VO Artist: You’re listening to ReachMD. Welcome to this medical industry feature, titled “Challenges and Best Practices in Counseling Adolescents About Contraception.” This program is sponsored by Merck & Co., Inc., and is intended for physicians in the United States.
Dr. Shepherd: Adolescence is when many of our patients begin to have their first sexual experiences.1,2 Are you prepared to talk to them about sexual health and contraception?
Hello, and welcome to Conversations in Contraceptive Care, a podcast all about counseling patients on contraception. I’m Dr. Jan Shepherd, a Clinical Associate Professor in Obstetrics and Gynecology at the University of Colorado School of Medicine. And I’m here with Dr. Molly Richards, who is an Associate Professor of Pediatrics‐Adolescent Medicine at the University of Colorado School of Medicine.
Dr. Richards: Hello, thank you for inviting me!
Dr. Shepherd: You’re welcome! Today we’re talking about what we, as healthcare providers, can do to provide the best possible contraceptive counseling services for our adolescent patients.
Adolescence is marked by major transitions and transformations, and it’s when many young people may become sexually active.1–3 And although the birth rate among adolescents aged 15 to 19 has declined in the U.S. in recent years, there were still almost 180,000 births in this age group in 2018.4,5 75% of pregnancies in this age group were unplanned in 2011.6 So, to me, it seems that providing contraceptive counseling is critical for our adolescent patients.
Dr. Richards: Yeah, you’re definitely right. Adolescents may be looking for information about sexual health and contraception but may not know where to go or what to ask. What we know is that formal sexual education is not mandatory in many states and, if it is, it might not include comprehensive education that also includes contraception.7 And so there’s certainly benefits to teens talking to their parents about contraception, but we also know that many teens don’t.8
Dr. Shepard: That’s true. An analysis of the 2011 to 2013 National Survey of Family Growth found that out of about 1,000 adolescent girls, only 52% discussed contraceptive options with their parents, and 40% didn’t receive formal birth control education in school.8
Dr. Richards: Yeah, so even when talking to healthcare providers, there might be a large gap in what adolescents want to discuss versus what they actually talk about.9 There was data published in 2020 from a nationally representative survey of about 1,500 13‐ to 26‐year‐olds, and they found that 65% of adolescents 15 to 18 really wanted to discuss contraception with their providers, but only about a third actually did. And, so we know that primary care providers, including pediatricians, play a key role in filling the need for contraceptive counseling for adolescents.
Dr. Shepherd: I completely agree—it’s a delicate topic, but a very important one to address. To that end, there are several organizations that have developed guidelines to facilitate this dialogue, including the Centers for Disease Control and Prevention and the American Academy of Pediatrics.1,10–12 These guidelines recommend a collaborative, patient‐centered approach, and then, of course, to counsel about the effectiveness and safety of contraceptive methods.
Dr. Richards, how do you handle the contraceptives discussion so that it’s right for your adolescent patients?
Dr. Richards: Right. Well, in my practice, I talk with every patient about sexuality and contraception, regardless of their gender, and I start this early, because it’ll be part of their life, even if they’re uncomfortable discussing it at younger ages.1,3 They really need to know that it’s safe and appropriate to talk about this with their provider.1,13 And this includes being really clear about confidentiality, with patients and their parents, and certainly spending part of the visit with the adolescent on their own.3,12 In my experience, if I explain the importance of establishing independence in their health care and the limitations of confidentiality with the parents, they really rarely refuse to leave to the room.
Dr. Shepherd: Agreed, I’ve seen the same thing. It’s really important for teens to feel safe when talking to their healthcare providers about sexual development and contraception.1,13 Once confidentiality has been discussed, how do you go about tailoring the rest of the conversation?
Dr. Richards: Well, first it’s important not to make any assumptions about their sexual identity or sexual attractions, and to be nonjudgmental about their behaviors.1,3,12 We know that risk‐taking is a normal part of adolescent development.3 And you can use motivational interviewing as a great tool with adolescents when talking about their risk‐taking.1 Because they need to have their own reasons for behavior change in order to make change successful.1 And, when I counsel on contraception, I ask about pregnancy intentions with all my patients, even in the younger patients, and we discuss together how contraception could be helpful in planning their future.1,10,11,13 I also ask any patient desiring birth control what they’re looking for in their birth control method, and what they’re worried about when it comes to contraception.10–13 Many patients that I see have fears about contraception and how it will affect their body and their futures.1,13 So it’s important to take these concerns seriously and address them as best as we can.
Dr. Shepherd: I think it’s also critical for healthcare providers to be aware that the pace at which each adolescent goes through the developmental stages can vary, so counseling needs to be individualized to match each patient.1,3,12,13
Dr. Richards: Yeah, you’re definitely right. Depending on their age or their knowledge level, they may need more time to explain things, and what I’ve found is that using models and pictures are really helpful, and that you need to spend some extra time in letting them feel comfortable asking questions, and having the ability to answer them appropriately.12,13
Dr. Shepherd: Great point. Healthcare providers should individualize counseling for each patient, ensuring that they counsel about, and ensure access to, a broad range of contraceptive options for patients who are interested.1,10–13 This includes educating adolescent patients about all contraceptive methods that are safe and appropriate for them.1,10–13
Dr. Richards: Yeah, and I want to point out that this includes long‐acting reversible contraception, or LARC.1,12–15 There have been misconceptions about whether LARCs are appropriate for use in adolescents, but the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Health and Medicine, all consider LARCs as appropriate contraceptive choices for adolescents.1,12–15
Dr. Shepherd: Let’s take a look at what contraceptive options adolescents are actually using. A 2017 analysis of over 14,000 high school students’ responses to the Youth Risk Behavior Survey found that approximately 26% used no method or withdrawal during last intercourse. Approximately 60% used shorter‐acting methods, such as condoms or the pill. LARC use was lower, with only about 5% reporting the use of an IUD or implant.2
Dr. Richards: Yeah, that’s right, and while I’m happy to see that many adolescents are using some form of contraception, which includes condoms to prevent both pregnancy and sexually transmitted infections, I just want to make sure that my patients are aware of all their possible options and really what might be best for them.2 Ultimately, I want to make sure my patients feel informed, that they understand how to use their chosen method, and that they have the right expectations about the potential side effects.1,10–12,14
Dr. Shepherd: Very well said. Thank you, Dr. Richards, for sharing your thoughts and joining me today.
Dr. Richards: Yeah, of course. Thank you so much for inviting me.
Dr. Shepherd: For everyone listening, I hope this podcast has provided you with an overview of some of the challenges and best practices when counseling adolescents about contraception. Thanks for joining us today on Conversations in Contraceptive Care.
VO Artist: The preceding program has been created and paid for by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. The information in this presentation is intended for healthcare professionals in the United States.
The references for the information discussed today are available in the transcript, which can be accessed on the site where you have listened to this podcast.
References:
- Ott MA et al. Pediatrics. 2014;134:e1257–e1281.
- Witwer E et al. Sexual Behavior and Contraceptive and Condom Use Among U.S. High School Students, 2013–2017. New York: Guttmacher Institute. 2018. https://www.guttmacher.org/report/sexual‐behavior‐contraceptive‐condom‐use‐us‐high‐ school‐students‐2013‐2017. Accessed March 17, 2020.
- American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. 2017. Chapter: Adolescence Visits. https://brightfutures.aap.org/Bright%20Futures%20Documents/BF4_AdolescenceVisits.pdf. Accessed March 17, 2020.
- Guttmacher Institute. Unintended Pregnancy in the United States. https://www.guttmacher.org/fact‐sheet/unintended‐pregnancy‐united‐states. Accessed March 17, 2020.
- Martin JA et al. Births: Final data for 2018. National Vital Statistics Reports; vol 68, no 13. Hyattsville, MD: National Center for Health Statistics. 2019. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_13‐508.pdf. Accessed March17,2020.
- Finer LB et al. N Engl J Med. 2016;374:843–852.
- Guttmacher Institute. Sex and HIV Education. https://www.guttmacher.org/state‐ policy/explore/sex‐and‐hiv‐education. Accessed April 27, 2020.
- Lindberg LD et al. J Adolesc Health. 2016;58:621–627.
- Santelli JS et al. J Adolesc Health. 2020. [inpress]
- Gavin L et al. MMWR Recomm Rep. 2014;63:1‒54.
- Gavin L et al. MMWR Morb Mortal Wkly Rep. 2017;66:1383‒1385.
- Committee on Adolescence. Pediatrics. 2014;134:e1244–e1256.
- ACOG Committee Opinion No. 710. Obstet Gynecol. 2017;130:e74–e80.
- ACOG Committee Opinion No. 735. Obstet Gynecol. 2018;131:e130–e139.
- Society for Adolescent Health and Medicine et al. J Adolesc Health. 2014;54:491−496.
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