Adolescent sexuality and use of contraception

Assistant Professor of Obstetrics and Gynecology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island

Assistant Professor, Adolescent Medicine, The Warren Alpert Medical School of Brown University,
Providence, Rhode Island

Despite the medical model that places adolescent sexuality in an “at risk” category, it is time to acknowledge that sexuality, sexual activity, and sexual relationships are a normal and healthy component of human development. Healthy sexuality includes the ability to be comfortable with and enjoy one’s own body, as well as express and enjoy love and intimacy throughout the lifecycle. Adolescence is a critical time in sexual development, and associated behaviors that arise during this phase of development often continue into later years, impacting morbidity, mortality, and quality of life. This article will review current thinking on addressing the sexual health needs of adolescents, including providing adolescent-friendly services, confidentiality, and contraception.

Human sexuality is a framework in which anatomy, physiology, psychology, sociology, and interpersonal interactions merge.¹ A major task of adolescent development is to progress in all these areas, plus to assume stable gender identity and sexual orientation in the context of all the other demands of adolescence.

Understanding unique terms related to sexuality can help health care professionals navigate this sensitive topic. Some of the basic ones are:

• Anatomic sex is a binary assignment of gender based on genitalia during infancy; it forms the basis for the gender in which the child is socially raised.

• Gender or gender identity is a more personal and cultural concept that refers to a sense of being male, female, or somewhere in between.² Gender identity is typically established in early childhood and may be a more fluid concept rather than binary male or female.³

• Gender role refers to how an individual presents the outward expression of gender identity and how gender may be presented to society.

• Sexual orientation, also established during early childhood and adolescence, is a pattern of emotional and physical attraction and arousal that may be dichotomized into heterosexual or homosexual, but may also lie somewhere in between.⁴

• Sexual behaviors are a variety of observable activities that can be performed alone (masturbation) or with others (eg, kissing, fondling, digital penetration, oral sex, and vaginal or anal penetration).

Sexual behavior in and of itself does not predict adolescent gender identity or sexual orientation.⁵ Gender and sexuality in the adolescent years may be fluid, with experimentation being normative. Parent, peer, media, and community norms of gender and sexuality affect individual youth’s self perception and value systems. Same-gender sexual attraction and contact can be a challenge, and normal for many teens. Adolescents may experience conflicts with their family, peers, and communities as their sexual and gender identity emerges. Potential difficulties and support resources are particularly important to identify for adolescents who may be transgender or homosexual.⁵

The best method to assess gender identity, sexual orientation, and risk behaviors can be simply to ask. A detailed and confidential interview in a safe and nonjudgmental setting can lead to a reliable and accurate history. Establishing good rapport and a feeling of trust between the adolescent and the provider is time intensive but essential to providing good care. A sexual history is best obtained in privacy and with the adolescent reassured that all information remains confidential. Being able to ensure this by asking a parent to leave the room is a necessary clinical skill for any provider of adolescent health care. Knowledge of state and local laws regarding privacy and minor consent is also critical (see the confidentiality section).⁶

Obtaining a complete and accurate sexual history can begin with detailed inquiries about:

• Sexual attraction and/or orientation

• Partner history

• Specific sexual activities (digital, oral, vaginal, and anal sex) and other sexual behaviors

• Contraceptive use including prior methods

• Reasons for contraception discontinuation

• History of STIs and methods of prevention, including condom use

Additional history or review of symptoms can include menarche and menstrual patterns; genitourinary complaints such as discharge, odor, external irritation, and dyspareunia; and prior pregnancies and their outcomes. Compassionate but direct questions about the possibility of abuse, sexual assault, or other nonconsensual sex should be included.

Obtaining accurate information about patient sexual behavior is essential because almost half (46%) of all US teens aged 15 to 19 years have had sex at least once.⁷ In addition, 20% of teenagers report having intercourse by 15 years of age. Approximately 83% of sexually active adolescent females and 91% of males report contraceptive use at the last intercourse.⁷ The most common methods used are male condoms and oral contraceptive pills followed by depot medroxyprogesterone acetate (DMPA) injections. Despite this, in the United States, approximately 750, 000 teens age 15 to 19 become pregnant each year, and 82% of these are considered unplanned.⁸ Among these pregnancies, 59% end in birth, 27% end in abortion, and the remainder result in miscarriages.⁹ The birth rate for US teenagers aged 15 to 19 is currently 41.5 per 1000 and the majority are unmarried.¹⁰ This rate is 2 to 4 times higher than the birth rates among adolescents in other developed countries such as Great Britain, Sweden, and France. One major reason for this difference is that adolescents in those countries are more likely to use contraception, especially highly effective hormonal methods, than US teens.¹¹ Therefore, counseling adolescents about using contraception and ensuring access to contraception to prevent pregnancy and also STIs are critical.

Providing contraception to female adolescents requires a detailed medical history to elicit any absolute or relative contraindications to starting hormonal contraception, prior efforts and obstacles to contraception, and preferences and capabilities. A pelvic examination, however, is not necessary prior to initiating hormonal contraceptives such as contraceptive pills, patches, rings, DMPA injections, or the etonogestrel implant. If the adolescent does not have any genital complaints, the pelvic examination can be deferred to a later visit.¹² Screening for chlamydia and gonorrhea, as recommended by the Centers for Disease Control and Prevention (CDC) for women younger than 25, can be accomplished through urine tests or a vaginal swab without a speculum.¹³ During contraceptive counseling it is important to review the different methods and frequency of use required, provide anticipatory guidance on potential side effects, provide tips on adherence (TABLE 1), advise using condoms in addition to hormonal contraception to prevent STIs, and counsel on how to access and use emergency contraception.^14,15

Tips to promote contraceptive success in adolescent and young adult patients

Traditionally, hormonal contraceptives are started on the first day of the next menstrual period or the Sunday after the onset of menses in order to rule out pregnancy. However, many adolescents often do not start their chosen contraceptive method after their menses arrives due to confusion about when to start, failure to fill the prescription, or an intervening pregnancy.¹⁶ The “Quick Start” method allows adolescents to start hormonal contraceptives on the same day as their clinic visit regardless of the day of their menstrual cycle (FIGURE).¹⁷ With “Quick Start,“ it is important to assess the adolescent’s recent sexual activity since her last menstrual period, administer a pregnancy test, and determine whether or not emergency contraception is advised prior to starting the method.

FIGURE 1

“Quick Start” initiation of new birth control method: pill, patch, ring, injection

*If pregnancy test is positive, provide options counseling. **Because hormonal emergency contraception (EC) is not 100% effective, check urine pregnancy test 2 weeks after EC use. Used with permission from RHEDI/The Center for Reproductive Health Education in Family Medicine, Montefiore Medical Center, New York. 2007. http://www.rhedi.org/contraception/downloads/quick_start_algorithm.pdf. Accessed July 28, 2010.

Studies show that sexually active adolescents will also be more motivated to use contraception if they are academically successful, believe pregnancy would be an impediment to their goals, and are involved in a stable relationship with a sexual partner.^18,19 Nevertheless, consistent and correct use of contraceptive methods can be challenging for adolescents. For example, weekly or monthly methods are likely better for adolescents than daily methods. Furthermore, it is important to consider recommending the most highly effective contraceptives and those that require the least attention, such as lUDs and implants.²⁰ With proper patient selection and counseling, IUDs and implants can be successful contraceptive options for some adolescents.²¹

One issue of special concern to adolescents is the effect of hormonal contraceptives on bone mineral density. DMPA does have advantages for adolescents in that it is private, has a low rate of failure, and only requires 4 visits per year for administration.²² However, due to its suppression of estrogen, DMPA can lead to a loss of bone mineral density in both adolescents and adults. Given that adolescents are building their peak bone mass, this is particularly worrisome. Most studies show, however, that the decrease in bone mineral density is temporary and reversible upon cessation of the method.²³ In addition, no studies have shown that DMPA use causes increased fractures either during use or afterwards. Of note, teen pregnancy itself can have adverse effects on bone mineral density due to hormonal changes. Given the evidence, most authorities agree that the advantages of using DMPA in teenagers to prevent pregnancy outweigh the risks of a loss in bone mineral density.²⁴

While many adolescents lack access to adequate health care, a clinician may be the one safe person for an adolescent to go to for accurate information, education, and assistance with getting services. Medical practices that do not differentiate between the needs of adolescents versus children or adults may miss opportunities to provide developmentally appropriate care. Accordingly, many reproductive health agencies have detailed recommendations and tools to develop adolescent-friendly health services (TABLE 2).^25,26

Youth-friendly sexual and reproductive health services

Confidential services are essential to providing high-quality sexual health care for adolescents and are considered a general standard of care.²⁷ It is generally accepted that most middle adolescents, and some younger teens, have the psychoemotional capacity to give informed consent and thus make decisions in care for certain health services.²⁸ Adolescents who are not confident in their privacy, especially about whether a parent or guardian will be informed, may alter their selection of providers and which services they accept, distort the interview and truth telling, as well as forgo care in its entirety.²⁹

Despite generally accepted professional recommendations about privacy and confidentiality, many states still limit access to confidential reproductive health services.²⁷ In some states, minors (less than 18 years of age) can legally access various aspects of health care related to pregnancy testing, contraception, pregnancy, STIs, substance use, and mental health concerns without obtaining the consent of a parent, if they are capable of giving informed consent. The specific laws vary from state to state.⁶ Legal access to consent assumes the provision of confidentiality.³⁰ Title X Family Planning programs allow for some protections and are designed to promote adolescent access to confidential services, including sexual health care. Efforts to limit access to confidential care sometimes originate from erroneous beliefs that adolescents’, parents’, and providers’ interests and priorities are in conflict.³¹

Recent studies also demonstrate that factors other than legal requirements additionally impact provision of confidential reproductive services. In a recent national sample of adolescents ages 12 to 17, only 40% of youth reported time alone with their pediatrician. Type of visit (preventive, anticipatory visit) and patient characteristics (older, male and non-Hispanic) predicted who was more likely to have the opportunity for a confidential discussion with their provider.³²

Despite fears that confidential health services undermine parent-teen relationships, many youth access reproductive health services with either parental knowledge or direct support.³³ For adolescents who want confidential services, those who are not sure their visit will be kept private are less likely to seek health care in the first place, and are less likely to receive certain medical services such as testing for sexually transmitted infections and early prenatal care.³³ In one study only 1% of teens would stop having sex if parental consent was mandated for obtaining contraception; 70% said they would not access a clinic for prescription contraception again if parental consent was required.³³

Sexuality and sexual exploration are a normal part of adolescent development and essential to establishing personal identity. The standard of care is for teenagers to have private and confidential discussions so that clinicians can elicit accurate sexual histories, ascertain risks, and provide appropriate counseling and recommendations. With almost half of teens in high school being sexually active, effective contraceptive screening and counseling is a critical component of adolescent health visits. Given the high rate of unintended adolescent pregnancies in the United States, effective adolescent contraception continues to be an elusive goal.

Sexuality, Reproduction & Menopause ©2011 Quadrant HealthCom Inc.