Many teenage mothers (and sometimes fathers) have doubts about when to talk to their daughter about safe sex, gynecological examination or contraception. When is it time to visit a specialist with your child? On the one hand, the parent does not want to be late with specific information and leave matters to their natural course. On the other - to jump out in front of the orchestra and offer rubber bands or hormonal contraception to a teenager who has not yet undergone sexual initiation.

Parents fear that moving too quickly in conversations and actions outside the traditional range of bees and butterflies may be seen by the child as a kind of permission to start cohabitation. Meanwhile, this is not so: a teenage gynecological consultation is, first of all, a manifestation of concern for her wellness and an element of prevention, unrelated to sex. The premature start of intercourse is often associated with youthful rebellion and curiosity, as well as pressure from the environment. Young people do not expect any approval or signal from their parents. Examination or talking to a doctor is unlikely to change their sex life decisions, but it can save the future in terms of general or reproductive health.

I think it's easier to be late

Population studies, even before the pandemic, show that the age of sexual initiation in Poland is between 16.9 - 17.4 years. We do not have current reliable data, based on a representative research group. Prof Zbigniew Izdebski's extensive analyses on Polish sexuality are produced every five years and we can expect them this year (the latest data is from 2017). Also this year, a report on the health behavior of school-aged children (HBSC) (Health Behaviour in School-aged Children) is to be produced in several dozen countries, including Poland.* However, given the current functioning of Polish schools, the implementation of the research may encounter various difficulties. In the school of Minister Przemysław Czarnek, the topic of sex seems almost unrealistic.

It is suspected that periodically the pandemic may have somewhat disrupted general trends in sexual behavior. In several countries, even a temporary decrease in sexual activity (in different age groups) was observed due to limited opportunities for social contacts, changes in priorities. However, the situation is unlikely to change permanently.

There is no doubt that for years the age of initiation in our country has been decreasing. Since 2014, this applies primarily to girls. Daughters engage in sexual activity approximately two years earlier than their mothers. For example: in 1990, HBSC research found that in the group of 18-year-olds, 36% of boys and 18% of girls declared that they had already had their first time. 20 years later, the loss virginity 45 per cent of boys and 38 per cent of girls had already declared before the age of majority. A 2014 study of 15-year-olds found that girls' and boys' ages of sexual initiation had already nearly equalized, with a slight tilt toward very young women. More than 18 percent of them said they had sexual initiation behind them (the boys' score was 16 percent).

Of course, almost every mom believes that the one in five girls who starts a sex life soon after the age of 15 is definitely not her daughter. Few parents have full knowledge of their children and their intimate sphere of life. This is understandable and quite natural. It doesn't have to fundamentally change for young women to be safe and healthy.

Choosing a doctor matters

- It would be ideal for every young woman to go to the gynecologist before starting intercourse. In the case of my patients, this happens quite often - says Prof. Marzena Dębska, obstetrician-gynecologist (pictured at the end of the gallery, at the top of the article), explaining that she feels a bit like a family gynecologist, because it is usually the mothers who are treated with her, then bring their daughters.

The first consultation with a gynecologist is extremely important. It is she who often decides how in the future a woman takes care of her intimate health, how often she is examined. A visit to the office, even for the most daring teenager, is a strong emotion. Even if a girl makes up with a face, she is definitely experiencing it. It is important that she be treated with respect and kindness. Here you can not rely on chance and you have to make sure that the patient is taken care of by a trusted doctor, to whom she will gladly return - emphasizes Prof. Dębska.

Of course, this does not have to be a mom's doctor, although such a solution seems reasonable for many reasons. Sometimes a teenager prefers to go to the doctor indicated by a friend or older sister. It also happens that she wants a change of gynecologist after the first visit. It must be respected. Something didn't play? Better change than giving up care.

The Polish Gynecological Society recommends that the first routine visit to the gynecological clinic should take place in the age range of 12-15 years, after the first menstruation. It is intended to be an opportunity to assess the course of the menstrual cycle, education about the female reproductive system, sexuality and contraception. It should also serve the implementation of preventive vaccination against HPV. **

Theoretically, such a consultation should be carried out in a special clinic for children and adolescents. There are not many of them. Undoubtedly, they are indispensable for children after traumatic experiences, with developmental disorders, up to the age of 15. The routine visit of a 15-16 year old to a regular office can certainly already be a successful and well-remembered experience.

Not too early?

At one time, doctors recommended the first routine visit no earlier than two years after the first menstruation. This is the right time for the menstrual cycle to stabilize and to be able to fully assess the regularity of the reproductive system. Why is this recommended acceleration and visits even a 12-year-old? It is not solely due to lowering the age of sexual initiation. This is primarily the concern of gynecologists for women's health. This is an opportunity to talk about vaccination against human papillomavirus, commonly called vaccination against cervical cancer. The school does not do this, pediatricians do not do it very often, so maybe gynecologists will convince that it is important?

The vaccine provides optimal protection when it is given before sexual initiation, that is, before the moment when infection can occur. Unfortunately, in Poland there are regularly problems with access to vaccines, there is a lack of awareness of the importance of such vaccinations, there are strong anti-vaccine movements, and partial reimbursement of only one, the cheapest preparation, did not contribute to the increase of interest in this form of prevention.

Polish women do not get vaccinated, do not do cytology, do not go to the gynecologist. And they are in the European top of cervical cancer deaths. Mortality due to cervical cancer in Poland is 70% higher than the average for the countries of the European Union.

- I assume that girls to whom the doctor will have the right approach, who will trust him, will learn that regular visits to the gynecologist are normal and necessary, that it is a shame not to be examined. Today's teens have a lot of access to knowledge, so I hope they take better care of their health than their moms. Recently, one patient told me that she did not get vaccinated because she is a deep believer. It wasn't about HPV at all, it was COVID-19. There was no talk of HPV at all. Unfortunately, there is still a lot to do in education - adds Prof. Dębska.

Mom can wait outside the door

Usually, the patients who come for the first visit to Prof. Dębska are over 15 years old. Most often, they plan to vaccinate or are already vaccinated against HPV and have not yet undergone sexual initiation. But this is not a standard at all.

- Usually, at the first meeting with a teenager, I do not examine her gynecologically, that is, in an armchair. We talk to each other first. If a girl does not report any complaints, menstruates properly, does not have intercourse - then I limit the medical examination to collecting a detailed anamnesis, measuring pressure and ultrasound examination through the abdomen. It helps to get used to me, to the office, to open up. We also talk about other topics — about adolescence, about school, sometimes about other problems. I always ask if a girl has a boyfriend or if they are planning intercourse, I bring up the topic of contraception. Usually, after some time, these patients return, often they are ready for a full examination.

The mothers of my patients are aware that their children are “educated” on the Internet and there is little that can be done about it. Sometimes they find it difficult to communicate with a rebellious teenager, which is also not surprising. It is often the case that they leave me alone with a young patient, giving me the chance to have a more honest conversation. There are things you don't want to say to your mom. This usually works. I learn more from the girl. I can at least know her plans and also ask her to report to me before she starts intercourse.

Pills are not just contraception

When a doctor plans to prescribe contraception to a minor, he must obtain the consent of the parent. According to Prof. Dębska, in the case of parents who bring a teenager to the gynecologist on their own, there is usually no such problem, because they usually also think about it and usually want to protect their daughter from premature parenthood.

- It is worse with those teenagers who have no one to accompany on the way to the doctor's office or if there is no such consent. If a teenager does not have good contact with his parents, there is no openness in their relationship, this can be the cause of powerful problems. There are teenagers who go to the gynecologist only when they are pregnant or who hide the fact of being pregnant and report even later - only at the time of delivery.

In the case of unplanned pregnancies, there is no question of any preparation or even the usual prevention with folic acid, which is indicated at least two months before pregnancy. I have had such patients as well. Several teenage girls came to me because of suspected malformations in the fetus. It is worth knowing that the risk of fetal malformations in very young, teenage women is similar to that of women in their 40s. Only the distribution of these defects is different - at a young age, anatomical defects predominate - spina bifida, skulls, bowel cleansing (the intestines go outside the abdominal cavity), in the elderly, genetic defects. These abnormalities may be related to age and lack of adequate prevention, improper nutrition, or the use of stimulants. These are just dramas. One of the patients I examined while pregnant gave birth to a child unable to live independently, who would require hospice care for years. This is an unimaginable mental and physical burden. And after all, this girl should be able to develop normally, go to school.

It is not at all so rare that young girls hide their pregnancy, until the moment when they begin to feel contractions and go to the hospital. Several times in the emergency room I happened to find that the cause of such abdominal pain was a three-kilogram bobas that was pushing itself into the world. It seems impossible that such a pregnancy can be hidden from parents or other household members. Even stranger for me are situations when a girl with a belly the size of a watermelon claims that she did not know that she was pregnant. Did she not pay attention to the fact that she did not have menstruation, that she was sick, did not feel movements? I have often wondered about this - is there a mechanism for suppressing this information? I pretend I don't see this pregnancy, then it will go away? Unbelievable. Pregnancy tests are in every pharmacy.

Remember that hormonal preparations are not only contraception. It is worth knowing that properly selected for age and situation can be treated as a treatment. We often prescribe them as an effective treatment for painful, heavy or irregular periods, acne or excessive hair. The contraceptive effect is obtained, as it were, “by the way.” It happens that the parent prefers to focus on these additional effects, not wanting to dwell on the intimate affairs of the child. Well, kids usually don't want to dwell on their parents' sex either, so I guess it's not a bigger problem. The girl is equally well protected also if she takes the pill mainly for acne.

‍Contraception is not everything

Of course, it happens that mom brings a 16-year-old daughter to the office, who is already pregnant and needs obstetric care. It also happens that very young women need treatment for sexually transmitted diseases.

- Recently, I am worried about quite a lot of bad results of cytology in young girls who have already started intercourse. We find precancerous conditions in them, requiring at least regular monitoring. Such results suggest that young people have more than one sexual partner and that they do not use condoms, which should be used together with hormonal contraception if we want to protect ourselves from sexually transmitted diseases. Cervical cancer is now also considered such a disease. At the age of ten it is difficult to talk about permanent relationships, and after all, a constant, faithful partner is one of the key factors in promoting intimate health.

Adults must not forget that an unplanned pregnancy is not the greatest misfortune that can befall a teenager. Infection with AIDS, hepatitis or other infectious diseases that, if improperly treated or untreated, threaten infertility and even loss of health and life. From them, the “pill” does not protect. That's why I always remind patients about condoms, which significantly reduce the risk of infection - concludes Professor Dębska.