Many Youth Face Grim STD Risks

Adolescents need skills and self-confidence to abstain or reduce

Network: 2000, Vol. 20, No. 3

Preventing HIV infections among adolescents is an excellent strategy for slowing the AIDS pandemic. About a third of the world's 34 million HIV-positive people are between 10 and 24 years old. In most parts of the world, most new HIV infections are among adolescents, particularly among females. Notably, a substantial number of pregnant adolescents in sub-Saharan Africa are infected. Moreover, about a third of the 333 million new sexually transmitted disease (STD) cases each year -- excluding HIV -- occur among people younger than 25, and recent data suggest that the adolescent STD epidemic is growing, adds Dr. Willard Cates, Jr., president of FHI and an expert on STDs.¹

"Younger people are more likely to adopt and maintain safe sexual behaviors than are older people with well-established sexual habits, making youth excellent candidates for prevention efforts," says Dr. Cates. "Reducing adolescent infections will ultimately result in fewer infections among all age groups."

However, many interrelated and complex factors that put adolescents at risk of STDs will not be changed easily or quickly. In many settings, these include poor education, unemployment and poverty. Also, urbanization tends to disrupt family relationships, social networks and traditional mores, while generating more opportunity for sexual encounters.

Adolescents in some places tend to delay their sexual debut, but others begin to have sex quite early. This is important because teenagers who have an early sexual debut are more likely to have sex with high-risk partners or multiple partners and are less likely to use barrier methods of contraception such as latex condoms, which offer STD protection.²

In an analysis of studies of adolescent sexual risk-taking in several developing countries, sexual debut as early as nine years was reported in Zimbabwe. In Chile, a third of young people reported having had sex before age 15. In the analysis, today's young people in Cambodia were becoming sexually active at younger ages than in the past. And in Costa Rica and Colombia, a trend among youth to have a wider repertoire of practices (anal and oral sex) was noted.³

Also putting both male and female adolescents at risk of STDs is their lack of information about sexual matters, as well as STD prevention, symptoms and treatment.

Approximately one quarter of some 1,000 students surveyed in Karnataka, India, mistakenly thought that a vaccine and a cure for HIV infection existed,⁴ while half of 970 secondary-school students surveyed in Nigeria did not know that HIV causes AIDS.⁵ In a survey of more than 300 U.S. college students, the majority of students knew little about human papilloma virus (HPV) infection, transmission or prevalence, although HPV infection is the most common STD in this age group and the primary cause of cervical cancer.⁶

Risk perception

Even when adolescents have accurate knowledge about STDs, they often do not heed warnings to reduce risky sexual behaviors. Some adolescents at high risk, for example, do not adopt safer behaviors because they incorrectly perceive their risk as low.

Familiarity with a sexual partner often leads to a perception of decreased risk. In a study from Malawi, girls perceived little risk in having sexual relations with a boy whose mother knew their family.⁷ In U.S. studies, adolescents assumed that STD prevalence among their close friends was lower than among other teens and were surprised if they became infected by a close friend.⁸ In one U.S. study of some 200 college students, inconsistent condom use was strongly associated with the belief that sexual partners were uninfected with HIV or other STDs. These beliefs were based on individuals' perceptions that they "knew" their partner's sexual history or "just knew" their partner was safe.⁹

"College students are a highly educated population," says Dr. Diane Civic, author of the report and a research associate at the U.S.-based Center for Health Studies in Seattle, WA. "Clearly, however, 'just knowing' that a partner is safe does not provide factual information on their HIV/STD status. Likewise, knowing a partner's sexual history does not ensure that they are disease-free."

Perceived risk can also decrease as a relationship matures. While half of the 200 U.S. college students in this study reported consistent condom use in the first month of their sexual relationships, condom use decreased as relationships progressed.

Also affecting perceived risk, says FHI's Dr. Cates, "is the tendency for adolescents in steady relationships to be more concerned about preventing pregnancy than the risk of contracting an STD. As oral contraception use increases, condom use decreases. However, dual protection against both STDs and pregnancy is best achieved by using both male condoms and effective female contraceptive methods."

Other adolescents at high risk may not adopt safer behaviors simply because they are passing through a stage of life in which risk-taking is particularly attractive. Many adolescents either feel they have nothing to lose or feel they are invulnerable and cannot lose. Others are strongly influenced by peers. As one respondent in a field study conducted in Kenya commented: "The youngsters of the new generation really look at sex like it is an 'in thing.' You know it is 'macho' now to go to bed with a woman. Even if it is going out for a social drink, you end up in the bedroom. The bottom line is that you will have sex."¹⁰

Condom access and skills

To avoid acquiring STDs, adolescents need to have the skills and self-confidence to either abstain from sexual relations or to use condoms consistently and correctly.

"Even boys should learn to say 'no' to risky sex," wrote Fred Otimgu, a student at St. Joseph's College in Layibi, Uganda, in a recent issue of Straight Talk, a newspaper for students that encourages youth to wait to have sexual relations or to use condoms. "When I suggested to my girlfriend that we use a condom and she refused, I left her because of my fear of HIV/STDs."

Correct and consistent use of latex condoms is the most effective means of preventing STD infection among sexually active people who are at risk. In many settings, condom use among adolescents has been increasing. However, adolescents may have difficulty obtaining condoms and knowing how to use them correctly.

Most 16- to 22-year-old participants in focus group discussions held in South Africa as part of a commercial marketing initiative said they did not use condoms due to lack of availability. Most of the 78 participants simply did not have the courage to ask for condoms at pharmacies and clinics. "Many said they were tired of being told that they should not be having sex or being refused condoms because the person who is supposed to be distributing them imposed their morality on the youth," says an HIV-positive man who helped conduct the focus groups.

For this reason, he said in an interview, "condoms need to be available wherever youth gather or 'hang out.' Also, most participants reported that they would prefer to purchase their condoms from their peers or younger sales people -- not someone who is old enough to be their parent. They would also prefer to get condoms from vending machines in such places as game arcades, public toilets, night clubs, music shops or Internet cafes."

Inexperience with condoms is another problem. Often unfamiliar with condoms and apt to engage in spontaneous sex, adolescents may have problems anticipating intercourse and putting on the condom in a timely manner. Peer-group pressure plays a role, either facilitating or inhibiting condom use. "Issues of image seemed to outweigh risks," says the HIV-positive man who helped conduct the South African focus groups. "If obtaining or using condoms was too embarrassing, boring or silly, they would prefer not to use them."

Girls more vulnerable

In developing countries, up to 60 percent of new HIV infections are among 15- to 24-year-olds, with generally twice as many new infections in young women than young men.¹¹ Recent studies in several African populations indicate that 15- to 19-year-old girls are five or six times more likely to be HIV-positive than boys their own age. In one area of Kenya, 22 percent of 15- to 19-year-old girls in the general population were HIV-infected, compared with just 4 percent of boys of the same age.¹²

Similarly, the reported incidence of syphilis, gonorrhea and particularly chlamydia has been generally higher among female teenagers than among males the same age throughout 16 developed countries (the United States, Canada, and 14 in Europe).¹³ For developing countries, very little age- or sex-specific data are available for STDs other than HIV.¹⁴

Why are young women more vulnerable than young men -- or older women -- to STD infection? In the adolescent female, a specific type of cell lining the inside of the cervical canal extends onto the outer surface of the cervix, where exposure to sexually transmitted pathogens is greater. These cells are more vulnerable to infections such as chlamydia and gonorrhea. As women age, this vulnerable tissue recedes and usually no longer extends onto the outer surface of the cervix.

Adolescent girls are also infected with HIV more often than are adolescent boys because many have sex with older men, who are more likely to be infected than adolescent men.¹⁵ Older men are more likely than younger men to be able to give gifts, money or favors. "The girl's friends can tell her that John bought shoes for her, Peter bought lipsticks, Lawrence bought earrings," says a participant in adolescent focus group discussions held in Benin City, Nigeria. "They will then say if she was going out with only Lawrence, who would have bought her the shoes and lipsticks?"¹⁶ Also, surveys show that young women are less likely than males of the same age to report condom use.¹⁷

Young male adolescents also face risks. In developing countries, older men, family members or peers often encouraged young men to begin having sex, often with potentially high-risk partners: sex workers, other men or older women.¹⁸ In Uganda, older women appear to seek younger boys for sexual favors¹⁹ and, in Malawi, younger boys seek older women.²⁰ In Mexico, Guatemala and Jamaica, most of young males' first sexual relationships have been reported to be with older women. In Mumbai, India, research indicated that older married women are sexual partners of some young male adolescents from the neighborhood.²¹ In addition, some young boys have sex with men. Often, relations involve unprotected anal sex, which can cause abrasions and cuts through which HIV can pass into the receptive partner's bloodstream.

In-depth interviews in Karachi, Pakistan, by a group promoting sexual health, called Aahung (an Urdu word meaning "harmony"), suggest that adolescent boys from low-income communities are at least as vulnerable to STDs as are girls. "Boys have much more freedom to experiment," said Shazia Premjee of Aahung in an interview.

"Boys also have more access to information about sex," she says, "much of which is filled with myths and misconceptions that lead to unhealthy behaviors. Unlike girls -- who generally are not allowed to leave the home unaccompanied after puberty and receive guidance from older, female members of the family -- boys do not talk about sexual health with adults in their households. Sexual misconceptions, therefore, are not corrected. Also, many of the boys we interviewed had had various sexual experiences with members of the same sex."

Both young men and women sell sex. But, unlike male adolescents who often become prostitutes voluntarily, girls usually do so against their wishes. In Thailand, young girls most commonly sell sex because their parents urgently need money.²² Young sex workers are at a higher risk of acquiring an STD than older prostitutes because they have less power to negotiate condom use with partners. The consequences can be grim. In Cambodia, for example, nearly a third of sex workers ages 13 to 19 years are infected with HIV.²³

Meanwhile, a substantial number of girls have sexual relations because they are physically coerced: In various populations, between a quarter and a third of young women report having experienced coerced sexual relations. The plight of the world's 100 million street children -- most of whom are between 11- and 14-years-old and live in the large cities of developing countries -- is even more bleak. In Guatemala, 95 percent of street girls had experienced sexual abuse. In Brazil, street youth are considered to be at high risk of HIV or STDs in part because of very early sexual debut, frequently the result of coercion.²⁴

Anal intercourse presents the greatest risk of sexual HIV transmission.²⁵ However, in numerous studies, heterosexuals have been found to use condoms less often for anal sex than for vaginal sex. ²⁶ Furthermore, a study among 800 sexually active New York City adolescents ages 13 to 21 years showed that females practicing anal sex (about 14 percent of the 483 women in the study) were less likely to use condoms with a non-steady -- and potentially more risky -- partner. Of young women who practiced anal intercourse, 84 percent never used condoms with steady partners, but even more -- 96 percent -- never used condoms with casual partners.²⁷

STD complications

STD treatment for adolescents is often inadequate for a variety of reasons, including the fact that many adolescents do not know about available services. Services may also be inaccessible because clinics are far away or have limited hours; tests and drugs may be too expensive; female adolescents may fear pelvic examinations (even though such exams may not be necessary); young people may be too embarrassed or feel too guilty to seek treatment; and health providers may be reluctant to serve adolescents. Health facilities in places as diverse as Antigua, Senegal and Thailand have been found to deny adolescents privacy and confidentiality, and staff have been rude in some places.²⁸

Not surprisingly, many adolescents with STD symptoms avoid established clinics. Adolescents from Benin City participating in focus group discussions reported that they first sought care from traditional healers or patent medicine dealers. Locally available herbs, roots, soda, and combinations of salt, potash, gin, lime and pepper fruit were mentioned more frequently than antibiotics as ways of treating STDs, especially by males.

Pregnant Adolescents Who Are HIV-positive
Percentage (15-19 years of age)
Botswana	28%
Kenya	21%
South Africa	13%
Uganda	11%
Zimbabwe	30%
Sources: World Health Organization; Joint United Nations Programme on HIV/AIDS; Kenya Girl Guides Association.

Correct diagnosis and treatment of STDs is particularly challenging among young women, since such STDs as gonorrhea and chlamydia are often asymptomatic. Female adolescents with symptoms tend to delay seeking help, compared with older women.²⁹

Delay or lack of treatment of STDs can have serious, even fatal, consequences. Untreated STDs -- particularly chlamydia and gonorrhea -- can cause pelvic inflammatory disease (PID) throughout the upper genital tract. Inflammation and scarring from this infection can either block the fallopian tubes or damage the tubal lining. Long-term consequences include chronic pain, tubal infertility or life-threatening ectopic pregnancy.

Not only is PID more common among sexually active female adolescents than older sexually active women, but female adolescents are more likely to be infected again and to experience a recurrence of PID. This is because, by beginning sexual activity early, they have more time to be infected. Repeated infections increase the risk of infertility.³⁰

Given PID's potentially severe consequences, including infertility and death, physicians should start treatment in all sexually active adolescents with presumed PID -- those experiencing lower abdominal pain with adnexal and cervical motion tenderness -- if other causes are not identified. Additional symptoms that support the diagnosis of PID include a fever (an oral temperature greater than 38 C or 100.4 F), leukorrhea (greater than 10 white blood cells/high-power field), and laboratory documentation of cervical infection with C. trachomatis or N. gonorrhoeae.³¹

If an STD-infected adolescent becomes pregnant, the disease can be transmitted to her fetus or infant. Bacterial vaginosis and trichomoniasis are related to preterm delivery and low-birthweight infants.

The following STDs can cause a variety of diseases in infants -- gonorrhea can cause conjunctivitis, sepsis and meningitis; chlamydia can cause conjunctivitis, pneumonia, bronchiolitis and otitis media; syphilis can result in congenital syphilis and neonatal death; hepatitis B can cause hepatitis and cirrhosis; herpes simplex virus can cause disseminated, central nervous system and localized lesions; and human papilloma virus can cause laryngeal papillomatosis. HIV can cause pediatric AIDS. Up to one in every three pregnant adolescents in some settings is HIV-infected.

-- Kim Best

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