UNIT 8: THE SRH CLINICAL VISIT AND THE ADOLESCENT CLIENT INTRODUCTION: Many of the health concerns adolescents will bring to a clinic are similar or even identical to those of adult clients, although some of the health and human rights issues raised by adolescent clients require special attention. Both screening and history taking must be tailored to the adolescent client, to include their rights to privacy, confidentiality, and informed choice. This unit explores what should be addressed in screening and history taking as well as ways in which the SRH visit can be made less stressful for both the service provider and the adolescent client. TRAINERÕS NOTE: This unit is designed to be delivered with youth trainers. The lesson and activities can be modified for an adult provider-only participant group, but trainers are strongly encouraged to include youth trainers. It is essential to ensure the participation of youth trainers with different types of disabilities within the training. Accommodation (sign language interpretation and/or Computer Aided Real-Time Transcription (CART)1 personal assistants, braille, large print, easy to read materials, etc.) should be provided as needed to ensure full participation of young trainers with disabilities. UNIT TRAINING OBJECTIVE: To prepare providers to serve the needs of the adolescent client during the SRH visit with special attention to screening and history taking. SPECIFIC LEARNING OBJECTIVES: By the end of the unit, participants will be able to: 1. Identify the elements that should be included in screening and history taking for adolescent sexual and reproductive health service provision. 2. Explain the physical exam and how it can be tailored to the needs of the adolescent client. 3. Discuss specific issues for adolescent client education, such as the menstrual cycle, sexual pleasure, and shared responsibility for sexual health. TOTAL TIME: 3 HOURS 10 MINUTES UNIT OVERVIEW: Session Methods Materials Time 8.1 Trainer presentation Role Plays Slides 8.1-8.22 Participant Handouts 8a Optional: Participant Handout 8b 1 hour 50 minutes 8.2 Trainer presentation Flipcharts and markers Slides 8.23-8.29 30 minutes 8.3 Group discussion Trainer Tool 8a Flipcharts and markers 45 minutes Unit Summary Take home research Participant Handouts 8a and 8b 5 minutes WORK FOR TRAINERS TO DO IN ADVANCE: * Review Slides 8.1-8.29 * Work with youth co-trainers to plan delivery of session activities * SO 8.1 Prepare copies of Participant Handouts. * SO 8.1 Find/Obtain copies of local Ministry of Health history taking form for participants. * SO 8.3 Print sample letters from adolescents and cut them into separate strips of paper. MAJOR REFERENCES AND TRAINING MATERIALS: FHI360. 2015. How to be reasonably sure a client is not pregnant. A Checklist: https://www.fhi360.org/sites/default/files/media/documents/checklist-pregnancy-english.pdf HEEADSSS: A Psychosocial Interview Format for Adolescents, Adapted from Contemporary Pediatrics, Getting Into Adolescent Heads, July 1988, John Goldenring, MD, MPH and Eric Cohen, MD. World Health Organization. 2010. Adolescent Job Aid: A handy desk reference tool for primary level health workers. Geneva: WHO. SPECIFIC OBJECTIVE 8.1: IDENTIFY THE ELEMENTS THAT SHOULD BE INCLUDED IN SCREENING AND HISTORY TAKING FOR ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH SERVICE PROVISION TIME 1 hour 50 minutes METHODS * Trainer presentation * Role play activity MATERIALS NEEDED * Slides 8.1-8.22 * Participant Handout 8a: HEEADSSS Psychosocial Interview for Adolescents * Optional: Participant Handout 8b: MoH History Form STEPS > TrainerÕs note: This program should be delivered by both the lead trainer and a youth counterpart, if available. IT IS ESSENTIAL TO ENSURE The participation of youth trainers with different types of disabilities WITHIN THE TRAINING. Accommodation should be provided as needed to ensure the full participation of young trainers with disabilities. The trainers should work together beforehand to decide how best to divide the information, with a preference towards the youth trainer delivering more of the content. Time: 20 minutes 1. Introduce the content of the presentation by explaining that there are issues to be aware of when planning services for adolescent clients. Present the Content: Tips for Providing Clinical SRH Services to Adolescents (Slides 8.1-8.6) below. Content: Tips for Providing Clinical SRH Services to Adolescents Slide 8.1-8.2: Clinical Screening Conducting a clinical screening for adolescents, especially for SRH services, can be uncomfortable and even challenging for both the adolescent as well as the provider. This is in part due to cultural or social perspectives and norms on adolescent sexuality and their use of health services and contraceptive methods. Many providers feel awkward discussing sexuality, sexual activity, and contraception with unmarried adolescents, perhaps because they donÕt want to be perceived as endorsing or encouraging adolescent sexual activity. As a result of stigma, prejudice, attitudinal and communication barriers, providers may feel even more uncomfortable when the client is an adolescent with a disability. Young people often sense this and may interpret provider discomfort as judgment or disapproval. Ask participants to reflect on previous sessions which discussed adolescence and key communication skills that should be used with an adolescent client and on the communication tips specifically related to clients with disabilities (also refer to the chapter ŅAdolescents with disabilitiesÓ). Ask what topic and/or service would they be most uncomfortable discussing with or providing to an adolescent client. Tell them to make a mental note of the topic or service that creates the greatest discomfort. 2. Explain to participants that there are a few tips to conducting an assessment of an adolescent client which can help ease anxieties for both the provider and the adolescent client. 3. Return to the presentation with Slide 8.3: Tips for Conducting an Assessment of an Adolescent Client below. Slides 8.3-8.6: Tips for Conducting an Assessment of an Adolescent Client * Ensure the adolescentÕs privacy and confidentiality. Parents, family members or other adults/caregivers should not be present when conducting an assessment unless the adolescent specifically gives permission or asks for an individual to be present. This rule is valid for all adolescent clients including clients with disabilities. * Be aware of your own beliefs and biases. A provider may be confronted with difficult situations which conflict with your beliefs and values. o Avoid making common assumptions, such as assuming that your adolescent client lives at home, has two parents, goes to school, gets along well with teachers and peers, and is heterosexual. o Be prepared to engage with youth in a non-judgmental and inclusive way as a respectful, caring health care provider, not as a parent or friend. * Start by introducing yourself. If a parent is present, introduce yourself to the adolescent first and have the adolescent introduce you to his/her parent. This sends a message that you as the provider are interested in the adolescent. * Explain that what is said to the provider is confidential. Ask the adolescent what they understand about confidentiality, acknowledge his/her response and then add your own views. * Ask non-threatening questions. At first, avoid asking direct questions about whether an adolescent is sexually active. Instead, ask some questions that help you get to know the adolescent client and that put the client at ease. For example, ask some questions about their living environment, school, leisure activities or work. o When youÕre ready to ask more direct questions about the clientÕs sexual and reproductive health, use indirect lines of inquiry. In other words, ask questions using the third person. For example, rather than asking an unmarried adolescent if s/he is sexually active, ask about the activities of his/her friends or peers: ŅAre any of your friends in relationships? Are they having sex?Ó Then ask how the client feels about their friendsÕ activities. You can then begin to ask if the adolescent client is also in a relationship, and so onÉ o If your client is married, ask how long she has been married, if she has friends who are married, and how she is settling into married life. Let her know you are willing to answer any questions or concerns she may have. * Use verbal and non-verbal language that normalizes rather than stigmatizes their behavior. Ensure that both your verbal and body language is friendly and non-judgmental at all times (see previous Unit 7). Unmarried sexually active adolescents often face immense social stigma Š both external and internal, and they may feel powerful shame or embarrassment. Sometimes a simple ŅI have seen and helped many young people with this same concern or problemÓ can ease their discomfort. o Married adolescents may be experiencing powerful pressure from family members and communities to bear children but may feel uncertain or unprepared for pregnancy and childbearing or may want to better space their next pregnancy. The provider can help by acknowledging this pressure they may be facing, supporting them to articulate their feelings and concerns, and exploring coping strategies. Source: WHO Adolescent Job Aid 4. Ask participants: What are the most common complaints among the adolescents you see in your practice? Do you sometimes feel that there are other concerns behind their initial complaint? How do you address that? Time: 45 minutes 5. Pass out Participant Handout 8a: HEEADSSS Assessment and ask participants to follow along as you go through the next few slides. Content: HEEADSSS Assessment (Slides 8.7-8.22) Slide 8.7: Client Background As noted, adolescence is a challenging time of emotional, social and physical change. Many adolescents make it through adolescence without major problems, but this is still a time of vulnerabilities, risks and experimentation. Many people, adolescents included, only seek help when they are experiencing a particular health issue or symptom. * Clients often only volunteer information that seems most relevant to the problem they think they have. Providers are often forced to fill in the gaps to be able to provide quality care to their client. * Adolescents also have many myths, misconceptions, and gaps in information about sexual and reproductive health and contraception. * Providers may wish to use a more rigorous and systematic approach to assessing adolescent clients to ensure they are able to fully discuss potential health and social risks and provide high-quality information and care. Slide 8.8: HEEADSSS Assessment The HEEADSSS assessment helps the provider to obtain a full picture of the adolescent, including behaviors, social factors, and potential warning signs in the adolescentÕs environment that could affect their health and wellbeing. HEEADSSS stands for: * Home and Environment * Education/Employment * Eating and Exercise * Activities * Drugs/Substances * Sexuality * Suicide/Depression * Safety > TrainerÕs Note: For the following slides on each component of the HEEADSSS Assessment, pause before showing the questions and ask participants to brainstorm what types of questions should be asked. Then, show the slide with the recommended HEEADSSS questions. Ask participants to keep the following in mind: How can they use the responses to assess: o The adolescentÕs evolving capacity. o Their general health needs. o Their sexual and reproductive health needs. Ask participants to evaluate in each section which questions, if any, are essential to ask even if they have limited time. Slide 8.9: Living environment Potential first line questions about clientsÕ living environment Where do you live? Who lives with you there? What are relationships like? Can you talk to anyone about stress? Who? Is there anyone new? Has someone left recently? Is there anything you would like to change about your living environment? > Pause for questions. Other questions to be asked if there is adequate time: * Have you moved recently? * If the client lives at home: Have you ever had to live away from home? Why? * Have you ever run away? Why? * Is there any physical violence where you live? Slide 8.10: Education/Employment Education/ Employment Do you go to school? If the answer is yes: Tell me about school For adolescents with disabilities: do they attend a disability-specific school or a mainstream school? Is your school a safe place? Why? Have you been bullied or harassed at school? On the way to school? Do you feel connected to your school? Do you feel you belong? Are there adults at school that you could talk to about something important? Who? Have there been any recent changes in your schoolwork? Are you failing any of your subjects? What are your future education plans and goals? Are you working? Where? How much? What are your future employment plans and goals? > Pause for questions Other questions to be asked if the client goes to school and if there is adequate time: * How many days of school have you missed this month/this semester? Why? * Have you changed schools in the past few years? * Tell me about your friends at school. * Have you ever had to repeat a class or a grade? * Have you ever been suspended from school? Have you ever considered dropping out? * How well do you get along with your classmates? * Have your work responsibilities increased? * What are your favorite subjects in school? Least favorite? Slide 8.11: Eating and Exercise Eating Does your weight or body shape cause you any stress? If so, tell me about it. What do you like or not like about your body? Have there been any recent changes in your weight? How would you describe your eating habits? Tell me about any exercise you do or get in your daily routine. > Pause for questions * What do you think is a healthy diet? Do you think you maintain a healthy diet? * How many meals do you have on a normal day? What do you eat at each meal? Have you done anything to manage your weight? * What would it be like if you gained 5 kilos? Lost 5 kilos? * Do you ever feel like your eating is out of control? Slide 8.12: Activities Activities What do you do for fun? What things do you do with your friends? Your family? What do you do in your free time? Are most of your friends from school or the community? Are they the same age as you? > Pause for questions Other questions to be asked if there is adequate time: * Do you spend time with mainly people of your same sex, or with a mixed group of young men and women? * Do you have one best friend or a few friends or a lot of friends? * Do you see your friends at school? After school? On weekends? * Do you do any regular sports or exercise? What are your hobbies or interests? * Do you attend church or mosque? * Do you watch a lot of television? How much? What are your favorite shows? * Do you spend a lot of time on your phone? The internet? How much? * Do you read for fun? What do you read? Slide 8.13: Drugs and substances Drugs Some young people try cigarettes, alcohol, marijuana or other drugs. Have you or your friends ever tried any of these? Do any of your family members drink, smoke or use drugs? If so, how do you feel about this? is it a problem for you? > Pause for questions Other questions to be asked if there is adequate time: * Have you or your friends ever tried any other drugs? Specifically, what? Have you ever used a needle to inject drugs? * How do you pay for cigarettes, alcohol, drugs? * Is there any history of alcohol or drug problems in your family? * Do you ever drink or use drugs when you are alone? Slides 8.14-8.16: Sexuality Sexuality (For girls) When did you first get your period (at what age?) When was your last menstrual period? How often do you get your period? Do you have any questions about your periods? How do you care for yourself during your menstruation? What do you do to manage menstrual flow? (For boys) Have you been circumcised? (If yes) at what age were you circumcised? Do you have any questions or concerns about the circumcision? Explain that voluntary medical male circumcision (VMMC) contributes to HIV prevention, along with the use of condoms and other safer sex practices. Ask if they are interested in VMMC. Are your friends in relationships? Have your friends had sex? Are you now involved in a relationship? Have you been involved in a relationship? How was that experience for you? How long have you been/were you in a relationship? Have any of your relationships been sexual Š that is, involved kissing or touching? Are you attracted to anyone now? Are you interested in boys? Girls? Not yet sure? Have you had sex? Was it a good experience? Are you comfortable with sexual activity? (Girls) Have you ever been pregnant? If yes, what was the outcome? (Boys) Have you ever gotten someone pregnant? If yes, what was the outcome? What things do you do to prevent pregnancy? (Use this opportunity to correct any myths or misinformation about ineffective pregnancy prevention practices, such as douching.) Do you currently use a contraceptive method? What method are you using now? Have you used any other methods? Do you regularly use condoms? What are some of the challenges you have experienced in using a contraceptive method? Condoms? Do you have any questions or concerns about your current method of contraception? If client is not currently using a method, ask if they are interested in using a contraceptive method, and if they have a method preference. Have you ever had any kind of discharge or sore that you are concerned about? Have you ever been tested for a sexually transmitted infection? Have you ever been treated for an STI? Are your vaccinations up to date? Have you been given the HPV vaccine? Have you ever been tested for HIV? What was the result? Have you had an experience in the past where someone did something to you that you did not feel comfortable with or that made you feel disrespected? What did you do? Have you ever been pressured or forced into doing something sexual that you didnÕt want to do? If someone abused you or hurt you, who would you talk to? > Pause for questions It is important to make sure that their immunizations are up to date, and at the very least, providers should ask if they have received the HPV vaccine. Adolescents can get the HPV vaccine even if they have already initiated sexual activity. Other questions to be asked (where relevant) and where there is adequate time: Menstruation * How many days do your periods last when they come? * How many pads (or cloths or equivalent) do you use a day Š at the beginning of your period? At the end? * Do you have pain with your periods? Is the pain constant throughout your period? * Does the pain prevent you from carrying out your daily activities? * What do you do to ease the pain? Slide 8.17: Suicide/Depression Mental health is emerging as a major health concern among adolescents. The assessment should seek to identify elements that correlate with anxiety or depression. If the screening is positive, adequate referral for detection should be scheduled. It is also important to check for potential violence and abuse situations. Suicide/ Depression Have you felt more stressed or anxious than usual? Do you feel sad or down more than usual? Do you ever have thoughts about hurting yourself or wishing you didnÕt exist? How have you handled these types of thoughts/feelings? Are you having trouble sleeping? Have you lost interest in activities that previously you deemed enjoyable? Have you lost interest in food? Do you feel it is difficult to cope with normal social interactions at a level you were previously used to? Tell me about a time when someone bullied you or made you feel uncomfortable. What did you do? > Pause for questions Other questions to be asked if there is adequate time: * Do you find yourself spending less time with friends and people you care about? * Would you rather just be by yourself most of the time? * Tell me about how you feel when you use social media, like Facebook. Does it make you feel sad? * Do you feel like youÕve lost interest in things you used to like to do? If so, can you tell me more? * Do you ever use alcohol or drugs to help you calm down or feel better? * Have you ever hurt yourself by cutting yourself to calm down or feel better? Slide 8.18: Safety Safety Have you ever been seriously injured? How? Have you ever made a decision that could have put you at risk of being hurt/harmed? How do you decide if a person or a situation is safe for you? Are you able to use a seatbelt in the car? Do you wear a helmet when riding a motorbike? Have you ever ridden in a car or on a motorbike with someone who was drunk or high? Is there a lot of violence where you live? School? Neighborhood? Workplace? Among friends? > Pause for questions Other questions to be asked if there is adequate time: * Have you ever been picked on or bullied? Is that currently a problem? * Have you ever gotten in a physical fight at school or your neighborhood? * Have you ever felt like you needed to carry a weapon to protect yourself? * Have you ever met in person someone you first met online? Do you have plans to meet someone that you met online? * Do you ever text and drive? Slides 8.19-8.20: Wrap Up To wrap up the assessment, * Have the adolescent sum up their life in one word or give a Ņweather reportÓ for their life. (e.g. sunny with a few clouds, cloudy and rainy, etc). * Ask them what they see when they look in the mirror each day. Look for adolescents who say they are bored. Boredom could suggest depression. * Ask them to tell you who they can trust and in whom they can confide if there are problems. Have them tell you why they trust this person. Tell the adolescent that s/he can also trust in you, the provider, to help with problems and answer questions. * Let the adolescent know you are interested in them as a whole person, and that you are someone who wants to help them lead a full, healthy life. * Give them an opportunity to express any concerns you have not covered. Ask for feedback about the interview. Let them know they can call or come back anytime. * For adolescents who report significant risk factors, let them know you are concerned. Ask if they are willing to make some changes or if they are interested in help to deal with their problems. Many adolescents may not recognize unhealthy lifestyles or patterns of behavior, because they see their actions not as problems but as solutions. As a provider, you can help them see health risk-taking behaviors and to develop better strategies for dealing with them. * Discuss what the providersÕ next steps would be if they identify health risk-taking behavior and ensure providers understand the importance of referring and supporting the client, who has decided to open up about violence, bullying, or if the provider has identified elements that correlate with anxiety or depression. * If the adolescentÕs life is going well, say so. Identify strengths and weaknesses and discuss how the adolescent can build on strengths and address weaknesses. Slide 8.21: Assessing SRH is an important aspect of adolescent history taking The HEEADSSS assessment includes questions regarding sexuality and SRH and it is important that these issues not be omitted when conducting history taking with an adolescent client. Young people may feel reluctant to seek specific SRH services but may be willing to seek care for other less sensitive concerns. This may also provide the adolescent with an opportunity to assess the ŅfriendlinessÓ of the provider and to determine if they can approach the provider for SRH information and care. Any history-taking, inclusive of SRH, should be personalized according to the gender, age, disability, marital status, and sexual orientation of the individual client, and all clients should be asked about their sexual activity and relationships, reproductive goals and intentions, and use of or interest in contraception and condoms. Slide 8.22: Screening for SGBV is essential Young people, especially young women, but also young men too often experience violence in the home, sexual coercion, forced sex, rape/sexual assault, intimate partner violence and gender and disability-based violence which can be committed by family members, neighbors, teachers, and peers, among others. Adolescent girls are 3 to 4 times more likely to experience violence or abuse. Young women may also be at risk for or have experienced harmful traditional practices, such as female genital mutilation/cutting. These topics will be addressed more fully in Unit 13 on Sexual and Gender Based Violence. Time: 45 minutes 6. Introduce the Activity. Ensure that all participants have copies of the HEEADSSS Assessment tool. If copies of the Ministry of Health intake/history taking form are available, distribute these as well. 7. Ask participants to break into pairs. Explain that they will practice conducting a HEEADSS Assessment. If you have young people participating, disperse them among the pairs to provide additional context, but instruct participants that each will have an opportunity to play both the adolescent client and the service provider. 8. Ask each participant to take a few moments to think of an adolescent client, such as a typical client they see for services or a client that they found interesting or challenging. Remind participants that this is a great opportunity for them to pick the case of a client with a disability, the potential challenges of supporting them and how to address and overcome these challenges. Once all participants have a client in mind, move on to the next instructions. 9. Ask them to take turns taking each otherÕs history using questions from the HEEADSSS Assessment and the Ministry of Health history form (if available). 10. Remind participants: During the initial history taking, it is important that providers use neutral, non-judgmental, respectful and inclusive language, and be aware of their assumptions (e.g. that the client is heterosexual) and non-verbal reactions and communications. 11. Give the pairs 10 minutes for their first history, then ask them to switch roles. 12. Give participants 10 minutes for the second history. Ask them to come back to the larger group when finished. 13. Debrief the activity. Ask for volunteers to respond to the following questions: * How did it feel to be the ŅproviderÓ asking questions? * How did it feel to be the adolescent client answering the questions? * Did it feel like there was enough time or did it feel rushed? * Did it feel like there was too much time or too many questions? * For those who portrayed adolescent clients, did you think the provider got all the information they needed to understand your character and your concern? * Did anyone feel like their provider didnÕt ask for key or crucial pieces of information? What other questions should have been asked? 14. If you have youth participants in the room, ask them if they felt like this exercise reflects the typical adolescent experience with service providers. In what ways was it different? If you have youth participants with disabilities in the room, take this opportunity to ask for their feedback and share this experience with all the participants. 15. Wrap up the activity by asking participants to discuss how providers can balance the need for time and efficiency against the need to gather crucial information from adolescent clients? PARTICIPANT HANDOUT 8A: HEEADSSS ASSESSMENT A Psychosocial Interview Format for Adolescents SPECIFIC OBJECTIVE 8.2: EXPLAIN THE PHYSICAL EXAM AND HOW IT CAN BE TAILORED TO THE NEEDS OF THE ADOLESCENT CLIENT TIME 30 minutes METHODS * Trainer presentation MATERIALS NEEDED * Slides 8.23-8.29 * Flipcharts and markers. * Handout 8C: How to Be Reasonably Sure a Client is Not Pregnant STEPS 1. Ask participants how they can help make adolescents more comfortable during a physical exam. Ask if any of them have strategies or techniques for making adolescent clients more comfortable before, during, or after physical exams. Write suggestions on flip charts. 2. Introduce the presentation. Say: Physical exams can be stressful for all kinds of clients, regardless of their age. For adolescent clients, there are some ways to address their discomfort and ensure that both the adolescent and the provider are protected and at ease during the clinical exam. Present Content: Adolescent Physical Exams (Slides 8.23-8.29) below. Content: Adolescent Physical Exams (Slides 8.23-8.29) Slide 8.23: Before the Physical Exam Explain why the physical examination is important. Respect the adolescent's need for privacy. If the adolescent is accompanied by a friend, parent, husband or other person, reach an agreement about whether they want this person to be present during the examination. Inform the adolescent about what the nature, purpose, and content of the examination is. Reassure the adolescent that any results of the exam will remain confidential. Offer to have the exam performed by a provider of the same sex. If this is not possible, make sure there is a same sex attendant in the room during the exam. Obtain the adolescentÕs consent to perform the examination. If the adolescent is below the legal age of consent for medical services, you will need to obtain consent from a parent or guardian. However, even if you have obtained consent from a parent or guardian, you should not proceed with the examination unless the adolescent agrees. A good rapport between the provider and client is essential. Slide 8.24: Assess for Pregnancy A pregnancy test can be administered, but if there are no pregnancy test kits, you can use the pregnancy checklist with the client. The checklist consists of six questions that providers ask clients while taking their medical history. If the client answers ŅyesÓ to any of these questions, and there are no signs or symptoms of pregnancy, then a provider can be reasonably sure that the woman is not pregnant. 3. Distribute Handout 8C The pregnancy checklist. Review the pregnancy checklist questions with the participants. Ask participants: Would it be difficult to use this checklist with adolescents? Why or why not? Would you trust the results of the checklist? Why or why not? Slide 8.25: Assessing the need for a pelvic exam A pelvic exam is not needed to obtain contraception. In many countries, routine pelvic exams are not common. If the adolescent is not pregnant and does not report current physical symptoms of or risk factors for an STI, there is no need for a pelvic exam. Slide 8.26: Prepare for the Physical Exam Protect her/his physical privacy as much as possible. Make sure curtains are drawn, doors are shut, and that no unauthorized person enters the room during the examination. Allow her/him to keep on her/his clothes except for what must be removed. Make sure to cover the parts of her/his body that are exposed. Never leave any part of the body exposed when not being examined. Provide reassurance throughout the exam. Explain what you are doing before you begin each step of the examination. Provide an opportunity for the adolescent to ask questions or relay concerns. Provide constant feedback in a non-judgmental, respectful and inclusive manner. "I see you have a small sore here, does it hurt?" Watch for signs of discomfort or pain and be prepared to stop the examination if needed. Slides 8.27-8.29: General Elements of a Physical Exam In the event you believe a physical exam is warranted, consider these elements of a good physical exam. Take great care to carry out all parts of the exam gently and smoothly to minimize discomfort and anxiety. Examine the external genitalia, including the anus, for ulcers, warts, discharge, trauma, or pubic lice. Conduct a dermatology exam, which can be as simple as an expanded examination of the buttocks and the perineum. Include an oral exam to look for any oral lesions or ulcers. If the client is a young man who is not circumcised, gently retract the foreskin to look for ulcers on the glans penis. If a vaginal examination is necessary, provide a chance for questions. Adolescent girls may fear that an object placed in the vagina will tear the hymen/affect her virginity. If so, tell her that the hymen only partially covers the vaginal opening. It allows menstrual blood to flow. Explain that the vagina is an elastic organ and that it can stretch when she relaxes. Let her see and touch the speculum. Get her permission before you touch her with your hand or the speculum. As you insert the speculum, ask her to bear down and take slow, deep breaths. The breast examination should become part of the general medical evaluation once girls have breasts. The most common concerns girls have about their breasts are whether they are too big or too small, when they are going to grow, and why one is bigger than the other. Reassure the client that there is no right or wrong breast size, that she is normal, and that it is common for one breast to be bigger than the other. Although breast cancer is rare during the adolescent years, girls should learn how to conduct breast self-examination. Similarly, boys should be taught to do testicular self-examination. Explain to the adolescent what healthy breast or testicular tissue feels like and what to look for when conducting a self-examination. Have the adolescent conduct a self-examination on their own breasts or testicles and ask questions about what they find. 4. Close the presentation by providing space and time for questions from the participants. PARTICIPANT HANDOUT 8C: HOW TO BE REASONABLY SURE YOUR CLIENT IS NOT PREGNANT (SOURCE FHI3602) How to be Reasonably Sure a Client is Not Pregnant Ask the client questions 1Š6. As soon as the client answers YES to any question, stop, and follow the instructions. Have you abstained from sexual 3. * If the client is planning to use an IUD, the 7 day window is expanded to 12 days.   If the client is concerned about an unintended pregnancy, offer emergency contraception if every unprotected sex act since last menses occurred within the last 5 days. SPECIFIC OBJECTIVE 8.3: DISCUSS SPECIFIC ISSUES OF CONCERN FOR ADOLESCENT CLIENTS, SUCH AS THE MENSTRUAL CYCLE, SEXUAL PLEASURE, AND SHARED RESPONSIBILITY FOR REPRODUCTIVE AND SEXUAL HEALTH TIME 45 minutes METHODS * Group brainstorm MATERIALS NEEDED * Sample letters from adolescents (Trainer Tool 8a: Sample Letters below) * Flipcharts and markers STEPS 1. Introduce the activity. Tell participants that there are issues related to puberty and being an adolescent that theyÕll need to be prepared to respond to, and that theyÕre going to practice those responses together now. 2. Distribute Sample Letters from Adolescents to participants. Ask for a volunteer to read the first letter out loud. 3. Ask participants to identify the issues raised by the letter. Note their responses on the flip chart. 4. Next, ask participants to brainstorm responses for the issues they identified. Note these on a separate flip chart. 5. Ask for a volunteer to compose out loud for the group a letter to respond to the adolescent in the first sample letter. Let the group comment on the response. 6. Repeat steps 2-5 for each of the sample letters. 7. If there is adequate time, ask participants to share any of their own experiences in answering the questions of adolescent clients. TRAINER TOOL 8C: SAMPLE LETTERS FROM ADOLESCENTS Adapted from Positively Informed, International WomenÕs Health Coalition IÕm a 15-year-old boy with a hearing disability and sometimes when I wake up in the morning, my pajama bottoms are sticky with a white substance. Is there something the matter with me or am I normal? Several days before I get my period, I get irritable and cry a lot. I also get a bad backache. My grandma keeps telling me that itÕs Ņall in my headÓ and that if I had a better attitude and tried harder, I wouldnÕt have such a bad time each month. Is she right? Am I causing myself to feel bad? My boyfriend is really pressuring me to have sex with him. IÕm not really comfortable with having sex yet, but I really love my boyfriend. He told me that if I love him, I will have sex with him, and if I donÕt there are plenty of other girls who will. I want to keep my boyfriend, how can I keep him without having sex? Can you explain to me why some students in my class still look like children and some look like adults? WeÕre all the same age! All my friends have their periods and are taller and I still look like a little girl. But IÕm almost 14! My mother says my day will comeÉ but I want to know when? And will I end up looking like everyone else eventually? IÕm not circumcised, and I canÕt pull my foreskin all the way back to wash properly. IÕm scared to tell anyone because I think it would be very painful to be circumcised. What can I do? My girlfriend says we should talk about contraception because she doesnÕt want to get pregnant, but I donÕt think thereÕs anything I can do. IsnÕt it the girlÕs job to stop pregnancy? My friends all tell me that there are ŅsafeÓ days every month where I can have sex and I wonÕt get pregnant, but IÕm still scared every time I have sex. One friend said I should have sex when IÕm having my monthly bleeding, because thereÕs no way I can get pregnant then. That sounds awful! WouldnÕt blood get everywhere? IÕm 16 and went through puberty about three years ago. But my penis is still quite small. When IÕm erect, it is about five inches long, which seems short, considering some of the movies IÕve seen. When it is soft, it shrinks down to practically nothing. This is very embarrassing, especially when IÕm bathing in public. I even try to get erect before I get into a shower, just so it looks bigger. IÕm still a virgin, and IÕm afraid that when I do have sex, IÕll be too small. Will that be a problem? I really enjoy sex, but IÕm afraid to tell my boyfriend how much I like it or what I like most. My friends say that boys canÕt know that you like sex or theyÕll want it all the time and will always be bothering me for sex. But I do want to have sex! Are my friends right? How can I hide from my boyfriend how much I like it? My friends all tell me that you can catch all kinds of diseases from performing oral sex on a woman, and that it makes you weak and unmanly. But I think I want to try? My girlfriend thinks IÕm strange for even thinking about it. How can I explain to her that I want her to enjoy herself too? I am 16. I have a spinal-cord injury as a result of a car accident. Can I have sex and have children as all my female friends? I am 15, I have a visual disability and I have a boyfriend. I want to learn about love, sex and relationship. Can you teach me? Unit 8 Summary TIME 5 minutes METHODS Homework MATERIALS NEEDED * Participant Handout 8a: HEEADSSS Assessment * Optional: Participant Handout 8b: MoH History Form * Participant Handout 8c: Pregnancy Checklist STEPS 1. Assign homework: Ask participants to take their handouts home. * If they have a Ministry of Health form, make revisions to supplement what they think will help them get more and better information from their adolescent clients. * If they donÕt have a Ministry of Health form, to create their own form or assessment worksheet to help them streamline their services. 2. Ask participants to bring back their sample forms on the day youÕve planned Unit 15: Designing Adolescent Services. 1 CART is a method to provide access to spoken communication for people with hearing, cognitive or learning disabilities. CART refers to the instant translation of the spoken word into text using a stenotype machine, notebook computer, and real-time software. The text produced by the CART service can be displayed on an individualÕs computer monitor, projected onto a screen, or made available using other display systems. 2 https://www.fhi360.org/sites/default/files/media/documents/checklist-pregnancy-english.pdf --------------- ------------------------------------------------------------ --------------- ------------------------------------------------------------ Module 16/Unit 10