Build skill in taking teen sexual histories
Why is it so important that providers develop their skills when it comes to taking an adolescent sexual history? Each year in the United States, there are about 19 million new sexually transmitted infections (STIs), almost half of which are in young people ages 15-24.1
Taking an adolescent sexual history is a critical skill to develop for adolescent health providers, says Alicia St. Andrews, MPH, CHES, coordinator of the San Francisco-based Adolescent Health Working Group, a nonprofit group aimed at strengthening the adolescent health provider network. Healthcare providers, including pediatricians and other primary care physicians, are in an ideal position to provide sexual health information, screening, and treatment to adolescents as part of preventive health care, observes St. Andrews. Unfortunately, while two-thirds of adolescent patients report wanting information about STIs and pregnancy from their healthcare providers, few have ever discussed these issues with their provider.2
"Many primary care providers lack the training or are uncomfortable discussing sexual health issues with their adolescent patients," notes St. Andrews. "In fact, fewer than half of primary care providers routinely ask adolescents about their sexual activity, and far fewer ask specifically about STIs, condom use, sexual orientation, number of partners, or sexual abuse, despite the fact that care guidelines universally recommend obtaining comprehensive sexual histories from adolescents."
The Adolescent Health Working Group has recently released Sexual Health: An Adolescent Provider Toolkit, an updated and expanded version of its 2003 California-based version.3 The new toolkit champions a paradigm shift from a deficit/risk-based perspective to one that embraces adolescent sexuality as positive and normative in this stage of development, says St. Andrews. (To download a free copy, go to the group's web site, www.ahwg.net. Under "Resources," select "For Providers," "Adolescent Provider Toolkit Series," and "Sexual Health, 2010, 2nd edition.")
What has been the response to the toolkit? St. Andrews says the group has received positive responses from primary care providers, school-based health providers, educators, and advocates who have utilized the Sexual Health Toolkit module and participated in related training.
It is important that providers create a safe and confidential environment for teens to discuss potential sexual health concerns before the visit, just as it is important to build safe conversations when taking a sexual history, advises Gail Bolan, MD, director of the Division of Sexually Transmitted Disease Prevention at the Centers for Disease Control and Prevention.
Strategies include having open-ended sexual health questions as part of a computer-based or paper-based general health assessment and making the confidentiality policy of the clinic available to the teen in the waiting room, exam room, or through a web site, notes Bolan. (Visit the AHWG web site, www.ahwg.net. Under "Resources," select "For Youth." Under "Understanding Minor Consent and Confidentiality in CA," select "Quiz: How Well do you Know Your Health Rights and Responsibilities?" Resource also is available in Spanish.)
Making resources available for parents on the importance of a confidential visit to providing the best care possible for their teen also can help set the stage, she notes. (Visit the AHWG web site, www.ahwg.net. Under "Resources," select "For Parents/Caregivers." Under "Understanding Minor Consent and Confidentiality in CA," select "Helping Your Teen Take Responsibility For Their Health." The source also is available in Spanish and Chinese.)
Confidentiality is a key element in talking with adolescents, according to Bolan. Teens are more likely to disclose sensitive information if consent and confidentiality are explained to them. Be sure to review the laws and limits of confidentiality, and review situations in which confidentiality may have to be breached, such as in cases of reported abuse or suicidal thoughts. (To check the Guttmacher Institute's overview of minor consent laws, go to its web site, www.guttmacher.org. Select "Adolescents," then under "State Policies in Brief," select "An Overview of Minors' Consent Laws".)
Cover the "5 P's"
What needs to be covered during the sexual health history? Use the "5 Ps" as a general guide4
- Partners: Use open-ended questions to determine the number, sex, and concurrency of the teen's sex partners.
- Practices: Be sure to explore what constitutes sex, whether it is vaginal, anal, or oral. Learn to be comfortable discussing the full range of sexual activities in which teens often engage, says Anita Nelson, MD, professor in the Obstetrics and Gynecology department at the David Geffen School of Medicine at the University of California in Los Angeles. Why? Results of a 2010 study indicate pharyngeal gonorrhea is as high in adolescent women from a children's hospital as in adult women from an STI clinic.5
- Protection against STIs: This is a chance to check condom use: in what situations they are and aren't used, and those situations that make it harder or easier to employ their use.
- Past STI history: Check the patient's history of STIs, including whether their partners have ever had an infection. Explain that adolescents who have had a previous STI are more likely to get another infection in the next few months; rescreening can greatly reduce the risk.
- Pregnancy prevention: Discuss whether your teen patient wants to become pregnant. Review current and future contraceptive options.
- Forhan SE, Gottlieb SL, Sternberg MR, et al. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics 2009; 124:1,505-1,512.
- American Academy of Pediatrics: Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence. Sexuality education for children and adolescents. Pediatrics 2001; 108:498-502.
- Monasterio E, Combs N, Warner L, et al. Sexual Health: An Adolescent Provider Toolkit. San Francisco: Adolescent Health Working Group, San Francisco; 2010.
- Bolan G. Taking An Adolescent's Sexual History. Podcast. Accessed at http://www.medscape.com/viewarticle/743130.
- Giannini CM, Kim HK, Mortensen J, et al. Culture of non-genital sites increases the detection of gonorrhea in women. J Pediatr Adolesc Gynecol 2010; 23:246-252.