I realized I couldn't postpone it any longer. I have been a general pediatrician for over 30 years but can still feel awkward and anxious talking with my “older” patients about sensitive topics. It was time for me to embarrass myself and my 14-year-old patient with those awful questions about drugs and sex. He was being seen for a “sports physical,” but since I occasionally get a positive response to these questions, I consider them a kind of necessary evil. “Believe me,” I wanted to say, “I don't enjoy this any more than you do. And don't worry, I won't tattle on you.”
“I have just a few more questions. Like I explained when you had your exam last year, what we talk about privately stays in this room.”
He nods quietly.
“Do you smoke?” I ask.
“Do you drink alcohol?”
“Any other drugs, like marijuana?”
I wonder if he can hear the relief in my voice. He is now 3 for 3, and I am feeling more comfortable with him and this whole line of questioning. Maybe adolescence hasn't changed as much as the newspapers and Hollywood would have us think. I hope he doesn't hang out with those weird-looking kids who pierce their bodies and congregate at the mall.
“How is your social life?”
“Are you dating?”
“So you used to date?”
“I used to, but now I just hang out with friends.”
I wonder how old he could have been when he was “dating.” Are we are even talking about the same thing? A simple “no” would have been so much easier for me than “not now.” If he had seen the look in my eyes or noticed the little bear attached to my stethoscope, he might have guessed that I am often more comfortable with 4-year-olds than teenagers. I consider looking the other way and skipping quickly past this “dating” business, but find myself wondering if he is hiding something from me. He is much too young for sex, of course, but I guess I should ask just in case.
“Are you attracted to men, women, or both?”
I realize that “men, women, or both” sounded wrong. I hope he didn't think I was asking if he is attracted sexually to adult men or women, but “boys, girls, or both” wouldn't have sounded quite right either. Anyhow, “just girls” is a fine answer and certainly the easiest for me. I guess it's time for the sex questions.
I go on.
“Have you been sexually active?”
After a few seconds, he says, “Not really.”
“Help me to understand what you mean by ‘not really.’ ”
He pauses again, then shrugs his shoulders.
I want to say, “No way, kid. You've had sex already?” I certainly hadn't when I was his age. I wish he wouldn't play games with me. Doesn't he know I get relentless when I sense a challenge? Does he want to do this the hard way or the easy way? He may as well tell me now. Is it sex or no sex?
I calm myself and say politely, “I am wondering if you have ever had sex with anyone.”
“Just oral sex.”
My jaw drops. I want to say, “Just oral sex?” I am feeling old, clearly a member of another generation. Whatever happened to good old-fashioned kissing and petting? I so wish he hadn't just told me this.
“I'm glad you feel comfortable sharing that with me.”
He nods approvingly with a slight grunt.
“Can you tell me a little more about this?”
“It's not a big deal, only hooking up a few times with friends.”
I am no longer feeling old. I am feeling ancient. I am clearly out of my element and very unsure how to respond. How can he be so casual about this? I wish I could talk to him about innocence, interpersonal intimacy, love, and maybe even religion and spirituality. I know preaching won't be welcome or effective. I consider an attempt at motivational interviewing but don't feel skilled or brave enough. What would I say? “So what do you like about oral sex? Anything you don't like about oral sex?” I can't quite believe I am having this conversation and wish I was better prepared. I remember that I need a few more specifics.
“With the oral sex, were you giving, receiving, or both?”
“Did you use a condom?”
I recognize, from a purely medical standpoint, that just receiving was a relatively safe and sensible choice, but the part of me that is still thinking about intimacy and love would have preferred that this had been more of a give-and-take arrangement. I yield briefly to the double standard and find myself worrying about the girls. Are they my patients, too? Would they tell me about this? Do their parents know? Are some of these parents the ones who decided to “wait a few years” when I advised HPV vaccine for their daughters? I am not surprised by the condom answer but nevertheless feel a little anger mixed in with my initial disbelief. I guess he could be doing things that are worse, some a lot worse. I realize that I would like this conversation to be over.
This time I am the one who pauses before pushing on.
“Well, with oral sex, at least you don't have to worry about pregnancy and babies. But you are putting yourself and your partners at risk of developing sexually transmitted infections, like herpes.”
He says nothing and breaks eye contact.
I feel inadequate and out of touch. This is not the same happy feeling I get when a parent thanks me profusely for “helping” a 2-year-old with a self-limited viral illness. I suspect that I haven't been very helpful in this instance and wonder where else he might get information or even advice and guidance. I don't suppose he can talk with his parents about this, and his teachers may not be very accepting either. I think about suggesting the Web and then realize that this may be where he learned about (or even watched) oral sex in the first place. I have far exceeded the allotted 20 minutes for this visit and remember that I have other patients waiting. Most of their problems aren't serious or urgent, but those parents and my nurses want me to be on time just the same. And for better or worse, the world of well babies and runny noses is much more comfortable and familiar.
I wrap up.
“We can talk about things like this anytime you want. Just tell your parents you want to talk to me about something private. The nurse will bring you the sports form in the waiting room. I hope your team has a good season and look forward to seeing you again next year.”
As I complete his sports form, I feel relieved but wistful. If he had asked me about this last year, I would have tried to convince him that he wasn't ready for sex. Should I have known then that I needed to address this with him? It's too late to turn his clock back, but how about my other patients? How will I know when it is time to start talking to them about sex, drugs, and rock ‘n’ roll? Is Tanner II too late? How about the very first pimple or pubic hair? What would I say to a prepubertal 12-year-old?: “Some teenagers are ‘not really’ sexually active but are having oral sex. Have you thought about trying this yourself? Oh, and if you don't have the slightest idea what I am talking about, you must promise not to tell your parents that we had this conversation.” I remind myself how easy it was to decide to become a pediatrician and how much I love my job. I resolve to become more adept at caring for my “grown-up” patients and pick up my next chart. It's another sports physical.
Published online: April 09, 2009
Specific elements of the dialogue in this commentary are drawn from the author's encounters with several patients. Gregory Hayden is professor of pediatrics at the University of Virginia where he has worked as a general pediatrician for 30 years.
© 2009 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.