Adolescence is a stage of transition from childhood to adulthood that includes rapid physical, cognitive, and psychosocial growth. ^{1 , 2} It is a critical period, as many behavioral patterns emerge during this period, which may persist throughout life. ³ Psychological well-being and overall health of adolescents are major concerns worldwide. ⁴ Adolescents engage in life-threatening behaviors, such as alcohol and substance use, unsafe sex, poor eating, and heightened risk-taking, which affects their psychological well-being. ^{4 , 5} According to the 2011 census, in India, 1/4 ^th of the population are adolescents (253 million), and 54% belong to the 10-14 age group, and nearly 46% are in the 15-19 years of age. ⁶

Adolescents are highly attracted to modern technologies because they are psycho-socially immature and more prone to smartphone addiction due to the influence of the environment and peers. ⁷ Reports highlight that adolescents are highly addicted to smartphones, equivalent to substances and various types of behavioral addiction. ⁸ A meta-analysis by Davey et al. showed prevalence of smartphone abuse among Indian adolescents to be approximately 39% - 44%. ⁹ Billieux et al. documented that problematic smartphone use (PSU) is defined as “an inability to regulate one’s use of the smartphone, which eventually involves negative consequences in daily life”. ¹⁰ It is a type of behavioral or psychological dependence on mobile devices that is closely linked to excessive digital media use, such as Internet addiction disorder. ¹¹ PSU has been associated with various psychopathologies. ¹²

Adolescents with PSU are highly exposed to viewing sexualized content through videos and reality programs. In addition to these sources, social media platforms and various mobile applications have increased sexual content. ¹³ The adolescents are more frequently engaged in online sex chat, and are thereby exposed to cyberbullying and online harassment. ¹⁴ PSU may lead to impulsiveness, which plays a pivotal role in an increased number of sexual partners. ¹⁵

The term sexual orientation refers to the sex to which individuals are sexually or romantically attracted. Gender identity refers to an individual’s basic sense of being male, female, transgender, or something else. ¹⁶ Gender orientation is biologically determined, and sexual expressions have many external influences, such as the media. However, there is a paucity of information on how PSU affects sexuality in adolescence. The present study aimed to understand the existing patterns of smartphone usage among late adolescents and their association with the development of adolescent male sexuality.

A total of 149 students were screened, and nine were excluded from the study because they were older. Among the remaining 140 students, 6 were unwilling to participate in this study; hence, they were excluded. The response rate was 95.7%. Of the 134 students, 98 were medical students, 20 were dental students, and 16 were allied health sciences students. Among the students, 90.3% were permanent residents of India, followed by 6.7% nonresidential Indians, and 3% foreign nationals. Most of the students resided in the hostel (85.1%), while 13.4% of the students lived at home, and 1.5% stayed in an apartment with friends.

In the present study, based on a predetermined cut off score of 31 on SAS-SV, the prevalence of problematic smartphone use (PSU) was 45.5% among the students.

As shown in Figure 2, 85 students obtained information about pubertal changes from friends, followed by books/magazines (81), schoolteachers (79), and movies (78). In contrast, fewer adolescents turned to mothers, ¹⁶ fathers, ¹⁷ or doctors ¹⁸ for information related to pubertal changes, ¹⁶ fathers, ¹⁷ or doctors ¹⁸ for information related to pubertal changes.

As shown in Table 1, regarding sexual orientation and gender identity among the students, 3% of the students desired to wear the dress of the opposite sex, while 94.8% did not, and 2.2% were not unsure. Among these students, 87.3% were happy with their current sexual identity, while 7.5% of them wanted to be members of the opposite sex. 86.6% Of students were comfortable with their genitalia, whereas 10.4% were unsatisfied. Romantic feelings towards the opposite sex were perceived to be normal by 91.8% of the students, while 5.2% felt abnormal, and 3% were not unsure. Out Of these students, 88% were attracted to the opposite sex, while 6% were attracted to the same sex, and 6% were attracted to both sexes.

Table 2 shows no significant association between PSU and gender identity or PSU and sexual orientation. Regarding the knowledge of adolescent sexuality, 72% attended classes on the topics related to sex in schools, 19% had not attended, and 9% were not sure.

Regarding normal male sexuality, 92.5% of the students were aware of the mental changes occurring during puberty, 90.3% were aware that adolescence was the final opportunity for growth (final height), and 83.6% of the study population indulged in masturbation. Among the adolescents indulged in masturbation, 28% felt guilty after masturbation, 30% felt masturbation caused severe damage to health, and 99.1% of the students preferred masturbation in private and thought it was not normal to masturbate in public. There was no statistically significant association between PSU on gender identity and sexual orientation ( Table 3) Table 3.

Responses		Problematic smartphone usage		P value
		No n (%)	Yes n (%)
Liking wearing clothes of the opposite sex	No	71 (54.6)	59 (45.4)	1
	Yes	02 (50.0)	02 (50.0)
Liking to be a member of the opposite sex	No	69 (55.6)	55 (44.4)	0.511
	Yes	04 (40.0)	06 (60.0)
Feeling uncomfortable with own genitalia	No	65 (54.2)	55 (45.8)	1
	Yes	08 (57.1)	06 (42.9)
Feeling that romantic feeling towards the opposite sex is normal	No	08 (72.7)	03 (27.3)	0.344
	Yes	65 (52.8)	58 (47.1)
Having attraction/feeling towards another person of the opposite sex	No	06 (54.5)	05 (45.5)	1
	Yes	67 (54.5)	56 (45.5)
Having attraction/feeling towards another person of the same sex	No	67 (53.2)	59 (46.8)	0.290
	Yes	06 (75.0)	02 (25.0)
Having attractions/feelings toward people of both sexes	No	66 (53.7)	60 (46.3)	0.071
	Yes	07 (87.5)	01 (12.5)

Statistical significance was set at P <0.05.

In our study, 90% students had watched pornographic content and one of the students had watched when he was 9 years old, 4.2% watched porn content before they turned 10, and 58% watched the porn content between 15-18 years. Most of the students (95%) wanted to watch the porn content alone, and 90.8% watched the porn content through smartphones. Regarding the frequency of watching porn content, 45% viewed less than once a week, and 37% watched 2-3 times per a week.

After watching the pornographic content, the psychological behaviour shows that 7.5% of the students felt altered perception of communicating with the opposite sex, 11.7% responded that watching porn content had altered the study pattern, and 12.5% answered that it affected their academic performance. However, 71% of the students revealed that they had been sexting at least once. Our study did not find a statistically significant association between PSU and exposure to pornographic content ( Table 4).

Sexuality, which involves showing interest in a desired activity, orientation, and preference, is a normal phenomenon during adolescence. Adolescent sexuality includes an array of factors, such as intimate partnerships, gender identity, sexual orientation, religion, and culture. ¹⁹ Adolescent sexuality development correlates better with the biopsychosocial model. ²⁰ The array of biological, psychological, and social factors plays a predominant role in the progression of adolescent sexuality. Social factors such as parents’ attitudes related to sexuality, parenting style, relationship with peers, and cultural influence are the major attributes of adolescent sexual attitudes. ²¹ Recently, the media have also greatly influenced adolescent sexuality. Adolescents have easy access to information on sexuality, sex crimes, and violence through the media, influencing their perceptions and attitudes toward sexuality. ²² Further, television and the Internet also provide fast access to sexual content, altering adolescents’ perception towards sexuality. ²³ Smartphone provides various benefits such as fast internet access, video calling, easy access to social media, and gaming. ²⁴ Increased smartphone use leads to addictive behavior. One commonly referred term is Problematic Smartphone Use (PSU), similar to behavioral addictions such as substance-related, gambling, and Internet addiction disorder. ²⁵ Adolescents are more vulnerable to problematic smartphone use because of the imbalance between the reward and behavioral control systems. ¹⁸ A recent meta-analysis showed that Indian adolescents are highly addicted to smartphones and exhibit problematic sexual behaviors. ⁹ So, we conducted the present study to evaluate the impact of problematic smartphone use on male adolescent sexuality development.

The prevalence of smartphone addiction based on the SAS-SV cut off score of 31 was found to be 45.5%, which reflects a higher PSU as compared to Chinese students (38.5%), ²⁶ European countries Belgium (21.5%) ²⁵ and American university students (20.1%). ¹⁵ This discrepancy might be due to differences in sampling methods and the rapid development of telecommunication with cheaper and faster internet along with an increase in the budget of smartphones in India. ²⁷

In our study, transvestism, is observed in 3% of the students. Among the participants, 10.4% reported dissatisfaction with their genitalia. Men’s attitudes toward genitals have been shown to affect their psychological status. Thus, in men with dissatisfied genitals, it creates a state of insecurity, and in men with contented genitals, it gives confidence. ²⁸ The majority of the participants, 91.8%) thought romantic feelings towards their female counterparts were normal. Romantic relationships during adolescence are essential for development and well-being. Further, it has a positive association with the development of personal identity, self-esteem, and social competence and is useful for career planning. It has been positively associated with the formation of personal identity, adaptability to change, self-esteem, social competence, scholastic achievement, and career planning. ²⁹ Late adolescence (16–18 years) occurs when consolidation of romantic bonds occurs, elevating the risk of a poor-quality romantic relationship. ³⁰ In our study, normal romantic relationships towards the opposite sex might be due to a greater preference for cyber-relationship applications such as web chats and social networking chat rooms. These social networking chat rooms offer online romantic relations, which might be heightened by excessive or problematic internet use. ³¹ We report 6% of same-sex attraction among the students; however, in a study conducted by Nama et al. among Canadian medical students in Ottawa, 18% of the medical students were involved in same-sex attraction or gay behavior. ³² Further, our study reported no significant associations between sexual orientation, gender identity, and PSU. In this study, a higher number of students (85%) obtained information regarding the pubertal changes from their friends. Previous studies have also revealed that males share information regarding puberty and first wet dreams with their friends. ³³

In this study, 72% of adolescents attended sex education in schools. In a study done by Kumar et al. shows that 97.1% of students like to have sex education during their school life period. ³⁴ Further, genital growth in boys has been reported to be associated with altered cognitive function. ³⁵ In this study, 92.5% of students were aware of mental changes during puberty, 90.3% aware that adolescence is a final opportunity for growth, and 83.6% of students had self-explored genitalia.

In this study, 28% of students felt guilty after masturbation, 30% felt masturbation could induce serious damage to health, and 99.1% preferred private masturbating practice and not in public. Similar to our report, a study conducted among Chinese students showed an association between floating anxiety, somatic and hysterical symptoms, and masturbation. ²

In our study, 90% of the students had viewed porn content, which is comparable to other studies conducted among adolescent boys in Sweden (98%) ³⁶ and Australia (87%). ³⁷ In the current study, 45% viewed porn content less than once a week, and 37% watched 2-3 times per a week, which is higher as compared to a study done among Polish students, where 34% viewed pornographic content once a week and 24% few times a week. ³⁸

In this study, watching pornographic content did not influence students’ psychological behavior and study patterns. Similar to our report, a study conducted on Croatian adolescents showed that viewing pornography displayed no significant negative alteration in adolescent subjective well-being, depression or anxiety, or self-esteem. ³⁹ In a study conducted by Šević et al. among Croatian adolescents, watching porn content or sexually explicit material online did not affect academic grades, study patterns, or well-being. ⁴⁰ In contrast, Beyens et al. reported that watching online pornographic content has a negative association with students’ academic performance when compared between baseline and six months. ⁴¹ Further, we did not observe a significant association between problematic smartphone use and pornographic content exposure.

The strength of this study is that it is the first of its kind to correlate adolescent sexuality with smartphone usage using a standardized questionnaire (Smartphone Addiction Scale – short version, SAS-SV). This study has some limitations. Considering the smaller sample size and enrolment of only health sciences students, the results cannot be generalized.

This study implies the formulation of structured awareness programs to be carried out by health professionals and to educate parents about handling adolescent issues. In addition, it encourages adolescent health programs to create knowledge about risky behaviors and community support groups. This study highlights the need to include comprehensive sex education as part of the school curriculum and to educate young Internet users on the safe and responsible use of the Internet.

The study was approved by the Institutional Ethics Committee on 15/01/2020 (approval number: IEC KMC MLR 01/2020/36) and the Head of the Institute. Eligible participants were contacted individually using the MS Teams platform. The purpose of the study, the role of their participation, the study procedure, and confidentiality were explained, and informed consent was obtained online using google forms from each participant.