Addressing adolescent sexuality

In this Ask the Experts feature, Infectious Diseases in Children Editorial Board member Amy Middleman, MD, MPH, MS Ed, discusses adolescent sexuality and its effect on health and well-being.

At what age should pediatricians begin counseling patients on sexual issues?

Sexual issues are only one subset of the larger issue of sexuality. Sexuality, as explained by the Sexuality Information and Education Council of the US (SIECUS) is about the total person — including how one relates to others in all ways, including sexually. As such, discussions involving sex in a broad context can begin early in the home and the pediatrician’s office.

Providers can start talking about peer relationships during early and late childhood; by asking these questions at a young age, kids can more easily transition to discussing other relationships when they are older. In addition, addressing physical issues, including breast development, hair growth and masturbation, during infancy and childhood with both parents and patients will help establish that these topics are natural and appropriate in the medical setting.

Using accurate names for body parts among young children sends the message that discussions about sex and sexuality are not so embarrassing that they have to be disguised with aliases. When children begin to change physically, this is the opportunity for providers to reassure patients about the changes and start discussing why the physical changes are taking place and how emotions and interactions with others may change as well. As patients develop physically, it is important to arm them with more explicit messages about reproductive health and safety, including refusal skills, condoms, pregnancy prevention and emergency contraception (this usually occurs when patients reach a sexual maturity rating of 2-3).

Of course, parents and patients should be encouraged to discuss these issues together; however, in the event a patient is not comfortable talking with a parent, it is imperative that these discussions with a provider take place in the context of qualified confidentiality with the parent out of the room. Adolescent medicine providers start having at least brief periods of time alone with patients between the ages of 11 and 12 years. The provider uses these discussions as a guide for how much information patients are ready for; one should ask if patients aged 11 years and older are involved or interested in any romantic relationships (avoiding heterosexual bias) and use their responses to guide further questioning.

It is always appropriate to ask patients of any age if anyone has ever touched them in a sexual way when they did not want or ask for such attention. Too often, children will only disclose sexual abuse when asked specifically, directly and in a nonjudgmental way. The key to success for providers in obtaining information about sexual issues is to develop a comfort in asking the questions and listening without judgment to the responses. As patients sense the safety in the discussions, providers will have greater opportunities to respond with meaningful risk-reduction counseling.

Is sexual activity concerning for health?

Early sexual activity is associated with a higher risk of sexually transmitted infections (STIs) and a higher risk of unintended pregnancy. Younger children, both males and females, may not be developmentally able to anticipate risk and prevent it effectively. In addition, early initiation of sexual activity translates into a longer period of time for exposure to disease and risk. Also of note, the same psychosocial factors that lead to early sexual debut as a risk behavior also serve as the basis for engagement in other risk behaviors.

Adolescent medicine specialists are familiar with this idea of “clustering” of risk behaviors. Studies have shown that those involved in one risk behavior (eg, early sexual debut) are more likely to be involved in other risk behaviors (eg, drug use, alcohol use, suicidal behaviors). It is important to screen males and females who are sexually active, not only for STIs and pregnancy (or pregnancy involvement for males), but to also screen for other risk behaviors affecting health, such as seatbelt use, drug use and violence.

What are some effective strategies to help patients avoid teen pregnancy, STIs and HIV?

Using the strategies described above, providers are likely to have the greatest success in eliciting information for directed counseling about the risks of pregnancy and STIs as a result of unprotected intercourse. However, adolescents are not always able to anticipate situations in which they might be at risk of acquiring these conditions. For this reason, it is helpful for providers to help adolescents anticipate situations in which they might be put at risk and brainstorm options for the patient to utilize to stay safe.

For example, a provider can take patients through a scenario of being pressured to have sex and review effective refusal strategies; or providers can encourage sexually active patients — including females — to carry a condom in their clothing (pockets, bras) in the event they want to have sex. More general factors associated with decreased sexual risk-taking include: parental monitoring (providers can let parents know that appropriate monitoring — not overly controlled monitoring — is associated with better outcomes); social connectedness with family, parents, and school; and comprehensive sex education that provides specific and useful information for students. The extent to which providers can advocate for these factors in patients’ lives may determine sexual behavior outcomes.

What advice can providers give to the parents of sexually active teens?

The most critical information parents need is that they are the most important determinant of their child’s behavior. Parents must provide a safety net of rules for their children in a supportive, non-punitive way. Authoritative (vs. authoritarian or permissive) parenting allows parents to provide unconditional love and nurturance to their children with high expectations and appropriate boundaries for behavior; however, it is a two-way relationship in which the parents and children listen to each other and negotiate as developmentally appropriate.

Children of parents who set clear expectations for behavior and follow-up on those expectations have been shown to have better health outcomes with respect to risk behaviors. If not having sex until a certain age is an expectation, it must be made clear and the reasons for it should be discussed openly with a child. If a child has already chosen to become sexually active, it is imperative that the parent set the expectations that the child will be safe — emotionally and physically.

Open discussions and communication with a caring adult (which can include a medical provider) are the keys to safety. If a parent continues to insist that a child who has already decided that sex is important to them is not allowed to have sex, then the child will not engage in discussions in which the parent can educate and help protect health. Ultimately, the goal is the child’s well-being.

Amy B. Middleman, MD, MPH, MS Ed, is Associate professor of Pediatrics in the Adolescent Medicine and Sports Medicine Section at Baylor College of Medicine, Houston, Texas. She is also an Infectious Diseases in Children Editorial Board member

Disclosure: Dr. Middleman reports no relevant financial disclosures.