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INTRODUCTION

Sexually transmitted infections (STIs) are common in adolescents and young adults; they are diagnosed with a disproportionate number of cases, and harbor much undiagnosed disease. Individuals aged 15–24 years make up one-fourth of sexually active individuals in the United States, yet acquired 46.6% of all gonorrhea and 63.1% of chlamydial infections in 2016.1 Less than 10% of high school students have ever been tested for human immunodeficiency virus (HIV) infection.2

Unprotected sexual intercourse and other behavioral risk factors contribute to the acquisition and transmission of STIs. According to the Centers for Disease Control and Prevention (CDC) 2017 Youth Risk Behavior Surveillance System, about 40% of US high school (grades 9–12) students report ever having had sexual intercourse.2 Among high school seniors, nearly 60% report a history of sexual intercourse, and nearly one-third of sexually active seniors report having had at least four sexual partners. Nearly a fifth (18.8%) report having consumed alcohol or used drugs during their last sexual encounter.2 Oral and anal sex with opposite sex partners (regardless of sexual orientation) are reported by both male and female young adults (aged 18–24 years) with sufficient frequency to deduce that adolescent minors also engage in these behaviors.3 Furthermore, the risk of pregnancy accompanies sexual activity; 13.8% of sexually active adolescents used neither condom nor other birth control method at the last intercourse, and only 8.8% reported dual (condom and hormonal birth control) use despite strong recommendations for these protective behaviors.2

Since 1991, the percentage of high school students reporting sexual intercourse onset before the age of 13 years, more than four lifetime partners, and recent sexual activity have all decreased,4 but without a decrease in the common reportable and treatable STIs.1 Sexually active adolescents are at high risk for contracting STIs for a variety of reasons. Many adolescents have a poor understanding of STI transmission, symptoms, and consequences of infection.5,6 The asymptomatic nature of these infections in many patients pose increased risk for transmission, especially when considering adolescent cognitive development. Teenagers are likely to equate the absence of symptoms with the absence of infection. Adolescents overestimate the scope of standard STI testing, complacently believing that they have been tested for “everything,” not just a few organism-specific diseases.7 Combining these conceptual distortions with evidence supporting the protracted maturation of the teenage and young adult brain’s executive function provides further basis for the adolescents’ participation in riskier sexual practices and consequent STIs.8–10

Behavioral, physiologic, and systemic factors contribute. While many adolescents report the use of condoms, they are not necessarily using them consistently2 or correctly.11,12 Condom use at last intercourse decreases from grades 10 to 12. Overall, 46.2% of high school students did not use a condom at their last intercourse. Condom use at last intercourse has decreased from 2003 to 2017, after a steady increase in the previous ...

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