Why Parents Should Leave the Room When I Ask About Sexual Health: An Acute Care Perspective

I DIDN’T THINK I WAS AVOIDING THIS TOPIC, BUT MAYBE I WAS….

1. My kids are definitely moving into the adolescent phase and I’m bracing myself for alllllll the health issues associated with that age group and risk-taking behaviors, and
2. In pediatric emergency medicine and urgent care, we see a fair number of kids/young adults come for reproductive/sexual health issues, and yet we don’t talk much about that. I certainly haven’t published much on it on my channels heretofore.

Until today. Time to intro the evaluation of sexually transmitted infections in acute care.

If I had to estimate, in my own career experience, I see a patient with the chief complaint of vaginal or penile “discharge” of some sort every other workday. Many acute care colleagues see it daily, and more- pelvic pain and pregnancy too. It’s happening, Carol— kids are engaging in sexual intercourse, and as parents, adult mentors, and caregivers, we need to know about some of the potential consequences they may face. We all know that there’s a lot written about this topic, but I’m going to describe the workup through the lens of the acute care visit, because that’s what I do and how I see it.

So I’m sure it’s not a stretch for you to understand that people don’t come to see ME in emergency medicine/urgent care for proactive wellness and planning as far as reproductive health goes. No indeed. They come when they’ve got a problem, and usually for females it’s typically pelvic pain and/or vaginal discharge and for males it’s almost exclusively penile discharge.

A few things to know about elements of the history and interview:

1. In the majority of states, teens have a right to confidentiality when it comes to reproductive health; this means that they can get care without parental consent. So they can go to a clinic or Emergency Department or Urgent care and get tested and treated without you knowing. They are protected by law.
2. I WILL ask you to step out of the room if you accompany your child to acute care and I am your physician. In fact, most of my colleagues will do the same. Largely for reason number one above, but also so that I can have an open and honest conversation with him/her in order to provide the best and most accurate care I can. I will let him/her know that our conversation will remain between us if they feel strongly but I will equally strongly try to convince them to disclose all the personal information to you. I’ll partner with them to explain things and set ground rules to make sure that the goal of getting them better is first and foremost, but I’m hoping that you will be aligned with me as far as the process goes.

In addition to a direct and honest conversation about symptoms, partners, and sexual activities, everyone and anyone who comes in with a complaint of pelvic pain gets a full physical exam.

This means that I actually look down there at the anatomy to see if there are any clues that can help with the diagnosis. For reasons that are unclear to me, this surprises a fair number of people. I mean, I wouldn’t NOT look in your ears if you came to see me with ear pain, so why would pelvic pain be any different? A full exam gets performed. And everyone of reproductive age gets a pregnancy test. Every single one. I have my fair share of stories of adolescent females who have denied sexual activity and yet wound up with a positive pregnancy test.

A battery of other swabs and urine tests are frequently sent as well, looking for all sorts of infections, from urinary tract infections to sexually transmitted infections, the most common being chlamydia, gonorrhea, and trichomonas (there are more of course). All of these are treatable, but if left untreated can have negative long term consequences including the inability to have children. So even though some of these tests can take several days to come back with results, we will often choose to treat empirically anyway, which means we give the medicine before the test results are complete.

In emergency medicine and urgent care, the patient-clinician relationship is not an established one. You don’t know me and I don’t know you.

Here is another reason why this situation is one where we will often give medicine prior to having test results: we can’t take a chance on the fact that our patients may not follow up and return for treatment if their test results are positive for infection. We have to capture the moment and treat, because that moment may never come around again, and what immediately goes through the mind of an emergency medicine doctor is that worst case scenario. I don’t want any of my patients to be facing sterility on any terms other than their own, so I’ll do whatever it takes to avoid that.

One very tricky part of managing patients with sexually transmitted infections is that the sexual partner needs to be treated also.

As you can imagine with adolescent patients, this can be especially challenging. Some teens have multiple partners, or are no longer in contact with partners, or are afraid to disclose who those partners are, so this part isn’t easy. Treating the partner(s) is key so that the infection doesn’t continue to get passed back and forth between people. Then of course the partner needs to get treatment. Easier said than done.

If you’re still reading this I’m guessing that you’re thinking a poke in the eye with a hot stick is sounding more appealing than the workup above, so in the spirit of avoiding all aspects of this blog post IRL, here are a few thoughts I’ll leave you with—

1. It’s never too late to talk to your kids about sexuality and reproductive health. Make it a low impact, non-judgy conversation so that your kids see you as a resource not a threat.
2. It’s ok to endorse abstinence of course, but pretty please talk to your kids about condom use. If you’re uncomfortable doing so, enlist the help of your child’s pediatrician or any solid clinician you trust.
3. If your child DOES end up in emergency/urgent care with a reproductive health condition, try your best to support them through appropriate treatment and not lose your cool. I guarantee you that won’t get you the results you want. Manage the immediate situation without emotion, and once that’s squared away you can resume the parenting messages you want to send.

I think we’ve got to amplify the conversations about the topic of sexual health, everyone. As uncomfortable and awkward as it can be. We want our kids to make smart choices and good decisions, so we need to arm them with facts and guidance in order for them to do so with maximum effectiveness. Let’s all do our part.