To the Editor:
The report by Silva and colleagues1 and the accompanying editorial2 have not only informed us about pregnancy outcome in juvenile systemic lupus erythematosus (SLE) but also reminded us of the importance of addressing sexual health within pediatric rheumatology. Schwarz and Manzi similarly advocated increasing attention to sexual health in adult rheumatology clinics3. However, addressing such issues within the context of adolescence demands different knowledge and expertise than that required in adult practice.
In a recent audit of 19 adolescents with SLE seen in a pediatric rheumatology clinic at our institution (median age 15 yrs, range 10–18), documentation of sexual health being addressed was found in only 4 patients4. In a similar audit of adolescents with juvenile idiopathic arthritis (mean age 19.2 yrs), documentation of sexual health was found in only 11.4% of case notes5, despite young people calling for sexual health information and advice within the context of their rheumatology care6. This is particularly pertinent in view of the use of methotrexate and biologics in pediatric rheumatology and the fact that at least a third of young people are likely to be sexually active prior to transfer to adult care7. The benefit of transitional care for adolescents that addresses such issues is highlighted by significant improvement in documentation of sexual health (albeit still suboptimal) following implementation of a transitional care program5.
In order to address sexual health within pediatric settings, developmentally appropriate methods of assessment and health promotion are required. Few adolescents will initiate discussion of such issues, so routine use of screening tools such as HEADSS (Home environment, Education/employment, peer-related Activities, Drugs, Sexuality, Suicide/depression)8 is useful within pediatric rheumatology clinics. Sexual health is also not all about preventing pregnancy, despite this often being the only aspect of sexual health discussed — 100% of health professionals reported discussion about infertility with male adolescents with cystic fibrosis, but only 38% discussed importance of condoms, thus ignoring the risk of sexually transmitted infections and unsafe sex9. A potential barrier to addressing sexual health issues in juvenile SLE is the lack of opportunity for young people to be seen independently of their parents and the triage of other competing medical problems. Service development for juvenile SLE must take this into consideration and advocate for confidential services for young people, with appropriate appointment duration and continuity of health professionals. Such rheumatology services must also ensure effective signposting to young-person-friendly sexual health clinics to ensure access to contraception, not only knowledge, as highlighted by Dr. Kaufman2. Finally, professionals with adolescent health expertise are integral to such services, although not universally available in pediatric and adult rheumatology10. The development of recent e-learning training resources in the UK (e.g., the Royal College of Paediatrics and Child Health; www.rcpch.ac.uk/ahp) is a welcome and exciting initiative from which rheumatology can only gain.