Clinics in Dermatology (2014) 32, 189195

Sexual health in adolescents

Ceri Slater, FRCP a,, Angela J. Robinson, FRCP b
a

Locum Consultant Sexual Health and HIV, Department of Medical GU, St Helier Hospital, Wrythe Lane,
Carshalton, SM5 1AA, London, United Kingdom
b
Consultant Sexual Health and HIV, Department of Genitourinary Medicine Mortimer Market Centre,
CNWL Foundation Trust, WC1E 6JB, London, United Kingdom

Abstract Young people are particularly vulnerable to poor sexual health outcomes of high rates of
sexually transmitted infections (STIs) and unwanted pregnancy. They partake in riskier sexual behaviors
with higher rates of sexual partner change and poor levels of contraception, including condom use.
Access to services may be limited either through lack of appropriate services or disinclination to seek
out services. We review the biological, cognitive, behavioral, and socioeconomic risk factors that
contribute to their poor sexual health outcomes. Details include the epidemiology, presentation and
complications of STIs and pregnancy in adolescents, the clinical assessment of adolescents,
contraception options, confidentiality, consent and safeguarding, and key characteristics of successful
adolescent services.
2014 Elsevier Inc. All rights reserved.

Introduction
Adolescence may be defined as age 10 to 19 years old,
and adolescents make up about 20% of the worlds
population.1
Good sexual health is important to individuals and to
society. Young people are particularly vulnerable to poor
sexual health outcomes, such as sexually transmitted
infections (STIs) and unwanted pregnancy. They partake in
higher risk sexual behaviors with higher rates of sexual
partner change; poor levels of contraception, particularly
condom use; and a bias against accessing health care, either
through lack of appropriate services or difficulty in accessing
services provided. Teenage pregnancy is associated with
lower birth weights, increased risk of mortality, and

Corresponding author. Tel.: +44 (0)2082962848; fax: +44(0)

2082962208.
E-mail address: cerislater@nhs.net (C. Slater).
0738-081X/$ see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.clindermatol.2013.08.002

exacerbated socioeconomic disadvantage. Teenage mothers

of lower level education may have parents who were also
teenagers at the time of conception. Young people,
particularly women, under the age of 20 years carry the
greatest burden of STIs.

Epidemiology
Controlling the transmission of STIs requires appropriate
surveillance systems. Such surveillance systems vary across
the European countries, but the European Centre for Disease
Prevention and Control (ECDC) has coordinated enhanced
surveillance of STIs in Europe since 2009. There are
components of laboratory training, surveillance, and dissemination of information, and 30 countries are covered.
Countries are not necessarily able to provide complete
information, but from 2009 are encouraged to comply with
an agreed set of variables. The ECDC surveillance is an
important source of information about the individual diseases
(see below).2 The UK has had a robust surveillance system

C. Slater, A.J. Robinson

Percentage <20 of total diagnoses
across all ages

190

Fig. 1

50
45

Males
Females

40
35
30
25
20
15
10
5
0
Chlamydia

Gonorrhoea

Syphilis

Warts

Herpes

Percentage of STI diagnoses among those aged b 20 years. GUM clinics, UK: 2008. Data courtesy of Pubic Health England.

for years in sexual health clinics through the Health

Protection Agency, and, more recently, Public Health
England. In women in 2008, between 33% and 50% of
STIs were diagnosed in those b 20 years3 (Figure 1).
Chlamydia trachomatis is the most frequently reported
STI in Europe with 76% of all cases reported in young people
between 15 and 24 years of age. The overall rate was 203 per
100,000 women and 145 per 100,000 in men in 2010. The
overall true incidence is likely to be higher than identified,
depending upon screening practices and test methodology,
which are very variable from country to country (Figure 2).
The UK contributed more than 60% of all cases reported in
2010 due to the inclusion of data from the UK national
chlamydia screening program. The largest increase in rates

Fig. 2

has been seen among 15 to 19 year olds. This may be partly

due to improved testing with nucleic acid amplification
tests (NAATs).
Gonorrhea was reported three times more often in men
than in women with young people between 15 and 24 years
of age accounting for 45% of all gonorrhea cases. In 2010,
the 20- to 24-year age group had the highest number of cases
with a preponderance of men. Also in 2010, in the 15- to 19year age group the sex ratio was reversed with more women
than men being affected. Overall, there were 32,028 cases
with a rate of 17.1 and 6.4 per 100,000 in men and women,
respectively. A quarter of these were reported in men having
sex with men (MSM). There is considerable heterogeneity in
reporting health care systems that might account for the large

Number of chlamydia cases per 100,000 population, EU/EAA countries 2010. Courtesy of ECDC.

Adolescent sexual health

variation in numbers of cases reported from various European
countries (Figure 3).
The total number of reported syphilis cases in 2010 was
17,884 with more than half reported in MSM. Fewer young
adults, between 15 and 24 years of age, were affected (17%)
compared with gonorrhea and chlamydia infection. The male
to female ratio is 3:1 with 55% of recorded transmissions due
to MSM activities. The male-to-female ratio indicates that
the rate increase in a number of countries in the past decade
may be due to increases of syphilis among the MSM group.
Reported congenital syphilis cases have remained stable for
more than 10 years with a total of 59 in 2010. It is suspected
that there is underreporting, with 9 of 30 countries reporting
no cases.
Cases of reported infection with HIV in adolescents in
Europe are low in comparison to older age groups, with only
11% of cases reported in 15 to 24 year olds. Rates of HIV
transmission are five times higher in 20 to 24 year olds than
in 16 to 19 year olds. With high rates of other sexually
transmitted infections, adolescents may be increasingly
vulnerable to HIV infection. Globally 42% of incident HIV
infections were in 15 to 24 year olds in 2010.4
Teenage pregnancy rates vary across countries and have
declined in 18 out of 21 developed countries between 2003
and 2009. The United Kingdom continues to have the
highest teenage pregnancy rate in Europe, while the United
States has the highest rate in the developed world, despite a
10 point fall in annual number of births per 1,000 women,
aged 15 to 19 over the same period.5

Fig. 3

191
Up to 50% of teenage pregnancies are unplanned with
conceptions in teenagers under 16 most likely to be
unintended and to end in termination in the UK. For
those who continue their pregnancy, the outcomes are often
poor for both the teenage parent and the child. There is
increased childhood ill-health including a 60% higher infant
mortality rate for babies born to teenage mothers in the UK.
Teenage mothers are three times more likely to have
postnatal depression, and there is an increased risk of both
the parent and the child living in long term poverty. In
developing countries, the maternal death rate in adolescents
is double that of older women. One reason is that
adolescents often enter pregnancy with reduced nutritional
stores threatening fetal and maternal health. Education and
access to comprehensive antenatal care as well as
contraception varies worldwide but is essential to reduce
these disparities.6,7

Risk factors
The burden of STIs disproportionately affects adolescents
as multiple factors interact to increase adolescents risk.
During adolescence, in girls increased estrogen exposure
causes the development of cervical ectopy. The exposed
columnar epithelium is more vulnerable to infection with
Neisseria gonorrhoeae, Chlamydia trachomatis, and the
herpes simplex virus. An immature genital tract immune
system increases this risk. In prepubertal adolescents, the

Number of gonorrhea cases per 100,000 population, EU/EAA countries 2010. Courtesy of ECDC.

192

C. Slater, A.J. Robinson

coitarche, multiple sexual partners, lack of condom use,
increased sexual violence, and increased alcohol and drug
use during sex. This is compounded if there is a lack of
parental support. Adolescents who have run away from home
are at particular risk.14
Different cultures, religions, and ethnic groups have
different sexual norms. These, too, influence sexual
behavior, in part due to what is perceived as acceptable.
The age of consent varies across Europe from as young as
13 years for girls in Spain. In some cultures, it is expected
that adolescent men will have sex with several women to
demonstrate their virility, while for women, the expectation
is they will marry before sex and have one lifetime partner.
Regardless of culture, adolescent women tend to have sex
with older men, increasing their risk of STIs.79,15

Sexually transmitted infections

The clinical presentation of chlamydial infection,
gonorrhea, syphilis, trichomoniasis, candidosis, bacterial
vaginosis, genital warts, molluscum contagiosum, hepatitis
B, HIV, and genital herpes in pre- and postpubertal
adolescents is the same as in adults. The presentations are
detailed in other contributions in this issue. Adolescents are
at greater risk of complications, such as pelvic inflammatory
disease (PID), including recurrent PID, infertility, ectopic
pregnancies, miscarriages, and mother to child disease
transmission.810
The increased prevalence of complications is a feature of
the increased prevalence of STIs in this age group and the
other additional biological and sociological factors. Adolescent girls have immature innate and humoral immunity,
increasing the risk of ascending infection and the subsequent
development of PID or disseminated infection.
Infections with Chlamydia trachomatis and Neisseria
gonorrhea are often asymptomatic. Adolescents are unaware

0.30

humoral immune system is poorly developed, the vaginal

epithelium and cervix have not begun to secrete mucous,
and the vaginal pH is high, reducing the vaginas defenses
against infection.8,9
The cognitive development of adolescents renders them
less able to anticipate or appreciate the consequences of their
actions. They are more vulnerable to peer pressure. They
have a greater number of partners. With frequency of partner
change, they are less able to negotiate condom use,
increasing their risk of STIs and unintended pregnancies.
Male adolescents in particular are more likely to have two or
more partners in a year. Their cognitive abilities, education,
and access to information may also affect their ability to
recognize their need for screening or treatment and their
ability to access services.10
With their tendency for more frequent partner change and
less adherence to medication, adolescents are more at risk of
reinfection11 (Figure 4). The risk is highest in the under
16 year olds and 11% to 12% of 16 to 19 year olds
presenting with an acute STI at a clinic become reinfected
with an STI within a year.12
Alcohol and drugs increase adolescent sexual risk taking,
especially in young women. When under the influence of
drugs or alcohol, they are less likely to use condoms, more
likely to have unplanned sex with a casual contact, and are
more vulnerable to abuse and exploitation, for example,
having sex in exchange for drugs. Alcohol is associated with
earlier sexual debut, STIs, and unplanned pregnancies.13
Socioeconomic factors also play an important part. The
poor have less access to sexual health education and
information. They are less able to access and afford health
services and contraception. There is also increased pressure
to have sex in exchange for money, gifts, or education and a
greater risk of violence and coercion with poorer safer sex
negotiating power.
Sexual or physical abuse in childhood is associated with
increased sexual risk taking behavior, including early

0.10

0.15

0.20

16-19
25-34

0.00

0.05

Probability of infection

0.25

<16
20-24
35+

.5

1.5

Time (Years)

Fig. 4 Acute STI reinfection by age group, England: 2008/9. 11-12% of 16 to 19 year olds presenting with an acute STI at a GUM clinic will
become reinfected with an STI within a year. Data courtesy of Public Health England.

Adolescent sexual health

of contracting infection and have no reason to attend for
investigation. Delay in seeking medical attention may also be
due to failure to recognize or appreciate the significance of
abnormal symptoms and signs, such as a change in vaginal
discharge or postcoital or intermenstrual bleeding. Ectopic
pregnancy is a further recognized complication of PID and
chlamydial infection. Mortality is highest in adolescents as
unawareness of being pregnant, failure to recognize or
appreciate the importance of symptoms, and delay in
presenting to services compound the problem. Health care
professionals themselves may fail to consider pregnancy in
the young adolescent and potential differential diagnoses.
Adolescent specific services and chlamydia screening programs using self-taken samples have been established to
improve access and detect and treat asymptomatic infection
to reduce the risk of complications.
In young women, syphilis infection is more likely to be
early stage disease and therefore infectious. Genital herpes is
more likely to be primary infection in this age group, causing
greater morbidity. Both of these scenarios increase the risk of
the mother passing the infection onto her unborn child either
ante- or perinatally, should she become pregnant.9
There is an increase in the risk of acquisition and
persistence of oncogenic human papillomavirus (HPV)
throughout adolescence. HPV increases the risk of cervical
dyskaryosis and carcinoma. The HPV vaccination program
in the developed world should ameliorate some of this risk
over time.

Clinical assessment of adolescents

Physical examination can be a distressing, uncomfortable,
and embarrassing experience for young people. Noninvasive
or self-taken samples are preferred. If an examination is
clinically indicated, the rationale and what is entailed should
be fully explained. A chaperone should be offered and
informed consent obtained.15
The tests taken in both postpubertal and prepubertal boys
and girls are as for adults and according to clinical
presentation and sexual history. The site of sampling may
need to be adapted if the young person is prepubertal to avoid
instrumentation. The examination of a prepubertal child
should normally be undertaken by an experienced pediatrician or a practitioner with equivalent expertise. In prepubertal boys, meatal swabs rather than urethral swabs can be
taken if indicated, followed by a first pass urine. Introital
swabs can be taken through the hymen or vulvo-perineal
swabs in prepubertal girls, especially if discharge is present;
in postpubertal girls who cannot tolerate a speculum, transhymenal swabs can be passed to obtain low vaginal
specimens and/or urine NAATs can be used. If there is any
concern about sexual abuse, then a chain of evidence may
be prudent.15
The choice of treatment of STIs in adolescents, as for
adults, must be guided by national guidelines and local

193
antibiotic sensitivities. This is particularly important with
the increased resistance of N gonorrhea to antibiotics. The
choice of antibiotic may need to be adapted, depending on
the young persons age and risk of pregnancy for girls.
Doses may need to be adjusted to take into account their age
and weight. Single dose treatment is preferable due to
improved adherence. Partner notification and the treatment
of partners remains an integral part of STI management for
adolescents, but may be more complex due to the increased
frequency and number of partner changes, increasing the
risk of reinfection.

Contraception
The prevalence and type of contraceptive use varies from
country to country. Except for sterilization, all contraception
methods that are appropriate and physiologically safe for
healthy adults are also appropriate for healthy postpubertal
adolescents. The choice of contraception depends not only
on its safety profile and comorbidities of the young person
but also on the frequency of sex and the type of relationships.
Long acting reversible contraceptives, such as a progestogen
implant or an intrauterine device (IUD or IUS), are more
effective and cost effective as they are not user dependent.
The use of a high dose progestogen injection is less favored
in adolescents due to its association with reduced bone
mineral density at a crucial time of bone development. Oral
hormonal contraceptives are a very reasonable choice for
those adolescents who will remember to take them. Condoms
remain essential to protect against STIs. For adolescents, it is
often wise to recommend both hormonal or IUD use and
condoms together to reduce the consequences of method
failure and the risk of infection.16
One particularly vulnerable group are married adolescent
girls, because they have more unprotected sexual intercourse,
have sex more frequently, and are less likely to use condoms
than unmarried adolescent girls.

Confidentiality, consent, and safeguarding

The legal age of consent for sexual activity varies from
country to country and according to sexual orientation. The
safety of a young person needs to be considered within the
legal framework of the country in which the young person
resides. The impact and outcome of a sexual act is affected
by this legal framework but is also influenced by community
traditions and values. Sexual activity for many adolescents is
an enjoyable consensual experience. Others may be the
victims of abuse or exploitation.
It is paramount to establish whether the adolescent has the
capacity to consent to sexual intercourse. How capacity for
consensual sexual activity is determined will vary from
country to country. In the UK, there is no specific test of

194

C. Slater, A.J. Robinson

capacity to consent to sexual intercourse. In UK law, Gillick

competence states: Children aged under 16 have the legal
capacity to consent to medical examination and treatment,
providing they can demonstrate sufficient maturity and
intelligence to understand and appraise the nature and
implications of the proposed treatment, including the risks
and alternative courses of action. It is often assumed that
Gillick competence is indicative of the ability to consent to
consensual sexual activity. For those aged 16 years and over,
the mental capacity act can be used. Any concerns that sex
was not consensual and therefore abuse has occurred, should
prompt the appropriate safeguarding measures such as
referral to social services.
According to the UK General Medical Council Guidelines: . . . doctors must safeguard and protect the health and
well-being of children and young people.1719

whether or not the child is aware of what is happening. The

activities may involve physical contact, including penetrative
(eg, rape, buggery, or oral sex) or nonpenetrative acts. They
may include noncontact activities, such as involving children
in looking at, or in the production of, sexual online images,
watching sexual activities, or encouraging children to behave
in sexually inappropriate ways.
Regardless of culture, age, and marital status, adolescents
need information about how their body works, sex, safer sex,
and reproduction. They need supportive adults around and to
be given the tools to negotiate safer sex or refuse sex
altogether. Sexual and reproductive health education has
been shown to reduce sexual initiation, frequency of sexual
intercourse and number of sexual partners, and increase
condom use and other contraceptive use.

Box 1 Adolescent Vulnerability Factors

Adolescent services

Lack capacity
Emotionally immature
Lack support from parents or other significant adults
Poor psychological wellbeing
Pre- pubertal rather than post-pubertal
Abuse of drugs or alcohol
Partner N 3 years older
Greater number of partners (current & lifetime)
Disclosure of current or previous sexual abuse or
exploitation
Isolated with poor social networks and support
Younger age
Homeless
Not attending school or work
Poor economic or occupational opportunities
Commercial sex worker
Being / previously internet groomed
A physical disability affecting communication
Learning difficulties
Having an STI and/or being pregnant

Confidentiality is an essential element for young people to

access services, but this must be balanced with the duty of
care to protect the young person from harm. The boundaries
of confidentiality should be explained to the young person
and the rationale for any disclosure to others, having
obtained consent if at all possible. Young people may not
recognize that their relationship is abusive or that they are
being groomed. Fear of the consequences may prevent
acknowledgement or disclosure. An adolescent is more at
risk of abuse or exploitation, if any of the features in Box 1
are present.
Child sexual abuse has been defined by the UK
government as: . . . forcing or enticing a child or young
person to take part in sexual activities, including prostitution,

Emerging adults have similar logical competencies as

adults but have different social and emotional factors, which
contribute to the differences in decision making and risk
taking. Health seeking behavior is influenced by difficulty in
accessing services and the inability to negotiate the health
care system. Adolescents may feel that they are unable to
attend without their parents, may fear being judged or
stigmatized or worry that their confidentiality will not be
maintained and that the staff will be unsympathetic.
Embarrassment, guilt, and concern about the examination
are common; therefore services must adapt themselves
appropriately to support young people seeking health care.
Rapid access to services for screening, testing, and treatment
with appropriate case management is a key pillar of infection
control. There are several requisites to providing adolescent
friendly services in order for adolescents to feel safe to attend
(Box 2).20 This can facilitate a reduction in the considerable
stigma associated with sexually transmitted infections,
particularly HIV, unwanted pregnancies, and termination
of pregnancies.

Box 2 Youre Welcome: Quality criteria for young people

friendly health services - 2011 edition

Confidential
Friendly, well trained, non-judgemental staff
Welcoming safe environment
Appropriate information and publicity
Clear communication
Joined up working with links to other relevant
services
Accessible at convenient times
Young peoples participation in design and delivery
of services

Adolescent sexual health

Sex education programs can be delivered through health
or education services. Evidence exists that providing
accurate information about how a young persons body
works, contraception, the benefits of delaying sexual
debut, the consequences of STIs and unintended pregnancies, as well as improving safer sex negotiating and
decision making skills, do reduce adolescent sexual health
risks.1,79

Conclusions
Young people often lack information about sexual
health, including basic knowledge and awareness of fertility
and sexually transmitted infections. While there are
important influences socially and culturally, there are
specific considerations for service provision and health
promotion that require health care professionals to focus on
what is important for young people. Providing a positive
experience may facilitate interventions including behavior
change and health promotion activities, which may also
address other determinants of ill health, such as smoking,
drug use, and alcohol abuse. Young people face a greater
burden of STIs and unwanted pregnancies that requires a
specific focus from health care professionals if their sexual
health is to improve.

References
1. Dehne K, Riedner C. Sexually transmitted Infections among adolescents. The need for adequate health services. Department of Child and
Adolescent Health and Development (CAH), WHO 2005 http://
whqlibdoc.who.int/publications/2005/9241562889.pdf.
2. European Centre for Disease Control Annual epidemiological
report. Reporting on 2010 surveillance data and 2011 epidemic
intelligence data. 2012:3353. http://www.ecdc.europa.eu/en/
publications/Publications/Annual-Epidemiological-Report-2012.pdf
1990-2010.
3. Health Protection Agency. Sexually transmitted infections and young
people in the United Kingdom: 2008 report. http://www.hpa.org.uk/
webc/HPAwebFile/HPAweb_C/1216022461534.

195
4. UNAIDS Fact Sheet Adolescents, young people and HIV. http://www.
unaids.org/en/media/unaids/contentassets/documents/factsheet/2012/
20120417_FS_adolescentsyoungpeoplehiv_en.pdf.
5. Child well-being in rich countries A comparative overview. Innocenti
Report Card 11 Unicef 2013; 2326, 49. http://www.unicef.org.uk/
Images/Campaigns/FINAL_RC11-ENG-LORES-fnl2.pdf.
6. Department of Health. Teenage pregnancy strategy: Beyond 2010
https://www.education.gov.uk/consultations/downloadableDocs/
4287_Teenage%20pregnancy%20strategy_aw8.pdf.
7. Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives
on the sexual and reproductive health of adolescents: Patterns,
prevention, and potential. Lancet. 2007;369:1220-1231.
8. Chinsembu KC. Sexually transmitted infections in adolescents. Open
Infect Dis J. 2009;3:107-117.
9. WHO. Sexually Transmitted Infections. Issues in Adolescent Health
and Development. WHO DISCUSSION PAPERS ON ADOLESCENCE. Department of Child and Adolescent Health and Development
World Health Organization, Geneva; 2004. http://whqlibdoc.who.int/
publications/2004/9241591420_eng.pdf.
10. Gray-Swain MR, Peipert JF. Pelvic inflammatory disease in adolescents. Curr Opin Obstet Gynecol. 2006;18:503-510.
11. Taddeo D, Egedy M, Frappier J-Y. Adherence to treatment in
adolescents. Pediatr Child Health. 2008;13:19-24.
12. Health Protection Report, Public Health England, UK. 2010;4: 34.
http://www.hpa.org.uk/hpr/archives/2010/hpr3410.pdfHealth Protection Agency.
13. Royal College of Physicians. Alcohol and Sex: A Cocktail for Poor
Sexual Health. Report of the Alcohol and Sexual Health Working Party.
London: RCP, 2011.
14. Richter L, et al. Reported physical and sexual abuse in childhood and
adult HIV risk behavior in three African countries: Findings from
Project Accept. AIDS Behave. 2013(9).
15. Rogstad K, Thomas A, Williams O, et al. UK National Guidelines on
the Management of STI and related conditions in young people. Int J
STD AIDS. 2010;21:229-241.
16. Clinical Effectiveness Unit, Faculty of Sexual & Reproductive
Healthcare Clinical Guidance. Contraceptive Choices for Young
People. Faculty of Sexual and Reproductive Health: March 2010
http://www.fsrh.org/pdfs/ceuGuidanceYoungPeople2010.pdf.
17. Cybulska B, Forster G, Welch J, et al. UK National Guideline on the
Management of Adult and Adolescent Complainants of Sexual Assault
CEG. BASHH: 2011. http://www.bashh.org/guidelines.
18. General Medical Council: 018 years: guidance for all doctors.
London:2007. www.gmc-uk.org/0-18.
19. Act Mental Capacity. Code of Practice. Department for Constitutional
Affairs. Crown Copyright. 2005;2007.
20. Youre Welcome: Quality criteria for young people friendly health
services2011. https://www.gov.uk/government/publications/qualitycriteria-for-young-people-friendly-health-services.