Challenges Facing STD Prevention in Youth
The U.S. Centers for Disease Control and Prevention (CDC) reports that overall incidence of STDs have increased dramatically in recent years.
Of particular concern are the increases among those between the ages of 15 and 24.
A paper published in February 2004 by researchers at the CDC and Family Health International estimates that nearly half of the nation’s new STD cases occur each year among adolescents and young adults (1).
According to their estimates, in the year 2000, 9.1 million cases of STDs occurred in sexually active Americans in this 15-24 age group.
In particular, human papillomavirus (HPV), trichomoniasis, and chlamydia were and continue to be the most prevalent—causing 88% of the new STD cases in those between the ages of 15 and 24.
In a corresponding article, the associated lifetime medical costs were tallied for an estimated $6.5 billion bill from these infections (2).
In recent years, the prevalence of sexually transmitted diseases (STDs) among adolescents has become a serious public health issue. Although this problem has been widely acknowledged in the health care community, the public has a limited understanding of this growing epidemic and of public health strategies that might bring it under control.
About half of the estimated three million total cases of chlamydia each year occur in young women between the ages of 15 and 19, and while chlamydia is curable with antibiotics, it is often a silent disease that, left untreated, can cause pelvic inflammatory disease (PID), infertility, and increased risk of contracting HIV 22, 23.
While females are biologically more susceptible to acquisition of many STDs, studies suggest adolescent males have earlier onset of sexual activity and more partners on average than females, which increase the risk of acquiring STDs 30. The lower reported rates of chlamydia and gonorrhea among adolescent men may, in part, suggest a statistical illusion, masking the fact that males are less likely to seek care and receive testing and treatment—and less likely to produce a reported case 31, 32. Since male adolescents who are asymptomatic account for a large part of infection in the general population, current recommendations for screening, which mostly exclude males, may be inadequate.
Screening for adolescent males was included as a recommendation in the 1998 CDC guidelines, but this recommendation was omitted in the more recent 2002 guidelines33.
Communities of color are disproportionately affected by STDs, and efforts to reach them will require increased resources and tailored outreach.
Teens from communities of color are disproportionately affected by STDs.
Young African American women experience at least 14 times the reported gonorrhea rates and about 6 times the chlamydia rates of young white women34, an elevated risk not easily explained with reference to variables such as sexual risk behaviors 35, 36.
Chlamydia rates among African American males ages 15 to 24 were 12 times higher than rates among young white males37.
Although African Americans comprise about 13% of the U.S. population, they accounted for over 50% of new HIV diagnoses reported in 2002 (38) and 49% of AIDS diagnoses in 2003 (39). Among women ages 13 to 24, African American and Hispanic females account for over 75% of reported HIV infections, although together they represent only about 26% of U.S. women in this age group 40.
HIV was the leading cause of death among African American women ages 25 to 34 in 2001 41.
The Why and How of Chlamydia Testing
Chlamydia trachomatis (CT) is the most common and costly bacterial STD in the U.S. with about three million new cases each year, and health care costs for the infection and its consequences exceed an estimated $3.5 billion per year 56.
Consequences can include pelvic inflammatory disease (PID) and infertility, yet most young women don’t know they have chlamydia due to its asymptomatic nature. Effective treatment is available to cure
the infection and prevent complications if administered early.
Researchers consistently find that young age is a strong predictor of infection57–62. CDC guidelines recommend screening sexually active women 25 years of age and younger annually for chlamydia. Furthermore, the 2002 CDC STD Treatment Guidelines recommend that all women be retested three to four months after treatment for chlamydia due to the high incidence of re-infection. Unfortunately, screening levels fall well below recommendations.
Results of inadequate screening are large numbers of infected, perhaps asymptomatic, individuals who continue, unknowingly, to transmit STDs to others, and who are at increased risk of vertical transmission during pregnancy, complications including PID, and acquiring HIV63.
Our youth today are growing up in a culture that surrounds them with sexual imagery and messages—but one in which marriage is often delayed until the late twenties or later. Historically, public health prevention messages have singled out abstinence as the most effective way to remain free of sexually transmitted infections.
Many adolescents remain poorly informed about the risk of STDs and about prevention measures. Knowledge deficits are alarming. For example:
• 40% of older adolescents surveyed by the Kaiser Family Foundation incorrectly believe that the contraceptive “pill” and “shot” protect against STDs and HIV 85.
• Efforts to tailor interventions and skill-building to the groups most in need are especially germane as racial and ethnic group disparities among adolescents are significant. For example:
• Hispanic teens were least likely to discuss contraception with their partners prior to sexual activity91.
• Among students reporting sexual intercourse in the past three months, 43% of Hispanic teens and 37% of white teens did not use a condom at last sexual intercourse compared to only 27% of African American teens 92.
• Hispanic females had the lowest rate of reported condom use at last sexual intercourse (52.3%) compared to other racial and ethnic groups93.
• Sexual intercourse among high school students was more common among African American teens (67.3%) than Hispanic (51.4%) and white (41.8%) teens 94.
• About 30% of African American teens reported a history of four or more sexual partners compared to approximately 16% of Hispanic teens and 11% of
white teens 95.
The risks to fertility posed by STDs are a potentially valuable teaching tool, yet this point is often lost.
Communication Surrounding—and Awareness of—STDs is Limited on Many Levels.
The parent–child connection
Parents in many cases also lack information about STDs and preventive measures, and they lack skills to counsel adolescents about these infections.
A national survey of parents of high school students conducted by
the Society for Adolescent Medicine found almost 60% were concerned about the consequences of adolescent sexual behavior, but 84% of parents did not believe their own child was sexually active 97.
Parents must understand true rates of adolescent sexual activity and be willing and able to interact with children about entertainment media portrayals of relationships in which the complexity of sexual relationships are trivialized and
risks are seldom, if ever, addressed.
The Heritage Foundation found that 75% of parents believe schools should teach children about abstinence and contraceptives, including condoms 98, but parents and family members also have important roles to play and should be incorporated in prevention education.
“Parents play many roles in helping their teens make healthy decisions,” says Susan L. Rosenthal, PhD, Director of the Division of Adolescent and Behavioral Health and Professor of Pediatrics at the University of Texas Medical Branch.
“They accomplish this by clearly communicating their values, helping teens to be more resistant to peer pressure, and helping teens with good health care decision-making. One should not assume that because adolescents want confidential care and desire to be in control of their information that parents are not active participants and highly influential.”
Parents, through their influence and involvement, can have powerful effects on adolescents’ behaviors, and parent–adolescent sexual risk communication can serve as a means of STD prevention.
While peer norms can positively influence health outcomes (for example, peer norms about refraining from sex can be protective against the onset of sexual activity101), peer pressure also remains an important factor driving early initiation of sex and other risk behaviors. Of note, the Kaiser Family Foundation found 60% of teens cited “many of their friends had already done it” as a factor influencing their decision to have sex102, and a similar number believed that their peers think having sex by age 15 is socially acceptable103.
Entertainment media present unrealistic portrayals of sex and relationships.
The third biennial report from the Kaiser Family Foundation, Sex on TV3, found over 80% of shows popular with teen viewers contained sexual content, a rate higher than shows for other audiences; however, only 15% of sexual encounters on TV alluded to the possible risks or responsibilities of sexual activity110.
Television can have serious negative effects on the sexual behavior of youth. Youth exposed to sexual content on television were more likely to overestimate the frequency of sexual activity among peers and have more permissive attitudes toward premarital sex 111, 112. Adolescents who watched television with high levels of sexual content were twice as likely to initiate sexual intercourse and also more likely to initiate other sexual activities113.
Television can play a constructive role in providing information and referrals. For example, MTV and the Kaiser Family Foundation provided a public education campaign on sexual health from 1999 to 2002. Over half of teens said they learned something new about STDs, and it promoted behavior changes such as increased discussion with partners about STDs and higher rates of STD testing and condom use compared to a control group which did not see the campaign 114.
However, the value of these efforts can be undermined when such messages confli
ct with other television programming, including suggestive music videos. In one study, for example, teens with high levels of exposure to rap videos, which often promote drug use, violence, and sex, were significantly more likely to acquire an STD 115.
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