Jessica is a 13-year-old who is in the office for her annual well-child visit. You decide this is the year you will begin discussing sexual health topics and provide Jessica with a confidential exam. Mom has been attentive to Jessica’s health care. How do you ask Mom to leave the room for part of the visit?
You are seeing Eric for a sports physical exam. During your time alone with the 16-year-old, he discloses that he is attracted to other males. What questions should you ask, what services should you offer him and how do you bill and maintain confidentiality?
A new AAP clinical report, Sexual and Reproductive Health Care Services in the Pediatric Settingfrom the Committee on Adolescence, offers guidance on how to routinize confidential sexual and reproductive health services in the pediatric primary care office. The report is available at http://pediatrics.aappublications.org/content/early/2017/10/19/peds.2017-2858 and will be published in the November issue of Pediatrics.
Importance of office visits, primary care role
An estimated 45% of U.S. 15- to 19-year-olds report having had vaginal intercourse with an opposite-sex partner; 2.5% of 15- to 19-year-old males report having had oral or anal sex with another male; and 11% of 15- to 19-year-old females report having had a sexual experience with another female, according to the National Survey of Family Growth.
Adolescents and young adults have significant sexual and reproductive health care needs. The highest rates of sexually transmitted infections (STIs), HIV and unintended pregnancy are reported among these age groups. These are all preventable health outcomes with potentially serious permanent sequelae.
Pediatricians can play a significant role in addressing their patients’ sexual and reproductive health needs, including preventing unintended pregnancies and STIs, and promoting healthy relationships.
The Academy, other professional medical organizations and government agencies have published guidelines and recommendations regarding the provision of sexual and reproductive health information and services. This clinical report can assist pediatricians to operationalize the provision of various aspects of sexual and reproductive health care into their practices. The report also provides guidance on overcoming barriers to giving this care routinely while maximizing opportunities for confidential health services delivery in their offices.
It is important that the pediatric office culture reflects adolescents’ and young adults’ health needs to reduce barriers to accessing care and make the setting more youth friendly.
Pediatric offices can extend their office hours to be convenient to adolescents and young adults and train staff to be friendly and welcoming to teenage patients. A separate waiting area with age-appropriate magazines and other media can make adolescent and young adult patients more comfortable. Office brochures should address common adolescent concerns, such as puberty, sexual development, sexual orientation or gender identity; making healthy decisions about sex; STIs; and contraception. All staff should be aware of office confidentiality policies and procedures.
Review confidentiality, office visit policies
At the beginning of the patient interview with parent/guardian present, it is helpful for the provider or staff to review confidentiality policies and the visit structure that includes time alone with the adolescent. The parent/guardian should be reassured that any serious or life-threatening concerns will be disclosed. After reviewing the nonconfidential information with the parent/guardian in the examination room, the parent should be asked to step out so the provider can review sensitive history questions and allow the adolescent to ask questions he or she might not feel comfortable asking or answering in front of another adult.
It is helpful to ask the adolescent directly what sexual behaviors are practiced (“What types of sexual experiences have you had?”) rather than “Are you sexually active?” because this can be interpreted in different ways. The Centers for Disease Control and Prevention suggests the “5 P’s” framework: asking about Partners, Pregnancy Prevention, Protection from STIs, Practices and Past history of STIs.
Pediatricians should be aware that Explanation of Benefits has the potential to inadvertently violate confidentiality for minors or young adults insured as dependents on a parent’s/guardian’s health insurance policy. Providers can take steps to minimize such breaches (e.g., use confidential coding practices) or refer the individual to settings that can provide confidential care (e.g., Title X or health department clinics). Electronic health records can assist in delineating parts of the medical records that are confidential from those that are not.
Dr. Burstein, a lead author of the clinical report, is health commissioner of Erie County, New York, and formerly with the Centers for Disease Control and Prevention.