OBJECTIVES: To determine the frequency of physician-documented sexual histories in female adolescents who presented to an emergency department (ED) with symptoms suggestive of a sexually transmitted infection (STI). Our secondary objectives were to determine if physician-documented sexual history is associated with increased STI testing and to compare the concordance of physician-elicited sexual histories with patient-documented sexual histories by using confidential questionnaires.
METHODS: We conducted a secondary analysis of a prospective study of female adolescents who presented to a pediatric ED with chief complaints of lower abdominal pain and/or genitourinary complaints. Patient charts were abstracted for the presence or absence of documented sexual histories and demographics. A subset of patients completed a questionnaire pertaining to sexual health.
RESULTS: The study population comprised 327 patients; 269 (82%) patients had a physician-documented sexual history, of which 204 (76%) reported being sexually active to the physician. Patient age (odds ratio [OR]: 2.6 [95% confidence interval (CI): 1.3–5.3]) and black race (OR: 2.0 [95% CI: 1.1–3.7]) were associated with physician-documented sexual history. The documentation of a sexual history was associated with increased STI testing (OR: 3.9 [95% CI: 2.0–7.6]). In the patients (n = 109) who completed the questionnaire, physician-elicited sexual histories were highly concordant with patient-documented sexual histories on questionnaire (Spearman r = 0.90; P < .001).
CONCLUSION: These results indicate that ED physicians should obtain sexual histories from symptomatic patients, because it may increase STI testing and subsequent detection. In future studies factors should be evaluated that affect physicians' willingness to assess sexual history in the ED patient.
WHAT'S KNOWN ON THIS SUBJECT:
Sexual histories are not routinely obtained among female adolescents in primary care settings. No previous study has evaluated the frequency of sexual history documentation among female adolescents who present to the emergency department with symptoms suggestive of a sexually transmitted infection.
WHAT THIS STUDY ADDS:
This is the first study to evaluate frequency of sexual history documentation among adolescent emergency department patients who presented with symptoms suggestive of a sexually transmitted infection and concordance of a physician-elicited sexual history with a patient-documented history on questionnaire.
Adolescents frequently present to the emergency department (ED) with complaints that are potentially suggestive of a sexually transmitted infection (STI). Biro et al1 found that more than two-thirds of adolescent patients with an STI presented with abdominal, genital, or urinary symptoms. Almost 16% of all ED visits are made by adolescents, with abdominal pain being the most common chief complaint2 and gynecologic and genitourinary disorders comprising 11% of female adolescent ED discharge diagnoses.3
Female adolescents are disproportionately affected by STIs, representing only 25% of the sexually active population but accounting for nearly half of all diagnosed STIs annually.4 Despite this high prevalence of STIs within the adolescent population, providers frequently fail to inquire about sexual behavior and assess STI risk.5,–,7 When female adolescents present to the ED with symptoms of lower abdominal pain or genitourinary symptoms, it is essential that sexual histories be obtained to assess for STI risk. In fact, it has been shown that obtaining a sexual history is a crucial step in assessing patient risk of STI exposure,8 but studies have revealed that sexual histories are not routinely obtained within the ED. In a recent study it was found that primary care physicians were more likely to document a sexual history than were ED physicians when adolescent patients presented with genitourinary symptoms.9 Similarly, in another study regarding the evaluation of adolescents who presented to the ED with urinary complaints, it was found that 30% of patients did not have a documented sexual history, and in that subset, only 1 patient had undergone STI testing.10 Moreover, in a survey of adolescents who presented to an urgent care center it was found that less than one-third of the adolescents reported having a sexual history obtained by the physician despite almost 90% reporting that they were willing to discuss their sexual health with the physician.11
To our knowledge, in no previous study has the frequency of sexual history documentation been evaluated in female adolescents who presented to an ED with symptoms suggestive of an STI, nor has the association of sexual history documentation with STI testing or the concordance of a physician-documented sexual history with a patient-documented sexual history on a confidential questionnaire. Therefore, given the need to better understand sexual history assessment in the ED, where adolescents frequently present with STI-related complaints, the primary objective of this study was to determine the frequency of a physician-documented sexual history in female adolescents who presented to an ED with lower abdominal and/or genitourinary complaints. Our secondary objectives were to determine if a physician-documented sexual history is associated with increased STI testing and to compare the concordance of a physician-elicited sexual history with a patient-documented sexual history on a confidential questionnaire.
This was a secondary analysis of a prospective study of STI prevalence in a consecutive sample of female adolescents who presented to a large, tertiary, urban, freestanding pediatric hospital ED with chief complaints that may be suggestive of an STI between August 2009 and January 2010.
Patients were included in the study if they were female adolescents between ages 14 and 19 and presented to the ED with chief complaints of lower abdominal, pelvic, or flank pain, and/or genitourinary symptoms including dysuria, or vaginal pain, discharge, lesions, itching, or bleeding. Patients were excluded if they were treated with antibiotics commonly used to treat STIs within the last 2 weeks of their ED visit, if they presented with pain related to recent abdominal trauma not related to sexual assault (eg, motor vehicle collision), if they were transferred to the ED with a specific diagnosis (eg, confirmed appendicitis transferred for subspecialty care), or if they were critically ill.
The study was approved by the hospital's institutional review board, and we were granted a waiver of written consent as well as a waiver of parental consent in an effort to preserve the confidentiality of the patients.
Charts were reviewed for presence or absence of sexual history documentation by the physician, and if sexual histories were documented, whether the patient reported being sexually active. In addition, patient demographics, chief complaints, and whether STI testing was performed were abstracted from the patient charts at the conclusion of the ED visit.
A subset of patients who comprised the study population was asked to complete a confidential Internet-based survey regarding their sexual health. This subset of patients was a nonrandomized convenience sample recruited on the basis of the availability of research associates for survey administration and ED time constraints. Patients were eligible to complete the questionnaire if they met study inclusion criteria. Patients were excluded from survey participation if they did not speak and read English, or were not developmentally capable of completing a survey, in addition to the overall study exclusion criteria. The questionnaire was developed by the investigators and was adapted from the 2003 version of the National Survey of Family Growth.12 It was initially pilot-tested on 10 adolescent patients for clarity and ease of use. No revisions were made to the initial questionnaire after pilot testing. The survey was available on a secure Web-based system (www.surveymonkey.com) that was accessible from computers within the patient examination rooms. A total of 44 questionnaire items included information regarding health care use, sexual activity, number of current and lifetime sexual partners, age of sexarche, and history of STIs. Treating physicians were unaware of which patients completed the questionnaire and did not have access to the questionnaire results at any time.
Our primary outcome measure was frequency of physician-documented sexual history. To better understand predictors of sexual history documentation by a physician, we examined patient age, race, lack of private insurance, and chief complaint as covariates. Our secondary outcome measure was the association of sexual history documentation and STI testing. In addition, as an exploratory analysis, we evaluated the concordance of a physician-documented sexual history with patient-documented sexual history on a confidential questionnaire, as defined by patient report of sexual activity, in a subset of patients.
Descriptive statistics were used to summarize demographic variables, including means, SDs, and ranges of continuous variables, and frequencies for categorical variables. Comparisons of categorical variables between documentation and nondocumentation of sexual histories were made using the χ2 test or the Fisher's exact test. Simple and multivariate logistic regression models were used to identify factors associated with documentation of a sexual history. Spearman correlation was used to determine concordance between physician-documented sexual history and patient-reported sexual history on confidential questionnaire. Data were analyzed by using Stata 11.0 (Stata Corp, College Station, TX). Statistical significance was defined as P < .05.
The study population consisted of 327 patients (Fig 1). Their demographics are presented in Table 1. Eighty-two percent (n = 269) of study patients had a physician-documented sexual history. Of these, 76% (n = 204) were documented as sexually active, either currently or previously.
Patient age and race were associated with physician documentation of sexual history (Table 2). In unadjusted models, patients 15 years and older were more likely to have sexual history documentation than 14-year-olds (odds ratio [OR]: 2.6 [95% confidence interval (CI): 1.3–5.3]). In addition, black patients were more likely to have a documented sexual history compared with other races (OR: 2.0 [95% CI: 1.1–3.7]). Chief complaint and lack of private insurance were not associated with sexual history documentation in univariate models (Table 2). In a fully adjusted model, age 15 and older (OR 2.4 [95% CI: 1.2–4.9]) and black race (OR: 1.9 [95% CI: 1.1–3.5]) were significantly associated with sexual history documentation.
Most importantly, we found a significant association between sexual history documentation and STI testing during the ED visit (OR: 3.9 [95% CI: 2.0–7.6]). Furthermore, when a physician documented that a patient was sexually active, the odds of STI testing increased by 6.8 (95% CI: 3.1–15.0) compared with patients who had no physician-documented sexual history.
In an exploratory analysis, we evaluated the concordance of a physician-documented sexual history with patient report of sexual activity on a confidential questionnaire, obtained from a subset of patients. A convenience sample of 109 patients was approached to participate in the survey. There were no survey refusals. There was no difference between the patients who completed the questionnaire and those who did not except that patients who completed the questionnaire were slightly older and less likely to have private insurance (See Table 1). Of the 109 who completed the survey, 13 (12%) did not have a physician-documented sexual history. Because patients who completed the survey were older and less likely to have private insurance, we adjusted for age and insurance status. After this adjustment, we found no difference between the patients who completed the survey and those who did not complete the survey with regards to physician documentation of sexual history (P = .09) or for physician documentation of the patient being sexually active (P = .05). Subgroup analysis revealed no difference in physician-documented sexual history and patient age, race, and nonprivate insurance among the patients who completed the questionnaire.
The questionnaire responses revealed that 82.6% (n = 90) of patients reported a history of being sexually active, with 67.9% (n = 61) of them reporting current sexual activity. Correlation testing showed significant agreement between physician-documented sexual history and patient self-reported sexual history on questionnaire (Spearman r = 0.90; P < .001). In addition, sexual history concordance was not affected by patient age, race, or insurance status.
The primary objective of this study was to examine the frequency of physician-documented sexual histories in the ED. We found that almost 20% of patients who presented with symptoms that may be suggestive of an STI did not have a physician-documented sexual history. Second, we noted that physician documentation of a sexual history was associated with increased STI testing, and when the physician-documented that the patient was sexually active, the association with STI testing was even stronger. We also examined the degree of concordance between physician-documented sexual history and self-reported sexual activity on a confidential instrument and found that there was a 90% agreement. Overall, these findings underscore the importance of taking a sexual history in the ED in this high-risk population because care may be altered on the basis of this information.
Given that studies have found that many adolescents often present to an ED with concerns related to STIs,10,13,14 it is troubling that almost 20% of the patients who presented with symptoms suggestive of an STI did not have a documented sexual history in our study. In one survey it was found that EDs are commonly cited as places people go to obtain STI treatment,14 and data from the US National Hospital Ambulatory Survey revealed that there are more than 170 000 ED visits made annually by adolescents for STIs.13 STIs can easily be confused with other symptoms related to the gastrointestinal and urinary systems.1 Given that these symptoms may be related to an STI, a sexual history is as vital as other elements of a patient's history, as the first step in identifying STIs may rely on the sexual history.
We identified certain patient characteristics that were associated with sexual history documentation. For example, we found that older patients were more likely to have a documented sexual history. Although previous studies have revealed that older adolescents are more likely to have STIs,13,15,16 this should be interpreted with caution because in most of these studies, younger patients were less likely to even undergo STI testing. Physicians must be mindful that younger adolescents may also be sexually active and at risk. Moreover, younger patients may not have as much insight as to the potential cause of their symptoms, and thus may not disclose sexual activity unless prompted by a physician. We also found that black patients were more likely to have a documented sexual history. Although previous studies have also found a higher prevalence of STIs in black patients,17,18 this does not negate the risk of STIs in nonblack patients.17,18 Therefore, when evaluating patients who present with symptoms that may be suggestive of an STI, it is important that physicians not make assumptions regarding teenagers' sexual activity. These assumptions can potentially lead to missed opportunities for STI identification. Interestingly, unlike in other studies,5 we did not find sexual history documentation to be associated with lack of private insurance, which is likely because ED physicians are often unaware of patient insurance status during their evaluation.
Most importantly, our study revealed that when a sexual history was documented, STI testing was almost 4 times more likely to be performed. In addition, our results echo the findings of a study by Torkko et al5 that revealed that preconceived ideas by providers about low-risk status in patients can lead to minimal risk assessment of their patients, thus jeopardizing patient health. Therefore, these findings have significant implications for STI detection.
An exploratory objective of our study was to assess the concordance of a physician-documented sexual history with a patient-documented sexual history on a confidential questionnaire. We found a high degree of concordance between these 2 modes of sexual history documentation. This is in contrast to other studies in which computer interviews have been compared with face-to-face interview reporting of sexual risk behaviors.19,20 In a study by Kurth et al20 they found patients reported that a computerized interview allowed for more honest reporting. In our study, given that physician-documented sexual histories were highly concordant with patient-documented history on computerized questionnaire, this indicates that patients were as forthcoming about their sexual history with physicians as with the confidential questionnaire. Our finding is supported by those of previous studies that have revealed that adolescents are amenable to sexual history assessment by physicians.8,11
Although previous studies have assessed the frequency of a physician-documented sexual history among adolescent patients, to our knowledge this is the first study in which sexual history documentation has been evaluated in a pediatric ED population of female adolescents who presented with symptoms that may be suggestive of an STI. An additional strength of this study was the study design, which allowed us to compare physician documentation of a sexual history with patient report on a confidential questionnaire.
There are some potential limitations to this study. This study was conducted at a single, urban, pediatric ED, and therefore, may not be generalizable to patients who frequent nonpediatric EDs or nonurban pediatric EDs. However, as the first study in which sexual history documentation in this adolescent ED population is evaluated, this study serves as the first step in designing larger, multicenter studies addressing this issue. Because this was a secondary analysis of a larger study, it may not have been powered to detect some of the factors that may be associated with documentation of a sexual history. Furthermore, there was potential for misclassification bias because a patient may have been asked about her sexual history, but the information may not have been documented by the physician. However, this would have biased our results toward the null and resulted in an underestimate of the OR for the association of STI testing and sexual history documentation. Moreover, barriers to sexual history taking and reporting were also not evaluated. With regards to the subset of patients who completed the questionnaire because a convenience sample of the study population was recruited to participate in the questionnaire, our findings may not be generalizable to our entire study population. In addition, although we were able to conclude that there is a high concordance between physician-documented sexual history and patient reported sexual history on computerized survey, we acknowledge that we cannot definitively conclude that the patients were forthcoming in discussing their sexual histories with the ED provider or with the questionnaire, especially in light of recent work by DiClemente et al21 that revealed that up to 6% of adolescents who had laboratory-confirmed STIs reported never having been sexually active. However, several studies have revealed that patients feel comfortable honestly reporting sensitive information to computerized surveys.19,20
On the basis of the findings of this study, ED physicians should obtain sexual histories in female adolescents who present with symptoms that may be suggestive of an STI because this may increase STI testing, subsequently leading to increased detection and treatment of STIs. Future efforts should focus on educating ED physicians on the importance of routinely obtaining a sexual history from adolescents presenting to the ED. Additional research is needed to understand barriers to taking a sexual history specific to the pediatric ED setting.
- Accepted March 2, 2011.
- Address correspondence to Monika Goyal, MD, Children's Hospital of Philadelphia, Department of Pediatrics, Division of Emergency Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- ED —
- emergency department
- STI —
- sexually transmitted infection
- OR —
- odds ratio
- CI —
- confidence interval
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- Copyright © 2011 by the American Academy of Pediatrics