National Academies Press: OpenBook
« Previous: 2 Patterns and Drivers of STIs in the United States
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

3

Priority Populations

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

INTRODUCTION

When seeing if you are going to have the ability to go get tested, you have to take into consideration the cost of living and if you can even spend that money to get tested or if you have to put it elsewhere. And worrying about personal safety in clinical environments, getting to clinical environments, just worrying about personal safety as a social determinant that I am faced with. And then recognizing institutionalized racism, especially in the clinical field, is definitely important, with the medical professionals not always listening to people of color, not always listening to queer people.… So, definitely, having institutionalized racism being a thing is a barrier for me.
—Participant, lived experience panel1

While any person who has sex (genital, anal, or oral) without barrier protection is at risk for a sexually transmitted infection (STI), risk varies over the life span and is influenced by social and societal factors. In the United States, STIs disproportionately affect individuals with intersecting social identities (e.g., race, ethnicity, gender, gender identities) who are often marginalized;2 in this chapter, these important intersections are highlighted and discussed. Other groups with a disproportionately high prevalence of STIs include men who have sex with men (gay, bisexual, same gender loving, and other men who have sex with men [MSM]) and other sexual and gender diverse people (e.g., transgender women), adolescents and young adults, and people of color (Black, Latino/a, American Indian/Alaska Native [AI/AN], and Native Hawaiian/Other Pacific Islander individuals). Pregnant people are important to consider because STIs can cause poor birth outcomes and infections can be transmitted in utero or via childbirth. Other groups with unique circumstances that require tailored services and attention include children, people with criminal legal system involvement, people with disabilities, and people with military experience.

Chapter 2 presented the epidemiology of STIs and highlighted data that demonstrate that young people and socially and economically marginalized populations experience the highest STI burden. Guided by the idea that sexual health is important for persons of all ages, this chapter begins with an overview of STIs across the life span, followed by sections

___________________

1 The committee held virtual information-gathering meetings on September 9 and 14, 2020, to hear from individuals about their experiences with issues related to STIs. Quotes included throughout the report are from individuals who spoke to the committee during these meetings.

2 “Marginalized” refers to those who have often suffered discrimination or have been excluded or marginalized from society and the health-promoting resources it has to offer, including inadequate access to key opportunities (such as health care) (Braveman, 2017).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

on other populations that require focused consideration. It also examines specific needs and concerns of marginalized groups who experience a disproportionately high percentage of STIs, due, in part, to multiple, interrelated social and societal influences. Its organizational structure is guided by the report’s conceptual model (see Chapter 1), with a focus on social and structural drivers of STI inequities. Some groups have a rich literature, but data are limited or missing for others (e.g., female sex workers, older people, some sexual and gender diverse people, and people with disabilities); shorter sections for these groups does not mean that the committee sees them of lesser importance but rather that more research is needed (see Chapter 2 for limitations of current STI surveillance systems). The committee recognizes that this chapter is therefore not inclusive of every population affected by STIs. In identifying common drivers, the committee acknowledges that some social and structural determinants might affect people differently among and within groups not included in this chapter. For each population discussed in this chapter, factors at each level of the committee framework are discussed (individual to structural factors; see Figure 1-3), but the committee recognizes that these factors are all interconnected, particularly that individual- and interpersonal-level factors are shaped by community- and structural-level factors.

STIs ACROSS THE LIFE SPAN

PREGNANCY AND INFANCY

STIs in pregnancy can have dire health and social consequences. STIs contribute to adverse outcomes and can cause serious neonatal and infant disease. Maternal chlamydia and gonorrhea can cause sight-threatening eye infections (Azari and Arabi, 2020) and pneumonias in infants (Xu et al., 2018). Many STIs, including chlamydia, gonorrhea, and trichomonas, cause premature rupture of membranes, preterm birth, and babies who are small for their gestational age (He et al., 2020; Silver et al., 2014). See Box 3-1 for key takeaway messages about STIs in pregnancy and infancy.

Comprehensive HIV screening and treatment has virtually eliminated perinatal HIV transmission in the United States (Wortley et al., 2001). Owing to comprehensive outreach, quality improvement strategies, and specific funding from states and the federal government, the rate of perinatal HIV transmission decreased from an initial 25 percent among births to people living with HIV to less than 1 percent by 2012, with subsequent decreasing trends (Taylor et al., 2017). In 2017, only 39 babies were born with HIV out of more than 3.8 million live births (CDC, 2020a), due primarily to universal prenatal HIV testing, perinatal prophylaxis provided to pregnant people infected with HIV and their infants, and

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

other strategies, including cesarean section (particularly when antiretroviral therapies were suboptimal) and providing infant formula to prevent transmission through breast milk (Nesheim et al., 2017).

People at risk for HIV and who can become pregnant are also at increased risk for other STIs. While HIV perinatal transmission has fallen, congenital syphilis continues to rise. The successful strategies used for HIV perinatal prevention can be applied to congenital syphilis, chlamydia, gonorrhea, and herpes simplex virus type 2 (HSV-2) (and sometimes HSV-1), which also can be transmitted in utero or during childbirth. These strategies include screening and prompt treatment in persons of childbearing age, especially when they are pregnant. In many jurisdictions, HIV screening is performed early in the pregnancy and in the third trimester, but may not include screening for other STIs.

Syphilis in Pregnancy

Untreated syphilis can be associated with miscarriage, preterm birth, stillbirth, impaired fetal growth and congenital infection (leading to infants born with bone deformities, jaundice, and neurological problems, including blindness and deafness), and neonatal death (Cooper and Sanchez, 2018). The impact of congenital syphilis includes not only infant mortality risks but long-term morbidity and increased health care costs. Across the United States, lack of adequate syphilis treatment for the pregnant person (despite timely diagnosis) was the most common missed prevention opportunity in one analysis; lack of timely prenatal care was

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

another common missed prevention opportunity (Kimball et al., 2020). Congenital syphilis is related to failures in screening because of structural, community, or individual issues, but it is nearly always grounded in social determinants of health.

It is imperative that prenatal care strategies are renewed, redesigned, and implemented with a comprehensive perspective so that pregnant people can access quality prenatal care that includes early trimester STI screening and treatment of curable (syphilis, gonorrhea, chlamydia) or chronic (HSV, HIV, hepatitis B virus [HBV]) infections. In one study, one in three women who transmitted syphilis to her baby was tested during pregnancy and might have contracted it after the initial test (The Lancet, 2018), emphasizing the potential need for multiple antenatal tests in people at high risk of syphilis infection. The Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists recommend syphilis screening during pregnancy at the first prenatal visit (which is ideally in the first trimester) and again in the third trimester and at delivery for those at higher risk, as well as after exposure to a partner with syphilis (AAP and ACOG, 2017; Workowski and Bolan, 2015). Syphilis during pregnancy should be treated with penicillin G to prevent transmission to the fetus (Workowski and Bolan, 2015). See Chapter 10 and Appendix B for more information.

Individual- and Interpersonal-Level Factors

Individual factors that could contribute to STIs during pregnancy are similar to those of people who are not pregnant and include young age, multiple sex partners, history of an STI, fewer years of education, and low income (Hogben and Leichliter, 2008; Wheeler et al., 2012). Additional factors include lack of uptake or adherence to treatment, and power inequality in relationships. These issues may be magnified in pregnancy because of the added stigma of the potential for transmission to the fetus or newborn. From a biological perspective, pregnancy-related immunosuppression also may contribute to excess risk. As described in Chapters 1 and 2, these individual-level factors are shaped by interpersonal-, institutional-, community-, and structural-level factors that affect STI prevention and care.

Interpersonal influences include perceived and practiced beliefs and values, parental attitudes, and the role of peers and sexual partners. For example, STIs that are acquired during pregnancy are often due to a partner’s behaviors. As stated in Chapter 2, an analysis of congenital syphilis cases found that half of pregnant women with syphilis in the study had no known risk factor; a history of an STI and more than one sexual partner in the past year were the most common risk factors in the other half (Trivedi et al., 2019).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Institutional-, Community-, and Structural-Level Factors

Missed opportunities of lack or delayed treatment and prenatal care are often fueled by situations beyond the individual’s control. Lack of timely, good-quality prenatal care can be related to structural barriers that may accompany salient psychosocial and behavioral factors, including lack of or late enrollment in prenatal care, lack of health insurance (such as Medicaid), cost of insurance copayments or out-of-pocket charges, lack of transportation or child care, unawareness of the pregnancy, unwanted or unplanned pregnancy, and mental health and substance use issues (Hogben and Leichliter, 2008; Mayer, 1997; Mazul et al., 2017; NASEM, 2019b). Undocumented immigration status and heightened federal immigration enforcement has discouraged pregnant people from accessing care if they fear discrimination or deportation (Bowen et al., 2015; Braveman et al., 2000; Daw and Sommers, 2017). Although emergency Medicaid covers the costs of labor and delivery for low-income people regardless of immigration status, it does not cover prenatal or postpartum care (DuBard and Massing, 2007; Swartz et al., 2017).

CHILDREN

STIs can be acquired at any stage of development—as a fetus in utero, as a newborn emerging from the birth canal, as a small child through sexual assault, or as a teenager, as discussed in the adolescent section.

Fetuses and Newborns

Intrapartum or peripartum, a fetus or newborn can acquire many STIs, including chlamydia, gonorrhea, syphilis, HIV, HBV, HSV, human papillomavirus (HPV), and, more rarely, hepatitis C virus (HCV), trichomoniasis, Mycoplasma genitalium, or human T-cell lymphotrophic virus type 1 (HTLV-1) (Petca et al., 2020; Sethi et al., 2012; Workowski and Bolan, 2015). Any of these can be devastating or even fatal. HIV, syphilis, and HBV are the focus of World Health Organization efforts to combine screening during pregnancy to ensure that HIV is suppressed, syphilis is cured, and HBV is prevented with active immunization of the infant and passive antibody therapy of the newborn (Aliyu et al., 2016; Cheung et al., 2019; Hamilton et al., 2017; Heston and Arnold, 2018; Vrazo et al., 2018; Wang et al., 2015). Chlamydia or gonorrhea can inoculate the eyes of a newborn passing through an infected birth canal, causing ophthalmia neonatorum, which can be dangerous to the developing cornea and lead to blindness (Hull et al., 2017). As discussed earlier, proper prenatal screening and treatment during antenatal and peripartum care can

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

immensely diminish STI risk to the fetus and infant. CDC recommends screening all pregnant people for HIV, syphilis, and HBV. Additional recommendations for chlamydia, gonorrhea, and HCV are based on age and/or behavioral risk factors. No evidence supports routine pregnancy screening for HSV-2, bacterial vaginosis (BV), or trichomoniasis in asymptomatic patients (Workowski and Bolan, 2015).

Children

In the United States, a child is sexually abused every 9 minutes (RAINN, 2020); 90 percent know their abuser, and 30 percent of abusers are family members (Darkness to Light, 2015). Children acquire STIs though sexual abuse perpetrated largely by men, or sometimes by older children, though adults are responsible for most transmission of syphilis, gonorrhea, chlamydia, HIV, HSV-2, and other STIs (Bechtel, 2010; Kawsar et al., 2008). All possible sexual assaults in children require carefully and sensitively conducted histories, physical exams with STI tests, and psychological evaluation and counseling for victims, siblings, and other affected family members (Gallion et al., 2016; Smith et al., 2018). Childhood sexual abuse is an adverse childhood experience that can affect physical and mental health through adulthood; see Chapter 2 for more information about how adverse childhood experiences are related to STIs.

Children of any age can be in situations that increase their risk of STI exposure, particularly if their households contain predatory adults or adolescents (Bechtel, 2010; Goldberg and Moore, 2018). Children who were assaulted earlier in life are at higher risk of acquiring STIs as adolescents for a variety of reasons, such as being at increased risk for engaging in behaviors related to STIs, continuing to live in an abusive environment, acquiring aberrant views of sex as a consequence of their earlier traumas, with depression and loss of self-esteem, for example, or confusing affective with sexual contact (Lalor and McElvaney, 2010). Substance abuse and addiction among parents or guardians or caretakers have been associated with childhood sexual abuse and STI risk (Levine et al., 2018; Lown et al., 2011; Sutherland, 2011). Childhood sexual abuse is also a risk factor for sexual revictimization in adulthood (Ports et al., 2016).

ADOLESCENTS

Adolescence spans several developmental stages as people transition from childhood to adulthood. Starting with puberty (which, on average, begins between 8 and 10) and crossing into adulthood (up to age 25), adolescence is a formative period in which young people have the

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

opportunity to positively develop, learn, grow, and mature when appropriately protected and supported (NASEM, 2019a). Puberty is a gradual development influenced by biological and social processes. It involves the development and maturation of primary and secondary sex characteristics, leading to reproductive maturity. Genetic and environmental factors both affect the timing of puberty. Puberty is also marked by neurobiological and psychosocial growth, including development of the brain, cognitive, emotional, and social skills, and self-identity (NASEM, 2019a). Adolescents experience “pubertal, neurobiological, cognitive, and psychosocial changes” that can lead them to “form healthy relationships with their peers and families, develop a sense of identity and self, and experience enriching and memorable engagements with the world” (NASEM, 2019a, p. 75). Adolescence is a time in which the sense of self evolves to include awareness and development of sexuality and sexual and gender identity. Although often viewed as a time in which young people engage in high-risk behaviors, adolescence is in fact “a period of great opportunity for adolescents to flourish and thrive” (NASEM, 2019a, p. 75). Nonetheless, STIs are common in this age group; for example, those aged 15–24 make up about 13 percent of the population, yet account for about half of STIs reported in the United States (see Figure 3-1). The literature on this group is vast, but is summarized below (see the section later in the chapter, too, on STIs among lesbian, gay, bisexual, transgender, and queer [LGBTQ+] youth). Box 3-2 summarizes important takeaway messages about adolescents and multi-level drivers of STIs in this population.

Individual-Level Factors

Sexual Initiation

Normative biological (e.g., hormones and physical growth) and social (e.g., sexual attraction and dating) development during adolescence

Image
FIGURE 3-1 Young people are disproportionately burdened by STIs.
SOURCE: Keller, 2020.
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

influences the onset of sexual behavior. This developmental milestone is important for increasing adolescents’ knowledge and experience with their sexuality, intimate relationships, and pleasure (Tolman and McClelland, 2011; Vasilenko et al., 2016). It also provides opportunities for risk, especially if it occurs during early adolescence, when young people may lack skills for healthy sexual decision making (Dahl, 2001; Steinberg, 2005). Research indicates that an early age of sexual debut is associated with STIs in adolescents (Epstein et al., 2014; Heywood et al., 2015; Kaestle et al., 2005; Lara and Abdo, 2016; Upchurch et al., 2004; von Ranson et al., 2000) and behaviors that increase risk for STIs, including a greater number of recent, lifetime, multiple, and concurrent sexual partners (Adimora et al., 2002; Epstein et al., 2014; Heywood et al., 2015; Kaplan et al., 2013; Sandfort et al., 2008; Sneed, 2009), and violent victimization, such as intimate partner or dating violence (Kaplan et al., 2013; Lowry et al., 2017; Seth et al., 2013).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Sexual Partnerships

While most adolescents remain sexually abstinent (approximately 60 percent of high school students in 2019) or engage in safer sexual behaviors, a smaller but sizable proportion engage in sexual behaviors that increase their risk for STIs (CDC, 2020e; Johnston et al., 2015; Kann et al., 2018; Vasilenko et al., 2015). The prevalence and pattern of adolescents’ sexual behaviors, including their partner selections, determine their risk for and exposure to STIs.

Multiple and concurrent sexual partners

Multiple sexual partnerships that occur within a short period (serial monogamy) and those that overlap in time (concurrent relationships) are prevalent patterns during adolescence and associated with increased risk for STIs (Ashenhurst et al., 2017; Boyer et al., 2000; CDC, 2020e; Habel et al., 2018; Johnston et al., 2015; Kann et al., 2018; Reed et al., 2012; Vasilenko and Lanza, 2014).

Nationally, among in-school adolescents, nearly one-tenth (8.6 percent) have had four or more lifetime sexual partners in 2019, which occurs more among boys (10.0 percent) than girls (7.2 percent), and more among Black students (13.3 percent) compared with their white (7.7 percent) and Latino/a (9.2 percent) peers (CDC, 2020e). Differences also occur by sexual identity, with a significantly higher percentage of lesbian, gay, or bisexual (11.1 percent) than heterosexual (8.2 percent) or unsure of their sexual identity (8.0 percent) students (CDC, 2020e). More students whose self-reported sexual partners were only same-sex or both sexes (23.6 percent) had sex with four or more lifetime sexual partners than students who had sexual contact with only the opposite sex (15.6 percent) (CDC, 2020e). Importantly, the proportion of students who had multiple lifetime sexual partners has declined dramatically over the past decade, from 13.8 percent in 2009 to 8.6 percent in 2019 (CDC, 2020e).

Exchange of sex

Adolescents’ exchange of sex for drugs, money, food, or shelter (sex exchange) is associated with STIs (Boyer et al., 2018; Edwards et al., 2006; Kaestle, 2012; Silverman, 2011), and STI-related risk factors, including multiple sexual partners (Lavoie et al., 2010; Marshall et al., 2010; Patton et al., 2014b; Raiford et al., 2014; Reilly et al., 2014), inconsistent condom use (Kaestle, 2012; Marshall et al., 2010), injection drug use (Edwards et al., 2006; Reilly et al., 2014) and use of other substances (Boyer et al., 2018; Kaestle, 2012; Patton et al., 2014b; Raiford et al., 2014; Reilly et al., 2014; Woods-Jaeger et al., 2013), and childhood trauma (London et al., 2017). Data from the National Longitudinal Study of Adolescent to Adult Health (referred to as Add Health) indicate that a relatively small percentage of adolescents, overall, have ever experienced sex exchange (2.3 percent), and that it is most prevalent among young men (62.9 percent of

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

this total). Not surprisingly, sex exchange occurs most commonly among groups of young people with difficult living conditions and social circumstances, including those who had recently run away from home or experienced homelessness, sexual coercion, childhood abuse, depression, cannabis3 use, or shoplifting (Edwards et al., 2006; Kaestle, 2012). Other influences include factors such as homelessness, unemployment even after participating in job training programs, housing instability, reliance on others for income, crime victimization, and perceived community norms indicating that sex exchange is common among peers (Boyer et al., 2017, 2018). Research on adolescent sex exchange calls for community resources that reduce the need for young people to engage in transactional sex.

Condom Use

Despite condoms being relatively affordable and accessible to many adolescents, condom use remains inconsistent among sexually active adolescents (Bauermeister et al., 2011; CDC, 2020e; Harper et al., 2018; Reece et al., 2010). Correct, consistent external condom use is particularly challenging for young women who need to rely on the cooperation of their sexual partners (Swan and O’Connell, 2012; Teitelman et al., 2008, 2011; Vasilenko et al., 2015). Key barriers that affect young women’s ability to negotiate with sexual partners about condoms include gendered powerlessness that fosters conditions that limit their power in sexual relationships (Chiaramonte et al., 2020; Lim et al., 2019; Wingood and DiClemente, 1998) and intimate partner violence (Fair and Vanyur, 2011; Rosenbaum et al., 2016; Seth et al., 2013). When sexual communication specifically about condoms does occur within relationships, however, adolescents are significantly more likely to use them (DePadilla et al., 2011; Noar, 2006; Schmid et al., 2015; Widman et al., 2014).

Relationship dynamics and condom use

Other relationship dynamics, such as the length and quality of sexual partnerships, are also related to adolescent condom use. Adolescents in new or casual relationships are more likely to use condoms and to do so more consistently (Fortenberry et al., 2002; Katz et al., 2000), whereas relationships that are characterized as serious or committed (Kusunoki and Upchurch, 2011; Sayegh et al., 2006) or having high levels of trust/love (Ewing and Bryan, 2015) and mutually high intimacy (Wildsmith et al., 2015) are associated with inconsistent condom use. Unfortunately, too few studies examine adolescent

___________________

3 The literature uses the terms “cannabis” and “marijuana”; for consistency, the report uses the genus name, “cannabis,” in part due to racist connotations associated with “marijuana” (Solomon, 2020).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

relationship dynamics over time. Matson et al. (2011) found that young women who changed from multiple sexual partnerships during adolescence to monogamous main partnerships decreased their condom use over time, those who changed from monogamous main partnerships to multiple sexual partnerships increased condom use, and those who did not change partnership patterns did not change condom use. Thus, young people may modify their condom use based on their perception of risk associated with their partners. Therefore, STI prevention strategies need to consider sexual relationship dynamics, such as their length and quality, gendered power imbalances, adolescents’ cognitive development (e.g., ability to plan ahead or project future consequences for behavior), and interpersonal skills (e.g., ability to assertively articulate one’s sexual and reproductive health [SRH] preferences), as well as salient gender and cultural norms that discourage open sexual health communication within sexual relationships.

Contraceptive use and condom use

Inconsistent condom use in adolescents is also related to young women’s contraceptive use, with recent evidence and trends suggesting that young women who use long-acting reversible contraceptives are less likely to consistently use condoms (Bastow et al., 2014; Pazol et al., 2010; Steiner et al., 2016; Walsh-Buhi and Helmy, 2018; Williams and Fortenberry, 2013). Research also suggests that young women who use both oral contraceptives and condoms are primarily motivated by preventing pregnancy rather than STIs (Crosby et al., 2001; Lemoine et al., 2017). Nationally, while sexual activity has declined among adolescents, condom use assessed at last sex among those who partake has also declined between 2009 (61.1 percent) and 2019 (54.3 percent) (CDC, 2020e). In 2019, more sexually active male (60.0 percent) than female (49.6 percent) high school students used a condom during their last sexual encounter. This was lower, however, among sexual minority students, with 41.3 percent of gay, lesbian, and bisexual students and 47.3 percent of students who are not sure of their sexual identity using condoms compared with 56.6 percent of heterosexual students. By race and ethnicity, Black (48.2 percent), Latino/a (56.2 percent), and white (55.8 percent) students used condoms. Overall, high school students’ condom use has declined dramatically over the past decade (CDC, 2020e). Some barriers for adolescents are embarrassment about or lack of funds for purchasing condoms, lack of knowledge in how to use them, and lack of preplanning and negotiation skills during sex (McCool-Myers et al., 2019). More nuanced studies are needed to examine adolescent condom use within a holistic person-centered context that accounts for partnership dynamics and change in use as adolescents mature and gain experience (Tolman and McClelland, 2011). More psychosocial research can aid in

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

a better understanding of the motivating factors and barriers that limit condom use related to or independent of young women’s contraceptive use and in identifying key targets for STI prevention interventions and risk-reduction counseling.

Co-occurring Health Conditions

Other coexisting influences on adolescents’ risk for and acquisition of STIs include mental health conditions, such as stress, anxiety, and depression (Brown et al., 2010; Champion, 2011; Gerassi et al., 2016; Hulland et al., 2015; Jackson et al., 2015; Khan et al., 2009); childhood exposure to trauma, including physical, emotional, and sexual abuse (Aalsma et al., 2011; Champion, 2011; Gavril et al., 2012; Gerassi et al., 2016; Girardet et al., 2009; London et al., 2017; Oshri et al., 2012); and experiences with intimate partner violence or teen dating violence (Seth et al., 2012, 2013; Vagi et al., 2015). The onset of psychiatric disorders typically occurs during adolescence and early adulthood. Specifically, one-half of all adult psychiatric disorders start by the age of 14, but are often untreated for 6–23 years after onset of symptoms (ACOG Committee on Adolescent Health Care, 2017a). Adolescents living with psychiatric disorders are more likely to engage in sexual risk behaviors, including condomless sex (Lee et al., 2016), yet are less likely to be screened for STIs (Lee et al., 2016; Workowski and Bolan, 2015). These health outcomes are prevalent among adolescents, significantly linked with other experiences related to STIs (e.g., substance use and homelessness), and central to adolescent sexual health decision making. These co-occurring health conditions disproportionately affect cisgender female adolescents, racial and ethnic minorities, LGBTQ+ populations (see later sections in this chapter), homeless and detained youth, and youthful substance users (Aalsma et al., 2011; Gerassi et al., 2016; Jackson et al., 2015; Oshri et al., 2012; Sales et al., 2016; Seth et al., 2012, 2013). Taken together, further research is clearly needed that provides a greater understanding of proximal behaviors and distal contextual factors that contribute to STI risk. STI prevention strategies that integrate a trauma-informed approach to prevention and risk-reduction efforts are also sorely needed (Sales et al., 2016). Health providers who screen adolescents for STIs need to also screen for trauma, mental health conditions, and substance use (Gerassi et al., 2016).

Alcohol and Other Substance Use

Alcohol and other substance use, such as cannabis and products delivered by electronic vapor devices (e.g., e-cigarettes and vaping pens), are prevalent during adolescence, including with high school students

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

(Cullen et al., 2019; Kann et al., 2018; McCabe et al., 2017), college students (Adefuye et al., 2009; Brown and Vanable, 2007; Wu et al., 2009), STI clinic patients (Carey et al., 2016; Senn et al., 2010), adolescents in the juvenile justice system (Bryan et al., 2018; Hendershot et al., 2010), participants in substance use treatment programs (Brooks et al., 2010; Hulland et al., 2015), and individuals with co-occurring mental health conditions (Cunningham et al., 2017).

Alcohol use

Alcohol use and misuse (e.g., binge or heavy drinking) during adolescence are associated with risky sexual behaviors, including commencing sexual activity at a young age (Epstein et al., 2014; Lowry et al., 2017), increased sexual activity (Brown et al., 2010), a higher number of lifetime partners (Carey et al., 2016), multiple partners (Aicken et al., 2011; Khan et al., 2012), casual or noncommitted partners (Claxton et al., 2015; Owen and Fincham, 2011), inconsistent condom use (Khan et al., 2012), condomless sex during the last sexual encounter and with casual or nonsteady partners (Brown and Vanable, 2007; Brown et al., 2010; Metrik et al., 2016), and sex with a partner infected with an STI (Khan et al., 2012). Several studies have also identified variation in findings by gender, including more sexual risk factors for young women than young men (Carey et al., 2016; Hutton et al., 2013; Owen and Fincham, 2011).

Cannabis use

Like alcohol use, cannabis use is associated with sexual behaviors and STIs (Hendershot et al., 2010; Lee et al., 2014). Cannabis, sometimes combined with other substances, such as alcohol, cocaine, opiates, and ecstasy (Metrik et al., 2016; Ritchwood et al., 2015), is associated with a number of STI-related risk indices (Bryan et al., 2012; Connell et al., 2009; Guzmán and Dello Stritto, 2012; Madkour et al., 2010; Tucker et al., 2012). It is also associated with higher STI incidence (Smith et al., 2010; Wu et al., 2009); increasing levels of cannabis use are associated with higher prevalence of STIs (De Genna et al., 2007; Smith et al., 2010). A number of these sexual risk factors are moderated by sex, race, and ethnicity (Kaestle, 2012; Ritchwood et al., 2015). Additionally, the landscape around the legality of cannabis has changed over the past 8 years. As of this report, 15 states and the District of Columbia had legalized recreational cannabis, with Washington and Colorado being the first to do so in 2012 (Infobase, 2020). Research on U.S. adult cannabis use, sexual behaviors, and STIs found that after including measured confounding variables to the model, the association between cannabis use and STIs was no longer significant (Patel et al., 2020), contrary to the evidence found in adolescent populations. Additionally, in a cohort study of MSM with 2014–2017 data, fewer participants tested positive for STIs if they only

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

used cannabis in the 6 months prior in comparison to those with no drug use or those with use of other drugs (Gorbach et al., 2019). This conflicting work highlights the need for continued exploration of understanding cannabis use in sexual relationships and its effect on STI transmission.4

Electronic cigarette use

While not directly linked to STIs, cigarette usage is a marker of high-risk behavior. Data indicate that e-cigarettes are now the most widely used tobacco product among adolescents (Cullen et al., 2019; King et al., 2018). Their use is associated with behaviors such as multiple sexual partners and condomless sex and often co-occurs with use of other substances (Chadi et al., 2019; Demissie et al., 2017; McCabe et al., 2017). Specifically, adolescents who had frequent or daily e-cigarette use were significantly more likely to also engage in binge drinking, cannabis use, and other illicit drug use (McCabe et al., 2017). A meta-analytic review noted higher cannabis use among youth who used electronic cigarettes (Chadi et al., 2019).

Substance use and co-occurring health conditions

Adolescents’ use of alcohol, cannabis, and e-cigarettes is associated with behaviors that increase risk for STIs (Brown and Vanable, 2007; Bryan et al., 2012; Demissie et al., 2017; Metrik et al., 2016). Cannabis, alcohol, and other substance use is also associated with co-occurring mental health conditions, such as stress, anxiety, depression, schizophrenia, and attention deficit disorders, which are also correlated with sexual behaviors (Hulland et al., 2015; Wilson and Cadet, 2009). Some studies focus on use as a single event (e.g., during the last sexual encounter), however, a measurement frame that often misses the broader interpersonal context of these behaviors. Longitudinal research can assess the temporal order of behaviors and the mechanisms that promote risk and prevention. Examining contextual mediators can increase understanding of how individual, social, and environmental factors interact to contribute to adolescent sexual and substance use behaviors. Thus, more successful STI prevention interventions could be developed and tailored for defined subgroups (Swartzendruber et al., 2013).

___________________

4 Cannabis arrests reflect significant racial bias; Black people are more than 3 times more likely to be arrested, despite usage rates almost equal to those of white people. This is true of states that have legalized cannabis, too (ACLU, 2020). Similarly, analysis of arrests in New York City shows Black and Latino people, males, and people aged 16–29 disproportionately affected by cannabis arrests (Golub et al., 2007). This unequal policing and enforcement disproportionately puts young Black and Latino men in contact with the criminal legal system; see the section later in this chapter on the association between that system and STIs.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Cognitive-Behavioral and Psychosocial Influences Related to STIs

Cognitive-behavioral and psychosocial influences on STI-related risk and protective factors in adolescents are well described, yet there is no single framework that fully captures the complex association of intersecting factors (Vasilenko and Lanza, 2014; Zimmer-Gembeck and Helfand, 2008). Variation in findings across studies is hard to interpret when different constructs are measured (e.g., knowledge, perceived personal risk, communication self-efficacy, attitudes toward condoms) and outcomes are characterized differently (e.g., sexual debut, condom use, partner concurrency, STI diagnosis). Many cognitive-behavioral and psychosocial variables are highly correlated, and some may be both antecedents and outcomes (McCree and Hogben, 2010). Nevertheless, strategies to prevent STIs in adolescents are informed by those antecedent mechanisms consistent across studies that underlie adolescents’ sexual health decisions and subsequent sexual behaviors (see Chapter 8 for a review of cognitive-behavioral and psychosocial theories of health and behavior change).

Summary of Individual-Level Factors and Future Considerations

Adolescents’ risk, prevention, and acquisition of STIs are the result of interrelated SRH behaviors and substance use that are influenced by antecedent cognitive-behavioral and psychosocial factors and intersecting health conditions within their social and environmental context. Longitudinal examination of these multi-dimensional and interrelated factors may provide insights into the manner in which sexual behaviors change with increasing age and experience and help to identify both health-motivating and risk-promoting individual-level factors. Additionally, more basic behavioral research and innovative STI prevention strategies that use a theoretically guided, person-centered, holistic approach to adolescent sexual health are needed (Hallfors et al., 2016; Tolman and McClelland, 2011), which must incorporate tenets of adolescent development, gender-based dynamics, cultural norms, and other social determinants.

Interpersonal-, Institutional-, Community-, and Structural-Level Factors

Adolescent sexual and contraceptive decision making and behavior occur in a context that increases or reduces STI risk. Some of the most important interpersonal, social, and contextual factors shaping the risk for and protection against STIs include (1) parental, peer, and sexual network influences; (2) sexual partner influences; (3) community and other environmental factors; (4) media and other digital communications; and (5) health care and health care access.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Interpersonal Factors

Parental influences

Parents provide an important social context for adolescent sexual decision making (Power to Decide, 2016) and behavior. Parents shape a wide range of adolescent sexual behaviors, including timing of first intercourse, frequency of sex, contraception use, and STI and HIV testing (Balaji et al., 2017; Gavin et al., 2015; Widman et al., 2016). Parent-based interventions designed to reduce adolescent STI exposure have shown efficacy in delaying sexual debut and promoting use of condoms and accessing of SRH services (Gavin et al., 2015; Guilamo-Ramos et al., 2019a). Specific parental behaviors and influences associated with reduced STI exposure include age-appropriate monitoring and supervision, parent–adolescent communication, and parent–adolescent relationship satisfaction (Coakley et al., 2017; Dittus et al., 2015; Guilamo-Ramos et al., 2016, 2019a). In particular, specific parental influences, such as STI-specific communication, are more likely to shape adolescent STI exposure than general parenting behaviors (Coakley et al., 2017; Guilamo-Ramos et al., 2016). Additionally, parental willingness for adolescents to have time alone with their health care providers encourages adolescents’ emerging autonomy, allows adolescents to build skills to manage and advocate for their own health, and enhances physician–adolescent trust and communication, including about topics such as sexual behaviors (Miller et al., 2018). See Box 10-1 in Chapter 10 for information on confidentiality, and Chapter 12 for more on the important role of parents in reducing STIs.

Peer influences

Adolescence is a developmental period in which peers play an increasingly critical role in shaping identity, social norms, and sexual behavior. Adolescent identity is partially shaped by peer perceptions (NASEM, 2019a). For example, adolescent STI exposure is, in part, affected by perceptions of peers’ behavior; they are more likely to engage in condomless sex when there are higher levels of perceived peer endorsement of it (NASEM, 2019a; van Hoorn et al., 2018). Compared to adults, adolescents have reduced emotional and reward regulation and are generally more likely to engage in risk-taking behaviors in the presence of peers (Hansen et al., 2019; NASEM, 2019a; van Hoorn et al., 2018). Peers also can play a protective role in adolescent sexual and contraceptive decision making. Specifically, adolescents with peers who (1) have positive social prototypes of adolescents who engage in protective sexual behavior, such as correct and consistent condom use and (2) are perceived to be engaging in safe sexual behavior are more likely to practice protective behaviors themselves (Hansen et al., 2019; NASEM, 2019a). Peer-based interventions have shown efficacy in shaping behaviors that reduce STI exposure, such as condom use (Patton et al., 2016).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Characteristics of social/sexual networks can predict adolescent negative SRH outcomes, including STIs (Fichtenberg et al., 2009). Adolescents in sexual networks with high STI prevalence are more likely to acquire STIs while engaging in the same sexual behaviors as those in sexual networks of low STI prevalence (Ellen et al., 2005; Macapagal et al., 2018).

Sexual partner influences

Sexual and romantic partners are an important social context that influences adolescent SRH outcomes (Staras et al., 2009). Factors associated with STIs include older sexual partners (Begley et al., 2003; Boyer et al., 1999; Ford and Lepkowski, 2004; Stein et al., 2008; Swartzendruber et al., 2013), casual partners (Lyons, 2017; Lyons et al., 2015), new sexual partnerships (Ott et al., 2011), and partners with a prior history of STIs (Staras et al., 2009). In addition, adolescents often misclassify a partner as monogamous, resulting in greater likelihood of STI exposure (Copen et al., 2019; Lenoir et al., 2006; Matson et al., 2018; Sanchez et al., 2016).

Couples’ communication is an important factor in adolescent STI exposure (Widman et al., 2014). Adolescent couples who report less communication regarding barrier methods and STI testing are more likely to engage in condomless sex and acquire STIs (Widman et al., 2014). Additionally, partner communication can have a protective role. Increased communication about barrier methods to prevent STIs, such as consistent and correct condom use, has been associated with enhanced condom use (Gause et al., 2018; Widman et al., 2014).

Ascribing to traditional gender norms regarding masculinity and femininity and perpetuating unequal gender roles has been associated with adolescent sexual behavior, including condomless sex (Rome and Miller, 2020). Adolescents who report low power in their sexual relationships are more likely to acquire STIs (Haberland, 2015; Rome and Miller, 2020). Interventions that address gender and power have been associated with decreased STI rates and reductions in unintended pregnancies (Haberland, 2015).

Another important consideration is intimate partner violence and reproductive coercion, which represent significant drivers of STI acquisition among adolescents. Intimate partner violence among adolescents is defined as physical, emotional, or sexual violence that occurs in a relationship where at least one partner is an adolescent or young adult (Rome and Miller, 2020). See Chapter 2 for more information.

Media and Other Digital Communications

Digital tools, such as dating apps, play a role in romantic and sexual relationships, especially among adolescents. Adolescents are most likely

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

to form romantic and sexual relationships through dating apps (Anderson et al., 2020). Approximately half of adolescents report ever using a dating app or website (Anderson et al., 2020). Adolescents who seek sexual partners online report higher rates of condomless sex and STI diagnoses (Anderson et al., 2020; Sawyer et al., 2018). This enhanced STI exposure has been attributed to the expanded sexual network size of adolescents on dating apps (Macapagal et al., 2018; Sawyer et al., 2018). Increasing attention has been placed on providing STI prevention and treatment services to adolescents using dating apps and websites (Cao et al., 2020; Macapagal et al., 2018). Research has also found that adolescents’ exposure to sexual media content in mainstream media influence sexual attitudes and behaviors (Coyne et al., 2019; Young and Jordan, 2013). Additionally, in a review and meta-analysis of adolescent exposure to sexually explicit websites and sexting, sexually explicit website exposure correlated with condomless sex, and sexting correlated with multiple recent sexual partners and other outcomes (Smith et al., 2016). See Chapter 6 for more discussion on the role of technology, including examples pertaining to adolescents and STIs.

Health Care and Health Care Access

When I was 18, I started going to the doctor on my own, and I got the question if I was sexually active. At first, I wasn’t. But by the time I finally said I was, it was kind of too late. I had already contracted three STIs, and one of them does not have a cure. If I had been able to open up to the doctor back [when I first became sexually active], I don’t think this would have happened. If we train doctors to build the trust of their patients, the patients wouldn’t mind opening up about sex.
—Participant, lived experience panel

Current normative screening and treatment approaches

National health organization guidelines recommend STI screening for sexually active adolescents based on behavioral, community, and population risk factors (Lee et al., 2016; Workowski and Bolan, 2015). As part of the clinical visit, CDC guidelines recommend that health care providers collect a complete sexual history from their adolescent patients (ACOG Committee on Adolescent Health Care, 2017b; Todd and Black, 2020; Workowski and Bolan, 2015). This may be accomplished more easily when adolescents talk with their health care providers alone. Furthermore, data from the National Survey of Family Growth shows that adolescents aged 15–17 who spent time alone with a health care provider were more likely to seek sexual and reproductive health care than adolescents who did not (Copen et al., 2016). The United States Preventive Services Task Force recommends

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

risk-reduction counseling for all sexually active adolescents, aimed at preventing STIs (Lee et al., 2016). Pre-exposure vaccination is currently available for HPV, HBV, and hepatitis A virus (HAV) (Workowski and Bolan, 2015), yet adolescent vaccination rates remain too low (Abdullahi et al., 2020). Barriers to vaccination uptake include lack of awareness and communication and misinformation among adolescents, their parents, and health care providers (Dibble et al., 2019).

For adolescents living with STIs, immediate onsite treatment, sexual partner referral for STI testing, and repeat STI screening after treatment are warranted (Lee et al., 2016; Workowski and Bolan, 2015). Clinical and nonclinical organizations have considerable variability in their STI screening/treatment of adolescents, despite national guidelines. For example, clinical guidelines recommend adolescents living in detention centers receive routine STI screening and treatment due to high STI prevalence (Workowski and Bolan, 2015). Short-term jail and juvenile detention facilities, however, often do not provide screening and have suboptimal STI treatment outcomes after diagnosis (Borschmann et al., 2020; Owusu-Edusei et al., 2013; Workowski and Bolan, 2015). Similarly, adolescents in the child welfare system have higher STI prevalence, yet are often overlooked in STI screening (Harmon-Darrow et al., 2020).

Health care barriers

Clinicians may experience barriers to initiating communication with adolescents about their sexual history for a variety of reasons, including (1) provider discomfort and lack of confidence; (2) beliefs regarding adolescent sexual behavior based on age, gender, sexual orientation, etc.; and (3) concern regarding parental permission and confidentiality (Fuzzell et al., 2017) (see Chapters 2, 10 [see Box 10-1], 11, and 12 for more information). For example, while all 50 states allow for minors to receive STI screening without parental permission, physicians can inform parents about screening and/or treatment in 18 states (Guttmacher Institute, 2019). Health care providers may recommend STI screening to groups with high HIV prevalence, such as Black and Latino adolescent MSM, who already experience racism, discrimination, gender bias, homophobia, transphobia, and other forms of stigma (Cuffe et al., 2016; NASEM, 2019a; Unemo et al., 2019).

Adolescent barriers to engagement and retention include costs associated with health care use and treatment, low health literacy, and organizations’ hours (“9 to 5”) not matching adolescent availability (NASEM, 2019a). Perceived stigma represents a significant barrier to STI screening and care; adolescents may be less likely to seek STI services if being classified as “high risk” conflicts with their desired identity (Cuffe et al., 2016; NASEM, 2019a). Recurring, daily treatment regimens may be a barrier to

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

adherence if youth prioritize short-term reward over long-term consequences (Unemo et al., 2019).

Need for new paradigms

While confidentiality is an important concern for youth, approaches that incorporate parents in adolescent sexual and reproductive delivery (Dittus, 2016; Ford et al., 2011; Guilamo-Ramos et al., 2019b) are encouraged by organizations and supported by professional guidelines (ACOG Committee on Adolescent Health Care, 2020; CDC, 2018a; SAHM, 2014). Triadic interventions (parent–adolescent–health care provider) have shown efficacy in reshaping negative SRH outcomes in adolescents (Guilamo-Ramos et al., 2011, 2020). See Chapter 8 for more information. Time alone with a health care provider supports adolescents’ autonomy; it can facilitate discussion of sexual behaviors and collection of a full sexual history, and allows for receipt of sexual and reproductive health services (Copen et al., 2016; Miller et al., 2018). Promising approaches to STI prevention and treatment can incorporate adolescent-specific considerations regarding confidentiality, perceived stigma, community STI prevalence, and treatment regimens. Improved framing of STI testing and treatment that moves beyond an emphasis on risk to one that incorporates positive adolescent identity is needed (Keller, 2020). Furthermore, community-based STI screening and treatment in locations where adolescents are present, primarily in contexts of high STI prevalence, have been identified as a promising approach (Shannon et al., 2019b). Finally, long-acting pre-exposure treatment or vaccination options for adolescents are needed (Unemo et al., 2019).

CISGENDER HETEROSEXUAL ADULTS

While LGBTQ+, adolescent, AI/AN, and other populations are disproportionately affected by STIs, certain groups of cisgender heterosexual adults are also heavily affected (e.g., Black heterosexual women and men and female sex workers). In moving from adolescence to adulthood, the number of sex partners and frequency of sexual activity generally decreases. For example, an analysis of data from the General Social Survey found that sexual activity decreased among women aged 25–34 and men aged 18–34 from 2000 to 2018; this decrease in sexual activity among men was observed mainly in unmarried men (Ueda et al., 2020). Individuals also may settle into more exclusive partnering, which typically leads to lower rates of STIs (Meier and Allen, 2009). High STI prevalence rates may manifest in subgroups that do not have this pattern of exclusive partnering, as with women engaging in transactional sex, persons who have mental illness, including substance use disorders, and the increasing number of single, older adults. In the United States, female sex workers

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

and those with mental illness experience high levels of marginalization and current services delivery models often fail to meet their STI prevention and care needs effectively. Population-based studies and good surveillance data also are lacking. Box 3-3 provides summarizing information for STIs among cisgender heterosexual adults.

Racial and Ethnic Minority Heterosexual People

Heterosexual people comprise a heterogeneous population. In particular, they come from diverse racial and ethnic backgrounds, and these subgroups each have a specific and unique STI burden and differ in the structural and social determinants of STIs differ. To ensure effective STI prevention and care among all heterosexual people, including those from marginalized racial and ethnic groups, services, programs, policies, and practices need to account for and be tailored to the distinct burden and structural and social determinants of racial, ethnic, and other subgroups.

Although research on racial and ethnic disparities in STIs and their structural and social determinants among heterosexual people in particular is limited, investigators have identified pronounced STI disparities across racial and ethnic groups in the U.S. population in general (see Chapter 2). As a result of pervasive anti-Black structural and interpersonal racism rooted in histories and legacies of slavery and medical experimentation targeting Black women and men, which shapes access to social and economic resources that influence STI risk, prevention, and care and exposure to risk factors today, Black–white STI disparities are especially

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

pronounced (CDC, 2019c) (see Chapter 2 for more information). Moreover, as a result of rampant structural and interpersonal discrimination against AI/AN people rooted in histories and legacies of settler colonialism and genocide, which affect access to social and economic resources that influence STI risk, prevention, and care and exposure to risk factors today, AI/AN men and women in general are also considerably more likely than their white counterparts to have an STI (CDC, 2019c). See the section later in this chapter on STIs among AI/AN people for more information.

The few studies that have specifically focused on racial and ethnic disparities in STIs among U.S. heterosexual people in particular have identified pronounced Black–white disparities in STIs, which are largely due to community- and structural-level factors that shape STI risk and access to STI prevention and care among Black heterosexual women and men. These factors include racial residential segregation and a disproportionate burden of poverty, unemployment, and incarceration, which influences the structure of sexual networks and exposure to STIs and access to STI-related services (Adimora and Schoenbach, 2005; Adimora et al., 2002; Bowleg and Raj, 2012; Hamilton and Morris, 2015). Moreover, racialized and gendered cultural norms, societal expectations, and sexual stereotypes shape heterosexual sexual relationships and STI risk among Black heterosexual women and men (Crooks et al., 2020), which contributes to Black–white STI disparities among heterosexual people in the United States.

Women Who Engage in Sex Work

While the true amount of transactional sex work among women in the United States is not known, an estimated 1 million women identify as sex workers (Lubin, 2012). An unknown additional number engage in informal transactional sex, such as for gifts, services, or money. Among unmarried women aged 20–45, Black women are more likely to report transactional sex with someone who is not a main partner compared to white women (13.1 percent versus 2.9 percent) (Dunkle et al., 2010). HIV prevalence was 4.9 percent among cisgender women who exchanged sex for money or drugs in four U.S. cities (Nerlander et al., 2020). There is far less information on other STIs among cisgender female sex workers in the United States, but one study in Baltimore found the incidence of chlamydia, gonorrhea, and trichomonas was 14.3, 19.3, and 69.1 per 100 person-years, respectively, among 250 study participants (Park et al., 2019).

Sex work increases exposure to STIs by increasing the number of often higher-risk sex partners. Women engaging in transactional sex often do not use condoms consistently (Medina-Perucha et al., 2019), due to

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

client preference, physical and sexual violence, or the monetary value of condomless sex in this context (Decker et al., 2020). In a meta-analysis of published studies of female sex workers, the average rate of inconsistent condom use for vaginal intercourse was 19 percent, but it was far higher (46 percent) for anal sex, despite high transmission risk for HIV and other STIs (Owen et al., 2020).

People who engage in sex work are more likely to live in poverty, be victims of sexual and physical abuse, be involved in the criminal legal system, and have substance use disorders and/or mental illness, and they more often access health care via emergency departments rather than primary care (Patton et al., 2014a). Transactional sex is associated with food insecurity, housing instability, substance abuse, and partner incarceration (Stoner et al., 2019). See Chapter 2 for more information on how alcohol and substance use, mental health, and housing instability are related to STIs. See, too, the section later in this chapter on STIs among people with criminal legal system involvement.

Attitudes about sex work in the United States lead to stigmatization and marginalization. While less than half (43 percent) of U.S. individuals think that sex work should be illegal (Moore, 2016), it is illegal in all states (it is legal in 10 counties in Nevada). Harsh police pressures on people who engage in sex work have been associated with increased risk of sexual/physical violence from clients or other parties, HIV/STI, and condomless sex (Platt et al., 2018). Some evidence indicates that possessing condoms may increase the chance that a woman is arrested for prostitution (Human Rights Watch, 2012). Most states punish people who engage in sex work and customers equally; however, nine states have harsher penalties for the customer (Colorado, Kansas, Massachusetts, Montana, Nebraska, New York, North Carolina, Tennessee, Utah) and two have harsher penalties for the person who engages in sex work (Delaware, Minnesota) (ProCon.org, n.d.)—see Chapter 9 for more information on the potential effect of decriminalizing commercial sex on STIs.

While male sex workers are not discussed in this report, they also have a high prevalence of STIs (see Bacon et al., 2006; Baral et al., 2015; Biello et al., 2020; Verhaegh-Haasnoot et al., 2015, for more information). Similarly, for information on cisgender heterosexual adults working in the adult film industry, see Goldstein et al. (2011), Rodriguez-Hart et al. (2012), and the section describing online pornography in Chapter 6.

Older Heterosexual Adults

There is a common notion that older people do not have sex and are not at risk for STIs, but the data do not support this idea (Nusbaum et al., 2004; Patel et al., 2003; Smith and Christakis, 2009). One study found 73

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

percent of respondents aged 57–64, 53 percent of those aged 65–74, and 26 percent of those aged 75–85 were sexually active (Lindau et al., 2007). Furthermore, there has been an uptick in the rates of some STIs among older people. For example, from 2017 to 2018, rates of reported syphilis cases increased 21.1 percent among those aged 55–64 and 28.6 percent among those aged 65 and older (CDC, 2019c). According to data from athenahealth, diagnosis rates for HSV-2, HBV, and trichomoniasis also increased from 2014 to 2017 for those aged 60 and older (Pereto, 2018). In 2018, more than half of people in the United States living with diagnosed HIV were aged 50 and older; though new HIV diagnoses are declining in this population, about one in six HIV diagnoses in 2018 were in this age group (CDC, 2020c).

Biological susceptibility may predispose older persons to STI risk through a weakened immune system, but there are other likely relevant factors, such as decreased vaginal lubrication and resulting friable vaginal tissue (Johnson, 2013). Relationship changes, such as divorce and partner death, can lead to new sexual relationships and may increase the risk of STIs (Sherman et al., 2005; Smith and Christakis, 2009). Older individuals may use online dating, where they are unacquainted with their partners and their sexual histories. Baby Boomers who matured during the sexual revolution of the 1960s/1970s may continue or revert to sexual behaviors that carry substantial risk for STI acquisition (Patel et al., 2003; Stall and Catania, 1994; Tuddenham et al., 2017). Seniors who were already married when sex education gained prominence may have missed “safer sex” talks aimed at younger generations. Additionally, medications such as sildenafil (Viagra) for men and hormonal replacement for women can reduce age-related physical barriers to having sex. Low risk awareness and embarrassment about sexuality among older persons, however, may result in both condomless sex and sex with more than one partner (Syme et al., 2017). Patients and health care providers alike also may overlook STI screening (Bauer et al., 2016; Bergeron et al., 2017; Haesler et al., 2016; Nusbaum et al., 2004; Thomason et al., 2015). For example, the majority of participants (about 65 percent) in a study of women aged 57 and older reported that sex is important, but less than one-quarter had talked about it with a physician (Bergeron et al., 2017). Similarly, a survey of 3,005 U.S. adults aged 57–85 found 38 percent of men and 22 percent of women had discussed sex with their provider since turning 50 (Lindau et al., 2007). Older adults may not consider oral or anal sex as ways of contracting or transmitting STIs and may forgo condoms because they do not fear pregnancy (Harvard Health Letter, 2018). Older adults also may face issues in accessing appropriate health care, reliable and accessible transportation, and other social determinants of health (Pooler and Srinivasan, 2018).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

SEXUAL AND GENDER DIVERSE POPULATIONS

MEN WHO HAVE SEX WITH MEN

MSM are a diverse and heterogeneous group with high community connectivity and gender privilege, yet they have distinct and unique vulnerabilities to STI transmission. This section highlights key elements from a body of scholarship that can frame existing and forthcoming STI interventions focused on this highly susceptible community. Particular attention is paid to Black and Latino MSM, given their disproportionate rates of STIs as a function of social and structural forces. Box 3-4 summarizes key information about STIs among MSM.

Individual-Level Factors

Penetrative anal sex is a potential factor causing increased biological susceptibility to STIs because of the thin lining of the rectum, which is easily damaged (CDC, 2019a). The number of recent or lifetime sex partners, rate of partnerships, and frequency of condomless intercourse affect STI transmission (CDC, 2019c; Glick et al., 2012). Given the increased rates of substance use, including use of drugs proximate to sexual activity (chemsex and erectile dysfunction drugs), behavioral disinhibition and greater frequency and duration of sex can create an environment where

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

STI transmission is more likely. Many MSM, especially from highly marginalized communities, may rely on substance use because it can remove deeply rooted inhibitions to intimacy; networks of substance users can create a sense of community (Benoit and Koken, 2012; Harawa et al., 2008; McKirnan et al., 2001; Schneider et al., 2013).

Many of these behaviors may relate to societal forces of discrimination and stigma, which can lead to internalized stigma/homophobia. In addition, MSM report higher rates of early experiences of childhood abuse and victimization (see Chapter 2 for more information).

Interpersonal-Level Factors

As discussed in Chapter 2, various network characteristics have been identified as contributing to individuals’ STI risk behaviors, risk perceptions, or infectious outcomes (see also Chapter 8). Specific assortative and disassortative mixing5 factors concentrate STIs within specific communities. These patterns, for example, undergird higher STI concentration within MSM as compared to heterosexual populations and higher concentration within Black MSM as a subgroup of all MSM. Overall population size is an important factor to consider when describing relative risk of STI infections in the context of such mixing, which tends to increase rates within smaller populations and community subpopulations. In addition, assortativity6 can be attributed to specific sex behaviors, including sex drug use, group sex, and condomless sex, which, when disassortative, can provide a network mechanism for onward STI transmission (Doherty et al., 2009; Schneider et al., 2013). Both types of mixing have been accelerated by dating apps (Beymer et al., 2014).

An additional network force is concurrency (overlapping partnerships). It provides opportunities for increased STI transmission at the partner level; the network risk increases substantially. Group sex is a clear case of concurrency; a potent mechanism for STI transmission exists, and overlapping sex acts take place within a short time. Additionally, group sex has the further accelerative effect of sharing infectious fluids between individuals from other network(s) who may have had indirect sex with someone else unknown to them (Friedman and Aral, 2001). Concurrency can be conceptualized in current understandings as being in an open relationship.

___________________

5 Displaying a preferential attachment to others with dissimilar attributes or behaviors.

6 Preferential attachment to others with similar attributes or behaviors.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Community-Level Factors

Community and other network norms are significant drivers of STIs among MSM. People prefer to have condomless sex for a variety of reasons. For MSM, the threat of HIV infection and its associated mortality earlier in the HIV epidemic served to instill an ethos and norm in favor of consistent condom use. As described in Chapter 6, perceptions of the declining severity of HIV and AIDS since the late 1990s have likely contributed to behavior changes, such as increases in condomless sex (Morgan et al., 2017) and condomless sex with casual partners, that may increase personal satisfaction with one’s sex life while also fueling increased rates of STIs among MSM (Schmidt et al., 2019b; Stenger et al., 2017). These relationships are complex, and other community norms could potentially contribute to STI transmission and increasing rates, such as increasing use of hookup apps, group sex, sex drug use, and condomless sex with pre-exposure prophylaxis to prevent HIV.

Having dense and assortative networks offers several key benefits, however, particularly with respect to health-seeking behavior, including the normalization of testing for STIs, such as HIV. Many MSM recognize the need for annual testing; others test more frequently, in line with CDC guidelines of every 3–6 months. Combined STI/HIV screening can be optimized based on sex behaviors and partnership patterns (Khanna et al., 2015). In addition, despite the general lack of culturally competent health systems with respect to sexual minority health, specialized sexual health centers exist that MSM use and share with other community members. Many health centers that specialize in LGBTQ+ health, for example, add to existing options for STI testing. Several have models for decreasing barriers, such as cost and time to obtain services (i.e., walk-in) and/or results (i.e., express service). These are typically safe spaces for MSM that complement other traditional STI clinics. Traditional STI clinics that provide care to MSM may have less cultural competency, but there can be anonymity factors in these spaces that some MSM prefer, particularly if these are not located where they work, live, or play.

Structural-Level Factors

Several societal forces drive STI transmission among MSM. Foremost are the insidious stigma, discrimination, and cultural violence forces directed toward sexual minorities in general and MSM in particular. While some progress has been made recently with marriage equality, persistent efforts continue to dehumanize MSM through unscientific policies and programs, including “gay conversion,” prohibiting adoption among same-sex couples, and barring school-based, same-sex sex education.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Intersectional social identities and positions are important considerations, as they may not allow for increased social capital among those with multiple marginalized statuses because these statuses are often stigmatized. This can result in additive and potentially multiplicative negative impacts on MSM health and well-being. Racism also works to marginalize MSM of color further, particularly in what should otherwise be “safe spaces” for queer people. They experience long-standing continued racism and resulting bigotry (Crawley, 2012). This is a particularly corrosive feature directed at people with multiple marginalized social identities and positions and is unfortunately often evident in organizations that promote sexual and gender minority health (Crawley, 2012). Racism clearly leads to un- and underemployment, housing instability, and criminal legal system involvement, which directly increase STIs in Black and Latino MSM (Newman and Berman, 2008).

Internalized homonegativity is a key factor that leads to increased STIs, substance use, poor mental health, and increased suicidality (Berg et al., 2016; Jeffries and Johnson, 2015; Newcomb and Mustanski, 2010). Limited positive self-perception and self-worth and limited support from kin can lead to acceptance-seeking behaviors, which can be associated with increases in STIs, overexpressed sexuality through increased partnerships, and sexual nonconformity.

TRANSGENDER AND GENDER DIVERSE ADULTS

Being uninsured and not having access to funds to get tested is another barrier. There’s the LGBTQ center where testing is free, but if I wanted to go to my regular health care provider, although I would be insured once a year to get testing, throughout the rest of the year, I would not be insured, so that is definitely a barrier. Then there’s just cost of living in general. When seeing if you have the ability to get tested, you have to take into consideration the cost of living and if you can even spend that money to get tested or if you have to put it elsewhere. And worrying about personal safety in clinical environments and getting to clinical environments is a social determinant that I am faced with.
—Participant, lived experience panel

Transgender Women

STI rates among transgender (trans) women, and Black and Latina trans women in particular, are some of the highest in the United States (Becasen et al., 2019; Poteat et al., 2014). High rates of infection suggest the importance of extragenital testing for STIs, with more than 80 percent of women with an extragenital gonococcal or chlamydial infection having a concurrent negative urogenital test. Black and Latina trans women

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

experience discernable gendered and racialized dynamics. They possess multiple marginalized statuses: the effects of their gender identity and sexual orientation, which have variable expression and form, are exacerbated by the forces of racial discrimination (Bostwick et al., 2014; Frost et al., 2015; Han et al., 2015). Box 3-5 includes key summarizing information about STIs among trans and gender diverse adults.

Individual-Level Factors

There are notable behavioral susceptibilities that may increase vulnerability to STIs among trans women, including higher rates of oral sex and receptive intercourse. Increased oral sex offers additional opportunities for STI acquisition. In addition, while trans women are often the receptive partner when engaging in sex, health care professionals and other health educators often assume this and may not necessarily provide information on topping or other insertive roles that can lead to STIs and may not be routinely tested and treated appropriately. Among trans women

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

without vaginoplasty, 16 percent have engaged in insertive anal sex with non-main, commercial partners in the past 30 days (Nemoto et al., 2014).

Some of the structural factors described below that affect trans women can lead to increased use of substances, including alcohol and/or sex drugs, that can result in concomitant decision-making impairment and less agency (see Chapter 2 for more information on the association between alcohol and substance use and STIs). Furthermore, the potential for needle sharing for hormone therapy or group silicone pumping could potentially lead to STI transmission. Research conducted with Black trans women in Los Angeles has shown that they are more likely to engage in hormone misuse (e.g., nonprescribed use) compared to trans women who are not Black (Clark et al., 2018). Behavioral interventions to reduce sexual risk for acquiring and transmitting STIs are urgently needed for young trans women (Kuhns et al., 2017).

Interpersonal-Level Factors

Similar to MSM, smaller networks can lead to greater likelihood of core groups overlapping with those at the periphery. Intersectional marginalization based on gender identity and race and ethnicity can foster partnerships with heterosexual men and MSM. Networks that include concurrent contacts driven by sex work and overlap between main and casual partners can drive STI transmission. In addition, evidence indicates that Black trans women’s sexual networks change significantly more than Black MSM’s and are generally less stable (Ezell et al., 2018). These dynamics are especially critical given the observed association between belongingness, well-being, and sexual health for trans women (Austin and Goodman, 2017; Barr et al., 2016; Katz-Wise et al., 2017).

Social spaces, including the house/ballroom community, gay families, or other families of choice can lead to increased contact with networks that engender higher STI rates. High rates of interpersonal violence also result in STI transmission. There are social supportive structures that can include other trans women, kin, and families of choice. Trans women are in similar structural network positions within MSM networks, which makes them as vulnerable to STIs as MSM; they may have additional vulnerability, however, with CDC deeming sexual relations with heterosexual men high risk (Ezell et al., 2018). Interventions to reduce STIs among trans women need to attend to risk behaviors within primary partnerships and to sex with partners outside the primary partnership; couples-based interventions that focus on trans women and their male primary partners are promising (Operario et al., 2011).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Institutional- and Community-Level Factors

Black and Latina trans women experience high levels of economic deprivation, substandard schooling, and violence in underserved communities; these community-level factors contribute to the disproportionate STI morbidity in these women. Cascading impacts of societal discrimination and transphobia lead to unemployment, housing instability, limited health insurance and gender-affirming care, and criminal legal system involvement, all of which are associated with increased STI transmission (Ezell et al., 2018). Trans people are twice as likely to experience homelessness as other members of the general population; this is associated with engagement in survival sex, which increases the risk of STIs. A study using data from the National Transgender Discrimination Survey found those assigned male at birth (AMAB) and Black, Latino/a, biracial, and multi-racial trans people were more likely to engage in survival sex than those assigned female at birth (AFAB) and white trans people (Kattari and Begun, 2016). Furthermore, segregation results in community members who often live, work, socialize, worship, and establish romantic and sexual partnerships in the same spaces (Bowleg and Raj, 2012); little is known about whether these interactional tendencies are comparable or intensified among trans women of marginalized racial and ethnic groups.

Social and community stigma against sex assignment variance affect gender identity, are associated with lower levels of education, and are linked to limited access to health-promoting resources. Such factors typify the comparable highly salient challenges trans women may face and share (Arnold et al., 2018; Frye et al., 2015; Graham, 2014). As compared to MSM, social norms around annual or frequent STI testing may not be part of the cultural identity, particularly given that trans communities tend to be smaller and more heterogeneous. Among trans women, for example, HPV prevalence is very high compared to MSM and knowledge disproportionately low; however, additional outreach could increase awareness and uptake of HPV vaccination (Singh et al., 2019). While social norms around STI prevention, such as HPV vaccination, may not be realized, any benefit from receiving gender-affirming care can be offset by health care systems that lack cultural competency. The few exceptions are typically specialized sexual health centers, particularly those that serve sexual and gender minority communities in urban STI epicenters; even there, however, trans women and people of color can be marginalized. Economic security, especially as related to social support and gender transition, need to be addressed by STI prevention programs (Nemoto et al., 2016).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Structural-Level Factors

Much of the similar social and structural factors that affect MSM impact trans women as well. MSM and trans women do not necessarily share a monolith of similar experiences. Trans women often face similar stigma and discrimination, however, as LGBTQ+ youth working through sexuality and gender identity, this is particularly true for trans women of marginalized racial and ethnic groups. While some improvements have occurred in sexual minority policy, the health and well-being of trans women have seen limited improvements, if any. There also has been open discrimination, including state-sanctioned discrimination, such as bathroom bills7 (Kralik, 2019) and conscientious objection laws8 (Dickens, 2009; Eberl, 2019; Perez-Brumer et al., 2018). Racism and transphobia intersect to further drive health inequities, as protections for health insurance for trans women under Section 1557 of the Patient Protection and Affordable Care Act were eliminated in June 2020 by the Trump administration. On January 20, 2021, however, President Biden issued an Executive Order on Preventing and Combating Discrimination on the Basis of Gender Identity and Sexual Orientation that will likely lead to rule-making to reverse this action (The White House, 2021).

Actions such as the Trump administration’s efforts to rescind protections for gender minorities are a form of structural violence that further impacts Black trans women who already experience limited access due to systematic racism that privileges specific insurance and ability to navigate increasingly complex health care systems. Such systems can relegate Black trans women to limited STI care options, including LGBTQ-focused clinics, emergency care, and STI clinics.

One of the most profound health inequities driven by intersecting gender identity (e.g., transphobia) and racial (i.e., racism) discrimination manifests in the horrific epidemic of homicide experienced by, in particular, Black trans women. Pronounced violence against trans women permeates all aspects of health and well-being and has led to the lowest life expectancy overall and particularly among Black trans women. This violence includes well-documented murders due to gender identity perpetrated by community members, as well as police harassment and brutality. Furthermore, criminalization and policing strategies that target

___________________

7 According to the National Conference of State Legislatures, bathroom bills are “legislation that would restrict access to multiuser restrooms, locker rooms, and other sex-segregated facilities on the basis of a definition of sex or gender consistent with sex assigned at birth or ‘biological sex’” (Kralik, 2019).

8 Within the health care field, conscientious objection laws allow health care providers to object to providing care (e.g., medical procedures) that conflicts with their religious, moral, or personal beliefs (Dickens, 2009; Eberl, 2019).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

people who engage in sex work exacerbate the harms and increase vulnerability to violence and STIs (Krüsi et al., 2014). These factors may further lead to internalized stigma and loss of self-worth, which affect STI transmission and other health vulnerabilities.

Conceptualization of sexuality and sexual orientation among Black trans women may change over time. Gender identity among Black trans women may be affected by flexibility in binary distinction in sexual identity (Galupo et al., 2016). This might be ascribed, in part, to the distinct racial disparities in gender transition programs and the current trajectory of medicalization (e.g., puberty suppression); Black trans women may transition later and identify early on as gay due to limited options for other identification (Lopez et al., 2018; Olson-Kennedy et al., 2016). Compared to both white trans women and to trans women with high income and education levels, Black trans women may find it may be substantially more difficult to access essential transition resources, such as puberty and hormone treatments and psychosocial support, financially and geographically. Gender affirmation (social, psychological, medical, and legal) is a social determinant of health uniquely affecting trans people’s health, including factors related to STIs (Reisner et al., 2016).

Transgender and Gender Diverse Assigned Female at Birth People

Although research on this topic is scarce, existing studies indicate that trans and gender diverse AFAB people—that is, those who identify as a man, trans man, transmasculine, another masculine gender identity, and/or a combination of or neither male/masculine nor female/feminine (Dutton et al., 2008), who are identified within HIV but not STI surveillance statistics (CDC, 2019b), are at risk of acquiring STIs from a range of sexual risk behaviors with partners of various genders and sexual orientations (Bauer et al., 2013; Kenagy, 2005; Kenagy and Hsieh, 2005; Reisner and Murchison, 2016; Reisner et al., 2014; Sevelius, 2009; Stephenson et al., 2017). Moreover, although research is limited, existing studies suggest that trans and gender diverse AFAB people with cisgender male sexual partners may be at particularly elevated risk of STIs, although those with AFAB partners (e.g., cisgender women, trans men) are also at risk (Bauer et al., 2013; Reisner et al., 2010; Sevelius, 2009; Stephenson et al., 2017).

Multi-Level Drivers

Trans and gender diverse AFAB people may be particularly susceptible to STIs as a result of social factors at the individual, interpersonal, community, and institutional levels that undermine their access to STI

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

prevention, testing, and care services and resources. These factors include high levels of participation in sex work and exposure to sexual violence, a lack of access to social, economic, political, and health care resources, limited access to tailored and relevant sexual health information, a lack of health care provider training and knowledge in trans health, and discrimination from health care providers and staff in the health care system. These factors are all shaped by structural factors (e.g., cultural norms, societal expectations and practices, laws, and policies) that foster pervasive gender identity–related stigma and discrimination toward trans and gender diverse individuals (e.g., transphobia) in various social systems and society in general (James et al., 2016; Reisner et al., 2014; Stephenson et al., 2017).

Intersectional Considerations

Studies also suggest that Black, Latino, and other trans and gender diverse AFAB people of color, who are exposed to not only transphobia but also racism and lack access to social, economic, and political resources and tailored health care and social services, may be at higher risk of STIs compared to their white counterparts (Kenagy, 2005; Xavier et al., 2005). For example, in a sample of trans men in Philadelphia, Pennsylvania, Black, Latino, bi/multi-racial, AI/AN, and Asian individuals were significantly more likely than their white counterparts to have engaged in condomless sex in the past year (Kenagy, 2005). In a sample of trans people in Ontario, Canada, those who experienced both racism and transphobia had significantly higher odds of engaging in STI risk behaviors compared to those who reported only one or no type of discrimination (Marcellin et al., 2013).

LESBIAN, BISEXUAL, AND OTHER SEXUAL MINORITY WOMEN

Overview

Sexual minority women (SMW; i.e., women who identify as lesbian, bisexual, or queer and women with same-sex sexual partners and/or sexual attractions) can acquire bacterial, viral, and parasitic STIs through a range of sexual behaviors with both AFAB and AMAB sexual partners (Gorgos and Marrazzo, 2011; Schick et al., 2015). Furthermore, the majority (up to 87 percent) of women who report same-sex sexual behavior have had male sexual partners at some point in their lives, and some continue to do so in the present (Gorgos and Marrazzo, 2011). STIs, including chlamydia, gonorrhea, trichomoniasis, syphilis, herpes, and HPV,

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

can be transmitted between AFAB sexual partners through oral-vaginal, vaginal-vaginal, digital-vaginal, and digital-anal contact and via sex toys for vaginal or anal penetration (Gorgos and Marrazzo, 2011; Marrazzo, 2004). Although chlamydia and gonorrhea transmission may be highest in the context of penile-vaginal intercourse, herpes, syphilis, and HPV also can be transmitted through skin-to-skin contact, further facilitating their transmission between AFAB sexual partners (Marrazzo, 2004). (See Box 3-6 for key takeaways.)

Data on STIs among SMW are not routinely collected and are thus very limited (Gorgos and Marrazzo, 2011). Existing data show that, on average, however, the overall prevalence of STIs is higher among SMW compared to non-SMW (i.e., women who identify as heterosexual and those with only male sexual partners and different-sex sexual attractions) (Everett, 2013; Reiter and McRee, 2016; Xu et al., 2010). In particular, STI prevalence is considerably higher among bisexual-identified women and those with both male and female sexual partners compared to heterosexual-identified women and those with only male sexual partners, respectively (Everett, 2013; Gorgos and Marrazzo, 2011; Reiter and McRee, 2016). Using Add Health data among U.S. adolescents, Everett found that STI prevalence was significantly higher among bisexual-identified women (those with only male sexual partners and both male and female sexual partners—51.1 and 64.1 percent, respectively) and women with both male and female sexual partners (both heterosexual- and

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

bisexual-identified—58.1 and 64.1 percent, respectively) compared to heterosexual-identified women with only male sexual partners (46.6 percent) (Everett, 2013). By contrast, lesbian-identified women were significantly less likely to report an STI compared to heterosexual women with only male sexual partners (32.0 versus 46.6 percent) (Everett, 2013).

Using National Health and Nutrition Examination Survey (NHANES) data among U.S. women aged 20–59, Reiter and McRee (2016, 2017) found that HPV prevalence was higher among SMW relative to non-SMW: 49.7 percent among lesbian, bisexual, and other non-heterosexual women (combined) versus 41.1 percent among heterosexual women and 55.9 percent among women with only female sexual partners and those with both male and female sexual partners (combined) compared to 41.0 percent among those with only male sexual partners. Specifically, the researchers observed higher levels of HPV among bisexual-identified women (57.7 percent), followed by heterosexual-identified (41.1 percent) and lesbian-identified (35.5 percent) women (Reiter and McRee, 2016, 2017).

NHANES data on U.S. women aged 18–59 indicate that HSV-2 prevalence was significantly higher among SMW (30.3 percent among women with only female or both male and female sexual partners in the past year and 36.2 percent among those with only female or both male and female sexual partners in their lifetime) compared to non-SMW (23.8 percent) (Xu et al., 2010). Additionally, HSV-2 prevalence varied widely among SMW—45.6 percent among those who self-identified as heterosexual and 35.9 percent and 8.2 percent among self-identified bisexual and lesbian women, respectively (Xu et al., 2010). Lastly, in a sample of adolescent and young adult U.S. women receiving care at family planning clinics in the Pacific Northwest, Singh et al. found that the prevalence of chlamydia was higher among those with only female sexual partners and those with both male and female sexual partners (combined; 7.1 percent) compared to those with only male sexual partners (5.3 percent) (Singh et al., 2011).

Individual-Level Factors

Research suggests that sexual orientation disparities in STI prevalence among women may be due to higher levels of victimization, including sexual abuse and violence, for bisexual women and those with both male and female sexual partners compared to heterosexual women and women with only male sexual partners, respectively (Austin et al., 2008; Everett, 2013; McNair, 2005). Other explanatory factors may include higher levels of STI-related sexual behaviors (e.g., higher number of sexual partners and anal sex acts), lack of social support, and limited access to social, economic, and health care resources among bisexual women and women with both male and female sexual partners, which is shaped by a broader

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

social context of structural and interpersonal discrimination toward SMW in general and bisexual women in particular (Dodge et al., 2016; Everett, 2013). Moreover, research suggests that SMW and health care providers alike perceive women with female sexual partners to be at low risk of acquiring STIs, which may in turn lead to a lack of engagement in STI prevention practices and low testing (Agénor et al., 2019b; Marrazzo et al., 2005; McNair, 2005; Muzny et al., 2013; Power et al., 2009; Schick et al., 2012).

Interpersonal- and Institutional-Level Factors

Studies indicate that SMW, in general, are excluded from sexuality education, lack access to accurate and relevant sexual health information that addresses their unique and specific needs and concerns (including STI transmission between partners AFAB), face notable barriers to patient–provider STI communication (including erroneous assumptions among health care providers that SMW are not at risk for STIs), and experience interpersonal discrimination in society in general and the health care system in particular—all of which may contribute to STI acquisition and a lack of access to and use of STI-related services among SMW (Agénor et al., 2019b; Jahn et al., 2019; McNair, 2005; Power et al., 2009).

Structural-Level Factors

Few studies have examined the association between structural stigma and sexual health. Charlton et al. found, however, that sexual minority adolescent women living in states with lower compared to higher levels of structural stigma—as measured by the density of same-sex partner households, proportion of high schools with gay-straight alliances, a composite variable of five state-level protective policies related to sexual orientation (e.g., employment non-discrimination policies), and public opinion toward sexual minorities data—were significantly less likely to have an STI diagnosis, adjusting for individual- and state-level covariates (Charlton et al., 2019). This study suggests that changing state-level laws and policies and social norms to be inclusive of sexual minorities may help mitigate STIs among young SMW (Charlton et al., 2019). Additionally, supportive social policy, such as civil union legislation, has been found to have a positive effect on the health of SMW, as measured by levels of stigma consciousness, perceived discrimination, depressive symptoms, and one indicator of hazardous drinking (Everett et al., 2016). Moreover, Agénor et al. (2019) found that the Patient Protection and Affordable Care Act of 2010, which extended dependent coverage and included a no

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

cost-sharing provision for preventive health services, were significantly associated with a higher prevalence of HPV vaccination among both lesbian and bisexual women in 2015 compared to 2007–2010, adjusting for temporal trends and demographic factors.

Intersectional Considerations

Investigators have found that STI prevalence may be higher among SMW of color relative to white SMW (Gorgos and Marrazzo, 2011; Singh et al., 2011). Intersectionality suggests that multiple forms of interpersonal and structural discrimination (e.g., sexism, racism, heterosexism, classism, xenophobia) may have a compounding and/or unique effect on the health outcomes (including risk behaviors and STIs) of multiply marginalized social groups (Ayala et al., 2012; Bowleg, 2008; Díaz et al., 2004; Mizuno et al., 2012). Although few studies have investigated the STI prevalence of racial and ethnic subgroups of SMW, Muzny et al. (2018) found that, in a sample of Southern Black women with female sexual partners and with low levels of socioeconomic resources, lifetime STI history was common, at a prevalence of 67.3 percent. The researchers also found a positive association between lifetime incarceration and intimate partner violence and lifetime STI history in this sample (Muzny et al., 2018). Singh et al. found that AI/AN (14.3 percent) and Asian/Pacific Islander (7.3 percent) women with only female sexual partners had a higher prevalence of chlamydia than their white counterparts (6.4 percent). The researchers also found that, among women with both female and male sexual partners, Latina women (12.7 percent) had the highest prevalence of chlamydia and Asian/Pacific Islander women (5.4 percent) had the lowest (Singh et al., 2011).

LGBTQ+ YOUTH

In queer youth, I would say … mistrust of the health care system and the lack of access to care, and that lack of access can be due to cost, fear of their family finding out through listing of things through insurance, and lack of gender-affirming care.
—Participant, lived experience panel

LGBTQ+ youth, including those who self-identify as lesbian, gay, bisexual, transgender, queer, or another sexual orientation or gender identity or have same-sex sexual partners, bear a disproportionate share of STIs and poor quality of sexual-orientation- and gender identity–specific sexual health care (Hafeez et al., 2017). Youth who engage in same-sex sexual activity are especially at an elevated risk of STIs (Benson and Hergenroeder, 2005). Box 3-7 provides key information about STI rates and drivers of STIs among LGBTQ+ youth.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Multi-Level Drivers of STIs

High STI rates among LGBTQ+ youth are not necessarily the result of an increased number of partners or frequency of sex; LGBTQ+ youth are more likely than heterosexual and cisgender youth to experience far-reaching health inequities that place them at a higher risk of STIs and HIV (Mustanski et al., 2014). For example, a 3-year prospective cohort study evaluating the presentation and persistence of syndemic conditions among young MSM underscore how health challenges persist across time as they emerge into adulthood (Halkitis et al., 2015). STI-related behaviors and mental health burdens that begin in youth are multi-faceted and interconnected. They are not the sole catalyst for or driver of higher STI burdens among LGBTQ+ youth, but rather need to be viewed as part of a bigger picture that includes behavioral and structural inequities. LGBTQ+ youth are more likely to be involved in health risk behaviors due to peer victimization. Other forms of victimization include childhood physical and sexual abuse, substance use, and homelessness due to family rejection (Friedman et al., 2011). LGBTQ+ youth experiencing unstable housing or homelessness are at increased risk of engaging in survival sex; trans youth and Black, Latino/a, and multi-racial LGBTQ+ youth who experience homelessness may be targeted for additional victimization as a result

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

of their multiple, intersecting marginalized social positions (Alessi et al., 2020). Young MSM are more likely to report forced sex compared to heterosexual young men who have sex with women, which increases their risk of acquiring an STI (Everett et al., 2014).

Structural barriers, such as lacking comprehensive sex health education in schools, negatively impact LGBTQ+ health (see Chapter 8 for more information on sex education). Structural barriers that align with racial disparities act as barriers to health care themselves, increasing the risk of HIV (Millett et al., 2012). A syndemic analysis highlights how behavioral and health-related determinants influence each other to both contribute to sexual health disparities (Halkitis et al., 2015).

Challenges within the health care provider education system are also significant. More than half of physician education programs in the United States lack training in LGBTQ+ health, and only 16 percent comprehensively address it (Khalili et al., 2015). Yet, health care providers can make a critical impact on the lives of LGBTQ+ youth by providing supportive, evidence-based, comprehensive SRH care (Wood et al., 2016). LGBTQ+ youth subgroups are distinct and have unique structural and social determinants of STIs and STI-related needs; these subgroups are discussed below.

Young MSM

Young men with male sexual partners are more likely than their counterparts with only female sexual partners to acquire STIs, including chlamydia and gonorrhea (Mayer, 2011). Furthermore, younger sexual minority men have greater odds of STIs in comparison to older sexual minority men (Grov et al., 2016). Bisexual boys are more likely to acquire STIs compared to their heterosexual peers (Everett et al., 2014). Pooled data from the 2005 to 2007 Youth Risk Behavior Survey encompassing more than 13,000 male respondents aged 12–18 years who reported at least one sexual partner found that bisexual-identifying adolescents were more likely to report multiple STI risk behaviors, such as a greater number of sex partners, concurrent sex partners, and younger age of first sex, compared to heterosexual-identified young men who have sex with women, heterosexual-identified young MSM, and gay-identified respondents (Everett et al., 2014). Overall, young sexual minority men who have sex with other men and those who identify as gay or bisexual are at an increased risk of STIs relative to young heterosexual men (Brewer et al., 2011; Mustanski et al., 2017).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Multi-Level Drivers of STIs

The multi-level drivers of STIs among young sexual minority men are those described above among the multi-level drivers of STIs for the broader sexual minority adolescents. Both network and behavioral factors influence HIV-STI coinfection. Data collected from sexual minority boys and young men in Houston and Chicago showed that syphilis-HIV coinfection was associated with having a sexual network with higher coinfection prevalence; syphilis monoinfection was associated with a higher number of social venues attended, and HIV monoinfection was associated with having more condomless top partners (Fujimoto et al., 2018).

Trans and Gender Diverse Youth

Trans and gender diverse (including non-binary, gender non-conforming, genderqueer, gender fluid, and agender) youth are disproportionately affected by STIs (Reisner, 2019; Reisner et al., 2015). In a sample of U.S. gender minority youth aged 16–24, one-third had a history of one or more STIs other than HIV; the most frequently diagnosed were chlamydia (55 percent), syphilis (48 percent), and gonorrhea (47 percent) (Reisner, 2019).

STIs affect subgroups of gender diverse youth differently. For example, in a national sample of gender minority youth, investigators found that the lifetime odds of being diagnosed with an STI were 4 times higher among people AMAB compared to people AFAB participants (Reisner, 2019). Similarly, in a study of adolescents in New Orleans and Los Angeles, trans women and non-binary individuals AMAB had a higher STI prevalence compared to other gender and sexual minority groups (Shannon et al., 2019a).

Multi-Level Drivers of STIs

Trans youth face multi-level barriers accessing and receiving health care services, such as economic marginalization and social stigma, which further contribute to both gender and age-related health disparities (Edmiston et al., 2016). Trans youth experience gender minority and social stressors, such as discrimination, rejection, nonaffirmation of gender identity by others, internalized transphobia, and anticipated stigma with age (Hatzenbuehler and Pachankis, 2016). In crossing the individual, interpersonal, and the structural, stressors range from the proximal, such as internalized transphobia and anticipated stigma, to the distal, such as gender-related discrimination, gender-related rejection, and nonaffirmation of identity (Hendricks and Testa, 2012; Rood et al., 2016).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Trans youths’ lack of preventative screening and other such efforts, for instance, are connected with the higher share of STIs observed in these youth and do not stem from a single cause, but are rather multi-factorial (Sharma, 2019). There are low levels of annual HIV (15.1 percent) and other STI (22.6 percent) testing among predominantly sexually active trans youth aged 15–24, with young trans women being less likely to report such testing (Sharma, 2019). The limited availability of evidence-based screening guidelines from expert organizations for trans people, lack of provider awareness surrounding risk assessment protocols, and lack of access to providers experienced in treating trans people all contribute to low testing levels (Edmiston et al., 2016).

Other drivers include being more vulnerable to risk taking (e.g., condomless sex, sex work, needle sharing), which emphasizes the need for preventative screenings for gender minority youth and more informed health care practices (Stieglitz, 2010).

Anatomic diversity among trans youth is a key issue when assessing gender minority youth risks for HIV and other STIs. Many trans youth have not undergone reconstruction procedures to replace birth anatomy with gender-affirming anatomy, even among those who sought gender-affirming treatment (Sharma, 2019). Trans youth may not feel entirely comfortable with their bodies and may be reluctant to undergo testing, even more so when gender-affirming health care services are scarce—especially in communities where gender-affirming health care services are restricted (Bostwick and Hequembourg, 2014).

Overall, using a syndemic and multi-level framework when analyzing key drivers of STIs among LGBTQ+ youth allows for a more accurate and holistic picture of how different personal, behavioral, and systemic factors affect sexual health outcomes.

Young Lesbian, Bisexual, and Other Sexual Minority Women

Young women with both male and female sexual partners are more likely to acquire an STI compared to those with only male sexual partners. In a study of approximately 30,000 sexually active college women aged 18–24, those who reported multiple female and male sexual partners in the past year were more likely to have had an STI (16 percent) relative to those with only male sexual partners (9 percent) (Lindley et al., 2008). In contrast, sexually active college women with only female sexual partners in the past year were less likely than those with only male sexual partners (9 percent) to report having an STI (6 percent) (Lindley et al., 2008).

Bisexual girls are more likely to acquire STIs relative to their heterosexual counterparts (Marrazzo and Gorgos, 2012; White Hughto et al., 2016). Likewise, a cohort study of 4,224 adolescent girls and young adult

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

women found that, after accounting for sociodemographic and sexual history, respondents identifying as bisexual or “mostly heterosexual” had significantly higher odds of being diagnosed with an STI in their lifetime so far compared to the completely heterosexual group (Charlton et al., 2011). In contrast, lesbian adolescents and young women had significantly lower odds of being diagnosed with an STI in their lifetime relative to completely heterosexual young women (Charlton et al., 2011).

Lesbian young women with an STI, however, had highly elevated odds of considering themselves at a very low risk of having an STI in comparison to heterosexual women (Kaestle and Waller, 2011). Research suggests that lesbian-identifying young women across all age groups are less likely to be tested for STIs and get regular pap smears (Aaron, 2001; Cochran et al., 2001; Marrazzo et al., 2001).

Multi-Level Drivers of STIs

Physicians’ and educators’ judgmental attitudes and assumptions of patient sexuality can severely jeopardize the health of young SMW (Arbeit et al., 2016). Specifically, health care providers may believe that lesbian women or women who only have sex with women do not need sexual health screening or sexual health education (Fishman and Anderson, 2003; Marrazzo et al., 1998). Restricted youth openness with health care providers was also associated with bisexual stigma within families, suggesting fear of disclosure to parents or guardians (Arbeit et al., 2016). In school settings, sexual health education was limited by a lack of STI risk information relevant to sex between women (Arbeit et al., 2016). On college campuses, sexual health education programs and providers need to recognize STI risk among lesbian students and young women who have sex with women by emphasizing that even women with only female partners are at risk for STIs (Lindley et al., 2008).

Cultural bisexual invisibility also can underlie implicit and unconscious inclinations to categorize people as either exclusive same- or other-sex attracted (i.e., lesbian or gay); extreme cases include an explicit denial of the existence of bisexuality itself (Bostwick and Hequembourg, 2014; Flanders et al., 2015).

Research Needs

Much less research about LGBTQ+ youth exists relative to adults, with few longitudinal follow-ups beyond 1 year (Mustanski et al., 2017). For example, because many federal, state, and local agencies have incomplete data on trans individuals, it is difficult to obtain accurate population-based estimates of their STI rates. Future studies need to include

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

adequate samples of trans youth and provide the option of indicating trans and non-binary sexual partners (Flanders et al., 2015). Additionally, representative samples with multi-dimensional measures of sexuality can add depth to current understandings of sexual minority status and health (Kaestle and Waller, 2011). More translational research is necessary not only to speak to the existence of health disparities, but also understand the mechanisms beyond the individual level and effective approaches to eliminate health disparities among LGBTQ+ youth (Mustanski et al., 2017). Research is also needed to determine the best strategies to decrease stigma and health care access issues and increase routine screening and care among LGBTQ+ youth (Shannon and Klausner, 2018).

OTHER POPULATIONS THAT REQUIRE FOCUSED CONSIDERATION

AMERICAN INDIAN/ALASKA NATIVE PEOPLE

Culturally, AI/AN people have a holistic perspective of well-being with corresponding values, traditions, and practices that ensure the physical, social, emotional, and spiritual health of individuals, families, and communities. Since colonization of the United States, however, many of these systems for promoting health have been disrupted or destroyed by federal legislation. Native populations have experienced genocide, forced relocation, violence, and widespread structural discrimination, resulting in intergenerational cycles of historical trauma. These insults operate across levels, ranging from the interpersonal to political, have been perpetuated over the entire history of the country, and have led to an array of health problems and inequities, including high rates of STIs, across multiple generations (NASEM, 2019b). Because of the disproportionate rates of STIs and the unique barriers faced by AI/AN people, they are highlighted here. Box 3-8 highlights key information about STIs and the multi-level drivers of STI disparities in AI/AN people.

Despite these impediments, Native people are actively working to reinvigorate their own cultural assets and protective health practices to promote individual and collective health and prosperity; multi-factorial, systems-level barriers, however, challenge this. Similar to other marginalized racial and ethnic groups, such as Black and Latino/a individuals, disparities in STIs among AI/AN people have been attributed in the literature to a variety of social conditions associated with lower socioeconomic status, including poverty, abuse, mental health problems, and alcohol disorders, as well as a lack of access to evidence-based sexual health education and clinical services that address their needs (Athar et al., 2013; Beckles and Truman, 2013; de Ravello et al., 2014; Ehlers et al., 2013; Hellerstedt et

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

al., 2006; Kaufman et al., 2007b; Rink et al., 2007). AI/AN people, however, have unique barriers that need to be considered to control health disparities, including STIs (CDC, 2019c; Harling et al., 2013).

One example of a unique barrier is the surveillance practice of only counting AI/AN people who declare that as their only race/ethnicity category. This leads to misclassification and under-reporting in national reporting systems. For example, per the 2010 U.S. Census, 5.2 million individuals reported their race as AI/AN, of whom 2.9 million self-identified as AI/AN alone and 2.3 million identified as AI/AN in combination with one or more other races (Norris et al., 2012). That latter would not be classified as AI/AN, misclassifying nearly half of this population. See Chapter 2 for more information about the limitations of STI surveillance systems.

There is a tendency to lump all AI/AN groups together, though there are 574 tribes in the federal registry, each with its own health promotion

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

practices and cultural factors that influence STI rates. Surveillance demonstrates the diversity of AI/AN people and suggests that those who live on reservations may have higher STI rates. Approximately 55.2 percent of AI/AN people live in areas where Indian Health Service (IHS) administers STI surveillance and care. IHS comprises 12 regional administrative units (also referred to as “areas”) with 625 service counties that often cross state lines and serve approximately 2.1 million AI/AN people through direct care, tribal health systems, and urban health centers. A comparison of STI rates for all races versus AI/AN people nationally versus AI/AN people in the IHS found, in 2010, that for chlamydia, the U.S. rate for all races was 397/100,000, whereas the all AI/AN rate was 585/100,000 and the IHS rate was 896/100,000; 9 of the 12 area units had rates higher than the U.S. all AI/AN rate. In 2010, for gonorrhea, the U.S. rate for all races was 129/100,000, whereas the all AI/AN rate was 95/100,000 and the IHS rate was 127/100,000; 5 of the 12 area units had rates higher than the all AI/AN rate (Walker et al., 2015).

Additionally, a study shows the proportion of minority populations residing in U.S. counties is positively associated with the odds of a county being a multi-STI hotspot (Owusu-Edusei and Chang, 2019). More specifically, a one-point increase in the percentage of Native residents was associated with a 3.3 percent increase in the odds of being a multi-STI hotspot; this increase was greater than for Black (3.2 percent) and Latino/a (1.6 percent) individuals (Owusu-Edusei and Chang, 2019). In the same study, lower population density, common in rural reservation locations, was positively associated with the odds of being in a multi-STI hotspot. This study shows marked differences in STI rates among Native people residing in urban versus rural locations.

Individual-Level Factors

Literature specific to the AI/AN population shows, as a whole, that sexual debut typically begins at a younger age than the national population (CDC, 2020e; de Ravello et al., 2014; Kaufman et al., 2004, 2007a). Early sexual initiation increases the amount of potential time and exposure to condomless sexual encounters. Other individual factors that increase the risk of STIs have been identified as occurring among Native individuals more frequently, including substance use, poor mental health, multiple sexual partners, inconsistent/incorrect condom use, and exposure to risky situations, including dating violence and parties where substance use is occurring (Blum et al., 1992; Kaufman et al., 2007a,b).

Data on substance use and mental health among AI/AN populations show differing trends. Some research identifies the highest rates of alcohol

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

use disorder, while other research indicates most AI/AN adults abstain from alcohol use and have the lowest rate of past month use of all U.S. groups (Grant et al., 2015; SAMHSA, 2011). Historically, the rate of alcohol use increased in parallel with colonization and the resulting historical and intergenerational trauma endured by Native communities (Whitbeck and Armenta, 2015). More Native adults report past-year mental health issues than in the general population (21 percent versus 18 percent), and Native youth have the highest rates of lifetime major depressive disorder and self-reported depression rates than any other ethnic/racial group (APA, 2017). Yet, other research conducted with AI/AN people shows high rates of positive mental health: in a sample of Native adults, 17.1 percent met criteria for depression, but 51.5 percent met criteria for “flourishing” or positive mental health (Kading et al., 2015). Therefore, additional research exploring the unique intersection of substance use, trauma, and STIs is needed in Native communities, considering the diversity within AI/AN groups. See Chapter 2 for more information on how alcohol and substance use and mental health are associated with STIs.

Several individual-level factors also have been demonstrated in the literature specific to AI/AN people that protect against poor sexual health outcomes, including higher academic performance, valuing school achievement, self-efficacy to abstain from sex, and greater sexual health knowledge (Griese et al., 2016; Henson et al., 2017; Kaufman et al., 2007a; Palacios and Kennedy, 2010). In addition, positive Native ethnic identity and connectedness to community and traditional cultural practices are protective against risk for STIs (Kaufman et al., 2007a).

Risk perception, or an individual’s belief about the likelihood of an adverse event occurring to them, is a well-known predictor of health behavior among all racial-ethnic groups and a key component of several theories of health behavior change. Not surprisingly, among Native communities for whom few evidence-based sexual health programs exist, misconceptions about STI prevention and transmission and the subsequent lack of feeling vulnerable or susceptible to STIs is an established risk factor (Chambers et al., 2018; Hafner and Craig Rushing, 2019; Markham et al., 2015). Lower perception of risk may be further exacerbated in Native communities that endure higher rates of poverty and other socioeconomic challenges and for whom STIs may not be an urgent threat. Alternatively, intention, specifically the intention to engage or abstain from sex, has been cited as an important factor in predicting protective sexual health practices (such as delayed sexual initiation and condom use) among both AI/AN people and other ethnic groups (Buhi and Goodson, 2007; Markham et al., 2015; Tingey et al., 2018).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Interpersonal-Level Factors

Interpersonal factors impacting STI risk and exposure that also may provide social support to reinforce protective sexual health norms can be organized across intimate partner, peer, and family domains.

Intimate Partner

A high rate of exposure to physical and sexual violence are documented in Native communities (Burnette, 2016). Physical and sexual violence create both direct and indirect pathways to increased STI transmission through an immediate loss in the ability to protect oneself from infection (direct) and impact of the experience on future emotional reactions, risk perceptions, communication skills, and ability to negotiate use of prevention methods with sexual partners (indirect) (Gesink et al., 2016; Masters et al., 2014; Thompson et al., 2017). More specifically, individuals who have experienced sexual and intimate partner violence may anticipate a negative reaction from a partner about a request to use a condom or perceive condomless sex as a lower-risk consequence than the potential for repeated abuse (Quina et al., 2000). Nationally, AI/AN women experience the highest rates of lifetime sexual assault (27.5 percent) and physical violence from an intimate partner (51.7 percent), compared with women of all other racial and ethnic groups (Rosay, 2016). In addition to preventing and addressing the underlying factors that lead to perpetrator violence, training in communication and partner negotiation skills may be especially important for STI prevention for AI/AN women.

Peer Influences

The literature documents the influence of peers in sexual health decision making among adolescents of all ethnicities, which is also true for Native youth and their peer networks. Research shows for Native youth and adolescents, more prosocial attitudes and the perception that their friends are engaging in fewer risky health behaviors have been identified as protective factors for abstaining from sex and using prevention methods (Dickens et al., 2012; Greene et al., 2018; Mitchell et al., 2007; Pu et al., 2013). Qualitative research with Native youth also shows nuance in the role of peer groups between girls and boys. More specifically, boys and girls describe social pressure from peers and a desire for connectedness, respectively, as a driving factor for engaging in condomless sex (Chambers et al., 2018).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Family Influences

Research conducted across a myriad of ethnic groups documents the impact of positive parent–child relationships and parent connectedness on lower participation in risky behaviors, including early sexual initiation and condomless sex. In Native communities, family is generally valued as the nexus of strength for individuals and shown to yield great influence on adolescents’ behavioral choices (Dalla and Gamble, 1996; Henson et al., 2017; MacPhee et al., 1996). For AI youth in particular, this also may be true for the extended family, especially among rural reservation-based youth who may be more likely than their urban counterparts to have larger proximal family networks on whom they rely for caregiving (LaFromboise and Dizon, 2003). Research specific to Native youth has found several family-level factors associated with abstention from sex, including parental warmth (e.g., responsiveness and communication) (Griese et al., 2016), higher perceived parental support, higher perceived parental knowledge, and monitoring of adolescent’s activities and friends (BigFoot and Funderbunk, 2010; Chewning et al., 2001; Griese et al., 2016; LaFromboise et al., 2006). As a result, additional research suggests and promotes including trusted family members in STI prevention and intervention efforts as a means to align with the collectivist nature of Native families and communities that may be protective against STI risk (Garwick et al., 2008; Tingey et al., 2017a).

Institutional-, Community-, and Structural-Level Factors

American Indian and Alaska Native, gay and bisexual men face a lot of culturally based stigma and concerns about confidentiality when it comes to seeking care for HIV services, for prevention services, especially in those tribal communities that are very rural where they don’t have access to any other health care except for their Native-sponsored or IHS-sponsored clinics where all of their family members work there or go there or are the doctor there, and they really don’t have a lot of options when it comes to preventive services.
—Participant, lived experience panel

School connectedness, or a sense of belonging to school, is an established community-level protective factor for STI prevention among all ethnic groups, including AI/AN people. More specifically, the opportunity to receive sexual health education, have social support from teachers and other caring adults, and engage in prosocial extracurricular activities are identified in the literature as significant protective factors for the sexual health behavior of Native youth (Catalano et al., 2004; Dickens et al., 2012; Moilanen et al., 2014). These same factors similarly have been established for preventing substance use among Native youth, which

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

is also a driving factor for engaging in condomless sex, suggesting programs targeting these issues may have dual prevention benefits (Tingey et al., 2016, 2017c). Reflecting this literature, school-based sexual health programming is a primary means for receiving medically accurate sexual health education for most U.S. youth (Talashek et al., 2003). Yet, for many Native youth, particularly those residing in rural reservation communities in the Southwest, school-based sexual health education is not required, and if available, parents may opt their children out of these classes. For example, in Arizona, which has the third highest percentage of Native Americans in any state (CDC, 2018b), just 31 percent of school districts provide sexual health education at all, and of those, the majority use abstinence-only curricula that focus exclusively on refraining from all sexual behavior (AZDHS, 1989; Day et al., 2017) and that have been found to be ineffective. See Chapter 8 for more information on sex education.

Other community-level factors central to STI prevention and treatment are access to and use of health care for routine STI screening. Research specific to AI/AN communities suggests that higher STI rates may be in part due to health care access barriers (Eitle et al., 2015; Taylor et al., 2011; Winscott et al., 2010). More specifically, approximately 40 percent of all AI/AN people rely on IHS for health care services, a historically underfunded system with limited capacity to provide high-quality, culturally relevant care (OIG, 2011; Warne and Frizzell, 2014). In AI/AN communities that are rural and/or reservation based, challenges to accessing health care are further exacerbated by geographic isolation and poverty. Overall, AI/AN people are more likely than white people to have transportation barriers to health care (Call et al., 2006; Richards and Mousseau, 2012). Additionally, research shows more than two-thirds of Native patients travel more than 120 miles round trip to access care at IHS (GAO, 2005). Close-knit communities, including those common to collectivist Native societies, may contribute to confidentiality concerns and/or stigma with seeking care for sensitive issues such as STIs. More specifically, Native patients obtaining care in communities with one or few health centers, such as at an IHS facility, may be uncomfortable completing STI screening and treatment because they might encounter family or friends at the facility (CDC, 2019c; Chambers et al., 2016a,b; Duran et al., 2005; Leston et al., 2012; Tingey et al., 2015). In sum, these access barriers can lead to missed appointments, delayed STI diagnosis, treatment, and partner notification, and treatment noncompliance (Call et al., 2006; Johnson et al., 2010; Syed et al., 2013).

In contrast, other research shows a protective effect of rural residency and access to IHS facilities: one study shows AI/AN women residing in rural areas and with public insurance were more likely to access STI screening and birth control services (Cahn et al., 2019). This study agrees

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

with older research showing that AI/AN people eligible for IHS health care were more likely to report a past-year visit with a provider than those not accessing IHS care (Zuckerman et al., 2004). Nevertheless, the majority of the U.S. AI/AN population lives in urban areas, where facilities and funding specific to Native health are more limited (Moss, 2010; Urban Indian Health Institute, n.d.). Thus, limited access to sexual health care in urban areas may also be fueling disparities in STIs among the AI/AN population.

Cultural and Societal Values and Policies

Research specific to AI/AN people highlights the strength of enculturation, as measured by participation in traditional Native activities, identification with AI/AN culture and ethnicity, and participation in spiritual traditions, as cultural/societal factors that protect against sexual health risk taking (Adams et al., 2006; LaFromboise et al., 2006). More specifically, engaging in cultural practices, such as visiting sacred sites, has been discussed as a method for imparting cultural values and spirituality, both strengths to be drawn on in potentially preventing risky sexual situations (Griese et al., 2016). This research suggests that programs that seek to engage participants in cultural practices and internalize cultural values can develop strengths and promote protective factors to bolster positive sexual health outcomes and may be both desirable and impactful in Native communities (McMahon et al., 2015).

Factors driving risk of and protection against STIs among Native people need to be framed by the history and resulting policies undermining access to sexual and reproductive health services, including STI prevention and treatment in Native communities (Arnold, 2014; Lawrence, 2000). For example, prohibitions on using federal funds for abortion (including at IHS facilities) and state/federal policies enacted in the 1970s and 1980s led to the sterilization of AI/AN women (Arnold, 2014; Lawrence, 2000). In addition, health care providers’ prescribing longer-acting modes of contraception (particularly Depo-Provera and Norplant) without adequate consent, counseling on side effects, or standardized monitoring has limited Native women’s control over their fertility (Smith, 2003, 2015). Not surprisingly, the combined effects of these local, state, and federal policies have produced skepticism and distrust of the medical system in some AI/AN women, which may further deter their use of STI health care services. Many researchers have therefore urged for culturally relevant sexual health education programming to alleviate mistrust of health care and concerns regarding discrimination (Craig Rushing et al., 2018; Gonzales et al., 2013; Kaufman et al., 2007a, 2009; Tingey et al., 2017b, 2019).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Sexual health programs also need to address gender inequities and the experience of stigma and structural discrimination to improve access to STI prevention and treatment. Compared to men of other ethnicities nationally, Native men have higher rates of STIs, likely driven by the fact that they have more comorbid risks, including substance abuse, mental health issues, unemployment, and low educational attainment (Rink et al., 2017).

Another subgroup experiencing inequities in sexual health is Two-Spirit individuals. “Two-Spirit” is an overarching term that describes Native people who are diverse in terms of their sexual orientation and gender identity. Native community-specific definitions and roles for gender and sexual orientation and cultural values around sexual health are more extensive and varied (Carrier et al., 2020; Kaufman et al., 2004). While contemporary use of Two-Spirit has become more widespread, Native conceptualizations of diverse gender identities, roles, and sexual orientations have existed for generations (Carrier et al., 2020). Two-Spirit people face numerous health disparities, including stigma, structural discrimination, violence, poor mental health, and substance abuse (Chae and Walters, 2009; Fieland et al., 2007; Nelson et al., 2011). These challenges are associated with increased sexual risk taking (Nelson et al., 2011). To be responsive to the unique needs of this group, interventions need to be data driven, culturally responsive, and fluid to navigate multiply oppressive forces among individuals in highly marginalized social positions (Argüello and Walters, 2018). In addition, service delivery systems may benefit from focusing on racism in LGBTQ+-centric contexts and heterosexism in more Native-centric ones and embracing the knowledge that there is “diversity within diversity” with regard to multiple socially located and marginalized individuals (Argüello and Walters, 2018).

PEOPLE WITH MILITARY EXPERIENCE

Stigma is still present, especially in the military. We have that interplay between those who are more conservative, if you will—those who are older, those who tend to be the leaders and be in charge—and those who are younger, who may be more open to what we would consider nontraditional sexuality and sexual behaviors. These are amplified by the very strict and rigid system within the military of those who are in charge versus those who are not in charge. I think understanding that this exists and putting into place methodologies to help break down that barrier are important.
—Participant, lived experience panel

STIs are the most commonly diagnosed infectious disease among U.S. military personnel (Stahlman and Oetting, 2017; Stahlman et al.,

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

2019), which is mostly composed of young, healthy, unmarried, sexually active, and highly mobile men and women (DOD, 2016). The prevalence of diagnosed STIs in military recruits and active-duty service members consistently exceeds that in civilian groups of comparable age, race, and ethnicity (Boyer et al., 2008; Deiss et al., 2019; Goyal et al., 2012; Masel et al., 2015; Stahlman et al., 2015). For example, in a large cohort study of female Marine Corps recruits who were screened for chlamydia, gonorrhea, and trichomoniasis at entry, 14.1 percent tested positive compared with 8.0 percent of women of a similar age in a national population-based study during the same period (Boyer et al., 2008). Although STI prevalence varies within branches of the military (Bautista et al., 2019; Deiss et al., 2016; Stahlman and Oetting, 2017), chlamydia (Stahlman and Oetting, 2017; Stahlman et al., 2019) and gonorrhea (Bautista et al., 2017, 2019) are the most commonly diagnosed STIs across all branches. These are universally treated once identified, but partner treatment is not universal and may lead to repeat infections (Stidham et al., 2015). Viral STIs, such as HIV and chronic hepatitis, may additionally interfere with service members’ readiness to perform their daily duties and restrict their availability for deployment (Armed Forces Surveillance Center, 2013; Gaydos et al., 2013). Box 3-9 summarizes key messages about STIs among people with military experience. Of note, for this report, the focus was primarily on recruits and active-duty service members, and veterans are discussed specifically in the context when describing the role that sexual trauma plays in the risk for STIs and other SRH outcomes.

Sociodemographic Risk Markers

Sociodemographic markers of STI risk in military personnel are also comparable to those identified in civilian populations. For example, STIs are identified at higher rates among the youngest age groups, mainly recruits and junior enlisted (early career) active-duty personnel (Bautista et al., 2017; Deiss et al., 2016; Stahlman and Oetting, 2017; Stahlman et al., 2019). Women, in particular, bear a disproportionately high share of STIs, in part because they are more frequently screened for asymptomatic infections (Bautista et al., 2017, 2019; Deiss et al., 2019). This occurs primarily within their first year of service (Gaydos et al., 2013) and annually during reproductive health care visits (Deiss et al., 2016). With few exceptions (Deiss et al., 2016; Harbertson et al., 2019; Hood et al., 2020; Stahlman and Oetting, 2017; Stahlman et al., 2019), there is a dearth of STI screening and surveillance data on male recruits and active-duty service members. Thus, it is difficult to fully assess the extent to which they asymptomatically acquire and transmit STIs.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Other sociodemographic markers of STI risk among military personnel include African American/non-Hispanic Black race (Bautista et al., 2017; Boyer et al., 2008; Deiss et al., 2016; Stahlman and Oetting, 2017; Stahlman et al., 2019) and other nonspecific references to race, such as “non-white” or “minority” (Hakre et al., 2011; Hood et al., 2020; Jordan et al., 2011). Furthermore, single marital status (Hakre et al., 2014; Harbertson et al., 2019; Stahlman et al., 2015), high school as the maximum educational attainment (Deiss et al., 2016, 2019; Hakre et al., 2014), and residence in rural locations (Boyer et al., 2006) or the South (Gaydos et al., 2003) are other risk markers for STIs in the armed forces. Lastly, consistent with civilian public health reports, having a history of STIs is an indicator of increased risk for acquiring a new or repeat STI (Bautista et al., 2017; Hakre et al., 2011; Hood et al., 2020). For example, a population-based surveillance study of servicewomen found that the likelihood of a

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

chlamydia diagnosis increased significantly with an increasing number of prior gonorrhea diagnoses, and the median time to the chlamydia diagnosis decreased with an increasing number of gonorrhea diagnoses (Bautista et al., 2019). These data on STI markers suggest the need for ongoing comprehensive STI screening, surveillance, and sexual health care for all recruits and junior enlisted service members; these are primarily young and racial and ethnic minorities and include increasing numbers of women in their peak reproductive years (DOD, 2016).

Sexual Behaviors

Sexual behaviors associated with STI risk in active-duty military personnel are highly prevalent and occur more frequently than the rates identified in comparable civilian groups (Goyal et al., 2012; Stahlman et al., 2015). Such behaviors include new (Stahlman et al., 2015; Thomas et al., 2001), casual (Deiss et al., 2019; Harbertson et al., 2015), and multiple sexual partnerships (O’Rourke et al., 2008; Stahlman et al., 2014, 2015). As with their civilian counterparts, military personnel use condoms inconsistently and infrequently (Deiss et al., 2019; Goyal et al., 2012; Harbertson et al., 2019; von Sadovszky et al., 2008).

Research also indicates that women report less frequent condom use than both their male military colleagues and their civilian female peers (Hwang et al., 2007; O’Rourke et al., 2008; Stahlman et al., 2014). A small qualitative study of active-duty young women (aged 18–25) in the U.S. Navy found that one-quarter reported anal intercourse in their most recent sexual encounter, most of which was condomless (86.7 percent). Women who listed sex with a casual male partner (42.2 percent) reported rarely or never using condoms (Deiss et al., 2019). Other research indicates that condom use among U.S. Army enlisted women was infrequent, with the most cited reasons for avoidance being irritation or inflammation, breakage, improper fit, or ruining the moment (von Sadovszky et al., 2008). Another qualitative study of women enlisted in the Navy documented that barriers to condom use included perceptions of being stigmatized as promiscuous after requesting condoms from sexual partners and fear that seeking condoms during deployments would reveal a violation of military policy, which prohibits sexual activity during deployments (Duke and Ames, 2008). A study of shipboard U.S. Navy and Marine Corps men and women found a higher prevalence of STIs and condom use primarily during deployments, when casual and transactional sexual activity are more likely. However, condomless sex was associated with hazardous alcohol use and drug use to enhance sexual experiences (Harbertson et al., 2019). As with other aspects of sexual health, military-based research has focused primarily on women, which leads to a partial understanding of

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

male condom use and the contextual factors surrounding nonuse. This is particularly problematic since men typically initiate and control condom use communication with their female sexual partners (Teitelman et al., 2011). Therefore, further research is needed regarding effective strategies to increase consistent condom use among military men and women.

Contextual Factors Associated with Sexual Behaviors

To date, few studies have examined social contextual influences on sexual behaviors in military personnel. However, a Department of Defense (DOD) study of health behaviors among active-duty military found 25.2 percent of men and 9.3 percent of women reported five or more sexual partners in the prior year. Among men and women in this study, binge drinking and illicit substance use, as well as unwanted sexual contact, were associated with higher numbers of sexual partners. High levels of personal life stress among women and psychological distress among men and women were also associated with multiple sexual partners (Stahlman et al., 2014). While service members who had two or more partners in the prior 12 months were significantly more likely to report a history of STIs, this association was even stronger for those with five or more partners (Stahlman et al., 2014). Other studies provide insights into the nature of casual sexual partnerships in the military context. Contrary to prior research findings, which assumed casual and transactional sex occurred primarily during deployments (Harbertson et al., 2017, 2019), a study of U.S. Navy and Marine Corps shipboard personnel conducted stateside assessed sexual behaviors in a 12-month period before deployment revealed that among those with a sexual partner outside of their primary partnership, 24 percent reported using a condom the last time they had sex, and 30 percent reported their outside partner was another service member. More women than men (50 versus 26 percent) reported their most recent STIs were acquired from another service member (Harbertson et al., 2015). This research highlights the social context surrounding STIs and sexual partnerships, including possible sexual networks that develop among military personnel who live and work in close proximity (Gaydos et al., 2015). Social and other contextual factors need to be examined further to better understand the most efficacious strategies to prevent and control STIs within the military, whether service members are stateside or deployed overseas.

Contraceptive Use and Unintended Pregnancy

Other factors associated with STIs in the military include contraceptive use and unintended (i.e., mistimed, unwanted, unplanned) pregnancy.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Contraceptive use among female service members is an important aspect of their personal reproductive care, but it is also inextricably linked to their military service (Harrington et al., 2017), as servicewomen cannot serve in combat while pregnant. Among servicewomen, unplanned pregnancy has been found to be univariately associated with young age, single marital status, inconsistent condom use, a new partner in the prior 6 months, and recent multiple partners. High STI rates have been found among servicewomen, particularly those who became pregnant. Navy enlisted women had a prevalence of chlamydial infection and pregnancy of 4.7 percent and 9.7 percent, respectively, with 48.3 percent of the pregnancies unplanned (Thomas et al., 2001). Among pregnant servicewomen, 13.8 percent were infected with chlamydia (Thomas et al., 2001).

Military Sexual Assault

Veterans with a history of sexual trauma might be at greater risk of having STIs, but they might actually have greater barriers to seeking care. Some women veterans who have a history of sexual trauma in the military may be somewhat reluctant to seek care in a VA facility because it may remind them of their previous traumatic experiences.
—Participant, lived experience panel

Military sexual assault, defined as physical contact of a sexual nature without voluntary consent that occurs while serving in the military (DOD, 2012; Suris and Lind, 2008), has been a long-standing problem. Among active-duty service members, military sexual assault is estimated to have occurred to 1.0 percent of men and 4.9 percent of women, with an average of approximately 2.5 incidents per 100 men and 9.6 incidents per 100 women over a 1-year period. The highest rate was among the most junior enlisted men and women and lower-ranked female officers (Morral et al., 2015). Other research indicates that 14.3 percent of service members reported unwanted sexual contact over the course of their lifetime (i.e., cumulative sexual abuse that occurs prior to and during military service); 42 percent of women reported a history of lifetime abuse, with 21.7 percent reporting unwanted sexual contact since joining the military, compared with 9.2 percent of lifetime sexual abuse among men (Barlas et al., 2013). Among veterans, military sexual assault occurred to 3–54 percent of women and up to 3 percent of men (Schuyler et al., 2017). The varying rates are partially explained by differences in the method of assessment (e.g., general open-ended question versus specific definitions), the type of sample (research versus clinical versus benefit seeking), and the definition used (i.e., military sexual trauma, which includes both harassment and assault, versus a focused definition of sexual assault) (Suris and Lind, 2008).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

There is ample evidence demonstrating the impact that military sexual assault has on mental (e.g., posttraumatic stress disorder, depression) and physical (e.g., pelvic pain, headaches, chronic fatigue) health and health behaviors (e.g., smoking, substance use, alcohol misuse) (Stahlman et al., 2015; Suris and Lind, 2008). Less is known, however, about its impact on sexual health (Schuyler et al., 2017). When lifetime sexual assault is examined among active-duty men and women and female veterans, research indicates that unwanted sexual contact is associated with a greater frequency of casual and multiple sexual partners, binge drinking, and illicit substance use (Stahlman et al., 2014). Other research has also found an association between military sexual trauma and STIs (Sadler et al., 2011; Turchik et al., 2012), and sex exchange for goods or services (Strauss et al., 2011). Despite limited reported data on sexual trauma and sexual health among male veterans, one study found that men with a history of military sexual trauma had nearly twice the odds of an STI diagnosis, compared with those who did not experience such trauma (Turchik et al., 2012). Other research has found significantly higher rates of HIV/AIDS among male veterans with a history of military sexual assault, compared with those without (Kimerling et al., 2007; Turchik et al., 2012). Together, these data demonstrate an unacceptably high prevalence of sexual assault and trauma and unwanted sexual contact in the U.S. military, which places service members at increased risk for numerous health consequences, including unintended pregnancy and STIs, such as HIV/AIDS. More research is needed to critically examine the impact that any form of sexual abuse has on the SRH of military personnel, including veterans. Such information is essential for devising effective approaches to prevent future occurrences and necessary for expanding support programs for those who are vulnerable and most affected. A small but compelling body of literature examines the military-specific social and cultural context in which military sexual assault occurs (Morral et al., 2015; Schuyler et al., 2017; Suris and Lind, 2008); despite its importance, this is beyond the scope of this current report. Nonetheless, the military-specific context of sexual assault needs to be a central factor in ongoing efforts that address the SRH of all military personnel including recruits, active-duty members, and veterans.

Alcohol Use

Alcohol use in the military is common (Barlas et al., 2013; Bray et al., 2013; Goyal et al., 2012), has long been an acceptable behavior that is interwoven in the military culture, rituals, and practices (Barry et al., 2013), and is affordable and easily accessible on U.S. installations (Ames et al., 2008). Excessive alcohol use, including binge drinking (at least

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

one episode during 1 month of five or more drinks on a single occasion for men or four or more drinks for women) and heavy use (a pattern of multiple episodes of binge drinking during 1 month) are also prevalent among U.S. personnel and associated with unintentional injuries, resulting in increased hospitalizations and health care costs and adversely affecting military readiness and work-related productivity (Barlas et al., 2013; Stahre et al., 2009).

A survey of 1,095 U.S. Army recruits found that 48.8 percent of male and 33.2 percent of female respondents reported binge drinking (O’Rourke et al., 2008), compared with about 14 percent in the general population (Naimi et al., 2003). A 2011 DOD anonymous survey found that 84.5 percent of service members were classified as current drinkers, with approximately one-third (33.1 percent) reporting binge drinking in the past 30 days (Barlas et al., 2013). Another study of a large shipboard cohort of U.S. Navy and Marine Corps military personnel that were surveyed just prior to deployment found that 39–54 percent screened positive for hazardous alcohol misuse, 27 percent for binge drinking, and 15 percent for dependent alcohol use, while 7 percent reported involuntary drug consumption history, based on the Alcohol Use Disorders Identification Test-Consumption (Harbertson et al., 2016).

Although an association between alcohol use and STIs has been established in the general population (Cook and Clark, 2005) (see Chapter 2), newer military-specific data are noticeably absent. The study of Navy-enlisted women, however, found an association between alcohol misuse (drinking until passing out or vomiting in the past 30 days) and a chlamydia diagnosis (Thomas et al., 2001). Several other studies identified an association between alcohol consumption and sexual risk behaviors, including inconsistent condom use among Army active-duty men (Jenkins et al., 2000), multiple sexual partnerships among Army female recruits (Eitzen and Sawyer, 1997), and condomless sex in a cohort of shipboard, male Marine Corps members (Shafer et al., 2002). Binge drinking also has been associated with ineffective contraceptive use during the last reported sexual encounter in Army recruits (O’Rourke et al., 2008) and sex under the influence of alcohol or drugs in the 3 months prior to recruit training entry in female Marine Corps recruits (Boyer et al., 2008). Lastly, more frequent episodes of alcohol intoxication were associated with multiple sexual partners in the past 12 months (Thompson et al., 2005). Collectively, these data provide strong evidence for the problem of alcohol use, including excessive use, in the U.S. military. In particular, they underscore the urgent need for further research that assesses the role that alcohol use and its concomitant behaviors and health outcomes have on the sexual health of military personnel. These factors need to be

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

central to any efforts to prevent STIs in all military personnel, particularly among those who are new recruits and in the early stages of their careers.

PEOPLE WITH DISABILITIES9

For me, the barriers to accessing screening and treatment would be navigating the world as a person with disabilities, and that goes along with my ability to work. And also navigating barriers like transportation, being able to get to those testing sites…. I use the LGBTQ center at Durham to learn about STI prevention. They go through Durham County services for providing STI testing. But since it is free, it’s only accessible during certain days of the week.
—Participant, lived experience panel

Box 3-10 provides key information about STIs among people with disabilities. People with disabilities include those with long-term physical, mental, intellectual, or sensory impairment, and they represent about 26 percent of the population; 13.7 percent of people with a disability have a mobility disability, and 10.8 percent of people with a disability have an intellectual or developmental disability (I/DD) (CDC, 2020b). Until recently, people with disabilities have not been included in population health data collection, analysis, and reports (Krahn et al., 2015). Literature on the association between disability and both STI and HIV risk is also very limited. Although people with an I/DD face disparities relating to SRH services (Powell et al., 2020), little is known about the prevalence of STIs and STI testing in this population (Greenwood and Wilkinson, 2013; Schmidt et al., 2019a). Further investigations into the intersection

___________________

9 The World Health Organization’s International Classification of Functioning, Disability and Health defines disability as an umbrella term for impairments, activity limitations, and participation restrictions (WHO, 2002).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

of disability and STI/HIV risk are needed (Doyle et al., 2020; Schmidt et al., 2020).

A nationally representative sample of middle-school- and high-school-age youth showed that 8 percent of male and 26 percent of girls with low cognitive ability had been exposed to an STI, compared to 3 percent of boys and 10 percent of girls with average cognitive ability (Cheng and Udry, 2005). A cross-sectional study that used special education data and Medicaid data from Philadelphia, Pennsylvania, for calendar year 2002 found that 3 percent of male and 5 percent of female participants were treated for an STI; among the female participants, those with intellectual disabilities (classified in this study as being in the “mental retardation [MR]” category) were at greatest risk (6.9 percent) and those in the emotionally disturbed or “no special education” category at lowest risk (4.9 percent each) (Mandell et al., 2008). An analysis of privately insured individuals with I/DD that used multi-variable models found they were significantly less likely to have an STI diagnosis, and no difference was found between groups on the odds of STI testing overall (Schmidt et al., 2019a). Based on this study, and evidence from prior studies, the authors concluded, however, that this might be explained, in part, by fewer sexual experiences, and protective factors such as increased supervision in social settings, and delayed onset of sexual activity compared to the general population (Schmidt et al., 2019a). Data on STI prevalence is not available for individuals with other types of disabilities.

Multi-Level Drivers

A variety of factors place young adults with I/DD at greater risk of an STI and sexual health disparities, including a lack of knowledge/understanding about sexuality and safe sex strategies and trouble relating health information to their own life experiences. One of the most pronounced disparities is a heightened vulnerability to sexual assault and abuse (Murray, 2019). Research suggests the tendency to desexualize or downplay the sexual needs of persons with I/DD has increased their health risks by limiting their access to sexual health information, reproductive health care, and counseling (Walters and Gray, 2018). Mosher et al. (2017) found that women with I/DD received fewer family planning services compared to women without disabilities, and the difference was larger for women of lower socioeconomic status. Further research is needed on other factors that affect the ability of people with disabilities to obtain the SRH services they need, including those related to STIs.

For specific subgroups of people with disabilities (both I/DD or physical/mobility disabilities), certain factors can compound the effects of having a disability, such as race and ethnicity, age, language, sex or

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

gender, poverty, and low education (Krahn et al., 2015). Having a disability is associated with an increased likelihood of lacking a high school education, less likelihood of employment, inadequate access to transportation, less access to the Internet, and an increased likelihood of having an annual income less than $15,000 (Krahn et al., 2015).

Living with a disability can present barriers to accessing health care services and navigating the health care system (CDC, 2020b; WHO, 2018). In the past year, one in three adults with disabilities did not have a regular health care provider and had an unmet health care need due to cost (CDC, 2020b), and one in four has not had a routine check-up in the past year (CDC, 2020b). People with disabilities are significantly less likely to receive preventive care despite higher rates of chronic disease than the general population (Krahn et al., 2015). Additional barriers include common misconceptions about disabilities, stigma, and providers’ attitudes (Krahn et al., 2015). There is a striking gap in available data for this population and in available services and supports to promote sexual health and prevent sexual abuse (Murray, 2019). See Chapter 2 for more information on how the social determinants of health are associated with STIs.

PEOPLE WITH CRIMINAL LEGAL SYSTEM INVOLVEMENT

The first time I got arrested I think I was 14. I feel like there were several opportunities when I was young that someone could have pulled me aside in the jails, especially in juvenile detention. A nurse, a counselor or somebody in public health could have pulled me aside and asked me “What are you doing?” “What are you participating in?” “How are you protecting yourself?” “How often are you getting tested?” and educated me on these things. I can’t tell you that I would necessarily have listened, but I think there were definitely opportunities for testing.
—Participant, lived experience panel

Inmates in jails and prisons face a disproportionate share of STIs (Krieger et al., 2019; Nowotny et al., 2020; Thomas et al., 2008; Wiehe et al., 2015; Wise et al., 2017). While most STIs were acquired before incarceration, some transmission does occur while imprisoned. The prevalence of HIV among incarcerated individuals is 4–5 times that in the general population (Wiehe et al., 2015). STI rates are also elevated in individuals whose sexual partners have been incarcerated recently (Green et al., 2012; Henderson, 2018; Khan et al., 2011a,b; Swartzendruber et al., 2012; Wiehe et al., 2015; Wise et al., 2017). Sexual risk can contribute to encountering the criminal legal system, such as through exchanging sex for money or drugs. Black and Latino/a people or those who are of lower socioeconomic status are more likely to be involved in the criminal legal system

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

after an accusation of a crime, due to fewer criminal defense resources and structural racism, and also to have less access to sexual health care services, due to poverty or bias and discrimination. These issues are examined in the context of services needed within the criminal legal system. See Box 3-11 for summarizing information about STIs among people with criminal legal system involvement.

Individual- and Interpersonal-Level Factors

Criminal legal system involvement shares some of the same risk factors for STIs in general, including substance use and mental illness (Alexander-Rodriguez and Vermund, 1987; Belenko et al., 2009; Hammett, 2009; Joesoef et al., 2006; Kouyoumdjian et al., 2012; Pelligrino et al., 2017; Spaulding et al., 2013; Tohme and Holmberg, 2012). Incarceration has been associated with concurrent sexual partnerships and transactional sex, though many other behavioral, educational, community, health care access, and socioeconomic attributes also contribute to the STI–incarceration syndemic (Khan et al., 2011b; Menza and Mayer, 2019; Muñoz-Laboy et al., 2013; Workowski and Bolan, 2015). Individuals in juvenile detention centers may have been accused of crimes or be deemed as “persons in need of supervision” who may be runaway and truant youth suffering sexual exploitation at home or after leaving home (Biglan et al., 1995; Brown et al., 2014; Gates et al., 2015, 2016; Rawstron et al., 1993; Senn et al., 2008; Vermund et al., 1990; Voisin et al., 2004). In addition, incarceration increases high-risk sexual behaviors because it destabilizes social and sexual networks in home communities, for both prisoners and their

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

spouses or partners left behind (Gates et al., 2015; Khan et al., 2011b). Some neighborhoods have high population ratios of women to men, when many men from that community are incarcerated. This may put women at risk when the remaining men have multiple concurrent sexual partners (Green et al., 2012; Pouget et al., 2010). Lower-income neighborhoods rarely have optimized primary care and public health services for STI recognition, treatment, follow-up, and partner notification. The lack of supportive networks among incarcerated individuals also can contribute to mental health issues and substance use–seeking behaviors, which elevate STI risks (Epperson et al., 2010; Knittel and Lorvick, 2019; Knittel et al., 2019). Prisoners are a vulnerable population; it has been estimated that approximately 3 percent of them experience sexual assault while in prison from either another inmate or prison staff (Bozelko, 2015; Sawyer and Wagner, 2020).

Institutional- and Community-Level Factors

The problem is not just the lack of resources; it’s the lack of thinking about people in those places as people, not just part of the system. These are systems designed to dehumanize the people held in them and also the people who work in them, including doctors and nurses. Often, when law enforcement is the hub of deciding whether you even have a health problem or if your health problem qualifies for other options than being incarcerated, it often still can dehumanize and fail to address your overall health.
—Participant, lived experience panel

The broader antecedents of STI risk among incarcerated adults and youth are multi-factorial. Yet, correctional facilities themselves represent a sort of a community with society norms that may emerge within the lifestyle context of incarceration. Interventions can be facilitated, paradoxically, by the immediate availability of the population and the comparatively high STI prevalence among inmates. Thus, STI education, screening, and treatment represent a significant public health opportunity within correctional facilities. Screening and treatment are feasible, as demonstrated in diverse correctional settings: jails, prisons, and juvenile detention facilities (Hammett, 2009; NCCHC, 2020; Owusu-Edusei et al., 2013). STI services are easier to promulgate in prisons than in many other settings. Jails and juvenile detention facilities are more challenged, however, due to high turnover rates for some entrants, who may be detained for just hours or 1 day. The ability of correctional facilities to track people and provide medical access to underserved and marginalized populations can facilitate overall STI control, but this depends on screening at entry. STI screenings are built into the intake procedure in some jails, prisons,

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

and juvenile detention centers, but by no means is this standard practice at all correctional facilities (Krieger et al., 2019). CDC and the Federal Bureau of Prisons have established screening guidelines to maximize the detection of STIs among high-risk and otherwise hard-to-reach individuals (Spaulding et al., 2018). Urine and blood samples can be taken to assess STIs during intake, and medications can then be provided. Prisoners with longer incarceration terms can be followed-up in prison to ensure cure or to evaluate incident infections from sexual engagement within the prison itself.

Rapid turnaround rates for screening and treatment, along with community follow-up, are essential in short-term stay facilities. In jails and juvenile detention centers, approximately 50 percent of entrants are released back into the community within 48 hours, making it challenging to provide screening results (Poteat et al., 2018; Wiehe et al., 2015; Wirtz et al., 2018). Nonetheless, given the prevalence of STIs among detainees and subsequent community transmission, ensuring rapid screening turnaround and community follow-up can make a significant impact in ending transmission. Successful strategies include screening at or shortly after intake, rapid receipt of screening results, same-day treatment when possible, reporting to the local department of public health, ensuring community follow-up for treatment and cure, and partner notification through public health outreach.

The United States needs to consider a harm reduction approach for incarcerated persons. While condoms are the mainstay of STI prevention, current policies in the vast majority of U.S. prisons hold that sex in prison is illegal and condoms are contraband (Tucker et al., 2007). In Europe, many countries view condom distribution as a harm reduction approach and have seen subsequent decreases in STIs (Sander et al., 2016).

Structural-Level Factors

Structural racism in society contributes insofar as persons of marginalized racial and ethnic groups are more likely to be arrested and incarcerated, are less likely to have ready access to preventive and therapeutic health care services, and may have fewer educational and economic advantages, due in large part to racism, discrimination, and underlying structural inequities (Brewer et al., 2019; Dyer et al., 2020; Ibragimov et al., 2020; NASEM, 2017). While providing STI screening and treatment in correctional facilities is cost effective given the high yield from screening in a high-prevalence population, use of this opportunity varies greatly in different states and geographic areas (Hammett, 2009; Owusu-Edusei et al., 2013). The United States spends far less per prisoner than other higher-income nations, though health care spending is higher than most

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

countries (Sridhar et al., 2018). Health service commitments to incarcerated persons vary by state and local jurisdiction. For example, health care spending per inmate varied dramatically in fiscal year 2015—from $2,173 in Louisiana to $19,796 in California (Pew Charitable Trusts, 2017).

Many prisoners have received suboptimal sexual health care prior to incarceration, such that screening by correctional facility health care providers represents an excellent opportunity to identify STIs and treat syphilis, gonorrhea, chlamydia, and trichomoniasis. Additional health care services can screen for, and mitigate harm from, HPV, HSV-2, bacterial vaginosis, and other reproductive tract infections (Hsu et al., 2011). Health services that are provided by correctional facilities directly or outsourced to for-profit or nonprofit organizations could mandate 2010 CDC-recommended STI screening and treatment as part of their service provisions (Senteio et al., 2010). A position statement of the National Commission on Correctional Health Care generally aligns with CDC recommendations for STI screening at intake (NCCHC, 2014). Given the recent rise in syphilis in the United States, screening is recommended for all incarcerated individuals (Wolfe et al., 2001). Guidelines are available from other organizations, including the American Public Health Association, the American Correctional Association, the Academy of Correctional Health Professionals, the American Correctional Health Services Association, the American Jail Association, the American Probation and Parole Association, the American College of Correctional Physicians, and the National Coalition of STD Directors (NCCHC, 2014). As HIV is screened for routinely, syphilis, HBV, HCV, and HSV-2 are easily added to this blood draw (Wang et al., 2015; Wirtz et al., 2018). Urine nucleic acid amplification test (NAAT) is convenient for gonorrhea and chlamydia. Adult and adolescent prisoners AFAB benefit from a pelvic examination that can evaluate trichomoniasis, HPV and cervical status, and bacterial vaginosis.

Intersectoral Considerations: Incarcerated Undocumented Immigrants

As of September 2020, there were 133 immigration detention facilities run by Immigration and Customs Enforcement (ICE, 2020). These facilities do not screen for STIs routinely and are not readily accessible to researchers. Studies of incarceration and STI prevalence are rare (Folch et al., 2016; Lederman et al., 2020). Immigrants may have infections seen rarely in the United States, such as human HTLV-I and HTLV-II that may be transmitted sexually, parenterally, and especially perinatally (Ansaldi et al., 2003). A subset of persons coming from countries with a loss of social cohesion may be at especially high STI risk and/or have suffered sexual violence (Bickell et al., 1991; Swartzendruber et al., 2012; Vermund

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

et al., 1990). While some undocumented people may be at high STI risk, as when exchanging sex for money, goods, or protection (Anderson et al., 2016; Gaines et al., 2013; Sangaramoorthy and Kroeger, 2013), others may be at lower risk because of mores from traditional societies that may have lower-risk sexual behaviors (Castillo-Mancilla et al., 2012). At the same time, traditional societies may have stigmas or taboos around sexual behaviors that can jeopardize timely and appropriate STI testing and care. Immigration detention centers can provide screening opportunities, but a stronger detention health infrastructure would be needed, with attendant positive client-centered attitudes that have not been dominant in recent U.S. political narratives (Parmet, 2018).

Intervention and Research Needs

High STI prevalence among incarcerated individuals reflects individual risk and community and societal dynamics that disadvantage persons with lower educational and socioeconomic status. Community-level STI services in disadvantaged communities need to be improved, but a bridge may be to optimize STI screening, education, and care among incarcerated adults and adolescents. Programs targeting incarcerated and detained persons can stop STI transmission cycles through diagnosis, treatment, and education. Research needs to focus on best practices for optimizing interventions, characterizing prevalence and risk, and improving service transitions for persons reentering the community. STI prevalence and feasibility of screening for understudied subpopulations, such as incarcerated immigrants, require further investigation. A greater understanding is needed as to why there are differences in screening/medical care between the states and in different geographical jurisdictions and of the impact of these differences. Correctional facilities, including juvenile detention and immigration detention centers, represent a high-impact, cost-effective opportunity to reduce STI rates with a highly vulnerable subgroup of society (Bonney et al., 2008; Flanigan et al., 2010; Smith et al., 2017; Tedeschi et al., 2007). The greatest impact will require collaboration between public health, health care, and criminal legal systems to improve services in vulnerable communities.

CONCLUDING OBSERVATIONS

As highlighted throughout this chapter, key STI data are missing for many high-priority populations. This differential availability of data further marginalizes people who are already disproportionally impacted by STIs. As discussed in a 2017 National Academies report, significant research and practical application challenges need to be addressed so that

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

knowledge can strategically and accurately inform interventions aimed at reducing or eliminating health inequities (NASEM, 2017). More research and specific attention is sorely needed to address data equity, including ensuring that current data systems capture appropriate categories of race and ethnicity consistently so that there are sufficiently large samples of some racial and ethnic groups and sexual minorities in population-level epidemiological studies. Furthermore, more and better metrics and indicators to capture a broader definition of health are needed, among other needs (see NASEM, 2017, 2020, for more discussion on this topic). The committee endorses the inclusion of expanded data collection and improved surveillance in populations underrepresented in current data as an objective of the STI National Strategic Plan: 2021–2025 (HHS, 2020).

Nonetheless, the available data show that STIs are not evenly distributed throughout the population, but rather are concentrated heavily among certain groups. Many of these groups, especially those with multiple social identities, are stigmatized and often socioeconomically disadvantaged. The underlying epidemiology and complex social and structural determinants outlined in Chapters 2 and 3 are crucial to understanding the state of STIs in the United States. These factors need to be taken into account when mounting any response to improving sexual health and reducing the epidemics of STIs.

REFERENCES

Aalsma, M. C., S. E. Wiehe, M. J. Blythe, Y. Tong, J. Harezlak, and M. B. Rosenman. 2011. Mental health screening and STI among detained youth. Journal of Community Health 36(2):300-306.

AAP (American Academy of Pediatrics) and ACOG (American College of Obstetricians and Gynecologists). 2017. Guidelines for perinatal care. 8th ed. Elk Grove, IL: American Academy of Pediatrics; American College of Obstetricians and Gynecologists.

Aaron, D. J., N. Markovic, M. E. Danielson, J. A. Honnold, J. E. Janosky, and N. J. Schmidt. 2001. Behavioral risk factors for disease and preventive health practices among lesbians. American Journal of Public Health 91(6):972-975.

Abdullahi, L. H., B. M. Kagina, V. N. Ndze, G. D. Hussey, and C. S. Wiysonge. 2020. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews 1(1):CD011895.

ACLU (American Civil Liberties Union). 2020. A tale of two countries: Racially targeted arrests in the era of marijuana reform. Washington, DC: American Civil Liberties Union.

ACOG (American College of Obstetricians and Gynecologists) Committee on Adolescent Health Care. 2017a. Committee opinion no. 705: Mental health disorders in adolescents. Obstetrics and Gynocology 130(1):e32-e41.

ACOG Committee on Adolescent Health Care. 2017b. Committee opinion no. 710: Counseling adolescents about contraception. Obstetrics and Gynocology 130(2):e74-e80.

ACOG Committee on Adolescent Health Care. 2020. Confidentiality in adolescent health care: ACOG committee opinion, number 803. Obstetrics and Gynocology 135(4):e171-e177.

Adams, G., S. A. Fryberg, D. M. Garcia, and E. U. Delgado-Torres. 2006. The psychology of engagement with indigenous identities: A cultural perspective. Cultural Diversity and Ethnic Minority Psychology 12(3):493-508.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Adefuye, A. S., T. C. Abiona, J. A. Balogun, and M. Lukobo-Durrell. 2009. HIV sexual risk behaviors and perception of risk among college students: Implications for planning interventions. BMC Public Health 9:281.

Adimora, A. A., and V. J. Schoenbach. 2005. Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. Journal Infectious Diseases 191(Suppl 1):S115-S122.

Adimora, A. A., V. J. Schoenbach, D. M. Bonas, F. E. Martinson, K. H. Donaldson, and T. R. Stancil. 2002. Concurrent sexual partnerships among women in the United States. Epidemiology 13(3):320-327.

Agénor, M., J. L. Jahn, E. Kay, R. A. Bishop, S. M. Peitzmeier, J. Potter, and S. B. Austin. 2019a. Human papillomavirus risk perceptions among young adult sexual minority cisgender women and nonbinary individuals assigned female at birth. Perspectives on Sexual and Reproductive Health 51(1):27-34.

Agénor, M., G. Murchison, J. Chen, D. Bowen, M. Rosenthal, S. Haneuse, and S. Austin. 2019b. Impact of the Affordable Care Act on human papillomavirus vaccination initiation among lesbian, bisexual, and heterosexual U.S. women. Health Services Research 55(1):18-25.

Aicken, C. R., A. Nardone, and C. H. Mercer. 2011. Alcohol misuse, sexual risk behaviour and adverse sexual health outcomes: Evidence from Britain’s National Probability Sexual Behaviour surveys. Journal of Public Health 33(2):262-271.

Alessi, E. J., B. Greenfield, D. Manning, and M. Dank. 2020. Victimization and resilience among sexual and gender minority homeless youth engaging in survival sex. Journal of Interpersonal Violence 1-24.

Alexander-Rodriguez, T., and S. H. Vermund. 1987. Gonorrhea and syphilis in incarcerated urban adolescents: Prevalence and physical signs. Pediatrics 80(4):561-564.

Aliyu, M. H., M. Blevins, C. M. Audet, M. Kalish, U. I. Gebi, O. Onwujekwe, M. L. Lindegren, B. E. Shepherd, C. W. Wester, and S. H. Vermund. 2016. Integrated prevention of mother-to-child HIV transmission services, antiretroviral therapy initiation, and maternal and infant retention in care in rural north-central Nigeria: A cluster-randomised controlled trial. Lancet HIV 3(5):e202-e211.

Ames, G. M., M. R. Duke, R. S. Moore, and C. B. Cunradi. 2008. The impact of occupational culture on drinking behavior of young adults in the U.S. Navy. Journal of Mixed Methods Research 3(2):129-150.

Anderson, L. E., G. A. Dingle, B. O’Gorman, and M. J. Gullo. 2020. Young adults’ sexual health in the digital age: Perspectives of care providers. Sexual & Reproductive Health Care 25:100534.

Anderson, S., K. Shannon, J. Li, Y. Lee, J. Chettiar, S. Goldenberg, and A. Krüsi. 2016. Condoms and sexual health education as evidence: Impact of criminalization of in-call venues and managers on migrant sex workers access to HIV/STI prevention in a Canadian setting. BMC International Health and Human Rights 16(1):30.

Ansaldi, F., M. Comar, P. D’Agaro, S. Grainfenberghi, L. Caimi, F. Gargiulo, B. Bruzzone, R. Gasparini, G. Icardi, F. Perandin, C. Campello, and N. Manca. 2003. Seroprevalence of HTLV-I and HTLV-II infection among immigrants in northern Italy. European Journal of Epidemiology 18(6):583-588.

APA (American Psychiatric Association). 2017. Mental health disparities: American Indians and Alaska Natives. https://www.psychiatry.org/File%20Library/Psychiatrists/Cultural-Competency/Mental-Health-Disparities/Mental-Health-Facts-for-American-Indian-Alaska-Natives.pdf (accessed February 21, 2021).

Arbeit, M. R., C. B. Fisher, K. Macapagal, and B. Mustanski. 2016. Bisexual invisibility and the sexual health needs of adolescent girls. LGBT Health 3(5):342-349.

Argüello, T. M., and K. Walters. 2018. They tell us “we don’t belong in the world and we shouldn’t take up a place”: HIV discourse within two-spirit communities. Journal of Ethnic & Cultural Diversity in Social Work 27(2):107-123.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Armed Forces Surveillance Center. 2013. Sexually transmitted infections, active component, U.S. Armed Forces, 2000-2012. Medical Surveillance Monthly Report 20(2):5-10.

Arnold, E. A., E. Sterrett-Hong, A. Jonas, and L. M. Pollack. 2018. Social networks and social support among ball-attending African American men who have sex with men and transgender women are associated with HIV-related outcomes. Global Public Health 13(2):144-158.

Arnold, S. B. 2014. Reproductive rights denied: The Hyde amendment and access to abortion for Native American women using Indian Health Service facilities. American Journal of Public Health 104(10):1892-1893.

Ashenhurst, J. R., E. R. Wilhite, K. P. Harden, and K. Fromme. 2017. Number of sexual partners and relationship status are associated with unprotected sex across emerging adulthood. Archives of Sexual Behavior 46(2):419-432.

Athar, H. M., M. H. Chang, R. A. Hahn, E. Walker, and P. Yoon. 2013. Unemployment—United States, 2006 and 2010. MMWR Supplements 62(3):27-32.

Austin, A., and R. Goodman. 2017. The impact of social connectedness and internalized transphobic stigma on self-esteem among transgender and gender non-conforming adults. Journal of Homosexuality 64(6):825-841.

Austin, S. B., A. L. Roberts, H. L. Corliss, and B. E. Molnar. 2008. Sexual violence victimization history and sexual risk indicators in a community-based urban cohort of “mostly heterosexual” and heterosexual young women. American Journal of Public Health 98(6):1015-1020.

Ayala, G., T. Bingham, J. Kim, D. P. Wheeler, and G. A. Millett. 2012. Modeling the impact of social discrimination and financial hardship on the sexual risk of HIV among Latino and Black men who have sex with men. American Journal of Public Health 102(Suppl 2):S242-S249.

Azari, A. A., and A. Arabi. 2020. Conjunctivitis: A systematic review. Journal of Ophthalmic & Vision Research 15(3):372-395.

AZDHS (Arizona Department of Health Services). 1989. R7-2-303. Sex education. https://azdhs.gov/documents/prevention/womens-childrens-health/rfga/prep-tribal/policy-proceduer-manual/attachment-d-r7-2-303-sex-ed-in-schools-rule.pdf (accessed November 19, 2020).

Bacon, O., P. Lum, J. Hahn, J. Evans, P. Davidson, A. Moss, and K. Page-Shafer. 2006. Commercial sex work and risk of HIV infection among young drug-injecting men who have sex with men in San Francisco. Sexually Transmitted Diseases 33(4):228-234.

Balaji, A. B., E. Oraka, A. M. Fasula, P. E. Jayne, M. G. Carry, and J. L. Raiford. 2017. Association between parent-adolescent communication about sex-related topics and HIV testing, United States. 2006-2013. AIDS Care 29(3):344-349.

Baral, S. D., M. R. Friedman, S. Geibel, K. Rebe, B. Bozhinov, D. Diouf, K. Sabin, C. E. Holland, R. Chan, and C. F. Cáceres. 2015. Male sex workers: Practices, contexts, and vulnerabilities for HIV acquisition and transmission. The Lancet 385(9964):260-273.

Barlas, F., W. Higgins, J. Pflieger, and K. Diecker. 2013. Department of Defense health related behaviours survey of active duty military personnel. http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0-508947957a0f/final-2011-hrb-active-duty-survey-report.pdf (accessed February 15, 2021).

Barr, S. M., S. L. Budge, and J. L. Adelson. 2016. Transgender community belongingness as a mediator between strength of transgender identity and well-being. Journal of Counseling Psychology 63(1):87-97.

Barry, A. E., M. L. Stellefson, B. Hanik, B. L. Tennant, S. D. Whiteman, J. Varnes, and S. M. Wadsworth. 2013. Examining the association between binge drinking and propensity to join the military. Military Medicine 178(1):37-42.

Bastow, B., J. Sheeder, and S. Teal. 2014. Do adolescents who initiate LARC use condoms with new partners? Contraception 90(3):296.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Bauer, G. R., N. Redman, K. Bradley, and A. I. Scheim. 2013. Sexual health of trans men who are gay, bisexual, or who have sex with men: Results from Ontario, Canada. International Journal of Transgender Health 14(2):66-74.

Bauer, M., E. Haesler, and D. Fetherstonhaugh. 2016. Let’s talk about sex: Older people’s views on the recognition of sexuality and sexual health in the health-care setting. Health Expectations 19(6):1237-1250.

Bauermeister, J. A., M. A. Zimmerman, and C. H. Caldwell. 2011. Neighborhood disadvantage and changes in condom use among African American adolescents. Journal of Urban Health 88(1):66-83.

Bautista, C. T., E. K. Wurapa, W. B. Sateren, S. M. Morris, B. P. Hollingsworth, and J. L. Sanchez. 2017. Repeat infection with Neisseria gonorrhoeae among active duty U.S. Army personnel: A population-based case-series study. International Journal of STD & AIDS 28(10):962-968.

Bautista, C. T., E. K. Wurapa, and J. L. Sanchez. 2019. Does the hazard of chlamydia increase with the number of gonorrhea diagnoses? A large population-based study among U.S. Army women. Journal of Women’s Health 28(2):220-224.

Becasen, J. S., C. L. Denard, M. M. Mullins, D. H. Higa, and T. A. Sipe. 2019. Estimating the prevalence of HIV and sexual behaviors among the US transgender population: A systematic review and meta-analysis, 2006-2017. American Journal of Public Health 109(1):e1-e8.

Bechtel, K. 2010. Sexual abuse and sexually transmitted infections in children and adolescents. Current Opinion in Pediatrics 22(1):94-99.

Beckles, G. L., and B. I. Truman. 2013. Education and income—United States, 2009 and 2011. MMWR Supplements 62(3):9-19.

Begley, E., R. A. Crosby, R. J. DiClemente, G. M. Wingood, and E. Rose. 2003. Older partners and STD prevalence among pregnant African American teens. Sexually Transmitted Diseases 30(3):211-213.

Belenko, S., R. Dembo, M. Rollie, K. Childs, and C. Salvatore. 2009. Detecting, preventing, and treating sexually transmitted diseases among adolescent arrestees: An unmet public health need. American Journal of Public Health 99(6):1032-1041.

Benoit, E., and J. A. Koken. 2012. Perspectives on substance use and disclosure among behaviorally bisexual black men with female primary partners. Journal of Ethnicity in Substance Abuse 11(4):294-317.

Benson, P. A., and A. C. Hergenroeder. 2005. Bacterial sexually transmitted infections in gay, lesbian, and bisexual adolescents: Medical and public health perspectives. Seminars in Pediatric Infections Diseases 16(3):181-191.

Berg, R. C., H. M. Munthe-Kaas, and M. W. Ross. 2016. Internalized homonegativity: A systematic mapping review of empirical research. Journal of Homosexuality 63(4):541-558.

Bergeron, C. D., H. H. Goltz, L. E. Szucs, J. V. Reyes, K. L. Wilson, M. G. Ory, and M. L. Smith. 2017. Exploring sexual behaviors and health communication among older women. Health Care for Women International 38(12):1356-1372.

Beymer, M. R., R. E. Weiss, R. K. Bolan, E. T. Rudy, L. B. Bourque, J. P. Rodriguez, and D. E. Morisky. 2014. Sex on demand: Geosocial networking phone apps and risk of sexually transmitted infections among a cross-sectional sample of men who have sex with men in Los Angeles county. Sexually Transmitted Infections 90(7):567-572.

Bickell, N. A., S. H. Vermund, M. Holmes, S. Safyer, and R. D. Burk. 1991. Human papillomavirus, gonorrhea, syphilis, and cervical dysplasia in jailed women. American Journal of Public Health 81(10):1318-1320.

Biello, K. B., W. C. Goedel, A. Edeza, S. A. Safren, K. H. Mayer, B. D. L. Marshall, C. Latkin, and M. J. Mimiaga. 2020. Network-level correlates of sexual risk among male sex workers in the United States: A dyadic analysis. Journal of Acquired Immune Deficiency Syndromes 83(2):111-118.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

BigFoot, D. S., and B. W. Funderbunk. 2010. Communique: Honoring children, making relatives: Indigenous traditional parenting practices compatible with evidence-based treatment. Washington, DC: American Psychological Association.

Biglan, A., J. Noell, L. Ochs, K. Smolkowski, and C. Metzler. 1995. Does sexual coercion play a role in the high-risk sexual behavior of adolescent and young adult women? Journal of Behavioral Medicine 18(6):549-568.

Blum, R. W., B. Harmon, L. Harris, L. Bergeisen, and M. D. Resnick. 1992. American Indian—Alaska Native youth health. JAMA 267(12):1637-1644.

Bonney, L. E., J. G. Clarke, E. M. Simmons, J. S. Rose, and J. D. Rich. 2008. Racial/ethnic sexual health disparities among incarcerated women. JAMA 100(5):553-558.

Borschmann, R., E. Janca, A. Carter, M. Willoughby, N. Hughes, K. Snow, E. Stockings, N. T. M. Hill, J. Hocking, A. Love, G. C. Patton, S. M. Sawyer, S. Fazel, C. Puljević, J. Robinson, and S. A. Kinner. 2020. The health of adolescents in detention: A global scoping review. Lancet Public Health 5(2):e114-e126.

Bostwick, W., and A. Hequembourg. 2014. “Just a little hint”: Bisexual-specific microaggressions and their connection to epistemic injustices. Culture, Health & Sexuality 16(5):488-503.

Bostwick, W. B., C. J. Boyd, T. L. Hughes, B. T. West, and S. E. McCabe. 2014. Discrimination and mental health among lesbian, gay, and bisexual adults in the United States. The American Journal of Orthopsychiatry 84(1):35-45.

Bowen, V., J. Su, E. Torrone, S. Kidd, and H. Weinstock. 2015. Increase in incidence of congenital syphilis—United States, 2012-2014. Morbidity and Mortality Weekly Report 64(44):1241-1245.

Bowleg, L. 2008. When Black + lesbian + woman ≠ Black lesbian woman: The methodological challenges of qualitative and quantitative intersectionality research. Sex Roles 59(5):312-325.

Bowleg, L., and A. Raj. 2012. Shared communities, structural contexts, and HIV risk: Prioritizing the HIV risk and prevention needs of Black heterosexual men. American Journal of Public Health 102(Suppl 2):S173-S177.

Boyer, C. B., J. M. Tschann, and M.-A. Shafer. 1999. Predictors of risk for sexually transmitted diseases in ninth grade urban high school students. Journal of Adolescent Research 14(4):448-465.

Boyer, C. B., M.-A. Shafer, C. J. Wibbelsman, D. Seeberg, E. Teitle, and N. Lovell. 2000. Associations of sociodemographic, psychosocial, and behavioral factors with sexual risk and sexually transmitted diseases in teen clinic patients. Journal of Adolescent Health 27(2):102-111.

Boyer, C. B., M. A. Shafer, L. M. Pollack, J. Canchola, J. Moncada, and J. Schachter. 2006. Sociodemographic markers and behavioral correlates of sexually transmitted infections in a nonclinical sample of adolescent and young adult women. The Journal of Infectious Diseases 194(3):307-315.

Boyer, C. B., L. M. Pollack, J. Becnel, and M. A. Shafer. 2008. Relationships among sociodemographic markers, behavioral risk, and sexually transmitted infections in U.S. female Marine Corps recruits. Military Medicine 173(11):1078-1084.

Boyer, C. B., L. Greenberg, K. Chutuape, B. Walker, D. Monte, J. Kirk, and J. M. Ellen. 2017. Exchange of sex for drugs or money in adolescents and young adults: An examination of sociodemographic factors, HIV-related risk, and community context. Journal of Community Health 42(1):90-100.

Boyer, C. B., O. J. Santiago Rivera, D. M. Chiaramonte, and J. M. Ellen. 2018. Examination of behavioral, social, and environmental contextual influences on sexually transmitted infections in at risk, urban, adolescents, and young adults. Sexually Transmitted Diseases 45(8):542-548.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Bozelko, C. 2015. Why we let prison rape go on. https://www.nytimes.com/2015/04/18/opinion/why-we-let-prison-rape-go-on.html (accessed February 15, 2021).

Braveman, P., K. Marchi, S. Egerter, M. Pearl, and J. Neuhaus. 2000. Barriers to timely prenatal care among women with insurance: The importance of prepregnancy factors. Obstetrics and Gynocology 95(6 Pt 1):874-880.

Braveman, P., E. Arkin, T. Orleans, D. Proctor, and A. Plough. 2017. What is health equity? And what difference does a definition make? Princeton, NJ: Robert Wood Johnson Foundation.

Bray, R. M., J. M. Brown, and J. Williams. 2013. Trends in binge and heavy drinking, alcohol-related problems, and combat exposure in the U.S. military. Substance Use & Misuse 48(10):799-810.

Brewer, R., C. Daunis, S. Ebaady, L. Wilton, S. Chrestman, S. Mukherjee, M. Moore, R. Corrigan, and J. Schneider. 2019. Implementation of a socio-structural demonstration project to improve HIV outcomes among young Black men in the Deep South. Journal of Racial and Ethnic Health Disparities 6(4):775-789.

Brewer, T. H., J. Schillinger, F. M. Lewis, S. Blank, P. Pathela, L. Jordahl, K. Schmitt, and T. A. Peterman. 2011. Infectious syphilis among adolescent and young adult men: Implications for human immunodeficiency virus transmission and public health interventions. Sexually Transmitted Diseases 38(5):367-371.

Brooks, A., C. S. Meade, J. S. Potter, Y. Lokhnygina, D. A. Calsyn, and S. F. Greenfield. 2010. Gender differences in the rates and correlates of HIV risk behaviors among drug abusers. Substance Use & Misuse 45(14):2444-2469.

Brown, J. L., and P. A. Vanable. 2007. Alcohol use, partner type, and risky sexual behavior among college students: Findings from an event-level study. Addictive Behaviors 32(12):2940-2952.

Brown, J. L., A. M. Young, J. M. Sales, R. J. DiClemente, E. S. Rose, and G. M. Wingood. 2014. Impact of abuse history on adolescent African-American women’s current HIV/STD-associated behaviors and psychosocial mediators of HIV/STD risk. Journal of Aggression, Maltreatment & Trauma 23(2):151-167.

Brown, L. K., W. Hadley, A. Stewart, C. Lescano, L. Whiteley, G. Donenberg, and R. DiClemente. 2010. Psychiatric disorders and sexual risk among adolescents in mental health treatment. Journal of Consulting and Clinical Psychology 78(4):590-597.

Bryan, A. D., S. J. Schmiege, and R. E. Magnan. 2012. Marijuana use and risky sexual behavior among high-risk adolescents: Trajectories, risk factors, and event-level relationships. Developmental Psychology 48(5):1429-1442.

Bryan, A. D., R. E. Magnan, A. S. Gillman, E. A. Yeater, S. W. Feldstein Ewing, A. S. Kong, and S. J. Schmiege. 2018. Effect of including alcohol and cannabis content in a sexual risk-reduction intervention on the incidence of sexually transmitted infections in adolescents: A cluster randomized clinical trial. JAMA Pediatrics 172(4):e175621.

Buhi, E. R., and P. Goodson. 2007. Predictors of adolescent sexual behavior and intention: A theory-guided systematic review. Journal of Adolescent Health 40(1):4-21.

Burnette, C. E. 2016. Historical oppression and Indigenous families: Uncovering potential risk factors for Indigenous families touched by violence. Family Relations 65(2):354-368.

Cahn, M. A., S. M. Harvey, and K. Gonzales. 2019. Use of sexual health services among American Indian and Alaska Native women. Women & Health 59(9):953-966.

Call, K. T., D. D. McAlpine, P. J. Johnson, T. J. Beebe, J. A. McRae, and Y. Song. 2006. Barriers to care among American Indians in public health care programs. Medical Care 44(6):595-600.

Cao, B., H. Bao, E. Oppong, S. Feng, K. M. Smith, J. D. Tucker, and W. Tang. 2020. Digital health for sexually transmitted infection and HIV services: A global scoping review. Current Opinion in Infectious Diseases 33(1):44-50.

Carey, K. B., T. E. Senn, J. L. Walsh, L. A. Scott-Sheldon, and M. P. Carey. 2016. Alcohol use predicts number of sexual partners for female but not male STI clinic patients. AIDS and Behavior 20(Suppl 1):S52-S59.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Carrier, L., J. Dame, and J. Lane. 2020. Two-spirit identity and Indigenous conceptualization of gender and sexuality: Implications for nursing practice. Creative Nursing 26(2):96-100.

Castillo-Mancilla, J., A. Allshouse, C. Collins, M. Hastings-Tolsma, T. B. Campbell, and S. Mawhinney. 2012. Differences in sexual risk behavior and HIV/AIDS risk factors among foreign-born and U.S.-born Hispanic women. Journal of Immigrant and Minority Health 14(1):89-99.

Catalano, R. F., K. P. Haggerty, S. Oesterle, C. B. Fleming, and J. D. Hawkins. 2004. The importance of bonding to school for healthy development: Findings from the social development research group. Journal of School Health 74:252-261.

CDC (Centers for Disease Control and Prevention). 2018a. Health care providers and teen pregnancy prevention. https://www.cdc.gov/teenpregnancy/health-care-providers/index.htm (accessed December 16, 2020).

CDC. 2018b. Tribal population. https://www.cdc.gov/tribal/tribes-organizations-health/tribes/state-population.html (accessed February 9, 2021).

CDC. 2019a. Anal sex and HIV risk. https://www.cdc.gov/hiv/risk/analsex.html (accessed November 19, 2020).

CDC. 2019b. Issue brief: HIV and transgender communities. https://www.cdc.gov/hiv/pdf/policies/cdc-hiv-transgender-brief.pdf (accessed February 15, 2021).

CDC. 2019c. Sexually transmitted disease surveillance 2018. Atlanta, GA: Department of Health and Human Services.

CDC. 2020a. Diagnoses of HIV infection in the United States and dependent areas, 2018: Children aged <13 years. https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-31/content/children.html (accessed November 18, 2020).

CDC. 2020b. Disability impacts all of us. https://www.cdc.gov/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html#:~:text=61%20million%20adults%20in%20the,is%20highest%20in%20the%20South (accessed November 19, 2020).

CDC. 2020c. HIV and older Americans. https://www.cdc.gov/hiv/group/age/olderamericans/index.html (accessed November 19, 2020).

CDC. 2020d. HIV and youth. https://www.cdc.gov/hiv/group/age/youth/index.html (accessed November 19, 2020).

CDC. 2020e. Youth Risk Behavior Survey, data summary & trends report, 2009-2019. Atlanta, GA: Centers for Disease Control and Prevention.

Chadi, N., R. Schroeder, J. W. Jensen, and S. Levy. 2019. Association between electronic cigarette use and marijuana use among adolescents and young adults: A systematic review and meta-analysis. JAMA Pediatrics 173(10):e192574.

Chae, D. H., and K. L. Walters. 2009. Racial discrimination and racial identity attitudes in relation to self-rated health and physical pain and impairment among two-spirit American Indians/Alaska Natives. American Journal of Public Health 99(Suppl 1):S144-S151.

Chambers, R., L. Tingey, A. Beach, A. Barlow, and A. Rompalo. 2016a. Testing the efficacy of a brief sexual risk reduction intervention among high-risk American Indian adults: Study protocol for a randomized controlled trial. BMC Public Health 16:366.

Chambers, R., L. Tingey, B. Mullany, S. Parker, A. Lee, and A. Barlow. 2016b. Exploring sexual risk taking among American Indian adolescents through protection motivation theory. AIDS Care 28(9):1089-1096.

Chambers, R. S., S. Rosenstock, A. Lee, N. Goklish, F. Larzelere, and L. Tingey. 2018. Exploring the role of sex and sexual experience in predicting American Indian adolescent condom use intention using protection motivation theory. Frontiers in Public Health 6:318.

Champion, J. D. 2011. Context of sexual risk behaviour among abused ethnic minority adolescent women. International Nursing Review 58(1):61-67.

Charlton, B. M., H. L. Corliss, S. A. Missmer, A. L. Frazier, M. Rosario, J. A. Kahn, and S. B. Austin. 2011. Reproductive health screening disparities and sexual orientation in a cohort study of U.S. adolescent and young adult females. Journal of Adolescent Health 49(5):505-510.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Charlton, B. M., M. L. Hatzenbuehler, H. J. Jun, V. Sarda, A. R. Gordon, J. R. G. Raifman, and S. B. Austin. 2019. Structural stigma and sexual orientation-related reproductive health disparities in a longitudinal cohort study of female adolescents. Journal of Adolescence 74:183-187.

Cheng, M. M., and J. R. Udry. 2005. Sexual experiences of adolescents with low cognitive abilities in the U.S. Journal of Developmental and Physical Disabilities 17(2):155-172.

Cheung, K. W., M. T. Y. Seto, and T. T.-H. Lao. 2019. Prevention of perinatal hepatitis B virus transmission. Archives of Gynecology and Obstetrics 300(2):251-259.

Chewning, B., J. Douglas, P. K. Kokotailo, J. LaCourt, D. S. Clair, and D. Wilson. 2001. Protective factors associated with American Indian adolescents’ safer sexual patterns. Maternal and Child Health Journal 5(4):273-280.

Chiaramonte, D., R. L. Miller, K. Lee, O. J. Santiago Rivera, I. D. Acevedo-Polakovich, S. McGirr, J. L. Porter, J. M. Ellen, and C. B. Boyer. 2020. Gendered powerlessness in at-risk adolescent and young women: An empirical model. AIDS Care 32(10):1333-1342.

Clark, K., J. B. Fletcher, I. W. Holloway, and C. J. Reback. 2018. Structural inequities and social networks impact hormone use and misuse among transgender women in Los Angeles county. Archives of Sexual Behavior 47(4):953-962.

Claxton, S. E., H. K. DeLuca, and M. H. van Dulmen. 2015. The association between alcohol use and engagement in casual sexual relationships and experiences: A meta-analytic review of non-experimental studies. Archives of Sexual Behavior 44(4):837-856.

Coakley, T. M., S. Randolph, J. Shears, E. R. Beamon, P. Collins, and T. Sides. 2017. Parent-youth communication to reduce at-risk sexual behavior: A systematic literature review. Journal of Human Behavior in the Social Environment 27(6):609-624.

Cochran, S., V. Mays, D. Bowen, S. Gage, D. Bybee, S. Roberts, R. Goldstein, A. Robison, E. Rankow, and J. White. 2001. Cancer-related risk indicators and preventive screening behaviors among lesbians and bisexual women. American Journal of Public Health 91(4):591-597.

Connell, C. M., T. D. Gilreath, and N. B. Hansen. 2009. A multiprocess latent class analysis of the co-occurrence of substance use and sexual risk behavior among adolescents. Journal of Studies on Alcohol and Drugs 70(6):943-951.

Cook, R. L., and D. B. Clark. 2005. Is there an association between alcohol consumption and sexually transmitted diseases? A systematic review. Sexually Transmitted Diseases 32(3):156-164.

Cooper, J. M., and P. J. Sanchez. 2018. Congenital syphilis. Seminars in Perinatology 42(3):176-184.

Copen, C. E., P. J. Dittus, and J. S. Leichliter. 2016. Confidentiality concerns and sexual and reproductive health care among adolescents and young adults aged 15-25. NCHS data brief, No. 266. Hyattsville, MD: National Center for Health Statistics.

Copen, C. E., J. S. Leichliter, I. H. Spicknall, and S. O. Aral. 2019. Sexually transmitted infection risk reduction strategies among U.S. adolescents and adults with multiple opposite-sex sex partners or perceived partner nonmonogamy, 2011-2017. Sexually Transmitted Diseases 46(11):722-727.

Coyne, S. M., L. M. Ward, S. L. Kroff, E. J. Davis, H. G. Holmgren, A. C. Jensen, S. E. Erickson, and L. W. Essig. 2019. Contributions of mainstream sexual media exposure to sexual attitudes, perceived peer norms, and sexual behavior: A meta-analysis. Journal of Adolescent Health 64(4):430-436.

Craig Rushing, S., D. Stephens, R. Shegog, J. Torres, G. Gorman, C. Jessen, A. Gaston, J. Williamson, L. Tingey, C. Lee, A. Apostolou, C. Kaufman, and C. M. Markham. 2018. Healthy native youth: Improving access to effective, culturally-relevant sexual health curricula. Frontiers in Public Health 6:225.

Crawley, A. T. 2012. Can you be BLACK and work here? Social justice activist organizing and BLACK aurality. In Black genders and sexualities, edited by S. McGlotten and D. Davis. New York: Palgrave Macmillan. Pp. 173-186.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Crooks, N., A. Wise, and T. Frazier. 2020. Addressing sexually transmitted infections in the sociocultural context of black heterosexual relationships in the United States. Social Science & Medicine 263:113303.

Crosby, R. A., R. J. DiClemente, G. M. Wingood, C. Sionean, B. K. Cobb, K. Harrington, S. L. Davies, E. W. Hook, 3rd, and M. K. Oh. 2001. Correlates of using dual methods for sexually transmitted diseases and pregnancy prevention among high-risk African-American female teens. Journal of Adolescent Health 28(5):410-414.

Cuffe, K. M., A. Newton-Levinson, T. L. Gift, M. McFarlane, and J. S. Leichliter. 2016. Sexually transmitted infection testing among adolescents and young adults in the United States. Journal of Adolescent Health 58(5):512-519.

Cullen, K. A., A. S. Gentzke, M. D. Sawdey, J. T. Chang, G. M. Anic, T. W. Wang, M. R. Creamer, A. Jamal, B. K. Ambrose, and B. A. King. 2019. E-cigarette use among youth in the United States, 2019. JAMA 322(21):2095-2103.

Cunningham, K., D. A. Martinez, L. A. J. Scott-Sheldon, K. B. Carey, M. P. Carey, and M. R. Team. 2017. Alcohol use and sexual risk behaviors among adolescents with psychiatric disorders: A systematic review and meta-analysis. Journal of Child & Adolescent Substance Abuse 26(5):353-366.

Dahl, R. E. 2001. Affect regulation, brain development, and behavioral/emotional health in adolescence. CNS Spectrums 6(1):60-72.

Dalla, R. L., and W. C. Gamble. 1996. Native American Navajo teenage parenting women, cross-generational support and implications for policy. Paper presented at National Council on Family Relations, Kansas City, MO.

Darkness to Light. 2015. Child sexual abuse statistics: Perpetrators. https://www.childsafehouse.org/wp-content/uploads/perpetrators.pdf (accessed November 16, 2020).

Daw, J. R., and B. D. Sommers. 2017. Immigration, pregnancy, and heath insurance: New evidence and ongoing debate. Obstetrics and Gynocology 130(5):935-937.

Day, J. K., A. Tanaka, A. Cherian, Q. Morrow, R. Reeves, V. Hadd-Wissler, and S. T. Russell. 2017. “Comprehensive” sexuality education in Arizona schools: Searching for a clearer understanding of policies and practices regarding sexuality education. Tucson, AZ: The Frances McClelland Institute for Children, Youth, and Familes, The University of Arizona.

De Genna, N. M., M. D. Cornelius, and R. L. Cook. 2007. Marijuana use and sexually transmitted infections in young women who were teenage mothers. Women’s Health Issues 17(5):300-309.

de Ravello, L., S. Everett Jones, S. Tulloch, M. Taylor, and S. Doshi. 2014. Substance use and sexual risk behaviors among American Indian and Alaska Native high school students. Journal of School Health 84(1):25-32.

Decker, M. R., J. N. Park, S. T. Allen, B. Silberzahn, K. Footer, S. Huettner, N. Galai, and S. G. Sherman. 2020. Inconsistent condom use among female sex workers: Partner-specific influences of substance use, violence, and condom coercion. AIDS and Behavior 24(3):762-774.

Deiss, R., R. J. Bower, E. Co, O. Mesner, J. L. Sanchez, J. Masel, A. Ganesan, G. E. Macalino, and B. K. Agan. 2016. The association between sexually transmitted infections, length of service and other demographic factors in the U.S. military. PLoS One 11(12):e0167892.

Deiss, R., M. Byrne, S. M. Echols, S. M. Cammarata, L. Potswald, E. Gomez, J. A. Curry, E. Garges, G. Macalino, B. K. Agan, and M. F. Bavaro. 2019. Extragenital chlamydia infection among active-duty women in the United States Navy. Military Medicine Research 6(1):3.

Demissie, Z., S. Everett Jones, H. B. Clayton, and B. A. King. 2017. Adolescent risk behaviors and use of electronic vapor products and cigarettes. Pediatrics 139(2):e20162921.

DePadilla, L., M. Windle, G. Wingood, H. Cooper, and R. DiClemente. 2011. Condom use among young women: Modeling the theory of gender and power. Health Psychology 30(3):310-319.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Díaz, R. M., G. Ayala, and E. Bein. 2004. Sexual risk as an outcome of social oppression: Data from a probability sample of Latino gay men in three U.S. cities. Cultural Diversity and Ethnic Minority Psychology 10(3):255-267.

Dibble, K. E., J. L. Maksut, E. J. Siembida, M. Hutchison, and K. M. Bellizzi. 2019. A systematic literature review of HPV vaccination barriers among adolescent and young adult males. Journal of Adolescent and Young Adult Oncology 8(5):495-511.

Dickens, B. M. 2009. Legal protection and limits of conscientious objection: When conscientious objection is unethical. Medicine and Law 28(2):337-347.

Dickens, D. D., S. E. Dieterich, K. L. Henry, and F. Beauvais. 2012. School bonding as a moderator of the effect of peer influences on alcohol use among American Indian adolescents. Journal of Studies on Alcohol and Drugs 73(4):597-603.

Dittus, P. J. 2016. Promoting adolescent health through triadic interventions. Journal of Adolescent Health 59(2):133-134.

Dittus, P. J., S. L. Michael, J. S. Becasen, K. M. Gloppen, K. McCarthy, and V. Guilamo-Ramos. 2015. Parental monitoring and its associations with adolescent sexual risk behavior: A meta-analysis. Pediatrics 136(6):e1587-e1599.

DOD (Department of Defense). 2012. Department of Defense annual report on sexual assault in the military: Fiscal year 2011. https://apps.dtic.mil/dtic/tr/fulltext/u2/a564805.pdf (accessed December 24, 2020).

DOD. 2016. 2016 demographics: Profile of the military community. Office of the deputy assistant secretary of defense. http://download.militaryonesource.mil/12038 (accessed February 15, 2021).

Dodge, B., D. Herbenick, M. R. Friedman, V. Schick, T.-C. Fu, W. Bostwick, E. Bartelt, M. Muñoz-Laboy, D. Pletta, M. Reece, and T. G. M. Sandfort. 2016. Attitudes toward bisexual men and women among a nationally representative probability sample of adults in the United States. PLoS One 11(10):e0164430.

Doherty, I. A., V. J. Schoenbach, and A. A. Adimora. 2009. Sexual mixing patterns and heterosexual HIV transmission among African Americans in the southeastern United States. Journal of Acquired Immune Deficiency Syndromes 52(1):114-120.

Doyle, K. E., C. Sionean, G. Paz-Bailey, N. D. Hollis, D. Kanny, C. Wejnert, and N. S. Group. 2020. High prevalence of disability and HIV risk among low socioeconomic status urban adults, 17 U.S. Cities. Disability and Health Journal 13(1):100834.

DuBard, C. A., and M. W. Massing. 2007. Trends in emergency Medicaid expenditures for recent and undocumented immigrants. JAMA 297(10):1085-1092.

Duke, M. R., and G. M. Ames. 2008. Challenges of contraceptive use and pregnancy prevention among women in the U.S. Navy. Qualitative Health Research 18(2):244-253.

Dunkle, K. L., G. M. Wingood, C. M. Camp, and R. J. DiClemente. 2010. Economically motivated relationships and transactional sex among unmarried African American and white women: Results from a U.S. national telephone survey. Public Health Reports 125(Suppl 4):90-100.

Duran, B., J. Oetzel, J. Lucero, Y. Jiang, D. K. Novins, S. Manson, and J. Beals. 2005. Obstacles for rural American Indians seeking alcohol, drug, or mental health treatment. Journal of Consulting and Clinical Psychology 73(5):819-829.

Dutton, L., K. Koenig, and K. Fennie. 2008. Gynecologic care of the female-to-male transgender man. Journal of Midwifery & Women’s Health 53(4):331-337.

Dyer, T. V., R. E. Turpin, R. Stall, M. R. Khan, L. E. Nelson, R. Brewer, M. R. Friedman, M. J. Mimiaga, R. L. Cook, C. O Cleirigh, and K. H. Mayer. 2020. Latent profile analysis of a syndemic of vulnerability factors on incident sexually transmitted infection in a cohort of Black men who have sex with men only and Black men who have sex with men and women in the HIV Prevention Trials Network 061 study. Sexually Transmitted Diseases 47(9):571-579.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Eberl, J. T. 2019. Conscientious objection in health care. Theoretical Medicine and Bioethics 40(6):483-486.

Edmiston, E. K., C. A. Donald, A. R. Sattler, J. K. Peebles, J. M. Ehrenfeld, and K. L. Eckstrand. 2016. Opportunities and gaps in primary care preventative health services for transgender patients: A systematic review. Transgender Health 1(1):216-230.

Edwards, J. M., B. J. Iritani, and D. D. Hallfors. 2006. Prevalence and correlates of exchanging sex for drugs or money among adolescents in the United States. Sexually Transmitted Infections 82(5):354-358.

Ehlers, C. L., I. R. Gizer, D. A. Gilder, and R. Yehuda. 2013. Lifetime history of traumatic events in an American Indian community sample: Heritability and relation to substance dependence, affective disorder, conduct disorder and PTSD. Journal of Psychiatric Research 47(2):155-161.

Eitle, D., K. Greene, and T. M. Eitle. 2015. American Indians, substance use, and sexual behavior: Do predictors of sexually transmitted infections explain the race gap among young adults? Sexually Transmitted Diseases 42(2):64-67.

Eitzen, J. P., and R. G. Sawyer. 1997. Sexually transmitted diseases: Risk behaviors of female active duty U.S. Army recruits. Military Medicine 162(10):686-689.

Ellen, J. M., B. A. Brown, S. E. Chung, J. J. Potterat, S. Q. Muth, T. W. Valente, and N. S. Padian. 2005. Impact of sexual networks on risk for gonorrhea and chlamydia among low-income urban African American adolescents. The Journal of Pediatrics 146(4):518-522.

Epperson, M. W., N. El-Bassel, M. Chang, and L. Gilbert. 2010. Examining the temporal relationship between criminal justice involvement and sexual risk behaviors among drug-involved men. Journal of Urban Health 87(2):324-336.

Epstein, M., J. A. Bailey, L. E. Manhart, K. G. Hill, J. D. Hawkins, K. P. Haggerty, and R. F. Catalano. 2014. Understanding the link between early sexual initiation and later sexually transmitted infection: Test and replication in two longitudinal studies. Journal of Adolescent Health 54(4):435-441.

Everett, B. G. 2013. Sexual orientation disparities in sexually transmitted infections: Examining the intersection between sexual identity and sexual behavior. Archives of Sexual Behavior 42(2):225-236.

Everett, B. G., P. W. Schnarrs, M. Rosario, R. Garofalo, and B. Mustanski. 2014. Sexual orientation disparities in sexually transmitted infection risk behaviors and risk determinants among sexually active adolescent males: Results from a school-based sample. American Journal of Public Health 104(6):1107-1112.

Everett, B. G., M. L. Hatzenbuehler, and T. L. Hughes. 2016. The impact of civil union legislation on minority stress, depression, and hazardous drinking in a diverse sample of sexual-minority women: A quasi-natural experiment. Social Science & Medicine 169:180-190.

Ewing, S. W., and A. D. Bryan. 2015. A question of love and trust? The role of relationship factors in adolescent sexual decision making. Journal of Developmental and Behavioral Pediatrics 36(8):628-634.

Ezell, J. M., M. J. Ferreira, D. T. Duncan, and J. A. Schneider. 2018. The social and sexual networks of Black transgender women and Black men who have sex with men: Results from a representative sample. Transgender Health 3(1):201-209.

Fair, C. D., and J. Vanyur. 2011. Sexual coercion, verbal aggression, and condom use consistency among college students. Journal of American College Health 59(4):273-280.

Fichtenberg, C. M., S. Q. Muth, B. Brown, N. S. Padian, T. A. Glass, and J. M. Ellen. 2009. Sexual network position and risk of sexually transmitted infections. Sexually Transmitted Infections 85(7):493-498.

Fieland, K. C., K. L. Walters, and J. M. Simoni. 2007. Determinants of health among two-spirit American Indians and Alaska Natives. In The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations, edited by I. H. Meyer and M. E. Northridge. Springer Science+Business Media. Pp. 268-300.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Fishman, S. J., and E. H. Anderson. 2003. Perception of HIV and safer sexual behaviors among lesbians. Journal of the Association of Nurses in AIDS Care 14(6):48-55.

Flanders, C. E., C. Dobinson, and C. Logie. 2015. “I’m never really my full self”: Young bisexual women’s perceptions of their mental health. Journal of Bisexuality 15(4):454-480.

Flanigan, T. P., N. Zaller, C. G. Beckwith, L. B. Bazerman, A. Rana, A. Gardner, D. A. Wohl, and F. L. Altice. 2010. Testing for HIV, sexually transmitted infections, and viral hepatitis in jails: Still a missed opportunity for public health and HIV prevention. Journal of Acquired Immune Deficiency Syndromes 55(Suppl 2):S78-83.

Folch, C., J. Casabona, A. Espelt, X. Majó, M. Meroño, V. Gonzalez, L. Wiessing, J. Colom, and M. T. Brugal. 2016. High prevalence and incidence of HIV and HCV among new injecting drug users with a large proportion of migrants—is prevention failing? Substance Use & Misuse 51(2):250-260.

Ford, C. A., A. F. Davenport, A. Meier, and A. L. McRee. 2011. Partnerships between parents and health care professionals to improve adolescent health. Journal of Adolescent Health 49(1):53-57.

Ford, K., and J. M. Lepkowski. 2004. Characteristics of sexual partners and STD infection among American adolescents. International Journal of STD & AIDS 15(4):260-265.

Fortenberry, J. D., W. Tu, J. Harezlak, B. P. Katz, and D. P. Orr. 2002. Condom use as a function of time in new and established adolescent sexual relationships. American Journal of Public Health 92(2):211-213.

Friedman, M. S., M. P. Marshal, T. E. Guadamuz, C. Wei, C. F. Wong, E. Saewyc, and R. Stall. 2011. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. American Journal of Public Health 101(8):1481-1494.

Friedman, S. R., and S. Aral. 2001. Social networks, risk-potential networks, health, and disease. Journal of Urban Health 78(3):411-418.

Frost, D. M., K. Lehavot, and I. H. Meyer. 2015. Minority stress and physical health among sexual minority individuals. Journal of Behavioral Medicine 38(1):1-8.

Frye, V., L. Wilton, S. Hirshfied, M. A. Chiasson, D. Usher, D. Lucy, J. McCrossin, E. Greene, B. Koblin, and The All About Me Study. 2015. “Just because it’s out there, people aren’t going to use it.” HIV self-testing among young, Black MSM, and transgender women. AIDS Patient Care and STDs 29(11):617-624.

Fujimoto, K., C. A. Flash, L. M. Kuhns, J.-Y. Kim, and J. A. Schneider. 2018. Social networks as drivers of syphilis and HIV infection among young men who have sex with men. Sexually Transmitted Infections 94(5):365.

Fuzzell, L., C. G. Shields, S. C. Alexander, and J. D. Fortenberry. 2017. Physicians talking about sex, sexuality, and protection with adolescents. Journal of Adolescent Health 61(1):6-23.

Gaines, T. L., A. E. Rudolph, K. C. Brouwer, S. A. Strathdee, R. Lozada, G. Martinez, S. M. Goldenberg, and M. L. Rusch. 2013. The longitudinal association of venue stability with consistent condom use among female sex workers in two Mexico–USA border cities. International Journal of STD & AIDS 24(7):523-529.

Gallion, H. R., L. J. Milam, and L. L. Littrell. 2016. Genital findings in cases of child sexual abuse: Genital vs. vaginal penetration. Journal of Pediatric and Adolescent Gynecology 29(6):604-611.

Galupo, M. P., S. B. Henise, and N. L. Mercer. 2016. “The labels don’t work very well”: Transgender individuals’ conceptualizations of sexual orientation and sexual identity. International Journal of Transgenderism 17(2):93-104.

GAO (Government Accountability Office). 2005. Health care services are not always available to Native Americans. Washington, DC: Government Accountability Office.

Garwick, A. W., K. L. Rhodes, M. Peterson-Hickey, and W. L. Hellerstedt. 2008. Native teen voices: Adolescent pregnancy prevention recommendations. Journal of Adolescent Health 42(1):81-88.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Gates, M. L., M. Staples-Horne, J. Cartier, C. Best, V. Walker, D. Schwartz, and W. Yoo. 2015. Understanding psychosocial and high-risk sexual behaviors among detained juveniles: A descriptive study protocol. JMIR Research Protocols 4(4):e144.

Gates, M. L., M. Staples-Horne, J. Cartier, C. Best, R. Stone, V. Walker, B. Hastings, W. Yoo, N. C. Webb, and R. L. Braithwaite. 2016. A call to develop evidence-based interventions to reduce sexually transmitted infections in juvenile justice populations. Journal of Health Care for the Poor and Underserved 27(2A):34-44.

Gause, N. K., J. L. Brown, J. Welge, and N. Northern. 2018. Meta-analyses of HIV prevention interventions targeting improved partner communication: Effects on partner communication and condom use frequency outcomes. Journal of Behavioral Medicine 41(4):423-440.

Gavin, L. E., J. R. Williams, M. I. Rivera, and C. R. Lachance. 2015. Programs to strengthen parent-adolescent communication about reproductive health: A systematic review. American Journal of Preventative Medicine 49(2 Suppl 1):S65-S72.

Gavril, A. R., N. D. Kellogg, and P. Nair. 2012. Value of follow-up examinations of children and adolescents evaluated for sexual abuse and assault. Pediatrics 129(2):282-289.

Gaydos, C. A., M. R. Howell, T. C. Quinn, K. T. McKee, Jr., and J. C. Gaydos. 2003. Sustained high prevalence of Chlamydia trachomatis infections in female Army recruits. Sexually Transmitted Diseases 30(7):539-544.

Gaydos, J. C., K. T. McKee, Jr., and C. A. Gaydos. 2013. The changing landscape of controlling sexually transmitted infections in the U.S. military. Medical Surveillance Monthly Report 20(2):2-4.

Gaydos, J. C., K. T. McKee, Jr., and D. J. Faix. 2015. Sexually transmitted infections in the military: New challenges for an old problem. Sexually Transmitted Infections 91(8):536-537.

Gerassi, L., M. Jonson-Reid, and B. Drake. 2016. Sexually transmitted infections in a sample of at-risk youth: Roles of mental health and trauma histories. Journal of Child & Adolescent Trauma 9(3):209-216.

Gesink, D., L. Whiskeyjack, T. Suntjens, A. Mihic, and P. McGilvery. 2016. Abuse of power in relationships and sexual health. Child Abuse & Neglect 58:12-23.

Girardet, R. G., S. Lahoti, L. A. Howard, N. N. Fajman, M. K. Sawyer, E. M. Driebe, F. Lee, R. L. Sautter, E. Greenwald, C. M. Beck-Sagué, M. R. Hammerschlag, and C. M. Black. 2009. Epidemiology of sexually transmitted infections in suspected child victims of sexual assault. Pediatrics 124(1):79-86.

Glick, S. N., M. Morris, B. Foxman, S. O. Aral, L. E. Manhart, K. K. Holmes, and M. R. Golden. 2012. A comparison of sexual behavior patterns among men who have sex with men and heterosexual men and women. Journal of Acquired Immune Deficiency Syndromes 60(1):83-90.

Goldberg, A., and J. Moore. 2018. Domestic minor sex trafficking. Child and Adolescent Psychiatric Clinics of North America 27(1):77-92.

Goldstein, B. Y., J. K. Steinberg, G. Aynalem, and P. R. Kerndt. 2011. High chlamydia and gonorrhea incidence and reinfection among performers in the adult film industry. Sexually Transmitted Diseases 38(7):644-648.

Golub, A., B. D. Johnson, and E. Dunlap. 2007. The race/ethnicity disparity in misdemeanor marijuana arrests in New York City. Criminology & Public Policy 6(1):131-164.

Gonzales, K. L., A. K. Harding, W. E. Lambert, R. Fu, and W. G. Henderson. 2013. Perceived experiences of discrimination in health care: A barrier for cancer screening among American Indian women with type 2 diabetes. Women’s Health Issues 23(1):e61-e67.

Gorbach, P. M., M. Javanbakht, C. L. Shover, R. K. Bolan, A. Ragsdale, and S. Shoptaw. 2019. Associations between cannabis use, sexual behavior, and sexually transmitted infections/human immunodeficiency virus in a cohort of young men who have sex with men. Sexually Transmitted Diseases 46(2):105-111.

Gorgos, L. M., and J. M. Marrazzo. 2011. Sexually transmitted infections among women who have sex with women. Clinical Infectious Diseases 53(Suppl 3):S84-S91.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Goyal, V., K. M. Mattocks, and A. G. Sadler. 2012. High-risk behavior and sexually transmitted infections among U.S. active duty servicewomen and veterans. Journal of Women’s Health 21(11):1155-1169.

Graham, L. F. 2014. Navigating community institutions: Black transgender women’s experiences in schools, the criminal justice system, and churches. Sexuality Research and Social Policy 11:274-287.

Grant, B. F., R. B. Goldstein, T. D. Saha, S. P. Chou, J. Jung, H. Zhang, R. P. Pickering, W. J. Ruan, S. M. Smith, B. Huang, and D. S. Hasin. 2015. Epidemiology of DSM-5 alcohol use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry 72(8):757-766.

Green, T. C., E. R. Pouget, M. Harrington, F. S. Taxman, A. G. Rhodes, D. O Connell, S. S. Martin, M. Prendergast, and P. D. Friedmann. 2012. Limiting options: Sex ratios, incarceration rates, and sexual risk behavior among people on probation and parole. Sexually Transmitted Diseases 39(6):424-430.

Greene, K. M., D. Eitle, and T. M. Eitle. 2018. Developmental assets and risky sexual behaviors among American Indian youth. The Journal of Early Adolescence 38(1):50-73.

Greenwood, N. W., and J. Wilkinson. 2013. Sexual and reproductive health care for women with intellectual disabilities: A primary care perspective. International Journal of Family Medicine 2013:642472.

Griese, E. R., D. B. Kenyon, and T. R. McMahon. 2016. Identifying sexual health protective factors among Northern Plains American Indian youth: An ecological approach utilizing multiple perspectives. American Indian and Alaska Native Mental Health Research (Online) 23(4):16-43.

Grov, C., D. Cain, H. J. Rendina, A. Ventuneac, and J. T. Parsons. 2016. Characteristics associated with urethral and rectal gonorrhea and chlamydia diagnoses in a U.S. national sample of gay and bisexual men: Results from the One Thousand Strong panel. Sexually Transmitted Diseases 43(3):165-171.

Guilamo-Ramos, V., A. Bouris, J. Jaccard, B. Gonzalez, W. McCoy, and D. Aranda. 2011. A parent-based intervention to reduce sexual risk behavior in early adolescence: Building alliances between physicians, social workers, and parents. Journal of Adolescent Health 48(2):159-163.

Guilamo-Ramos, V., J. J. Lee, and J. Jaccard. 2016. Parent-adolescent communication about contraception and condom use. JAMA Pediatrics 170(1):14-16.

Guilamo-Ramos, V., A. Benzekri, and M. Thimm-Kaiser. 2019a. Parent-based interventions to affect adolescent sexual and reproductive health: Reconsidering the best evidence vs all evidence. JAMA Pediatrics 173(9):821-823.

Guilamo-Ramos, V., M. Thimm-Kaiser, A. Benzekri, C. Rodriguez, T. Fuller, L. Warner, and E. Koumans. 2019b. Father-son communication about consistent and correct condom use. Pediatrics 143:e20181609.

Guilamo-Ramos, V., A. Benzekri, M. Thimm-Kaiser, P. Dittus, Y. Ruiz, C. M. Cleland, and W. McCoy. 2020. A triadic intervention for adolescent sexual health: A randomized clinical trial. Pediatrics 145(5):e20192808.

Guttmacher Institute. 2019. Minors’ access to STI services. https://www.guttmacher.org/statepolicy/explore/minors-access-sti-services (accessed December 23, 2020).

Guzmán, B., and M. E. Dello Stritto. 2012. The role of socio-psychological determinants in the sexual behaviors of Latina early adolescents. Sex Roles 66:776-789.

Habel, M. A., J. S. Leichliter, P. J. Dittus, I. H. Spicknall, and S. O. Aral. 2018. Heterosexual anal and oral sex in adolescents and adults in the United States, 2011-2015. Sexually Transmitted Diseases 45(12):775-782.

Haberland, N. A. 2015. The case for addressing gender and power in sexuality and HIV education: A comprehensive review of evaluation studies. International Perspectives on Sexual and Reproductive Health 41(1):31-42.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Haesler, E., M. Bauer, and D. Fetherstonhaugh. 2016. Sexuality, sexual health and older people: A systematic review of research on the knowledge and attitudes of health professionals. Nurse Education Today 40:57-71.

Hafeez, H., M. Zeshan, M. A. Tahir, N. Jahan, and S. Naveed. 2017. Health care disparities among lesbian, gay, bisexual, and transgender youth: A literature review. Cureus Journal of Medical Science 9(4):e1184.

Hafner, S. P., and S. Craig Rushing. 2019. Sexual health, STI and HIV risk, and risk perceptions among American Indian and Alaska Native emerging adults. Prevention Science 20(3):331-341.

Hakre, S., D. M. Brett-Major, D. E. Singer, R. J. O’Connell, W. B. Sateren, J. L. Sanchez, B. K. Agan, N. L. Michael, and P. T. Scott. 2011. Medical encounter characteristics of HIV seroconverters in the U.S. Army and Air Force, 2000-2004. Journal of Acquired Immune Deficiency Syndromes 56(4):372-380.

Hakre, S., R. J. Oyler, K. A. Ferrell, F. Li, N. L. Michael, P. T. Scott, and B. P. Petruccelli. 2014. Chlamydia trachomatis infection rates among a cohort of mobile soldiers stationed at Fort Bragg, North Carolina, 2005-2010. BMC Public Health 14:181.

Halkitis, P. N., F. Kapadia, K. L. Bub, S. Barton, A. D. Moreira, and C. B. Stults. 2015. A longitudinal investigation of syndemic conditions among young gay, bisexual, and other MSM: The P18 Cohort Study. AIDS and Behavior 19(6):970-980.

Hallfors, D. D., A. A. Haydon, C. T. Halpern, and B. J. Iritani. 2016. Patterns of risk behavior change from adolescence to emerging adulthood: Implications for HIV/STD racial disparities. In Drug use trajectories among minority youth, edited by Y. F. Thomas and L. N. Price (pp. 367-398). Dordrecht, The Netherlands: Springer Science+Business Media.

Hamilton, D. T., and M. Morris. 2015. The racial disparities in STI in the U.S.: Concurrency, STI prevalence, and heterogeneity in partner selection. Epidemics 11:56-61.

Hamilton, E., B. Bossiky, J. Ditekemena, G. Esiru, F. Fwamba, A. E. Goga, M. P. Kieffer, L. D. Tsague, R. van de Ven, R. Wafula, and L. Guay. 2017. Using the PMTCT cascade to accelerate achievement of the global plan goals. Journal of Acquired Immune Deficiency Syndromes 75(Suppl 1):S27-S35.

Hammett, T. M. 2009. Sexually transmitted diseases and incarceration. Current Opinion in Infectious Diseases 22(1):77-81.

Han, C. S., G. Ayala, J. P. Paul, R. Boylan, S. E. Gregorich, and K. H. Choi. 2015. Stress and coping with racism and their role in sexual risk for HIV among African American, Asian/Pacific Islander, and Latino men who have sex with men. Archives of Sexual Behavior 44(2):411-420.

Hansen, A., C. C. Turpyn, K. Mauro, J. C. Thompson, and T. M. Chaplin. 2019. Adolescent brain response to reward is associated with a bias toward immediate reward. Developmental Neuropsychology 44(5):417-428.

Harawa, N. T., J. K. Williams, H. C. Ramamurthi, C. Manago, S. Avina, and M. Jones. 2008. Sexual behavior, sexual identity, and substance abuse among low-income bisexual and non-gay-identifying African American men who have sex with men. Archives of Sexual Behavior 37(5):748-762.

Harbertson, J., P. T. Scott, J. Moore, M. Wolf, J. Morris, S. Thrasher, M. D’Onofrio, M. P. Grillo, M. B. Jacobs, B. R. Tran, J. Tian, S. I. Ito, J. McAnany, N. Michael, and B. R. Hale. 2015. Sexually transmitted infections and sexual behaviour of deploying shipboard U.S. military personnel: A cross-sectional analysis. Sexually Transmitted Infections 91(8):581-588.

Harbertson, J., B. R. Hale, E. Y. Watkins, N. L. Michael, and P. T. Scott. 2016. Pre-deployment alcohol misuse among shipboard active-duty U.S. military personnel. American Journal of Preventative Medicine 51(2):185-194.

Harbertson, J., K. De Vera, P. Scott, R. Shaffer, N. Michael, and B. Hale. 2017. Factors associated with not using a condom at last sex among sexually active U.S. Navy and Marine Corps personnel across a shipboard deployment. Open Forum Infectious Diseases 4(Suppl 1):S102.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Harbertson, J., P. T. Scott, H. Lemus, N. L. Michael, and B. R. Hale. 2019. Cross-sectional study of sexual behavior, alcohol use, and mental health conditions associated with sexually transmitted infections among deploying shipboard U.S. military personnel. Military Medicine 184(11-12):e693-e700.

Harling, G., S. Subramanian, T. Bärnighausen, and I. Kawachi. 2013. Socioeconomic disparities in sexually transmitted infections among young adults in the United States: Examining the interaction between income and race/ethnicity. Sexually Transmitted Diseases 40(7):575-581.

Harmon-Darrow, C., K. Burruss, and N. Finigan-Carr. 2020. “We are kind of their parents”: Child welfare workers’ perspective on sexuality education for foster youth. Children and Youth Services Review 108:104565.

Harper, C. R., R. J. Steiner, R. Lowry, S. Hufstetler, and P. J. Dittus. 2018. Variability in condom use trends by sexual risk behaviors: Findings from the 2003-2015 national Youth Risk Behavior Surveys. Sexually Transmitted Diseases 45(6):400-405.

Harrington, L. A., K. A. Shaw, and J. G. Shaw. 2017. Contraception in U.S. servicewomen: Emerging knowledge, considerations, and needs. Current Opinion in Obstetrics and Gynecology 29(6):431-436.

Harvard Health Letter. 2018. Sexually transmitted disease? At my age? Harvard Health Publishing, https://www.health.harvard.edu/diseases-and-conditions/sexually-transmitted-disease-at-my-age (accessed February 15, 2021).

Hatzenbuehler, M. L., and J. E. Pachankis. 2016. Stigma and minority stress as social determinants of health among lesbian, gay, bisexual, and transgender youth: Research evidence and clinical implications. Pediatric Clinics of North America 63(6):985-997.

He, W., Y. Jin, H. Zhu, Y. Zheng, and J. Qian. 2020. Effect of Chlamydia trachomatis on adverse pregnancy outcomes: A meta-analysis. Archives of Gynecology and Obstetrics 302(3):553-567.

Hellerstedt, W. L., M. Peterson-Hickey, K. L. Rhodes, and A. Garwick. 2006. Environmental, social, and personal correlates of having ever had sexual intercourse among American Indian youths. American Journal of Public Health 96(12):2228-2234.

Hendershot, C. S., R. E. Magnan, and A. D. Bryan. 2010. Associations of marijuana use and sex-related marijuana expectancies with HIV/STD risk behavior in high-risk adolescents. Psychology of Addictive Behaviors 24(3):404-414.

Henderson, L. 2018. The sexual health of African American and white men: Does former incarceration status matter? In Inequality, crime, and health among African American males. Research in Race and Ethnic Relations, Vol. 20: Emerald Publishing Limited. Pp. 53-71.

Hendricks, M., and R. Testa. 2012. A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice 43:460.

Henson, M., S. Sabo, A. Trujillo, and N. Teufel-Shone. 2017. Identifying protective factors to promote health in American Indian and Alaska Native adolescents: A literature review. Journal of Primary Prevention 38(1-2):5-26.

Heston, S., and S. Arnold. 2018. Syphilis in children. Infectious Disease Clinics of North America 32(1):129-144.

Heywood, W., K. Patrick, A. Smith, and M. Pitts. 2015. Associations between early first sexual intercourse and later sexual and reproductive outcomes: A systematic review of population-based data. Archives of Sexual Behavior 44:531-569.

HHS (Department of Health and Human Services). 2020. Sexually Transmitted Infections National Strategic Plan for the United States: 2021-2025. Washington, DC: Department of Health and Human Services.

Hogben, M., and J. S. Leichliter. 2008. Social determinants and sexually transmitted disease disparities. Sexually Transmitted Diseases 35(12 Suppl):S13-S18.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Hood, K. B., L. M. Pollack, D. D. Jackson, and C. B. Boyer. 2020. Associations among behavioral risk, sociodemographic identifiers, and sexually transmitted infections in male and female Army enlisted personnel. Military Medicine. doi: 10.1093/milmed/usaa247.

Hsu, K., K. Jolin, J. Miller, T. Lincoln, R. Lubelczyk, and A. E. Nijhawan. 2011. Managing STDs in the correctional setting: A guide for clinicians. Sylvie Ratelle and NCSD.

Hughes, G. D., C. Hoyo, and T. R. Puoane. 2006. Fear of sexually transmitted infections among women with male migrant partners—relationship to oscillatory migration pattern and risk-avoidance behaviour. South African Medical Journal 96(5):434-438.

Hull, S., S. Kelley, and J. L. Clarke. 2017. Sexually transmitted infections: Compelling case for an improved screening strategy. Population Health Management 20(Suppl 1):S1-S11.

Hulland, E. N., J. L. Brown, A. L. Swartzendruber, J. M. Sales, E. S. Rose, and R. J. DiClemente. 2015. The association between stress, coping, and sexual risk behaviors over 24 months among African-American female adolescents. Psychology, Health & Medicine 20(4):443-456.

Human Rights Watch. 2012. Sex workers at risk: Condoms as evidence of prostitution in four US cities. https://www.hrw.org/report/2012/07/19/sex-workers-risk/condoms-evidence-prostitution-four-us-cities# (accessed November 19, 2020).

Hutton, H. E., M. E. McCaul, G. Chander, M. W. Jenckes, C. Nollen, V. L. Sharp, and E. J. Erbelding. 2013. Alcohol use, anal sex, and other risky sexual behaviors among HIV-infected women and men. AIDS and Behavior 17(5):1694-1704.

Hwang, L. Y., M. A. Shafer, L. M. Pollack, Y. J. Chang, and C. B. Boyer. 2007. Sexual behaviors after universal screening of sexually transmitted infections in healthy young women. Obstetrics and Gynocology 109(1):105-113.

Ibragimov, U., S. Beane, S. R. Friedman, J. C. Smith, B. Tempalski, L. Williams, A. A. Adimora, G. M. Wingood, S. McKetta, R. D. Stall, and H. L. Cooper. 2020. Police killings of Black people and rates of sexually transmitted infections: A cross-sectional analysis of 75 large U.S. metropolitan areas, 2016. Sexually Transmitted Infections 96(6):429-431.

ICE (Immigration and Customs Enforcement). 2020. Detention facility locator. https://www.ice.gov/detention-facilities (accessed December 24, 2020).

Infobase. 2020. Marijuana: Should the United States legalize marijuana? Issues & Controversies. http://icof.infobaselearning.com/icofprintarticle.aspx?articleID=1621aa&citation=mla (accessed November 19, 2020).

Jackson, J. M., P. Seth, R. J. DiClemente, and A. Lin. 2015. Association of depressive symptoms and substance use with risky sexual behavior and sexually transmitted infections among African American female adolescents seeking sexual health care. American Journal of Public Health 105(10):2137-2142.

Jahn, J. L., R. A. Bishop, A. S. L. Tan, and M. Agénor. 2019. Patient-provider sexually transmitted infection prevention communication among young adult sexual minority cisgender women and nonbinary assigned female at birth individuals. Women’s Health Issues 29(4):308-314.

James, S. E., J. L. Herman, S. Rankin, M. Keisling, L. Mottet, and M. Anafi. 2016. The report of the 2015 U.S. Transgender survey. Washington, DC: National Center for Transgender Equality.

Jeffries, W. L. t., and O. D. Johnson. 2015. Homonegative attitudes and risk behaviors for HIV and other sexually transmitted infections among sexually active men in the United States. American Journal of Public Health 105(12):2466-2472.

Jenkins, R. A., P. R. Jenkins, E. D. Nannis, K. T. McKee, Jr., and L. R. Temoshok. 2000. Correlates of human immunodeficiency virus infection risk behavior in male attendees of a clinic for sexually transmitted disease. Clinical Infectious Diseases 30(4):723-729.

Joesoef, M. R., R. H. Kahn, and H. S. Weinstock. 2006. Sexually transmitted diseases in incarcerated adolescents. Current Opinion in Infectious Diseases 19(1):44-48.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Johnson, B. K. 2013. Sexually transmitted infections and older adults. Journal of Gerontological Nursing 39(11):53-60.

Johnson, P. J., K. F. Carlson, and M. O. Hearst. 2010. Healthcare disparities for American Indian veterans in the United States: A population-based study. Medical Care 48(6):563-569.

Johnston, L. D., P. M. O’Malley, J. G. Bachman, J. E. Schulenberg, M. E. Patrick, and R. A. Miech. 2015. Monitoring the Future national survey results: HIV/AIDS risk & protective behaviors among adults ages 21 to 40 in the U.S., 2004-2014. Ann Arbor, MI: Institute for Social Research, University of Michigan.

Jordan, N. N., S. E. Lee, G. Nowak, N. M. Johns, and J. C. Gaydos. 2011. Chlamydia trachomatis reported among U.S. active duty service members, 2000-2008. Military Medicine 176(3):312-319.

Kading, M. L., D. S. Hautala, L. C. Palombi, B. D. Aronson, R. C. Smith, and M. L. Walls. 2015. Flourishing: American Indian positive mental health. Society and Mental Health 5(3):203-217.

Kaestle, C. E. 2012. Selling and buying sex: A longitudinal study of risk and protective factors in adolescence. Prevention Science 13(3):314-322.

Kaestle, C. E., and M. W. Waller. 2011. Bacterial STDs and perceived risk among sexual minority young adults. Perspectives on Sexual and Reproductive Health 43(3):158-163.

Kaestle, C. E., C. T. Halpern, W. C. Miller, and C. A. Ford. 2005. Young age at first sexual intercourse and sexually transmitted infections in adolescents and young adults. American Journal of Epidemiology 161(8):774-780.

Kann, L., T. McManus, W. A. Harris, S. L. Shanklin, K. H. Flint, B. Queen, R. Lowry, D. Chyen, L. Whittle, J. Thornton, C. Lim, D. Bradford, Y. Yamakawa, M. Leon, N. Brener, and K. A. Ethier. 2018. Youth risk behavior surveillance—United States, 2017. MMWR Surveillance Summaries 67(8):1-114.

Kaplan, D. L., E. J. Jones, E. C. Olson, and C. B. Yunzal-Butler. 2013. Early age of first sex and health risk in an urban adolescent population. Journal of School Health 83(5):350-356.

Kattari, S. K., and S. Begun. 2016. On the margins of marginalized: Transgender homelessness and survival sex. Affilia 32(1):92-103.

Katz, B. P., J. D. Fortenberry, G. D. Zimet, M. J. Blythe, and D. P. Orr. 2000. Partner-specific relationship characteristics and condom use among young people with sexually transmitted diseases. The Journal of Sex Research 37(1):69-75.

Katz-Wise, S. L., S. L. Budge, E. Fugate, K. Flanagan, C. Touloumtzis, B. Rood, A. Perez-Brumer, and S. Leibowitz. 2017. Transactional pathways of transgender identity development in transgender and gender nonconforming youth and caregivers from the Trans Youth Family Study. The International Journal of Transgenderism 18(3):243-263.

Kaufman, C. E., J. Beals, C. M. Mitchell, P. Lemaster, A. Fickenscher, and The Pathways of Choice and Healthy Ways Project Teams. 2004. Stress, trauma, and risky sexual behaviour among American Indians in young adulthood. Culture, Health & Sexuality 6(4):301-318.

Kaufman, C. E., J. Desserich, C. K. Big Crow, B. Holy Rock, E. Keane, and C. M. Mitchell. 2007a. Culture, context, and sexual risk among Northern Plains American Indian youth. Social Science & Medicine (1982) 64(10):2152-2164.

Kaufman, C. E., L. Shelby, D. J. Mosure, J. Marrazzo, D. Wong, L. de Ravello, S. C. Rushing, V. Warren-Mears, L. Neel, S. J. Eagle, S. Tulloch, F. Romero, S. Patrick, and J. E. Cheek. 2007b. Within the hidden epidemic: Sexually transmitted diseases and HIV/AIDS among American Indians and Alaska Natives. Sexually Transmitted Diseases 34(10):767-777.

Kaufman, C. E., C. M. Mitchell, J. Beals, J. A. Desserich, C. Wheeler, E. M. Keane, N. R. Whitesell, A. Sam, and C. Sedey. 2009. Circle of life: Rationale, design, and baseline results of an HIV prevention intervention among young American Indian adolescents of the Northern Plains. Prevention Science 11(1):101-112.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Kawsar, M., S. Long, and O. P. Srivastava. 2008. Child sexual abuse and sexually transmitted infections: Review of joint genitourinary medicine and paediatric examination practice. International Journal of STD & AIDS 19:349-350.

Keller, L. 2020. Reducing STI cases: Young people deserve better sexual health information and services. Guttmacher Policy Review 23. https://www.guttmacher.org/gpr/2020/04/reducing-sti-cases-young-people-deserve-better-sexual-health-information-and-services (accessed November 16, 2020).

Kenagy, G. P. 2005. Transgender health: Findings from two needs assessment studies in Philadelphia. Health & Social Work 30(1):19-26.

Kenagy, G. P., and C. M. Hsieh. 2005. The risk less known: Female-to-male transgender persons’ vulnerability to HIV infection. AIDS Care 17(2):195-207.

Khalili, J., L. B. Leung, and A. L. Diamant. 2015. Finding the perfect doctor: Identifying lesbian, gay, bisexual, and transgender-competent physicians. American Journal of Public Health 105(6):1114-1119.

Khan, M. R., J. S. Kaufman, B. W. Pence, B. N. Gaynes, A. A. Adimora, S. S. Weir, and W. C. Miller. 2009. Depression, sexually transmitted infection, and sexual risk behavior among young adults in the United States. Archives of Pediatrics & Adolescent Medicine 163(7):644-652.

Khan, M. R., L. Behrend, A. A. Adimora, S. S. Weir, B. L. White, and D. A. Wohl. 2011a. Dissolution of primary intimate relationships during incarceration and implications for post-release HIV transmission. Journal of Urban Health 88(2):365-375.

Khan, M. R., M. W. Epperson, P. Mateu-Gelabert, M. Bolyard, M. Sandoval, and S. R. Friedman. 2011b. Incarceration, sex with an STI- or HIV-infected partner, and infection with an STI or HIV in Bushwick, Brooklyn, NY: A social network perspective. American Journal of Public Health 101(6):1110-1117.

Khan, M. R., A. T. Berger, B. E. Wells, and C. M. Cleland. 2012. Longitudinal associations between adolescent alcohol use and adulthood sexual risk behavior and sexually transmitted infection in the United States: Assessment of differences by race. American Journal of Public Health 102(5):867-876.

Khanna, A., S. M. Goodreau, D. Wohlfeiler, E. Daar, S. Little, and P. M. Gorbach. 2015. Individualized diagnosis interventions can add significant effectiveness in reducing human immunodeficiency virus incidence among men who have sex with men: Insights from Southern California. Annals of Epidemiology 25(1):1-6.

Kimball, A., E. Torrone, K. Miele, L. Bachmann, P. Thorpe, H. Weinstock, and V. Bowen. 2020. Missed opportunities for prevention of congenital syphilis—United States, 2018. Morbidity and Mortality Weekly Report 69:661-665.

Kimerling, R., K. Gima, M. W. Smith, A. Street, and S. Frayne. 2007. The Veterans Health Administration and military sexual trauma. American Journal of Public Health 97(12):2160-2166.

King, B. A., D. G. Gammon, K. L. Marynak, and T. Rogers. 2018. Electronic cigarette sales in the United States, 2013-2017. JAMA 320(13):1379-1380.

Kissinger, P., S. Kovacs, C. Anderson-Smits, N. Schmidt, O. Salinas, J. Hembling, A. Beau-lieu, L. Longfellow, N. Liddon, J. Rice, and M. Shedlin. 2012. Patterns and predictors of HIV/STI risk among Latino migrant men in a new receiving community. AIDS and Behavior 16(1):199-213.

Knittel, A. K., and J. Lorvick. 2019. Self-reported sexually-transmitted infections and criminal justice involvement among women who use drugs. Addictive Behaviors Reports 10:100219.

Knittel, A. K., B. H. Lambdin, M. L. Comfort, A. H. Kral, and J. Lorvick. 2019. Sexual risk and criminal justice involvement among women who use drugs. AIDS and Behavior 23(12):3366-3374.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Kouyoumdjian, F. G., D. Leto, S. John, H. Henein, and S. Bondy. 2012. A systematic review and meta-analysis of the prevalence of chlamydia, gonorrhoea and syphilis in incarcerated persons. International Journal of STD & AIDS 23(4):248-254.

Krahn, G. L., D. K. Walker, and R. Correa-De-Araujo. 2015. Persons with disabilities as an unrecognized health disparity population. American Journal of Public Health 105(Suppl 2):S198-S206.

Kralik, J. 2019. “Bathroom bill” legislative tracking. https://www.ncsl.org/research/education/-bathroom-bill-legislative-tracking635951130.aspx (accessed December 4, 2020).

Krieger, D., C. Abe, A. Pottorff, X. Li, J. Rich, and A. E. Nijhawan. 2019. Sexually transmitted infections detected during and after incarceration among people with human immunodeficiency virus: Prevalence and implications for screening and prevention. Sexually Transmitted Diseases 46(9):602-607.

Krüsi, A., K. Pacey, L. Bird, C. Taylor, J. Chettiar, S. Allan, D. Bennett, J. S. Montaner, T. Kerr, and K. Shannon. 2014. Criminalisation of clients: Reproducing vulnerabilities for violence and poor health among street-based sex workers in Canada—a qualitative study. BMJ Open 4(6):e005191.

Kuhns, L. M., M. J. Mimiaga, S. L. Reisner, K. Biello, and R. Garofalo. 2017. Project Lifeskills—a randomized controlled efficacy trial of a culturally tailored, empowerment-based, and group-delivered HIV prevention intervention for young transgender women: Study protocol. BMC Public Health 17(1):713.

Kusunoki, Y., and D. M. Upchurch. 2011. Contraceptive method choice among youth in the United States: The importance of relationship context. Demography 48(4):1451-1472.

LaFromboise, T. D., and M. Dizon. 2003. American Indian children and adolescents. In Children of Color: Psychological Interventions with Culturally Diverse Youth, edited by J. T. Gibbs and L. N. Huang. San Francisco, CA: Jossey-Bass. Pp. 45-90.

LaFromboise, T. D., D. R. Hoyt, L. Oliver, and L. B. Whitbeck. 2006. Family, community, and school influences on resilience among American Indian adolescents in the upper midwest. Journal of Community Psychology 34(2):193-209.

Lalor, K., and R. McElvaney. 2010. Child sexual abuse, links to later sexual exploitation/high-risk sexual behavior, and prevention/treatment programs. Trauma Violence Abuse 11(4):159-177.

Lara, L. A. S., and C. H. N. Abdo. 2016. Age at time of initial sexual intercourse and health of adolescent girls. Journal of Pediatric and Adolescent Gynecology 29(5):417-423.

Lavoie, F., C. Thibodeau, M. H. Gagné, and M. Hébert. 2010. Buying and selling sex in Québec adolescents: A study of risk and protective factors. Archives of Sexual Behavior 39(5):1147-1160.

Lawrence, J. 2000. The Indian Health Service and the sterilization of Native American women. American Indian Quarterly 24(3):400-419.

Lederman, E., A. Blackwell, G. Tomkus, M. Rios, B. Stephen, A. Rivera, and P. Farabaugh. 2020. Opt-out testing pilot for sexually transmitted infections among immigrant detainees at 2 Immigration and Customs Enforcement Health Service Corps–staffed detention facilities, 2018. Public Health Reports 135(1 Suppl):82S-89S.

Lee, K. C., Q. Ngo-Metzger, T. Wolff, J. Chowdhury, M. L. LeFevre, and D. S. Meyers. 2016. Sexually transmitted infections: Recommendations from the U.S. Preventive Services Task Force. American Family Physician 94(11):907-915.

Lee, Y. M., A. Cintron, and S. Kocher. 2014. Factors related to risky sexual behaviors and effective STI/HIV and pregnancy intervention programs for African American adolescents. Public Health Nursing 31(5):414-427.

Lemoine, J., S. B. Teal, M. Peters, and M. Guiahi. 2017. Motivating factors for dual-method contraceptive use among adolescents and young women: A qualitative investigation. Contraception 96(5):352-356.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Lenoir, C. D., N. E. Adler, D. L. Borzekowski, J. M. Tschann, and J. M. Ellen. 2006. What you don’t know can hurt you: Perceptions of sex-partner concurrency and partner-reported behavior. Journal of Adolescent Health 38(3):179-185.

Leston, J. D., C. M. Jessen, and B. C. Simons. 2012. Alaska Native and rural youth views of sexual health: A focus group project on sexually transmitted diseases, HIV/AIDS, and unplanned pregnancy. American Indian and Alaska Native Mental Health Research (Online) 19(1):1-14.

Levine, E. C., O. Martinez, B. Mattera, E. Wu, S. Arreola, S. E. Rutledge, B. Newman, L. Icard, M. Muñoz-Laboy, C. Hausmann-Stabile, S. Welles, S. D. Rhodes, B. M. Dodge, S. Alfonso, M. I. Fernandez, and A. Carballo-Diéguez. 2018. Child sexual abuse and adult mental health, sexual risk behaviors, and drinking patterns among Latino men who have sex with men. Journal of Child Sexual Abuse 27(3):237-253.

Lim, S., T. W. Powell, Q.-L. Xue, V. L. Towe, R. B. Taylor, J. M. Ellen, and S. G. Sherman. 2019. The longitudinal association between perceived powerlessness and sexual risk behaviors among urban youth: Mediating and moderating effects. Journal of Youth and Adolescence 48(8):1532-1543.

Lindau, S. T., L. P. Schumm, E. O. Laumann, W. Levinson, C. A. O’Muircheartaigh, and L. J. Waite. 2007. A study of sexuality and health among older adults in the United States. New England Journal of Medicine 357(8):762-774.

Lindley, L. L., C. L. Barnett, H. M. Brandt, J. W. Hardin, and M. Burcin. 2008. STDs among sexually active female college students: Does sexual orientation make a difference? Perspectives on Sexual and Reproductive Health 40(4):212-217.

London, S., K. Quinn, J. D. Scheidell, B. C. Frueh, and M. R. Khan. 2017. Adverse experiences in childhood and sexually transmitted infection risk from adolescence into adulthood. Sexually Transmitted Diseases 44(9):524-532.

Lopez, C. M., D. Solomon, S. D. Boulware, and E. R. Christison-Lagay. 2018. Trends in the use of puberty blockers among transgender children in the United States. Journal of Pediatric Endocrinology and Metabolism 31(6):665-670.

Lown, E. A., M. B. Nayak, R. A. Korcha, and T. K. Greenfield. 2011. Child physical and sexual abuse: A comprehensive look at alcohol consumption patterns, consequences, and dependence from the National Alcohol Survey. Alcoholism, Clinical and Experimental Research 35(2):317-325.

Lowry, R., L. Robin, and L. Kann. 2017. Effect of forced sexual intercourse on associations between early sexual debut and other health risk behaviors among US high school students. Journal of School Health 87(6):435-447.

Lubin, G. 2012. There are 42 million prostitutes in the world and here’s where they live. https://www.businessinsider.com/there-are-42-million-prostitutes-in-the-world-and-heres-where-they-live-2012-1 (accessed January 6, 2021).

Lyons, H. A. 2017. Heterosexual casual sex and STI diagnosis: A latent class analysis. International Journal of Sexual Health 29(1):32-47.

Lyons, H. A., W. D. Manning, M. A. Longmore, and P. C. Giordano. 2015. Gender and casual sexual activity from adolescence to emerging adulthood: Social and life course correlates. Journal of Sex Research 52(5):543-557.

Macapagal, K., D. A. Moskowitz, D. H. Li, A. Carrión, E. Bettin, C. B. Fisher, and B. Mustanski. 2018. Hookup app use, sexual behavior, and sexual health among adolescent men who have sex with men in the United States. Journal of Adolescent Health 62(6):708-715.

MacPhee, D., J. Fritz, and J. Miller-Heyl. 1996. Ethnic variations in personal social networks and parenting. Child Development 67(6):3278-3295.

Madkour, A. S., T. Farhat, C. T. Halpern, E. Godeau, and S. N. Gabhainn. 2010. Early adolescent sexual initiation as a problem behavior: A comparative study of five nations. Journal of Adolescent Health 47(4):389-398.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Mandell, D. S., C. C. Eleey, J. A. Cederbaum, E. Noll, M. K. Hutchinson, L. S. Jemmott, and M. B. Blank. 2008. Sexually transmitted infection among adolescents receiving special education services. The Journal of School Health 78(7):382-388.

Marcellin, R. L., G. R. Bauer, and A. I. Scheim. 2013. Intersecting impacts of transphobia and racism on HIV risk among trans persons of colour in Ontario, Canada. Ethnicity and Inequalities in Health and Social Care 6(4):97-107.

Markham, C. M., S. Craig Rushing, C. Jessen, T. L. Lane, G. Gorman, A. Gaston, T. K. Revels, J. Torres, J. Williamson, E. R. Baumler, R. C. Addy, M. F. Peskin, and R. Shegog. 2015. Factors associated with early sexual experience among American Indian and Alaska Native youth. Journal of Adolescent Health 57(3):334-341.

Marrazzo, J. M. 2004. Barriers to infectious disease care among lesbians. Emerging Infectious Diseases 10(11):1974-1978.

Marrazzo, J. M., and L. M. Gorgos. 2012. Emerging sexual health issues among women who have sex with women. Current Infectious Disease Reports 14:204-211.

Marrazzo, J. M., L. A. Koutsky, K. L. Stine, J. M. Kuypers, T. A. Grubert, D. A. Galloway, N. B. Kiviat, and H. H. Handsfield. 1998. Genital human papillomavirus infection in women who have sex with women. The Journal of Infectious Diseases 178(6):1604-1609.

Marrazzo, J. M., L. A. Koutsky, N. B. Kiviat, J. M. Kuypers, and K. Stine. 2001. Papanicolaou test screening and prevalence of genital human papillomavirus among women who have sex with women. American Journal of Public Health 91(6):947-952.

Marrazzo, J. M., P. Coffey, and A. Bingham. 2005. Sexual practices, risk perception and knowledge of sexually transmitted disease risk among lesbian and bisexual women. Perspectives on Sexual Reproductive Health 37(1):6-12.

Marshall, B. D., K. Shannon, T. Kerr, R. Zhang, and E. Wood. 2010. Survival sex work and increased HIV risk among sexual minority street-involved youth. Journal of Acquired Immune Deficiency Syndromes 53(5):661-664.

Masel, J., R. G. Deiss, X. Wang, J. L. Sanchez, A. Ganesan, G. E. Macalino, J. C. Gaydos, M. G. Kortepeter, and B. K. Agan. 2015. Seroprevalence and seroincidence of herpes simplex virus (2006-2010), syphilis (2006-2010), and vaccine-preventable human papillomavirus subtypes (2000-2010) among U.S. military personnel. Sexually Transmitted Diseases 42(5):253-258.

Masters, N. T., W. H. George, K. C. Davis, J. Norris, J. R. Heiman, A. J. Jacques-Tiura, A. K. Gilmore, H. V. Nguyen, K. F. Kajumulo, J. M. Otto, and C. A. Stappenbeck. 2014. Women’s unprotected sex intentions: Roles of sexual victimization, intoxication, and partner perception. Journal of Sex Research 51(5):586-598.

Matson, P. A., N. E. Adler, S. G. Millstein, J. M. Tschann, and J. M. Ellen. 2011. Developmental changes in condom use among urban adolescent females: Influence of partner context. Journal of Adolescent Health 48(4):386-390.

Matson, P. A., J. D. Fortenberry, S. E. Chung, C. A. Gaydos, and J. M. Ellen. 2018. Weekly variations in feelings of trust predict incident STI within a prospective cohort of adolescent women from a US city. Sexually Transmitted Infections 94(8):594-597.

Mayer, J. P. 1997. Unintended childbearing, maternal beliefs, and delay of prenatal care. Birth 24(4):247-252.

Mayer, K. H. 2011. Sexually transmitted diseases in men who have sex with men. Clinical Infectious Diseases 53(Suppl 3):S79-S83.

Mazul, M. C., T. C. Salm Ward, and E. M. Ngui. 2017. Anatomy of good prenatal care: Perspectives of low income African-American women on barriers and facilitators to prenatal care. Journal of Racial and Ethnic Health Disparities 4(1):79-86.

McCabe, S. E., B. T. West, P. Veliz, and C. J. Boyd. 2017. E-cigarette use, cigarette smoking, dual use, and problem behaviors among U.S. adolescents: Results from a national survey. Journal of Adolescent Health 61(2):155-162.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

McCool-Myers, M., A. Myo, and J. A. Carter. 2019. Barriers to purchasing condoms in a high HIV/STI-risk urban area. Journal of Community Health 44(4):836-843.

McCree, D. H., and M. Hogben. 2010. The contribution to and context of other sexually transmitted diseases and tuberculosis in the HIV/AIDS epidemic among African Americans. In African Americans and HIV/AIDS: Understanding and addressing the epidemic, edited by D. H. McCree, K. Jones, and A. O’Leary. New York: Springer.

McKirnan, D. J., P. A. Vanable, D. G. Ostrow, and B. Hope. 2001. Expectancies of sexual “escape” and sexual risk among drug and alcohol-involved gay and bisexual men. Journal of Substance Abuse Treatment 13(1-2):137-154.

McMahon, T. R., J. D. Hanson, E. R. Griese, and D. B. Kenyon. 2015. Teen pregnancy prevention program recommendations from urban and reservation Northern Plains American Indian community members. American Journal of Sexuality Education 10(3):218-241.

McNair, R. 2005. Risks and prevention of sexually transmissible infections among women who have sex with women. Sexual Health 2(4):209-217.

Medina-Perucha, L., H. Family, J. Scott, S. Chapman, and C. Dack. 2019. Factors associated with sexual risks and risk of STIs, HIV and other blood-borne viruses among women using heroin and other drugs: A systematic literature review. AIDS and Behavior 23(1):222-251.

Meier, A., and G. Allen. 2009. Romantic relationships from adolescence to young adulthood: Evidence from the National Longitudinal Study of Adolescent Health. The Sociological Quarterly 50(2):308-335.

Menza, T. W., and K. H. Mayer. 2019. HIV and sexually transmitted infection vulnerability among heterosexual couples involved in the criminal justice system—the corrections connection. JAMA Network Open 2(3):e191165.

Metrik, J., A. J. Caswell, M. Magill, P. M. Monti, and C. W. Kahler. 2016. Sexual risk behavior and heavy drinking among weekly marijuana users. Journal of Studies on Alcohol and Drugs 77(1):104-112.

Miller, V. A., E. Friedrich, J. F. García-España, J. H. Mirman, and C. A. Ford. 2018. Adolescents spending time alone with pediatricians during routine visits: Perspectives of parents in a primary care clinic. Journal of Adolescent Health 63(3):280-285.

Millett, G. A., J. L. Peterson, S. A. Flores, T. A. Hart, W. L. Jeffries, P. A. Wilson, S. B. Rourke, C. M. Heilig, J. Elford, K. A. Fenton, and R. S. Remis. 2012. Comparisons of disparities and risks of HIV infection in Black and other men who have sex with men in Canada, UK, and USA: A meta-analysis. The Lancet 380(9839):341-348.

Mitchell, C. M., N. R. Whitesell, P. Spicer, J. Beals, C. E. Kaufman, and the Pathways of Choice Healthy Ways Project Team. 2007. Cumulative risk for early sexual initiation among American Indian youth: A discrete-time survival analysis. Journal of Research on Adolescence 17(2):387-412.

Mizuno, Y., C. Borkowf, G. A. Millett, T. Bingham, G. Ayala, and A. Stueve. 2012. Homophobia and racism experienced by Latino men who have sex with men in the United States: Correlates of exposure and associations with HIV risk behaviors. AIDS and Behavior 16(3):724-735.

Moilanen, K. L., C. A. Markstrom, and E. Jones. 2014. Extracurricular activity availability and participation and substance use among American Indian adolescents. Journal of Youth and Adolescence 43(3):454-469.

Moore, P. 2016. Significant gender gap on legalizing prostitution. https://today.yougov.com/topics/politics/articles-reports/2016/03/10/prostitution (accessed November 19, 2020).

Morgan, E., B. Skaathun, N. Lancki, A. D. Jimenez, J. Ramirez-Valles, R. Bhatia, S. MasielloSchuette, N. Benbow, N. Prachand, and J. A. Schneider. 2017. Trends in HIV risk, testing, and treatment among MSM in Chicago 2004-2014: Implications for HIV elimination planning. Journal of Urban Health 94(5):699-709.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Morral, A. R., K. L. Gore, T. L. Schell, B. Bicksler, C. Farris, B. Ghosh-Dastidar, L. H. Jaycox, D. Kilpatrick, S. Kistler, A. Street, T. Tanielian, and K. M. Williams. 2015. Sexual assault and sexual harassment in the U.S. military: Volume 2. Estimates for Department of Defense service members from the 2014 rand military workplace study. Santa Monica, CA: RAND Corporation.

Mosher, W., T. Bloom, R. Hughes, L. Horton, R. Mojtabai, and J. L. Alhusen. 2017. Disparities in receipt of family planning services by disability status: New estimates from the National Survey of Family Growth. Disability and Health Journal 10(3):394-399.

Moss, M. 2010. American Indian health disparities: By the sufferance of Congress? Hamline Journal of Public Law & Policy 32:59.

Muñoz-Laboy, M., J. Garcia, A. Perry, V. Guilamo-Ramos, J. Lee, and K. V. Lotz. 2013. Social network factors associated with sexually transmitted infections among formerly incarcerated Latino men. International Journal of Sexual Health 25(2):163-168.

Murray, B. L. 2019. Sexual health education for adolescents with developmental disabilities. Health Education Journal 78(8):1000-1011.

Mustanski, B., A. Van Wagenen, M. Birkett, S. Eyster, and H. L. Corliss. 2014. Identifying sexual orientation health disparities in adolescents: Analysis of pooled data from the Youth Risk Behavior Survey, 2005 and 2007. American Journal of Public Health 104(2):211-217.

Mustanski, B., B. A. Feinstein, K. Madkins, P. Sullivan, and G. Swann. 2017. Prevalence and risk factors for rectal and urethral sexually transmitted infections from self-collected samples among young men who have sex with men participating in the Keep It Up! 2.0 randomized controlled trial. Sexually Transmitted Diseases 44(8):483-488.

Muzny, C. A., C. A. Rivers, E. L. Austin, and J. R. Schwebke. 2013. Trichomonas vaginalis infection among women receiving gynaecological care at an Alabama HIV clinic. Sexually Transmitted Infections 89(6):514-518.

Muzny, C. A., A. E. Perez, E. F. Eaton, and M. Agenor. 2018. Psychosocial stressors and sexual health among southern African American women who have sex with women. LGBT Health 5(4):234-241.

Naimi, T. S., R. D. Brewer, A. Mokdad, C. Denny, M. K. Serdula, and J. S. Marks. 2003. Binge drinking among U.S. adults. JAMA 289(1):70-75.

NASEM (National Academies of Sciences, Engineering, and Medicine). 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press.

NASEM. 2019a. The promise of adolescence: Realizing opportunity for all youth. Washington, DC: The National Academies Press.

NASEM. 2019b. Vibrant and healthy kids: Aligning science, practice, and policy to advance health equity. Washington, DC: The National Academies Press.

NASEM. 2020. Understanding the well-being of LGBTQI+ populations. Washington, DC: The National Academies Press.

NCCHC (National Commission on Correctional Health Care). 2014. STI testing for adolescents and adults upon admission to correctional facilities. https://www.ncchc.org/STI-testing-upon-admission (accessed December 23, 2020).

NCCHC. 2020. STI testing for adolescents and adults upon admission to correctional facilities. https://www.ncchc.org/STI-testing-upon-admission (accessed November 18, 2020).

Nelson, K. M., J. M. Simoni, C. R. Pearson, and K. L. Walters. 2011. “I’ve had unsafe sex so many times why bother being safe now?”: The role of cognitions in sexual risk among American Indian/Alaska Native men who have sex with men. Annals of Behavioral Medicine 42(3):370-380.

Nemoto, T., B. Bödeker, M. Iwamoto, and M. Sakata. 2014. Practices of receptive and insertive anal sex among transgender women in relation to partner types, sociocultural factors, and background variables. AIDS Care 26(4):434-440.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Nemoto, T., T. Cruz, M. Iwamoto, K. Trocki, U. Perngparn, C. Areesantichai, S. Suzuki, and C. Roberts. 2016. Examining the sociocultural context of HIV-related risk behaviors among kathoey (male-to-female transgender women) sex workers in Bangkok, Thailand. Journal of the Association of Nurses in AIDS Care 27(2):153-165.

Nerlander, L. M., S. Handanagic, K. L. Hess, A. Lutnick, C. B. Agnew-Brune, B. E. Hoots, S. L. Braunstein, S. N. Glick, E. Higgins, P. Padgett, S. M. Schuette, D. Broz, W. Ivy, 3rd, A. Smith, A. Thorson, and G. Paz-Bailey. 2020. HIV prevalence among women who exchange sex for money or drugs—4 U.S. cities. Journal of Acquired Immune Deficiency Syndromes 84(4):345-354.

Nesheim, S. R., J. Wiener, L. F. Fitz Harris, M. A. Lampe, and P. J. Weidle. 2017. Brief report: Estimated incidence of perinatally acquired HIV infection in the United States, 1978-2013. Journal of Acquired Immune Deficiency Syndromes 76(5):461-464.

Newcomb, M. E., and B. Mustanski. 2010. Internalized homophobia and internalizing mental health problems: A meta-analytic review. Clinical Psychology Review 30(8):1019-1029.

Newman, L. M., and S. M. Berman. 2008. Epidemiology of STD disparities in African American communities. Sexually Transmitted Diseases 35(12 Suppl):S4-S12.

Noar, S. M. 2006. A 10-year retrospective of research in health mass media campaigns: Where do we go from here? Journal of Health Communication 11(1):21-42.

Norris, T., P. L. Vines, and E. M. Hoeffell. 2012. 2010 census brief: The American Indian and Alaska Native population: 2010. Washington, DC: U.S. Census Bureau.

Nowotny, K. M., M. Omori, M. McKenna, and J. Kleinman. 2020. Incarceration rates and incidence of sexually transmitted infections in U.S. counties, 2011-2016. American Journal of Public Health 110(Suppl 1):S130-S136.

Nusbaum, M. R. H., A. R. Singh, and A. A. Pyles. 2004. Sexual healthcare needs of women aged 65 and older. Journal of the American Geriatrics Society 52(1):117-122.

OIG (Office of Inspector General). 2011. Access to mental health services at Indian Health Service and tribal facilities. Washington, DC: Department of Health and Human Services.

Olson-Kennedy, J., P. T. Cohen-Kettenis, B. P. C. Kreukels, H. F. L. Meyer-Bahlburg, R. Garofalo, W. Meyer, and S. M. Rosenthal. 2016. Research priorities for gender nonconforming/transgender youth: Gender identity development and biopsychosocial outcomes. Current Opinion in Endocrinology, Diabetes, and Obesity 23(2):172-179.

Operario, D., T. Nemoto, M. Iwamoto, and T. Moore. 2011. Unprotected sexual behavior and HIV risk in the context of primary partnerships for transgender women. AIDS and Behavior 15(3):674-682.

O’Rourke, K., A. Richman, M. Roddy, and M. Custer. 2008. Does pregnancy/paternity intention predict contraception use? A study among U.S. soldiers who have completed initial entry training. The Journal of Family Planning and Reproductive Health Care 34(3):165-168.

Oshri, A., J. G. Tubman, and M. L. Burnette. 2012. Childhood maltreatment histories, alcohol and other drug use symptoms, and sexual risk behavior in a treatment sample of adolescents. American Journal of Public Health 102(Suppl 2):S250-S257.

Ott, M. A., A. Katschke, W. Tu, and J. D. Fortenberry. 2011. Longitudinal associations among relationship factors, partner change, and sexually transmitted infection acquisition in adolescent women. Sexually Transmitted Diseases 38(3):153-157.

Owen, B. N., R. F. Baggaley, J. Elmes, A. Harvey, Z. Shubber, A. R. Butler, R. Silhol, P. Anton, B. Shacklett, A. van der Straten, and M. C. Boily. 2020. What proportion of female sex workers practise anal intercourse and how frequently? A systematic review and meta-analysis. AIDS and Behavior 24(3):697-713.

Owen, J., and F. D. Fincham. 2011. Effects of gender and psychosocial factors on “friends with benefits” relationships among young adults. Archives of Sexual Behavior 40(2):311-320.

Owusu-Edusei, K., Jr., and B. A. Chang. 2019. Investigating multiple-reported bacterial sexually transmitted infection hot spot counties in the United States: Ordered spatial logistic regression. Sexually Transmitted Diseases 46(12):771-776.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Owusu-Edusei, K., Jr., T. L. Gift, H. W. Chesson, and C. K. Kent. 2013. Investigating the potential public health benefit of jail-based screening and treatment programs for chlamydia. American Journal of Epidemiology 177(5):463-473.

Palacios, J., and H. P. Kennedy. 2010. Reflections of Native American teen mothers. Journal of Obstetric, Gynecologic, and Neonatal Nursing 39(4):425-434.

Park, J. N., C. A. Gaydos, R. H. White, M. R. Decker, K. H. A. Footer, N. Galai, B. E. Silberzahn, K. Riegger, M. Morris, S. S. Huettner, S. T. Allen, and S. G. Sherman. 2019. Incidence and predictors of chlamydia, gonorrhea and trichomonas among a prospective cohort of cisgender female sex workers in Baltimore, Maryland. Sexually Transmitted Diseases 46(12):788-794.

Parmet, W. 2018. Immigration and health care under the Trump administration. In Health Affairs Blog (January 18).

Patel, D., B. Gillespie, and B. Foxman. 2003. Sexual behavior of older women: Results of a random-digit-dialing survey of 2,000 women in the United States. Sexually Transmitted Diseases 30(3):216-220.

Patel, E. U., J. L. White, C. A. Gaydos, T. C. Quinn, S. H. Mehta, and A. A. R. Tobian. 2020. Marijuana use, sexual behaviors, and prevalent sexually transmitted infections among sexually experienced males and females in the United States: Findings from the National Health and Nutrition Examination Surveys. Sexually Transmitted Diseases 47(10):672-678.

Patton, G. C., S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Afifi, N. B. Allen, M. Arora, P. Azzopardi, W. Baldwin, C. Bonell, R. Kakuma, E. Kennedy, J. Mahon, T. McGovern, A. H. Mokdad, V. Patel, S. Petroni, N. Reavley, K. Taiwo, J. Waldfogel, D. Wickremarathne, C. Barroso, Z. Bhutta, A. O. Fatusi, A. Mattoo, J. Diers, J. Fang, J. Ferguson, F. Ssewamala, and R. M. Viner. 2016. Our future: A Lancet commission on adolescent health and wellbeing. The Lancet 387(10036):2423-2478.

Patton, R., F. C. Blow, A. S. Bohnert, E. E. Bonar, K. L. Barry, and M. A. Walton. 2014a. Prevalence and correlates of transactional sex among an urban emergency department sample: Exploring substance use and HIV risk. Psychology of Addictive Behaviors 28(2):625-630.

Patton, R. A., R. M. Cunningham, F. C. Blow, M. A. Zimmerman, B. M. Booth, and M. A. Walton. 2014b. Transactional sex involvement: Exploring risk and promotive factors among substance-using youth in an urban emergency department. Journal of Studies on Alcohol and Drugs 75(4):573-579.

Pazol, K., M. R. Kramer, and C. J. Hogue. 2010. Condoms for dual protection: Patterns of use with highly effective contraceptive methods. Public Health Reports 125(2):208-217.

Pelligrino, N., B. H. Zaitzow, M. Sothern, R. Scribner, and S. Phillippi. 2017. Incarcerated Black women in the southern USA: A narrative review of STI and HIV risk and implications for future public health research, practice, and policy. Journal of Racial and Ethnic Health Disparities 4(1):9-18.

Pereto, A. 2018. Patients over 60? Screen for STIs. https://www.athenahealth.com/knowledge-hub/clinical-trends/over-60-stis-may-not-be-done-you (accessed January 14, 2021).

Perez-Brumer, A., A. Nunn, E. Hsiang, C. Oldenburg, M. Bender, L. Beauchamps, L. Mena, and S. MacCarthy. 2018. “We don’t treat your kind”: Assessing HIV health needs holistically among transgender people in Jackson, Mississippi. PLoS One 13(11):e0202389.

Petca, A., A. Borislavschi, M. E. Zvanca, R. C. Petca, F. Sandru, and M. C. Dumitrascu. 2020. Non-sexual HPV transmission and role of vaccination for a better future (review). Experimental and Therapeutic Medicine 20(6):186.

Pew Charitable Trusts. 2017. Prison health care costs and quality. https://www.pewtrusts.org/-/media/assets/2017/10/sfh_prison_health_care_costs_and_quality_final.pdf (accessed February 15, 2021).

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Platt, L., P. Grenfell, R. Meiksin, J. Elmes, S. G. Sherman, T. Sanders, P. Mwangi, and A.-L. Crago. 2018. Associations between sex work laws and sex workers’ health: A systematic review and meta-analysis of quantitative and qualitative studies. PLoS Medicine 15(12):e1002680.

Pooler, J., and M. Srinivasan. 2018. Issue brief: Social determinants of health and the aging population. https://impaqint.com/sites/default/files/issue-briefs/Issue%20Brief_SDOHandAgingPopulation_0.pdf (accessed November 19, 2020).

Ports, K. A., D. C. Ford, and M. T. Merrick. 2016. Adverse childhood experiences and sexual victimization in adulthood. Child Abuse & Neglect 51:313-322.

Poteat, T., S. L. Reisner, and A. Radix. 2014. HIV epidemics among transgender women. Current Opinion in HIV and AIDS 9(2):168-173.

Poteat, T. C., M. Malik, and C. Beyrer. 2018. Epidemiology of HIV, sexually transmitted infections, viral hepatitis, and tuberculosis among incarcerated transgender people: A case of limited data. Epidemiologic Reviews 40(1):27-39.

Pouget, E. R., T. S. Kershaw, L. M. Niccolai, J. R. Ickovics, and K. M. Blankenship. 2010. Associations of sex ratios and male incarceration rates with multiple opposite-sex partners: Potential social determinants of HIV/STI transmission. Public Health Reports 125(Suppl 4):70-80.

Powell, R. M., S. L. Parish, M. Mitra, and E. Rosenthal. 2020. Role of family caregivers regarding sexual and reproductive health for women and girls with intellectual disability: A scoping review. Journal of Intellectual Disability Research 64(2):131-157.

Power, J., R. McNair, and S. Carr. 2009. Absent sexual scripts: Lesbian and bisexual women’s knowledge, attitudes and action regarding safer sex and sexual health information. Culture, Health & Sexuality 11(1):67-81.

Power to Decide. 2016. Parent power (October 2016): Survey says. https://powertodecide.org/what-we-do/information/resource-library/parent-power-october-2016-survey-says (accessed December 23, 2020).

ProCon.org. n.d. U.S. federal and state prostitution laws and related punishments. https://prostitution.procon.org/us-federal-and-state-prostitution-laws-and-related-punishments (accessed December 3, 2020).

Pu, J., B. Chewning, I. D. St Clair, P. K. Kokotailo, J. Lacourt, and D. Wilson. 2013. Protective factors in American Indian communities and adolescent violence. Maternal and Child Health Journal 17(7):1199-1207.

Quina, K., L. Harlow, P. Morokoff, G. Burkholder, and P. J. Deiter. 2000. Sexual communication in relationships: When words speak louder than actions. Sex Roles 42:523-549.

Raiford, J. L., J. H. Herbst, M. Carry, F. A. Browne, I. Doherty, and W. M. Wechsberg. 2014. Low prospects and high risk: Structural determinants of health associated with sexual risk among young African American women residing in resource-poor communities in the south. American Journal of Community Psychology 54(3-4):243-250.

RAINN (Rape, Abuse & Incest National Network). 2020. Children and teens: Statistics. https://www.rainn.org/statistics/children-and-teens (accessed January 5, 2021).

Rawstron, S. A., K. Bromberg, and M. R. Hammerschlag. 1993. STD in children: Syphilis and gonorrhoea. Genitourinary Medicine 69(1):66-75.

Reece, M., D. Herbenick, V. Schick, S. A. Sanders, B. Dodge, and J. D. Fortenberry. 2010. Condom use rates in a national probability sample of males and females ages 14 to 94 in the United States. The Journal of Sexual Medicine 7(Suppl 5):266-276.

Reed, S. J., A. Bangi, N. Sheon, G. W. Harper, J. A. Catania, K. A. Richards, M. M. Dolcini, and C. B. Boyer. 2012. Influences on sexual partnering among African American adolescents with concurrent sexual relationships. Research in Human Development 9(1):78-101.

Reilly, K. H., A. Neaigus, T. Wendel, D. M. Marshall IV, and H. Hagan. 2014. Correlates of selling sex among male injection drug users in New York City. Drug and Alcohol Dependence 144:78-86.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Reisner, S. L., and G. R. Murchison. 2016. A global research synthesis of HIV and STI biobehavioural risks in female-to-male transgender adults. Global Public Health 11(7-8):866-887.

Reisner, S. L., B. Perkovich, and M. J. Mimiaga. 2010. A mixed methods study of the sexual health needs of New England transmen who have sex with nontransgender men. AIDS Patient Care and STDs 24(8):501-513.

Reisner, S. L., J. M. White, J. B. Bradford, and M. J. Mimiaga. 2014. Transgender health disparities: Comparing full cohort and nested matched-pair study designs in a community health center. LGBT Health 1(3):177-184.

Reisner, S. L., R. Vetters, J. M. White, E. L. Cohen, M. LeClerc, S. Zaslow, S. Wolfrum, and M. J. Mimiaga. 2015. Laboratory-confirmed HIV and sexually transmitted infection seropositivity and risk behavior among sexually active transgender patients at an adolescent and young adult urban community health center. AIDS Care 27(8):1031-1036.

Reisner, S. L., A. Radix, and M. B. Deutsch. 2016. Integrated and gender-affirming transgender clinical care and research. Journal of Acquired Immune Deficiency Syndromes 72.

Reisner, S. L., L. Jadwin-Cakmak, L. Sava, S. Liu, and G. W. Harper. 2019. Situated vulnerabilities, sexual risk, and sexually transmitted infections’ diagnoses in a sample of transgender youth in the United States. AIDS Patient Care and STDs 33(3):120-130.

Reiter, P. L., and A. L. McRee. 2016. HPV infection among sexual minority women: Does it matter how sexual orientation is measured? Cancer Epidemiology, Biomarkers, and Prevention 25(3):559.

Reiter, P. L., and A. L. McRee. 2017. HPV infection among a population-based sample of sexual minority women from USA. Sexually Transmitted Infections 93(1):25-31.

Richards, J., and A. Mousseau. 2012. Community-based participatory research to improve preconception health among Northern Plains American Indian adolescent women. American Indian and Alaska Native Mental Health Research 19(1):154-185.

Rink, E., R. Tricker, and S. M. Harvey. 2007. Onset of sexual intercourse among female adolescents: The influence of perceptions, depression, and ecological factors. Journal of Adolescent Health 41(4):398-406.

Rink, E., K. FourStar, and M. P. Anastario. 2017. The relationship between pregnancy prevention and STI/HIV prevention and sexual risk behavior among American Indian men. The Journal of Rural Health 33(1):50-61.

Ritchwood, T. D., H. Ford, J. DeCoster, M. Sutton, and J. E. Lochman. 2015. Risky sexual behavior and substance use among adolescents: A meta-analysis. Children and Youth Services Review 52:74-88.

Rodriguez-Hart, C., R. A. Chitale, R. Rigg, B. Y. Goldstein, P. R. Kerndt, and P. Tavrow. 2012. Sexually transmitted infection testing of adult film performers: Is disease being missed? Sexually Transmitted Diseases 39(12):989-994.

Rome, E. S., and E. Miller. 2020. Intimate partner violence in the adolescent. Pediatrics in Review 41(2):73-80.

Rood, B. A., S. L. Reisner, F. I. Surace, J. A. Puckett, M. R. Maroney, and D. W. Pantalone. 2016. Expecting rejection: Understanding the minority stress experiences of transgender and gender-nonconforming individuals. Transgender Health 1(1):151-164.

Rosay, A. B. 2016. National Institute of Justice research report: Violence against American Indian and Alaska Native women and men: 2010 findings from the National Intimate Partner and Sexual Violence Survey. Washington, DC: Department of Justice.

Rosenbaum, J. E., J. Zenilman, E. Rose, G. Wingood, and R. DiClemente. 2016. Predicting unprotected sex and unplanned pregnancy among urban African-American adolescent girls using the theory of gender and power. Journal of Urban Health 93(3):493-510.

Sadler, A. G., M. A. Mengeling, C. H. Syrop, J. C. Torner, and B. M. Booth. 2011. Lifetime sexual assault and cervical cytologic abnormalities among military women. Journal of Women’s Health 20(11):1693-1701.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

SAHM (Society for Adolescent Health and Medicine). 2014. Sexual and reproductive health care: A position paper of the Society for Adolescent Health and Medicine. Journal of Adolescent Health 54(4):491-496.

Sales, J. M., A. Swartzendruber, and A. L. Phillips. 2016. Trauma-informed HIV prevention and treatment. Current HIV/AIDS Reports 13(6):374-382.

SAMHSA (Substance Abuse and Mental Health Services Administration). 2011. Results from the 2009 National Survey on Drug Use and Health: Summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Sanchez, D. M., V. J. Schoenbach, S. M. Harvey, J. T. Warren, A. A. Adimora, C. Poole, P. A. Leone, and C. R. Agnew. 2016. Association of perceived partner non-monogamy with prevalent and incident sexual concurrency. Sexually Transmitted Infections 92(4):266-271.

Sander, G., A. Scandurra, A. Kamenska, C. MacNamara, C. Kalpaki, C. F. Bessa, G. N. Laso, G. Parisi, L. Varley, M. Wolny, M. Moudatsou, N. H. Pontes, P. Mannix-McNamara, S. Libianchi, and T. Antypas. 2016. Overview of harm reduction in prisons in seven European countries. Harm Reduction Journal 13(1):28.

Sandfort, T. G., M. Orr, J. S. Hirsch, and J. Santelli. 2008. Long-term health correlates of timing of sexual debut: Results from a national U.S. study. American Journal of Public Health 98(1):155-161.

Sangaramoorthy, T., and K. Kroeger. 2013. Mobility, Latino migrants, and the geography of sex work: Using ethnography in public health assessments. Human Organization 72(3):263-272.

Sawyer, A. N., E. R. Smith, and E. G. Benotsch. 2018. Dating application use and sexual risk behavior among young adults. Sexuality Research & Social Policy 15(2):183-191.

Sawyer, W., and P. Wagner. 2020. Mass incarceration: The whole pie 2020. Northampton, MA: Prison Policy Initiative.

Sayegh, M. A., J. D. Fortenberry, M. Shew, and D. P. Orr. 2006. The developmental association of relationship quality, hormonal contraceptive choice and condom non-use among adolescent women. Journal of Adolescent Health 39(3):388-395.

Scarinci, I. C., I. C. Garcés-Palacio, and E. E. Partridge. 2007. An examination of acceptability of HPV vaccination among African American women and Latina immigrants. Journal of Women’s Health 16(8):1224-1233.

Schick, V., J. G. Rosenberger, D. Herbenick, and M. Reece. 2012. Sexual behaviour and risk reduction strategies among a multinational sample of women who have sex with women. Sexually Transmitted Infections 88(6):407-412.

Schick, V., B. Van Der Pol, B. Dodge, A. Baldwin, and J. D. Fortenberry. 2015. A mixed methods approach to assess the likelihood of testing for STI using self-collected samples among behaviourally bisexual women. Sexually Transmitted Infections 91(5):329-333.

Schmid, A., N. R. Leonard, A. S. Ritchie, and M. V. Gwadz. 2015. Assertive communication in condom negotiation: Insights from late adolescent couples’ subjective ratings of self and partner. Journal of Adolescent Health 57(1):94-99.

Schmidt, E. K., B. N. Hand, K. N. Simpson, and A. R. Darragh. 2019a. Sexually transmitted infections in privately insured adults with intellectual and developmental disabilities. Journal of Comparative Effectiveness Research 8(8):599-606.

Schmidt, R., P. J. Carson, and R. J. Jansen. 2019b. Resurgence of syphilis in the United States: An assessment of contributing factors. Infectious Diseases 12:1178633719883282.

Schmidt, E. K., C. Brown, and A. Darragh. 2020. Scoping review of sexual health education interventions for adolescents and young adults with intellectual or developmental disabilities. Sexuality and Disability 38:439-453.

Schneider, J. A., B. Cornwell, D. Ostrow, S. Michaels, P. Schumm, E. O. Laumann, and S. Friedman. 2013. Network mixing and network influences most linked to HIV infection and risk behavior in the HIV epidemic among Black men who have sex with men. American Journal of Public Health 103(1):e28-e36.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Schuyler, A., S. Kintzle, C. L. Lucas, H. Moore, and C. Castro. 2017. Military sexual assault (MSA) among veterans in Southern California: Associations with physical health, psychological health, and risk behaviors. Traumatology 23(3):223.

Senn, T. E., M. P. Carey, and P. A. Vanable. 2008. Childhood and adolescent sexual abuse and subsequent sexual risk behavior: Evidence from controlled studies, methodological critique, and suggestions for research. Clinical Psychology Review 28(5):711-735.

Senn, T. E., M. P. Carey, and P. A. Vanable. 2010. The intersection of violence, substance use, depression, and STDs: Testing of a syndemic pattern among patients attending an urban STD clinic. Journal of the National Medical Association 102(7):614-620.

Senteio, C., S. W. Collins, R. Jackson, S. Welk, and S. Zhang. 2010. Effective resources supporting healthy sexual behavior in formerly incarcerated persons. American Journal of Sexuality Education 5(4):362-376.

Seth, P., D. L. Lang, R. J. Diclemente, N. D. Braxton, R. A. Crosby, L. K. Brown, W. Hadley, and G. R. Donenberg. 2012. Gender differences in sexual risk behaviours and sexually transmissible infections among adolescents in mental health treatment. Sexual Health 9(3):240-246.

Seth, P., R. J. DiClemente, and A. E. Lovvorn. 2013. State of the evidence: Intimate partner violence and HIV/STI risk among adolescents. Current HIV Research 11(7):528-535.

Sethi, S., G. Singh, P. Samanta, and M. Sharma. 2012. Mycoplasma genitalium: An emerging sexually transmitted pathogen. The Indian Journal of Medical Research 136(6):942-955.

Sevelius, J. 2009. “There’s no pamphlet for the kind of sex I have”: HIV-related risk factors and protective behaviors among transgender men who have sex with nontransgender men. Journal of the Association of Nurses in AIDS Care 20(5):398-410.

Shafer, M. A., C. B. Boyer, R. A. Shaffer, J. Schachter, S. I. Ito, and S. K. Brodine. 2002. Correlates of sexually transmitted diseases in a young male deployed military population. Military Medicine 167(6):496-500.

Shannon, C. L., and J. D. Klausner. 2018. The growing epidemic of sexually transmitted infections in adolescents: A neglected population. Current Opinion in Pediatrics 30(1):137-143.

Shannon, C. L., E. M. Keizur, A. Fehrenbacher, D. Wood-Palmer, W. Ramos, M. Koussa, J. Fournier, S. J. Lee, D. Patel, W. N. Akabike, S. E. Abdalian, M. J. Rotheram-Borus, and J. D. Klausner. 2019a. Sexually transmitted infection positivity among adolescents with or at high-risk for human immunodeficiency virus infection in Los Angeles and New Orleans. Sexually Transmitted Diseases 46(11):737-742.

Shannon, C. L., M. Koussa, S. J. Lee, J. Fournier, S. E. Abdalian, M. J. Rotheram, and J. D. Klausner. 2019b. Community-based, point-of-care sexually transmitted infection screening among high-risk adolescents in Los Angeles and New Orleans: Protocol for a mixed-methods study. JMIR Research Protocols 8(3):e10795.

Sharma, A., E. Kahle, K. Todd, S. Peitzmeier, and R. Stephenson. 2019. Variations in testing for HIV and other sexually transmitted infections across gender identity among transgender youth. Transgender Health 4(1):46-57.

Sherman, C. A., S. M. Harvey, and J. Noell. 2005. “Are they still having sex?” STIs and unintended pregnancy among mid-life women. Journal of Women & Aging 17(3):41-55.

Silver, B. J., R. J. Guy, J. M. Kaldor, M. S. Jamil, and A. R. Rumbold. 2014. Trichomonas vaginalis as a cause of perinatal morbidity: A systematic review and meta-analysis. Sexually Transmitted Diseases 41(6):369-376.

Silverman, J. G. 2011. Adolescent female sex workers: Invisibility, violence and HIV. Archives of Disease in Childhood 96(5):478-481.

Singh, D., D. N. Fine, and J. M. Marrazzo. 2011. Chlamydia trachomatis infection among women reporting sexual activity with women screened in family planning clinics in the Pacific Northwest, 1997 to 2005. American Journal of Public Health 101(7):1284-1290.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Singh, V., B. Gratzer, P. M. Gorbach, R. A. Crosby, G. Panicker, M. Steinau, R. Amiling, E. R. Unger, L. E. Markowitz, and E. Meites. 2019. Transgender women have higher human papillomavirus prevalence than men who have sex with men—two U.S. cities, 2012-2014. Sexually Transmitted Diseases 46(10):657-662.

Smith, A. 2003. Not an Indian tradition: The sexual colonization of native peoples. Hypatia 18(2):70-85.

Smith, A. 2015. Conquest: Sexual violence and American Indian genocide. Durham, NC: Duke University Press.

Smith, A. M., J. A. Ferris, J. M. Simpson, J. Shelley, M. K. Pitts, and J. Richters. 2010. Cannabis use and sexual health. The Journal of Sexual Medicine 7(2 Pt 1):787-793.

Smith, J. M., A. Z. Uvin, A. Macmadu, and J. D. Rich. 2017. Epidemiology and treatment of hepatitis B in prisoners. Current Hepatology Reports 16(3):178-183.

Smith, K. P., and N. A. Christakis. 2009. Association between widowhood and risk of diagnosis with a sexually transmitted infection in older adults. American Journal of Public Health 99(11):2055-2062.

Smith, L. W., B. Liu, L. Degenhardt, J. Richters, G. Patton, H. Wand, D. Cross, J. S. Hocking, S. R. Skinner, S. Cooper, C. Lumby, J. M. Kaldor, and R. Guy. 2016. Is sexual content in new media linked to sexual risk behaviour in young people? A systematic review and meta-analysis. Sexual Health 13(6):501-515.

Smith, T. D., S. R. Raman, S. Madigan, J. Waldman, and M. Shouldice. 2018. Anogenital findings in 3569 pediatric examinations for sexual abuse/assault. Journal of Pediatric and Adolescent Gynecology 31(2):79-83.

Sneed, C. D. 2009. Sexual risk behavior among early initiators of sexual intercourse. AIDS Care 21(11):1395-1400.

Solomon, M. M., K. H. Mayer, D. V. Glidden, A. Y. Liu, V. M. McMahan, J. V. Guanira, S. Chariyalertsak, T. Fernandez, and R. M. Grant. 2014. Syphilis predicts HIV incidence among men and transgender women who have sex with men in a preexposure prophylaxis trial. Clinical Infectious Diseases 59(7):1020-1026.

Solomon, R. 2020. Racism and its effect on cannabis research. Cannabis and Cannabinoid Research 5(1):2-5.

Spaulding, A. C., J. Miller, B. G. Trigg, P. Braverman, T. Lincoln, P. N. Reams, M. Staples-Horne, A. Sumbry, D. Rice, and C. L. Satterwhite. 2013. Screening for sexually transmitted diseases in short-term correctional institutions: Summary of evidence reviewed for the 2010 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Sexually Transmitted Diseases 40(9):679-684.

Spaulding, A. C., T. L. Lemon, and M. So. 2018. Measuring correctional experience to inform development of HIV, sexually transmitted infection, and substance use interventions for incarcerated Black men who have sex with men. American Journal of Public Health 108(S4):S237-S239.

Sridhar, S., R. Cornish, and S. Fazel. 2018. The costs of healthcare in prison and custody: Systematic review of current estimates and proposed guidelines for future reporting. Frontiers in Psychiatry 9:716.

Stahlman, S., and A. A. Oetting. 2017. Sexually transmitted infections, active component, U.S. armed forces, 2007-2016. Medical Surveillance Monthly Report 24(9):15-22.

Stahlman, S., M. Javanbakht, S. Cochran, A. B. Hamilton, S. Shoptaw, and P. M. Gorbach. 2014. Self-reported sexually transmitted infections and sexual risk behaviors in the U.S. military: How sex influences risk. Sexually Transmitted Diseases 41(6):359-364.

Stahlman, S., M. Javanbakht, S. Cochran, A. B. Hamilton, S. Shoptaw, and P. M. Gorbach. 2015. Mental health and substance use factors associated with unwanted sexual contact among U.S. active duty service women. Journal of Traumatic Stress 28(3):167-173.

Stahlman, S., N. Seliga, and A. A. Oetting. 2019. Sexually transmitted infections, active component, US armed forces, 2010-2018. Medical Surveillance Monthly Report 26(3):2-10.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Stahre, M. A., R. D. Brewer, V. P. Fonseca, and T. S. Naimi. 2009. Binge drinking among U.S. active-duty military personnel. American Journal of Preventative Medicine 36(3):208-217.

Stall, R., and J. Catania. 1994. AIDS risk behaviors among late middle-aged and elderly americans. The National AIDS Behavioral Surveys. Archives of Internal Medicine 154(1):57-63.

Staras, S. A., R. L. Cook, and D. B. Clark. 2009. Sexual partner characteristics and sexually transmitted diseases among adolescents and young adults. Sexually Transmitted Diseases 36(4):232-238.

Stein, C. R., J. S. Kaufman, C. A. Ford, P. J. Feldblum, P. A. Leone, and W. C. Miller. 2008. Partner age difference and prevalence of chlamydial infection among young adult women. Sexually Transmitted Diseases 35(5):447-452.

Steinberg, L. 2005. Cognitive and affective development in adolescence. Trends in Cognitive Sciences 9(2):69-74.

Steiner, R. J., N. Liddon, A. L. Swartzendruber, C. N. Rasberry, and J. M. Sales. 2016. Long-acting reversible contraception and condom use among female U.S. high school students: Implications for sexually transmitted infection prevention. JAMA Pediatrics 170(5):428-434.

Stenger, M. R., S. Baral, S. Stahlman, D. Wohlfeiler, J. E. Barton, and T. Peterman. 2017. As through a glass, darkly: The future of sexually transmissible infections among gay, bisexual and other men who have sex with men. Sexual Health 14(1):18-27.

Stephenson, R., E. Riley, E. Rogers, N. Suarez, N. Metheny, J. Senda, K. M. Saylor, and J. A. Bauermeister. 2017. The sexual health of transgender men: A scoping review. Journal of Sex Research 54(4-5):424-445.

Stidham, R. A., E. C. Garges, and S. A. Knapp. 2015. Expedited partner therapy to combat Neisseria gonorrhoeae and Chlamydia trachomatis in military populations: Can we apply this best practice? Military Medicine 180(8):876-881.

Stieglitz, K. A. 2010. Development, risk, and resilience of transgender youth. Journal of the Association of Nurses in AIDS Care 21(3):192-206.

Stoner, M. C. D., D. F. Haley, C. E. Golin, A. A. Adimora, and A. Pettifor. 2019. The relationship between economic deprivation, housing instability and transactional sex among women in North Carolina (HPTN 064). AIDS and Behavior 23(11):2946-2955.

Strauss, J. L., C. E. Marx, J. C. Weitlauf, K. M. Stechuchak, K. Straits-Tröster, A. W. Worjoloh, C. B. Sherrod, M. K. Olsen, M. I. Butterfield, and P. S. Calhoun. 2011. Is military sexual trauma associated with trading sex among women veterans seeking outpatient mental health care? Journal of Trauma & Dissociation 12(3):290-304.

Suris, A., and L. Lind. 2008. Military sexual trauma: A review of prevalence and associated health consequences in veterans. Trauma Violence Abuse 9(4):250-269.

Sutherland, M. A. 2011. Examining mediators of child sexual abuse and sexually transmitted infections. Nursing Research 60(2):139-147.

Swan, H., and D. J. O’Connell. 2012. The impact of intimate partner violence on women’s condom negotiation efficacy. Journal of Interpersonal Violence 27(4):775-792.

Swartz, J. J., J. Hainmueller, D. Lawrence, and M. I. Rodriguez. 2017. Expanding prenatal care to unauthorized immigrant women and the effects on infant health. Obstetrics and Gynecology 130(5):938-945.

Swartzendruber, A., J. L. Brown, J. M. Sales, C. C. Murray, and R. J. DiClemente. 2012. Sexually transmitted infections, sexual risk behavior, and intimate partner violence among African American adolescent females with a male sex partner recently released from incarceration. Journal of Adolescent Health 51(2):156-163.

Swartzendruber, A., J. M. Zenilman, L. M. Niccolai, T. S. Kershaw, J. L. Brown, R. J. Diclemente, and J. M. Sales. 2013. It takes 2: Partner attributes associated with sexually transmitted infections among adolescents. Sexually Transmitted Diseases 40(5):372-378.

Syed, S. T., B. S. Gerber, and L. K. Sharp. 2013. Traveling towards disease: Transportation barriers to health care access. Journal of Community Health 38(5):976-993.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Syme, M. L., T. J. Cohn, and J. Barnack-Tavlaris. 2017. A comparison of actual and perceived sexual risk among older adults. Journal of Sex Research 54(2):149-160.

Talashek, M., K. Norr, and B. Dancy. 2003. Building teen power for sexual health. Journal of Transcultural Nursing 14:207-216.

Taylor, A. W., S. R. Nesheim, X. Zhang, R. Song, L. F. FitzHarris, M. A. Lampe, P. J. Weidle, and P. Sweeney. 2017. Estimated perinatal HIV infection among infants born in the United States, 2002-2013. JAMA Pediatrics 171(5):435-442.

Taylor, M. M., B. Reilley, S. Tulloch, M. Winscott, A. Dunnigan, M. Russell, and J. T. Redd. 2011. Identifying opportunities for chlamydia screening among American Indian women. Sexually Transmitted Diseases 38(10):947-948.

Tedeschi, S. K., L. E. Bonney, R. Manalo, K. H. Mayer, S. Shepardson, J. D. Rich, and M. A. Lally. 2007. Vaccination in juvenile correctional facilities: State practices, hepatitis B, and the impact on anticipated sexually transmitted infection vaccines. Public Health Reports 122(1):44-48.

Teitelman, A. M., S. J. Ratcliffe, M. M. Morales-Aleman, and C. M. Sullivan. 2008. Sexual relationship power, intimate partner violence, and condom use among minority urban girls. Journal of Interpersonal Violence 23(12):1694-1712.

Teitelman, A. M., J. Tennille, J. M. Bohinski, L. S. Jemmott, and J. B. Jemmott, 3rd. 2011. Unwanted unprotected sex: Condom coercion by male partners and self-silencing of condom negotiation among adolescent girls. Advances in Nursing Science 34(3):243-259.

The Lancet. 2018. Congenital syphilis in the USA. The Lancet 392(10154):1168.

The White House. 2021. Executive order on preventing and combating discrimination on the basis of gender identity or sexual orientation. https://www.whitehouse.gov/briefingroom/presidential-actions/2021/01/20/executive-order-preventing-and-combatingdiscrimination-on-basis-of-gender-identity-or-sexual-orientation (accessed February 4, 2021).

Thomas, A. G., S. K. Brodine, R. Shaffer, M. A. Shafer, C. B. Boyer, S. Putnam, and J. Schachter. 2001. Chlamydial infection and unplanned pregnancy in women with ready access to health care. Obstetrics and Gynocology 98(6):1117-1123.

Thomas, J. C., B. A. Levandowski, M. R. Isler, E. Torrone, and G. Wilson. 2008. Incarceration and sexually transmitted infections: A neighborhood perspective. Journal of Urban Health 85(1):90-99.

Thomason, A., N. Capps, L. Lefler, and G. Richard-Davis. 2015. Factors affecting gynecologic and sexual assessment in older women: A lesson for primary care providers. Healthcare (Basel, Switzerland) 3(3):683-694.

Thompson, J. C., T. C. Kao, and R. J. Thomas. 2005. The relationship between alcohol use and risk-taking sexual behaviors in a large behavioral study. Preventive Medicine 41(1):247-252.

Thompson, R., T. Lewis, E. C. Neilson, D. J. English, A. J. Litrownik, B. Margolis, L. Proctor, and H. Dubowitz. 2017. Child maltreatment and risky sexual behavior. Child Maltreatment 22(1):69-78.

Tingey, L., R. Strom, R. Hastings, A. Parker, A. Barlow, A. Rompalo, and C. Gaydos. 2015. Self-administered sample collection for screening of sexually transmitted infection among reservation-based American Indian youth. International Journal of STD & AIDS 26(9):661-666.

Tingey, L., M. F. Cwik, S. Rosenstock, N. Goklish, F. Larzelere-Hinton, A. Lee, R. Suttle, M. Alchesay, K. Massey, and A. Barlow. 2016. Risk and protective factors for heavy binge alcohol use among American Indian adolescents utilizing emergency health services. American Journal of Drug and Alcohol Abuse 42(6):715-725.

Tingey, L., R. Chambers, N. Goklish, F. Larzelere, A. Lee, R. Suttle, S. Rosenstock, K. Lake, and A. Barlow. 2017a. Rigorous evaluation of a pregnancy prevention program for American Indian youth and adolescents: Study protocol for a randomized controlled trial. Trials 18(1):89.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Tingey, L., R. Chambers, S. Rosenstock, A. Lee, N. Goklish, and F. Larzelere. 2017b. The impact of a sexual and reproductive health intervention for American Indian adolescents on predictors of condom use intention. Journal of Adolescent Health 60(3):284-291.

Tingey, L., M. Cwik, R. Chambers, N. Goklish, F. Larzelere-Hinton, R. Suttle, A. Lee, M. Alchesay, A. Parker, and A. Barlow. 2017c. Motivators and influences on American Indian adolescent alcohol use and binge behavior: A qualitative exploration. Journal of Child & Adolescent Substance Abuse 26(1):75-85.

Tingey, L., R. Chambers, S. Rosenstock, F. Larzelere, N. Goklish, A. Lee, and A. Rompalo. 2018. Risk and protective factors associated with lifetime sexual experience among rural, reservation-based American Indian youth. Journal of Primary Prevention 39(4):401-420.

Tingey, L., C. Sutcliffe, R. Chambers, H. Patel, A. Lee, S. Lee, L. Melgar, A. Slimp, A. Rompalo, M. Craig, and C. Gaydos. 2019. Protecting our future generation: Study protocol for a randomized controlled trial evaluating a sexual health self-care intervention with Native American youth and young adults. BMC Public Health 19(1):1614.

Todd, N., and A. Black. 2020. Contraception for adolescents. Journal of Clinical Research in Pediatric Endocrinology 12(Suppl 1):28-40.

Tohme, R. A., and S. D. Holmberg. 2012. Transmission of hepatitis C virus infection through tattooing and piercing: A critical review. Clinical Infectious Diseases 54(8):1167-1178.

Tolman, D. L., and S. I. McClelland. 2011. Normative sexuality development in adolescence: A decade in review, 2000-2009. Journal of Research on Adolescence 21(1):242-255.

Trivedi, S., C. Williams, E. Torrone, and S. Kidd. 2019. National trends and reported risk factors among pregnant women with syphilis in the United States, 2012-2016. Obstetrics and Gynocology 133(1):27-32.

Tucker, J. D., S. W. Chang, and J. P. Tulsky. 2007. The catch 22 of condoms in U.S. correctional facilities. BMC Public Health 7:296.

Tucker, J. S., G. W. Ryan, D. Golinelli, B. Ewing, S. L. Wenzel, D. P. Kennedy, H. D. Green, Jr., and A. Zhou. 2012. Substance use and other risk factors for unprotected sex: Results from an event-based study of homeless youth. AIDS and Behavior 16(6):1699-1707.

Tuddenham, S. A., K. R. Page, P. Chaulk, E. B. Lobe, and K. G. Ghanem. 2017. Patients fifty years and older attending two sexually transmitted disease clinics in Baltimore, Maryland. International Journal of STD & AIDS 28(4):330-344.

Turchik, J. A., J. Pavao, D. Nazarian, S. Iqbal, C. McLean, and R. Kimerling. 2012. Sexually transmitted infections and sexual dysfunctions among newly returned veterans with and without military sexual trauma. International Journal of Sexual Health 24(1):45-59.

Ueda, P., C. H. Mercer, C. Ghaznavi, and D. Herbenick. 2020. Trends in frequency of sexual activity and number of sexual partners among adults aged 18 to 44 years in the U.S., 2000-2018. JAMA Network Open 3(6):e203833.

Unemo, M., H. S. Seifert, E. W. Hook, 3rd, S. Hawkes, F. Ndowa, and J. R. Dillon. 2019. Gonorrhoea. Nature Reviews Disease Primers 5(1):79.

Upchurch, D. M., W. M. Mason, Y. Kusunoki, and M. J. Kriechbaum. 2004. Social and behavioral determinants of self-reported STD among adolescents. Perspectives on Sexual Reproductive Health 36(6):276-287.

Urban Indian Health Institute. n.d. Urban Indian Health. https://www.uihi.org/urban-indian-health (accessed November 19, 2020).

Vagi, K. J., E. O’Malley Olsen, K. C. Basile, and A. M. Vivolo-Kantor. 2015. Teen dating violence (physical and sexual) among U.S. high school students: Findings from the 2013 National Youth Risk Behavior Survey. JAMA Pediatrics 169(5):474-482.

Valverde, E. E., T. Painter, J. D. Heffelfinger, J. D. Schulden, P. Chavez, and E. A. DiNenno. 2015. Migration patterns and characteristics of sexual partners associated with unprotected sexual intercourse among Hispanic immigrant and migrant women in the United States. Journal of Immigrant and Minority Health 17(6):1826-1833.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

van Hoorn, J., E. M. McCormick, C. R. Rogers, S. L. Ivory, and E. H. Telzer. 2018. Differential effects of parent and peer presence on neural correlates of risk taking in adolescence. Social Cognitive and Affective Neuroscience 13(9):945-955.

Vasilenko, S. A., and S. T. Lanza. 2014. Predictors of multiple sexual partners from adolescence through young adulthood. Journal of Adolescent Health 55(4):491-497.

Vasilenko, S. A., D. A. Kreager, and E. S. Lefkowitz. 2015. Gender, contraceptive attitudes, and condom use in adolescent romantic relationships: A dyadic approach. Journal of Research on Adolescence 25(1):51-62.

Vasilenko, S. A., K. C. Kugler, and S. T. Lanza. 2016. Latent classes of adolescent sexual and romantic relationship experiences: Implications for adult sexual health and relationship outcomes. Journal of Sex Research 53(7):742-753.

Verhaegh-Haasnoot, A., N. H. Dukers-Muijrers, and C. J. Hoebe. 2015. High burden of STI and HIV in male sex workers working as Internet escorts for men in an observational study: A hidden key population compared with female sex workers and other men who have sex with men. BMC Infectious Diseases 15:291.

Vermund, S. H., T. Alexander-Rodriguez, S. Macleod, and K. F. Kelley. 1990. History of sexual abuse in incarcerated adolescents with gonorrhea or syphilis. Journal of Adolescent Health Care 11(5):449-452.

Voisin, D. R., L. F. Salazar, R. Crosby, R. J. DiClemente, W. L. Yarber, and M. Staples-Horne. 2004. The association between gang involvement and sexual behaviours among detained adolescent males. Sexually Transmitted Infections 80(6):440-442.

von Ranson, K., S. Rosenthal, F. Biro, L. Lewis, and P. Succop. 2000. Longitudinal risk of STD acquisition in adolescent girls using a generalized estimating equations model. Journal of Pediatric and Adolescent Gynecology 13(2):87.

von Sadovszky, V., N. Ryan-Wenger, S. Germann, M. Evans, and C. Fortney. 2008. Army women’s reasons for condom use and nonuse. Women’s Health Issues 18(3):174-180.

Vrazo, A. C., J. Firth, A. Amzel, R. Sedillo, J. Ryan, and B. R. Phelps. 2018. Interventions to significantly improve service uptake and retention of HIV-positive pregnant women and HIV-exposed infants along the prevention of mother-to-child transmission continuum of care: Systematic review. Tropical Medicine & International Health 23(2):136-148.

Walker, F. J., E. Llata, M. Doshani, M. M. Taylor, J. Bertolli, H. S. Weinstock, and H. I. Hall. 2015. HIV, chlamydia, gonorrhea, and primary and secondary syphilis among American Indians and Alaska Natives within Indian health service areas in the United States, 2007-2010. Journal of Community Health 40(3):484-492.

Walsh-Buhi, E. R., and H. L. Helmy. 2018. Trends in long-acting reversible contraceptive (LARC) use, LARC use predictors, and dual-method use among a national sample of college women. Journal of American College Health 66(4):225-236.

Walters, F. P., and S. H. Gray. 2018. Addressing sexual and reproductive health in adolescents and young adults with intellectual and developmental disabilities. Current Opinion in Pediatrics 30(4):451-458.

Wang, A.-L., Y.-P. Qiao, L.-H. Wang, L.-W. Fang, F. Wang, X. Jin, J. Qiu, X.-Y. Wang, Q. Wang, J.-L. Wu, S. H. Vermund, and L. Song. 2015. Integrated prevention of mother-to-child transmission for human immunodeficiency virus, syphilis and hepatitis B virus in China. Bulletin of the World Health Organization 93(1):52-56.

Warne, D., and L. B. Frizzell. 2014. American Indian health policy: Historical trends and contemporary issues. American Journal of Public Health 104(Suppl 3):S263-S267.

Wheeler, R., V. A. Earnshaw, T. Kershaw, and J. R. Ickovics. 2012. Postpartum sexually transmitted disease: Refining our understanding of the population at risk. Sexually Transmitted Diseases 39(7):509-513.

Whitbeck, L. B., and B. E. Armenta. 2015. Patterns of substance use initiation among Indigenous adolescents. Addictive Behaviors 45:172-179.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

White Hughto, J. M., K. B. Biello, S. L. Reisner, A. Perez-Brumer, K. J. Heflin, and M. J. Mimiaga. 2016. Health risk behaviors in a representative sample of bisexual and heterosexual female high school students in Massachusetts. Journal of School Health 86(1):61-71.

WHO (World Health Organization). 2002. Towards a common language for functioning, disability and health. Geneva, Switzerland: World Health Organization.

WHO. 2018. Disability and health. https://www.who.int/news-room/fact-sheets/detail/disability-and-health (accessed November 19, 2020).

Widman, L., S. Choukas-Bradley, S. W. Helms, C. E. Golin, and M. J. Prinstein. 2014. Sexual communication between early adolescents and their dating partners, parents, and best friends. Journal of Sex Research 51(7):731-741.

Widman, L., S. Choukas-Bradley, S. M. Noar, J. Nesi, and K. Garrett. 2016. Parent-adolescent sexual communication and adolescent safer sex behavior: A meta-analysis. JAMA Pediatrics 170(1):52-61.

Wiehe, S. E., M. B. Rosenman, M. C. Aalsma, M. L. Scanlon, and J. D. Fortenberry. 2015. Epidemiology of sexually transmitted infections among offenders following arrest or incarceration. American Journal of Public Health 105(12):e26-e32.

Wildsmith, E., J. Manlove, and N. Steward-Streng. 2015. Relationship characteristics and contraceptive use among dating and cohabiting young adult couples. Perspectives on Sexual Reproductive Health 47(1):27-36.

Williams, R. L., and J. D. Fortenberry. 2013. Dual use of long-acting reversible contraceptives and condoms among adolescents. Journal of Adolescent Health 52(4 Suppl):S29-S34.

Wilson, N., and J. L. Cadet. 2009. Comorbid mood, psychosis, and marijuana abuse disorders: A theoretical review. Journal of Addictive Diseases 28(4):309-319.

Wingood, G. M., and R. J. DiClemente. 1998. Partner influences and gender-related factors associated with noncondom use among young adult African American women. American Journal of Community Psychology 26(1):29-51.

Winscott, M., M. Taylor, and K. Kenney. 2010. Sexually transmitted diseases among American Indians in Arizona: An important public health disparity. Public Health Reports 125(Suppl 4):51-60.

Wirtz, A. L., P. T. Yeh, N. L. Flath, C. Beyrer, and K. Dolan. 2018. HIV and viral hepatitis among imprisoned key populations. Epidemiologic Reviews 40(1):12-26.

Wise, A., T. Finlayson, L. Nerlander, C. Sionean, G. Paz-Bailey, and for the NHBS Study Group. 2017. Incarceration, sexual risk-related behaviors, and HIV infection among women at increased risk of HIV infection, 20 United States cities. Journal of Acquired Immune Deficiency Syndromes 75.

Wolfe, M. I., F. Xu, P. Patel, M. O’Cain, J. A. Schillinger, M. E. St Louis, and L. Finelli. 2001. An outbreak of syphilis in Alabama prisons: Correctional health policy and communicable disease control. American Journal of Public Health 91(8):1220-1225.

Wood, S. M., C. Salas-Humara, and N. L. Dowshen. 2016. Human immunodeficiency virus, other sexually transmitted infections, and sexual and reproductive health in lesbian, gay, bisexual, transgender youth. Pediatric Clinics of North America 63(6):1027-1055.

Woods-Jaeger, B. A., A. Sparks, K. Turner, T. Griffith, M. Jackson, and A. F. Lightfoot. 2013. Exploring the social and community context of African American adolescents’ HIV vulnerability. Qualitative Health Research, 23(11):1541-1550.

Workowski, K. A., and G. A. Bolan. 2015. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommendations and Reports 64(RR-03):1-137.

Wortley, P. M., M. L. Lindegren, and P. L. Fleming. 2001. Successful implementation of perinatal HIV prevention guidelines. A multistate surveillance evaluation. MMWR Recommendations and Reports 50(RR-6):17-28.

Wu, L. T., C. L. Ringwalt, A. A. Patkar, R. L. Hubbard, and D. G. Blazer. 2009. Association of MDMA/ecstasy and other substance use with self-reported sexually transmitted diseases among college-aged adults: A national study. Public Health 123(8):557-564.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

Xavier, J. M., M. Bobbin, B. Singer, and E. Budd. 2005. Needs assessment of transgendered people of color living in Washington, DC. International Journal of Transgenderism 8(2-3):31-47.

Xu, F., M. Sternberg, and L. Markowitz. 2010. Women who have sex with women in the United States: Prevalence, sexual behavior and prevalence of herpes simplex virus type 2 infection-results from National Health and Nutrition Examination Survey 2001-2006. Sexually Transmitted Diseases 37:407-413.

Xu, J., L. Yu, B. Fu, D. Zhao, and F. Liu. 2018. Influence of different delivery modes on the clinical characteristics of Chlamydia trachomatis pneumonia. European Journal of Pediatrics 177(8):1255-1260.

Young, S. D., and A. H. Jordan. 2013. The influence of social networking photos on social norms and sexual health behaviors. Cyberpsychology, Behavior, and Social Networking 16(4):243-247.

Zimmer-Gembeck, M. J., and M. Helfand. 2008. Ten years of longitudinal research on U.S. adolescent sexual behavior: Developmental correlates of sexual intercourse, and the importance of age, gender and ethnic background. Developmental Review 28(2):153-224.

Zuckerman, S., J. Haley, Y. Roubideaux, and M. Lillie-Blanton. 2004. Health service access, use, and insurance coverage among American Indians/Alaska Natives and whites: What role does the Indian Health Service play? American Journal of Public Health 94(1):53-59.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×

This page intentionally left blank.

Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 113
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 114
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 115
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 116
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 117
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 118
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 119
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 120
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 121
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 122
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 123
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 124
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 125
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 126
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 127
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 128
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 129
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 130
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 131
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 132
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 133
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 134
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 135
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 136
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 137
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 138
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 139
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 140
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 141
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 142
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 143
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 144
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 145
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 146
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 147
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 148
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 149
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 150
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 151
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 152
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 153
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 154
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 155
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 156
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 157
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 158
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 159
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 160
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 161
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 162
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 163
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 164
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 165
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 166
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 167
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 168
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 169
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 170
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 171
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 172
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 173
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 174
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 175
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 176
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 177
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 178
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 179
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 180
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 181
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 182
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 183
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 184
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 185
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 186
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 187
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 188
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 189
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 190
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 191
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 192
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 193
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 194
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 195
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 196
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 197
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 198
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 199
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 200
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 201
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 202
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 203
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 204
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 205
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 206
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 207
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 208
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 209
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 210
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 211
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 212
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 213
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 214
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 215
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 216
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 217
Suggested Citation:"3 Priority Populations." National Academies of Sciences, Engineering, and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. doi: 10.17226/25955.
×
Page 218
Next: 4 STI Economics, Public-Sector Financing, and Program Policy »
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm Get This Book
×
Buy Paperback | $110.00 Buy Ebook | $89.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

One in five people in the United States had a sexually transmitted infection (STI) on any given day in 2018, totaling nearly 68 million estimated infections. STIs are often asymptomatic (especially in women) and are therefore often undiagnosed and unreported. Untreated STIs can have severe health consequences, including chronic pelvic pain, infertility, miscarriage or newborn death, and increased risk of HIV infection, genital and oral cancers, neurological and rheumatological effects. In light of this, the Centers for Disease Control and Prevention, through the National Association of County and City Health Officials, commissioned the National Academies of Sciences, Engineering, and Medicine to convene a committee to examine the prevention and control of sexually transmitted infections in the United States and provide recommendations for action.

In 1997, the Institute of Medicine released a report, The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Although significant scientific advances have been made since that time, many of the problems and barriers described in that report persist today; STIs remain an underfunded and comparatively neglected field of public health practice and research. The committee reviewed the current state of STIs in the United States, and the resulting report, Sexually Transmitted Infections: Advancing a Sexual Health Paradigm, provides advice on future public health programs, policy, and research.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!