Episode 4: Child and Adolescent Sexual Health with Dr. Beth Kuzma

In this episode of the MICNP podcast, Dr. Beth Kuzma discusses the critical aspects of adolescent health, focusing on HPV vaccination, sexual health education, and the challenges faced by today's youth. The conversation emphasizes the importance of early education, the impact of technology, and the role of parents in guiding their children through complex issues like sexting and consent. Dr. Kuzma also highlights the need for healthcare providers to create a welcoming environment, utilize effective screening tools, and approach discussions with cultural sensitivity. The episode concludes with best practices for engaging with adolescents and fostering open communication.

Takeaways

The recommended age for HPV vaccination is 11 to 12 years.

Early exposure to vaccines can have a significant impact on health outcomes.

Sexting is a prevalent issue among adolescents today.

Parents play a crucial role in discussing sexual health with their children.

Confidentiality is vital in adolescent healthcare, especially regarding sensitive topics.

Utilizing screening tools can help assess adolescent health effectively.

Creating a welcoming environment in healthcare settings is essential for youth.

Cultural sensitivity is important when discussing sexual health with diverse populations.

Recognizing warning signs in adolescent behavior can aid in early intervention.

Healthcare providers should remain open and non-judgmental to foster trust with young patients.

Theme music

• Keyboard, Bass: Clementine Kanfom
• Guitar: Tyler McDonald
• Drums: Andrew Padfield
• Mixed, Mastered: Andrew Padfield

Michigan Council of Nurse Practitioners (MICNP): Website

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Chapters

• 0:00 Introduction to the MICNP Podcast with Dr. Beth Kuzma
• 3:26 The Importance of Trauma-Informed Care
• 5:09 Challenges Facing Today's Youth
• 8:18 Understanding Sexting and Its Implications
• 10:26 Current State of Sexual Education
• 12:34 Navigating Parental Controls and Privacy
• 14:58 Building Trust with Adolescents
• 17:33 Providing Confidential Health Services
• 22:07 Understanding Minor Consent Laws
• 24:44 Addressing Pediatric Sexual Health Concerns
• 28:29 The HPV Vaccine
• 33:38 Navigating Youth Culture and Communication
• 36:45 Cultural Sensitivity in Sexual Health Discussions
• 37:51 Effective Assessment Tools for Adolescent Health
• 39:04 Promoting Sex Positivity in Healthcare
• 41:54 Cultural Sensitivity in Sexual Health Discussions
• 43:00 Effective Assessment Tools for Adolescent Health
• 45:38 Creating a Safe Environment for Adolescents

Transcript

Rachel Hetzner (01:43)
Welcome to the MICNP podcast where we have Dr. Beth Kuzma, family nurse practitioner with us today. Welcome to our show, Dr. Kuzma. Hey, awesome. Hello, I am Rachel Hetzner, president-elect for Michigan Council of Nurse Practitioners or MICNP and the co-host of the MICNP podcast.

Justin Hooks (01:52)
Yay! Awesome.

Jen McConnell (01:53)
Woo!

Beth Kuzma (01:55)
Thanks.

Excited to be here.

Justin Hooks (02:08)
everyone, I'm Justin Hooks, the chair of the education committee for MICNP and the other co-host for the MICNP podcast.

Jen McConnell (02:15)
Hello, I am Jen McConnell, the PR and marketing chair for MICNP and producer and stand-in host when I need to be for the MICNP podcast.

Justin Hooks (02:22)
So before we get started and jump into this wonderful topic, we have Dr. Kuzma here. Do you mind introducing yourself to our listeners and kind of explain how important this topic is to you?

Beth Kuzma (02:34)
Absolutely. So hi everyone, I'm Beth Kuzma. I'll give you a little background about me professionally. I'm a clinical associate professor at the University of Michigan School of Nursing, and I'm the director of our advanced practice nursing programs. I teach primarily in our family nurse practitioner program, and I do have an active clinical practice as a family nurse practitioner. Currently, my practice is at Corner Health in Ypsilanti, where I work with youth age.

12 to 26 provide a lot of different services, including gender affirming care, sexual health care, risk reduction, all of those things. So this topic is really important to me personally. And this is what I do in my practice with my patients. I am a mother, a 13 year old girl. So it's personally then also really important as an educator to make sure that our future nurse practitioners.

Justin Hooks (03:15)
Okay.

Rachel Hetzner (03:17)
you

Beth Kuzma (03:22)
understand what appropriate sexual health education and care is for you.

Rachel Hetzner (03:26)
So before we get started, we ask our guests the same question. If there was something you know now that you wish you knew when you started your practice in healthcare, what would you tell that person? I know, it's a tough one.

Beth Kuzma (03:39)
Definitely is a tough one. I feel like there's lots of things I would tell myself, especially because a lot has changed. I was 16 when I started in healthcare as a nurse aide, and I've been an NP for 17 years. It feels crazy that it's been 17 years, but so, you know, lots of things. I mean, I even think about when I was a nurse aide, I remember being taught like to teach to speak to my older patients and call them sweetie and hun and baby and like all the things I feel like I gag for now. It's insane. But one thing that really stands out, it's related to what our topic is and really where my scholarship has been in the last like five to 10 years is around trauma-informed care. I feel like I didn't know anything about trauma adverse childhood experiences and trauma-informed care.

Justin Hooks (04:04)
Mwahahahah

Beth Kuzma (04:27)
Early on, most of my education throughout my bachelor's, master's and doctoral education. And so just to realize how, you know, the things that people have been through in their life impact their health. And we can think that we know what's going on with them, but often we're only touching the surface. so creating a safe environment where our patients trust us and want to share more components of who they are than we can really get to the root cause and be able to provide better healthcare because

Rachel Hetzner (04:56)
I'm surprised every day by some of the trauma that my patients tell me that they're going through and I'm like, geez, I can't even imagine.

Beth Kuzma (05:03)
Yeah, it's

Justin Hooks (05:03)
Everyone has a story is what I say. Everyone has a story.

Rachel Hetzner (05:07)
So true.

Beth Kuzma (05:08)
Absolutely.

Justin Hooks (05:09)
So where do we start? This is gonna be so fun and I'm so excited for this. So thank you again for joining us tonight. So let's start with adolescents and sexual education and their healthcare. What's going on with our youth and what are some of the stuff that their youth are facing today?

Beth Kuzma (05:26)
So youth today are still facing lots of the same things that everyone has faced throughout history, right? Their bodies, their brains, their emotions are changing, they're developing, they have increased sexual desire, curiosity, they're risk-taking, experimenting, figuring out who they are. They might be engaging in different types of sexual activity, they're trying to learn about sex and figure out where to find the right information. . . school, through parents, through peers, wherever they can find it. However, this era and this age group now does have some additional challenges that certainly I didn't growing up because the internet changed everything, know, especially since that key point in time in 2007 with the first iPhone. You know, what you have a full functioning computer at your fingertips where you can get to anything and

Justin Hooks (06:08)
yeah.

Beth Kuzma (06:18)
the available information, media, websites that are now on the internet has exploded since the internet first began. So lots and lots of content.

Justin Hooks (06:26)
It's kind of

funny because you said like iPhones and how I'm thinking about now is iPhone, the screens used to be so small and now how big they are. And I was thinking as you were talking about access to different material on their phone, now it's even larger. So they're not squinting.

Beth Kuzma (06:43)
Right, right.

And you know, everyone's carrying them at their hip at all times. So it's like what they have access to at any time they want, pretty much. Which also includes, unfortunately, something that can be difficult to talk about, but pornography. It is very available, all different types. Doesn't really have many blocks to stop young people from actually clicking and opening it up, they might have to say something like, yes, I'm 18 or older. And then they can fully access all different types of images. And their brains are often not ready for what they encounter.

Justin Hooks (07:12)
Wow.

Wow.

Beth Kuzma (07:20)
So it is definitely a different world than many of us grew up in. And it's hard as adults to imagine, like, why would I want to talk to my kids about pornography or why? Because it's a reality for them, right? Like, us not talking about it doesn't help them because they're seeing things and they're hearing things from their friends. And believe me, it makes me sick. But I am living in this world where I, my children come home and tell me things that I am horrified by. But...

Justin Hooks (07:32)
Okay.

geez

Beth Kuzma (07:50)
I've just got to be there. I've got to hear what they have to say and help them figure out what to do with that.

Rachel Hetzner (07:55)
They're gonna hear those things anyway, so you might as well be a place that they can come and talk about things.

Beth Kuzma (08:02)
Yeah, and then also thinking about with smartphones besides what you can find on the internet, what people can make themselves on their own phones and share with others. Yeah.

Rachel Hetzner (08:11)
Yeah.

Justin Hooks (08:13)
Ha.

Rachel Hetzner (08:14)
Thank

Beth Kuzma (08:14)
So it's all these things that we never thought about.

Rachel Hetzner (08:15)
So, yeah, yeah.

Crazy, crazy times. So I have a question. What is sexting? Is that still a thing? I have young children, but I want to be up with the times and know what to prepare myself with. But I wonder what they may or may not see in the future. What ways do you think that we can discuss this with our patients even and our children?

Justin Hooks (08:24)
Good question.

Beth Kuzma (08:41)
It's a great question. And yes, sexting is very much a thing. It's a thing with young people. It's a thing of all ages. It has now become and often seen as a normal part of sexual relationships. And honestly, it was a very difficult pill for me to swallow, but I'm starting to just say like, this is... the reality that we're facing and I need to roll with those times to be able to help my patients, but we really need to change the thoughts of like, if they're going to do it to when they're going to do it. And if we can, just like talking about sex in general, you can delay the onset of when they engage in sex by having open conversations. The same thing can be true of sexting. So when they choose to do that, ideally they're gonna be more mature and make better decisions and maybe be in safe relationships where it won't be as big of a deal as if they're younger and not protecting themselves. So let's,

Justin Hooks (09:38)
⁓ sorry.

Beth Kuzma (09:38)
oh, go ahead, please.

Justin Hooks (09:39)
I was just wondering, like, do, when you talk about, like, health education, like sexting, I know sexual education in the school system is very political, but we're not trying to be political here, but is there some minimal education that they teach with the sex ed about sexting for the curriculum that they know, like, what to watch out for, or is that still kind of what the parents are doing?

Beth Kuzma (10:01)
Right now it's still what the parents are doing. So current sex ed in Michigan is a minimum of abstinence only, and then schools can choose to add more information. It doesn't even have to be current evidence-based. And the current sex ed laws are more than 20 years old. And so just imagine how much things have changed in the world in the last 20 years. So unfortunately, yeah.

Justin Hooks (10:15)
How?

Rachel Hetzner (10:24)
Wow, I didn't realize that.

Justin Hooks (10:26)
Mm-mm.

Beth Kuzma (10:26)
Yep, so there actually is a push for it right now. There was a bill last year, House Bill 6068, but that is actually going to be changing and they'll be reintroduced because of the way the session goes. But to update our sex ed laws for the first time in 20 years to consider trauma-informed principles and to make sure that it is current evidence-based and looking at being inclusive of different gender identities, sexuality, sexual orientation, different behaviors.

Justin Hooks (10:47)
Good

Beth Kuzma (10:54)
how to prevent coercion, lots of different things, and including the

Justin Hooks (10:57)
night.

Beth Kuzma (10:58)
digital media and how to navigate that, because that is a reality of young people today. So we'll see what happens.

Justin Hooks (11:00)
So this is a state-based, right? So the sex ed, even like, I guess, not only what we can do as nurse practitioners to practice, just even the education, like the sexual education varies dependent on the state, it seems like. Cause I know in Michigan you have to have like a teaching certificate to be like a sex ed teacher. That's kind of interesting that you just told us that it's 20 years out of date.

Beth Kuzma (11:27)
Yeah, yeah. it's not even just state. So there's like a minimum that the state has, but each district itself has their own process to determine what information they provide, how current it is, how often they review it. So certainly within and across states, it's different, but then also looking at different districts, even different schools.

Justin Hooks (11:46)
Wow.

Jen McConnell (11:47)
Wow, I really hope that they include in that bill updating those 1970 movies about sex ed because those were very good.

Justin Hooks (11:55)
Hehehehehe

Beth Kuzma (11:58)
And there are some school districts that that is what they still use is old materials from the 70s and 80s and they have not updated them at all. Other districts have very current.

Jen McConnell (12:02)
no.

Justin Hooks (12:02)
Wow.

Jen McConnell (12:07)
The kids see the corded

Justin Hooks (12:08)
Wow.

Jen McConnell (12:09)
phones and they don't know what those are,

Beth Kuzma (12:12)
a little rotary dial.

Rachel Hetzner (12:12)
Kids are like, of course I didn't want to watch that, it's from the 70s.

Justin Hooks (12:17)
You

Beth Kuzma (12:19)
That's like my grandparents, you know?

Rachel Hetzner (12:20)
You're right!

Beth Kuzma (12:21)
That's what the boomers do, that's at least my daughter. Anyone who's older than her, she calls a boomer. I'm like, no, my parents are boomers, I'm not a boomer. But anyone over like youth culture is a boomer, apparently.

Rachel Hetzner (12:29)
over his death.

Justin Hooks (12:31)
Yeah.

Jen McConnell (12:34)
you

Justin Hooks (12:35)
thought we were advanced. I don't want to date myself, but I'm the big four zero. And I thought back then when I was like 18, Cinemax, for example, and it has another name for it, but seeing something like that was a big thing. And now I guess I feel really old by thinking that our youth are just looking at it on the phones and using dating apps and stuff like that. You were talking about like sexing, is there parental controls or anything you recommend? How do you have this discussion with the parents or someone like me that now I'm afraid to have kids?

Beth Kuzma (13:12)
That's a great question. There are lots of different types of options for parent control. So each individual phone, the model themselves, like the little phone handbook, you can certainly look on YouTube and find different ways to do that within the phone. There's also software products that you can add to your phone. You can use filters through your router that blocks like which device can access certain websites, certain applications. I use something

called a bark phone. So it's like a product that I pay a monthly fee and I'm not, you people do whatever they want. This is not like selling, but this is just one there's other services too. so I pay a monthly fee, it has a product, it monitors everything my daughter does. And it'll send me alerts. When there's something related to medically concerning content, profanities, you know, they have all of these different types of flags, I can limit the types of apps just through this like

Justin Hooks (13:42)
Wow.

Beth Kuzma (14:05)
program, I can say how much time they can be on. Yeah, so there's all different ways of doing it. And it's not like you have to have a phone that's from this company that you pay. I just found that easier than reading a manual to figure out how to do it. there are lots and lots of resources now. I mean, I just imagine like when the first iPhone came out, there was no filters. These were like unfettered access to all of these things. none of us we were trying to figure it out as things were.

Justin Hooks (14:06)
Wow.

Rachel Hetzner (14:07)
Wow, that's great.

Jen McConnell (14:16)
Thank

Rachel Hetzner (14:17)
you

Justin Hooks (14:29)
Thank you.

Beth Kuzma (14:32)
being sold. So now we have way more resources than we did in the past.

Jen McConnell (14:36)
So I do have another question. So we as older people and parents go, yeah, that's awesome. That's great. But I'm sure there's some kids that wouldn't think that's so great. Like you're invading my privacy. So what kind of conversation would you introduce to parents and kids saying like, yes, you need to be protected, so how would we go about as providers?

Justin Hooks (14:54)
Thank

Jen McConnell (14:58)
educating our parents and having that open discussion with the child or adolescent about those kinds of protections.

Beth Kuzma (15:07)
I mean, it's certainly an important thing to talk about and that's certainly something I am living every day. My daughter can't stand that I get alerts and I can see her texts. So first of all, I can't see everything. I just see these little blurbs, but I'm like, listen, you need to learn how to live in this world and navigate how to safely make choices using a device. And this just helps you and your family figure out how to make those decisions and externally enforced, right? But you're still learning skills and understanding what's like okay and what's not okay and asking for permission and help when you can't access something. might say, my daughter might say to me like, well, why can't I have Pinterest or why can't I have this app? And it's like, well, there might be things, know, that, cause once you click on something, you can't unsee it. And I'd like to protect you as long as I can and help you figure out.

Rachel Hetzner (15:50)
Yeah. Yeah.

Beth Kuzma (15:58)
controlling what you're accessing.

Justin Hooks (15:59)
Kind of one of those things in the position that you're in is a good thing and a bad thing. So you can be the good person and the bad person to your children, unfortunately, but they won't understand it now. But I'm going to assure you even they will probably get it later and that will be much better than seeing that. So you're doing a good job and I thank you for all the work that you do.

Beth Kuzma (16:22)
Thank you for that. It definitely isn't easy, especially when they're like, mom, it really bothers me that you are seeing all of these things. I'm like, well, we are paying for the phone. It is ours. If you would like a smartphone, if you would like to be able to text your friends and have calls and video chat, this is the choice that we have. We can choose not to have a phone. We can choose to have a watch that you can call and only text 10 people, you know, but this is how I can feel safer.

Rachel Hetzner (16:23)
Really.

Justin Hooks (16:45)
So.

Beth Kuzma (16:49)
I know I can't stop everything, right? There's zero chance that that's gonna happen. But at least I can feel like I'm gonna reduce the chance that, you know, she's gonna be exposed to things. And so I usually actually try to be pretty frank with my patients and parents, like, I'm navigating this myself. And this is, we're all trying to figure this out. This is what's working for me. There's different options for other people. And you, you know, just to help them guide and figure out what will work for them as a family.

Rachel Hetzner (17:14)
So you mentioned bringing it up to your patients and their parents. The American Academy of Pediatrics recommends that primary care health care providers offer an age appropriate, confidential, sexual, reproductive health services regularly during the adolescent visits. What does this look like within your practice? How do you go about doing that?

Beth Kuzma (17:33)
I have lots of different ways that I do this, but I follow the standard guidelines. We talk about all the things that we should, but I've modified the way that I do things trying to use tools I already have in practice. So as an adolescent health provider, we use different risk assessments. So one can be GAPS which is the guidelines for adolescent preventative services, or the HEADDS mnemonic, or the RAPS, which is the rapid.

Justin Hooks (17:35)
Okay.

Rachel Hetzner (17:36)
I'm

Beth Kuzma (17:57)
assessment of adolescent preventative services that asks questions about like sex, sexuality, are you using condoms, different things like that. And so I kind of use the tools we have, we're already asking the questions and then I kind of add on like, what are your thoughts about this? Do you have exposure to these kinds of things? And it's hard to say, can I give you a cookie cutter answer? No, because there's different youth with different ages and different development.

Justin Hooks (18:07)
Wow.

Beth Kuzma (18:22)
exposed to different things. So you sort of have to be nuanced and listen to your patient, hear what they're saying, and then you adapt, ask more questions if they're sharing more information, pull back if their face looks shocked,

Rachel Hetzner (18:29)
Sure. Sure.

Beth Kuzma (18:34)
if no idea what you're talking about, which happens, you

Rachel Hetzner (18:35)
Yeah. They're like, what did

Justin Hooks (18:38)
You like?

Rachel Hetzner (18:39)
you just say?

Beth Kuzma (18:40)
I mean, it definitely happens that I worked with patients with a very broad range of experiences where I've had like 15 year olds who have never been in a relationship, have never held a hand, you know, are like, I've never even thought about kissing someone, which I'm not so sure that I actually 100 % believe that, but you know, there are some thoughts in their brain at some point, at least they're right. Or there's like,

Justin Hooks (18:42)
Yeah.

⁓

I probably dream about it is what I think.

Rachel Hetzner (19:03)
But then when you approach

pornography and sexting, they're like, what?

Beth Kuzma (19:06)
What?

Justin Hooks (19:06)
Yeah.

Beth Kuzma (19:07)
Yeah, and I usually try to test the waters in the sense of like, what are you hearing in school? What are you like, so that's very distant. It doesn't feel so invasive of like, you're asking me about my choices. Like, what happens? What is with the rumors about people? Are they in relationships? What kind of things are they doing? Are people seeing videos? Has anyone sent any pictures of their private parts? You know, like, and then you can kind of move into like,

depending on how they respond. Like, what about your friends? I mean, what's going on in that group? Has that ever happened? And what do you think about that? Is that something you've done or you've thought about? So you just sort of like start further and move in. So it's like making them be a little more comfortable. I always try to be like, we can talk about anything. You can ask me anything. I will not shame you. won't, you know, we are a safe space. And I've been asked all sorts of questions. I...

answer them as frankly as possible and I think that that just helps them realize like, okay, I really can ask you things and then they'll keep asking me more and then we can have some good conversation.

Justin Hooks (20:09)
And then the mom's like, why did they change that visit from a 20 minute to a 40 minute? Is there something that I need to be concerned about or something?

Beth Kuzma (20:14)
You

Justin Hooks (20:17)
But you mentioned like those tools, are they integrated in your EMR system that you're using or do we have to kind of look them up like on a website? How does it work for you?

Beth Kuzma (20:27)
I've seen it integrated into the EMR. My clinic, currently use the RAPS, which is the Rapid Assessment of Adolescent Preventative Services. So it's actually its own system that our practice pays for, that it's computer-based. So the patient in the lobby on the tablet is answering the questions. We get that, we have those answers, and then we review it. You can do it by paper, like the MA or whoever's checking them in. can be in that like...

Justin Hooks (20:38)
wow.

Beth Kuzma (20:52)
stack on the clipboard that while they're waiting they're filling it out and you can use that. But they're also on websites. These are pretty standard ways of assessing what youth are up to. I also think it's really important with youth to talk about confidential services and minor consent and what are the laws. So I always make sure that I am very clear about that. So when I have young people, I call it private and then we talk about confidential as well.

Justin Hooks (20:54)
Wow.

Beth Kuzma (21:17)
I actually start at age 10, where when I'm doing a well visit, I will start the visit and say, we're gonna talk with me and you and your parent, and we'll do the physical, but then I'm gonna ask parent, guardian, whomever to step out so we can have time to have a private conversation. I think it's really important that young people own their own health and we have a relationship so they feel comfortable talking to me. And then that's a really good opportunity to kind of talk about things.

when they're 13 to 17, they fall into minor consent. But I will tell 10-year-olds what the minor consent laws are so they know as they grow up what they legally have access to. And so I lay that out very clearly to them and say that I'm here as a resource and I want to be supportive if they need anything.

Rachel Hetzner (22:00)
Can you explain that a little bit more? What are the minor consent laws and what age ranges would those fall in and whatnot?

Beth Kuzma (22:07)
varies based on state, but it's a really good question. But in Michigan, the minor consent laws are youth age 13 to 17 can access certain services. So things related to testing for sexually transmitted infections, testing and treatment for sexually transmitted infections, testing for HIV, pregnancy testing, pregnancy care, substance use treatments, where they can access care without their parents' consent.

Rachel Hetzner (22:10)
Okay.

Beth Kuzma (22:29)
They can also, 14 to 17, can get a limited number of mental health services. So I think it's up to 12 social work visits or counseling visits without their parent knowing. But I also, it's really important when you're establishing trust and relationships to be very clear about the boundaries. So when you have to breach confidentiality, because there's no way better than to break a relationship.

Justin Hooks (22:39)
⁓ wow.

Rachel Hetzner (22:42)
Okay.

Beth Kuzma (22:55)
is to not tell them when you have to share that information and then you've shared it. So I'm pretty clear that like the information we talk about is between you and I, unless you're telling me you're going to hurt yourself, you tell me you're going to hurt someone else or someone is hurting you. And I have to make sure that you are safe and the people around you are safe. And usually it's like, okay, that's fair.

Justin Hooks (23:13)
That's a really good way to say it.

Rachel Hetzner (23:15)
Yeah, that is a really good way to say it. What about, so if they're 10, the one that you were referring to earlier, do you just ask their parents for consent to talk to them privately and then they give you that and you're able to do that?

Beth Kuzma (23:23)
Mm-hmm.

I don't ask, I just say this is what I do. I think it's really important that we have this time. I essentially treat it as private, right? Like most of the things we're talking about are very benign, but it's just setting up that relationship and comfort and trust. If something came up, I would talk to the young person and say, I really think I need to talk to your parent about this. Let's talk about it together. Or what do you like me to talk about it

Rachel Hetzner (23:37)
Okay.

Sure, yeah.

Beth Kuzma (23:55)
by myself? Especially in those ages that don't fit the minor consent rule.

But it's really just sort of like when it's a non-threatening age, when they're not worried that their kids having sex, when they're not worried that their kids are into drugs, they can start to feel more comfortable sort of letting them have that space and it becomes normal.

Justin Hooks (24:08)
Mm-hmm.

Rachel Hetzner (24:13)
Yeah, that's a good opportunity

to do that.

Jen McConnell (24:16)
Yeah, we do that. You know, a lot of us when we see older adults too, we do that where we take them aside, especially those of us who've worked in hospital systems. We ask them about their safety, especially older adults even if they're having any financial abuse or physical verbal. So I feel like this kind of falls under under a way. Like you said, it's, you know, establishes trust, but it also gives us a second to kind of see, are you feeling safe where you're at? Is anyone hurting you? 

You know, there's been a lot of stuff that has happened in the past to children in terms of sexual stuff in the news that we have to be worried about and it does change how we approach things as healthcare providers. So I think that's great. So I did want to ask you Dr. Kuzma I know for all providers that are treating children, our practices really include our carefully worded explanations and education of why we are asking specific intimate questions because I mean, they're very personal, and what we're doing when we're doing physical assessments. So we do things we assess and document tanner staging, substance use, signs of physical and sexual abuse, and human trafficking. So what kind of things should a provider consider alarming when it comes to pediatric sexual health?

Beth Kuzma (25:28)
You know, that's a hard question because I, you know, you know that there are definitely things that are concerning and you need to report. But it can be hard as adults, things that we might think are alarming are actually what's normal in youth culture. And so there is this, have your poker face, like where you are open to hearing whatever is said. So then you can talk about things. Obviously there's going to be,

Justin Hooks (25:42)
Wow.

Beth Kuzma (25:53)
potential situations that you might have to call Child Protective Services or like Human Trafficking Line to make a report. But in general, kids with youth, young people, will say things that

can be shocking to older people. And so we have to sort of school ourselves to be like, okay, all right. Sometimes they use words we don't understand. And so I will always say like, can you tell me what that means? What are you talking about here?

Justin Hooks (26:14)
It's

Beth Kuzma (26:19)
I use Urban Dictionary a lot sometimes, like when I'm like, I don't know what that is. To look certain things up.

Justin Hooks (26:23)
a good point. Like the new thing, the term sick. Like I don't get that. Like I was.

Rachel Hetzner (26:26)
man.

Justin Hooks (26:32)
I had a younger individual that was maybe like 20 and we were doing gender affirming care and I was like talking about to stop strong for example and they just kept saying sick, sick. And I was like, is something wrong? like, am I missing something? And I didn't realize that was like, that it was a cool thing. Like that's cool. Like I didn't completely generational dated myself again. So yeah.

Rachel Hetzner (26:55)
You're such a boomer.

Beth Kuzma (26:57)
Well, like my daughter will say like, that's eating. And like, that means that's like really awesome. I'm like, eating? Okay. It works, right? I guess it works for you. We're changing definitions of words. Okay. but no.

Justin Hooks (27:03)
wow.

Even like insults

are so much better now. Like go pick grass or what do they say? I try to get caught up to go touch grass. That's it. Yeah.

Beth Kuzma (27:15)
Go touch grass. Yes, it's basically

Rachel Hetzner (27:19)
grass.

Beth Kuzma (27:22)
like when you're a gamer and you're like in the in the house and you're like not leaving outside. So go outside and touch some grass. I mean, it's like you get fresh air, right? Like get some sunshine.

Justin Hooks (27:26)
Yep.

Like, this kind of makes me want to be like a kid again because they have way cooler way of saying things than what we did, I think. So like your job is probably, you probably love this because you can stay abreast of like the lingo, right?

Rachel Hetzner (27:31)
Bye.

Beth Kuzma (27:33)
Ugh.

Well, as soon as I think I know what I'm talking about, they're like in a whole new whole new word. Like it's it's hilarious. So as soon as like I've caught on, they're like, that's not cool anymore. There's a grownup who knows what we're talking about. I'm moving on to the next thing. Yeah, it's really funny. But in general, I think just being open to not being alarmed in general, what people tell you, because you want to hear

what they have to say and want to be able to connect them with resources and support them and their family. And young people can read us, right? They see our face, they see our reactions. And if they're telling us something that they really are curious about or want accurate information and we act shocked, they're going to shut down and not ask us anymore. You know, so it's an interesting thing that we have to work on.

Justin Hooks (28:17)
yeah.

Yeah.

really good point.

Rachel Hetzner (28:29)
Dr. Kuzma, in terms of recommended vaccines that protects individuals, adolescents from different sexually transmitted infections and things that can come from that, the HPV vaccine, there's a lot of different recommendations in terms of what we hear for when you should start discussing these vaccines with parents and patients. And when do you recommend

Justin Hooks (28:52)
.

Rachel Hetzner (28:55)
starting these conversations, having that vaccine available for them to receive it, and how do you approach it if someone's a little resistant to that?

Beth Kuzma (29:05)
So the age that you can safely give the HPV vaccine starts at age nine, that recommended age to administer is 11 to 12. So standard we give the vaccine around 11 to 12, but I'll start talking about it at nine to say this is something they can have now if you're open to that. If you prefer to wait, we do recommend by 11 and 12. It's important for early exposure to these vaccines because then it has more effect to prevent genital warts.

cervical cancer, lots of other HPV related diseases. So I usually just kind of include it in like, your child is due for all of these vaccines. Here's what they are. Here are the vaccine information sheets. Here's what this is going to feel like the common side effects. I don't single out the HPV vaccine. It is a normal recommendation. So I'm not like, ⁓ and there's this HPV vaccine that you know that

Justin Hooks (29:55)
The sexual one.

Rachel Hetzner (29:58)
Yeah.

Beth Kuzma (30:01)
Because the kids

aren't, they have

Rachel Hetzner (30:03)
Absolutely. No. It's just, yeah, it's like the regular MMR.

Beth Kuzma (30:03)
no idea. They're not thinking about it in terms of sex. They're like, I get another shot, you know. So as much as possible I do that. There might be some parents who already have ideas about the HPV vaccine. They're the ones that are going to come with questions and ask me, would you give this to your child? What do you think about this? And is it okay if I delay? Of course it's okay if you delay. I would recommend you do it. I think it's a really great tool we have to help our young people.

Justin Hooks (30:09)
Mm-hmm.

Rachel Hetzner (30:20)
Yeah. Yep.

Beth Kuzma (30:29)
stay healthy and prevent lifelong conditions that can be related to sexual behaviors. But, you know, I will respect what people's decisions are and I give them information. I'll ask them questions. If they have specific questions they'd like information about, I try to have a pretty candid conversation and connect them with evidence-based resources. Some people will never say yes, and that's okay. That's their choice, right? And then others...

Justin Hooks (30:41)
Okay.

Beth Kuzma (30:55)
We'll be like, okay, that's great. Thank you. You reassured me and that's fine. I'd love my child to have that. What's interesting though is a lot of young people, they turn 18 of a child of a parent who didn't want them to have the HPV vaccine when they were a child will actually choose to get it themselves when they're 18.

Justin Hooks (31:01)
I remember like when I was a nurse practitioner student and I did my pediatric rotations, I worked with a wonderful doctor and she really, she had her own private practice so she could do it, but she only took vaccinated children.

And so if you were unvaccinated, you were not a part of her practice. But when she was talking about the HPV vaccine specifically, and I never learned this in nurse practitioner school, but she said, it's not just sex. Did you know HPV is head and neck cancers? And she talked about the head and neck cancer because the parents, you know, like even me at the time, I just thought HPV was sexually related.

Beth Kuzma (31:41)
Mm-hmm.

Rachel Hetzner (31:42)
Sure.

Justin Hooks (31:50)
and I didn't know and so she was discussing it to the parents that not only are you protecting about stuff down there, but it's also stuff in the head and neck and I had to like walk out of room and Google it and she was right.

Rachel Hetzner (32:02)
Yeah, and for males too, penile cancers, anal cancers, all of those as well.

Beth Kuzma (32:03)
You can.

Yeah, the vaccine

makers, they have actually like an image that you can request like copies of it that'll show like all the different types of things, types of cancers in particular that it protects against. So then you can say like, look at all these amazing things. We have a vaccine to prevent multiple types of cancer. What a great tool we have for our patients.

Jen McConnell (32:28)
Yeah, so I was thinking that you said the minimum age was nine. So the nine year olds that you possibly could give this vaccine to, if you maybe, for instance, have a patient who starts talking about sexual encounters at a very young age, are those the types of patients that you might be thinking, okay, this kid might need this at nine or 10 versus 11 or 12, or maybe even like 15, or you work in an urgent care and you have a child that

Rachel Hetzner (32:28)
Absolutely.

Jen McConnell (32:54)
you know, maybe is relating some sexual, I don't know, interactions at a younger age. Are those the ones that we're kind of thinking like it's safe to give them at nine, although we like to wait until 11 or 12. Are those the kind of patients that you were talking about if you give them at a younger age?

Beth Kuzma (33:09)
I honestly try to approach it like the same, like my standard recommendations, I want it by 11 or 12, but you can get it as early as nine. but if there are younger people who are engaging in some concerning things like a nine year old saying, that they might have had a sexual exposure, I have other concerns that we need to talk about. And so, no, I don't target like my HPV vaccine based on those behaviors. I usually try to just say.

Justin Hooks (33:28)
Very true.

Beth Kuzma (33:34)
You can get it this early, we're going to talk about it, but I definitely want you to have it by 11 or 12.

Beth Kuzma (33:38)
But there are some behaviors that can be concerning, especially related to media.

If young people are sexting at younger ages, if they're sexting and showing their face or some other identifiable feature, there can be significant concerns with those kind of behaviors that unfortunately I've seen it in practice where a young person is in a relationship, was asked to share an image, they share an image with their body, then the other person in their adolescent brain made some bad decisions and shared that image with other people who

Justin Hooks (34:01)
Wow.

Beth Kuzma (34:08)
shared that image with other people. And it has caused significant distress, bullying, depression, suicidality, young people leaving school. But it's online too and in media so it can even go outside of school buildings and school districts and it can follow young people wherever they go depending on how things are shared. So yeah, I mean some of those things is like helping them.

Rachel Hetzner (34:08)
my.

Justin Hooks (34:10)
BOOM

Rachel Hetzner (34:11)
Wow.

Justin Hooks (34:29)
Jeez.

Beth Kuzma (34:34)
figure out what to do with that information. And ideally we could prevent that by having conversations early, but sometimes that's not possible. And then we see the negative impact and we do have to work through whatever that unique situation is. Young people can be addicted to pornography. I've heard stories of people as young as nine and 10 having a pornography addiction. were inadvertently just doing a normal search. Something popped up.

Justin Hooks (34:52)
Yep.

Rachel Hetzner (34:55)
Wow.

Beth Kuzma (34:59)
They clicked on it, they were curious, they saw something they had never seen before, and then it became something that they kept wanting to see. And it does impact young people's entire life, and it can change their future relationships, their future sexual health.

Yeah.

Justin Hooks (35:15)
That's

so scary. One bad outcome was just the trauma. There's people that have been robbed and it sort of affects them. So we've been talking a lot about primary care interventions. A lot of our members also work like urgent care or pick up that urgent care or like ER too. So we have nurse practitioners as part of my camp that do those kinds of settings.

Beth Kuzma (35:27)
Mm-hmm.

Justin Hooks (35:38)
Are there some warning signs that we need to be, you know, look out for compared to something that you see every day that we might miss?

Beth Kuzma (35:47)
think it's, again, another really good question that it's hard because a lot of these things come out when you develop relationships over time. So it's a little bit easier to say, here's how you can do this in primary care, because you know your patients, you know your parents, you know their families. It's a little bit harder in the acute care setting. you may not have this like glaring red flag that's gonna pop out at you, but I think if you come and approach care in those settings with what's called like sex positivity, so it's not...

Justin Hooks (35:59)
Yep.

Beth Kuzma (36:14)
from a shaming place. It's that being interested in engaging in sex is normal and healthy, that people can have pleasure and have strong, healthy relationships and sexual relationships, that it's free from coercion, that they can give consent. I think that's the best way to consider how things are done in the acute care setting when someone comes in who might want testing for a sexually transmitted infection.

you know, coming from a more open mindset.

Justin Hooks (36:39)
So say we're working at the urgent care setting and we do like a UTI that's positive and I think you know where I'm going with this, that it might be positive for something else. How would you approach that? Like if they're a minor, cause I, I'll tell you, I take care above 18 and if I, if I was working at urgent care, you would be my phone a friend and say, how do I do, what, how do I tell this person they're positive for an STD and what do I have to do? Cause I'm kind of new to that area.

Beth Kuzma (36:59)
So it depends on the situation. Like, are you meeting like a parent who's in the room with them and we have to like separate the parent to have this conversation with a young person? Do you collect their cell phone number individually so you can give that, because often those results don't come when they're in the office or in the practice, you actually have to call. It is a very difficult situation to navigate and you have to be intentional about it. Because let's say I didn't collect the young person's cell phone number, then

Justin Hooks (37:25)
Yeah, true.

Beth Kuzma (37:36)
The number you have is the parent's number. And then you want to give the results. And then the parents like, well, I'm their guardian. I'm their parent. I have the legal right to access their results. And then you say, well, actually, you don't. So that'll either upset them or they're going to have an idea of what that result is. So then you inadvertently breach confidentiality in that sense. So I think making sure that if you're seeing a minor who has the legal right to minor consented services, making sure that you

Justin Hooks (37:37)
Cool.

So.

Rachel Hetzner (37:51)
Bye.

Beth Kuzma (38:02)
if they have their own cell phone or their own personal way to reach out to them that you collect that information. Because I cannot tell you how many times when someone swore up and down that they were not having sex, that things came back and they clearly were. So we had to navigate how to figure out who to talk to. And I even document my notes separately. So even if there is a UTI and I'm treating the UTI, I will have a separate note that's like a

Justin Hooks (38:10)
yeah.

Beth Kuzma (38:26)
minor consented note about the things that are related to sexually transmitted infection.

Justin Hooks (38:30)
Really good.

Beth Kuzma (38:31)
separate.

Jen McConnell (38:31)
Yeah, Dr. Kuzma

Rachel Hetzner (38:31)
Yeah, that's good to know.

Beth Kuzma (38:32)
Yeah.

Jen McConnell (38:33)
you mentioned sex positivity, a lot of, you know, there's a lot of families that culturally maybe are not sex positive. And so you might be the first provider or we would be the first provider to kind of have that approach. And, you know, we all know we've got a certain amount of time in any setting, urgent care or primary, to really build that trust and get that information to them as best we can. So yeah, that could be really challenging.

Beth Kuzma (38:58)
It absolutely can.

Rachel Hetzner (38:58)
What are new approaches to sexual health or healthy sexual behaviors for our youth?

Beth Kuzma (39:04)
So I mean, I think honestly, the idea of sex positivity, because even thinking about the biomedical model that many of us have been educated in, even looking at evidence-based guidelines to approach sexual health, it's all very problem focused, right? Like you have an infection and I'm going to treat it. You have a symptom and I'm gonna figure out what that symptom is and that problem is. And yes, those are real and those are things we have to do.

But sex in and of itself and sexual behaviors and sexual relationships are not inadvertently, they are naturally not always bad or negative that, you know, sex can be a very healthy thing to engage in and can be something that people enjoy if they're in a respectful, safe relationship. So in the sex positivity lens, it's not like you're just gonna develop the skill with one patient that you're seeing. It's actually takes, I need to stop and think about myself.

and how I feel about sex and how comfortable I am, because how you create that environment is, I'm going to present myself as someone who is very comfortable asking questions, answering questions, and talking about sex. That it sets the stage that this is a safe environment and I am someone who you can talk to about these things. And I won't judge you and I won't berate you or make you feel bad about the decisions that you're making.

Justin Hooks (39:55)
Thank you.

You brought up so many good points too, and sex is not just a singular thing, like gender, for example. There's expression, then there's identity. And so there is a cultural aspect of this, and especially in the clinic that you work. Do you mind kind of sharing how you talk about some cultural things for providers that, because we...

I always say when you assume things, you know what happens, right? And so I don't want to make that mistake. And so what are some trends that you're seeing culturally or do you mind kind of talking a little bit about that?

Beth Kuzma (40:58)
Let me think about that. So I would say at least culturally is to understand that you should not make assumptions about someone's sexual identity orientation, the type of relationship that they're in or their gender identity. People can present in all sorts of ways. People could be married to like an opposite sex and still identify as either gay or bi or whatever that is. People engage in all types of behaviors. So I think being

open to that, trying to use language that's pretty neutral, not assuming that if someone says they're married that they're married to someone of the opposite sex, or asking the question like, are you married? Do you have a wife? Or using certain gender terms can really shut the door for someone who doesn't have that. That's not their sexuality. That's not their orientation. That's not what their relationship looks like. And so you can really miss important information to help them be as healthy as possible if we don't.

ask the right questions because they won't feel safe sharing who they are with you.

So in addition to some of the things that I just shared, know, looking at someone's religious beliefs and their cultural identity, they certainly impact sexual health behaviors, certainly beliefs around sexual health and what's appropriate, what's not in the context of what type of relationship. You know, every family is going to have their own beliefs. So I think we have to figure out what those are and we're working with.

Justin Hooks (42:04)
I'll hear you.

Beth Kuzma (42:16)
parents and youth as partners. Sometimes there can be a divide between what the young person is actually engaging in and what the parents believe is appropriate. We still have a good conversation we understand, but then when we're having that private or confidential conversation, I will talk to the youth as openly as possible. I don't want to separate.

young people from their parents, so it's not like I'm trying to pull them away. I actually try to figure out like how to have a conversation with them and encourage them to talk to their parents within their belief system to navigate these conversations. It's important, right? Like our beliefs, our cultures are a huge part of who we are and a part of families, so we can't avoid that conversation.

Justin Hooks (42:36)
Okay.

Beth Kuzma (42:55)
And it's hard to say like this one way of answering it, right? Because there's so many different belief systems.

Justin Hooks (42:55)
So we kind of, I know,

Rachel Hetzner (43:00)
so Dr. Kuzma, I have a question for you. If you are seeing a patient, you have a limited amount of time, you don't suspect that there's anything too significant going on, what are some of the assessment tools and what are some of the topics that you like to include in your visit?

Beth Kuzma (43:15)
Thank you for that question. It's very, important in adolescent health. We're using screening tools all the time. Risk assessment is really important thinking about where adolescent brain development is. They're taking risks, right? So we want to ask about the most common things that put their health at risk that they might be engaging in. So start with sort of benign things like, are you wearing your seat belts? Are you wearing a helmet when you ride your bike? And how much screen time do you have?

Justin Hooks (43:37)
Knee pads with roller blades.

Rachel Hetzner (43:38)
Yes, yes.

Ease and do it.

Beth Kuzma (43:43)
And then

like kind of move into like sex, drugs and rock and roll, you know, but I also asked like about crushes and, you know, behaviors and kissing and touching and, and it's hard to give you an exact example, right? Because I will ask more detailed questions for older youth than younger youth or youth that maybe have a little more experience than others, mental health, substance use, alcohol use, sexual health, if they are engaging in sexual.

Rachel Hetzner (43:48)
Yep.

Justin Hooks (43:48)
if

Beth Kuzma (44:10)
behaviors, what kind of things are they doing to protect themselves? Are they safe at home? They have an adult that they can talk to if they need anything. You know, we also ask about all the other things that we ask of other young people and adults. Do you have food at home? Do you have, you know, safe transportation and access to like the ability to engage in healthy physical activity? You want to know that they're sleeping okay. Yeah, so it's a pretty broad list, but

Justin Hooks (44:23)
Good.

Beth Kuzma (44:36)
We want to really get into the ones that are going to put their health the most at risk.

Justin Hooks (44:40)
Okay.

Rachel Hetzner (44:42)
And then also the like we had talked about the different screening tools. Screening is very important part of our job as MPs. What are your go-to tools that we can use to take care of the adolescent population?

Beth Kuzma (44:56)
So like I mentioned before, the HEADSS acronym, it's H-E-A-D-S-S. HEADSS is like home situation, education, activities, drugs, sex, and suicides. So we're asking specific questions. There's the GAPS, which is the Guideline for Adolescent Preventative Services, asks the same kind of questions. They just are in a different format. Or the RAPS, which is R-A-A-P-S, which is the Rapid Assessment for...

Adolescent Preventative Services, again, ask a lot of these same questions just in a different format. You'll get to the same place. I think whatever you have access to in your practice, as long as you have a standard tool that you're using, you're not missing important questions.

Justin Hooks (45:36)
Wow, this is really amazing.

Rachel Hetzner (45:37)
Yeah, I think we covered

Justin Hooks (45:38)
Dr. Kuzma, what are some best practices for

providers like myself when taking care of adolescents and how to have a more welcoming environment for them?

Beth Kuzma (45:48)
There's a lot of things we can do for environment, right? So we wanted to have images that show youth. We want them to say, it's not just old people in the clinic, but people that look like you come here, right? And so you're welcome. And also if you have queer and trans youth, you have a rainbow or something that says, I'm somebody who you can talk to. But also having the resources and the tools available that young people are going to need.

Justin Hooks (45:56)
like us.

Beth Kuzma (46:13)
So I'm very fortunate in my practice, we have condoms that we give out. So if young people are having sex, I can send them with a brown paper bag full of condoms. We have condom cards. So if they want to like where they can go and get condoms for free in their community. If they have Medicaid insurance, Medicaid covers condoms with no copay. So we know sort of where those resources are and we provide them. Yeah. So I think just knowing what kind of risks they're engaging in.

Justin Hooks (46:21)
Amazing.

Rachel Hetzner (46:21)
you

Justin Hooks (46:29)
Wow. No way.

Rachel Hetzner (46:35)
I didn't realize that.

Beth Kuzma (46:40)
We're asking these questions, now how can we help them? And we want to make sure that we have a solid list of what's in their community, what they can access to get the things they need to keep themselves healthy.

Rachel Hetzner (46:50)
That's awesome. Dr. Kuzma, it's been a true honor to have you as part of our podcast. We appreciate you donating your honorarium back to MICNP to support our PAC

Justin Hooks (46:59)
Yay!

Rachel Hetzner (47:00)
Is there anything

else that we may have missed that you feel is important for nurse practitioners in taking care of adolescents?

Beth Kuzma (47:07)
thing I would say is just a general approach. You know, avoid the shock value, you know, keep leaning in, asking questions, remaining open and curious. Young people need help too, and we need to create that safe space for them. So how we approach, how we behave when we're in their space, the questions we're asking and answering really helps let them know that they're valued and that we care about their health.

Justin Hooks (47:30)
That's some very strong and powerful last words. And so with that said, all good things must come to an end. And so that's a wrap. Please stay tuned for more engaging topics, educational opportunities, whether you're a student, a seasoned nurse practitioner, or a healthcare leader, we're here to keep you informed, inspired, and connected. Please make sure you sign up for the 2025 annual MICNP Conference.

being held at the Westin Southfield on October 10th through October 12th, 2025. Please check our website for further educational offerings.

Jen McConnell (48:04)
Tune in as we amplify the voice of nurse practitioners and work together to shape the future of healthcare. Subscribe now and stay tuned for expert conversations, legislative updates, and the latest in NP practice in Michigan. we can't wait for our next episode. Trust me, it's coming soon. For members to claim CE credit, please use the code TEEN, T-E-E-N, in your evaluation form posted on our website. See you next time.

Justin Hooks (48:16)
Yeah.