Teens and STDs: A New Message for a Healthy Millennium

from School Health Reporter, Spring 2003

By Kim K. Dernovsek, MD, Assistant Clinical Professor University of Colorado Health Sciences Center

The December 9, 2002 cover of Newsweek pictured a Colorado teen couple that had chosen to remain sexually abstinent. The feature covered “The new virginity,” scribing, “Why more teens are choosing not to have sex.” Newsweek was relaying what the statistics confirm: There has been a reversal of the increasing rates of sexual experience during the 1970’s and 1980’s. The prevalence of sexual experience, defined as ever having had sexual intercourse, decreased 16 percent from 1991 through 2001. In 2001, 65.6 percent of ninth graders and 39.5 percent of twelfth graders never have had sexual intercourse.

Furthermore, 79 percent of teens ages 12–19 surveyed in 2002 do not think it is embarrassing to admit they are virgins and 93 percent of teens want a strong message from society to abstain from sex until they are at least out of high school. Fifty-five percent of teens, ages 15–19, who had had sex wished they had waited longer.

These youth are choosing abstinence as a lifestyle (hereafter referred to as lifestyle abstinence”), countering hesitations medical professionals may have had about whether abstinence was “realistic.” Approaching a cultural “tipping point,” physicians, nurses, parents and patients need a thorough understanding of why two decades of “safe/safer sex” (condom) messages have failed miserably in protecting sexually active teens. Knowledge of the most common sexually transmitted diseases (STDs), their modes of transmission, and their devastating health consequences substantiates why lifestyle abstinence is the best prevention strategy.

STDs and Teens

Of 15 million new STDs occurring annually, one in four occurs in teenagers.   Once sexually active, teens are at risk for the same problems as any other sexually active person. Teen females are at particular increased risk since the adolescent cervix, prior to its conversion to squamous epithelium, is more susceptible to infection.

Chlamydia

Previously the most common STDs were syphilis and gonorrhea, bacterial infections with distinct identifiable signs and symptoms that are curable with antibiotics. In recent years there has been a rise in chlamydia bacterial infection, ich is frequently asymptomatic, thus often remaining undetected and untreated. The infected patient may transmit to others, unknowingly. Forty percent of untreated chronic cases go on to pelvic inflammatory disease (PID) and 20 percent of cases of PID result in infertility.

Herpes Progenitalis

Incurable, genital herpes virus (HSV)  infects 45 million (21.9 percent) of Americans ages 12 and older. The seroprevalence of HSV-2 in the US rose 30 percent from 1976 through 1994, with the fastest increase among white teens ages 12 to 19 years old.  It is noteworthy that increasing awareness of “safe” sex practices occurred during roughly the same period. Herpes is transmitted through direct contact: kissing, sexual contact (vaginal, oral or anal sex), or skin-to skin contact and can be transmitted with or without the presence of sores or symptoms. Furthermore, considering that the practice of oral sex may be used by teens to prevent pregnancy, it is alarming that 30 percent of first episode genital herpes is now HSV-1 in type,5 the most likely source of which is from shedding in the mouth.

Human Papilloma Virus

It is estimated that 20 million Americans are currently infected with human papilloma virus (HPV) and that 5.5 million new infections occur annually. The peak prevalence is in women under age 25, of whom 28-46 percent are infected with HPV. HPV genital warts may be present in up to 13 percent of sexually active adults.  Clinically normal skin and mucosa in the vicinity of HPV-associated lesions may contain HPV; it is unclear whether treatment of HPV-associated lesions is useful in prevention of transmission.   5 HPV infection is associated with 95 percent of the 13,000 cases of cervical cancer in the United States annually, of which there are about 4,000 deaths.

HIV/AIDS, Hepatitis and Others

HIV/AIDS is an incurable fatal viral disease transmitted through contact with infected blood, semen, cervical secretions and breast milk, typically spread during sexual contact, through needles and syringes, or from mother to baby during pregnancy and birth.  Sexual transmission of hepatitis C can occur and may account for up to 20 percent of HCV infections.5 Viral hepatitis can progress to chronic active hepatitis and/or cirrhosis. Approximately one third of liver transplants are for hepatitis C.

Other reasons for concern about teen sexual activity include unintended pregnancy, pubic lice, non-gonococcal urethritis, bacterial vaginosis, trichomoniasis, chancroid, granuloma inguinale and lymphogranuloma venereum. Molluscum contagiosum and scabies are common infections that are not primarily sexually transmitted, yet can be transmitted by the intimacy of sexual contact. The adverse psychosocial effects of STDs are well known to all clinicians; teens are not spared. In monetary terms, the CDC estimates that 17 billion dollars annually     are spent on the direct and indirect expenses associated with all STDs.

The Problem Has Changed: The Solution Must Change

Prior to proposing a prevention strategy, precise clarity about what one is attempting to prevent is required.  Previously, the problem requiring prevention was limited to teen pregnancy with later focus on HIV/AIDS.  Because both sperm and HIV are transmissible via ejaculate, condom use theoretically made sex “safe” from both, and hence the strategy and term:  “safe sex.” As incurable STDs with skin-to-skin transmission capability trended upward, the term “safer sex” began appearing in the literature.  Considering the gravity of the medical consequences and incurability of many of these newer sexually transmitted diseases, primary prevention of all infection must redefine our starting point in strategy development.

Prevention of All Infection: Reconsidering Strategies

The first prevention strategy to consider would be reduction of the duration of infectivity. This is done by curing the condition and preventing its transmission. This is unachievable, however, until a cure for viral infections is developed. Compounding the problem of incurability is that herpes, HIV, HPV, syphilis and Chlamydia have asymptomatic periods during which an unknowingly infected person may be spreading the disease.

Another strategy would be to reduce the efficacy of transmission via condoms. This works best for prevention of infections delivered by body fluids such as HIV/AIDS and gonorrhea. Yet, consistent condom use decreased the risk of transmission of HIV/AIDS by 85 percent according to a panel of 138 experts who reviewed 28 papers in 2001 and issued The Condom Report.4 How acceptable is this figure given that this retrovirus is invariably fatal? 

In practice, condom failure occurs via method failure (failure of the condom itself) and/or user failure (actual incorrect condom use) or simple nonuse.  Despite a two-decade campaign, it is known that condoms are not used consistently even at risk of death.  In a study of HIV discordant couples, whom one could assume to be very motivated partners since one has HIV, and the other one doesn’t, only 48.4 percent “always” used a condom.

The problem with STDs such as syphilis, HPV and herpes, is that the condom simply does not cover all of the potentially infected skin, leaving the sexual partners at risk for transmission.  For example, regarding HPV, The Condom Report concluded there is “…no epidemiologic evidence that condom use reduced the risk…” adding that it “might afford some protection…”4

Abstinence: True Primary Prevention

There remains a primary prevention strategy that is 100 percent effective, 100 percent of the time for all STDs and all unintended pregnancies:  Abstinence from all sexual activity until selection of a lifelong diseasefree partner. The 2002 STD Treatment Guidelines published by the CDC state the most reliable way to avoid STD transmission is to abstain from sexual intercourse (i.e., oral, vaginal or anal sex) or to be in a long-term, mutually monogamous relationship with an uninfected partner.5 The 2001 CDC fact sheets8 on HPV, gonorrhea, syphilis and herpes substantiate the need to correctly counsel on maintenance of sexual health via choice of a sexually abstinent lifestyle:

• Abstinence is the most effective strategy to prevent HPV infection. Two uninfected individuals who have no other sex partners besides each other cannot get genital HPV infection.
• Condoms do not provide complete protection from all STDs. Sores and lesions of other STDs on infected men and women may be present in areas not covered by the condom, resulting in transmission of infection to another person.
• Two people who know they are not infected and who have sex with no one but each other cannot contract syphilis.
• However, condoms do not provide complete protection, because a herpes lesion may not be covered by the condom and viral shedding may occur.

Promoting Sexual Health Via Behavior Change

In medicine we have effected positive behavior changes by encouraging child helmets, seat belts, tobacco cessation, CPR /911 knowledge and decreased use of inappropriate antibiotics. Medical counseling is expected for weight reduction, smoking cessation and alcohol intake reduction. Certainly the health of the genitalia, reproductive tract and psyche, and the preservation of life itself are worthy of correct counseling in lifestyle sexual abstinence.

Those skeptical as to whether sexual behavior can be changed are referred to the Ugandan success. This African nation is successfully promoting abstinence and fidelity and simultaneously demonstrating remarkable success in the fight against HIV/AIDS.  The report, What Happened in Uganda ?           Declining HIV Prevalence, Behavior Change, and the National Response, describes dramatic delay of sexual debut, “… among youth age 13-16 nearly 60 percent of boys and girls reported having already ‘played sex’ in 1994, but in 2001 that proportion was down to less than 5 percent.”  The authors further state, “… the effect of HIV prevention interventions in Uganda (particularly partner reduction)  during the past decade appears to have had a similar impact as a potential medical vaccine of 80 percent efficacy.”7

Health professionals and parents should encourage in every way the trend toward lifestyle abstinence in our youth. Parents need to be advised that their disapproval of adolescent sex and contraception use has been shown to be protective for early sexual debut. Early sexual debut poses untold dangers due to the expanded numbers of diseases and the severity of their secondary sequelae. Lifestyle abstinence must be from all forms of sexual activity and encouraged until selection of lifelong partner. This is the new prevention message for a healthy millennium.

All views expressed in the article above are those of the author. We understand that there are differing views on this issue.