Does talking about the bird and the bees with teens give you the heebies jeebies? Don’t know where to start with discussion about sexuality with families? Join the Cribsiders and Dr. Tracey Wilkinson (assistant professor at Indiana University School of Medicine and general pediatrician) for this timely conversation on the importance of sexual health and the role all pediatricians can play in advancing reproductive justice.
Reproductive Justice is defined by the SisterSong Collective as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.” The Sister Song Women of Color Reproductive Justice Collective was founded in 1997 by women of color who wanted to transform systems that impact the reproductive lives of marginalized communities (SisterSong).
It is important to remember that choices around reproductive health do not happen in isolation, but rather occur in the socio cultural political climate in which our patients live.
Puberty and emerging sexuality is a normal part of development. Young children may express feelings of attraction and echo the terms they hear adults around them use. Both caregivers and pediatricians can give children language to express how they feel at an age and development appropriate level. The Sexual Education and Information Council of the United States has a guide on Comprehensive Sexual Education which can be a good resource for learning how to discuss elements of attraction, relationships, development etc for different age ranges. Brighter Future is also a helpful resource for having conversations across the developmental stages.
Being confident in your interviews can put your patients at ease. Normalizing the conversation about sex can promote healthy sexuality and open communication. Let patients know that you ask everyone these questions, even if the patients feel like their answers should be obvious.
Simple terms are best. Young patients might not understand terms like “gender identity” As you go through the interview, you should be able to adapt your language to their understanding.
Don’t forget to check out our episode on Gender Affirming Care for more information.
The following examples are adapted from Dr. Wilkinson and the National Coalition for Sexual Health.
Starting the Conversations
“What questions do you have about your body and sex?”
“Some of my patients feel as though they’re more of a boy or a girl, or even something else, while their body changes in another way. How has this been for you?”
“How do you think of yourself? As a boy, girl or something else”
“Who do you find cute? Boys, girls, both? Neither or someone else?”
“Who do you find yourself attracted to?”
“When you are more than friends with someone, are you doing things above the belt or below the belt?”
“Have you ever had sex with someone? By “sex” I mean vaginal, oral, or anal sex.”
“There are different parts of your body that can touch – your lips, your hands, your private parts. Does this happen in your relationship with others?”
“Is sex something that you want to have?”
The HEADSS Assessment is just a way to frame the social history and can happen at any age, not necessarily only during adolescence. Encourage individual time with the clinician as early as you see developmentally appropriate. This one on one discussion time isn’t just about having the “sex, drugs, and rock and roll” conversation. You can ask patients about home life or school environment. This helps caregivers understand that this private time is a routine part of their child’s care. Clinicians are able to share with patients that the skill of independently and privately answering questions in a healthcare setting is important. As patients age, you can layer on different elements of the HEADSS Assessment.
The American Academy of Pediatricians affirm that “[a]ll children and adolescents need to receive accurate education about sexuality to ultimately understand how to practice healthy sexual behavior (AAP 2016).” Comprehensive Sexual Education covers: human development, relationships, personal skills, sexual behavior, sexual health and socio cultural influences (Sexuality Information and Education Council of the United States). There is variability in the type of sexual education that children may receive, if they receive any education at all. Pediatricians have the opportunity to educate patients and families at each visit (AAP 2016).
Dr. Wilkinson encourages clinicians to challenge the concept of safe sex which frames sex as solely risk taking. This framing focuses on the negative consequences of sex (unintended pregnancies, sextually transmitted infections) which can create a sense of fear and shame around behaviors. Even the way that clinicians are taught to ask about sex, the “medically-derived risk-assessment/prevention, screening, and treatment approach” can leave young people feeling that sex is inherently bad (Adolescent Reproductive and Sexual Health Education Project. 2018). Healthy Sexuality instead recognizes that healthy sexual expression is different from risk. By having a more neutral to positive framing, clinicians can expand conversations from just sexual behavior to sexuality and relationships. Dr. Wilkinson frames the conversation by highlighting that the human body and its ability to develop sexually is amazing and positive, and not awkward or embarrassing.
Dr. Wilkinson recommends starting the conversation by asking if a patient has “ever been more than friends with someone,” to help gauge the direction of the conversation. Remember that there can be a lot of different activities that happen prior to sexual intercourse. Don’t be fooled by the answer of “no” if you ask a patient if they are sexually active! The average age of sexual debut is 17 years old (Magnusson 2015), but remember that each patient is an individual!
Understand the laws in your state about what kind of sexual health care minors can consent to with or without parental involvement. The Guttmacher Institute has a table that outlines important laws by state.
Dr. Wilkinson recommends that all adolescents have a trusted adult that they can go to discuss issues of sexual health and behavior, it is ideal if that person can be their parent / caregiver. Clinicians can help patients discuss their sexual health with their parents during the visit. Offering to be a mediator can help adolescents make that first step.
Let patients know that you will work to keep documentation private, but breaches of privacy can happen (open access notes, insurance billing, patient throwing away trash from contraception etc). Work to ensure that patients have individual access to their patient portal and know what Title X clinics are in your area.
Take the time to ask patients about their desire to have sex and if they enjoy having sex. Discussing the answers can illuminate unhealthy patterns in relationships or medical problems that may require further investigation. Recognize that the media doesn’t always have healthy presentations of relationships and sex.
Patients receive information about contraception from different sources (families, friends, media). Birth control method choice is not always driven by efficacy, but side effect profile. Respect your patient’s worries about contraception and the contraception that your patient will use is the best one for them!
Dr. Wilkinson counsels patients on birth control how often you have to take them. Daily medications are easy to change and stop. Methods that are monthly or every year don’t rely as heavily on you remembering a daily medication, but require a trip to the clinic to change or stop.
Centering the patient’s request also helps mitigate the concern for coercion. Marginalized communities have often been targets of reproductive injustices such as eugenics and forced sterilization. Understand the deep mistrust that marginalized communities have when engaging with healthcare systems and work to make healthcare systems more equitable and accountable.
Discuss emergency contraception with all patients and situations where patients should use it. Prescribing emergency contraception with refills can help overcome barriers to access.
This episode aims to destigmatize sexuality discussions in pediatrics within the key framework of reproductive justice.
After listening to this episode listeners will…
Dr Wilkinson receives project funding as Principal Investigator from Cooper Surgical, Organon, and Merck. The Cribsiders report no relevant financial disclosures.
Nwora C, Castillo J, WIlkinson T, Cruz M, Masur S, Chiu C, Berk J, “#85Let’s Talk About Sex – The Pediatrician’s role in encouraging healthy exploration of sexuality”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ May 24, 2023.
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