The birthday present

Originally published in The Medical Post, VOLUME 37, NO. 6, Feb 13, 2001

A teen seeks her doctor’s advice when her boyfriend asks for sex as his birthday gift

One of the great joys of adolescent practice is when one is able to have a positive influence upon one’s patient. Once your patient trusts your judgment and counsel, the ability to affect positive change in their lives improves dramatically.

Erica (not her real name), 16 years old, dropped in to the high school clinic. Her complaint was dry skin in the usual atopic areas and flaky eyelids. I gave her some cortisone ointment and asked her to return in about a week. She came back pleased to report the condition had improved. Without missing a beat, she announced she was having bouts of depression for about a year since beginning high school. Her parents were arguing daily and she feared they were heading for a divorce. She felt powerless to stop them. She said her father was critical about her work and that her best efforts were never good enough. She felt she could not approach her parents about her depression because she feared they would be disappointed with her.

I usually give the patient some “homework” after the preliminary evaluation to better understand their concepts of friendships, relationships and their self-image. Questions asked include:

* “What do you like and dislike about yourself?” (focuses on personality and physical characteristics);
* “What is good and bad about you?” (focuses on the moral and ethical implications of their behaviours and actions);
* “What are your definitions of a friendship and relationship?”

The answers to these questions provide a wealth of information. The physician is able to see possible contradictions and congruencies in their reasoning. It also indicates a willingness on the part of the patient to participate in their treatment. I asked her to return to the clinic for followup.

She could not give any examples of what she liked about herself. She disliked her nose and hair and thought her bad qualities were her attitude and that she let stress build up within her.

After further history was elucidated, it was clear she was depressed. Her school performance was declining. I recommend using the Child and Youth Depression Screening and Rating Scale to help with the diagnoses (Patient Care, April 1996). Her score was 75 (over 50 suggests major depressive disorder).

She raised an additional problem she was having with her boyfriend of two months. She said he cared for her and “is in tune with my moods and feelings.” The problem was that he asked her to have sex with him for his birthday. She initially agreed but was now having reservations. I asked her to consider the positive and negatives of agreeing to his request. She admitted there were more negatives but that she was afraid of saying “no” to people.

There is a useful set of concepts to introduce to your patients that can provide them with the tools necessary to deal with interpersonal problems.

The first deals with the concept of the “true” versus “false” self. The true self usually can discern right from wrong. We sometimes refer to this as the alarm bell that goes off in our head. When we ignore this alarm, we do so at out own peril. People who follow this inner voice tend to respect themselves and their motives. They become more self-confident and self-reliant. They are not afraid to say “no.”

The false self is best described as following a path or decision contrary to doing the right thing. The person directs anger inward. They know what they are doing is wrong but they follow through with it anyway. They lose respect for themselves. They have a difficult time saying “no.”

The second focuses upon two straightforward statements, the Two Rules as I call them: “It is not what people say but rather how they act that reveals their true intent,” and “People always do things for a reason.”

I would like to emphasize that before any solutions are offered to the patient, there are some issues to keep in mind. A good trusting relationship must exist for us to be effective in treating adolescents. This may take weeks or months to develop. It is an investment in time that pays huge dividends. We have a natural tendency to offer suggestions to help our patients. However, teens will listen when they ask for your opinion. Before offering your opinion, let them know they may not get the answer they are expecting. Let them again decide whether they want to hear what you want to say to them. You have given them an “out.”

Usually at this point of the process, they are curious to know what it is you might say to upset them. However, they rarely become upset because of how the lead-up was presented.

In this particular situation, although the solution is obvious (“tell him no way”), some adolescent patients may chafe at someone telling them what to do. I like to engage them with their own words and statements from their written answers to their homework questions and use them to better evaluate their situation. In Erica’s case, she was terrified her boyfriend would dump her. She had little in the way of support from her parents. Her father was distant and not providing the emotional support and stability that she needed.

Erica went through this exercise in detail. Why would her boyfriend dump her because she refused to have sex with him for his birthday? He claimed to love her. He was in tune with her feelings. But then why did his actions betray his claims? Was he not objectifying her? What was his real intent? She also knew the right thing to do was not to have sex with him. But she loved him! Needless to say, she admitted to being very confused.

In the end, after several sessions and much deliberation, she decided against being a birthday present. He promptly dumped her. Initially upset she saw her decision was the correct one. In fact, her boyfriend made many overtures to resuming the relationship. She felt better because she did not compromise herself and had some measure of control of her life. She was able to apply the Two Rules and determine motive. She could then listen to her true self and be comfortable with her decision.

I am in no way suggesting this method is a panacea for all adolescent ills. But it has served well in helping many of our adolescent patients. Erica continues to see me at my office. She is now 21 years old and in university. She is happy and in a stable relationship. She admits she cringes when she thinks about what she actually contemplated doing six years ago.

So why did she open up and discuss her depression in the first place? When I asked her, she replied, “Because you cured my eyelid problem. My other doctor didn’t take this problem seriously. I wasn’t about to bring up anything else because he didn’t seem to care about my skin problem.”

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