A 17-year-old girl presents to the pediatric rheumatology clinic for follow-up of recently diagnosed systemic lupus erythematosus (SLE) characterized by class IV lupus nephritis, photosensitive rash and antiphospholid antibody positivity. She is currently being treated with prednisone, mycophenolate mofetil, and hydroxychloroquine. She is accompanied by her mother, who has been very involved in the patient’s care.
You Might Also Like
Explore This IssueApril 2020
As part of routine adolescent assessment, the patient’s mother is asked to leave the exam room so a confidential psychosocial assessment can be performed using the HEADSS (home, education/employment, activities, drugs, sexuality, suicide/depression) framework.
During questioning, a sexual history is collected, and the patient is asked about her sexual orientation, sexual activity, contraception use, gender identity and preferred pronouns. The patient discloses that she is attracted to boys, is not currently sexually active and is not on hormonal contraception. She identifies as a girl and prefers the pronouns she/her.
The mother is brought back into the exam room, and the visit is concluded thereafter.
Several hours later, the rheumatologist receives a message from the front desk staff that the patient’s mother called and expressed anger about the questions her daughter was asked while she was out of the room. She feels it was inappropriate and unprofessional for the rheumatologist to ask her daughter about her sexuality and gender identity during a visit for her lupus.
Did the rheumatologist cross a line?
Talking to Teens
Adolescence is a common time for many rheumatologic diagnoses to first present. Apart from their medical conditions, teens often struggle with a host of psychosocial stressors involving mental health, substance use and sexuality. Physicians are afforded a unique opportunity to build relationships with their adolescent patients and help them navigate this challenging period of life.
The American Academy of Pediatrics, through its Bright Futures initiative, recommends psychosocial screening of adolescent patients at least annually.1 However, it has been estimated that up to one-third of insured adolescents have not had a single preventive care visit between the ages of 13 and 17.2 Therefore a visit to the rheumatology clinic is an opportunity to build trusting relationships and discuss sensitive psychosocial topics.
The HEADSS assessment for conducting a psychosocial interview was first published in Contemporary Pediatrics in 1988 by John Goldenring, MD, MPH, JD, and Eric Cohen, MD, who refined a framework originally developed by Harvey Berman, MD, in 1972.3 It has undergone multiple iterations over the past several decades, but serves to facilitate a conversation between the provider and the patient in a confidential manner.
Although many of the HEADSS components, including mental health, substance use and sexual activity, have clear impacts on our rheumatology treatment strategies and medical decision making, other components, such as sexual orientation and gender identity, may have less obvious relevance.
This raises the question, should the rheumatologist even be asking these questions? Is this the appropriate setting?