The invisibility of adolescent sexual development in foster care: Seriously addressing sexually transmitted infections and access to services

Adolescents residing in foster care are at higher risk for acquiring sexually transmitted infections (STIs) and human immune deficiency virus (HIV) compared to their non-foster care peers. A literature review was conducted to determine whether youth residing in foster care face different barriers to sexual health care compared to their peers in the general population and, if so, what those barriers are. The review revealed barriers common to adolescents in general as well as additional barriers specific to the ecosystem of adolescents in foster care. Systemic issues that decreased access to sexual health services included child welfare policies that were either missing or implemented without fidelity; complicated financial factors; barriers to service utilization; lack of collaboration between child welfare and medical professionals; and limited information provided to foster youth on their sexual health and development. Consent and confidentiality issues that foster youth face in seeking sensitive health services also need to be resolved. More research is needed on how to facilitate development of coherent policies and effective practices that promote sexual health care access for adolescents in foster care.     

Qualitative evaluation of historical and relational factors influencing pregnancy and sexually transmitted infection risks in foster youth

PurposeTo explore how attitudes, norms, behaviors, responses to early life experiences, and protective factors influence pregnancy and sexually transmitted infection risks from the perspectives of current and former foster youth to inform the development of prevention strategies.MethodsWe conducted semi-structured individual qualitative interviews with a diverse sample of 22 current/former foster youth aged 15–21 years (63% female; average age = 18.6 years). We then used Theoretical Thematic Analysis to systematically analyze the data for key themes related to sexual health in four categories: 1) norms and attitudes, 2) responses to early life experiences, 3) protective factors, and 4) youth-driven intervention ideas.ResultsParticipants reported a range of sexual experience levels, varied sexual orientations, and also reported varied life experiences prior to and during foster care. We detected several norms and attitudes that likely contribute to risks of early pregnancies and sexually transmitted infections. These included that one can tell by looking whether a partner is trustworthy or has a sexually transmitted infection, that condoms aren't necessary with long-term or infrequent partners or if birth control is used, and that teen pregnancy is an inevitable event. With respect to responses to early life experiences, youth frequently described difficulties dealing with strong emotions in the context of romantic and/or sexual relationships; many attributed these difficulties to early experiences with biological family members or in foster care. Participants linked emotion regulation difficulties with struggles in trust appraisal, effective communication, and impulsive behaviors. Youth also described a variety of protective factors that they felt helped them prevent sexual risk behaviors or improved their lives in other respects. Finally, participants endorsed factors likely to improve intervention acceptability and efficacy, including an open, non-judgmental group-based environment, involvement of peer mentors, and inclusion of caregiver and caseworker training components.ConclusionsTrauma-informed, tailored intervention strategies which address key norms and attitudes and provide broad-based assertiveness and emotion regulation skills are likely to be the most effective strategies to reduce risks of teen pregnancies and sexually transmitted infections among teens in foster care. Group-based interventions that involve peer mentors and caregiver and caseworker components may be especially acceptable and effective for teens in foster and/or kinship care.     

Parent–youth communication to reduce at-risk sexual behavior: A systematic literature review

There are nearly 110 million cases of sexually transmitted infections (STIs) in the United States. The Centers for Disease Control and Prevention estimate that annually there are more than 19.7 million new STI cases. Of those, more than half are accounted for by youth aged 15–24 years. Although some STIs are not considered to be life threatening, they can lead to severe health problems, risk of HIV infection, or infertility if they are not properly treated. Some research has shown that parent–youth communication can reduce youth’s at-risk sexual behaviors. The following is a systematic review of the literature on parent–youth sexual communication and family-level interventions designed to reduce risky sexual behavior in youth.     

Latino Adolescent Reproductive and Sexual Health Behaviors and Outcomes: Research Informed Guidance for Agency-Based Practitioners

Latinos are the largest and fastest growing minority youth group in the United States. Currently, Latino adolescents experience higher rates of teen pregnancy compared to any other racial or ethnic group and have disproportionately high levels of sexually transmitted infections and HIV. Latino teens are also affected by a number of social problems such as school dropout, poverty, depression and limited access to healthcare, which contributes to disparities in reproductive health outcomes for this population. Relatively few intervention research studies and programs have been dedicated to reducing sexual risk among Latino youth, despite their particular vulnerabilities in experiencing negative reproductive health outcomes. We provide recommendations for identifying the unique reproductive health needs of Latino youth and specific applied strategies so that agency-based social workers and other providers can develop family-based interventions that improve adolescent Latino sexual and reproductive health.     

Risky Sexual Behaviors and Pregnancy Outcomes in Young Adulthood Following Substantiated Childhood Maltreatment: Findings From a Prospective Birth Cohort Study

Childhood maltreatment is associated with a range of adverse mental and physical health outcomes, including increased rates of sexually transmitted infections (STIs) later in life. However, the impact on risky sexual behaviors and pregnancy outcomes has not been adequately studied. This is particularly true for physical abuse, emotional abuse, and neglect. We examined associations between prospectively substantiated childhood maltreatment and reports of risky sexual behaviors by men and women, as well as selected pregnancy outcomes in women. We followed up 3,081 (45.7% female) participants from the Mater-University of Queensland Study of Pregnancy, a prospective Australian birth cohort study. Using logistic regression, we examined the association between substantiated childhood maltreatment from birth to 14 years, and self-reported risky sexual behaviors and youth pregnancy outcomes at the 21-year follow-up. In adjusted analyses, children who had experienced multiple childhood maltreatment exhibited more risky sexual behaviors than their nonmaltreated counterparts. In specific models, those exposed to each form of childhood maltreatment, independent of co-occurring forms of childhood maltreatment, had an increased likelihood of risky sexual behaviors, particularly an early sexual debut and, for women, youth pregnancy. Neglect was also associated with multiple sexual partners, and emotional abuse with higher rates of miscarriage. There was no difference between men and women in how different forms of childhood maltreatment predicted risky sexual behaviors in young adulthood. All forms of substantiated childhood maltreatment, including multiple substantiations, were associated with risky sexual behavior in both sexes as well as higher rates of youth pregnancy in women. Moreover, emotional abuse persistently predicted miscarriages in young adult women. Understanding the association between childhood maltreatment and risky sexual behaviors and youth pregnancy outcomes may help suggest preventive strategies.     

A review of literature: An examination of the correlation between attachment styles and adolescent girls’ sexual behaviors

ABSTRACT

This literature review examines eight studies of parental attachment styles, sexual behavior, and health outcomes among adolescent girls. The review focuses on studies that analyzed the perceived relationships between parents and their adolescent daughters and whether instabilities of life experiences correlated with risky sexual behaviors and if high-risk sexual behaviors were associated with an increase of sexually transmitted infections, unplanned pregnancies, and other poor health outcomes in adolescent girls. Findings show adolescent girls with insecure parental attachment styles were at a higher risk of sexual behaviors, early pregnancies, and transmission of sexually transmitted infections (STI’s). The most common finding in the studies reviewed was the significant association of how higher parental communication and monitoring may prevent risky sexual behaviors at an earlier age. Recommendations for mental and health care providers include the development of treatment programs to address the importance of parent-attachment relationships and multifaceted health needs of adolescents girls. Programs can be strengthened by involving other family members, improving parent-daughter communication and relationships and emphasizing system-level change (policy, procedure, practice). Adding these elements may ultimately lead to sustained improvements over time. Future research on other family social factors (e.g., divorce and separation of attachment figure, poverty, and single-parent homes) associated with attachment and high-risk behaviors is warranted. More research is needed to exam how secure attachments among adolescent girls may prevent earlier sexual encounters, unplanned pregnancies, and STI’s.     

Alcohol and Sexual Health Behavior: “What We Know and How We Know It”

Alcohol, despite salutary associations with sexuality, has been implicated in sexual health problems. This review examines the relationship between alcohol and outcomes related to sexual health. Methodological considerations limiting causal assertions permissible with nonexperimental data are discussed, as are advantages of experimental methods. Findings from laboratory experiments are reviewed evaluating causal effects of acute alcohol intoxication on a variety of outcomes, including sexual arousal, sexual desire, orgasm, and sexual risk behaviors related to sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). Several variables exerting mediating and moderating influences are identified. It is concluded that acute alcohol intoxication is capable of exerting a causal impact on multiple constituent components of sexual responding related to sexual health. Both alcohol expectancy and alcohol myopia theories have been supported as explanations for these causal effects. Furthermore, for sexual risk behavior, noteworthy recent developments include research highlighting the importance of women’s sexual victimization history and men’s condom use resistance. Limitations and implications associated with this body of research are also discussed.     

Relationships Between Social-Emotional Intelligence and Sexual Risk Behaviors in Adolescent Girls

Social-emotional intelligence (SEI) has been linked with a number of health behaviors in adolescent populations. However, little is known about the influence of SEI on sexual behavior. This study examined associations between three indicators of SEI (intrapersonal skills, interpersonal skills, stress management skills) and adolescent girls’ sexual risk behaviors. Data come from a cross-sectional sample of sexually active adolescent girls (ages 13 to 17 years) at high risk for pregnancy (N = 253), recruited from health care clinics in a Midwest metropolitan area during 2007 and 2008. Results of multivariable regression models controlling for participants’ age and race/ethnicity indicated that each aspect of SEI was related to distinct sexual risk behaviors. Specifically, girls with greater intrapersonal skills had significantly fewer male sex partners in the past six months (b = ?0.16). Participants with greater interpersonal skills reported earlier communication with their sexual partner about sexual risk (b = 0.14), and those with a better ability to manage stress reported more consistent condom use (b = 0.31). Study findings suggest that SEI may provide a protective buffer against sexual risk behaviors. Building adolescent girls’ social and emotional skills may be an effective strategy for reducing their risk for early pregnancy and sexually transmitted infections.     

The Interplay between Online and Offline Explorations of Identity,Relationships, and Sex: A Mixed-Methods Study with LGBT Youth

Although the Internet is commonly used by lesbian, gay, bisexual, and transgender (LGBT) youth to explore aspects of sexual health, little is known about how this usage relates to offline explorations and experiences. This study used a mixed-methods approach to investigate the interplay between online and offline explorations of multiple dimensions of sexual health, which include sexually transmitted infections, sexual identities, romantic relationships, and sexual behaviors. A diverse community sample of 32 LGBT youth (ages 16–24) completed semi-structured interviews, which were transcribed and then qualitatively coded to identify themes. Results indicated that, although many participants evaluated online sexual health resources with caution, they frequently used the Internet to compensate for perceived limitations in offline resources and relationships. Some participants turned to the Internet to find friends and romantic partners, citing the relative difficulty of establishing offline contact with LGBT peers. Further, participants perceived the Internet as an efficient way to discover offline LGBT events and services relevant to sexual health. These results suggest that LGBT youth are motivated to fill gaps in their offline sexual health resources (e.g., books and personal communications) with online information. The Internet is a setting that can be harnessed to provide support for the successful development of sexual health.     

A Pilot Study to Evaluate Ethnic/Racial Differences in Depressive Symptoms,Self-Esteem,and Sexual Behaviors Among Men Who Have Sex with Men

Men who have sex with men (MSM) are at risk for certain physical and psychological health conditions. Ethnic minority MSM are at an increased risk related to the combination of sexual minority and ethnic minority status. The purpose of this pilot study was to compare the levels of depressive symptoms, self-esteem, and sexual behaviors by ethnicity in a sample of MSM (N = 70) residing in South Florida. More than one-third of the sample (N = 26; 37%) had high levels of depressive symptoms. Using non-parametric statistics, statistically significant differences were noted in the levels of depressive symptoms as African-American MSM had higher levels of depressive symptoms when compared to the other ethnic groups. Statistically significant differences were not found when self-esteem and sexual behaviors were compared by ethnicity. Regardless of ethnicity, MSM in this study were at risk for the sequela of depressive symptoms and infections with HIV and/or sexually transmitted infections because of the high levels of unsafe sexual behaviors. More research is needed to explore the relationship of mental health and sexual behaviors among the various ethnic groups of MSM.     

Sexual needs, control, and refusal: how "doing" class and gender influences sexual risk taking

The poor are disproportionately affected by unintended pregnancy and sexually transmitted infections (STIs). We know relatively little, however, about the sexual processes behind these disparities. Despite studies of gender enactment's influence on sexual behaviors, few analyses examine the sexual "doing" of social class. We conducted sexual history interviews with 36 women and men, half middle class and half poor and working class. Most respondents reported that men have greater sexual appetites than women, but the middle class were more likely to cite social influences while the poor and working-class respondents primarily ascribed biological origins. The social construction of sexual controllability among the middle class contributed to perceptions that sex was a containable force. Poor and working-class women described men's sexual needs as physiologically irrepressible, which shaped sexual refusal. Our findings move beyond socioeconomic status (SES) as a "risk factor" and explore two examples of how gender and social class mediate people's sexual selves and health.     

Latent classes of older foster youth: Prospective associations with outcomes and exits from the foster care system during the transition to adulthood

Youth in the foster care system face considerable challenges during the transition to adulthood. However, there is significant variability within this population. This study uses person-oriented methods and a longitudinal dataset of youth aging out of foster care to examine differences in how subgroups of foster youth fare during the transition to adulthood. We identified four distinct latent classes, consistent with prior person-oriented studies of this population, and validated these classes by examining differences on additional relevant factors at age 17. After establishing these classes, we tested their predictive validity by examining differences in outcomes at age 19 in domains relevant to the transition to adulthood, including education and employment, problem behaviors, and mental health problems. Finally, given the importance of extended foster care in promoting better outcomes, we used survival analysis to prospectively examine whether class membership was associated with differences in the rates at which youth left foster care between ages 17 and 19. One large group of youth exhibited moderate behavior problems and left care quickly, while another large group of resilient youth had favorable outcomes and left care relatively slowly. A small group exhibited considerable behavior and mental health problems, but left care more slowly, and a very small group was characterized by a history of pregnancy. Findings suggest considerable variability in service need among older foster youth. Implications for service provision during the transition to adulthood are discussed.     

Sexual health programming for vulnerable youth: Improving knowledge,attitudes, and behaviors

PurposeAmong girls in foster care, 48% become pregnant at least once by age 19 (Dworsky & Courtney, 2010). Youth in or at-risk for foster care (YFC) report limited knowledge about, access to, and use of condoms; ambivalent attitudes towards teen parenting; and participation in other risky behaviors. For the current study, we adapted and supplemented an evidence-based sexual health program called SiHLE, using a systematic adaptation framework (ADAPT-ITT, Wingood & DiClemete, 2008), to address the unique and targeted needs of youth living in a temporary shelter due to lack of housing. Youth in this study were either in foster care and awaiting placement, or having serious family problems and were at-risk of entering the foster care system.MethodsThirty-six youth participated in SiHLE-YFC during their stay at a temporary shelter. Four 90-minute sessions focused on increasing sexual health knowledge, improving attitudes towards and self-efficacy of condom use, and developing core skills such as problem-solving and communication.ResultsAs hypothesized, youth showed high satisfaction with the intervention and significant improvement in sexual health knowledge from pre to post. At one-month follow-up, youth continued to show significant improvement in sexual health knowledge, along with a significant reduction in risky sexual behaviors. Though not significant, there were moderate effect sizes for changes in attitudes towards teen pregnancy and condoms. There were no changes in attitudes towards teen parenting.ConclusionTaken together, findings suggest that sexual health education directly targeting the unique needs of YFC may improve sexual health knowledge and behavior, and are discussed in the context of challenges associated with intervention and research with this population.     

What Pediatric Subspecialists Need to Know About Sexual and Reproductive Health: A Review of the American Board of Pediatrics Content Outlines for Subspecialty Certifying Examinations

ABSTRACT

Many adolescents with complex medical conditions regard their subspecialty providers as an important source of clinical information including sexual and reproductive health information related to their medical condition. Thus, training for pediatric subspecialty providers should include clinically relevant sexual and reproductive content. The purpose of this study is to understand what disease-relevant sexual and reproductive health information is currently included in content outlines for each of the available pediatric subspecialty certifying examinations. The American Board of Pediatrics (ABP) offers 17 subspecialty certifying examinations; 13 content outlines are available on the ABP website which defines the body of knowledge to be tested. Each available outline underwent content analysis for sexual and reproductive health information. A team of adolescent medicine physicians identified seven thematic areas including: 1) puberty; 2) sexual behavior and identity; 3) fertility; 4) contraception; 5) sexually transmitted infections; 6) other genital pathology; 7) pregnancy. Across disciplines, learning objectives related to sexual behavior, sexual identity, fertility, contraception and pregnancy were the most limited. However, content related to puberty, sexually transmitted infections and other genital pathology was better represented. Overall, disease-and treatment-specific sexual and reproductive health information was sparse. Most subspecialty content outlines contain very little disease-specific sexual and reproductive health information despite the growing adolescent and young adult population with complex medical conditions in the care of pediatric subspecialists. Further studies are needed to explore if lack of sexual and reproductive information on board exams relates to the knowledge base and skill set of pediatric subspecialists.     

Sexual Behaviors and Sexually Transmitted Diseases of Lesbians

ABSTRACT

The Boston Lesbian Health Project surveyed 1633 lesbians about their health status, health related behaviors and health problems. This paper reports on those parts of the questionnaire that dealt with sexual behaviors and sexually transmitted diseases. The sample was predominantly monogamous, but few had been in their present relationship for more than five years. Sexual practices were similar to those reported in previous studies of lesbians and to those reported in a study of heterosexual women. Sexually transmitted diseases were rare in women who had never had sex with a male partner. The majority of the sample did report a history of male sexual partners and therefore are at risk for abnormal pap smears and other sexually transmitted diseases.     

Adolescents’ Use of the Internet for Sex Education: A Thematic and Critical Review of the Literature

ABSTRACT. A thematic and critical literature review was conducted to determine what is known about adolescents’ experiences with online sex education. Four major themes could be discerned from the literature, revealing that: (a) adolescents report engaging with sex information online; (b) adolescents are interested in a number of topics, including sexually transmitted infections and pregnancy; (c) the quality of adolescent-targeted sex information online can be lacking, but adolescents can evaluate these sources; and (d) Internet-based interventions can increase adolescents’ sexual health knowledge. Inconsistencies in the literature are discussed and suggestions are made for future research.     

The relationship between indicators of sexual compulsivity and high risk sexual practices among men and women receiving services from a sexually transmitted infection clinic

Sexual compulsivity, defined by sexual preoccupation and lack of sexual impulse control, is related to high‐risk sexual behaviors. However, little is known about the prevalence and predictors of sexual compulsivity in people at high risk for contracting sexually transmitted infections (STIs). In the current study, patients receiving diagnostic and treatment services (85% African American) at an urban STI clinic completed measures of demographic characteristics, sexual compulsivity, substance use, and sexual behaviors. Measures were administered to 492 men and 193 women using confidential procedures and audio computer‐assisted interviewing technology. Results showed that men and women receiving STI clinic services frequently endorsed multiple indicators of sexual compulsivity. In this mostly African American sample, individuals with scores above the 80th percentile on the sexual compulsivity scale (translating to over one standard deviation above the mean) had more sex partners, engaged in higher rates of sexual risk behaviors with casual or one‐time sex partners, and were nearly four times as likely to have been recently diagnosed with multiple STIs than were individuals who scored below the 80th percentile. Although sexual compulsivity scores were associated with alcohol and other drug use, associations between sexual compulsivity and sexual risks were not accounted for by substance abuse. Findings suggest an urgent need for interventions to help men and women with sexual preoccupations and poor sexual impulse control to reduce their risks for sexually transmitted infections.     

The relationship between indicators of sexual compulsivity and high risk sexual practices among men and women receiving services from a sexually transmitted infection clinic

Sexual compulsivity, defined by sexual preoccupation and lack of sexual impulse control, is related to high-risk sexual behaviors. However, little is known about the prevalence and predictors of sexual compulsivity in people at high risk for contracting sexually transmitted infections (STIs). In the current study, patients receiving diagnostic and treatment services (85% African American) at an urban STI clinic completed measures of demographic characteristics, sexual compulsivity, substance use, and sexual behaviors. Measures were administered to 492 men and 193 women using confidential procedures and audio computer-assisted interviewing technology. Results showed that men and women receiving STI clinic services frequently endorsed multiple indicators of sexual compulsivity. In this mostly African American sample, individuals with scores above the 80th percentile on the sexual compulsivity scale (translating to over one standard deviation above the mean) had more sex partners, engaged in higher rates of sexual risk behaviors with casual or one-time sex partners, and were nearly four times as likely to have been recently diagnosed with multiple STIs than were individuals who scored below the 80th percentile. Although sexual compulsivity scores were associated with alcohol and other drug use, associations between sexual compulsivity and sexual risks were not accounted for by substance abuse. Findings suggest an urgent need for interventions to help men and women with sexual preoccupations and poor sexual impulse control to reduce their risks for sexually transmitted infections.     

Sexual Education,Gender Ideology,and Youth Sexual Empowerment

Sexual education plays an essential role in preventing unplanned pregnancy and the transmission of sexually transmitted infections (STIs). School-based sexual education programs, in particular, may be well positioned to address social factors that are empirically linked to negative sexual health outcomes, such as traditional social norms surrounding gender and sexuality. However, youth are seldom granted access to sexual education programs that explicitly address these issues. This study presents findings from a pretest–posttest survey of a sexual education program that did. It was designed for eighth graders (N=95) in the context of a school–community collaboration. The study assessed the links between several components of sexual empowerment, including gender ideology, sexual knowledge, and contraceptive beliefs. Findings link participation in the sexual education program to more progressive attitudes toward girls and women, less agreement with hegemonic masculinity ideology, and increases in sexual health and resource knowledge. Structural equation models suggest that traditional attitudes toward women were significantly related to hegemonic masculinity ideology among both boys and girls, which was in turn negatively related to safer contraceptive beliefs.