Abstract
OBJECTIVE:
To evaluate the attitudes of adolescents toward communicating with their doctor about different aspects of their sexuality.
METHODS:
The present descriptive survey was conducted with the participation of teenagers from four high schools in Sherbrooke, Quebec. In each school, the students of two grade 8 classes (≤14 years of age) and two grade 10 classes (≥15 years of age) anonymously completed a self-administered questionnaire. Permission from the school board and parental consent for every participant was obtained.
RESULTS:
A total of 387 adolescents completed the self-administered questionnaire. The response rate for the study was 98%. Only 27% of the respondents remembered being questioned by their doctor about sexuality, and 17% of the respondents had already brought up the topic of sexuality themselves with their doctor. More than one-half (57%) of the adolescents reported they would be moderately comfortable to totally comfortable discussing sexuality with their doctor if they felt the need to. Overall, when asked to evaluate their degree of comfort if questioned on specific questions about their sexuality, 73.8% to 99.5% believed they would be moderately to totally comfortable responding. Nevertheless, there was a statistically significant difference between age groups, with the older age group being more comfortable than the younger age group (P<0.001). There was no difference between the level of comfort among boys and girls answering the same questions. Respondents believed that their treating physician should discuss sexuality with them (73.8%) and, in the majority of cases (78%), that he/she should initiate the conversation.
CONCLUSION:
Regardless of age or sex, teenagers considered themselves to be at ease discussing sexuality with their doctor and found it an important topic best brought up by their practitioner.
Keywords: Adolescents, Communication, Physician practice patterns, Sexuality
Abstract
OBJECTIF :
Évaluer les attitudes des adolescents envers la communication de divers aspects de leur sexualité à leur médecin.
MÉTHODOLOGIE :
Les chercheurs ont effectué le présent sondage descriptif avec la participation des adolescents de quatre écoles secondaires de Sherbrooke, au Québec. Dans chaque école, les étudiants de deux classes de 8e année (14 ans ou moins) et de deux classes de 10e année (15 ans ou plus) ont répondu anonymement à un questionnaire autoadministré. Les chercheurs avaient obtenu l’autorisation de la commission scolaire et le consentement parental à l’égard de chaque participant.
RÉSULTATS :
Au total, 387 adolescents ont rempli le questionnaire autoadministré. Le taux de réponse à l’étude s’élevait à 98 %. Seulement 27 % des répondants se souvenaient s’être fait poser des questions par leur médecin au sujet de la sexualité, et 17 % avaient déjà soulevé eux-mêmes la question avec leur médecin. Plus de la moitié (57 %) des adolescents ont déclaré qu’ils se seraient sentis modérément ou totalement à l’aise de discuter de sexualité avec leur médecin s’ils en ressentaient le besoin. Dans l’ensemble, lorsqu’on leur demandait d’évaluer leur degré d’aisance à se faire poser des questions précises sur leur sexualité, de 73,8 % à 99,5 % pensaient qu’ils seraient modérément ou totalement à l’aise d’y répondre. Néanmoins, on constatait une différence statistiquement significative entre les groupes d’âge, le groupe plus âgé se disant plus à l’aise que le groupe plus jeune (P<0,001). On ne constatait pas de différence entre le degré d’aisance des garçons et des filles à répondre aux mêmes questions. Les répondants trouvaient que leur médecin traitant devrait parler de sexualité avec eux (73,8 %) et, dans la majorité des cas (78 %), qu’il devrait amorcer la conversation.
CONCLUSION :
Quel que soit leur âge ou leur sexe, les adolescents se disaient à l’aise de discuter de sexualité avec leur médecin et trouvaient qu’il s’agissait d’un sujet important qu’ils préféraient voir soulevé par leur praticien.
Previous studies have shown that many physicians and residents believe that they need more specific training regarding young patients’ sexual issues. Indeed, a study by Lena et al (1) found that 89% of paediatric residents who responded to the survey questionnaire reported a desire for further training on this topic. Moreover, 75% of physician respondents agreed that sexual orientation should be addressed more often during clinical training (2). As a result, it appears that paediatricians and other physicians who work with adolescents find it difficult to talk with them about sexuality (1–4). Two previous studies (3,4) have shown that 68% to 70% of paediatricians do not ask their patients about their sexual orientation, identity or behaviour. This is believed to occur mainly because they do not know how to address the issue, they fear offending their young patients and they do not believe they know enough about homosexual and bisexual patients’ needs. Furthermore, most paediatricians declared being unfamiliar with community resources for homosexually oriented youth (1,3,4).
Does this reluctance of physicians to talk about sexuality reflect the feelings of adolescents? A study by Rawitscher et al (5) demonstrated that adolescents want their physicians to give them information about various aspects of sexuality, including sexually transmitted infections, condoms, safe sex and HIV. Another study by Schuster et al (6) established that greater than one-half of adolescents would find it helpful to discuss sexuality with their doctor.
The overall goal of the present study was to evaluate the attitudes of adolescents with regard to communicating with their physician about the different aspects of their sexuality, such as sexual behaviours, sexual orientations and sexual attractions. More specifically, the main objective was to determine how comfortable teenagers were when talking about sexuality with their physician and whether there was a difference on this topic between the two age groups (≤14 versus ≥15 years of age) and according to sex. In addition, we aimed to determine the best questions for the doctor to ask if he wanted to question adolescents about their sexual orientation, identity or behaviour. Finally, we also investigated whether physicians regularly question adolescents about sexuality and whether teenagers believe that it is important for their physician to talk about sexuality with them.
METHODS
The present study was a descriptive survey involving teenagers from four high schools, chosen randomly from a group of nine high schools, in Sherbrooke, Quebec (population approximately 200,000). The survey took place over a period of approximately one month. Both private and public schools were evaluated (two private schools and two public schools) to provide a sample more representative of the various regional socioeconomic levels. In each high school, students from two grade 8 classes and two grade 10 classes completed a questionnaire. Because the study subjects were <18 years of age, retained parental content was obtained. Consent for the survey was also obtained from the school boards and school principals involved.
The students were invited to complete an anonymous self-administered questionnaire in an isolated cardboard booth (voting-booth style). All the students from the same class received the questionnaire and explanations about how to complete it at the same time from a member of the research team (NH). Students who had obtained parental consent received the questionnaire (Appendix), while those who did not obtain parental consent received a faux questionnaire (the first page from the real questionnaire bearing a clear instruction not to answer). All participants received a sheet containing general information about sexuality, so students whose parents had declined to let them participate could read it and, thus, made it impossible to differentiate them from the other students who were completing the questionnaire. The mean time taken to complete the questionnaire was 10 min. Once a student had completed the questionnaire, it was collected confidentially. The questionnaires (including the faux questionnaires) were gathered and placed in a large envelope identified with a code comprised of a number and a letter (school/class). Each student received a list of available community resources including phone numbers and Internet addresses in case the student had questions or worries about sexual orientation or identity.
The questionnaire was written by the authors based on data from the literature (3,7–10), and in particular from a study by Perrin et al (10), which proposed using many open questions about adolescent sexuality (Appendix). The scale was established by the authors and based on a similar questionnaire about quality of life. The content of the questionnaire was validated by two experts in adolescent medicine and psychology. The pertinence, clarity and timing (duration of test) of the questions were validated with a group of three girls and four boys between 14 and 15 years of age.
The questionnaire began with demographic questions. The participant was then asked if he/she had ever discussed sexuality with his doctor. The central part of the questionnaire was a situational scenario where the participant was asked to indicate, on a scale of one to 10, his/her level of comfort in answering a series of questions regarding different aspects of sexuality. The student was then asked which question, from a multiple set of questions, would be the best question his doctor could ask him to initiate a conversation about sexuality. Finally, the youth was asked if he believed the doctor should discuss sexuality with him/her and, if so, who should bring up the topic: the doctor or himself/herself. Incomplete questionnaires were kept for analysis. The questions that were answered by the participants were considered for the present study.
A descriptive analysis of the population was performed by examining categorical variables (frequencies and percentages) and continuous variables (means and SDs). The χ2 test was used to compare discrete stratified variables (ie, comfort level) according to categorical variables (ie, girl versus boy and ≤14 versus ≥15 years of age). Comfort level was divided into three subgroups: one to three (a little to not at all comfortable), four to seven (moderately comfortable) and eight to 10 (very to totally comfortable).
RESULTS
A total of 387 adolescents (who had obtained parental consent) agreed to participate in the present study and completed the self-administered questionnaire. Six parents refused to have their child participate in the present study; therefore, the response rate of the study was 98%. The population was divided into two age groups (≤14 years of age [50.3%] and ≥15 years of age [49.7%]). There were more girls than boys (65% versus 35%) because one of the randomly chosen private schools was a girls-only school. The number of questionnaires that were collected from private schools was higher than that from public schools (60% versus 40%). However, there were no statistically significant differences between the questions that were answered by the participants from public and private schools.
Only 27% of respondents recalled being previously questioned by their physician about sexuality. Girls had been questioned more often than boys (32% versus 17%; P<0.05) and participants from the older age group had been questioned more often than participants from the younger age group (33% versus 20%; P<0.001). Only 17% of youths had previously brought up the subject with their doctor. Girls had brought up the subject with their doctors more often than boys (21% versus 11%; P<0.05) and participants from the older age group had brought up the subject with their doctors more often than participants from the younger age group (23% versus 10%; P<0.001). However, 57% of adolescents who completed the questionnaire claimed they would be moderately to totally comfortable talking with their doctor about sexual activities if they felt the need to.
When answering the question regarding their level of comfort with respect to discussing their sexual activities with their doctor, most students in both age groups reported being moderately to totally comfortable. Nevertheless, there was a statistically significant difference between the age groups, with the older age group being more comfortable then the younger age group (P<0.001). On the other hand, there was no difference in the level of comfort between boys and girls answering the same question.
Overall, according to their responses to the situational scenarios, most participants (73.8% to 99.5%) said they would be moderately to totally comfortable (four to 10 on the questionnaire scale) answering various questions pertaining to sexuality. In the older age group, 68.6% to 95.7% stated they would be very comfortable, while greater than 50% of the younger age group said they would be very comfortable, except for questions c (45.5%) and h (47.4%) (Table 1). In both age groups, the questions that adolescents were more comfortable in answering were: “Do you have a girlfriend/boyfriend?” (when talking about heterosexual relationships) and “Are you attracted to boys/girls?” (when addressing attraction to the opposite sex). For all the questions asked, the older age group was significantly more comfortable with answering than the younger age group. When comparing boys and girls, there was a statistically significant difference for questions c through d (for heterosexual relationships), h through i (for heterosexual relationships) and k, with boys being more comfortable than girls answering those questions (Table 2). Girls were statistically significantly more comfortable answering question c (homosexual relations) than boys. Regardless of age and sex, adolescents appeared to be more comfortable with questions about heterosexual behaviour than same-sex behaviour.
TABLE 1.
Level of comfort* of adolescents answering a series of questions regarding different aspects of sexuality according to their age
| Situational scenarios | Level of comfort |
Age, years
|
||
|---|---|---|---|---|
| ≤14 | ≥15 | P | ||
| a–b) Do you have a boyfriend/girlfriend? (heterosexual relation) |
1–3 | 29 (15.3) | 1 (0.5) | <0.05 |
| 4–7 | 29 (15.3) | 11 (5.8) | ||
| 8–10 | 158 (83.2) | 179 (93.7) | ||
| Total | 190 | 191 | ||
| a–b) Do you have a boyfriend/girlfriend? (homosexual relation) |
1–3 | 29 (5.7) | 16 (9.9) | <0.05 |
| 4–7 | 31 (17.8) | 13 (8.0) | ||
| 8–10 | 114 (65.5) | 133 (82.1) | ||
| Total | 174 | 162 | ||
| c–d) Have you ever been sexually involved with a boy/girl? (heterosexual relation) |
1–3 | 31 (17.5) | 14 (7.3) | <0.0001 |
| 4–7 | 70 (37.0) | 46 (24.1) | ||
| 8–10 | 86 (45.5) | 131 (68.6) | ||
| Total | 189 | 191 | ||
| c–d) Have you ever been sexually involved with a boy/girl? (homosexual relation) |
1–3 | 45 (26.2) | 22 (13.6) | <0.05 |
| 4–7 | 29 (16.9) | 25 (15.4) | ||
| 8–10 | 98 (57.0) | 115 (71.0) | ||
| Total | 172 | 162 | ||
| e) Do you consider yourself gay/lesbian, bisexual or heterosexual? | 1–3 | 22 (11.5) | 13 (6.8) | <0.001 |
| 4–7 | 32 (16.8) | 10 (5.2) | ||
| 8–10 | 137 (71.7) | 168 (88.0) | ||
| Total | 191 | 191 | ||
| f–g) Some of my patients your age date boys, girls or both. Are you attracted to boys/girls? (heterosexual relation) |
1–3 | 4 (2.1) | 1 (0.5) | <0.05 |
| 4–7 | 19 (10.1) | 7 (3.8) | ||
| 8–10 | 165 (87.8) | 176 (95.7) | ||
| Total | 188 | 184 | ||
| f–g) Some of my patients your age date boys, girls or both. Are you attracted to boys/girls? (homosexual relation) |
1–3 | 33 (18.0) | 11 (6.1) | <0.001 |
| 4–7 | 30 (16.4) | 22 (12.2) | ||
| 8–10 | 120 (76.6) | 148 (81.8) | ||
| Total | 183 | 181 | ||
| h–i) There are many ways of being sexual with another person: kissing, having sexual intercourse…have you ever been sexual with a boy/girl? (heterosexual relation) |
1–3 | 36 (18.9) | 16 (8.4) | <0.0001 |
| 4–7 | 64 (33.7) | 39 (20.4) | ||
| 8–10 | 90 (47.4) | 136 (71.2) | ||
| Total | 190 | 191 | ||
| h–i) There are many ways of being sexual with another person: kissing, having sexual intercourse…have you ever been sexual with a boy/girl? (homosexual relation) |
1–3 | 42 (23.9) | 21 (12.6) | <0.05 |
| 4–7 | 33 (18.8) | 31 (18.6) | ||
| 8–10 | 101 (57.4) | 115 (68.9) | ||
| Total | 176 | 167 | ||
| j) Do you have any questions or concerns about your sexual attractions? | 1–3 | 22 (11.4) | 12 (6.3) | <0.05 |
| 4–7 | 40 (20.7) | 25 (13.1) | ||
| 8–10 | 131 (67.9) | 154 (80.6) | ||
| Total | 193 | 191 | ||
| k) Do you have any questions or concerns about sexual things you have been doing? | 1–3 | 32 (17.1) | 12 (6.3) | <0.001 |
| 4–7 | 51 (27.3) | 42 (22.1) | ||
| 8–10 | 104 (55.6) | 136 (71.6) | ||
| Total | 187 | 190 | ||
Data presented as n (%).
Level of comfort: 1–3 (not at all to a little comfortable); 4–7 (moderately comfortable); 8–10 (very to totally comfortable). For each question of the questionnaire, the total number of respondents is indicated
TABLE 2.
Level of comfort* of adolescents answering a series of questions regarding different aspects of sexuality according to their sex
| Situational scenarios | Level of comfort | Girls | Boys | P |
|---|---|---|---|---|
| a–b) Do you have a boyfriend/girlfriend? (heterosexual relation) |
1–3 | 3 (1.2) | 1 (0.7) | ns |
| 4–7 | 29 (11.7) | 11 (8.2) | ||
| 8–10 | 215 (87.0) | 122 (91.0) | ||
| Total | 247 | 134 | ||
| a–b) Do you have a boyfriend/girlfriend? (homosexual relation) |
1–3 | 22 (10.0) | 23 (19.8) | <0.05 |
| 4–7 | 36 (16.4) | 8 (6.9) | ||
| 8–10 | 162 (73.6) | 85 (73.3) | ||
| Total | 220 | 116 | ||
| c–d) Have you ever been sexually involved with a boy/girl? (heterosexual relation) |
1–3 | 39 (15.7) | 8 (6.1) | <0.05 |
| 4–7 | 81 (32.7) | 35 (28.5) | ||
| 8–10 | 128 (51.6) | 89 (67.4) | ||
| Total | 248 | 132 | ||
| c–d) Have you ever been sexually involved with a boy/girl? (homosexual relation) |
1–3 | 38 (17.3) | 29 (25.4) | ns |
| 4–7 | 41 (18.6) | 13 (11.4) | ||
| 8–10 | 141 (64.1) | 72 (63.2) | ||
| Total | 220 | 114 | ||
| e) Do you consider yourself gay/lesbian, bisexual or heterosexual? | 1–3 | 21 (8.5) | 14 (10.5) | ns |
| 4–7 | 28 (11.4) | 14 (10.5) | ||
| 8–10 | 197 (80.1) | 105 (78.9) | ||
| Total | 246 | 133 | ||
| f–g) Some of my patients your age date boys, girls or both. Are you attracted to boys/girls? (heterosexual relation) |
1–3 | 4 (1.7) | 1 (0.8) | ns |
| 4–7 | 19 (7.9) | 7 (5.4) | ||
| 8–10 | 219 (90.5) | 122 (93.8) | ||
| Total | 242 | 130 | ||
| f–g) Some of my patients your age date boys, girls or both. Are you attracted to boys/girls? (homosexual relation) |
1–3 | 27 (11.1) | 17 (14.0) | ns |
| 4–7 | 40 (16.5) | 12 (9.9) | ||
| 8–10 | 176 (72.4) | 92 (76.0) | ||
| Total | 243 | 121 | ||
| h–i) There are many ways of being sexual with another person: kissing, having sexual intercourse…have you ever been sexual with a boy/girl? (heterosexual relation) |
1–3 | 43 (17.3) | 9 (6.8) | <0.05 |
| 4–7 | 72 (29.0) | 31 (23.3) | ||
| 8–10 | 133 (53.6) | 93 (69.9) | ||
| Total | 148 | 133 | ||
| h–i) There are many ways of being sexual with another person: kissing, having sexual intercourse…have you ever been sexual with a boy/girl? (homosexual relation) |
1–3 | 39 (17.3) | 24 (20.3) | ns |
| 4–7 | 44 (19.6) | 20 (16.9) | ||
| 8–10 | 142 (63.1) | 74 (62.7) | ||
| Total | 225 | 118 | ||
| j) Do you have any questions or concerns about your sexual attractions? | 1–3 | 28 (11.3) | 6 (4.5) | ns |
| 4–7 | 44 (17.7) | 20 (15.0) | ||
| 8–10 | 176 (71.0) | 107 (80.5) | ||
| Total | 248 | 133 | ||
| k) Do you have any questions or concerns about sexual things you have been doing? | 1–3 | 35 (14.3) | 9 (6.9) | <0.05 |
| 4–7 | 64 (26.2) | 27 (20.8) | ||
| 8–10 | 145 (59.4) | 94 (72.3) | ||
| Total | 244 | 130 |
Data presented as n (%).
Level of comfort: 1–3 (not at all to a little comfortable); 4–7 (moderately comfortable); 8–10 (very to totally comfortable). For each question of the questionnaire, the total number of respondents is indicated. ns Not significant
A list of questions with the aim of initiating a conversation about sexuality with adolescents was proposed to the participants (question 9, Appendix). Among the questions proposed, the respondents believed that the three best questions to initiate a dialogue with them about sexuality would be: “Do you have a boyfriend or a girlfriend?” (28%), “Have you ever been sexually involved with a boy or a girl?” (20%) and “Do you have any questions or concerns about your sexual attractions?” (10%). There was no statistically significant difference between the age groups or sexes with respect to the preferred questions.
When asked if they believed their doctor should talk about sexuality with them, 72% of the teenagers answered “yes” and in the majority of cases (78%), they said they would prefer the doctor to introduce the topic. Again, there were no statistically significant differences between the age groups or between sexes.
DISCUSSION
Several studies have shown that adolescents are rarely questioned by their paediatrician about different aspects of their sexuality because doctors are afraid of offending their young patients and do not know how to address the issue (1,3,4,10). On the other hand, sexuality raises concerns and questions in teenagers’ minds (6). As a result, they want their clinician to give them information about safe sex, condoms and HIV (11). However, no studies have explored specifically how adolescents would feel if their physician asked them questions about their sexuality, or which questions would be the best to make them feel comfortable talking about it. Our study emphasizes the level of comfort of adolescents in the teenager-doctor relationship with regard to answering different questions about their own sexuality, a perspective that is rarely considered. Despite the fact that our study did not include the general population of adolescents (eg, it did not include teenagers who are on the street or out of school), we consider that, with the number of students answering our questionnaire, our study represents the studied population (ie, the adolescents [≤14 and ≥15 years of age] attending Sherbrooke high schools [private and public schools]).
The present study found that adolescents reported they would be moderately to very comfortable discussing sexuality with their doctor, regardless of age or sex. However, even if the majority of the older and younger teens indicated they would be very comfortable, the number of adolescents in the younger group indicating that they would be very comfortable was always lower than the number of adolescents in the older group. Furthermore, both age groups clearly stated they believed it was important that the doctor bring up the topic with them. Adolescents reported being more comfortable with heterosexual sex behaviour questions compared with same-sex questions. Both groups also helped us identify the three best questions to initiate a dialogue with them about sexuality: “Do you have a boyfriend or a girlfriend?”, “Have you ever been sexually involved with a boy or a girl?” and “Do you have any questions or concerns about your sexual attractions?”. These questions (which are not referring to a specific or their intimate sexual orientation or sexual behaviour) were most likely easier to answer.
Two previous studies (5,12) have already shown that most teenagers value their physician’s opinion about sex, but approximately one-half are uncomfortable talking to their doctor about sexual problems, such as sexually transmitted infections or sexual orientation (5). That is why at least one of the questions mentioned above should be part of all routine questionnaires with adolescent patients to be able to bring up the subject of sexuality while making them feel comfortable.
Because the youths we surveyed had to answer hypothetical questions, percentages (reflecting level of comfort) may be slightly overestimated. An in-field study could be beneficial in verifying these results. Another limitation of the study was that that were more girls than boys who completed the questionnaires.
CONCLUSION
The present study was the first that clearly demonstrated that adolescents are moderately to totally comfortable with being questioned by their doctor about sexuality. The take-home messages from our research are unambiguous. Adolescents indicate that they would be comfortable talking about all aspects of their sexuality with their physician. Addtional studies examining the effect of better educating doctors about the best ways to approach the topic of sexuality with teenagers by surveying both doctors and adolescents after an awareness campaign could be beneficial. It would also be interesting to compare the level of comfort of adolescents answering heterosexual or homosexual questions, in relation to their sexual orientation.
We hope that, as a result of the present study, teenagers will be questioned more often about sexuality and will be more at ease answering these questions. We also hope that better adolescent-doctor communication will follow and that doctors will feel better-equipped to talk about sexuality with their young patients without being afraid to offend them.
APPENDIX
Footnotes
FUNDING: The authors did not receive any funding for the present study.
DISCLOSURES: The authors have no conflicts of interest or financial relationships relevant to the present article to disclose.
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