The Hidden Epidemic Confronting Sexually Transmitted Diseases (1997) / Chapter Skim
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FACTORS THAT CONTRIBUTE TO THE HIDDEN EPIDEMIC
FACTORS THAT CONTRIBUTE TO THE HIDDEN EPIDEMIC
Pages 69-117
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From page 69... ...
· Only 11 percent of teenagers surveyed reported getting most of their information regarding STDs from their parents or other family members. · Among prime-time network television shows, there is only 1 portrayal of protective behavior or comment regarding STDs for every 25 instances of sexual behavior shown.
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From page 70... ...
Asymptomatic infection also contributes to the spread of viral STDs including HIV infection, hepatitis B virus infection, genital herpes, and human papillomavirus infection. HIV infection is a prime example of how certain STDs that may go unrecognized for many years allow wide dissemination of infection before it is detected and treated.
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From page 71... ...
The determinants of condom use are discussed in Chapter 4. Other Biological Factors Other biological factors that may increase risk for acquiring, transmitting, or developing complications of certain STDs include presence of male penile foreskin, vaginal douching, risky sexual practices, use of hormonal contraceptives or intrauterine contraceptive devices, cervical ectopy, immunity resulting from prior sexually transmitted or related infections, and nonspecific immunity conferred by normal vaginal flora.
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From page 72... ...
Certain sexual practices such as receptive rectal intercourse predispose to STDs. As mentioned in Chapter 2, STDs such as HIV infection and hepatitis B virus infection are more easily acquired by rectal intercourse than by vaginal intercourse.
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From page 73... ...
has also been found to be a risk factor for HIV infection (Moss et al., 1991~. Among women attending an STD clinic and among college women, cervical ectopy was positively associated with use of oral contraceptives and with chlamydial infection; ectopy disappeared with increasing age (Critchlow et al., 1995~.
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From page 74... ...
However, the study found that only about half of all health plans cover preventive care such as routine gynecological examinations that may be important in detection of asymptomatic sexually transmitted infections. Managed care organizations may provide better coverage for certain STDrelated services than do many indemnity health plans, but they pose different challenges to the prevention of STDs, particularly for many Medicaid beneficiaries enrolled in managed care.
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From page 75... ...
Health insurance coverage influences where people obtain STD services. A recent study found that uninsured women and those covered by Medicaid were far more likely to obtain reproductive health services from a public or community-based clinic rather than a private physician's office, compared to women who were covered by either a managed care organization or other private health insurance (Sonenstein et al., 1995~.
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From page 76... ...
Louis ME, Edlin BR. Substance abuse and the spread of sexually transmitted diseases.
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From page 77... ...
Impact of Crack Cocaine on STD Transmission Numerous studies show that drug use is associated with increased risk of STDs, including HIV infection. Marx and colleagues (1991)
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From page 78... ...
Edlin and others (1994) reported in a multisite study that crack smokers were at greater risk for HIV infection compared to persons who did not smoke crack.
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From page 79... ...
In a survey of attendees at an STD clinic, drug and alcohol use was found to correlate with unprotected sex during their most recent sexual intercourse (CDC, 1990~. In a multiple logistic regression analysis controlling for age, race, income, number of sex partners, and other variables, failure to use condoms was significantly associated with drug and alcohol use at the last sexual encounter for heterosexual men.
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From page 80... ...
The age discrepancy between older men and younger, sometimes adolescent, females may predispose to power imbalances in the relationship, thus increasing the potential for involuntary intercourse, lack of protective behavior, and exposure to STDs (Finkelhor and Associates, 1986~. In addition, early initiation of sexual intercourse among adolescent males with an older female partner has been shown to increase the number of sex partners later in life (Weber et al., 1992~.
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From page 81... ...
Runaways and homeless adolescents are at increased risk for STDs because they tend to be more sexually active than other adolescents (Hein et al., 1978~; have multiple high-risk sexual behaviors that include trading sex for drugs or money (AMA, Council on Scientific Affairs, 1989; Sugerman et al., 1991; Sherman, 1992; Forst, 1994~; have high levels of substance use (Manov and Lowther, 1983; Sugerman et al., 1991; Sherman, 1992~; and are frequently sexually and physically abused by others (AMA, Council on Scientific Affairs, 1989~. A survey of states regarding preg
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From page 82... ...
Adolescents in detention facilities may represent "core" transmitters of STDs since they have problems, such as high rates of drug and alcohol use and poor access to health care, that place them at continuing risk for STDs (Shafer, 1994~. Compared to other adolescents, those in detention facilities tend to have engaged in sexual intercourse earlier and more frequently; have engaged in unsafe sexual practices more often; and have higher rates of STDs (Bell et al., 1985; DiClemente et al., 1991; Weber et al., 1992; Oh et al., 1994~.
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From page 83... ...
From 1990 through 1995, the number of prisoners grew at an annual rate of 7.9 percent. Inmates in correctional facilities have high levels of communicable diseases, including tuberculosis, hepatitis B virus infection, and HIV infection and other STDs (Glaser and Greifinger, 1993~.
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From page 84... ...
, it is unclear if prisoners in correctional facilities are more likely to acquire STDs, including HIV infection, during incarceration or outside in the community (Dolan et al., 1995~. While it is possible that the frequency of unprotected sexual intercourse or injecting drug use among prisoners is typically higher while they are not in confinement (Decker et al., 1984; Horsburg et al., 1990)
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From page 85... ...
Follow-up of released detainees who test positive for STDs and notification of partners who are not inmates are considered to be rare. Migrant Workers STDs, including HIV infection, are major health problems among migrant workers (Jones et al., 1991; CDC, 1992a)
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From page 86... ...
In this section, the committee summarizes the basis for the stigma surrounding STDs, the reticence to deal openly with sexual behaviors, and the impact of these two factors on preventing STDs. Sexuality and Secrecy in the United States Perhaps more than any other aspect of life, sexuality reflects and integrates
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From page 87... ...
It influences how, with whom, and with what level of safety people engage in sexual behaviors. However, sexuality is a value-laden subject that makes people including health care professionals, researchers, educators, and the public feel anxious and uncomfortable talking about it.
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From page 88... ...
For some individuals, opposition to research in sexual behavior can represent very deepseated fears and doubts about the role and significance of sexuality in personal life and the appropriateness of addressing this issue in public (di Mauro, 1995~. The paradoxical nature of sexuality in the United States is further illustrated by a mass media culture that portrays casual sexual activity as the norm, while data show that most Americans disapprove of adult women having premarital sexual intercourse (Klassen et al., 1989~.
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From page 89... ...
In this section, the committee describes how the constraints on acknowledgment and open discussion of sexuality adversely impact sexuality education programs for adolescents, open communication between parents and their children and between sex partners, balanced messages from the mass media, education and counseling activities of health care professionals, and community activism for STDs. Impact on Sexuality Education for Adolescents Traditionally, sexual behavior has been regarded as a personal issue and involvement by schools or health care professionals has been seen as intrusive.
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From page 90... ...
Effective school-based programs and other means to educate children regarding sexuality might be less important if all parents discussed these issues with their children. Children who do not have open information exchange with their parents or others regarding sexuality may be less likely to communicate openly with their sex partners in the future, and thus be less likely to implement protective behaviors than others.
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From page 91... ...
teenagers by primary source of information regarding STDs, 1995. SOURCE: ASHA (American Social Health Association)
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From page 92... ...
. To do so, however, requires feeling comfortable about sexuality and having open communication regarding sexual behaviors.
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From page 93... ...
Another recent study that examined the influence of mass media on eight potentially risky behaviors, including sexual intercourse, found that adolescents who had engaged in more risky behaviors listened to radio and watched music videos and movies on television more frequently than those who had engaged in fewer risky behaviors, independent of demographic factors (Klein et al., 1993~. The reluctance and past refusal of mass media to become involved in the dissemination of information regarding STDs and other sexual issues is not new.
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From page 94... ...
Despite the current lack of involvement of mass media in promoting messages regarding healthy sexual behaviors, the mass media can be an extremely powerful ally in efforts to prevent STDs. HIV prevention messages delivered through mass media have been effective in increasing knowledge and changing behavior (Flora et al., 1995~.
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From page 95... ...
In addition, the Media Project2 has been working with television producers and writers to improve the content of sexual messages in television shows and to increase the promotion of healthy sexual behaviors. A coalition of organizations with an interest in sexuality education, the National Coalition to Support Sexuality Education, recently issued a consensus statement and suggested guidelines for incorporating information regarding healthy sexual behavior and STDs into the mass media (Box 3-2~.
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From page 96... ...
The media play a major role in educating Americans about sexuality, gender roles, and sexual behaviors. Sexual images and references may be commonplace in the media, but sexuality is much broader than the media typically portray.
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From page 97... ...
· When describing, alluding to, or portraying sexual intercourse, include steps that should be taken for prevention, such as using contraceptives and condoms to prevent unwanted pregnancy and information about the full spectrum of sexually transmitted diseases. · When an unprotected sexual encounter results in negative consequences, realistically portray or refer to the possible, specific, short- and long-term repercussions of the individual's decision-making process.
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From page 98... ...
Limited time and resources also constrain clinicians from communicating with their patients regarding STDs and sexuality. If STDs are not seen as a high
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From page 99... ...
Impact on Community Activism The stigma associated with STDs hinders public discourse and, as a result, community activism for STDs other than HIV infection. Because having an STD is still socially unacceptable, there are few if any patient-based constituent groups who advocate publicly or lobby for STD-related programs.
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From page 100... ...
Because school-based sexual health education, mass media interventions, and public discussion regarding sexual health issues are much more common in many other developed countries, it follows that private communication regarding these issues between parents and children, and between couples is also more common in those societies than in the United States. Another major factor that may explain the observed differences in STD rates is universal access to health services in other developed countries.
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From page 101... ...
Another significant development is that a new level of sexual discourse is developing, characterized by an increased willingness to talk publicly and explicitly about sexuality topics. Despite the recent surge of research activity regarding sexual behaviors, the knowledge base is still limited, and many epidemiological studies of human sexuality are outdated (Laumann, Gagnon, et al., 1994~.
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From page 102... ...
Trends in Sexual Activity Although the discomfort and secrecy surrounding sexuality in Amenca have limited scientific knowledge and prevented many parents and others from recognizing that adolescents as well as adults are sexually active, there are some scientific data regarding sexual activity. These data suggest that adolescents and young adults are not only sexually active but have very high rates of high-nsk sexual behavior.
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From page 103... ...
Data from CDC's Youth Risk Behavior Surveillance System shows that from 1990 through 1993, the proportion of high school students who reported being sexually experienced, ever having sexual intercourse
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From page 104... ...
SOURCE: Kost K, Forrest JD. American women's sexual behavior and exposure to risk of sexually transmitted diseases.
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From page 105... ...
However, despite the recognition of HIV infection and other STDs during this period, with the exception of increased condom use, there were no significant changes in sexual practices such as number of partners and other high-risk sexual practices among the students surveyed from 1975 through 1989. A follow-up study, however, showed that almost three-quarters of college women reported "always or almost always" using condoms in 1995 (Peipert et al., 1996~.
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From page 106... ...
Women and sexually transmitted diseases: the dangers of denial. New York: American Medical Women's Association, 1994.
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From page 107... ...
In contrast, population-based studies suggest that the prevalence of antibodies to herpes simplex virus type 2, which causes about 85 percent of initial episodes of genital herpes, was 21.7 percent in 1990 (Johnson et al., 1993~. The reason for the substantial differences between the low prevalence of self-reported genital herpes infections and the far higher true prevalence of the disease may be misperceptions regarding the clinical manifestations of genital herpes infections.
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From page 108... ...
The secrecy surrounding sexuality impedes sexuality education programs for adolescents, open discussion between parents and their children and between sex partners, balanced messages from mass media, education and counseling activities of health care professionals, and community activism regarding STDs. Opponents of sexuality education programs for adolescents are likely to deny the possibility that their children are sexually active.
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From page 109... ...
Sexually transmitted diseases in females in a juvenile detention center. Sex Transm Dis 1985;12:140-4.
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From page 110... ...
. Current trends: heterosexual behaviors and factors that influence condom use among patients attending a sexually transmitted disease clinicSan Francisco.
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From page 111... ...
Behavioral risk factors for sexually transmitted diseases in American households.
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From page 112... ...
Cocaine use and risky injection and sexual behaviors. Drug Alcohol Depend 1995;37:7-14.
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From page 113... ...
American women's sexual behavior and exposure to risk of sexually transmitted diseases. Fam Plann Perspect 1992;24:244-54.
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From page 114... ...
Soap opera portrayals of sex, contraception, and sexually transmitted diseases. J Communications 1989;39:76-83.
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From page 115... ...
Sexual behavior and sexually transmitted diseases among male adolescents in detention. Sex Transm Dis 1994;21: 127-32.
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From page 116... ...
Gee L, DiGiorgio-Haag L, et al. Relationship between drug use and sexual behaviors and the occurrence of sexually transmitted diseases among high-risk male youth.
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From page 117... ...
Effect of changes in human ecology and behavior on patterns of sexually transmitted diseases, including human immunodeficiency virus infection.
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