Doctors don’t discuss their teen patients’ sexuality on a consistent basis, a new study finds. But more than that, when they do discuss LGBT concerns, it’s seldom with the language and tone conducive to building an environment safe enough to have such a discussion.

While the American Academy of Pediatrics offers a set of recommendations doctors can use to broach the topic of sexuality and sexual identity with their younger patients, the emerging research suggests this advice is rarely followed, if effective at all. Understanding a 16-year-old’s fear of coming out of the closet or negotiating their friend groups during uncertain times requires more than a canned phrase, the researchers argue. It takes a conversation.

“What the doctor asks or brings up about sexuality sets the tone, and gay and lesbian youth are very good about reading adults to determine who is safe to confide in,” said lead investigator Stewart C. Alexander, an associate professor of consumer science at Purdue University, in a statement. “They ask themselves, ‘Can I disclose this information to this adult?'”

Alexander studies health communication, and along with colleagues from Duke University, Indiana University, and the University of Michigan, the team analyzed recorded interactions between doctors and patients. Each patient was between 12 and 17 years old, their conversations with doctors about issues of sex and sexual attraction. In total, 49 doctors and 293 patients comprised the study.

To the lament of the researchers, doctors were able to carry on inclusive and open discussions only three percent of the time. These two traits make up the bulk of the study’s concern, as teens who feel like they live on the fringe of their social circles often struggle to find ways to move back in. With the right strategies, doctors may be able to act as a helpful point of contact.

“The physicians I know want to do a good job, so we’re trying to identify best practices, and hopefully these examples will provide them additional context for strengthening these conversations,” added Cleveland Shields, co-investigator and professor of human development and family studies at Purdue.

Some of these best practices actually involve starting the conversation early, before the issues become a concern. A 12-year-old may not be sexually mature enough to discuss his or her feelings, but that unknowing could be used to both parties’ advantage. As the child matures into his or her teen years, assuming the doctor has built a level of comfort, discussing sexuality will already seem natural, rather than a chore.

More generally, doctors can narrow the focus of their conversations to build trust. Asking questions like “Usually girls your age start to become interested in boys or other girls or both. Have you started to become interested in others?” and “I know some teenagers who are attracted to girls. I know some teenagers who are attracted to boys, and I know some who are attracted to both. Have you started to think about these things?” may go a long way toward breaking the distant and sterile doctor-patient dynamic.

Another strategy is to use the patient’s friends as a foot in the door. Discussing what friends are up to is far less discomfiting than relaying personal feelings. But they offer the side benefit of getting teens warmed up to the idea of a frank discussion, especially one that’s relatively close to home. Physicians can then switch back to a discussion with the patient that makes frequent use of abstract ideas, with references not to “you” but “somebody” and “people.”

“Open, inclusive conversations can help youths realize there is no threat, and this can be a great start for building trust with the physician who is someone they are likely to see year after year,” Shields said. This is especially true, he adds, as doctors strive to empower their patients and give them a sense of independence. “We want to provide them with autonomy so they can be a consumer of their own health.”

Source: Alexander S, Fortenberry J, Pollak K, Bravender T, Østbye T, Shields C. Physicians Use of Inclusive Sexual Orientation Language During Teenage Annual Visits. LGBT Health. 2014.