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Addressing sexual health with adolescents must be a priority

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Practical solutions to improve sexual health care

 

Sexual development – including puberty, dating and coitarche – is a hallmark of adolescence. By late adolescence, the majority of teens are sexually active. A recent Centers for Disease Control and Prevention report revealed that sexually transmitted infections are at an all-time high in the United States, with the majority of infections occurring in adolescents. Conversely teen birth rates are at historic lows, although it remains unclear if this trend will continue as federal funding to teen pregnancy prevention programs has been cut. Given this changing environment, pediatricians must advocate and provide education for teens and their families on sexual health and development.

National organizations have authored practice guidelines to assist clinicians in providing care for teens. Despite these efforts, recent research has demonstrated that we are frequently falling short of providing optimal care. The question remains: How can pediatricians in a busy practice integrate these guidelines?

This clinical report from the American Academy of Pediatrics focuses on practical solutions to improve sexual health care for teens. Clinicians can learn how to create a welcoming environment for teens, including LGBTQ youth; explain confidentiality to patients and their families; obtain sensitive histories; and effectively counsel adolescents on healthy relationships, safe sex, and pregnancy prevention. This report also outlines sexually transmitted infection screening and treatment guidelines. Implementing these changes – such as asking family to step out during the confidential history – can help identify and treat underlying risk behaviors in adolescents and support the development of the teen “patient-in-training.”
 

Kelly Curran , MD, is assistant professor in the section of adolescent medicine in the department of pediatrics at the University of Oklahoma, Oklahoma City. She also is a member of the Pediatric News editorial advisory board. Dr. Curran was asked to comment on the AAP clinical report. Email her at pdnews@frontlinemedcom.com .


 

FROM PEDIATRICS

 

You are an important source of sexual and reproductive information for adolescents, and can be instrumental in preventing unintended pregnancies and sexually transmitted infections as well as promoting healthy relationships. A new clinical report from the American Academy of Pediatrics’ Committee on Adolescence provides a variety of tools and techniques to help you with these discussions with your patients.

Confidentiality and consent are two of the most important factors to consider when discussing sexual health with adolescents, according to Arik V. Marcell, MD, and Gale R. Burstein, MD, coauthors of the report (Pediatrics. 2017. doi: 10.1542/peds.2017-2858). As confidentiality is promoted over the course of time, adolescents are more likely to return for care. Promoting a confidential environment also allows adolescent patients to feel free to communicate about sensitive topics such as sexual behaviors, partners, or gender. This is especially true for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth, who may need more social indications that you and your office are sympathetic to sensitive issues. One way to do this is to post an office policy that details the confidential services you provide and ensure that the post is visible to all parents and adolescents. Explain this information at the beginning of the visit, starting at age 11-14 years. State laws regarding consent and confidentiality vary from state to state. The Guttmacher Institute and the Center for Adolescent Health and the Law provide resources summarizing laws for each state.

Clear and effective communication is another important feature in providing sexual health care to adolescents. Adolescence is a time of great change, and many adolescents may not feel comfortable asking questions, even though they want them answered. The AAP report recommends utilizing several interview techniques to get solid answers from adolescents.

Asking direct but open-ended questions is a great way to get useful answers from adolescents and it avoids yes/no answers. After listening to a patient’s response, use a reflection response, or one that mirrors the feeling of the patient. This allows the patient to feel that he or she is being heard. Restating and summarizing the interview also is an effective tool and allows the patient to understand what has been discussed. Asking questions that provide insight into the patient allows you to better understand the patient as a person. The use of reassuring and supportive statements is important to support patients and allow them to feel more comfortable, according to the report.

A doctor talking to her patient. javi_indy/ Thinkstock
When communicating, it is key to remember the use of gender-neutral terms and clarifying statements. The use of gender-neutral language allows you to communicate with patients without navigating gender issues; one example is to use the person’s name instead of pronouns. Adding sexual orientation questions also can be a useful technique; in such a case, ask the person what pronouns he or she prefers. Clarifying statements allow the physician to ensure that they are fully understanding the patient. If you have any questions concerning patient communication, the “The 5 P’s: Partners, Prevention of Pregnancy, Protection From STDs, Practices, and Past History of STDs” in the report provide a framework to complete a sexual history.

Apart from communication strategies and creating a safe and welcoming environment where confidentiality is promoted, there are several topics from the report to focus on.

• Reproductive life plans. It is important to broach this topic with adolescents. Many adolescents don’t have a pregnancy plan or understand how this would affect their lives. Asking questions concerning the desire to become pregnant, how many children the patient would like to have and when, and past and present pregnancy status will help adolescents plan and understand the issues surrounding pregnancy.

• Sexual assault and sexual abuse. These topics are particularly relevant to adolescents. Young people aged 12-34 years experience some of the highest rates of rape and sexual assault. When questioning a young person about sexual assault, questions should include whether she has been touched by anyone in an uncomfortable way, forced into unwanted sexual contact, or whether she has been “date raped” (Pediatrics. 2008. doi: 10.1542/peds.2008-1581). When dealing with sexual assault, you always should comply with state guidelines regarding abuse, rape, and incest.

• Physical exams. These exams, including breast and female and male genital exams, should be approached with care. When conducting a physical exam, you always should have a chaperone present and allow the option of letting a parent or guardian be in the room. You always should describe what areas will be examined and inform the patient that if he or she feels uncomfortable at any point to tell you to stop. Some adolescents may not feel comfortable with their bodies and with disrobing; in this event, offering a gown may help make the patient more comfortable. It is important these exams are done to identify any pathologies and indications of sexual maturity.

Dr. Cora C. Breuner, chairperson of the AAP Committee on Adolescence
Dr. Cora C. Breuner
Cora C. Breuner, MD, highlighted in an interview several topics from the report to focus on, including human papillomavirus immunizations and counseling adolescents concerning sexual health. While the AAP immunization schedule has recommendations for HPV immunizations, the United States is behind in this regard. This may be a contributing factor to higher rates of cervical and rectal cancer compared with rates in other developed nations. The importance of this immunization must be impressed on patients and their parents, she emphasized.

In addition, counseling adolescents concerning sexual health should include contraception information (Pediatrics. 2014, Oct 1. doi: 10.1542/peds.2014-2300). This should include information about condoms as well as long-acting reversible contraceptive methods, said Dr. Breuner, chairperson of the Committee on Adolescence.

None of the contributors to the report had relevant financial disclosures.
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