Abstract
Background
In the United States (US), rates of teenage pregnancy and sexually transmitted infections (STI) remain exceptionally high and racial and ethnic disparities persist. Emergency departments (ED) care for over 19 million adolescents each year, the majority being minority and low socioeconomic status. Single-center studies demonstrate infrequent use of contraceptives among adolescent ED patients and an association between risky sex and behaviors such as alcohol and drug use; however, no multi-center ED data exist. The objective of this study was to (1) determine the prevalence of sex without contraceptives in a large multi-center adolescent ED study and (2) assess patient demographic and risky behaviors associated with sex without contraceptives.
Methods
Participants aged 14–17 (n=3247) in 16 pediatric EDs across the US completed an electronic survey. Questions focused on validated measures of risky sex, use of alcohol, tobacco, marijuana and other drugs, as well as depression and violence. In this secondary analysis, we constructed univariable and multivariable models to identify demographic and behavioral factors associated with sex without contraceptives (our primary outcome), separately for adolescent males and females.
Results
In the prior year, 17.4% (236/1356) of males and 15.8% (299/1891) of females had sex without contraceptives. In the multivariable model, sex without contraceptives for both genders was more likely among teens who were black, with conduct problems and participated in casual sex, binge drinking, or cannabis use. Sex without contraceptives was also more likely among Hispanic and cigarette smoking males, as well as depressed females.
Conclusions
Adolescent ED patients across the US are participating in risky sexual behaviors that increase their likelihood of pregnancy and STI acquisition. These adolescents report a number of problem behaviors, including substance use, which are strongly correlated with unprotected sex. The ED visit may be an opportunity to identify at-risk adolescent patients, address risky behaviors, and intervene to improve adolescent health.
Introduction
In the United States, reducing disparities in unintended teenage pregnancy and sexually transmitted infections (STI) is a public policy priority.1,2 Despite declines over decades, the rate of unintended teenage pregnancy in the US remains one of the highest in the industrialized world.3 Young adults account for nearly half of the 20 million cases of STI diagnosed annually.4 Access to contraceptives vary by geographic location, while teens living in poverty and of minority status disproportionally experience unplanned pregnancies and STIs.5 Novel interventions to eliminate these disparities are needed.
Emergency departments (ED) care for over 19 million adolescents each year, the majority being ethnic and racial minorities.6,7 Single center ED studies demonstrate high sexual activity rates and infrequent use of effective hormonal birth control among adolescents.8–10 STI rates among adolescent ED patients range from 4–26% depending on symptomology.11–13 Single center adolescent ED studies reveal how infrequent use of condoms is associated with other high risk behaviors, such as violence and substance abuse; yet referral to preventive care shows limited success. 14–16 Efforts are needed to address concomitant co-morbidities in this high risk adolescent population.
Very little is known about how demographics and risky behaviors link to high risk sex among adolescents who present for care in EDs across the US. Understanding how contraceptive use is associated with other risky health behaviors is important to better identify these at risk youths in the acute care setting and design clinical interventions that address a constellation of risky adolescent behaviors. Therefore, it was the objective of this secondary analysis to assess the demographics and risky behaviors associated with the variable use of contraceptives among adolescents presenting to the ED for medical care.
Methods
Study design and setting
We performed a planned secondary analysis of data from an Institutional Review Board-approved prospective observational cohort study designed to test the validity of a brief alcohol screen in 16 pediatric EDs within the Pediatric Emergency Care Applied Research Network (PECARN). 17 Sites were located in the Northeast, Middle Atlantic, West, Midwest, and Southwest regions of the US, primarily in urban areas. All sites received Institutional Review Board approval and a Certificate of Confidentiality was obtained. This study was funded by the National Institute of Alcohol Abuse and Alcoholism and the Health Resources and Services Administration.
Study participants
Eligibility criteria included the following: (1) age 12–17 years (2) seen in the ED for a non–life-threatening health condition; and (3) medically, cognitively, and behaviorally stable. Additional criteria excluded youth who were (1) in severe acute emotional distress (i.e. suicidal); (2) cognitively impaired; (3) unaccompanied by an adult or guardian; (4) unable to read and speak English or Spanish or whose parents were unable to read and speak English or Spanish; and (5) were previously enrolled in this study or had neither a telephone nor an address of residence. For the purpose of this analysis, given the low rates of sexual activity among 12 and 13 years old adolescents in the US, we limited our results to participants age 14–17 years and to those who had a non-missing response (n = 3,247).
Study procedures
Each of the 16 sites received a screening schedule based on research staff availability that included five 4-hour screening shifts per site each week. The shifts were randomly chosen with greater weight given to times when the age group of interest most frequently visits the participating EDs. However, times spanned morning to night and all days of the week. Patients were screened consecutively in the order of ED arrival to minimize selection bias. Research coordinators approached parents or guardians and explained the study in detail. Parents provided written informed consent; adolescents provided written informed assent. Adolescents then completed a criterion assessment battery self-administered on a tablet computer in English or Spanish in a private location to maintain confidentiality. This assessment battery included validated measures of substance use and risk behavior, including validated questions of alcohol use and misuse, tobacco, marijuana and other drug use, violence, and other risky behaviors such as sex without contraceptives and/or with someone you did not know well. Participants had the option of using an audio computer-assisted self-interview. Participants received a $10 gift card for participation in the survey. Detailed procedural methodology is described elsewhere.17
Key outcome measures
Data for our primary outcome came from participants’ answer to the Reckless Behavioral Questionnaire (RBQ) item, “How many times in the past 12 months have you had sex without contraceptives (withdrawal and having sex at a ‘safe’ time on the menstrual cycle doesn’t count as a contraceptive)?”18 The RBQ is a validated 10-item scale used to evaluate past year risky behaviors among high school and college samples, namely substance abuse patterns.18 Sex without contraceptives was reported as categories (0, 1, 2–5, 6–10, >10 times within the past year) and was dichotomized for the primary analysis. Individual questions about substance abuse over the past year were administered. The Diagnostic Interview Schedule for Children (DISC), adapted for a Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis, assessed substance use disorders.19 The Global Appraisal of Individual Needs (GAIN) screened for behavioral health disorders, including conduct disorder and peer aggression.20 The Mental Health Inventory (MHI-5) screened mood and is considered a general indicator of mental health status; a score <70 is considered the cutoff for significant depressive symptoms.21 The lower the score, the higher the risk of depressed mood. Casual sex was defined as sex with someone the participant did not know well in the past 12 months.
Data Analysis
We used both unadjusted and mutually adjusted logistic regression models to investigate the association between adolescent characteristics and sex without contraceptives. We analyzed females and males separately because of differential contraceptive decision-making based on gender.22,23 We evaluated the univariable association of sex without contraceptives by gender with each variable. Candidate variables included age, race, ethnicity, casual sex (sex with someone the participant did not know well in the past 12 months), DSM-5 alcohol use disorder, frequency of binge drinking, marijuana use, smoking, drug use, MHI-5 score, and number of GAIN-reported conduct problems. Those variables significant at the p<0.2 level in the univariable analysis were considered in each of the two multivariable models. To arrive at parsimonious models, a stepwise variable selection method was utilized with a drop-out p-value threshold of 0.05. The data were examined for potential outliers. Correlation between model variables was calculated and examined for collinearity. We looked for data points with excessive influence on the model results and inspected linearity of the logit. To examine model fit, we calculated c-statistics and performed the Hosmer and Lemeshow test. We also performed leave-one-out cross-validation. We used SAS, version 9.4, software for all analyses.
Results
Of 7545 adolescents who were screened, eligible, and approached for participation, baseline surveys were completed by 5001 (66.3%). Of these, 4855 answered the RBQ question on sex without contraceptives, with 3247 between the ages of 14–17 included in the analyses. Sex without contraceptives was reported 1 time by 5.3% (100/1891) of females and 6.7% (91/1356) of males, 2–5 times by 5.6% (105/1891) of females and 6.4% (87/1356) of males, 6–10 times by 2.0% (37/1891) of females and 1.7% (23/1356) of males, and >10 times by 3.0% (57/1891) of females and 2.6% (35/1356) of males. Table 1 displays the proportion of participants having sex without contraceptives by sociodemographic and substance use characteristics. Overall, 16.5% (535/3247) participants had sex without contraceptives in the prior year, with 44.1% (236/535) being males and 55.9% (299/535) being females. Table 1 also indicates that rates of sex without contraception rise steady for both males and females from age 14 to 17.
Table 1:
Demographics, substance use, depressive symptoms, and conduct problems associated with sex without contraceptives by gender in the prior 12 months.
| Males | Females | |||||
|---|---|---|---|---|---|---|
| Sex without contraceptives | Sex without contraceptives | |||||
| No (n = 1120) |
Yes (n = 236) |
Overall (n = 1356) |
No (n = 1592) |
Yes (n = 299) |
Overall (n = 1891) |
|
| Age | ||||||
| 14 | 364 (32.5%) | 29 (12.3%) | 393 (29.0%) | 425 (26.7%) | 18 (6.0%) | 443 (23.4%) |
| 15 | 302 (27.0%) | 53 (22.5%) | 355 (26.2%) | 447 (28.1%) | 74 (24.7%) | 521 (27.6%) |
| 16 | 271 (24.2%) | 74 (31.4%) | 345 (25.4%) | 405 (25.4%) | 101 (33.8%) | 506 (26.8%) |
| 17 | 183 (16.3%) | 80 (33.9%) | 263 (19.4%) | 315 (19.8%) | 106 (35.5%) | 421 (22.3%) |
| Race | ||||||
| Unknown or Not Reported | 142 (12.7%) | 40 (16.9%) | 182 (13.4%) | 244 (15.3%) | 54 (18.1%) | 298 (15.8%) |
| White | 543 (48.5%) | 78 (33.1%) | 621 (45.8%) | 771 (48.4%) | 108 (36.1%) | 879 (46.5%) |
| Black | 305 (27.2%) | 90 (38.1%) | 395 (29.1%) | 391 (24.6%) | 97 (32.4%) | 488 (25.8%) |
| American Indian/Alaska Native/Asian/Hawaiian | 50 (4.5%) | 12 (5.1%) | 62 (4.6%) | 60 (3.8%) | 11 (3.7%) | 71 (3.8%) |
| More Than One Race | 80 (7.1%) | 16 (6.8%) | 96 (7.1%) | 126 (7.9%) | 29 (9.7%) | 155 (8.2%) |
| Ethnicity | ||||||
| Unknown or Not Reported | 32 (2.9%) | 12 (5.1%) | 44 (3.2%) | 48 (3.0%) | 12 (4.0%) | 60 (3.2%) |
| Hispanic or Latino | 251 (22.4%) | 74 (31.4%) | 325 (24.0%) | 411 (25.8%) | 89 (29.8%) | 500 (26.4%) |
| Not Hispanic or Latino | 837 (74.7%) | 150 (63.6%) | 987 (72.8%) | 1133 (71.2%) | 198 (66.2%) | 1331 (70.4%) |
| Casual sexa | ||||||
| I prefer not to answer | 3 (0.3%) | 3 (1.3%) | 6 (0.4%) | 1 (0.1%) | 1 (0.3%) | 2 (0.1%) |
| No | 1066 (95.2%) | 158 (66.9%) | 1224 (90.3%) | 1556 (97.7%) | 233 (77.9%) | 1789 (94.6%) |
| Yes | 51 (4.6%) | 75 (31.8%) | 126 (9.3%) | 35 (2.2%) | 65 (21.7%) | 100 (5.3%) |
| Alcohol use disorderb | ||||||
| No | 1078 (96.3%) | 217 (91.9%) | 1295 (95.5%) | 1539 (96.7%) | 273 (91.3%) | 1812 (95.8%) |
| Yes | 18 (1.6%) | 14 (5.9%) | 32 (2.4%) | 14 (0.9%) | 20 (6.7%) | 34 (1.8%) |
| Unknown | 24 (2.1%) | 5 (2.1%) | 29 (2.1%) | 39 (2.4%) | 6 (2.0%) | 45 (2.4%) |
| Binge drinkingc | ||||||
| I prefer not to answer | 8 (0.7%) | 0 (0.0%) | 8 (0.6%) | 10 (0.6%) | 7 (2.3%) | 17 (0.9%) |
| Never | 1023 (91.3%) | 168 (71.2%) | 1191 (87.8%) | 1436 (90.2%) | 195 (65.2%) | 1631 (86.3%) |
| Less than monthly | 59 (5.3%) | 38 (16.1%) | 97 (7.2%) | 113 (7.1%) | 60 (20.1%) | 173 (9.1%) |
| Monthly or more | 30 (2.7%) | 30 (12.7%) | 60 (4.4%) | 33 (2.1%) | 37 (12.4%) | 70 (3.7%) |
| Marijuana used | ||||||
| I prefer not to answer | 80 (7.1%) | 16 (6.8%) | 96 (7.1%) | 109 (6.8%) | 16 (5.4%) | 125 (6.6%) |
| 0 to 1 time | 924 (82.5%) | 129 (54.7%) | 1053 (77.7%) | 1333 (83.7%) | 164 (54.8%) | 1497 (79.2%) |
| 2 or more times | 116 (10.4%) | 91 (38.6%) | 207 (15.3%) | 150 (9.4%) | 119 (39.8%) | 269 (14.2%) |
| Cigarette smokinge | ||||||
| Unknown or Not Reported | 10 (0.9%) | 9 (3.8%) | 19 (1.4%) | 16 (1.0%) | 6 (2.0%) | 22 (1.2%) |
| No | 1047 (93.5%) | 175 (74.2%) | 1222 (90.1%) | 1452 (91.2%) | 208 (69.6%) | 1660 (87.8%) |
| Yes | 63 (5.6%) | 52 (22.0%) | 115 (8.5%) | 124 (7.8%) | 85 (28.4%) | 209 (11.1%) |
| Drug usef | ||||||
| No | 1031 (92.1%) | 176 (74.6%) | 1207 (89.0%) | 1442 (90.6%) | 231 (77.3%) | 1673 (88.5%) |
| Yes | 49 (4.4%) | 42 (17.8%) | 91 (6.7%) | 71 (4.5%) | 52 (17.4%) | 123 (6.5%) |
| Unknown | 40 (3.6%) | 18 (7.6%) | 58 (4.3%) | 79 (5.0%) | 16 (5.4%) | 95 (5.0%) |
| Depressive symptomsg | ||||||
| N | 1078 | 224 | 1302 | 1532 | 290 | 1822 |
| Mean (SD) | 74.8 (16.09) | 70.0 (18.30) | 74.0 (16.59) | 66.1 (19.65) | 56.9 (21.01) | 64.7 (20.15) |
| Number of reported conduct problemsh Median [Q1, Q3] | 1.0 [0.0, 2.0] | 2.0 [1.0, 4.0] | 1.0 [0.0, 2.0] | 1.0 [0.0, 2.0] | 2.0 [1.0, 4.0] | 1.0 [0.0, 2.0] |
Casual sex is defined as sex with someone the participant did not know well in the past 12 months.
Alcohol Use Disorder is defined by the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) diagnosis of mild, moderate or severe alcohol use disorder.
Binge drinking is defined as 5 or more (males) and 4 or more (females) alcoholic drinks on 1 occasion.
Marijuana use refers to any use in the past year.
Cigarette smoking over the past year.
Illicit drugs refers to any use of cocaine, crystal methamphetamine, lysergic acid diethylamide (LSD), phencyclidine (PCP), synthetic cannaboid (K2), heroin, inhalants, or prescription drugs over the past year.
Depressed mood was defined by the Mental Health Inventory (MHI-5) score as less than 70. The lower the score, the higher the risk of depression.
Conduct problems as defined by the GAIN.
Table 2 displays results from logistic regression analysis. In the univariable regression model, all variables were significantly associated with sex without contraceptives. In the multivariable logistic regression model, for both genders, sex without contraceptives was more likely among black (versus white) teens (Odds Ratio (OR) (95% Confidence Interval (CI))=2.83 (1.75–4.60) for males and 2.39 (1.59, 3.60) for females), those who had conduct problems (OR (95%CI) = 1.18 (1.06, 1.32) for males and 1.16 (1.05, 1.28) for females), and teens who participated in casual sex (OR (95%CI) = 4.76 (2.60, 8.70) for males and 4.61 (2.41, 8.82) for females), binge drinking (OR (95%CI) = 2.46 (1.22, 4.97) for males and 2.78 (1.63, 4.75) for females), or marijuana use (OR (95%CI) = 1.74 (1.01, 2.99) for males and 3.39 (2.17, 5.30) for females). Among males, sex without contraceptives was more likely among Hispanic (versus non-Hispanic) teens (OR (95%CI) = 2.19 (1.23, 3.92)) and cigarette smokers (OR (95%CI) = 2.13 (1.06, 4.31)), while among females, it was more likely among those who reported depressive symptoms (OR (95%CI) = 0.84 (0.76, 0.92)). Leave-one-out cross-validation resulted in a drop in AUC from 0.818 to 0.787 for males and from 0.813 to 0.801 for females.
Table 2:
Logistic Regression Predicting Sex Without Contraceptive Use
| Male |
Female |
|||||||
|---|---|---|---|---|---|---|---|---|
| Odds Ratio (95% CI) |
P-valuei | Adjusted Odds Ratio (95% CI) |
P-valuei | Odds Ratio (95% CI) |
P-valuei | Adjusted Odds Ratio (95% CI) |
P-valuei | |
| Race | <.01 | <.01 | <.01 | <.01 | ||||
| Black vs White | 2.05 (1.47, 2.87) | 2.83 (1.75, 4.60) | 1.77 (1.31, 2.39) | 2.39 (1.59, 3.60) | ||||
| American Indian/Alaska Native/Asian/Hawaiian vs White | 1.67 (0.85, 3.28) | 1.33 (0.53, 3.32) | 1.31 (0.67, 2.57) | 1.58 (0.65, 3.85) | ||||
| More Than One Race vs White | 1.39 (0.77, 2.50) | 1.18 (0.53, 2.60) | 1.64 (1.05, 2.58) | 1.76 (0.94, 3.27) | <.01 | |||
| Hispanic or Latino vs Not Hispanic or Latino | 1.65 (1.20, 2.25) | <.01 | 2.19 (1.23, 3.92) | <.01 | 1.24 (0.94, 1.63) | 0.13 | ||
| Casual sexa | 9.92 (6.70, 14.70) | <.01 | 4.76 (2.60, 8.70) | <.01 | 12.40 (8.04, 19.13) | <.01 | 4.61 (2.41, 8.82) | <.01 |
| Alcohol Use Disorderb | 3.86 (1.89, 7.89) | <.01 | 8.05 (4.02, 16.14) | <.01 | ||||
| Binge Drinkingc | <.01 | 0.02 | <.01 | <.01 | ||||
| Less than monthly vs Never | 3.92 (2.53, 6.08) | 2.46 (1.22, 4.97) | 3.91 (2.76, 5.53) | 2.78 (1.63, 4.75) | ||||
| Monthly or more vs Never | 6.09 (3.58, 10.36) | 2.31 (0.93, 5.71) | 8.26 (5.05, 13.52) | 2.06 (0.89, 4.75) | ||||
| Marijuana used | 5.62 (4.04, 7.82) | <.01 | 1.74 (1.01, 2.99) | 0.04 | 6.45 (4.82, 8.62) | <.01 | 3.39 (2.17, 5.30) | <.01 |
| Cigarette smokinge | 4.94 (3.31, 7.37) | <.01 | 2.13 (1.06, 4.31) | 0.03 | 4.79 (3.50, 6.54) | <.01 | ||
| Drug usef | 5.02 (3.23, 7.81) | <.01 | 4.57 (3.11, 6.71) | <.01 | ||||
| Depressive symptomsg | 0.85 (0.78, 0.92) | <.01 | 0.80 (0.76, 0.86) | <.01 | 0.84 (0.76, 0.92) | <.01 | ||
| Conduct problemsh | 1.37 (1.28, 1.47) | <.01 | 1.18 (1.06, 1.32) | <.01 | 1.52 (1.42, 1.63) | <.01 | 1.16 (1.05, 1.28) | <.01 |
Casual sex is defined as sex with someone the participant did not know well in the past 12 months.
Alcohol Use Disorder is defined by the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) diagnosis of mild, moderate or severe alcohol use disorder.
Binge drinking is defined as 5 or more (males) and 4 or more (females) alcoholic drinks on 1 occasion.
Marijuana use refers to any use in the past year.
Cigarette smoking over the past year.
Illicit drugs refers to any use of cocaine, crystal methamphetamine, lysergic acid diethylamide (LSD), phencyclidine (PCP), synthetic cannaboid (K2), heroin, inhalants, or prescription drugs over the past year.
Depressed mood was defined by the Mental Health Inventory (MHI-5) score as less than 70. The lower the score, the higher the risk of depression.
Conduct problems as defined by the GAIN.
P-values correspond to the omnibus test for variable significance.
Adjusted odds ratios are only shown for variables retained by model selection.
The c-statistic for the multivariable male and female models are 0.818 and 0.813, respectively. The Hosmer and Lemeshow P-values are 0.1039 and 0.5777, respectively
Discussion
This is largest study to date to examine high risk sex patterns among an ED adolescent population. In this multi-center study, we found that almost 1 in 5 adolescent ED patients age 14–17 had sex without contraceptives in the past year. That number increased with age, with 1 in 4 teens aged 17 years having sex without contraceptives in the past year. This risk was similar for males and females. Although we cannot assume that the partners with which these adolescents are not using contraceptives are the casual partners, having sex without contraceptives in our study was significantly associated for both males and females with having had casual sex over the past year. Thus, a subset of adolescent ED patients are having sex without contraceptives and casual sex, escalating their risk of teenage pregnancy and STIs.
Sex without contraceptives was also associated with being black (versus white) and Hispanic (for males). This finding strengthens single center data. In one urban ED caring for predominently African American teens, 21% of surveyed adolescents reported using no contraception at last intercourse.8 Similarly, in another urban ED caring for predominently Hispanic teens, over half of the 250 sexually active teens surveyed used no condom at last intercourse, with one quarter using no contraceptive at all at last intercouse.24 Although our analysis does not control for socioeconomic status nor take into account societal inequities facing minority populations, this finding does correlate with national data regarding the higher risk of unintended pregnancy and STI for these ethnic and racial groups, further illuminating how disparities affect teens in the ED as well.5
Certain risky behaviors were associated with sex without contraceptives such as binge drinking, marijuana use, and conduct problems. This is important because it suggests that adolescent ED patients who present with the latter problems should be evaluated for the former and vice versa. For example, ED visits for depression and suicidality are rising in the US.25,26 We found that adolescents females who suffer from depression and poor mental health were more often having sex without contraceptives. Given this finding, ED providers should consider, when evaluating adolescents presenting for such psychiatric complaints, further assessments for unprotected sex, and the resulting need for STI and pregnancy testing as well as emergency contraception provision.
Our findings are consistent with prior national surveys that highlighted high risk sex among adolescents. Although our findings are difficult to compare to national survey data, given differences in the phrasing of survey questions, the prevalence of sex without contraceptives in our cohort was high. The National Survey of Family Growth (NSFG) surveyed teens aged 15–19 and found that 14% of females and 7% of males reported having not used contraceptives at last intercourse.27 Similarly, the Youth Risk Behavior Surveillance System (YRBSS) reported that at last intercourse an estimated 14% of high school students did not use any contraceptive.28 Our data also highlight early initiation of high risk sex. According to the NSFG, 18% of males and 13% of females in the US have ever had sexual intercourse by age 15.29 In our cohort of 15 year-olds, 16.5% of our population had sex without contraceptives over the past year.
Limitations
First, our primary outcome was sex without contraceptives over the past year. Other surveys ask about contraceptive use at last or first intercourse to minimize recall bias. Second, the RBQ question does not specifically identify condoms as a contraceptive, which might have resulted in inaccurate responding. Also, the way the RBQ asks about last contraceptive use only accounts for the one-sided perspective of the surveyed participant. Particularly males may not be aware of the hormonal contraceptives used by their sexual partners, especially if these sexual partners are casual; this may have falsely increased the prevalence of sex without contraceptives among male adolescents. In addition, we must assume that a proportion of sexual encounters involved hormonal contraceptives alone and no condoms. This increases our populations risk of STIs. Third, a proportion of participants chose “I prefer not to answer” or “unknown” for marijuana and drug use, respectively; if these participants were all drug users, then that would have affected the results of our regression models. Fourth, although we used validated measures, we must also appreciate the complex social contexts and decision making which influence adolescent sexual behaviors that may not have been captured by our question set. Fifth, certain issues such as partner violence, reproductive coercion, and sex trafficking, which are important to consider when considering adolescent risky sexual patterns, were not addressed in our dataset. When considering future sexual health ED-based interventions, we should consider the complicated context within which risky sexual behaviors occur and address directly with the adolescent. Finally, our models were only internally cross-validated. While the results remain stable, the findings require further validation to become more definitive.
Conclusions
This multi-center study indicates that about 1 in 5 adolescent ED patients engage in sex without contraceptives. These adolescents also report a number of problem behaviors, including conduct problems and substance use, which are strongly correlated with sex without contraceptives. A study such as this one pushes us to think about the broad context of our role as ED providers. 30 Adolescents are participating in high risk sex and using the ED for medical care. While we recognize the ED is busy with limited resources, our current standards of care often do not address these behaviors, putting our patients at risk for a multitude of unintended consequences, such as pregnancy and STIs. The ED visit may be an opportunity for medical providers to screen and identify adolescents who are at-risk for unintended teenage pregancy and STIs and intervene to improve their sexual health. The ED may provide a unique opportunity for adolescents to ask questions about sexual health because of the relative anonymity of the ED compared to primary care. The answers to such questions might trigger a brief educational or motivational intervention in the ED, and/or a referral, (e.g., back to their primary care provider or to a community agency). These interventions should also consider the high probability of other co-occurring risk factors in this population, such as substance use, and how they affect sexual risk behavior. The ED visit may be an opportunity to address other risky adolescent behaviors. The ED can play a significant role in the health outcomes of our adolescent patients, but more research is needed to understand the best practices to do so.
Acknowledgments
Financial support: This work was supported in part by the National Institute of Alcohol Abuse and Alcoholism (1R01AA021900 to Drs Spirito and Linakis). This project is supported in part by the Health Resources and Services Administration, Maternal and Child Health Bureau, Emergency Medical Services for Children Network Development Demonstration Program, under cooperative agreements U03MC00008 and U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC22684, and U03MC22685. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, the Health Resources and Services Administration, the US Department of Health and Human Services, the National Institute of Health (NIH) or the US Government. Dr. Lauren Chernick was supported by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH), through grant number KL2TR001874 and by the National Institute of Child and Health Development, through grant number 1K23HD096060–01.
Footnotes
Conflicts of Interest: LC, TC, JB, FA, BM, CM, RA, BS, AS, JL, RR, and CC report no conflict of interest.
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