Paediatricians should do more to address male adolescent sexual health

Young people have the right to be informed and access appropriate health-care services about their health, including sexual matters. They also have the right to be treated in a confidential, culturally appropriate, positive and respectful manner. While components of a sexual history and health discussion vary and are tailored to the individual and their own circumstances, it is paediatricians who are failing our young people by not providing them with the opportunity for sexual health discussion, with males missing out the most. A recent study by Alexander et al. found that 35% of annual adolescent health visits made no mention at all of sex. When such ‘discussions’ took place, they lasted an average of 36 seconds and rarely involved any input from the young person. None of the 253 adolescents (aged between 12 and 17 years and just over half being female) initiated discussions on sex. Half of all conversations were responses to yes or no (closeended) questions. Females were twice more likely to spend time talking about sex than males. Unfortunately, these are not new or surprising findings. Sexual health is raised more often with females and older youth. American primary care providers are three 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 condoms. There appears to be greater ease in covering issues of menstruation, sexually transmitted illnesses (STIs) and contraception than male sexual health issues. While the ‘physiological agenda’ of doctors is to provide information on contraception and screen and treat STIs, adolescents are more interested in the course of normal pubertal progression, making sense of relationships and countering sexual misinformation. Ignoring their concerns leads to disengagement, so it is vital to meld the two, like in any good conversation. It is important to raise the issue of dating violence, which occurs in approximately 10% of adolescents and males may be perpetrators, victims or both. A significant concern is that a quarter of adolescent sexual encounters involve alcohol (in up to 34% of Australian male reports) or drug use and that 50% of new STI cases occur among young men and women. All sexual experiences should be free of coercion, discrimination and violence. Many Australian teenagers perceive the age of sexual consent of 16 years as a barrier to be overcome. After all, many teenagers will drink and smoke before they can legally purchase and use these substances at age 18. The thrill of an illicit action is lost when it is made legal. Loss of virginity is occasionally seen as a milestone akin to attaining a driver’s licence (with similarly perceived attached kudos), and some teenagers will initiate sex to ‘get it out of the way’ or as practice and experience for a future partner. A generational culture of YOLO (‘You Only Live Once’) does not help. In 2008 in Australia, 70% of Year 10 and 88% of Year 12 students had experienced some form of sexual activity, 40% had experienced sexual intercourse and 44% had experienced oral sex. Thirty-two per cent had reported ever having unwanted sex. The majority of male adolescents practice serial monogamy, averaging one sexual partner per year, and male Australian Year 12 students are more likely to have three or more sexual partners than females (43% and 34%, respectively). Pubertal initiation is trending earlier, particularly among nonHispanic white boys, at approximately 10 years of age. While there is no evidence to suggest cognitive development and maturation are occurring at a similar earlier time, exposure to social and peer influences tends to support the need for education. Viewing videos of sex predicts adolescent initiation of sexual behaviour. Increasingly, because of access, children learn about sex online via the use of pornography. Pornography as sex educator skews the young person’s view of sex and sexual roles. It is known that earlier maturing boys engage in more risk-taking behaviours and late developers (associated with obesity) experience teasing, bullying, mental health issues (poor self-esteem, anxiety and depression) and substance use. This emphasises the need for dialogue about quality sex education and parental discussion. In Australia, the most popular source of sexual information among males was school programmes (49%) and among females was their mother (62%). Many secondary school teachers feel unsupported in teaching sex education to their students, with few receiving formal training in the area. Counselling of the normalcy of pubertal progression and velocity is indicated by paediatricians to counter misinformation, investigate pathology (folliculitis from currently ‘fashionable’ pubic hair shaving, trauma, tinea cruris, varicocoeles, etc) and allay fears (such as gynaecomastia and pearly penile papules). Klinefelter syndrome affects approximately 1 in 600 males and may have gone undetected. Testicular cancer Correspondence: Dr Anthony A Zehetner, Department of Adolescent Medicine, The Children’s Hospital at Westmead, Cnr Hainsworth Street and Hawkesbury Road, Locked Bag 4001, Westmead, Sydney, NSW 2145, Australia. Fax: +61298452517; email: Anthony.Zehetner@health.nsw.gov.au