1. Sexual History-Taking: Essential Questions
Special thanks to Dr. John Steever and Dr. Erica Gibson for being the main contributors on this module.

2. Objectives
Identify barriers to adolescents seeking and receiving health services
Understand state laws surrounding consent and confidentiality
Take a sexual history from an adolescent patient
Increase personal comfort level and confidence when taking sexual histories from adolescent patients
Utilize tools and resources on adolescent sexual health

3. What Does It Mean to Be Adolescent-Friendly?

4. Adolescent-Friendly Health Services Include
Comfortable, confidential, safe space maintained by office staff and providers
Communicating respectfully and appropriately
Screening for high-risk behavior
Awareness of how ability, age, culture, gender identity, sexual orientation, religion, or socioeconomic status can affect an adolescent’s reproductive health

5. Adolescents For the most part, adolescents are: Adolescents are not:
Healthy
Resilient
Independent yet…vulnerable
Adolescents are not:
Big children
Little adults 

6. What Barriers Prevent Adolescents From Seeking Care?
Inaccessible locations and/or limited services
Limited office hours
Lack of money, insurance, and transportation
Poor communication by providers
Insensitive attitudes of care providers
Lack of provider knowledge and skills
Perceived lack of confidentiality and restrictions (parental consent/notification)
Additionally, adolescents face many structural and external barriers that may limit access and willingness to utilize health services.
Primarily, confidentiality concerns can significantly limit health care utilization for adolescents. A recent study of girls younger than 18 years old attending family planning clinics found that 47% would no longer attend if their parents had to be notified that they were seeking prescription birth control pills or devices, and another 10% would delay or discontinue STI testing or treatment. [i]
Clinician-related barriers also exist, including insensitive attitudes on the part of providers, lack of knowledge and skills regarding reproductive and sexual health, insufficient or inadequate communication, and clinician discomfort with the discussion of sexual behavior with adolescents. [ii]
Since teenagers often rely on others for transportation, geographically inaccessible locales can be formidable structural barriers to care.
Sources:
[i] Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls’ use of sexual health care services. JAMA 2002;288:710–4.
[ii] Huppert JS, Adams Hillard PK. Sexually transmitted disease screening in teens. Curr Womens Health Rep 2003;2:451–8. .

7. ALL Youth Need Sexual and Reproductive Health Care
Adolescents can:
Engage in healthy relationships that may include sexual activity
Participate in decision-making around pregnancy and STI prevention 

8. What Is Healthy Sexuality?
Sexual development and growth is a natural part of human development
Healthy sexuality is expressing the sexual aspects of yourself that minimizes health risks
Healthy sexuality is expressing the sexual aspect of yourself that minimizes risk to physical and mental health and emphasizes appropriate adult sexual health and well being.
Risk is activity that compromises a youth’s health and well-being

9. Sexual Orientation Sexual Attraction Sexual Behavior
Paradigm of Sexuality
Remember that sexuality is multifaceted and not limited to sexual behaviors or risks. It involves many aspects of an individual:
Sexual Orientation
Gender Identity
Biological Sex
Sexual Attraction
Sexual Behavior
Biological Sex
Gender Identity

10. Confidentiality Is Essential

11. Confidentiality Is Developmentally Expected
Expected need for increasing autonomy
Increasing intellectual capacity to give informed consent
Opportunity to take responsibility for health
Providers must feel comfortable with providing confidential care to youth and young adults
Adolescents demonstrate an increasing need for autonomy. The stage of development is characterized as a transition from the dependence of childhood to the independence of adulthood. This process does not occur overnight. Additionally, adolescents have been shown to have increasing intellectual capacity to give informed consent. Many studies have demonstrated that by age 14 most adolescents posses adult decision-making capacity.
Sources:
Kuther T. Medical decision-making and minors: issues of consent and assent. Adolescence. 2003;38:343–358.
Petersen A, Leffert N, Graham B, et al. Promoting mental health during the transition into adolescence. In Health Risks and Developmental Transitions during Adolescence. In: Eds J. Schulenberg, J. L. Maggs & A. K. Hierrelmann. New York: Cambridge University Press, 1997.
This slide was developed by Ryan Pasternak, MD, MPH, ARHEP faculty member, and Director of Adolescent Medicine at Louisiana State University Medical Center.

12. Professional Consensus
Professional organizations support confidential adolescent health care.
ACOG ‘88
SAM ‘92
AMA ‘92
AAFP ‘89
AAP ‘89
The American College of Obstetricians and Gynecologists, the Society for Adolescent Health and Medicine, the American Medical Association, the American Public Health Association, and the American Academy of Pediatrics have reached consensus that:
Minors should not be compelled or required to involve their parents in their decisions to obtain abortions, although they should be encouraged to discuss their pregnancies with their parents and other responsible adults.
American Academy of Pediatrics, Committee on Adolescence. The Adolescent’s Right to Confidential Care When Considering Abortion. Pediatrics;1996:746–751.
American College of Obstetricians and Gynecologists. ACOG Statement of Policy: Confidentiality in Adolescent Health Care. Washington, DC: American College of Obstetricians and Gynecologists; 1988.
American Public Health Association. Resolution 9001: adolescent access to comprehensive reproductive health care. Am J Public Health. 1991;81:241.
Council on Scientific Affairs, American Medical Association. Confidential health services for adolescents. JAMA. 1993;269:1420–1424.
Society for Adolescent Medicine. Position statements on reproductive health care for adolescents. J Adolesc Health. 1991;12:657–661.
This slide was developed by Ryan Pasternak, MD, MPH, ARHEP faculty member, and Director of Adolescent Medicine at Louisiana State University Medical Center.

13. Sexual Health Services and Confidentiality
JAMA study of 556 sexually active adolescents visiting a family planning clinic
59% would stop using ALL health services
If mandatory parental notification was required for contraception
11% would delay HIV or STI testing and treatment
In a study of 556 unmarried, sexually active females attending family planning clinics in Wisconsin by Reddy et al., 59% indicated they would stop using all sexual health care services if their parents were informed that they were seeking prescribed contraceptives. 11% indicated they would discontinue or delay STD tests or treatment, even though the survey made it clear that mandatory parental notification would occur only for prescribed contraceptives. Only 1% would stop having sex. (Source: Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls' use of sexual health care services. JAMA. 2002;288:710–714. )
This apparent contradictory behavior is not uncommon in adolescents nor is it unusual in adults.
This slide was developed by Ryan Pasternak, MD, MPH, ARHEP faculty member, and Director of Adolescent Medicine at Louisiana State University Medical Center.
Teens forgo care they believe is essential due to confidentiality concerns
Confidentiality rated as the most important aspect of a sexual health service
Beyond staff friendliness, location, or hours
Teens report being more likely to answer questions honestly with assurances of confidentiality.
1% would stop having sex
Reddy DM, et al. JAMA. 2002;288:710–714.

14. Confidentiality: Parental Perspective
Parents are not the enemy
Parents are experiencing their own adjustment to their child’s adolescence
Providers have an opportunity to educate parents about the need for confidentiality in the provider-patient encounter
It is important to remember that in the vast majority of cases, parents have accompanied their children to the health care provider’s office out of genuine concern. They too are having to adjust to their teenagers new independence. Unfortunately, in discussing confidentiality it seems as though we are against parental involvement which is absolutely not the case. Health care providers should encourage parental involvement but leave the decision of when and how to the adolescent patient.

15. Discuss Confidentiality in Advance
Inform parents about confidentiality policy before visit
Letter home:
Detail when parent will be included in clinical visit and when not
Discuss billing issues if possible
Display materials (posters or brochures discussing importance of doctor/patient confidentiality)
Not always possible in all clinical circumstances.

16. Starting the Conversation and Asking Sensitive Questions

17. Case: Angela
Angela is a 16-year-old who has been your patient since she was a toddler but you haven’t seen her in 2 years
She comes in today for a sports physical
How do you begin the visit?
What questions do you need to ask? 

18. Communication Tips (1) Establish rapport
Provide confidentiality assurance and establish limits of confidentiality
Ask permission
Normalize
Note nonverbal cues

19. Communication Tips (2)
Minimize note-taking, particularly during sensitive questioning
Talk in terms the adolescent will understand
Developmentally appropriate questions
Ask open-ended questions
Practice listening skills

20. Communication Tips (3) Avoid the surrogate parent and adolescent roles
It’s a conversation…not an interrogation!
What purpose does the information serve?
Healthy respect and regard for privileged information

21. Comprehensive HEEADSSS
H: Home
E: Education/Employment
E: Eating
A: Activities
D: Drugs
S: Suicide/depression
S: Sexuality
S: Safety
*Additional questions:
Strengths, Spirituality
The HEEADDSSS model is a useful tool for taking a comprehensive psychosocial history for adolescent patients.
The HEEADDSSS Model was originally developed in 1972 by physicians. ARSHEP faculty, Melanie Gold, DO, DABMA, FAAP, FACOP developed the corresponding questions for this model.
The components of the model reflect the common causes of morbidity and mortality among adolescents, including unintended pregnancy and sexually transmitted diseases.
The health care provider who sees adolescents must be willing to take a developmentally appropriate psychosocial history, and may get more results by using non-traditional modes of physician-patient questioning.
The HEEADDSSS questions should be asked without a parent in the room unless the adolescent specifically gives permission or asks for a parent’s presence. If the questions are asked and answered with other people in the room, document this on chart and note that this was by patient request.
Some practitioners add yet another “S” to assess strengths, points of resiliency, or confidence in the patient.
Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics

22. SHEEADSSS S: Strengths/Spirituality H: Home E: Education/Employment
E: Eating
A: Activities
D: Drugs
S: Sexuality
S: Suicide/depression
S: Safety
You may want to ask questions about strengths first thereby reversing the HEEADSSS screening in order to emphasize your patient’s positive qualities. Taking this strengths-based approach
References:
Goldenring JM, Rosen DS. Getting into adolescent heads: an essential update. Contemp Pediatr. 2004;21(1):64-90.
Ginsburg KR. Viewing our adolescent patients through a positive lens. Contemp Pediatr. 2007;24(1):65-76.
Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm. Findings from the National Longitudinal Study on Adolescent Health. JAMA. 1997;278(10):
Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics

23. Utilizing HEEADSSS Ask less-sensitive questions first on each topic
Can use written questionnaire in waiting room
Provider should follow up on answers drawing concern
Time limitations make model difficult
It’s a biopsy; not a comprehensive psychosocial evaluation. Need to know your referral resources.

24. Other Clinical Interview Tools
GAPS: AMA Guidelines for Adolescent Preventive Services
Bright Futures: Collaboration between AAP and Bureau of Maternal Child Health Care)
Trigger Questionnaire: Developed by Office of Managed Care in the New York State Department of Health
ACOG Tool Kit: Designed by the ACOG Committee on Adolescent Health Care to help every office care for adolescent patients

25. What Is a Sexual Health History?

26. Sexual History Tips Reassure confidentiality
Take history when the patient is still dressed
Assess development and structure questions accordingly
Watch for concrete vs. abstract answers
Avoid assumptions of heterosexuality

27. Why Is a Sexual History Important?
Affirm healthy behaviors
Address patient questions or concerns
Provide interventions for risk behaviors
Prevention counseling
Explore potential dysfunctions

28. Sexual History-Taking Template
Gender identity
Sexual orientation
Sexual coercion and abuse
Sexual activity
Number of partners
Frequency of intercourse
Type of sex practices
STI history and risk assessment
Pregnancy history and risk assessment
Contraceptive behaviors
Substance use
Elements uniformly present in templates for sexual and reproductive history taking include questions and discussions on: sexual orientation, sexual activity; number of partners; frequency of intercourse; type of sex practices; sexual abuse experience; STI history and risk assessment; contraceptive behaviors, and pregnancy history and risk assessment. Added elements in some history taking and counseling templates include discussions on substance use as a sexual and reproductive health risk.

29. When to Take a Sexual History
Adolescents should have a sexual history taken at all preventative care visits
A sexual history is important and frequently relevant to the HPI
Take sexual history at least annually

30. Providing Developmentally Appropriate Counseling
Recognize sexual developmental milestones
When Counseling
Can your patient think abstractly or concretely?
Age development
Recognize variations:
Very mature 14-year-old vs. an immature 17-year-old
This slide was developed by Tonya Chaffee, MD, ARHEP faculty member, and Assistant Professor of Pediatrics at University of California at San Francisco Medical Center.

31. Discussing Sexual and Romantic Relationships
Have you ever had a crush on a boy or girl? What was that like?
Have you ever had a romantic relationship with someone?
How would you describe it?

32. Relationships Matter
Figure courtesy of the University of Chicago Press. From the American Journal of Sociology, Vol. 100, No. 1. "Chains of affection: The structure of adolescent romantic and sexual networks," Bearman PS, Moody J, Stovel K.

33. Assessing the Health of the Relationship
What does a healthy relationship look like to you?
How often are you and your partner together? How does your partner feel about you hanging out with other friends?
(If sexually active) Who makes the decisions about when to have sex and what kind of contraceptives you should use?
Disagreements and arguments are a normal part of any intimate relationship. What is it like when you and your partner get into an argument? How do you usually resolve it?

34. Characteristics of a Healthy Relationship
Nonviolent conflict resolution
Open and honest communication
Right to autonomy for both people
Shared decision-making
Trust
Mutual respect
Individuality
Empathy
Healthy relationships have open and honest communication. No relationship is conflict free, but the key to a healthy relationship is knowing how to resolve those conflicts.
Belief in non-violent conflict resolution/anger control—how we express anger is what makes the difference between healthy and unhealthy relationships
Ability to negotiate and adjust to stress
Open and honest communication—each partner needs to say exactly what they mean without interruption
Partners work together to make decisions—about the relationship or their own interests
Belief in partner’s right to autonomy—individuals in a relationship need to be free to pursue their own interests, make their own decisions and take their own actions
Individuality—not choosing who you are or what you do to please your partner
Shared decision making
Trust—partners are able to rely on one another
Mutual Respect—each person values the other and understands personal boundaries
Honesty—when someone says something, it’s actually what they mean
Compromise
Fighting fair—when disagreeing, partners stick to the subject of the argument without getting emotional or insulting
Empathy—taking time to figure out a partner’s feelings
Sources:
Catallozzi et al. (2011). Understanding control in adolescent and young adult relationships. Arch Pediatr Adolesc Med, 165 (4), 313–319.
Glass et al. (2011) Adolescent dating violence: prevalence, risk factors, health outcomes, and implications for clinical practice. Curr Opin Pediatr, 23(4): 379–83.
Adapted from, “Hanging out or Hooking Up: Clinical Guidelines on responding to Adolescent Relationship Abuse” by Elizabeth Miller, MD, PhD and Rebecca Levenson, MA.

35. Risk Factors for Unhealthy Relationships
Partner is 3-5 years older
Exposure to violence in the household or community
Early sexual activity
Low education level
Sexual risk-taking
Substance abuse
Sources:
Catallozzi et al. (2011). Understanding control in adolescent and young adult relationships. Arch Pediatr Adolesc Med, 165 (4), 313–319.
Glass et al. (2011) Adolescent dating violence: prevalence, risk factors, health outcomes, and implications for clinical practice. Curr Opin Pediatr, 23(4): 379–83.

36. Signs Linked to Intimate Partner Violence (IPV)
Depression/anxiety
Changes in eating patterns
Changes in social relationships
Substance abuse
Abdominal pain/pelvic pain
Physical findings inconsistent with stated mechanism of injury, or findings associated with intentional injury (patterned marks, bruises in varied stages of healing, burns)
St. Mars, T., RN,BSN, CEN, Valdez, A.M., RN, MSN, CEN. (2007). Adolescent dating violence: understanding what is “at risk?” Journal of Emergency Nursing, 33(5): 492–494.

37. IPV and Adolescents
Intimate Partner Violence is bi-directional, meaning girls and boys report being both the victims and the perpetrators
9.3% of females and 9.5% of males report being hit, slapped, or physically hurt on purpose by their boyfriend or girlfriend
11.8% of females and 4.5% of males have ever been physically forced to have sex
Sources:
Glass et al. (2011) Adolescent dating violence: prevalence, risk factors, health outcomes, and implications for clinical practice. Curr Opin Pediatr, 23(4): 379–83.
Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, Surveillance Summaries, August 2, MMWR 2012;61(No. 4).

38. About Abstinence
Encourage abstinence within context of comprehensive sex education and self-esteem enhancement
If patient is already sexually active and is not comfortable with the decision or is not enjoying intercourse:
Discuss other options for intimacy between partners
Discuss ways patient can communicate decision to partner
Abstinence from sexual activity is optimal for pregnancy and STI prevention. However, as research indicates nearly half of teenagers in the United States have had sexual intercourse.
For those patients contemplating first sex, abstinence should be promoted in an open, honest dialogue.
Providers should answer questions regarding sex and sexuality honestly, respecting the patient’s culture and circumstances.
Ultimately, the patient’s decision should be respected.
Patients who have already engaged in sexual intercourse, may consider becoming abstinent if they are uncomfortable with their decision or are not enjoying intercourse.
Providers assess patients’ desire to become abstinent.
Is his/her partner supportive?
Has he/she considered other options for sexual intimacy?

39. Discussing Readiness for Sexual Initiation
Some questions providers can ask to begin to explore a teen’s sexuality are:
How does one know one is ready for sex?
What is important in a relationship?
Can she/he say no?
How does one deal with anger, rejection, and loneliness?
Can she/he openly talk to partners about their feelings?

40. Discussing Sexual Activity
Sexual behavior is a spectrum
Includes coital and noncoital activities:
Kissing
Self and partner masturbation
Oral, anal, and vaginal sex

41. Assessing Sexual Orientation
Are you romantically interested in men, women, or both?
Are you comfortable with your feelings?
Have you ever had sex with someone of your same gender?
For younger teens: when you imagine yourself in a relationship in the future is it with a man, a woman, or both?
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Dr. Melanie A. Gold.

42. Assessing Gender Identity
Do you think of yourself as male, female, neither, or both?
What pronoun do you use (she, he, they, sie*)?
*Sie is a gender-neutral pronoun sometimes used by members of the transgender community
Are you comfortable with your feelings?
How do you think your parents/teachers/friends would react (have reacted) to your gender identity?
Gender identification includes understanding one's existence as male or female, and the roles and responsibilities of being a man or a woman.
Transgender is an umbrella term to describe the full range of individuals who have a strong belief, often from childhood onwards, that they were born into a body with the wrong physical gender and incorporate one or more aspects, traits, social roles, or characteristics of the other gender.
Transgenderism includes:
transsexuals (individuals who have had sex-reassignment surgery),
androgynes (those with an androgynous presentation and whose behavior combines both genders or is gender-neutral),
intersexuals (those who are born with sex chromosomes, external genitalia, or an internal reproductive system that is not considered standard for either male or female), and
cross-dressers (clinically known as transvestism).
transgender individuals can live full or part-time as members of the opposite gender.
Regardless, all transgender individuals should be consistently referred to by the pronouns of their self-identified gender.
Prevalence rates of transgender populations are not clearly established.
Source:
American college of Obstetricians and Gynecologists. Health care for transgender individuals. In: Special issues in women’s health. Washington, DC: ACOG; 2005 p. 75–88.

43. Assessing Sexual Behavior
How old were you when you first had sex? Include anal, oral, and vaginal.
What was the date of your last intercourse?
What kind of protection did you use at last sex?
Condoms? Hormonal contraception?
Do you have a current partner?
How long have you been with your partner?
How many sexual partners have you had?
How many sexual partners have you had in the past 3 months?
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Dr. Melanie A. Gold.
Don’t
Ask “Are you sexually active?”
Use gendered-biased pronouns when referring to sexual partners
Use judgmental language
Use slang unless patient offers it first Do
Assure confidentiality
Explain why you are asking sensitive questions
Ask patient to describe specific sexual behaviors
Add “second tier” questions to assess comfort with behavior

44. Orientation vs. Behavior
Orientation does not always = behavior
Majority of women who have sex with women (53–99%) have had sex with men
While respecting a patient’s identification, you should inquire about sexual behaviors with partners of all genders.
Source of second bubble: Diamant AL, Schuster MA, McGuigan K, Lever J. Lesbians’ sexual history with men: implications for taking a sexual history. Arch Intern Med 1999;159:2730–6.

45. Sexual Satisfaction
How often do you have pain during sexual intercourse or other sexual activities?
Are you satisfied with how often you have sexual relations and with what you do with your sexual partner?
Any problems becoming aroused, getting an erection, getting lubricated (wet), or having an orgasm?

46. Sexual Health Have you ever had any infections?
Do you know what the symptoms of STIs are? Tell me.
Have you ever been tested for an STI? Tell me more.
How about your partner?
Sexual dysfunction?
Unintended pregnancies
Sexual violence
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Dr. Melanie A. Gold.

47. Place Matters "Broken windows" and the risk of gonorrhea.
D Cohen, S Spear, R Scribner, P Kissinger, K Mason, and J Wildgen
(Am J Public Health. 2000;90:230–236)

48. Gonorrhea Rate (Mean +/- SD)
Place Matters
Broken Windows Groups
Poverty Groups
Sample Size
Gonorrhea Rate (Mean +/- SD)
Low 25
27.4 +/- 12.5
High 10
25.0 +/- 9.0 4
32.3 +/- 9.9 16
52.0 +/- 15.8
"Broken windows" and the risk of gonorrhea.
D Cohen, S Spear, R Scribner, P Kissinger, K Mason, and J Wildgen
(Am J Public Health. 2000;90:230–236)

49. Assessing Pregnancy History
Have you ever been pregnant or gotten anyone pregnant? What were the outcomes?
Do you have any concerns about your fertility?
When (if ever) would you like to get pregnant and have children?
Are you doing anything to prevent an unintended pregnancy?

50. Discussing Contraception
What have you used for pregnancy prevention?
What was your experience?
How about your friends?
Would you like me to tell you about some of the options available?

51. Angela: Case Continued
Angela tells you she has a boyfriend she has been dating for about 4 months
She has not had sex but thinks she might be ready in a few months
She agrees to come back to talk about options for contraception 

52. Case: Angela
Before she leaves, what preventive measures do you discuss with Angela for the future?
Complete HPV vaccine series
Emergency contraception
Over-the-counter
Advance prescription still possible
Does not protect against STIs
Condom use
Give patient condoms to take home

53. Take-Home Messages
All adolescents need sexual and reproductive health care
Positive sexuality is part of healthy development
Confidentiality is essential
Taking about sexuality with patients helps them avoid unintended pregnancies and STIs

54. Provider Resources and Organizational Partners
for Youth
Academy of Pediatricians
American Civil Liberties Union Reproductive Freedom Project
College of Obstetricians and Gynecologists
of Reproductive Health Professionals
for Adolescent Health and the Law
glma.org Gay and Lesbian Medical Association

55. Provider Resources and Organizational Partners
Institute
janefondacenter.emory.edu Jane Fonda Center at Emory University
Morehouse School of Medicine
NARAL Pro-Choice New York Teen Outreach Reproductive Challenge (TORCH)
North American Society of Pediatric and Adolescent Gynecology
for Reproductive Health

56. Provider Resources and Organizational Partners
Information and Education Council of the United States
for Adolescent Health and Medicine
Planned Parenthood Federation of America
Reproductive Health Access Project
Spence-Chapin Adoption Services

57. Please Complete Your Evaluations Now57