How pediatricians can improve sexual and reproductive care

Pediatricians should do more to address sexual and reproductive health, according to a new clinical report published in Pediatrics. The report offers guidance on the what and how in sexual health for pediatric practices.

Arik V. Marcell, MD, MPH, associate professor of General Pediatrics and Adolescent Medicine at Johns Hopkins University, Baltimore, Maryland, and lead author of the report, says pediatricians need to understand their role in addressing sexual and reproductive healthcare gaps in services for teenagers and young adults.

“This clinical report is designed to make it easy for primary care clinicians to understand what they need to do to address gaps in sexual and reproductive healthcare services delivery to adolescents and young adults,” Marcell says, adding that the paper also offers guidance on how pediatricians can make confidential sexual and reproductive health services routine in their offices. “It provides an overview of key recommended services and links to all related policy and clinical reports published by the American Academy of Pediatrics (AAP), as well as other related key federal, national, and professional guidelines. It is also designed to help educate parents and teens to learn that these are services their healthcare providers should be offering to them on an annual basis, if not more often.”

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Pediatricians play a huge role in many aspects on development for children and teenagers, but addressing sexual and reproductive needs can come with a unique set of challenges, from provider discomfort to confidentiality concerns where parents are involved. The need is certainly there, however. An estimated 45% of 15- to 19-year-olds in the United States have had vaginal intercourse with a member of the opposite sex; 2.5% of boys in that age range have reported having anal or oral sex with another male; and 11% of girls report having a sexual experience with another female, according to the report. Their youth does not exempt them from risk, either. Sixty-five percent of Chlamydia and 50% of gonorrhea cases occur in 15- to 24-year-olds, according to the clinical report, and teenaged pregnancy and child sex trafficking remain major public health concerns.

The established relationship many adolescents have with their pediatrician makes pediatric providers an ideal source for information, screening, and assessment when it comes to sexual and reproductive health. They can identify risk, offer preventive care or therapeutic intervention, and facilitate discussions with parents. Numerous reports tout the benefits of addressing sexual and reproductive health in the pediatric office, but the National Survey of Family Growth reveals that just one-third of teenaged patients have received information on contraception, sexually transmitted infection education, or prevention of human immunodeficiency virus (HIV) infection from their doctor.

A recent AAP survey also found that whereas 86% of pediatricians discussed puberty and reproductive health with their patients, only two-thirds addressed contraception or abstinence, and just 18% discussed sexual orientation or gender identity, according to the report. There are also numerous recommendations that support setting aside confidential, private time with teenagers during an exam to discuss sexual and reproductive health, yet the authors note that the average amount of time spent discussing sexuality during pediatric visits is 36 seconds.

Pediatric offices should offer a convenient, safe environment for adolescents in order to reduce barriers to sexual and reproductive healthcare. This can include extending office hours to accommodate teenagers and offering a welcoming, open environment, the report suggests. Confidentiality in the form of coded explanations of benefits and offering private time alone with the patient without parents present are key to creating an open environment wherein teenaged patients will ask questions and share concerns.

Confidentiality is a key concern in this population, and Marcell says providers have to be aware of the effects of standard billing and paperwork policies that may compromise a patient’s rights.

“We also hope that providers are better informed about how patients’ explanations of benefits have the potential to inadvertently violate confidentiality for minors or young adults insured as dependents on a parent’s or guardian’s health insurance policy and how they can take steps to minimize such breaches or refer the individual to settings that can provide confidential care,” Marcell says.

Parents can be involved in nonconfidential health discussions, and a parent or other chaperone should be present during the physical examination, according to the report.

Routine screening for sexually transmitted infections (STI) is not recommended in most cases outside of evidence of infection or high-risk behaviors, but counseling on high-risk behaviors and STI risk reduction is recommended to occur regularly. Pediatricians should also discuss family planning goals, contraception, immunizations such as human papillomavirus (HPV), and hygiene with teenaged patients.

The report emphasizes that greater focus on sexual and reproductive health in children and teenagers is a necessity for well-rounded care, and it’s an area in which pediatricians are lacking right now.

“Research demonstrates that primary care providers, including pediatricians, are not up to par in providing sexual and reproductive healthcare to adolescents and young adults, and that there is much room for improvement to ensure all adolescents and young adults get the care they need,” Marcell says. “It is our hope that this report will help to close the gap in the sexual and reproductive healthcare services they provide to adolescents and young adults, and to ensure the care they provide represents quality care and that all adolescents and young adults in the United States are receiving these services on an at least on annual basis.”