Adolescent sexuality and reproductive health: where are we in 2004?

Abstract

This issue of the Journal is devoted exclusively to articles in the area of adolescent sexuality and reproductive health. These 14 articles highlight a number of the critical issues associated with the emergence of sexuality during adolescence and young adulthood. To put these papers in perspective, the most recent United States data on adolescent sexuality and reproductive health (11 of the 14 papers in this issue of the Journal are from the United States) is encouraging, with some specific caveats. I would welcome hearing from our international colleagues to help our readers gain a more global view of adolescent sexuality and reproductive health. Adolescent pregnancy rates are at their lowest level in over decade with a rate of 85.6 per 1,000. This rate represents a 27% decrement over the past decade from 116.9 per 1,000 in 1990. Associated with this decrease in pregnancy rate, the birth rate has dropped to 48.7 per 1,000, and the abortion rate has also fallen to 24.7 per 1,000 (1Ventura S.J Abma J.C Mosher W.D Henshaw S Revised pregnancy rates, 1990–97, and new rates for 1998–99 United States.National Vital Statistics Reports. 2003; 52: 1-15Google Scholar). The good news about the pregnancy rates is accompanied by good news in the area of postponement of initiation of sexual intercourse, and use of contraception: more adolescents are delaying the initiation of sexual intercourse and those who are initiating are more likely to use some form of contraception. Data from the current Youth Risk Behavior Surveillance System (YRBSS) report that 45.6% of high school students have had sexual intercourse once and that of those who have initiated sexual intercourse, almost 58% have used a condom at last intercourse (2Brener N Lowry R Kann L et al.Trends in sexual risk behaviors among high school students —United States, 1991–2001.MMWR Morb Mortal Wkly Rep. 2002; 5: 856-859Google Scholar, 3Grunbaum J.A Kann L Kinchen S.A et al.Youth risk behavior surveillance— United States, 2001.MMWR Morb Mortal Wkly Rep. 2002; 5: 1-62Google Scholar). Once again, rates of initiation of sexual intercourse have dropped by 16% over the past decade. This good news cuts across all racial and ethnic groups; however, Black and Hispanic adolescents have much higher rates of pregnancy than their same age White peers. Rates of initiation of sexual activity gathered by the YRBSS indicate that by 9th grade, Black and Hispanic adolescents are much more likely to have reported sexual intercourse than their White peers. However, by 12th grade, the differences among racial and ethnic groups are far less pronounced, with all racial and ethnic groups appearing more similar. With regard to condom use, Black adolescents report the highest rates of condom use of any racial and ethnic group and White Nonhispanic adolescents are the most likely to use oral contraceptives (3Grunbaum J.A Kann L Kinchen S.A et al.Youth risk behavior surveillance— United States, 2001.MMWR Morb Mortal Wkly Rep. 2002; 5: 1-62Google Scholar). The data on sexually transmitted infections (STIs) is mixed. Rates of reported gonorrhea in adolescents have fallen dramatically over the past decade; dropping to a rate of 476.4 per 100,000 in 2002 as compared to 1,114.4 per 100,000 in 1990. This is a 57% decrease in a little over ten years. The decreasing rate cuts across all ethnic and racial groups, although Black adolescents still account for over three-quarters of the adolescent cases (4Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 2003. Tables 12B, 22B, 35B. Available at http://www.cdc.gov/std/stats/toc2002.htm, Accessed March 09, 2004Google Scholar, 5Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 1994. Tables 9B, 21B. Available at http://wonder.cdc.gov/wonder/STD/Title3000.html. Accessed March 08, 2004Google Scholar). With regard to Chlamydia, the rates of reported infection continue to rise. In 2002, the rates were reported at 1,483 per 100,000, a 37% increase since 1996 (4Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 2003. Tables 12B, 22B, 35B. Available at http://www.cdc.gov/std/stats/toc2002.htm, Accessed March 09, 2004Google Scholar, 6Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 2001. Table 11B. Available at http://www.cdc.gov/std/stats00/toc2000.htm. Accessed March 09, 2004Google Scholar). The increase is probably due to a number of different factors: the institution in 2000 of universal reporting of Chlamydia as a reportable STI to public health departments, better screening techniques and the institution of screening for Chlamydia as a Health Plan and Employer Data Information Set (HEDIS) measure as a quality of care indicator for health plans (4Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 2003. Tables 12B, 22B, 35B. Available at http://www.cdc.gov/std/stats/toc2002.htm, Accessed March 09, 2004Google Scholar, 6Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 2001. Table 11B. Available at http://www.cdc.gov/std/stats00/toc2000.htm. Accessed March 09, 2004Google Scholar, 7National Committee on Quality Assurance: HEDIS 2002: Technical Specifications, Volume 2. Washington, D.C.: National Committee on Quality Assurance, 2002Google Scholar). Vesely and her colleagues in this issue of the Journal offer a theoretical explanation for the good news on sexual behavior and its outcomes (8Vesely SK, Wyatt VH, Oman RF, et al. The potential protective effects of youth assets from adolescent sexual risk behaviors. J Adolesc Health 2004;34:356–65Google Scholar). This paper supports a growing body of literature on the importance of positive youth development and the protective factors that these assets may have on promoting a delay in the initiation of sexual intercourse. Equally important, the study provides a more expansive view on the value of positive youth development in encouraging responsible sexual behavior, the use birth control use with the onset of sexual activity. These cross sectional data do not provide causal links, but give us a roadmap for further investigative work. Two other papers in the Journal continue to affirm the high rates of STIs in “at-risk” populations and the need for improving outreach, education and continuous screening in our most vulnerable adolescents. DiClemente and his colleagues studying a group of African-American pregnant adolescents reported a prevalence rate of 23.5% for one of the three STIs assessed by nucleic acid amplification testing or for syphilis as assessed by RPR (9DiClemente RJ, Wingood GM, Crosby RA, et al. A descriptive analysis of STD prevalence among urban pregnant African-American teens: Data from a pilot study. J Adolesc Health 2004;34:376–83Google Scholar). Even though most adolescents were knowledgeable about the use of barrier methods to prevent STIs, these pregnant adolescents were ineffective at using condoms to prevent STIs. In another study from Canada, Shields and her colleagues report a prevalence rate for Chlamydia of 8.6% in street youth, a rate almost 9 times higher than that reported in the general Canadian youth population (10Shields SA, Wong T, Mann J, et al. Prevalence and correlates of chlamydia infection in Canadian street youth. J Adolesc Health 2004;34:384–90Google Scholar). An Adolescent Health Brief in the Journal this month helps us to further understand how to access at-risk populations and make certain that they get screened. Chacko and her colleagues propose the use of a Transtheoretical Model to understand strategies to improve STI screening. Even though this model may be helpful in assisting with the process of self disclosure and screening, one of the study's important findings is the critical importance of the need for privacy in STI screening (11Chacko MR, Von Sternberg K, Velasquez MM. Gonorrhea and chlamydia screening in sexually active young women: The process of change. J Adolesc Health 2004;34:424–27Google Scholar). Privacy may itself not enable adolescents to utilize the resources that are traditionally used in the Transtheoretical Model. Ford and her colleagues recently examined the possible use of self-test urine screen tests for STIs in nontraditional settings. Clearly, these settings may facilitate the opportunity for privacy in screening since the young person can initiate the testing herself/himself outside of the traditional clinical setting (12Ford CA, Jaccard JJ, Millstein SG, et al. Young adults' attitudes, beliefs and feelings about testing for curable STDs outside of clinic settings. J Adolesc Health 2004;34:266–9Google Scholar). Given that many of the adolescents who need to be tested are high risk, the use of these self-tests presents some positive opportunities to screen youth. However, these tests pose some logistical problems in making certain that we develop effective outreach programs for treatment and follow up for our most vulnerable youth. Two additional papers and one commentary from the International Community further emphasize the importance of community-based programs, school-based interventions, and explicit government policies. Lou and his colleagues in China demonstrate the positive effect of a comprehensive sex education and reproductive health program on increasing contraceptive use at the onset of sexual intercourse for both males and females (13Lou CH, Wang B, Shen Y, et al. Effects of a community-based sex education and reproductive health service program on contraceptive use of unmarried youths in Shanghai. J Adolesc Health 2004;34:433–40Google Scholar). The unique qualities of this intensive program include information, counseling and skills building with sustainable results 20 months following conclusion of the program. In a study from Zambia, Agha and Van Rossem find much more modest effects from a single session school-based peer sexual health intervention (14Agha S, Van Rossem R. Impact of a school-based peer sexual health intervention on normative beliefs, risk perceptions and sexual behavior of Zambian adolescents. J Adolesc Health 2004;34:441–52Google Scholar). A commentary about Uganda highlights the effectiveness of a national strategy to reduce human immunodeficiency virus (HIV) (15Blum R.W Uganda AIDS Prevention: A,B,C and politics.J Adolesc Health. 2004; 34: 428-439Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar). Assisting young people to make responsible decisions will require efforts that are comprehensive and culturally sensitive if we intend to achieve outcomes that are sustained over time (15Blum R.W Uganda AIDS Prevention: A,B,C and politics.J Adolesc Health. 2004; 34: 428-439Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 16Lerner R.M Castellino D.R Contemporary developmental theory and adolescence Developmental systems and applied developmental science.J Adolesc Health. 2002; 31: 122-135Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar). Collectively the papers in this issue of the Journal raise a series of ongoing issues that need further elucidation: the importance of mandated programs in achieving more optimal outcomes as reported by immunization rates by Jacobs and Meyerhoff (17Jacobs RJ, Myerhoff AS. Effect of middle school entry requirements on hepatitis B vaccination coverage. J Adolesc Health 2004;34:420–23Google Scholar), the disparity between national data and local data showing that even with the good news overall nationally, we have large numbers of adolescents who are adversely affected by unsafe sexual behavior (9DiClemente RJ, Wingood GM, Crosby RA, et al. A descriptive analysis of STD prevalence among urban pregnant African-American teens: Data from a pilot study. J Adolesc Health 2004;34:376–83Google Scholar, 10Shields SA, Wong T, Mann J, et al. Prevalence and correlates of chlamydia infection in Canadian street youth. J Adolesc Health 2004;34:384–90Google Scholar, 18Gwadz MV, Clatts MC, Leonard NR, et al. Attachment style, childhood adversity and behavioral risk among young men who have sex with men. J Adolesc Health 2004;34:402–413Google Scholar); the role of sexual identity in determining risk status for unsafe sexual behavior (18Gwadz MV, Clatts MC, Leonard NR, et al. Attachment style, childhood adversity and behavioral risk among young men who have sex with men. J Adolesc Health 2004;34:402–413Google Scholar); and how to more effectively introduce positive youth development programs to assist with postponement of initiation of sexual behavior and the encouragement of responsible sexual behavior (8Vesely SK, Wyatt VH, Oman RF, et al. The potential protective effects of youth assets from adolescent sexual risk behaviors. J Adolesc Health 2004;34:356–65Google Scholar, 19Catalano R.F Hawkins J.D Berglund M.L et al.Prevention Science and Positive Youth Development Competitive and Cooperative Frameworks?.J Adolesc Health. 2002; 31: 230-239Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar).