FIGURE. No caption available.

Despite 20 years of media saturation about the ongoing need to practice safe sex and/or abstinence, adolescents continue to engage in behaviors that put them at risk for STIs, including HIV. The Centers for Disease Control and Prevention (CDC) reports that over 40% of all adolescents have engaged in sexual intercourse, with this figure rising to 60% of high school seniors. Adolescents have the highest incidence of chlamydia, gonorrhea, and human papillomavirus infection, with over 3 million teens contracting an STI each year. In addition, in the United States, one quarter of new HIV infections occur among people between the ages of 13 and 21 annually (CDC, 2004a).

Among sexually active students, 49% of girls and 35% of boys reported they did not use a condom the last time they had sex (CDC, 2004a). Among some populations such as adolescents in the juvenile justice system, condom use is even lower and rates of early sexual activity and multiple partners is higher than in community-dwelling samples. More than half of adolescents in the juvenile justice system reported sexual activity by age 12, and 60% had more than one sexual partner in the previous 3 months (Teplin, Mericie, McClelland, & Abram, 2003).

To be effective, prevention programs must engage the diverse elements of their target adolescent audience. The 12-year-old girl with the body of a mature women and the 16-year-old football player have different educational needs and goals, as do a 14-year-old pregnant Hispanic teen, a 12-year-old Caucasian victim of sexual abuse, and a 17-year-old incarcerated male. Unfortunately, many programs, particularly those that are school-based, do not account for (1) age-related differences in cognitive functioning; (2) differences in the ways that females and males view, and actually experience, sex; (3) differences in cultural backgrounds; and (4) differences in sexual preferences. Prevention programs that take these differences into account have a better chance of being more responsive to adolescent's needs, and therefore more effective. Nurse researchers have studied prevention of STIs/HIV with adolescents, focusing on the importance of recognizing differences in racial and ethnic groups, sexual expression, and specific risk groups such as pregnant or homeless teens (Jemmott, Jemmott, Hines, & Fong, 2001;Koniak-Griffin et al., 2003;Rotheram-Borus et al., 2003).

Adolescent Development

The physical changes of puberty generally occur in girls between 9 and 13 and in boys between 10 and 14 years of age (Neinstein, 2002). For girls, menarche is always preceded by a growth spurt and initial breast development. For boys, the sequence is growth spurt, testicular enlargement, and doubling of phallus size (Neinstein, 2002).

Cognitive changes that occur during adolescence include a broadening of thought processes from a thinking style that is childlike and concrete to one that is more adultlike, including an expanded ability to think conceptually, make connections, and understand consequences (American Academy of Pediatrics [AAP], 2002). As they gain self-awareness, adolescents start to change their life goals from the probably unattainable (such as professional sports person or rock star) to more reasonable goals such as teacher, lawyer, mechanic, or secretary.

Another area of development is the psychological struggle to construct a personal identity and move away from the ready acceptance of ideas and activities endorsed by parents (AAP, 2002). Peer activities become more important than those with family, with a literal metamorphosis occurring as adolescents construct their individuality through clothing, body adornment, and behaviors.

These changes in physical, cognitive, and psychological development result in the daily expenditure of large amounts of physical and psychic energy and frequently lead to behaviors that appear self-centered (Neinstein, 2002). As a result, adolescents often perceive an imaginary audience that is focusing on them, their bodies, their clothes, or the obvious deficiencies of their parents. Self-centeredness also takes the form of ego inflation and is coupled with a sense of invulnerability that easily leads to behaviors such as driving under the influence of alcohol ("I know that I can handle it") or having sex without a condom ("Nothing will happen to me") (Friedman, Fisher, Schonberg, & Alderman, 1998).

Girls and boys experience the changes of adolescence differently. In general, girls have strong negative feelings about their body changes with little subjective or objective knowledge about these changes (Hayward, 2003). They report greater ambivalence about leaving childhood than boys do and have greater anxiety about their new bodies. While girls believe that their worth depends heavily on appearance (which many perceive to be inadequate), boys report that they look forward to adulthood, are pleased with their new bodies, and have a positive sense of self-governance (Hayward, 2003).

Indicators of adolescent mental health reflect these gender differences. Across the United States, middle and high school girls reflect a decrease in self-esteem, while the self-esteem of middle and high school boys is increasing (Siegel, Yancey, Aneshensel, & Schuler, 1999). Girls report lower expectations of life, are more vulnerable to depression, and attempt suicide four times more frequently than boys (CDC, 2004b; Commonwealth Fund, 1997).

Sensitivity to race/ethnicity and to sexual preferences is important in STI/HIV prevention programs.

Gender also influences the sexual expectations and behaviors of adolescents, with boys applauded for having sexual experiences and gaining self-esteem as a result. In contrast, girls are expected to control and deny their sexual urges, and if or when they do have sex, it generally results in diminished self-esteem (Aubrey, 2004). Girls report looking for romance and love in their relationships, while boys are more interested in friendship and sex. STI and HIV prevention messages frequently ignore such differences and assume that condom ads like "just zip it" or "no glove/no love" are equally appropriate for girls and for boys. However, the reality is that boys make the decisions about the use of condoms, while girls are limited to persuading or reacting to a male who refuses to use a condom. Girls often fear or experience abuse from their partners as a result of requesting use of a condom (Koniak-Griffin, Lesser, Uman, & Nyamathi, 2003). Messages, strategies, or programs to prevent unsafe sex that ignore gender differences are not likely to be effective.

In addition to gender differences, younger teens (11 to 14 years) and older teens (15 to 17 years) show significant differences in physical characteristics, cognitive skills, and emotional stability (AAP, 2002). Younger teens are experiencing rapid physical growth, while older teens are integrating the physical changes that have already occurred. The development of the nervous system leads to differences in the thinking styles between younger and older teens. Younger teens, with nervous systems still maturing, make decisions impulsively and depend on trial and error reasoning. In contrast, older teens can think abstractly and plan ahead. Younger teens exhibit abundant curiosity and seek mechanical knowledge about body parts and functions but are often unable to visualize how diagrams of internal organs relate to their bodies (Yarber, 1995). Older teens can understand how a general concept (such as the probability of pregnancy) applies to them and make the connection between cause and effect of unprotected intercourse and pregnancy.

Reasons teens give for initiating sexual behaviors also reflect age differences. Younger teens report that their own curiosity and pressure from partners or peers are powerful influences on initial sexual experiences, while older teens report emotional and physical attraction or substance use as behavioral influences (Rosenthal et al., 2001).

Cultural issues also impact adolescent behaviors (Vinh-Thomas, Bunch, & Card, 2003). For example, adolescents of Hispanic backgrounds have been shown to respond to messages that integrate ideas about respect and family (Villarruel, 1998). Hispanics are not a uniform group, however, and have different countries of origin, immigration status, and level of acculturation, which creates considerable diversity in this population. HIV in Hispanics from Puerto Rico reflect higher rates of injecting drug use than among new immigrants from Mexico, where heterosexual transmission is more common (CDC, 2002). African-American adolescents may have negative attitudes about HIV and AIDS prevention (Braithwaite & Tailor, 2001). Beliefs that condoms actually contain HIV virus, that condom use is the equivalent of genocide, and that HIV is a problem only for homosexuals are common in many cultures (Braithwaite & Tailor, 2001). If the nurse is not a member of the racial/ethnic group to whom the program is directed, it is important to use peer educators and role models from the community to help bridge cultural differences (Streng, 2000).

Because most adolescent programs are based on a heterosexual population, the gay and lesbian subculture of adolescents might be excluded from sexual risk reduction programs. All prevention programs should acknowledge, however, that differences in sexual orientation exist (Ryan, Futterman, & Stine, 1998). Gay, lesbian, bisexual, and transgender adolescents (as well as adolescents who are questioning their sexual identity) exist in every community of teenagers, and while they might not be readily visible or identified, it is important to explicitly recognize their presence. Program personnel should always use language that focuses on behaviors ("males who have sex with males") rather than on labels ("gay men") to avoid stereotyping. It is also best to institute a zero tolerance policy about the use of pejorative terms about sexual minorities; this sets a clear standard of support for this population.

Four Prevention Program Essentials

In contrast to secondary prevention programs that provide clinical services to adolescents, primary prevention programs work to address the antecedents of sexual behaviors. Following are four elements that have been shown in the literature to contribute to successful primary prevention programs.

Nurses often address the sexual experiences of adolescents in the context of a disease model. Slogans such as "postpone sex," "just say no," or "if you must have sex, use a condom" convey a judgmental or negative attitude toward sexuality and imply that adolescent interest in sex is abnormal (Coalition for Positive Sexuality [CPS], 1997). It is important to remember that adolescent sexuality is not pathologic but a part of normal development as human beings. Emphasizing sexual health rather than discussing sex exclusively as behavior that has only bad consequences, such as pregnancy or STIs, results in more effective work with adolescents (AAP, 2001). A sexual heath emphasis focuses on differences between sexuality and sex, positive relationships, ways to express caring and affection, and noncoital sexual expression, including masturbation. By openly discussing the myths surrounding sex, the risks and consequences of STIs, and the special needs of gay and lesbian youth, adolescents learn to communicate their feelings and to make positive sexual health decisions, which may include the decision to postpone sex. Specific ways for nurses to assist adolescents include displaying an openness to questions (no matter how discomforting or embarrassing); opening discussions with queries about what adolescents hear their friends discussing; and holding short, targeted talks on topics requested by teens.

Energizing younger teens to dream broadly about "what they want to be when they grow up" and urging older teens to look concretely at future choices make interesting roundtable discussions. A helpful strategy is to encourage all teens to consider how sexual decisions fit into future life goals and realistic ways to achieve those goals.

Peers exert enormous influence on the decisions that adolescents make about life and about sexual behaviors. We know that adolescents are more likely to engage in sexual activities if their friends are sexually active (Nahom et al., 2001). The strong influence of peers is harnessed when peer counseling is incorporated into programs for adolescents. Peer counselors who are 2 to 4 years older than program participants have been shown to be effective in transmitting information and counseling younger adolescents on safe sex (Streng, 2000). Matching for sex, ethnicity, and lifestyle (that is, familiarity with the behavior being discussed) will increase the credibility of peer counselors (Streng, 2000). While it may not be possible to use peer counselors who are perfect matches, an attempt should be made to have counselors and program participants be similar on at least two of the concepts of "peerness."

Open-ended questions, active listening techniques, and clear understandable language make adolescents feel more comfortable in any setting. Avoid giving advice or using directive phrases like "If I were you, I'd[horizontal ellipsis]" and "I'd do what your father says about[horizontal ellipsis]." Adolescents perceive that their lives are filled with authority figures, and nurses might be more effective if they objectively help adolescents consider choices and make wise decisions. Because adolescents are highly sensitive to criticism, nurses should be nonjudgmental in both verbal and nonverbal communication. For example, adolescents who have already had sexual intercourse may regard words like "virgin" and "abstinence" as implicitly critical. Nurses should clarify the meaning of terms they use and eliminate any possibility of misinterpretation. Also important are clear definitions of words like sex and intercourse, because adolescents often ask "Is oral sex included when talking about sex?" and "Is anal sex intercourse?" Finally, the best communication is achieved when nurses and adolescents develop a satisfying two-way relationship. By learning about the unique perspectives of adolescents and asking about their goals, families, and friends, nurses acquire information and understanding. In turn, adolescents learn to express themselves and thrive in a nonthreatening and nonjudgmental atmosphere (Plintz, 2002).

With limited exceptions, all adolescents in the United States have the right to confidential diagnosis and treatment of STIs without parental consent or knowledge, and in many states, adolescents are able to access HIV counseling and testing and expect confidentiality (English & Kenny, 2003). Confidentiality particularly affects girls, who frequently state that unless program confidentiality is assured, they will withdraw from prevention or treatment programs but will not stop the behaviors that prompted their attendance (Ford, Millstein, Halpern-Felsher, & Irwin, 1997). Nurses have a responsibility to be aware of local laws about adolescent rights and provider responsibilities (Maradiegue, 2003). Web sites such as those of the Society of Adolescent Medicine (www.adolescenthealth.org/ ) and the Center for Adolescent Health & the Law (www.adolescenthealthlaw.org/Index.htm ) have current information about legal issues and are available for specific queries.

Nurses need to balance the responsibility to maintain the confidence of adolescent patients with the desire to involve families in prevention programs. For a teen, the presence of a loving, supportive family is invaluable. Nurses should encourage all teens to talk with their parents about sexuality issues. Offering to be a facilitator at parent-adolescent discussions or involving a sibling or extended family member might be helpful to some adolescents who are having communication problems with their parents. However, it is important to remember that cohesive, supportive families are not a reality for all adolescents, so alternatives must be found for young people who do not have such resources.

Decisions about the kind and amount of information that is shared with parents are, in part, determined by local community norms, the availability of alternative resources, and the philosophy of the sponsoring agency. Nurses can work with prevention programs by helping to draft a confidentiality statement at the onset of any program. Web sites of nursing organizations such as the National Association of State School Nurse Consultants (http://lserver.aea14.k12.ia.us/swp/tadkins/nassnc/ ), the Association of Women's Health, Obstetric and Neonatal Nurses (www.awhonn.org/awhonn ), or the Adolescent Health Working Group (www.ahwg.net/resources/toolkit ) provide policy positions and draft statements on confidentiality that can be modified for different types of programs. The policy should clearly state that, as mandated by law, sexual and physical abuses are exceptions to the general policy of confidentiality. Whatever decision a prevention program makes about confidentiality, adolescents must be made explicitly aware of the policy. Nurses working in the program must be knowledgeable of and comfortable with the policy and be certain that they adhere to it, even in uncomfortable circumstances.

Conclusion

The high rates of STIs and HIV transmission among adolescents are strong indicators of the need for vigorous prevention programs. Clinical suggestions for prevention programs for adolescents by gender and age are presented in Figures 1 and 2. Planning programs based on these particular variables could lead to more successful outcomes and prevention of illness among adolescents.

Clinical suggestions for age- and gender-specific prevention programs for adolescents ages 11-14.

Clinical suggestions for age- and gender-specific prevention programs for adolescents ages 15-17.

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