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19 August 2005
Adolescent Sexuality and Doctor Counseling: Moral Dilemma or Health Issue?
by Angie Rankman 
While we often talk about adult sexuality, all too often adolescent sexuality is thrown into the too hard basket, and consequently neglected. But this attitude belies the real concern that parents have for their teenagers and the risky behavior in which they may be involved, especially sexual behavior and the possible consequence of teenage pregnancy. The questions that make the issue of adolescent sex even murkier have to do with morality and health. Do we consider adolescent sex a moral or health issue? While both should be equally respected, it would be difficult to imagine a strong reason for ignoring the health aspects of adolescent sexuality entirely. Adolescent counseling on sexuality, via their doctor, is necessary for both the safety and well being of adolescents. However, recent studies suggest that doctors rarely council teenagers on health issues and consequences related to sexual relationships and practice.
Part of the reason for this may be the strong moral opposition that some parents have toward this complex and sensitive issue. But parents also admit that their fears are often irrational, an admission that shows parents are all too often in two-minds about their offspring’s private lives. They want desperately to be good parents and respect the doctor patient confidentiality of their child, while also wanting to employ measures - that may in the end be fruitless - at curtailing their teenager’s sexual behavior. These intense thoughts and emotions are reflected in parent responses to the introduction of parental notification laws (PNLs) when, for example, their child asks a doctor for contraception. The bottom line is that kids need a person to confide in, someone in a position of responsibility to whom they can ask what they might otherwise consider to be difficult, awkward and embarrassing questions. It is probably rare that parents ever successfully fulfill the role of confidant, which leaves doctors’ expertise and the oath of confidentiality the best arena for teenagers to feel comfortable in openly expressing their concerns. Of course, this is reliant on whether the doctor facilitates the opportunity for teenagers to ask such questions. Ultimately, it is the welfare of adolescents that is in danger of being ignored due to the kid gloves approach used by many doctors in fear of any potential legal or parental repercussions such a relationship may engender.
According to results of a Stanford School of Medicine study, published in the Journal of Adolescent Health, fewer than 50 percent of adolescent medical checkups include preventive health counseling, despite the demonstrated effectiveness of doctor-delivered advice in promoting a healthy lifestyle as well as reducing risky behavior in teens. The study follows a decade old recommendation, made by the American Medical Association, for yearly health counseling targeting teen smoking, unintended pregnancy and other preventable miseries. "When we look at the services these adolescents are receiving, we simply find they are not receiving many services that are strongly recommended," said co-author Randall Stafford, associate professor of medicine at the Stanford Prevention Research Center.
The Stanford study was comprehensive, and involved examining health services teens received during almost 337 million outpatient visits between 1993 and 2000, as reported in two national databases from the National Center for Health Statistics. A significant finding of the study revealed that while teens were most likely to be counseled on diet and exercise, only 5 percent of all checkups included counseling related to HIV and other sexually transmitted diseases. This is a concern, because a University of California study shows that teens consider oral sex to be safe, with one in seven participants thinking that the risk of STDs from oral sex would be zero. "There is not much data about the chances of sexually transmitted infections due to oral sex, but there is a real risk," said Bonnie Halpern-Felsher, associate professor of adolescent medicine at the University of California. "When teens are engaging in or considering oral sex, they need to know about methods to keep themselves safe from physical as well as emotional risks," Halpern-Felsher continued. The study also added that health professionals had to play a more active role in aligning adolescent perceptions with real situations.
Of most concern is the discovery that the rate for family planning discussions was only about 8 percent. Lead author Jun Ma, research associate at the Stanford Prevention Research Center, concedes that this is a “really alarming" statistic, considering that the most common reason for teen girls' medical visits are for prenatal care, and the most common diagnosis pregnancy. Ma’s research also showed that teens tend to trust doctors' advice. So physician visits offer a valuable opportunity to nudge adolescents towards healthy behaviors. It would appear on the face of it that the solution to this situation is a no-brainer. But things are rarely so simple.
Other research shows that parents have mixed feelings when it comes to confidential counseling of their children, even though confidentiality is the only real way the system could work. In a study investigating the question of whether parents should be notified when minors request prescribed contraceptives, published in the Archives of Pediatrics & Adolescent Medicine, parental opinion was roughly split down the middle. "Since 2000, more than a dozen states have considered repealing or modifying laws that allow minors to consent to reproductive or other health care, or have considered restricting access to confidential care for minors," the article states. This is where legalities could become dangerously obstructive, and many organizations feel legal barriers should not hamper treatment when dealing with potential health risks of patients unable to obtain reproductive services.
The study used data from telephone surveys of over 1,000 parents of children aged 13 to 17 years. Survey participants were asked whether or not they thought it was a good idea that people aged 17 years or younger could obtain contraceptive or birth control without a parent's consent. Participants were also asked if they thought a law should exist that requires parental notification when a teen requests birth control from a clinic. Well over half the parents thought PNLs were a good idea, but in their entirety the results reflected a more complex thought process. To their credit, over 96 percent of participants could foresee at least one negative consequence resulting from such laws, like teens having more unprotected sex. Most of the parents also accepted that there should be some room to allow for exceptions to PNLs, with adolescents subject to abuse or incest being the most commonly supported exception. Few parents (15 percent) felt teenagers would have less sex if PNLs existed, with even fewer parents (4 percent) believing the laws would cause teenagers to stop having sex altogether.
Marla E. Eisenberg, from the University of Minnesota, concluded that: "Although parents may intellectually recognize the need for adolescents to have access to confidential care, support for PNLs may arise from other factors such as fear of unknown others making decisions about their children's health, the desire to monitor their children's activities, and global beliefs about the appropriate role or parents," the authors write. "Educating parents about the potential negative consequences of parental notification could change their support of PNLs."
The desired result in regard to teenage sexuality might be that they completely abstain from sex until they have reached an appropriate age, and therefore maturity. But we all know, it’s not that simple, and it seems unlikely that adolescents will abstain from sex entirely, which isn’t to say that parents and health professionals should cease trying to engage with teens on this issue. The evidence seems to point, in fact, toward a greater emphasis on confidential counseling of teens and sexuality, not laws that crash through the doctor-patient relationship. With such laws it would be hard to imagine how such open lines of communication on sexuality could be achieved. But if doctors are given more leeway on the sorts of questions they can ask, there may be less diagnosis of both unwanted pregnancies and STDs.
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