September is Sexual Health Awareness Month, a perfect time for Pediatricians to discuss this topic with adolescent patients and their parents. This month, tackle your review of sexual health with these high-yield pearls you must know from the Adolescent Medicine & Sexual Health section of our Pediatrics Core.
Special Issues of Adolescents
There are many health and development issues that become relevant when a child reaches adolescence–especially in the areas of sexual development, social development, and mental health. Test questions about adolescence frequently involve sexually transmitted infections (STIs), birth control, menstrual irregularities, pregnancy, testicular pain/masses, substance abuse, injuries, mental illness, emancipation rights, and/or guidelines for preventive health care.
Adolescents receive much of their care in emergency departments, often for non-urgent reasons. In office and clinical settings, adolescents more often seek care for acute episodic illnesses and are often hesitant to agree (or bother) to attend routine preventive care visits. Preventive care visits generally comprise slightly >25% of all visits. The most common reasons for other visits are related to suspected or actual pregnancy, STIs, upper respiratory infections, acute musculoskeletal injuries, and acne vulgaris.
It is important to remember that many adolescents present with a chief complaint that they feel is “more acceptable” or “less threatening” than their true concern; e.f., a 15-year-old adolescent girl who presents with a “sore throat” but has missed a period and fears she is pregnant.
Pregnancy and related conditions account for most female adolescent hospitalizations, dwarfing all other causes.
Prevalence of STIs
On average, teens in the U.S. have sex for the 1st time at 16-17 years of age. Approximately 40% of high schoolers report having had sexual intercourse; 30% report being currently sexually active. Prevalence of current sexual activity increases with age, rising from 10% in 9th graders to 57% in high school seniors. Adolescents and young adults commonly acquire STIs; 15- to 24-year-olds represent 50% of all new STIs. Prevalence rates vary, but 10-25% of sexually active adolescents have C. trachomatis (many are asymptomatic). The reported rates of Chlamydia and gonorrhea are highest among females 15-19 years of age. The incidence of HSV infection is as high as 30% in some adolescent populations; most are asymptomatic. An additional concern is that 20-60% of sexually active female adolescents have HPV infection, predisposing them to cervical cancer.
Prevention
Prevention of STIs include:
- Risk assessment, education and counseling
- Behavioral factors that increase the risk of acquiring an STI include:
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- A recent (within 60 days) new sex partner
- Multiple sex partners; sex partner with multiple other partners
- Sex with partners recently treated for an STI
- No or inconsistent condom use
- Trading sex for money or drugs; sexual contact with a sex worker(s)
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- Vaccination: hepatitis A, hepatitis B, and HPV vaccines
- Accurate diagnosis, treatment, and counseling of adolescents with STIs and their sexual partner(s)
Abstinence is the most reliable way to prevent STIs. However, we are dealing with adolescents (50% of whom are estimated to be sexually active), so a male condom is the cheapest and—thinking “real world” here—the most effective means of prevention available. Use of male condoms has been associated with a decreased risk of transmission of HIV, chlamydia, gonorrhea, herpes simplex virus, and HPV. Female condoms appear to be effective as mechanical barriers for viruses, including HIV; however, no studies have evaluated their effectiveness in the prevention of other STIs. Vaginal spermicides are not effective in preventing STIs, and rectal spermicides increase the risk of transmission because of their role in facilitating damage to the rectal mucosa. Vaginal sponges and diaphragms are protective against cervical gonorrhea and Chlamydia, but not HIV. Additional preventive strategies include antiretroviral therapy to prevent HIV infection and suppressive antiviral therapy of individuals with genital HSV.
Reporting and Confidentiality
STIs on the nationally notifiable diseases reporting list include syphilis, gonorrhea, Chlamydia, chancroid, hepatitis B, hepatitis A, and HIV (confirmed cases and possible perinatally acquired cases). The laboratory or the provider, depending upon the state, is responsible for reporting. STI reports are strictly confidential. In most states, they are protected from subpoena by statute.
Pregnant Adolescents
Test all pregnant women for Rhesus type and antibody screen, hematocrit or hemoglobin and mean corpuscular volume, rubella and varicella immunity, urine protein and urine culture, syphilis, HIV, hepatitis B, and C. trachomatis. Pregnant adolescents with risk factors for gonorrhea or who live in a high-prevalence area should be screened for N. gonorrhoeae. Screen for hepatitis C antibodies in pregnant women at high risk. Routine screening for Trichomonas vaginalis and bacterial vaginosis is not recommended.
Routine screening for HSV infection in asymptomatic women is generally not recommended. Sample any lesions suspicious for HSV for culture and polymerase chain reaction (PCR) testing; cesarean delivery (C-section) to decrease the risk of neonatal infection is indicated only for those patients with clinically apparent infection. If clinically feasible, avoid a fetal scalp monitor during labor when the mother presents with active genital herpes infection.
The presence of genital warts at the time of delivery is not an indication for C-section
Review Everything You Should Know for Sexual Health Awareness Month
Review everything you need to brush up on for Sexual Health Awareness Month in the Peds Core.
For more on diagnosing and treating STIs, potential complications and more, see the Adolescent Medicine & Sexual Health section of our Pediatrics Core. The Core is a perfect refresher for board exams or your daily practice. We'll let you know about other important awareness days and where to go in the Core to brush up.
Already have the Core? Start on page 120 in Book 1 to brush up on the treatment of adolescent issues, developing adolescents, sexually transmitted infections and more.
Have the digital Peds Core? You can search specific terms like pregnancy or STI to bring up all the relevant pages.
