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Sexual and Reproductive Health Care: A Position Paper of the Society for Adolescent Health and Medicine

  • The Society for Adolescent Health and Medicine

      Background

      Guiding framework

      Sexual and reproductive health (SRH) is an important aspect of normal adolescent growth and development that encompasses biological sex, gender roles and identity, sexual orientation, sexual behavior, and reproduction [

      ICPD Programme of Action Summary. International Conference on Population and Development Cairo, Egypt: United Nations Department of Public Information; DPI/1618/POP–March 1995. Available at: http://www.unfpa.org/public/cache/offonce/home/sitemap/icpd/International-Conference-on-Population-and-Development/ICPD-Summary. Accessed December 5, 2013., 1994.

      ,

      World Health Organization. Defining sexual health: Report of a technical consultation on sexual health, 28–31 January 2002, Geneva. Geneva, Switzerland: WHO Press. Available at: http://www.who.int/reproductivehealth/publications/sexual_health/defining_sh/en/index.html. Accessed November 25, 2013.

      ]. Achieving healthy adolescent sexual development involves managing the many physical, social, and emotional changes experienced during adolescence. Medically accurate and developmentally appropriate SRH education and barrier-free access to related clinical services [
      • World Health Organization
      Preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries.
      ] contribute to successful navigation of this developmental task. In recognition of this important fact, the United Nations declared that comprehensive sexual health information and services constitute a basic right for adolescents as articulated in the United Nations Convention on the Rights of the Child [
      • Committee on the Rights of the Child
      United Nations Convention of the Rights of the Child. General comment No 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (art. 24).
      ]. To support the adolescent's right to the highest attainable standard of health, the Convention specifically identifies “the right to control one's health and body, including sexual and reproductive freedom to make responsible choices,” and this right is achieved through “access to a range of facilities, goods, services and conditions that provide equality of opportunity for every child.” Sociocultural context, laws, policies, and economics, however, affect access to these basic rights.

      Stating the problem

      Young people require access to a wide range of SRH education and clinical services to promote positive sexual development [
      • Schalet A.T.
      Beyond abstinence and risk: A new paradigm for adolescent sexual health.
      ] and reduce adverse social, economic, and health consequences of sexual behaviors [
      • Kirby D.
      Emerging answers: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases.
      ,
      • Manlove J.
      • Romano-Papillo A.
      • Ikramullah E.
      Not yet (programs to delay first sex among teens).
      ,
      • Susheela Singh S.
      • Darroch E.
      Adding it up: Costs and benefits of contraceptive services—estimates for 2012. Guttmacher Institute.
      ]. Compared with all other age groups, adolescents and young adults experience disproportionately high rates of preventable sexual behavior morbidities including sexually transmitted infections (STIs), human immunodeficiency virus (HIV), and unintended pregnancy [
      • Finer L.B.
      • Zolna M.R.
      Unintended pregnancy in the United States: Incidence and disparities, 2006.
      ,

      United Nations. Economic and social council. Commission on population and development. Adolescents and youth: Report of the Secretary-General. E/CN.9/2012/2. Available at: http://www.youthcoalition.org/attachs/SG%20Report_Adolescent%20and%20Youth.pdf. Accessed December 5, 2013.

      ]. In addition, youth who do not conform to sociocultural norms of sexual and gender expression often do not have access to SRH services that are tailored to their needs [
      • Grossman A.H.
      • D'Augelli A.R.
      Transgender youth: Invisible and vulnerable.
      ,
      • Allen L.B.
      • Glicken A.D.
      • Beach R.K.
      • et al.
      Adolescent health care experience of gay, lesbian, and bisexual young adults.
      ].

      Positions and Recommendations

      The Society for Adolescent Health and Medicine recognizes that it is critical to address the SRH needs of young people from both a health and a human rights perspective and proposes the following positions and recommendations to improve the health of adolescent and young adult populations. These positions relate to the areas of the Society for Adolescent Health and Medicine mission.
      • 1.
        Adolescents should have universal access to comprehensive SRH information and services that are evidence based, confidential, developmentally appropriate, and culturally sensitive.
      Comprehensive sexuality education programs in schools and communities have been found to improve academic performance, delay and reduce frequency of sexual intercourse, reduce number of sexual partners, increase use of condoms and other forms of contraception, and reduce negative health consequences (e.g., unintended pregnancy and STIs) [
      • Alford S.
      • Bridges E.
      • Gonzalez T.
      • et al.
      Science and success: Sex education and other programs that work to prevent teen pregnancy, HIV, and sexually transmitted infections.
      ,

      Guide to Community Preventive Services. Sexual behavior: Youth development behavioral interventions coordinated with community service to reduce sexual risk behaviors in adolescents. Last updated: Feb 2008. Available at: www.thecommunityguide.org/hiv/youthdev-community.html. Accessed December 5, 2013.

      ,
      • Kohler P.K.
      • Manhart L.E.
      • Lafferty W.E.
      Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy.
      ]. Access to services in school-based health care centers has been shown to increase SRH services and contraception use [

      Future of Sex Education. National sexuality education standards: Core content and skills, K-12. J Sch Health 2012;Jan, Supplement.

      ,
      • Soleimanpour S.
      • Geierstanger S.P.
      • Kaller S.
      • et al.
      The role of school health centers in health care access and client outcomes.
      ,
      • Strunk J.A.
      The effect of school-based health clinics on teenage pregnancy and parenting outcomes: An integrated literature review.
      ]. Delivery of behavioral health interventions using mobile technology (e.g., smartphones and tablets) to deliver behavioral health interventions has shown promising results [
      • Fjeldsoe B.S.
      • Marshall A.L.
      • Miller Y.D.
      Behavior change interventions delivered by mobile telephone short-message service.
      ,
      • Heron K.E.
      • Smyth J.M.
      Ecological momentary interventions: Incorporating mobile technology into psychosocial and health behaviour treatments.
      ].
      Access to care and delivery of evidence-based care have been shown to improve adolescent SRH. For example, vaccination against human papillomavirus decreases cervical cancer, routine screening increases detection of asymptomatic STIs, contraceptive education addresses family planning needs, and delivery of preconception health services improves pregnancy outcomes [
      • World Health Organization
      Selected practice recommendations for contraceptive use.
      ,

      Advisory Committee on Immunization Practice (ACIP). ACIP recommendations. Available at: http://www.cdc.gov/vaccines/pubs/ACIP-list.htm. Accessed November 25, 2013.

      ,
      • Hagan Jr., J.F.
      • Shaw J.S.
      • Duncan P.
      • et al.
      Bright Futures: Guidelines for health supervision of infants, children, and adolescents-Third edition.
      ,
      • Jack B.W.
      • Atrash H.
      • Coonrod D.V.
      • et al.
      The clinical content of preconception care: An overview and preparation of this supplement.
      ,
      • Workowski K.A.
      • Berman S.
      Sexually transmitted diseases treatment guidelines, 2010.
      ]. Measures to increase access such as embedding health education and clinical services in nontraditional settings [
      • Johnson D.
      • Harrison P.
      • Sidebottom A.
      Providing sexually transmitted disease education and risk assessment to disengaged young men through community outreach.
      ] and using mobile units for homeless youth [
      • Busen N.H.
      • Engebretson J.C.
      Facilitating risk reduction among homeless and street-involved youth.
      ] can help to reach disenfranchised youth and connect them with SRH information and related services.
      Adolescents are more likely to seek health services, disclose health risk behaviors, and return for follow-up care when confidentiality is assured [
      • Ford C.A.
      • Millstein S.G.
      • Halpern-Felsher B.L.
      • et al.
      Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care. A randomized controlled trial.
      ]. Without confidentiality, adolescents may forego necessary health care, especially those teens at greatest risk [
      • Berlan E.D.
      • Bravender T.
      Confidentiality, consent, and caring for the adolescent patient.
      ,
      • Lehrer J.A.
      • Pantell R.
      • Tebb K.
      • et al.
      Forgone health care among U.S. adolescents: Associations between risk characteristics and confidentiality concern.
      ]. Major health organizations have recommended that all adolescents have time alone with their clinician for confidential health discussions and services [

      American Medical Association. Guidelines for adolescent preventive services. 1992.

      ,
      Achieving quality health services for adolescents.
      ,
      • Ford C.
      • English A.
      • Sigman G.
      Confidential health care for adolescents: Position paper for the society for adolescent medicine.
      ]. While the majority of adolescents report that a parent is aware of their receipt of SRH care, a significant minority would engage in less safe sexual practices if confidential care was not available [
      • Jones R.K.
      • Boonstra H.
      Confidential reproductive health care for adolescents.
      ].

      Recommendations for youth-serving professionals

      • 1.1
        Use SRH-related educational interventions that are evidence based and effective [
        • National Prevention Council
        National prevention strategy: America's plan for better health and wellness.
        ]; focus on the emotional, intellectual, physical, and social aspects of youth's SRH [

        Future of Sex Education. National sexuality education standards: Core content and skills, K-12. J Sch Health 2012;Jan, Supplement.

        ]; and address physical, intellectual, social, and/or emotional challenges.
      • 1.2
        Consider alternative outreach strategies to ensure continuity of SRH services and improve follow-up for youth who are transient or who are otherwise unable to access mainstream services [
        • National Assembly on School-Based Health Care
        Position statement: The role of school based health centers (SBHCs) in improving health equity and reducing health disparities.
        ,
        • DuPlessis H.M.
        • Cora-Bramble D.
        Providing care for immigrant, homeless, and migrant children.
        ].
      • 1.3
        Use new evidence-based research findings and incorporate into existing SRH curriculums and interventions in a timely manner.
      • 1.4
        Be aware of and promote the availability of confidential SRH services to ensure that adolescents, especially those at greatest risk, do not forego needed care [
        • Berlan E.D.
        • Bravender T.
        Confidentiality, consent, and caring for the adolescent patient.
        ,
        • Lehrer J.A.
        • Pantell R.
        • Tebb K.
        • et al.
        Forgone health care among U.S. adolescents: Associations between risk characteristics and confidentiality concern.
        ].

      Recommendations for health care providers

      • 1.5
        Discuss confidentiality with patients and families during early adolescence to set expectations about the transition from childhood to adolescence. Educate about the need for adolescents to develop autonomy and assume more responsibility for their own health and health care.
      • 1.6
        Health care providers and health systems should ensure fidelity to policies regarding confidential SRH services in areas such as electronic health records, encounter sheets, clinical and laboratory billing practices, and receipt of explanation of benefits.
      • 1.7
        Professionals should be aware of the benefits and challenges of new technologies (e.g., mobile devices, personal electronic health records, and patient portals) and be ready to adopt and implement these new technologies to deliver SRH, once evidence has been accumulated to inform education and clinical care.
      • 2.
        Health care providers should have the knowledge and skills to deliver SRH services that have been proven effective in clinical settings.
      The onset of puberty heralds the physiologic and anatomic changes that occur concurrently with the complicated cognitive, emotional, and social development of adolescents [
      • Craig K.R.
      • Biro F.M.
      Normal pubertal physical growth and development.
      ,
      • Cromer B.A.
      Adolescent physical and social development.
      ]. By understanding the varied changes in the pubertal process, providers who care for adolescents can serve as a resource for their patients and families. In particular, special attention needs to be paid to vulnerable groups. These include lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth who are at greater risk for bullying, suicide, and substance use [
      • Coker T.R.
      • Austin S.B.
      • Schuster M.A.
      The health and health care of lesbian, gay, and bisexual adolescents.
      ].
      According to the World Health Organization's (WHO's) SRH—Core Competencies for Primary Health Care [
      • World Health Organization
      Sexual and reproductive health: Core competencies in primary care.
      ], a trained and competent workforce is necessary to implement policies and best practices in all settings. However, studies examining SRH providers' knowledge, attitudes, and behaviors have documented significant deficiencies [
      • Coles M.S.
      • Makino K.K.
      • Phelps R.
      Knowledge of medication abortion among adolescent medicine providers.
      ,
      • Marcell A.V.
      • Wibbelsman C.
      • Siegel W.
      • et al.
      Male adolescent sexual and reproductive health care: Clinical report for the Committee on Adolescent Health. American Academy of Pediatrics.
      ], suggesting the need for improvements in SRH providers' training. Overall recommendations are listed below, with content-specific recommendations in the following sections.

      Recommendations for health care providers

      • 2.1
        Have the knowledge and skills to address core SRH areas for all adolescents and provide services based on the most up-to-date evidence-based care recommendations.
      • 2.2
        Follow professional guidelines when conducting a comprehensive sexual health history, examination, counseling and education, testing and treatment [

        Advisory Committee on Immunization Practice (ACIP). ACIP recommendations. Available at: http://www.cdc.gov/vaccines/pubs/ACIP-list.htm. Accessed November 25, 2013.

        ,
        • Hagan Jr., J.F.
        • Shaw J.S.
        • Duncan P.
        • et al.
        Bright Futures: Guidelines for health supervision of infants, children, and adolescents-Third edition.
        ,
        • U.S. Preventive Services Task Force
        ,
        • World Health Organization
        Medical eligibility criteria for contraceptive use. Fourth edition, 2009.
        ,

        International union against sexually transmitted infections. IUSTI guidelines. Available at: http://www.iusti.org/sti-information/guidelines/default.htm. Accessed December 5, 2013.

        ].
        Guidelines for the delivery of SRH may vary by state, region, or country. It is important to be aware of your local guidelines.
        1Guidelines for the delivery of SRH may vary by state, region, or country. It is important to be aware of your local guidelines.
      • 2.3
        Improve comprehensive SRH education of health care providers during graduate and postgraduate training, as well as through continuing education opportunities, by using practicum and skills-based learning experiences.
      • 2.4
        Offer basic SRH curriculum for all clinical and nonclinical staff in medical settings where adolescents receive care.
      • 2.5
        Discuss healthy relationships and screen for sexual abuse, coercion, and intimate-partner violence with all youth to help prevent and reduce harmful effects of unhealthy relationships [
        • De Koker P.
        • Mathews C.
        • Zuch M.
        • et al.
        A systematic review of interventions for preventing adolescent intimate partner violence.
        ].
      • 2.6
        Provide LGBTQ youth extra guidance and support to promote positive development and optimal health [
        Recommendations for promoting the health and well-being of lesbian, gay, bisexual, and transgender adolescents: A position paper of the society for adolescent health and medicine.
        ].

      Pregnancy prevention

      Risk factors contributing to teen pregnancy are complex and occur at multiple levels—the individual, family, peer/community, and social-political systems [
      • Kirby D.
      • Lepore J.
      Sexual risk & protective factors: Factors affecting teen sexual behavior, pregnancy, childbearing and sexually transmitted disease: Which are important? Which can you change?.
      ]. The interventions that are most effective in reducing sexual risk and preventing teen pregnancy are comprehensive and multifaceted. These include programs that help youth build upon their strengths to identify goals, develop skills, engage in and complete schooling, plan futures, and meaningfully participate in their schools and communities [
      • Kirby D.
      Emerging answers: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases.
      ]. In addition, decades of research have shown that comprehensive education about both abstinence and contraception, in contrast to abstinence-only interventions, delays the onset of sexual behavior, reduces the number of sexual partners, and improves the use of contraceptives [
      • Kirby D.
      Emerging answers: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases.
      ,
      • Santelli J.
      • Ott M.A.
      • Lyon M.
      • et al.
      Abstinence and abstinence-only education: A review of U.S. policies and programs.
      ]. Equally important is access to confidential, safe, convenient, and low/no-cost contraceptives and family planning services that protect adolescents and their partners from unintended pregnancy as well as STIs and HIV/AIDS [
      • Kirby D.
      Emerging answers: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases.
      ,
      • Soleimanpour S.
      • Geierstanger S.P.
      • Kaller S.
      • et al.
      The role of school health centers in health care access and client outcomes.
      ]. Because adolescents are at particularly high risk for inconsistent or incorrect use of contraception [
      • Martinez G.
      • Copen C.E.
      • Abma J.C.
      Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2006-2010 national survey of family growth.
      ], highly effective long-acting reversible contraception (LARC) methods—intrauterine devices and contraceptive implants—are now recommended as first-line contraception for adolescents by the American College of Obstetrics and Gynecology [
      Committee opinion no. 539: Adolescents and long-acting reversible contraception: Implants and intrauterine devices.
      ]. For women of any age beyond menarche, the WHO does not place any restrictions of the use of contraceptive implants and states that the advantages of using intrauterine devices in this population generally outweigh the risks [
      • World Health Organization
      Medical eligibility criteria for contraceptive use. Fourth edition, 2009.
      ]. Despite significant evidence of their safety, acceptability, and effectiveness among adolescents [
      Committee opinion no. 539: Adolescents and long-acting reversible contraception: Implants and intrauterine devices.
      ], LARC methods are underutilized in teens [
      • Yen S.
      • Saah T.
      • Hillard P.J.
      IUDs and adolescents–an under-utilized opportunity for pregnancy prevention.
      ].

      Recommendations for health care providers

      • 1.
        Keep up-to-date on evidence-based pregnancy prevention research and contraceptive effectiveness for adolescents.
      • 2.
        Encourage patients to protect themselves from unintended pregnancy and STIs by considering delay of sexual debut and by adopting safer sexual practices.
      • 3.
        Follow guidelines for safely prescribing and managing contraceptives set out by national or international bodies [
        • World Health Organization
        Selected practice recommendations for contraceptive use.
        ,
        U.S. Selected Practice Recommendations for Contraceptive Use, 2013: Adapted from the World Health Organization selected practice recommendations for contraceptive use, 2nd edition.
        ].
      • 4.
        Consider provision of LARC as first-line pregnancy prevention methods for adolescents and young adults [
        Committee opinion no. 539: Adolescents and long-acting reversible contraception: Implants and intrauterine devices.
        ].

      Pregnancy and abortion

      The vast majority of adolescent pregnancies are unintended [
      • Finer L.B.
      • Zolna M.R.
      Unintended pregnancy in the United States: Incidence and disparities, 2006.
      ], and over a third of these end in abortion [
      • Ventura S.J.
      • Curtin S.C.
      • Abma J.C.
      • et al.
      Estimated pregnancy rates and rates of pregnancy outcomes for the United States, 1990-2008.
      ]. While contraception is highly effective in reducing unintended pregnancy [
      • Santelli J.S.
      • Lindberg L.D.
      • Finer L.B.
      • et al.
      Explaining recent declines in adolescent pregnancy in the United States: The contribution of abstinence and improved contraceptive use.
      ], providers must have the knowledge and skills to care for teens who do become pregnant. At a minimum, this includes offering on-site pregnancy detection and pregnancy-options counseling [
      • Klein J.D.
      Adolescent pregnancy: Current trends and issues.
      ] about all options—including continuing a pregnancy, adoption, and elective termination. If the health care provider does not feel comfortable providing unbiased, accurate information regarding pregnancy options, he or she should promptly refer that patient to such services. While it is helpful for a young woman to have the support of a parent, other trusted adult, or peer when considering her options, the ultimate decisions about social support and pregnancy outcome rest with the pregnant adolescent.
      Among adolescents who elect to continue a pregnancy, research shows that outcomes are improved with accessible and affordable prenatal care, counseling, education, and postnatal services [
      • Fleming N.A.
      • Tu X.
      • Black A.Y.
      Improved obstetrical outcomes for adolescents in a community-based outreach program: A matched cohort study.
      ]. Adolescents who choose to terminate a pregnancy need access to safe, confidential, and affordable comprehensive abortion care [
      The adolescent's right to confidential care when considering abortion. American Academy of Pediatrics. Committee on Adolescence.
      ], especially as barriers to accessing services are particularly challenging for poor and minority women [
      • Dehlendorf C.
      • Weitz T.
      Access to abortion services: A neglected health disparity.
      ]. While the WHO has spoken out on the need for expanding access to medication abortion [
      • Shah I.H.
      • Weinberger M.B.
      Expanding access to medical abortion: Perspectives of women and providers in developing countries.
      ], many adolescent health providers still have knowledge gaps about this service [
      • Coles M.S.
      • Makino K.K.
      • Phelps R.
      Knowledge of medication abortion among adolescent medicine providers.
      ].

      Recommendations for health care providers

      • 1.
        Be aware of local and regional resources that provide unbiased options counseling and medical services for teens choosing to continue or terminate a pregnancy.
      • 2.
        Offer support to teens in navigating parental consent and notification laws [
        • Henshaw S.K.
        • Kost K.
        Parental involvement in minors' abortion decisions.
        ] when parental notification is not feasible due to safety or other significant concerns [
        • Coles M.S.
        • Makino K.K.
        • Stanwood N.L.
        • et al.
        How are restrictive abortion statutes associated with unintended teen birth?.
        ].

      Sexually transmitted infections

      Adolescents and young adults have the highest incidence of STIs worldwide [
      • Dehne K.
      • Riedner G.
      Sexually transmitted infections among adolescents: The need for adequate health services.
      ], and the direct and indirect costs of these are significant [
      • Owusu-Edusei Jr., K.
      • Chesson H.W.
      • Gift T.L.
      • et al.
      The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008.
      ]. Untreated STIs can result in serious health problems including infertility, pelvic pain, and increased rate of HIV infection [

      Deal C, Cates W, Peeling R, et al. Long-term clinical sequelae of sexually transmitted infections in women [conference summary]. Emerg Infect Dis [serial Internet 2004. Available at: http://wwwnc.cdc.gov/eid/article/10/11/04-0622_02_article.htm. Accessed September 10, 2013.

      ], and asymptomatic infections contribute to their continued spread. National public health agencies publish guidelines for STI screening and treatment that are adapted to reflect regional epidemiology. Given the higher incidence of infection in adolescent and young adults, agencies often have specific guidelines for screening this population [

      International union against sexually transmitted infections. IUSTI guidelines. Available at: http://www.iusti.org/sti-information/guidelines/default.htm. Accessed December 5, 2013.

      ].

      Recommendations for health care providers

      • 1.
        Provide STI and HIV education, counseling, and services to all adolescents.
      • 2.
        Incorporate STI education and prevention strategies into well-adolescent and contraception visits.
      • 3.
        Encourage immunizations, especially against human papillomavirus and hepatitis A and B viruses [
        • Beharry M.S.
        • Coles M.S.
        • Burstein G.R.
        Adolescent immunization update.
        ].
      • 4.
        Offer screening for STIs to all sexually active teens [
        • Workowski K.A.
        • Berman S.
        Sexually transmitted diseases treatment guidelines, 2010.
        ] and cervical cancer screening per current recommendations [
        • Massad L.S.
        • Einstein M.H.
        • Huh W.K.
        • et al.
        2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors.
        ].
      • 5.
        Provide prompt, effective, and confidential STI treatment to all adolescents and their partners, recognizing the important role of expedited partner therapy in disease prevention [
        • Workowski K.A.
        • Berman S.
        Sexually transmitted diseases treatment guidelines, 2010.
        ].
      • 3.
        Providers should encourage developmentally appropriate communication about SRH between parents/caregivers and their children.
      Communication with youth about SRH that is accurate, respectful, and frequent and acknowledges the importance of adolescent romantic relationships has been shown to promote autonomy and healthy self-regulation around intimacy and sex [
      • Lerand S.J.
      • Ireland M.
      • Boutelle K.
      Communication with our teens: Associations between confidential service and parent-teen communication.
      ]. Parents have an important role in this aspect of their adolescents' SRH. Parental connectedness, support, and monitoring, along with parent–child communication, have been found to be associated with reduced sexual risk taking behavior among adolescents [
      • Kirby D.
      Emerging answers: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases.
      ,
      • Kalina O.
      • Geckova A.M.
      • Klein D.
      • et al.
      Mother's and father's monitoring is more important than parental social support regarding sexual risk behaviour among 15-year-old adolescents.
      ]. Parental discussion of SRH issues contributes to adolescents' improved knowledge and attitudes about sex [
      • Wight D.
      • Fullerton D.
      A review of interventions with parents to promote the sexual health of their children.
      ], delayed sexual debut [
      • Markham C.M.
      • Tortolero S.R.
      • Escobar-Chaves S.L.
      • et al.
      Family connectedness and sexual risk-taking among urban youth attending alternative high schools.
      ], and greater likelihood that they receive SRH services [
      • Commendador K.A.
      Parental influences on adolescent decision making and contraceptive use.
      ]. However, parents may need guidance in how to discuss pubertal and sexual issues with their children. Difficulties in communicating about sexual health issues are associated with limited parental communication around puberty and sexual development [
      • Beckett M.K.
      • Elliott M.N.
      • Martino S.
      • et al.
      Timing of parent and child communication about sexuality relative to children's sexual behaviors.
      ]. Health care visits afford providers an opportunity to assist parents in understanding normative adolescent development. As a young person matures, it is essential that health care providers help parents navigate the parental developmental task of perceiving, accepting, and interacting with the adolescent as a sexual being.

      Recommendations for youth-serving professionals and health care providers

      • 3.1
        Encourage parents and adolescents to have open discussions about SRH [
        • Ford C.
        • English A.
        • Sigman G.
        Confidential health care for adolescents: Position paper for the society for adolescent medicine.
        ].
      • 3.2
        Provide guidance and support regarding developmentally appropriate ways in which to effectively communicate about SRH with their children.
      • 3.3
        Provide medically accurate SRH information geared toward parents that is easily accessible and understandable.
      • 3.4
        Encourage adolescents to communicate with their parents about important health issues and health care decisions related to SRH, providing it is safe to do so [
        • Lerand S.J.
        • Ireland M.
        • Boutelle K.
        Communication with our teens: Associations between confidential service and parent-teen communication.
        ].

      Recommendations for health care providers

      • 3.5
        Discuss puberty, sexuality, and sex with patients and parents during well-adolescent visits, making sure to address LGBTQ issues.
      • 3.6
        Engage parents of adolescents with chronic health problems and physical or cognitive challenges who may need additional support in recognizing the SRH needs of their children [
        • Tepper M.S.
        Becoming sexually able: Education to help youth with disabilities.
        ].
      • 4.
        Access to SRH should be available to all adolescents, regardless of socioeconomic status, race, ethnicity, intellectual or physical ability, gender, sex, or geographic location.
      Substantial progress has been made in designing culturally sensitive health interventions. Nonetheless, racial/ethnic and economic disparities in access to contraceptive services and in rates of unintended pregnancies, STIs, and HIV persist [,
      • Gavin L.
      • MacKay A.P.
      • Brown K.
      • et al.
      Sexual and reproductive health of persons aged 10-24 years - United States, 2002-2007.
      ]. Significant gaps also exist in services to males [
      • Marcell A.V.
      • Wibbelsman C.
      • Siegel W.
      • et al.
      Male adolescent sexual and reproductive health care: Clinical report for the Committee on Adolescent Health. American Academy of Pediatrics.
      ], LGBTQ youth [
      • IOM (Institute of Medicine)
      The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding.
      ], street-involved youth [
      • DuPlessis H.M.
      • Cora-Bramble D.
      Providing care for immigrant, homeless, and migrant children.
      ], and those who reside in juvenile justice residential facilities [
      Health care for youth in the juvenile justice system.
      ]. Intellectually disabled, physically disabled, sexual minority, and sexually active religious adolescents are less likely to report having received SRH education and care [
      • Hall K.S.
      • Moreau C.
      • Trussell J.
      Lower use of sexual and reproductive health services among women with frequent religious participation, regardless of sexual experience.
      ,
      • McRee A.L.
      • Haydon A.A.
      • Halpern C.T.
      Reproductive health of young adults with physical disabilities in the U.S.
      ,
      • Hoffman N.D.
      • Freeman K.
      • Swann S.
      Healthcare preferences of lesbian, gay, bisexual, transgender and questioning youth.
      ].

      Recommendations for health care providers

      • 4.1
        Understand his or her patient population and tailor services that are sensitive to gender, gender identity, gender expression, and sexual orientation in addition to race, ethnicity, genetics, spirituality, religion, and culture.
      • 4.2
        Ensure that youth in traditionally underserved populations have access to equitable SRH information and clinical services.
      • 4.3
        Collaborate with professional organizations to develop and advocate for strategies to address disparities in SRH service delivery.
      • 4.4
        Monitor changes to the health care system to assess their impact on access, delivery, and health outcomes for high-risk youth.
      Within the context of a human rights perspective, SRH information and services should be provided to adolescents and young adults in a confidential and respectful manner by competent, nonjudgmental, and sensitive providers. To accomplish this, adolescents need to have universal access to information that is accurate and clinical services that are evidence based and comprehensive. In turn, health care providers need to be equipped with the knowledge and skills to deliver SRH services. Special attention needs to be paid to underserved populations in order to reduce health disparities. This requires coordinated efforts of adolescents themselves, their families, medical providers, youth-serving professionals in schools and communities, and larger sociopolitical systems.

      Acknowledgments

      We thank Dr. Colette Auerswald from the University of California, Berkley, for her comments on an earlier version of the manuscript and the peer reviewers at SAHM for their feedback.
      Prepared by (in alphabetical order):
      Pamela J. Burke, Ph.D., F.N.P., P.N.P.
      Boston Children's Hospital
      and Northeastern University
      Boston, Massachusetts
      Mandy S. Coles, M.D., M.P.H.
      Boston Medical Center
      Boston, Massachusetts
      Giuseppina Di Meglio, M.D., M.P.H.
      Montreal Children's Hospital/McGill University Health Center
      Montreal, Quebec, Canada
      Erica J. Gibson, M.D.
      Columbia University
      New York, New York
      Sara M. Handschin, M.S., PA-C.
      Seattle Children's Hospital
      Seattle, Washington
      May Lau, M.D., M.P.H.
      University of Texas Southwestern Medical Center
      Dallas, Texas
      Arik V. Marcell, M.D., M.P.H.
      The Johns Hopkins University
      Baltimore, Maryland
      Kathleen P. Tebb, Ph.D.
      University of California, San Francisco
      San Francisco, California
      Kim Urbach, P.N.P.
      University of Rochester Medical Center
      Rochester, New York

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