1. PRCH © 2006 1 Providing Reproductive Healthcare to Adolescents Yolanda Wimberly, MD, MSC

2. PRCH © 2006 2 Outline   Adolescent patient population   Adolescent friendly health services   Adolescent sexuality and the clinical interview

3. PRCH © 2006 3 Objectives By the end of this presentation, participants will be able to: Discuss characteristics of early, middle and late adolescence Describe 3 elements of adolescent friendly health services Utilize the HEEADSSS model of patient interviewing

4. PRCH © 2006 4 Early Adolescence 11-14 Characterized by a spurt of growth Beginning of sexual maturation Start to think abstractly

5. Adolescent Sexual Development Preadolescents: Gender identity established Low physical and mental investment in sexuality Begin to establish information from family, friends, and school. Early Adolescents Curiosity about one’s body and that of others Sexual fantasies begin Masturbation may begin or increase

6. PRCH © 2006 6 Middle Adolescence 15-17 Physical changes of puberty are complete Develop a stronger sense of identity and relate more strongly to peer group Thinking becomes more reflective

7. Adolescent Sexual Development Middle Adolescents: Increase exploring of sexuality including physical contact, dating, petting, casual relationships, both coital and non-coital contact

8. PRCH © 2006 8 Late Adolescence 18 -21 years The body continues to develop and takes adult form Development of distinct identity and more settled ideas and opinions

9. Adolescent Development and Sexuality Late adolescents: Sexual behaviors more expressive, less exploitative, with development of more close and intimate relationships Development of abstract thought--> able to anticipate and appreciate consequences of their actions

10. PRCH © 2006 10 The Culture of Adolescence Peer dependent Egocentric Distinct language and dress Popular culture influence Ongoing search for identity

11. PRCH © 2006 11 An Adolescent’s Identity Includes: Race and Ethnicity Socio-Economic Status Ability Gender Identity Sexual OrientationFamily Structure Peer Group Geography Religion/ Spirituality Genetics Stage of Development

12. PRCH © 2006 12 “Minority” Status in One or More of An Adolescent’s Identity Can Affect: How and where health care is sought Ability to obtain and pay for quality care Patient / health care provider interaction Societal stereotyping and marginalizing

13. PRCH © 2006 13 The Healthcare Provider

14. PRCH © 2006 14 Healthcare Providers’ Identities Race and Ethnicity Religion Medical Specialty Parental Status Profession Age Marital Status Sexual Orientation Gender Identity Training Background

15. PRCH © 2006 15 Healthcare Provider: Issues to Confront Before Seeing an Adolescent Patient How comfortable are you talking to adolescents? What are your feelings/beliefs about adolescent sexuality? Are you able to separate your own values in order to treat your patient?

16. PRCH © 2006 16 Self-Evaluation During a Clinical Encounter How do you react when confronted with a patient situation that does not fit your expectations? Does the situation provoke feelings of anxiety and discomfort? Are you able to assess what is going on within yourself as well as within the patient? www.diversityRx.org

17. PRCH © 2006 17 Elements of Adolescent Friendly Services

18. PRCH © 2006 18 Elements of Adolescent Friendly Services: Confidential Adolescent-specific Multi- and interdisciplinary Accessible Financially affordable Adolescent-focused materials on display Peer educator component Adequate space Flexible scheduling Comprehensive services Continuity of care Help transitioning into the adult medical care system

19. PRCH © 2006 19 Confidentiality = Trust

20. PRCH © 2006 20 Rationale for Confidentiality Clinically essential Decision to seek care Disclosure of behaviors Follow-up for care Ford et al. “Confidentiality Assurances” 562 High school students Randomized to confidentiality vs. no confidentiality Disclosure 47% vs. 39% (p<0.05) Follow-Up 67% vs. 53% (p<0.05) (Ford et al., 1997)

21. PRCH © 2006 21 Rationale for Confidentiality Of unmarried sexually active girls <18 yrs 59% would stop using FP clinics if mandatory parental notification needed to get prescriptions 1% would stop having sex (Reddy et al., 2002)

22. PRCH © 2006 22 Rationale for Confidentiality Developmentally expected Emotional need for increasing autonomy Increasing intellectual capacity to give informed consent (Kuther, 2003; Petersen & Leffert, 1995)

23. PRCH © 2006 23 Rationale for Confidentiality Professional commitment ACOG ‘88 SAM ’92 AMA ’92 AAFP ’89 AAP ’89

24. PRCH © 2006 24 Meeting the Adolescent and Parent for the First Time Meet first with adolescent and parent together Suggest that the adolescent introduce his/her parent Discuss confidentiality up-front Your level of comfort is important

25. PRCH © 2006 25 Discussing Confidentiality: Asking the Parent to “Please step out…” Lay out the course of the visit Explain the office/clinic policy regarding visits Validate parental role in their child’s health and well being Elicit any specific questions or concerns Direct questions and discussion to the youth while attending to and validating parental input

26. PRCH © 2006 26 Asking the Parent to “Please step out…” Invite the parents to have a seat in the waiting room Assure them that you will call them prior to closing the visit Invite parent back before close of visit to wrap-up

27. PRCH © 2006 27 Keeping Care Confidential Inadvertent disclosures of information include: Billing Telephone messages Responses to parental inquiries

28. PRCH © 2006 28 How to Tell Discuss with adolescent Whether others need to be informed Why others need to be involved Justify your reasoning/level of concern Who to involve Who is going to do the talking What information to share When to tell, time frame

29. PRCH © 2006 29 The Clinical Interview

30. PRCH © 2006 30 Comprehensive HEEADSSS H:Home E: Education/Employment E: Exercise/Eating A: Activities D: Drugs S: Suicidality/Depression S: Sexuality S: Safety S: Spirituality (Optional)

31. PRCH © 2006 31 Other Clinical Interview Tools GAPS: AMA Guidelines for Adolescent Preventive Services Bright Futures: Collaboration between AAP and Bureau of Maternal Child Health Care) Trigger Questionnaire: Developed by Office of Managed Care in the New York State Department of Health ACOG Tool Kit: A designed by the ACOG Committee on Adolescent Health Care to help every office care for adolescent patients

32. PRCH © 2006 32 Sexuality

33. PRCH © 2006 33 Sexual Orientation Paradigm of Sexuality Gender Identity Sexual Behavior Sexual Attraction Biological Sex

34. Percentage of High School Students Who Ever Had Sexual Intercourse, by Sex* and Race/Ethnicity,** 2007 * M > F ** B > H > W National Youth Risk Behavior Survey, 2007

35. Percentage of High School Students Who Ever Had Sexual Intercourse, 1991 – 2007 1 Decreased 1991-2007, p <.05 National Youth Risk Behavior Surveys, 1991 – 2007

36. Range and Median Percentage of High School Students Who Ever Had Sexual Intercourse, Across 34 States and 22 Cities, 2007 State and Local Youth Risk Behavior Surveys, 2007

37. Percentage of High School Students Who Had Sexual Intercourse for the First Time Before Age 13 Years, by Sex* and Race/Ethnicity,** 2007 * M > F ** B > H > W National Youth Risk Behavior Survey, 2007

38. Percentage of High School Students Who Had Sexual Intercourse for the First Time Before Age 13 Years, 1991 – 2007 1 Decreased 1991-2005, no change 2005-2007, p <.05 National Youth Risk Behavior Surveys, 1991 – 2007

39. Range and Median Percentage of High School Students Who Had Sexual Intercourse for the First Time Before Age 13 Years, Across 36 States and 22 Cities, 2007 State and Local Youth Risk Behavior Surveys, 2007

40. Percentage of High School Students Who Had Sexual Intercourse with Four or More Persons During Their Life, 1991 – 2007 National Youth Risk Behavior Surveys, 1991 – 2007 1 Decreased 1991-2007, p <.05

41. Percentage of High School Students Who Were Currently Sexually Active,* by Sex and Race/Ethnicity,** 2007 * Had sexual intercourse with at least one person during the 3 months before the survey. ** B > H > W National Youth Risk Behavior Survey, 2007

42. Percentage of High School Students Who Were Currently Sexually Active,* 1991 – 2007 National Youth Risk Behavior Surveys, 1991 – 2007 * Had sexual intercourse with at least one person during the 3 months before the survey. 1 Decreased 1991-2007, p <.05

43. Percentage of High School Students Who Used a Condom During Last Sexual Intercourse,* by Sex** and Race/Ethnicity,*** 2007 * Among the 35.0% of students nationwide who had sexual intercourse with at least one person during the 3 months before the survey. ** M > F *** B > W National Youth Risk Behavior Survey, 2007

44. Percentage of High School Students Who Used a Condom During Last Sexual Intercourse,* 1991 – 2007 National Youth Risk Behavior Surveys, 1991 – 2007 * Among students who had sexual intercourse with at least one person during the 3 months before the survey. 1 Increased 1991-2003, no change 2003-2007, p <.05

45. Percentage of High School Students Who Used Birth Control Pills Before Last Sexual Intercourse,* by Sex** and Race/Ethnicity,*** 2007 * To prevent pregnancy, among the 35.0% of students nationwide who had sexual intercourse with at least one person during the 3 months before the survey. ** F > M *** W > B, H National Youth Risk Behavior Survey, 2007

46. Percentage of High School Students Who Used Birth Control Pills Before Last Sexual Intercourse,* 1991 – 2007 National Youth Risk Behavior Surveys, 1991 – 2007 * To prevent pregnancy, among students who had sexual intercourse with at least one person during the 3 months before the survey. 1 No significant change over time

47. Range and Median Percentage of High School Students Who Drank Alcohol or Used Drugs Before Last Sexual Intercourse,* Across 35 States and 22 Cities, 2007 * Among students who had sexual intercourse with at least one person during the three months before the survey. State and Local Youth Risk Behavior Surveys, 2007

48. Percentage of High School Students Who Were Ever Taught in School about AIDS or HIV Infection, by Sex* and Race/Ethnicity,** 2007 * F > M ** W, B > H National Youth Risk Behavior Survey, 2007

49. Range and Median Percentage of High School Students Who Were Ever Taught in School about AIDS or HIV Infection, Across 35 States and 20 Cities, 2007 State and Local Youth Risk Behavior Surveys, 2007 0

50. Range and Median Percentage of High School Students Who Were Ever Taught in School about AIDS or HIV Infection, Across 35 States and 20 Cities, 2007 State and Local Youth Risk Behavior Surveys, 2007 0

51. Percentage of High School Students Who Were Ever Taught in School about AIDS or HIV Infection, 1991 – 2007 National Youth Risk Behavior Surveys, 1991 – 2007 1 Increased 1991-1997, decreased 1997-2007, p <.05

52. Percentage of High School Students Who Were Tested for HIV*, by Sex** and Race/Ethnicity,*** 2007 * Does not include tests conducted when donating blood. ** F > M *** B > W, H National Youth Risk Behavior Survey, 2007

53. Percentage of High School Students Who Were Tested for HIV,* 2005 – 2007 National Youth Risk Behavior Surveys, 2005 – 2007 * Does not include tests conducted when donating blood. 1 No significant change over time

54. PRCH © 2006 54 Percentage of Males and Females Ages 15-19 Reporting Ever Having Had Oral Sex: 2002 NSFG *With partner of the opposite sex

55. PRCH © 2006 55 Sexual/Reproductive Health History Menstrual history Sexual orientation Gender identity Age at first intercourse Vaginal, oral, anal sex history Contraceptive history Pregnancy history Timing of childbearing plans Number of lifetime sexual partners, including same-sex encounters Number of partners in last 3-6 months History of STIs Sexual satisfaction History of survival sex, sexual victimization, unwanted or coerced sex

56. PRCH © 2006 56 Sexual History: Information Gathering and Information Giving Educate and empower to facilitate behavior change Ask him/her if think their behavior is risky, and what they can do to change it? (Motivational Interviewing) Harm reduction: Meet them where they’re “at” and empower them to make the changes they want. Avoid lecturing Be clear, ask if they understand or quiz them on what you just counseled. Help them set “goals” for change.

57. PRCH © 2006 57 Sexual Behavior Questions Don’t Ask “Are you sexually active?” Use gendered-biased pronouns when referring to sexual partners Use judgmental language Use slang unless patient offers it first Do Assure confidentiality Explain why you are asking sensitive questions Ask patient to describe specific sexual behaviors and contraceptive practices Add “second tier” questions to assess comfort with behaviors.

58. PRCH © 2006 58 Assessing Sexual Behavior How old were you when you first had voluntary sex? Include anal, oral and vaginal. What was the date of your last intercourse? Do you have a current partner? How long have you been with your partner? How many sexual partners have you had? How many sexual partners have you had in the past 3 months?

59. PRCH © 2006 59 Healthy Sexuality vs. Sexual Risk Behaviors Sexual development and growth is a natural part of human development Healthy sexual expression different than sexual risk Risk characterized by: Coercion Sexual activity while drunk or high Sexual activity to fill an emotional void

60. Developing a Healthy Sexuality Some questions providers can ask to begin to explore a teen’s sexuality are: How do they know their ready for sex? What is important in a relationship? Can they say no? How do they deal with anger, rejection, and loneliness? ? Can they openly talk to their partner about their feelings?

61. PRCH © 2006 61 Sexual Minority Youth 2 - 4.5% of high school students self- identify as gay, lesbian, or bisexual Limited data Existing data are underestimates Many youth have difficulty understanding complexity of sexual attractions or fear disclosure

62. PRCH © 2006 62 Identifying A Sexual Minority Patient Ask about sexual attractions (can use Scale 1-10) Ask if sexually attracted to opposite/same/both sexes Ask about sexual behaviors, but DO NOT ASSUME they are having sex Identify behaviors that may be putting them at risk

63. PRCH © 2006 63 Assessing Sexual Orientation: Examples Are you romantically interested in men, women or both? Are you comfortable with your feelings? Have you ever had sex with someone of your same gender? For younger teens: when you imagine yourself in a relationship in the future is it with a a man, a woman or both?

64. PRCH © 2006 64 Assessing Gender Identity When you think of yourself as a person, do you think of yourself as male, female, neither or both? What pronoun do you use (she, he, they, sie*)? Are you comfortable with your feelings? How do you think your parents/teachers/friends would react (have reacted) to your gender identity? *Sie is a gender neutral pronoun sometimes used by members of the transgender community

65. PRCH © 2006 65 Counseling Teens About Abstinence Encourage abstinence within context of comprehensive sex education and self-esteem enhancement If patient is already sexually active and is not comfortable with the decision or is not enjoying intercourse: Discuss other options for intimacy between partners Discuss ways patient can communicate decision to partner

66. PRCH © 2006 66 Discussing STI Risk During the Clinical Encounter

67. PRCH © 2006 67 Scope of Sexually Transmitted Infections 18.9 million new cases of STIs each year ½ of which occur in people ages 15-24 Most are asymptomatic and remain undiagnosed By age 25, at least 1 in 2 sexually active people will have contracted an STI Economic costs of treatment ~ $6.5 billion/ yr

68. PRCH © 2006 68 Unique Risks for STI’s Why are youth/young adults most at risk for STI’s? Biologically more at risk (cervical ectopy and CT in girls) Poor knowledge or misperceptions of STD risk for themselves, leads poorer decision making skills Providers barriers in appropriate assessment for risk, screening, and managing Incorrect or infrequent condom use?

69. PRCH © 2006 69 Assessing and Facilitating Condom Use Did you use condoms the last time you had sexual intercourse? How often do you use condoms? All of the time? Most of the time? Some of the time? Can you tell me how to put on a condom?

70. PRCH © 2006 70 Assessing STI History Have you ever had any STIs? Do you have any concerns about having one now? Do you know what the symptoms of STIs are? Tell me. Have you ever been tested for an STI? When was the last time? Would you like to be tested today?

71. PRCH © 2006 71 Discussing and Educating About Pregnancy Risk During the Clinical Encounter

72. PRCH © 2006 72 Teenagers and Pregnancy Risk

73. PRCH © 2006 73 Teen Pregnancy Can happen to even the most “responsible teens” Increased risk with: Lack of access to contraception Positive or ambivalent feelings toward pregnancy Early sexual initiation Family members or peers who are or have been teen mothers Depression and/or low self-esteem

74. PRCH © 2006 74 Declining Teenage Pregnancy Rates Guttmacher Institute, 2005

75. PRCH © 2006 75 Disparities Persist Between Racial Minorities and Whites Pregnancies per 1,000 women aged 15-19, 2002

76. PRCH © 2006 76 Pregnancy Outcomes for Teenagers 15- 19 Years by Race and Hispanic Origin, 1990 and 2002 All RacesWhiteBlack Hispanic 116.3 75.4 98.8 65.0 223.8 134.2 169.1 131.5 Rates per 1,000 women

77. PRCH © 2006 77 Assessing Pregnancy History Have you ever been pregnant or gotten anyone pregnant? What were the outcomes? Do you have any concerns about your fertility? When (if ever) would you like to get pregnant and have children?

78. PRCH © 2006 78 Discussing Contraception Have you ever been on any type of hormonal contraception? If yes, what was your experience? Have any of your friends? If yes, what were their experiences? Would you like me to tell you about some of the options available?

79. PRCH © 2006 79 Female Contraceptive Use at First Intercourse by Year of First Premarital Intercourse, NSFG, 2002

80. PRCH © 2006 80 Male Contraceptive Use at First Intercourse by Year of First Premarital Intercourse, NSFG, 2002

81. PRCH © 2006 81 Factors Affecting Contraceptive Use Knowledge of contraceptive methods Side effects Knowledge of non-contraceptive benefits Attitudes toward pregnancy Peer attitudes Partner and parental support Satisfaction with provider and costs Access to confidential care

82. PRCH © 2006 82 Factors Affecting Contraceptive Choice of Method Peer influences Effectiveness Benefits vs. risk Side effects Non-contraceptive health benefits Frequency of intercourse Number of partners Risk for STIs Motivation and self- discipline Cultural acceptability Cost of medical care/method Access to medical care/method Privacy considerations

83. PRCH © 2006 83 Considerations Before Initiating Contraception with Adolescents Pelvic exam: Not necessary if asymptomatic for STIs Pap smear: Not indicated until female is 21 or has been sexually active for 3 years Emphasize hormonal contraceptives do not prevent STIs Discuss emergency contraception and offer to write an advance prescription

84. PRCH © 2006 84 Wrap Up Adolescents are culture unto themselves Providing care to adolescent patients requires ability to confront biases head-on Confidentiality is key to competent adolescent friendly care This allows for an open, honest discussion of healthy sexuality and ways to be safe

85. PRCH © 2006 85 Please Complete Your Evaluations Now.