Sexual Education

Sexual education is a topic of constant debate. There are several questions surrounding the issue including who should be responsible for teaching sexual education and at what age it should be introduced to children. With children becoming involved in and exposed to sexual experiences at younger and younger ages than before, many argue that sexual education should take place at a young age. Whether it be taught by parents, in schools, or by physicians, children must be educated on this risky behavior to help reduce teenage pregnancy and sexually transmitted diseases.

Introduction and Questions
The first video in this case was pretty ridiculous. The doctor was completely unprofessional and really did nothing right. In fact, it couldn't have gotten any worse. Talking to any patient about certain sensitive subjects such as sex and STDs should be approached in a well thought out manner. This is even more important when speaking to teenagers or someone from a different culture who may hold different views on certain subjects. Tammy is a young African American girl who seems to not know much about sexual health but is open to discussing her problem. Young people are having sex at an earlier age and the CDC reports that nearly three out of four high school seniors have sexual intercourse by the time they graduate. In the United States, an estimated 15.3 million new cases of sexually transmitted diseases (STDs) occur each year, at least one-quarter of them among teenagers. Young adults aged 15 to 19, both male and female, have the highest rates of chlamydia and gonorrhea, the two most common sexually transmitted diseases. Many schools have classes (which we have all taken) to "teach" young people about sex and development. It would seem that these statistics might indicate that these courses are not effective given the increase in STDs among teenagers.

'''Is it the family unit, physician, or educational system that should be responsible for teaching teenagers and children the hazards of unprotected sex and sexual practices? Where does religion fall into this mix and how do we broach the subject of teaching kids about sex and STDs in more conservative settings where parents and/or community leaders may be hesitant to talk about such subjects with youth? There are a lot of answers that can be posted to these questions so where should we, as health professionals looking out for the best interest of our patient, begin?'''

Discussion
The first video is an obvious example of how not to act, I don’t think one needs to spend time discussing its obvious faults. It’s more of a bad joke then anything else.

As for assessing blame for why she lacks an understanding of safe(er) sex, we could debate the distribution for blame forever and it will not change this example one bit. Blame the schools, the church, and the parents; you still have a teenager who is ill informed and making poor choices. As a physician your time is better spent on how to salvage this situation. The only option is to educate and have the patient take ownership of their condition and future.

A Public health approach to STD prevention: Uganda has had some success in bringing down its HIV infection rate compared to its neighbors. The government has been very involved in a public health effort that has been termed the ABC approach: Abstinence--Encouraging those who are not sexually active to maintain abstinence, Be faithful--Encouraging those who are sexually active to be faithful to one partner, Condoms--Encouraging those who are sexually active to always use condoms.

The Ugandan president, the government, public health authorities and churches have all taken active roles in promoting the program. Activities have included speeches by the president, advertising by the public health authorities, and regular large group meetings and activities with music and speakers sponsored by the churches.

Do you think that programs like this could work in the U.S.? Why or why not?

Generally speaking, American television, literature, music, and culture glorifies and glamorizes sex. While that is the case, on the main and in the mainstream, abstinence movements are unlikely to get much attention.

If anywhere, the best bet for abstinence movements would be in subcultures, such as religious ones, but even some of the most conservative and traditional spiritual communities have found themselves having to re-evaluate their views and tactics in order to appease their patrons.

Just as any social education (sex, professionalism, etc.), I believe it works best when we have united/cooperative approach by families, physicians, schools, and religious organizations. When one of the component is weaken (for example, family unit), others must step up. Schools, unfortunately, are under the pressure of policy makers who may or may not understand the risks/devasting effects of STDs and pregnancy. I do not believe it is wrong for religion to preach their belief; if it's the true teaching that no sex until marriage, so teach that to the followers.

Uganda program is effective because everyone is working together. I do agree that we Americans are not very fond of being told what to do, especially from the authorities. But, if we enpowered the teens (instead of talking down) and gave them the FACTS, we can truly say we have done all we can. What's happening now is that our kids are not getting accurate and complete education. When the government move the funds from "comprehensive" education to "just-say-no" education, many are found in the position of not knowing how to protect themselves. I got the sex education: it consisted of watching video of STD lesions without discussion. That was in westend Richmond.

NPR did a really good segment on sex education. I will try to find it and post it here.

The role of the physician as an educator is important. As I speak with patients about their various conditions, if it becomes obvious that the patient does not understand their condition, I will often ask the patient, "Has anyone ever explained to you..." I often find the answer is "no" and will then attempt to offer an explanation in terms that I think the patient will understand.

As is the case with sex and STDs, my limited interactions to date have come primarily with adolescents. This group is often reluctant to ask questions about these topics so if the interview requires asking about sex / STDs, I may ask an open-ended, somewhat non-specific question such as, "Do you have any questions about this stuff?" (If the patient presents with a chief complaint related to a possible STD, then the questioning is more focused.) Given the time pressures of patient encounters, if the patient says "no," then I'll move on to the next subject. However, if the patient does have a question, it is a nice opportunity for patient education, even if it is just for a minute.

The doctor did an excellent job with the second patient encounter. I feel that she demonstrated an efficient approach to the STD encounter. She encouraged the patient to talk about her symptoms and concerns, and was factual and patient in explaining what to expect. I think any female will be somewhat uncomfortable with this sort of encounter, so the attitude of the physician will have a lot to do with how much the patient will open up and give information as well as respond to the advice.

Tammy's case made me think about the role of her parents in this situation. Teens in Virginia under 18 can get contraception from their local health department without obtaining parental conset (Texas and Utah are the only states that require parental consent at this point for contraception provided by state funding). Do you all think the law in Virginia is more helpful or harmful in preventing unwanted teen pregnancy/STDs?

Should parents be more involved in their children's sexual health? After all, parental consent for minors is needed for every other medical procedure I can think of, from a visit to the doctor's office for a common cold to surgery.

Should parents be more involved in their children's sexual health?

Ideally, parents and teens would have open conversations regarding sexual health. However, I think a lot of it depends on the culture of the family. Some families are very close and can openly discuss issues without feeling awkward or stifled. On the other hand, some families won't even spell the word sex. In this case, it would be good for the children to have some sort of resource to go to. Reputable websites are even a good option if teens don't want to talk to teachers or health professionals. www.sexetc.org is actually a website created by teens where they can discuss everything from sex to alcohol to violence.

I've only seen a few sexually related complaints in preceptorships, but I've had good luck with making clear a desire to fix the problem straight from the outset. That often makes it a bit easier to gather the needed information as you go along... odds are that they want the problem fixed, too.

Teenagers get plenty of the statistics and platitudes in health class and are often disinterested or put off by hearing more of them. Personally, I have found it better to demonstrate genuine concern about them, and about the direct tangible consequences of risky behavior. That tends to hit a bit closer to home.

I was reminded today of how patients sometimes "fall into" sexual encounters, that perhaps they did not intend to experience. My first patient today was a man who started off very haltingly, explaining that he was embarrassed by what had happened. He was studying with a female friend, and the study date had led to sex. He had used a condom, but the condom had broken. A few days later, he was experiencing dysuria. On exam, he had a thin, clear penile discharge. I diagnosed him with urethritis, likely Chlamydia, and treated him with a 7-day course of Doxycycline, with tests pending on the discharge for Chlamydia and Gonorrhea. He was given a handout on Chlamydia and a contact card to give to his partner. I gave him some verbal educational information, similar to that we have discussed above. He also accepted some condoms from a container we have in our exam rooms. I was reminded how easy it is for our patients to contract a sexually transmitted infection (STI), and hoped that this patient would not return later with another STI, especially one that was not so straight forward in its treatment and eradication as Chlamydia.

''Should parents be more involved in their children's sexual health? After all, parental consent for minors is needed for every other medical procedure I can think of, from a visit to the doctor's office for a common cold to surgery.''

I believe parents play a very important role in a child's understanding of health care. If a child grows up seeing a parent going to a physician and openly/honestly talking about their health problems then this provides a framework for them to build onto in the future. When a STD or other sensitive issue arises these children or adolescents may feel more comfortable discussing these private problems with a physician. More importantly, if a child has a good relationship with a physician then there is higher chance of avoiding these problems in the first place. I feel that doctors must emphasize (especially with minors and/or teenagers) the boundaries of confidentiality so they feel comfortable with these topics. The worse case scenario is for teenagers to have an STD and have no where to turn and thus must suffer physical discomfort and continue to spread the disease. Thus, parents are the catalyst for a good STD prevention program for their children.

Recommended Resources
http://www.agi-usa.org/pubs/ib_2-01.html
 * Alan Guttmacher Institute - Sex Education: Politicians, Parents, Teachers and Teens:

Adolescents' Reports of Parental Knowledge of Adolescents' Use of Sexual Health Services and Their Reactions to Mandated Parental Notification for Prescription Contraception: http://jama.ama-assn.org/cgi/content/abstract/293/3/340
 * Journal of the American Medical Association--

http://www.sexetc.org

Links to Cases
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