Adolescents involved with the juvenile justice system have higher rates of risky sexual behaviors, resulting in high rates of sexually transmitted infections and increased risk of human immunodeficiency virus, early or complicated pregnancy, and parenting issues. Comorbid substance abuse, gang association, mental health issues, and history of having been abused as children result in further elevated rates. Girls and lesbian, gay, bisexual, and transgender youths represent growing subpopulations with special risks. Increasingly diverted to community-based alternatives, juvenile justice–involved teens obtain most of their medical care from community providers, who need to understand their risks to provide appropriate, optimal care.
Key points
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Juvenile justice-involved youths reside primarily in the community and receive health care from community providers.
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Adolescents involved with the correctional system report more high-risk sexual behaviors that lead to disproportionate rates of negative health outcomes.
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Pediatric providers are uniquely positioned to identify and address high-risk sexual behaviors and comorbid substance abuse and mental health issues in this underserved population.
Approximately 70,800 US youths were housed in more than 2500 juvenile justice (JJ) residential placement facilities nationwide according to the most recent statistics from the Office of Juvenile Justice and Delinquency Prevention. Despite 25 years of movement away from juvenile incarceration toward decriminalization and diversion to community-based programs, the United States still incarcerates a higher percentage of youths than any other developed country. However, most of the 2 million juveniles arrested and processed by the courts are remanded to community programs or probation. Higher rates of risky sexual and substance use behaviors reported by JJ-involved youths, compared with noninvolved peers, present the community with public health risks. High rates of recidivism mean that there is often a revolving door through which many JJ-involved youths shuttle between detention and home communities. One-fifth of youths remanded to JJ residential placements were returned to the community in less than 2 weeks, and many return to detention repeatedly.
Pediatricians are in a unique position to address factors that place children at risk for entry into the JJ system and to provide continuity of care, screening, and treatment of detained youths when they return to community care. Pediatric providers are also positioned to be powerful advocates for social policy changes and funding to remediate the social determinants of health (poverty, family dysfunction, substance and child abuse, and depression), which are predictors of JJ involvement.
Higher rates of sexually transmitted infections (STIs), including chlamydia, gonorrhea, syphilis, and human immunodeficiency virus (HIV), have been reported in both juveniles and adults entering correctional facilities and also in those returning to community settings. Reported rates underestimate the problem, because the lack of available testing and treatment in many juvenile facilities leads to underreporting. The risk behaviors in which adolescents engage are clearly recognized as the root cause of such health outcomes. Because risky sexual behaviors themselves are correlated with early death, disability, and socioeconomic challenges, they have long been recognized as a public health priority. Recent national surveys of high school youths indicate that today’s adolescents are reporting less frequent sexual intercourse encounters, fewer sexual partners, less substance use before sex, and increased condom and other contraceptive use. However, in the JJ population, these decreases are not being seen. It is essential to address not only the sexual risk behaviors and their consequences in this population but also the individual, family, and sociodemographic factors that contributed to those behaviors.
Sexual risk persists during and after any justice system contact
A longitudinal study of 1829 youths detained between 1995 and 1998 in Chicago’s Cook County Juvenile Detention Center aimed to identify HIV/STI risk behaviors at baseline and again at follow-up 3.5 to 4.5 years later. More than 60% engaged in 10 or more sexual risk behaviors at baseline and approximately two-thirds persisted or increased that pattern at follow-up. Of youths who reported unprotected vaginal sex at baseline, more than 50% of boys and almost 70% of girls maintained this behavior 3 to 4 years later. Having unprotected sex while drunk or high was reported at follow-up by 75% of boys and 60% of girls. More than half the study subjects had a substance use disorder at baseline, increasing at follow-up to greater than 80% use. At the time of that study, injection drug use was uncommon at both baseline and follow-up. Given that the epidemiology of HIV has shifted toward increased heterosexual transmission, accounting for one-third of current AIDS cases, up from 4% in early HIV reporting, this population is at high risk for HIV/AIDS. Most of these behaviors were more prevalent among youths who were arrested and returned to the community, compared with those who were incarcerated, so community health providers must be part of the solution, developing comfort in communicating with high-risk youths and in using motivational interviewing to change behaviors.
Increased STI/HIV risks follow not only detention or incarceration, but also any encounters with the justice system. Police encounters or arrests may be a proxy for other factors that predict increased STI/HIV risk. A retrospective cohort study of adults and juveniles having had any contact with the Marion County, Indiana justice system looked at STI occurrence and HIV incidence rates in the year following arrest or incarceration, compared with the county’s nonoffender rates. Offender rates were higher in general, but rates for chlamydia (2968 per 100,000) and gonorrhea (2305 per 100,000) were higher than for syphilis (278 per 100,000) and HIV (61 per 100,000). Rates were up to 2.8 times higher in women than in men and 6.9 times higher in blacks than in whites. Chlamydia and gonorrhea rates were highest among 15 to 19 year olds. Incident HIV was highest in 20 to 44 year olds, suggesting likely exposure during adolescence. Interestingly, those arrested, but not detained, had higher annual rates of testing positive for these STIs in follow-up compared with those who were incarcerated, presumably because sexual activity in jail and prison is prohibited.
Sexual risk persists during and after any justice system contact
A longitudinal study of 1829 youths detained between 1995 and 1998 in Chicago’s Cook County Juvenile Detention Center aimed to identify HIV/STI risk behaviors at baseline and again at follow-up 3.5 to 4.5 years later. More than 60% engaged in 10 or more sexual risk behaviors at baseline and approximately two-thirds persisted or increased that pattern at follow-up. Of youths who reported unprotected vaginal sex at baseline, more than 50% of boys and almost 70% of girls maintained this behavior 3 to 4 years later. Having unprotected sex while drunk or high was reported at follow-up by 75% of boys and 60% of girls. More than half the study subjects had a substance use disorder at baseline, increasing at follow-up to greater than 80% use. At the time of that study, injection drug use was uncommon at both baseline and follow-up. Given that the epidemiology of HIV has shifted toward increased heterosexual transmission, accounting for one-third of current AIDS cases, up from 4% in early HIV reporting, this population is at high risk for HIV/AIDS. Most of these behaviors were more prevalent among youths who were arrested and returned to the community, compared with those who were incarcerated, so community health providers must be part of the solution, developing comfort in communicating with high-risk youths and in using motivational interviewing to change behaviors.
Increased STI/HIV risks follow not only detention or incarceration, but also any encounters with the justice system. Police encounters or arrests may be a proxy for other factors that predict increased STI/HIV risk. A retrospective cohort study of adults and juveniles having had any contact with the Marion County, Indiana justice system looked at STI occurrence and HIV incidence rates in the year following arrest or incarceration, compared with the county’s nonoffender rates. Offender rates were higher in general, but rates for chlamydia (2968 per 100,000) and gonorrhea (2305 per 100,000) were higher than for syphilis (278 per 100,000) and HIV (61 per 100,000). Rates were up to 2.8 times higher in women than in men and 6.9 times higher in blacks than in whites. Chlamydia and gonorrhea rates were highest among 15 to 19 year olds. Incident HIV was highest in 20 to 44 year olds, suggesting likely exposure during adolescence. Interestingly, those arrested, but not detained, had higher annual rates of testing positive for these STIs in follow-up compared with those who were incarcerated, presumably because sexual activity in jail and prison is prohibited.
Girls: a juvenile justice minority population with unique risk profiles
Although girls continue to comprise a minority of detained and arrested juveniles, the number of arrested and detained girls has been substantially increasing in recent years. In 2011, girls comprised nearly 30% of all nationwide juvenile arrests. Because of the increasing use of programs to divert youths arrested for minor infractions to community settings or probation, rather than lock-up, juvenile incarceration rates overall have been decreasing over the past 2 decades. However, the rate of decrease for girls (8%) has been much lower than for boys (18%), meaning that arrested girls are still disproportionately remanded to incarceration versus community diversion compared with boys.
Child Abuse, Substance Use, and Mental Heath Issues Increase Girls′ Sexual Risks
Girls in the JJ system are significantly more likely than boys in the system to have been victims of sexual and/or physical abuse before incarceration. Rates of abuse in JJ-involved girls are 3.5 to 10 times higher than rates for their male counterparts. These findings of significantly different male and female histories reported by youths in JJ settings suggest the need for both gender-specific and gender-sensitive female programming and PTSD/child abuse/trauma training for staff and medical providers.
Leve and colleagues (2015) followed 166 JJ-involved girls from adolescence to young adulthood, reporting that a history of sexual abuse correlated with increased rates of unsafe sexual behaviors in young adulthood, which in turn was associated with acquiring an STI, putting these girls at greater risk for acquiring HIV/AIDS. Discomfort talking with partners about safer sex practices moderated the association between sexual abuse history and unsafe sex in young adulthood. Girls with a history of sexual abuse, who also have difficulty talking to partners about sex practices, reported an 8.5 times higher rate of unsafe sex practices compared with their JJ peers without sexual abuse histories. Few studies have evaluated how the relationship between child abuse and sexual risk-taking functions. Lopez and colleagues investigated possible mediators in the pathway leading from child maltreatment to noncondom use, a behavior usually highly correlated with other sexual risk-taking behaviors. Basing their hypotheses on the theory that females’ sense of self-worth, empowerment, and identity is rooted in relationships with others, they predicted that intimate partner relationships would have a powerful impact on condom use. Although depressive self-concept and condom use self-efficacy were significantly related to noncondom use for white girls only, they were not mediators. There was evidence, for African-American girls only, that child maltreatment results in a pathway from depressive feelings and lower self-worth to substance use (self-medication), which may then lead to noncondom use.
A history of sexual abuse has long been correlated with more serious delinquency compared with counterparts without that history. It was commonly thought that childhood abuse predicted higher rates of promiscuity, teenage pregnancy, and prostitution. However, Widom and Kuhns’ 1996 prospective study of 1575 children referred for physical or sexual abuse between 1967 and 1971 found only the likelihood of engaging in prostitution differentiated the abused group from the nonabused group, and that finding applied only to girls. The highest rates of prostitution correlated with a history of physical abuse (12.8%), followed by sexual abuse (10.5%) and neglect (9%). Childhood sexual abuse was not found to be predictive of teenage pregnancy or promiscuity in this study. Exposure to interparental violence or child abuse does increase 7-fold the likelihood that girls will commit a violent act and will be referred to JJ, compared with an age-matched community sample not exposed to domestic violence. A case-controlled study of children aged 0 to 11 years, processed for child physical or sexual abuse between 1967 and 1971, followed up in 2013, reported that boys, but not girls, with histories of physical abuse were significantly at greater risk than controls for being arrested for sexual offenses (odds ratio [OR] 2.21; confidence interval, 1.38–3.40). A history of sexual abuse did not significantly predict arrest for sexual offenses (OR 2.13).
Significantly higher rates of comorbid mental health problems in girls entering the JJ system add to the likelihood of risky sexual behaviors compared with non JJ-involved community peers and also compared with boys in the system. Risky sexual behavior (multiple partners, partners injecting drugs, failure to use condoms during intercourse), prevalent among JJ-involved girls, is also associated with substance use.
Higher Female Rates of Sexually Transmitted Infections and Risky Sexual Behaviors and Partners
Seventy-six percent of girls in a short-term JJ facility reported being sexually active with initial sexual experience before 14 years of age. Girls in one study reported 3 or more sexual partners with 10% reporting trading sex for money during their teenage years. In comparison, only 48% of high school girls in a population-based survey reported having had sexual experience and only 13% reported having 4 or more lifetime sexual partners. An earlier study of detained girls reported that the average number of lifetime sex partners was 8.8. Rates of STIs (20%–42%) discovered during health evaluations in JJ facilities, are much higher than those in community samples.
Compared with JJ-involved boys, JJ girls are reported to have higher rates of STDs. They are also more likely to engage in other risky sexual practices, including unprotected sex, sex with high-risk partners, and trading sex for money. Compared with boys, girls in a study of teens (N = 523) in a southern US city juvenile detention center reported significantly greater knowledge, less peer influence, more positive attitudes toward condoms, higher recognition of risk of STIs, and greater self-efficacy on paper; but surprisingly they reported less actual condom use compared with male peers. This gendered paradox (higher self-efficacy, yet lower condom use) may reflect negative partner attitudes toward condoms in relationships in which the boy has more power or other factors that differentially impact girls’ difficulty communicating and asserting their preferences.
Girls in the JJ system tend to have older sexual partners than either male counterparts in the system or non–JJ-involved girls. One study reported that one-third of girls in a JJ facility indicated sexual involvement with a partner more than 5 years older. Age difference alone usually creates a power differential; but in addition, some of these older partners may be acting as pimps, who exercise complete financial, emotional, and physical control over the girls ( Boxes 1 and 2 ).
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Unprotected vaginal or anal sex
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Sex with high-risk partners (intravenous drug use, prostitution)
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Nonuse of condoms
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Multiple sexual partners
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Sex under the influence of drugs/alcohol
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Sex for money; survival sex for food/shelter
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JJ/corrections involvement
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Low self-efficacy
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Depressive self-concept
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Exposure to marital violence/physical or sexual child abuse or neglect
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School expulsion/suspension
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Difficulty communicating with partners about safe sex
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Older or more powerful partners
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Mental health comorbidity
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Substance abuse or use as self-medication
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Gang involvement
Given that most of the girls who tested positive for a sexually transmitted disease (STD) in detention were triaged to the community in either diversion programs or nonsecure home detention, these rates of STDs and behaviors that place partners at risk constitute a significant public health challenge. Primary care providers must be aware of this issue, as it now affects youths in their practices. Clinicians will be more successful in addressing these issues if they are knowledgeable about adolescent sexuality and STD testing and treatment (see Zoon Wangu and Gale R. Burstein’s article, “ Adolescent Sexuality: Updates to the Sexually Transmitted Infection Guidelines ,” in this issue) and also comfortable and skilled in communication with adolescents about sexuality and comorbid risks (see Betsy Pfeffer and colleagues, “ Interviewing Adolescents about Sexual Matters ,” in this issue). Comorbid substance use disorders in JJ-involved girls correlate with increased rates of risky sexual behavior. One study found that 96% girls with substance use disorders were sexually active; 62% had multiple partners within the preceding 3 months; and 59% had unprotected intercourse in the prior month. Providers must recognize and screen for multiple interacting risks: substance use, risky sexual behaviors, home and school difficulties, and mental health issues.
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