Monday, July 1, 2013

Pediatricians' Pride:Upgrading Care of LGBTQ Youth

If a pediatrician sees somewhere around fifty patients a day in a busy practice, there is a good chance that she will see a youth who identifies as LGBTQ, short for lesbian, gay, bisexual, transgender or questioning.   A "questioning" youth, according to the AAP is "anyone struggling with sexual attractions and identity formation,"  according to a summary of the new policy published in AAP News.

The AAP's Committee on Adolescence has just come out with recommendations for providers on how to best approach and care for these youth.  According to the lead author of the study, the approach is that "these children...are normal; they are just different." The emphasis in the article and its recommedations is on the good general physical and mental health of LGBTQ youth.  An updated guideline helps provide compassionate care in a few special areas based on the epidemiology and social  behaviours of LGBTQ youth.  We know a lot more about them than we did even in 2004 when the last official statement on caring for this subset of the population came out.

"Sexual Minority" youth is a term used in the report to describe LGBTQ youth.  Some may quibble with this term but the spirit of the report is an admirable one.  Sexual minority youth may be at higher risk for early sexual activity, multiple partners, and unprotected sexual encounters and therefore higher risk for STI's.  The report also points out that "Many adolescents who self-report as lesbian or gay may have sex with members of the opposite sex, and thus behaviors do not equal identity" Recognizing this is important for practitioners since they should not assume that a lesbian teen is free from the risk of pregnancy.  Providers need to ask questions using gender neutral language (e.g. "Tell me about your partner?")and do a complete assessment.

Caring for youth means really caring and when providers stop to evaluate their own biases and knowledge and the lacunae that sometimes make them appear insensitive, they will be able to engage their patients in a refreshing and interesting way that not only spices up everyday routines in practice but will endear them to some of their most needy and interesting patients.

image from via Google images

Tuesday, April 30, 2013

Seven Questions Your Health Care Provider Should Ask Your Teen

Although the average doctor face-time is somewhere around 6-7 minutes with a pediatrician these days, it might actually be possible for the most dedicated among them to squeeze in a few potentially life-saving questions.  Here are seven such queries that help educate and elucidate around issues of relationships, risk, romance and sexuality.

ONE: Who do you hang out with? Tell me about your friend group. (gently opening with relationships and friends...)

TWO: On the spectrum of gay to straight or somewhere between, where would you say you are now?(...recognizing that this is a spectrum and a fluid status....)

THREE: Have you ever had an unwanted sexual experience? Have you ever had a sexual experience you regretted?(.....letting the teen know that the doctor cares and that this is a safe place if and when he/she is ready to talk about it....)

FOUR: Have you had skin-to-skin contact below the waist with another person? That's skin-to-skin contact below the waist with any body parts.  Think about that. (...avoiding altogether the concept of "sex" and getting at risky behaviours and a "spectrum" of sexual activity....)

FIVE: Would you say that your romantic relationships or dates have been respectful? How about safe from STD and pregnancy worries?(...allowing for some evaluation of relationships and permission to discuss concerns about STDs,  contraception,  power imbalances, abusive situations or unhappiness....)

SIX: How do you really feel about condoms? Do you know how to use them?(...recognizing that almost no one prefers them but hey! let's be real...what are the alternatives?)

SEVEN: (for boys): Do you know how to do a testicular self exam?(...healthy bodies are sexy and testicular cancer is a young man's disease)

On a given day I can imagine re-prioritizing these questions or adding others.  But these seven are openers to many dialogues.  It should go without saying that these conversations with teens need to happen in a private setting, without parents present, with the reassurance of confidentiality made explicit and with clothes on.  For all parties, including parents in the waiting room, the benefit of these conversations is enormous and gratifying: healthier, savvier kids; reassured parents; and practitioners who know they have done their job well.
image from via

Monday, April 8, 2013

Parents Reluctant to Vaccinate Kids against HPV?

As one of the medical providers at Barnard College, I am asked every day by students to be tested for STD's.  When I ask them what tests in particular they have in mind, they often answer "all of them."

We, like most clinicians in this kind of clinic only screen for HIV, chlamydia and gonorrhea. And that is not "all" of the STDs. As a followup question I often inquire whether the student has had the three HPV, often called by its brand name, Gardisil, vaccine.  I have been shocked in the year I have been working there by how often students are not aware if they got the vaccine; do not know what HPV is or say that their parents "didn't want them" to get it. Then I launch into my little speech about how they can make their own decisions now and we have a tutorial on HPV.

Now a new study just released in the prestigious journal Pediatrics sheds some light on this situation.  It shows that over half of parents of teens are not vaccinating their teens against Human Papillomavirus or HPV. And the share of unvaccinated teens has increased even though they are making this decision against the medical advice from their own medical providers.

The three most common reasons for not vaccinating against HPV were:
  • my child is not sexually active
  • the vaccine is not needed or not necessary
  • safety concerns/side effects

These reasons linger and in fact increased over the study period from 2008 to 2010 in spite of scientific, medical and public health advice to the contrary.

So what is HPV vaccine and what do most clinicians who see teens and young adults say about it?
  • HPV is the most common sexually transmitted disease.
  • HPV is ubiquitous and easily transmitted even with non-intercourse sexual activities (read "oral sex")
  • By age 18 over 70% of sexually active adolescents have already acquired HPV
  • Their are over 100 sub types of HPV
  • Most healthy people will clear HPV from their system through natural immune mechanisms
  • BUT, four of the 100 subtypes do not clear spontaneously.
  • These four subtypes cause cervical cancer, head and neck cancers, and genital warts
  • Men and women, young men and women, and girls and boys are all equally susceptible to infection with HPV
  • The HPV vaccine was designed to protect agains the four nasty subtypes of the virus that cause most of the lasting and disfiguring diseases (warts and cancers)
  • The vaccine is recommended for boys and girls ages 12 and up
  • Finally, the vaccine is exceptionally safe and effective
  • PS: it requires a series of three shots and it hurts a bit more than the average immunization.
It is my belief that the marketers from Merck should have called this vaccine "the first shot we have to protect against cancer. " The mistake was in connecting the vaccine with sex, teens and heaven forbid, teen sexuality. This was the cue for Michelle Bachman to get on board with those who talk about the "ravages" of HPV vaccine.  

The denial mechanisms that parents need to stay sane as they dare to think about their teens becoming sexually active in a dangerous world have held them back from making smart decisions about this shot.    We don't' wait until our kids step on a rusty nail to get a tetanus shot.  We shouldn't wait until they are infected or have abnormal Pap smears to give them the HPV shot. Besides it would be too late by then.

Call for an appointment today if your children have not had the vaccine.  At least listen to what experts have to say.  And remember when the eighteen year old comes in to see me in college and is ready to make her own decision--having done some reading, research and chatting with friends, it is often too late for the vaccine to work.

image from

Thursday, March 21, 2013

Talking Teen Sexuality with Parents

I have a date with the Mamaroneck PTA.

"Are you sure you want to talk about that?"
"Can you make it funny?"

And then came the understated undercurrent of advice to make it appropriate for parents of middle schoolers, kids with disabilities and special needs, and moms and dads of high school students, some of whom are about ready to go off to college.

You might watch HBO's Girls.  But you might also think that cannot be your daughter who is having unprotected sex, poking Qtips in her ears and getting sexually transmitted diseases and pregnant.  Even though the demographic of the show is precisely the white middle class, highly educated metropolitan cohort that many of Mamaroneck's students go on to inhabit,  it still is not your daughter.

So here is a preview of what I will be discussing at the PTA/SEPTA meeting on April 29:

  • What's new in Contraception?
  • STDs: diagnosis, prevalence and prevention
  • LGBTQ in our families
  • Promoting health relationships for young people
  • Tips on raising sexually healthy children
  • and---because even though you might think you can talk about "everything" with your children, you (or they) probably won't--the final topic of the evening is:
  • Seven questions your pediatrician/provider should be asking your teen girl and boy
You will go away empowered to understand the culture that is not just on TV, to arm yourself with information and to advocate for your children so that they have the kind of medical care they and you deserve in order to prepare them for the terrain they walk today and will traverse tomorrow.

image by from Google images

Monday, January 28, 2013

Moments of Repair

In my effort to return to blogging and posting about teens and young adults and their myriad issues beyond head injury and concussion,  I am publishing the second installment of a wonderfully elegant piece on communicating with our teenage children.

This article which I am re-naming "Moments of Repair" because I think it is such a lovely thought for all of us to hold onto even when dealing with our adult peers was written by a colleague of mine, the clinical psychologist Kenneth Barish.  Dr Barish is Clinical Associate Professor of Psychology, Weill Medical College, Cornell University. He is the author of Pride and Joy: A Guide to Understanding Your Child’s Emotions and Solving Family Problems (Oxford University Press, 2012).  Dr Barish and I have shared experiences over the years with families and kids and his advice is always helpful. He is in private practice in Westchester County, New York.


When parents are often angry and critical of their children, children, in turn, become angry and argumentative, stubborn and defiant. Argument begets argument.  When we argue frequently with our children, children become good at arguing.

Here are some additional recommendations that have been helpful to many families in beginning to turn around vicious cycles of criticism, argument, and defiance:

·      Set aside time, every day, to listen to your child’s concerns.

In every family, especially when we are anxious and frustrated, parents will become critical and may say hurtful things to their children. At these times, it is important for us to take the lead and begin to repair these hurtful interactions.

In these moments, make a deliberate effort to set aside criticism and judgment as long as you can. Acknowledge your child’s or adolescent’s disappointments, frustrations, and hurt feelings, and every small gesture she makes toward cooperation and compromise.  The following advice is important enough to say again:  Tell her what is right about what she is saying or doing before you tell her what she is doing wrong.

Children learn invaluable lessons from moments of repair.  They learn that, although it is not always easy, moments of anger and misunderstanding are moments, and they can be repaired. This may be the most important lesson we can teach our children, the lesson that is most vital to their emotional health.  Disappointments are disappointments.  Bad feelings are not forever.

·      When you need to criticize, criticize thoughtfully and gently.

·      Express appreciation.
Criticism - and the resentment it creates - although necessary in small doses, is a toxin.  Appreciation is the antidote for resentment.

·      Give Them Time
In talking with children about any difficult problem, do not insist on an immediate response. Even minor criticisms evoke defensiveness in most children; a defensive wall quickly comes up. Children (and perhaps, especially adolescents) need time to think about, and eventually accept, our instruction and advice. When you bring up a problem, place the problem before your child, ask her to think about it, and then plan a discussion for the following day. You can always end with, “Let’s talk about this again tomorrow.”

 image from 
via Google images

Wednesday, January 23, 2013

Kobe Bryant on Concussions and Rest

It’s one thing when a state law or a policy that comes down from above says that resting is the best treatment for concussion.  But it’s another when a star player like Kobe Bryant has something to say about it.

Commenting in the LA Times and re-quoted on, Bryant said of his teammate, Paul Gasol who missed five games due to a concussion:

“I was a little angry with him the other day because he’s coming to practice and coming to the games,’ Bryant said. ‘Stay home. Cut all the lights off. Just rest. Let your brain rest. But he wants to be around [the team]. That’s the type of teammate he is.”

What Bryant is recognizing is that healing from a concussion requires athletes, especially at the NBA level to do something that often runs counter to who they are.  That’s to withdraw from the limelight, the locker room, the home territory with the friends and teammates and be quiet and REST.

According to the basketball blog site TrueHoops, the NBA has gotten serious about concussion management.  Even though the degree and frequency of hits may not be what we see in the NFL, they are implementing a multistep protocol to keep players safe in the short and, maybe most importantly, the long run.  Under the guidance of Dr Jeffrey Kutcher, the program is taking hold.  Kutcher is quoted on Slamonline as saying:  “the policies need to reflect the fact that it’s a team effort to diagnose concussions and look out for injuries, because the injured athletes oftentimes don’t know they're injured.”

 It does seem surprising that we have very little to offer injured players other than vigilance—no medication, no shots (meaning vaccinations), no therapy of any kind.  But as Bryant says: ‘It just takes time. There’s nothing you can do really to expedite it. It’s not a muscle. You can’t massage it. There’s nothing you can do. You just rest.’”

image from via Google images