The pediatric and family medicine communities need to do a better job of assessing sexual activity in adolescent patients, screening sexually active teens for sexually transmitted diseases, and counseling them about how to avoid becoming infected in the future.
Recently, a report of data from the 2003–2004 National Health and Nutrition Examination Survey (NHANES) revealed that one in four American teenagers had at least one prior sexually transmitted disease (STD). This should provide strong support for clinicians to incorporate guidelines from the Centers for Disease Control and Prevention and the American Academy of Pediatrics into their practices.
The survey found that 26% of a nationally representative sample of 838 adolescent girls aged 14–19 years were infected with at least one STD, while 15% had more than one. For the entire U.S. population, this translates to more than 3.2 million adolescent girls with human papillomavirus, chlamydia, herpes simplex virus, and/or trichomonas infections. The analysis excluded the prevalence of gonorrhea, syphilis, and HIV infections, although of course our adolescent population can contract those as well.
The data confirm that although the rate of teen pregnancy has recently declined, adolescent sexual behavior remains prevalent. While I'm not aware of data regarding the reasons for the drop in pregnancies among teens, I suspect that it's due at least in part to increased use of birth control, as well as abortion, rather than a large shift away from sexual behavior.
Indeed, teenagers—and even some preteens—are having sex. Clinicians need to ask adolescent patients if they are engaging in sexual behavior, and if so, to test them annually for STDs, screen for HIV (“Screen Sexually Active Teens for HIV,” PEDIATRIC NEWS, February 2007, p. 20) and counsel those who choose sexual activity about how to approach it safely and responsibly. And we need to start early. The CDC found that these infections, especially HPV, occur quickly after sexual debut. In fact, the STD prevalence was already 20% among those who reported just 1 year of sexual activity.
While there were racial differences—48% of black teens had at least one STD, compared with 20% of white teens—we should never assume that any early sexual activity is limited to specific racial or socioeconomic groups. This is an issue for every clinician, whether you practice in an urban, suburban, small-town, or rural setting. Yes, some of your patients are at greater risk than others—but you can't be sure which ones without asking about sexual activity.
Screening should take place annually at routine visits as well as at acute care visits whenever possible. Particularly in the adolescent age group, I think we need to take advantage of every opportunity. Specifically, teens should be asked if they're sexually active, and if so, what kind of activity they engage in, whether it is with members of their own or the opposite gender, and whether they use barrier protection (condoms).
All sexually active teens should be counseled about the importance of condoms and their proper use. For a variety of reasons, condom use is currently quite low among adolescents. Teen boys often don't want to use them because they decrease sensitivity or simply aren't seen as “manly.” An excellent resource for how to talk to teens about condoms is available at www.hws.wsu.edu/healthycoug/Men/condoms.html
Sexually active females should be screened yearly for Neisseria gonorrhoeae and Chlamydia trachomatis using a cervical or urine GC/CT nucleic acid amplification test, with urine being the preferred method today.
For males who have had sex with other males in the past year, an annual RPR (rapid plasma reagin) test for syphilis is recommended, along with annual pharyngeal gonorrhea cultures for those who have engaged in oral sex and rectal GC/CT swabs for those engaging in receptive anal intercourse. Although there are no specific recommendations for heterosexual males, we have learned that STDs can be asymptomatic. Personally I think screening is appropriate because it can be done easily with a urine specimen.
Recent CDC guidelines recommend that all sexually active individuals be screened annually for HIV, beginning at age 13. I endorse that recommendation, although many states have maintained the requirement for written informed consent for HIV testing, which places a barrier to proceeding. At least now all 50 states allow adolescents to sign their own consent forms without the need for a parental signature.
Although screening for HPV is not recommended, we can now offer the HPV vaccine to all of our female patients prior to sexual debut. Potentially, we will soon be able to offer it to our male patients as well.