The low status of women and economic development policies that move the male work force away from families and communities into urban industrial centers contribute to the epidemics of STD/HIV in many developing countries (24, 48, 51). The relatively poor educational opportunities for women leave them ill-prepared for economic survival outside of marriage, especially after child-bearing. This problem, where coupled with the emergence of urban or periurban male slums, fosters casual and commercial sex and a new generation of urban or periurban teenagers with one available parent (who may be a sex worker) and without a stabilizing extended family or community.
In summary, interrelated factors, including separation of families with male urban migration, low status of women, increasing urban, periurban, and interurban prostitution, a demographic transition characterized by growing and destabilizing excesses of teenagers and young adults no longer under the regulatory influence of a nuclear or extended family or community, and war, migration, and travel, have fostered changes in sexual behavior and epidemics of STD in developing countries during the 20th century. Many similarities are evident in the United States.
In the United States, bacterial STDs, such as gonorrhea, syphilis, and chancroid, concentrate in black and Hispanic populations, particularly among teenagers. The enormous disparity between blacks and whites in annual rates of gonorrhea and syphilis has actually grown since 1985. Because this disparity largely depends upon basic structural disparities in socioeconomic attainment and in access to health care, it is not surprising that the determinants of the STD epidemic in the United States and in developing countries are similar. Race and ethnicity should be viewed not as risk factors per se but as risk markers for a more complex set of underlying socioeconomic, cultural, political, behavioral, and environmental risk factors.
Specifically, the nature of the demographic transition in black and Hispanic U.S. populations, a steeply rising proportion of children being born to unmarried mothers, fragmentation of the family and community, counter-productive social welfare policies, and a unique form of commercial sex related to use of crack cocaine have been the prime determinants of changing sexual behaviors; and the failure of the public