Research Agenda for Adolescent Sexual Health
This is a writing sample from Scripted writer Kirsten Paulus
ABSTRACT: Adolescents are a high-risk group for STIs (such as Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomoniasis, and Syphilis) in the United States. This is attributable to: (a) biological development; (b) self-confidence and efficacy in condom negotiation; (c) engagement in risk-taking behaviors (substance use and unprotected sex); (d) family and relationship dynamics; (e) stigma; (f) lack of STI testing and treatment; (g) social cohesion, social capital, and community characteristics; (h) healthcare providers’ protocols (or lack thereof); and (i) media representation of sexually explicit content. There is a need for more robust research data to support increasing efforts to decrease STI rates among adolescents, which are aimed at addressing the aforementioned determinants. We identify four key research strategies: (1) examine the role of sexual content in media on adolescent sexual behavior; (2) investigate adolescent experiences of condom use negotiation; (3) differentiate sexual experiences among vulnerable youth; (4) establish adolescent knowledge about safe sex.
INTRODUCTION:
Adolescents are a population of high priority in sexual and reproductive public health, particularly in concern with sexually transmitted infections (STIs). Roughly 40% of United States adolescents engage in sexual intercourse, and 10% report to have had at least 4 sexual partners by the age of 18[1]. According to the Centers for Disease Control and Prevention, the population of individuals aged 15-24 years make up roughly half of annual newly reported STIs[1-3]. There is also an estimated 1 in 20 adolescent females who are sexually active and currently infected with Chlamydia[1,3]. Risk-taking behaviors, such as not practicing regular condom use and engaging in substance use, are highly common among adolescents, which increases their risk of STIs[2-7]. For example, in a national survey it was found that only 53.8% of adolescents reported that they wore a condom[1-2,6]. This occurs in addition to the phenomenon that very few adolescents seek out sexual health care and education that can treat and prevent STIs, oftentimes as a result of disinformation about sexual behavior and promiscuity in media, environmental barriers to access of care, and inadequate policy response from health professionals[3,7]. Therefore, adolescents oftentimes have untreated STI infections, which can cause harmful and sometimes even irreversible health complications including pelvic inflammatory disease (PID), which is an inflammation of the female genital tract[1,4,7]. PID can later lead to irreversible damage to the uterus, fallopian tubes, and surrounding tissue, leading to further consequences such as pelvic pain, infertility, and ectopic pregnancy[1,4,7]. All adolescents are at risk of proctitis, conjunctivitis, and reactive arthritis if STIs are not treated[1].
Existing research on adolescent STI risk provides evidence that adolescents are a high-risk group for STIs for several reasons[8]. Using the ecosocial framework, existing research has found determinants of STI transmission and acquisition at the individual, interpersonal, community, and systems levels. First, adolescents’ prefrontal cortex is still developing and can make risky behaviors seem more appealing without acknowledging the repercussions[7]. Adolescents’ self-confidence and efficacy in condom negotiation, as well as being willing to say “no” to unprotected sexual intercourse affects condom use too[9-10]. Relationship dynamics between partners, as well as power distribution, are related to condom use, particularly in respect to negotiation as a result of an imbalance of emotional intimacy power[9,11-12]. Family dynamics and parent-child communication influence condom use too, with greater communication about sex resulting in an increased rate of condom use[9,11].
Perceived stigma by adolescents themselves in healthcare settings surrounding STIs and concerns about preserving confidentiality and anonymity are major barriers to getting STI tests or having conversations with doctors about their sex lives and health status[8,13]. Liddon et al. 2022 found that within the past year, roughly one-fifth of sexually active high school students reported testing for an STI; more females than males reported testing as well[14]. Most adolescents have never even received an STI test—roughly 17% of females and 7% of males were found to have been tested within the last year in a 2018 national survey[7]. Even with low rates of testing, adolescents are the most common age group in the United States to have reported to be infected with Neisseria gonorrhoeae and Trichomonas vaginalis[7]. Community characteristics have also been found to influence STI risk such as affiliation with social organizations, social support, and school environments[9]. Social cohesion and engagement in local clinics, after-school programs, and school clubs increase condom use, as they promote safe sexual behaviors and oftentimes provide condoms to students in the community[9]. In the community, condoms are not always accessible and available to all adolescents which has a major impact on STI risk as those who carry condoms are more likely to use them[9]. Social capital such as trust, reciprocity, and co-operation among members in adolescents’ social networks can prevent or promote sexual-risk taking[9]. Finally, on the structural level, clinical practice guidelines affect adolescent condom use, as many healthcare professionals are not required to discuss sexual health with adolescent patients, or they fail to provide an environment in which adolescents feel safe enough to discuss their sex lives[9,15]. Media also promotes and supports risky sexual behaviors on all platforms such as having multiple partners, not using a condom (particularly to preserve male pleasure), and even forced sex—this can be seen in shows such as HBO’s Euphoria[9].
Clearly, adolescents are uniquely vulnerable to STIs through multiple biological, behavioral, and cultural perspectives as evidenced by existing research. However, there are still some gaps in current research that need to be addressed. There is a need to better understand how media influences sexual behavior and how the internalization of sexual situations in media is processed and later enacted by adolescents. Additionally, it is necessary to better understand how condom negotiation skills can be developed, encouraged, and practiced among adolescents. Information on vulnerable youth (such as homeless, racial minority, sexual minorities, or gender minorities) is also lacking, which provides challenges to these subgroups that may be more at-risk of STIs compared to the average adolescent. Finally, there is a lack of research surrounding what sex education adolescents receive before or after they become sexually active and what knowledge they currently possess. Establishing a research agenda will prioritize research to address these gaps in the literature, ultimately ensuring an enhancement of our understanding of adolescent risk of STIs.
RESEARCH AGENDA:
Examine the role of sexual content in media on adolescent sexual behavior. Exposure to explicit sexual content in media has been found to be related to engagement in sexual activity[16]. Non-explicit sexual content is associated with sexual behavior and attitudes as well[17]. Representations of sexual situations and sexual behaviors in media set a precedent for adolescents in respect to their own view on sex and their resultant sexual behaviors[16-17]. Media can also establish stigma that adolescents lock on to and that become pervasive in adolescent social networks[16-17]. Specifically, television shows that portray sexually explicit content are becoming increasingly popular. The effect of easily accessible sexual content, and the glorification of irresponsible and unhealthy sexual practices on adolescent risk-taking behaviors are not well understood, but are crucial for identifying the most influential factors in determining condom usage to prevent STIs.
Investigate adolescent experiences of condom use negotiation. Self-efficacy, self-confidence, manipulation, and role beliefs all impact condom negotiation during sexual encounters[18]. In many circumstances adolescents participate in unwanted unprotected sex as a result of condom coercion or self-silencing of their own condom negotiation[18]. In other cases, even if adolescents intend to use condoms, sexual desire and relationship motivation or how well sexual partners know one another can impede on condom use at time of sex[19]. It is not quite understood why so many adolescents have the intent to use condoms to protect themselves from STIs, but in reality, only about 50% of adolescents use them when they do engage in sex[1,2-6]. Further exploration of this phenomenon can better inform interventions to increase condom use at each sexual encounter among adolescents.
Differentiate sexual experiences among vulnerable youth. Adolescents who are homeless, racial or ethnic minorities, and sexual minorities are at an even more increased risk of STIs compared to the general adolescent population[20-22]. Those who suffer from social disadvantage oftentimes participate in more risky behaviors, such as having unprotected sex[20-22]. They can also suffer from poor access to healthcare or perceived stigma and discrimination by providers, which deters adolescents from seeking out STI testing and treatment[20-22]. Vulnerable youth have slipped through the cracks of adolescent STI research. It is necessary to understand vulnerable adolescents’ perceived risk of STIs, confidence in protecting themselves from STIs, and their actual rate of condom use during sex. However, this has to be done through an approach that specifically responds and caters to their unique needs as minority youth.
Establish adolescent knowledge about safe sex. There has been a decline in the receipt of formal sex education for adolescents[23]. There has been ongoing research and debate on what the best approach to sex education is, from the context in which it is given to the actual information being provided. It is known that a majority of adolescents prefer a sex-positive education curriculum, which implies that they are in fact intending to be or are already sexually active and want to be safe doing it[24]. Other studies have found that parents and schools should work collaboratively to provide sex education[25]. However, very little research has been done to establish what adolescents are and are not learning, as it has focused mostly on the how, where, and when education should occur. It is necessary to understand what adolescents are learning about sex to better explain why so many adolescents are engaging in unprotected sex and not seeking out testing and treatment for STIs.
CONCLUSION: This research agenda will help public health professionals take one step closer to preventing STIs by learning about influences on adolescent sexual behaviors, the condom negotiation process, what information adolescents are receiving about sex, and how to cater to unique needs of the most vulnerable youth so they no longer slip through the cracks of public health interventions.
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