Salient Areas of Adolescent Health 479control efforts shifting from gonorrhea to chlamydia and
syphilis, and (d) STD risk behaviors being fueled by illicit
drugs (see Cates & Berman, 1999). These factors probably
also affect patterns of HIV transmission in the United
States, where it is rapidly becoming a disease of the young
and the non-White population. While only 1% of all re-
ported AIDS cases represent teenagers (ages 13 to 19), 20%
of cases represent young adults (ages 20 to 29). With a
mean incubation period of seven to ten years from HIV in-
fection to AIDS, it is obvious that most of the young
adults with AIDS acquired the disease as teenagers (Belzer
& Neinstein, 1996). Persons of color are markedly overrep-
resented, comprising 55% of all cases among young people
ages 13 to 24 (see Belzer & Neinstein, 1996). Finally, most
AIDS cases are still occurring in the male population, but
women, adolescents, and children are now the groups with
the fastest growth of new infections in the United States. As
heterosexual transmission increasingly becomes the major
form of transmission (as it is in most of the world), adoles-
cents will become increasingly affected (see Glazer et al.,
1998).
STD prevention efforts that have emphasized abstinence
and/or delaying the start of sexual activity have met with
extremely limited success (see R. Brown, 2000; Cates &
Berman, 1999). A general increase in public awareness
seems to have had some effect on condom use, with use at
last intercourse reported to range from 27% to 66% in stud-
ies of adolescents, rates that are at least twice as high as those
in the 1970s, although less than half the teenagers who used
condoms reported doing so all the time (see Cates & Berman,
1999). Speci“c interventions tailored to promote safe sexual
practices suggest that it may be easier to reduce some risky
behaviors than others. A group of adolescents hospitalized
for psychiatric problems responded to an intensive AIDS ed-
ucation program by reporting that they were more likely to
discontinue unprotected sex and sex with homosexual men
than they were to discontinue injecting drugs or sharing nee-
dles (Ponton, DiClemente, & McKenna, 1991). Metzler,
Biglan, Noell, Ary, and Ochs (2000) provided behavioral in-
tervention to adolescents recruited in public STD clinics,
who (at 6-month follow-up) reported no increase in condom
use but some reduction (particularly for nonminority males)
in other risk behaviors: number of sexual partners, non-
monogamous partners, sex with strangers, and use of mari-
juana before or during sex. They note that the relatively
few interventions with some success addressed attitudes,
decision making, risk recognition, and coping skills in addi-
tion to education. An entirely different strategy is prevention
via vaccination, currently being employed for hepatitis B.
Unfortunately, the highest risk populations of teenagers have
been those least likely to have received vaccination (Cates &
Berman, 1999).PregnancyIn the past 20 years, there has been an increase in contracep-
tion use at “rst intercourse, from 48% in 1982, to 65% in
1988, to 78% in 1995, largely the result of increased condom
use, especially by non-Hispanic White teenagers (see R.
Brown, 2000; Phillips, 1997a). However, almost one-quarter
of young women remain unprotected at “rst intercourse. A
larger number are unprotected subsequently because most
young women (60%) delay seeking medical contraceptive
services for at least a year after beginning sexual activity, and
even those who do use contraception do not all do so consis-
tently or correctly (see Neinstein, Rabinovitz, et al., 1996;
Phillips, 1997a).
Effective contraception requires acceptance of one•s sexu-
ality; acknowledgment of risk; access to contraceptives;
planning ahead; ability to communicate with one•s partner;
taking active measures on eachoccasion to prevent only pos-
siblefuture consequences; acceptance of side effects; coping
with attitudes of peers, partners, family, and the larger com-
munity; and the perception of a positive future that will be
threatened by pregnancy (see Phillips, 1997a). Even adults
have dif“culties in many of these areas and, given their
developmental stage, consistent contraception poses particu-
lar challenges for adolescents. These obstacles to contracep-
tion result in more than one million pregnancies annually
among teenage girls, the overwhelming majority being
unintentional; approximately half of teenage pregnancies
end in abortion and about half in live births (see Neinstein,
Rabinovitz, et al., 1996).
Abortion is almost always considered to be a negative
event, although remarkably little is known about the
decision-making process. The early literature on psychologi-
cal sequelae of abortion focused on psychopathological
responses, largely based on case studies or “ndings from self-
selected groups. More recent empirical studies of American
women undergoing legal abortions suggest that the experi-
ence does not pose major psychological hazards for most
women (see Adler et al., 1992), with feelings of relief and
happiness being reported more frequently and with more in-
tensity than feelings of guilt and sadness. While most women
appear to cope well after an abortion, some do experience
signi“cant distress and other negative outcomes. This
appears more likely for women who are younger, nulli-
parous, unmarried, and whose culture or religion prohibits
abortion; other factors include delaying abortion until the
second trimester, viewing pregnancy as highly meaningful,