478 Adolescent Health
teenagers are dif“cult to obtain because much of the available
national data is obtained from high school students and thus
does not include young adolescents or teenagers who are not
in school. There is evidence that out-of-school teenagers are
considerably more likely to have had intercourse than those
still in school (70% versus 45%) as well as engage in other
risky behaviors (see Neinstein, 1996c). As a rough estimate,
half of girls and almost two-thirds of boys will have had sex-
ual intercourse by the age of 15 (see R. Brown, 2000). Urban
rates tend to be higher, with as many as 24% of teenagers
ages 12 to 13 having had sexual intercourse (see R. Brown,
2000).
This change in sexual activity is clearly a national phe-
nomenon, with a downward shift in age evident across all
subgroups of the adolescent population. Nevertheless, there
are variations among individuals and subgroups of teenagers,
re”ecting such factors as maternal educational level, age of
menarche, intelligence, attitudes toward achievement and
religion, extent of peer in”uence, and parenting style. In gen-
eral, earlier sexual activity is correlated with other risk
behaviors although less so for African American adolescents
(see R. Brown, 2000).
The earlier onset of sexual intercourse has resulted in a
very large number of teenagers who are sexually active and
thus vulnerable to adverse health effects from sexually trans-
mitted disease and unintended pregnancy. In addition to in-
tercourse, the downward shift in age includes many sexual
activities that are traditionally precursors to intercourse
(e.g., heavy petting) or substitutes for intercourse (see
Phillips, 1997a). Reported sexual practices of virginal high
schoolers, males and females, included fellatio with ejacula-
tion (11% and 8%), cunnilingus (9% and 12%), and anal
intercourse (1% and .4%; see R. Brown, 2000). While avoid-
ing the risk of pregnancy, such extra-intercourse sexual ac-
tivity still presents the risk of sexually transmitted disease.
Sexually Transmitted Disease
The increased number of teenagers becoming sexually active
at younger ages prompts concern regarding sexually transmit-
ted disease (STD) not only because there is a longer time for
potential exposure but also because of the cumulative effect on
number of sexual partners. For example, of women who were
sexually active by age 15, 25% reported 10 or more lifetime
sexual partners, in contrast to 6% of those who delayed sex-
ual activity until age 20 (see Cates & Berman, 1999). Also,
teenagers may be more vulnerable to infection if they are ex-
posed, both because they are less likely to use protection con-
sistently and because their immune and reproductive systems
are less well-developed than those of adults (e.g., cervical
ectopy in adolescents leaves more vulnerable tissue exposed;
R. Brown, 2000). Signi“cant sequelae of STDs include pelvic
in”ammatory disease, lowered fertility, sterility, congenital
syphilis, and life-threatening disorders such as ectopic
pregnancy, pelvic abscesses, cancer, and death from AIDS
(R. Brown, 2000; Cates & Berman, 1999; Glazer, Goldfarb, &
James, 1998).
STDs are dif“cult to control because of their exponential
spread and because those who are infected (especially
women) are often asymptomatic and hence can unwittingly
transmit the infection. This results in prevalence rates among
young people that are considered to be of epidemic propor-
tions. Rough estimates indicate that three million adolescents
(1 in 4 sexually active teenagers) acquire an STD every year
(R. Brown, 2000). Accurate prevalence rates are dif“cult to
obtain because only gonorrhea, syphilis, and AIDS are re-
quired to be reported to the Centers for Disease Control, and
many cases are not reported despite the requirement. Because
of its prevalence and the reporting requirement, gonorrhea
is often used as a marker of STD patterns in general, although
other STDs are more common (e.g., chlamydia is four times
as prevalent) and include currently incurable diseases such as
genital herpes and genital warts.
Overall, the incidence of gonorrhea decreased in the
United States from 1975 through 1996, with a more recent in-
crease of 9% from 1997 to 1999 (D. Brown, 2000). The de-
crease was slower for adolescents than for older age groups,
resulting in the second-highest rates of gonorrhea occurring
in the 15- to 19-year age group (20 to 24 being the highest;
see Cates & Berman, 1999). In 1999, the highest rate of
gonorrhea of all ages and racial groups was that of African
American teenagers, with rates being particularly high in
mid-Atlantic and southern cities (D. Brown, 2000). Further,
rates have remained stable or increased for African American
teenagers, in contrast to the general decline seen for White
and Hispanic teenagers and for older African Americans. The
effect of these trends has been to widen the racial gap
for teenagers with regard to gonorrhea (and presumably
most other STDs). Rates among African American teenagers
(male and female) were 12 times and 9 times as high as those
among White teenagers in 1981; by 1991, the rates were
44 times and 15 times as high (see Cates & Berman, 1999).
In 1999, the highest rate of gonorrhea of all ages and racial
groups was that of African American teenagers, with rates
being particularly high in mid-Atlantic and southern cities
(D. Brown, 2000).
The racial difference among teenagers probably re”ects
various factors, including (a) greater success with preven-
tion messages in White communities, (b) public STD clinics
being overwhelmed and underfunded, (c) publicly funded