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Dedicated Public STD Clinics
The earliest public STD clinics were established in the 1910s, despite substantial resistance by organized medical societies (Brandt, 1985). The concept of dedicated public STD clinics is based on evidence that many persons with STDs prefer anonymous and confidential services, cannot afford to obtain care elsewhere, and are unable to obtain care from private sector health care professionals who are unable or unwilling to provide STD care. These clinics are often seen as the "safety net" for STD-related services. Historically, the stigma associated with having a disease associated with sexual intercourse has discouraged more universal use of public STD clinics and prompt health-seeking behavior for symptoms of STDs in general (Brandt, 1985). Public STD clinics and HIV programs provide the largest proportion of specialized STD-related care in the United States. Various government agencies support STD prevention activities by providing funds, setting standards, or by directly providing care. Public STD clinics usually receive a combination of federal, state, and local funds. The only federal agency that supports dedicated public STD clinics is the CDC, which primarily funds patient education, partner notification, outreach, and other prevention services rather than direct clinical services. State and local health departments also provide financial support for these clinics and programs and are often given responsibility for operating the clinics under federal policies and guidelines.
A recent five-center survey of more than 2,500 patients attending dedicated public STD clinics in the United States showed that users of such clinics are generally young (38 percent under 25 years of age), disproportionately of certain racial or ethnic groups (49 percent African American), and at high risk for multiple STDs (Celum et al., 1995). Approximately 15 to 20 percent of patients attending these clinics are adolescents; the median age of patients attending these clinics is approximately 23 years. The clinics generally provide care for approximately twice as many men as women. Persons who use dedicated public STD clinics tend to have a high prevalence of other health problems, including HIV infection, unintended pregnancy, and drug and alcohol use (Kassler et al., 1994; Zenilman et al., 1994; Weinstock et al., 1995). For example, in one inner-city public STD clinic, 46 percent of women attending the clinic were not using contraception and two-thirds had at least one prior pregnancy (Upchurch et al., 1987).
A significant proportion of dedicated public STD clinic patients have private insurance coverage. In the survey by Celum and others (1995) mentioned above, approximately 31 percent of male and 24 percent of female patients seen in dedicated public STD clinics had private health insurance (Figure 5-1). These data suggest that a large number of privately insured patients use public STD