The term sexually transmitted infections (STIs) denotes more than 25 infectious organisms transmitted by sexual activity and the myriad clinical manifestations that they can cause. The health consequences range from mild acute illnesses (eg, urethritis or vaginitis) to severe long-term complications (eg, urethral stricture, permanent compromise of reproductive ability) to life-threatening conditions (eg, cancer). Adolescents are particularly vulnerable to STIs because they frequently have unprotected intercourse, are biologically more susceptible to infection, and are likely to have social pressures that substantially increase their risk (Eng & Butler, 1997).

The hidden nature of the processes and the sociocultural taboos related to sexual activity make STIs difficult health problems. These concerns clearly present obstacles to treatment and prevention. Lack of awareness, fragmentation of STI-related services, inadequate training of health care providers, lack of health insurance, and inadequate investment in STI prevention also hinder prevention efforts (Centers for Disease Control and Prevention [CDC], 1995b). Because of their knowledge of patients’ social, cultural, and familial relationships, primary care practitioners who treat adolescents are perfectly poised to have a major impact on the management and prevention of STIs (Lappa, Coleman, & Moscicki, 1998).

The male phallus and its associated ejaculate are ideally suited for transmission of STIs. The skin covering the shaft is a prime location for the festering wounds that accompany many STIs, including herpetic ulcers, syphilitic chancres, and genital warts (human papillomavirus [HPV]). The skin-to-skin or mucous membrane contact that occurs during sexual activity allows for easy transmission of viral, bacterial, or parasitic elements necessary for the propagation of many diseases. Also, the seminal emission during sexual activity can be deposited orally, vaginally, or anally, allowing for passage of various disease-causing agents. Equally damaging is the fact that while the penis can be free of any obvious abnormalities and the affected male asymptomatic, he can still transfer infective organisms to his sexual partner.

These infections often affect the male urethra, testes, and epididymis. These structures are contiguous, so simple urethritis can easily evolve into a serious case of epididymo-orchitis. Furthermore, long-term consequences of infection of these structures can lead to significant health problems, such as urethral stricture, scrotal/testicular abscess, and male-factor infertility. In the female, vaginal and cervical infections may lead to pelvic inflammatory disease (PID) and the potential for tubo-ovarian abscess, ectopic pregnancy, and infertility.

Because STIs are the most commonly reported infectious diseases in the world, they constitute a persistent major public health problem (World Health Organization, 1992). More than 68 million Americans (25% of the population) now have an incurable STI, including herpes, HPV, hepatitis B, and human immunodeficiency virus (HIV). By age 24 years, one in three sexually active people in the United States has had an STI. One in five Americans older than 12 years has genital herpes (Hopkins, 1998). The impact on individuals, their contacts, and society is staggering. Each year, an estimated 15 million new STIs occur, and approximately 3 million American adolescents will contract an STI (Joffe, 1997). Without even considering the tremendous impact of HIV, the average yearly cost of STIs in the United States is about $10 billion. Annually, the cost of HIV alone is nearly $7 billion (Gunn, Rolfs, Greenspan, et al., ). In terms of human suffering, the cost is immeasurable.

Adolescents (ages 15–19) are second only to young adults in terms of numbers of STIs reported annually. More young people are developing STIs during their teen years than ever before. In many countries, more than half of the adolescent population has unprotected intercourse before age 16 years (The World’s Youth, 1994). Furthermore, more than 60% of HIV infections in many developing countries occur among individuals ages 15 to 24 years (Sernderowitz, 1995).

As huge numbers of teenagers engage in sexual activity and with adolescents often having nonchalant attitudes for risk-taking behaviors, it is no wonder that 3 million cases of adolescent STIs occur every year. A recent publication regarding adolescent perceptions noted that 59% did not believe that oral sex constituted having “had sex.” An astounding 19% responded similarly regarding penile–anal intercourse (Sanders & Reinisch, 1999).

The clinical and sexual histories are the primary components that help providers effectively and efficiently estimate a patient’s risk for STIs. Seventy percent of adolescents state that they would like to discuss sexual health with their practitioners, but less than 50% say that they have done so (Moscicki, Millstein, Broering, et al., 1993). The purpose of the history in an asymptomatic adolescent is to elicit behavioral risks that guide clinicians in ordering appropriate screening tests and to provide the opportunity for preventive counseling. In symptomatic patients, the history should elicit symptoms and behavioral risks. While simple on the surface, these discussions can be quite challenging (Lappa et al., 1998).

The practitioner must establish a trusting alliance with the patient to facilitate an open discussion on very sensitive and private matters. For some adolescents, a primary care practitioner who has a long-term relationship with the family already may have established that trust. For others, however, this family relationship may engender the fear of disclosure to the patient’s parents. The caregiver must be aware of these concerns and assure the adolescent of confidentiality. It is often necessary and appropriate to excuse the parent during the sexual history evaluation. Studies demonstrate that adolescents guaranteed confidentiality are far more likely to volunteer sensitive information vital to the success of taking the sexual history (Ford, Millstein, Halpern-Felsher, et al., 1996).

Once the practitioner–patient relationship is solid, sexual history taking should first focus on a general discussion of normal physical development, a primary concern to most adolescents. Providers should discuss variations in development and discourage comparisons to peers.

Once suspicions for STIs arise or patients volunteer such information, then providers should undertake specific questioning to elicit behavioral risks. Behavior risks that are key to STI history are early age of sexual activity, multiple partners, history of sexual abuse or rape, lack of condom use, homosexuality or bisexuality, anal sex, history of past STIs, substance abuse, and use of sex in exchange for money or food (Lappa et al., 1998).

Specific conditions and their management are discussed in the following section. With any condition, providers should always approach the patient with sensitivity and understanding.

Prevention of STIs among sexually active adolescents is of the utmost importance, given the significant health and financial issues involved. In addition, viral STIs, such as herpes, condyloma, hepatitis, and HIV, must be prevented, because no true cures exist. Effective prevention programs must be multidisciplinary, involving the clinical, basic, and social sciences.

While abstinence will clearly prevent the transmission of STIs, this goal seems unrealistic. According to the CDC, two thirds of 12th graders and nearly 40% of eighth graders report having had sexual intercourse. Seventy percent of male teenagers ages 14 to 19 years who attended teen health clinics reported having more than one sexual partner during the previous year (Kegeles, Adler, & Irwin, 1988). Furthermore, nearly 25% of high school males report having more than four sexual partners during their adolescence (Kann, Warren, Harris, et al., 1995).

Three levels of prevention exist. Primary prevention involves reducing the actual incidence of new cases of STIs. This level of prevention should take place in arenas easily accessible to adolescents, such as schools and the media. Secondary prevention is aimed at reducing the number of current cases of STI through early detection and effective treatment. Finally, tertiary prevention is aimed at diminishing the biologic and psychological complications of STIs and preventing the long-term sequelae of these diseases (Ehrhardt, Fishbein, Washington, et al., 1990).

Specific prevention messages must be tailored to each patient and his or her specific risks. Caregivers should be direct and clear when giving advice on measures one can
take to prevent the acquisition and transmission of STIs (Bishop-Townsend, 1996). While it is easy to tell an adolescent that abstinence is the best way to avoid STIs, programs espousing this approach have never been shown to delay intercourse or reduce its frequency (Christopher & Roosa, 1990).

Some programs, often led by adolescents themselves, have attempted to deter early intercourse by emphasizing the risks and consequences of STIs and unwanted pregnancies. Studies have shown that these programs did consistently raise the knowledge level but also failed to reduce unprotected intercourse or pregnancy (Dawson, 1986). Other programs promote safer sex as a means of decreasing the transmission of STIs. The promotion of condom use is easy, yet data from the national Youth Risk Behavior Surveys revealed that only 50% of adolescents between 1991 and 1995 used condoms “at last intercourse” (Warren et al., 1998). A more extensive discussion of these prevention programs is beyond the scope of this chapter. It should be noted that recently, the first randomized controlled trial of an abstinence intervention compared with a safer-sex intervention revealed that the latter program was clearly superior in reducing unprotected sexual intercourse among adolescents (Jemmott, Jemmott, & Fong, 1998). No other programs have yet proved successful in reducing the level of unprotected sexual intercourse among adolescents.

While the problem remains rampant, signs are encouraging. Between 1993 and 1996, gonorrhea rates dropped 35% among males ages 15 to 19 years. In addition, between 1991 and 1997, the percentage of adolescents who reported ever having had intercourse decreased, and the prevalence of condom use among sexually active teenagers increased (CDC, 1998). The combined efforts of families, schools, community organizations, religious organizations, and health professionals have made these improvements possible.