Clinicians missing mark on sex talk with teens
As a family planning clinician, you should be prepared to discuss sexuality with your adolescent patients. Know, however, that you might be the first provider to do so. In a study looking at discussions held between pediatricians and family medicine physicians and teen-age patients, results show less than two-thirds of such interactions included talk about sex, sexuality, or dating during annual visits.1
Previous studies on discussions of sex during doctors' visits have been based on information teens or physicians have reported after visits.2,3 To capture naturally occurring conversations, scientists in the current study used audio recordings of annual visits, including camp and sports physicals, for 253 adolescents. The patients, ages 12 to 17, visited pediatricians and family medicine physicians at 11 North Carolina clinics.
The researchers listened to the recordings for any mention of sexual activity, sexuality, or dating. Their analysis shows physicians brought up sex in 65% of visits, with conversations lasting an average of 36 seconds. The other 35% of visits included no mention of sex.
"As researchers, we knew no study has existed that has examined how these conversations sounded, and we wanted a better idea of where current practice stands regarding these discussions," explains Stewart Alexander, PhD, associate professor of medicine in the Department of Medicine at Duke
University Medical Center, Durham, NC. "Initially, we were planning to examine the quality of counseling teens about sex but found that the conversations were quite different — even when they occurred."
As researchers listened to the provider-patient interactions, they realized that specific training might be able to help providers improve these discussions, says Alexander, who served as lead author of the current paper. The research team is developing training to address these issues, Alexander states.
Check your approach
It is important for providers to engage adolescents in discussions about sex. In the current study, none of the adolescents initiated discussions on sex, which reinforces the need for clinicians to start the conversation. As research progresses in identifying successful strategies providers can use to engage teens in discussions to help promote healthy sexual development and decision making, what can you do to facilitate such interactions with your adolescent patients?
For starters, clinicians wishing to address issues of sexuality with adolescents should remember that confidentiality discussions are best when they occur before the topics of sex are introduced, says Dennis Fortenberry, MD, MS, professor of pediatrics and medicine at the Indiana University School of Medicine in Indianapolis. Younger adolescents might have limited understanding of the legal and ethical nuances of confidentiality, but almost all have definite understandings of privacy, explains Fortenberry, a co-author of the current study.
One way to introduce sexuality with young patients is to ask first about relationships, says Fortenberry. For young people in a relationship, follow-up questions can address specific behaviors with their relationship partner, their feelings about those behaviors (including whether the behavior was consensual), and expectations for future behaviors, he states.
"These types of questions allow exploration as well of the adolescent's boundaries about sexual activity, which are quite clearly formed for many," says Fortenberry, who has guided an Indiana University research program focused on adolescents during the past 17 years. "I often ask specifically about kissing because it is a very common experience, is associated with far less social disapproval than other forms of sexual interaction, and is easy to acknowledge."
For young people who don't identify a current relationship, clinicians can follow up with a question about past relationships and behaviors, or with a question about sexual contact with someone who wasn't considered a relationship partner, says Fortenberry.
When responding to reports of specific sexual behaviors, including abstinence, Fortenberry suggests a question such as "what was good (or bad) about your decision to have sex?" or "what was good (or bad) about your decision to abstain?"
What is "sex talk?"
Some clinicians use questions about pubertal development as an entrée to asking about sex, says Fortenberry. However, asking young men about pubic hair development or young women about their menstrual periods does not constitute "sex talk." [Looking for more information on conducting initial reproductive health visits in teens? Check the HEEADSSS (Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, and Safety from injury and violence) method of interviewing covered in the Contraceptive Technology Update article, "How to get into heads of teens in initial visit," January 2014, p. 8.]
Clinicians also should remember that many young people are still developing a sexual identity so that unwarranted assumptions about heterosexuality often are revealed through the use of specific words that presume the gender of a partner, observes Fortenberry. Gender-neutral questions can allow discussions with sexual minority youth who often feel invisible in sexuality discussions, he states.
- Alexander SC, Fortenberry JD, Pollak KI, et al. Sexuality talk during adolescent health maintenance visits. JAMA Pediatr 2013; doi: 10.1001/jamapediatrics.2013.4338.
- Henry-Reid LM, O'Connor KG, Klein JD, et al. Current pediatrician practices in identifying high-risk behaviors of adolescents. Pediatrics 2010; 125(4):e741-e747.
- Kitts RL. Barriers to optimal care between physicians and lesbian, gay, bisexual, transgender, and questioning adolescent patients. J Homosex 2010; 57(6):730-747.