorrhea and chlamydia – These are serious bacterial infections of the genital tract. They can lead to pelvic inflammatory disease (PID) in people whose sex assigned at birth is female; this can cause severe pain, lead to infertility (inability to become pregnant), and/or increase the risk of ectopic pregnancy (pregnancy implanting in a fallopian tube or elsewhere outside of the uterus). In people whose sex assigned at birth is male, gonorrhea and chlamydia also can cause a problem called "epididymitis," which is when the epididymis (a small structure that sits on top of the testicle and stores sperm) becomes inflamed.

Both gonorrhea and chlamydia can be cured with antibiotics. It is important to be screened for these infections if you have had sex because most people do not have any symptoms. (See "Patient education: Gonorrhea (Beyond the Basics)" and "Patient education: Chlamydia (Beyond the Basics)".)

●Genital herpes – This is a viral infection that causes painful or itchy sores or blisters in the genital area. The sores heal but can reappear at any point later in life. There is no cure.

The virus that causes genital herpes can be spread even when there are no sores present. Most people with herpes do not have symptoms so they do not know that they could infect their sex partner(s). Treatment with medication can shorten the length of time the sores last and decrease the risk of repeat outbreaks. If you have been diagnosed with herpes, talk with your doctor about the option of daily medication that can reduce your risk of repeat outbreaks and spread of herpes to sex partners. (See "Patient education: Genital herpes (Beyond the Basics)".)

●Hepatitis B virus – This is a viral infection that can cause liver disease. In most cases, the disease goes away after the initial illness, but in some people, serious liver damage or liver failure can occur. Most children and teens are vaccinated against this infection with a series of three shots. You should speak to your health care clinician if you are not sure if you have had this vaccine. (See "Patient education: Hepatitis B (Beyond the Basics)".)

●Hepatitis C virus – Hepatitis C virus is a viral infection that can cause serious liver damage or liver failure. Liver disease can occur even in people without symptoms. Hepatitis C is diagnosed with a blood test. Hepatitis C infection can usually be treated with medications and, with newer treatments, can often be cured. (See "Patient education: Hepatitis C (Beyond the Basics)".)

●Syphilis – This is an infection that can cause an ulcer on the genitals or anus. It has become more common in teens and young adults, especially in certain cities and areas of the United States. Sometimes you may not notice the ulcer because it does not usually cause pain or may be on the inside of the vagina or anus. It is important to see your health care clinician right away if you notice any sores or ulcers. Syphilis sores usually heal but can cause serious long-term problems if untreated. Syphilis can usually be cured with antibiotics.

●Trichomonas – Trichomonas ("trich") is a common infection caused by a tiny parasite that can cause itching and/or a discharge from the vagina or penis, although some people have no symptoms. If a sex partner tells you that they have been diagnosed with trichomonas, you should seek treatment right away even if you have no symptoms. Trichomonas can be cured with antibiotics.

Prevention and screening for STIs — The only way to be sure you will not get an STI is to avoid sexual activity completely. STIs can be transmitted through sexual intercourse, oral sex, anal sex, and using fingers, other body parts, or sex toys that have come in contact with another person's genitals or body fluids. STIs can be transmitted between partners of any sex.

It is not possible to tell by looking at someone whether they have an STI. Even if the other person tells you they do not have an STI or says they are "clean," you cannot be sure this is true. That is because the person may not know if they are infected. Also, some teens may not be completely truthful about many things in relationships, including whether they may have been exposed to an STI.

Using protection can help protect both you and your partner(s). There are other ways to lower your risk of STIs, too.

Condoms and dental dams — People who are sexually active can reduce their risk of getting an STI by using a latex or polyurethane condom every time they have sex. External condoms (also known as "male condoms" or just "condoms") are worn on the penis, helping to prevent body fluids from passing to another person. Unlubricated condoms can be used for oral sex. Internal condoms (also known as "female condoms") are also available and can be placed in the vagina to help prevent fluids from passing from one person to another. When two people are having vaginal sex, only one partner should wear a condom. If both people wear a condom, the condoms could rub together and move out of place.

Dental dams are squares of latex that can be used when performing oral-vaginal sex or oral-anal sex. A dental dam can be made by cutting an unlubricated condom lengthwise so it forms a square. (See "Patient education: Barrier and pericoital methods of birth control (Beyond the Basics)".)

Condoms and dental dams reduce the risk of getting an STI, but they do not eliminate the risk completely. Condoms can break or leak, allowing passage of body fluids and transmission of infection. In addition, condoms do not completely cover all of the skin that is exposed during sex; herpes and HPV can be passed by skin-to-skin contact. Other birth control methods, like the pill or intrauterine device (IUD), help to prevent pregnancy but do not reduce the risk of STIs. (See 'Pregnancy and birth control' below.)

You can reduce the risk that an external condom will break or slip off in two ways. First, make sure the penis is completely hard before putting on the condom. Also, be sure to squeeze and hold the tip of the condom as you roll the rest of it down the penis, making sure there is no air pocket (like a small balloon) at the end of the penis. After ejaculation during vaginal sex, the penis should be pulled out of the vagina while it is still a little hard. It is important to hold the condom around the base of the penis when pulling out to prevent leakage of semen into the vagina. Similar precautions should be taken before and after anal sex.

Immunizations — Immunizations (vaccines) are another way to reduce the risk of two specific STIs (HPV and hepatitis B). Your doctor or other health care clinician can talk to you about which immunizations you are eligible for. Most children and adolescents are routinely immunized against hepatitis B in the United States. The HPV vaccine is now available to all children aged nine years and older. (See "Patient education: Human papillomavirus (HPV) vaccine (Beyond the Basics)".)

Regular check-ups — Regular check-ups with your doctor or other health care clinician are important for all teens, but they are particularly important if you are thinking about becoming sexually active. Your doctor or other health care clinician can talk to you about ways to prevent pregnancy and STIs, as well as the need for regular testing for STIs, including HIV. Since STIs can affect different parts of the body and some do not cause symptoms, it is important to speak honestly with your clinician about your sexual behavior to get appropriate testing. If you do not feel like you can speak freely with your clinician, or you think you are not getting the care or support you need, you can ask for a referral to a different clinician. Your local health department should also be able to provide STI and HIV screening at low or no cost to you.

PREGNANCY AND BIRTH CONTROL — Pregnancy is a serious potential consequence of sex and can happen if semen gets into the vagina. Semen contains sperm, which can lead to pregnancy even if ejaculation does not happen.

The only way to definitively prevent pregnancy is to not have vaginal intercourse. There is no reliable way to determine a "safe" time of the month when pregnancy cannot happen; menstrual cycles can be irregular during adolescence. Teens should know that pregnancy is possible any time they have vaginal intercourse, including the first time, during the menstrual period, and anytime between menstrual periods.

Birth control methods are available that can reduce the risk of pregnancy to near zero. However, birth control methods other than condoms do not reduce the risk of STIs. The best, most effective methods of birth control are the long-acting reversible contraceptive (LARC) methods. These include the subdermal implant (brand name: Nexplanon) and the intrauterine device (IUD; sample brand names: Skyla, Mirena, ParaGard). The implant is a small hormone-containing rod inserted just under the skin in the arm. The IUD is a small, T-shaped device inserted into the uterus. Both methods must be placed and removed by a trained health care professional. LARC methods work for up to 3, 8, or 10 years depending on the method. LARC methods are reversible, with rapid return to fertility after removal. (See "Patient education: Long-acting methods of birth control (Beyond the Basics)".)

Other birth control methods include oral contraceptive pills, patches, injections, and the vaginal ring. These are considered to be good methods of preventing pregnancy, but they require more effort on the part of the person using them. For example, you must remember to take a pill every day, change a patch once a week, or see your doctor or nurse for a shot every three months. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

Some methods, such as condoms and spermicide, can be purchased without a prescription. A condom should be used every time you have sex, even if another method is used to prevent pregnancy. (See "Patient education: Barrier and pericoital methods of birth control (Beyond the Basics)".)

If you use birth control but it fails (eg, the condom breaks or you miss a pill), or if you had sex without any form of birth control, you can take emergency contraception (EC) to reduce the risk of pregnancy. EC is also known as the "morning after pill." It can be taken within five days of having unprotected sex but is more effective the sooner it is taken after unprotected sex. In many states it is available over the counter at pharmacies, but depending on your age, you may need a prescription from your doctor. Some pharmacies do not carry EC or other forms of birth control, so you may need to seek one that does. EC is not the same as a medical abortion; EC reduces risk of pregnancy but does not end a pregnancy that already exists. (See "Patient education: Emergency contraception (Beyond the Basics)".)

If you or your partner does get pregnant unintentionally, there are options. Your health care professional can help. Parenthood, adoption, and abortion are potential options. Abortion is a safe and legal option, although it may be necessary to get permission from a parent or guardian (or seek permission from a judge) depending on your age and the laws where you live. (See "Patient education: Abortion (pregnancy termination) (Beyond the Basics)".)

If you decide to have sex, it is critical to make sure that you and your partner(s) have accurate information about the available birth control options. The best time to decide on a method of birth control is before you start having sex. If you are sexually active or thinking about becoming sexually active and want to prevent pregnancy, talk with your health care professional about starting birth control.

SUMMARY — Adolescent sexuality is influenced by many factors, including your gender identity, sexual orientation, the culture you live in, and how your body develops. During the teen years, you will develop a sense of your own sexuality, one that will lead to satisfying, mature sexual relationships later in life.

Although it is normal for teens to want to begin to experiment with physical intimacy, many teens are not able to understand the consequences of sexual activity for themselves and their partner. By taking it slowly, getting reliable information, and delaying sex until you are sure you are ready, you can help make sure that your sexuality is a healthy, positive aspect of your life.

WHERE TO GET MORE INFORMATION — Your health care clinician is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces 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.

Patient education: Teen sexuality (The Basics)
Patient education: Sexually transmitted infections (The Basics)
Patient education: Normal puberty (The Basics)
Patient education: Early puberty (The Basics)
Patient education: Epididymitis (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Testing for HIV (Beyond the Basics)
Patient education: Genital warts in women (Beyond the Basics)
Patient education: Cervical cancer screening (Beyond the Basics)
Patient education: Human papillomavirus (HPV) vaccine (Beyond the Basics)
Patient education: Gonorrhea (Beyond the Basics)
Patient education: Chlamydia (Beyond the Basics)
Patient education: Genital herpes (Beyond the Basics)
Patient education: Hepatitis B (Beyond the Basics)
Patient education: Barrier and pericoital methods of birth control (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Emergency contraception (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Sexual development and sexuality in children and adolescents
Contraception: Issues specific to adolescents
Pregnancy in adolescents
Sexually transmitted infections: Issues specific to adolescents

The following organizations also provide reliable health information.

●American Social Health Association

     (www.iwannaknow.org)

●Nemours Foundation

     (www.teenshealth.org)

●Planned Parenthood

     (www.plannedparenthood.org/info-for-teens)

●Centers for Disease Control and Prevention

     (www.cdc.gov)