Comprehensive sexual health assessments for adolescents

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Setting the stage for a conversation about sexual health

Health care providers (HCPs) are uniquely positioned to provide education for adolescents they see in practice and help improve their sexual and reproductive health (SRH). Adolescents are unlikely to reveal SRH concerns without prompting and may not seek care unless confidentiality is assured ^[1]-[5]. The U.S. Centers for Disease Control and Prevention (CDC’s) framework for SRH has been adapted here to ‘7 Ps’: an approach to assessment covering the following topics: Partners, Practices, Protection from sexually transmitted infections (STIs), Past history of STIs, Prevention of pregnancy, Permission (consent), and Personal (gender) identity ^[6]. SRH is an essential component of care for all adolescents, including those with developmental disabilities and chronic health conditions, who may be as sexually experienced as their peers ^[7][8].

Canadian data suggest that roughly 30% of adolescents aged 15 to 17 years have had penile-vaginal sex at least once (Figure 1). While only 10% of males and 8% of females report first genital intercourse occurring before age 15 years ^[9][10], adolescents may engage in sexual activities apart from penile-vaginal intercourse, such as masturbation, digital sex, oral sex, and anal intercourse (Figure 2) ^[11]. Also, expressed sexual attraction may not always align with a person’s sexual practices. For this reason, asking questions about specific types of sexual behaviours, regardless of orientation, enables HCPs to offer anticipatory guidance and screening.

Pregnancy

The timing of last menstrual period (LMP) must be assessed for all sexually active teens. A pregnancy test should be offered when LMP precedes a health encounter by more than 4 weeks or when the teen seems unsure of the date. When a pregnancy test is positive, HCPs should counsel on options or refer to a clinician who can offer timely counselling. For teens who are wishing to avoid pregnancy, contraceptive needs should be discussed. In addition to consistent condom use, recommended methods of birth control are discussed in this CPS statement: Contraceptive care for Canadian youth ^[12]. Consider supplying latex condoms in your clinical space at no cost.

For teens who are ambivalent about contraception or considering pregnancy, a multivitamin containing folic acid should be recommended. Also, optimal immunization with measles-mumps-rubella (MMR), varicella, and hepatitis B vaccines should be ensured. Two CPS documents, Meeting the needs of adolescent parents and their children and Adolescent pregnancy, are helpful resources for HCPs protecting teen pregnancies.

LGBTQ+ youth

LGBTQ+ youth include those who identify as lesbian, gay, bisexual, transgender, two-spirit, queer, questioning, intersex, or non-binary. LGBTQ+ youth are at increased risk for adverse health issues, such as STI acquisition, bullying, depression, anxiety, low self-esteem, substance use, suicide attempts, and insecure housing ^[13][14]. Transgender individuals have increased rates of suicidal ideation and suicide attempts compared with cisgender individuals (those whose gender identity matches their sex assigned at birth) ^[15]. Parental support of sexual orientation and gender identity as well as timely access to gender-affirming treatments are important protective factors ^[16][17]. Numerous barriers exist for LGBTQ+ youth to access health care ^[18]. Offering an inclusive, open, and welcoming space where no-one makes assumptions about identities, attractions, or sexual behaviours is an important component of care.

STIs

STIs can be transmitted via digital, oral, genital, or anal sexual contact. Adolescents are a high-risk group for STIs, both for biological and behavioural reasons ^[19]-[25]. Risk factors are numerous (Table 1). Knowledge of local epidemiology patterns will inform screening practice recommendations. Refer to the Public Health Agency of Canada (PHAC) for Canadian data ^[19].

Table 1. Risk factors for STIs
Any sexually active youth < 25 years old
Inconsistent or no condom use Sexual contact with someone known to have STI New partner >2 partners in past year Serial monogamy No contraception or only non-barrier contraception (e.g. oral contraceptive, intrauterine device, or Depo Provera) Injection drug use Any drug use (e.g., alcohol, marijuana, others – esp. if associated with sex) Previous STI	Any unsafe sexual practices (e.g., involving exchange of blood or sharing sex toys) Sex workers and their clients Survival sex (e.g., exchange of sex for food, shelter, or drugs) Street involvement/precarious housing Anonymous sex (sex with a stranger after meeting online or elsewhere) Experience of sexual assault or abuse
Adapted from reference [19]

STIs (including chlamydia and gonorrhea) are often asymptomatic. Asymptomatic teens can readily believe themselves to be uninfected. Other infections that can affect teens without symptoms, or where primary symptoms are easily or often missed, include human papillomavirus (HPV), syphilis, human immunodeficiency virus (HIV), hepatitis, and genital herpes. When they are symptomatic, STIs can present in non-specific ways, as conjunctivitis, rash, dysuria, inguinal adenopathy, ulcer, vaginal or urethral discharge, prostatitis, or with anal or pharyngeal symptoms. In sexually active females or trans males, irregular vaginal bleeding or undifferentiated abdominal pain may be the presenting symptom.

Complications of untreated STIs include pelvic inflammatory disease, prostatitis, chronic pelvic pain, infertility, and effects on a developing fetus or neonate. ALL sexually active youth under 25 years of age should be offered annual screening (Table 2). Additional risk factors (e.g., the mention of a new partner) should increase frequency of screening. For immunodeficient or symptomatic adolescents, additional testing is recommended ^[19]. Clinicians should remember to screen for STIs even though Pap testing and routine pelvic exams are no longer recommended for sexually active teens ^[26]. Routine screening has been facilitated by new technologies, such as nucleic acid amplification tests (NAATs) on urine for any sexually active teen, and self-collected vaginal swabs (see Diagnosis and management of sexually transmitted infections in adolescents ) ^[27].

HIV pre-exposure prophylaxis (PrEP) is an intervention that reduces HIV transmission in high-risk populations. PrEP involves prescribing long-term, daily antiretroviral medication for individuals before they become exposed to HIV, to reduce risk of acquisition ^[28]. HIV post-exposure prophylaxis (PEP) involves taking antiretroviral medication to prevent HIV seroconversion after high-risk exposure has occurred. Treatment decisions regarding use of PEP and PrEP and HIV treatment must be made collaboratively, in consultation with an infectious disease specialist in HIV or a health care team with expertise ^[21].

Table 2. Recommended STI screening for asymptomatic immunocompetent youth
Specimens	Testing	Population to test
First catch urine* (*refers to first part of urinary stream) OR Urethral or cervical swab OR Vaginal swab (may be self-collected)	NAAT for: Chalmydia trachomatis AND Neisseria Gonorrhoeae (NG)	All sexually active youth<25 years
Pharyngeal swab	Culture for Chlamydia and NG   (and/or NAAT if available in local lab)	Those who have performed oral sex
Anal swab   Insert swab 2 to 3 cm into the anal canal, press laterally to sample epithelium. If visible fecal contamination, discard the swab and obtain another	Culture for Chlamydia  and NG (and/or NAAT if available in local lab)	Those who report anal receptive intercourse (including MSM)
Serology	Syphilis serology HIV serology	All sexually active youth
Consider serology	Hepatitis B Hepatitis A Hepatitic C	All sexually active youth <25 years with no or uncertain vaccination history   Particularly if oral/anal contact   If personal or partner history of IV drug use
Cervix Papanicolaou (Pap) smear	Liquid-based cytology	Varied age of initiation per provincial/territorial guidelines – not before age 21 years (applies to females as well as trans males with intact cervixes)

 

• STI screening should be conducted with informed consent. A special consent form for HIV testing is not necessary. The PHAC recommends against using “cumbersome forms” that may be a barrier to testing.   • Screening for HIV and syphilis should be done using an “opt-out” approach prefaced by the following: “Urine and blood testing are part of the routine screening that we offer to all sexually active teens. Even though the risk of HIV and syphilis may be low, treatments are available, and so it is important to identify infections that may be there even without symptoms. Is this ok with you?”

The HCP offering screening should inform the teen that they may be contacted by public health in the event of a positive screen, communicate positive STI results promptly, and provide treatment to the patient, and to partners when possible.

The HCP should also review immunization history to ensure that teens with an STI are up-to-date for the following vaccines: HPV, hepatitis A and B (for men having sex with men (MSM) and others having anal sex), varicella, and MMR (for pregnancy implications). They must arrange for catch-up vaccines or doses when needed.

While no barrier method is 100% effective against STI transmission, latex condoms offer the best protection available for sexually active youth. Spermicide-coated condoms can promote STI transmission and should be avoided. For teens with latex allergy, polyurethane or polyisoprene condoms should be recommended despite increased likelihood of breakage ^[29]. Dental dams (latex or polyurethane sheets) can reduce STI transmission between mouth and vagina or anus.

Sexual consent laws and other legal considerations

In 2008, Canadian legislation increased the age of consent for non-exploitative sexual activity to 16 years of age. There are “close in age” exceptions to the law (Table 3) ^[30][31]. Discussion with your local Child Protection Agency (CPA) is recommended when there is a concern or advice is needed.

Early age of initiation of sexual activity should prompt HCPs to consider sexual abuse or assault. Clinicians have a duty to report suspected sexual abuse or exploitation of children (although reporting age varies among provinces/territories).

Sexting is another issue with possible legal implications that should be addressed with youth. Teens can be convicted for possessing and distributing child pornography, even when the picture they are sending is of themselves ^[32].

Table 3. Age of consent for sexual activity in Canada
Under 12 years	12 to 13 years	14 to 15 years	16 years	Under 18 years
Cannot consent to any sexual activity	Can consent to non-exploitative sex as long as age difference does not exceed 2 years	Can consent to non-exploitative sex as long as age difference does not exceed 5 years	Can consent to non-exploitative sex	Cannot consent to exploitative sex, e.g.: Pornography Prostitution Sex with a person in a position of trust or authority

Teen dating violence

Teen dating violence (TDV) is “physical, sexual, psychological, or emotional violence within a dating relationship, including stalking”. TDV can occur in-person or electronically, and might involve a current or former dating partner ^[33]. One U.S. study reported 21% of dating females and 10% of dating males as having experienced TDV ^[34]. TDV is associated with depression, anxiety, substance use, antisocial behaviours, suicidal ideation, and higher risk for TDV later in life. Intoxication with substances (alcohol in particular) is associated with sexual assault ^[35]. Consider referral to local crisis or sexual assault team in cases of TDV.

Summary

SRH is an essential component of care for all adolescents (Table 4). Using a ‘7 Ps’ approach to ensure comprehensive sexual health assessment is recommended. Creating a positive and inclusive space will welcome ALL youth, including those who are members of the LGBTQ+ community. All sexually active youth younger than age 25 should be screened annually for STIs. Comprehensive sexual health visits can improve the overall health of adolescents. HCPs should routinely initiate discussions about SRH, dispel myths, address contraceptive needs, offer STI screening and treatment, screen for safe relationships, and administer relevant vaccines.

Table 4. Overview of comprehensive sexual and reproductive health assessment

Inclusive, welcoming space (no assumptions)

Confidentiality (and limits) reviewed with teen

‘7 Ps’ approach to sexual and reproductive health * Partners Practices Protection from STIs Past history of STIs Prevention of pregnancy Permission (consent) Personal identity (gender identity)

Consider pregnancy test when LMP is more than 4 weeks earlier Options counselling in the event of positive test

STI screen for all sexually active youth younger than 25 years (Table 2) At least annually – more often when risk factors for STIs are present (Table 1)

Recommend condom use to all sexually active youth Preferably latex, without spermicide Polyurethane or polyisoprene condoms in cases of latex-allergy (consider having a supply to offer at no cost in your clinical space)

Discuss contraceptive options

Review indications for emergency contraception (consider having some types freely accessible in your clinical space)

Ensure relevant vaccines are up-to-date (HPV, hepatitis A and B, varicella, MMR)

Consider PEP or PrEP in consultation with an expert in HIV prophylaxis and treatment If risk for HIV transmission is high If risk for hep B transmission is high and a teen is unvaccinated or  non-immune

Be aware of sexual consent laws (Table 3) Consult with your local child protective agencies, as necessary

Assess relationship safety Consent, teen dating violence, sexting

Arrange follow-up When STI screen test is positive, advise teens that they may be contacted by Public Health In the event of a positive screen, treat patient and partner(s)

HIV human immunodeficiency virus; HPV human papillomavirus LMP last menstrual period; MMR measles mumps rubella; PEP post-exposure prophylaxis; PrEP pre-exposure prophylaxis; STI Sexually transmitted infection

*The ‘7 Ps’ have been adapted from reference [6]

Recommended resources

• STI Canada App
• www.sexandu.ca 
• IUC Expert App
• Safer sex resource for teens: https://www.optionsforsexualhealth.org/sexual-health/sexually-transmitted-infections/safer-sex-tips

Acknowledgements

This practice point has been reviewed by the Community Paediatrics and Infectious Diseases and Immunization Committees of the Canadian Paediatric Society.

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CANADIAN PAEDIATRIC SOCIETY ADOLESCENT HEALTH COMMITTEE
Members: Holly Agostino MD, Marian Coret MD (Resident Member), Karen Leis MD (Board Representative), Alene Toulany MD, Ashley Vandermorris MD, Ellie Vyver MD (Chair)
Liaisons: Megan Harrison MD (CPS Adolescent Health Section)
Principal author: Natasha Johnson MD

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.