Vol. 6 Issue 18
Teens & STDs
Abstinence-based education isn't enough
Like most states, Texas has good news and bad news about teens and sexually transmitted diseases (STDs).
"As a whole, genital herpes in the Texas teen population is decreasing," said Bethany McClean, MSN, RN-BC, FNP, director of school-based health services, JPS Health Network, Fort Worth, TX.
That's the good news. The bad news: STDs in teens in Tarrant and Bexar counties are increasing across the board.
"In Tarrant County, genital herpes and chlamydia in teens are increasing," McClean said. "We have seen a big outbreak of herpes in the 15- to 18-year-old age range."
McClean, who manages the 10 JPS neighborhood clinics affiliated with the school districts in Tarrant County, said the network had 30,000 visits to its school-based clinics in 2007. She said Tarrant County experienced a 5.7 percent increase in chlamydia and a 9.4 percent increase in gonorrhea in the 10- to 19-year-old age group during 2005-06. According to CDC's Division of STD Prevention, chlamydia and gonorrhea are typically caused by bacteria that can be killed with antibiotics and are the most common curable STDs among teens.1
South of Tarrant County, in Bexar County, the San Antonio Metropolitan Health District reported a 36 percent increase in chlamydia and a 30 percent increase in gonorrhea in both males and females in 2006.2
"Although we continue to make progress at reducing teen pregnancy rates, there are still areas that require improvement, especially teens having a second pregnancy prior to age 20," said Linda Hook, RN, director of preventive health clinics, University Health (UH) System, San Antonio. In addition, there is a concern for the number of new HIV and syphilis transmission cases among the teen population."
In February, the UH system integrated its nine Metro Health clinics into the organization. The nine clinics were part of the City's Health Department (Metropolitan Health District). The 125 staff members who worked for the city in these clinics became employees of University Health System with a vision to prioritize preventive health.
According to Leni Kirkman, the system's executive director of corporate communications and marketing, Metro Health is the health authority for the community and responsible for surveillance, epidemiology and communicable diseases.
"We now have a whole spectrum of community care," Kirkman said. "The synergy between the nurses at the clinics and the hospitals is strong, and they benefit by working together."
As a former emergency department nurse, Hook said she cared for adolescent patients with STDs experiencing acute pain. Now that the clinics have been absorbed into the hospital system, Hook and her team can take a more preventive mode to the growing issue of STDs and teens.
"We are now able to connect the hospital with the [neighborhood] clinics and teach the community together," Hook said.
Teens are at high behavioral risk for acquiring most STDs, according to the CDC, which reported herpes increased among teens nationwide throughout the early 1990s.1McClean said herpes is also increasing in Tarrant County.
"We experienced 12 new cases of genital herpes in teens since January," McClean said. "Chlamydia is on the rise in young females because they don't feel or see the symptoms. Most STDs are silent, unlike herpes symptoms. They know when they have herpes. They feel flu-like, have a fever, and experience burning pain and blisters on their genitals."
McClean noted the difference in diagnosing atypical herpes cases.
"We have seen six cases of atypical herpes in our teens in the past 6 months," she said. "At least half of our diagnosed herpes cases are atypical, which has a milder presentation with a small amount of irritation and pain. This type of herpes is becoming even more silent, but we are becoming more aware."
McClean explained the numbers aren't necessarily going up. Rather, nurses are getting better at recognizing the subtle symptoms of atypical herpes, which includes burning sensation, generalized discomfort and the absence of a lesion.
"Teens often do not understand the long-term effects of these diseases, especially syphilis, herpes, and HIV," Hook said. "Getting teens to understand that sometimes the treatment is not just a simple pill or shot, but a disease that will be with you forever [can be challenging]."
Hook said teens need to become more aware of the "big 3."
"The 'big 3' are gonorrhea, chlamydia and syphilis. Neurosyphylis can cause death. With syphilis, however, we can get the virus out of the body if treated in time," Hook said.
McClean added at least one-third of the teen patients commit to a life of abstinence once they learn of their STD diagnosis.
"Teens feel invincible," McClean said. "They are angry and shocked, and truly can't believe it happened to them. Many say they can't afford condoms. But even a free condom can't address their invincibility."
However, she said most can afford the $4 medication used to treat herpes.
"Valtrex is very expensive; however, most of the patients can afford to buy the in-store formulary acyclovir," McClean said.
"We have to find teachable moments to reach these teens," Hook said. "We have to educate our teens about community resources. We have to reassure them we offer safe and private counseling with easy access to healthcare."
Hook and her team conduct small health education groups for teens.
"Teens work well in small groups in the local clinics," she said. "We focus on parental involvement and getting the teen in early to be tested."
McClean agrees. "The answer is good education and parental involvement," she said.
Polling About Pregnancy
Hook and her team conducted an informal survey involving 400 interviews of pregnant women ages 18-25 about their unplanned pregnancies. According to Hook, 80 percent did not have a Pap smear prior to conception.
About half of the teens surveyed did not understand the reproductive process of fertility. "Interestingly, they didn't understand how they got pregnant in the first place," Hook said.
Thirty percent of the males surveyed thought "safe sex" equated to birth control pills only. "There was a serious disconnect between 'safe sex' and the use of condoms," she added.
Public Programs & the Law
Spearheaded by the CDC, both Tarrant and Bexar counties have established several government-funded, abstinence-based public STD programs to educate their communities, including the school districts. These programs include Worth the Wait, Project Safe and Project Worth.
"It's very clear abstinence is what CDC tells us to [teach]," Hook said. "But these teens are struggling." It's also clear to Hook that abstinence-only education isn't enough.
"When a girl is pregnant or when a teen is diagnosed with an STD, only then can we talk to them about these issues," Hook said. "Nurses must get parental permission to talk to a child about STDs; they educate parents about STDs during well-child checkups and immunization visits. Nursing is the key, but many times nurses are caught in the middle between legislative mandates, school boards, parents and children. The school board only allows the school nurse to talk about abstinence. Only after the fact can the nurse talk about the anatomy of oral, rectal and vaginal routes and the transmission of disease."
According to Texas legislative requirements, agencies that accept Department of State Health Services funding must notify Child Protective Services if a child is 13 or younger and diagnosed with an STD or is pregnant, Hook said. However, parents do not have to be notified when a 14-year-old comes in with a possible STD, she said. "Between the ages of 14 and 16, if the partner is more than 3 years older than the patient, healthcare professionals must report that as well. Texas has a strong law of reporting. The intent is good, but we need to make sure the education is equally as good."
Speaking the Language
"As a nurse, we have to meet them where they are," Hook said. "We have to make sure we get the right health information to our teens. We have to speak to the community."
This may require using multiple languages. The growing Hispanic population in Texas has precipitated a need for Spanish-speaking nurses in the neighborhood clinics. "About 70 percent of the nurses in our clinics speak Spanish," Hook said.
McClean said each clinic has at least two staff members who speak Spanish. "However, we've had an influx of teens from Africa who speak French. We have a translation service department and the translator can meet at the school-based clinics which is a great help," she said.
Education Begets Prevention
According to Family First Aid, Help for Troubled Teens, when it comes to STDs, the U.S. offers inadequate education.3Based on the organization's Web site, the CDC reports 19 million new STD infection cases occur every year, with nearly 50 percent of them being people between the ages of 15 and 24. The Web site further states the American Social Health Association reports half of all new HIV infections occur in teenagers.3
It is apparent many of the current and alarming STD statistics could be reduced with proper education. Abstinence-only education simply isn't enough.
References for this article can be accessed at www.advanceweb.com/nurses. Click on Education, then References.
Amy McGuire is regional editor at ADVANCE.