Talking with Adolescents about Sexuality in the Office Setting ...

Talking with Adolescents About Sexuality in the Office Setting
Several studies have shown that adolescents welcome conversations about sexuality with physicians, and that these conversations do make a difference in helping youths to make good decisions about their sexual health. One might presume, then, that the absence of conversation cannot help youths make good decisions, and that correct information and the opportunity to talk about sexuality with a concerned and informed health care provider cannot harm young people. Given the morbidity of sexually risky behaviors, the mandate is clear in terms of the importance of finding opportunities during the course of routine health care to talk about physical, emotional, and sexual development. The reluctance of physicians to talk about sexuality with teenagers in the office setting is due to several factors, including lack of information, discomfort about how to begin the conversation, the belief that such discussions either do no good or precipitate problematic sexual behavior, and lack of reimbursement for the time required for such conversations.

Prior to starting a conversation with a young patient about sexual issues, the privacy of the physician-patient relationship must be clearly established. Ideally, this understanding can be articulated during their early adolescence, with parents present, before the need for private conversations. The physician can most usefully frame his or her role as being one in which another adult professional is a resource for youths to help them address health care concerns, including those about sexual functioning. Unless there is serious jeopardy to health or life, few parents are hesitant to allow a trusted family physician assurance of privacy when talking with teenagers. The American Academy of Family Physicians has published a document for guidance on confidentiality with youths that may be helpful for parents and young people; it articulates the boundaries of this agreement. Appendix A offers a consent form that parents can sign to show that they respect the need for confidentiality between their son or daughter and the family physician.

The developmental stage of the young person, rather than chronologic age, should guide the conversations about sexuality with youths in the office setting. Early adolescents need reassurance and information about their changing bodies, changing relationships within the family, and the beginnings of emotional "incontinence" that may be as confusing to the youth as it is to adults. Middle adolescents generally are dealing with the need to fit into their peer group, beginning separation from family, and learning more "adult" forms of social interaction. At this stage the perception of what one's peer group is doing and values is probably the most important predictor of whether a single adolescent is likely to engage in similar behaviors. Thus if a 15-year-old believes that most of his or her peer group is having intercourse, the odds are high that he or she will be engaging in first coitus soon, regardless of whether he or she feels emotionally and physically ready for such intimacy. Adolescents who choose not to be sexually active in the face of the belief that most of the peer group is active need positive reinforcement for their ability to make decisions that are "different." Finally, during late adolescence the concerns about sexuality center around decisions about long-term intimate relationships, decisions about goals for family, more understanding and concern about the tenuousness of adolescent love relationships, and more integration of peer relationships into overall life goals. Figure 23.1 offers a "roadmap" for the selective screening of adolescents related to sexual health.

The physician should also consider what other complicating factors (substance abuse, poverty, school performance problems, family problems, poor self-esteem) make it likely that a particular adolescent is at risk for early or problematic sexual activity. Finally, reinforcement of adolescents for protecting their health should be a goal of any screening visit.7

Depending on whether there is increased risk for adverse outcome to health, whether there are concerns that require more detailed follow-up, or whether the adolescent is already involved in intimate relationships that may require further health care, the physician must make a specific assessment about how often to see the adolescent, whether to arrange follow-up regularly to allow more opportunity for conversation, or whether to make sure the adolescent simply is comfortable in requesting office visits if there are further needs or concerns. Given the health problems that occur in adolescents related to sexual decision making and behavior, it is not excessive to see adolescents who are involved in sexual relationships at least yearly or more frequently if they are young or are in need of further discussion, information, and evaluation.

Examination of the adolescent related to sexual health depends on the physical maturity, level of sexual activity, and acknowledgment of a reason for the examination. With early adolescents, general examinations that provide reassurance and the opportunity to discuss bodily change are usually sufficient. The decision about when to initiate pelvic examinations with adolescent girls is guided by first coitus, problems with gynecologic symptoms, or the need for contraception prior to coitus. For virginal adolescent girls, pelvic examinations are not necessary in the absence of gynecologic symptoms or concerns or an anticipated need for contraception. For boys, an examination provides the opportunity to provide education about changing bodies, teaching testicular self-examination, and talking about concerns regarding the body and maturational differences. Screening for sexually transmitted diseases (STDs) with adolescents is guided by whether there has been coitus, with the frequency of screening related to the presence of risk factors. Speculums used for the initial pelvic examination for adolescent girls must be small and warm, with adequate explanation ahead of the examination to minimize psychological or physical distress to the young woman.

Source: http://www.articles2day.org/2012/08/talking-with-adolescents-about.html

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