I ADOLESCENTS ^12 ^99 ^126 ^181

Assessment of an adolescent’s developmental stage is necessary to guide the provision of appropriate preventive health care. Adolescents of the same age are often at different stages of pubertal, psychosocial, and cognitive development.

Adolescent Development

Adolescence is a time of psychosocial, cognitive, and physical develop­ment as young people make the transition from childhood to adulthood. Physical and cognitive development usually occur on different timetables and are rarely synchronous. Therefore, the obstetrician-gynecologist may encounter adolescents who have matured physically but not cogni­tively. Most young adolescents (12-14-year-olds) should be expected to be concrete thinkers with poor or inconsistent abstract reasoning or problem-solving skills. Middle-aged adolescents (15-17-year-olds) often assume they are invulnerable. They may assume, for example, that risks apply to their friends but not to themselves. Generally, older adolescents (18-21-year-olds) have acquired problem-solving abilities and have rela­tively consistent abstract reasoning. Thus, the clinical approach to counsel­ing a cognitively younger adolescent will differ from the approach taken with a cognitively older adolescent or an adult.

An adolescent’s initial visit for reproductive health guidance, screening, and provision of preventive services should take place between the ages of 13 years and 15 years. The exact timing and scope of the initial visit will depend on the individual girl and her physical and emotional devel­opment. Gynecologic problems may necessitate a visit at an earlier age (see also the “Pediatric Gynecology” section earlier in Part 3).

The primary health risks for adolescents are behavioral, such as a seden­tary lifestyle, poor diet, smoking, alcohol and drug use, driving under the influence of drugs or alcohol, violence, early initiation of sexual activity, and poor use of contraception and sexually transmitted infection (STI) protection. Evidence indicates that knowledge-based education is not as successful in altering these behaviors as skill-based, communication-based, or activity-related strategies. For example, the gynecologist faced with a 15-year-old with an STI may have more success in preventing future infec­tion by role-playing teen-to-teen communication strategies or discussing avoidance strategies (such as avoiding parties that serve alcohol), or dis­cussing how to acquire and use condoms if the patient plans on continu­ing to be sexually active. The same amount of time spent discussing only the hazards of sexual activity (eg, potential for pregnancy and STIs) is likely to be less effective. Health care providers should provide the best possible

Box 3-25. Normal Menstrual Cycles in Young Females

Reprinted from Menstruation in girls and adolescents: using the menstrual cycle as a vital sign.

Box 3-26. Menstrual Conditions That May Require Evaluation ^

Menstrual periods that

• have not started within 3 years of thelarche

• have not started by 13 years of age with no signs of pubertal development

• have not started by 14 years of age with signs of hirsutism

• have not started by 14 years of age with a history or examination suggestive of excessive exercise or eating disorder

• have not started by 14 years of age with concerns about genital outflow tract obstruction or anomaly

• have not started by 15 years of age

• are regular, occurring monthly, and then become markedly irregular

• occur more frequently than every 21 days or less frequently than every 45 days

• occur 90 days apart even for one cycle

• last more than 7 days

• require frequent pad or tampon changes (soaking more than one every 1-2 hours)

Reprinted from Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. ACOG Committee Opinion No. 349. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1323-8.

care to respond to the needs of their adolescent patients. This care, at a minimum, should include comprehensive reproductive health services, such as sexuality education; counseling; mental health assessment; diag­nosis and treatment regarding pubertal development; access to contracep­tives and abortion; pregnancy-related care; and the prevention, diagnosis, and treatment of STIs. Efforts to include partners in services and counsel­ing when appropriate may be helpful to the adolescent. If the patient is sexually active, appropriate screening should be performed (see also “The Physical Examination and Screening” later in this section).

Because the primary health risks to adolescents are behavioral, screen­ing for behavioral risk factors is critical. In addition, it is important to screen for eating disorders and other weight issues, blood pressure prob­lems, and mental health disturbances (such as anxiety; depression; and physical, sexual, and emotional abuse).

Ideally, the adolescent preventive visit also involves a parent or guard­ian. Parents can be counseled on normal adolescent development issues and strategies to deal with adolescent behavioral health risks. The College recommends parental counseling sessions three times during the adoles­cent years as part of preventive care: at least once during their child’s early adolescence, once during middle adolescence, and preferably once during late adolescence.

Confidentiality and Consent in Adolescent

Health Care

Confidentiality refers to protection of the privileged and private nature of information shared during a health care encounter and other informa­tion and records about the encounter. Concerns about confidentiality are a major obstacle to the delivery of health care to adolescents. Although ensuring confidentiality is relatively simple when providing services to adults, providing the same degree of confidentiality protection to adoles­cents is usually less straightforward. The legal status of a minor and legal requirements for parental consent before the provision of medical services often encumber the patient-clinician relationship or place limits on the potential for protection of confidentiality. Confidentiality sometimes is interpreted to be a type of secrecy. This philosophy is counterproductive. Parents and physicians share a common goal—the health and well-being of the adolescent. The philosophy should be one of collaboration to maxi­mize the likelihood of raising a healthy adolescent.

A confidential relationship can facilitate the open disclosure of health histories and risky behaviors that require medical intervention and might otherwise be hidden. However, concerns about confidentiality can be significant barriers to adolescents seeking reproductive care and provid­ing accurate historical information. Common risk-taking behaviors and problems that adolescents may not share with their parents include eat­ing disorders, tobacco use, substance use, sexual activity, and date rape. Many parents of sexually active adolescents are aware of the fact that, or strongly suspect that, their child is sexually active. In some cases and with the adolescent’s permission, the clinician can facilitate the adolescent’s discussing this activity with her parent(s) or guardian(s). However, some sexually active adolescents would avoid a reproductive health visit or not disclose sexual activity if the clinician did not clarify that this information was confidential.

Adolescent confidentiality also may be compromised by economic con­siderations because few adolescents have the ability to pay for health care services without the aid of a parent or other adult. Moreover, explanations of benefit forms issued by insurers are sent to the policyholders, usually the parent, which also could compromise the confidentiality of care received by adolescents.

Physicians should work with their office staff to establish office proce­dures and routines that safeguard the privacy of their adolescent patients whenever possible. Office personnel should recognize the issues of con­fidentiality relating to billing, reviewing claims, and reporting laboratory results. The handling of these issues should be communicated clearly to the adolescent and any involved parents or guardians during the visit. When these mechanisms and procedures compromise a patient’s request for confidentiality, policies should be implemented that allow payment alternatives, such as reduced fees, sliding scales, and timed installment payments; patient referral to a practice or agency where subsidized care is offered; or both.

Legal Considerations

Clinicians should be familiar with federal and state laws that affect confi­dentiality and the current state statutes on the rights of minors to consent to health care services. State laws mandate the reporting of suspected physical or sexual abuse of minors to the appropriate authority. All states require consent for the treatment of a minor from a person legally entitled to authorize such care. Exceptions to this requirement for consent vary by state. Examples of exceptions include the following:

• Emergencies, when immediate treatment is needed to safeguard the life or health of the minor

• Treatment of “emancipated minors,” including minors who are married, who are members of the armed forces, who live apart from their parents and are self-supporting, and who are themselves parents

• Specific health care services, such as contraceptive services, prena­tal care and delivery, STI services, human immunodeficiency virus (HIV) testing and treatment, treatment for drug and alcohol abuse, and mental health treatment, when protected by state law

In these cases, minors generally have the right to privacy and the right to prevent clinicians from disclosing information about the care they receive. Each state has different regulations, and clinicians should become aware of those that apply to their practices. A listing of state laws that is updated monthly is available (www.guttmacher.org/statecenter/); state medical societies also may be able to provide useful resources (www.ama-assn.org/ ama/pub/about-ama/our-people/the-federation-medicine/state-medical- society-websites.page).

Courts have increasingly recognized the growing independence of minors and the seriousness of their health care needs. Case law in some jurisdictions has established the right of a “mature minor” to consent to some forms of health care without prior parental consent. A mature minor generally is defined as an adolescent younger than the age of majority—set at 18 years in most states—who, although living at home as a dependent, demonstrates the cognitive maturity to give informed consent. When deciding whether to accept a court-determined mature minor as a patient, clinicians should evaluate their personal views. If their own views on autonomy and confidentiality would conflict with the provision of medical care to a minor declared independent by the courts, the patient would be better served by a referral to a physician experienced in such care. A minor’s right to obtain an abortion without parental consent or notification is one area in which the rights of a minor frequently have been restricted statuto­rily. Many states have adopted mandatory parental consent or notification laws of some form, with an alternative allowing for judicial bypass in lieu of involving a parent or guardian.

Addressing Confidentiality

Adolescents are more likely to develop trusting relationships with their health care providers when the issue of confidentiality has been addressed satisfactorily. Clinicians should discuss confidentiality with each adoles­cent and, as appropriate, with her parent(s) or guardian(s) during the ini­tial visit, which helps establish rapport and outline expectations. Table 3-13 describes the logistics of an adolescent office visit that supports confiden­tiality.

Parents and adolescents should be informed that they each have a private relationship with the clinician and should be made aware of any restrictions on confidentiality. For example, it should be explained that if the adolescent discloses any risk of significant bodily harm to herself or others, or if the clinician suspects physical or sexual abuse, the clinician will breach confidentiality. Practitioners should encourage and facilitate communication between a minor and her parent(s) or guardian(s) and should emphasize their shared goal of the health and well-being of the minor. During the course of the visit, clinicians are encouraged to speak individually with the adolescent and her parent(s) or guardian(s), allow­ing for maximal information to be shared and for each to feel included in decision making. Physicians should reassure parents that they will encour­age the adolescent to include her parents in important health decisions. The goal is to encourage and facilitate family communication; maintaining confidentiality need not preclude working toward this goal.

The Physical Examination and Screening ^437

Appropriate physical examination, laboratory testing, and immuniza­tions are outlined in the periodic assessment for 13-18-year-olds (see also

Table 3-13. An Adolescent Office Visit That Supports Confidentiality

*If the parent wishes to speak with you about her concerns privately, this should be done before the confidential visit with the patient.

Tarent may be present, at patient's discretion.

Reprinted from American College of Obstetricians and Gynecologists. Confidentiality in adolescent health care. In: Guidelines for adolescent health care [CD-ROM]. 2nd ed. ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011. p. 9-17.

“Well-Woman Care: Assessments & Recommendations” at www.acog.org/ wellwoman). Pelvic examination is not a routine part of the annual assessment in females 13-18 years of age unless medically indicated. The College recommends beginning cervical cytology screening at age 21 years, irrespective of the sexual activity of the patient. This is based on the current understanding of human papillomavirus (HPV) infection in the adolescent patient and the pathophysiology of cervical cancer (see also the “Well-Woman Annual Health Assessment” and “Cancer Screening and Prevention” sections earlier in Part 3 and the “Abnormal Cervical Cytology” section in Part 4). Testing for STIs is recommended for all sexu­ally active adolescents and can be performed without the need for cervical sampling (see also “Sexually Transmitted Infections” later in this section).

Tanner staging of breast and pubic hair development should be included in the recommended physical examination. The College publishes pam­phlets to educate the adolescent about her changing body, menstruation, and the first gynecologic visit (see Resources). Evaluation of the menstrual cycle should be included. Clinicians should ask at every visit for the first date of the patient’s last menstrual period.

Pubertal Progress and Menstrual History

Pubertal progress and menstrual history should be obtained. A variety of menstrual conditions should prompt evaluation, including absence of menses with no signs of pubertal development by age 13 years; absence of menses within 3 years of thelarche; and absence of menses by age 15 years. Absence of menses by age 14 years with signs of hirsutism or concerns of excessive exercise, eating disorders, or genital outflow tract abnormalities also deserves evaluation (see Box 3-26).

Obstetrician-gynecologists should counsel adolescent patients about the proper use of tampons to decrease the risk of toxic shock syndrome. Patients should be advised to use tampons with the lowest absorbency needed to absorb their menstrual flow, change their tampon at least every 4-8 hours (or more often on the first days of their period), read all of the instructions that come with tampons, and avoid the use of tampons when they do not have their period.

Hypertension

All adolescents should be screened annually for hypertension. Guidelines for blood pressure screening in adolescents have been developed by the National Heart, Lung, and Blood Institute National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Hypertension in adolescence is diagnosed after three consecutive blood pressure readings are above the 95th percentile on three separate occasions. Body size directly affects normal blood pressure, so a blood pressure interpreted as normal in a mature reproductive female may represent hypertension in a young adolescent.

Lipid Disorders

To determine their risk of developing hyperlipidemia and adult coronary heart disease, adolescents should be screened by history and selected adolescents should undergo lipid testing. For more information, see the guidelines developed by the National Heart, Lung, and Blood Institute Expert Panel on Blood Cholesterol in Children and Adolescents in the Bibliography.

Obesity and Eating Disorders

All adolescents should be screened annually for obesity and eating dis­orders by determining weight and stature, calculating a body mass index (BMI) for age, and asking about body image, eating patterns, activity levels, and sedentary behavior.

Obesity

The Centers for Disease Control and Prevention (CDC) defines an adoles­cent as obese if she has a BMI in or above the 95th percentile for her age. An adolescent whose BMI is equal to or greater than the 85th percentile-for­age, but less than the 95th percentile-for-age is considered to be overweight. A calculator that determines adolescent BMI for age percentile is available at http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx. Adolescents with a BMI in or above the 95th percentile for age should have an in-depth dietary and health assessment to determine psychosocial morbidity and the risk of obesity-related disease. Early referral to a nutrition program skilled in car­ing for adolescents and an exercise specialist may be warranted.

Overweight adolescents also should have a dietary and health assess­ment to determine psychosocial morbidity and risk of future cardiovascu­lar disease if they have any of the following:

• Their BMI has increased by two or more units during the previous

12 months

• There is a family history of premature heart disease, obesity, hyper­tension, or diabetes mellitus

• They express concern about their weight

• They have elevated blood pressure or serum cholesterol levels

Obstetrician-gynecologists are strongly encouraged to provide these assessments. It is important to note that weight loss is recommended for adolescents only in certain circumstances. Older overweight and obese adolescents who have completed linear growth or those with comorbidi­ties (such as polycystic ovary syndrome) who are obese, for example, may require weight loss. More often, among adolescents who are still growing in height, the goal is to slow the rate of weight gain while achieving normal growth and development.

Eating Disorders

All adolescents should be screened annually for eating disorders, using common symptoms and weight formulas as a guide. Substantial weight loss or patient preoccupation with dieting should alert the obstetrician­gynecologist to the possibility of an eating disorder. In addition, results of vital sign testing and a careful cardiac examination to listen for arrhythmias may help to confirm the presence of eating disorders and identify patients who need emergency hospitalization (see also the “Psychosocial Issues” section later in Part 3).

Sexually Transmitted Infections

All sexually active adolescents should be counseled regarding safe sex practices and contraception. In addition, routine screening for chlamydial infection, gonorrhea, and HIV is recommended for all sexually active ado­lescents. Urine screening for chlamydial infection and gonorrhea should be done if pelvic examination is otherwise not indicated or circumstances do not allow for the examination. Despite these recommendations, which are consistent with the CDC and other major medical professional groups, only 40% of eligible women who receive their medical care from com­mercial or Medicaid health plans are screened for chlamydial infection annually.

Expedited partner therapy is the clinical practice of treating the sex partners of patients, in whom STIs are diagnosed, by providing prescrip­tions or medications to the patient to take to his or her partner(s) without the health care provider first examining the partner(s). Expedited partner therapy is recommended in the management of gonorrhea and chlamydial infections when the partner is unlikely or unable to otherwise receive in-person evaluation and appropriate treatment. The changes to CDC treatment recommendations to require an intramuscular cephalosporin as first-line treatment for gonorrhea will be an impediment to expedited partner therapy (see Bibliography). In addition, the legality of expedited partner therapy is ambiguous in some states and overt legal impediments exist in others. Clinicians who practice in states where expedited partner therapy is legal should use it for eligible patients (see also the “Sexually Transmitted Infections” section earlier in Part 3).

Human Papillomavirus Vaccination

Vaccination against HPV is now part of the recommended immunization of young women (see also “Well-Woman Care: Assessments & Recom­mendations” at www.acog.org/wellwoman). The College recommends HPV vaccination for females aged 9-26 years. Cervical cytology screening recommendations are not affected by HPV vaccination status and should be followed regardless of vaccination status (see also the “Immunizations” section and the “Sexually Transmitted Infections” section earlier in Part 3).

Cervical Cytology Screening

Recommendations regarding cervical cytology screening in adolescents underwent marked changes in 2009. It is now recommended that cervi­cal cancer screening should begin at age 21 years, regardless of the sexual activity of the patient. Human papillomavirus infections are very com­monly acquired by young women shortly after first intercourse, and most are cleared by the immune system within several years without producing neoplastic changes. Most types of cervical dysplasia in adolescents regress as well. Adolescents are more successful in clearing HPV as compared with older women.

For those adolescents who have previously undergone screening with abnormal results, health care providers should consult the most current guidelines from the American Society for Colposcopy and Cervical Pathology (see Resources). The rationale for the guidelines is that most cervical intraepithelial neoplasia grades 1 and 2 regress in adolescents. Surgical excision or destruction of cervical tissue in a nulliparous adoles­cent may be detrimental to future fertility and cervical competency (see also the “Abnormal Cervical Cytology” section in Part 4).

Counseling

Screening provides an excellent opportunity to counsel adolescents about healthy lifestyles. Counseling and guidance should be directed at the risk behaviors and issues identified by the history, screening questionnaire, and physical examination.

Calcium and Vitamin D Intake

Most bone mass is achieved between ages 12 years and 20 years. The Institute of Medicine has determined that the recommended dietary allow­ance of calcium for adolescents aged 9-18 years is 1,300 mg/d. The aver­age calcium intake in adolescent girls is less than 900 mg/d. The preferred approach to meeting these recommendations is through dietary sources. Other approaches include supplements and calcium-fortified foods. Vitamin D has a role in calcium absorption, muscle performance, and bal­ance. The most common sources are fortified milk, cereals, egg yolks, salt­water fish, and liver. The recommended daily allowance of vitamin D for adolescents is 600 international units daily. There are two different types of supplemental vitamin D—vitamin D₃ (cholecalciferol) and vitamin D₂ (ergocalciferol)—which have recently been determined to be equally effec­tive for bone health.

Smoking

Approximately one quarter of high school seniors currently use tobacco. Females are as likely as males to be smokers. All adolescents should be asked annually about their use of tobacco products, and a cessation plan should be provided for adolescents who smoke or use any tobacco prod­ucts. The Public Health Service recommends providing adolescent smokers with counseling interventions to aid them in quitting smoking. Because of an adolescent’s preoccupation with body image, all adolescents should be counseled on the effects of smoking and other tobacco products on their hair, skin, fingernails, teeth, and breath, as well as on athletic performance. Parents who smoke should be encouraged to stop for their and their chil­dren’s health benefit. For more information and resources, see also the “Substance Use and Abuse” section earlier in Part 3.

Alcohol and Substance Abuse

Substance and alcohol use are major factors in injuries and deaths in ado­lescents. They contribute to accidents, homicide, and suicide, which repre­sent the first, third, and fourth leading causes of death in this age group. In addition, adolescents using alcohol and substances are more likely to make poor decisions regarding sexuality or to be involved in date rape situations. All health care providers, including obstetrician-gynecologists, can reduce the harmful effects of substance use and abuse by routinely asking about such use, providing education about substances, assisting patients who wish to discontinue use, and referring when there is evidence of substance abuse or dependence.

Screening is critical. All adolescents should be asked annually about their use of alcohol, illicit drugs, prescription and nonprescription medica­tions, and performance-enhancing drugs. This should be done in private after providing assurances of confidentiality and indications of the limits of confidentiality (eg, evidence of serious harm to self or others). Many state laws protect the confidentiality of minors with regard to substance abuse detection and treatment. Urine screening for drug use without the adoles­cent’s knowledge and consent is not recommended and is illegal in many states. The American Academy of Pediatrics recommends that parental permission is not sufficient for involuntary drug testing of the adolescent with decisional capacity and that testing should be conducted noncovertly, confidentially, and with informed consent in the same context as for other medical conditions.

Adolescents whose substance use endangers their health should receive substance abuse counseling and treatment and be assessed for co-occurring depression, anxiety, and other mental disorders. The American Academy of Pediatrics recommends that parents receive information on how to monitor and prevent alcohol consumption in adolescents. If parents con­sume alcohol themselves, they should be encouraged to do so in modera­tion and to restrict their children from consuming their supplies (see also the “Substance Use and Abuse” section earlier in Part 3).

Body Piercing and Tattoos

Body piercing and tattoos are relatively common. Among adolescents and young adults, body piercings are more common than tattoos. Body pierc­ing may involve the eyebrow, nipple, nasal septum, tongue, lips, navel, labia, and clitoral hood. The evolution of tattoos and body piercing into a more mainstream practice has been propelled by media stars and profes­sional athletes. Studies among adolescents and young adults indicate that the driving forces behind body art include a desire for a form of decoration, enhancement of self-identity, peer acceptance, and group membership. However, in some adolescents, tattoos and piercings may serve as mark­ers for other high-risk behaviors, including violence, substance abuse, and unprotected sexual activity. If an adolescent is planning on having pierc­ings or tattoos, she should be strongly counseled about the potential risks to her health. Piercings and tattoos carry the risk of exposure to viral infec­tions, including HPV, herpes virus, hepatitis B, hepatitis C, hepatitis D, and HIV, although transmission of HIV has not been documented. And, the presence of genital jewelry may increase condom breakage. Noninfectious complications include metal allergies, keloids, sarcoidal tissue reaction, epidermal cyst, torn earlobes, urethral obstruction, and airway obstruction. Based on limited evidence, there also is concern that the piercing of lower back tattoos for epidural anesthesia administration may transfer pigment dyes to the epidural space.

Depression and Suicide

Depression is common in adolescents, and suicide is the third leading cause of death in this age group. Risk factors for suicide are listed in Box 3-27. Risk is highest when the adolescent can describe a plan for time, location, and means of suicide and has easy access to the means, especially medications or firearms. If an adolescent has any of these risk factors, the follow-up questions noted in Box 3-28 are appropriate. Adolescents who

Box 3-27. Risk Factors for Suicide or Suicide Attempts ^

• Previous suicide attempts

• Family history of suicide and mental health disorders

• History of self-injurious behavior, such as cutting

• History of alcohol or other substance abuse

• Exposure to other youth who have attempted or committed suicide

• Feelings of sadness, hopelessness, and helplessness

• Expression of thoughts of suicide, death, or dying or strong interest in the afterlife

• Being in a sexual minority (gay, lesbian, bisexual, transgender, and ques­tioning youth) or culturally alienated (eg, recent immigrant)

Reprinted from American College of Obstetricians and Gynecologists. Mental health disorders in adolescents. In: Guidelines for adolescent health care [CD-ROM]. 2nd ed. ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011. p. 85-96.

Box 3-28. Sample Follow-up Questions to Assess Suicide Risk of Adolescents With Risk Factors for Suicide ^

Questions should be asked in a nonjudgmental, direct, and nonthreatening manner. The clinician may begin with, “Sometimes adolescents dealing with similar issues or problems get very down and start to question life itself. Does this happen to you?”

A positive answer should be followed with questions such as the following:

• “Have you ever thought about suicide or harming yourself?”

• “Are you thinking about suicide now?”

• “Do you have a plan for suicide?” If yes, ask details of the plan.

• “Have you ever attempted suicide in the past?”

When any risk of suicide attempt is identified or admitted, the adolescent should be referred to a crisis mental health agency or emergency department for assessment by a mental health professional.

Reprinted from American College of Obstetricians and Gynecologists. Mental health disorders in adolescents. In: Guidelines for adolescent health care [CD-ROM]. 2nd ed. ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011. p. 85-96. are suicidal require emergency referral to a mental health professional. Parents should be counseled that children and adolescents should not have access to weapons or firearms or potentially lethal medications. One group of adolescents that deserves special concern and very careful screening are lesbian and bisexual teens who have a high relative risk of depression (see also the “Lesbians and Bisexual Women” section later in Part 3).

Adolescents with severe or recurrent depression should be referred to a mental health professional for therapy. Depression in adolescents is seri­ous in terms of morbidity and mortality. It never should be assumed to be part of normal adolescent moodiness (see also the “Depression” section later in Part 3).

Motor Vehicle Accidents

Parents and adolescents should be counseled on the prevention of motor vehicle accidents and related injuries, including the use of seat belts and avoiding riding with a driver who is under the influence of drugs or alcohol. A form developed by Students Against Destructive Decisions formalizes an agreement on how adolescents would deal with difficult situations and fos­ters a discussion with parents on this subject. This form is available through the organization’s web site at www.sadd.org/contract.htm. Distracted driv­ing is another growing cause of motor vehicle accidents among teenagers. Adolescents underestimate the dangers associated with distracted driving and overestimate their driving abilities. According to the 2011 Youth Risk Behavior Survey, 32.8% of high school students nationwide had sent text messages or e-mailed while driving a car or other vehicle on at least 1 day during the 30 days before the survey. For more information on education and prevention, see www.sadd.org/issues_distracted.htm.

Violence

Approximately one third of adolescent murder victims are female, and of them, one third are killed with a firearm. Nearly one half of all violent juve­nile rapes, robberies, and assaults occur between noon and 6 PM. Violence perpetrated by girls is increasing. Excessive exposure to the media can cause increased violent behavior and callousness toward violence. Some advocates advise that parents and families reduce the risk by using vio­lence rating systems for television and games and limiting access to media violence. Limiting firearm access and closely supervising adolescents are critical measures for prevention, and encouraging involvement in family activities, clubs, sports, and school also is recommended.

Sexuality

Sexual Identity

Children as young as 10 years can recognize their sexual orientation as attraction to a particular sex. By high school, approximately 10% of Minnesota youth responding to a statewide health questionnaire said they were unsure about their orientation, with 4.5% reporting lesbian attraction and 1% reporting lesbian behavior. Lesbian adolescents must navigate the same developmental tasks as heterosexual peers. These tasks include accepting their sexual identity and deciding about sexual behaviors.

Clinicians should word questions regarding sexuality carefully to include same-sex relationships. Referring to a partner rather than a boy­friend is one strategy. The screening questionnaire may include queries on sexual orientation. Clinicians should be aware that the suicide risk is twofold to sixfold greater in gay and lesbian youth, and these adolescents account for almost one third of all completed adolescent suicides. Youth who self-identify as lesbian or gay during high school are also at higher risk of victimization and substance abuse at an earlier age. In addition, they are more likely to engage in sexual risk behaviors than their heterosexual peers. Therefore, screening for STIs is important.

Adolescents who are lesbians face additional challenges in development as they learn to accept their sexual identity. They may find it difficult to ask for, or they may not receive, understanding and acceptance from their par­ents, family, and friends. Appropriate referrals for counseling and support groups for the lesbian adolescent and her family should be considered (see also the “Lesbians and Bisexual Women” section later in Part 3).

Sexuality Education

The College strongly encourages parents to be involved actively in educat­ing their children about sexuality and employing strategies that reduce the likelihood of adolescent pregnancy. Providing supervision and encourag­ing family and community activities are excellent strategies.

The College supports the inclusion of comprehensive, medically accu­rate, age-appropriate sexuality education from kindergarten through 12 th grade as an integral part of health education in schools and communities. Sexuality education should encourage young people to delay becoming sexually active and, if sexually active, to use contraception and barrier protection to prevent unintended pregnancy and STIs. These twin goals are essential in all sexuality education programs. The College encourages its members to advocate for, and participate in, sexuality education.

Since the mid-1990s, sexuality education in the United States increas­ingly has emphasized sexual abstinence and restricted information about contraception and risk reduction. Federal support from 1996 to 2010 for abstinence-only education, along with other factors, had contributed to a growing emphasis on limiting sexuality education so as to exclude accu­rate instruction about contraception, abortion, and sexual orientation. Abstinence-only education has been criticized for withholding information on contraception and other aspects of human sexuality and for provid­ing information that is not medically accurate. Comprehensive sexuality educational curricula, by contrast, not only promote abstinence but also incorporate reproductive health information, including both the risks and benefits of various methods of contraception, STI prevention, and forms of sexual expression that provide alternatives to intercourse.

Most research of abstinence-only education has shown no effect on delaying sexual initiation, return to abstinence, or number of sexual part­ners. However, one theory-based abstinence-only program that was not moralistic and did not emphasize abstinence until marriage reduced initia­tion of sex over the next 2 years. Two thirds of 48 selected comprehensive programs that supported abstinence and the use of condoms and contra­ceptives for sexually active teens have shown positive effects on behavior, including delayed initiation of sex, decreased number of sexual partners, and increased condom or contraceptive use. None increased sexual activ­ity. However, positive effects across settings depend on carrying out all the original program components rather than implementing only some of them.

The College supports the efforts of communities to implement effective comprehensive sexuality education for adolescents that includes the fol­lowing components:

• Parental involvement in children’s sexuality education

• Scientifically accurate information about sexuality, STIs, contracep­tion, and preventive health care

• Encouragement of abstinence from sexual intercourse as a healthy choice for adolescents, particularly young adolescents

• Efforts to increase effective use of contraceptives, including latex condoms and dual use of condoms with other effective contracep­tive methods, by sexually active adolescents

• Efforts to increase availability and use of long-acting reversible con­traceptive methods by sexually active adolescents

• Ongoing rigorous evaluation of the effectiveness of a variety of forms of sexuality education in terms of their effects on sexual behavior and contraceptive use, as well as unintended pregnancy and abortion rates

Obstetrician-gynecologists can be resources for support and assistance to sexuality education programs in their communities. Sexuality education is an important component of efforts to decrease unintended pregnancy and STIs. In addition, increased availability of confidential reproductive health services—including family planning; abortion; and services for the prevention, diagnosis, and treatment of STIs—is critical. For more infor­mation on sexuality education, see the College’s resource Guidelines for Adolescent Health Care.

Risk of Pregnancy and Disease

Each year in the United States, an estimated 757,000 adolescents become pregnant. More than one half of these pregnancies (56%) end in a live birth, 28% end by abortion, and 15% end by miscarriage or stillbirth. Few adolescents choose to place their children for adoption; most choose to parent their children, a decision that has lifelong consequences. Although U.S. adolescent pregnancy rates have declined from a previous high of more than 1 million per year, rates still are the highest of any developed nation. The decline in adolescent pregnancy can be attributed to slight declines in sexual activity and increased use of contraception.

The percentage of high school students who reported ever having sexual intercourse declined during 1991-2001 (54.1-45.6%), although it did not change significantly from 2001 to 2011 (45.6-47.4%). The prevalence of high school students reporting current sexual activity decreased from 37.5% in 1991 to 33.7% in 2011. The percentage of high school students who had engaged in sexual intercourse with four or more partners during their lifetime decreased during 1991-2001 (18.7%-14.2%) and then did not change significantly from 2001 to 2011 (14.2-15.3%). Data show that the likelihood of having experienced sexual intercourse increases steadily with age.

Condom use at last coitus among sexually active adolescents increased from 46.2 % in 1991 to 60.2% in 2011. More contraceptive options are also available to adolescent women. Most notably, the use of intrauter­ine devices among adolescents has been found to be safe and effective. Intrauterine devices and contraceptive implants can be offered to adoles­cents as a reliable form of birth control. Emergency contraception may be used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse (see also the “Family Planning” section earlier in Part 3).

Girls from higher-income households are more likely than those from lower-income households to use contraception at first coitus and to abort their pregnancy. The combination of these factors results in fewer pregnant adolescents in affluent schools compared with schools in lower socioeco­nomic areas, sometimes giving the erroneous impression that coital activity is significantly less common in adolescents from higher socioeconomic backgrounds.

It has been estimated that although young people aged 15-24 years represent only 25% of the sexually experienced population, they acquire nearly one half of all new STIs. The CDC estimates that more than 1 in 10 sexually active female adolescents have chlamydial infections. It also is estimated that at least one half of all new HIV infections in the United States are among individuals younger than 25 years. Adolescent females are at greatest risk of STIs because they often fail to use condoms correctly and consistently, are biologically more susceptible to infection, frequently have multiple sequential sexual partners, and face many obstacles to the use of health care (see also the “Sexually Transmitted Infections” section earlier in Part 3).

Noncoital sexual activity most commonly co-occurs with coital activ­ity. Oral and anal sex are more common among adolescents who have already had vaginal coitus. According to the 2006-2008 National Survey of Family Growth, 45% of females aged 15-19 years reported having had oral sex with an opposite-sex partner. Most adolescents do not use barrier protection for noncoital sexual activities. It is critical to screen adolescents for noncoital sexual activity and to educate them that these activities carry a risk of acquiring STIs and about ways to protect themselves. Adolescents may not consider themselves “sexually active” if they are engaging only in noncoital sexual activity (see also the “Sexually Transmitted Infections” section earlier in Part 3).

Unintended Pregnancy Options Counseling

Rates of unintended pregnancy are higher for adolescents than for any other age group. In the event of an unintended pregnancy, the adolescent who is ambivalent about her pregnancy, like any patient, should be coun­seled about her options: continuing the pregnancy to term and raising the infant, continuing the pregnancy to term and placing the infant for legal adoption, or terminating the pregnancy. In cases of conscientious objec­tion, where a clinician declines to provide requested care to a patient for moral or religious reasons, transfer of primary clinical responsibility to another clinician is in the patient’s best interest. The discussion with the patient also should determine her wishes as to what counseling resources should be offered to her partner, if any, or what information should be given to her parents (if she is a dependent adolescent). Some states require parental notification or consent before a minor can obtain an abortion. In some states, pregnancy in individuals younger than a certain age is consid­ered child abuse and must be reported. All health care providers should be aware of their state laws in this regard.

Sexual and Reproductive Coercion, Sexual Assault, and Sexual Abuse

Sexual and reproductive coercion, sexual assault, and sexual abuse are widespread in the adolescent population. Obstetrician-gynecologists are in a unique position to address these issues and provide screening and clinical interventions to improve health outcomes. Because evidence demonstrates that violence and poor reproductive health outcomes are strongly linked, health care providers should screen adolescent girls for intimate partner violence and reproductive and sexual coercion at periodic intervals, such as annual examinations and new patient visits. Health care providers also should screen routinely for a history of sexual assault.

Sexual and Reproductive Coercion

Sexual coercion includes a range of behaviors that a partner may use related to sexual decision making to pressure or coerce a person to have sex without using physical force. These behaviors include repeatedly pressuring a partner to have sex; threatening to end a relationship if the person does not have sex; forcing sex without a condom or not allow­ing other prophylaxis use; intentionally exposing a partner to an STI, including HIV; or threatening retaliation if notified of a positive STI test result. In the 2006-2010 National Survey of Family Growth, females aged 18-24 years whose first coitus was before age 20 years were asked about whether or not their first sexual intercourse experience was desired. Of women whose age at first coitus was 17 years or younger, 27.8% reported that their first sex was not voluntary. For those who had first sex at age 14 years or younger, 18% reported that they “really didn’t want it to happen,”compared with 8.9% among those who delayed first sex to age 18 years or 19 years.

Reproductive coercion is related to behavior that interferes with con­traception use and pregnancy. The most common forms of reproductive coercion include sabotage of contraceptive methods, pregnancy coercion, and pregnancy pressure. In a qualitative study of adolescent females, 25% reported that their abusive male partners were trying to get them pregnant through interference with planned contraception, forcing the female part­ners to hide their contraceptive methods.

Sexual Assault and Abuse

Sexual assault is a crime of violence and aggression and encompasses a continuum of sexual activity that ranges from sexual coercion to contact abuse (unwanted kissing, touching, or fondling) to rape. Because defini­tions vary among states, sexual assault is sometimes used interchangeably with rape. The Federal Bureau of Investigation uses the following recently revised, more comprehensive definition of rape to track statistics for the annual Uniform Crime Report: “Penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim.” The Federal Bureau of Investigation’s change does not affect definitions under federal or state criminal laws; the new definition only applies for statistical pur­poses, so that crimes under existing state laws will now be counted by the federal government.

Methods of obtaining data influence estimates of the incidence and prevalence of rape and sexual assault. Data compiled from reports to law enforcement officials underestimate the incidence of sexual assault. The 2010 National Intimate Partner and Sexual Violence Survey reported that 42% of female rape victims experienced their first completed rape before the age of 18 years.

Victims of sexual assault who are of reproductive age are at risk of unintended pregnancy and STIs. Unintended pregnancy is especially high among adolescents who are assaulted because of their relatively low use of contraception. Therefore, emergency contraception and prophylaxis for STIs should be available and provided. Health care providers who have an objec­tion to providing emergency contraception should arrange for provision of emergency contraception, as indicated. Sexual assault victims are also at risk of mental health conditions, such as posttraumatic stress disorder. The physician who examines victims of sexual assault has a responsibility to be aware of state and local statutory or policy requirements that may involve the use of evidence-gathering kits.

The age at which an adolescent may consent to sexual intercourse varies by state and is generally 16-18 years. Sexual assault that occurs in child­hood, defined by most states as younger than 14 years, is considered child abuse. Laws requiring the reporting of child abuse, including sexual abuse, exist in every state. The College, along with the American Academy of Family Physicians, the American Academy of Pediatrics, and the Society for Adolescent Health and Medicine, support the following guidance:

• Sexual activity and sexual abuse are not synonymous. It should not be assumed that adolescents who are sexually active are, by defini­tion, being abused. Many adolescents have consensual sexual rela­tionships.

• It is critical that adolescents who are sexually active receive appro­priate confidential health care and counseling.

• Open and confidential communication between the health care provider and the adolescent patient, together with careful clinical assessment, can identify most sexual abuse cases.

• Physicians and other health providers must know their state laws and report cases of sexual abuse to the proper authority, in accor­dance with those laws, after discussion with the adolescent and par­ent, as appropriate.

It is critical to empower adolescents with preventive strategies in an attempt to avoid future violence. This must be done with skill for patients who have already been abused, as they may conclude they should or could have prevented the previous abuse and put blame on themselves rather than the perpetrator. Many adolescents have not developed the skills to recognize and avoid potentially dangerous dating or social situations. It is important to counsel adolescents that alcohol and substance use increases vulnerability to sexual assault. Adolescents should be aware of the dangers of date rape drugs and know how to avoid being a victim (see Resources). Some adolescents have distorted perceptions of violence and fail to rec­ognize a partner’s behavior as violent. (For more information on sexual assault and abuse, see the “Abuse” section later in Part 3.)

Adolescents With Disabilities

Adolescence is a time of transition for all teenagers and their families. For an adolescent with physical or intellectual and developmental disabilities, the onset of menstrual cycles, the expression of sexuality, and the possibility of pregnancy can provide significant challenges for the patient and her caregivers. Adolescent girls, particularly those who have had a disability from early childhood, require a smooth transition from the care of the pediatrician or family physician, who often provided and coordinated all health care services, to a multitude of health care providers, who may not offer health care management services. It is incumbent upon the obstetrician-gynecologist to participate in service coordination for the adolescent with disabilities, as well as to provide direct gynecologic and reproductive care. A positive, respectful experience in early adolescence can affect the adolescent’s self-esteem and willingness to seek out future reproductive health services.

Knowledge of the adolescent’s preferred mode of communication and the health care provider’s patience are critical to ensure optimal health care delivery. It is important to make every attempt to address and communi­cate with the adolescent directly as well as with her caregiver.

Ascertaining the capacity of the adolescent with intellectual and developmental disabilities to provide informed consent can be complex. Multiple interviews over the course of time and involving a person trained in communication with a person with intellectual and developmental dis­abilities may be required to ascertain the patient’s comprehension of the nature of the procedure and its effect on her. Even when it is determined that the adolescent does not have the capacity to consent, it is important to gain her assent before commencing a procedure. The determination of the capacity to consent should be made based on the level of risk to the patient. Increased scrutiny is necessary with more invasive or risky proce­dures. As with all adolescents, it is important for the health care provider to be aware of state regulations regarding the nature of the activities to which an adolescent can legally consent and to note that these statutes can vary from state to state.

Guidelines for primary and preventive reproductive health care—such as cervical cytology screening, STI screening, pelvic examination, psychosocial risk screening, and review of immunization status—are the same as those for adolescents without disabilities (see also “The Physical Examination and Screening” earlier in this section). If an external genital examination, speculum examination, or bimanual examination is clinically indicated in an adolescent with disabilities, it may be necessary to alter the position and method of examination. (For more information, see the “Women With Disabilities” section later in Part 3). As for all adolescents, the patient’s medical history should include screening for the following: eating disor­ders; tobacco, alcohol, and drug use; depression; abuse; sexual activity; and sexual abuse. Immunizations are important for all adolescents with disabilities and could be especially important for those who have immuno­suppression issues. In general, the patient’s pediatrician will have followed the recommended schedule of vaccinations by age. Because of the high risk of sexual assault for adolescents with disabilities, HPV vaccination is strongly recommended as early as possible, beginning at age 9 years.

Frequently, caregivers may look to the obstetrician-gynecologist for guidance about menstrual issues. Requests for amenorrhea for menstrual manipulation are frequent, and the health care provider should offer information and counseling in this area. Abnormal uterine bleeding assessment and therapy in adolescents with disabilities follows the same general approach as that of patients without disabilities except for special considerations, such as menstrual hygiene and the higher risk of abnormal bleeding that is due to medical conditions. A menstrual history should be discussed in detail to determine the effects on the patient’s health and well-being. Possible causes of menstrual difficulties in adolescents with disabilities include obesity, thyroid disease, genetic disorders, antiepileptic and psychiatric medications, polycystic ovary syndrome, and cervicitis. The most important issue to determine is how the bleeding, whether it is normal or irregular, affects the adolescent’s life. Clinicians also should always consider the possibility that any patients with irregular bleeding could be pregnant. If, after evaluation, the adolescent, her family, and the health care provider decide that limiting menstruation is warranted, the least invasive, least harmful, and most reversible intervention should be used. Hysterectomy is very rarely indicated for adolescents with disabilities (eg, for cancer treatment). Abnormal bleeding is almost always managed medically for a teenager without disabilities. The same should be true for adolescents with disabilities. For more information on evaluation and management, see the “Abnormal Genital Bleeding” section in Part 4.

The obstetrician-gynecologist can offer guidance regarding the expres­sion of healthy, safe, and consensual sexual activity for adolescents with disabilities and address parental concerns about their vulnerability to abuse and pregnancy. If the adolescent indicates she is interested in sexual activity, the clinician should assess her ability to consent to voluntary sexual activity and her history of sexual activity. Abuse is often a concern of families when an adolescent with disabilities, with or without cognitive impairment, reaches puberty and menarche. Rates of sexual assault are high among individuals with disabilities. Clinicians must be vigilant in looking for signs, symptoms, or changes in behavior that may be indica­tors of sexual abuse in those patients who may not be able to communicate details of their abuse.

The degree of cognitive impairment and physical disability of the ado­lescent and access to appropriate education and supervision greatly affects the contraception methods that best meet the needs of adolescent with disabilities. It is critical to assess who is requesting the contraception and to assess the adolescent’s safety as well as her ability to consent to sexual activity. Pregnancy and parenting for adolescents with physical or intellec­tual and developmental disabilities may have unique medical and social aspects, but rarely are precluded by the disability itself. Discussions regard­ing the implications of pregnancy and parenting should be initiated with all adolescents in the context of the educational sessions on sexuality and contraception.

The onset of menses and the awakening of sexuality can be unsettling to patients and their families. Obstetricians-gynecologists have the obligation to do no harm, involve the adolescent with disabilities as much as possible in any decisions, and ensure that she is comfortable, safe, and prepared for her life as a woman of reproductive age, whatever her abilities may be. Please see the College’s resource Reproductive Health Care for Adolescents With Disabilities for more information.

Bibliography­

Access to emergency contraception. Committee Opinion No. 542. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1250-3. [PubMed] [Obstetrics & Gynecology]

Addressing health risks of noncoital sexual activity. Committee Opinion No. 582. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:1378-83. [PubMed] [Obstetrics & Gynecology]

Adolescents and long-acting reversible contraception: implants and intrauterine devices. Committee Opinion No. 539. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:983-8. [PubMed] [Obstetrics & Gynecology] Adoption. Committee Opinion No. 528. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:1320-4. [PubMed] [Obstetrics & Gynecology]

American College of Obstetricians and Gynecologists. Guidelines for adoles­cent health care [CD-ROM]. 2nd ed. ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011.

American College of Obstetricians and Gynecologists. Reproductive health care for adolescents with disabilities: supplement to Guidelines for adolescent health care. 2nd ed. ed. Washington, DC: American College of Obstetricians and Gynecologists;

2012. Available at: http://www.acog.org/Resources_And_Publications/Guidelines_ for_Adolescent_Health_Care/Reproductive_Health_Care_for_Adolescents_With_ Disabilities. Retrieved July 23, 2013.

American Medical Association. State medical society websites. Available at: http:// www.ama-assn.org/ama/pub/about-ama/our-people/the-federation-medicine/ state-medical-society-websites.page. Retrieved September 26, 2013.

Black MC, Basile KC, Breiding MJ, Smith SG, Walters ML, Merrick MT, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Atlanta (GA): National Center for Injury Prevention and Control; Centers for Disease Control and Prevention; 2011. Available at: http://www.cdc.gov/ ViolencePrevention/pdf/NISVS_Report2010-a.pdf. Retrieved July 30, 2013.

Centers for Disease Control and Prevention. Guidance on the use of expedited partner therapy in the treatment of gonorrhea. Atlanta (GA): CDC; 2012. Available at: http://www.cdc.gov/std/ept/GC-EPT-GuidanceNov-2012.pdf. Retrieved July 29,

2013.

Chamberlain L, Levenson R. Addressing intimate partner violence, reproductive and sexual coercion: a guide for obstetric, gynecologic and reproductive health care settings. 2nd ed. Washington, DC: San Francisco (CA): American College of Obstetricians and Gynecologists; Futures Without Violence; 2012. Available at: http://www.futureswithoutviolence.org/userfiles/file/HealthCare/reproguidelines_ low_res_FINAL.pdf. Retrieved September 10, 2013.

Chandra A, Mosher WD, Copen C, Sionean C. Sexual behavior, sexual attraction, and sexual identity in the United States: data from the 2006-2008 National Survey of Family Growth. Natl Health Stat Report 2011;36:1-36. [PubMed]

Copen CE, Chandra A, Martinez G. Prevalence and timing of oral sex with opposite­sex partners among females and males aged 15-24 years: United States, 2007-2010. Natl Health Stat Report 2012;56:1-16. [PubMed] [Full Text]

Department of Health and Human Services. Impacts of four Title V, Section 510 abstinence education programs: final report. Washington, DC: HHS; 2007. Available at: http://aspe.hhs.gov/hsp/abstinence07/report.pdf. Retrieved September 27, 2013.

Department of Health and Human Services, Office on Women's Health. Date rape drugs. Washington, DC: HHS; 2008. Available at: http://www.womenshealth.gov/ publications/our-publications/fact-sheet/date-rape-drugs.pdf. Retrieved September 27, 2013.

Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH, Hawkins J, et al. Youth risk behavior surveillance—United States, 2011. Centers for Disease Control and Prevention. MMWR Surveill Summ 2012;61(4):1—162. [PubMed] [Full Text] English A, Ford CA. The HIPAA privacy rule and adolescents: legal questions and clinical challenges. Perspect Sex Reprod Health 2004;36:80-6. [PubMed] [Full Text] Expedited partner therapy in the management of gonorrhea and chlamydia by obstetrician-gynecologists. Committee Opinion No. 506. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:761-6. [PubMed] [Obstetrics & Gynecology]

Federal Bureau of Investigation. Summary Reporting System (SRS) user manual version 1.0. Criminal Justice Information Services (CJIS) Division, Uniform Crime Reporting (UCR) Program. Washington, DC: FBI; 2013. Available at: http:// www.fbi.gov/about-us/cjis/ucr/nibrs/summary-reporting-system-srs-user-manual. Retrieved November 25, 2013.

Fiore MC, Jaen CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2008. Available at: http://www.ahrq.gov/professionals/clinicians-providers/guide lines-recommendations/tobacco/clinicians/treating_tobacco_use08.pdf. Retrieved July 26, 2013.

Ford C, English A, Sigman G. Confidential Health Care for Adolescents: position paper for the society for adolescent medicine. J Adolesc Health 2004;35:160-7. [PubMed]

Guttmacher Institute. State center. Available at: http://www.guttmacher.org/state- center/. Retrieved September 27, 2013.

Human papillomavirus vaccination. Committee Opinion No. 588. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:712-8. [PubMed] [Obstetrics & Gynecology]

Institute of Medicine. Dietary reference intakes tables and application. Available at: http://www.iom.edu/Activities/Nutrition/SummaryDRIs/DRI-Tables.aspx. Retrieved July 24, 2013.

Martinez G, Copen CE, Abma JC. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2006-2010 national survey of family growth. Vital Health Stat 23 2011;(31):1-35. [PubMed]

Menstrual manipulation for adolescents with disabilities. ACOG Committee Opinion No. 448. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:1428-31. [PubMed] [Obstetrics & Gynecology]

Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. ACOG Committee Opinion No. 349. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1323-8. [PubMed] [Obstetrics & Gynecology]

Miller E, Decker MR, Reed E, Raj A, Hathaway JE, Silverman JG. Male partner pregnancy-promoting behaviors and adolescent partner violence: findings from a qualitative study with adolescent females. Ambul Pediatr 2007;7:360-6. [PubMed] Nicoletti A. Perspectives on pediatric and adolescent gynecology from the allied health care professional. Teens, tattoos and body piercing. J Pediatr Adolesc Gynecol 2004;17:215-6. [PubMed] [Full Text]

Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. National Cholesterol Education Program. Pediatrics 1992;89(part 2):525-84. [PubMed]

Reproductive and sexual coercion. Committee Opinion No. 554. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:411-5. [PubMed] [Obstetrics & Gynecology]

Sexual assault. Committee Opinion No. 592. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:905-9. [PubMed] [Obstetrics & Gynecology] Shain BN. Suicide and suicide attempts in adolescents. American Academy of Pediatrics Committee on Adolescence. Pediatrics 2007;120:669-76. [PubMed] [Full Text]

Sterilization of women, including those with mental disabilities. ACOG Committee Opinion No. 371. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:217-20. [PubMed] [Obstetrics & Gynecology]

Students Against Destructive Decisions. Distracted driving. Available at: http://sadd. org/issues_distracted.htm. Retrieved September 27, 2013.

The fourth report on the diagnosis, evaluation, and treatment of high blood pres­sure in children and adolescents. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics 2004;114:555-76. [PubMed] [Full Text]

The initial reproductive health visit. Committee Opinion No. 598. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:1143-7. [PubMed] [Obstetrics & Gynecology]

Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health 2004;36:6-10. [PubMed] [Full Text]

Welliver D, Welliver M, Carroll T, James P. Lumbar epidural catheter placement in the presence of low back tattoos: a review of the safety concerns. AANA J 2010;78:197-201. [PubMed]

Resources

Adolescent confidentiality and electronic health records. Committee Opinion No. 599. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:1148-50. [PubMed] [Obstetrics & Gynecology]

American Academy of Pediatrics. AAP policy. Available at: http://pediatrics.aappub lications.org/site/aappolicy/index.xhtml. Retrieved September 27, 2013.

American College of Obstetricians and Gynecologists. Adolescent health care. Washington, DC: American College of Obstetricians and Gynecologists; 2013. Available at: http://www.acog.org/About_ACOG/ACOG_Departments/Adolescent_ Health_Care. Retrieved September 30, 2013.

American College of Obstetricians and Gynecologists. Birth control-especially for teens. Patient Education Pamphlet AP112. American College of Obstetricians and Gynecologists; 2013.

American College of Obstetricians and Gynecologists. Having a baby-especially for teens. Patient Education Pamphlet AP103. Washington, DC: American College of Obstetricians and Gynecologists; 2013.

American College of Obstetricians and Gynecologists. Annual women's health care.

Available at: http://www.acog.org/wellwoman. Retrieved October 1, 2013.

American College of Obstetricians and Gynecologists. You and your sexuality- especially for teens. Patient Education Pamphlet AP042. Washington, DC: American College of Obstetricians and Gynecologists; 2013.

American College of Obstetricians and Gynecologists. Your changing body- especially for teens. Patient Education Pamphlet AP041. Washington, DC: American College of Obstetricians and Gynecologists; 2012.

American College of Obstetricians and Gynecologists. Your first gynecologic visit- especially for teens. Patient Education Pamphlet AP150. Washington, DC: American College of Obstetricians and Gynecologists; 2011.

American Medical Association. Confidential care for minors. In: Code of medical ethics of the American Medical Association: current opinions and annotations. 2012-2013 ed. Chicago (IL): AMA; 2012. p. 185-7.

American Society for Colposcopy and Cervical Pathology. Updated consensus guidelines on the management of women with abnormal cervical cancer screening tests and cancer precursors. Frederick (MD): ASCCP; 2013. Available at: http://www. asccp.org/Guidelines. Retrieved September 27, 2013.

Bright Futures. American Academy of Pediatrics. Available at: http://brightfutures. aap.org. Retrieved July 20, 2013.

Center for Adolescent Health and the Law. Available at: http://www.cahl.org. Retrieved September 27, 2013.

English A, Bass L, Boyle AD, Eshragh F. State minor consent laws; a summary. 3rd ed. Chapel Hill (NC): Center for Adolescent Health & the Law; 2010.

Food and Drug Administration. Inked and regretful: removing tattoos. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm336842.htm. Retrieved July 30, 2013.

Future of Sex Education Initiative. National sexuality education standards core content and skills, K-12. Available at: http://www.futureofsexeducation.org/docu ments/josh-fose-standards-web.pdf. Retrieved July 30, 2013.

Guide to Community Preventive Services. Preventing HIV/AIDS, other STIs, and teen pregnancy: group-based abstinence education interventions for adoles­cents. Available at: http://www.thecommunityguide.org/hiv/abstinence_ed.html. Retrieved July 30, 2013.

Guttmacher Institute. Adolescents. Available at: http://www.guttmacher.org/sec tions/adolescents.php. Retrieved September 27, 2013.

Massad LS, Einstein MH, Huh WK, Katki HA, Kinney WK, Schiffman M, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. 2012 ASCCP Consensus Guidelines Conference; Obstet Gynecol 2013;121:829-46. [PubMed] [Obstetrics & Gynecology] Morreale MC, Stinnett AJ, Dowling EC, editors. Policy compendium on confidential health services for adolescents. 2nd ed. Chapel Hill (NC): Center for Adolescent Health & the Law; 2005.

National Campaign to Prevent Teen and Unplanned Pregnancy. Available at: http:// www.thenationalcampaign.org. Retrieved September 27, 2013.

North American Society for Pediatric and Adolescent Gynecology. Tools for the cli­nician. Available at: http://www.naspag.org/index.php/professionalspage/6-tools- fortheclinician. Retrieved September 27, 2013.

Reproductive health care for adolescents with human immunodeficiency virus. Committee Opinion No. 572. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:721-6. [PubMed] [Obstetrics & Gynecology]

Students Against Destructive Decisions. Contract for life. Available at: http://www. sadd.org/contract.htm. Retrieved July 30, 2013.