Talking about sexual side effects: Countering don't ask, don't tell

Adolescent Psychiatry, 2008 by Harmon, Ashley

Winning paper for the American Society for Adolescent Psychiatry. Award for best paper by a resident in psychiatry.

Abstract

It is indisputable that sexuality plays a significant role in adolescent development and is intertwined in much of adolescent psychopathology as well. Yet, sexuality is often left unexplored in clinical practice (Andrews, 2000). Regardless of the reasons for this-whether it is the result of the clinician's anxiety or the patient's-the understanding of the meaning of his or her sexuality is crucial to effective treatment. The purpose of this chapter is to explore the helpful role that discussions about sexuality can play in the treatment of adolescent patients and how the failure to do so may affect the patient's compliance. It will illustrate how discussions of sexuality may be explored within the context of sexual side effects that patients may experience, secondary to psychopharmacologic treatment.

Sexual activity as normal and risky behavior

From its beginning, psychoanalytic thought describes the importance of sexuality in adolescent development (Moore and Rosenthal, 1993). Nonetheless, information about normal sexual development in adolescence has remained incomplete. Numerous surveys have focused on facts and figures, but shied away from asking about subjective aspects of sexual experience (Yates, 2003). For example, the Youth Risk Behavior Surveillance System (YRBSS), sponsored by the Centers for Disease Control (CDC), monitors teenagers' sexual behavior as part of its concern about the health risks posed by adolescent sexual activity. According to data from the 2003 YRBSS, 47 percent of U. S. high school students reported ever having sexual intercourse. Nationwide, 7.4 percent of students had sexual intercourse for the first time before the age of 13 years. Approximately one third of students surveyed had had sexual intercourse in the three months preceding the survey. Of note, the percentage of sexually active students who used a condom during their last sexual intercourse increased from 46 percent in 1991 to 63 percent in 2003 (Centers of Disease Control and Prevention, 2004). From a public health perspective, sexual behavior in adolescents is considered a "risk-taking" behavior. This is indeed true when one considers the increased risk of sexually transmitted diseases and pregnancy. These data also remind us that in normal psychosexual development in contemporary North America, physical expression of sexuality precedes emotional and cognitive development regarding the meaning of sexual activity (Beausang, 2000).

The facts that sexual activity is normative for many of today's adolescents, and that such behavior carries with it significant risks, underscore the importance of discussing sexuality with teenage patients. In addition to providing opportunities for interventions to promote health and safety, such discussions can aid in the diagnostic process. An example is the determination of when sexual behavior represents the symptom of hypersexuality that is associated with psychopathology and when it represents normal development. In addition to mood states, sexual activity patterns can be indicative of sequelae from traumatic experiences (Saewyc, Magee, and Pettingell, 2004). In addition to clarifying a diagnostic picture, understanding what sexual activity means to an adolescent within the context of relationship may shed light on their interpersonal styles and abilities.

The fact that a high proportion of adolescents are sexually active also means that they are likely to have major concerns about medications that affect sexual function. Failure to anticipate these concerns may result in poor adherence to medication regimens. One way of introducing the topic of sexuality in a neutral way is to discuss sexual side effects. This should be done in the context of discussing medication in general, for reasons that will be discussed in the following section.

General issues related to medication and adolescents

There are complex psychodynamic meanings associated with having medications prescribed and taking them, as Chubinsky and Rappaport (2006) have recently discussed. They point out that meanings impact psychosocial treatment and vice versa in a complex, dynamic way. They also state that an approach that takes into account the meaning of the patient's symptoms to him or her-that is, one that incorporates a biopsychosocial framework-is imperative to making the correct diagnosis, understanding symptoms, and monitoring clinical improvement. They maintain this is true whether a psychiatrist is providing both psychotherapy and medication management or whether the treatment of a patient is split between two clinicians. They point out that a strong therapeutic alliance can facilitate a patient's sharing his or her experience of symptoms, exploring ambivalence, or agreeing to take medication.

Most would agree that building an alliance with an adolescent is critical to treatment. At the same time, such an alliance is particularly fragile with an adolescent (Meeks and Bernet, 2001). A strong therapeutic alliance facilitates treatment compliance. This is especially true when the treatment involves medications with side effects. When the side effects involve sexual functioning, they are likely to be particularly concerning in a group where there are already significant concerns about being "normal" and anxieties about sexual functioning (Robinson, 2001). Meeting with an adolescent alone and discussing the limits of confidentiality are common ways that clinicians attempt to build alliances. Exploring the psychodynamic meanings of medications to the patient impacts the alliance by helping the patient feel that the psychiatrist is interested in what is important to him or her. The importance of sexual dysfunction for adolescents is illustrated in the following case example.