The Issue

Every year, 3 million teenagers -- 13% of all young people between the ages of 13 and 19 -- contract an STD. This represents about 25% of sexually experienced adolescents. Adolescents also have significantly higher rates of sexually transmitted diseases than other age groups. For example:

• Adolescent women are much more likely to have chlamydial infection than older women and are also more likely to have repeat infections.¹
• Men aged 15 to 19 have the second highest gonorrhea rates among men; women 15 to 19 years old have the highest annual gonorrhea rates among women.²
• Gonorrhea and syphilis rates among adolescents, while declining, are disproportionately high for African American youth compared to white and Hispanic youth.³

STD-related services are typically targeted to adult men, rather than constructed to respond to the unique circumstances of adolescents [or women]. Some of the barriers to accessing STD services that are particularly critical for adolescents include location and hours of services, the presence of adults in the clinic, perceived discomfort with invasive diagnostic tests, and the stigma associated with STDs.

Opportunities:

1. Improvements in diagnosis and treatment. Some barriers to seeking health care for adolescents can be overcome through both testing and treatment that have recently become available. For example, urine tests for chlamydia and gonorrhea will provide a non-invasive screening technique that can easily be performed by staff who are accessible and acceptable to teenagers. In addition, single dose oral therapy, as exists for gonorrhea and chancroid, has recently become available for chlamydia, obviating the need for infected adolescents or their partners to take medication for the usual seven days.
2. Advent of school-based and school-linked clinics. Such readily accessible health care settings increase the chances that teenagers will seek health care promptly for diagnosis and treatment of STDs. Since these clinics are comprehensive rather than categorical (i.e. family planning or reproductive health-oriented), the fear of peer-imposed stigmatization based on the service they seek is lessened. School-based clinics also offer the opportunity to link STD diagnosis and treatment to other co-existing health problems.
3. Increased recognition by policymakers and service providers of multi-faceted problems faced by adolescents. Such issues as unwanted teen pregnancy and teen violence have increased the awareness of many decision-makers and service providers about the unique combination of developmental, biological, and psycho-social challenges faced by adolescents.
4. Hepatitis B Vaccine for Teens. Under the Vaccines for Children (VFC) Program, many adolescents and other youngsters (i.e., persons < 19 years of age) -- including those who have an STD or who attend an STD clinic -- are eligible to receive free hepatitis B immunization.

Challenges:

1. Restructuring of health care delivery systems. The movement toward managed care threatens to collapse specialized clinics and services into one system that includes all age groups and all health care services. Since adolescents obtain routine health care less often than any other age group and are even less likely to seek care for stigmatizing health problems such as STDs, elimination of categorical adolescent health care may contribute to an already disturbingly high rate of STDs among teens. Ascendancy of managed care organizations also may threaten the existence of school-based and school-linked clinics as well as other services tailored to meet adolescent needs.
2. Synergy of biological and behavioral changes. Adolescence is the only time in the life cycle when biological and behavioral changes act together, thereby increasing the risk for STDs and their complications. For example, since physical development is not yet complete, adolescent females who are exposed to STDs are probably at greater risk than older individuals for acquiring several of these infections. Changes in the surface structure of the cervix, which occurs during adolescent years, is associated with increased risk of acquiring chlamydia, human papillomavirus, and probably HIV infection.
3. Perception of invulnerability of adolescents. Adolescents typically perceive themselves to be "invulnerable" and under estimate and deny the risks they face. They engage in serial monogamy, are emotionally invested in relationships that are short-lived, and thus are exposed to numerous partners over time.
4. Acceptance of adolescents as sexual beings. Sexual feelings are very normal for adolescents and are frequently acted upon. Many believe it would be best for adolescents to abstain completely from sexual behavior in order to avoid potentially negative consequences, such as unwanted pregnancies, STDs, and HIV infection. Substantial political difficulties in dealing with issues of adolescent sexuality exist in our society.
5. Reaching youth in high-risk situations. Adolescents who are not in school -- including those who neither attend nor have completed school and incarcerated youth -- are at higher risk for STD/HIV infections than adolescents in school. These youth are not easily reached by conventional prevention programs.
6. Reaching lesbian/gay/bisexual youth. The societal stigma associated with being lesbian or gay along with the assumption of heterosexuality in most conventional service delivery or prevention programs increases the likelihood that lesbian/gay/bisexual youth have limited access to health care services.

Recommendations:

1. School-based programs, health departments, and interested care providers should help adolescents better assess their individual risks of acquiring STDs, offer them care services, and facilitate risk reduction behaviors.
2. STD prevention programs should collaborate with those care providers, facilities, and organizations interested in assuring that adolescents receive effective and appropriate health care to identify and reduce the barriers to obtaining STD prevention services that adolescents are likely to confront.
3. Providers likely to see adolescents for health care, including managed care providers, should receive STD-related training that addresses the unique developmental, biological, and psycho-social aspects of these serious health threats.
4. Programs that offer health, education, or social services to adolescents should provide specific and adequate information about how and when to utilize STD prevention and diagnostic services. Furthermore, STD/HIV prevention programs should help adolescents understand that some risks associated with sexual intercourse are age-related and may be specific to young people. Such information may facilitate open and honest discussions about sexual behaviors.
5. Sexual health-related prevention programs should collaborate with existing community-based, innovative efforts to reach out-of-school and gay/lesbian/bisexual youth.

¹Division of STD Prevention, Sexually Transmitted Disease Surveillance 1994, CDC, Atlanta, 1995.

²Ibid.

³Ibid.