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Adolescent sexual health must remain a top priority globally
To have the first themed issue for Sexually Transmitted Infections as adolescent sexual health is fortuitous. The United Kingdom has the unenviable position of being top of the league tables for teenage pregnancy in western Europe with 9 in 1000 girls aged 13–15 and 63 in 1000 girls aged 16–19 becoming pregnant.1 Although there has been a resurgence of sexually transmitted infections (STIs) diagnosed across all age groups tested in genitourinary medicine (GUM) clinics,2 the greatest rise in prevalence rates has been seen with chlamydial and gonococcal infections in young men and women, especially teenagers.
Concern about sexual health of adolescents is not confined to the United Kingdom. As can be seen from the published papers in this issue of the journal, the problem is global. The majority of young people live in developing countries where the burden of STIs and HIV is greatest.3 Unicef has emphasised the importance of preventative strategies targeting young people if the HIV epidemic is to be stemmed.4 European countries that have been more successful in reducing teenage pregnancy and STI prevalence rates than the United Kingdom have over the past 10 years seen a resurgence of these.5 Even in Sweden, which has previously had low prevalence rates of STIs and teenage pregnancy, an increase in termination of pregnancy and STI rates has been reported.6
Adolescence is a time of risk taking as part of the process of growing up. Age at first intercourse in the United Kingdom has been falling, with a median reported age at first intercourse of 16 in girls and boys.7 Young people are more likely to have concurrent relationships, monogamous relationships of short duration and higher frequency of acquisition of new partners.8 All of these factors favour increased transmission of STIs. There may be increased susceptibility of younger women to infection and sequelae through physiological influences such as cervical ectopy.9 Some youngsters are more vulnerable, particularly “looked after” children and those previously abused, which brings other allied emotional and social difficulties.10 Young people report having more risky sex under the influence of alcohol but the nature of the association is complex, as highlighted in the recent report by Alcohol Concern.11 For both sexes, regret at having first intercourse too early is associated with being drunk or “stoned.”12 Recreational drugs have been studied extensively as factors in HIV risk behaviour in homosexual men but little research has looked at drug use and acquisition of STIs. Crosby et al have shown that marijuana use is a strong predictor of Trichomonas vaginalis infection in young African-American women.13
Chlamydia trachomatis is the commonest infection that affects adolescents. Effective screening of this young age group poses a challenge. Efforts to implement screening must also address healthcare providers’ attitudes and perceptions as to its value, cost effectiveness, and simplicity of testing methods.14 There must be sufficient resource to provide outreach services and nucleic acid amplification tests for non-invasive sampling techniques. Sadly, in the United Kingdom, despite knowing that high prevalence rates exist, a national chlamydia screening programme is just being rolled out and in the first instance will include only 10 centres.15 Other countries have already instigated screening programmes and in the United States post-treatment rescreening has been suggested in the latest guidelines.16 Reinfection has been associated with young age,17–21 although there is evidence that many adolescents temporarily change their behaviour following diagnosis with an STI by abstaining or using condoms.22 In this age group consideration should be given to rescreening and novel ways of managing partners.
The legal framework, including the age of consent for sexual intercourse and offering treatment services to young adolescents, varies between countries. Young people rate confidentiality as a high priority when attending services. In the United Kingdom colleagues providing sexually transmitted infection or HIV services are anxious about legal aspects when caring for under 16s. Clinicians in England are left with the difficulty of balancing the rights of the young person to confidentiality and treatment, as defined by the Fraser ruling,23 with child protection issues associated with the Children Act 198924 and the European Convention of Human Rights, where no “case law” related to these complex issues yet exists. Guidelines for setting up of “Young Persons Services” previously published highlight the problems.25 The national guidelines for the management of suspected sexually transmitted infections in children and young people26 published in this issue of the journal (324) are extensive and provide a framework for good practice in relation to confidentiality and consent. The importance of acting in the best interests of the child and ensuring discussion with the multidisciplinary team is essential when making difficult decisions about the management of a young person below the age of consent. The guidelines also cover aspects of the management of children who may have a sexually transmitted infection including diagnosis/treatment of STIs and signs of sexual abuse. The appendices include proformas that can be used to improve the quality of history taking in respect of assessing possible abuse, and for processing samples which require a chain of evidence. The issue of chain of evidence and retention of specimens is uncertain and is currently being assessed by key stakeholders; when a consensus is reached the guidelines will be amended accordingly.
For adolescents, greater effort is needed in service provision, health promotion, and research to identify the interventions that are most likely to succeed. This requires close collaboration between health services, education, and sociobehavioural initiatives. When adolescents are asked where they wish to get information about sex, parents come high on the list.27,28
Dr Robbie Morton’s obituary is in this issue. He was a great proponent of having accessible services for young people with friendly, approachable staff. He always maintained that sex education should be given to parents alongside any initiatives for adolescents. With some evidence suggesting that ease of family discussion about sex has an effect on the likelihood of teenage pregnancy,29 and that promotion of parent-child communication may impact on sexual behaviour,30 we need to ensure that sufficient heed is paid to parents’ sex education. The Teenage Pregnancy Strategy31 highlighted that parents are given little help in talking to their children about sex but, even in 2001, 39% of young people said they had been given no information about sex by their parents.32 Adolescent sexual health must remain a top priority globally if any impact is to be made on unwanted pregnancies and the rising prevalence of HIV and sexually transmitted infections.
Adolescent sexual health must remain a top priority globally