**2. Inherent risk of the adolescent period**

Adolescence is a period of rapid physical, social–emotional, and sexual change, characterized by experimentation and exploration as one searches to define their own identity. For many, sexual debut occurs during adolescence. A number of behavioral, biological, and cultural factors among sexually active adolescents and young adults lead to higher risk of acquiring an STI in this age group. Biologically, young women are more susceptible to STIs because of increased cervical ectopy (which refers to columnar cells, usually located within the cervical canal, being located on the outer surface of the cervix). These areas of ectopy are fragile with thin, vascularized epithelium and thus blood vessels lie in close contact with the vaginal environment; possibly diminishing mucosal barriers to sexually transmitted infections.

Beyond biological factors, adolescents are more likely to engage in unprotected sex, have multiple sexual partners, and use drugs and alcohol, which may result in high risk sexual behaviors [6].

According to the Centers for Disease Control and Prevention (CDC), condom use, as reported by sexually active high school students, is inconsistent. Among US high school students surveyed in 2017, 46% did not use a condom the last time they had sex [6]. Young women are using very effective and long-lasting contraceptive options like intrauterine devices and implants at higher rates and should be applauded for this, but these offer no protection against STIs such as gonorrhea or chlamydia [6].

Sexual minority youth, identified as lesbian, gay, bisexual, transgender (LGBT), represent a subset of the adolescent population at heightened risk for sexually transmitted infections. While many LGBT youth are resilient and thriving, the effects of homophobia, heterosexism, and parental rejection may result in psychological distress and a subsequent increase in self-destructive risk behaviors [7]. Sexual minority youth are more likely to report having intercourse, initiating intercourse at younger ages (before age 13), have a greater number of sexual partners (≥4 partners), and are less likely to use barrier contraception compared to heterosexual or cis-gender peers [7]. LGBT youth have higher rates of homelessness, which results in increased sexual violence and survival sex [7]. Transgender teens (particularly male to female transgender youth) have higher rates of HIV and STIs and selfreport lower rates of preventive health checkups and overall poorer health [7, 8].

## **3. Utilization of health care by adolescents**

Utilization of health care by adolescents (LGBT, heterosexual, and cis-gender alike) is complicated, and their overall usage of health care is low. Higher rates of STIs among adolescents may reflect barriers to accessing preventive care and services for sexual and reproductive health. The American Academy of Pediatrics (AAP) recommends at least one preventive health visit per year. The data, however, show that only 40–80% of adolescents report a primary care visit within 12 months [9–11]. A 2010 study of insured adolescents, revealed that one-third had no preventive care visits between the ages of 13 through 17 years, and another 40% had only one preventive care visit during this 4 year period of their lives [12]. Barriers in accessing care include believing they only need appointments when sick, lack of transportation, conflict between school and clinic hours, concerns about confidentiality, lack of health insurance, inability to pay for contraception or STI testing, and stigma surrounding accessing STI services [10].

While non-preventive care visits are slightly more frequent among adolescents (approximately 1–1.5 visits per year among adolescents age 11 through 17 years), a busy practice environment and short encounters with a clinician may not afford

**9**

*Adolescents and Young Adults: Targeting the Unique Challenges of This High Risk Group*

the opportunity for full discussions of sexual health, risk taking behaviors, and concerns outside of the presenting problem [12]. Nordin and colleagues recommend a no-missed-opportunities paradigm, by which all adolescent visits, regardless of busy practice environments and short encounters with a clinician, be viewed as an opportunity to provide preventive care services [12]. One clinic successfully increased the number of preventive health visits for adolescents by "flipping" acute/ sick visits into well-care visits when patients were overdue [13]. Given the disproportionate burden of STIs among adolescents, preventive visits including discussions about sexuality and sexual risk factors are of paramount importance.

The AAP, American Medical Association, and Society for Adolescent Medicine recommend that physicians discuss sexuality with youth as part of routine healthcare. Physicians have an important role in helping adolescents develop healthy relationships and behaviors. However, when adolescents intersect with healthcare, physicians may not feel fully equipped or have the expertise in managing specific sexual health needs. The literature suggests that primary care pediatricians are not consistent in having important discussions regarding sexuality and sexual risktaking behaviors with adolescents [14]. In a survey of AAP members who provide health supervision visits to adolescent patients, 58% of pediatricians self-reported a lack of interest in adolescent health issues [14]. Perhaps more alarming is the fact that <9% of those surveyed were very familiar with AAP policies or CDC recommendations regarding STI and HIV testing for youth [14]. Additionally, 25% of providers did not know their own state laws regarding testing of teens for STIs without parental consent [14]. While pediatricians believed that reproductive health services were an important part of adolescent health care delivery, less than half (46%) recommend STI testing for all sexually active teenagers and the vast majority (>70%) did not prescribe or distribute condoms, or provide education on

Given that adolescents are not always consistent with seeing their primary physicians for preventive visits, providers need to utilize other opportunities for screening for STIs. School-based health centers (SBHCs) are another important place where adolescents may access health care. SBHCs remove some of the common barriers to health care for this age group, including scheduling and transportation, as the clinics are located where the adolescents already spend their days in school. Many of these centers are in urban areas, and they primarily serve high schools, alternative schools, or schools with a combination of grade levels [15]. Adolescents who use SBHCs have been shown to have more primary care visits and fewer emergency department visits than those who do not use these clinics. Although SBHCs are sometimes prohibited from dispensing contraceptives by school district policy or state law, some are able to provide these services, and they

Adolescents also seek care in emergency departments (EDs). The ED has been described as a critical "safety net", treating patients without other sources of care [16]. Adolescents make up about 15% of the patient population in the emergency department [17, 18]. One study found that 18% of 10–17-year-olds, and 25% of 18–24-year-olds, had visited an emergency department in the previous year [19]. And the rates of STIs found for this patient population in this venue are significant [20–23]. PID is the most common diagnosis among adolescents seeking care for STIs in US EDs and studies have unfortunately shown incorrect treatment of PID in

While the ED is a readily-available place for adolescents to receive health care, it poses many challenges, especially given the complex nature of adolescent health care. Goyal et al. demonstrated that, in adolescents presenting to the ED with genitourinary complaints, the prevalence of STIs was 26% [21]. Schneider et al.

*DOI: http://dx.doi.org/10.5772/intechopen.86251*

effective condom use [14].

also can screen for and treat STIs.

this setting [24, 25].

#### *Adolescents and Young Adults: Targeting the Unique Challenges of This High Risk Group DOI: http://dx.doi.org/10.5772/intechopen.86251*

the opportunity for full discussions of sexual health, risk taking behaviors, and concerns outside of the presenting problem [12]. Nordin and colleagues recommend a no-missed-opportunities paradigm, by which all adolescent visits, regardless of busy practice environments and short encounters with a clinician, be viewed as an opportunity to provide preventive care services [12]. One clinic successfully increased the number of preventive health visits for adolescents by "flipping" acute/ sick visits into well-care visits when patients were overdue [13]. Given the disproportionate burden of STIs among adolescents, preventive visits including discussions about sexuality and sexual risk factors are of paramount importance.

The AAP, American Medical Association, and Society for Adolescent Medicine recommend that physicians discuss sexuality with youth as part of routine healthcare. Physicians have an important role in helping adolescents develop healthy relationships and behaviors. However, when adolescents intersect with healthcare, physicians may not feel fully equipped or have the expertise in managing specific sexual health needs. The literature suggests that primary care pediatricians are not consistent in having important discussions regarding sexuality and sexual risktaking behaviors with adolescents [14]. In a survey of AAP members who provide health supervision visits to adolescent patients, 58% of pediatricians self-reported a lack of interest in adolescent health issues [14]. Perhaps more alarming is the fact that <9% of those surveyed were very familiar with AAP policies or CDC recommendations regarding STI and HIV testing for youth [14]. Additionally, 25% of providers did not know their own state laws regarding testing of teens for STIs without parental consent [14]. While pediatricians believed that reproductive health services were an important part of adolescent health care delivery, less than half (46%) recommend STI testing for all sexually active teenagers and the vast majority (>70%) did not prescribe or distribute condoms, or provide education on effective condom use [14].

Given that adolescents are not always consistent with seeing their primary physicians for preventive visits, providers need to utilize other opportunities for screening for STIs. School-based health centers (SBHCs) are another important place where adolescents may access health care. SBHCs remove some of the common barriers to health care for this age group, including scheduling and transportation, as the clinics are located where the adolescents already spend their days in school. Many of these centers are in urban areas, and they primarily serve high schools, alternative schools, or schools with a combination of grade levels [15]. Adolescents who use SBHCs have been shown to have more primary care visits and fewer emergency department visits than those who do not use these clinics. Although SBHCs are sometimes prohibited from dispensing contraceptives by school district policy or state law, some are able to provide these services, and they also can screen for and treat STIs.

Adolescents also seek care in emergency departments (EDs). The ED has been described as a critical "safety net", treating patients without other sources of care [16]. Adolescents make up about 15% of the patient population in the emergency department [17, 18]. One study found that 18% of 10–17-year-olds, and 25% of 18–24-year-olds, had visited an emergency department in the previous year [19]. And the rates of STIs found for this patient population in this venue are significant [20–23]. PID is the most common diagnosis among adolescents seeking care for STIs in US EDs and studies have unfortunately shown incorrect treatment of PID in this setting [24, 25].

While the ED is a readily-available place for adolescents to receive health care, it poses many challenges, especially given the complex nature of adolescent health care. Goyal et al. demonstrated that, in adolescents presenting to the ED with genitourinary complaints, the prevalence of STIs was 26% [21]. Schneider et al.

*Psycho-Social Aspects of Human Sexuality and Ethics*

**2. Inherent risk of the adolescent period**

**3. Utilization of health care by adolescents**

and stigma surrounding accessing STI services [10].

high risk sexual behaviors [6].

Adolescence is a period of rapid physical, social–emotional, and sexual change, characterized by experimentation and exploration as one searches to define their own identity. For many, sexual debut occurs during adolescence. A number of behavioral, biological, and cultural factors among sexually active adolescents and young adults lead to higher risk of acquiring an STI in this age group. Biologically, young women are more susceptible to STIs because of increased cervical ectopy (which refers to columnar cells, usually located within the cervical canal, being located on the outer surface of the cervix). These areas of ectopy are fragile with thin, vascularized epithelium and thus blood vessels lie in close contact with the vaginal environment;

Beyond biological factors, adolescents are more likely to engage in unprotected sex, have multiple sexual partners, and use drugs and alcohol, which may result in

According to the Centers for Disease Control and Prevention (CDC), condom use, as reported by sexually active high school students, is inconsistent. Among US high school students surveyed in 2017, 46% did not use a condom the last time they had sex [6]. Young women are using very effective and long-lasting contraceptive options like intrauterine devices and implants at higher rates and should be applauded for this, but these offer no protection against STIs such as gonorrhea or chlamydia [6]. Sexual minority youth, identified as lesbian, gay, bisexual, transgender (LGBT), represent a subset of the adolescent population at heightened risk for sexually transmitted infections. While many LGBT youth are resilient and thriving, the effects of homophobia, heterosexism, and parental rejection may result in psychological distress and a subsequent increase in self-destructive risk behaviors [7]. Sexual minority youth are more likely to report having intercourse, initiating intercourse at younger ages (before age 13), have a greater number of sexual partners (≥4 partners), and are less likely to use barrier contraception compared to heterosexual or cis-gender peers [7]. LGBT youth have higher rates of homelessness, which results in increased sexual violence and survival sex [7]. Transgender teens (particularly male to female transgender youth) have higher rates of HIV and STIs and selfreport lower rates of preventive health checkups and overall poorer health [7, 8].

Utilization of health care by adolescents (LGBT, heterosexual, and cis-gender alike) is complicated, and their overall usage of health care is low. Higher rates of STIs among adolescents may reflect barriers to accessing preventive care and services for sexual and reproductive health. The American Academy of Pediatrics (AAP) recommends at least one preventive health visit per year. The data, however, show that only 40–80% of adolescents report a primary care visit within 12 months [9–11]. A 2010 study of insured adolescents, revealed that one-third had no preventive care visits between the ages of 13 through 17 years, and another 40% had only one preventive care visit during this 4 year period of their lives [12]. Barriers in accessing care include believing they only need appointments when sick, lack of transportation, conflict between school and clinic hours, concerns about confidentiality, lack of health insurance, inability to pay for contraception or STI testing,

While non-preventive care visits are slightly more frequent among adolescents (approximately 1–1.5 visits per year among adolescents age 11 through 17 years), a busy practice environment and short encounters with a clinician may not afford

possibly diminishing mucosal barriers to sexually transmitted infections.

**8**

found that in adolescents presenting to the ED with non-genitourinary complaints, the prevalence of STIs was 10% [22]. Given the nature of emergency care and lack of continuity, there is concern that patients testing positive but were not treated in the ED may become lost to follow up, and therefore remain untreated [26]. This needs to be balanced with antibiotic stewardship and development of antibiotic resistant organisms associated with overtreatment [27]. This highlights some of the complexities of adolescent STI reduction initiatives in the ED setting.
