Committee on Adolescent Health Care
This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care in collaboration with committee members Oluyemisi A. Adeyemi-Fowode, MD and Karen R. Gerancher, MD.
ABSTRACT: Obstetrician–gynecologists have the opportunity to promote healthy relationships by encouraging adolescents to discuss past and present relationships while educating them about respect for themselves and mutual respect for others. Because middle school is a time when some adolescents may develop their first romantic or sexual relationships, it is an ideal timeframe for obstetrician–gynecologists and other health care providers, parents, and guardians to play a role in anticipatory guidance. Creating a nonjudgmental environment and educating staff on the unique concerns of adolescents are helpful ways to provide effective and appropriate care to this group of patients. Obstetrician–gynecologists and other health care providers caring for minors should be aware of federal and state laws that affect confidentiality. Obstetrician–gynecologists should screen patients routinely for intimate partner violence along with reproductive and sexual coercion and be prepared to address positive responses. Furthermore, obstetrician–gynecologists should be aware of mandatory reporting laws in their state when intimate partner violence, adolescent dating violence, or statutory rape is suspected. Pregnant and parenting adolescents; lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ) individuals; and adolescents with physical and mental disabilities are at particular risk of disparities in the health care system. The promotion of healthy relationships in these groups requires the obstetrician–gynecologist to be aware of the unique barriers and hurdles to sexual and nonsexual expression, as well as to health care. Interventions to promote healthy relationships and a strong sexual health framework are more effective when started early and can affect indicators of long-term individual health and public health.
Recommendations and Conclusions
The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions:
Interventions to promote healthy relationships and a strong sexual health framework are more effective when started early and can affect indicators of long-term individual health and public health.
Because middle school is a time when some adolescents may develop their first romantic or sexual relationships, it is an ideal timeframe for obstetrician–gynecologists and other health care providers, parents, and guardians to play a role in anticipatory guidance.
Obstetrician–gynecologists have the opportunity to promote healthy relationships by encouraging adolescents to discuss past and present relationships while educating them about respect for themselves and mutual respect for others.
Creating a nonjudgmental environment and educating staff on the unique concerns of adolescents are helpful ways to provide effective and appropriate care to this group of patients.
Obstetrician–gynecologists who treat adolescent patients should provide resources for parents and caregivers and encourage continued parental involvement.
Defining Healthy Relationships
Healthy relationships consist of sexual and nonsexual elements Table 1. Key aspects of a healthy relationship include respect and communication, and healthy sexual elements include not only physical intimacy, but mutuality and pleasure as well. As stated by the American Academy of Pediatrics, “healthy sexuality includes the capacity to promote and preserve significant interpersonal relationships; value one’s body and personal health; interact with [others] in respectful and appropriate ways; and express affection, love, and intimacy in ways consistent with one’s own values, sexual preferences, and abilities” 1. Obstetrician–gynecologists have the opportunity to promote healthy relationships by encouraging adolescents to discuss past and present relationships while educating them about respect for themselves and mutual respect for others. It is important to discuss with adolescents that there is a wide range of “normal;” for example, some relationships will involve sexual intimacy and others will not.
Learning to develop healthy relationships is a lifelong process and is influenced by a variety of factors, including family, religion, social norms, media exposure, peers, and school, where most adolescents spend the majority of their time. The processes in which early family influences play a role in an adolescent’s future relationships, at least in the domain of romantic relationships, include parental modeling and deidentification from parents 2. As part of a medical visit, obstetrician–gynecologists may assess an adolescent’s knowledge of and experiences with parental and family relationships.
Defining Unhealthy Relationships
Although the primary focus of counseling should be helping an adolescent define a healthy relationship, there are clear elements that characterize an unhealthy one. Aspects of unhealthy relationships include disrespect, intimidation, dishonesty, and abuse Table 1. Physical violence between dating partners (intimate partner violence) and sexual dating violence (sexual assault and reproductive and sexual coercion) are common events in adolescent relationships. In one study of young females in grades 9–12, 10.7% had been forced to engage in sexual activities they did not want to do, including kissing, touching, or sexual intercourse; 11.3% reported having been forced to have sexual intercourse when they did not want to; and 9.1% reported having been physically hurt on purpose by someone they were “going out with” or dating within the 12 months before being surveyed 3. Furthermore, misogyny and sexual harassment (eg, “catcalling,” touching without permission, insulting with sexualized words) are pervasive among adolescents and young adults. Of women aged 18–25 years, 87% reported experiencing at least one such event in their lifetime 4.
Understanding Adolescent Development
Adolescence is the time frame of psychosocial, cognitive, and physical development when young people make the transition from dependent child to independent adult. Although explorations of gender identity, sexuality, relationships, and intimacy occur throughout a lifespan, adolescence is a critical developmental period 5. The physical and cognitive developments are rarely synchronous; therefore, the obstetrician–gynecologist may encounter adolescents who have matured physically but not cognitively. Young adolescents (12–14 year olds) are typically concrete thinkers with poor or inconsistent abstract reasoning or problem-solving skills. Middle-aged adolescents (15–17 year-olds) often assume they are invulnerable. They may assume, for example, that risks apply to their friends but not to themselves. Generally, older females (18–21 year olds) have acquired problem-solving abilities and have relatively consistent abstract reasoning. Thus, the clinical approach to counseling a cognitively younger adolescent will differ from the approach taken with a cognitively older adolescent or an adult 6. Research in neuroscience demonstrates that adolescents may have limitations to their capacity for consequential thought and ability to imagine alternative outcomes 7; thus, judgement can lag, and adolescents may not always make wise or healthy decisions. Adolescence is a time to prepare for future relationships by learning healthy skills such as compromise, negotiation, conflict resolution, setting healthy boundaries, and other potentially protective behavior.
The Role of the Obstetrician–Gynecologist
The initial reproductive health visit recommended for girls ages 13–15 years provides the opportunity for obstetrician–gynecologists to educate the adolescent and accompanying parent or guardian on numerous age-appropriate health issues 8. Because middle school is a time when some adolescents may develop their first romantic or sexual relationships, it is an ideal time frame for obstetrician–gynecologists and other health care providers, parents, and guardians to play a role in anticipatory guidance. In addition to counseling about reproductive and general health, the visit also may include a discussion about healthy relationships. Creating a nonjudgmental environment and educating staff on the unique concerns of adolescents are helpful ways to provide effective and appropriate care to this group of patients. Resources on preparing medical practices for adolescent patients and talking with adolescents are available in the American College of Obstetricians and Gynecologists’ Adolescent Guide 9. Obstetrician–gynecologists and other health care providers caring for minors should be aware of federal and state laws that affect confidentiality 10. Statutes on the rights of minors to consent to health care services vary by state, and obstetrician–gynecologists should be familiar with the regulations that apply to their practice. Useful sources of information on state laws include the Guttmacher Institute 11 and the Center for Adolescent Health and the Law 12 13.
Obstetrician–gynecologists may counsel adolescents and young women to define their current relationships as well as their expectations or hopes for future ones. Because current and future relationships may involve sexual intimacy, comprehensive sexuality education should begin in early childhood and continue through a person’s lifespan 14. Obstetrician–gynecologists should screen routinely for intimate partner violence along with reproductive and sexual coercion and be prepared to address positive responses 15 16. Additionally, noncoital sexual behavior is a common expression of human sexuality for adolescents and adults, and obstetrician–gynecologists should actively engage patients in discussions about all sexual behavior to assess patient perceptions as well as risks 17. Romantic relationships without sexual intimacy or sexual elements also are important and should be discussed. In addition, obstetrician–gynecologists have the unique opportunity to act “bi-generationally” by asking their adult patients about their adolescents’ reproductive development and sexual education 18.
Multiple tools exist to assist obstetrician–gynecologists in their efforts to promote healthy relationships in adolescents. Counseling starts with the ability to ask age- and education-appropriate open-ended questions that allow an adolescent to express herself Box 1. Because adolescents use a variety of media sources to fill in knowledge gaps, online communication and online sources of information should be addressed along with their benefits and potential dangers 18. For more information, see Committee Opinion No. 653, Concerns Regarding Social Media and Health Issues in Adolescents and Young Adults 19. Numerous reliable online resources exist and can be shared with patients and their families (see the For More Information section). Regardless of which tools are chosen, obstetrician–gynecologists have the potential to play a unique and important role in educating adolescent patients about healthy relationships as well as identifying troubled partnerships. Obstetrician–gynecologists should be aware of mandatory reporting laws in their state when intimate partner violence, adolescent dating violence 20, or statutory rape is suspected. Obstetrician–gynecologists also should be aware that adolescents who have recently experienced the breakup of a romantic relationship may be at greater risk of mental health issues, suicidal ideation, and self-harm. In a group of adolescents aged 10–18 years who sought counseling for a romantic concern, the most common concern was postrelationship issues, including breakups. Female adolescents were more concerned about the dissolution stage of relationships when compared with males, who showed greater concern about the establishment stage 21.
Sample Questions and Talking Points for the Obstetrician–Gynecologist When Talking to an Adolescent About Healthy Relationships
The obstetrician–gynecologist can start the discussion with a framing statement about privacy and confidentiality: “Before we get started, I want you to know that everything here is confidential, meaning that I will not talk to your family about what is said unless you tell me that [insert the laws in your state about what is necessary to disclose]. Also I am not able to control what insurance companies send to caregivers in regard to billing information. Some tests that I order might be listed on the bill and may raise questions with your caregivers.”
“Before we get started, I want you to know that everything here is confidential, meaning that I will not talk to your family about what is said unless you tell me that [insert the laws in your state about what is necessary to disclose]. Also I am not able to control what insurance companies send to caregivers in regard to billing information. Some tests that I order might be listed on the bill and may raise questions with your caregivers.”
Why is confidentiality vital?
Adolescents gain more ownership over their own health. Encourage adolescents to be active participants in their health care as a step toward becoming adults and taking on more responsibility.
Confidentiality provides a safe space to ask questions. Talking to adolescents one-on-one also gives adolescents a chance to ask questions or give information about which they may feel self-conscious. Adolescents often have questions or concerns that they may feel embarrassed to talk about in front of their parents or guardians.
Confidentiality builds trust. Experimenting with a range of behavior is common among adolescents and young adults. Adolescents often do not disclose this behavior to their parents. When gaining the adolescents’ trust, encourage them to discuss issues with their parents.
Sample Questions and Talking Points
“We’ve started talking to all of our patients about safe and healthy relationships because they can have a large effect on your health.”
“What sort of things do you do with your friends? How would your friends describe you?”
“How do you feel about relationships in general or about your own sexuality?”
“What makes a relationship good? What makes it bad? What does respect look like in a relationship?”
“What qualities are important to someone you would date or go out with?”
“Tell me a bit about your relationships. Are you in a relationship with anyone? How long have you been together? What about your previous relationships?”
“Has any person that you have been on a date with said things to hurt your feelings on purpose, blamed you for bad things they did, put you down for your looks, or threatened to start dating someone else? Have you done these things?”
“What do you do if you are feeling sad, angry, or hurt by your partner?”
“If you are sexually active, does your partner support you using birth control?”
“Has your partner ever interfered with your birth control method or refused your request to use condoms?”
“Has your partner ever forced you to do something sexually that you did not want to do?”
“Have you ever felt unsafe in a relationship?”
“Has any person that you have been on a date with slapped, physically twisted your arm, pushed, grabbed, shoved or physically hurt you? Have you done these things?”
“Have you ever had sex in exchange for money or some other favor or payment?”
“During the past 2 weeks, how often have you had little interest or pleasure in doing things?”
“During the past 2 weeks, how often have you felt down, depressed, or hopeless?”
“During the past 2 weeks, have you had thoughts that you would be better off dead or of hurting yourself in some way?”
“Respect is the foundation for healthy, happy, and safe relationships.”
“In mutually respectful relationships there should be safety, support, individuality, equality, trust, and communication.”
“Pay attention to how certain situations make you feel—good and bad—and trust your instincts when you feel disrespected.”
“If you ever feel uncomfortable or unsafe in a relationship, there are resources available to help. You can always talk to me and I will help you. You also can talk to your parents, teacher, counselor, or call a helpline.”
Data from Thompson MP, Basile KC, Hertz MF, Sitterle D. Measuring intimate partner violence victimization and perpetration: a compendium of assessment tools. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2006. Available at: https://stacks.cdc.gov/view/cdc/11402. Retrieved June 28, 2018; Chown P, Kang M, Sanci L, Newnham V, Bennett DL. Adolescent health: enhancing the skills of general practitioners in caring for young people from culturally diverse backgrounds. GP Resource Kit. 2nd ed. Sydney: NSW Centre for the Advancement of Adolescent Health and Transcultural Mental Health Centre, 2008. Available at: http://www.health.nsw.gov.au/kidsfamilies/youth/Documents/gp-resource-kit-revised-2nd-edition.pdf. Retrieved June 27, 2018; Futures Without Violence. RESPECT! Challenge action toolkit. San Francisco (CA): Futures Without Violence, 2015. Available at: https://www.futureswithoutviolence.org/respect-challenge-toolkit-2/. Retrieved June 27, 2018; and Patient Health Questionnaire (PHQ) screeners. Available at: https://www.phqscreeners.com. Retrieved June 28, 2018.
Involving Parents and Caretakers
Obstetrician–gynecologists may provide guidance for parents and families and suggest tools to help in their discussions with their adolescents Box 2. When surveyed, a large proportion of young women expressed a desire to receive more information or guidance on some emotional aspect of romantic relationships either from a parent (70%) or in a health or sex education class at school (65%) 4. Important aspects to communicate include the following:
Encourage good relationship modeling. The family unit plays an important role in a young person’s sexual health 22. Supportive relationships with parents or other caregivers enable adolescents to develop interpersonal skills that influence their choice of partners and views on relationships.
Encourage parents to discuss sex. Adolescents who recall a parent talking with them about sex are more likely to report delaying sexual initiation and increasing condom and contraceptive use 23. Although mothers primarily communicate with adolescents about sex, fathers play a role in their adolescents’ sexual socialization 23; thus, it is important for obstetrician–gynecologists to encourage involvement by both parents when possible. Open communication should pertain to all children in the family, male and female. The benefits of parenting extend beyond helping adolescents avoid sexual risk. Parent discussion also enhances adolescents’ capacity to have positive sexual relationships 24. Parental involvement, knowledge of reproductive health, and effective communication can modify adolescents’ sexual behavior 22 25.
Encourage parents to monitor media. Parental monitoring to reduce exposure to a highly sexualized media environment (eg, television, the internet, social media) may offer protection against early sexual initiation 24 26. In contrast to sometimes unreliable sources in the media or friends, parents are uniquely suited to engage and educate their children about sexual health; notably, many adolescents cite parents as preferred sources for accurate sex-related information 27. In some studies, interventions that engage parents and youth in sexual health communication and incorporate parental monitoring have been associated with increased comfort in discussing sex and content expertise for parents and decreased sexual risk behavior among youth 27.
Encourage parents to be flexible in their approach. Because adolescents’ sexual knowledge and behavior change throughout adolescence, parental approach to discussing sex with their adolescents should change as well. Parents should be counseled that adolescent sexual behavior is a normal developmental milestone and parents should receive information about the profound neurocognitive, social, and emotional changes that occur during adolescence 7.
Provide resources for parents and guardians. Obstetrician–gynecologists who treat adolescent patients should provide resources for parents and caregivers and encourage continued parental involvement. Resources to help parents talk to their adolescents are included in the For More Information section.
For Parents and Families: Ten Tips on Talking About Healthy Relationships With Adolescents
Encourage open, honest, and thoughtful reflection. Talk openly with adolescents about healthy relationships. Allow them to articulate their values and expectations for healthy relationships. Be willing to talk openly and respect differences of opinion. Rather than dismissing ideas as “wrong,” encourage debate, which helps young people reach their own understanding.
Be sensitive and firm. Parenting an adolescent is not easy, especially when it comes to helping him or her navigate the way through relationships. To be effective, you will need to find the balance between being sensitive and firm. Try to adapt to the changes faced by your adolescent. Realize that the decisions you make sometimes will be unpopular with your adolescent.
Understand adolescent development. Adolescence is all about experimentation. From mood swings to risk taking, “normal” teenage behavior can appear anything but normal. New research, however, reveals that brain development during these formative years plays a significant role in adolescents’ personality and actions. Knowing what is typical adolescent development is critical to helping you better understand and guide young people.
Understand the pressure and the risk adolescents face. Children and young adolescents face new and increasing pressure about sex, substance abuse, and dating. Young adolescents may express a desire to have parents and role models take time to listen to them and help them think through the situations they face. Be that person!
Take a clear stand. Make sure adolescents know how you feel about disrespect, use of abusive or inappropriate language, controlling behavior, or any forms of violence.
Make the most of teachable moments. Use television episodes, movies, music lyrics, news, community events, or the experiences of friends to discuss the characteristics of healthy and unhealthy relationships.
Discuss how to be an upstander. Teach adolescents how to stand-up for friends when they observe unhealthy treatment of their peers.
Accentuate the positive. Conversations about relationships do not need to focus solely on risky behavior or negative consequences. Conversations also should address factors that promote healthy adolescent development and relationships.
Be an active participant in your adolescent’s life. Explore ways to know more about your adolescent’s friends and interests. Find activities you can do together.
Be prepared to make mistakes. You will make mistakes. Accept that you will make mistakes, and continue to help adolescents make responsible choices while trying to balance being sensitive but firm.
Adapted from Futures Without Violence. 10 tips on talking about healthy relationships with teens. San Francisco (CA): Futures Without Violence; 2014. Available at: https://www.futureswithoutviolence.org/wp-content/uploads/10Tips_healthyrelationships1.pdf. Retrieved June 28, 2018.
Pregnant and parenting adolescents; lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ) individuals; and adolescents with physical and mental disabilities are at particular risk of disparities in the health care system 28 29 30. Adolescents with physical and cognitive disabilities often are considered to be asexual and, thus, have been excluded from sexuality education 18. However, every adolescent has the capability to form relationships, and no group should be marginalized or omitted from receiving information about healthy sexual and nonsexual relationships. Needs of subgroups will vary and discussions should provide an open environment for patients to express their unique concerns. The promotion of healthy relationships in these groups requires the obstetrician–gynecologist to be aware of the unique barriers and hurdles to sexual and nonsexual expression, as well as to health care.
Effect of Interventions
Interventions to promote healthy relationships and a strong sexual health framework are more effective when started early and can affect indicators of long-term individual health and public health 31. Early intervention programs in middle schools have demonstrated sustained positive effects on female and male students’ attitudes toward issues of gender equality and adolescent dating violence 32. Brief interventions in an emergency department showed a reduction in moderate and severe dating victimization in patients aged 14–18 years 33. Continuing interventions, including sexual and reproductive health counseling, education, and contraceptive availability, have been effective in increasing adolescent knowledge about sexual health and contraception, resulting in increased use of contraception and a decrease in unintended pregnancy 34. In addition to effects on the individual adolescent, intervention programs have demonstrated effects on policy and practice 35. Obstetrician–gynecologists should support programs that encourage sexual health 14.
For More Information
The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/HealthyRelationships.
These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.