Introduction
Over one-third of high school students report having ever had sexual intercourse, with over half of high school seniors stating that they have had sex. Almost one-fifth (16%) of high school seniors report having had four or more sex partners. Of students who are sexually active, only 54% report using a condom with their last sexual encounter.
Although sexually transmitted infections (STIs) affect people of all ages, adolescents are at increased risk. 
Inconsistent condom use, early sexual debut, and increased numbers of partners increase the chances of contracting an STI. Rates of reported Chlamydia trachomatis infections, though decreasing slightly in recent years, remain highest in adolescents and young adults (AYAs) ages 15 to 24 years, with almost two-thirds of these infections reported in this age group in 2020. Other STIs, including Neisseria gonorrhoeae and syphilis, have seen increased prevalence in recent years.
Transmission of STIs is through sexual contact, and STIs can only be definitively prevented by abstaining from sexual activity. Risk can be decreased by consistent, correct condom use and by ensuring that partners have been tested and are negative for STIs. Vaccination against hepatitis B and human papillomavirus (HPV) dramatically lowers the risk of these viral STIs. The risk of contracting an STI increases with increasing number of partners. STIs are endemic in some communities, and this may confer a greater risk than individual sexual practices. Black and Indigenous populations have the highest rates of STI, highlighting the racial and ethnic health disparities and barriers to care that can affect these populations.
Providers who care for adolescents must have comfort and experience screening, recognizing, testing, and treating these infections given their high prevalence. A free, easy-to-navigate, and self-paced STI online curriculum is available at https://www.std.uw.edu/ .
Consent and confidentiality
A comprehensive and inclusive sexual history is key to understanding what screening and care an adolescent needs ( Fig. 20.1 , also see Chapter 2 for more information on confidential interview). All major professional organizations, including the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, recommend that developmentally appropriate confidential care be provided to all adolescents. (See Chapter 2 for more information on confidentiality for adolescents.) The opportunity to have a private discussion with their provider is vital to allowing adolescents to take increased responsibility for their own health care. This is especially important when it comes to sexual and reproductive health. Adolescents are more likely to seek necessary reproductive health services when they believe these services will be provided confidentially. Providers must remain nonjudgmental and engage in shared decision making in order to establish an effective therapeutic relationship with their patients. The Centers for Disease Control and Prevention (CDC) has a video that highlights some patient perspectives on the importance of these conversations in the medical visit.
There is a shift in conversations with adolescents about STIs, moving away from shame and stigma, as highlighted by Dr. Teodora Elvira Wi, a World Health Organization leader, in her outstanding TED Talk. She emphasizes the importance of reframing these discussions with our patients. (See https://www.ted.com/talks/teodora_elvira_wi_how_talking_about_sex_could_end_stis .)
Currently, all 50 states and the District of Columbia allow minors to consent to STI testing and treatment; certain states require a minor to be of a certain age to provide consent. Some states include protection of a minor’s confidentiality in their legislation, whereas others allow for parental notification. The right to human immunodeficiency virus (HIV) testing and treatment is explicitly included as part of this in 32 states. State-specific laws regarding confidentiality and parental notification can be accessed at the Guttmacher Institute ( www.guttmacher.org ).
Screening guidelines
Sexually active cisgender women younger than 25 years should be screened at least yearly for N. gonorrhoeae and C. trachomatis using a provider- or patient-collected vaginal swab; both modalities have equal sensitivity and specificity. First-catch urine screening can also be employed, though swabs are preferred in patients with a vagina because of somewhat higher sensitivity. In populations with a high prevalence of Trichomonas vaginalis infections (e.g., sexual health clinics, teen clinics, detention facilities), screening for this organism is also recommended.
Patients who engage in receptive anal or oral intercourse may be screened at these sites as well; the Food and Drug Administration cleared two brands of nucleic acid amplification tests (NAATs) for extragenital screening in 2019. Before this clearance, many large academic and commercial laboratories performed internal validation studies, enabling providers to use these tests on extragenital specimens.
Syphilis screening should be offered to patients with increased risk of infection or in areas of high prevalence. Although a diagnosis of infection requires a two-step laboratory process, screening can be done first with a nontreponemal test, either Venereal Disease Research Laboratory (VRDL) or rapid plasma reagin (RPR). If this test is positive, additional treponemal tests such as the fluorescent treponemal antibody absorbed (FTA-ABS) test or the Treponema pallidum passive particle agglutination (TP-PA) assay are necessary for confirmation. Screening with a treponemal test first, followed by a nontreponemal test (reverse-sequence algorithm) is also acceptable.
Screening in the transgender and gender diverse (TGD) AYA population should be approached based on anatomy and specific sexual practices. TGD people who have a vagina, uterus, or cervix should receive screening equivalent to cisgender women (i.e., annual gonorrhea and chlamydia screening, Pap smears starting at age 21). If a TGD person has had gender-affirming surgery, screening guidelines may differ based on their anatomy.
Screening recommendations are summarized in Table 20.1 . Treatment options for positive screening tests are included in Table 20.2 .
| Infection | Population | Specimen | Testing Modality |
|---|---|---|---|
| Chlamydia trachomatis | Sexually active persons with a vagina/cervix <25 years old | Vaginal swab or first-catch urine | NAAT |
| Neisseria gonorrhoeae | Sexually active persons with a vagina/cervix <25 years old | Vaginal swab or first-catch urine | NAAT |
| Trichomonas vaginalis | Consider in high-prevalence populations | Vaginal swab or first-catch urine |
|
| Syphilis (Treponema pallidum) | Consider in high-prevalence populations (current HIV or other STI, history of incarceration or sex work, sex with MSM, living in area with higher rate of syphilis) | Serum |
|
| Human papilloma virus | Persons 21 years or older with a cervix | Cervical cells | Pap smear |
| HIV | Screen all sexually active persons aged 13–64 years at least once in lifetime a | Serum | Combined immunoassay for HIV-1/HIV-2 antigen/antibody |
a In addition, screen periodically based on (1) personal risk factors: >1 sex partner since most recent HIV test, sex work, and injection drug use and (2) sex partner(s) risk factors: injection drug use, HIV infection, sex with MSM.
| Infection | Type of Organism | Possible Signs and Symptoms | Treatment |
|---|---|---|---|
| Chlamydia (uncomplicated urogenital infection) | Gram-negative bacterium |
|
|
| Gonorrhea (uncomplicated urogenital infection) | Gram-negative bacterium |
|
|
| Trichomonas | Parasite | Vaginal discharge |
|
| Syphilis (primary, secondary, or early latent) | Bacterium (Spirochete) |
| Benzathine penicillin G 2.4 million units IM once |
| Genital warts (external: vulva, perineum, external anus) | Virus | Papular, flat, or verrucous warts |
|
| HSV (genital herpes) | Virus |
|
|
Sexually transmitted infections
Bacterial infections
Chlamydia and gonorrhea are both spread by sexual contact (genital, anal, or oral). Detection of these infections with regular screening is important because untreated infections can lead to complications including pelvic inflammatory disease, tubal scarring, and infertility, as well as increased risk of ectopic pregnancy and chronic pelvic pain. Both infections can also be transmitted vertically from a pregnant person to an infant during childbirth. As reinfection among adolescents is common, counseling on adherence to treatment and techniques to prevent reinfection are paramount.
Chlamydia
C. trachomatis ( Box 20.1 ), a gram-negative intracellular pathogen, is the most common reportable bacterial infection in the United States. The highest prevalence is in AYA females (ages 15–24 years). Although most chlamydial infections are asymptomatic, patients can present with vaginal discharge, abnormal vaginal spotting, bleeding (particularly postcoital bleeding), dysuria, or pelvic pain. On examination, the cervix may appear normal, or there may be evidence of mucopurulent cervicitis such as pus from the os or cervical friability.
- •
Spread by sexual contact (genital, anal, or oral).
- •
Can be transmitted vertically from a pregnant person to infant during childbirth.
- •
Transmission can only be definitively prevented by abstaining from sexual activities.
- •
Risk can be decreased by consistent, correct condom use, and by ensuring that partners have been tested and are negative.
- •
Infections must be reported to the health department.
- •
Sexual partners should be empirically treated.
There is increasing evidence of rectal chlamydia infections among cisgender women presenting to sexual health clinics, even in the absence of reported receptive anal intercourse. Like genitourinary (GU) chlamydia infections, most rectal infections are asymptomatic. Some experts have hypothesized that inadequately treated or untreated rectal chlamydia may lead to autoinoculation of the urogenital tract, leading to recurrent chlamydial infections. Current treatment of chlamydia is with oral doxycycline for 7 days. Treatment with a single dose of azithromycin is an alternative, but this is less effective at eradicating the organism, particularly in the rectal tissue (see Table 20.2 ). Partners also should be treated.
Gonorrhea
N. gonorrhoeae ( Box 20.1 ) is a gram-negative bacterium and is the second most common reportable bacterial infection in the United States. Like chlamydial infections, gonococcal infections in people with a cervix are often asymptomatic. If signs or symptoms are present, they can include mucopurulent cervicitis, vaginal discharge, abnormal vaginal bleeding, or pelvic pain.
N. gonorrhoeae has developed resistance to most antibiotics, and parenteral ceftriaxone is the only first-line treatment currently recommended by the CDC (see Table 20.2 ). If the recommended treatment regimen is not used, test of cure is recommended 3 to 4 weeks after completing therapy. Patients with suspected antimicrobial-resistant gonorrhea should be evaluated with culture and antimicrobial susceptibility testing. Suspected treatment failures should be reported to the CDC using a form or through the CDC website (see Table 20.2 ). Partners also should be treated.
Trichomoniasis
T. vaginalis is a protozoan infection that is sexually transmitted and is most commonly diagnosed in patients with a cervix. Routine screening is not recommended for asymptomatic, HIV-negative people, except in at-risk populations. Trichomonas infections may be asymptomatic or may present with a frothy vaginal discharge, dysuria, pruritus, and possibly pelvic pain/lower abdominal pain. The characteristic “strawberry cervix” ( Fig. 20.2 ) of trichomoniasis is seen in a minority of infected patients but is highly specific to this infection. T. vaginalis infection is associated with increased risk of HIV transmission and adverse pregnancy outcomes such as premature rupture of the membranes.
Trichomonas can be transmitted via sexual contact with a partner who has the infection. Transmission via anal or oral intercourse has not been well described. Recommended treatment of trichomoniasis is oral metronidazole for 7 days, though alternative regimens are available. Topical antiinfective agents (such as metronidazole vaginal gel) do not reliably eradicate the infection and should not be used. Sexual partners should be treated.
Syphilis
Syphilis, caused by the spirochetal bacteria T. pallidum, is an STI with manifestations that depend on the stage of the disease. Patients with primary syphilis may present with a painless ulcer (chancre), which often begins as a papule and may progress to an ulcer. This lesion resolves within days to weeks. If undetected and untreated, the infection may proceed to latent syphilis, where there are no visible signs or symptoms of the disease, or to secondary or tertiary syphilis. The stages of syphilis infection are highlighted in Table 20.3 .
| Early Syphilis | Late Syphilis | Neurosyphilis | Latent Syphilis |
|---|---|---|---|
|
|
|
|
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
