The epidemiology of sexually transmitted infections in adolescents

This article addresses the epidemiology of several common sexually transmitted infections (STIs) in adolescents. Chlamydia is a common occurrence in adolescents, more so than is gonorrhea, but both are of particular concern because they may cause pelvic inflammatory disease. Many experts recommend screening for chlamydia in sexually active adolescents, particularly females. Trichomonas vaginalis is significant as a marker for risk of contracting other STIs and because of its association with pregnancy complications and with increased risk of transmission of HIV. Genital herpes simplex virus (HSV) infection, which usually has been caused by HSV-2, is a common finding in adolescents, and it now is caused also by HSV-1 in some populations. Human papillomavirus (HPV), though widespread in adolescents, usually is a self-limited infection, and malignancy resulting from HPV is a rare occurrence in this age group. The least common of the diseases discussed below is syphilis, but a recent sharp increase in incidence has occurred in men who have sex with men.     

Psychosocial issues in primary care of lesbian, gay, bisexual, and transgender youth

Lesbian, gay, bisexual, and transgender youth are at risk for a multitude of physical, emotional, and social health problems. During the past decade it has been well documented that these youth have higher-than-average rates of depression, suicide attempts, substance abuse, sexually transmitted diseases, school failure, family rejection, and homelessness. The focus of this article is to outline skills and strategies that can assist the health practitioner in creating an optimal health care experience for sexual minority youth. Models of individual and family adaptation, a clinical path, and a referral list are presented. Current health care delivery sites are examined, and recommendations are given for improvement of both practitioner skills and health care programs targeting these youth.     

Infrequent parental monitoring predicts sexually transmitted infections among low-income African American female adolescents

OBJECTIVE: To prospectively determine (using an 18-month follow-up period) the association between African American female adolescents' perceptions of parental monitoring and their acquisition of biologically confirmed infection with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. DESIGN: A prospective cohort study of 217 African American female adolescents enrolled in the control arm of a randomized trial of a human immunodeficiency virus prevention intervention program. SETTING AND PARTICIPANTS: A volunteer sample of adolescents (aged 14-18 years) recruited from low-income neighborhoods characterized by high rates of unemployment, substance abuse, violence, and sexually transmitted diseases. MAIN OUTCOME MEASURES: Adolescents provided 2 self-collected vaginal swab specimens. One was tested for C. trachomatis and N. gonorrhoeae DNA with ligase chain reaction. The other was used to inoculate culture medium for T. vaginalis. Identical assay procedures were repeated at the 6-month, 12-month, and 18-month follow-up intervals. RESULTS: Adjusted odds ratios indicated that adolescents who perceived infrequent parental monitoring at baseline were 1.8 (95% confidence interval, 1.01-3.21) and 2.4 (95% confidence interval, 1.22-4.87) times more likely to acquire chlamydia or trichomoniasis, respectively, compared with their counterparts who perceived greater levels of monitoring. Similarly, adolescents who perceived infrequent parental monitoring were 2.1 (95% confidence interval, 1.16-3.74) times more likely to test positive for a sexually transmitted infection during the course of the 18-month follow-up period. CONCLUSIONS: Adolescents' perceptions of their parental-monitoring levels predicted subsequent acquisition of biologically confirmed chlamydia and trichomoniasis infections. These findings suggest that expanded efforts leading toward effective clinic- and community-based sexually transmitted infection intervention programs involving parents may be warranted.     

Nondisclosure of sexual orientation to a physician among a sample of gay, lesbian, and bisexual youth

BACKGROUND: The American Medical Association, the American Academy of Pediatrics, and the Society for Adolescent Medicine recommend discussing sexual orientation as part of the health supervision of all adolescents. Little is known about whether lesbian, gay, and bisexual (LGB) youth hide their orientation from health care providers, which can potentially lead to missed opportunities in identifying individual health risks and provide appropriate screening and counseling. OBJECTIVES: To describe the health care experiences of a nonclinical sample of LGB youth and identify factors associated with disclosure and nondisclosure of orientation to physicians. DESIGN: Community-based participatory study using a self-administered questionnaire. SETTING: Los Angeles youth empowerment conference held in October 2003 targeting high school-aged LGB youth. PARTICIPANTS: One hundred thirty-one youth aged 14 to 18 years who identified themselves as LGB. Main Outcome Measure Physician's knowledge of participant's sexual orientation. RESULTS: Thirty-five percent of the sample reported that their physician knew they were LGB. Bisexual youth were less likely than gay and lesbian youth to have disclosed. The strongest predictor of disclosure was having discussed sex or sexual health of any kind with a physician (odds ratio, 15.47; 95% confidence interval, 4.34-55.18). When asked what a physician could do to make talking about being LGB more comfortable, 64% of participants chose the survey response, "Just ask me." CONCLUSIONS: Even among a nonclinical sample of LGB youth who were open enough about their orientation to attend a conference on the subject, only 35% reported that their physician knew their orientation. The results indicate that physicians had not discussed sexuality with most LGB youth in the study and that most youth would welcome such a discussion.     

Adolescents and sexually transmitted infections: knowledge and behaviour in Italy

OBJECTIVE: Sexually transmitted infections (STI) among adolescents continue to be an important public health problem for many industrialized and developing countries. This study evaluated knowledge and behaviour in adolescents regarding prevention of STI. METHODS: Information was obtained by using self-reported questionnaire from a random sample of 644 undergraduate students at university and at public high schools aged 14-20 years in Catanzaro (Italy). RESULTS: Only 14.2% of respondents knew about the main STI and that they can be transmitted through sexual intercourse with HIV seropositive partners; this knowledge was significantly higher among adolescents who had had a higher number of sexual partners in their lifetime and who had received information from physicians about STI. A total of 33.8% reported having had sexual intercourse at least once and the mean age at first intercourse was 16 years. Older males and adolescents with employed mothers were more likely to have reported having had a sexual experience. The prevalence of using condoms every time during sexual intercourse was 51.8% and such behaviour was more likely in younger adolescents and males. The prevalence of condom use on the last occasion of sex was 71.9%. Younger adolescents, those with a higher perception of the risk of contracting STI and those with lesser knowledge about STI were independent predictors for using condoms. The mean total score of the respondents' perception of a risk of contracting STI was 5.8. CONCLUSIONS: Evidence to develop and implement strategies with the hope of improving adolescents' level of knowledge and reducing unsafe sexual practices.     

The role of self-efficacy and relationship quality in partner notification by adolescents with sexually transmitted infections

OBJECTIVE: To evaluate the role of self-efficacy, anticipated negative consequences, and relationship quality in patient-initiated sex partner notification following treatment for sexually transmitted infections. SUBJECTS: Two hundred forty-one 13- to 20-year-old subjects (83% women; 83% African American) diagnosed with gonorrhea, chlamydia, trichomonas, or nongonococcal urethritis. Subjects were patients at a public sexually transmitted diseases clinic or primary care adolescent clinics. METHODS: Structured interviews at enrollment and 1 month following treatment. At enrollment, recent sexual partners were identified. Coital frequency, partner-specific sexually transmitted infection notification self-efficacy, anticipated consequences of notification, and relationship quality were measured with multi-item scales. At 1 month, subjects were asked whether partners had been notified and about the timing of notification relative to treatment. RESULTS: Subjects reported 279 partners. Of these, 61% of women's partners and 52% of men's partners were notified. Multiple logistic regression adjusted by generalized estimating equations showed that notification was predicted by antecedent notification self-efficacy (adjusted odds ratio, 1.16; 95% confidence interval, 1.03-1.30) and relationship quality (adjusted odds ratio, 1.17; 95% confidence interval, 1.08-1.27). Age, sex, race/ethnicity, prior sexually transmitted infection, coital frequency, and anticipated consequences were not related to partner notification. CONCLUSIONS: Partner notification is increased among persons with higher levels of self-efficacy and in relationships with stronger affiliative and emotional ties. Self-efficacy and partner communication could be especially amenable to interventions to increase patient-initiated partner notification for curable sexually transmitted infections.     

Management of sexually transmitted infections in pubertal children

Sexually transmitted infections (STI) comprise a variety of infections transmissible through sexual contact. Mutually consenting sexual relationships have become commonplace in adolescence and sexual abuse or exploitation awareness has risen, resulting in increased presentations of children with sexual health concerns. Difficulties persist in diagnosing and managing STIs in children. With increased emphasis on paediatrician's involvement in transitional care, competence in sexual history taking and clinical presentation recognition remains essential. Additionally, an awareness of strengths and limitations of diagnostic modalities needs to be present. Furthermore, specific additional issues in this age group such as independent consent for diagnosis and treatment, fear of pregnancy and privacy and confidentiality concerns should be addressed carefully. Failure to address these issues may lead to disengagement with health services resulting in potentially adverse short- and long-term health and social consequences in young persons. This review aims to provide an overview of an approach to diagnosing and managing a pubertal child with an STI and the consideration of the unique issues surrounding children's care.     

Prevention and intervention of sexually transmitted diseases in adolescents.

Adolescents are the age group at greatest risk for acquiring sexually transmitted diseases. Sexually transmitted disease intervention programs based on behavioral change theories that emphasize self-efficacy and motivational enhancement may provide adolescents with skills to change risk behavior patterns. School-based sexually transmitted disease programs can reach the majority of the at-risk adolescent population. Community-based programs attempt to change community norms for a targeted high-risk population and are particularly helpful in reaching adolescents who are not in school. Finally, clinic-based interventions serve adolescents seeking health care, not only encouraging abstinence and safer sex practices for prevention of sexually transmitted disease but also providing opportunities for early detection and treatment. All three have their advantages, but each may neglect a significant portion of the population at risk. Development of structured sexually transmitted disease intervention programs utilizing school, community, and clinic settings merits further study.     

Subsequent sexually transmitted infection in urban adolescents and young adults

OBJECTIVE: To compare the rates of subsequent infection with Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis in a group of high-risk adolescents and young adults. METHODS: At the time of treatment, 444 unmarried teenagers and young adults aged 13 to 25 years were enrolled from an urban sexually transmitted disease clinic and 3 community-based primary care clinics. Subjects were infected with C trachomatis, N gonorrhoeae, or T vaginalis, were diagnosed as having nongonococcal urethritis (in men), or were uninfected sexual contacts with one of these infections. Subjects returned at 1, 3, 5, and 7 months. RESULTS: The rate of subsequent infection was substantial. Forty percent of men and 53% of women who were uninfected contacts at enrollment were estimated to be infected within 7 months; 60% of men and 73% of women infected at enrollment were estimated to be reinfected. Among women, subjects who were infected at enrollment had a shorter time to subsequent infection (median, 140 days) compared with uninfected contacts (median, 209 days) (P =.04). Among men, findings were similar, but the difference in median time to subsequent infection was not significant (P =.08). Baseline characteristics that predicted shorter time to reinfection were female sex and infection at enrollment. When sexual behaviors in the 2 months preceding each subsequent data collection visit were included in the model, only being female and reporting at least one new interval sexual partner were significant predictors of subsequent sexually transmitted infections. CONCLUSIONS: These data support recent research that has found high rates of subsequent infection among high-risk adolescents and young adults. Contacts of a sexually transmitted infection appear to be at equally high risk for subsequent infection as those with a personal history of infection. Our data suggest that more frequent than annual screening for N gonorrhoeae, C trachomatis, and T vaginalis would be appropriate in at-risk adolescent and young adult populations, including individuals who are uninfected sexual contacts to a sexually transmitted infection.