Discussing Sexual History with Adolescents in Mental Health Treatment

Discussing Sexual History with Adolescents in Mental Health Treatment
Discussing Sexual History with Adolescents in Mental Health Treatment

Being aware of patients' sexual history and current sexual activity is essential in providing mental health treatment to adolescents and young adults. The CDC estimates that youth between the ages of 15 and 24 make up just over one-quarter of the sexually active population, but account for half of the 20 million new sexually transmitted infections that occur in the United States each year.1

Studies have repeatedly shown that people with severe mental illness are at least 5 times more likely to develop HIV and other sexually transmitted diseases than the regular population.2

Often, psychiatrists are the only physicians with whom many of these otherwise healthy young people may have contact. For this reason, it is vitally important that psychiatrists take a thorough sexual history, recognize a patient's potential risk factors related to their sexual history and mental health diagnosis, and provide education and referrals for appropriate treatment when necessary.

Helping young people feel comfortable talking with you about their sexual activity can be challenging. Here are some helpful tips. The first step is to make sure that you have time alone with the patient. In a recent article in the Journal of Adolescent Health, it was reported that teens and their doctors tended to discuss the greatest number of topics when parents were present for only part of the visit and the fewest number of topics when parents were present for the entire visit. 

Secondly, discuss confidentiality. Explain that while you do have obligations as a mandated reporter, you cannot disclose other things that are not safety concerns without their permission.3 And lastly, be prepared to provide culturally sensitive responses.  Let your patient know, through both body language and words, that they can discuss anything with you. Take the time to be aware of how your own cultural values, beliefs and assumptions may influence your reactions and delivery of care. 

Once you and your patient develop an alliance that allows for open dialogue about their sexual activity, you can begin to identify individuals at risk for sexually transmitted diseases (STDs). The CDC recommends using the "5 Ps" as a general guide for taking a patient's sexual history. The "5 Ps" stand for: Partners, Practices, Protection from STDs, Past history of STDs, and Prevention of Pregnancy.

Ask questions to determine the number, sex, and concurrency of your patient's sex partners. Explore the types of sexual activity that your patient engages in. Ask about condom use, and situations that make it harder or easier to use condoms. Ask about the teen's history of STDs, including whether their partners have ever had an STD. And finally, explore whether your patient wants to become pregnant and discuss current and future contraceptive options. 

Certainly, patients who engage in risky sexual behavior are at higher risk for STDs. However, young people with a history of trauma or mental illness may be at an even greater risk. Research has found a relatively consistent association between childhood sexual abuse and higher rates of sexual risk behaviors.4 Similar associations were found in patients with substance dependence, schizophrenia spectrum, antisocial disorders, mania and even depression.5 And while it remains unclear whether mental health status causes risky sexual behavior or risky sexual behavior has a negative impact on mental health, or some other factor(s) affect both, there definitely seems to be an association.

Ultimately, better understanding our patient's risks for sexual risky behavior allows for an opportunity to provide adequate education and appropriate referrals. Helping our patients recognize the importance of their sexual health as a part of their total health is an essential part of what we do; and must never be overlooked.

Melissa Vallas, MD, is lead psychiatrist at Children's System of Care, Alameda County (California) Behavioral Health Care Services Agency.

References

  1. Forhan SE, et al. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics. 2009;124:1505-1512.
  2. Rosenberg SD, et al. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health. 2001; 91(1): 31–37.
  3. Goodman M. How should doctors talk to teen patients? West J Med. 2000; 172(3): 207.
  4. Senn TE, et al. Childhood and adolescent sexual abuse and subsequent sexual risk behavior: Evidence from controlled studies, methodological critique, and suggestions for research. Clin Psychol Rev. 2008; 28(5):711-735.
  5. Ramrakha S, et al. Psychiatric disorders and risky sexual behavior in young adulthood: cross sectional study in birth cohort. BMJ.  2000; 321:26.
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