Tips for talking to teens about STDs

,

Applied Evidence

Tips for talking to teens about STDs

J Fam Pract. 2009 February;58(2):76-81a

By

Anush S. Pillai, DO, FAAFP

These practical steps can help you turn a potentially uncomfortable encounter into a meaningful dialogue.

PDF Download

References

1. Eaton DK, Kann L, Kinchen S, et al. and the CDC. Youth risk behavior surveillance—United States, 2007. Morb Mortal Wkly Rep. 2008;57(SS-4):1-136.

2. Diller J. Cultural Diversity: A Primer for the Human Services. Belmont, Calif: Wadsworth Publishing Company; 1999:8-26.

3. Centers for Disease Control and Prevention. Sexually transmitted diseases: treatment guidelines, 2006. Morb Mortal Wkly Rep. 2006;55(RR-11):1-100.

4. Rietmeijer CA. Risk reduction counseling for prevention of sexually transmitted infections: how it works and how to make it work. Sex Transm Inf. 2007;83:2-9.

5. Ma R. Special report: one-to-one counseling can reduce STI risk. The Practitioner. April 26;2007:81.-

6. The clinical approach to the patient with possible STD. In: Marrazzo J, Ocbamichael N, Meegan A, Stamm WE. The Practitioner’s Handbook for the Management of STDs. 4th ed. Seattle, Wash: University of Washington; 2007:1-7.

7. American Medical Association (AMA). Guidelines for Adolescent Preventative Services (GAPS). [Recommendations Monograph]. Chicago, Ill: AMA; 1997.

8. Creegan L, ed. Behavioral Counseling for STD/HIV Risk Reduction. National Network of STD/HIV Prevention Training Centers; August 2007. Available at: http://www.stdhivtraining.org/resource.php?id=19&ret=clinical_resources. Accessed December 31, 2008.

9. CDC. STD Health Communication, Executive Summary HPV. 2004. Available at: http://www.cdc.gov/std/HealthComm/ExecSumHPVGenPub2004.pdf. Accessed December 31, 2008.

10. Bauer HM, ed. The Clinical Approach to the STD Patient. National Network of STD/HIV Prevention Training Centers; August 2007. Available at: http://www.stdhivtraining.org/resource.php?id=21&ret=clinical_resources. Accessed December 31, 2008.

11. Sophocles A. Time is of the essence: coding on the basis of time for physician services. Fam Pract Manag. 2003;10:27-31.

12. The House Committee on Energy and Commerce. Making the Internet safe for kids: the role of ISP’s and social networking sites, Day 2. Hearing Webcast. Available at: http://archives.energy-commerce.house.gov/reparchives/108/Hearings/06282006hearing1955/hearing.htm. Accessed January 7, 2009.

13. National Suicide Prevention Lifeline home page. Available at: www.suicidepreventionlifeline.org. Accessed December 31, 2008.

14. Brown NL. Internet-based hotline to counsel abused young people. Healthline.com Web site. Available at: www.healthline.com/blogs/teen_health/2008/04/internet-based-hotline-to-counsel.html. Accessed December 31, 2008.

15. Rape, Abuse & Incest National Network home page. Available at: www.rainn.org. Accessed December 31, 2008.

16. Brackbill R, Sternberg M, Fishbein M. Where do people go for treatment of sexually transmitted diseases? Fam Plann Perspect. 1999;3:10-15.

17. CDC. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. Atlanta, Ga: US Department of Health and Human Services; 2006.

18. Hodge JG, Jr, Pulver A, Hogben M, et al. Expedited partner therapy for sexually transmitted diseases: assessing the legal environment. Am J Public Health. 2008;98:238-243.

Practice recommendations

Annual physical exams and sports physicals are ideal opportunities to raise issues of sex and sexually transmitted infections (STIs) (B).
Meet with young patients alone when asking about sexual habits, activity, preferences, or other sensitive matters (C).
Evidence supports the use of expedited partner therapy (EPT) in treating gonorrhea and Chlamydia (A).

Strength of recommendation (SOR)

Good-quality patient-oriented evidence
Inconsistent or limited-quality patient-oriented evidence
Consensus, usual practice, opinion, disease-oriented evidence, case series

As you conclude a routine annual physical exam of a 14-year-old girl, you ask her if she has any questions. With some hesitation, she tells you about a “friend” of hers who recently had sex with her boyfriend. She has heard many rumors from her friends, television, and chat lines. She doesn’t think her friend got pregnant, but is worried that she might have caught something. She tells you that her friend is also uncertain about whether—and how—to tell her parents.

How would you respond? Would you be comfortable helping your patient, and her parents, discuss this delicate matter in a meaningful way?

Though most clinicians are adept at diagnosing and treating sexually transmitted infections, far fewer feel skilled enough to counsel teens and parents about them. STIs (the new and politically appropriate terminology for STDs) are commonly encountered in family medicine; knowing how to discuss the many associated issues with teens and parents is paramount—especially when you consider the statistics.

FAST TRACK

Roughly 15% of high school students have had sex with 4 or more people.

According to the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance System (YRBSS):¹

47.8% of 9th to 12th graders have had sexual intercourse.
7.1% of children have had intercourse before age 13.
14.9% of high school students have had sexual intercourse with 4 or more people.
38.5% of sexually active 9th to 12th graders did not use condoms during their last sexual encounter.

Opening Pandora’s box—carefully

As family physicians, we must be willing not only to discuss sexual issues if asked, but to raise them with patients and parents, when appropriate. The CDC offers training for health professionals in obtaining a sexual history and counseling and educating patients (http://depts.washington.edu/nnptc). Unfortunately, little information exists on how to tailor education to the values and beliefs of an individual family or to the broader cultural mores of the society in which the young person lives.² Nonetheless, there are many things you can do to improve the conversations you have.

FAST TRACK

Additional recommended reading can be found online in TABLE W2, available at www.jfponline.com.

For starters, ask open-ended questions and use understandable and normalizing language.³ Educate patients regarding the various STIs and methods of prevention—ie, proper condom use, abstinence, limiting the number of sexual partners, changes in sexual practices, and vaccination.^4-6 Ask patients about their use of and motivation to use condoms and contraceptive methods, as well as their sexual orientation, number of sexual partners, if they have ever exchanged sex for money or drugs, and prior history of STIs.⁷ To facilitate communication, familiarize yourself with sexual slang terms.

Focus on dispelling myths such as the misconception that contraceptive pills protect against STIs ( TABLE W1 , available online at www.jfponline.com). Educate parents, too, about STIs, how to counsel their children, and prevention strategies, including available vaccinations.

TABLE W1
Dispelling common myths about STIs

MYTH	FACT
Oral contraceptives protect against STIs	Oral contraceptives do not protect against STIs. Neither do vaginal rings or IuDs. use condoms to minimize the risk of infection transmission.
Condoms are 100% effective	Effectiveness depends on proper technique and a condom must be used every time to be effective.
Nonvaginal sex (oral, anal, sex toys) doesn’t carry risk	Oral and anal sex can spread STIs, as can sharing sex toys.
Risk is only present if there is ejaculation	Sexual contact even in the absence of ejaculation (coitus interruptus) is potentially risky, especially if skin or mucosal integrity is damaged. any exposure to body fluids is a risk.
All STIs are treatable	Many STIs, such as hepatitis, HIV, herpes, and syphilis cannot be permanently cured.
HIV, human immunodeficiency virus; IUDs, intrauterine devices; STIs, sexually transmitted infections.

TABLE W2
Additional recommended reading

Gunter J. Genital and perianal warts: new treatment opportunities for human papillomavirus infection. Am J Obstet Gynecol. 2003;189(suppl):S3-S11.
St. Lawrence JS, Montaño DE, Kasprzyk D, et al. STD screening, testing, case reporting, and clinical and partner notification practices: a national survey of US physicians. Am J Public Health. s002;92:1784-1788.
Guide to Clinical Preventive Services, 2007: Recommendations of the US Preventive Services Task Force. Agency for Healthcare Research and Quality; 2007. AHRQ Publication No. 07-05100.
Van Vranken M. Prevention and treatment of sexually transmitted diseases: an update. Am Fam Physician. 2007;76:1827-1832.
Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:166-169.