Contents

• Abstract
• Video Police Request For Pic Of Teen's Penis Widely Condemned
• NORMAL MALE PUBERTY
• COMMON CONCERNS ASSOCIATED WITH MALE PUBERTAL CHANGES
  • Delayed puberty
  • Precocious puberty
  • Gynecomastia
  • Genital development
  • Physical differences and abnormalities
  • Erections, ejaculation and masturbation
• CLINICAL WORK WITH ADOLESCENT BOYS
  • Violence and illegal activity
  • Substance use and abuse
  • Reproductive health issues and sexual orientation
  • Mental health
• Video Is your penis size 'normal'?
  • Attention deficit-hyperactivity disorder
  • Eating disorders (26)
  • Special populations of adolescent males
• MALE ADOLESCENT ACCESS TO HEALTH CARE
• Video Does Penis Size Really Matter?
• CONCLUSION
• Acknowledgments
•  

Adolescent male health 

Abstract

Issue Section:

 Original Article

Although adolescent males have as many health issues and concerns as adolescent females, they are much less likely to be seen in a clinical setting. This is likely related to both individual factors and the health care system itself, which is not always encouraging and set up to provide comprehensive male health care. There is increasing interest in addressing the needs of young men, as evidenced by the fact that there have been a number of recent publications to draw attention to issues of adolescent male health (1–4).

The majority of adolescents seeking health care are female, particularly in adolescent health clinic settings. At the teen health clinic of the Montreal Children's Hospital (Montreal, Quebec) (personal communication), 85% to 90% of adolescents are female. Teenage girls have many reasons for seeking health care, such as gynecological concerns (menstrual problems, contraception and pregnancy), eating disorders and mental health issues (adjustment difficulties, anxiety and depression).

The present paper provides an overview of the common health problems and concerns of adolescent males, and offers ways to improve their access to health care.

NORMAL MALE PUBERTY

For 96% of North American males, puberty begins between 9.8 and 14.2 years, with a mean of 11.8 years (approximately two years later than girls). Sexual maturity rating (SMR) in boys assesses genitalia development and pubic hair patterns from stage I to stage V (5,6). It usually takes an average of two years to progress from stage II to stage IV and another two years from stage IV to stage V.

Pubertal development follows a fairly consistent and predictable sequence of events, although the onset and duration vary depending on genetics, nutrition, health status and psychological factors (7). It is important to understand this process to be able to answer concerns about growth and puberty. For males, there are notable events during this sequence:

• Puberty begins (SMR II) with testicular enlargement (gonadarche) to a volume greater than or equal to 4 mL (a length greater than or equal to 2.5 cm).

• Penis size increases (first in length and then in diameter), followed by pubic hair growth (pubarche).

• First ejaculation (spermarche) occurs around SMR III, usually approximately one year after the onset of SMR II.

• During SMR III to SMR IV, growth velocity increases, the voice starts to change and gynecomastia occurs.

• Peak height velocity (5.8 cm/year to 13.1 cm/year) usually correlates with SMR IV.

• Facial and axillary hair growth follows.

• Normal testicular volume in the fully developed male is between 15 mL and 25 mL (4 cm to 6 cm in length), and is achieved in SMR V.

COMMON CONCERNS ASSOCIATED WITH MALE PUBERTAL CHANGES

Adolescents can experience many concerns or worries about growth and puberty (8,9). They rarely consult a physician, and during a medical visit for other conditions, they do not always feel comfortable bringing up these issues. 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?’

Delayed puberty

Delayed puberty is defined as no evidence of an increase in testicular volume (greater than or equal to 4 mL) or length (greater than or equal to 2.5 cm) by 15 years of age. In most cases of delayed puberty for adolescent males, there is no evidence of organic pathology accounting for this; they have constitutional delay of puberty. This condition is eight times more common in boys than in girls, and there is often a positive family history. The psychological consequences of pubertal delay in boys are noteworthy because there is evidence of emotional distress, poor body image and low self-esteem (9). These boys are also more likely to be teased or bullied.

Precocious puberty

Precocious puberty in males is defined as testicular enlargement before 8.5 years of age or the appearance of pubic hair before the ninth birthday (10). The condition always requires investigation because an underlying organic condition is far more likely (particularly intracranial pathology) in boys than it is in girls. The psychological consequences for early maturing boys are also significant. Because they appear older than their peers, they may face increased social pressure to conform to adult norms; society may view them as more emotionally advanced (11). However, their cognitive and social development may lag far behind their appearance. Studies have also shown that early maturing boys are more likely to be sexually active and are more likely to participate in risky behaviours (12).

Gynecomastia

Gynecomastia is a frequent concern of boys who may find their breast development embarrassing or worry that there is something wrong with them. Unilateral or bilateral gynecomastia is common in middle puberty, affecting up to 70% of boys. It is usually mild, less than 3 cm to 4 cm. It is rarely related to underlying conditions such as testicular neoplasms, Klinefelter's syndrome, medications or drug use (anabolic steroids or heavy marijuana use). Boys can be reassured that most of their friends also have or will have the same condition, and that it will resolve in one to two years without intervention. In obese boys, the condition may be worsened by pseudogynecomastia (13).

Genital development

Genital development is a concern of many boys who may wonder about the size or shape of their penis, but they are unlikely to bring it up without some prompting by the care provider. Adolescents may have an unfounded perception of normal or desirable penis size, particularly if they have been exposed to pornography or have encountered commercial products reported to change the size of the penis. The physician should emphasize that young men come in all shapes and sizes, as do their penises, and should point out the relative unimportance of penis size for sexual function and satisfaction (9). If necessary, the physician should strongly caution against the use of any chemical or mechanical interventions claiming to change penis size. The mean penile flaccid length is 8.2 cm to 9.7 cm, with a range between 5.0 cm and 15.5 cm. The mean erect length is 15.1 cm, with a range between 11.4 cm and 19.0 cm. There is no predictable relationship between the size of the flaccid penis and erect length.

Physical differences and abnormalities

Physical differences and abnormalities of the genitals can be very distressing to the developing young man (14). Pearly, grayish-white penile papules are small, 1 mm to 3 mm in size, and found along the corona of the penis (base of the glans). They are found in 15% to 20% of adolescents and require no treatment. They are relevant only because the young man can be concerned about them or because they could be mistaken for condyloma – which differ because they are not shiny, are usually bigger and of varying size.

Adolescents with congenital abnormalities of the genitals (such as hypospadias) should be given the opportunity to discuss the situation. With their evolving sexuality, new questions or concerns about physical appearance or sexual functioning may arise. Adolescents with hypospadias should be asked about the possible curvature of their penis when in the erect state (chordee). Varicoceles are found in 10% to 15% of adolescent boys. They are unilateral and most often (90%) involve the left testicle. Small varicoceles are not of concern. Larger ones may need to be referred for urological opinion because they may interfere with spermatogenesis. A hydrocele is a fluctuant, transluminating cystic mass surrounding the testicle. The history and physical examination should exclude an inguinal hernia. If the testicle is normal in consistency and contour, ultrasonography is not needed to detect a testicular tumour. Surgical intervention is based on the size of the lesions, which can cause discomfort or embarrassment to the adolescent.

A young male patient with phimosis is unlikely to discuss it with the physician because topics relating to erection are particularly uncomfortable for boys to talk about. If the foreskin is tight on the glans during examination, the physician should ask about possible paraphimosis, a condition in which, during an erection, the foreskin is retracted behind the glans and restricts blood flow, leading to pain, edema and possible vascular compromise. It is a surgical emergency if the foreskin cannot be brought back to the normal position by pressing firmly on the glans with fingers to release the pressure of the blood flow coming in, with countertraction on the foreskin. The adolescent boy with phimosis should be told to retract the foreskin often to increase its elasticity and allow it to be retracted behind the glans.

Erections, ejaculation and masturbation

Erections, ejaculation and masturbation are topics that are rarely brought up by adolescent boys; however, that should not be taken to mean the topics are not of interest. During puberty, particularly early puberty, spontaneous erections are common, which can be very embarrassing for the young man (15). Normalizing this for the teen, coupled with reassurance that over time this will improve, can be helpful. The vast majority of young males will experience masturbation and nocturnal emissions before 18 years of age. It is appropriate to tell teenagers that masturbation is common and normal, and that it does not lead to any physical or mental illness. Although it is unusual, some boys need reassurance that spontaneous erections and masturbation are not signs that they are perverted or have an unhealthy mind. Both should be considered to be aspects of normal sexuality for adolescents. (16). Very rarely, masturbation can become a compulsive behaviour that the teen is concerned about or a parent becomes aware of. In this situation, an underlying mental health problem or past trauma should be investigated. The most common form of sexual dysfunction in young men is premature ejaculation. This self-limiting condition usually resolves as the boy matures. Other forms of impotence or erectile dysfunction are unusual during the adolescent years.

Priapism is a persistent painful penile erection, unassociated with sexual stimulation, but it can be associated with local irritation, blunt perineal trauma or the use of drugs (alcohol and marijuana). Involvement of a urologist early in the management of priapism is important.

CLINICAL WORK WITH ADOLESCENT BOYS

Clinical encounters with teenage boys are often brief and usually due to an acute illness or injury, or a physical complaint. Common chief complaints include acute infections (such as strep throat or mononucleosis), dermatological problems (particularly acne), exacerbation of a chronic condition (such as asthma) and sports-related injuries. Although neoplasms in teenagers are unusual, they are the leading medical cause of death in teenage boys (17).

The overall mortality rate for young men increases almost sixfold between 10 to 14 years of age and 20 to 24 years of age. Although males 10 to 14 years of age have only a slightly greater mortality rate than females (25/100,000 versus 16.6/100,000), those 20 to 24 years of age have almost three times the mortality rate of females (142/100,000 versus 48.2/100,000). Most of these deaths are due to unintentional injuries (motor vehicle crashes), suicide and homicide, all of which are often associated with alcohol and substance abuse. The presence of firearms in the house significantly increases the risk of suicide in adolescent males (18).

Violence and illegal activity

Violence and illegal activity can be of concern in adolescent boys. Adolescents who have been physically or mentally abused at home and have been bullied at school may be more susceptible to get into fights or be violent. Male youth commit 80% of all youth crimes (19), and the average age of male youth involvement in crime is 16 years. Poor school performance has been identified in some reports as one of the most important predictors of criminal behaviour (20).

Substance use and abuse

Use of alcohol and marijuana is very prevalent in the adolescent population. Males are much more likely than females to binge drink (five or more drinks at one time) and also drive a vehicle while intoxicated (4). It is important for health care professionals to identify adolescents who initiate alcohol or substance use at an early age, because they may be involved in multiple health risk behaviours (21).

Reproductive health issues and sexual orientation

Many adolescent males report being sexually active at a young age, and approximately 50% have had sexual intercourse before 18 years of age. Those who engage in multiple risk behaviours are more likely to have unprotected sexual intercourse, increasing the rate of pregnancy and STIs. Despite the public health efforts to educate teens about prevention of STIs, condoms are used consistently by less than 70% of males between 15 and 19 years of age (22). Heterosexual orientation should not be presumed in young men, and questions about dating and sexual attraction should be sex neutral. Having had sexual activity with someone of the same sex does not mean the teen is gay; many gay teens have never had sexual encounters with someone of the same sex. The McCreary Centre Society's 2003 adolescent health survey (23), which surveyed thousands of teens in British Columbia, found that 1.5% of all boys identified themselves as bisexual, mostly homosexual or 100% homosexual, whereas 3.5% of boys said that they had had sex with someone of the same gender in the past year.

Mental health

Mood and anxiety disorders are among the most prevalent mental health conditions affecting youth. Major depressive disorders, suicidal ideation and adolescent adjustment reactions should be considered in the male who presents with psychosocial changes (decrease in school performance, increasing conflict with parents and authority, loss of interest in activities or frequent, or minor somatic complaints). Boys may be reluctant to seek care for emotional problems, fearing that this may be perceived as a weakness. Therefore, it is of utmost importance for the clinician to bring up these topics with young men. Depression and suicide are being recognized with increasing frequency among adolescent male patients, and it is important to recognize that agitation and aggression could be a sign of depression in adolescent boys, more so than in girls. Although suicide attempts requiring medical attention are more common for females, the completed suicide rate is far greater for males. Suicidal ideation in young men, particularly if associated with alcohol and drug use, should always be taken seriously, and appropriate referrals should be made to mental health services. It is also important to recognize early psychosis, which often presents during the teen years.

Video Is your penis size 'normal'?

Attention deficit-hyperactivity disorder

Attention deficit-hyperactivity disorder (ADHD) has a prevalence of 7.5% to 9.4% in adolescents (24). Males are approximately three times more likely to have ADHD than females, and those with untreated ADHD and school failure may have associated comorbidities such as oppositional defiant disorder and conduct disorder. These youth may exhibit behaviours such as truancy, substance abuse, family and peer conflict. Driving vehicles is also problematic, with increased associated accidents and traffic violations (25). A comprehensive approach to treatment, including dealing with educational needs, medication and any comorbid conditions, is important.

Eating disorders (26)

Disturbances of body image and diet are less prevalent in males than females; nevertheless, it is more common than generally believed (approximately 10% of cases of anorexia and bulimia nervosa). Recent Canadian data (27) indicate that for early-onset eating disorders (diagnosed before 14 years of age), the number of males affected is higher than females (ratios of 10:4.5 versus 10:1 for early-onset versus late-onset). In addition to the typical symptoms, presenting symptoms of eating disorders in boys may include overexercise, intense bodybuilding, the use of anabolic steroids, and preoccupation with body shape and musculature. Weight loss or gain may occur. The symptoms can go undetected for long periods of time because they may not be alarming to parents, teachers or coaches. Much research on eating disorders excludes males, but some factors are believed to increase the risk of disordered eating among males, including participation in certain sports (such as wrestling or running) and premorbid obesity. Psychiatric comorbidity is common, particularly depression, low self-esteem and substance abuse. Treatment and outcome seem to mirror that of females with eating disorders.

Although not classified as an eating disorder, obesity rates are rising in adolescent males. This may be related to increased sedentary activities (television, video games, computers and Internet use), fewer aerobic activities and increased portions in meals (4).

Special populations of adolescent males

Although it would be impossible to discuss the health issues of all special populations of teenage boys, there are several groups that have the potential to experience marginalization and victimization more often than ‘mainstream’ boys. These special groups, depending on circumstance, may experience health and mental health difficulties more often than their peers. These young men include incarcerated youth, street youth, Aboriginal youth, gay or transgendered youth, inner-city youth, recent immigrants, and youth victims of abuse, violence or neglect. A few examples may illustrate the importance of recognizing these higher risk youth and the issues that they are facing.

The McCreary Centre Society surveyed incarcerated and homeless youth in British Columbia and wrote a manuscript titled “A Moment for Boyz” (3). They found that 9% of incarcerated male youth were involved in sexual favours for financial gain. This was even higher among homeless or street-involved youth (27% of boys). In another study (28) in 1995, street youth in Vancouver and Toronto were found to be disproportionately male, and 25% of them had lived on the street for more than three years. Many had a past history of physical and sexual abuse during childhood (28). A final example involves males who are, or who worry they might be homosexual. These young men have a higher rate of suicide, at-risk behaviours and are more often victims of violence (29–33). Without a doubt, health care for these special populations of young men can pose extra challenges; nonetheless, it is important to identify these young men and offer them as much comprehensive health care as possible. Early identification of high-risk youth, forging an alliance and inviting them to return to see the physician have the potential to reduce negative health outcomes.

MALE ADOLESCENT ACCESS TO HEALTH CARE

With the plethora of possible reasons to see a health care provider, why is it that so few adolescent clinics have a large male clientele? Some of this is likely related to the young person's developmental stage (34), because some young males may feel invincible, thus denying or not acknowledging their need to interact with the health care system. Conversely, admitting to illness may make them feel vulnerable and as if they are not living up to a perceived standard of male behaviour. Young males are often much more reluctant than girls to discuss issues involving mental health, relationships or sexuality (35). Parents may also play a role because they may not encourage health maintenance visits, feeling that their son is healthy. Fathers may not role model good self-care and the need for health maintenance visits. One study (34) showed that 24% of men said that they would wait as long as possible before seeing a clinician, despite illness or pain.

Despite these obstacles (real and perceived), there are ways to attract and connect with adolescent boys (36). One place to start is with the parents of young men. When boys are in their prepubertal years, physicians can make sure that they have educated the parents about the value of health maintenance visits for their soon-to-be teenager. Parents can be educated on the need to assume an active role during their sons transition from childhood into young adulthood to ensure that they receive routine and preventive health care, care for chronic health conditions and medical evaluation for somatic symptoms.

Video Does Penis Size Really Matter?

For most males (65%), the sex of the physician is not important (37,38). Of far greater importance is the communication about and empathy for the adolescents' concerns, as well as the professional's comfort with the adolescent.

It is vital to take every opportunity with an adolescent boy to talk about issues beyond the presenting complaint. Time may not always allow for a thorough HEADSS interview at each visit (39,40), but at the very least, the physician can let the teen know about the importance of regular checkups and that they are welcome to contact the physician if they experience any concerns about their health or well being. Physicians should allow for opportunities during health care visits to teach adolescent males about signs and symptoms of diseases. They can take opportunities during preparticipation athletic examinations to assess and refer as needed for health risk behaviours and exposure to violence and abuse. When planning follow-up visits with teen boys, especially those with chronic conditions, frequent, short visits can be more productive than infrequent visits in which there is much to discuss.

The most important tool for connecting with the adolescent male by far is good communication. Because many boys find it hard to talk about themselves, it is important to start with nonthreatening questions and progress to more sensitive areas, even going back and forth from sensitive questions to more neutral topics. For some boys, too many personal topics at one visit may be overwhelming, and returning to these topics at subsequent visits may be better tolerated. The reasons for more intimate questions should be explained. Boys may not naturally see a connection between psychosocial stressors and physical symptoms. Also, boys are often more open to authority figures, taking a problem-solving approach rather than spending time delving into emotional aspects or causes of their problems.

Confidentiality is very important with adolescent boys, and they may need reassurance, more than once, that the physician's conversations with them will remain private. Of course, an explanation of the limits of confidentiality should precede the interview. When encountering an adolescent male in the health care setting, physicians should assess and foster protective factors to promote resiliency.

CONCLUSION

The health of adolescent males is an interesting and important area. Although this is generally a physically and emotionally healthy group, there are significant health care issues involving puberty, sexual health, risk behaviours, substance use and mental health. These issues present challenges to the physician, but also important opportunities to connect with young men, teach them about how their bodies work, reduce the incidence of risky behaviours, and intervene early in young men with psychosocial problems such as mood, body image or substance use problems. Physicians must be knowledgeable about their common health concerns so that they can anticipate which issues may be important to them. The physician's success with teenage boys depends on their ability to take the time to ask the teen about their lives and their skill in communicating with them.

Acknowledgments

The authors thank Dr Sheri Findlay, Dr Jean-Yves Frappier and Dr Marc Girard for their contributions to the present article.

Contents

• Abstract
• Video Police Request For Pic Of Teen's Penis Widely Condemned
• NORMAL MALE PUBERTY
• COMMON CONCERNS ASSOCIATED WITH MALE PUBERTAL CHANGES
  • Delayed puberty
  • Precocious puberty
  • Gynecomastia
  • Genital development
  • Physical differences and abnormalities
  • Erections, ejaculation and masturbation
• CLINICAL WORK WITH ADOLESCENT BOYS
  • Violence and illegal activity
  • Substance use and abuse
  • Reproductive health issues and sexual orientation
  • Mental health
• Video Is your penis size 'normal'?
  • Attention deficit-hyperactivity disorder
  • Eating disorders (26)
  • Special populations of adolescent males
• MALE ADOLESCENT ACCESS TO HEALTH CARE
• Video Does Penis Size Really Matter?
• CONCLUSION
• Acknowledgments
•