CHICAGO - When it comes to treating adolescents, pediatricians need to ask questions, have a high index of suspicion, and screen for sexually transmitted diseases (STDs).
In addition, pediatricians should not only treat patients, but also their partners. They should schedule follow-up appointments and do repeat cultures if the child has an STD. STD education is also a key factor before, during, and after infection of STDs in adolescents.
"Educate the adolescent, their parents, and their families so that they have a better understanding of the whole process," said Virginia Bishop-Townsend, MD, MPH, attending physician at Children's Memorial Hospital.
The highest rate of gonorrhea is found in females ages 15-19. Adolescents also have the highest rate of human papillomavirus (HPV) and chlamydia. Studies indicate that 9% of adolescents with acute HPV infection either have had sexual contact with a chronically infected person or with multiple sex partners, or they gave their sexual preference as homosexual. The message is these adolescents are probably symptomatic so these figures underestimate the true rates of STD's in this age group.
"What are some reasons why adolescents are a special population?" she asked at the 1999 Spring Session of the American Academy of Pediatrics held here.
A potential reason, said Townsend, is related to developmental issues in which they feel they are invulnerable, or maybe they are aware of other people who have contracted an STD. It is even possible they can regurgitate to their clinician all of the information given to them, but, "technically speaking, they think that it is not going to happen to them and so they engage in unprotected sex."
Developmentally, when in middle or late adolescence and under stress, adolescents have a tendency to regress back to an early developmental level in which they do not know how to negotiate effectively the use of something like condoms.
Adolescents also face multiple obstacles in receiving health care. Sometimes, said Townsend, they are ashamed, afraid of a lack of confidentiality, do not have the money, do not know who to see for treatment, or, when they do go for treatment, they have to come back with their parents.
"Sometimes they are also afraid of finding out that they have an STD for fear that they may be abused on one end or that their partner may no longer want to have a relationship with them, especially in instances in which their partner is symptomatic."
According to Townsend, questions regarding the patient's sexual history should be proactively included as part of their clinical history. "To my knowledge, or at least in my experience, adolescents will not typically open up and start talking about their STDs or their at-risk behavior. For the majority of the kids it is sort of a game, and the game is that I, as a provider, am going to try to get as much information as I can to provide them with the information that I feel they need. It is a partnership."
To get the patient's psychosocial history, Townsend said she asks questions about the patient's home environment; educational environment and academic performance; activities, acquaintances, and altercations, and whether their friends use drugs, are pregnant, or are sexually active; suicide; sexual history; and, drugs and cigarette use.
Townsend also asks about depression. Finding out why he or she cries is crucial because a lot of teens cry when they are angry, which is different from crying when sad, hopeless or helpless.
When asking about a patient's sexual history, she first asks what type and how often protection is used, regardless of gender.
"The kids feel that they have every right to say that they are not sexually active if they are not engaging in a sexual act in front of you in the exam room. If you don't realize that you may misinterpret and think that they are not sexually active," she said.
She also asks about the number of partners they presently have, how many they have had, and their partner's history. "I ask about partners," said Townsend, "because if you ask about boyfriends, they are only going to talk to you about people they had a steady relationship with and who they consider a boyfriend and you may miss out on the other people whom they may have had sex with."
When taking a history of STDs, patients should be asked if they have ever been pregnant or gotten someone pregnant, and when they first became sexually active. When asking how old the patient was when he or she first became sexually active, Townsend advises, "You have to swallow before you ask this because 25% to 30% will say that they have been sexually abused."
She advised being careful when asking the question and feeling comfortable with the person being interviewed; if the clinician begins to look uncomfortable, the patient will clam up.
"Be careful how you ask the questions and use jargon that you are comfortable with." She recommended using understandable language, asking open-ended questions, reassuring the patient, and including descriptions of specific action the patient can take to avoid acquiring or transmitting STDs.
She recommends the interviewer examine his or her own attitudes before having the patient or family in the room with them. Terms of confidentiality must also be defined.
Counseling skills are needed to effectively deliver prevention messages with respect, compassion, and a nonjudgmental attitude, which she said is extremely difficult and takes practice because sometimes, especially for teenagers, the patient will feel like they are being judged, and they will not hear the message.
"It is important to have someone convey the information in a way that possibly you would like to have received the information yourself if you were at that age," Townsend said.
When talking with adolescents about STDs, she suggested talking with the respect that you would give to adults, using multiple ways of teaching each point, maintaining their attention, recognizing and answering their questions, and respecting their confidentiality.
"Some of these kids, regardless if you share the information with the parents or not, will give you the information because they want help, and in my experience, many of the kids who I see the first time may not want the parents involved, but by the second visit approximately 95% say that it is okay to share the information with the parents."
For more information:
- Bishop-Townsend V. Section on adolescent health-Update on adolescent care in the pediatric office. Session H323. Presented at the American Academy of Pediatrics 1999 Spring Session. April 17-20. Chicago.
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