You’ve probably heard the statistics: 30% of females in this country are sexually active by age 15, 70% by age 18. One in 10 teenage girls older than 15 gets pregnant each year. The National Commission to Prevent Infant Mortality says that one in eight babies born in 1989 was born to an adolescent. Two thirds of those teen mothers are not married.
Unplanned pregnancies are only one part of a much larger and more disturbing picture. Rates of sexually transmitted disease (STDs) are highest in the adolescent age group. Gonococcal and chlamydial infections, among others, can cause pelvic inflammatory disease, with the possibility of future ectopic pregnancies and infertility. Condylomata can be precancerous and require intensive laser or chemical therapy. Herpes is still incurable, and human immunodeficiency virus infection among adolescents is rising at an alarming rate.
You may be aware of the statistics and the consequences of early sexual activity, but, like many physicians, you may assume they apply primarily to inner-city clinic populations. Surely teenagers from good families who attend school regularly and do well there don’t have these problems. Their parents usually make the same assumption.
One of our consultants, Diane A. Dimond, MD, a pediatrician in private practice in Norfolk, Va., treats teenagers from middle-class to upper-class families. About two thirds are white and one third are black. Perhaps her patients are similar to those you usually see. Their parents want the best for their children and believe they are providing it. But in this solidly middle-class practice, about two girls a week are treated for an STD, three or four a week come in for gynecologic examinations and birth control (although the official complaint is often “irregular periods”), and about one girl a month turns out to be pregnant. Most of these girls have not dropped out of school or become delinquents. Some are honor students.
The Consequences of Sexual Activity
Teenagers as a group are amazingly ignorant of the consequences of sexual activity, and parents often appear to be totally clueless about their children’s social lives. Parents frequently claim to have had no idea that their child is sexually active until the physician has to sit down and, with the youngster’s permission, talk about a recently acquired herpes.
Primary care physicians are ideally placed to deal with these adolescent sexuality issues. In many communities, pediatricians may not offer gynecologic care, obstetrician-gynecologists may not see patients younger than 18 or 19 except when an advanced pregnancy makes it necessary, and specialists in adolescent medicine may be few and far between.
In any case, most teens who have been in a family physician’s care would rather stay with the doctor they have known and trusted since childhood. As this physician, you have a unique opportunity to influence their behavior through education and counseling–to help teenagers understand their bodies, to encourage them to make wise decisions about sexual activity, and to provide them with information on contraception and STDs.
Dealing with Sexually Active Teens
Dealing with adolescents can be a challenging and rewarding part of medical practice. You have to like dealing with teenagers to be successful at it–excited for their victories, understanding of their daily stresses, sympathetic to their setbacks. The optimism of teenagers–their hope for the future, their sense of being immortal–can be immensely attractive. Unfortunately, those are the very traits that make them so vulnerable in matters of sexuality.
If possible, furnish one of your examining rooms with age-appropriate posters and educational materials on puberty, sex, pregnancy, birth control, STDs, and AIDS. Cover a wall in the examining room with racks of these materials. Try to put all adolescents, regardless of their chief complaint, in that room, because something hanging on the wall may catch their eye and spark a conversation. Try also to cluster appointments for teenage patients on certain days of the week, so that they’ll see people their own age in the waiting room. And always examine teens in private, out of the presence of parents.
Make it clear to adolescent girls and their parents that the children are welcome to remain with you for gynecologic care. If you are performing a girl’s first pelvic examination, take time to explain the procedure and answer questions beforehand, while the girl is still fully dressed. During the examination, explain step-by-step what is happening. Tell the patient that what you are doing should not hurt, ever. An internal examination may be a little uncomfortable; but if it hurts, something may be wrong, or the examination is being done incorrectly.
In order to discuss sex frankly with teens, you need to be comfortable in the role of confidant or confessor. You do not have to be a buddy or pal. You should be able to offer your opinion and advice, and you will find that they are usually welcome.
A few sexually active teens are girls who for one reason or another are starved for affection. They look for it in every young man they encounter. Sometimes they want to get pregnant because they think a baby will give them the love they crave. Many more girls are romantics, however, and enter into a sexual relationship because they believe they’re in love. Falling into (and out of) love is a normal, necessary part of adolescent development. But a lovesick 15-year-old girl in a fully sexual relationship may not have the emotional and intellectual resources to pick up and go on when the romance is over. Once a girl becomes sexually active, she usually continues to be so with future partners, and at an earlier stage in the relationship.
Talking to Teens About Sex
Physicians need to start talking to teens early in their sexual development. They need to look at every prepubescent child as a potentially sexual being who has questions, concerns, and worries about sex. Appropriate sex education can dissuade some teens from early sexual activity, with all the risks it entails, and protect those who choose to engage in sex from some of the hazards. Counseling is most effective if it is directed at young teens who aren’t yet sexually active.
Make handouts a routine part of your sexual counseling. At least two sets are advisable. One set, for patients 10 and 11 (or younger, in some cases), might deal with the physical changes of puberty, menstruation, and reproduction. The other set, for 12-15-year-olds, should be more explicit and comprehensive and deal with sexual activity, pregnancy, birth control, STDs, and safe sex practices.
Whenever a teenager is in the office–for a sore throat, a sports physical, or some other reason–spend five minutes during the physical examination asking questions:
* How’s school? Are you enjoying it? How are your grades?
* Do you have a boyfriend (or girlfriend)?
* What do you like to do for fun?
* Do you have a job? How many hours a week
do you work?
* Do you smoke? What about drinking or using other drugs?
* When was your last menstrual period?
* Are you sexually active?
The answers to these questions can be very revealing. Teens will answer honestly if they feel you are being open with them, and you tell them their answers will not leave the room. Some simply need to feel they have an objective listener. Some parents who bring a child in for a routine visit may raise their eyebrows if the teen shares your conversation and shows them the literature you’ve provided, but most will be grateful that you’ve broached these topics.
It’s often appropriate to tell a teen who is on the brink of a sexual relationship, “I think you’re too young for sex, not physically, maybe, but emotionally and psychologically, and here are my reasons.” Then add, “But if you should decide to become sexually active, or already are, please let us keep you safe.” Rather than moralize, protect the teen’s physical and emotional health the best way you can.
With patients you know well, especially when you sense they are uncertain and looking for your approval, you might try to buy time. Say something like, “OK, you’re in love. Let’s wait three months, until your 16th birthday. If you’re still in love then, we’ll put you on the pill.” Three months later, you may hear, “No. He’s history, and am I glad I didn’t.” This approach may work if a girl is not yet sexually active and comes to you for advice.
Providing Information on Contraception
You may want to provide information on contraception when the patient is 13, give or take a year or two depending on physical and social development. You can’t rely on parents or school sex education courses to provide this information. The courses may not be explicit enough, or your patient may not have taken in what has been said. Teenagers need to understand that the pill prevents pregnancy (if taken on schedule) but doesn’t prevent STDs; that a latex condom, especially when used with a spermicidal foam, can prevent STDs and pregnancy, but only if used correctly and every time; and that membrane condoms provide less protection than latex. Remind them that all forms of contraception involve risks, but that the risks of unprotected sex are even greater.
Never discuss with parents what teenagers have told you, unless you have the teen’s permission. Even then, it is a good idea to talk to parents only in the teen’s presence. When anxious parents call to ask for information, tell them to ask their youngsters. But do encourage teen patients with sexually related problems to talk to their parents. Point out that the parents may have to be told eventually, if the teen needs to see a specialist or get practical assistance in dealing with pregnancy.
When it’s time to break the news to parents, you may want to play the role of advocate and mediator. You will probably need to arrange referrals to gynecologists and psychotherapists. Depending on the patient’s needs, you may also need to make referrals to adoption and other social service agencies, to the health department (for birth control), and, on a few occasions, to an abortion facility. Society as a whole must make an effort to slow down the rites of passage, the events and privileges that celebrate “growing up” and “coming of age.” When girls are given the symbols of adult female sexuality while they are still children–pierced ears in infancy, makeup and sexy clothes at 8, steady boyfriends and school dances at 10 or 11–a 15-year-old may feel that in order to be grown up she has to engage in sex.
Many parents go along with these trends because they want their daughters to hold their own with peers and to have all the material things they didn’t have themselves. Parents need to be supported in taking a stand and saying No, if that’s what they believe.
Parents may need to be reminded to try not to push their children through childhood so fast, to allow their children time to simply be themselves. You might suggest that they look for healthy ways to build their child’s self-esteem, such as by rewarding academic success or talents in athletics, the arts, or wherever their child can shine. Encourage parents to talk to daughters about women who are role models of achievement.
The facts of life are unchangeable. Girls mature approximately two years earlier than boys. But that budding 11-year-old girl, who looks and acts 11, should still be able to be pals with a 12-year-old boy. She should not be trying to attract the 16-year-old’s attention. Girls of this age should have time to relate to boys as human beings and as friends, with all their similarities and differences, before the overwhelming call of nature beckons.
The primary care physician has a crucial role to play in protecting patients from the consequences of too-early sexual activity. You can help young people and their parents recognize and prepare for the changes that sexual maturity brings. You can be a ready source of information and guidance on everything from sexual abstinence to contraception. Above all, you can encourage openness and honesty between parents and children.