Adolescent Contraception and the Clinician: An Emphasis on Counseling and Communication

Adolescent pregnancy continues to be a serious public health problem in the United States, resulting in tremendous family upheaval and negative social and economic consequences. The problem of adolescent pregnancy is a major issue in the minds of Americans. Perhaps this is best exemplified by the amount of time President Clinton devoted to the subject in his 1995 State of the Union address. His time on the subject was well received by the American public: 26% of Americans said that the strong national effort to reduce teen pregnancy was their favorite proposal. In comparison, 25% of the public said health care reform, and 22% said an increase in the minimum wage were their favorite proposals. The only proposal that “beat out” the teen pregnancy proposal in the poll was an issue to initiate tax breaks for the middle class! 1 Just slightly less than 1 in 10 American adolescent females becomes pregnant each year. Approximately half of these pregnancies end in birth and half end in abortion. 2,3 Fortunately, there is a favorable declining trend in teen pregnancy, although the US continues to have a significant problem. The 1995 National Survey of Family Growth has shown a small, but first ever, decrease in the percent of 15 to 19-year-old women who have ever had coitus. The numbers are: 1982 = 47%; 1988 = 53%; 1990 = 55%, and 1995 = 50%. 4 This, coupled with an increased use of contraception (mainly condoms), has resulted in a slight decrease in teen births. 5 It appears that approximately 80% of this decrease in the teen pregnancy rate is attributable to an increase in contraception, and 20% is attributable to abstinence. 6 Although these numbers are encouraging, the problems stemming US teen sexuality are still monumental. An international perspective helps draw this into focus. The US teen pregnancy rate is approximately 10-fold higher than rates seen in Japan or the Netherlands, and it is approximately two-fold higher than in countries such as Britain and Canada. 7 Pregnancy is only one of the hazards of teen sexuality. Sexually transmitted diseases (STDs) and their consequences are perhaps an even greater problem. Sexually transmitted diseases are rampant in the sexually active adolescent population. In a recent study evaluating female military recruits, the Chlamydia prevalence was 9.2%. 8 Almost 10% of sexually active females between the ages of 15 and 19 years have had more than one sexual partner in the last 3 months, 3 a pattern that has been called serial monogamy. Where Have We Gone Wrong in Adolescent Sexuality There are multiple reasons why we have the highest rate of teenage pregnancy in the developed world. One is that adolescent health care delivery is a challenge to our medical community. In 1992, the American Medical Association, supported by many other professional organizations, published their Guideline to Adolescent Preventive Visits proposal promoting and providing structure for proposed yearly adolescent preventive visits to deal with the multitude of problems confronting this vulnerable age group. 9 This proposal included preventive counseling and health care visits for teens (yearly) and parents (two times during the adolescent years) to include care relating to sexuality, substance abuse, mental health, and violence, major causes of morbidity and mortality in adolescents. In summarizing how our nation had gone wrong in adolescent health care, the author of the Guideline to Adolescent Preventive Visits commentary noted three major failures 10 : 1. We are inconsistent in our message. 2. We are not age-appropriate. 3. We have relied on knowledge-based education. Certainly, each of these three issues is critical. Lack of consistency in messages can be seen daily in the media. The average teen sees approximately 14,000 instances of sex on television each year, but in only 165 of those instances do any ill consequences, such as a disease or pregnancy, ensue. 11 Magazine covers, MTV, and rock songs constantly sell and portray sex as the teen norm and as a behavior that is without any significant risks. Relying on a knowledge-based approach is another reason we have such significant adolescent health issues. Knowledge alone has not been shown to effect adolescent behavioral change. Teens who have been exposed to knowledge-based sex education programs have a significant increase in knowledge on testing but have not delayed coitus nor been more likely to use contraception. 13 Programs that tend to be successful in changing behavior are skill-building, problem-solving, and communication-based. 12 Another reason we have been unsuccessful is the lack of an age-appropriate approach, which is particularly important to clinicians. Surveys have often shown that there is a significant discrepancy between what adolescents wanted to discuss with clinicians and what they had discussed. In one survey, although 70% of teens wanted to discuss STDs and 66% wanted to discuss contraception, these subjects were only discussed by 18% and 22% of their physicians, respectively. 14 Dealing with the issues of adolescent cognitive development appears to be difficult for the US medical community. Psychologists, such as Jean Piaget (1896–1980), have observed that adolescents progress through development during adolescence. Specific characteristics are typical in each age group: 12 to 14-year-olds, 15 to 17-year-olds, and 18 years and older. Consistent problem solving and abstract thinking is generally only seen in teens ages 18 years and older, 15 to 17-year-olds are inconsistent problem solvers, and 12 to 14-year-olds tend to be cognitively concrete. 15 Understanding teenage cognitive skills is critical to providing contraception in the adolescent population. The typical 12 to 14-year-old often can not even envision any negative consequence if they are active sexually. The 15 to 17-year-old may typically understand the possibility of negative consequences but will perceive them as unlikely to occur. Those 18-years-old and older often understand the risks and that the risks apply to them. Clinicians need to understand that adolescence is a time of social and cognitive growth. Clinicians should adapt their approach to adolescents by helping them problem solve, recognize risks, and communicate more effectively with partners, rather than focusing solely on building knowledge on sexuality topics. Although adolescents are often called young adults, they are not adult in their cognitive skills. Clinicians must approach this challenging age group with this understanding and an armory of excellent communication skills to provide excellence in contraceptive care. Application of General Principles to Adolescent Counseling in Contraception The general approach to adolescent contraception should focus on keeping the clinician–patient encounter interactive. Several concrete suggestions may help clinicians realize these goals. These include avoiding “yes/no” questions, keeping clinician speaking-time short and focused, and avoiding the word “should.” Avoiding yes/no questions is one easily applied method of keeping encounters interactive. A primary goal of the clinician is to assess the cognitive development of the adolescent. By encouraging dialogue beyond mere yes/no responses, the teen must verbalize and explain questions and concerns. Counseling should be directed at a given adolescent’s cognitive level in a skill-building format. Appreciation and validation of concerns appropriate to a specific patient are important. Clinicians may think this approach takes too much time. In actuality, a didactic approach that results in giving patients methods that they are unable or unwilling to use is much more time-inefficient and counter-productive. The technique of keeping the conversation focused and pertinent is critical to good time-management in adolescent reproductive care. If clinicians find themselves lapsing into talking for more than 1 minute, they have transitioned from the goal of keeping counseling interactive into a didactic mode. The clinician may be addressing concerns or issues of no interest or importance to their specific patient. Using the word “should” is also a noninteractive communication technique. Specific examples of interactive, non-yes/no questioning and skill building are included next in this chapter. Specific Contraception ABSTINENCE Abstinence deserves emphasis, especially in young teenagers. Almost half of all teens who have been intimate say they have performed something sexual that they were not ready to do. 27 Clinicians should begin counseling preteens and young adolescents through interactive techniques. Basically, this interactive technique could be summarized not as “just say no,” but instead as “know how to say no” to sex. Role-playing can be helpful. Figure 1 presents a communicational approach to helping teens gain the skills that may allow them to decline coitus. 16FIG. 1: With permission from The Contraceptive Report. 16Does abstinence promotion in school and community settings work? In a research review performed by the National Task Force on Effective Programs commissioned by the National Campaign to Prevent Teen Pregnancy, no programs that were abstinence-only have been effective, but some programs that had abstinence promotion in addition to contraception information and skills were effective in increasing abstinence. This research review included all studies published in peer review journals with at least a quasi experimental design and sample size of 80. 12 CONDOMS Condom use, as reported by the National 1997 Youth Risk Behavior Survey, has increased during the last decade, but condom use was still only reported (to the Division of Adolescent and School Health) by approximately 50% of adolescent females at last coitus. 17 Adolescents often perceive condoms as a contraceptive rather than as a method of preventing STDs, although hopefully, this trend is changing with AIDS education. Condom counseling should focus on the various problems and barriers that adolescents must navigate to use them successfully. The clinician’s line of questioning for the patient who is not always using a condom may be: “The last time you did not use a condom, why did you not?” If the patient cannot describe the circumstances, this may indicate she is concrete in her cognitive skills. In this case, a variety of common reasons could be presented to her, such as “Did it break or slip? Was it not available? Were you in the ‘heat of the moment’ and it took too long to use? or Does your boyfriend not like them?” Then, counseling is directed at specifically solving the issue of why the condom was not used. In contrast, a knowledge-based counseling approach would be directed at why condoms should be used and how a condom decreases disease and pregnancy. ORAL CONTRACEPTIVES Oral contraceptives (OCs) and condoms are the most common contraceptive methods chosen by American teens. Many clinicians promote the so-called belt and suspender approach to adolescent contraception and STDs, promoting simultaneous use of OCs and condoms. Each adolescent considering OCs should be specifically queried regarding her concerns. This should be performed in an interactive format, such as “What concerns you?” or “What is the worse thing you have heard about the pill?” rather than merely asking yes/no or open-ended questions, such as “Do you have any concerns about the pill?” The main concern adolescents have regarding OCs is that they will gain weight. 18 Whereas this may seem trivial, from the adolescent psychosocial perspective, it is a concern that is completely age-appropriate. During early adolescence, teens become concerned with body image and by the mid-teen years, they are interested in their appearance. Controlled studies have proven that OCs do not cause weight gain. 19 Another specific problem that adolescents have is remembering to administer the pill daily. Clinicians and their assistants can aid adolescents in solving this problem by helping them establish memory cues such as placing the pill by their toothbrush, in their underwear drawer, or another similar cue. This is yet another example of problem solving counseling that is a contrast to the traditional knowledge-based counseling that focuses on how and why the pill prevents pregnancy. Adolescents should also be counseled regarding missed pills and given anticipatory guidance about breakthrough bleeding and amenorrhea. Finances, pill renewal issues, and who to call with questions should be clearly outlined. Open phone lines appear especially critical in continuation of OCs. In one study, almost 70% of adolescents who continued OCs had called back for advice, compared with none of the patients who discontinued. 20 Another issue that may contribute to the reluctance of adolescents to seek contraception and OCs is fear of a pelvic examination. Although a pelvic examination is not required for an OC prescription, most adolescents and many providers do not know this fact. In 1986, almost 70% of girls ages 12 to 17 years agreed with this statement: “Adolescents postpone seeing a provider due to fear of the pelvic examination.”21 Adolescents who delay a pelvic examination on a first visit will often allow an examination on a later visit to screen for infections and cervical cytology. Fear of the examination can also be decreased by discussing the sensation of the examination with the patient. Research about anxiety in relation to medical procedures in patients of all ages has shown that informing the patient about the sensation they will feel is a more successful strategy to lessen anxiety than merely informing the patient what is being performed technically. 22 DEPO-PROVERA/NORPLANT Although only a small proportion of the adolescent population uses the long-acting progestin methods of contraception, they have obvious benefits in terms of not requiring any daily pill administration activity or action at the time of coitus. Like oral contraceptives, they do not protect against STDs. Counseling issues include anticipatory guidance regarding menstrual patterns and, in the case of Depo-Provera, how the patient will access the provider every 12 weeks for her injection. EMERGENCY CONTRACEPTION Approximately 10% of women in Finland younger than the age of 25 years have used emergency contraception. 23 For this method to be better-used in the US, women must be aware of the method. Specific counseling issues regarding adolescents include the fact that a common label for emergency contraception is the “morning after pill.” Concrete-thinking adolescents (and mature women) often conclude from that phrase that there is only a small window of opportunity (the next morning!) to consider this method and do not understand it is the standard to offer emergency contraception for up to 72 hours after unprotected coitus. All adolescents should know emergency contraception is available, when it is appropriate, and how to access emergency contraception. This can often be accomplished by giving patients handouts and providing a brief discussion between the nursing assistants and the teen, rather than using clinician time. Involvement of Parents Parents (and guardians) are critical and central to the problem of teen sexuality. 24 The National Longitudinal Study on Adolescent Health clearly showed that a high level of parent–family connection and a greater number of shared activities are correlated with delay in coitus and protective against pregnancy. Unfortunately, children have lost approximately 10 to 12 hours of parental time per week compared with children in the 1960s. Clinicians must work with parents in the area of teen sexuality. 25 Confidentiality is critical in teen reproductive care. However, confidentiality does not translate to secrecy. Teens should be encouraged to involve their parents; however, approximately one-fourth of adolescents will avoid contacting providers with sensitive subjects if there is any chance their parents would find out. 26 The Guideline to Adolescent Preventive Visits proposal includes two parental counseling visits to help parents discuss these issues and prepare to deal with adolescent psychosocial development. The majority of parents who have teens have not had conversations of any depth regarding sexuality, teen pregnancy, or STDs. 24 Handouts from organizations may help parents break some of the barriers and initiate discussions. Examples of handouts include “Helping Your Teen Make Responsible Choices” and “Teens and Sex ” from the AMA, 28 both of which have master resource sheets available for reproduction and distribution. In addition, the “Ten Tips for Parents” is available from the National Coalition to Prevent Teen Pregnancy. A variety of other professional organizations including American College of Obstetrics and Gynecology, American Academy of Pediatrics, and American Academy of Family Practice, in addition to Nurse Practitioner and Physician Assistant organizations, also have excellent resources for parents of teens that are available to both their own members and non-members. One concrete example to share with parents includes how they can help their children avoid risky situations. Many young American teens have coitus during the “latch key” hours (3:30–5:30 pm during weekdays) when they are unsupervised. Structured after-school activities or supervision may help at these times. Alcohol and drugs have obvious potential to effect sexual decisions. Almost 20% of teens who have had an intimate relationship admit to performing something sexual that they otherwise would not have performed if they had not been influenced by the effects of alcohol or drugs. Parents should consider 29 locking-up or monitoring any liquor in homes. Long-term Goal The prevention of teen pregnancy is a societal problem that requires changes in many diverse areas, including the media, economic opportunity, parental involvement, and improvement in access and delivery of medical care. Clinicians can best serve the adolescent population by encouraging parental involvement and by giving teens consistent messages that are age/developmentally appropriate. Education that is communication, skill building, and problem-solving-based rather than didactic knowledge-based should be provided. For the medical community to optimally serve this population, care must become preventive rather that reactive. Teen boys are often a forgotten part of the equation in pregnancy and STD prevention. Preventive yearly care, as proposed by the American Medical Association in Guideline to Adolescent Preventive Visits proposal, 30 for males and females, is a sensible step toward improving adolescent medical care and the promotion of better lives for adolescents and their families.

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