Counseling Adolescents

STDs, pregnancy risk, and fertility: Practical tips to address adolescent misconceptions and reproductive needs

Associate Professor of Clinical Pediatrics, Morehouse School of Medicine, Atlanta, Georgia

Corrine received a diagnosis of pelvic inflammatory disease (PID) at age 16 from a hospital-based healthcare provider who told her that PID would make her infertile. Although the clinician was—as is so often the case—trying to scare her into practicing safe sex (or abstaining from sexual activity), Corrine interpreted the information to mean that she was infertile. As is typical of adolescents, she lacked the cognitive maturity to process new and conflicting information. Therefore, when her gynecologist subsequently told her that she likely was fertile and could become pregnant, Corrine did not believe her. She did not use birth control and had frequent unprotected sex with multiple partners. She also adopted an “I’ll shown them” attitude—again common among adolescents, who often feel that they are being scrutinized by adults—and actually sought to become pregnant and thus prove her initial healthcare counselor wrong. Over the next 3 years, she had 3 additional PID infections, became pregnant at age 19, and contemplated an abortion. At that time, she was in school and her relationship with the father was unstable (a common condition for adolescents who practice serial monogamy). Ultimately, she chose to have the child. She lives with her mother and is trying to “make the best of things.”

Pediatricians receive training in the cognitive and behavioral development of adolescents; however, clinicians who also provide care for this population—particularly in terms of their reproductive needs—may have been trained primarily to manage adult populations. Often, they focus on pregnancy prevention. Given the high rate of STDs and PID in adolescent girls, prevention of infertility should be equally important. PID may be caused by infection with Chlamydia trachomatis or Neisseria gonorrhoeae, as well as Trichomonas vaginalis, Gardnerella vaginalis, and Mycoplasma genitalium. Tubal infertility occurs in 8% of women after one episode of PID, 20% after 2 episodes, and 50% after 3 episodes.¹ The risk of ectopic pregnancy is increased 6- to 10-fold after PID.

Chlamydia and gonorrhea are the most commonly reported communicable diseases; the largest reported number of cases occur in adolescent girls ages 15 to 19.² Of the approximately 1.2 million cases of chlamydia reported in the United States in 2008, 342,875 were in girls 15 to 19 years of age. This article focuses on STDs that impact fertility and provides practical strategies for risk reduction; however, sparse data are available in this field.

Biology plays a role

The adolescent girl’s reproductive tract increases her risk of acquiring an STD. The large mucosal surface of the adolescent vagina and cervix results in prolonged exposure to infected semen.^2-4 Increased cervical ectopy also increases susceptibility: pathogens tend to infect columnar cells in ectopy, and not squamous cells covering the surrounding cervix and vagina. Columnar epithelial cells have greater adhesion to C trachomatis, resulting in an increased biological affinity for chlamydia during adolescence. An immature cervix and smaller introitus are more prone to trauma and tearing, easing transmission of pathogens.

Insights into the adolescent mind

Adolescents think concretely; therefore, practitioners who seek to influence behavior should be aware of the importance of speaking plainly and telling the adolescent specifically what to do.⁵ For example, rather than saying, “If you decide that you want to have sex, use a condom,” the clinician should be prepared to provide details: which store to go to, its address, the specific aisle, and how much money to bring. The adolescent must be taught how to use the condom. Even with this specific guidance, adolescents are often unable to plan ahead for condom use; most adolescent sexual activity is unplanned.

Elkind’s theory of adolescent egocentrism may provide insight into the thought processes of adolescents.⁶ They may feel that all actions are being watched and scrutinized by others—and therefore may be confrontational or desire to prove others wrong. They may also feel unique and invulnerable—and be more likely to engage in behavioral risk taking.⁶ They may believe that STDs happen to other people but not to them or their sexual partners. To challenge these ideas, ask an adolescent, “What does a person who has an STD look like?” She’ll probably describe someone who is dirty, homeless, or a prostitute. Ask if the teen’s favorite film star or music artist could have an STD. The answer will probably be “no.” And ask, “How do you know that someone does not have an STD?” The answer will may be, “He dresses well, has a car,” etc. Follow up by stating that anyone can have an STD: you can’t tell by appearances—anyone, no matter how wealthy, famous, or well dressed can have an STD.

Sexually active teenagers typically have one partner at a time for relatively brief periods. Generally, they do not view themselves as having multiple partners and, therefore, may not accurately assess their risks for STDs. To help them understand the implications of serial monogamy on STD risk, the clinician may ask a patient, “If you continue on your current path, how many partners will you have had by age 20?” As the patient works out the math, she may reevaluate her risk—now and in the future.

Behaviors that increase risk of STDs

A woman whose first sexual intercourse occurred when she was younger than 15 years is nearly 4 times as likely to report a bacterial STD and more than twice as likely to report PID, compared with a woman who first had sex after age 18.⁷ Having a new sexual partner is also a predictor of an STD because the partner’s sexual history and infection status are uncertain.7 Having more than one sexual partner at a time increases exposure, and therefore increases risk of acquiring an STD.

Use of alcohol and other substances that impair judgment can increase the likelihood of engaging in sexual intercourse without a condom, with multiple partners, or with high-risk partners.⁸

The lower the age at first intercourse, the less likely it is that a condom will be used. Having an older partner or being in a relationship with an imbalance of power also are risk factors in that sexual negotiation is absent, and involuntary intercourse can occur. A history of sexual abuse or assault may increase risk.⁹

Mental health problems also contribute to behavioral risk factors. A patient who has an STD with comorbid and untreated or undertreated bipolar disorder, schizophrenia, or conduct disorder is likely to repeat behavior that contributed to infection.

Lack of adult supervision may increase opportunity for sexual activity and thus may increase STD risk.

Societal and socioeconomic risk factors

Societal and institutional risk factors for STDs include the lack of adequate sex education; most adolescents are unaware of the symptoms and signs of an STD aside from, perhaps, abnormal discharge. I am often asked to bring along pictures of severe disease when I give a talk at a high school about STD prevention, but showing these images to adolescents can have unintended effects. An adolescent who sees an image of a serious case of genital herpes may think that, because neither she nor her partner looks that way, then both partners must be “OK.” A more effective strategy is to show an image of normal genitalia, and to emphasize that infection could be present despite the normal appearance. It may be useful to show an adolescent an image of mild disease.

What the data show

Trent and coworkers illuminated adolescent perceptions of fertility and STDs using data from the Adolescent Health Study, a population-based telephone survey of urban household adolescents from a high STD-prevalence community.¹⁰ The majority of adolescents reported that childbearing was somewhat or very important, and young females were more likely to identify chlamydia and PID as causes of fertility problems. Seventy-two percent perceived some chance that they would have future fertility problems, and 58% thought they had little or no control over developing fertility problems in the future.

In an earlier study, 21.5% of 200 sexually active nulliparous females 14 to 18 years of age expressed fertility concerns. Additionally, researchers found that perception of infertility was associated with a history of discussing infertility (with anyone), desire for pregnancy, history of STD, and having an older boyfriend. Importantly, the researchers found that adolescents who doubted their fertility used contraceptives less frequently than others.¹¹

The facts, filtered through the adolescent mind

The healthcare provider’s approach to discussing fertility with an adolescent female depends on the adolescent’s intellectual maturity, particularly when the objective is to dispel the false but widely held assumption that having had an STD leaves her infertile. Telling an adolescent girl that her STD has likely left her infertile can backfire, as the adolescent mind may interpret that statement as a license to use no birth control.

In such cases, concrete explanations may be helpful. For example, instead of talking about percentages, ask the patient to imagine 100 girls in a room. Tell her that after the first STD, between 10 and 20 girls in the room will have trouble getting pregnant. This concrete approach helps the adolescent understand that, even though she had PID, she may be among those girls in the room who can still get pregnant, even though the PID may cause other problems.

Assessing future risks

A sexually active female 25 years of age and younger who has been treated for an STD should have repeat testing 3 to 4 months posttreatment¹² because of the risk of reinfection. She should also be counseled, perhaps through role-playing, to help her to discuss her STD with her partner and develop strategies to deal with a partner who becomes accusative or refuses to believe that—without symptoms—he has an infection.

Clinicians—as well as parents—should also talk about the positive reasons to delay onset of sexual activity. We can teach adolescents how to prevent pregnancy and avoid STDs. Concerns about pregnancy, STDs, or HIV/ AIDs may prompt adolescents to delay onset of sexual activity.¹³ With these concerns addressed, what are the positive reasons to help adolescents make the decision to delay sexual activity? Discuss the importance of positive goals: forming a strong relationship with a long-term partner (vs a boyfriend who may be gone in 2 months), adhering to religious values, meeting family expectations, graduating from high school, going to college, etc.

What are the practical steps that a clinician can take? I find that adolescents who do not become sexually active share 2 characteristics:

1) They are kept busy and supervised in the afternoon until the parents get home, perhaps through after-school programs, sports, or staying at a neighbor’s home where an adult is present, and

2) Their parents actively inquire about their activities and know what they’re doing.

When I ask adolescents, “Why haven’t you had sex?” the responses I get most often are: (1) “My mom is nosey and gets on my nerves,” and (2) “I’m too busy.” In the end, it’s not that they don’t want to be sexually active, they just don’t have the opportunity!

The Centers for Disease Control and Prevention reports that racial minorities face disparities across the 3 reportable STDs chlamydia, gonorrhea, and syphilis.¹⁴ While racial disparities persist overall, African Americans, especially young African-American women, are the most heavily affected. (Young African-American women face significantly higher rates of chlamydia and gonorrhea than any other group, while the highest rates of syphilis are among African-American men.¹⁴)

The United States Preventive Services Task Force recommends annual screening for sexually active women who are 25 years old and younger.¹⁵ The area that I serve has very high rates of these infections, with a prevalence of chlamydia of 27% and of gonorrhea of 8%. In my practice, I screen adolescents for chlamydia and gonorrhea every 6 months, or with each partner change, whichever is more frequent. Data from a randomized controlled trial of chlamydia screening in a managed care setting suggest that screening programs can reduce incidence of PID by as much as 60%.¹⁶ Chlamydia screening and reporting are likely to expand further in response to the recently implemented Healthcare Effectiveness Data and Information Set (HEDIS) measure for chlamydia screening of sexually active women 15 through 25 years of age who receive medical care through managed care organizations.

Sexuality, Reproduction & Menopause ©2010 Quadrant Healthcom Inc.