The Adolescent
Case 5.6 Sexual Identity
156 The Adolescent
OBJECTIVE
General: Alert, oriented, quiet; in no apparent distress.
Vital s igns: Temperature: 98.6F — oral; BP: 118/78 left arm sitting; HR: 68 beats per minute; RR: 18;
height: 72 inches; weight: 185 pounds, BMI: 25.1.
HEENT : Head: Normocephalic/atraumatic (NC/AT); hair intact; no alopecia. Eyes: PERRLA; equal ocular movement (EOM) intact; sclera white; conjunctiva clear and noninjected; no ocular discharge.
Ears: Tympanic membrane (TM) pearly grey; landmarks visible bilaterally; no effusion, perforation, or bulging noted. Nose: Nares patent, septum midline, no rhinorrhea or epistaxis. Mouth/Throat:
Clear, no erythema or exudates; good dentition.
Neck: Supple; full range of motion (FROM); no cervical lymphadenopathy.
Cardiac: RRR; S1 and S2 audible; no murmur, rub, or gallop.
Respiratory: Symmetrical; good air exchange; no abnormal breath sounds, clear to auscultation bilaterally (CTAB).
Abdomen: Normoactive bowel sounds × 4; soft, nontender/nondistended (NT/ND); no hepato- splenomegaly; + femoral pulses.
Back: Spine straight; isolevel scapula and hips.
Genitourinary: Normal circumcised male genitalia; testes descended bilaterally; no masses or pain;
Tanner V genitalia/pubic hair; no discharge noted; no hernia present. Anus patent; no lesion; hemor- rhoid, or anal fi ssure.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Urinalysis ___Urine culture ___HIV
___Venereal Disease Research Laboratory (VDRL) ___GC/Chlamydia test through urine or urethra ___Wet mount
___Herpes virus (HSV)
Which differential diagnoses should be considered at this point?
___Urinary tract infection ___Urethritis
___Phimosis
___Sexually transmitted infection (STI)
What problems would you want to address today, and why?
___Dysuria ___Sexual identity ___Medications ___STI screening ___Vaccines
___That he came here alone
Sexual Identity 157
What question(s) would be appropriate to ask in order to address the patient ’ s sexual orientation in the most respectful way possible?
Are any referrals needed?
What if Samuel stated that he is feeling depressed and thinking of “ ending it all ” ?
RESOLUTION
Diagnostic t esting: A urinalysis, using either dipstick or laboratory testing, should be performed to check for a urinary tract infection. Obtain a urine culture and sensitivity if the urinalysis is positive for infection. Obtain an HIV test and explain about options of HIV testing. Explain that testing is anonymous or confi dential. A VDRL is necessary to check for syphilis. Urine testing or a urethral probe can be used to test for GC/Chlamydia. A wet mount should be obtained to check for causes of dysuria. Check for HSV if there is a concern about genital herpes infection.
What problems would you want to address today, and why?
1. Dysuria — You should determine the underlying cause of dysuria as it might be due to conditions such as urinary tract infection, urethritis, phimosis, penile condyloma, herpes simplex virus infec- tion, or contact dermatitis.
2. Sexual identity — Samuel ’ s “ like this ” comment is worth exploring. Discuss sexuality and prefer- ences in a nonjudgmental manner. Offer support and assess whether he feels safe at home or at school. Offer screening for depression, anxiety, and safety as they are immensely important issues in adolescents with sexual identity problems.
3. Screening for STIs — Samuel is currently sexually active with a same - sex partner, possibly more than one partner. He should be screened for sexually transmitted infections.
4. Medications — Samuel is currently on (Methylphenidate 10 mg by mouth every day for ADHD and Escitalopram 10 mg by mouth every day). Ask why he is on these medications, who pre- scribed the medications, and how long he has been on them.
5. HPV vaccine — In October 2009, the Food and Drug Administration approved the use of the quadrivalent vaccine in boys and men aged 9 – 26 years for the prevention of genital warts.
Subsequently, the Advisory Committee on Immunization Practices (Centers for Disease Control and Prevention [CDC], 2010 ) supported the permissive use of the quadrivalent vaccine for this indication and recommended that funding be provided for this purpose through the Vaccines for Children program. Among men having sex with men (MSM) and immunosuppressed men and women, anal HPV infection leads to a high disease burden of warts, AIN, and anal cancer. Male vaccination against HPV has the potential to lead to a substantial reduction in the burden of these diseases, therefore quadrivalent HPV vaccine is recommended. (Palefsky, 2010 ).
What question(s) would be appropriate to ask in order to address the patient ’ s sexual orientation in the most respectful way possible?
Interviewing an adolescent is a process that requires interest and patience from the health care pro- vider. The interview with an adolescent is important, because it not only allows a provider to collect information, but it also sets the tone for future interactions (Woods & Neinstein, 2008 ). The confi den- tiality agreement and reasons why confi dentiality would need to be broken (abuse, suicide, homicide) should be explained to the adolescent at the fi rst visit and as necessary.
Establishing rapport with an adolescent patient is vital, yet it is perhaps one of the most diffi cult parts of the visit. Woods and Neinstein (2008) suggest the following:
1. Always introduce yourself. Tell the adolescent your role and your agenda for this particular visit.
Shaking the hand of the adolescent is recommended as it may help ease their anxiety as well as acknowledge that they are the center of the attention in the room at the present time.
158 The Adolescent
2. Explain the “ confi dentiality agreement ” and inform the adolescent of when it may be broken. A confi dentiality contract is an agreement that commits you to keeping your conversation private, unless the adolescent is at risk of harming him/herself or others. The key to a successful examina- tion is to establish a sense of confi dentiality with the adolescent and honoring it. Emphasize that when there are concerns regarding their safety, you are to share this information to their parents.
3. Start the conversation with easy topics such as things he/she enjoys doing and some general conversational topics. This will enable you to gain insights into the adolescent ’ s personality and mood.
4. Give him/her a chance to talk and voice their opinions.
5. Always treat the adolescent ’ s comments respectfully and seriously. It is important to keep in mind that you should be treating him/her as an adult. The adolescent will appreciate it and it will help to ease his/her anxiety during the visit.
Go further and ask about issues that concern the adolescent. Listening is vital to developing a rapport with an adolescent. Remember always to stay focused on what the adolescent is telling you and to try to understand the adolescent ’ s perspective. As with any routine visits with an adolescent, be sure to emphasize the importance of safe sex practices. Tell patient to always use condoms. Assess the patient ’ s knowledge of STIs, how to prevent them from acquiring and transmitting them, and how to seek help should they become infected with one.
What question(s) would be appropriate to address the patient ’ s sexual orientation in the most respectful way possible?
• “ Tell me about your friends! ”
• “ Are you in a relationship, or do you like one person in particular? ” • “ Is your special friend a boy, a girl, or both? ”
• “ Are you sexually active? ”
• “ How old were you when you had your very fi rst sexual encounter? ” • “ Are you involved with another individual in a sexual relationship? ” • “ How many partners have you had sex with? ”
• “ Do you always have protected sex? ”
• “ What do you know about sexually transmitted infection s ( STI s)? ” • “ How do you keep yourself free from STIs? ”
• “ Have you ever been tested for an STI? ” Are any referrals needed?
Lesbian, gay, bisexual, and transgender adolescents may face adverse medical consequences due to physical and psychological changes in lifestyle and risky sexual behaviors. Most sexually transmitted infections are due to unprotected sexual contact. During receptive anal intercourse, the already fragile rectal mucosa is easily damaged causing transmission of pathogens (Meininger & Remafedi, 2008 ).
Referrals may not be necessary at this time. However, a referral to a mental health professional may be warranted if you suspect the patient is feeling depressed, fears for his safety, or is having suicidal thoughts or ideation. Make sure to assess if the patient has a support system (namely adult supports in the family) and has access to a lesbian, gay, bisexual, transgender ( LGBT ) group in school or in the community from where he can seek information and help.
What if Samuel stated that he is feeling depressed and thinking of “ ending it all ” ?
Always treat suicidal thoughts or ideation seriously. Kennebeck (2010) suggests that the fi rst step is to fi nd out if he is in danger of acting on his suicidal thoughts. Ask direct, but sensitive questions such as:
• “ Are you thinking about hurting yourself?
• “ Are you thinking about committing a suicide? ” • “ Have you thought about how you would do it? ” • “ Do you have the means to do it? ”
• “ When would you do it? ”
Sexual Identity 159
Secondly, always be on the lookout for common signs throughout your interaction with the patient.
The following may be signs if one is considering suicide (Sherer, 2008 ).
• Making suicidal remarks such as “ I just want to end it all, ” or “ I wish I were dead. ” • Being preoccupied with death and dying.
• Abuse of alcohol and illicit drugs
• Change in normal routine or social interaction and being completely out of one ’ s normal character.
• Giving away belongings
• Saying goodbye to people as if he/she was going away for a long time.
If you believe that the patient is at risk of suicide, never leave the patient alone and be sure to seek emergency help by dialing 911 so that the patient can be taken to the hospital emergency room in a prompt manner, as this patient may need to be hospitalized until the suicidal crisis has passed. You will also be required to notify a family member or close friend regarding the matter.
If you believe the patient is not in immediate danger, always offer your support. Encourage the patient to seek treatment, as patients with severe depression or who have suicidal thoughts may not have the courage to seek help on their own. Encourage the patient to communicate with you to express their feelings. Be supportive, respectful, and understanding and express your opinions without placing blame or being judgmental.
REFERENCES AND RESOURCES
Centers for Disease Control and Prevention ( 2010 ). FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP) . MMWR Morbidity and Mortality Weekly Report , 59 , 630 – 632 .
Kennebeck , S. , & Bonin , L. ( 2008 ). Evaluation and management of suicidal behavior in children and adolescents . UpToDate. Retrieved from http://www.uptodateonline.com
Meininger , E. , & Remafedi , G. ( 2008 ). Gay, lesbian, and transgender adolescents . In Neinstein et al. (Ed.), Adolescent health care: a practical guide ( 5th ed. ). Philadelphia, PA : Lippincott Williams & Wilkins .
Palefsky , J. M. ( 2010 ). Human papillomavirus - related disease in men: Not just a women ’ s issue . Journal of Adolescent Health , 46 , 555 – 564 , 614 .
Sherer , S. ( 2008 ). Suicide . In Neinstein et al. (Ed.), Adolescent health care: A practical guide ( 5th ed. ). pp. 555 – 564 . Philadelphia, PA : Lippincott Williams & Wilkins .
UpToDate . Evaluation and management of suicidal behavior in children and adolescents . http://www.uptodate.
com/contents/evaluation-and-management-of-suicidal-behavior-in-children-and-adolescents?source=
preview&selectedTitle=6%7E150&anchor=H3#H3
Woods , E. R. , & Neinstein , L. S. ( 2008 ). Offi ce visit, interview techniques, and recommendations to parents . In Neinstein et al. (Ed.), Adolescent health care: A practical guide ( 5th ed. ). pp. 33 – 43 . Philadelphia, PA : Lippincott Williams & Wilkins .