Doctors are missing a prime opportunity to share information about sex with their teenage patients by failing to broach the subject during checkups, according to researchers at Duke Medicine.

The study, published Dec. 30, 2013, in JAMA Pediatrics, found that less than two thirds of doctors and teenage patients talk about sex, sexuality or dating during annual visits, and the conversations that occur last less than a minute on average.

"It's hard for physicians to treat adolescents and help them make healthy choices about sex if they don't have these conversations," said lead author Stewart Alexander, Ph.D., associate professor of medicine at Duke. "For teens who are trying to understand sex and sexuality, not talking about sex could have huge implications."

During annual visits, doctors can promote a range of healthy behaviors to teenage patients by talking about issues such as smoking, drinking and wearing seatbelts.

Sex is another topic that the American Academy of Pediatrics recommends physicians address with teens. While these conversations may be uncomfortable for the patient and provider alike, they are important opportunities to discuss sexual development, sexually transmitted infections and pregnancy prevention.

One-on-one confidential time during annual visits is recommended to allow for these sensitive conversations. Confidential discussions help establish trusting relationships between doctors and patients and foster candid disclosures from adolescents.

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Past studies on discussions of sex during doctors' visits were based on information teens or physicians reported after visits. To capture naturally occurring conversations, Duke researchers gathered audio recordings of annual visits, including camp and sports physicals, for 253 adolescents. The teens, ages 12 to 17, visited pediatricians and family medicine physicians at 11 clinics in North Carolina.

The researchers listened to the recordings for any mention of sexual activity, sexuality or dating. They found that physicians brought up sex in 65 percent of visits, with conversations lasting an average of 36 seconds. The other 35 percent of visits included no mention of sex. None of the adolescents initiated discussions on sex, reinforcing the need for physicians to start the conversation.

"We saw that physicians spent an average of 22.4 minutes in the exam room with their patients. Even when discussions about sex occurred, less than 3 percent of the visit was devoted to topics related to sex," Alexander said. "This limited exchange is likely inadequate to meet the sexual health prevention needs of teens."

Adolescents' engagement in these discussions varied. When physicians asked them questions about sex, about half of the teens responded to yes or no questions with limited discussion, and a meager 4 percent of teens had prolonged conversations with their doctors.

Female adolescents were more than twice as likely to spend more time talking about sex than their male counterparts. While females may have more to discuss when it comes to birth control and pregnancy prevention, the finding raises the concern that males could be missing out on benefits of annual visits.

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"The implication for males is troublesome because as they get older, they become less likely to routinely see physicians outside of checkups or sports physicals," said Alexander. "Thus, the annual visits become essential and are perhaps the only opportunity for physicians to address the sexual behaviors of adolescent boys."

The researchers also found that older teens were more likely to talk about sex in their visits than younger teens, despite the fact that current guidelines recommend that doctors start these conversations in early adolescence before teens are sexually active.

"There's a saying that it's always better to have the conversation two years too soon than one day too late," Alexander said. "If you're one day too late, the teens may already be engaging in sexual behaviors that have consequences for them."

Longer visits and confidentiality both raised the chances that sex was mentioned. Only 31 percent of visits included a confidential discussion between the physician and patient, but when they did, sex was four times more likely to come up.

"Although adolescents have access to information on sex from a variety of sources, physicians could do more in support of teens' healthy sexual development," said Alexander. "Initiating conversations demonstrates to adolescents that talking about sex is a normal part of a checkup, and may open the door for more extensive discussions."

The researchers are currently analyzing the content of the conversations on sex, which could contribute to future recommendations for sexual health interviews. Additional training on interviews could help providers navigate these tricky conversations more easily.