Thirty-six seconds isn’t enough.
In 2014, an observational study of audio-recorded conversations between 253 adolescents aged 12–17 and 49 physicians during health maintenance visits found that the average amount of time spent on the topic of sexual development and sex behaviors was 36 seconds. In 35% of visits, there was no discussion of the topic at all.
Our teens deserve better. As clinicians, we need to develop confidence around supporting teens as they explore their own sexuality. We need to be comfortable counseling them on developing positive intimate relationships. We cannot wait for kids and families to bring questions to us; starting early with honesty, compassion, and positivity can go a long way toward helping young people transition into adulthood in a healthy way.
Below are my tips for starting these important conversations:
Changes on the Inside, Changes on the Outside
Young people have bodies and hormones that are changing rapidly. During pre-adolescent visits, I like to introduce the concept of puberty as changes on the outside (hair! Deodorant! Growth spurt!) and on the inside (more privacy! New sleep patterns! Sexual desire!). Framing discussions in this way offers guideposting for kids and parents alike, a way to telegraph a reminder that the changes co-occur and are a normal part of growth and development. If you grew 3 inches last year and now you need deodorant, then we also need to talk about crushes and consent.
Affirm, Include, and Asking for a Friend
As young people start to develop sexual desire, we need to normalize romantic and sexual feelings. Equally important, we need to have a vocabulary robust enough to affirm all sexual orientations. I often start by telling kids and families that they might know someone who has a crush, a boo, a bae, or a thing for someone special. It might be a person they know from school or extracurriculars, or it might be someone they encounter in the media. By opening the conversation with naming desire as a concept normalizes it — and then, after, check with your patient and their family to see if there are questions for follow up. If not, move on. As a clinician, I almost never need to know the details of who a patient liked in fifth grade, but I do need to effectively communicate that it’s OK to like people, and whomever it is, it’s normal. Framing the conversation as “asking for a friend,” or “you may know someone who” are amazing ways to dim the intensity of the spotlight many young people dislike about a health maintenance exam.
Consent, Consent, Always Consent
As soon as young children have bodily awareness, I’m asking before I touch: “Can I listen to your lungs?” or “I need to see your chest. Are you ready?” In early adolescence, this becomes much more explicit with strong declarative sentences, directed at patients: “Your body is yours alone. No one, not me, not any adult, can touch your body without your permission. If anything feels uncomfortable or you don’t want to do it, you have the right to say no and that person has to stop. Only yes means yes. Shrugs, eye rolls, and sighs are not a yes.” Modeling consent in an exam visit is an effective way to pair an information-sharing moment with an experience.
In Illinois, and in many other states, patients receive rights to medical privacy for information and care surrounding mental health, substance use and abuse, sexual health (including both access to STI screening and treatment), and pregnancy-related issues at age 12. I tend to ask adults to leave the room during an adolescent exam because “they’re a teen now, and we need some privacy to talk about teen stuff,” which satisfies most adults most of the time. Once the door has closed, I very explicitly explain the teen’s legal right to confidential care on these topics. Many teens do not know they have legal rights. Naming their rights as rights helps empower our youth to use them in situations when they, or someone they know, needs help.
More Than Risk: Consent, the Remix
Bodies are supposed to feel good, and intimacy should feel good, too. Sometimes that truth gets lost in the weeds of talking about the risks associated with high-risk sex. Yes, our teens carry the highest burden of STIs and we need to counsel them. One of the most effective risk-reduction methods is to have young people feel comfortable exercising affirmative consent. Put another way, when teens feel they have control to say “stop” when something doesn’t feel good, we know that the sex and/or relationships they are engaging in are, overall, much lower risk. When talking to young adults I often use the phrase: “Your body is yours to use in any way you want. Bodies are supposed to feel good. A normal part of being a teen is wanting to be close with other people — emotionally, physically, or both. Nobody has the right to touch you in ways that do not feel good to you.”
Often, I ask students if they feel like school has done an adequate job at teaching them about sexual health. Most of my patients say yes, I think in an effort to hurry things along. “Great,” I reply, “so then I have a pop quiz: Can you get pregnant from oral sex, like blow jobs or going down on someone? Can you get chlamydia from oral sex?” The young person’s ability to answer both of these questions, and the level of confidence they show in their answers, is a helpful way for me to decide if we are starting at 101, 201, or 301 in the exam room. I then ask, “What’s the easiest way to not get pregnant or get someone else pregnant?” The answer I’m looking for is: don’t have penis-vagina penetrative sex. Answers like “use a condom” speak to a very small section of the sexual experiences our youth have, so it’s important that we are creating space to talk about all kinds of sexual intimacy. I say, “To me, sex is any time your hands, mouth, or genitals are on someone else’s hands, mouth, or genitals. So, in your life have you ever been sexually active?” Then, I take an enormous pause to listen to their answer.
In exams today, I am trying to move beyond binary thinking, which asks: “With men, women, or both?” Instead, I try to be more specific: “Where have your genitals [or mouth, or anus] had contact with someone else’s mouth, vagina, penis, anus, foreign object?” Then, even more pausing, more listening. Next, I ask, “Condoms and/or barriers all the time, sometimes, or never?” A final round of pausing and listening. Then, we talk about condoms: how to check for expiration, how to open and use on a penis or vagina. We talk about how barriers are the best way to avoid STIs, some of which we can treat and cure, some of which we can only manage (but not cure). We talk about pre-exposure prophylaxis if they are at risk of exposure to HIV. If the person is sexually active and agrees to screening, I make sure I have their personal cell phone number, not just the adult’s number in the chart.
After the teen has disclosed information about the kind of intimacy they are engaged in, I can have a more targeted conversation about birth control and contraception. If I have someone who is engaged in, or thinking about, penis-vagina penetrative sex, with or without condoms, it feels much more organic to then ask or offer contraceptive options. If there is some dissonance between a teen’s self-perceived risk of pregnancy or STI and my own perception of their risk, I will name that, too. “I hear you saying you have sex with this person, but you don’t like using condoms. I’m worried about you two getting pregnant. Are you trying to get [them] pregnant?” Take a giant pause here. Be prepared for anything. If a teen does not desire pregnancy, explore the ways to lower the risk of that occurring. Ask what kinds of contraception they know about. Tell them about the options, starting with the more confidential ones, like a Depo shot right now, if appropriate. Make sure all teens, regardless of gender expression, anatomy, or current sexual health practices know about contraception — as there are many benefits to use beyond just contraception.
Take It Online, but Better Than Google
Make sure teens know how to find high-quality information about the topics they have questions about (or when they have that “still processing” look on their face). Many teens have their phone with them during the visit. It’s OK for them to take it out and open a new private browser tab to explore. Some of my best resources include: bedsider.org (English/Spanish), which has my favorite menu of contraception as well as Q&As, and testimonials; scarleteen.com (English), which has information about bodies, gender, and sexual identity, with some cool options for asking questions by text, message, or live chat; amaze.org (AMAZE Org on YouTube, look under playlists for multiple languages), which discusses puberty, sexuality, and contraception in animated videos that are 2–3 minutes long.
Even When It All Feels Hard
In speaking with many of my colleagues, I know that candor on these topics can provoke feelings of awkwardness or even unpreparedness. There are amazing resources to help develop a script that builds confidence and, most importantly, helps cultivate your own authentic voice. Perhaps this will never be your favorite conversation to start, but it is vital to the health of our next generation.
How do you broach uncomfortable or taboo topics with patients? Share your tips and tricks in the comments.
Dana Kroop is a family NP based in Chicago, Illinois. Originally trained in the history and philosophy of science at University of Chicago and Cambridge University, she spent her first professional years working in education at The Field Museum of Natural History. Driven to use science communication to best empower individuals, she then decided to become a family NP, training at the University of Illinois under an HRSA-funded ANEE Traineeship, and then completing her post-graduate residency at Community Health Center, Inc. Dana is a bilingual Spanish speaker and currently works at a Federally Qualified Health Center on Chicago's West Side. She is a 2020–2021 Doximity Op-Med Fellow.