Crosby, Richard A. PhD*†; DiClemente, Ralph J. PhD*†‡§; Wingood, Gina M. ScD, MPH*†; Rose, Eve MPH*; Levine, David MD, FAAP∥
ADOLESCENTS DETAINED FOR LEGAL OFFENSES are a highly vulnerable population for the acquisition and transmission of sexually transmitted diseases (STDs). 1 Recent surveillance, for example, indicated that rates of gonorrhea among adolescent detainees were 152 and 42 times greater among males and females, respectively, than among adolescents in the general population. 2 Surveillance surveys have consistently shown high rates of chlamydial and trichomonas infection among detained adolescents. 3–8 One potential explanation for these observations is that adolescents violating laws are also likely to reside in neighborhoods where STD prevalence (and therefore transmission probability) is high.
In addition, numerous studies suggest that detained adolescents, when compared to samples of nondetained adolescents, are more likely to engage in STD-associated risk behaviors that may lead to HIV infection. For example, DiClemente and colleagues found that detained adolescents were significantly more likely than adolescents from a school-based sample to report an early age of sexual debut and to have multiple sex partners. 9 Findings from a recent study of adolescents in Mississippi showed that overall sexual-risk profiles of detained adolescents in this study were significantly greater than for adolescents sampled from homeless shelters. 10
However, these and similar studies have not investigated the sexual risk profiles of adolescents with a history of detention in comparison with their peers who have never been detained. Moreover, similar studies of adolescents charged with or convicted of a crime (but not sentenced to detention) are lacking. Given that at least 630,000 adolescents are adjudicated each year, 11 empirical evidence addressing the potential for greater sexual risk-taking among this population is warranted.
Problem Behavior Theory suggests that adolescents’ risk behaviors co-occur (or cluster), thereby creating a constellation of risk behaviors among many adolescents. 12 Based on this theory, the proposition that adolescents with a history of adjudication (i.e., charged with or convicted of a crime) may report substantially greater risk for STD acquisition is quite reasonable. This determination could be useful for identifying high-risk adolescents within a community as priority populations for interventions promoting safer sex behaviors.
Targeted intervention is particularly important among adolescent populations disproportionately affected by STDs, such as African American adolescents residing in the urban South. 13 Accordingly, the purpose of this exploratory study was to compare the self-reported sexual risk profiles of African American adolescents (residing in Atlanta, GA) stating a history of adjudication to the risk profiles of those not reporting adjudication.
Study participants were adolescents enrolled in a multisite randomized trial of a brief human immunodeficiency virus (HIV) prevention program. Only data collected from the baseline assessment at the Atlanta site were used for the current study. The study recruited adolescents (15–21 years of age) from primary care clinics and through outreach activities (e.g., street outreach, posters, flyers, and referral from friends).
The inclusion criterion was sexual activity (vaginal or anal) within the past 90 days. Adolescents who were currently pregnant, were attempting to become pregnant, or had given birth within the past 90 days were excluded. Adolescents with known HIV-positive serostatus were also excluded.
Eligible adolescents (n = 477) were invited to participate in the study. Adolescents listened to a standardized brief overview of the study, including requirements of participation and amount of compensation provided. Informed consent was obtained from adolescents 18 years of age or older. Assent and parental consent were obtained for adolescents 15 to 17 years of age. The University Institutional Review Board approved all study protocols.
A total of 330 adolescents enrolled in the study and completed baseline assessments, yielding a participation rate of 69%. The majority (n = 304; 92%) of these adolescents self-identified as African American and therefore comprised the sample for the current study.
Adolescents completed a 30-minute questionnaire using audio computer-assisted self-interviewing (A-CASI) technology. Evidence suggests that A-CASI technology may facilitate adolescents’ disclosure of personal information such as their sexual risk behaviors. 14,15 Many of the questions on the A-CASI asked about behaviors during the past 90 days. To facilitate recall, adolescents were given a 90-day calendar; a standardized script was used to help adolescents document memorable events during the recall period.
Subsequently, adolescents were trained to use the laptop computers, e.g., they were shown how to enter responses using the number and letter keys, function keys were defined, and three questions were used for practice. Research staff remained in the testing room to answer any questions and to assist with operation of the computers. The adolescents were given $50 for their participation.
The following question was used to determine adolescents’ history of adjudication: “Have you ever been in juvenile detention, arrested, or charged with or convicted of a crime other than a minor traffic violation?” Adolescents’ sexual risk profile was determined by assessing age of sexual debut, whether they had ever had any of three STDs (gonorrhea, chlamydia, or trichomoniasis) diagnosed, and whether they had ever had sex with someone they had met the same day. Throughout the questionnaire, sex was defined as including both penile-vaginal sex (defined to adolescents as “when a man inserts his penis into a woman's vagina”) and anal sex (defined to adolescents as “when a man puts his penis into a man's or woman's anus or butt”). Two questions used a recall period of “the last time”: (1) “The last time you had sex, did you or the other person use a condom?” and (2) “The last time you had sex, were you using drugs or alcohol?”
Remaining measures used a 90-day recall period. Two measures of condom use were assessed: (1) never used and (2) always used. Given that adolescents who use condoms may not always use them correctly, 16–18 we also assessed frequency of sex during this recall period as part of their overall sexual risk profile. Number of sex partners and whether adolescents had sex with someone they knew or suspected had an STD were also assessed. Adolescents were also asked if they had been diagnosed with an STD (gonorrhea, chlamydia, or trichomoniasis) in the past 90 days.
First, continuous-level measures were evaluated for normality by determining if skewness or kurtosis ratios exceeded an absolute value of 2.0. Because these measures were not normally distributed, they were dichotomized by a median split. Strength of bivariate associations between adjudication history and each measure in the sexual risk profile was assessed by prevalence ratios, their 95% confidence intervals, and corresponding P values.
To control for potential confounding, adolescents’ age, gender, and level of education were each tested for associations with adjudication history (t-tests were used to measure associations between age and adjudication history, as well as education and adjudication history). Only the association between gender and adjudication history (assessed by a chi-square test) achieved significance with alpha set at 0.05. Because gender was also significantly associated with the measures composing the sexual risk profile, this variable was used as a covariate to calculate adjusted odds ratios of sexual risk measures achieving bivariate significance.
Hierarchal logistic regression analysis, controlling for the influence of gender (by forcing this variable separately into the first block of the model), was used to calculate adjusted odds ratios, their 95% confidence intervals, and corresponding P values.
Characteristics of the Sample
Average age of the adolescents was 18.5 years (standard deviation [SD] = 1.6). Forty percent reported they had not finished high school, 34% reported they had obtained a high school diploma (or equivalent), and 26% reported receiving education beyond high school. Females comprised 59% of the sample. The median frequency of sexual experiences reported in the past 90 days was eight (range, 1–100). Twenty-six percent of the adolescents reported a history of adjudication. Adjudication history was significantly more common among males (38.5%) than females (17.9%; P = 0.0001).
Table 1 displays bivariate associations between adolescents’ adjudication history and each of the measures comprising the sexual risk profile. With the exception of measures pertaining to condom use, each of the associations achieved significance. Associations with three measures of STD history were particularly strong. Compared to those who had never been adjudicated, adjudicated adolescents were about twice as likely to report a history of STD diagnosis and more than three times as likely to report an STD diagnosis in the past 90 days. Furthermore, adjudicated adolescents were about 6.4 times more likely to report recent sex with someone whom they suspected or knew had an STD.
Table 2 displays gender-adjusted odds ratios for associations achieving bivariate significance. After adjustment for the effects of gender, each of the three measures pertaining to STD history remained significant and substantially strong. Furthermore, measures of drug/alcohol use during last sex and more frequent sex remained significant. Adjudicated adolescents were about 2.6 times more likely than their nonadjudicated counterparts to report using drugs or alcohol during their last sexual experience. Similarly, adjudicated adolescents were about 2.2 times more likely than their nonadjudicated counterparts to be classified as having more frequent sex in the past 90 days.
Four measures achieving bivariate significance failed to achieve significance after adjustment for gender. For each of these measures, males were significantly more likely than females to report the risk behavior: sexual debut before age 13 years, multiple partners, sex with partner met on the same day, and sex with a nonmonogamous partner. These gender effects substantially weakened associations between adjudication history and each of the four measures.
In this exploratory study, controlled analyses suggested that African American adolescents with a history of adjudication may have greater risk for acquisition of STDs than their peers not reporting adjudication. However, this inflated risk may not be attributable to differences in condom use. For example, fewer than one fifth of the adolescents reported not using condoms 100% of the time they had sex, and this high rate of use did not differ by adjudication history (Table 1). Instead, the findings suggest that adjudicated adolescents may be located in sexual networks wherein the prevalence of STDs is greater, thereby magnifying their odds of STD acquisition despite levels of condom use that are similar to those reported by their nonadjudicated counterparts. Although other explanations may be tenable, a network explanation is highly plausible.
Previous evidence suggests that differential STD prevalence among adolescents’ sexual networks may account for the disproportionate infection of African American adolescents. 19–21 Our findings raise the possibility that network differences, based on adjudication history, may exist within communities of African American adolescents. Indeed, previous research suggests that adolescents reporting they engage in risky behaviors (of any kind) tend to associate with other adolescents who also engage in these risky behaviors. 22–26
Specific findings supporting a network explanation include the point that adjudicated adolescents were 3.6 and 4.5 times more likely, respectively, than their counterparts to report ever having one of three STDs (gonorrhea, chlamydia, and trichomoniasis) or to report having one of these three STDs in the past 90 days. The finding that adjudicated adolescents were about nine times more likely to report recent sex with a partner whom they suspected or knew had an STD also suggests that adjudicated adolescents may disproportionately be exposed to sexual networks of high STD prevalence.
Although our findings regarding drug/alcohol use during last sex and relatively more frequent sex in the past 90 days cannot be directly linked with greater STD risk, they may serve as a marker for a greater propensity for sexual risk-taking among adjudicated adolescents. Consistent with Problem Behavior Theory, 12 these findings suggest that behaviors compatible with adjudication (i.e., various infractions of the law), substance use behaviors, and frequent sexual activity may co-occur.
Clearly, one implication of this observation is that future research efforts might investigate whether adjudicated adolescents share similar psychosocial profiles with regard to antecedents of STD-associated risk behaviors. Such research should also account for the likelihood that adolescents residing in high-risk neighborhoods (i.e., places characterized by crime) may face greater odds of adjudication if their neighborhoods have an increased police presence (thereby suggesting that neighborhood variables may precede both adjudication and STD-associated risk behavior).
Despite the use of A-CASI technology, the findings are limited by the use of self-reported measures, particularly with regard to the past acquisition of STDs. Findings are also limited by the use of a cross-sectional study design; similar investigations using prospective designs are warranted. In addition, the use of a nonprobability sample limits generalization to other African American adolescents. Furthermore, the participation rate of 69% could indicate a sampling bias, thus further limiting the generalizability of the findings. Conceivably, higher-risk adolescents may have been less likely to participate in the study. Thus, the findings may underrepresent the risk of both adjudicated and nonadjudicated adolescents.
It should also be noted that adolescents’ network affiliations may be an important uncontrolled variable that could have confounded our observed associations (i.e., networks may have a causal relationship with adjudication as well as adolescents’ STD-associated risk behaviors). Finally, it should be noted that assessing condom use can be highly problematic. 27 Thus, if measurement error of this behavior systematically differed between adjudicated and nonadjudicated adolescents, our findings relevant to condom use behaviors may be biased.
Implications for Prevention
Findings of this exploratory study suggest the possibility that African American adolescents may use condoms on a relatively consistent basis, regardless of adjudication history. Thus, it is conceivable that public health efforts to promote condom use have favorably influenced adjudicated and nonadjudicated African American adolescents. However, adjudicated adolescents may be more likely to affiliate with sexual networks that share a proclivity for engaging in sexual risk beyond the nonuse of condoms. Moreover, any level of inconsistent or incorrect condom use among adjudicated adolescents may be disproportionately risky in comparison with use among their nonadjudicated counterparts, who may affiliate with sexual networks with a lower prevalence of STDs.
Thus, STD prevention programs that specifically target adjudicated African American adolescents may benefit less from a focus on promoting consistent use and more on a focus of avoiding sex with persons known or suspected of having an STD. Unfortunately, such a focus is highly problematic in that prevention messages may unintentionally lead adolescents to make unfounded judgments about a person's STD status. Alternatively, intensified screening and treatment of persons belonging to the sexual networks of adjudicated adolescents may be an effective prevention strategy. Such a strategy would lower STD prevalence in adjudicated adolescents’ sexual networks, thereby decreasing their overall risk of STD acquisition. Network-based interventions could also focus on reducing sexual risk behaviors of adjudicated adolescents.
Further research could investigate the utility of screening newly adjudicated adolescents for STDs and then using the index cases as a means of subsequently locating, screening, and treating members of their sexual networks. If successful, this strategy might offer substantial STD-protective benefit to adjudicated adolescents. Using adjudicated adolescents as an entry point into sexual networks may also provide an opportunity to address shared (network) patterns of STD-associated risk behavior through the application of small-group intervention techniques with established efficacy. 28–30
Controlled findings of this exploratory study suggest that African American adolescents who have ever been adjudicated may also be more likely than their nonadjudicated counterparts to report acquisition of STDs, to have sex with someone known or suspected of having an STD, to engage in sex more frequently, and to use drugs/alcohol during sexual encounters. This apparent clustering of risk behavior, combined with potentially greater levels of STD prevalence in the sexual networks of adjudicated adolescents, may represent an important intervention point for STD reduction efforts.
1. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press, 1997.
2. Centers for Disease Control and Prevention. HIV/AIDS education and prevention programs for adults in prisons and jails and juveniles in confinement facilities: United States, 1994. MMWR Morb Mortal Wkly Rep 1996; 45: 268–271.
3. Shafer MA, Hilton JF, Ekstrand M, et al. Relationship between drug use and sexual behaviors and the occurrence of sexually transmitted diseases among high risk male youth. Sex Transm Dis 1993; 20: 307–313.
4. Oh MK, Smith KR, O'Cain M, et al. Urine based screening of adolescents in detention to guide treatment for gonococcal and chlamydial infections: Translating research into intervention. Arch Pediatr Adolesc Med 1998; 152: 52–56.
5. Oh MK, Cloud GA, Wallace LS, et al. Sexual behavior and sexually transmitted diseases among male adolescents in detention. Sex Transm Dis 1994; 21: 127–132.
6. Canterbury RJ, McGarvey EL, Sheldon-Keller AE, et al. Prevalence of HIV-related risk behaviors and STDs among incarcerated adolescents. J Adolesc Health 1995; 17: 173–177.
7. Pack RP, DiClemente RJ, Hook EW, Oh MK. High prevalence of asymptomatic STDs in incarcerated minority male youth: A case for screening. Sex Transm Dis 2000; 27: 175–177.
8. Patricia J, Bair RM, Baillargeon J, et al. Risk behaviors and the prevalence of chlamydia in a juvenile detention facility. Clin Pediatrics 2000; 39: 521–527.
9. DiClemente RJ, Lanier MM, Horan PF, Lodico M. Comparison of AIDS knowledge, attitudes, and behaviors among incarcerated adolescents and a public school sample in San Francisco. Am J Public Health 1991; 81: 628–629.
10. St. Lawrence JS, Crosby RA, O'Bannon RO. Adolescent risk for HIV infection: Comparison of four high risk samples. J HIV/AIDS Prev Educ Adolesc Children 1999; 3: 63–85.
11. Policy Research Associates. Co-occurring disorders and justice center: facts. Available at gainsctr.com/facts./ Accessed on October 23, 2002.
12. Jessor R, Donovan JE, Costa FM. Beyond Adolescence: Problem Behavior and Young Adult Development. New York: Cambridge University Press, 1991.
13. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2001. Atlanta: U.S. Department of Health and Human Services, 2002.
14. Turner CF, Ku L, Rogers SM, et al. Adolescent sexual behavior, drug use, and violence: increased reporting with computer survey technology. Science 1998; 280: 867–872.
15. Michaud P, Narring F, Ferron C. Alternative methods in the investigation of adolescents’ sexual life. J Adolesc Health 1999; 25: 84–90.
16. Crosby RA, DiClemente RJ, Wingood GM, et al. Correct condom application among African Am adolescent females: The relationship to perceived self-efficacy and the association with confirmed STDs. J Adolesc Health 2001; 29: 194–199.
17. Crosby RA, Yarber WL. Perceived versus actual knowledge about correct condom use among US adolescents: results from a national study. J Adolesc Health 2001; 28: 415–420.
18. Crosby RA, Sanders S, Yarber WL, et al. Condom use errors and problems among college men. Sex Transm Dis 2002; 29: 552–557.
19. Fullilove RE. Race and sexually transmitted diseases. Sex Transm Dis 1998; 25: 130–131.
20. Aral SO, Holmes KK. Social and behavioral determinants of the epidemiology of STDs: Industrialized and developing countries. In: Holmes KK, Sparling PF, Mardh P, et al., eds. Sexually Transmitted Diseases. New York: McGraw-Hill, 1999: 39–76.
21. Laumann EO, Youm Y. Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sex Transm Dis 1999; 26: 250–261.
22. Wingood GM, DiClemente RJ, Crosby RA, et al. Gang involvement and the health of African-American female adolescents. Pediatrics 2002; 110( 5): e57.
23. Prinstein MJ, Boergers J, Spirito A. Adolescents’ and their friends health-risk behavior: factors that alter or add to peer influence. J Pediatric Psychol 2001; 26: 287–298.
24. La Greca AM, Prinstein MJ, Fetter MD. Adolescent peer crowd affiliation: linkages with health-risk behaviors and close friendships. J Pediatric Psychol 2001; 26: 131–143.
25. Patterson GR, Dishion TJ, Yoerger K. Adolescent growth in new forms of problem behavior: macro- and micro-peer dynamics. Prev Science 2000; 1: 3–13.
26. Tolson JM, Urberg KA. Similarity between adolescents and best friends. J Adolesc Res 1993; 8: 274–288.
27. Crosby RA, DiClemente RJ, Holtgrave DR, Wingood GM. Design, measurement, and analytic considerations for testing hypotheses relative to condom effectiveness against non-viral STIs. Sex Transm Infect 2002; 78: 228–231.
28. St. Lawrence JS, Brasfield TL, Jefferson KW, et al. Cognitive-behavioral intervention to reduce African American adolescents’ risk for HIV infection. J Consult Clin Psychol 1995; 63: 221–237.
29. Jemmott JB, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial. JAMA 1998; 279: 1529–1536.
30. Shain RN, Piper JM, Newton ER, et al. A randomized, controlled trial of a behavioral intervention to prevent sexually trans-mitted disease among minority women. N Engl J Med 1999; 340: 93–100.