Adolescents May Not Always Receive Essential Reproductive Health Services from Their Pediatrician
Most respondents to a national survey of pediatricians who treat adolescents said that they talked with these patients about sexual health and high-risk behaviors during routine visits, but many did not offer the counseling and services necessary to help them protect their reproductive health.1 While more than eight in 10 pediatricians routinely asked about patients’ reproductive health and sexual activity, a little more than half provided reproductive health services (e.g., STD screening and prescriptions for contraceptives), and nearly half advised all sexually active patients to be tested for STDs. The strongest predictors of offering reproductive health services were having a policy to ensure patients’ confidentiality and practicing in an inner city (odds ratios, 2.8 and 3.1, respectively).
About half of STDs detected each year in the United States occur among 15–24-year-olds, and the American Academy of Pediatrics (AAP) and other professional organizations have prioritized STD screening and counseling for adolescents. To assess service availability and pediatricians’ methods of evaluating and treating high-risk patients, investigators analyzed data from a national survey conducted by the AAP in May–September 2005.
In a mailed questionnaire, a randomly selected sample of practicing pediatricians provided information on their demographic characteristics; their main practice location and its services; and their procedures -regarding confidentiality, STD testing, counseling and assessment of high-risk behaviors (unprotected sex, past STD diagnosis and multiple sexual partners). To be included in the analyses, respondents had to treat patients aged 11 or older; the final sample consisted of 468 pediatricians.
The respondents were, on average, 45 years old, and about half were female. Nine in 10 worked in a suburb or an urban -setting; the remainder worked in rural areas. About one-fifth of pediatricians worked in an inner city. Respondents practiced alone or with a -partner (18%); at a medical school, hospital or clinic (26%); or in a private group practice (54%).
Some 83–86% of pediatricians always discussed reproductive health and sexual activity with teenage patients, and 54–62% routinely covered abstinence, contraception, condoms and STDs; however, just 18% asked about sexual orientation or identity at each visit. Fifty-eight percent reported that they had guidelines to ensure patients’ confidentiality.
Fifty-six percent of pediatricians’ practices offered reproductive health services. The majority of this group tested for common STDs (74–81%); prescribed the pill (85%), the injectable (68%) and the patch (63%); and provided condoms (53%).
While most respondents routinely assessed patients for high-risk behaviors, only one-fifth had a standardized approach for doing so. Overall, the majority of pediatricians advised high-risk patients to get tested for HIV (66%) or other STDs (69%). However, the proportions routinely recommending these tests for all sexually active patients were lower—28% and 46%, respectively. One-quarter reported that they did not know if state law required minors to have parental consent for an STD test.
Though almost all respondents believed that high-risk behaviors and STD prevention were important topics to address with adolescent patients, three-quarters indicated that time constraints prevented them from doing so. Among other limitations, 55–69% reported that they were untrained or not interested in STD counseling, they or their patients were uncomfortable with this topic, or they were not paid adequately by patients’ insurance for this service.
A multivariate analysis controlling for characteristics of pediatricians and their practices showed that female pediatricians and those aged 45 or younger had an increased likelihood of providing reproductive health services (odds ratio, 1.7 for each). Those who had a confidentiality policy had elevated odds of offering these services (2.8) and condoms (3.5). In addition, pediatricians in inner cities were more likely than those practicing in the suburbs to provide these services (3.1) and condoms (4.2). Compared with those who practiced alone or with a partner, pediatricians working in hospitals or clinics also had elevated odds of offering condoms to adolescent patients (3.0).
The researchers note that their findings could have been influenced by social desirability and nonresponse biases. Even so, they conclude that their findings emphasize the importance of having a confidentiality policy to help ensure that adolescents can be "forthcoming about their true health concerns." They also propose that pediatricians offset STD infection risk by bringing up the issue of sexual orientation with their patients, which could lead to beneficial discussions. The investigators conclude, "It is critical that pediatricians understand that all adolescents who engage in sexual or other risky behavior(s) are at risk."—S. Ramashwar