April 1996
SAN FRANCISCO—When discussing sexual activity with adolescents, the goal should be to encourage candid communication, according to Walter D. Rosenfeld, MD, a specialist in adolescent health.
The sequence of questions should flow from less personal to more personal. Pediatricians should avoid using words that could be misinterpreted as labels. For instance, when questioning male adolescents about sexual activity, avoid asking them flat out if they are homosexual, Rosenfeld said.
Instead, ask them if they have any romantic relationships. "Then go right to the chase: Do you have sex with other guys, with girls, or with both?" said Rosenfeld, who is Director of Adolescent Medicine at Morristown (N.J.) Memorial Hospital.
Many male adolescents who engage in sex with others of the same gender do not consider themselves gay, said Rosenfeld. Some consider themselves bisexuals. Moreover, "many adolescents aren't sure what their sexual orientation is yet," said Rosenfeld, who also is Associate Professor of Clinical Pediatrics, Columbia University, New York.
During a session on sexually transmitted diseases (STDs) at the American Academy of Pediatrics annual meeting here, Rosenfeld advised pediatricians on how to communicate effectively with adolescents on the subject of sex.
Adolescents reason that pediatricians would initiate discussion of sex-related issues if those issues were important to their health. "If you don't bring it up, they won't bring it up," Rosenfeld told listeners.
Noni E. MacDonald, MD, who also spoke at the STD session, told pediatricians, "Your language is very important. You need to remember that many adolescents don't know the technical medical terms that you use."
![[bar]](/art/gradred.gif){kind=small}
Furthermore, Rosenfeld stated that pediatricians should not come across as reluctant to discuss sexual matters until patients are age 18. "There is no magical or psychologic transformation that occurs when a young person becomes 18 years old," he said. Rosenfeld told colleagues that any sexually active female patient should have a pelvic examination, regardless of her age, Rosenfeld said. "There is actually nothing logical about waiting until age 18," Rosenfeld said.
Sexually active female adolescents who have not had STDs or abnormal Pap smears should have a pelvic examination done annually, Rosenfeld said. "If the patient is in a very high-risk category because of multiple partners and new relationships," he said, "you may want to do pelvic examinations more than once a year. If they've had an abnormal Pap before, you certainly do need to do it more than once a year."
"Many pediatricians, I'm well aware, do not do office gynecology, but I would hope that most pediatricians include the genitalia as part of examinations," Rosenfeld said.
Pediatricians must obtain a detailed STD history, said MacDonald, who is Chief of the Division of Infectious Diseases at Children's Hospital of Eastern Ontario, Ottawa. Pediatricians should ask when symptoms began relative to their presentation in the office. They should ask patients how old they were when they became sexually active. She noted that "the earlier you have your sexual debut, the more likely you are to have an STD."
Pediatricians also should ask how many sexual partners the patient has had in the past couple of months, and the nature of the sexual contact. Pediatricians should ask patients if they previously have had an STD. "If you've had an STD before, you're much more likely to have an STD again," MacDonald said.
Pediatricians also should ask patients if they use barrier methods of contraception and if they or their partners could be pregnant. Also, pediatricians should ask patients if their partners have any signs or symptoms suggestive of an STD. Pediatricians also should ask patients when they last had any antimicrobial treatment. Recent antibiotic use could result in negative cultures for pathogens.
Patients who have urethritis or cervicitis as indicated by pyuria or discharge should be treated, and pediatricians can treat the patient at the initial visit while awaiting test results, Rosenfeld said. If microscopic examination shows Gram-negative intracellular diplococci, the patient can be treated for gonorrhea and for chlamydia as well as other causes of nongonococcal urethritis. Pediatricians who practice in places with low rates of gonorrhea can treat patients for nongonococcal urethritis, and defer treatment for gonorrhea as long as specimens are cultured for Neisseria gonorrhoeae. If cultures grow N gonorrhoeae, pediatricians can bring the patient back for gonorrhea treatment. Both gonorrhea and chlamydia frequently are asymptomatic.
Treatment for uncomplicated gonorrhea is one, 125-mg, intramuscular dose of ceftriaxone, or one, 400-mg, oral dose of cefixime, or one, 500-mg, oral dose of ciprofloxacin. Treatment for chlamydia and other nongonococcal infections includes either 100 mg of doxycycline orally twice daily for 7 days or one 1 g of azithromycin orally.
For patients who have recurrent infections, pediatricians might consider that patients are not complying with drug therapy, are infected with drug-resistant organisms such as Mycoplasma or Ureaplasma or have become reinfected. Patients might get reinfected if their partners were not treated or if patients had new partners.
If female patients have vaginal discharge, ask them about the odor, quantity, color, and consistency of the discharge. Bad-smelling and copious discharge may indicate Trichomonas infection, Rosenfeld said. Fishy odor and the presence of clue cells on microscopic examination of the discharge can indicate bacterial vaginosis. Clue cells are vaginal epithelial cells with so many intracytoplasmic inclusions that cell borders are obscured, Rosenfeld explained.
"Often, there are many intracytoplasmic inclusions in [vaginal] epithelial cells in patients who don't have bacterial vaginosis, but when you have so many [inclusions] the nucleus border or the cell border begins to be obscured, that's bacterial vaginosis," Rosenfeld said.
Bacterial vaginosis can be treated with 500 mg of metronidazole orally twice a day for 7 days or with 2 g of metronidazole as a single dose. Another alternative is to use a metronidazole gel, which is inserted into the vagina twice a day for 5 days. Pediatricians also can prescribe clindamycin cream, which is applied intravaginally once daily for 7 days.
Physicians who find syphilis or chancroid should suspect the presence of other STDs, including HIV infection. Syphilis and chancroid indicate that people are in a group engaging in behaviors that put them at high risk for HIV infection.
The first urine test for Chlamydia as recently approved by the Food and Drug Administration.
You can express your views on this
article, or other relevant themes, in the
Infectious Diseases in Children
Specialty Forums.
