Primary care physicians avoid discussing sexual issues with adolescents at their annual visits, according to a report published online Dec. 30 in JAMA Pediatrics.
In a study analyzing audio-recorded yearly checkups between 49 pediatricians or family physicians and 253 of their adolescent patients, fully one-third of these visits included no mention at all of any topic touching on sexuality, including physical development, emotional development, STDs, pregnancy, sexual orientation, intercourse behaviors, other sexual behaviors, sexual abuse, or dating.
And even when such "discussions" did take place, they lasted an average of 36 seconds and rarely involved much input from the patients, said Stewart C. Alexander, Ph.D., of the department of medicine, Duke University Medical Center, Durham, N.C., and his associates.
These findings, taken together with other revealing results of what may be the first study to observe discussions of sexuality between physicians and adolescents, indicate that "physicians are missing opportunities to educate and counsel adolescent patients on healthy sexual behaviors and prevention of STDs [sexually transmitted diseases] and unplanned pregnancy."
The investigators assessed the frequency and duration of talk regarding sexual issues using data from Teen CHAT, a randomized trial that examined how health care providers talked to overweight adolescents about attaining a healthy weight. That trial began making audio recordings of annual health visits in 2009 and is ongoing.
For their analysis, Dr. Alexander and his colleagues assessed 253 recordings collected from annual visits at three academic and eight community-based primary care practices during a 4-year period. Participating physicians included 40 pediatricians and 9 family physicians.
All the patients were aged 12-17 years, and the mean age was 14.3 years. Just over half were girls; 47% were black, and 40% were white.
The physicians spent a mean of 22.4 minutes in the examination room with the adolescents. Talk regarding sexuality occurred in only 65% of visits and was initiated by the physician in every case; no patient ever brought up the topic, and many were reluctant to engage other than to answer specific questions with a "yes" or a "no."
When sexual issues were discussed, in 2% of visits, the physician spoke about sexual issues without attempting to engage the adolescent, and in another 2%, the physician spoke and the adolescent responded nonverbally. In 17%, adolescents made a mean of two yes or no responses. These "discussions" tended to last no more than 30 seconds.
To put this time frame in context, it takes more than 35 seconds just to read aloud the questions regarding sexual health that are suggested in American Academy of Pediatrics guidelines for adolescent health visits, without allowing any time for answers, the investigators noted (JAMA Ped. 2013 [doi:10.1001/jamapediatrics.2013.4338]).
Something approaching conversation about sexual issues occurred in only 35% of visits. In these cases, the adolescents made a mean of 7 statements to the physicians’ 14 statements over the course of 68 seconds.
Somewhat more complete conversations occurred in the remaining 8% of visits: the adolescents made a mean of 9 statements to the physicians’ 17 statements during interactions that averaged 103 seconds in 4% of visits, and the most talkative adolescents made a mean of 20 statements to the physicians’ 26 statements during 114-second interactions in 4% of visits.
Among the study’s other interesting findings:
• Asian physicians were nearly 90% less likely than those of other ethnicities "to have a sexuality talk of any length."
• When physicians specifically explained patient confidentiality, adolescents were four times more likely to discuss sexual issues during the visit. Unfortunately, physicians explained confidentiality in only 31% of the visits in this study.
• For every additional minute spent on the visit, there was a 6% increase in the likelihood that longer, more engaged conversation concerning sexual issues would take place.
• Black adolescents were nearly 60% more likely than those of other ethnicities to talk about sexual issues and nearly twice as likely to converse for longer than 30 seconds.
• Physicians were more likely to initiate discussions of sexual issues with girls than with boys, with black patients than with those of other ethnicities, and with older rather than younger adolescents.
Overall, the study findings indicate that physicians must be proactive in addressing sexual issues with adolescents and should spend more time discussing them. "Even if adolescents are reluctant to engage in sexuality talk, physicians initiating such a conversation sends 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," Dr. Alexander and his associates said.