Questions to ask young male patients about Sexual Development and Maturity

Overview

The lower mean age of boys entering puberty was long thought to be 9.5 years old, but surveillance data suggests that there are more boys initiating puberty under this limit every year ¹  During adolescence, a number of changes occur for boys, including the physical, psychological, and social changes associated with puberty, and the majority of male adolescents report the initiation of sexual behavior.² Many of these events, including sexual initiation, are associated with preventable consequences that can lead to significant morbidity and mortality.³ During this same time period, the number of health visits typically declines, particularly among older male adolescents, and there is a shift from routine to more time-limited acute visits. ^{4 (2-4 as cited in 5)}   In addition, males tend to increase seeking healthcare at acute care clinics and emergency departments. Not only does this have consequences for continuity of care, but also in terms of expense. (Rafferty)

The most important psychological and psychosocial changes in puberty and early adolescence are the emergence of abstract thinking, the growing ability of absorbing the perspectives or viewpoints of others, an increased ability of introspection, the development of personal and sexual identity, the establishment of a system of values, increasing autonomy from family and more personal independence, greater importance of peer relationships of sometimes subcultural quality, and the emergence of skills and coping strategies to overcome problems and crises. All these changes can be looked on as developmental tasks during normal development, but they can also help in understanding developmental deviations and psychopathological disorders.⁶

For young men’s sexual health, these broader contextual influences span both cultural beliefs and codes of conduct related to masculinity and gender, as well as early romantic relationships and their social contexts, including peers, families, providers, and communities. These contextual influences can either support or undermine a young man’s sexual development.⁷

Delayed puberty is more common among boys and is defined as lack of testicular enlargement by age 14, lack of pubic hair by age 15, or a time lapse of more than 5 years from the start to the completion of genital enlargement. Although adolescents are typically uncomfortable about being different from their peers, boys in particular are likely to feel psychologic stress and embarrassment from delayed puberty.

The initial evaluation of delayed puberty should consist of a complete history and physical, basic laboratory tests to look for signs of chronic disease, and hormone level tests. A bone age test also may be helpful. Boys under the age of 16 with delayed puberty who are otherwise healthy most likely have a normal or constitutional delay. For these adolescents, the doctor may elect to reassess at 6-month intervals to ensure that puberty begins and progresses normally.⁸  

Early and delayed pubertal timing, including short stature, can result in negative consequences for the developing male. Consequences can include higher mean levels of aggression and delinquency. Earlier-maturing boys might have more frequent involvement in risk-taking behaviors, and later maturing boys might have lower levels of confidence and self-efficacy and increased experiences of teasing, bullying, mental health issues, and substance abuse.^8,10,11 Even a common issue such as acne, which affects which affects 95% of male adolescents, can be related to self-reported embarrassment, lower self-esteem, depression and anxiety.^{12 (as cited in 13)}

On average, the age of first male masturbation occurs between 12 and 14 years of age.  Masturbation is common, ranging from 36% reporting masturbation 3 to 4 times per month to 10% reporting every other day or daily.¹⁴  Masturbation is often not addressed by health education classes or parental advice, which can be distressing for young boys. (Rafferty)  Health care providers can reassure male adolescents that self-masturbation is a normal behavior and can be a positive expression of sexuality and a way to delay having sex and its associated risks. Health care providers can also assist male adolescents with information and resources about normal sexual physiology and function that might not otherwise be available at home or school. 

 Young men are often surprised that sexual dysfunction is relatively common in their age group. Discussing sexual dysfunction with a clinician is often difficult or embarrassing for men of any age. The clinician may need to prompt the young man to discuss sexual function in the context of how sexually satisfying their relationships may be.¹⁵

It is important that health care professionals ask boys questions about growth and pubertal development starting in the early teen years or even in the prepubertal years. One way to introduce these topics is to ask the teen whether he has any concerns about topics such as athletic performance, strength or endurance. These topics can naturally lead to questions about how the young man is feeling about his changing body. Opening up discussions around these topics serves many purposes – it lets the young teen know that doctors are interested and are available to talk to about these topics; it is a way to introduce preventive issues in the area of sexual health, and it opens the door to future counselling on nutrition and exercise patterns, sexuality, contraception and sexually transmitted infections (STIs). It is important to remember that teens may not always be direct in their questions for the doctor. For example, teens worried about their development may express this through general complaints or indirect questions about body function. The discussion can be initiated while doing the medical history or when examining the adolescent by asking questions such as, ‘Do you have any worries or questions about your height or physical appearance?’ or ‘Do you have any concerns about the development of your genitals?’¹⁶

To elicit any concerns the adolescent male patient may have about his sexual development, during the initial physical examination the provider should ask open-ended but explicit questions, such as “Do you know what puberty is or how kids’ bodies change during their teenage years?” As the interview proceeds the clinician can become more personal and invasive in their questioning. (Rafferty)