Sexual Development and Sexuality in Children and Adolescents
Evidence-Based Clinical Guidelines for Healthcare Professionals
Professor Mykhailo Medvediev
Pubertal Development
Pubertal Development in Girls
Puberty is a normal stage of maturation during which girls undergo significant physical and hormonal changes. It typically begins between the ages of 8-13 years and lasts several years. This period is marked by the development of secondary sexual characteristics and the achievement of reproductive maturity.
Key changes include breast development, a growth spurt, the appearance of pubic and underarm hair, and the onset of menstruation (menarche).
Hormonal Process
Hormonal Regulation of Puberty
Pubertal development in girls is governed by a complex interaction of hormones initiated in the brain. This hormonal cascade ensures the maturation of the reproductive system and the formation of secondary sexual characteristics.
Hypothalamus and GnRH
The hypothalamus begins to release gonadotropin-releasing hormone (GnRH) in pulses, signaling the start of puberty.
Pituitary Gland and FSH/LH
GnRH stimulates the pituitary gland, which in turn releases follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
Ovaries and Estrogen
FSH and LH act on the ovaries, stimulating them to produce estrogen, which is key for the development of breasts and the uterus.
Progesterone and Maturation
Subsequently, the ovaries also begin to produce progesterone, preparing the body for ovulation and menstruation, completing the maturation cycle.
Pubertal Development
The Tanner Scale: Staging Puberty
The Tanner Scale, or Sexual Maturity Rating (SMR), is a five-point scale used to describe the progression of physical changes during puberty in both males and females. These stages are based on visible external primary and secondary sexual characteristics.
Understanding the Tanner stages helps healthcare professionals assess pubertal timing and progression, identify potential abnormalities, and guide discussions about sexual health development with adolescents and their families.
1
Stage 1: Prepubertal
No physical signs of puberty are yet present. This stage is typical before age 8 for girls.
2
Stage 2: Early Changes
Initial signs appear, such as breast budding (thelarche) and sparse, straight pubic hair.
3
Stage 3: Moderate Progression
Breast enlargement continues, pubic hair becomes darker, coarser, and more curled. A significant growth spurt often begins.
4
Stage 4: Advanced Development
Breasts achieve a more adult shape, and pubic hair density increases, covering a larger area. Menarche typically occurs in this stage.
5
Stage 5: Adult Maturity
Full adult physical characteristics are achieved, with mature breast contours and pubic hair distribution extending to the inner thighs.
Introduction
Understanding Human Sexuality
Human sexuality is an essential part of human development and the human experience. Developing sexuality encompasses complex interactions between gender and sexuality, involving chromosomes, anatomy, hormones, physiology, psychology, interpersonal relationships, and sociocultural influences.
This presentation provides evidence-based guidance for healthcare professionals working with children and adolescents, based on international clinical recommendations and research.
Source: UpToDate - Sexual development and sexuality in children and adolescents
Key Concepts
Terminology and Paradigm of Sexuality
Assigned Sex at Birth
Designated according to genetic, hormonal, and anatomic characteristics. Not a strict binary; includes diversity of intersex conditions.
Gender Identity
Individual's innate sense of feeling male, female, androgynous, combination of both, or neither. Generally established during early childhood but may evolve across lifespan.
Sexual Orientation
Pattern of physical and emotional arousal regarding gender(s) of persons to whom individual is romantically, physically, or sexually attracted.
Sexual Behavior
Specific behaviors involving sexual activities, useful for STI screening and risk assessment. Does not determine gender identity or sexual orientation.
Reference: Levine DA, Committee On Adolescence. Pediatrics 2013; 132:e297
Intersections of Gender and Sexuality
Gender and sexuality are broad, intersecting concepts that encompass various aspects of human identity. Understanding these intersections is crucial for providing comprehensive, affirming care to all adolescents.
Source: UpToDate Clinical Guidelines, Figure 1
Developmental Stages
Adolescent Development Framework
01
Early Adolescence (10-14 years)
Onset of puberty, concrete thinking, preoccupations with physical changes, egocentric approach to sexuality. Sexual curiosity and exploration may begin.
02
Middle Adolescence (15-18 years)
Completion of physical puberty changes. Can begin to imagine consequences but may still engage in risk-taking behaviors. Patterns of romantic relationships emerge.
03
Late Adolescence (18+ years)
More mature social skills, empathy, understanding of risks. Development of intimate and serious relationships. Mature understanding of physical self and sexual identity.
Reference: UpToDate Table 1 - Adolescent Development
Development of Healthy Sexuality
Key Tasks
  • Understanding personal interests and behaviors
  • Identifying activities that promote positive sexual experiences
  • Active expression of sexual behaviors
  • Capacity for meaningful intimate relationships
  • Understanding consent and body autonomy
Sexual development occurs in the context of identity formation and human development. One task for healthy adolescent development is acquisition of mature and responsible sexual identity.
Source: Breuner CC, Mattson G. Pediatrics 2016; 138
Epidemiology
Adolescent Sexual Behavior in the United States
38%
Sexual Activity
High school youth reporting having had sexual intercourse
27%
Currently Active
High school students currently sexually active
12%
9th Graders
Current sexual activity in 9th grade students
42%
12th Graders
Current sexual activity in 12th grade students
Prevalence of current sexual activity increases significantly with age. Early sexual debut (before age 13) is associated with higher risk of unwanted sexual experiences.
Reference: CDC Youth Risk Behavior Survey 2019-2021
Trends in Adolescent Sexual Behavior
Decreasing Rates
Sexual intercourse rates decreased from 38% to 30% (2019-2021)
Multiple Partners
Sex with more than four persons decreased from 9% to 6%
Oral Sex
Over 50% of youth age 15-24 report oral sex with different-sex partner; <10% use protection
Source: Youth Risk Behavior Survey, CDC 2021
Clinical Practice
Setting Up the Clinical Visit
Office Preparation
  • Staff trained in adolescent care with diverse sexual identities
  • Inclusive clinic materials and administrative intake
  • Gender-neutral bathrooms
  • Pronoun badges for staff
  • Open, nonjudgmental terminology
Respect for diversity begins with front desk staff and clinic setup. Health care facilities must demonstrate respect for gender, race/ethnicity, sexual orientation, and physical appearance differences.
Reference: Marcell AV, Burstein GR. Pediatrics 2017; 140
Removing Barriers to Care
Accessibility
Clinic hours, transportation, insurance, billing, and self-pay costs must be considered
Privacy & Confidentiality
Lack of or perceived lack of privacy is a major barrier to open discussion
Consent Laws
Mandatory parental consent laws may prevent adolescents from seeking care
Provider Biases
Political, religious, and ethical beliefs can create barriers to comprehensive care
Stigma
Provider, caregiver, or patient discomfort with sexuality topics must be addressed
Source: Institute of Medicine - Adolescent Health Services 2009
Privacy & Confidentiality
Understanding Privacy and Confidentiality
Privacy
Individual's ability to control the timing, amount, and circumstances under which information about oneself is disclosed.
Confidentiality
Treatment of information once it has been disclosed. Information recorded in medical records may be available to parents/caregivers depending on state laws.

Critical Point
Most adolescents require absolute privacy to talk candidly about their sexuality. Always ask partners, friends, or caregivers to leave the examination room before beginning sensitive discussions.
Reference: Ford C, English A, Sigman G. J Adolesc Health 2004; 35:160
Permission, Privacy, and Confidentiality
Obtaining permission to discuss sexuality and reviewing privacy and confidentiality help establish basic trust between medical provider and adolescent patient. Concerns about confidentiality are frequently cited as reasons to avoid seeking health care.
Explicit assurance of privacy and confidentiality (and exceptions) regarding discussions of emerging sexuality helps adolescents understand what to expect and what types of sensitive information they may safely disclose.
Source: Committee On Adolescence. Pediatrics 2013; 132:198
Communication Strategies
How to Discuss Sexuality: Normalize
Early Childhood
Aspects of sexuality, including body autonomy, can be discussed in developmentally appropriate ways from early childhood. Include questions about gender play, preferences, body image, and expression.
Prepubertal Years
Provider's questions about child's activities and preferences demonstrate that adults should be interested in child's identity development and provide models for communication.
Adolescence
Safe and respectful conversations may help adolescents better understand sex and its role in their lives. Goal is for adolescents to understand their body, communicate about pleasure, and feel free to ask questions.
Reference: Alderman EM, Breuner CC. Pediatrics 2019; 144
Use Appropriate Language
Use professional yet familiar and comfortable terminology. Developmentally appropriate language is particularly important for youth with neurodiversity or developmental delay.
Examples:
  • Replace "fellatio" or "cunnilingus" with "oral sex"
  • Use "top" or "bottom" for anal insertive/receptive sex
  • Ask gender-diverse persons how they prefer to refer to body parts
  • Use "front sex" and "back sex" when appropriate
When youth use unfamiliar terminology, ask for clarification: "I am not familiar with that term. Can you tell me what you mean?"
Source: UpToDate Clinical Guidelines - Communication Strategies
Avoid Assumptions
Sexual Orientation
Do not assume all patients are heterosexual. Ask gender-neutral questions about "crushes" or "romantic or sexual partners" rather than "boyfriends" or "girlfriends."
Behavior vs. Identity
Heterosexual youth may have same-gender partners. Gay or lesbian youth may have different-gender partners. Either group may abstain from sexual activity.
Contraception Needs
Self-identified lesbian or transmasculine persons may require birth control. Transmasculine people can and do get pregnant.
Complex Patients
Youth with neurodiversity, developmental delays, chronic illnesses, or gender diversity may be involved in romantic or sexual relationships.
Reference: Houtrow A, Elias ER, Davis BE. Pediatrics 2021; 148
Sexuality Education
Comprehensive Sexuality Education
Comprehensive sexual health education is an essential component of preventive health guidance for all youth. Successful sexuality education includes risk and resiliency, disease prevention and treatment, and the message that sexuality can enhance well-being.
Health care providers are a valued and trusted source of information and advice about sexuality. Education should be delivered in homes, schools, and community settings.
Reference: Breuner CC, Mattson G. Pediatrics 2016; 138
Evidence for Comprehensive Sex Education
Improved Knowledge
Comprehensive programs significantly improve sexual health knowledge among adolescents
Reduced Risk Behaviors
Evidence-based programs reduce penetrative sexual behaviors and improve condom use
School-Based Success
Programs across grade levels with positive, inclusive approaches show strong support
State Policy Impact
States requiring sexuality education have lower rates of sexually active youth and higher contraception use
Reference: Goldfarb ES, Lieberman LD. J Adolesc Health 2021; 68:13
Clinical Assessment
Taking a Sexual History
Introduction
"I am going to ask you about intimate and personal details of your sexual behaviors, partners, and other activities so I can know what to suggest for screening, testing, and healthy sex decisions."
Key Information
  • Date of last sexual activity
  • Type of sexual activity (digital, oral, vaginal, anal, other)
  • Which body parts were used
  • History of STIs or pregnancies
  • Age at sexual debut
  • Use of substances with sex
  • Feeling threatened or coerced
Reference: Workowski KA, Bachmann LH. MMWR Recomm Rep 2021; 70:1
Specific Sexual Behaviors and Risk
1
Digital Penetration
Touching or penetrating vagina or anus with fingers. Less risky than penile penetration but not entirely risk-free.
2
Oral Sex
Kissing, licking, or sucking on penis, scrotum, vagina, or anus. Lower risk than anal/vaginal penetration but can transmit STIs.
3
Anal Sex
Unprotected penile-anal sex associated with increased risk of HIV and STI transmission.
4
Vaginal Sex
Unprotected vaginal sex (insertive or receptive) associated with increased STI transmission risk.
Going through a list of specific body parts can help educate youth about sexual behaviors that increase their risk of STI. Direct and explicit conversation helps normalize the discussion.
Source: CDC STI Treatment Guidelines 2021
Assessing Contraception and Condom Use
Condom Use
How often and with whom they use condoms. Date of last sexual activity without a condom. Separate STI prevention from contraception conceptually.
Contraception Type
Type of contraception for themselves and their partner. Date of last sexual activity without contraception. Discuss problems with previous methods.
Male Involvement
Include young heterosexual males in screening and education to improve their contribution to family planning decisions.
Reference: Grubb LK, Powers M. Pediatrics 2020; 145
Victimization Screening
Screening for Coerced Sex
Key Questions
  • "Have you ever had unwanted sex?"
  • "Have you ever felt pressured to have sex even though you did not want to?"
  • "Have you ever been in a position where the sex went further than you wanted it to?"
  • "Have you needed to trade sex for money, food, or a place to stay, or for drugs?"
Coerced sex is common in adolescence and may be associated with suicidal thoughts, substance use, and concerns about personal safety.
Source: UpToDate Clinical Guidelines - Victimization Assessment
Risk Reduction
Pregnancy Prevention Strategies
Abstinence Support
Support adolescents who decide to abstain from sexual activity as the most effective means to avoid pregnancy
Universal Discussion
Discuss contraception with all adolescents, including males and females who have sex with females
Method Selection
Help adolescents choose appropriate contraceptive methods based on individual needs and preferences
Male Engagement
Engage male adolescents in family planning decision-making to promote shared responsibility
The majority of adolescent pregnancies are unplanned. Any person may become pregnant if sperm and oocytes are involved.
Reference: Committee on Adolescence. Pediatrics 2014; 134:e1244
STI Prevention Counseling
A disproportionate number of STIs occur in adolescents and young adults. STI prevention counseling must be developmentally appropriate and balance the importance of adolescent sexual development with risk avoidance and harm reduction.
01
Support Abstinence
Support delaying sexual debut as early age of first intercourse is a risk factor for pregnancy and STI acquisition
02
Demonstrate Condom Use
Show appropriate techniques for condom use and recommend consistent and correct use as most effective STI prevention strategy
03
Discuss PrEP
Discuss HIV pre-exposure prophylaxis for adolescents unable or unwilling to use condoms or who engage in high-risk behaviors
04
Model Communication
Model effective communication and partner negotiation skills for adolescents
Reference: Grubb LK. Pediatrics 2020; 146
HIV Prevention
HIV Pre-Exposure Prophylaxis (PrEP)
Indications for PrEP
  • Adolescents not able or willing to use condoms consistently
  • Sexual behaviors with partners at high risk for HIV infection
  • Available as daily oral medication or six-month long-acting injection
DoxyPEP
Doxycycline post-exposure prophylaxis for prevention of syphilis, chlamydia, and gonorrhea in selected high-risk individuals.

Evidence-Based Prevention
PrEP and DoxyPEP represent important advances in STI prevention for adolescents and young adults at high risk. Patient selection and counseling are critical for success.
Reference: CDC Prevention Guidelines 2021
Teen Dating Violence
Teen Dating Violence (TDV)
Definition
TDV includes psychological, physical, and sexual aggression in adolescent dating relationships
Prevalence
Common in adolescent relationships, more common in sexual minoritized and gender-diverse adolescents
Associated Risks
More common in adolescents engaging in other risk activities such as drug and alcohol use
Routine Discussion
Routine discussion of TDV opens opportunities for education and intervention
Source: UpToDate - Adolescent Relationship Abuse
Sexual Minority Youth
Sexual Minimized and Gender-Diverse Youth
Increased Health Risks
  • Child abuse and bullying
  • Sexual harassment
  • Teen dating violence
  • Mental health problems (depression, anxiety, suicide)
  • Disordered eating and body image issues
  • Substance use
  • Unprotected sex with risks for STIs and pregnancy
There is substantial research documenting increased risk behaviors, victimization, and adverse health outcomes among sexual minoritized and gender-diverse youth. Prevention strategies must be tailored to address these specific risks.
Reference: Levine DA. Pediatrics 2013; 132:e297
Supporting Sexual Minority Youth
Affirming Environment
Create clinic spaces that explicitly welcome and affirm sexual minoritized and gender-diverse youth through inclusive materials, staff training, and open communication.
Mental Health Support
Screen for depression, anxiety, and suicidal ideation. Provide or refer to mental health services experienced in working with LGBTQ+ youth.
Community Resources
Connect youth with LGBTQ+ community organizations, support groups, and online resources for peer support and education.
Source: Committee On Adolescence. Pediatrics 2013; 132:198
Motivational Interviewing
Motivational Interviewing Techniques
Clinicians with expertise in adolescent sexual health care use motivational interviewing, harm reduction, and trauma-informed care. These approaches create an open dialogue that invites honest answers, focuses on individual strengths and goals, increases knowledge, builds skills, and promotes personal responsibility.
Open-Ended Questions
Use questions that invite detailed responses rather than yes/no answers to understand adolescent's perspective and experiences
Reflective Listening
Demonstrate understanding by reflecting back what the adolescent has shared, validating their feelings and experiences
Affirm Strengths
Recognize and build on adolescent's existing strengths, positive behaviors, and protective factors
Support Autonomy
Emphasize adolescent's right to make their own decisions while providing information to support informed choices
Reference: UpToDate Table 7 - Motivational Interviewing
Trauma-Informed Care
Trauma-Informed Approach
Key Principles
  • Recognize prevalence and impact of trauma
  • Create physically and emotionally safe environment
  • Promote patient choice and control
  • Collaborate and build trust
  • Empower patient voice
  • Address cultural and gender issues

Reducing Stress During Examination
Use trauma-informed techniques to reduce patient stress during physical examinations. Explain each step, obtain ongoing consent, allow patient to control pace, and provide options for support person presence.
Many adolescents have experienced trauma, including sexual abuse or assault. Using trauma-informed approaches helps create safe spaces for disclosure and healing.
Reference: UpToDate Table 8 - Trauma-Informed Care
Resources
Additional Support and Resources
Online Resources
Advocates for Youth, Amaze, American Social Health Association "I wanna know", National Youth Advocacy Coalition, SIECUS, CDC Resources for Adolescent Health
Community Services
Know what resources exist for youth in your community, state, and nationally. Provide referrals to mental health services, LGBTQ+ organizations, and reproductive health clinics
Educational Materials
Provide trustworthy educational materials appropriate for adolescent reading level and cultural background. Use multimedia approaches including videos and interactive content
Source: Multiple validated online resources for adolescent sexual health
Clinical Guidelines
Evidence-Based Practice Guidelines
1
American Academy of Pediatrics
Multiple policy statements on adolescent sexual health, LGBTQ+ youth care, and comprehensive sexuality education
2
CDC Guidelines
STI Treatment Guidelines 2021, Youth Risk Behavior Surveillance, HIV Prevention recommendations
3
ACOG Recommendations
Committee opinions on adolescent contraception, sexual health services, and reproductive health care
4
Society for Adolescent Health and Medicine
Position papers on confidentiality, consent, and comprehensive sexual health services
Reference: Society Guideline Links - Adolescent Sexual Health
Key Recommendations Summary
Clinical Practice
  • Create affirming, inclusive clinical environments
  • Ensure privacy and confidentiality
  • Use developmentally appropriate language
  • Avoid assumptions about sexual orientation or behavior
  • Normalize sexuality discussions from early childhood
Risk Reduction
  • Provide comprehensive sexuality education
  • Discuss contraception with all adolescents
  • Demonstrate proper condom use
  • Screen for STIs and offer PrEP when appropriate
  • Screen for victimization and dating violence
Source: Comprehensive review of UpToDate clinical guidelines
Implementation
Implementing Best Practices
Assess Current Practice
Review current clinic policies, staff training, and materials for inclusivity and comprehensiveness
Train Staff
Provide ongoing training for all staff on adolescent sexual health, LGBTQ+ affirming care, and trauma-informed approaches
Update Materials
Ensure all clinic materials, forms, and educational resources are inclusive and up-to-date
Monitor Outcomes
Track patient satisfaction, screening rates, and health outcomes to continuously improve care
Reference: Institute of Medicine - Adolescent Health Services 2009
Future Directions
Emerging Issues and Future Research
Technology Integration
Interactive computer modules, text messaging, and social media networks offer new frameworks for health education. Digital health interventions show promise for reaching adolescents with sexual health information.
Evolving Terminology
Many youth refuse categorization, self-identifying with more diffuse terminology regarding gender and sexuality (gender queer, queer, pansexual, fluid). Providers must remain open to learning new terminology.
Continued research is needed on effective interventions for diverse populations, long-term outcomes of comprehensive sexuality education, and optimal strategies for supporting sexual minoritized and gender-diverse youth.
Reference: Bailey JV, Murray E. Cochrane Database Syst Rev 2010
Conclusion: Comprehensive Approach to Adolescent Sexual Health
Evidence-Based Care
Use international guidelines and research to provide comprehensive, affirming sexual health care
Inclusive Practice
Create welcoming environments for all adolescents regardless of sexual orientation or gender identity
Prevention Focus
Emphasize both risk reduction and positive sexual development through education and counseling
Ongoing Support
Provide continuous care, resources, and referrals to support healthy adolescent development
Human sexuality is an essential part of human development. By providing comprehensive, evidence-based care, healthcare professionals can support adolescents in developing healthy, responsible sexuality and meaningful intimate relationships.
Professor Mykhailo Medvediev
Primary Source: UpToDate - Sexual development and sexuality in children and adolescents. https://www.uptodate.com/contents/sexual-development-and-sexuality-in-children-and-adolescents