Meeting the Needs of Young Clients:
A Guide to Providing Reproductive Health Services to Adolescents

Chapter 6: Counseling Young People about Reproductive Health

See Also:

Network 20.3: Adolescent Reproductive Health

"Nowadays there's more danger in not talking about sexuality than in talking about it." ­ Secondary school teacher in Cote d'Ivoire

Counseling is critical for all reproductive health clients, including adolescents. As with adults, adolescents should have:

• Adequate information about reproductive health issues.
• A choice of contraceptive methods to ensure that they can protect themselves against unplanned pregnancy and STIs.
• The opportunity to make decisions and take actions without pressure or coercion.
• The assurance of confidentiality.
• Services and information provided in a nonjudgmental manner.

The goal of counseling is to provide young people with facts that will enable them to make informed, voluntary decisions. You should offer information and guidance, but ultimately, the adolescent must decide whether to use contraception, which method to use, whether to continue or discontinue a method, whether he or she needs a contraceptive method that also offers STI protection, or whether to seek STI treatment.

You may be reluctant to discuss sexual health issues with young adults. You may believe that adolescents should not be sexually active, that only married youth should be sexually active or that sexual activity is acceptable for boys but not girls. You may be embarrassed or uncomfortable discussing sexual details with youth.

It is important, however, not to let personal feelings and biases get in the way of professional behavior. Ideally, you should:

• Be a reliable, factual source of information about reproductive health, including pregnancy and STI prevention.
• Create an atmosphere of privacy, respect and trust, so that young people will feel free to ask questions, voice concerns and discuss intimate sexual issues.
• Engage in a dialogue or open discussion with the young person.
• Offer choices and do not judge the young person's decisions. Accept his or her right to choose and the choices made.

Questions to ask adolescents

In talking with young people about reproductive health issues, you can begin by asking questions about:

• Sexual knowledge, attitudes and behaviors.
• Reproductive goals.

To help build rapport with young people, you can begin with general questions about the young person's life and interests.

• Do you go to school? What do you like or not like about your classes?
• Do you work? Tell me about your job.
• Tell me about your family.
• Tell me about your friends.
• Do you have a boyfriend/girlfriend?
• Why did you come here today?
• How can we help you?

As you and the client feel more comfortable talking together, you can ask more intimate questions about sexual knowledge and experience, such as:

• Have you had sexual relations before? (For some adolescents, the term "sexual intercourse" or "sexually active" may be unclear. Instead, providers may want to ask about specific sexual activities, such as touching genitals, vaginal intercourse, oral sex or anal intercourse.)
• Did you plan to have sex at those times?
• How did you feel about this experience? Was it pleasant? Was it unpleasant?
• Has anyone ever forced you to have sex?
• Do you plan to have sexual relations in the near future?
• Are you physically attracted to men? To women? To both? To neither? How do you feel about these attractions?
• Do you have one sexual partner, or have you had more than one partner in the past?
• Are your partners members of the opposite sex, the same sex or both?

What you can do

In a positive client- provider relationship, the provider listens as well as talks. You should explain and share knowledge about reproductive health, but you should also give young people plenty of time to talk, express their concerns and ask questions. You should listen carefully, respect their wishes and experiences and provide relevant information in language that is simple to understand.Your actions and attitudes are the key to successful client-provider relationships. At the beginning of any counseling session with young people, you can:

• Explain that:
  • Adolescence is a time when young people begin to change ­ their bodies change, they are curious and they want to experiment.
  • Interest in sex is normal.

  • What happens to them as adolescents can affect their future reproductive health.

• Assure young people of confidentiality. (Explain that there may be exceptions if the client discusses suicide, homicide or sexual abuse.)
• Explain that it is necessary to ask sensitive questions when discussing pregnancy and STI prevention.

During counseling sessions on reproductive health, there are several things you can do to improve client-provider interactions:

• Use simple language and short sentences. Avoid technical terms.

• Use nonjudgmental language. For example, avoid saying, "You should " Instead say, "You can " or "You may want to think about this "

• Ask questions about young clients' fears and concerns.

• Correct erroneous information.

• Refrain from offering nonmedical advice.

• Encourage young people to ask questions.

• Be aware of language and slang adolescents use to discuss sexual issues. Ask them to clarify what they mean. For example, a young person may say they engage in oral sex. You may think they are talking about mouth-penis contact, when they may be talking about kissing.

The percentage of women who have given birth by age 18 ranges from 1 percent in Japan to 53 percent in Niger.

• Use "reflective listening." Paraphrase the young person's statements and repeat them back to him or her. This shows empathy and confirms that the young client understands what you are saying. If a young woman says she is concerned about preventing pregnancy, you can say, "So, you want to prevent pregnancy now. You want to wait to have children." If a young man says he wants to prevent STIs, you can say, "I understand that you want to learn how to prevent sexually transmitted infections. You have questions about protecting yourself and your partner."

• Ask open-ended questions that will lead to discussion rather than questions that require "yes" or "no" answers. For example, ask, "What do you know about contraception?" rather than "Do you know about contraception?" Or ask, "What do you know about sexually transmitted infections?" rather than "Do you have an STI?"

• Make sure young clients understand what you are saying to them. Do not simply ask, "Do you understand what I have said?" as clients may be embarrassed to admit they do not. Instead, ask questions that will help determine if the young person understands. For example, after you have explained condom use to a young man, you can say, "Tell me when you should use a condom and how you put it on." You can also ask, "What are the symptoms of an STI?" or, for young women, "What will you do if you miss more than one pill?"

• Learn to read "body language." Be conscious of what your own body language is communicating by the way you stand, sit or make eye contact.

• Let adolescents do the talking. Ask questions and let them tell you what they know. Correct misinformation.

• Do not stereotype or treat all adolescents the same; treat each young person as an individual.

Remember: Good counseling takes time. This is especially true with adolescents, who may need basic information about reproductive health, plus specific information about preventing pregnancy and STIs. Setting aside time to talk at length with young people may be difficult for service providers, many of whom are already overworked. But thorough counseling is important. It can reduce the number of return visits, help young women prepare for contraceptive side effects and reduce contraceptive discontinuation and help young adults learn how to use methods correctly and how to prevent STIs. In the long term, good counseling can improve reproductive health. It is worth the investment of time.

In Zambia, young people outlined what they want from health providers:

Confidentiality. Information. Acceptance (no moralizing or judgment). Respect for opinions. Environment in which they can decide for themselves. Welcoming and comfortable environment. Services provided at times that are convenient for adolescents.* * Bernstein S. The State of the World Population: The New Generations. Ed. Marshall A. New York: United Nations Population Fund, 1998.

Questions for Providers and Program Managers about Counseling Young People

? To counsel effectively about reproductive health, health workers must have technical expertise as well as communications skills. Has your clinic or program worked to train employees in these areas? What more can you do? ? What do you do to ensure adolescents that their privacy and confidentiality will be respected during counseling? ? Do you provide counseling for pregnancy prevention? STI prevention? If not, how could you incorporate this? ? Does your clinic or program offer HIV testing? Do you offer counseling before and after testing? Where do you refer HIV-positive youth for additional help? ? Do providers at your clinic have enough time to counsel clients adequately? If not, what kinds of changes would you have to make to ensure they have time for counseling?

Counseling about Contraception

Your goals in counseling young people about contraception are to help them:

• Identify their reproductive intentions (to begin, postpone or space childbearing) and assess their risk of pregnancy.
• Determine whether they will use contraception.
• Decide which method is best for them.

"We thought about using contraceptives, but we don't use them ­ in the drugstore people will notice you and we don't like that." ­ Young man in Colombia

Questions to ask adolescents

In counseling youth about contraception, you can begin by asking these questions:

• For young women: Have you ever been pregnant? For young men: Have you ever impregnated anyone?
• How did/do you feel about the pregnancy? How did/will your partner feel? How did/will your parents react?
• For young women: Would you like to become pregnant in the near future? Why or why not? For young men: Would you like to have children right away? Why or why not?
• What do you know about contraception?
• How do you feel about using contraception?
• Have you ever used contraception before? What did you like or not like about that method?
• Which method would you like to use? Why would you like this method?
• What do you know about this method?
• Can you discuss contraception with your partner?
• If you choose to use contraception, how will your partner feel?
• What would prevent you from using your chosen method effectively?
• If you have a baby now, are you breastfeeding? If you are pregnant, do you plan to breastfeed?

What you can do: pregnancy prevention

• Explain that there are a variety of ways to prevent pregnancy.
• Explain that the best way to prevent pregnancy is to abstain from sexual intercourse.
• Explain that some contraceptive methods protect against STIs while others do not.
• Emphasize that while all methods are medically safe for young people, some are more appropriate than others.
• Ask the young person which method he or she wants to use and what he or she knows about that method.
• Explain how the chosen method works, correct usage, possible side effects and how to cope with them and problems that indicate a need to see a health worker.
• Refer the young person elsewhere if he or she chooses a method the clinic does not offer.
• Give young people a chance to practice putting condoms on models or to practice negotiating condom use. (See role-play activity in Chapter 3 on "Preventing Pregnancy.")
• Explain that the young person has a right to change his or her mind and stop using a method or to select another method.
• Ask the young person to repeat back to you instructions on the use of the chosen contraceptive.
• Explain how the young person can get a resupply of methods (more condoms, more pills, etc.) if needed.

Counseling about Sexually Transmitted Infections

Because of shame, fear, concerns about privacy and worries about costs, adolescents may not seek STI treatment. They may try to diagnose their illnesses themselves then seek treatment from pharmacies, traditional healers, friends or relatives. If and when they do come to a health clinic, they may do so after months of self-treatment.

In counseling young people about STIs, your goals are to help them:

• Assess their risks of contracting an STI.
• Consider their partner's risk of contracting an STI and determine how that risk affects them.
• Outline strategies they can use to prevent STIs (abstinence, condom use, monogamy with an uninfected partner).
• Identify symptoms that may indicate they have an STI.
• Identify resources or locations for STI treatment.

Questions to ask adolescents

In counseling clients about STIs, you can ask the following questions:

• What do you know about sexually transmitted infections?
• What do you do to prevent STIs?
• Have you had an STI before?
• For young men: Do you have difficulty urinating now? Do you have a burning feeling when you urinate? Do you have an unusual discharge from your penis? Do you have ulcers, sores or blisters on or near your penis? Do you have any painless, fleshy growths in your genital area?
• For young women: Do you have frequent urination? Is it painful when you urinate? Do you have an unusual discharge from your vagina? Does this discharge have a bad odor? Do you have blisters, sores or ulcers near your vagina? Do you have any soft, fleshy growths near your vagina? Do you have pain or tenderness in your lower abdomen? Do you have fever or chills?
• Do you think you might be at risk for an STI? Why or why not?
• Do you think your partner(s) is (are) at risk for STIs? Have they had any STI symptoms?
• Can you discuss STI protection with your partner? How will he or she react?
• Have you ever used a condom? Did you like using it? Was it easy or difficult to use?
• If you wanted to use protection against STIs, what obstacles would you encounter?

What you can do: STI prevention

In counseling sexually active clients about STI prevention, you can:

• Outline ways to prevent STIs:
  • Future abstinence.
  • Correct and consistent use of condoms.
  • Mutually monogamous relationships with uninfected partners.
• Explain symptoms. Explain that for women, STIs are often asymptomatic.
• Provide comprehensive information about treatment, including:
  • How to take medication.
  • The importance of finishing all medication.
  • The need for sexual abstinence or condom use while taking medication.
  • Reasons to stop taking medication and signs that indicate a need to return to the clinic.
  • The need for partners to be treated.
• Emphasize that the long-term consequences of STIs are serious. They include infertility, STI transmission to newborns, miscarriage, stillbirth and death.
• Emphasize that people who contract STIs are at greater risk for contracting HIV.
• Explain that STIs can be spread not only through vaginal intercourse, but also through oral sex, anal sex or genital-to-genital contact.
• Demonstrate condom use and give clients a chance to put condoms on models.
• Encourage young women and men to develop communication skills so they can discuss STI and HIV risks and negotiate condom use.
• Recommend female condoms, if available, for young women whose partners refuse to use male condoms.
• Help clients identify risky behaviors and encourage clients to modify their actions.
• Describe symptoms and advise clients to seek treatment when symptoms appear or if they think they may have been exposed to an STI.
• Diagnose STIs or refer clients to other health clinics for diagnosis and treatment.

For clients who have been diagnosed with STIs or who are treated presumptively for STI symptoms, you can offer treatment for partners as well.

When managing STIs, health clinics can offer services for:

• Primary prevention ­ prevention among young people who do not yet have an STI. This includes information on how to reduce the risks of acquiring STIs, including abstinence, condom use and mutual monogamy.

• Secondary prevention ­ diagnosis and treatment of clients who already have an STI and their partners, plus information on how clients can protect themselves against reinfection.

"I am not afraid to buy condoms because it is my life. ... As long as I believe that condoms could save my life, I will not be bothered about [what people think]." ­ Out-of-school youth in Ethiopia

Counseling about HIV/AIDS

When counseling about HIV, you should talk to young people about risks, prevention and treatment.

Questions to ask adolescents

Many of the questions you ask to help young people assess their STI risks can be modified to help them assess their HIV risks. For example:

• What do you know about HIV/AIDS?
• What do you do to prevent HIV/AIDS?
• Do you know someone who has/had AIDS? What was your relationship to this person?
• Do you think you might be at risk for HIV/AIDS? Why or why not?
• What are the symptoms of HIV/AIDS?
• Do you think your partner(s) is (are) at risk for HIV/AIDS? Has your partner had any STI symptoms?
• Can you discuss HIV protection with your partner? How will he or she react?
• Have you ever used a condom? Did you like using it? Was it easy or difficult to use?
• If you wanted to use protection against HIV, what obstacles would you encounter?

What you can do: HIV prevention

In counseling young adults, you can:

• Stress that young people who delay sexual activity reduce their HIV risks.
• Explain that decreasing the number of sexual partners reduces HIV risks.
• Explain that young people can reduce their risks if they are in a mutually monogamous relationship.
• Explain that STIs increase the chance of acquiring and transmitting HIV.
• Emphasize that the male latex condom provides the best protection against HIV for young people who are sexually active. The female condom also provides protection.
• Describe HIV/AIDS symptoms.
• Help youth learn how to communicate with partners about HIV prevention and treatment.
• Refer sexual partners for HIV testing.
• For young men, discuss the increased risk of contracting HIV during encounters with sex workers.
• For young women, explain the increased risk of contracting HIV during sexual encounters with older men (e.g., sugar daddies).
• For adolescents who are in the military, working as truck drivers or working in jobs that take them away from their regular partner ­ or whose partners may be engaged in these activities ­ explain that sex with casual partners may significantly increase their risk of HIV.

What you can do: HIV testing

For young people who are concerned about AIDS, you may want to recommend HIV testing. Special counseling is required for clients who decide to take this step.

Before testing:

• Explain how HIV is transmitted.
• Explain the test ­ that it will determine the presence of HIV antibodies in the blood. These antibodies do not necessarily mean a person has yet developed AIDS.
• Explain the advantages of testing:
  • Early diagnosis can mean a longer, healthier life since it can provide clients with opportunities to better care for their health.
  • Testing can enable a couple to make decisions about future pregnancies.
  • Knowledge of HIV status can help adolescents prevent transmission to uninfected partners.
• Understand that clients may have reactions to HIV testing, such as:
  • Distress.
  • Anxiety.
  • Uncertainty.
  • Depression.
  • Fear that partners and families may suffer.
  • Fear of discrimination by the community, coworkers or relatives.
  • Concern they may not have access to treatment.
• Talk about the emotional, social and medical consequences of an HIV-positive or HIV-negative test result.
• Help the client make a plan for what he or she will do if the HIV test is positive.
• Discuss ways to prevent HIV transmission.

After testing:

• Counsel the client in person, in a private place, when possible.
• If test result is negative:
  • Explain that this could mean the client is not infected.
  • Explain that this could mean he or she is infected but it is too early for HIV antibodies to be present in the blood. If
  • the client thinks he or she has been exposed to HIV,
  • another test should be done in six months.
  • Counsel about prevention, emphasizing the use of condoms during each act of intercourse.
• If test result is positive, explain:
  • The importance of using condoms to prevent reinfection, which can hasten the progression of the virus.
  • How to maintain health.
  • How to avoid transmitting HIV to others.
• Ask questions:
  • What does this test result mean to you?
  • What are you worried about?
  • How can I help you?
  • Do you want to know more?
  • What questions do you have?
• Refer the young person to other agencies that work with HIV-positive individuals (mental health, economic assistance, transportation, etc.).
• Schedule a follow-up session to plan long-term health care and support.