Transcript Sexual History-Taking: Essential Questions

Sexual History-Taking:
Essential Questions

Objectives
 Identify barriers to adolescents seeking and receiving health
services
 Understand state laws surrounding consent and confidentiality
 Take a sexual history from an adolescent patient
 Increase personal comfort level and confidence when taking
sexual histories from adolescent patients
 Utilize tools and resources on adolescent sexual health
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What Does It Mean to Be
Adolescent-Friendly?
Adolescent-Friendly Health Services
Include
 Comfortable, confidential, safe space maintained by
office staff and providers
 Communicating respectfully and appropriately
 Screening for high-risk behavior
 Awareness of how ability, age, culture, gender
identity, sexual orientation, religion, or socioeconomic
status can affect an adolescent’s reproductive health
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Adolescents
 For the most part,
adolescents are:
 Healthy
 Resilient
 Independent
yet…vulnerable
 Adolescents are not:
 Big children
 Little adults
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What Barriers Prevent Adolescents
From Seeking Care?
 Inaccessible locations and/or limited services
 Limited office hours
 Lack of money, insurance, and transportation
 Poor communication by providers
 Insensitive attitudes of care providers
 Lack of provider knowledge and skills
 Perceived lack of confidentiality and restrictions
(parental consent/notification)
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.
ALL Youth Need Sexual and
Reproductive Health Care
 Adolescents can:
 Engage in healthy
relationships that may
include sexual activity
 Participate in decisionmaking around
pregnancy and STI
prevention
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What Is Healthy Sexuality?
Sexual development and growth is a
natural part of human development
Healthy sexuality is expressing the
sexual aspects of yourself that
minimizes health risks
Risk is activity that compromises a youth’s
health and well-being
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Sexual
Orientation
Sexual
Attraction
Paradigm of
Sexuality
Biological
Sex
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Sexual
Behavior
Gender
Identity
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Confidentiality Is Essential
Confidentiality Is Developmentally
Expected
 Expected need for increasing autonomy
 Increasing intellectual capacity to give informed
consent
 Opportunity to take responsibility for health
 Providers must feel comfortable with providing
confidential care to youth and young adults
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Professional Consensus
Professional organizations support confidential
adolescent health care.
ACOG ‘88
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SAM ‘92
AMA ‘92
AAFP ‘89
AAP ‘89
Sexual Health Services and
Confidentiality
JAMA study of 556 sexually active adolescents
visiting a family planning clinic
If mandatory
parental
notification was
required for
contraception
59% would stop using
ALL health services
11% would delay HIV or
STI testing and treatment
1% would stop having
sex
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Reddy DM, et al. JAMA. 2002;288:710–714.
Confidentiality: Parental Perspective
 Parents are not the enemy
 Parents are experiencing their own adjustment to
their child’s adolescence
 Providers have an opportunity to educate parents
about the need for confidentiality in the providerpatient encounter
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Discuss Confidentiality in Advance
 Inform parents about confidentiality policy before visit
Letter home:
• Detail when parent will be included in
clinical visit and when not
• Discuss billing issues if possible
 Display materials (posters or brochures discussing
importance of doctor/patient confidentiality)
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Starting the Conversation and
Asking Sensitive Questions
Case: Angela
 Angela is a 16-year-old who
has been your patient since
she was a toddler but you
haven’t seen her in 2 years
 She comes in today for a
sports physical
 How do you begin the visit?
 What questions do you need to
ask?
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Communication Tips (1)
 Establish rapport
 Provide confidentiality assurance and establish limits
of confidentiality
 Ask permission
 Normalize
 Note nonverbal cues
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Communication Tips (2)
 Minimize note-taking, particularly during sensitive
questioning
 Talk in terms the adolescent will understand
 Developmentally appropriate questions
 Ask open-ended questions
 Practice listening skills
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Communication Tips (3)
 Avoid the surrogate parent and adolescent roles
 It’s a conversation…not an interrogation!
 What purpose does the information serve?
 Healthy respect and regard for privileged information
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Comprehensive HEEADSSS
 H: Home
 E: Education/Employment
 E: Eating
 A: Activities
 D: Drugs
 S: Suicide/depression
 S: Sexuality
 S: Safety
 *Additional questions:
 Strengths, Spirituality
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Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014.
SHEEADSSS
 S: Strengths/Spirituality
 H: Home
 E: Education/Employment
 E: Eating
 A: Activities
 D: Drugs
 S: Sexuality
 S: Suicide/depression
 S: Safety
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Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014.
Utilizing HEEADSSS
 Ask less-sensitive questions first on each topic
 Can use written questionnaire in waiting room
 Provider should follow up on answers drawing
concern
 Time limitations make model difficult
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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: Designed by the ACOG Committee
on Adolescent Health Care to help every office care
for adolescent patients
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What Is a Sexual Health History?
Sexual History Tips
 Reassure confidentiality
 Take history when the patient is still dressed
 Assess development and structure questions
accordingly
 Watch for concrete vs. abstract answers
 Avoid assumptions of heterosexuality
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Why Is a Sexual History Important?
 Affirm healthy behaviors
 Address patient questions or concerns
 Provide interventions for risk behaviors
 Prevention counseling
 Explore potential dysfunctions
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Sexual History-Taking Template
 Gender identity
 Sexual orientation
 Sexual coercion and abuse
 Sexual activity
 Number of partners
 Frequency of intercourse
 Type of sex practices
 STI history and risk assessment
 Pregnancy history and risk assessment
 Contraceptive behaviors
 Substance use
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When to Take a Sexual History
 Adolescents should have a sexual history taken at all
preventative care visits
 A sexual history is important and frequently relevant
to the HPI
 Take sexual history at least annually
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Providing Developmentally
Appropriate Counseling
 Recognize sexual developmental milestones
 When Counseling
Can your patient think abstractly or concretely?
 Age
development
 Recognize variations:
Very mature 14-year-old vs. an immature 17-yearold
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Discussing Sexual and
Romantic Relationships
 Have you ever had a crush on a boy or girl? What
was that like?
 Have you ever had a romantic relationship with
someone?
 How would you describe it?
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Relationships Matter
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Assessing the Health of
the Relationship
 What does a healthy relationship look like to you?
 How often are you and your partner together? How
does your partner feel about you hanging out with
other friends?
 (If sexually active) Who makes the decisions about
when to have sex and what kind of contraceptives
you should use?
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Characteristics of a Healthy
Relationship
 Nonviolent conflict resolution
 Open and honest communication
 Right to autonomy for both people
 Shared decision-making
 Trust
 Mutual respect
 Individuality
 Empathy
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Risk Factors for Unhealthy
Relationships
 Partner is 3-5 years older
 Exposure to violence in the household or community
 Early sexual activity
 Low education level
 Sexual risk-taking
 Substance abuse
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Signs Linked to Intimate Partner
Violence (IPV)
 Depression/anxiety
 Changes in eating patterns
 Changes in social relationships
 Substance abuse
 Abdominal pain/pelvic pain
 Physical findings inconsistent with stated mechanism
of injury, or findings associated with intentional injury
(patterned marks, bruises in varied stages of healing,
burns)
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IPV and Adolescents
 Intimate Partner Violence is bi-directional, meaning
girls and boys report being both the victims and the
perpetrators
 9.3% of females and 9.5% of males report being hit,
slapped, or physically hurt on purpose by their
boyfriend or girlfriend
 11.8% of females and 4.5% of males have ever been
physically forced to have sex
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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
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Discussing Readiness for Sexual
Initiation
 Some questions providers can ask to begin to
explore a teen’s sexuality are:
 How does one know one is ready for sex?
 What is important in a relationship?
 Can she/he say no?
 How does one deal with anger, rejection, and
loneliness?
 Can she/he openly talk to partners about their
feelings?
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Discussing Sexual Activity
 Sexual behavior is a spectrum
 Includes coital and noncoital activities:
 Kissing
 Self and partner masturbation
 Oral, anal, and vaginal sex
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Assessing Sexual Orientation
 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 man, a woman, or
both?
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Assessing Gender Identity
 Do you think of yourself as male, female, neither, or
both?
 What pronoun do you use (she, he, they, sie*)?
 *Sie is a gender-neutral pronoun sometimes used by
members of the transgender community
 Are you comfortable with your feelings?
 How do you think your parents/teachers/friends
would react (have reacted) to your gender identity?
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Assessing Sexual Behavior
 How old were you when you first had sex? Include
anal, oral, and vaginal.
 What was the date of your last intercourse?
 What kind of protection did you use at last sex?
 Condoms? Hormonal contraception?
 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?

Orientation vs. Behavior
Orientation does not always = behavior
Majority of women who have sex with women (53–
99%) have had sex with men
While respecting a patient’s identification, you should inquire
about sexual behaviors with partners of all genders.
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Sexual Satisfaction
 How often do you have pain during sexual
intercourse or other sexual activities?
 Are you satisfied with how often you have
sexual relations and with what you do with your
sexual partner?
 Any problems becoming aroused, getting an
erection, getting lubricated (wet), or having an
orgasm?
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Sexual Health
 Have you ever had any infections?
 Do you know what the symptoms of STIs are? Tell me.
 Have you ever been tested for an STI? Tell me more.
 How about your partner?
 Sexual dysfunction?
 Unintended pregnancies
 Sexual violence
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Place Matters
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Place Matters
Broken
Windows
Groups
Poverty
Groups
Sample Size
Gonorrhea
Rate (Mean
+/- SD)
Low
Low
25
27.4 +/- 12.5
Low
High
10
25.0 +/- 9.0
High
Low
4
32.3 +/- 9.9
High
High
16
52.0 +/- 15.8
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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?
 Are you doing anything to prevent an unintended
pregnancy?
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Discussing Contraception
 What have you used for pregnancy prevention?
 What was your experience?
 How about your friends?
 Would you like me to tell you about some of the
options available?
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Angela: Case Continued
 Angela tells you she has
a boyfriend she has been
dating for about 4 months
 She has not had sex but
thinks she might be ready
in a few months
 She agrees to come back
to talk about options for
contraception
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Case: Angela
 Before she leaves, what preventive measures do you
discuss with Angela for the future?
 Complete HPV vaccine series
 Emergency contraception
• Over-the-counter
• Advance prescription still possible
• Does not protect against STIs
 Condom use
• Give patient condoms to take home
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Take-Home Messages
 All adolescents need sexual and reproductive health
care
 Positive sexuality is part of healthy development
 Confidentiality is essential
 Taking about sexuality with patients helps them avoid
unintended pregnancies and STIs

Provider Resources and Organizational
Partners
 www.advocatesforyouth.org—Advocates for Youth
 www.aap.org—American Academy of Pediatricians
 www.aclu.org/reproductive-freedom American Civil Liberties
Union Reproductive Freedom Project
 www.acog.org—American College of Obstetricians and
Gynecologists
 www.arhp.org—Association of Reproductive Health
Professionals
 www.cahl.org—Center for Adolescent Health and the Law
 glma.org Gay and Lesbian Medical Association
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Provider Resources and Organizational
Partners
 www.guttmacher.org—Guttmacher Institute
 janefondacenter.emory.edu Jane Fonda Center at Emory
University
 www.msm.edu Morehouse School of Medicine
 www.prochoiceny.org/projects-campaigns/torch.shtml NARAL
Pro-Choice New York Teen Outreach Reproductive Challenge
(TORCH)
 www.naspag.org North American Society of Pediatric and
Adolescent Gynecology
 www.prh.org—Physicians for Reproductive Health
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Provider Resources and Organizational
Partners
 www.siecus.org—Sexuality Information and Education Council
of the United States
 www.adolescenthealth.org—Society for Adolescent Health and
Medicine
 www.plannedparenthood.org Planned Parenthood Federation of
America
 www.reproductiveaccess.org Reproductive Health Access
Project
 www.spence-chapin.org Spence-Chapin Adoption Services
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Please Complete Your Evaluations Now
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