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A Visit to the Children Gynecologist Office


by Elena Chernomazova 

Olga Makkaveyskaya
In the middle 1980's pediatric policlinic facilities started hiring specialists in children's and adolescent gynecology. At the same time, medical schools started training programs in pediatric gynecology where students learned, along with the specifics related to the physiology of young patients, about the psychological aspects of teenagers' apprehension of problems associated with their sexual development, reproductive health and sexual interactions. Placement of gynecologists' offices in pediatric policlinic facilities facilitates the access of young girls with reproductive health problems to specialists. Prior to this change, girls had to face the unpleasant prospect of being referred either to specialized gynecological clinics or skin/venereal disease dispensaries, which sometimes had a negative psychological impact on them. 
"We see girls under 17 years of age, beginning with newborns," says Olga Makkaveyskaya, a children's gynecologist in Moscow pediatric policlinic 12. "At their first visits young patients are usually accompanied by their mothers, but girls of eleven and twelve begin to come by themselves. As they reach fifteen, girls are enrolled in an adult gynecology network but may still visit their old doctor who would render all necessary services and consultations." 

Do some girls look scared when they visit you for the first time?

Yes, they do. This type of examination, especially for the first time, is always scaring. A child would be afraid of metallic instruments and of not knowing what is going to happen to her. What should you expect of them when even mothers sometimes do not know anything about how we examine children. "Are you going to see her at that chair of yours? She's virgin, you know," they would say sometimes. Be it known, that we examine girls through rectum which is absolutely harmless.
In general, dependent on a girl's mental an and nervous status and family's emotional health, some of them overcome their fear and take examination easily. In some other cases, however, the fear is so strong that we have to postpone it till better times. As for me, I always do everything I can to make girls feel comfortable. But you must understand that gynecological chair is not a pleasant place to get onto.
What health problems make girls come here most often? And how do they depend on their age?
Girl of 7-8 years rare visit us; this age is not associated with any serious problems. Some complaints about breast hardening is all they may turn up with, and they arise as the natural course of early sexual development.
Teenagers are our most frequent patients because of menstrual dysfunction which is usually associated with a variety of somatic diseases and infections.
Often such dysfunction is caused by seemingly insignificant comorbidities, such as a cold or flu. Sometimes, however, menstrual cycle is ruined with an inappropriate lifestyle or bad habits. In particular, it may stop at all as the result of obesity complicated with unreasonably restrictive diet.
Pediatric gynecologists conduct annual examination of entire female teenage population for sexually transmitted diseases (STD) and other reproductive health problems in order to guarantee their early detection and appropriate treatment.
Sexual revolution fruits are no secret: they are as bad in Russia as they are in the West. Russian National Public Opinion Study Center 1995 survey revealed that about half of male and over one-third of female respondents of sixteen years of age in Moscow and St. Petersburg had already tasted it. Too early beginning of active sexual life, along with lack of proper education in basics of safe sex, result in catastrophic rates of STD occurrence and unwanted pregnancies among teenagers. All these factors produce strong negative impact on reproductive health of the young generation. The RF Ministry of Health reports that only 6.3% of girls are absolutely healthy at the point of their graduation from high schools.
The Ministry of Health regulations require that one gynecologist should serve 1,000 population enrolled in pediatric policlinics. The policlinic where Olga Makkaveyskaya works is responsible for provision of health services to students of 11 public schools. During annual medical examination period, one class a day schedule is effectuated, and girls come in scores. Pediatric policlinics are short of staff children gynecologists and have to ask for assistance of adult gynecologists from municipal health networks.

When syphilis or gonorrhea is suspected, cases are usually referred to skin/venereal disease dispensaries. What other STDs may be detected in patients so young?

In past six months we examined 6,518 teenagers in our service area; 1,450 of them had various STDs: non-specific vaginal diseases (coccal flora), genital herpes, trichomoniasis, chlamidiosis. The most frequent diagnosis is bacterial vaginosis.
Bacterial vaginosis is a condition that may be caused by a variety of microorganisms which are a sort of hybrid between viruses and bacteria. Usually, these microbes act as parasites on the cell membrane, but may also penetrate it and make the cell serve their purposes like a virus would do. The immune system of a woman would not recognize these hostile agents and react to them. Clinical manifestations of such conditions are usually scarce - minor secretions, unpleasant smell. On the other hand, chlamidiosis, for example, would often mask itself with characteristic symptoms of other diseases: cholecystitis, rheumocarditis, cystitis and so forth.
Many persons are ignorant about the fact that they are carriers of such misfortune with the potential to share their ill luck with others. By the way, these infections are not only transmittable through sexual contacts, but may be also acquired by a newborn from its infected mother. The most unpleasant health hazard associated with various vaginoses is that they corrupt young girls' health in a latent manner and may result in infertility.
Could you share your opinion of what makes girls start their sexual activities so early?
We should admit that our annual examinations detect more and more sexually active teenagers. As for reasons, 60% of girls explain their sexual debuts with "being in love" or "falling in love" with their partners, while 17% simply feel curious of what adults experience.
In my practice, I met cases where virtuous, homely girls would start on disorderly sexual intercourse just to prove they were no "odd ducks" and have "some expertise" to boast with. Furthermore, some girls confessed that early beginning for them was a remedy for fear of finding themselves lonely, with no partner or husband to support them. Could you suspect such motives in a fourteen-year old girl?! By the way, their physiology is rather underdeveloped, and they hardly experience any pleasure or satisfaction with sex.
Moreover, most girls gain their first sexual experience in an environment far from romantic. Seventeen per cent of girls enter their first sexual contact being heavily drunk, usually at some party. On the next day, some of the would not even remember what had happen to them and have to learn it from their friends who happened to be more sober that night. Sometimes, circumstances are more dramatic; sometimes violent rape is the very first sexual experience of a girl. For example, one of my patients was unfortunate to ask for a lift, and the driver took the whole advantage of it. She ended up raped in deep forest.
Having tasted it once, many girls are eager to repeat and do it "successfully": 86% of them do it on the same day; 36% - within a week; and 26% - within a month. 64% of girls do it with the same sexual partner, while 15% are more diverse in their preferences.
What would be your advice to parents who look forward to an opportunity to talk with their daughters about their behavior, but have no idea of how to approach them with the subject of sexual affairs?
Many parents, in fact, do ask this question. My advice is rather simple: never overemphasize the issue. Approach it in a matter-of-fact mode. For example, when watching some film on TV together, just ask your daughter some hand-off questions: do you think, she's right? did you like it? what would you do in her place? Her answers may tell you much. Another opportunity is the tactics of open doors when you discuss private life issues of your friends and their children and relatives with your husband or a close friend of yours; I bet, your daughter cannot fight the temptation to silently listen to what you are talking about; and it will be up to you to make her learn as many useful lessons as you are able to invent. Girls are curious; and as soon as you speak of themes that are usually a conventional taboo, you would be surprised of how absorbed in listening to and learning of what you have to deliver they become.
As for me, being a health professional, I do my best to talk to them frankly. By the way, outsider's advice often works better, because it is not so frequent and aggressive and obligatory as the advice by family members. You may follow stranger's recommendations, or you may do the contrary - nobody cares. You are the only one to decide with no pressure upon you.
I remember cases when mothers would burst in happy tears of gratitude: "How did you manage it? She just wouldn't listen to us anymore! Family was no longer an authority to her!"
Yes, teenagers tend to be neglectful about elders' advice. They think they have wits enough to decide for themselves. In fact, however, their self-assurance is fake; behind the resentful mask, utter chaos rules in teenagers' minds: neither some steady position in life nor an internal core are present in them. In this situation, parents face an uneasy task of upbringing their children's will to behave like they would like to, and not as the street may dictate. You will never achieve it with threats and prohibitions; the only way is to make friends with your own child and try to make her trust you and believe in her aptitude to behave appropriately. Girls who trust their parents are at far lower risk of premature sexual adventures than their counterparts who do not.
Is a girl's early sexual experience in any way associated with her family social status?
I wouldn't say so. It may happen in any family, irrespective of how wealthy girl's parents are. Other factors affect a girl's behavior in much more imperative manner. For instance, it is the loss of live contact with her mother which forces a girl to behave inadequately. Such families are the last to know about their daughters' sexual adventures. Some time ago, two 14-year old ladies turned up here for voluntary examination. They confessed that "two years ago they were stupid and happened to have an affair". Well, mothers are entitled to free access to their immature daughters' medical records. One of them was rather shocked with what she learned: "Wow, doctor! Is it true? She was only twelve then! Yes, I saw condoms in her purse, but she told me that it was her girl-friend who shoved them in there to make fun of her." I would say that such ignorance of what is up with your own children is based on rather uncomplicated underlying reason: mothers are simply too preoccupied with their own business to pay enough attention to them.
By the way, I can tell virgins from teenage girls with some "experience" right from the start: they look differently, behave differently, move differently.
What contraceptives would you recommend to your teenage patients?
First of all, as soon as they have started their sexual activities, I would recommend that every girl protect herself with a combination of tools. For example, young patients may find it expedient to use condoms together with spermacides (available as creams, pills and suppositories). Such a combination is helpful to effectively avoid both undesirable pregnancies and STD infections. In this case, protection reliability rate nears 99%. Unfortunately, no gadget may guarantee 100% safety. Some patients of 16-17 years of age are prescribed with a monophase hormonal contraceptives that contain low doses of female hormones. The only prerequisite is that a girl would live with a regular partner. Low-hormone contraceptives guarantee girls against impregnation - and, at the same time, they are absolutely harmless from the standpoint of how the may affect their physiological development. Moreover, they contain hormones that may prove helpful in cases of painful menstruation and the monthly cycle disorders. Hormones make monthly secretions scarce and rare, which is suitable for most girls. Moreover, pills are helpful to delay a menstruation whenever a girl may need to travel abroad and so forth. Therefore, girls feel much easier with such a helper available. However, once they have stopped taking it, their fertility is restored completely!
Do you inform teenagers about available methods to avoid unwanted pregnancies and STD infections?
Teenagers rarely give a thought to how they could protect themselves from what you are talking about. They are so immature that usually just would not bother either to protect themselves or access the information available from a variety of sources. Therefore, I have to act as a lecturer at every medical examination. I don't mind. As for lectures, I read a lot of them at schools, where twenty to thirty listeners are present every time I deliver my message. And in my office every patient is handed with free booklets on why the abortion is harmful, and what contraceptives are available, and so forth.
Teenagers are informed to the extent we allow them to be informed. And this depends not only on our efforts to inform them, but also on our inborn culture, education, and, most of all, on our willingness to help our children through the natural process of sexual maturing. Unfortunately, many mothers complain that they feel helpless to do anything with popular magazines' (such as Cool Girl) influence on their daughters. Well, informational press is too heavy today, and children suffer it too.
Standards change time to time. And so did the standards of how girls and boys behave. Elders are in shock: what a sexual discrepancy! Hold on, daddies and mammies. "Pilot" copulations are not to be feared. They simply help strengthen future marriages. Changing of partners is nothing to be worried about from the standpoint of the young generation. And so is the constant decrease of minimal age requirements to partners in sex.
With all the above in mind, what would be your recommendations for sexual educators in public schools?
In the process of education, the moral aspect of sexual intercourse should be emphasized. First of all, teenagers must learn about the price they will have to pay for any bodily pleasure. Be it known, that they pay with their health. And we, children gynecologists, do our best to repair damages thus inflicted .



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