Episode Transcript
Hi and welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics! I am Jennifer Louis-Jacques, a pediatrician, Adolescent Medicine specialist and an Associate Professor of Pediatrics at the University of Virginia.
During your Pediatrics clerkship, you will have the opportunity to see adolescent patients in the inpatient and outpatient settings. If you recall from Episode 6- Before Your First Adolescent Well Visit, the psychosocial assessment is particularly important as the leading causes of death for the adolescent population (unintentional injury, homicide and suicide) are related to behavior. Utilizing the SSHADESS or HEADSS framework will help you obtain the essential information you need for a complete psychosocial assessment. In today’s podcast, I will focus on obtaining a sexual history, a component of the psychosocial assessment, as well as STI screening and treatment recommendations. I hope that you will feel better prepared to obtain a sexual history and propose a management plan after listening.
Obtaining the sexual history of an adolescent patient can be clinically relevant in many different scenarios. It is important in overall well care as discussed in Episode 6, but can be critical for some chief complaints. It is not uncommon for adolescent patients to present to outpatient urgent or emergency care settings with concerns such as vaginal/penile discharge, menstrual irregularity, lower abdominal pain and unintentional weight loss. In all of these scenarios, sexually transmitted infections or STIs should be on your differential. Why is that? The prevalence of STIs in the adolescent population is quite high. According to 2021 CDC data, the highest rates of chlamydia and gonorrhea infections are in the 15-19 and 20-24 yrs. age groups. So how can you get the information you need to explore that possibility? This is where the sexual history becomes relevant. The sexual history can be sensitive for any patient especially adolescents. As such, it can feel intimidating to obtain that information. How can you make sure you get all the necessary information in a respectful manner? Knowing the relevant components of a sexual history will go a long way in reducing any anxiety you may experience.
With that, I would like to introduce you to a sexual history framework that will help you remember all the components of a complete sexual history. Before doing that, I would like to pause here and remind you of the importance of confidentiality in obtaining a sexual history. In general, adolescents can consent for STI testing and treatment (note the actual age can vary from state to state. Here in Virginia it is 13 depending on the circumstances). This means that for the most part parental notification and permission are not needed. However, the reality is that in an age where we rely on electronic medical records/e-prescribing and insurances often generate EOBs or explanation of benefits we cannot often guarantee 100% confidentiality. Therefore, the safest bet is to tell your patient you will try to honor confidentiality to the best of your ability. In these tricky situations, it is best to make no promises before speaking with your resident and/or attending. Saying something such as “The team taking care of you today will do its best to honor confidentiality to the best of our ability. If it seems that we may be limited we will talk to you before making any decisions.”
So let’s talk about the 5Ps! The 5 Ps framework was created by the CDC to help guide health professionals’ dialogues about patients’ sexual health. Before reviewing each P it is important for me to say that this framework should be tailored to the patient sitting in front of you. You may not need to address each P with every patient. Therefore, think about what information you need before starting the interview.
The 5 Ps are as follows: partners, practices, protection from STIs, past history of STIs and pregnancy intention. Let’s go through each of them.
Partners: Who are the partners of your patient? Knowing the gender and number of partners will help you determine your patient’s risk for a STI. Your questions should not make assumptions about gender or sexual orientation. Here are some examples: “You mentioned that you are sexually active. How many partners do you currently have? What is the gender of your partner (s)? I would like to point out here that adolescents at times can be quite concrete in their thinking. By that I mean they will interpret words literally. It is not uncommon for some teens to interpret “sexually active” to mean sexually active recently and not count the sexual encounter they had the week or month before presentation. To avoid confusion just asking “Are you having sex?” can be helpful.
Practices: The kind of sex that your patient engages in will inform your risk assessment for STI acquisition and help you determine where and what to screen for. Explaining to your patient how this information is clinically important to your evaluation is important. Saying something like “People who have sex often engage in different types of sex. It would be helpful for me to know what type of sex you have so I can know what infections, if any, you might be at risk for.” Sometimes patients, especially adolescents, may not be clear on what is meant by type of sex. So being explicit using medical language and not slang can be helpful. “What body parts are involved when you have sex?” “Do you have genital sex (penis in vagina)?” “Do you have anal sex (penis in anus)?” “Do you have oral sex (mouth on penis, vagina or anus)?”
Protection from STIs: It is important to understand how your patient does or does not protect themselves from acquiring STIs. This information will help you with risk assessment as well as guide counseling related to risk reduction. It is not enough to inquire if your patient uses protection. Asking about type of protection used as well as frequency of use will help you determine how well your patient is protected against infection. It can also serve as the basis for safe sex counseling. As I mentioned earlier it is helpful to be explicit with adolescent patients.
“What type of protection do you use-condoms, dental dams?” Here is a way to ascertain frequency: “If you had sex 10 times, how many times out of 10 do you use a condom?” I am going to talk a little more about STI screening and treatment shortly. When approaching safe sex counseling it is important to figure out what your patient already knows. “What have you heard about protecting yourself from infections?” Use this as an opportunity to correct misinformation your patient may have about the topic. Come from a place of non-judgement and lean into the fact that most adolescents will view you, a member of the healthcare team as a legitimate source of information. “I have heard this from other patients and if it is ok with you I would like to share with you what I know about the topic.” In situations where adolescent patients express discomfort about bringing up the topic with a partner helping them come up with a script through role play may be helpful. You can say something like: “Next time your partner says he does not want to use a condom, what do you think you can say?”
Past history of STIs: A prior history of STIs places your patient at risk for STIs now. Thus asking about past history will help you with risk assessment. “Have you ever been diagnosed with a STI? If so were you treated?” “Do you know if your former or current partner(s) has ever been diagnosed/treated for a STI?”
Pregnancy Intention: You may identify that your patient (or their partner) is at risk for pregnancy during your interview. It is important to ask if pregnancy is something that is desired and not assume that it is not. Asking “Is pregnancy something that you are interested in at this time?” is a good way to further explore intentions. If pregnancy is not currently desired it is reasonable to ask “Is it ok if we talk about ways to prevent pregnancy today?”
So those are the 5 Ps! For most adolescent patients the 5 Ps will be sufficient to obtain a complete sexual history. However, in some cases it may be helpful to delve a little more deeply to ascertain HIV risk. The adolescent population remains the population least likely to know their HIV status. Opt-out HIV testing, meaning a patient needs to decline testing, is recommended at least once by the American Academy of Pediatrics between the ages of 16-18 yrs to in areas where the HIV prevalence is > 0.1%. The following three questions can help you decide whether HIV screening is indicated. However, it is important to remember that there is no downside to screening for HIV in a sexually active adolescent. It is important to normalize HIV screening for your patient. Consider saying “I see you have never been screened for HIV. I recommend that we do that today as part of your evaluation.” The questions to ascertain HIV risk are:
Have you or any of your partners ever injected drugs?
Have you or any of your partners ever exchanged money for drugs or sex?
Is there anything else about your sexual practices that I need to know about?
If you decide that HIV screening is indicated for your patient you should follow the CDC’s HIV testing algorithm. I’ve included the link in the show notes. The first test to order is a 4th generation Ag/Ab test. If positive, the test would need to be followed up with a HIV-1/ 2 differentiation immunoassay. A positive immunoassay would diagnose your patient with HIV.
Now that you have gotten a complete sexual history, you can use that history to guide your management plan (testing and treatment). The CDC’s 2021 STI Treatment Guidelines should be your primary reference on this topic. You can find them online as well as through the specific app. I have also included links in the show notes. You probably know that there are several STIs that exist, but it does not make sense to screen sexually active adolescent patients for every one of them. That would not be a good use of healthcare dollars. Applying likelihood ratios to the sexual history you obtained can help you create a hypothesis driven plan. Remember I mentioned earlier that adolescents are at particular risk for chlamydia and gonorrhea. It is recommended that sexually active women be screened annually for chlamydia and gonorrhea through age 24 with nucleic acid amplified tests or NAATs. Urine, vaginal and cervical swabs are acceptable samples for testing. The sensitivity of tests using vaginal and cervical swabs is slightly higher than urine based tests. As such, you should consider when a test with high sensitivity would be preferred. For example, is your patient symptomatic- abdominal pain, discharge? There are no specific screening recommendations for heterosexual males. A good rule of thumb is to use what is happening in the female population to guide screening decisions. Urine based NAATs are the recommended tests for males. First line treatment in men and women with chlamydia is Doxycycline 100 mg by mouth twice a day for seven days. Gonorrhea infections are treated with 500 mg of Ceftriaxone given once intramuscularly. In cases where chlamydia has not been ruled out your patient should then be treated with Doxycycline as I just mentioned. There are alternative treatment regimens for each infection that you can find in the CDC STI Treatment Guidelines.
With what I have just reviewed, you should be able to obtain an extensive sexual history from adolescent patients. I encourage you to think about how you want to ask questions so that you can feel authentic during the interview. Remember that a sexual history is an important part of an overall medical history. Being able to obtain one is one way that you can ensure that your patients’ receive high quality healthcare.
OUTRO:
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