Should doctors be talking to teens about sexuality?

A US study recently showed that many doctors do not initiate discussions about sexuality with their adolescent patients in one-third of yearly checkups.
Audio recordings of yearly checkup visits of 253 patients aged 12 to 17 (mean age 14.3 years) with physicians showed that only 65 percent of those visits included some discussion of sex, sexuality, and/or dating. The majority of those discussions lasted less than 40 seconds. [JAMA Pediatr 2013. doi:10.1001/jamapediatrics.2013.4338]
“Because many adolescents currently find it difficult to initiate sexuality discussions with adults, adolescents would prefer that physicians bring up the topic of sex and sexuality,” they said. “However, while physicians report comfort with sexual history taking, they report discomfort and lack of confidence in discussing sex and sexuality.”
Forty-nine physicians were part of the US-based study, 80 percent of whom were pediatricians, and the average duration of practice was over a decade. Verbal permission from parents and assent from patients was obtained and recorders were known to be in the examination room.
Out of 253 health maintenance visits, 165 (65 percent) included some sexual content. The average duration of any sexuality talk was 36 seconds, with 35 percent having 0 seconds devoted to topics related to sexuality, 30 percent having 1-35 seconds, and 35 percent having ≥36 seconds. The most loquacious patients (4 percent of visits) made a mean 20 statements in response to a doctor’s 26 over 114 seconds. Patients never initiated discussion of sexuality.
Certain factors increased the likelihood that the patient would open up to discussion. Visits during which confidentiality was explicitly stated (31 percent) increased the likelihood of patients engaging in talk of sexual topics four-fold. Longer visits also increased the likelihood of a discussion about sex, with each minute associated with a 6 percent increase in potential discussion.
Patients who were female or older or African American were also more likely to engage in a discussion of sexuality, although the researchers suggested that boys could be missing out on the benefits of counsel and by neglecting younger patients, physicians lost the opportunity to identify adolescents contemplating sexual activity and talk about risks and develop contingency plans.
They also pointed out that Asian physicians (6 percent) were associated with less sexuality talk compared with white or African American physicians.
However, difficulty bringing up sexuality during visits seems common across cultures, for a variety of reasons.
Dr. Philip Koh, deputy medical director of Senior Family Physician Healthway Tampines Clinic in Singapore, cited brief consultation times – 5 to 10 minutes – and high patient load as obstacles to discussing sexuality with adolescents. More importantly, it is not common practice for adolescents to have yearly physicals with a pediatrician or general physician. In addition, Koh noted that parents will often accompany their children to the doctor, which is a strong deterrent for all parties not to discuss sexuality.
“[Adolescents] don’t come alone and can’t approach us with questions. For us to broach the topic it does not seem appropriate in many circumstances,” he said. “We do broach sex education topics when they come for things that are related, like urinary tract infections or vaginal discharge.”
Human papillomavirus (HPV) vaccinations may provide an opportunity to discuss sexuality, Koh said, but not many girls receive the vaccine and those that do tend to be in their early 20s.
“Even if adolescents are reluctant to engage in sexuality talk, physicians initiating such conversations send a clear message to adolescents that sexuality is an appropriate and normal discussion topic at health maintenance visits, which may open the door for more extensive and detailed discussions during future visits,” the researchers said.
The study was limited by participants being part of an overweight cohort study, higher weight being linked to riskier sexual behavior for those who are sexually active, although the researchers noted that shouldn’t affect how physicians spoke to them about sexuality. The presence of an audio recorder may have discouraged discussion and the contents of the discussions were not analyzed, which the researchers note would be useful to examine in further studies.