Enhancing Adolescent Care: Communicating for Better Sexual Health

1. Sexual History-Taking: Essential Questions

2. Objectives • Identify barriers to adolescents seeking and receiving health services • Understand state laws surrounding consent and confidentiality • Take a sexual history from an adolescent patient • Increase personal comfort level and confidence when taking sexual histories from adolescent patients • Utilize tools and resources on adolescent sexual health

3. What Does It Mean to Be Adolescent-Friendly?

4. Adolescent-Friendly Health Services Include • Comfortable, confidential, safe space maintained by office staff and providers • Communicating respectfully and appropriately • Screening for high-risk behavior • Awareness of how ability, age, culture, gender identity, sexual orientation, religion, or socioeconomic status can affect an adolescent’s reproductive health

5. For the most part, adolescents are: • Healthy • Resilient • Independent yet…vulnerable • Adolescents are not: • Big children • Little adults Adolescents

6. What Barriers Prevent Adolescents From Seeking Care? • Inaccessible locations and/or limited services • Limited office hours • Lack of money, insurance, and transportation • Poor communication by providers • Insensitive attitudes of care providers • Lack of provider knowledge and skills • Perceived lack of confidentiality and restrictions (parental consent/notification) .

7. Adolescents can: • Engage in healthy relationships that may include sexual activity • Participate in decision-making around pregnancy and STI prevention All Youth Need Sexual and Reproductive Health Care

8. What Is Healthy Sexuality? Sexual development and growth is a natural part of human development Healthy sexuality is expressing the sexual aspects of yourself that minimizes health risks Risk is activity that compromises a youth’s health and well-being

9. Sexual Orientation Sexual Attraction SexualBehavior Paradigm of Sexuality Gender Identity Biological Sex

10. Confidentiality Is Essential

11. Confidentiality Is Developmentally Expected • Expected need for increasing autonomy • Increasing intellectual capacity to give informed consent • Opportunity to take responsibility for health • Providers must feel comfortable with providing confidential care to youth and young adults

12. Professional Consensus

13. Sexual Health Services and Confidentiality JAMA study of 556 sexually active adolescents visiting a family planning clinic 59% would stop using ALL health services If mandatory parental notification was required for contraception 11% would delay HIV or STI testing and treatment 1% would stop having sex Reddy DM, et al. JAMA. 2002;288:710–714.

14. Confidentiality: Parental Perspective • Parents are not the enemy • Parents are experiencing their own adjustment to their child’s adolescence • Providers have an opportunity to educate parents about the need for confidentiality in the provider-patient encounter

15. Discuss Confidentiality in Advance • Inform parents about confidentiality policy before visit • Letter home: • Detail when parent will be included in clinical visit and when not • Discuss billing issues if possible • Display materials (posters or brochures discussing importance of doctor/patient confidentiality)

16. Starting the Conversation and Asking Sensitive Questions

17. Angela is a 16-year-old who has been your patient since she was a toddler but you haven’t seen her in 2 years • She comes in today for a sports physical • How do you begin the visit? • What questions do you need to ask? Case: Angela

18. Communication Tips (1) • Establish rapport • Provide confidentiality assurance and establish limits of confidentiality • Ask permission • Normalize • Note nonverbal cues

19. Communication Tips (2) • Minimize note-taking, particularly during sensitive questioning • Talk in terms the adolescent will understand • Developmentally appropriate questions • Ask open-ended questions • Practice listening skills

20. Communication Tips (3) • Avoid the surrogate parent and adolescent roles • It’s a conversation…not an interrogation! • What purpose does the information serve? • Healthy respect and regard for privileged information

21. Comprehensive HEEADSSS • H: Home • E: Education/Employment • E: Eating • A: Activities • D: Drugs • S: Suicide/depression • S: Sexuality • S: Safety • *Additional questions: • Strengths, Spirituality Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014.

22. SHEEADSSS • S: Strengths/Spirituality • H: Home • E: Education/Employment • E: Eating • A: Activities • D: Drugs • S: Sexuality • S: Suicide/depression • S: Safety Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014.

23. Utilizing HEEADSSS • Ask less-sensitive questions first on each topic • Can use written questionnaire in waiting room • Provider should follow up on answers drawing concern • Time limitations make model difficult

24. Other Clinical Interview Tools • GAPS: AMA Guidelines for Adolescent Preventive Services • Bright Futures: Collaboration between AAP and Bureau of Maternal Child Health Care) • Trigger Questionnaire: Developed by Office of Managed Care in the New York State Department of Health • ACOG Tool Kit: Designed by the ACOG Committee on Adolescent Health Care to help every office care for adolescent patients

25. What Is a Sexual Health History?

26. Sexual History Tips • Reassure confidentiality • Take history when the patient is still dressed • Assess development and structure questions accordingly • Watch for concrete vs. abstract answers • Avoid assumptions of heterosexuality

27. Why Is a Sexual History Important? • Affirm healthy behaviors • Address patient questions or concerns • Provide interventions for risk behaviors • Prevention counseling • Explore potential dysfunctions

28. Sexual History-Taking Template • Gender identity • Sexual orientation • Sexual coercion and abuse • Sexual activity • Number of partners • Frequency of intercourse • Type of sex practices • STI history and risk assessment • Pregnancy history and risk assessment • Contraceptive behaviors • Substance use

29. When to Take a Sexual History • Adolescents should have a sexual history taken at all preventative care visits • A sexual history is important and frequently relevant to the HPI • Take sexual history at least annually

30. Providing Developmentally Appropriate Counseling • Recognize sexual developmental milestones • When Counseling • Can your patient think abstractly or concretely? • Age development • Recognize variations: • Very mature 14-year-old vs. an immature 17-year-old

31. Discussing Sexual and Romantic Relationships • Have you ever had a crush on a boy or girl? What was that like? • Have you ever had a romantic relationship with someone? • How would you describe it?

32. Relationships Matter

33. Assessing the Health of the Relationship • What does a healthy relationship look like to you? • How often are you and your partner together? How does your partner feel about you hanging out with other friends? • (If sexually active) Who makes the decisions about when to have sex and what kind of contraceptives you should use?

34. Characteristics of a Healthy Relationship • Nonviolent conflict resolution • Open and honest communication • Right to autonomy for both people • Shared decision-making • Trust • Mutual respect • Individuality • Empathy

35. Risk Factors for Unhealthy Relationships • Partner is 3-5 years older • Exposure to violence in the household or community • Early sexual activity • Low education level • Sexual risk-taking • Substance abuse

36. Signs Linked to Intimate Partner Violence (IPV) • Depression/anxiety • Changes in eating patterns • Changes in social relationships • Substance abuse • Abdominal pain/pelvic pain • Physical findings inconsistent with stated mechanism of injury, or findings associated with intentional injury (patterned marks, bruises in varied stages of healing, burns)

37. IPV and Adolescents • Intimate Partner Violence is bi-directional, meaning girls and boys report being both the victims and the perpetrators • 9.3% of females and 9.5% of males report being hit, slapped, or physically hurt on purpose by their boyfriend or girlfriend • 11.8% of females and 4.5% of males have ever been physically forced to have sex

38. About Abstinence • Encourage abstinence within context of comprehensive sex education and self-esteem enhancement • If patient is already sexually active and is not comfortable with the decision or is not enjoying intercourse: • Discuss other options for intimacy between partners • Discuss ways patient can communicate decision to partner

39. Discussing Readiness for Sexual Initiation • Some questions providers can ask to begin to explore a teen’s sexuality are: • How does one know one is ready for sex? • What is important in a relationship? • Can she/he say no? • How does one deal with anger, rejection, and loneliness? • Can she/he openly talk to partners about their feelings?

40. Discussing Sexual Activity • Sexual behavior is a spectrum • Includes coital and noncoital activities: • Kissing • Self and partner masturbation • Oral, anal, and vaginal sex

41. Assessing Sexual Orientation • Are you romantically interested in men, women, or both? • Are you comfortable with your feelings? • Have you ever had sex with someone of your same gender? • For younger teens: when you imagine yourself in a relationship in the future is it with a man, a woman, or both?

42. Assessing Gender Identity • Do you think of yourself as male, female, neither, or both? • What pronoun do you use (she, he, they, sie*)? • *Sie is a gender-neutral pronoun sometimes used by members of the transgender community • Are you comfortable with your feelings? • How do you think your parents/teachers/friends would react (have reacted) to your gender identity?

43. Assessing Sexual Behavior • How old were you when you first had sex? Include anal, oral, and vaginal. • What was the date of your last intercourse? • What kind of protection did you use at last sex? • Condoms? Hormonal contraception? • Do you have a current partner? • How long have you been with your partner? • How many sexual partners have you had? • How many sexual partners have you had in the past 3 months?

44. Orientation vs. Behavior Orientation does not always = behavior Majority of women who have sex with women (53–99%) have had sex with men While respecting a patient’s identification, you should inquire about sexual behaviors with partners of all genders.

45. Sexual Satisfaction • How often do you have pain during sexual intercourse or other sexual activities? • Are you satisfied with how often you have sexual relations and with what you do with your sexual partner? • Any problems becoming aroused, getting an erection, getting lubricated (wet), or having an orgasm?

46. Sexual Health • Have you ever had any infections? • Do you know what the symptoms of STIs are? Tell me. • Have you ever been tested for an STI? Tell me more. • How about your partner? • Sexual dysfunction? • Unintended pregnancies • Sexual violence

47. Place Matters

48. Place Matters

49. Assessing Pregnancy History • Have you ever been pregnant or gotten anyone pregnant? What were the outcomes? • Do you have any concerns about your fertility? • When (if ever) would you like to get pregnant and have children? • Are you doing anything to prevent an unintended pregnancy?

50. Discussing Contraception • What have you used for pregnancy prevention? • What was your experience? • How about your friends? • Would you like me to tell you about some of the options available?