1 Adolescents and STDs Ina Park, MD, MSCalifornia Prevention Training Center And California Department of Public Health
2 Roadmap Overview of Adolescence Sexuality/Sexual BehaviorAdolescents and STD Epidemiology Factors contributing to risk Factors that may protect adolescents
3 ADOLESCENCE: AN OVERVIEWCaveat: Adolescence is a culturally defined phase of life, usually bridging what is considered childhood to adulthood -- many argue that it is becoming longer and longer with young people relying on their parents and deferring physical and financial independence well in to their 20’s or even 30’s
4 Independent, yet vulnerableAdolescents are: Healthy Resilient Independent, yet vulnerable Adolescents are not: Big children Little adults Adolescents PRCH 2012
5 The Culture of AdolescencePeer dependent Egocentric Distinct language and dress Popular culture influence Ongoing search for identity The Culture of Adolescence PRCH 2012
6 Early Adolescence 11–14 Characterized by a spurt of growthBeginning of sexual maturation Start to think abstractly The early adolescent is usually considered 11–14 years old. It is important for physicians to understand the different phases of adolescence in order to connect with the adolescent patient in a meaningful way. For example, counseling a younger teenager about cigarette cessation must be accomplished in a concrete fashion (e.g., focus on bad breath, teeth staining, or the cost of cigarettes) and not with the distant threat of future cancer. As adolescents age and are capable of more abstract thoughts, counseling methods will change. Sources: Forman S, Emans S. Current Goals for Adolescent Health Care. Hospital Physician. 2000;27–42. Adolescent Friendly Health Services: An Agenda for Change. The World Health Organization, Available at: PRCH 2012
7 Middle Adolescence 15–17 Physical changes of puberty are completeDevelop a stronger sense of identity and relate more strongly to peer group Thinking becomes more reflective Mid-adolescents are usually 15–17 years old. PRCH 2012
8 Late Adolescence 18 and olderThe body continues to develop and takes adult form Development of distinct identity and more settled ideas and opinions 18 and above PRCH 2012
10 Poll: What is the average age of first sexual intercourse reported by U.S adolescents?Chat: Which group has the younger age of first intercourse, males or females? (type in chat box)
11 Percentage of High School Students Who Ever Had Sexual Intercourse, by Sex,* Grade,* and Race/Ethnicity,* 2015 MORE than 50% of U.S. adolescents have had sex by the time they reach the age of 18 Average age is 17 for both males/females Data for this slide are from the 2015 National Youth Risk Behavior Survey. This slide shows percentages of high school students who ever had sexual intercourse. The percentage for all students is The percentage for Male students is The percentage for Female students is The percentage for 9th grade students is The percentage for 10th grade students is The percentage for 11th grade students is The percentage for 12th grade students is The percentage for Black students is The percentage for Hispanic students is The percentage for White students is All Hispanic students are included in the Hispanic category. All other races are non-Hispanic. Note: This graph contains weighted results. For this behavior, the prevalence for male students is higher than for female students. The prevalence for 10th grade students is higher than for 9th grade students. The prevalence for 11th grade students is higher than for 9th grade students. The prevalence for 11th grade students is higher than for 10th grade students. The prevalence for 12th grade students is higher than for 9th grade students. The prevalence for 12th grade students is higher than for 10th grade students. The prevalence for 12th grade students is higher than for 11th grade students. The prevalence for Black students is higher than for White students. (Based on t-test analysis, p < 0.05.) *M > F; 10th > 9th, 11th > 9th, 11th > 10th, 12th > 9th, 12th > 10th, 12th > 11th; B > W (Based on t-test analysis, p < 0.05.) All Hispanic students are included in the Hispanic category. All other races are non-Hispanic. Note: This graph contains weighted results. National Youth Risk Behavior Survey, 2015
12 Percentage of High School Students Who Ever Had Sexual Intercourse, 1991-2015*These are results from the National Youth Risk Behavior Surveys, This slide shows percentages from 1991 through 2015 for high school students who ever had sexual intercourse. The percentage for 1991 is The percentage for 1993 is The percentage for 1995 is The percentage for 1997 is The percentage for 1999 is The percentage for 2001 is The percentage for 2003 is The percentage for 2005 is The percentage for 2007 is The percentage for 2009 is The percentage for 2011 is The percentage for 2013 is The percentage for 2015 is 41.2. Significant linear trends (if present) across all available years are described first followed by linear changes in each segment of significant quadratic trends (if present). For this behavior, based on linear and quadratic trend analyses using logistic regression models controlling for sex, race/ethnicity, and grade (p < 0.05), the prevalence decreased from 1991 to 2015. *Decreased [Based on linear and quadratic trend analyses using logistic regression models controlling for sex, race/ethnicity, and grade (p < 0.05). Significant linear trends (if present) across all available years are described first followed by linear changes in each segment of significant quadratic trends (if present).] Note: This graph contains weighted results. National Youth Risk Behavior Surveys,
13 What Is Healthy Sexuality?Sexual development and growth is a natural part of human development Healthy sexual expression is different than sexual risk Risk would be activity that compromises the youth’s health & well being
14 The Abstinence-Only (No-Sex) ParadigmProvides a code, not empowerment Gives limited tools for navigating relationships other than marriage Makes sex between teens hard to discuss when it does happen Despite investment of federal funds, not shown to be effective The abstinence only (until marriage paradigm) stigmatizes adolescent sexuality and all sexual expression outside the context of a heterosexual marriage. The approach makes sex an either–or thing rather than viewing sexual activity as part of a continuum of a repertoire of sexual behaviors through which adolescents act on desires, express feelings, and explore intimacy—and it is a continuum—the first crush, the first kiss, the first date, the first time. The paradigm gives very limited tools for youth to navigate romantic relationships not oriented toward finding a marriage partner. It provides an external code of behavior, not an empowerment to make self-directed sexual choices. The stigma that it attaches to sexual exploration outside the context of heterosexual marriage makes teenage sex very difficult to discuss with adults (parents, health care providers, etc.) when it does happen. For over two decades the US federal government has spent millions of dollars on programs that advocate abstinence until marriage and that withhold information on contraception. These programs often exclude information on even the most basic topics in human sexuality such as puberty, reproductive anatomy, and sexual health, and they have not been shown to be effective. Source last bullet: Trenholm C et al. Impacts of Four Title V, Section 510, Abstinence Education Programs: Final Report, submitted to the U.S. Dept. of Health & Human Services, Office of the Assistant Secretary for Planning & Evaluation. Princeton, NJ: Mathematica Policy Research, 2007.
15 Sex-as-Risk-Taking ParadigmMakes sex a disease rather than part of development Does not distinguish healthy sexual expression from sexual risk Instills fear, not sense of mastery/control Leaves out the pleasurable and relational contexts of sexuality This “sex-as-risk-taking” paradigm tends to focus solely on the negative consequences of youthful sexual expression—STIs, unintended pregnancy, and relationship violence being among them. Not only does this approach fail to distinguish healthy sexual expression from disease and sexual risk, it also instills in youth a sense of fear rather than mastery and control. Moreover, it leaves out the positive and pleasurable aspects sexuality and the skills that youth can gain through their intimate relationships. Even some more comprehensive sexuality education programs have focused only “sex as risk-taking” behavior that can only result in unwanted pregnancies and horrible sexually transmitted infections. Even the way we collect data about adolescents, through the “Youth Risk Behavior Surveillance Survey” is set up to highlight identifying risk as a primary goal. This survey is the leading source on adolescent health from the CDS and is a clear example of this paradigm’s prevalence among public health professionals, clinicians and researchers on adolescent behavior in the U.S.
16 “Sex as Risk” in Current PracticeMedically-derived risk-assessment/prevention, screening, and treatment approach Results in discussions that are based on: Narrow definitions of sexual health Focus on specific sexual behaviors as part of risk-assessment strategy instead of personal development and interpersonal relationships Although there are examples in the literature of sexual-history-taking guides that include discussions on the positive and relational aspects of adolescent sexuality, the dominant themes in the dialogues betweens physicians and adolescents highlight a medically-derived prevention, screening, detection, and treatment approach to adolescent sexuality. Such a schema results in discussions that are based on narrow definitions of sexual health and behavior focused on risk-assessment strategy instead of interpersonal relationships and personal development. It leaves providers without a template for an affirming, empowering, and educational discussion with adolescents about the normalcy of feelings and arousals, choice, sexual decision-making, responsibility, and relationships. Another way to put it is that this “Sex as Risk” paradigm does not open up conversations about sexuality “above the waist,” i.e., the way youth view and experience their sexuality and relationships, which are an important aspect of their sexual health.
17 Sex Is a Secret [My mother] hasn’t asked me [whether I am having sex] and I haven’t told her…I’d rather her not ask me straight out.” —16-year-old American teen Teens keep sex a secret Some parents prefer “not to know” Secrecy weighs especially on girls The final theme in the dramatization of adolescent sexuality is that of sex as a secret. Parents tend to be ambivalent in their communication about sex, conveying that it would be a disappointment to them if their teenage children became sexually active. (Exception to this rule are some fathers about their sons). Some do not address the topic at all, other than to warn against danger. Others may talk about contraception but make clear they do not want their children to have sex. Only half of the girls in this study say their parents have talked with them about contraceptive methods (matches data from the National Survey for Family Growth.) As a consequence of silence, prohibitions, and ambivalence, many young people say that they do—or would not—confide in their parents about sexual activity. This secrecy leads to a disconnection between parents and teens, and especially for girls a kind of psychic “bifurcation.” They experience their roles as “good” daughters and their sexual development in conflict. This is problematic because they carry a “psychic burden” and they are unable to draw on their parents for support to navigate sex and relationships. The theme of secrecy and disconnect is most pronounced for girls, who face greater stigmatization for sex, but also there for boys.
18 A New Paradigm Adolescent sexuality is a normal process of psychosocial and biological development Sexuality is a continuum along which youth move as maturity and relationships permit Adults play vital roles in providing resources and supporting the development of skills The paradigm that will be outlined today differs from the risk and abstinence paradigms that have prevailed. It was developed out of Schalet’s comparative research, but also integrates concepts and research from feminist psychology, public health, and positive youth development. Before going into the different components of the conceptual model, let’s take a look at three underlying precepts, namely that it is normal for adolescents to develop sexually and to start to explore their sexuality in feelings, relationships, and if they so choose, behavior; that sexuality comprises a continuum of feelings and behaviors, and that teens ideally move along that continuum as their maturity and relationships permit; that adults play a vital role in providing the resources (health care, information, etc.) as well supporting the development of the skills youth need to explore sexuality and relationships. The article that will be most useful for this part of the presentation is: Amy T. Schalet “Beyond Abstinence and Risk: A New Paradigm for Adolescent Sexual Health.” Women’s Health Issues 21 (3S); S5–S7.
19 Chat: Which adults/peers have the strongest influence on a teen’s decisions about sex? Type in order in the chat box… Friends Media Parents Religious Leaders
20 The Power of Parents
21 Think back to when you were an adolescent…Holly Howard, 18 Lindsey Clopp, 17 Ina Park, 17
22 Chat: What messages did you hear about sexual activity when you were an adolescent?Type in the chat box
23 ABCD2 = HEALTHY SEXUALITYA New Paradigm ABCD2 ABCD2 = HEALTHY SEXUALITY AUTONOMY (develop sexual autonomy) BUILD good relationships CONNECTEDNESS (foster connectedness) DIVERSITY/DISPARITIES (recognize diversity, reduce disparities) Read what each word stands for: AUTONOMY: Develop sexual autonomy BUILD: Build good relationships CONNECTEDNESS: Foster connectedness. DIVERSITY/DISPARITIES: Recognize diversity; remove disparities Thumbs up if you’d heard of this, thumbs down if you hadn’t
24 Condom Icon Created by: Aha-SoftAdolescents face increased risk for STDs We are going to briefly describe a few of them: Biological Cognitive Behavioral Risk for Sexual Abuse Social/Institutional Condom Icon Created by: Aha-Soft From the Noun Project
25 POLL: What proportion of STDs in the US are attributed to 15-24yr olds?30% 40% 50% 60% 70%
26 CDC STI Estimates 50% of new STIs are among young people 15-24, even though they make up only 25% of the population Source: Young people (ages 15-24) are particularly affected, accounting for half (50 percent) of all new STIs, although they represent just 25 percent of the sexually experienced population. CDC’s analysis suggests that there are more than 110 million STIs overall among men and women nationwide. This estimate includes both new and existing infections. Some prevalent infections – such as HSV-2 and HIV – are treatable but lifelong infections. HPV accounts for the majority of prevalent STIs in the United States. While there is no treatment for the virus itself, there are treatments for the serious diseases that HPV can cause, and vaccines are available to prevent some types of HPV infection
27 Chlamydia — Rates of Reported Cases by Age Group and Sex, United States, 2015
28 Gonorrhea — Rates of Reported Cases by Age Group and Sex, United States, 2015
29 Chlamydia — Rates of Reported Cases Among Women Aged 15–24 Years by State, United States and Outlying Areas, 2015 NOTE: Rates for Guam and the Virgin Islands were calculated by using the 2010 population estimates.
30 Consequences of STIs among Adolescents
36 Risk Factors: CognitiveEarly adolescence: concrete thinking Often unable to plan ahead for condoms Serial monogamy in short relationships leads to multiple partners quickly Personal fable Unable to judge risk for STIs “Other people get STIs” There are several cognitive factors that place adolescents at disproportionate risk for STIs. Early adolescence is characterized by concrete thinking. This can inhibit an adolescent’s ability to plan ahead for the need for condoms. Additionally, it may affect an adolescent’s understanding of the future ramifications of an STI.[i] Having multiple partners is a major risk factors for STIs. In adolescence, most teens are only sexually active with one person at a time which may imply safety from infection. However, adolescent romantic relationships are often very short. Serial monogamy can lead to many lifetime partners and an increase in risk.[ii] Elkind’s (1967) theory of adolescent egocentrism proposes two distinct but related constructs—the imaginary audience and the personal fable. These two concepts are interrelated. The imaginary audience describes an adolescent’s egocetrism and perception that everything they do is being watched and scrutinized by others. The personal fable is an adolescent’s sense of personal uniqueness which can yield a sense of invulnerability commonly associated with behavioral risk-taking. [ii] Sources: Elkind D. Egocentrism in adolescence. Child Development 1967;38: 1025–1034. Ellen JM. Boyer CB, Tschann JM, Shafer MA. Adolescents' perceived risk for STDs and HIV infection. Journal of Adolescent Health 1996;18:77–181 Picture credit: Wall Street Journal (http://www.wsj.com/articles/SB )
37 Risk Factors: BehavioralAge at First Intercourse Sexual Activity with New/Older Partner Multiple Sexual Partners Substance Use Mental Health Women with first sexual intercourse
38 Risk Factors: Intimate Partner ViolenceTeen girls who are abused by male partners are 3× more likely to become infected with an STI/HIV than non-abused girls. Adolescents rarely self-report dating violence and may not recognize their exposure to dating violence as abuse. Direct questions (with yes or no answers) may not be effective. Adapted from, “Hanging out or Hooking Up: Clinical Guidelines on responding to Adolescent Relationship Abuse” by Elizabeth Miller, MD, PhD and Rebecca Levenson, MA. (pg.15) Girls may fear retaliation from partners when notifying them of STI infection Infographic: Elizabeth Miller & Rebecca Levenson. Hanging out or Hooking Up: Clinical Guidelines on responding to Adolescent Relationship Abuse
39 Risk Factors: Social/InstitutionalAdolescent Not Being Treated and Screened Lack of Sex Ed Regarding Risk and Symptoms Lack of Insurance/ $ to Pay Lack of Transportation Concerns About Confidentiality Stigma There also exist many social and institutional risk factors that contribute to adolescents’ disproportionate risk for STIs, including: Lack of sex education regarding how to protect oneself from sexually transmitted infections, including condom use; Lack of insurance or ability to pay for services; Lack of transportation to clinics or doctors offices; Concerns about confidentiality which may inhibit young people from seeking care; Stigma regarding STI testing and diagnosis.
40 Who is most at-risk for an STD? Risk Factors & MarkersSexual practices or behaviors new partner multiple partners partner with other partners casual partners improper or inconsistent condom use earlier age at first sexual activity Young age (15-35) Racial and ethnic minorities are disproportionately affected Substance abusers Exposure to an STD History of certain STDs )
41 STI Protective FactorsPeer support for contraception and condoms Communication with parents about sex Connection to family Connection to school and future success Connection to community organizations
42 ABCD2 = HEALTHY SEXUALITYA New Paradigm ABCD2 ABCD2 = HEALTHY SEXUALITY AUTONOMY (develop sexual autonomy) BUILD good relationships CONNECTEDNESS (foster connectedness) DIVERSITY/DISPARITIES (recognize diversity, reduce disparities) Read what each word stands for: AUTONOMY: Develop sexual autonomy BUILD: Build good relationships CONNECTEDNESS: Foster connectedness. DIVERSITY/DISPARITIES: Recognize diversity; remove disparities