Adolescents and Sexually Transmitted Diseases William L. Yarber, Anthony V. Parrillo
ABSTRACT: Sexually transmitted diseases (STDs) are a serious health problem for adolescents. occurring in an estimated one-quarter of sexually active teen-agers. Many of the health problems - including STDs result from specific risktaking behaviors. Determinants of STD risks among adolescents include behaviorial. psychological, social, biological, institutional factors. Education is an important component in S T D control in adolescents. The goal of education is to increase adolescent self-efficiency in practicing STD prevention and risk-reduction. A comprehensive approach including quality, theory-based education. accessible and effective health clinics, and improved social and economic conditions has the most promise of controlling STDs in adolescents. (J Sch Health. 1992;62(7):331-338)
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ood health typically is considered a trait of adolescence and, in fact, most young people are free from serious health problems. However, the overall morbidity and mortality rates for teen-agers are remarkably high, and adolescents have had the largest increase in mortality than any other age gr0up.l Many of the health problems result from specific risk-taking behaviors. During adolescence, many teen-agers initiate sexual activities and begin experimenting with drugs, including injected drugs, alcohol, and cigarettes. Even though some of these behaviors, particularly the sexual ones, are considered typical and normal components of adolescent development, many can result in vulnerability to a myriad of health problems. One outcome of unprotected intercourse is sexually transmitted disease (STD). STDs are common infections affecting adolescents.
PREVALENCE A N D HEALTH IMPACT The exact incidence of STDs among adolescents is unknown. Not all STDs are reportable, and the reportable STDs rarely are reported completely.* However, estimates of prevalence are made. These estimates are based on several sources of data including systems for reporting infectious diseases (syphilis and gonorrhea are reportable in all states), surveys of visits to office-based practices, records of patients attending specialized health facilities, and data derived from nationally representative samples of the populati~n.~,~ According to Cates and Raul,' STD incidence among adolescents grew to epidemic levels in the 1960s and 1970s. Cates' concluded the rate continued at record-high levels in the 1980s. For age groups that include adolescents, the U.S. Centers for Disease Control (CDC)6stated that people younger than age 25 account for two-thirds of an estimated 12 million people acquiring an STD each year in the US. SpecificaIIy for the adolescent ages, the U.S. Dept. of Health and Human Services concluded at least 25% of sexually active teen-agers have become infected with STD.' The American Social Health Association' stated: Adolescents . . . are particularlyseriously affected by STDs. Every year 2.5 million adolescents conWilliam L. Yarber, HSD, FASHA. CHES, Professor, Health Educalion, Dept. of Applied Health Science, Indiana University, Bloomington, IN 47405; and Anthony V. Parrillo, MS. CHES. Assistant Professor, Dept. of Community Health, School of Allied Health Sciences, East Carolina University, Greenville, NC 27858.
tract an STD - about one of every six. In fact, during the 1980s the highest rates for some STDs in the United States were among adolescents, particularly lo w-income, urban adolescents. Sexualiy active adolescent women are hit especially hard. The total number of adolescent cases cited by the American Social Health Association may be inflated as some of the cases may be repeats within the same year. Also, the recent CDC Youth Risk Behavior Survey (YRBS) of 11,631 students nationally found 4% of all high school students reported having had an STD.9 The actual proportion of adolescents infected with an STD may be higher than the YRBS prevalence since the data does not include out-of-school teen-agers who, in general, have higher STD risk. Examination of incidence and prevalence estimates for specific STDs also reveals the seriousness of STD among adolescents. A brief summary of incidence for bacterial STDs and viral STDs is presented. For a more thorough discussion of STD prevalence by disease among teen-agers, the readers should consult the cited references of this section, especially Cates.' Bacterial SlDs. For gonorrhea, the total number of cases reported to CDC decreased by 25% (1 million to 750,000) between 1975-1989. Even though teen-agers shared in this decrease, cases of gonorrhea declined more slowly for teen-agers than for other age groups. Considering the shrinking of the adolescent population in the 1970s, it can be concluded that gonorrhea rates increased for both teen-age males and teen-age females during the 1980s. Ethnic differences in gonorrhea trends occurred among teen-agers. White teen-age males and White teen-age females had a slower decline than their older counterparts, while gonorrhea cases and rates for Black teen-agers increased between 1981- 1989?J0 In 1989, syphilis had reached its highest level since post-World War 11, but teen-agers apparently had suffered less from the increase than older age groups. However, the number and rate of syphilis cases in Black teenagers, especially females, has been increasing.4JoJ1 Chlamydia infections are believed to cause more lower genital tract infections among teen-agers than gonorrhea." But trend data of chlamydia infections among teen-agers is not available since such infections are not reported in all states. Based on cultures obtained during pelvic examinations, the prevalence of cervical * - ~ ~studies chlamydia is between 8% and ~ O V O . ~Most indicate cervical chlamydia among adolescents is at least
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two times more common than gonorrhea, and teen-age females have a greater risk of chlamydia infections than older females. l 6
Lastly, a recent congressional report stated that AIDS has become the sixth leading cause of death among individuals ages 15-24.26
Viral STDs. Trends in viral STDs among adolescents have followed the same course as their bacterial c o ~ n t e r p a r t s . ~ JThe ~ J ~number of medical visits for females ages 15-19increased for both genital herpes and genital warts during the past two decades. For symptomatic genital herpes, visits increased from an estimated 15,000yearly visits in 1966to an estimated 125,000visits in 1989. The estimated number of visits for teen-agers for genital wart infections increased from approximately 50,000 in 1966 in 1966 to nearly 300,000 in 1989. For both of these viral STDs, visits to private clinicians represent only a small portion of symptomatic cases. Very few teen-agers have AIDS. For most teens with AIDS, the predominant route of human immunodeficiency virus (HIV) infection was from contaminated blood products received prior to the mid-1980s.19However, 19% and 24% of all cumulated AIDS cases have been diagnosed in the 20- to 29-year-old age group in males and females, respectively.’O A large proportion of those ages 20-29 diagnosed with AIDS were most likely infected as teen-agers because the time between infection with HIV and the onset of AIDS is several years. Many of these young adults became infected via sexual intercourse. Without medical attention, some STDs can lead to permanent body damage. For example, blindness, cancer, heart disease, sterility, and even death can occur. These sequelae do not often occur in adolescence; many of the severe problems may not appear until adulthood. Females suffer more damage from STDs than do males. However, many more males have died from AIDS. Lower genital tract infections among adolescents have their greatest impact in future years. If not treated, cervical gonorrhea and chlamydia lead to pelvic inflammatory disease (PID), often resulting in chronic pelvic pain, infertility, and ectopic pregnancy.’’ More than 1 million U.S. women yearly experience an episode of PID, with about 20% of the cases occuring in t e e n - a g e r ~ . ~Age-specific ~.~~ rates of PID are highest for adolescent females when appropriate adjustments are made for sexual activity.” WestromZ3concluded the risk of PID in the sexually active 15-year-old female is estimated to be 1 in 8. At least 25% of women with acute PID suffer one or more serious long-term sequelae, with tubal infertility being the most common complication. Westrom” reports that younger women appear to have a better fertility prognosis after PID than older women. Ectopic pregnancy following PID is another serious STD sequelae. Ectopic pregnancy has risen dramatically in the U.S.during the past two decades, from less than 10,000 cases in the 1960s to more than 80,000 cases in 1988.10,25 STD organisms, especially chlamydia and gonorrhea, are associated with at least half and possibly 75% of all cases of ectopic pregnancies.*’Cates2’stated though older women have a higher risk of ectopic pregnancy than young women, ectopic pregnancy represents the cumulative effect of recurrent tubal infections, many of which occurred in the teen-age years.
DETERMINANTS OF STD RISK IN ADOLESCENTS STD risk involves not only the factors that determine the probability of having an infected sexual partner, but also those factors that might influence the probability of infection if exposed and the probability of disease and complications if infected. Determinants of risk for these components among adolescents include behavioral, psychological, social, biological, and institutional factors. These risk factors are complex and interrelated, and cumulatively influence STD rates in adolescents. Boyer’’ said the essential first step in controlling STDs in adolescents is to understand the factors that influence risk. Further research on the influence of determinants of STD risk among adolescents is needed. This section briefly describes the major determinants of STDs using selected studies; a more thorough discussion of risk factors can be found in Boyer,’’ Aral and Holmes,’ and Cates.” Behavioral Factors. These factors include sexual behaviors, drug use, and health care behaviors. Of these behaviors, sexual activity is considered the most crucial risk factor for acquisition of STDs.” Sexuality-related risk behaviors include age of first coitus, current and lifetime number of sexual partners, contact with casual sexual partners, frequency and type of coitus, patterns of sexual behavior, and use of barrier prophylaxis. Age of first sexual intercourse has been associated with number of recent and lifetime partners and disease outcomes such as cervical carcinoma. The earlier the coital debut the longer the interval of exposure to different sex partners. CDC’s National Survey of Family Growth reported first coital experience for adolescent females occurred at increasingly earlier ages through the 1970s and 1980s, and that the proportion of coitallyexperienced teen-age females also increased. ’* The YRBS found the reported median age of initial coitus was 16.1 and 16.9 years for male and female high school students, respectively. About one-third of male students and one-fifth of female students initiated coitus before age 15.29 In 1988, adolescents who had sexual intercourse earlier in life reported greater numbers of sex partners.’* For those initiating coitus before age 18, 75% reported having two or more partners and 45% reported having four or more partners. Only 20% of those initiating coitus after age 19 reported having had more than one partner, with 1% having four or more partners. Aral and Holmes’ stated that people who have multiple sex partners over a short time period, such as several months, are at increased risk for gonorrhea, syphilis, chlamydia, and chancroid. They also noted increased numbers of sex partners during a lifetime is associated with a greater cumulative risk for acquiring viral infections such as hepatitis B, genital herpes, genital warts, and HIV. Nineteen percent of students of the YRBS reported having four or more lifetime sex partne~s.’~ In fact, the 15-19 age interval appears to be
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the highest risk interval for exposure to multiple partners.‘ Once teen-agers decide to be sexually involved with others, the use of prevention methods, such as condoms, becomes important. Latex condoms, when used properly, have been found to be an effective barrier against chlamydia, gonorrhea, genital herpes, genital warts, and HIV.30J1Reported use of condoms at coitus by adolescents ranges from 38% to 66%, depending on the ~tudy.’~”~ About 45% of the YRBS subjects reported condom use at last coital epi~ode.’~ Recent studies have indicated that Black teen-age males are using condoms more often (and having intercourse less often) than White m a l e ~ . ~Progress ~ J ~ has been made on increasing condom use among adolescents. Reported use at last intercourse is two to three times higher than reported use in the 1970s.‘ Current surveys indicate less than half of teen-agers who recently used condoms did so all the time.‘ Fineberg” noted sporadic condom use in highrisk settings will frequently result in STD acquisition. Biglan et al” found adolescents who most need to be using condoms - those who are sexual with multiple partners, with partners having many partners, or with partners not known well - are the ones least likely to use them. Drug and substance use is another behavioral determinant of increasing STD rates. For example, there have been recent outbreaks of STDs among adolescents using crack cocaine. A study of 222 teen-age crack users in San Francisco found 41% reported a history of STDS.)~ Crack use promotes high-risk sexual behaviors by temporarily increasing sex drive, and is associated with the exchange of sex for drugs or money. This sexual behavior exposes individuals to multiple partners and creates a “core” group of persons with high prevalence of S T D S . ~ ~ J ~ Though the use of alcohol and non-injected drugs does not directly expose one to STD organisms, their use often decreases the person’s use of STD preventive measures.‘O Failure to use condoms and multiple sex partners have been associated with alcohol and drug use.” Though school-based data apparently indicates a decrease in adolescents’ use of drugs,“ injected drug use remains a serious problem among teen-agers. For the YRBS subjects in grades 9-12, 1.5% reported injected drug use.29 Hence, many students are at risk for HIV infection because they use injected drugs and share their needles. Importantly, the YRBS students with four or more partners were significantly more likely to report injected drug use (5.1%) than were students with fewer lifetime sex partner^.'^ Many adolescents, particularly females, may be at higher risk because they have coitus with persons who inject drugs. The Biglan et a13*study examined the relationship between risky sexual behaviors and other “problem” behaviors. They found adolescents were more likely to engage in high-risk sexual behavior when they also were engaging in other types of problem behavior, including antisocial behavior, cigarette smoking, alcohol use, and illicit drug consumption. They concluded it is important to give attention to “at risk” youth in HIV prevention efforts.
Psychobgical Factors. Several psychological factors, such as self-esteem, self-efficacy, personal values, locus of control, and motivation are associated with STD risk behavior. FisherJ2 stated adolescents’ sexual activities and preventive behaviors appear to be largely influenced by their sexual feelings, thoughts, and fantasies. In adolescents, these factors influence sexual activity and preventive practices. Adolescents possess generalized and stable feelings about sexuality which influence their sexual behaviors. Some adolescents are erotophilic (having mostly positive feelings about sexuality), some are erotophobic (having mostly negative feelings about sexuality), and some fall in between. Fisher“ noted numerous studies indicate erotophobia has been found to interfere with the performance of pregnancy and STD/HIV preventive behaviors. Erotophobia interferes with self-acknowledgement of forthcoming sexual activity and the need for prevention, the learning of preventive information, communication with others about sexuality, performance of preventive acts, and the consistent use of contraception by both genders. A sense of invulnerability encouraging risk-taking characterizes many adolescents Many teen-agers believe they will never come in contact with anyone infected with an STD. Social Factors. Data on the prevalence of STD among adolescents indicate the highest STD rates occur in younger adolecent females, innercity youth, and ethnic minority teens. When STD data are calculated by age and adjusted relative to the proportion of sexually active individuals in the total population, adolescents (particularly females) have the highest incidence of gonorrhea and rates of hospitalizations for PID?7-44945 Inner-city minority teens have high rates of STDs.Black teen-agers, in contrast to White counterparts, are more likely to have been infected with an STD.U.49 Hispanic teen-age females have a higher rate of chlamydia compared to their White counterparts.’O Factors such as poor role models, lack of economic and educational opportunities, and inaccessibility of adequate health care services may contribute to high STD prevalence in these adolescent groups. The environment also contributes to STD risk. The media has glorified sex without counterbalancing prevention r n e s s a g e ~ . ~Further, ~ - ~ ~ cultural ambivalence toward sexuality produces confusing messages for adolescents. Rarely do parents or social institutions encourage adolescents to acknowledge their sexuality and plan for its expression and subsequent preventive responsibilities.’ Biological Factors. The average age for menarche has decreased this century.’‘ Hence, adolescents can begin sexual activity early, increasing the number of years of possible exposure to STDs. Also, the columnar epithelum in the uterine cervix of the young adolescent may not provide as much protection from STDs as the tissue in the mature institutional Factors. Teen-age access to STD services is an important component of prevention. Ideally, medical services should be convenient to adolescents, such as being located in high-risk neighborhoods and in schools. One solution to accessibility is school-based
to prevent risk behavior? Why do teen-agers fail to change health clinics. However, only slightly more than 300 risk-taking behaviors despite knowledge of possible serious schools provided such clinics, with more than one-half health outcomes? The development of effective programs diagnosing and treating S T D S . Fewer ~ ~ than 20% disis hindered by this lack of understanding. Further, the pense any kind of contraception. Despite student suptesting of various educational and counseling approaches port of school-based clinics, they continue to be controfor teen-agers are needed particularly to identify strategies versial, particularly those offering services such as conresulting in sustained behavior modification. The basic dom d i s t r i b ~ t i o n . ~ ~ , ~ ~ needs of science include the development of better ways to Schools have an opportunity to be an important contributor to STD control. Unfortunately, the quality of detect asymptomatic STDs, better antibacterial therapies, school STD education frequently has not been adedevelopment of viral therapies, and development of vaccines for more STDs.’v2I quate. Traditionally, schools have over-emphasized the Education is a major component of STD control in biological/medical aspects of STD and gave inadeadolescents. Certainly, medical services and therapies are quate attention to behavioral messages, health-promoting attitude enhancement, and skill d e v e l ~ p m e n t . ~ ~ central to STD control, but motivating young people to practice STD prevention and risk reduction represents the STD education is insufficiently addressed in state health most desirable and potentially most effective preventi m and sexuality curricula and mandate^.^^,^^ STD approach. Given the importance and opportunity of preventive messages that include risk-reduction, such as educational intervention, the entire next section is devoted condom use, in contrast to the abstinence-only message, to this control strategy. have been subjected to successful censorship With the emergence of HIV infection and AIDS, many schools have centered their attention on EDUCATIONAL STRATEGIES providing HIV/AIDS education, and STD education Educational intervention is essential to combating STD has received inadequate a t t e n t i ~ n .Despite ~~ the fact in adolescents. Effective behavioral prevention programs that most schools include STD education, such educamust be developed based on accepted principles of learntion often is deficient, suffering from inadequate ing, education, and adolescent development and culture. materials and teacher competency, insufficient inImportant guiding principles for STD education for adostructional time, and inappropriate instructional lescents are discussed below. approach.7*64-69-71 Integration with HIV Education. As stated earlier, with the emergence of the HIV and AIDS problem, school CONTROL ST RATEGI ES and public agencies mainly have focused their attention on providing HIV/AIDS education, resulting in minor attenControlling STDs among adolescents is an enormous tion to other STDs. However, educators and the federal challenge, requiring understanding, innovation, commitgovernment are now calling for the integration of STD ment, and resources. To be effective, control strategies education and HIV/AIDS education. Both STDs and HIV must address a variety of important issues. are communicable diseases; transmission and prevention The U.S. federal government has identified several behaviors are similar. This approach will also require less goals for STD control among adolescents in its document, instructional time. Recent educational material has reflectHealthy People: National health promotion and disease ed this integrated a p p r 0 a ~ h . 7 + ~ ~ - ~ ~ s ~ ~ prevention objectives. Goals for reduction of disease Goal and Expected Outcomes. The goal of STD incidence and risk behavior and medical services were instruction is to prepare students to make intelligent, selfdeveloped. directed decisions about their health so they can change or The availability and quality of STD services for adoavoid behavior that puts them at risk for These lescents are important components in controlling the behavioral decisions can be expressed as desired outcomes, spread of STD. Unfortunately,the most vulnerable groups which help guide the instructionalcontent and methodolooften are not being served adequately. Reaching these gy. Following instruction, the student will: groups will require the services of the traditional STD Avoid sexual exposure to STD/HIV. clinics, as well as the involvement of other groups such as Not use injected drugs or share needles. family planning clinics, drug treatment centers, communResist peer pressure to practice risky behavior. ity health centers, public and private hospitals, private Recognize early symptoms of STD/HIV infection. physicians, educational institutions, and social services Avoid exposing others if an STD/HIV infection is organizations. Further, the quality of services at treatment diagnosed or suspected. sites can be improved through improved case manageSeek prompt medical care if an STD/HIV infection ment, age-specific counseling, partner contact tracing, and is suspected. site safety and appeal.7 Follow a physician’s directions if treated for STD/ Innovations in detecting and treating STDs in teenHIV. agers are needed.21For example, firstcatch urine screening Get all sex and drug-use partners to medical care if can be collected from asymptomatic, sexually active adoone has STD/HIV. lescent males undergoing athletic physical examination^.'^ Simpler treatment schedules, like singledose treatment for Be supportive and helpful to persons infected with STD/HIV. chlamydia, also would be helpful.” Research, an important control component, includes Serve as an accurate source of STD/HIV information and advice. both behavioral and basic science research. Further study of factors that influence teen-age sexual behavior would be Serve as a positive role model to others. helpful. For example, what determinants can be modified Seek the help of others concerning STD/HIV issues.
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Promote STD/HIV education, research, and health care.69 Theoreticaland Methodological Approach. Studies on the efficacy of sexuality education and smoking prevention programs for adolescents indicate programs with a theoretical base are the most effective. For example, two new risk-reduction sexuality education curricula (Postponing Sexual Involvement7’ and Reducing the have several prevention benefits and are based on social learning theory, social inoculation theory, and cognitive-behavioral theory. These theories, as well as the health belief model, the value expectancy theory, and the theory of reasoned action, should be considered when developing program^.^^^^^^^^ Interventions based on these theories are behaviorallybased and usually combine selected behavioral-related cognitive messages with the development and practice of social and personal prevention skills. These skills include negotiation with a dating partner, finding health services, and resisting social pressure. Decision-making, communication skills, role playing, positive peer modeling, and clear norms against unprotected sex are emphasized. Unprotected coitus can be reduced by both delaying onset of intercourse and increasing use of condoms. If the goal is to reduce unprotected sex, Postponing Sexual and Reducing the Risk16 can be impleInv~lvement’~ mented. CDC emphasized the behavioral approach to STD education in its document, Guidelines for STD Education.79 In addressing school STD education, CDC said: Quality STD instruction means that students will be taught ways to avoid STD, to recognize STD symptoms, to access STD clinics or other health care providers, to follow treatment instuctions if infected, and to refer all sex partners f o r medical care. A school curriculum which focuses on the teachings of STD biomedical facts detracts from the purpose of STD education and does not represent a quality unit of instruction. FisheP has developed a seven-step model of sequential preventive behavior acts for STD/HIV and pregnancy prevention, which focuses more on increasing protection during coitus. He suggests teen-agers should be taught behavioral skills and should be encouraged to rehearse them until they are firmly in place. To avoid STD/HIV and pregnancy, teen-agers must 1) accept their sexuality, 2) learn relevant preventive information, 3) make an active decision to engage in preventive behaviors, 4) bring up and negotiate prevention with their partners, 5 ) perform more or less public preventive acts, such as condom purchasing and HIV testing, 6 ) consistently practice preventive behaviors and reinforce themselves and their partners for practicing prevention, and 7) be able to shift preventive scripts. This approach requires strong instructor competencies, since methodology beyond the lecture approach is required. The teacher must, for example, be able to lead group activities, to communicate with students, and to create a safe learning environment. Preservice education may be required to enhance teacher skill. Varied Settings. To be most effective, STD educa-
tional programs must reach teen-agers in multiple community settings. Schools, which reach more than 46 million students annually,’ can play a major role in STD education. Nearly all young people will receive STD education if all schools offer it. Youth-serving agencies, like Girls, Inc., Boys Club, and YMCA also can provide STD education. A sizable portion of youth are not served by schoolbased programs. There are approximately 9 million young people ages 14-21 who do not attend school.8o Many of these people have multiple health risks, inciuding risk for STD infection. Reaching this population requires special and innovative efforts. It is important that the content and methodology of STD education account for the heterogeneity and within-group differences among teen-agers. Social and cultural factors, such as religion, values, gender roles, economic conditions, and individual differences must be considered in designing effective programs. Because of differences in the culture of various adolescent groups, an effective educational program for one group may not be effective for another group.z7 Community Involvement. Since school STD education involves sexual issues, many communities have found it beneficial to involve selected community members and students in program policy development and review of instructional materials. This approach usually results in strong endorsement of the program. An STD education committee can handle questions, concerns, and complaints about the program. National surveys indicate most community members endorse a thorough discussion of STD and HIV prevention in schools. For example, 94% of parents believe that public schools should teach about HIV/AIDs, and more than 80% want their children to be taught about safe sex as a way of preventing AIDS.” Sometimes members of the local advisory group or other community members strongly advocate that their particular moral stance related to sexuality be promoted in the curriculum. School officials should be sensitive to these views, but stand firm for a curriculum based on student and public health needs, educational principles, and the philosophy of STD education presented here.69 Instructional Materials and Resources. A need exists for quality instructional materials for STD education. A recent study of more than 4,000 sexuality education teachers found 80% indicated they need more assistance, including better instructional materials, in teaching about STDs.O2 Often state and local health and education departments can help educators identify and develop curricula. Most health and sexuality-related professional organizations can offer assistance. Further, several recent publications represent current STD education philosophy. For example, a checklist of performance standards for HIV/AIDS education curricula for adolescents may be helpful to educator^.^' This publication lists more than 70 criteria for the development of new curricula or the evaluation of existing curricula. Even though the document addresses HIV education specifically, the criteria are nearly universally applicable to the integrated STD/HIV education approach. The World Health Organization recently issued an im-
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portant document on school AIDSISTD education that discusses 17 issues pertinent to the implementation of a school program on AIDS/STD. Issues from gaining acceptance of the program to the content of curricula are addressed." The Sex Information and Education Council of the US. recently published Guidelines for Comprehensive Sexuality Education, Kindergarten - 12th Grade." These Guidelines, developed by a national task force of sexuality and health experts, provides a framework for educators in creating new or improving existing programs. Six key concepts are broken down into 36 topics, of which STDs and HIV infection is one topic. More than 40 messages about STD/HIV are listed. A major contribution of the Guidelines is the delineation of messages at four different developmental levels: early elementary, upper elementary, middle school, and high school. A government-sponsored, prototype STD/HIV curriculum - STDs and HIV: A guide for today's young aduW9 - recently has been developed. This secondary school curriculum, which includes a student manual and instructor's guide, is based on several theoretical approaches shown to reduce risk-taking behaviors. The curriculum is behaviorally-based and integrates both STD and HIV messages. A Component of Comprehensive Health Education. To be most effective, school STD education
should be provided as part of a quality, comprehensive health education program. Such placement is logical since the goal of STD education is to prepare students to make wise health-promoting decisions.69A recent secondary school study found HIV education in health science classes produces more desirable HIV-related attitudes than such instruction in biology classes.*' Ideally, STD education would be incorporated into a unit or course on human sexuality and family life education which is part of a comprehensive health instructional program. Such an arrangement is advantageous since sexuality issues, sexual decision-making, and communication skills can be more thoroughly discussed or taught, CONCLUSION STDs are a serious health problem among young adults, occuring in an estimated one-quarter of sexually active teens. Adolescent females and low-income, urban minority youth are especially affected. Teen-agers are at higher risk for STD than other age groups. The STDs of young adults have their most severe consequences in later life, particularly affecting reproductive health. Teen-agers are at risk of STDs and HIV/AIDS because of their sexual behavior and injected drug use patterns. Early sexual involvement, having multiple partners, and failure to consistently use condoms contribute to risk. Other behavioral patterns, as well as psychological, biological, institutional, and social factors, also enhance STD risk among adolescents. Further identification of determinants is needed. To be effective, intervention programs should consider the determinants of risk, especially social and cultural conditions and adolescent development. Controlling STDs in adolescents involves several
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components, including improved clinical service, research, and education. STD treatment and counseling should be accessible to teen-agers and provided at schools and in neighborhoods when possible. Better diagnostic, treatment, and counseling services can enhance control efforts. Education is an important component in STD control in adolescents. The goal of education is to increase adolescent selfefficiency in practicing STD prevention and risk-reduction. Theory-based programs are likely to be the most effective. STD education also should be sensitive to the unique traits of adolescent subcultures, should integrate HIV messages, and should occur at various community settings. School programs are especially important since they can reach most teenagers. However, special efforts are needed to educate out-Of -school youth . A comprehensive approach including quality education, accessible and effective health clinics, and improved social and economic conditions has the most promise of controlling STDs in adolescents. Providing these conditions is an enormous challenge, requiring committed health professionals and national leaders and adequate resources. References 1. Irwin CE. The theoretical concept of at-risk adolescents. Adol Med State Art Reviews. 1990,l: 1- 14. 2. Aral SO, Holmes KK. Epidemiology of sexual behavior and sexually transmitted diseases. In: Holmes KK, Mardh P-A. Sparling PF, Wiesner PJ, Cates W Jr, Lemon SM, Stamm WE, eds. Sexually Transmitted Diseases. 2nd ed. New York. NY: McGraw-Hill; 1990: 19-36. 3. Strobino DM. The health and medical consequences of adolescent sexuality and pregnancy: A review of the literature. In: Hofferth SL, Hayes C, eds. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing, Vol 11. Washington, DC: National Academy Press; 1987:93-122. 4. Cates W Jr. Teenagers and sexual risk taking: The best of times and worst of times.J Adol Health. 1991;12:84-94. 5. Cates W Jr, Raul JL. Adolescents and sexually transmitted diseases: An expanding problem. J Adol Health Care. 1985;6:257-261. 6, Sexual& Transmitted Disease Surveillance 1990. Atlanta, Ga: Centers for Disease Control; 1991. 7. US Dept of Health and Human Services. Healthy People 2000: National health promotion and disease prevention objectives. Boston, Mass: Jones and Bartlett; 1992. 8. 1989 Annual Report. Research Triangle. NC: American Social Health Association; 1989. 9. Sexual behavior among high school students - United States 1990. MMWR. 1992;40:885-888. 10. Division of STD/HIV Prevention Annual Report 1989. Atlanta, Ga: Centers for Disease Control; 1990. 11. Moran JS, Aral SO, Jenkens WC, Peterman TA, Alexander ER. The impact of sexually transmitted diseases on minority populations in the United States. Public Health Rep. 1989;104:560-565. 12. Batteiger BE, Jones RB. Chlamydial infections. Infect Dis Clin North Am. 1987;1:55-81. 13. Donovan P, Waszak CS. School-Based Clinics Enter the '90s: Update. evaluation. and future challenges. Washington, DC: Center for Population Options; 1989. 14. Hammerschlag MR. Chlamydial infections. J Pediatr. 198%1 14:727-734. 15. Tooney KE, Rafferty MP, Stamm WE. Unrecognized high prevalence of Chlamydia trachomatis cervical infection in isolated Alaskan Eskimo population. JAMA. 1987;258:53-56. 16. Shafer M-A. Prager V. Schalwitz J, Vaughan E, Moscicki B. Brown R, et al. Prevalence of urethral Chlamydia trachomatis and Neirseria gonorrhoeoe among asymptomatic, sexually active boys. J Infect Dis. 1987;156223-224. 17. Becker TM, Stone KM, Cates W Jr. Epidemiology of genital herpes infections in the United States: The current situation. J Reprod
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Med, 1986;31:359-364. 18. Becker TM, Stone KM, Alexander ER. Genital papillomavirus infection: A growing concern. Obstet Gynecol Clin North Am. 1987;14389-3%. 19. National Research Council. AIDS: The second decade. Washington, DC:National Academy Press; 1990. 20. HIV/AIDS Surveillance Report. Atlanta, Ga: Centers for Disease Control; April 1992. 21. Cates W Jr. The epidemiology and control of sexually transmitted diseases in adolescents. Adol Med State Art Rev. 199o;l: 409-427. 22. Shafer M-A, Sweet RL. Pelvic inflammatory disease in adolescent females: Epidemiology, pathogenesis, treatment, and sequelae. Pediatr Clin North Am. 1989;36:513-532. 23. Washington AE, Sweet RL, Shafer M-A. Pelvic inflammatory disease and its sequelae in adolescents. J Adol Health Care. 1985;6: 298-310. 24. Bell TA, Homes KK. Age-specific risks of syphilis, gonorrhea, and hospitalized pelvic inflammatory disease in sexually experienced US women. Sex Trawm Dis. 1984;11:291-295. 25. Westrom L. Incidence, prevalence, and trends in acute pelvic inflammatory disease and its consequences in industrialized countries. Am J Obstet Gyncol. 1980;138:880-892. 26. Harrington NL. Among teens, AIDS takes bigger toll. Chicago Tribune. April 12, 1992. 27. Boyer CB. Psychosocial, behavioral, and educational factors in preventing sexually transmitted diseases. Adol Med State Art Rev. 1990;1:597-613. 28. Premarital sexual experience among adolescent women United States, 1970-1988.MMWR. 1991;39:929-932. 29. Selected behaviors that increase risk for HIV infection among high school students - United States, 1990. MMWR. 1992;41: 231-240. 30. Darrow WW. Condom use and use-effectiveness in high-risk populations. Sex Transm Dis. 1989;16:157-160. 31. Feldblum PJ, Fortney JA. Condoms, spermicides, and the transmission of human immunodeficiency virus: A review of the literature. Am J Public Health. 1988;78:52-54. 32. Keges SM, Adler NE, Irwin CE. Sexually active adolescents and condoms: Changes over one year in knowledge; attitudes and use. Am J Public Health. 1988;78:460-461. 33. Sonnensten FL, Pleck JH, Ku LC. Sexual activity, condom use and AIDS awareness among adolescent males. Fam Plum Perspect. 198R21:152-158. 34. Weisman CS, Nathanson CA, Ensminger M, Teitelbaum MA, Robinson JC, PIichta S. AIDS knowledge, perceived risk and prevention among adolescent charts of a family planning clinic. Fam Plann Perspect. 1989;21:213-217. 35. Ku L, Sonensten FL, Pleck JH. Patterns of HIV risk and prevention behaviors among teenage men. Public Health Rep. 1992;107(2):13 I 138. 36. Pleck JH. Correlates of black adolescent males’ condom use. J Ado1 RB. 1989;4:247-253. 37. Fineberg HV. Education to prevent AIDS: Prospects and obstacles. Science. 1988;239:592-5%. 38. Biglan A, Metzler CW, Wirt R, Ary D, Noell J, Ochs L, et al. Social and behavioral factors associated with high-risk behavior among adolescents. J Behav Med. 1990;13:245-261. 39. Fullilove RE, Fullilove MT, Bonser BP, Gross BP. Risk of sexually transmitted disease among black adolescent crack users in Oakland and San Francisco, Calif. JAMA. 1990,263:851-855. 40. Zabin LS, Hardy JB, Smith EA, et al. Substance use and its relation to sexual activity among inner-city adolescents. J Adol Health Care. 1986;7:320-331. 41. Johnson LD, O’Malley RM, Bachman JG. National Trends in Drug Use and Related Factors Among American High School Students and Young Adults, 1975-1986. Rockville, Md: National Institute on Drug Abuse; 1987. 42. Fisher WA. All together now: An integrated approach to preventing adolescent pregnancy and STD/HIV infection. SIECUS Rep. 1990;18(4): 1-I I. 43. Greydanus DE. Risk-taking behaviors in adolescence. JAMA. 1987;258:2110. 44. Aral SO,Schaffer JE, Mosher WD, Cates W Jr. Gonorrhea rates: What denominator is most appropriate? Am J Public Health. 1988;78:702-703. 45. Bell T, Hein K. Adolescents and sexually transmitted diseases.
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In: Holmes KK, Mardh P, Sparling PF, Wiesner PJ, eds. Sexually Transmitted Diseases. New York, NY: McGraw-Hill, 198473-84. 46. Hardy JB. Sexually transmitted diseases among adolescents. Maryland Med. 1987;36:938-W2. 47. Holmes KK. Bell TA, Berger RE. Epidemiology of sexually transmitted diseases. Urol Clin North Am. 1984;11:3-13. 48. Oh MK, Feinstein RA, Pass RF. Sexually transmitted diseases and sexual behavior in urban adolescent females attending a family planning clinic. J Adol Health Care. 1988;9:67-71. 49. Sexually transmitted disease in the US. Stat Bull. 1986;67(OctDec):3-10. 50. Shaffer M-A, Beck A, Blane B, Dole P, Irwin CE, Sweet R, et al. Chlamydia trachomatis: Important relationship to race, contraception. lower genital tract, and Papanicolaou smears. J Pediatr. 1984;104:141-146. 51. Bearinger LH. Study group report on the impact of television on adolescent views of sexuality. JAdol Health Care. 1990;11:71-75. 52. Brown EF, Hendee WR. Adolescents and their music: Insights into the health of adolescents. JAMA. 1989;262:1659-1663. 53. Brown JD, Childers KW, Waszak CS. Television and adolescent sexuality. J Adol Health Care. 1990,11:62-70. 54. Wyshak 0, Frisch RE. Evidence of secular trend in age of rnenarche. N Engl J Med. 3982;306:1033-1035. 55. Ostergard DR. The effect of age, gravidity. and parody on the location of the cervical squamocolumnar junction as determined by colposcopy. Am J Obstet Gynecol. 1977;12959-60. 56. Manoff SB, Gayle HG, Mays MA, Rogers MF. Acquired immunodeficiency syndrome in adolescents: Epidemiology, prevention and public health issues. Pediatr Infect Dis J. 1989;8:309-314. 57. Waszak C, Neidell S . School-Based and School-Linked Clinics: Update 1991. Washington, DC: Center for Populations Options, 1991.
58. Pacheco M, Powell W, Cole C, et al. School-based clinics: The politics of change. J Sch Heulth. 1991;61(2):92-94. 59. Black JL. School-based clinics: Filling unmet needs for teens. Contemp Pediatr. 1989;(March):I17-140. 60. Kroger F, Yarber WL. STD content in school health textbooks: An evaluation using the worth assessment procedure. J Sch Health. 1984,54(1):4 1-44, 61. Kroger F, Wiesner PJ. STD education: Challenges for the 80’s. J Sch Health. 1981;51(4):242-246. 62. Yarber WL. AIDS Education: Curriculum and health policy. Bloomington, Ind: Phi Delta Kappa Educational Foundation; 1987. 63. The Health of Youth: Facts for action. Youth and Sexually Transmitted Diseuses. Geneva, Switzerland: World Health Organizatin; 1989. 64. de Mauro D. Sexuality education 1990: A review of state sexuality and AIDS education curricula. SIECUS Rep. 1989/199O;l8(2): 1-9. 65. Haffna DW. 1992 report card on the states: Sexual rights in America. SIECUS Rep. 1992;20(3): 1-7. 66. Yarber WL. While we stood by. .the limiting of sexual information to our youth. J Health Educ. To be published. 67. McCarthy MM, Cambron-McCabe N. Public School Law: Teachers’andstudents’rights.Boston, Mass: Allyn and Bacon; 1992. 68. Attacks on the Freedom to Learn. Washington, DC: People for the American Way; 1991. 69. Yarber WL. STDs and HIV: A guide for today’s young adults. Reston, Va: AAHPERD Publications; To be published. 70. Calamidas EG. AIDS and STD education: What’s really happening in our schools? J Sex Educ Therapy. 1990,16:54-63. 71. Forest JD, Silverman J. What public school teachers teach about preventing pregnancy, AIDS and sexually transmitted diseases. Fam Plann Perspect. 1989;21:65-73.
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72. Adger H, Schafer M-A, Sweet RL, Schachter J. Screening for Chlamydia trachomatis and Neisseria gonorrhoeae in adolescent males: Value of first-catch urine examination. Lancet. 1984;2:944. 73. National GuidelinesTask Force. Guidelinesfor Comprehensive Sexuality Education, Kindergarten 12th Grade. New York, NY: Sex Information and Education Council of US; 1991. 74. School Health Education to Prevent AIDS and Sexually Transmitted Diseuses. Geneva, Switzerland: World Health Organization, 1992. 75. Howard M, McCabe JB. Helping teenagers postpone sexual involvement. Fam Plann Perspect. 1991;22:21-26. 76. Kirby D, Barth RP. Leland N, Fetro JV. Reducing the risk:
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Impact of a new curriculum on sexual risk-taking. Fam Plann Perspecl. 199 1 ;23: 25 3-263. 77. Allensworth DD, Symons CW. A theoretical approach to school-based HIV prevention. J Sch Health. 1989;59(2):59-65. 78. Flora JA, Thorensen CE. Reducing risk of AIDS in adolescents. Am Psychol. 1988;43:965-970. 79. US Dept of Health and Human Services. Guidelinesfor STD Educalion. Atlanta, Ga: Centers for Disease Control, Division of Sexually Transmitted Diseases; 1985. 80. Roper WL. Current approaches to prevention of HIV infection. Public Health Rep. 1991;106:111-115,
81. Gallup MA, Clark DC. The 19th annual Gallup Poll of the public’s attitudes toward the public schools. Phi Delfa Kappan. 1987;69: 17-30. 82. Risk and Responsibility: Teaching sex education in America’s schools foday. New York, NY: The Alan Guttmacher Institute; 1989. 83. Yarber WL. Performance standards for the evaluation and
development of school HIV/AIDS education curricula for adolescents. SIECUS Rep. 1989; 17(6): 18-26. 84. Clark JK, Yarber WL. Two curricular settings of a HIV education unit related to secondary school students’ HIV knowledge and attitude. J Health Educ. To be published.
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Correction: The Micro Audiometrics ad printed on page 248 of the August 1992 issue of the Journal was misprinted. The ad is reprinted here. We apologize for the misprinting.
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ABSTRACT: Sexually transmitted diseases (STDs) are a serious health problem for adolescents. occurring in an estimated one-quarter of sexually active teen-agers. Many of the health problems - including STDs result from specific risktaking behaviors. Determinants of STD risks among adolescents include behaviorial. psychological, social, biological, institutional factors. Education is an important component in S T D control in adolescents. The goal of education is to increase adolescent self-efficiency in practicing STD prevention and risk-reduction. A comprehensive approach including quality, theory-based education. accessible and effective health clinics, and improved social and economic conditions has the most promise of controlling STDs in adolescents. (J Sch Health. 1992;62(7):331-338)
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ood health typically is considered a trait of adolescence and, in fact, most young people are free from serious health problems. However, the overall morbidity and mortality rates for teen-agers are remarkably high, and adolescents have had the largest increase in mortality than any other age gr0up.l Many of the health problems result from specific risk-taking behaviors. During adolescence, many teen-agers initiate sexual activities and begin experimenting with drugs, including injected drugs, alcohol, and cigarettes. Even though some of these behaviors, particularly the sexual ones, are considered typical and normal components of adolescent development, many can result in vulnerability to a myriad of health problems. One outcome of unprotected intercourse is sexually transmitted disease (STD). STDs are common infections affecting adolescents.
PREVALENCE A N D HEALTH IMPACT The exact incidence of STDs among adolescents is unknown. Not all STDs are reportable, and the reportable STDs rarely are reported completely.* However, estimates of prevalence are made. These estimates are based on several sources of data including systems for reporting infectious diseases (syphilis and gonorrhea are reportable in all states), surveys of visits to office-based practices, records of patients attending specialized health facilities, and data derived from nationally representative samples of the populati~n.~,~ According to Cates and Raul,' STD incidence among adolescents grew to epidemic levels in the 1960s and 1970s. Cates' concluded the rate continued at record-high levels in the 1980s. For age groups that include adolescents, the U.S. Centers for Disease Control (CDC)6stated that people younger than age 25 account for two-thirds of an estimated 12 million people acquiring an STD each year in the US. SpecificaIIy for the adolescent ages, the U.S. Dept. of Health and Human Services concluded at least 25% of sexually active teen-agers have become infected with STD.' The American Social Health Association' stated: Adolescents . . . are particularlyseriously affected by STDs. Every year 2.5 million adolescents conWilliam L. Yarber, HSD, FASHA. CHES, Professor, Health Educalion, Dept. of Applied Health Science, Indiana University, Bloomington, IN 47405; and Anthony V. Parrillo, MS. CHES. Assistant Professor, Dept. of Community Health, School of Allied Health Sciences, East Carolina University, Greenville, NC 27858.
tract an STD - about one of every six. In fact, during the 1980s the highest rates for some STDs in the United States were among adolescents, particularly lo w-income, urban adolescents. Sexualiy active adolescent women are hit especially hard. The total number of adolescent cases cited by the American Social Health Association may be inflated as some of the cases may be repeats within the same year. Also, the recent CDC Youth Risk Behavior Survey (YRBS) of 11,631 students nationally found 4% of all high school students reported having had an STD.9 The actual proportion of adolescents infected with an STD may be higher than the YRBS prevalence since the data does not include out-of-school teen-agers who, in general, have higher STD risk. Examination of incidence and prevalence estimates for specific STDs also reveals the seriousness of STD among adolescents. A brief summary of incidence for bacterial STDs and viral STDs is presented. For a more thorough discussion of STD prevalence by disease among teen-agers, the readers should consult the cited references of this section, especially Cates.' Bacterial SlDs. For gonorrhea, the total number of cases reported to CDC decreased by 25% (1 million to 750,000) between 1975-1989. Even though teen-agers shared in this decrease, cases of gonorrhea declined more slowly for teen-agers than for other age groups. Considering the shrinking of the adolescent population in the 1970s, it can be concluded that gonorrhea rates increased for both teen-age males and teen-age females during the 1980s. Ethnic differences in gonorrhea trends occurred among teen-agers. White teen-age males and White teen-age females had a slower decline than their older counterparts, while gonorrhea cases and rates for Black teen-agers increased between 1981- 1989?J0 In 1989, syphilis had reached its highest level since post-World War 11, but teen-agers apparently had suffered less from the increase than older age groups. However, the number and rate of syphilis cases in Black teenagers, especially females, has been increasing.4JoJ1 Chlamydia infections are believed to cause more lower genital tract infections among teen-agers than gonorrhea." But trend data of chlamydia infections among teen-agers is not available since such infections are not reported in all states. Based on cultures obtained during pelvic examinations, the prevalence of cervical * - ~ ~studies chlamydia is between 8% and ~ O V O . ~Most indicate cervical chlamydia among adolescents is at least
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two times more common than gonorrhea, and teen-age females have a greater risk of chlamydia infections than older females. l 6
Lastly, a recent congressional report stated that AIDS has become the sixth leading cause of death among individuals ages 15-24.26
Viral STDs. Trends in viral STDs among adolescents have followed the same course as their bacterial c o ~ n t e r p a r t s . ~ JThe ~ J ~number of medical visits for females ages 15-19increased for both genital herpes and genital warts during the past two decades. For symptomatic genital herpes, visits increased from an estimated 15,000yearly visits in 1966to an estimated 125,000visits in 1989. The estimated number of visits for teen-agers for genital wart infections increased from approximately 50,000 in 1966 in 1966 to nearly 300,000 in 1989. For both of these viral STDs, visits to private clinicians represent only a small portion of symptomatic cases. Very few teen-agers have AIDS. For most teens with AIDS, the predominant route of human immunodeficiency virus (HIV) infection was from contaminated blood products received prior to the mid-1980s.19However, 19% and 24% of all cumulated AIDS cases have been diagnosed in the 20- to 29-year-old age group in males and females, respectively.’O A large proportion of those ages 20-29 diagnosed with AIDS were most likely infected as teen-agers because the time between infection with HIV and the onset of AIDS is several years. Many of these young adults became infected via sexual intercourse. Without medical attention, some STDs can lead to permanent body damage. For example, blindness, cancer, heart disease, sterility, and even death can occur. These sequelae do not often occur in adolescence; many of the severe problems may not appear until adulthood. Females suffer more damage from STDs than do males. However, many more males have died from AIDS. Lower genital tract infections among adolescents have their greatest impact in future years. If not treated, cervical gonorrhea and chlamydia lead to pelvic inflammatory disease (PID), often resulting in chronic pelvic pain, infertility, and ectopic pregnancy.’’ More than 1 million U.S. women yearly experience an episode of PID, with about 20% of the cases occuring in t e e n - a g e r ~ . ~Age-specific ~.~~ rates of PID are highest for adolescent females when appropriate adjustments are made for sexual activity.” WestromZ3concluded the risk of PID in the sexually active 15-year-old female is estimated to be 1 in 8. At least 25% of women with acute PID suffer one or more serious long-term sequelae, with tubal infertility being the most common complication. Westrom” reports that younger women appear to have a better fertility prognosis after PID than older women. Ectopic pregnancy following PID is another serious STD sequelae. Ectopic pregnancy has risen dramatically in the U.S.during the past two decades, from less than 10,000 cases in the 1960s to more than 80,000 cases in 1988.10,25 STD organisms, especially chlamydia and gonorrhea, are associated with at least half and possibly 75% of all cases of ectopic pregnancies.*’Cates2’stated though older women have a higher risk of ectopic pregnancy than young women, ectopic pregnancy represents the cumulative effect of recurrent tubal infections, many of which occurred in the teen-age years.
DETERMINANTS OF STD RISK IN ADOLESCENTS STD risk involves not only the factors that determine the probability of having an infected sexual partner, but also those factors that might influence the probability of infection if exposed and the probability of disease and complications if infected. Determinants of risk for these components among adolescents include behavioral, psychological, social, biological, and institutional factors. These risk factors are complex and interrelated, and cumulatively influence STD rates in adolescents. Boyer’’ said the essential first step in controlling STDs in adolescents is to understand the factors that influence risk. Further research on the influence of determinants of STD risk among adolescents is needed. This section briefly describes the major determinants of STDs using selected studies; a more thorough discussion of risk factors can be found in Boyer,’’ Aral and Holmes,’ and Cates.” Behavioral Factors. These factors include sexual behaviors, drug use, and health care behaviors. Of these behaviors, sexual activity is considered the most crucial risk factor for acquisition of STDs.” Sexuality-related risk behaviors include age of first coitus, current and lifetime number of sexual partners, contact with casual sexual partners, frequency and type of coitus, patterns of sexual behavior, and use of barrier prophylaxis. Age of first sexual intercourse has been associated with number of recent and lifetime partners and disease outcomes such as cervical carcinoma. The earlier the coital debut the longer the interval of exposure to different sex partners. CDC’s National Survey of Family Growth reported first coital experience for adolescent females occurred at increasingly earlier ages through the 1970s and 1980s, and that the proportion of coitallyexperienced teen-age females also increased. ’* The YRBS found the reported median age of initial coitus was 16.1 and 16.9 years for male and female high school students, respectively. About one-third of male students and one-fifth of female students initiated coitus before age 15.29 In 1988, adolescents who had sexual intercourse earlier in life reported greater numbers of sex partners.’* For those initiating coitus before age 18, 75% reported having two or more partners and 45% reported having four or more partners. Only 20% of those initiating coitus after age 19 reported having had more than one partner, with 1% having four or more partners. Aral and Holmes’ stated that people who have multiple sex partners over a short time period, such as several months, are at increased risk for gonorrhea, syphilis, chlamydia, and chancroid. They also noted increased numbers of sex partners during a lifetime is associated with a greater cumulative risk for acquiring viral infections such as hepatitis B, genital herpes, genital warts, and HIV. Nineteen percent of students of the YRBS reported having four or more lifetime sex partne~s.’~ In fact, the 15-19 age interval appears to be
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the highest risk interval for exposure to multiple partners.‘ Once teen-agers decide to be sexually involved with others, the use of prevention methods, such as condoms, becomes important. Latex condoms, when used properly, have been found to be an effective barrier against chlamydia, gonorrhea, genital herpes, genital warts, and HIV.30J1Reported use of condoms at coitus by adolescents ranges from 38% to 66%, depending on the ~tudy.’~”~ About 45% of the YRBS subjects reported condom use at last coital epi~ode.’~ Recent studies have indicated that Black teen-age males are using condoms more often (and having intercourse less often) than White m a l e ~ . ~Progress ~ J ~ has been made on increasing condom use among adolescents. Reported use at last intercourse is two to three times higher than reported use in the 1970s.‘ Current surveys indicate less than half of teen-agers who recently used condoms did so all the time.‘ Fineberg” noted sporadic condom use in highrisk settings will frequently result in STD acquisition. Biglan et al” found adolescents who most need to be using condoms - those who are sexual with multiple partners, with partners having many partners, or with partners not known well - are the ones least likely to use them. Drug and substance use is another behavioral determinant of increasing STD rates. For example, there have been recent outbreaks of STDs among adolescents using crack cocaine. A study of 222 teen-age crack users in San Francisco found 41% reported a history of STDS.)~ Crack use promotes high-risk sexual behaviors by temporarily increasing sex drive, and is associated with the exchange of sex for drugs or money. This sexual behavior exposes individuals to multiple partners and creates a “core” group of persons with high prevalence of S T D S . ~ ~ J ~ Though the use of alcohol and non-injected drugs does not directly expose one to STD organisms, their use often decreases the person’s use of STD preventive measures.‘O Failure to use condoms and multiple sex partners have been associated with alcohol and drug use.” Though school-based data apparently indicates a decrease in adolescents’ use of drugs,“ injected drug use remains a serious problem among teen-agers. For the YRBS subjects in grades 9-12, 1.5% reported injected drug use.29 Hence, many students are at risk for HIV infection because they use injected drugs and share their needles. Importantly, the YRBS students with four or more partners were significantly more likely to report injected drug use (5.1%) than were students with fewer lifetime sex partner^.'^ Many adolescents, particularly females, may be at higher risk because they have coitus with persons who inject drugs. The Biglan et a13*study examined the relationship between risky sexual behaviors and other “problem” behaviors. They found adolescents were more likely to engage in high-risk sexual behavior when they also were engaging in other types of problem behavior, including antisocial behavior, cigarette smoking, alcohol use, and illicit drug consumption. They concluded it is important to give attention to “at risk” youth in HIV prevention efforts.
Psychobgical Factors. Several psychological factors, such as self-esteem, self-efficacy, personal values, locus of control, and motivation are associated with STD risk behavior. FisherJ2 stated adolescents’ sexual activities and preventive behaviors appear to be largely influenced by their sexual feelings, thoughts, and fantasies. In adolescents, these factors influence sexual activity and preventive practices. Adolescents possess generalized and stable feelings about sexuality which influence their sexual behaviors. Some adolescents are erotophilic (having mostly positive feelings about sexuality), some are erotophobic (having mostly negative feelings about sexuality), and some fall in between. Fisher“ noted numerous studies indicate erotophobia has been found to interfere with the performance of pregnancy and STD/HIV preventive behaviors. Erotophobia interferes with self-acknowledgement of forthcoming sexual activity and the need for prevention, the learning of preventive information, communication with others about sexuality, performance of preventive acts, and the consistent use of contraception by both genders. A sense of invulnerability encouraging risk-taking characterizes many adolescents Many teen-agers believe they will never come in contact with anyone infected with an STD. Social Factors. Data on the prevalence of STD among adolescents indicate the highest STD rates occur in younger adolecent females, innercity youth, and ethnic minority teens. When STD data are calculated by age and adjusted relative to the proportion of sexually active individuals in the total population, adolescents (particularly females) have the highest incidence of gonorrhea and rates of hospitalizations for PID?7-44945 Inner-city minority teens have high rates of STDs.Black teen-agers, in contrast to White counterparts, are more likely to have been infected with an STD.U.49 Hispanic teen-age females have a higher rate of chlamydia compared to their White counterparts.’O Factors such as poor role models, lack of economic and educational opportunities, and inaccessibility of adequate health care services may contribute to high STD prevalence in these adolescent groups. The environment also contributes to STD risk. The media has glorified sex without counterbalancing prevention r n e s s a g e ~ . ~Further, ~ - ~ ~ cultural ambivalence toward sexuality produces confusing messages for adolescents. Rarely do parents or social institutions encourage adolescents to acknowledge their sexuality and plan for its expression and subsequent preventive responsibilities.’ Biological Factors. The average age for menarche has decreased this century.’‘ Hence, adolescents can begin sexual activity early, increasing the number of years of possible exposure to STDs. Also, the columnar epithelum in the uterine cervix of the young adolescent may not provide as much protection from STDs as the tissue in the mature institutional Factors. Teen-age access to STD services is an important component of prevention. Ideally, medical services should be convenient to adolescents, such as being located in high-risk neighborhoods and in schools. One solution to accessibility is school-based
to prevent risk behavior? Why do teen-agers fail to change health clinics. However, only slightly more than 300 risk-taking behaviors despite knowledge of possible serious schools provided such clinics, with more than one-half health outcomes? The development of effective programs diagnosing and treating S T D S . Fewer ~ ~ than 20% disis hindered by this lack of understanding. Further, the pense any kind of contraception. Despite student suptesting of various educational and counseling approaches port of school-based clinics, they continue to be controfor teen-agers are needed particularly to identify strategies versial, particularly those offering services such as conresulting in sustained behavior modification. The basic dom d i s t r i b ~ t i o n . ~ ~ , ~ ~ needs of science include the development of better ways to Schools have an opportunity to be an important contributor to STD control. Unfortunately, the quality of detect asymptomatic STDs, better antibacterial therapies, school STD education frequently has not been adedevelopment of viral therapies, and development of vaccines for more STDs.’v2I quate. Traditionally, schools have over-emphasized the Education is a major component of STD control in biological/medical aspects of STD and gave inadeadolescents. Certainly, medical services and therapies are quate attention to behavioral messages, health-promoting attitude enhancement, and skill d e v e l ~ p m e n t . ~ ~ central to STD control, but motivating young people to practice STD prevention and risk reduction represents the STD education is insufficiently addressed in state health most desirable and potentially most effective preventi m and sexuality curricula and mandate^.^^,^^ STD approach. Given the importance and opportunity of preventive messages that include risk-reduction, such as educational intervention, the entire next section is devoted condom use, in contrast to the abstinence-only message, to this control strategy. have been subjected to successful censorship With the emergence of HIV infection and AIDS, many schools have centered their attention on EDUCATIONAL STRATEGIES providing HIV/AIDS education, and STD education Educational intervention is essential to combating STD has received inadequate a t t e n t i ~ n .Despite ~~ the fact in adolescents. Effective behavioral prevention programs that most schools include STD education, such educamust be developed based on accepted principles of learntion often is deficient, suffering from inadequate ing, education, and adolescent development and culture. materials and teacher competency, insufficient inImportant guiding principles for STD education for adostructional time, and inappropriate instructional lescents are discussed below. approach.7*64-69-71 Integration with HIV Education. As stated earlier, with the emergence of the HIV and AIDS problem, school CONTROL ST RATEGI ES and public agencies mainly have focused their attention on providing HIV/AIDS education, resulting in minor attenControlling STDs among adolescents is an enormous tion to other STDs. However, educators and the federal challenge, requiring understanding, innovation, commitgovernment are now calling for the integration of STD ment, and resources. To be effective, control strategies education and HIV/AIDS education. Both STDs and HIV must address a variety of important issues. are communicable diseases; transmission and prevention The U.S. federal government has identified several behaviors are similar. This approach will also require less goals for STD control among adolescents in its document, instructional time. Recent educational material has reflectHealthy People: National health promotion and disease ed this integrated a p p r 0 a ~ h . 7 + ~ ~ - ~ ~ s ~ ~ prevention objectives. Goals for reduction of disease Goal and Expected Outcomes. The goal of STD incidence and risk behavior and medical services were instruction is to prepare students to make intelligent, selfdeveloped. directed decisions about their health so they can change or The availability and quality of STD services for adoavoid behavior that puts them at risk for These lescents are important components in controlling the behavioral decisions can be expressed as desired outcomes, spread of STD. Unfortunately,the most vulnerable groups which help guide the instructionalcontent and methodolooften are not being served adequately. Reaching these gy. Following instruction, the student will: groups will require the services of the traditional STD Avoid sexual exposure to STD/HIV. clinics, as well as the involvement of other groups such as Not use injected drugs or share needles. family planning clinics, drug treatment centers, communResist peer pressure to practice risky behavior. ity health centers, public and private hospitals, private Recognize early symptoms of STD/HIV infection. physicians, educational institutions, and social services Avoid exposing others if an STD/HIV infection is organizations. Further, the quality of services at treatment diagnosed or suspected. sites can be improved through improved case manageSeek prompt medical care if an STD/HIV infection ment, age-specific counseling, partner contact tracing, and is suspected. site safety and appeal.7 Follow a physician’s directions if treated for STD/ Innovations in detecting and treating STDs in teenHIV. agers are needed.21For example, firstcatch urine screening Get all sex and drug-use partners to medical care if can be collected from asymptomatic, sexually active adoone has STD/HIV. lescent males undergoing athletic physical examination^.'^ Simpler treatment schedules, like singledose treatment for Be supportive and helpful to persons infected with STD/HIV. chlamydia, also would be helpful.” Research, an important control component, includes Serve as an accurate source of STD/HIV information and advice. both behavioral and basic science research. Further study of factors that influence teen-age sexual behavior would be Serve as a positive role model to others. helpful. For example, what determinants can be modified Seek the help of others concerning STD/HIV issues.
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Promote STD/HIV education, research, and health care.69 Theoreticaland Methodological Approach. Studies on the efficacy of sexuality education and smoking prevention programs for adolescents indicate programs with a theoretical base are the most effective. For example, two new risk-reduction sexuality education curricula (Postponing Sexual Involvement7’ and Reducing the have several prevention benefits and are based on social learning theory, social inoculation theory, and cognitive-behavioral theory. These theories, as well as the health belief model, the value expectancy theory, and the theory of reasoned action, should be considered when developing program^.^^^^^^^^ Interventions based on these theories are behaviorallybased and usually combine selected behavioral-related cognitive messages with the development and practice of social and personal prevention skills. These skills include negotiation with a dating partner, finding health services, and resisting social pressure. Decision-making, communication skills, role playing, positive peer modeling, and clear norms against unprotected sex are emphasized. Unprotected coitus can be reduced by both delaying onset of intercourse and increasing use of condoms. If the goal is to reduce unprotected sex, Postponing Sexual and Reducing the Risk16 can be impleInv~lvement’~ mented. CDC emphasized the behavioral approach to STD education in its document, Guidelines for STD Education.79 In addressing school STD education, CDC said: Quality STD instruction means that students will be taught ways to avoid STD, to recognize STD symptoms, to access STD clinics or other health care providers, to follow treatment instuctions if infected, and to refer all sex partners f o r medical care. A school curriculum which focuses on the teachings of STD biomedical facts detracts from the purpose of STD education and does not represent a quality unit of instruction. FisheP has developed a seven-step model of sequential preventive behavior acts for STD/HIV and pregnancy prevention, which focuses more on increasing protection during coitus. He suggests teen-agers should be taught behavioral skills and should be encouraged to rehearse them until they are firmly in place. To avoid STD/HIV and pregnancy, teen-agers must 1) accept their sexuality, 2) learn relevant preventive information, 3) make an active decision to engage in preventive behaviors, 4) bring up and negotiate prevention with their partners, 5 ) perform more or less public preventive acts, such as condom purchasing and HIV testing, 6 ) consistently practice preventive behaviors and reinforce themselves and their partners for practicing prevention, and 7) be able to shift preventive scripts. This approach requires strong instructor competencies, since methodology beyond the lecture approach is required. The teacher must, for example, be able to lead group activities, to communicate with students, and to create a safe learning environment. Preservice education may be required to enhance teacher skill. Varied Settings. To be most effective, STD educa-
tional programs must reach teen-agers in multiple community settings. Schools, which reach more than 46 million students annually,’ can play a major role in STD education. Nearly all young people will receive STD education if all schools offer it. Youth-serving agencies, like Girls, Inc., Boys Club, and YMCA also can provide STD education. A sizable portion of youth are not served by schoolbased programs. There are approximately 9 million young people ages 14-21 who do not attend school.8o Many of these people have multiple health risks, inciuding risk for STD infection. Reaching this population requires special and innovative efforts. It is important that the content and methodology of STD education account for the heterogeneity and within-group differences among teen-agers. Social and cultural factors, such as religion, values, gender roles, economic conditions, and individual differences must be considered in designing effective programs. Because of differences in the culture of various adolescent groups, an effective educational program for one group may not be effective for another group.z7 Community Involvement. Since school STD education involves sexual issues, many communities have found it beneficial to involve selected community members and students in program policy development and review of instructional materials. This approach usually results in strong endorsement of the program. An STD education committee can handle questions, concerns, and complaints about the program. National surveys indicate most community members endorse a thorough discussion of STD and HIV prevention in schools. For example, 94% of parents believe that public schools should teach about HIV/AIDs, and more than 80% want their children to be taught about safe sex as a way of preventing AIDS.” Sometimes members of the local advisory group or other community members strongly advocate that their particular moral stance related to sexuality be promoted in the curriculum. School officials should be sensitive to these views, but stand firm for a curriculum based on student and public health needs, educational principles, and the philosophy of STD education presented here.69 Instructional Materials and Resources. A need exists for quality instructional materials for STD education. A recent study of more than 4,000 sexuality education teachers found 80% indicated they need more assistance, including better instructional materials, in teaching about STDs.O2 Often state and local health and education departments can help educators identify and develop curricula. Most health and sexuality-related professional organizations can offer assistance. Further, several recent publications represent current STD education philosophy. For example, a checklist of performance standards for HIV/AIDS education curricula for adolescents may be helpful to educator^.^' This publication lists more than 70 criteria for the development of new curricula or the evaluation of existing curricula. Even though the document addresses HIV education specifically, the criteria are nearly universally applicable to the integrated STD/HIV education approach. The World Health Organization recently issued an im-
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portant document on school AIDSISTD education that discusses 17 issues pertinent to the implementation of a school program on AIDS/STD. Issues from gaining acceptance of the program to the content of curricula are addressed." The Sex Information and Education Council of the US. recently published Guidelines for Comprehensive Sexuality Education, Kindergarten - 12th Grade." These Guidelines, developed by a national task force of sexuality and health experts, provides a framework for educators in creating new or improving existing programs. Six key concepts are broken down into 36 topics, of which STDs and HIV infection is one topic. More than 40 messages about STD/HIV are listed. A major contribution of the Guidelines is the delineation of messages at four different developmental levels: early elementary, upper elementary, middle school, and high school. A government-sponsored, prototype STD/HIV curriculum - STDs and HIV: A guide for today's young aduW9 - recently has been developed. This secondary school curriculum, which includes a student manual and instructor's guide, is based on several theoretical approaches shown to reduce risk-taking behaviors. The curriculum is behaviorally-based and integrates both STD and HIV messages. A Component of Comprehensive Health Education. To be most effective, school STD education
should be provided as part of a quality, comprehensive health education program. Such placement is logical since the goal of STD education is to prepare students to make wise health-promoting decisions.69A recent secondary school study found HIV education in health science classes produces more desirable HIV-related attitudes than such instruction in biology classes.*' Ideally, STD education would be incorporated into a unit or course on human sexuality and family life education which is part of a comprehensive health instructional program. Such an arrangement is advantageous since sexuality issues, sexual decision-making, and communication skills can be more thoroughly discussed or taught, CONCLUSION STDs are a serious health problem among young adults, occuring in an estimated one-quarter of sexually active teens. Adolescent females and low-income, urban minority youth are especially affected. Teen-agers are at higher risk for STD than other age groups. The STDs of young adults have their most severe consequences in later life, particularly affecting reproductive health. Teen-agers are at risk of STDs and HIV/AIDS because of their sexual behavior and injected drug use patterns. Early sexual involvement, having multiple partners, and failure to consistently use condoms contribute to risk. Other behavioral patterns, as well as psychological, biological, institutional, and social factors, also enhance STD risk among adolescents. Further identification of determinants is needed. To be effective, intervention programs should consider the determinants of risk, especially social and cultural conditions and adolescent development. Controlling STDs in adolescents involves several
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components, including improved clinical service, research, and education. STD treatment and counseling should be accessible to teen-agers and provided at schools and in neighborhoods when possible. Better diagnostic, treatment, and counseling services can enhance control efforts. Education is an important component in STD control in adolescents. The goal of education is to increase adolescent selfefficiency in practicing STD prevention and risk-reduction. Theory-based programs are likely to be the most effective. STD education also should be sensitive to the unique traits of adolescent subcultures, should integrate HIV messages, and should occur at various community settings. School programs are especially important since they can reach most teenagers. However, special efforts are needed to educate out-Of -school youth . A comprehensive approach including quality education, accessible and effective health clinics, and improved social and economic conditions has the most promise of controlling STDs in adolescents. Providing these conditions is an enormous challenge, requiring committed health professionals and national leaders and adequate resources. References 1. Irwin CE. The theoretical concept of at-risk adolescents. Adol Med State Art Reviews. 1990,l: 1- 14. 2. Aral SO, Holmes KK. Epidemiology of sexual behavior and sexually transmitted diseases. In: Holmes KK, Mardh P-A. Sparling PF, Wiesner PJ, Cates W Jr, Lemon SM, Stamm WE, eds. Sexually Transmitted Diseases. 2nd ed. New York. NY: McGraw-Hill; 1990: 19-36. 3. Strobino DM. The health and medical consequences of adolescent sexuality and pregnancy: A review of the literature. In: Hofferth SL, Hayes C, eds. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing, Vol 11. Washington, DC: National Academy Press; 1987:93-122. 4. Cates W Jr. Teenagers and sexual risk taking: The best of times and worst of times.J Adol Health. 1991;12:84-94. 5. Cates W Jr, Raul JL. Adolescents and sexually transmitted diseases: An expanding problem. J Adol Health Care. 1985;6:257-261. 6, Sexual& Transmitted Disease Surveillance 1990. Atlanta, Ga: Centers for Disease Control; 1991. 7. US Dept of Health and Human Services. Healthy People 2000: National health promotion and disease prevention objectives. Boston, Mass: Jones and Bartlett; 1992. 8. 1989 Annual Report. Research Triangle. NC: American Social Health Association; 1989. 9. Sexual behavior among high school students - United States 1990. MMWR. 1992;40:885-888. 10. Division of STD/HIV Prevention Annual Report 1989. Atlanta, Ga: Centers for Disease Control; 1990. 11. Moran JS, Aral SO, Jenkens WC, Peterman TA, Alexander ER. The impact of sexually transmitted diseases on minority populations in the United States. Public Health Rep. 1989;104:560-565. 12. Batteiger BE, Jones RB. Chlamydial infections. Infect Dis Clin North Am. 1987;1:55-81. 13. Donovan P, Waszak CS. School-Based Clinics Enter the '90s: Update. evaluation. and future challenges. Washington, DC: Center for Population Options; 1989. 14. Hammerschlag MR. Chlamydial infections. J Pediatr. 198%1 14:727-734. 15. Tooney KE, Rafferty MP, Stamm WE. Unrecognized high prevalence of Chlamydia trachomatis cervical infection in isolated Alaskan Eskimo population. JAMA. 1987;258:53-56. 16. Shafer M-A. Prager V. Schalwitz J, Vaughan E, Moscicki B. Brown R, et al. Prevalence of urethral Chlamydia trachomatis and Neirseria gonorrhoeoe among asymptomatic, sexually active boys. J Infect Dis. 1987;156223-224. 17. Becker TM, Stone KM, Cates W Jr. Epidemiology of genital herpes infections in the United States: The current situation. J Reprod
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Impact of a new curriculum on sexual risk-taking. Fam Plann Perspecl. 199 1 ;23: 25 3-263. 77. Allensworth DD, Symons CW. A theoretical approach to school-based HIV prevention. J Sch Health. 1989;59(2):59-65. 78. Flora JA, Thorensen CE. Reducing risk of AIDS in adolescents. Am Psychol. 1988;43:965-970. 79. US Dept of Health and Human Services. Guidelinesfor STD Educalion. Atlanta, Ga: Centers for Disease Control, Division of Sexually Transmitted Diseases; 1985. 80. Roper WL. Current approaches to prevention of HIV infection. Public Health Rep. 1991;106:111-115,
81. Gallup MA, Clark DC. The 19th annual Gallup Poll of the public’s attitudes toward the public schools. Phi Delfa Kappan. 1987;69: 17-30. 82. Risk and Responsibility: Teaching sex education in America’s schools foday. New York, NY: The Alan Guttmacher Institute; 1989. 83. Yarber WL. Performance standards for the evaluation and
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Correction: The Micro Audiometrics ad printed on page 248 of the August 1992 issue of the Journal was misprinted. The ad is reprinted here. We apologize for the misprinting.
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