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Department: Peak Technique

Adolescent sexual health

How to begin the conversation

Tyson, Teresa PhD, RN

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doi: 10.1097/01.NME.0000653216.54747.04
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Talking about sex may be uncomfortable for the healthcare provider and adolescent during preventive visits or hospitalization. However, the sexual history of an adolescent is crucial to address risky sexual behaviors and improve sexual health outcomes among this age group. According to the CDC, risky sexual behaviors among US adolescents is a major public health concern. Nearly 800,000 young women ages 15 to 19 become pregnant in the US each year, most of them unintentionally, and half of the roughly 19 million new sexually transmitted infections (STIs) diagnosed each year are among 15- to 24-year-olds.

Taking a sexual health history during preventive visits or hospitalization is an opportunity for the nurse to provide education and counseling regarding sexuality and safer sex practices for adolescents. As nurses, we're on the frontline when it comes to patient education and identifying needed resources for adolescents and their families. Before beginning the sexual health history of an adolescent, you need to be aware of developmental stages, cultural considerations, and societal influences. This article will help you begin the conversation about sexual health with adolescent patients by providing communication strategies and age-specific considerations for discussing sexual issues.

Physical development

Adolescence is a period of significant physical, cognitive, and psychosocial growth and development, characterized as a transition to adulthood. This transitional period is also a vulnerable time and associated with cultural and social influences that ultimately affect health outcomes and the adolescent's future.

Adolescence includes three major stages of development: early, middle, and late. Identifying your patient's developmental stage will guide your communication approach and the topics discussed.

Early adolescence, age 11 to 13, is the onset of puberty. The development of breast tissue, pubic hair, and menarche mark the onset of puberty in females. Whereas the enlargement of testes and voice changes signify the onset in males. At this age, adolescents are concrete thinkers, which means that they're still limited in their rational thinking and decision-making process. In addition, this stage of development is associated with conforming to peer norms and fitting in. The adolescent may also experience a surge of sexual feelings and role confusion that's associated with the onset of puberty. That's why it's important to explain to the adolescent that these feeling are part of the growth and development process and transition to adulthood.

This a good time to ask the adolescent, “What questions do you have about your body and sex and what does sex mean to you?” If silence is noted, you can say, “I share with all patients your age that puberty marks sexual maturity and you can get pregnant or get someone pregnant during puberty.” This is a good segue to discussing sexual behaviors, such as vaginal intercourse, oral and anal sex, and associated risks such as unintentional pregnancy, HIV, and STIs. This is also an appropriate time to mention that kissing and petting may often to lead to sexual activity and negative consequences. Additional topics of discussion should include safer sex practices, such as the use of condoms, contraceptives, and responsible decision-making.

Middle adolescence, age 14 to 16, is characterized by physical and sexual maturity; interest in relationships and physical attraction to peers begins. Cognitively, adolescents can think abstractly and often perceive that they're invincible and nothing will happen to them. This perception is often associated with risky behaviors. In this age group, the adolescent has an increased need for acceptance among peers. Based on this development, the topics of discussion should include statistics on HIV and STI rates and pregnancy, including preventive measures, safe practices, and responsible decision-making.

Late adolescence, age 17 to 21, is the stage of fully developed physical, reproductive, and sexual characteristics. Cognitively, critical-thinking skills, realistic goal setting, and future orientation are present. Statistical information about the incidence of HIV and STIs, as well as information about using safe practices and responsible decision-making, is still relevant for this age group. The adolescent should be asked about family planning. For example, “Do you plan to start a family anytime soon?” This question will guide the follow-up questions such as, “What are you doing to prevent pregnancy, HIV, and STIs?” This is an opportunity for effective use of contraceptives and HIV prevention.

Cultural considerations and societal influences

Other considerations when assessing the sexual health of adolescents include cultural awareness and societal influences, such as online dating apps, Internet pornography, and social media platforms. Cultural sensitivity and awareness are of the utmost importance before discussing sexual health with adolescents. For example, a discussion of highly sensitive topics such as sexuality may be prohibited and considered taboo in some cultures. In these cases, it's recommended to first establish if there are any spiritual or cultural considerations regarding beliefs and practices (see Communicating with parents).

Online dating apps are often referred to as “hook-up” sites. The term hook-up is used to describe casual sex or uncommitted encounters. This hook-up culture is perceived as the new sexual norm associated with late adolescents and young adults, which further places this age group at risk for HIV, STIs, and pregnancy.

Exposure to Internet pornography, along with the adolescent's physical and cognitive stage of development, may influence sexual attitudes and behaviors and lead to risk-taking behaviors. You should begin the conversation by sharing facts about pornography such as, “Pornography is often perceived as real sexual activity by your age group; however, pornography isn't real life.” This is a good time to ask, “Have you ever had sex with anyone? By ‘sex’ I mean vaginal, oral, or anal sex.” Reiterate that this information will help you keep the adolescent healthy. If the response is “yes,” provide information on preventive and safer sex practices. If the response is “no,” respond with, “If and when this changes, please let me know so I can help you stay healthy.” If silence is noted, include both of the above responses.

Similarly, social media can influence adolescent sexual attitudes and behaviors. Social media influencers get tens of thousands of comments and millions of likes. Adolescents may strive to obtain the same image and be accepted by peers and social media followers. However, this chase for popularity can lead to something that's unrealistic and unobtainable. You may ask, “How often do you use social media and what do your friends post about?” This gives you an opportunity to provide information on cyberbullying, sexting, and the benefits and consequences of social media. You can also offer resources for additional information on these topics, as well as how to navigate social networking.

Beginning the conversation

Create a safe and nonjudgmental atmosphere by assuring the adolescent that everything discussed will be confidential unless the shared information may cause harm to him- or herself or others. Reassure the adolescent that information shared will help the healthcare team provide care and help him or her stay healthy and deal with common situations teens experience.

Start with general conversation such as asking about school and activities of interest. Then share facts and statistics about adolescent sexual behaviors and inform the adolescent that you share this information with all patients in his or her age group. Beginning the conversation with facts creates a nonjudgmental learning environment. For example, discuss the increase in HIV and STIs in adolescents and the fact that these diseases are preventable.

Next, share facts related to why STIs are higher in this age group. For example, teens experience a period of hormonal and physical changes that's part of the normal growth and development process; however, these changes are associated with sexual exploration and risky behaviors that may lead to negative consequences. Reassure the adolescent that these feelings and experiences are part of the transition into adulthood but also emphasize that choices made can have life-changing outcomes.

Topics of discussion

At this point, you can use icebreakers to begin the conversation about the adolescent's sexual behaviors. For example, “When I say the word ‘sex,’ what does that mean to you?” If you're met with silence, the follow-up response may include sharing how sexuality is portrayed in the media and clarifying misconceptions about sex such as oral sex isn't considered sex. Discuss the risks of unprotected sex and safer sex practices such as condom use and contraceptives. Provide available resources such as mobile phone apps to answer questions about sexual topics. Encourage the adolescent to talk with parents or someone he or she can trust to discuss concerns and questions and help navigate sexual issues.

It's important to be inclusive of lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents when completing the sexual health history. You can begin the conversation by asking questions about gender identity, sexual attraction, and sexual orientation. For example, you may say, “Your body changes a lot during adolescence and, although this is normal, it can also be confusing. Some of my patients feel like they're more of a boy or a girl, or even something else. How has this been for you?” If adolescents disclose gender identity and/or attraction to the same sex or both genders, ask if they've told anyone and if there's a trusted adult with whom they can talk. You can offer to help adolescents have this conversation and navigate the situation. It's also important to assess safety at home and school and refer these adolescents to a counselor and/or care specialist to provide support, information, and resources on LGBTQ issues.

Safer and healthier

In summary, adolescence is a vulnerable period in which teens engage in behaviors that pose a risk to their health and safety. Taking a sexual health history provides an opportunity for nurses to address risky sexual behaviors, promote positive sexual health, and provide education and counseling. To improve sexual health outcomes, it's vital to be aware of age-specific considerations and create an open and nonjudgmental space to address sexual health concerns. Ultimately, the goal is to decrease risky sexual behaviors in this age group.

Communicating with parents

When completing an adolescent sexual health history, follow the age-specific guidelines for reproductive healthcare and treatment without parental consent. These guidelines vary by state, so it's important to know the parameters where you practice. When communicating with parents about the sexual health assessment, explain that the sexual history is part of the preventive visit for all adolescents to keep them healthy and provide the opportunity to answer questions. Explain that you'll first meet together to obtain pertinent health information and identify concerns parents may have. The next part of the visit involves meeting with the adolescent alone to allow the adolescent to be accountable for his or her own health. You may also explain to parents that interviewing adolescents alone helps establish rapport and trust and provides privacy to alleviate feelings of embarrassment when sexual topics are discussed. Assure parents that they'll be informed of any information of which they should be aware and discuss the guidelines if needed. The final part of the sexual health history involves meeting with both the adolescent and parent(s) together to answer any questions and clarify information.

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Early adolescent exam: Speaking with the parent

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A 12-year-old female patient is scheduled for her well-child visit with her primary care provider. She's accompanied by her mother who she lives with as an only child. Her mother is a single parent and works outside the home. After school, she goes home with her best friend until her mother gets home from work. She attends middle school and enjoys spending time with her friends, as well as being involved in youth activities at her church. Her menses started at age 11 and occurs regularly, lasting 3 to 5 days. What conversation do you need to have with her mother before beginning the visit with the adolescent?

Explain to the patient and her mother what to expect during the visit. Tell them that you'll meet with them together and then the adolescent separately. Assure the mother that you'll obtain pertinent health information and answer any concerns she has before speaking with her daughter alone. Tell her that meeting with her daughter alone establishes rapport and trust with healthcare professionals and allows the adolescent to be accountable for her own health and decisions. You can also reassure the mother that meeting with the adolescent alone provides privacy and alleviates feelings of embarrassment when sexual topics are discussed, and that you'll let her know if there are concerns of which she should be aware.

Middle adolescent exam

A 16-year-old male patient is seen in the office for his sports physical. He enjoys playing basketball and is looking forward to the upcoming season. He spends much of his time with his friends and teammates. He also enjoys playing video games and watching sports in his spare time. He just received his driver's license and is excited about getting his own car. He has a girlfriend and is looking forward to spending more time with her now that he has his driver's license.

The patient is accompanied by his mother. As in the previous scenario, inform them that you'll be meeting with the adolescent separately and you'll ensure privacy and confidentiality, except for information that poses harm to the adolescent or others. Inform the adolescent that you'll ask him some questions about his sexual health that you ask all patients his age. Ask, “Have you been sexually active in the past year? Sexually active meaning having vaginal, oral, or anal intercourse.” If the response is “yes,” ask him, “Do you have sex with women, men, or both?” Also ask, “How many sexual partners have you had in the past year?” Share information about safer sex practices, such as the use of condoms, contraceptives, and responsible decision-making.

Late adolescent exam

A 19-year-old male patient has an office visit to receive vaccinations for college admission. He's excited to be admitted to his top college choice and he's actively involved in music and his youth church group. He enjoys spending time with his family and friends and currently lives with his parents. At this age, the patient may not be accompanied by a parent.

As with the previous scenarios, begin the conversation by letting the adolescent know that you'll ask him questions about his sexual health because it's important to his overall health. First, ask if he has questions or concerns about his sexuality or health. If he doesn't have questions or concerns, you can proceed to the series of questions about sexual health discussed in the middle adolescent scenario and share information about safer sex practices.

REFERENCES

Ashcraft AM, Murray PJ. Talking with parents about adolescent sexuality. Pediatr Clin North Am. 2017;64(2):305–320.
Breuner CC, Mattson GCommittee on Adolescence, Committee on Pyschosocial Aspects of Child and Family Health. Sexuality education for children and adolescents. Pediatrics. 2016;138(2). pii: e20161348.
Centers for Disease Control and Prevention. Sexual risk behaviors can lead to HIV, STDs, and teen pregnancy. 2019. http://www.cdc.gov/healthyyouth/sexualbehaviors/index.htm.
    Centers for Disease Control and Prevention. STDs in adolescents and young adults. 2019. http://www.cdc.gov/std/stats18/adolescents.htm.
      Kyle T, Carman S. Essentials of Pediatric Nursing. 3rd ed. Philadelphia, PA: Wolters Kluwer; 2016.
        National Coalition for Sexual Health. Asking essential sexual health questions. https://nationalcoalitionforsexualhealth.org/tools/for-healthcare-providers/asset/Asking-Essential-Sexual-Health-Questions.pdf.
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