Despite the existence of guidelines to assess risky behaviors among adolescents, the literature describes provider hesitancy to perform comprehensive sexual health assessments during routine exams.1-4 It is imperative to address adolescent sexual behaviors as a health promotion topic prior to initiation of sexual activity.
The need for more widespread sexual health assessment is reflected in a recent national survey of adolescent sexual behavior.5 More than 60% of high school seniors self-reported sexual activity, and 46% of all high school students reported having had intercourse. Of these sexually active teens, 34% had engaged in intercourse in the previous 3 months. Thirty-nine percent did not use condoms with their last coitus, and 77% were not using hormonal contraception. Fourteen percent reported having had four or more sexual partners.5
Although the teen birth rate in the U.S. has declined almost every year since 1991, it is still one of the highest among industrialized countries.6,7 An estimated 25% of the sexually active population are between ages 15 and 24; half of new sexually transmitted infections (STIs) are in this age group.6 Just a decade ago, 48% of STIs occurred in 15- to 24-year-olds.8
Common adolescent concerns such as low academic achievement; social, behavioral or emotional issues; and mental health and substance abuse problems are risk factors for early coital debut.9
The American Academy of Pediatrics position statement on sexuality education for children and adolescents recommends sexual education as a lifelong process.9 Issues should be covered in early well-child visits to support parent-child discussions, to address confidentiality, and to incorporate family values. Pediatric providers must have resources for education about prevention counseling, as well as resources to refer to as necessary.
The human papillomavirus (HPV) vaccine is a prevention strategy aimed at reducing the incidence of the STI responsible for the majority of cervical cancer.8 The vaccine is 100% effective at preventing HPV if the three-dose series is completed prior to coital debut.10
Although the vaccine has been available since 2006 and research shows it is safe and effective, uptake is still under 50% and dose completion is only 32%.11 Race and age disparities have been reported.11,12
As much as 90% of mothers may intend to vaccinate their daughters against HPV.2 Predictors of knowledge about HPV and the HPV vaccine, parental intention for vaccination, and provider factors related to uptake of the vaccine have been described.2 Provider recommendation has been strongly associated with vaccination.2,12 Establishing office policies and reminder systems for vaccine delivery can help improve uptake and dose completion.
Critical Components of Assessment
Preparing the office as an appropriate setting for adolescent sexual health assessment is crucial. Training staff and providers to follow guidelines for confidentiality and to offer private, uninterrupted exams is necessary to elicit sensitive historical information. Having educational materials, supplies and equipment available will assist NPs and PAs to provide age-related anticipatory guidance. Providing information from community resources will facilitate follow-up on issues that cannot be handled in the primary care office.
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A person's sexual health history begins early and occurs within the context of the developmental task of identity - specifically sexual identity. A good start is to assess the teen's knowledge base and address misconceptions. Being aware of parental input, school curricula and peer influence are all part of the assessment.
Begin the sexual health assessment by inquiring about relationships and sexual behaviors of friends. This can be a conduit to proceed to more personal questions about the patient. The American College of Obstetricians and Gynecologists (ACOG) has developed an approach known as GATHER (Table 1).13
The issue of confidentiality has been a source of contention. Most states have laws requiring a minor's consent for sexual healthcare. Providers must familiarize themselves with state laws and provide adequate access to care for teens.
ACOG also has developed a "Toolkit for Teen Care"13 that provides information on how to prepare the office to make adolescents feel comfortable and to address issues such as confidentiality. This toolkit also includes information to facilitate adolescent growth and development.
Barriers to addressing adolescent sexual health concerns in primary care include providing a realistic time frame for the visit, addressing parental presence during the history, and having adequate support to offer appropriate prevention counseling.4 Providers must use effective therapeutic communication techniques to elicit information with parents present and ask parents to step out for the physical exam portion to delve into more sensitive issues. Confidentiality laws lend support for gathering some information privately.
While parents are out of the room, explain confidentiality so that teens will be more likely to provide accurate information necessary for decision making. Before bringing parents back into the room, discuss the next step in the plan: involving the parents. Offer options for how and when to achieve this. Some teens are willing to share information with parents in the office with the support of the provider. Others are comfortable with the provider sharing information with parents when teens are present. If the teen is not willing to share sexual health information at this time, the issue can be revisited at follow-up. The ACOG toolkit provides guidance for this process.13
Counseling, Screening, Treatment
Providing sexual risk reduction strategies as part of anticipatory guidance can positively affect sexual behaviors. Significant changes in clinical outcomes have been demonstrated, with increased condom use reported by women who have received targeted educational interventions.14 In a national survey of pediatricians, 87% said they believed sexual risk reduction was as or more important than reducing other risky behaviors, but only 28% of them provided prevention counseling on this topic more than 75% of the time.4
Sexual risk reduction for younger teens involves provider-mediated discussions to promote parent-teen communications. Delaying coital debut and reducing high-risk behaviors should be a focus of discussion during prevention counseling, and it must occur prior to the first sexual encounter. When sexual negotiation skills are used, interventions with socioeconomically disadvantaged women have led to behavioral changes.14 Seizing opportunities to help young teens practice saying no in the office is possible when counseling occurs early in development.
Addressing sexual health issues in a 15-minute time slot is not possible. These visits require at least 30 to 45 minutes, even when a pelvic exam is not performed. Selecting appropriate billing codes for billable time spent counseling is one method to receive adequate payment for this complex service. The ACOG toolkit provides billing and coding guidelines.13
The AAP recommends annual screening of all asymptomatic sexually active teens, and standard urine-based tests are readily available for use in primary care settings to facilitate early detection of STIs (Table 2).15,16
NPs and PAs in primary care can treat positive test results according to current STI treatment recommendations.17 Pelvic examinations are not necessary without clinical evidence of pelvic inflammatory disease.17 Pregnancy prevention is another crucial aspect of adolescent sexual healthcare, and contraception counseling can occur in primary care settings.
Implications for Practice
NPs and PAs are in an excellent position to promote healthy sexual behaviors in adolescents. By discussing abstinence, delay of coital debut and safe sexual practices (with those who are sexually active), we can better meet the needs of our adolescent population. Offering adolescent-friendly care to promote disclosure of sensitive issues is essential to meet this challenge.
1. Sussman AL, et al. HPV and cervical cancer prevention counseling with younger adolescents: implications for primary care. Ann Fam Med. 2007;5(4):298-304.
2. Cassidy B, Schlenk A. Uptake of the human papillomavirus vaccine: a review of the literature and report of a quality assurance project. J Pediatr Health Care. 2012;26(2):92-101.
3. Zacharyczuk C. Straight talk needed on STI prevention for adolescents. Infectious Disease News. http://www.healio.com/infectious-disease/news/print/infectious-disease-news/%7B895F567A-4E59-4031-AE0E-EC6F3C78E10F%7D/Straight-talk-needed-on-STI-prevention-for-adolescents
4. Miller K, et al. Pediatricians' role and practices regarding provision of guidance about sexual risk reduction to parents. J Prim Prev. 2008;29(3):279-291.
5. Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States, 2009. MMWR Surveill Summ. 2010;59(5):1-142.
6. The American College of Obstetricians and Gynecologists. Adolescent Facts Pregnancy, Births and STDs. https://www.acog.org/%7E/media/Departments/Adolescent%20Health%20Care/AdolescentFactsPregnancyAndSTDs.pdf
7. Hamilton BE, Ventura SJ. Birth rates for U.S. teenagers reach historic lows for all age and ethnic groups. Natl Center for Health Statistics Data Brief. 2012;89.1-7. http://www.cdc.gov/nchs/data/databriefs/db89.pdf
8. Centers for Disease Control and Prevention. STD-prevention counseling practices and human papillomavirus opinions among clinicians with adolescent patients - United States. 2004. MMWR. 2006;55(41):1117-1120.
9. American Academy of Pediatrics: Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence. Sexuality education for children and adolescents. Pediatrics. 2001;108(2):498-502.
10. Markowitz LE, et al. Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2007;56(RR-2):1-24.
11. Centers for Disease Control and Prevention. National and State Vaccination Coverage Among Adolescents Aged 13 Through 17 Years - United States, 2010. MMWR. 2011;60(33)1117-1123.
12. Dorell CG, et al. Human papillomavirus vaccination series initiation and completion, 2008-2009. Pediatrics. 2011;128(5):830-839.
13. American College of Obstetricians and Gynecologists. Tool Kit for Teen Care, Second Edition. 2009. http://www.acog.org/About_ACOG/ACOG_Departments/Adolescent_Health_Care/Tool_Kit_for_Teen_Care__Second_Edition
14. Sheperd J, et al. Interventions for encouraging sexual lifestyles and behaviours intended to prevent cervical cancer (Review). Cochrane Datab Syst Rev. 2009;2:1-30 .
15. Hagan J, et al, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2008: 515-575.
16. Centers for Disease Control and Prevention. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections-2002. MMWR. 2002;51(RR-15):1-38.
17. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR. 2010;59(12):1-114.