The Silent Treatment

When Kerry Washington was in high school at Spence, she was known as the Condom Lady. An aspiring actress with a heart-shaped face, she was one of a troupe of teens, trained at Mount Sinai hospital, who traveled around New York doing safe-sex skits in schools. For years, she played a virgin on stages across the city. Meanwhile, at Spence, she was passing out condoms to anyone who asked. “They knew this was my after-school job,” she says of her classmates. “They were coming to me as a friend who had more information and had read a few more books than they had. I know they weren’t going to their parents.”

She knows this, says Kerry, who is now 21, because as cool as she was on the subject, she still didn’t welcome heart-to-heart talks with her own parents about her sex life. “My mom knew I was sexually active in high school, but I had a lot of issues about wanting to be a perfect daughter. I wanted to protect my mom from all this scary stuff. Once, I had a scare that I had an STI a sexually transmitted infection. I didn’t talk to her about it. I had a scare that I was pregnant. I didn’t talk to her about it.”

An Upper East Side mother of three teenage girls, one of whom developed a weight problem in high school, says she knows just enough to be aware that she doesn’t know much at all. “This is a heartrending transition,” says the woman. “You’re just baffled that this lovely child you adore is pushing so far from you and is so unreachable, and you can’t figure out what the hell is going on with her.” This much the mother was told by her daughter: She didn’t want to talk about her diet with her pediatrician. She felt it was not a childish problem.

Parents who micromanaged their children through toilet training and sleep upsets, who saw the pediatrician more often in strep season than they saw their spouses, who sought the best medical care offered the modern American child, find the information blackout of adolescence deeply unnerving. Teenage girls are developmentally wired to evade their parents’ anxious attention to detail. Too bad this happens just at the time of highest risk from smoking, eating disorders, and sexually transmitted diseases. And at the very time they’re entering the Bermuda Triangle of health care.

The teenage girl is almost no doctor’s primary business. She’s getting too old for the pediatrician, but she’s hardly the bread and butter of the internist or family practitioner. Those few experts who do specialize in adolescent medicine (there are fewer than 1,000 physician members, across the country, of the national Society for Adolescent Medicine) contend that the average physician’s checklist approach – do you smoke? Do you drink? Do you exercise? Check, check, check – does not shed much light on the byzantine mesh of emotional and developmental changes that drive an adolescent’s life. And it doesn’t get at the truth; pro forma questions, or none at all, are like a license to lie, say girls interviewed.

Many generalists were never trained to ask adolescent-specific questions, and they’re not comfortable asking, say adolescent specialists. Moreover, “in an age of managed care and financial restraints, people feel that taking care of adolescents is a financial liability,” says Dr. Andrea Marks, who treats teenagers at her office on East 90th Street. “To sit and talk to an adolescent will take me half an hour.”

And there’s one more problem: “Adolescents don’t have a great reputation with doctors,” says Marks, whose office is an aerie of soft couches in green leafy prints. “They’re difficult, and doctors like to feel confident that they can help somebody.”

Combine that disconnect with an adolescent’s growing desire for privacy, and you can end up with a virtual wall of silence. This is especially true when a parent is choosing, paying, and possibly sharing an internist or gynecologist with her daughter. “It sets up this dynamic of ‘How do I know this is confidential if my mother is coming in next week?’ ” Kerry Washington notes.

In fact, most adolescent-medicine specialists work in hospital-based clinics that operate by design as confidential zones (though doctors have the right to contact parents in a crisis and, as a rule, encourage teens to bring parents). Many high-school students have found their way, often through guidance counselors, to a Planned Parenthood, the Door (a Manhattan combination social club-clinic for teens), an in-hospital clinic such as the one at St. Luke’s-Roosevelt, or the Mount Sinai Adolescent Health Center on East 94th Street. The only stand-alone center in Manhattan, Mount Sinai gets 40,000 visits – including girls on secret missions from New Jersey and Westchester – each year.

It’s counterintuitive that a generation of mothers who are better informed and more watchful of their own health than any before them could be missing the story with their own daughters. Yet a decade’s worth of statistics, collected by public-health agencies and foundation-funded reports on adolescent health, suggest that girls are in crisis; when they reach the age of their mothers, they may be facing significant osteoporosis; cardiovascular disease; and that expensive curse of so many boomers, infertility.

Here’s a scorecard: Among teenage girls, pregnancy rates are dropping or at least leveling off, depending on who interprets the data. Analysts at the Alan Guttmacher Institute credit girls’ use of longer-term, more reliable contraception, including Depo-Provera, though many of the girls interviewed for this story credited morning-after contraception (see box). And under threat of aids, more teens are using condoms, though four in ten still do not.

But sexually transmitted diseases are passed along so freely that an astounding percentage of girls in New York, and nationally, are walking around with infections. Among girls between the ages of 15 and 19 who are tested in New York City, nearly a third – 31 percent – are infected with chlamydia. It’s an easily treated disease, but it often has no symptoms. AMA guidelines say sexually active teens should be screened by a doctor every six months. The consequences of untreated chlamydia may be damaged Fallopian tubes, infertility, or ectopic pregnancy.

Human papilloma virus, linked to cervical cancer, is not tracked by the city Health Department, but the director of Mount Sinai’s Adolescent Health Center, Dr. Angela Diaz, calls it epidemic. She is alarmed that more and younger girls have abnormal pap smears. Some 32 percent of girls screened through North Shore University Hospital in Manhasset have HPV, and some 38 percent screened through Montefiore in the Bronx do, says Dr. Martin Fisher, president of the Society for Adolescent Medicine.

Why so much infection? “There’s a double risk for adolescent women,” says Dr. Isaac Weisfuse, New York’s assistant commissioner for health in the Bureau of Sexually Transmitted Disease Control. Not only do many practice risky sexual behavior, he says, “but the cervix of adolescent women is more susceptible to infections like chlamydia than the cervix of older women.”

Then there’s the spreading discomfort with food and normal eating. “Everyone I know has something going on,” says a 16-year-old honors student at the High School for Environmental Studies. She herself tried to maximize weight loss last spring by fasting through the first three days of softball practice. She says of her friends, “Like today, they’re only eating crackers, or a girl will skip lunch all week so she can have a brownie Friday.”

Few in the field trust the statistics on eating disorders – some say 2 percent of teen girls reach the disease state at some point during adolescence, some say 10 percent – but the statistics don’t even get at the ubiquity of eating-related problems. Some 18 percent of high-school girls surveyed by the Commonwealth Fund, according to a 1997 report on adolescent health, said they’d tried bingeing and purging. Odd eating tics and discomfort with food have become so common, especially among affluent girls, says Marks, that the same girls who so healthfully avoid red meat may also be avoiding breakfast and lunch on a regular basis. And second-generation eating disorders are increasingly showing up in doctors’ offices – the daughters of Manhattan moms who can’t get comfortable around a piece of grilled chicken.

It’s now known that the peak period for women to develop bone mass is in their teenage years; skeletal construction is just about finished by age 20. “We are very concerned about osteoporosis among many of these girls,” says Fisher. He is reluctant to predict with certainty that skeletal problems will be more common among this generation, considering the rate at which estrogen-replacement therapy is improving. But he does note that teens who are protected by a genetic predisposition toward stronger bones “lose their advantage” with just a few months of an eating disorder. And others, he believes, may never be able to rebuild artificially what they lost.

Doctors like Diaz who treat mostly poorer teens are more concerned with rising rates of obesity, and its lifelong chain of associated risks. City girls who go to private schools are exposed to plenty of sports, but Diaz hears constantly from her patients that they have nowhere to exercise, even at school. What they share in common with wealthier teens, Diaz says, is that they fend for themselves at many if not most meals, and her patients often make fast food their staples.

Smoking among teens had been on the decline since its peak in the seventies, but some statistical data suggest that in 1995, the trend began to reverse. Some 40 percent of white high-school girls now smoke, the most among teenagers. Teenagers are still developing lung capacity, which smoking retards; cancer risks aside, they’re setting themselves up for asthma and bronchial disease. Plus smoking is linked with increased infertility.

Though the overall rates of drinking and illegal drug-taking among teens have declined since the seventies, girls have caught up with boys.

“A lot of families and young women think they have had a preventive-care visit because they’ve had a school physical or a team physical or a camp physical,” says Dr. Jonathan Klein, one of the nation’s top researchers in adolescent medicine, at the University of Rochester’s medical school. “But oftentimes it’s very short and directed toward: Is this person safe to play?” Research has found that 80 percent of teens see a doctor for fifteen minutes a year, or less.

Quickie physicals, though, may have as much to do with doctors’ reticence as expedience has. The mother of a Dalton 13-year-old says she switched her daughter from a pediatrician to Marks two years ago, after she had asked the pediatrician to talk to her daughter about menstruation and other physical changes. “He said, ‘I don’t think so,’ ” says the mother, who half laughs in astonishment as she recalls the conversation. “The man teaches pediatrics at NYU, he’s bright and engaging, he’d been wonderful, but it was clear he just wasn’t going to do this.”

Of course, the discomfort goes both ways. Marie Torres, a 16-year-old junior at the High School for Humanities, recently had a checkup with a New York Hospital pediatrician. She couldn’t wait to get out of there. “I don’t like when he touches me. He says, ‘Take off your pants,’ and I say, ’What?’ He’s really a nice man, but it feels very awkward.”

So what is to be done? Sensibly, doctors like Fisher and Klein have concluded that they’re not going to change the ways information fails to pass between teens and their parents. What they propose instead is to install a second line, between teens and their doctors.

In 1995, the American Medical Association, with Klein as a principal author, published guidelines aimed at radically changing the primary and preventive care of teens. The AMA suggested that pediatricians establish office policies for seeing teens confidentially, and Klein goes further in suggesting that sometime around puberty, parents should be told that their place is not in the examining room. The report, called Guidelines for Preventive Services, prescribed a long list of conditions doctors should screen for, and suggested that in a 30-minute exam there had to be time for some open-ended Q&A. “The physical examination and lab tests have the lowest yield for any useful information,” says Marks. “The art is in asking the right questions.”

But picture your pediatrician’s office, with the choo-choo-wallpaper border and the needlepoint Bert and Ernie over the desk. Imagine your pediatrician following these AMA guidelines: “Sexually active adolescents should be asked about their use and motivation to use condoms and contraceptive methods, their sexual orientation, the number of sexual partners they had in the past six months, if they have exchanged money for drugs, and their history of prior pregnancy or STDs.”

The alternative for the mother who thinks her daughter may need to talk to someone about birth control is to send her to her gynecologist. “So in walks this 15-year-old girl to a gynecologist’s office filled with a lot of pregnant and middle-aged women sitting there,” suggests Marks, who has one of only two Manhattan full-time private practices in adolescent medicine. “It’s as much of a mismatch as it is with a pediatrician.”

There are, of course, pediatricians who are good with adolescents, who can gracefully make the psychological leap between the exam room with the colicky baby and the one with the suicidal teen. Some larger pediatric practices often include someone who concentrates on teens. Internal- and family-medicine residents of newer vintage have also been exposed to more training and rotations through adolescent medicine than their senior colleagues have, Klein notes, “but I’ve been doing this long enough to think that we’re not going to get a change just by training clinicians.” If a teen’s doctor doesn’t suggest that their visits be confidential, Klein says, then parents should swallow hard and suggest it themselves.

Klein notes the alarm about girls, and their relationships with doctors, raised by the Commonwealth Fund report. The authors reported that two thirds of the girls surveyed thought their doctors should discuss drugs, alcohol, smoking, eating disorders, STDs, and pregnancy prevention with them, but less than a third said their doctors did. Half of younger girls and a third of older girls said they had no opportunity to talk confidentially with their doctors.

In clinics like the one she runs at Mount Sinai, serving 40,000 residents mostly of the Bronx and uptown Manhattan, Diaz tries to ensure that kids see the same doctor every time and build a relationship. And “because I run this place and I make sure it happens,” says Diaz, teens are closely questioned about their habits, moods, and concerns, as well as whether they have suffered any sort of physical or sexual abuse, which is a strong predictor of depression.

At the other end of the economic spectrum, Marks’s practice is a model for what care would look like in a world where there were looser financial limits on the time a doctor could spend with a patient. Marks structures her patient relationships so that parents get comfortable with her and then step out of the picture. In fact, many mothers of her patients say their daughters schedule their own visits and, once they reach high school, generally visit Marks’s office alone.

An initial patient meeting with Marks is an hour long. She spends the first half taking medical histories from parents and hearing their concerns. Then she brings the adolescent in. “I’ll say, ‘I didn’t mean to exclude you from the beginning, but the reason I set up my visit this way is because sometimes my patients have private or confidential matters that they want to share with me, so it would be awkward to do it the other way around.’

“I also tell them that if I ever need to speak to their parents about something that is of great concern, I won’t do it behind their backs.” Marks says the art is to make the teens feel that their agenda – not her checklist – is the guiding force in the relationship. She does go down the risky-business checklist, not so much because she expects to hear rigorously honest answers as to lay the groundwork for getting at problems. “I’ll have patients who call me six months later and say, ‘Dr. Marks, remember you asked me if I was smoking cigarettes? Well, I didn’t tell the truth at the time, but I really want to stop and I don’t know what to do.’ “

This kind of doctor-patient encounter can be jarring to kids, said the mother of that Dalton 13-year-old. “The first time my daughter went there, she said, ‘I’ll tell you something. She is so nosy. She asked me questions about you and Daddy and my friends, and that’s none of her business.’ We had to have the discussion about how health has to do with psychological and emotional wellness, and why it’s important for her to talk about these things.”

This particular parent feels an almost rueful gratitude at having that second line installed: “Wouldn’t I want her to talk to me instead? Yes, of course.” But this mother also had the experience not long ago of hearing one of her daughters’ friends try to explain to her the difference between cocaine and heroin addiction. It was off-the-wall. “I just had to say stop, stop the misinformation.

“If she’s going to turn to someone else for this information,” the mother said, “I would love for her to call a doctor.”

The Silent Treatment