The United States should be proud of its declining teenaged pregnancy rates over the past several years, with data from 2016 revealing a continued and significant decrease in birth rates in adolescents aged 15 to 19 years from 2007 to 2016.1 However, we still lag far behind other developed nations.2 Moreover, adolescents and young adults still share a disproportionate burden of sexually transmitted infections (STIs) compared with other age groups.3–5 The Centers for Disease Control and Prevention estimate that individuals aged 15 to 24 years account for one-half of all new STIs in the United States and one-quarter of new HIV diagnoses but account for only one-quarter of the population that is sexually active.6,7 Despite this, one-third of adolescents have health maintenance examinations without any mention of sexual health. If sexual health is discussed at all, it is for an average of merely 36 seconds.8
The American Academy of Pediatrics emphasizes the significant role that pediatricians can play in preventing these avoidable health outcomes, primarily by focusing on the pediatric office setting.9 However, it is time for pediatric hospitalists to embrace sexual and reproductive health, including STI and HIV testing, as routine inpatient care regardless of the chief complaint or reason for admission. Currently, there is limited research in this area. In this issue of Hospital Pediatrics, 3 important articles related to sexual and reproductive health for adolescents are presented in which researchers look beyond the classic office scenario to the hospital setting. Studies have already revealed that adolescents are open to receiving contraceptive counseling in a variety of settings, such as school-based health centers,10,11 the emergency department (ED),12–14 and while hospitalized on the wards.15 The researchers in these 3 Hospital Pediatrics articles contribute to the literature by providing evidence that hospitalists want to provide sexual health services,16 that documentation of sexual history must be improved on the hospital wards,17 and that hospitalized adolescents find HIV screening acceptable.18
The authors of “Contraception for Adolescents and Young Adults in the Inpatient Setting: The Providers’ Perspective” contribute to the conversation on whether contraceptive services should be offered in the inpatient settings by offering the perspective of medical providers. This brief report by Goldstein et al16 reveals an important finding: >80% of providers surveyed thought it would be appropriate to start a contraceptive for inpatients. Additionally, more than one-third of the respondents had already done so. A lack of training in contraception, little exposure to adolescent patients, and concerns about confidentiality were all listed as barriers. The authors highlight that providers want to and may already willingly provide these services.
To assess contraceptive needs, providers must take a sexual history. Also in this issue is “Documentation of Sexual History in Hospitalized Adolescents on the General Pediatrics Service” by Riese et al.17 This retrospective chart review of adolescents aged 14 to 18 years admitted to a pediatric hospitalist service revealed that documentation of sexual history in the chart occurred in just less than two-thirds of the charts reviewed (62.4%) and was more likely to be documented for adolescent girls and older adolescents (aged 16 to 18 years) compared with younger adolescents. Certainly, a limitation of the study is that the lack of documentation does not necessarily mean that a sexual health study was not taken. The study findings reveal that it is not standard practice to assess high-risk patients (such as patients who are boarding for psychiatric placement). Although assessing the sexual histories of approximately two-thirds of adolescent patients is a great start, pediatric hospitalists may have the ability to spend more time with patients than would a primary care provider. Additionally, hospitalists have the ability to return at a later time, when parents or guardians are not around, to document a more complete history, which would mean that one might expect this number to be higher.
STI testing may be done as part of the ED visit for an adolescent who is then subsequently hospitalized. However, if it is not done in the ED, the wards are another opportunity to provide these services. In “Acceptance of Routine HIV Testing by Hospitalized Adolescents and Young Adults,” Bhalakia et al18 explored how routine HIV testing on admission to an urban, academic, pediatric hospital was received by patients aged 13 to 24 years. The authors found that approximately one-half of the patients (47%) accepted HIV testing. Nearly all the adolescents and young adults surveyed (96%) agreed that the hospital is a good place to offer HIV testing. This study reveals that regardless of admission diagnosis, adolescents and young adults perceive hospitalizations to be appropriate for nonprimary care providers to ask about STIs, even the most stigmatized of STIs. This study helps dispel a potential misconception that adolescents would object to HIV testing in the hospital and provides an opportunity to ensure that all adolescents know their HIV status and follow the recommendations of numerous professional organizations that recommend routine HIV testing in adolescence.
With evidence continuing to emerge that offering contraceptive options and STI and HIV testing among adolescents are acceptable and effective in venues outside of primary care offices, one must reflect on what barriers might exist to prevent pediatric hospitalists from incorporating this into their practices. In a recent report regarding the development of curriculum for pediatric hospitalist fellowship, sexual health was not mentioned.19 This is a huge oversight, especially for those who may go on to practice in rural areas without access to adolescent medicine specialists or pediatric gynecologists, who otherwise are available for consultation. Pediatric hospitalists should be able to handle several conditions in adolescence that may require hospitalization, such as abnormal uterine bleeding or pelvic inflammatory disease. Hospitalists should be comfortable with pelvic examinations and obtaining histories that are pertinent to these conditions; therefore, a solution might be to ensure that pediatric hospitalist fellowships include contraceptive management and sexual history taking as required training competencies.
Some might think that sexual and reproductive health are best explored in the primary care setting, especially because there are already so many constraints on time and patient care for hospitalists. However, pelvic inflammatory disease may present as abdominal pain and later as chronic pelvic pain, and Chlamydia can cause abnormal uterine bleeding. These diagnoses potentially make the discussion of reproductive and sexual health easier because they may be key differential diagnostic entities related to the chief complaint. Furthermore, conversations about sexual health can be valuable even for patients who are admitted with issues without a direct connection to sexual health, such as an asthma exacerbation or a broken bone. Given the elevated rate of STIs and unplanned pregnancy, it is worthwhile to take the time in the history and physical examinations to explore this topic, especially because many adolescent patients are open to these discussions.15
Pediatric hospitalists have an opportunity to initiate and bridge sexual and reproductive health services. It may seem daunting to incorporate this into all of the other responsibilities that are required, but here are some recommendations to get started9 :
Know the confidentiality laws in your state. The Guttmacher Institute is an excellent resource (www.guttmacher.org). All 50 states allow minors to consent to STI testing and treatment;
Know if parents or guardians have access to the patient’s electronic medical record.9 Some electronic medical records allow for confidential notes or documentation;
Spend time alone with every adolescent patient after explaining confidentiality and its limitations;
Know the resources in your area. Seek out community resources that can help support sexual and reproductive services for adolescents. Title X–funded clinics offer confidential and often low-cost or no-cost care. Family planning clinics can be found at https://www.opa-fpclinicdb.com/;
Practice asking questions related to sexual health. The American Academy of Pediatrics Committee on Adolescence has outlined numerous techniques for how to interview an adolescent, including questions related to gender identity, sexuality, and sexual health9 ; and
Communicate information back to the adolescent’s primary care provider. Primary care providers have a shared interest in preventing unplanned pregnancy and STIs. Work collaboratively with primary care providers on all aspects of a patient’s care, including sexual health.
Adolescents deserve accurate and comprehensive sexual health care no matter where they are, whether in a school-based health center, a primary care provider’s office, or while admitted to the hospital. If we continue to think of this responsibility as only for the primary care provider at a health maintenance visit, we are missing out on opportunities to connect with patients on this important health topic. Moreover, it is possible that by not addressing these issues, harm could come to patients (such as sequelae from an untreated STI or an unintended pregnancy). The barriers listed in “Contraception for Adolescents and Young Adults in the Inpatient Setting: The Providers’ Perspective” can be overcome. For example, pediatric hospitalist fellowship programs could have increased exposure to adolescents and include training in sexual and reproductive health so that hospitalists feel prepared to address these issues. By becoming more familiar with confidentiality and this practice, pediatric hospitalists can provide essential sexual health services to adolescents, including HIV testing or the initiation of contraception.
The author acknowledges Dr S. Bryn Austin for her feedback on the draft of this article.
FUNDING: No external funding.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.