Amy Coopes writes:
Sexting, labiaplasty and sex education in schools took centre stage at a popular session on adolescent health for Australian and New Zealand obstetricians and gynaecologists at their recent annual scientific meeting in Adelaide.
Titled “The Novice Adventurer”, the plenary session took delegates to the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) conference through the tips and traps of treating young patients, traversing a complex legal, ethical and sociological landscape.
International guest speakers Professor Adam Balen (UK) and Professor Jennifer Dietrich (USA) offered an update on the management on some of the common and more complex conditions seen in the burgeoning field of paediatric and adolescent gynaecology (PAG).
Dietrich, a Professor of Paediatrics at Baylor College of Medicine and immediate past president of NASPAG, the international peak organisation for PAG specialists, said patients could present with anything from disorders of puberty and menstruation through to contraception and STI screening, cancer, trauma, and congenital abnormalities of the reproductive tract.
The field had “exploded” in the past decade, she said, with a growing body of evidence supporting better outcomes for paediatric specialists, and a demonstrated need for their services: “intimate, personal care delivered in an age-appropriate fashion” where communication was key.
“If you open the doors, they will come,” Dietrich told delegates. “These people are out there and they need our help.”
Issues facing teenage girls
Setting the scene for her talk, Dietrich, who works at the Texas Children’s Hospital, shared some of the facts on teenage girls in the US. One in four would experience sexual assault, 22 percent were already sexting, and there were almost 20 million new cases of STIs among 15-24 year olds in the United States every year, with half of all adolescents sexually active by the age of 17.
The average age a young girl would become the victim of sex trafficking was just 12-14 years old, Dietrich said, and bullying was all too common, whether at school (20 percent) or online (16 percent). More than one third (36 percent) of girls in the later years of secondary school were using cannabis, 1 in 5 (22 percent) were drinking alcohol and 14 percent were smoking tobacco.
Dietrich’s talk sparked some consternation on social media after she shared American College of Obstetricians and Gynaecologists (ACOG) guidance recommending teenage girls pay their first visit to a gynaecologist between the ages of 13 and 15.
As indicated in the tweets below, primary care and generalist doctors argued such advice had no place in Australia, where most adolescents could be capably cared for by their GP.
See more of the Twitter commentary here.
Australian context
Dr Rebecca Deans, from the University of New South Wales, shared some Australian data showing that 8.8 percent of adolescents had sent a nude image, with this rate reaching 20 percent among 18-year-olds. Among 11-15 year olds, 15 percent said they had seen or received a sexual image.
Navigating the legal landscape around consent, sex and social media was a potential minefield, not only for the teenagers involved but also their treating doctors, said Deans, taking delegates through a legislative 101 on treating minors, assessing competence, and when to report concerns.
Adolescence was a time of negotiating newfound autonomy and nascent desire, said Deans, describing the difficulty of striking a balance between “criminalising exploration and protecting (minors) from exploitation”.
She impressed on delegates that every discussion with an adolescent patient on contraception should involve an assessment of any potential illegality (age of consent, abuse, non-consensual acts), a pregnancy test and STI screen, and a comprehensive discussion of the risks, benefits and adverse effects of their chosen method, alternatives, as well as education on proper use.
Consideration should be given to the HPV vaccine, and safe sex and avoidance of sexually transmitted infections discussed, added Deans.
How not to alienate young people
Sexual health physician Tonia Mezzini stole the show with a role play on the Dos and Don’ts of seeing a teenage patient. The take home message was “You’re not cool. Deal with it”.
“One of the things that I think people make the mistake in assuming is that, (when) dealing with young people you need to be down on their level and get with the program and use the jargon, and you can’t because you just look like an idiot, and that really alienates young people,” said Mezzini in an interview after the session.
“It’s a bit like parenting in the sense that you need to be friendly, but you are not their friend.”
Mezzini told delegates the black and white “sudden death” mentality of teenagers meant they were very quick to pass judgment and, once done, it was very difficult to retrieve the relationship, with the doctor pitted in an unwitting battle against the received wisdom of the patient’s peer group and Dr Google.
It was so important to get things right, Mezzini said, describing the adolescent contraceptive consultation as a “supercharged” encounter where the ground rules were different and there was much more at stake, with the opportunity to stave off the serious physical and psychological consequences of damaging early sexual encounters.
Building rapport, showing a genuine interest in the young person’s agenda and explaining why you were asking certain questions were a few good rules of thumb, she said, also offering advice on how to get the insistent 1% of parents out of the room (“Start with humour, but be firm if you need to, you’re within your rights to insist as a practitioner”).
Mezzini told delegates it was not enough to provide information about the mechanics of sex, contraception and STIs; doctors needed to explore the meaning of and motivations for sex and understand the inner world of their young patients. Skyrocketing numbers of teenagers presenting in distress to the nation’s Emergency Departments suggested that, at present, these needs were not being met, she said.
She also championed a robust sex and relationships curriculum in schools, lamenting the abolition of the Safe Schools program as a “terrible failure”.
“There is an overwhelming body of evidence that shows that in countries where kids get sexual health and relationship information at an age appropriate level — starting in primary school, all the way through their adolescence — they have lower rates of teenage pregnancy, lower rates of STIs and generally go better on all sorts of sexual health outcomes,” Mezzini said.
Demand for labiaplasty soars
Her comments were echoed by Balen, a Professor of Reproductive Medicine from the University of Leeds, who said the system was failing to adequately counsel teenagers on normal sexual development and future fertility.
A narrow focus on safe sex and contraception had seen numbers of teenage girls presenting for labiaplasty snowball over the past two decades, to represent 10 percent of all referrals to his paediatric gynaecology clinic.
Likening the practice to female genital mutilation, Balen said the majority of these young women presented with variations of normal anatomy and had unrealistic expectations gleaned from pornography and the Internet. He called for better education, not only of young girls but also doctors, on the issue.
Melbourne-based paediatric gynaecologist Sonia Grover said her experience was that patients often got their ideas about what “normal” labia looked like from sex education materials, and that one in four girls she saw were actually brought in by concerned mothers.
Balen said sex and relationships education – which has not been mandatory until recently in the UK – should not be delivered as a stand-alone subject but integrated throughout every subject of the curriculum in order to demystify the topic and discourage stigmatisation and taboo.
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