Check your counseling when it comes to teens
Check your counseling when it comes to teens
When it comes to contraceptive counseling for adolescents, consider asking these three questions at the beginning of each session:
1. "Have you had sex?" A direct question will elicit a direct answer, says Liana Clark, MD, clinical assistant professor of pediatrics at The Children's Hospital of Philadelphia. Questions such as, "Are you sexually active?" can be easily misconstrued by teens, who may equate "sexually active" with "sleeping around."
2. "If you have had sex, did you use contraception? If not, what kept you from using it?" Those questions assess teens' knowledge of contraceptives, initiate dialogue about concerns surrounding the subject, and sound a warning bell for teens who may be ambivalent about using birth control.
"One thing that I always suggest is that the physician or clinician ascertain specifically what fears or concerns or worries the individual patient has, then individualize from there," says Paula Hillard, MD, professor of obstetrics and gynecology at the University of Cincinnati Col lege of Medicine and chairwoman of the Commit tee on Adolescent Health at the American College of Obstetricians and Gynecologists in Washing ton, DC.
"Depending on the age and sophistication and communication skills of the adolescent, sometimes I ask, 'What's the worst thing you've heard about the pill?' That can allow me then to tailor my discussion."
3. "Why no protection?" If teens are sexually active but not using contraception, probe a little further into the reasons, says Catherine Stevens Simon, MD, associate professor of pediatrics at the University of Colorado Health Sciences Center in Denver and director of the Colorado Adolescent Maternity Program.
If they say, "I didn't get around to it," find out why. Teens make time for things that are important to them. Ask them, "Why is it that contraception was so low on the list for you?" she suggests. "Was it because you were afraid of your parents, or had you heard something about birth control that scared you, or did you really not mind that much one way or the other, or had you been having sex for a while and you thought maybe you were sterile?"
Don't assume that fear of pregnancy is first on the list with every teen-ager, Stevens Simon cautions. A study of participants in the Colorado Adolescent Maternity Program identified teen mothers who had not used contraception consistently prior to their first pregnancy due to lack of motivation to prevent childbearing and concerns about contraceptive side effects. Those teens were most likely to conceive again.1
A provider who approaches teens with a list of contraceptives and points out their advantages and disadvantages is going to miss those adolescents who, for a variety of reasons, don't see any reason to use birth control, she says. Even if a particular method offers low side effects, those teens won't choose it because they are unmotivated to protect themselves from pregnancy.
Making pregnancy unattractive
If a teen isn't interested in using birth control, she may have a mindset against any method and spend the counseling session shooting down suggestions about various birth control options. Any prescription contraceptive method may be discarded at the first minor side effect, Stevens Simon says. The result is a teen who may be turned off to any form of contraception.
For those teens, a more constructive use of a contraceptive counseling session may include a discussion of what events would make getting pregnant undesirable. For example, family planning clinicians could ask: "Would you mind getting pregnant? What would make you mind? What could you think of that would compete with parenthood right now for you?" At the end of the session, you haven't eliminated birth control or preached about pregnancy prevention. You've simply asked the patient to consider what might make parenthood look less attractive, she explains.
One way to help prevent many teen problems is to schedule a "well-teen" visit for girls ages 13 through 15, advocates the American College of Obstetricians and Gynecologists. This initial session includes preventive counseling on such issues as sexually transmitted diseases, sexual abuse, and drug and alcohol abuse.
Hillard uses a "well-teen" session as a "get-acquainted" time with a new teen patient. "At that visit, I discuss all kinds of things. I'm trying to get to know that teen. I'm trying to let her know, first of all, the fact that she can talk to me confidentially. I'm trying to ascertain if she's already engaging in some risk-taking behaviors that I'm concerned about, and I'm not just talking about sexual activity. I'm talking about some of the other things that go hand in glove with it, such as substance abuse. By having these conversations, we hope that prior to the time the teen is sexually active, she knows she can come to us."
The session does not have to include a physical exam, although the provider may wish to do a quick check if a particular situation arises, such as the patient's mention of a vaginal discharge. The provider may decide to do a brief exam or schedule a follow-up visit, she says.
Reference
1. Stevens Simon C, Kelly L, Singer D, et al. Reasons for first teen pregnancies predict the rate of subsequent teen conceptions. Pediatrics 1998; 101:E8.
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