Related Pages

STD information for students

References/ suggested reading material

Information for young people

Adolescent Sexual Behaviour
Information for Students

Introduction

Puberty

Adolescence

Adolescents and Sexually Transmitted Diseases

Treatment and Counselling

Introduction

Sexual thoughts, feelings, and behaviours, present throughout life, are often accentuated during adolescence. Puberty provides visible, undeniable evidence of physical maturity, obvious maleness or femaleness, and the ability to reproduce. The normal developmental task of establishing an adult sexual identity and the capacity for intimacy may be frustrated by the prolonged interval between attainment of reproductive maturity and social permission to express one's sexuality as an adult. Numerous surveys have suggested increased sexual experimentation by increasing numbers of teenagers at younger ages each year.

Often the outcome of these behaviour can have adverse consequences such as unplanned pregnancy and sexually acquired infections. It is necessary to understand some of the features of puberty and adolescence which increase the risk of STDs and their attendant complications.

Puberty

Puberty results in a physically mature individual whose body habitus and secondary sexual characteristics usually testify unmistakably to maleness or femaleness and who is able to reproduce. The sequence of pubertal events is remarkably similar for most individuals despite broad variation in the timing and duration of the process. The onset of puberty is believed due to decreasing sensitivity of the hypothalamic-pituitary-gonadal axis to feedback inhibition by gonadal steroids, triggered by genetic potential with environmental factors. Increased secretion of gonadotropin stimulates gonadal growth and increased levels of circulating gonadal steroids, oestrogens and androgens, which stimulate end organ responses such as growth of sexual hair skeletal maturation, and development of reproductive organs.

The average age of onset of male puberty is 11 to 12 years, range 9 to 14 years. The first evidence is increased testicular size followed within a few months by the growth of pubic hair. During the next 4 to 5 years, testicular growth continues, the scrotum becomes large, darker, and more rugated, and the penis enlarges in length and circumference. Pubic hair becomes dark, curled, and dense, filling the pubic triangle and extending up the abdomen, to the perineum and to the inner thighs. The peak height velocity is reached in mid to late puberty. Spontaneous erections occur with increasing frequency. Sperm may be found in the urine and seminal emissions begin, usually in mid-puberty, as spontaneous nocturnal emission ("wet dreams") or in response to masturbation or sexual intercourse. The average male adolescent may be fertile by age 15, physically mature by 16 or 17, and full-grown by 18 to 20 years. Those who have early onset of puberty may be fertile as they enter their teens.

Females begin puberty at an average age of 10-11 years, slightly earlier than males, with a normal range of 8 to 13 years. The first sign is breast tissue enlargement beneath the nipple and areola, extending beyond the areola and maturing in size and consistency over several years. Pubic hair appears within a few months of breast buds and progresses as in males, but usually more rapidly than breast maturation. The peak height velocity is early in female puberty, often 2 to 3 year ahead of males. The first menstrual period usually occurs 2 to 3 years after onset of puberty, as the growth rate is slowing. It may take months to years to achieve mature menstrual cycles with consistent monthly ovulation. It is believed that many young women are not fertile - sufficiently mature to ovulate and sustain an implanted embryo - until the late teens. However, early teenaged pregnancies attest to early fertility in some, usually girls who had early puberty with menarche at 10 to 11 years.

Adolescence

Adolescence is the period of psychosocial development beginning in the preteen years, usually in conjunction with pubertal onset, and extending until the individual assumes an adult role in society. The stage of psychosocial development and the level of cognitive maturation strongly influence each adolescent's response to any health concern, including those related to sexuality.

Early adolescence corresponds to ages 10 to 15 years, when most youth are entering high school. Most early adolescents are progressing through puberty, intensely aware of physical changes, and concerned about any changes which they perceive as "abnormal". They tend to exaggerate and worry about physical symptoms, although they may have difficulty verbalizing their concerns. Early adolescents are beginning to separate from childhood and their parents but tend to vacillate between adult-like and child-like behaviour. They have rapid wide mood swings, become easily upset and emotional, and alternate between extreme cooperation and extreme resistance to adult guidance.

Sexually, as pubertal events occur, early adolescents may (re)discover masturbation and other pleasurable self-stimulation. They form close friendships with same-sex peers and may experiment sexually with them usually to satisfy curiosity. Middle adolescence, typically ages 14 to 18 years, finds youth continuing education or seeking employment. Puberty usually is complete, adult size is approaching and fertility often is a reality. Middle adolescents struggle the most with the development of self-identity, and autonomy.

Middle adolescents have increased mobility and independence and less adult presence and protection. Risk-taking behaviour involving driving, substance use, and/or sexual activity may have harmful consequences which the adolescent is unable to anticipate or effectively prevent. Experimentation seems to be a normal, even necessary part of adolescent development. Contemporary society often tolerates and even promotes adolescent experimentation with smoking, drinking, and sex yet hesitates to provide adolescents with the knowledge and means of avoiding consequences.

Sexually, most middle adolescents have discovered masturbation and practice it with varying frequency. By age 17, approximately half of all adolescents have experienced sexual intercourse, some before puberty, many first at age 15 to 16. Coital frequency ranges from only once to several times a week. Sexual activity may include oral-genital or anal sex, especially as more adolescents learn about these varieties of sexual expression. Most adolescents have heterosexual relationships, although many have experimented with homosexual intimacy.

Late adolescence refers to the years past high school, from age 17 to 18 into the early twenties. Most late adolescents are physically adult, accepted as adults in their environments, and fertile. They are self-supporting or pursuing educational or vocational training to become able to support both self and a family. Their self-identity is consistent with the realities of their size, shape, and abilities and with societal limits and expectations. Late adolescents have a well-established sexual identity, usually heterosexual, and the ability to have intimate relationships that satisfy the emotional and sexual needs of both partners. Many have achieved parenthood one or more times, some are married, with or without children, and some have been divorced. Yet many have not yet reached the level of psychosocial maturity that would facilitate a healthy family life for themselves, their partners and their children.

Adolescents and Sexually Transmitted Diseases

Puberty and adolescence contribute to the incidence and clinical features of STDs in youth. During puberty, genital maturation increases the capacity for intercourse and the internal genital tract becomes fully patent in both sexes allowing any acquired infections to spread. In females, oestrogenization decreases the susceptibility of the vulva and anterior vagina to most infections and alters vaginal flora and pH. Until several years after menarche, the squamocolumnar junction is located on the exposed vaginal surface of the cervix, gradually progressing to the endocervical canal as thin columnar cells are transformed to layers of thick squamous cells. The exposed columnar epithelium is especially likely to become infected with gonorrhoea or chlamydia if there is contact with infected partners. The transition zone itself is susceptible to carcinogenic factors, including various infectious organisms. There is now good epidemiological evidence that early age of first intercourse correlates with precancerous and cancerous changes to the cervix.

Denying the possibility of harm, early and middle adolescents are less likely than others to use preventive methods when engaging in sexual intimacy and more likely to deny symptoms of infection. Adolescents who do suspect an infection may be embarrassed or frightened and delay seeking treatment for days to weeks. Once diagnosed, they may fail to complete therapy, especially if symptoms diminish, and/or may fail to appear for test of cure. They may fail to inform partners, because of anger, shame, or fear of accusations of infidelity. Adolescents who have a series of short-lived relationships each of which includes intercourse increase their risk of exposure to infection and complicate the task of contact tracing.

Adolescent contraceptive practices affect the risk of infections. Many adolescents never use a method or rely solely on the oral contraceptive. Whether or not oral contraceptives increase susceptibility to certain infections - they clearly reduce the impetus to use a barrier method or to involve males in prevention. Adolescents who decide or can be persuaded to use barrier methods seldom use them consistently and often use them incorrectly. IUDs are rarely advised for adolescents and should never be considered for those at high risk for infection or for poor compliance with close follow-up.

STD control in adolescents, as in other age groups, may be frustrated by the high frequency of asymptomatic states, the presence of antibiotic-resistant strains, and the adolescent practice of partial treatment with self-prescribed antibiotics obtained from friends. Health professionals, inadequately trained about STDs, may miss the correct diagnosis in an adolescent whose presentation is atypical or whose range of sexual behaviours is never addressed. Limited accessibility of services, costs, and staff attitudes provide additional barriers to health care.

Treatment and Counselling

Adolescents found to be infected with any STD should be counselled about the infection(s), the possible complications, the importance of informing partner(s) to seek diagnosis and treatment, and the critical importance of completing therapy as recommended and returning for test of cure. The clinician should offer to screen, treat, and educate the sexual partner(s) whenever practical. Single-dose treatment on site is strongly recommended for adolescents. When there is no single-dose treatment, adolescents may comply best with twice daily oral antibiotics.

If adolescents are willing to postpone first coitus, they remain at some risk for transmission of STDs through noncoital intimate behaviours; however, it may be unrealistic to expect adolescents to abstain from all physical expressions of sexuality, especially if marriage is unlikely until the mid to late twenties.

Adolescents who will not be persuaded to abstain from intercourse must be well informed about the risks of all forms of sexual intimacy and provided with the knowledge and methods for prevention of infection and pregnancy. Teenagers should be encouraged to use condoms, with every coital act, whether or not the female is using the oral contraceptive pill. Adolescents should be instructed about "safe sex" which may require description or at least mention of practices such as anal intercourse which increase the risk of serious infections or injuries.

Sex education or family life education does not guarantee prevention of consequences, will not ensure abstinence, and has not been shown to increase sexual experimentation. Teenagers who have been exposed to appropriate sex education tend to delay first intercourse, to use contraception when they have intercourse and to avoid pregnancy.

Top of Page