Doctors walk fine line on teen pregnancy

When we heard Jamie Lynn Spears, the sibling of Britney, was with child at age 16, we shrugged; just another Hollywood event, we said to ourselves. When word leaked out that Bristol Palin, daughter of the Republican vice presidential nominee, is pregnant, we tut-tutted. "So much for abstinence teaching," we said. Probably more than a few mothers let out a "there but for the grace of God go I" sigh.

Teenage pregnancy is hardly a surprise any more. The teen pregnancy rate in the United States is among the highest in the industrialized world, according to the Centers for Disease Control and Prevention. In the wake of a spate of teen pregnancies at Gloucester High, the school committee is debating whether to have contraception available on the premises. Noted one teen in favor of the change, "Gloucester is sexually active." The same could be said for most any suburb.

So how do pediatricians handle this challenge? There is no set script. Each physician brings his or her own set of values, training, and religious principles to practice, and each has a different set of priorities for the 15 or 20 minutes of an adolescent visit.

But one thing is important: When it comes to sexuality and a myriad of other transitional health issues, developing teens must see their pediatrician as their personal doctor - not their mother's or father's. One approach is to ask parents to wait in the waiting room, to allow for a one-on-one, teen-to-doctor, talk. Parents can be consulted before or after the exam. I see both adolescent boys and girls in my practice, and addressing their sexuality is important for both - although the issue tends to weigh more heavily on the adolescent girls, as they are most often the ones left with the responsibility for the pregnancy.

The one-on-one approach is used with teens as young as 11, to establish a zone of privacy and confidentiality that they can build on in the following years, when they may need help with contraception, sexual identity, drug use, or other sensitive matters.

This is an ideal approach, but in today's complicated world, problems can arise. First of all, many parents are not comfortable being shut out of the exam room. "This is my child, and I darn well want to know what is going on," is the view of some. Often the pre-pubescent teen may want the comfort of a parent in the room. Some adolescents are still joined at the hip with their mother or father, and balk at sharing personal information with anyone else. It can be a tough sell to persuade such a family that talking privately is, ultimately, in everybody's best interest.

The other unfortunate problem with giving an adolescent private time with a doctor is the chaperone issue. Doctors are acutely aware that they are vulnerable to charges of sexual impropriety if any sensitive discussion or physical exam is done without a third party witness. A simple breast exam can be misconstrued by a sensitive or paranoid teenager - or by her parents. Each doctor has their own response to this situation. Usually, we assess the risk based on the relationship with the family. In situations where complaints seem likely, or teens prefer it, parents are invited to stay in the room.

Even with the guarantee of confidentiality, many teens will not directly admit to sexual activity. Odd complaints about irregular periods and acne may prompt a request for birth control pills - which are indeed sometimes prescribed for those conditions - when the real need is to avoid pregnancy. Even those teens who can raise the issue do so indirectly, heading out the door at the end of an exam by asking, "Oh, by the way, do you know where I can get the pill?"

Another problem is - perhaps predictably, in this dollar-conscious age - the billing issue. While Pap smears are no longer required before prescribing a birth control pill (the new guidelines from the Academy of Obstetricians and Gynecologists recommend a Pap smear within three years of onset of sexual activity or age 21, whichever is first), sexually active teens - both boys and girls - still need to be screened for sexually transmitted diseases. Chlamydia and gonorrhea screening can now be done by a urine test, but a parent still may receive a bill for the test.

And if teens have multiple partners, they may need a pelvic exam to screen for human papilloma virus. Parents receiving a bill for these tests may rightfully inquire about why these tests were done.

Of course, pediatricians encourage adolescents to discuss their sexuality with parents if possible. After all, the parent-doctor-adolescent triad is not meant to be a conspiracy but a team. But many parents have a hard time accepting the sexuality of their children.

The importance of these exam room conversations is underscored by findings on the failure of the abstinence programs promoted in many schools. A Mathematica Policy Research Inc. study funded by Congress and released last year found that abstinence programs for older elementary students and middle schools had no effect in reducing rates of teen sexual activity - and that teens in the program were no more likely to delay their first sexual experience than other teens. That leaves parents and physicians to guide teens about the best, and safest, approach to sexuality.

We need to face the facts - our kids are having sex - and arm them with information. Adding to the urgency of this crisis is the fact that girls are getting their periods earlier; the average age now is 12.5 years - almost five months earlier than in 1988, according to the National Health and Nutrition Examination. And for some girls, of course, it arrives even earlier. Just ask the mother of the 11-year-old girl who came to me for missed periods, and whose pregnancy test came back positive.

Dr. Victoria Rogers McEvoy is chief of pediatrics of the Mass. General West Medical Group and assistant professor at Harvard Medical School.