13: Adolescents

This chapter offers a practical behavioral framework to assist those who provide health care to teenagers. Stages of adolescent development along with behavioral correlates are discussed, as are suggestions for effective patient–doctor communication, interviewing, and provision of health services. From a physiologic perspective, adolescence is the interval between the onset of puberty and the cessation of body growth. In psychosocial and behavioral terms, it is the time during which adult body image and sexual identity emerge; independent moral standards, intimate interpersonal relationships, vocational goals, and health behaviors develop; and the separation from parents takes place. Although some of these tasks may begin prior to puberty and evolve into adulthood, they provide the foundation for understanding adolescent behavior.

Health Status & Trends

Most teenagers are healthy. Compared with other age groups, mortality rates for teenagers are low. The majority of health problems in teenagers are behavior related and include unwanted pregnancy; sexually transmitted infections (STIs); weapon carrying; interpersonal violence; suicidal ideation; alcohol, cigarette, and illicit drug use; and dietary and exercise patterns. Nationally, accidents are the leading cause of death for most populations of teenagers, although homicide (often gang related) leads in some geographic locations. Socioeconomic status and population density, rather than ethnic or racial grouping, define the neighborhoods most at risk for gunshot deaths. Nonetheless, the most common reasons for acute office visits for teenagers are routine or sports physicals, upper respiratory infections, and acne. One of the major challenges to a provider caring for teenagers is eliciting a history that reveals health risk behaviors. Because most adolescent mortality and morbidity are preventable and because many behaviors such as sexual practices, diet, exercise, and substance use that result in adult disease begin in adolescence, ignoring this age group means missing a major public health opportunity.

In 1992, the American Medical Association published Guidelines for Adolescent Preventive Services (GAPS), the first set of developmentally and behaviorally appropriate comprehensive health care guidelines for adolescents, emphasizing anticipatory, preventive, and patient-centered services. Guidelines for Adolescent Preventive Services suggest that promotion of adolescent health and prevention of disease involve a partnership encompassing patients, parents, schools, communities, and health care providers. Although these guidelines have existed for several decades, and have been shown to be valuable as care standards and as quality measures, there is little evidence that they are being widely implemented.

Adolescent health outcomes—perhaps more than for any other population—are closely linked to cultural, educational, political, and economic policies at the local and national level. Handguns and bullying are both relevant examples. For example, the availability of handguns is not a problem that the health practitioner can resolve during an office visit, yet making them less available would substantially benefit the health of many teenagers. There would very likely be less depression and suicidal ideation if more schools instituted zero tolerance programs for bullying and developed programs that promoted diversity.

The Internet and all forms of related electronic communication including social networks, texting, and instant messaging have profoundly changed the way we all interrelate socially and how we receive and disseminate health-related and behavioral information. Adolescents and young adults are, and will likely continue to be, at the forefront of this communication transformation. It is essential that those providing care to adolescents understand how these communication developments might have beneficial and detrimental influences on this population. Electronic social networks are a good example. Such networks for adolescents with chronic diseases might serve as a positive influence to improve medication compliance and decrease the sense of isolation. Conversely, bullying through social networks has been the cause of depression and even suicide. It is especially important to understand these influences because there is compelling evidence that teens who feel connected to parents, school, and community are less likely to participate in health-compromising behavior than teens who feel isolated or disconnected. It should be expected that the evolution of new forms of electronic communication will continue to play a role in how teenagers connect to all facets of their environment including those that relate to health and well-being.

Medical services for teenagers need to be appropriate for each developmental stage. Each of the three recognized developmental stages in adolescence is distinguished by physical, cognitive, and behavioral hallmarks. Not all adolescents fit perfectly into each phase, and they often progress at different rates from one phase to the next. Moreover, rates of physical, cognitive, and behavioral development may not be congruent. For example, a 14-year-old girl who is physically mature may be emotionally and cognitively unable to decide about sexual intimacy and the potential consequences.

Early Adolescence (Ages 11–14)

Physical

Rapid growth causes physical and body image changes. Many teenagers question whether their growth is “normal,” and commonly there is a good deal of somatic preoccupation and anxiety. Gynecomastia, for example (a common transient problem for boys), may cause concern, and prevent participation in physical education class. Because the topic may be too embarrassing for an already self-conscious teenager, clinician-initiated reassurance is essential when the condition is identified during a physical examination. Early or later onset of puberty has widely variable effects. Early puberty may be associated with the increased likelihood of weight concern and excessive dieting and other eating disorders in girls, but it may result in greater self-esteem and athletic prowess in boys. Because self-esteem is linked closely with physical development and peer group attractiveness, teens who develop later than their peers may have self-esteem problems. Among early adolescents, questions and concerns about menstruation, masturbation, wet dreams, and the size of their breasts (too large or too small) and genitals are common. These questions need to be anticipated and specifically and carefully addressed. Endocrine disorders related to sexual maturation are likely to emerge; early diagnosis and treatment can improve health and self-esteem.

Social

In adolescence, peer group involvement increases and family involvement decreases. Friendships are idealized and are mostly same gender. Close peer relationships coupled with curiosity about body development may result in homosexual and other sexual experimentation, anxiety, and fear. Although some heterosexual relationships are initiated, contact with the opposite sex frequently occurs in groups. Often by this age adolescents have access to the Internet, participate in online social networks, and use cell phones. How they are used and potentially monitored will often become an important issue of family discussion.

Cognitive

The transition from concrete to abstract thinking begins. Because experience and emotion play important roles in decision making, improved cognition alone is not enough to prevent many teenagers from making impulsive decisions with little regard for consequences. Increased cognitive ability linked with the search for identity often leads teenagers to test limits both at home and at school. Daydreaming is common.

Middle Adolescence (Ages 15–17)

Physical

The issues of early adolescence may continue, although most physical development is complete by the end of this phase.

Social

Independence, identity, and autonomy struggles intensify. Peer groups may become more important than family to some teenagers and result in increasing teen–parent conflict. Experimentation with alcohol, drugs, and sex is common. A sense of invincibility coupled with impulsiveness leads to relatively high rates of automobile accidents and interpersonal violence. Suicide, impulsively linked to failed love relationships, or poor self-esteem because of difficulty finding peer group acceptance may also occur during this phase. Despite adhering to peer group norms regarding music, dress, and appearance (including body piercing, tattoos, clothes, hair color, and makeup), the expression of individuality is common. Many teenagers find identity and support in school, sports, community, or church activities. For teenagers whose support systems or community resources are inadequate, gangs may supplement personal strength and provide a sense of identity. Teenagers from alienated and disenfranchised ethnic groups are at particular risk for gang activity. In spite of slowly improving cultural acceptance, gay, lesbian, and transgendered teenagers may feel increased isolation, alienation, and bullying (see Chapter 17). This may lead to depression, sexual promiscuity, or suicide. The Internet leads to easy linkage to social networks for minority youth, such as those with chronic diseases, who in the past might have felt isolated and now can gain access to social and psychological support. Those same networks, however, also make it much easier for sexual encounters and resulting exposure to STIs or unintended pregnancy.

Cognitive

Improved reasoning and abstraction allow for closer interpersonal relationships and empathy in this group. Evaluation of future academic and vocational plans becomes important. Poor school performance may heighten anxiety and concern about vocational choices and lead to “escape” in drugs and alcohol. Practical guidance that identifies strengths and builds self-esteem can help avoid frustration and failure.

Late Adolescence (Ages 18–24)

Physical

Body growth is usually no longer a concern. The quest to become comfortable with one’s physical appearance often continues throughout adulthood.

Social

If the adolescent’s development has occurred within the context of a supportive family, community, school, and peer environment, individual identity formation and separation will be complete. In reality, however, at least some developmental issues usually remain unresolved into adulthood. Late adolescents typically spend more time developing monogamous interpersonal relationships and less time seeking peer group support. Ideally, decision making, based on an individualized value system, is modulated by limit setting and compromise.

Cognitive

Vocational goals should now be set in practical terms, and there should be realistic expectations about education and work.

A general health assessment should include a review of systems and an evaluation of health-related behavior. This should include risk factors for accidents, STIs, including human immunodeficiency virus (HIV), pregnancy, interpersonal violence (including past physical or sexual abuse), nutrition, substance use, exercise, sleep, learning, and mental health problems. Guidance about promoting healthful behaviors and preventing disease should be integrated into the discussion. Inclusion of these factors is considered community standard of care for adolescents. Documentation of health encounters ideally should be done electronically; it is therefore recommended that a standard written protocol be developed so that all elements described above can be documented and searched for quality assessment. From the patient’s perspective, the clinician’s inquiries and assessment of some behaviors may be viewed as embarrassing, intrusive, or trivial. It is therefore helpful to explain, prior to questioning, that (1) the same questions are asked of all patients and that (2) the encounter goal is patient self-awareness and health education. During the interview it is important to reinforce and praise healthy decisions, such as sexual abstinence.

Confidentiality

Certain ground rules are important. Ensure the adolescent that, unless homicide or suicide is threatened or ongoing abuse is reported, all conversations are confidential, and the information will not be shared with parents, teachers, or other authorities without permission. Discussions about sex and drugs should always occur in private unless otherwise requested by the patient. If the patient is accompanied by a parent, solicit parental concerns, and then ask the adult to leave the room and conduct the interview in private. It is also helpful to let the parent know (if present) about the confidential nature of the patient–clinician conversation.

Although most teenagers want to receive health information and discuss personal behavior, these discussions must generally be initiated by the physician. Many teenagers are not accustomed to interacting in such participatory, nonjudgmental conversations with adults. The willingness of a teenager to share personal or intimate information depends on the perceived receptiveness of the provider. Teenagers need to feel that they have permission to share personal, behavior-related information. For example, it is usually not difficult for patients and clinicians to discuss routine chronic medical conditions such as diabetes or asthma. Control of these conditions in some teenagers, however, may be related more to dietary indiscretions and cigarette use, than to insulin or inhaler use. Such health-compromising behaviors must be identified before they can be dealt with; comments, facial expressions, or body language indicating disapproval can undermine the patient’s willingness to disclose confidential behavior (Table 13-1).

Most electronic medical record systems now include patient web-portals that allow secure communication between patient and provider. This type of system potentially makes communication easier and faster for all involved. Issues around confidentially and parental access make independent use by minors problematic, although is often supported by many parents. Future systems will likely also include embedded video (telemedicine) linkage, and the same issues related to parental control will apply. See Table 13-2 for Quality and Safety suggestions.

Legal Issues

Many practitioners worry about the legality of evaluating and treating teenagers without parental consent. Because laws vary by state, it is essential to become familiar with the applicable local statutes. Many states permit the diagnosis and treatment of teenagers with sex-, drug-, and alcohol-related problems without parental notification or consent. States do vary at the age about which teens can receive such services without parental permission. Likewise, most states permit medical care if a condition is potentially life threatening. Documentation of the rationale leading to the decision to proceed without parental permission, in a potential “life-threatening” situation, is essential.

Interview Organization

A comprehensive health risk assessment should cover issues dealing with home, education, activities, drug use, sexual practices, and suicidal ideation (HEADSS). Using the HEADSS format helps with organization and standardization. Assessing cognitive ability using interactive dialogue needs to be done in the first few minutes of the interview. The following interview goals and questions facilitate communication.

Home

1. Goal— Determine household structure, family structure and function, conflict-resolution skills, the possibility of domestic violence, and presence of chronic illness in the family (see Chapter 11).

2. Questions—“Who lives where you live?” If only one parent is at home, the interviewer should inquire about the other parent’s whereabouts, visitation pattern, reasons for leaving (especially domestic violence and substance abuse), and whether the teen moves back and forth between parents. Teenagers caught between divorced parents or those who feel neglected may “act out” and get into trouble to gain parental attention, sometimes in the hope that their problems will reunite separated parents. For single-parent families, the patient can be asked, “Does your mom or dad date? How do you get along with the people he or she dates?” Questions about domestic violence should include “What happens when people argue in your house?” and “Does anyone get hurt during arguments? How about you?” and “What if someone has been drinking or using drugs and they argue?” and “Have you ever seen your mother hit by anyone?” “Are there guns in your house?” If there are, ask if they are always locked and who has a key. Educate parents and patients about accidental gunshots. Ask about siblings, including their health and whereabouts. Somatization may be learned by observing a family member who receives attention for a chronic medical condition. Learning about extended family members living in the household is also important and will likely be revealed with the first question above.

Education

1. Goal—Identify attention deficit hyperactivity disorder (ADHD) and other learning disabilities, school performance, cognitive ability, and vocational potential.

2. Questions—“What grade are you in?” “What type of grades do you get?” “How do they compare with your grades last year?” Falling grades may indicate family, mental health, or substance-abuse problems. “Have you ever been told you had a learning problem?” “Can you see the blackboard?” Most teenagers respond that everything in school is okay. Specific questions about courses and content need to be asked, including the student’s favorite and worst subjects and his or her career aspirations. Generally, teenagers who perform well in school are less likely to participate in multiple health risk behaviors. The teen should be asked about attendance, and truancy or other school troubles. Teenagers with drug problems may enjoy going to school because, although they may rarely attend class, school is where they visit friends and purchase or sell drugs. Students who get all “A’s” should be asked about school-related stress and what would happen if they did not receive high grades. Depression and even suicide can be related to unrealistic grade expectations by teenagers and their parents.

Activities

1. Goal—Evaluate the patient’s social interactions, Internet use and purposes of use, interests, and self-esteem.

2. Questions—“What do you do for fun?” “Are you involved in school, community, or religious activities, such as youth groups, clubs, or sports?” Self-esteem is often related to successful participation in these activities. Teenagers actively involved in “productive” activities are less likely to participate in delinquent behavior. The clinician should ask about gang or fraternity/sorority membership, either of which can be a source of inappropriate peer pressure. Gangs may provide the strongest sense of family or community available to some teenagers.

Questions should be asked about dietary habits, including the frequency and amount of “junk” food, who cooks, and dieting or self-induced vomiting (see Chapter 23). It is also important to inquire about patients’ physical activities, and to educate and to make recommendations about regular exercise, protective headgear, and seatbelts. Internet assessment should include types of sites visited and purpose of use.

Drugs

1. Goal—Evaluate the patient’s current habits, patterns of use, and the genetic or environmental risk factors (Table 13-3). Distinguish between those who drink because of social, cultural, and peer pressure, those who are genetically predisposed, and those who drink or use illicit drugs because of comorbid mental health problems.

2. Questions—It is less threatening to begin by asking, “Are you aware of alcohol or drug use at your school?” and “Do any of your friends drink or use drugs?” followed by “Have you ever tried alcohol or drugs?” The physician should inquire specifically about cigarettes, alcohol, marijuana, recreational “pills” (e.g., ecstasy, ketamine), cocaine, lysergic acid diethylamide (LSD), crystal methamphetamine, anabolic steroids, and heroin. The quantity, frequency, circumstances, and family patterns of use are important. To learn about family drinking, ask specific questions about each parent and both maternal and paternal grandparents, including whether anyone in the family attends Alcoholics Anonymous (AA) or other self-help groups. When parents do not recognize or admit to a problem, a child may not identify them as alcoholics. The teenager should be asked to describe the parent’s pattern of alcohol use. “Have you ever seen your mother or father drunk?” If the answer is yes, then ask “When and how frequently?” The CRAFFT questions (Table 13-4) have been validated as a useful brief screening test for teenagers suspected of substance abuse. Two or more YES answers on the CRAFFT indicate a significant problem.

Recognition of a parental problem is also essential. Even the best treatment program will fail if a teenager is discharged back into the home of an actively using parent. The willingness of parents to change either their own drinking or family behavior patterns is one of the best predictors of adolescent treatment success.

Among many teenagers, the use of drugs and alcohol is often not considered abnormal or dangerous. Only about 5–10% of teenage drinkers or drug users develop substance-abuse problems as adults. Because serious physical consequences, other than accidents, usually do not occur until later in life, there is little negative association with alcohol or drug use. Abused, neglected, disabled, or chronically ill teenagers may consider drugs or alcohol one of the few things that, at least temporarily, make them feel good and accepted by peers. If legal involvement, school problems, or family conflict are present, it is important to assess the role of alcohol and drugs. Even if use seems minimal, it should be pointed out that problems are best solved sober.

Referral to a substance-abuse expert is indicated when use significantly interferes with school, family, or social functioning. Anticipatory guidance should address age-appropriate concerns. Advising teenagers to stop smoking cigarettes because of the possibility of future lung cancer and heart disease is usually meaningless. Talking about wrinkled skin, bad breath, and yellow teeth is much more relevant to body image concerns and far more likely to prevent or stop cigarette use. Similarly, the association between alcohol and date rape is more important to teenage girls than are other future consequences.

Sex

1. Goal—Determine the level of the patient’s sexual involvement and sexuality, use of birth control, protection against STIs, and any history of abuse.

2. Questions—An opening question such as “Have you ever been sexually involved with anyone?” is preferable to “Are you sexually active?” The word active is notoriously misinterpreted. Questions need to be open ended and should not assume heterosexual orientation. Assumptions about boyfriends or girlfriends inhibit discussion or questions about homosexual partners or feelings. Because teenagers frequently practice serial monogamy, the sequential number of different partners and their ages should be determined. Ask whether they have ever met anyone on the Internet for sexual reasons and the circumstances related to that encounter. A 15-year-old teenager with a peer group partner is at less risk for STIs, especially HIV, than is one with a substantially older partner. For the sexually involved, discuss birth control techniques and condoms. One of the most common reasons for not using a condom is the belief that birth control pills provide adequate protection against STIs. When appropriate, physicians should reinforce sexual abstinence with congratulations and support.

Sexual abuse is unfortunately common. A history of such incidents should be sought by asking, “Have you ever been touched sexually when you did not want to be?” Obtaining this history may be pivotal in helping a teenager who has developed abuse-related behavioral problems, such as sexual promiscuity, depression, substance abuse, delinquency, and an eating or somatization disorder.

Unwanted pregnancy among teenagers is still at epidemic proportions. Risk factors are complex but include ignorance, lack of access to family planning services, cultural acceptance, and poor self-esteem.

Suicide

1. Goal—Identify serious mental health problems and distinguish them from normal adolescent affect and moodiness. Primary risk factors are listed in Table 13-5.

   Distinguishing significant psychiatric illness from normal fluctuations in a teenager’s affect is challenging. In spite of the general perception to the contrary, most teenagers are not maladjusted, and the rates of mental health problems are no higher than in adults. Few teenagers announce that they are feeling depressed or are in emotional turmoil. Depression may be reflected in sexual promiscuity, drug and alcohol abuse, or in the commission of violent and delinquent acts. Chronic somatic complaints such as headache, abdominal pain, or chest pain without an identifiable biological explanation may also indicate depression secondary to abuse.

2. Questions—Practitioners should identify vegetative signs of depression, such as sleep disturbance, decreased appetite, hopelessness, lethargy, continuous thoughts about suicide, hallucinations, or illogical thoughts. It should also be noted that many of these symptoms may also be caused by substance abuse. Evaluation of lethargy should be done from the patient’s perspective. Energy may be low relative to the parents’ desires or expectations—but sufficient for the teenager. There may be insufficient energy to clean, help with household chores, or complete homework but plenty of energy available to play sports, go on a date, party with friends, travel miles, and wait for hours to obtain concert tickets.

This case illustrates several important adolescent issues. First, teenagers may concretely interpret questions. When Lauren was asked by the nurse if she was taking any medication, she answered honestly. A combination of clinical judgment at the time of interview related to Lauren’s inattentiveness, knowledge that teenagers may interpret concretely, and that they may not make the connection between behavior and health consequences are all important to this case. Second, teenagers seek peer conformance. Medication compliance problems may relate to avoiding peer awareness of medications and, therefore, being labeled as different. Taking medication at school, camp, or at the house of a friend may all make a teenager feel different. Lastly, instructions about medications should be given in terms of what is important to the patient. Lauren may have known that medication was beneficial for school performance, but may not have realized that it would improve concentration with other tasks that required focus and attention.

The connection between increased substance use, declining grades, and the brother’s death seems obvious. Because the substance use began insidiously, and significant trouble did not occur until more than a year after his brother’s death, neither Jeff nor his parents associated the events. Furthermore, this is a family that seemingly does not share emotions, and Jeff never learned how to discuss his feelings. In this case, simply learning about his drug use, home situation, school performance, and activities was not enough. The facts all confirmed his substance abuse but did not explain it. With a teenager who previously has been without significant behavioral problems, it is crucial to search for personal or family events, including losses, that underlie and precipitate behavior change.

Both Jeff and his parents must be made aware of the connection between the substance use and the brother’s death. It is imperative that Jeff acknowledge his drug problem and be referred to a practitioner experienced in treating adolescents with substance-abuse problems (see Chapter 24). Although Jeff should respond to psychotherapy that addresses his grief and loss, psychotherapy may not be effective if mind-altering substances are being used concomitantly.

Homeless & Runaway Teenagers

There is a heterogeneous group of between 500,000 and 2 million homeless teenagers in the United States. Some are homeless because their families are, some live on the streets for brief periods of time, and others find shelter with friends or relatives. Those who leave home, do not return, and no longer depend on parents for financial support or shelter constitute a significant proportion and may be more precisely called throwaways. Before they leave home, these teenagers have usually had repeated contacts with social service agencies and have histories of severe parental conflict and high rates of physical and sexual abuse. Family abandonment because of sexual orientation is not uncommon. The social network designed to protect them has failed, and their experience of neglect, abuse, and abandonment results in a distrust of adults and institutions.

Leaving home and living on the streets may initially be a liberating experience. Once on the street, multiple substance use is common, often becoming a short-term pleasant escape from an otherwise dismal existence. Survival often depends on trading sex for drugs, food, or shelter. Other survival techniques, such as selling drugs and theft, create risks for interpersonal violence and victimization. Poor self-esteem, depression, and suicidal ideation are common in this group. Usually—within weeks or months—the liberating experience of independence becomes one of desperation and hopelessness.

The initial medical evaluation may seem overwhelming. Many of these patients qualify for emancipated minor legal status and may be eligible for Medicaid or other entitlements. Distrust of adults, the inability to navigate a complicated health system, and reluctance to disclose personal information may, however, keep them from receiving benefits and proper health care. It is important for the clinician to prioritize such a patient’s health issues and be familiar with community referral sources. Shelter, food, safety, social support, substance abuse and mental health counseling, and medical evaluation are all usually necessary. Developing a trusting working relationship is essential and may require several visits. Keeping medical appointments and complying with referrals may be complicated by a reversed sleep–wake cycle. In some cases, it may be that texting can be used beneficially for appointment and medication reminders. As with other teenagers, questions about sex and drugs are best kept in a medical context; it should be made clear that they are asked only because of their health implications. Rather than asking whether a teenager has been a “prostitute,” asking, “Have you ever had sex in order to obtain drugs, food, or a place to sleep?” is nonjudgmental and will be readily understood. Questions about sexual orientation may be confusing to a teenager with a history of sexual abuse and survival sex and may provoke anxiety and shame. These issues are best raised after a stable living situation and support system have been established.

Chronic Disease & Disability

At least 2 million teenagers in the United States have chronic disabilities or diseases. Although this is a diverse group, its members share some similar behavioral issues. Unlike other teenagers whose identity and self-esteem are molded by the acceptance of a peer group, chronically ill or disabled teenagers have limited ability to conform and often have poor self-esteem. Too frequently this leads to depression, family conflict, and social isolation.

Like those of other teenagers—issues usually revolve around physical, social, and sexual development. Frank discussions, including realistic assessments of their hopes and expectations, need to be initiated by the physician. It is crucial to identify and encourage the interests and skills that may realistically be expected to strengthen self-esteem. Predictors of successful coping include friendships with healthy as well as ill or disabled peers, parents who are not overly protective, involvement with family activities, and appropriate household responsibilities.

Chronically ill teenagers are often “noncompliant” with medical regimens. Adolescence is no less a time of experimentation, self-discovery, and testing of limits for the chronically ill teen than for other teens, and chronically ill teenagers—like others—are often noncompliant. Issues about compliance are often issues about control and of testing of limits. The struggle for independence conflicts with the limitations of the disability itself as well the relationship with parents and health care providers. Supportive electronic social networks of teens with similar disorders might greatly decrease the sense of social isolation, and texting reminders has the potential for improving medication compliance. Table 13-6 lists some suggestions for ways of improving compliance.

Gay & Lesbian Youth

Gay and lesbian teenagers are at risk for social isolation, depression, STIs, substance abuse, and interpersonal violence. The relationships they develop with a health care provider may help them cope with the negative stereotyping they receive from other parts of society. A nonjudgmental and supportive attitude by the clinician helps lessen the weight of such cultural negativity.

Although some teenagers may volunteer information about their homosexual concerns or ideation, many do not unless they are specifically asked or given permission to do so. Some teens may have feelings of anxiety, shame, and guilt about same-sex experiences. Such experiences are common, especially among young adolescents who may not yet have firm sexual identity. Such experiences do not necessarily reflect future sexual orientation. The risk of HIV infection increases when gay teenage boys have older partners, who themselves may have had multiple partners. Inquiry about Internet use and actual sexual encounters is essential to get a sense of potential health risk behaviors and exposure to STIs. Table 13-7 lists some suggestions for working with gay and lesbian youth.