Published onChildren's Doctor
Case: “Jessica” is a bright 16-year-old high school freshman. She and her dad presented to our office in West Philadelphia for a copy of her immunization records. Our team noted that Jessica was overdue for a well visit and saw I had an open slot. The family willingly accepted the appointment, turning their five minute encounter with us for records into a more comprehensive holistic preventive care visit.
While Jessica is an extremely motivated high school student who wants to go to college, she had many concerns to share: chronic abdominal pain, loneliness, despair during the pandemic, and significant family disruption. After completing her depression screen, Jessica shared that her positive symptoms centered on her tenuous relationship with her mother, who had “kicked her out of the house” three months ago. Jessica reported on her tablet-based adolescent wellness screen that she has relationships with both men and women and identifies as bisexual.
Because of her plans for the future, she also discussed wanting to start a contraceptive method and her fear of sexually transmitted infections. Her physical symptoms were vague headaches, abdominal pain, increased cramping with her menstrual cycle, and light vaginal discharge.
Discussion: We screened Jessica for all sexually transmitted infections (STIs), including a urine NAAT assay for gonorrhea, chlamydia, and trichomonas, and blood for HIV and RPR (syphilis) studies. A urine pregnancy test was negative.
Results showed her urine NAAT test was positive for chlamydia; all others were negative. We had consented Jessica for texting lab results, which helped us schedule her for in-office treatment. Her symptoms resolved, and she was referred for long-acting, reversible contraception, as well as provided condoms for safer sex.
Health disparities are used to measure progress toward health equity. Health disparities are potentially avoidable when attention is paid to systematic health differences that negatively affect socially disadvantaged groups, such as people who are and have been historically marginalized, excluded, disenfranchised, and/or discriminated against.
Sexually transmitted infections soar
According to a groundbreaking report released April 2021 by Centers for Disease Control and Prevention, there has been a 30% increase in reportable STIs from 2015 to 2019. The burden of STIs in the United States is also unequal with systemic racial and ethnic disparities (see table 1).
Table 1. Disparities in STI rates 2015-2019:
- Rates of African American or Black people were 5 to 8 times that of non-Hispanic white people
- Rates of American Indian or Alaska Native and Native Hawaiian or other Paciﬁc Islander people were 3 to 5 times that of non-Hispanic white people
- Rates of Hispanic or Latino people were 1 to 2 times that of non-Hispanic white people
Source: Reported STDs Reach All-time High for 6th Consecutive Year. Centers for Disease Control and Prevention website. Accessed May 5, 2021.
About half of all new STIs reported each year occur among individuals age 15 to 24. Despite the availability of treatment, adolescents’ sexual health needs often go unrecognized because of a reluctance to discuss them with a healthcare provider or lack of awareness that they need screening. Currently, the American Academy of Pediatrics, the U.S. Preventative Services Task Force, and the American College of Obstetrics and Gynecology all recommend annual chlamydia screening of sexually active young women; however compliance with this recommendation is low. Sexual healthcare is just as important as a physical exam or vaccination, so incorporating it into standard procedure for a well-visit is a logical step to promote adolescent health.
The COVID-19 pandemic has caused a worrisome disruption in adolescent health services. While young babies were prioritized for visits due to the tight vaccine schedule, many teens missed out on routine and urgent healthcare. A CHOP PolicyLab study found that the months immediately after the pandemic began, there was a dramatic reduction in the number of STI tests that were being performed. As testing numbers fell, the proportion of tests indicating positive STI results began to rise. For example: Comparing May 2019 to May 2020, positivity rates for chlamydia doubled early in the pandemic.
What can we learn from Jessica?
Many pediatricians feel uncomfortable discussing sex, sexuality, and gender with their patients. This is especially concerning when combined with 2 other forces: pre-existing and worsening disparities in routine access to healthcare for Black and Latinx teens, and worrisome disparities in positive STI testing rates for adolescents of color.
We need to measure disparities in adolescent well visits by race/ ethnicity, insurance type, language spoken, and age. Pediatricians should consider outreach campaigns to reach populations least likely to have received preventive care in the past year. We should also:
- Create a culture of compassion and active listening to your teen patients and their families.
- Ensure complete confidentiality and space to listen to your teens alone, bringing in family members only when and if the teen feels comfortable sharing.
- Implicit bias and racial discrimination may lead healthcare providers to screen women of color for STIs more often than other groups. Consider universal screening testing for sexually transmitted infections for all teens 15 and older, especially asymptomatic females, to reduce bias. Keep in mind that teens may not feel comfortable disclosing their sexual orientation, sexual history, and risk factors to you. Research tells us teens feel more comfortable disclosing sensitive information in tablet-based, nonverbal feedback.
- Screen all teenagers 12 and older for depression. Create a welcoming, nonthreatening environment where teens can feel safe sharing their mental health struggles. A landmark study in Pediatrics demonstrates that lesbian, gay, bisexual, transgender, gender nonconforming, and questioning (LGBTQ) adolescents and adults show elevated rates of depression and suicidality. By being open, active listeners to teens who may be hesitant to disclose their sexuality to other adults/caregivers, pediatricians can help teens achieve better overall health.
References and further readings
STIs Among Youth During COVID-19 May Be the Tip of the Iceberg. PolicyLab website. Accessed May 5, 2021.
Baams, L. Disparities for LGBTQ and gender nonconforming adolescents. Pediatrics. 2018;141(5);e20173004.
Categories: Children's Doctor Summer 2021