Kari Schneider, MD, FAAP, University of Minnesota Medical School
The 2018 Minnesota Adolescent Sexual Health Report, released in June by the Healthy Youth Development Prevention Research Center (HYD•PRC) at the University of MN, provides a great look at the sexual health of Minnesota’s youth. Most notably, adolescent pregnancy and birth rates are at “historic lows” with a 65 percent decline in the adolescent birth rate between 1990 and 2016. Unfortunately, however, sexually transmitted infections (STIs) continue to increase in the young people of our state. The rates of chlamydia and gonorrhea in MN reached all-time highs in 2017. Chlamydia at 440/100,000 (an increase of 4 percent from 2016) and gonorrhea at 123/100,000 (an increase of 28 percent) illustrate the disproportionate effect that these infections have on Minnesota’s adolescents and young adults.
How are STI rates increasing while pregnancy rates decrease? It likely comes down to condoms. According to the CDC, condom use, as reported by sexually active high school students, increased from 46 percent in 1991 to a high of 63 percent in 2003. Since then, there has been a small but steady decrease, to 57 percent in 2015. Young women are using very effective and long-lasting contraceptive options like IUDs and implants and should be applauded for this, but these offer no protection against STIs.
Certain demographic groups continually have disproportionately high STI rates – especially adolescents of color. Sexual minority, transgender, and gender diverse youth are also at higher risk. 2.7 percent of MN youth identify as transgender and gender diverse and they report higher rates of sexual activity, depressive symptoms, suicide attempts, and being victims of bullying. But how will you know your patient is at risk for these things, unless you talk with them? We recently presented at the 2018 Pediatric Academic Society meeting our findings from a survey conducted at the 2017 MN PRIDE festival (data not yet published). Sexual minority adolescents in our cohort (nearly 350) sought primary care at a greater rate than anticipated, but over 30 percent were not asked a sexual history and over 70 percent were not offered STI testing by their primary care providers. This data mirrors the study published in 2010 in JAMA Pediatrics by Alexander et al, where they audio recorded primary care annual visits for adolescents and found that 1/3 of all adolescents had visits without any mention of sexuality issues and when sexuality talk did occur, it was brief (average time spent was 36 seconds). Assessing sexual identity and activity can help physicians recognize, support, and protect not only the sexual health, but overall well-being of these adolescents and young adults.
Both the CDC and the US Preventative Services Task Force recommend screening for gonorrhea and chlamydia in sexually active women age 24 years and younger. The important point here is that they are recommending screening for ALL sexually active females in this age group and NOT just those engaging in high-risk behaviors. For men, there really is insufficient evidence to give strict recommendations and so they say to screen regularly in high prevalence clinical settings (ie the metro area) or populations with high burden of infection (such as men who have sex with men). An important aspect of screening should be obtaining a good phone number (preferably the patient’s confidential cell phone number) with which you can reach them with results.
Another tool in our arsenal against STIs in adolescents, and perhaps an underused one, is the use of expedited partner therapy (EPT). In an ideal world, partners of STI-positive patients would seek health care for evaluation, treatment, and counselling in person. This can prove to be a challenge in all ages, but especially in adolescents and unfortunately rates of reinfection in adolescents and young adults are high. A study by Gaydos et al in 2008 in the journal Sexually Transmitted Diseases reported up to 26 percent of adolescent and young adult women were reinfected with chlamydia with 12 months. The AAP has endorsed a position paper by the Society for Adolescent Health and Medicine supporting the use of EPT as a treatment option for heterosexual sex partners of adolescents with GC/CT when other partner treatment methods are impractical or unsuccessful. It is currently not recommended for men who have sex with men or women with trichomoniasis because of increased risk of coinfections and lack of supporting evidence in these populations.
EPT involves writing a prescription for the medication (it is acceptable to write “Expedited Partner Therapy” in place of the partners name; no date of birth needed) as well as providing treatment instructions, warnings about the medications, general health counseling, and a statement that advises the partner to seek medical evaluation in the setting of symptoms. You can access the CDC website www.cdc.gov/std/ept for more information on EPT including prescribing guidelines.
Addressing the sexual health of adolescents and young adults is multifaceted and truly is a team effort, requiring all of us (in any pediatric subspecialty) to be willing to do the following:
- Take advantage of any opportunity to talk with adolescents about their sexual health
- Offer STI screening to sexually active adolescents and obtain a confidential phone number at which you can reach them with results
- Stress the importance of condom use, including with those who already use contraceptives such as IUDs and implants
- Consider use of EPT to reach the partners of STI-positive patients