Sexuality and Gender in Adolescents

Sexual orientation and gender identity are a focus for many adolescents. Some adolescents feel comfortable exploring these aspects of themselves, whereas others struggle and may be afraid to reveal their sexual orientation or gender identity to friends or family members and may fear that they will not be accepted (1). Such concerns (especially during a time when social acceptance is critically important) can cause severe distress. Fear of abandonment by parents, sometimes real, may lead to dishonest or at least incomplete communication between adolescents and their parents. In some cases, these adolescents are bullied by peers. Threats of physical violence should be taken seriously and reported to school officials or other authorities. The emotional development of adolescents is best helped by supportive clinicians, friends, and family members.

Clinicians and sex education professionals should not make assumptions about an adolescent's sexual orientation or gender identity and should ask open-ended questions and provide sex education and medical care (1).

Gender identity starts to develop early on, often before adolescence. For some children and adolescents, the sex they were assigned at birth does not match their gender identity.

Definitions regarding gender identity include the following (1):

• Sex: Defined by the traits usually used to distinguish between males and females; sex refers especially to the physical and biologic traits that are physically evident at birth and is often captured in the phrases "assigned male at birth" (AMAB) and "assigned female at birth" (AFAB).

• Gender identity: An internal sense of being male, female, or something else, which may or may not correspond to an individual's sex assigned at birth or sex characteristics

• Gender expression: Clothing, physical appearance, and other external presentations and behaviors that express aspects of gender identity or role

• Gender incongruence: Marked and persistent experience of an incompatibility between a person’s gender identity and the gender expected of them based on their sex assigned at birth

• Gender dysphoria: Discomfort or distress related to an incongruence between an individual's gender identity and the sex assigned at birth; also refers to a specific diagnosis (2).

For more details and definitions please see table Definitions of Terminology Regarding Sex and Gender.

Patients with possible gender dysphoria should receive appropriate evaluation and care, which may include gender-affirming care (3, 4).

In the United States, prevalence rates of certain sexually transmitted infections (STIs) are highest among adolescents and young adults (1). Rates of chlamydia and gonorrhea are highest among females during their adolescent and young adult years (2), and many individuals acquire human papillomavirus (HPV) infection during that time.

Adolescents who initiate sex early in adolescence are at higher risk of STIs (1). Other adolescents at higher risk of STIs include the following:

• Those living in a detention facilities

• Those involved in commercial sex exploitation or survival sex and exchanging sex for drugs, money, food, or housing

• Young males who have sex with males (YMSM)

• Youths who are transgender

• Youths with disabilities, substance misuse, or mental health disorders

• Those having unprotected sex

Additional contributing factors include multiple sex partners, lack of education about safe sex practices, unprotected sex (failing to use barrier protection consistently and correctly), having sequential sex partnerships of limited duration or concurrent partnerships, lower socioeconomic status, and facing multiple obstacles to accessing health care.

Clinicians should counsel adolescents about STI prevention, screening, symptoms, and treatment. If indicated, adolescents should be offered postexposure prophylaxis for HIV, chlamydia, gonorrhea, and syphilis; and pre-exposure prophylaxis for HIV (1, 3, 4). Routine screening for STIs should be provided, when appropriate (1, 2, 5).