The sexual health assessment: getting the basics right
GP’s rooms that are adolescent friendly can help young people feel more comfortable. One way to do this is simply by displaying health education posters and pamphlets that are relevant to them. It may help to find out when young people are likely to use the clinic, such as on the way to school or university, and make convenient appointment times available to them.
A young person will better engage if the GP uses open, clear communication, avoids medical jargon and uses common day-to-day language. GPs could make it routine to see adolescents and young people initially with parents or guardians present and then tactfully ask to see the young person alone. Practice helps, so if this is done for less-confronting consultations such as sore throats it will begin to feel natural to the doctor and the patient.
How confidentiality applies in this context should be established early on, including the limitations to confidentiality. Young people are often particularly concerned that their parents will be told about the consultation. It is worth addressing this concern directly (a more detailed discussion of ‘Gillick competence’ can be found below).
Preparing an example of what to say and practising so that it comes naturally and in a nonconfronting manner is helpful. An example of what to say is: ‘Everything that we talk about here today is confidential, that means that I won’t speak to anyone else, like your parents, about the stuff we talk about unless you want me to. There are two exceptions to that rule. Firstly, if I think that you are at risk of hurting yourself; or secondly, if I think there is a risk that you will hurt someone else. Even if I do have to tell another person about what we’ve talked about, I’ll always talk to you first and try to come up with a plan that we are both happy with. Is that ok?’
Phrase questions carefully
Bridging questions can be helpful. For example, the more general lifestyle questions in the HEEADSSS assessment could be used first. Box 1 provides some suggested ways of introducing questions about sexual health. When moving on to sexual history, first ask the less confronting questions, such as ‘How long have you been sexually active for?’. Normalise without making assumptions, using questions such as ‘Are you seeing anyone at the moment?’, ‘Are you sexually active with this person?’, ‘Is this the only person you are seeing at the moment?’.
Try to establish the young person’s sexual orientation. We advise keeping this question simple, such as: ‘Do you have sex with men or women or both?’ Keep in mind that some young people may be feeling confused, embarrassed or guilty about their sexuality. It is best never to assume you have correctly identified a young patient’s sexuality. An innocent question such as ‘So, do you have a girlfriend?’ asked of a young man who is attracted to men may make it difficult to establish an effective relationship. Further, it is helpful to avoid the assumption that everyone means the same thing by ‘sex’. We recommend keeping terminology open, such as ‘any form of sexual contact’, as some people may consider oral sex or mutual masturbation to be sex.
When and how often to talk about sex
The realities of a busy general practice preclude undertaking sexual health risk assessments with all adolescents and young people at each consultation. It is, however, a must for patients presenting for contraceptive needs, STI screening, urogynaecological problems and mental health problems. Travel consultations may also be opportune times to raise the issue of sexual risk-taking behaviour.
In a busy clinic setting it is useful to be able to refer patients to reliable, youth-friendly and informative websites. A list of resources that could be recommended to a young person can be found in Box 2.