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ORIGINAL ARTICLE
Adolescent male health
Michael Westwood MB ChB MRCP(UK) FRCPC1, Jorge Pinzon MD FRCPC2
M Westwood, J Pinzon. Adolescent male health. Paediatr Child
Health 2008;13(1):31-36.
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 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. Working with adolescent boys
involves gaining the knowledge and skills to address concerns such as
puberty and sexuality, substance use, violence, risk-taking behaviours
and mental health issues. The ability to engage the young male patient
is critical, and the professional must be comfortable in initiating conversation about a wide array of topics with the teen boy, who may be
reluctant to discuss his concerns. It is important to take every opportunity with adolescent boys to talk about issues beyond the presenting
complain, and let them know about confidential care. The physician
can educate teens about the importance of regular checkups, and that
they are welcome to contact the physician if they are experiencing any
concerns about their health or well-being. Parents of preadolescent and
adolescent boys should be educated on the value of regular health
maintenance visits for their sons beginning in their early teen years.
La santé des adolescents de sexe masculin
Bien que les adolescents aient autant de problèmes et de préoccupations
reliés à leur santé que les adolescentes, ils sont beaucoup moins
susceptibles d’être traités en milieu clinique. Ce constat découle à la fois
de facteurs personnels et du système de santé lui-même, qui n’est pas
toujours encourageant et conçu pour offrir des soins complets aux hommes.
Pour travailler avec des adolescents, il faut acquérir les connaissances et les
compétences nécessaires afin d’aborder des préoccupations comme la
puberté et la sexualité, la consommation de drogues ou d’alcool, la
violence, les comportements de prise de risque et les problèmes de santé
mentale. Il est essentiel de pouvoir amener le jeune patient à se confier, et
le professionnel doit être à l’aise de discuter de toute une série de sujets
avec l’adolescent, qui peut hésiter à lui faire part de ses préoccupations. Il
est important de profiter de toutes les possibilités de discuter avec
l’adolescent d’autres questions que son problème courant et de lui parler
des soins confidentiels. Le médecin peut informer l’adolescent de
l’importance d’examens de santé réguliers et du fait qu’il peut appeler le
médecin s’il est préoccupé par sa santé ou son bien-être. Les parents de
préadolescents et d’adolescents doivent être informés de la valeur de
rendez-vous de suivi réguliers pour leur fils, dès le début de son
adolescence.
Key words: Adolescent male health; Puberty
lthough 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.
A
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).
1Adolescent
and Gynecology Program, Montreal Children’s Hospital, McGill University, Montreal, Quebec; 2Youth Health & Eating Disorders
Program, BC Children’s Hospital, University of British Columbia, Vancouver, British Columbia
Correspondence and reprints: Dr Michael Westwood, Adolescent and Gynecology Program, Montreal Children’s Hospital, 2300 Tupper Street,
Montreal, Quebec H3H 1P3. Telephone 514-695-6345, fax 514-631-3399, e-mail [email protected]
Accepted for publication November 20, 2007
Paediatr Child Health Vol 13 No 1 January 2008
©2008 Pulsus Group Inc. All rights reserved
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• 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.
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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
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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
Paediatr Child Health Vol 13 No 1 January 2008
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
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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.
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
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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.
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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.
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
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Paediatr Child Health Vol 13 No 1 January 2008
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
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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.
ACKNOWLEDGEMENT: The authors thank Dr Sheri Findlay,
Dr Jean-Yves Frappier and Dr Marc Girard for their contributions
to the present article.
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