Sexual health can be a sensitive topic to discuss. Asking open-ended questions and allowing time for your patient’s story to unfold can create a safe space for conversations about sexual health.
Almost 30% of high school students in 2019 report sex in the previous month, but less than 10% used both condoms and effective contraception. Female students of color are about twice as likely to become pregnant than whites. All clinicians can make a difference by talking to young people about their sexual health and well-being.
The CDC has hosted the Youth Risk Behavior Survey (YRBS) in the United States since 1991. The most recent output from the analyses of this data focused on sexual health and well-being. It stems from a confidential, nationally representative sample of almost 14,000 high school students in 2019. The results of this analysis, published on August 21, 2020 in the “Morbidity and Mortality Weekly Report (MMWR),” highlights critical public health gaps pertaining to sexually transmitted infections (STI) and risk of unplanned pregnancy in sexually active high school students. The analysis was limited to non-same-sex relationships in order to look simultaneously at STI and pregnancy risk. The report contains a large amount of data, however some key take home messages are:
1. Nationwide, ~27% of high school students reported being sexually active.
This was defined as having one or more sex partners in the three months prior to completing the questionnaire. However, “sex,” isn’t defined—many types of sex, such as oral sex, aren’t implicated in unplanned pregnancy.
2. Of these, ~50% used a condom at last sex.
3. Only ~9% of respondents used both condoms (to prevent STI), and a highly effective form of contraception (intrauterine device (IUD) or contractive implant) to prevent pregnancy.
4. Less than 1% of respondents reported using both a condom plus a highly effective method of contraception (IUD or implant), the so-called “Double Dutch” method.
5. Those with higher risk scores for sexual ill health, such as early age of sexual debut, and/or greater number of lifetime sex partners reported lower condom use.
6. Black and Latino respondents reported almost twice the pregnancy rates compared to white high school students.
7. ~90% reported use of either condoms or a method of contraception at last sex.
The authors write about the need to understand and address “structural issues” in order to progress to more equitable provision and access to STI/contraception service for all, irrespective of race/ethnicity. However, we’ve been discussing structural barriers and health inequity for decades—the issue is a failure to take action to address them. It was beyond the scope of this report to discuss other important barriers such as medical mistrust and lack of access to culturally and linguistically competent services. The calls for action to address sexual and reproductive health inequality are laudable and these data should galvanize us as clinicians and community members.
However, there are some key areas that are missing from the discussion in this report that are also frequently missing from other literature on sexual health and well-being. The YRBS only include male/female as options for gender identity, which renders high school students with other gender identities invisible, even though they have specific STI and contraception needs. The survey does not, nor is designed to, advocate for a person-centered approach to sexual health that involves the hard work of asking young people what they want, where, when, and provided by whom.
Medicalized approaches towards STI and contraception have, for too long, been disease-focused—the harms of STI, the intergeneration disadvantage that accompanies teenage pregnancy—instead of reframing the paradigm with a focus on self-efficacy and pleasure. Some basic principles for successful discussions about sexual health with high school students as well as people of all ages include:
1. Humility and honesty.
By acknowledging our own limitations and willingness to learn, we can work toward creating a trusting relationship with our patients.
2. Use language that patients understand and feel comfortable with. Ask:
“What pronoun do you prefer?”
“What words are you comfortable with when talking about your anatomy and sexual preferences?”
3. Allow space and time for the story to unfold by asking open-ended questions.
4. Reassure patients that each question is designed to understand their situation so that you can offer the best advice.
Explain why you ask what you ask and what purpose the question serves.
5. Consider sexual health training by contacting the National Network of STD clinical Prevention Training Centers.