When should I raise these issues?
As depicted in the opening vignette, an adolescent may raise a myriad of issues concerning sexual activity, which makes your preparedness all the more important.
Most of the time, however, you will need to broach the subject. Sports physicals and annual well-child/adolescent exams are ideal opportunities to bring up issues regarding sex. In fact, it is usually easier to address this topic—and information is better received—when children are in their late preteen years and seen during nonacute visits.
Other opportunities to address these issues are during an STI screening visit, upon discovery of an STI, or during evaluations for amenorrhea or dysmenorrhea (when concerns about pregnancy and sex would naturally arise).
How should I start the discussion?
It is difficult to address sensitive issues in a 15-minute visit. Consider scheduling an extended appointment so that critical messages are not rushed. Another option is to introduce the topic to the parent or patient, and then schedule a separate counseling visit to discuss things in detail. To create a relaxed atmosphere, conduct the initial interview (with patient alone or with parent attending) in your office rather than in an examination room.
Put patients at ease. Many young people feel shame and embarrassment when talking about their sexual activity or lack of sexual activity. They may also be self conscious about asking “stupid” questions. They may have difficulty making eye contact with you during the discussion, or may display such nervous behaviors as nail biting or foot shaking. However, they may also have a false sense of confidence about their activities. It could take time to get adolescents to open up. Victims of sexual assault may need much longer periods of time to get comfortable discussing sexual behavior.
To encourage rapport, put your pen away, sit down, make eye contact, and speak in a neutral, nonjudgmental tone ( TABLE 1 ). Talk with, and not at, the patient (with parents, too, if present) as you assess baseline knowledge and readiness to change behavior.8 After posing a question, listen without interrupting. Lean forward while listening, to let the patient know he or she has your complete attention. Once the patient or parent finishes stating their concerns, ask additional open-ended questions—eg, “Is there anything else you’d like to discuss?”
Promote risk reduction. Applaud any positive risk reduction the patient has already adopted, and offer other specific and achievable risk-reduction tactics. Suggest options rather than giving directives.8 Also explore any possible barriers to further risk reduction, such as mental health concerns, addiction, abuse, lack of education, or lack of social support.
Risk-reduction efforts include condom use, reducing or limiting the number of partners, enhancing partner communication, self-testing and partner-testing for STIs, and avoiding recreational drug use.8 Recommend that the patient ask his or her partner(s) about present and past sexual practices and prior partners.
Role playing, training in the use of condoms, or sessions with peer counselors can often help patients learn how to communicate with partners and take responsibility for their own behavior.
TABLE 1
Talking to teens about sex and their health: A conversation starter
| DR: So, Bryan, I’m wondering if we could talk a little bit about sex and your health. Bryan: Fine, I guess. DR: First, I want to mention that sexual experimentation in young men is normal. But a whole range of dangerous illnesses/infections can come from risky sexual behaviors, and that’s what I’d like to focus on today. So, before I start I’m curious if you have any questions about things you’ve heard from your friends about sex or sexually transmitted diseases? Bryan: Nope. DR: OK. I’m guessing this is pretty uncomfortable for you. Is there anything that might make this discussion a little easier? Bryan: For you to do all of the talking. DR: Got it. I might ask some simple yes or no questions just to make sure that you understand what I’m saying as we go along, but that will be it. I may also use some photos so you can have a clear idea about the way some of these things actually look so you can come to me if you notice anything unusual. At least you’ll have an idea about what might be happening and can come talk to me about it. Bryan: Yeah, sure. DR: So, the thing I want to make really clear is that I am going to start with the most basic information, show you what a condom is, and even give you one to try out privately at home. You don’t have to use it, but it makes sense for you to become familiar with it now, so that if there is ever a time when you might need it, you’ll know how. I’m not going to make any assumptions about what you know or don’t know, I’m going to give you some broad guidelines, and you can take whatever information you think is helpful. You with me so far? Bryan: Yes. DR: Your family may have certain rules about who you hang out with or what you do, and I want to make sure you know that I don’t want to contradict your parents. I just want to make sure that you have accurate information, so you can make decisions that will keep you safe and healthy. |