Teral Gerlt
Working with adolescents is both challenging and rewarding. Adolescent healthcare encounters are often situations in which the provider’s agenda may be quite different from that of the teen. There is so much that healthcare providers need to teach teens about healthy life behaviors and practices, and the reception is frequently lukewarm at best. Time, patience, and mutual respect are essentials for open communication.
Educational Objectives
1. Identify the developmental influences impacting adolescent behaviors and learning.
2. Describe important components when communicating with adolescents.
3. Identify factors that increase the risk for sexually transmitted infections (STIs).
4. Apply the Centers for Disease Control and Prevention (CDC) guidelines concerning management and treatment of STIs.
Case Presentation and Discussion
Leslie Montgomery, a 16-year-old white female, comes to your clinic today because she wants to start birth control pills. She has been in a new relationship for the past 2 months and wants to use something to keep her from getting pregnant “besides condoms.” She is very concerned about having to have a pelvic exam because she has never had one before. She was told by one of her girlfriends that she didn’t have to have one to start the pill. She also mentions that perhaps she should have an examination because she has a discharge that is new and she doesn’t like it.
How will you approach this teen? 
Approach to Taking a Sexual History from an Adolescent
Generally, adolescents, especially females, are reluctant to seek health care about sexuality concerns or issues unless they can depend upon a confidential environment in which to do so (Reddy, Fleming, & Swain, 2002). Therefore, it is important to establish confidentiality at the start. Also, keep in mind that an open, respectful, and nonjudgmental attitude is essential when working with adolescents in order to obtain a thorough sexual history and deliver prevention messages effectively.
Taking a sexual history should be integrated into the general health history. The clinician should reassure the individual that asking sexual questions is a normal part of clinical practice: “I’m going to ask you a few questions that I ask all my young-adult patients about their health and relationships” (Rakel, 2002, p. 14). Giving appropriate, factual information that uses medical-sexual terminology rather than slang is helpful to the extent that the teen understands what is being said.
One also needs to ask open-ended, broad, nonjudgmental questions that will allow the teen to discuss his or her ideas and sexual activities. For example, asking the question, “Have you ever had a romantic relationship with a boy or a girl?” allows for a more inclusive description of sexual activity than asking the traditional, “Are you sexually active?” question. Phrases such as “Explain how that happened,” “What happened next,” or “Tell me about a typical date” elicit more complete information than do close-ended questions. “When you think of people to whom you are sexually attracted, are they males, females, both, neither, or are you not sure yet?” is a useful question that opens up a conversation for youth struggling with their sexual orientation (Murphy & Elias, 2006). Questions that contain “why” can require a level of analysis beyond the capabilities of young people operating at a concrete level of cognition.
Phrase questions that may be emotionally laden in a way that lets clients know that their experience may not be exceptional (e.g., “Many people have been sexually abused or molested as children; did this happen to you?” [Rakel, 2002] or “How often do you masturbate?” rather than “Do you masturbate?” [Rakel]).
Begin the interview using open-ended questions, setting the tone to be accepting as much as possible. It is essential that you assure the teen that the information from the visit will be kept confidential unless the provider believes the teen may do harm to him- or herself or someone else.
The Centers for Disease Control and Prevention (CDC) has a practical set of questions to incorporate into the sexual history (see Box 29-1).
Further sexual history reveals that she and her partner do not always use condoms because her partner does not like them. Their last vaginal intercourse was this past weekend but she says, “we did use condoms that time.” Her current partner is an 18-year-old who dropped out of high school his junior year but is working. Age at first coitus for Leslie was 15 years and consensual. She has had two other sexual partners in the past. She states that she has never had anal intercourse but does have both oral and vaginal intercourse with her current partner. She has only had sex with males and has only used condoms as a birth control method.
Box 29–1 The CDC’s Five Ps
1. Partners
• “Do you have sex with men, women, or both?”
• “In the past 2 months, how many partners have you had sex with?”
• “In the past 12 months, how many partners have you had sex with?”
2. Prevention of pregnancy
• “Are you or your partner trying to get pregnant?”
• If no, “What are you doing to prevent pregnancy?”
3. Protection from STIs
• “What do you do to protect yourself from STIs and HIV?”
4. Practices
• “To understand your risks for STIs, I need to understand the kind of sex you have had recently.”
• “Have you had vaginal sex, meaning ‘penis in vagina sex’?”
• If yes, “Do you use condoms: never, sometimes, or always?”
• “Have you had anal sex, meaning ‘penis in rectum/anus sex’?”
• If yes, “Do you use condoms: never, sometimes, or always?”
• “Have you had oral sex, meaning ‘mouth on penis/vagina’?”
For condom answers:
• If never: “Why don’t you use condoms?”
• If sometimes: “In what situations, or with whom, do you not use condoms?”
5. Past history of STIs
• “Have you ever had an STI?”
• “Have any of your partners had an STI?”
Additional questions to identify HIV and hepatitis risk:
• “Have you or any of your partners ever injected drugs?”
• “Have any of your partners exchanged money or drugs for sex?”
• “Is there anything else about your sexual practices that I need to know about?”
Source: From Centers for Disease Control and Prevention. (2006b). Sexually transmitted diseases: treatment guidelines, clinical prevention guidance. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved September 17, 2008, from http://www.cdc.gov/std/treatment/2006/clinical.htm#clinical2
Menarche was at age 12; her cycles are usually regular every 28 to 30 days and last about 4 days. She complains of severe cramping for the first 2 days with medium flow. Her last menstrual period (LMP) was approximately 2 weeks ago, although she does not really keep track of dates for her cycles.
She denies a history of any skin lesions or rash, dysuria, abdominal pain, dyspareunia, or a sexually transmitted infection. She has noticed a little spotting a couple of times this last month, especially after having sex, and a little white vaginal discharge for the past few weeks.
She has a negative personal medical history. Her family history is positive for hypertension (father) and type 2 diabetes (maternal grandmother).
Leslie’s social history is positive for “occasional” alcohol at parties, which she describes as three to four drinks once a month. She admits to smoking socially when at parties, but denies any other drug use. She describes herself as a “good” student with a B average. She plans to go to college but is unsure what she wants to major in.
What are your concerns after getting this history?
See the STI risk factors listed in Box 29-2.
Leslie is at risk for both pregnancy and STIs due to irregular condom use and having three sexual partners in the last year. She is having some vaginal spotting, which could be related to a STI. She is also using both alcohol and tobacco.
What are your working diagnoses prior to your physical examination?
You start with the following working diagnoses:
• Contraceptive need
• Rule out pregnancy
• Rule out STIs
• Bloody vaginal spotting and discharge of unknown etiology
• Alcohol and tobacco use
What type of physical examination would you do?
In accordance with current recommendations of the American Cancer Society’s “Guidelines for Early Detection of Cervical Cancer,” which states that screening should begin approximately 3 years after first sexual intercourse (Saslow et al., 2002), she does not need a pap screening today. However, she does need a pelvic and STI examination.
What clinical findings are you looking for?
The three most common sexually transmitted infections in teenage women are chlamydia, gonorrhea, and syphilis. Chlamydia is the most common of these. In 30–70% of women chlamydia is asymptomatic, but the usual symptoms, if they appear, include vaginal discharge that may be clear to white or yellow; bloody vaginal spotting; dysuria and/or pyuria; mucopurulent cervicitis with edema, erythema, and hypertrophy; mild abdominal pain; Fitz-Hugh-Curtis syndrome (right upper quadrant pain); or foreign body sensation in eyes with conjunctivitis.
Box 29–2 Risk Factors for Sexually Transmitted Infections
• Adolescent younger than 15 years of age
• Sexually active adolescent, especially with two or more partners in 6 months, high frequency of intercourse, or high rate of new partners
• Use of drugs or alcohol, or other high-risk behaviors
• Pregnancy or abortion
• Homosexual
• Victim of abuse, rape, or incest
• Incarcerated, runaway, homeless, or in a group shelter or detention home
• Clients in sexually transmitted infection (STI) clinics or with any other STI or previous history of STI
• Lack of family availability; low level of parental support and monitoring
• Beliefs about normative behaviors among peers
• Inappropriate healthcare behaviors (e.g., not seeking medical care, not adhering to treatment regimen, failure to recognize symptoms, delay in notifying partners, nonuse of barrier contraceptive)
Sources: In Gerlt, T. J., Kollar, L. M., & Starr, N. B. (2009). Gynecologic conditions. In C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. Blosser (Eds.), Pediatric primary care (4th ed., p. 933). Philadelphia, WB Saunders; data from Biro, F. M., & Rosenthal, S. L. (1995). Adolescent STDs: diagnosis, developmental issues, and prevention. Journal of Pediatric Health Care, 9, 256–262; Bonny, A. E., & Biro, F. M. (1998). Recognizing and treating STDs in adolescent girls. Contemporary Pediatrics, 15, 119–143; Shrier, L. A. (2005). Bacterial sexually transmitted infections: gonorrhea, chlamydia, pelvic inflammatory disease, and syphilis. In S. J. Emans, M. R. Laufer, & D. P. Goldstein (Eds.), Pediatric and adolescent gynecology (5th ed., pp. 565–614). Philadelphia: Lippincott Williams & Wilkins.
Gonorrhea (GC) is also usually asymptomatic in women. The typical signs and symptoms of GC infection include dysuria; urethritis; thick, green, profuse vaginal discharge; cervicitis; bleeding; dyspareunia; Skene’s or Bartholin’s gland abscess; or exudative pharyngitis.
Syphilis is less common. The primary form usually presents with a single painless papule with serous discharge on a smooth base with raised edges. The location of the chancre may be vaginal, anal, or oral. In secondary syphilis, the classic copper-penny rash presents, generally on the palms of the hands and soles of the feet. There also may be mucocutaneous lesions and painless regional lymphadenopathy.
Height and weight, body mass index (BMI), blood pressure, thyroid, heart, lungs, breast, abdominal, and pelvic examinations are all parts of the assessment needed before beginning hormonal contraception and to rule out STIs.
Leslie’s general physical examination reveals: height 5’ 3”; weight 112 pounds; BMI 19.8 (25%); blood pressure 116/68. Her thyroid is smooth, without enlargement. Her heart rate is regular with no murmurs, rubs, or clicks. Lungs are clear to auscultation. Breasts are nontender, Tanner stage 4, without masses. Her abdomen is soft, nontender, with no masses, and without organomegaly.
Pelvic examination: Your examination reveals external genitalia without lesions, negative Bartholin’s, urethra, and Skene’s; Tanner stage 4. Her vagina is pink with normal ruga and minimal clear to white discharge. Her cervix appears nulliparous and pink with thick clear mucous at the os.
Bimanual examination: You perform a bimanual examination and find her uterus to be anteverted, firm, smooth, nontender, and nonenlarged; her adnexa is without masses or tenderness; and the cervix is firm, without cervical motion tenderness.
What laboratory studies would you order?
In deciding which studies to order, the provider needs to know what organisms to look for and the difference in and accuracy of tests.
Epidemiology
Sexually transmitted infections are considered an epidemic in the United States at this time. Their highest rates are among adolescents; almost half of the 19 million new cases yearly occur in teens (CDC, 2007). Young adults ages 15–24 years and young women between the ages of 15 and 19 have the highest rates of N. gonorrhoeae and C. trachomatis (CDC, 2006a). Youth in detention facilities; male homosexuals; injection drug users; and minorities, especially African Americans, are all at high risk.
Some factors that contribute to this epidemic in teenagers include the increasingly early age and frequency of sexual activity, inconsistent use of contraceptive and protective devices, physiologic characteristics that predispose adolescents to infection, adolescents’ lack of access to and use of health care, and societal influences. The increased use and availability of accurate screening tests for diseases, especially chlamydia, is another factor that may be contributing to the higher reported numbers of STIs.
Chlamydia Trachomatis and Testing
Chlamydia infection is the most frequently reported bacterial STI, with a rate of 347.8 cases per 100,000 reported in 2006, up 5.6% from 2005 (CDC, 2007). Adolescent females have the highest percentage of these cases. Young women ages 15 to 19 years old account for 37% of the chlamydia infections, and 20-to 24-year-olds represent 36%. Because of the increased incidence in female adolescents, all sexually active young women in this age group should be screened at least annually because chlamydia is frequently asymptomatic. Untreated chlamydia can progress to pelvic inflammatory disease (PID); as many as 40% of women with untreated infections develop PID, and 20% of those may lose their fertility (CDC, 2007).
For sexually active adolescents with possible chlamydia, many family planning clinics use direct immunofluorescent smears. Nucleic acid hybridization tests (DNA probes) and nucleic acid amplification testing (NAAT) are acceptable alternatives for teens, especially in high-prevalence populations. Only NAATs can be done using either a cervical swab or urine and, thus, are the preferable testing method for adolescents (CDC, 2006a). It is important to note, however, that if chlamydia is suspected in younger children, a culture is the only acceptable method to diagnose this agent. Chlamydia in young children may be associated with sexual abuse and must be correctly identified. Therefore, culture results, not DNA detection, must be used.
Gonorrhea and Testing
Gonorrhea is caused by Neisseria gonorrhoeae, a nonmotile, gram-negative diplococcus. It is often found along with chlamydia or other STIs. The gonorrhea rate for 2006 was 120.9 cases per 100,000, which is up 5.5% from 2005 and an increase for the second year in a row (CDC, 2007). The highest rate for adolescents occurs in the 15- to 19-year-old group. There are more reported cases of GC in African Americans than whites (18:1). The infection is often asymptomatic, with as many as 80% of young women infected with GC reporting no symptoms (Stamm & McGregor, 2001). Untreated GC can also progress to PID, with the issue of infertility as a possible outcome.
The definitive test for gonorrhea in women is a culture on selective media with determination of penicillin resistance. DNA probes and NAATs are also available for GC testing (Spigarelli & Biro, 2004). NAATs are more reliable with cervical swab testing than urine testing for GC (Shrier, 2005); gram stains of vaginal discharge or cervical secretions are not recommended (CDC, 2006a).
Syphilis and Testing
Syphilis, caused by Treponema pallidum, is a motile spirochete with a prevalence rate of 3.3 cases per 100,000 in 2006, an increase of 13.8% from 2005. Although the majority of this increase (11.8%) was in males and primarily in men having sex with men (MSM), the rate for women increased for the second year in a row (from 0.9 per 100,000 to 1.0 in 2006). Furthermore, the rate of congenital syphilis, after being down 12% from 2004 to 2005 to 8.2 per 100,000 live births, went up to 8.5 in 2006 (CDC, 2007).
To test for syphilis, direct visualization with dark-field microscopy or direct immunofluorescent antibody (DFA) provides definitive results. Several serologic nontreponemal tests including the Venereal Disease Research Laboratories (VDRL), rapid plasma reagin (RPR), and the automated reagin test correlate with disease activity. Because they decline after treatment, they are used to monitor disease progression. Treponemal tests such as the fluorescent treponemal antibody absorption (FTA-ABS) and the microhemagglutination test for Treponema pallidum (MHA-TP) are confirmatory, but once positive, they usually remain so for years (CDC, 2006a).
HIV and Testing
HIV is another sexually transmitted infection that can occur in persons who engage in unprotected sexual intercourse. Adolescents in the United States are often at risk due to their sexual behaviors. Although the Youth Risk Behavior Survey for 2007 indicated a decrease in those who have ever had sexual intercourse, the decreases have leveled off. Condom use has also leveled off at about 61.5% (CDC, 2008). Thus, adolescents are still at risk for this serious disease.
Usually HIV is diagnosed by tests for antibodies against HIV-1, although some combination tests also detect antibodies against HIV-2. The first step in diagnosing this condition is the use of a sensitive screening test, either the enzyme immunoassay (EIA) or the newer rapid test. The latter test has allowed clinicians to make a significantly accurate presumptive diagnosis of HIV-1 infection within half an hour. Reactive screening tests must then be confirmed by a supplemental test such as the Western blot (WB) or an immunofluorescence assay (IFA) (CDC, 2006a).
All 50 states require most STIs to be reported; however, mandated reporting rules vary from state to state. All 50 states allow adolescents to be evaluated and to receive confidential treatment for STIs, but management of children younger than 13 years old requires coordination between the pediatric provider and child protective authorities.
Laboratory Tests for Leslie
The wet mount of vaginal secretions was checked immediately after the pelvic examination was completed. The results, which included saline for microscopic examination to look for white blood cells (WBCs), clue cells, trichomonads, and bacteria and the 10% potassium hydroxide (KOH) for whiff test and microscopic examination to look for yeast (branching hyphae and spores), were all negative. You also checked a urine specimen for pregnancy and the result was negative.
Specimens were also sent to the laboratory.
Chlamydia: NAAT on cervical swab
Gonorrhea: NAAT on cervical swab
Recommended blood work for rapid plasma reagin (RPR) for syphilis and an enzyme immunoassay (EIA) for HIV were declined by Leslie.
Making the Diagnosis
What is your assessment?
First, Leslie has a contraceptive need, which she has expressed and is evident from her sexual history. Second, she also has a possible sexually transmitted infection that, if diagnosed, needs treatment.
Management
What will be your plan, given the two diagnoses you have made?
You mentally outline your plan as follows:
• Contraceptive need.
• Patient education about oral contraceptive pills (OCPs).
• Patient education about condom use.
• Provide an Rx for OCPs.
• Rule out a sexually transmitted infection: chlamydia, gonorrhea, syphilis, or HIV.
• Await lab results.
• Patient education and counseling about safer sex.
Counseling of the Adolescent
The adolescent’s perspectives about sexual activities that are appropriate for them may not match those of the primary care clinician. Teens and young adults are faced with media portrayal of sexuality at a time when they are using role models for their own behaviors. Family and community cultural norms as well as peer group pressures can affect the attitudes and beliefs about sexuality and sexual behaviors that they are developing (American Academy of Pediatrics [AAP], 2001; Brown & Brown, 2006). All these influences need to be considered and addressed when counseling the teen.
Using the answers given by the adolescent in the sexual history will help guide the counseling and education provided to the individual teen. Trust, honesty, mutual respect, an open nonjudgmental attitude, and confidentiality are extremely important to the adolescent (Burgis & Bacon, 2003). It may take several visits for the trust relationship to grow before the adolescent is willing to divulge more private thoughts and behaviors. The clinician’s job is to assure the adolescent of the confidential nature of the relationship and provide opportunities for trust to develop.
Adolescents need to know that they have choices about sexual behaviors that have different outcomes. Adolescents should be counseled that abstinence is the most effective strategy for the prevention of pregnancy, STIs, and HIV/AIDS (American Academy of Family Physicians [AAFP], 2006; AAP, 2001; American College of Obstetricians and Gynecologists [ACOG], 2005). It is a choice to remain abstinent and a choice to become sexually active, not just something that happens, and with that choice comes responsibilities. Open communication and respect for self and partner will lead to choices that include protection from STIs and pregnancy.
Counseling and Development
Counseling adolescents requires that the clinician make adjustments based on the teen’s stage of psychosocial developmental (Burgis & Bacon, 2003; Clark, 2003) because not all teens are developmentally at the same level. Piaget demonstrated that early adolescents, ages 12–14 years, are concrete thinkers and lack the ability to comprehend the abstract thought of “what if.” When counseling youth at this age, the healthcare provider needs to use language that is characterized by simple concrete terms. Pictures, direct questions, and statements will help facilitate their understanding. Middle adolescents such as Leslie, ages 15–17 years, are starting to understand abstract concepts but often regress to concrete thinking in stressful situations. The clinician needs to adjust the approach to the middle adolescent accordingly, helping him or her to identify inconsistencies in reasoning and guide the teen’s thought processing through to logical consequences of choices and behaviors. Late adolescents, ages 18–21 years, generally have abstract thought more firmly established and are future oriented. However, this ability will vary, as with the general adult population.
Contraceptive and Safer Sex Counseling
Clinicians who provide contraceptive and safer sex counseling to adolescents should understand that the successful use of any method requires a complex process of knowledge, decision-making skills, and public behaviors. It is also important to use gender-neutral phrasing when discussing safer sex and contraception and not assume heterosexuality. To use contraceptives/protective barriers successfully, an individual must master the following (Gerlt, Blosser, & Dunn, 2009):
• Knowledge for contraception: Most adolescents need to learn about a barrier method for contraception, such as male or female condoms, to prevent an STI as well as about a variety of hormonal methods for contraceptive purposes.
• Ability to plan for the future: Adolescents need to admit to themselves that they will have sex in the future and that they have the ability and resources necessary to use a contraceptive method consistently and correctly. Further, they must be willing to use the chosen method of protection consistently, not just when it is convenient to do so.
• Willingness to acquire needed contraceptive/barrier methods publicly: Adolescents wanting to be successful in using contraceptive/barrier methods successfully will need to be public with requests for contraceptive and/or protective devices; for example, to purchase condoms at a local pharmacy or to seek services at the local clinic, school-based health facility, or private practice. This is not an easy step for many teens and may need rehearsal.
• Communication skills: Adolescents must be able to communicate with another person or persons such as their partner, healthcare provider, pharmacist, or salesperson about their individual contraceptive/ protective barrier needs. The ability to express their feelings about sexual activity, how it affects them, and the thinking behind their decisions to be sexually active is also a needed communication skill.
The next afternoon you receive a faxed lab report: Leslie’s NAAT is positive for chlamydia but negative for GC.
What is your plan now?
You need to consider how to contact Leslie to assure her confidentiality. Will you treat her partner too? If not, who will you refer him to? Do you need to report to the public health officials, or will your lab do that? Many healthcare systems have guidelines or protocols to help you answer these questions.
Per CDC guidelines (CDC, 2006a), treatment of an uncomplicated chlamydial infection includes:
• Azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice a day for 7 days.
• Refer partners for treatment. It is recommended to treat the last partner and any partner exposed within the 60 days before the onset of symptoms.
• Recommend that the client abstain from intercourse for 1 week after single dose treatment or until completion of a 7-day course. The client also needs to abstain until after her partner has completed treatment.
• Rescreen 3 to 4 months after the positive test because a high prevalence of C. trachomatis infection is found in women with a chlamydial infection in the preceding several months. Reinfection is usually the cause of infection and elevates the risk for PID.
For general STI treatment measures, see Box 29-3.
After contacting Leslie, she wants to come into the clinic to take her one-time dose of azithromycin and talk further about this new issue. When you see her the next day, she is very upset about having an STI and does not know how to talk with her boyfriend about this. How did this happen? Did he give it to her or her him? Was he cheating on her? Will this make her unable to have babies?
How will you answer her questions?
You answer Leslie’s many questions and reassure her that with treatment her risk of long-term sequelae is minimal; however, with reinfection the risk would increase. You help her problem solve talking with her partner about the chlamydial infection and plan for his evaluation and treatment. Once again you review with Leslie the guidelines for practicing safer sex in the future and role play negotiating skills that she can use with her partner.
Box 29–3 General Treatment Measures for Sexually Transmitted Infections
• Have patient abstain from sexual intercourse until patient and partner are cured (treatment complete and symptoms resolved). The consequences of untreated sexually transmitted infections (STIs) should be explained.
• Test for other STIs, including hepatitis B, human immunodeficiency virus, bacterial vaginosis, and trichomonas.
• Notify, examine, and treat all partners of patient for any identified or suspected STI.
• Report STIs to the state health department. Reporting to appropriate authorities is important to identify those at risk, recognize new strains, and assess the extent of infection in the community and the effect of prevention efforts.
• Provide regular sex health assessment including Papanicolaou (pap) testing, vaginal examination, and testing for STIs.
• Give hepatitis B and HPV vaccines if not done already.
• Discuss safer sex practices, including abstinence and use of condoms.
• Educate and counsel about complications and transmission of STIs, as well as perinatal consequences.
Source: From Gerlt, T. J., Kollar, L. M., & Starr, N. B. (2009). Gynecologic conditions. In C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. Blosser (Eds.), Pediatric primary care (4th ed., p. 936). Philadelphia: WB Saunders.
When will you see Leslie again?
You plan to see her again in 3 to 4 months for a repeat NAAT, to see how she is doing with her OCPs, and to generally check in. Keeping frequent contact with the adolescent helps build rapport and your education and counseling can be reinforced.
Key Points from the Case
1. Understanding the developmental level of your patient is essential for excellent care.
2. Open, honest, and nonjudgmental communication is crucial when working with adolescents.
3. Understanding the risk factors for STIs and why adolescents are inherently at risk by nature is important to their care.
4. Knowing where to find information, guidelines, and evidence-based resources (e.g., CDC, AAP, your healthcare system, etc.) will simplify your work.
REFERENCES
American Academy of Family Physicians. (2006). Adolescent health care, sexuality and contraception. Retrieved September 20, 2008, from http://www.aafp.org/online/en/home/policy/policies/a/adol3.html
American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence. (2001). Sexuality education for children and adolescents. Pediatrics, 108, 498–501.
American College of Obstetricians and Gynecologists. (2005). Committee on Adolescent Health Care Resource Guide: Adolescent sexuality and sex education. Retrieved September 20, 2008, from http://www.acog.org/departments/dept_notice.cfm?recno=7&bulletin=3271
Biro, F. M., & Rosenthal, S. L. (1995). Adolescent STDs: diagnosis, developmental issues, and prevention. Journal of Pediatric Health Care, 9, 256–262.
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Centers for Disease Control and Prevention. (2006b). Sexually transmitted diseases: treatment guidelines 2006, clinical prevention guidance. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved September 17, 2008, from http://www.cdc.gov/std/treatment/2006/clinical.htm#clinical2
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Clark, L. R. (2003). Tips for clinicians: approaching the adolescent patient from a psychodevelopmental framework. Journal of Pediatric and Adolescent Gynecology, 1, 327–330.
Gerlt, T. J., Blosser, C. G., & Dunn, A. M. (2009). Sexuality. In C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. Blosser (Eds.), Pediatric primary care (4th ed., pp. 395–410). Philadelphia: Elsevier.
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Saslow, D., Runowicz, C. D., Solomon, D., Moscicki, A. B., Smith, R. A., Eyre, H. J., et al. (2002). American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA: A Cancer Journal for Clinicians, 52, 342–362.
Shrier, L. A. (2005). Bacterial sexually transmitted infections: gonorrhea, chlamydia, pelvic inflammatory disease, and syphilis. In S. J. Emans, M. R. Laufer, & D. P. Goldstein (Eds), Pediatric and adolescent gynecology (5th ed., pp. 565–614). Philadelphia: Lippincott Williams & Wilkins.
Spigarelli, M. G., & Biro, F. M. (2004). Sexually transmitted disease testing: evaluation of diagnostic tests and methods. Adolescent Medicine Clinics, 15, 287–299.
Stamm, C. A., & McGregor, J. A. (2001). Diagnosing and treating STDs in young women. Contemporary Pediatrics, 18, 53–67.