Conducting an assessment
Health workers should not make assumptions about the sexual activity of adolescent clients. A comprehensive SRH assessment should be carried out as part of routine care to establish sexual activity, risk, the presence of STIs, level of knowledge, competence and vulnerability.
An objective, holistic approach. When discussing sexual and reproductive health issues with adolescents, it is important to establish a rapport with the client, beginning a discussion with non-threatening issues and asking indirect questions (e.g. about their friends’ and peers’ activities instead of their own) when possible. It is also helpful to use clear, direct language and to avoid using complicated medical terminology or adolescent lingo. This contributes to a clear understanding of key issues while avoiding any perceptions that a provider is making value judgments. When conducting a history regarding an adolescent’s sexual activity or practices, it helps to explain why you are asking such questions and indicate that you discuss sexual activities with all adolescents. This can be effective in emphasizing that a provider has no intention of judging the adolescent’s activities; rather that it benefits an adolescent to gain the knowledge that allows him or her to make choices about their sexual health and their relationships with sexual partners. Additionally, SRH consultations offer health providers an opportunity to assess knowledge and to correct misconceptions.
Assessment of sexual activity. It is important to establish the status and type/s of an adolescent’s sexual activity in order to clearly identify potential risk and to avoid making assumptions about sexual orientation and behaviour. One of the main tasks of the SRH service provider is to look for signs and symptoms of STIs that will require further diagnosis and treatment. The Adolescent job aid provides detailed information on conducting physical examinations and conducting sexual health assessments. SRH assessments should also include use of condoms and confirmation of knowledge about correct usage; and the need for hormonal contraception, taking into account potential interactions between some ARTs and hormonal contraceptives. Annex 1 of Medical eligibility criteria for conceptive use clearly outlines understanding of the interactions between ART and hormonal contraceptives. Furthermore establishing the sexual activity of an adolescent client also identifies the need for cervical cancer screening and human papilloma virus (HPV) vaccination.
Assessment of competence. While national and local laws may stipulate ages of consent for sexual health and reproductive services, most legal systems recognize ‘mature minors’ on the basis of marital status, pregnancy, parenthood and independent living arrangements. Health providers should be aware of local laws and extenuating circumstances; however, the overarching consideration should always be the well-being of the adolescent.
Health providers may need to assess competence to consent to SRH services. This can depend on actual age, whether an adolescent is a mature minor or the general level of understanding and capacity for autonomy of the adolescent. This can also be an opportunity to assess knowledge and misconceptions that will need to be addressed. Please refer to the HIV Testing and Counselling section for more information regarding issues of consent.
Ideally, providers could try to assess the capacity of an adolescent to consent to sex and to manage their sexual relationships. Questions regarding whether the adolescent is comfortable, or feels safe, with the sex they are having, power imbalances, age differences, receipt of gifts or money for sex, and other forms of coercion can reveal issues that may require attention, support or referral. Providers should also be vigilant for signs of vulnerability and/or abuse, being particularly aware of those among adolescents with disabilities. Special counselling tools or referral to protective as well as therapeutic services may be required in these cases.