STDs, STIs, HIV - Archive

AAP Releases Teen Pregnancy Policy (7/05)

The American Academy of Pediatrics, through its Committee on Adolescence led by Dr. Jonathan D. Klein, published a report, “Adolescent Pregnancy: Current Trends and Issues,” in the July 2005 issue of the organization’s journal, Pediatrics

The report is a great disappointment.  It is primarily an ideological treatise which rehashes old, failed arguments which suggest that condoms and contraceptives are the primary solution for the teen pregnancy problem.  (Fifty-seven of the 74 references are more than five years old and most new credible references on important issues have been ignored.) [Medical Institute Advisory]
 

Almost as egregious as this poor scientific scholarship, however, is what was omittedDr. Klein and his committee, who one would suppose care about the “whole child,” never discuss the following issues:
The psychosocial impact of adolescent sexual activity.
For example, sexually active adolescents, both boys and girls, are far more likely to be depressed and to attempt suicide than youth who are still virgins. Condoms and contraceptives do not solve this problem.

The problem of an increasing number of lifetime sexual partners.
The majority of adolescents who become sexually active frequently change sexual partners and will have an increased number of lifetime sexual partners.  An increased number of lifetime sexual partners is one of the greatest risks for acquiring a sexually transmitted infection (STI/STD).

The problem of STIs among adolescents is an epidemic.
1. Approximately 50 percent of adolescents who are sexually active are infected with Human Papilloma Virus.  HPV is the cause of 99 percent of cervical cancer and 99 percent of truly abnormal pap smears.  This cancer is causing about as many deaths among women as AIDS.

 2. Approximately 10 percent of adolescents who are sexually active are infected with chlamydia which is a major cause of infertility.  STI is the major cause of infertility in America today.

3. Approximately 20 percent of adolescents are infected with herpes, a life-long and disabling problem.

The failure of oral and injectable contraceptives in reducing the risk of STIs. Oral and injectable contraceptives, which are advocated in this AAP paper, give no protection against any STI.

The lack of accurate information about condom effectiveness. The National Institutes of Health [NIH] and other sources now note that condoms have limited value in reducing the risk of STIs.  The most up-to-date data acknowledges that condoms, if used 100 percent of the time, do reduce the risk of HIV by 85 percent. 

For the infections that are most common to adolescents (such as chlamydia, gonorrhea, herpes) condoms, even when used 100 percent of the time, only reduce the risk of infection by approximately 50 percent. 

For HPV, which is the most common STI/STD for adolescents, condoms provide no risk reduction for infection.  There may be some risk reduction for some of the problems caused by HPV, such as reduced risk of cervical cancer, and reduced risk of genital warts.

Other problems about condoms and contraceptives.  How can condoms or contraceptives solve the problems when:

– 60 percent of adolescents under age 15 have involuntary sex

– Up to 67 percent of adolescent pregnancies are fathered by adult men

– Approximately 20 percent want to be pregnant

– 25 percent were under the influence of drugs or alcohol at last sex

The issue of parental involvement. Although this AAP paper does mention, it does not emphasize parental involvement as the primary factor in adolescents avoiding risk behaviors.  All studies of adolescent risk behavior decision-making note that adolescents who are the least likely to be involved in risk behavior are those who have the best connectedness with their parents.  The majority of adolescents say their parents are the primary influence in their lives.

The recent neuroscience reports about the adolescent brain.   The paper totally ignores the new studies about the adolescent brain, which demonstrate that the prefrontal cortex, the source of mature decision making, is not completely developed in humans until the mid-twenties.  The implication of this science is that adolescents need appropriate and healthy guidance, presented in an unambiguous fashion, from adults.  It is a disservice to youth to assume that they are going to be involved in risk behavior.

The recent studies about sexuality education programs. A full review of comprehensive sexuality education programs shows that only one of those programs has reduced pregnancy rates among adolescents.  This was the Carrera Program which originated in New York and has lowered pregnancy rates primarily by having their young women receive injectable hormone shots on a regular basis.  The problem with this program is that although their teen pregnancy rates have been low, they have never published the STD rates among these young women.

The AAP paper also ignores literature about abstinence education programs that show a dramatic impact. In 1991 the Public Health Department of Monroe County, New York, which includes the city of Rochester, had an effective abstinence program shown by scientific studies to produce a significant and practical drop in teen pregnancy rates for that county compared to surrounding counties.

The most recent study reported in the peer reviewed literature was about the Best Friends program which originated in Washington, DC.  The Best Friends girls were found to be six times less likely to have premarital sex.  It also was found that they were eight times less likely to use drugs than girls not involved in the program.  The Diamond Girls, the ones who stayed with the program throughout high school, were 120 times less likely to have premarital sex than girls who were not in the program. 

This study, published in Adolescent Family Health, is the most sophisticated and thorough study of the cause of the decline in teen pregnancy in the United States. It clearly shows that increased abstinence accounted for 67 percent of the decrease in pregnancy rates for girls 15-19 and accounted for a 51 percent drop in the birth rate for single teenage girls for ages 15-19.

The American Academy of Pediatrics has done a great disservice to American adolescents for whom they are presumed to care.  They have also done a disservice to parents and policy makers. 

It would be appropriate for the American Academy of Pediatrics to immediately consider the “whole child,” including the issues of psychosocial problems, increased number of sexual partners, increased risk of STI, and the limitations of condoms and contraceptives, and retract or modify this report.

In doing so, it should also emphasize the importance of parents guiding young people away from risk behavior, and should not be fatalistic about young people. 

The National Campaign to Prevent Teen Pregnancy consistently shows in its annual surveys that 90 percent of teens feel that they need a strong message about sexual abstinence all the way through the completion of high school

In these same surveys, 2/3 of teens consistently say that it is wrong for teens, through the completion of high school, to have sexual intercourse whet
her they use
protection or not, and 2/3 of teens who have had sexual intercourse wish they had waited.
 

It is incumbent on the American Academy of Pediatrics to consider these opinions of teens.  Their adolescent specialists probably see a high risk group of teenagers and for those young people they undoubtedly give excellent care.  It would be best for them not to be so pessimistic about the great majority of young people who do not fall into the category of high risk teens. 

We need to encourage American culture to support teens in making the very best decisions.  We should help them decide not to be sexually active before they are married and that they should return to sexual abstinence if they are presently sexually involved.

Additional Information

Over 60 million Americans are currently infected with an STD and 15 million new cases of sexually transmitted infection occur each year.1

One quarter of these new STD infections occur in people between 15 and 19, and two-thirds occur in those under the age of 25. 2

Even with 100 percent use (which is uncommon), condoms at best only reduce the risk (not eliminate it) of STDs (sexually transmitted diseases).

There is virtually no evidence that condoms reduce the risk of HPV infection at all, though they may slightly decrease the number of people who go on to get warts or cervical cancer.
HPV is the single most common STD in America. In one recent study half of the sexually active 18- to 22-year-old women were infected with HPV.3

If used 100 percent of the time (which is uncommon), condoms only reduce the risk of chlamydia and gonorrhea infection by about half.
Approximately 700,000 new chlamydia and 360,000 new gonorrhea cases are reported yearly in the U.S. 4 This means that approximately 10% of sexually-active adolescent women are infected with chlamydia.
Based on the limited studies, it appears condoms only reduce the risk of herpes by half at best. Genital herpes infects nearly a quarter of Americans 12 and older and almost half of all African Americans.

Sexually active girls are more than 3 times more likely to be depressed than are girls who are not sexually active. Boys who are sexually active are more than twice as likely to be depressed as are those who are not sexually active.

Sexually active girls are nearly 3 times more likely to attempt suicide than are girls who are not sexually active. Sexually active boys are 8 times more likely to attempt suicide than are boys who are not sexually active.

20% of teens aged 12-18 years using the pill get pregnant within 6 months.5

23% of unmarried, non-cohabiting women under 20 years of age using condoms get pregnant within a year.6

50% of contracepting teens cohabiting with a boyfriend get pregnant within a year.7

References

1. American Social Health Association. Sexually Transmitted Diseases in America: How Many Cases and at What Cost? Menlo Park, CA: Kaiser Family Foundation; 1998.

Centers for Disease Control and Prevention. Tracking the Hidden Epidemics—Trends in STDs in the United States 2000. Available at: http://www.cdc.gov/nchstp/dstd/dstdp.html. Accessed on September 20, 2001.

2. Eng TR, Butler WT, eds. The Hidden Epidemic—Confronting Sexually Transmitted Disease. Institute of Medicine. Washington, DC:  National Academy Press; 1997.

3. Peyton CL, Gravitt PE, Hunt WC, et al. Determinants of genital human papillomavirus detection in a US Population. J Infect Dis. 2001;83:1554-1564.

4. Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention. Sexually Transmitted Disease Surveillance 2000. 2001.

5. Dinerman L. Wilson M, Duggan A, Joffe A. Outcomes of adolescents using levonorgestrel implants vs. oral contraceptives or other contraceptive methods. Arch Pediatrics Adolescent Medicine. 1995; 149:967-972.

6. Haishan Fu, et al.  Contraceptive failure rates: new estimates from the 1995 national survey of family growth.  Family Planning Perspectives.  1999;31(2):56-63.  Table 2 is available at http://www.agi-usa.org/pubs/journals/3105699.html.

7. Fu H, Darroch J, Haas T, Ranjit N. Fam Plann Perspect 1999; 31:56-63. 

[The Medical Institute Advisory, 7July2005. For further references for the data in this Advisory, please see The Medical Institute’s website or contact the office at [email protected].   www.medinstitute.org]