This likely explains why, according to a recent study, health care providers in one emergency department tested adolescent females for sexually transmitted infections despite the fact that they denied sexual intercourse. What is not well explained, however, is why black adolescents who denied intercourse were tested 15 times more often than their white counterparts.
In emergency rooms, doctors do not have the luxury of long-term interactions during which we can determine a patient’s character. Nor do patients have the opportunity to develop enough trust in us to be completely honest. These interactions are further complicated by the patients’ fear of being judged and rushed ER visits.
It only takes one or two patients who blatantly lie to your face, to the detriment of their own health, to turn you into a skeptic. The take home for us ER providers — physicians, nurse practitioners and physician assistants — is to never take anything for face value.
Adolescents bring unique challenges to the table. Many are at the age where speaking out loud about sex is still embarrassing. No matter how many times we reassure them that we will not inform their parents of our discussion, they are wary. And, in extreme situations, you never get to privately interview the teen because the parent refuses to leave the room.
So, when an adolescent arrives in the emergency department with abdominal pain, urinary symptoms or vaginal complaints, it is hard not to suspect and test for sexually transmitted infections, even if they deny ever having sex — especially since the consequences of missing one of these infections can be life-threatening.
Untreated sexually transmitted infections can lead to scarring, causing infertility long before a teenage girl even considers conceiving a child, or ectopic pregnancy — a life-threatening emergency where the pregnancy is growing outside of the uterus. The infections themselves can worsen, forming pus in the abdomen or spreading to the rest of the body, causing major illness.
As ER providers, there is a good chance that we will never see these adolescents again. They will not follow up with their pediatricians. They will never call for their test results, and often, they are not being truthful in the first place. For those reasons, we tend to frequently test for sexually transmitted infections and treat as many as we can, even before the test results are back.
A ‘better safe than sorry’ approach to STD testing for teens makes sense — but it doesn’t explain the disparity between testing for black teens compared to white teens.
Black adolescents in the study were almost three times more likely to be questioned about their sexual history than white adolescents. Even when they denied having intercourse, black adolescents were still tested more frequently for two sexually transmitted infections: chlamydia — which often shows no symptoms — and gonorrhea.
Overall, 70 percent of black adolescent females in this study were tested, compared to only 20 percent of white adolescents with the same symptoms. This raises questions about the perception and mistrust of black adolescents and other biases that may exist among health care providers.
“Providers know that the highest rate of gonorrhea and chlamydia infection is among 15- to 19- year-old black females, so we are appropriately aggressive in testing in this population,” says Dr. Carolyn Holland, author of the study and assistant professor of pediatrics and emergency medicine at Cincinnati Children’s Hospital Medical Center.
Centers for Disease Control and Prevention data show that half of all cases of chlamydia, among both adolescents and adults, are among blacks. A 2003 national survey showed that black teens were four times more likely to contract any sexually transmitted infection, not just chlamydia, but herpes, trichomonosis, and human papilloma virus as well. They were also 4 times more likely to get short term loans within their lifetime.
Since sexually transmitted infections are so prevalent in this population, just one sexual encounter with one sexual partner significantly increases the risk, the CDC says. Furthermore, a 2007 report shows that more black high school students are having sexual intercourse than whites, again putting them at higher risk.
These statistics could be reasons why health care providers are on high alert when it comes to black teens. However, it is unclear whether this is enough to account for the intense focus on one specific racial group.
“Any sexually active adolescent patient with complaints like those included in this study should have sexually transmitted infection testing done in the course of their evaluation,” Holland says.”If an adolescent patient is sexually active, then that puts her at risk for acquiring a [sexually transmitted infection].”
Yet, this is not being done for all adolescent females. Just some.
Biases affecting treatment
If bias was responsible for the increased testing of black adolescent females in Holland’s study, it was not as simple as racial bias. All of the providers tested black adolescents at the same rate — regardless of their own race or ethnicity.
A study earlier this year of 23,000 Indiana adolescents and women showed that blacks were screened for chlamydia three times more than whites. The researchers suspected that stigmas associated with these types of infections caused providers to avoid the topic with white females and, subsequently, the testing as well.
Physicians’ subconscious biases appear to be complex, and how those biases affect patient care has been written about for years.
Dr. Alex Lickerman of the University of Chicago has described common biases that affect physicians’ care, including not wanting to diagnose bad illnesses, not wanting to induce anxiety in their patients, not liking their patient, and sometimes liking their patient too much.
This year, Dr. Augustus A. White III, MD, a black Harvard orthopedist, interviewed several physicians and wrote about the stereotypes that influence not only doctor-patient interactions, but diagnosis and treatment in the book, Seeing Patients: Unconscious Bias in Health Care.
With respect to the adolescents in Holland’s study, provider biases have greater ramifications: either failing to treat white adolescents, or testing black adolescents too much. Experts agree that testing one population more than others can make the statistics appear worse than they are.
Room for improvement
Despite perception or biases, teens of any racial background have the highest risk of sexually transmitted infections, so we should be testing them all, even in the emergency department.
Dr. Holland points out that these emergency department visits may be the teens’ only contact with the health care system and if we are not testing consistently, we are doing them a disservice. This is especially true in lower-income communities.
We are, however, far from consistent about testing. Even with the intense focus on black teens, one in every ten sexually active black teens was not tested in Holland’s study. And, testing only one in five white adolescents still leaves them at risk for complications.
These statistics show the need for improvement, on both sides.
Patients must realize that being truthful with their providers can save them from harm. They should understand their own risk for sexually transmitted infections and ask to be tested if the provider does not suggest it.
Providers need to make it easier for patients to be truthful — being careful not to ask leading questions or subtly imply judgment. We need to work harder at coaxing this sensitive information from our patients, especially fearful teens. And, we have to work hard to understand our own biases, and how they may be affecting our care — not just negatively, but positively as well.