Sexual abstinence counseling of adolescents by physicians.
Physicians in primary care may not be counseling adolescent patients adequately, particularly in areas involving sexuality. One reason is that teenagers do not routinely see physicians; they visit the office-based physician less than do any other age group, and their visits usually are short (Office of Technology Assessment, 1991; Society for Adolescent Medicine, 1992). These circumstances do not lend themselves to the comprehensive assessment needed for meeting adolescents' physical and psychosocial needs (Gans, McManus, & Newacheck, 1991). Additionally, some physicians do not want to counsel adolescents. Residents have admitted deficiencies in their counseling skills and that they lack interest in additional training to improve them (Figuerora, Kolasa, Hover, Murphy, Dent, Aushman, & Irons, 1991). Another study reported that adolescents were not receiving counseling on their health care interests (Malus, LaChance & Lamy, 1987). Teenagers are often uncomfortable talking about their sexuality, and if the physician fails to introduce the subject, a valuable counseling opportunity is likely to be missed. (Marks, Fisher, & Lasker, 1990; Stewart, 1987). Approximately one million teenagers become pregnant each year and approximately 2.5 million contract a sexually transmitted disease (Olsen, Weed, Ritz, & Jenson, 1991; Koop, 1988). Sexual activity at earlier ages has proven to adversely affect many teenagers' sense of self-worth (Lenaz, Callahan, & Bedney, 1991). With such serious consequences and the alarming numbers of both adolescent pregnancy and sexually transmitted diseases, the medical community has a responsibility to advocate responsible sexual behavior (Pastorek, 1992). Stewart (1987) suggests that the goals of sexuality counseling should be to help adolescents sort out their feelings, make them aware of the consequences of their choices, and finally, guide them in making appropriate decisions.
In order to improve the training of physicians in counseling teenagers on sexuality it is important to understand their current behaviors. It is also important to know how effective physicians believe their interventions can be. To this end pediatricians and family physicians were surveyed about these behaviors and beliefs, with particular emphasis on physicians' attitudes toward attempts to counsel sexual abstinence.
The physicians surveyed were faculty members of the East Carolina University School of Medicine, residents in pediatrics or family practice at Pitt County Memorial Hospital, and community pediatricians and family practitioners. The survey was self-administered and distributed in the physicians' hospital mail boxes or mailed with a stamped, return envelope. A follow-up mailing was sent to nonresponders. The survey was designed to elicit (1) demographic data and practice characteristics; (2) clinical practices pertinent to the adolescent (sexual development, contraception, sexual peer pressure, and other sexuality topics); (3) opinions regarding the effectiveness of physician counseling about sexuality and the value of additional training. Questions included matters related to abstinence and contraception counseling, sexual habits, sexually transmitted diseases, ways to deal with peer pressure relating to sex, normal sexual development, and sexual abuse. The study was approved by the Institutional Committee on Research with Human Subjects. Responses were coded and computer tabulated. The data were analyzed for differences, using SAS, and based on professional status, specialty, gender, political characterization, marital status, and whether there were children in the physician's home.
Completed questionnaires were returned by 53 physicians, for an overall response rate of 42.7% (Table 1). No statistical differences were found in the physicians' responses based on gender, professional status, specialty, age, political characterization, marital status, or whether there were children in the home (Table 1).
Table 2 includes the topics on which physicians counseled adolescents rarely or never, only if requested, and regularly. Some topics such as contraception, menstrual history, HIV and STD prevention, and risk of pregnancy are regularly covered by most physicians. Topics such as nocturnal emissions, female sexual responses, sexual fantasies, homosexuality, rape prevention, incest, and description of the female menstrual cycle to males are less frequently discussed.
Respondents reported that they regularly discussed contraception with their female patients 86.3% of the time, and counseled male patients 64.7% of the time regarding contraception (t = -3.71; p = .0005). They reported counseling male and female teenagers on contraception and sexually transmitted diseases at similar ages, with the mean age of 12.9 years.
No respondents reported feeling very effective in how they counsel adolescents; 49% felt minimally effective. Only 21.6% reported that with additional training they could be very effective; 19.6% indicated they still would be minimally effective with additional training.
Since increasing adolescents' knowledge of their own sexuality may help them make responsible choices, this would lower the rates of both adolescent pregnancy and sexually transmitted diseases. Many studies have shown that teenagers acquire information mainly from their peers rather than from more knowledgeable sources such as parents, teachers, or physicians (Hoffman, 1989). This often results in the transmission of inaccurate information as well as elevation of peer pressure. Adequately counseling these adolescents about sexuality could delay the start of sexual activity (Olsen et al., 1991; McAnarney & Hendee, 1989), and thus could help reduce rates of sexually transmitted diseases and pregnancy. Physicians have been encouraged to take a more active role in counseling adolescents but face a variety of barriers. We did find that primary physicians in one community were regularly discussing areas of sexuality including HIV and STD prevention, contraception, and risks of pregnancy. However, there are numerous topics physicians discussed rarely/never or only if requested. Discussion is needed to determine if topics such as sexual abstinence, masturbation, and sexual abuse can be effectively undertaken by physicians since it may be that they consider it their role only to make specific interventions or give prescriptions that will have an effect on the physiological outcome of sexual activity.
Demographics of Respondents (n=53) by percent
Male 78.8 Female 21.2
Faculty 51.0 Resident 49.0
Family Practice 62.7 Pediatrics 37.3
20-29 26.9 30-39 40.4 40-49 25.0 50+ 7.7
POLITICAL BIAS (by self characterization)
Liberal 25.5 Moderate 45.1 Conservative 23.5 Do not know 2.0 No answer 3.9
CURRENT MARITAL STATUS
Single 21.2 Divorced 3.8 Married 69.2 Living w/someone 5.8
AGE OF CHILDREN IN HOME (Years)
10-14 21.2 15-17 7.7 18-20 9.6
[TABULAR DATA FOR TABLE 2 OMITTED]
This study is limited by being confined to one community, and by the small sample size and response rate. Although there were more male than female respondents, more family physicians than pediatricians, more respondents under age 40, variation in political self characterization, and more married than single respondents, there were no statistical differences in their responses. However, the results are consistent with those of other studies which indicate that physicians are deficient in adolescent health counseling skills and somewhat pessimistic about the effectiveness of their attempts. Unlike respondents in the study by Figueroa et al. (1991), some respondents in the present study indicated that with additional training they could provide better counseling for adolescent patients.
Since none of the physicians described their counseling as "very effective," training programs need to focus on the way they talk to adolescents about sexuality. Our finding that female adolescents almost always receive more counseling about sexuality issues than do male adolescents may indicate that the physicians considered the female the responsible party when it comes to decisions about sex; therefore, any training should include sensitivity to sexual bias.
Sexual abstinence for unmarried teenagers has the theoretical advantage of being the most effective means for lowering rates of pregnancy and sexually transmitted diseases. While 75% of respondents report talking regularly with teenagers about contraception, less than 50% discuss abstinence. Barriers mentioned include fear of being judgmental and closing off future avenues of communication. Further work needs to be done to explore ways for physician to be more comfortable and more confident about recommending sexual abstinence in a way that affirms the worth of the adolescent and may open new avenues of communication.
Primary care physicians have taken the initiative in discussing issues surrounding pregnancy and disease prevention. They need to consider discussing other issues of sexuality that involve both the physical and psychological health of teenagers.
The authors acknowledge the assistance of Leslie Worthington for data analysis and Jerri Harris for editorial support. This work was funded in part by the Kellog Foundation, Inc., Battle Creek, Michigan.
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Dean Patton, M.D., Associate Professor and Chair of Family Medicine; Kathryn Kolasa, Ph.D., R.D., Professor and Section Head, Department of Family Medicine; Shelly West, B.S., M.A., Medical Student; Thomas G. Irons, M.D., Associate Vice Chancellor, East Carolina University School of Medicine, Greenville, North Carolina.
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|Author:||Patton, Dean; Kolasa, Kathryn; West, Shelly; Irons, Thomas G.|
|Date:||Dec 22, 1995|
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