It seems like every time I turn around nowadays, I learn something new about what my colleagues are doing -or not… A recent article published online in JAMA Pediatrics, Dec. 30/13 (abstract: http://archpedi.jamanetwork.com/article.aspx?articleid=1791584 ) suggests that we in the medical profession are not doing enough to disseminate information about sexual health -especially to teenagers. The study was from the USA (North Carolina), and so might not be universally applicable, but it got me thinking.
I suspect the problem is not confined to the study area reported; it is all too probable -if not understandable- in most countries, but Canada is the one with which I have the most experience, so let me begin with it. Teenagers in any country, are a difficult group: they are usually healthy and often unaccustomed to visiting a doctor except with a specific complaint to be resolved. The age difference between a teen and her doctor, or nurse, is usually significant and often an impediment to easy and trustful communication. And sometimes her world-view and experience clouds the risk and her own consequence-assessment of her behaviour -especially if others are engaging in it. Many have yet to learn from their mistakes…
Another not insignificant factor -at least in this country- is the frequent accompaniment into the doctor’s office of the teen by her mother. A totally understandable and laudable practice, at least a priori. Sometimes it is to give the young girl confidence on her first visit, or to make sure that she asks the right questions and of course receives the correct answers. But it does make it difficult to delve more than superficially into the sexual history, contraceptive needs, and more particularly, issues surrounding normal, healthy sexual functioning: such things as pain, lubrication, orgasm or even partner expectations. There are a lot of questions that are both embarrassing and difficult for her to raise, let alone answer, with a parent present. A mother can be a two-edged sword…
And I suppose that one of the cardinal rules of medicine –Listen first, talk later– is also turned on its head with teen sexuality: teens seldom ask about it, in my experience. They’ll ask about contraception (sometimes) or sexually transmitted diseases -and more specifically whether or not I think they have one- but almost never about other sexually related concerns unless I ask them. Whether it’s because I am a male and generationally distant, or because they are too embarrassed to raise the subject -especially when the answers so obviously lie just a mouse-click away- I’m not sure. But I can say that when I do raise the subject, after a short, suspicious period of feigned indifference, most seem relieved.
As a male gynaecologist dealing with often nervous, and bashful teenage girls, the problem is usually finding a way to work into the subject of sexual health without alarming or further embarrassing the patient -the younger ones in particular. Indeed, wherever possible I try to have them seen by my female associates instead, recognizing that they may feel more comfortable dealing with another woman. No doubt this could be seen as an abdication of my responsibility to a patient in need of care, but in many cases it’s a more sensitive approach, and one that may ultimately prove more valuable and helpful to the teen at a particularly impressionable -not to mention vulnerable- stage of her life.
But in reality, and given the exigencies and problems inherent in finding available specialists, I realize that sometimes we -the patient and I- must attempt to transcend both the gender and the generational gap as best we can. And so, with regard to inquiries about sexual health, I try to fall back on experience and advice from my more seasoned colleagues. It’s usually inappropriate to inquire without a reason -it smacks too much of prurient curiosity even from a health professional. But sometimes it can be a careful addendum to questions about contraception. Or perhaps during the queries about some other problem for which they have sought help -pain, for example. I am often asked to see a young patient discovered to have an ovarian cyst (a not uncommon, but often painful result of irregular or absent ovulation in younger teenagers -benign, but nonetheless frightening). The discussion lends itself to asking if she gets pain with such things as exercise, bowel movements… or intercourse -a natural progression of embarrassing yet understandably relevant questions that allows further pursuit of the topic. A rather different approach is to embed the sexual questions in the lengthy and detailed initial history that allows the girl to see that you are being thorough -not intrusive. It is unabashed subterfuge, I admit, but in many such circumstances, the end does justify those means. Or is it just me?
So I can understand why it may seem that the sexual health inquiry appears to be absent or minimal -in the study at mentioned at the beginning, at any rate. One must first achieve rapport -a relationship deemed to be both trustworthy and private- and this takes time; it seldom occurs on the first visit, and almost never with the mother present. It is a long-term goal and cannot be hurried. Even those admittedly tentative answers to the thorough and hopefully sensitive consultation history may need to be reconsidered -re-approached as it were- once she has come to know and trust you.
I think all of us in the position of health care advisers wrestle with these challenges and recognize that our goal in promoting teen sexual health should be to interfere less and to educate more; to facilitate her ability to make informed choices; to help her to recognize and avoid risks; and perhaps most important of all, to be sensitive to her growing independence and to let her understand that we celebrate it. Criticism will only turn her away.
But we are all learning; communication between age groups and genders is often riven with inadvertent blunders and unplanned insensitivity. Words -questions- can be met with sullen withdrawal or sudden suspicion and mistrust. Anger. Rejection. Embarrassed silence… It was Oscar Wilde who said: Experience is the name every one gives to their mistakes. And yet we must never forget that experience teaches -even across generations. Rapport is not often given freely, it must be won, and its path frequently winds through a dark, mysterious forest of little mistakes.