Foster children at risk for sexually transmitted diseases

ABSTRACT: Past studies have documented multiple health problems among foster children. However, one potential problem seldom addressed is that of sexually transmitted diseases (STDs) . The author discusses the risk of foster children having or contracting STDs and presents general information on the incidence, consequences, and symptoms, especially for females, of five of the most common sexually transmitted diseases-syphilis, gonorrhea, chlamydia, genital herpes, and genital human papillomavirus. Recommendations for intervention by social workers in health care and child-welfare settings are presented.

DURING THE FISCAL YEAR 1993 more than 659,000 children were served by the foster-care system in the United States. An estimated 460,000 children were still in foster care at the end of that same fiscal year, and it is projected that, by 1995, 500,000 to 600,000 children will be in care (Halfon, English, Allen, & DeWoody, 1994). Approximately 70% of these children live in foster-family homes, with the remainder residing in group homes, residential treatment centers, or institutional settings. Most of these foster children are Medicaid eligible (Halfon et al., 1994).

Studies indicate that foster children exhibit high rates of physical and emotional illnesses (see Hochstadt, Jaudes, Zimo, & Schachter, 1987; Kavaler & Swire, 1983; Moffat, Peddie, Stulginskas, Pless, & Steinmeitz, 1985; Risley-Curtiss, 1990; Schor, 1982). For example, in a sample of 688 foster children, Kavaler and Swire (1983) found that 74% showed some significant physical abnormality. More recently, Risley-Curtiss (1993) found that 91% of 1,910 children entering foster care had some kind of physical health problem.

One health problem for which many foster children are at risk and that is often overlooked is sexually transmitted diseases (STDs). In the United States approximately three million teenagers acquire an STD each year (Centers for Disease Control, 1993). Yet, of seven published studies on the physical health of foster children (Chernoff, Combs-Orme, Risley-Curtiss, & Heisler, 1994; Hochstadt et al., 1987; Kavaler & Swire,1983; Moffat et al., 1985; Schor, 1982; Shah, 1972; White & Benedict, 1985), only one study specifically addressed STDs (Shah, 1972). Flaherty and Weiss's (1990) more recent study on abused and neglected children addressed STDs; however, not all the children were entering foster care, and the study was published in a medical journal. None of the studies published in social work/child welfare journals in the United States has included STDs in their reports of health problems of foster children. Moreover, even though STD screening is recommended in the 1988 Standards for Health Services for Children in Out-of-Home Care (Child Welfare League of America, 1988b), no specific information on STDs is provided.

This lack of attention to the issue of STDs among foster children is not surprising. Sexually transmitted diseases, in general, have not received the attention they warrant (Donovan, 1993). At least one study suggests that teenage women may not be getting STD tests proportional to their risk (Mosher & Aral, 1991). The current AIDS crisis has diverted attention from other less obviously deadly STDs (Cates, 1988; Wertheimer, 1990). Information about these other STDs among children in the social work/child welfare literature is generally hard to come by. Finally, health care for foster children in general has received low priority in the past (Kavaler & Swire, 1983; Schor, 1988; Shah, 1972). Evidence suggests that caseworkers often are unaware of the health status of their foster children (Schor, 1989; White & Benedict, 1985) and of their sexual activity (Polit, White, & Morton, 1987; Risley-Curtiss, 1990).

A result of this inattention is that many social workers in the health and child-welfare fields are unaware of the incidence and consequences of STDs other than AIDS and of the high risk of foster children contracting or having an STD. The purpose of this article is to identify STD risk factors in the foster-care population and to summarize information for social workers in health and child-welfare settings regarding the incidence, consequences, and symptoms of five of the most common STDs, especially among females. Policy and practice recommendations are discussed.

A discussion of AIDS is not included because it is beyond the scope of this article. The reader, however, must keep in mind that AIDS is the most deadly STD and that behaviors that put one at risk for other STDs also put one at risk for exposure to HIV. AIDS and the issues it is generating (e.g., screening and confidentiality) have received widespread mass and professional media attention (see Anderson, 1984, 1986; Child Welfare League of America, 1988a; Gurdin & Anderson, 1987; McMillen & Groze, 1991; Tourse & Gundersen, 1988). Although this attention is appropriate and has brought some attention to other STDs, it has unfortunately also led many people to regard these other STDs, most of which are curable, as less harmful and of less concern (Donovan, 1993). The information presented here will help counter this tendency to overlook other STDs, given the fact that they may be a risk factor for HIV exposure (Cates & Hinman, 1991).

Foster Children at Risk

Anyone who is sexually active, especially with more than one partner, and does not use barrier contraceptives such as condoms and/or a diaphragm with spermicide (Donovan, 1993; Stone, Grimes, & Magder, 1986) is at high risk for contracting many STDs. The risk, however, is even higher if one is a young, poor, minority female from the inner city (Braverman, Biro, Brunner, Gilchrist, & Rauh, 1990; Chambers, 1990).

Although published information on the sexual activity of foster children is lacking, demographics and information from several studies suggest that many foster children fit highrisk profiles for having or contracting STDs. For example, minority children make up a large proportion of children in foster care, and African Americans, Hispanics, and American Indians are often overrepresented in the system (Arizona Supreme Court State Foster Care Review Board, 1993; Cox & Cox, 1984; Hubbell, 1981; Risley-Curtiss, 1993). The majority of foster children are poor (Arizona Supreme Court State Foster Care Review Board, 1993; Cox & Cox, 1984) and from urban areas. Females make up approximately half of the substitute-care population (see Arizona Supreme Court State Foster Care Review Board, 1993; Risley-Curtiss, 1993; Schor, 1989), and although the age at which children enter care seems to be decreasing, a great many adolescents remain in care.

In addition, 75% of children in foster care enter the system because of some kind of maltreatment (U.S. Department of Health and Human Services, 1988), including sexual abuse. Sexually transmitted diseases are potential sequelae of such abuse and must be considered in the overall management of care (Kramer & Jason, 1982). Moreover, a recent study of incarcerated adolescents found that those who had been sexually abused at some point in their lives were 3.4 times as likely to become infected with an STD as were those who had not been sexually abused (Vermund, Alexander-Rodriquez, Macleod, & Kelley, 1990). This suggests that having a history of sexual abuse is a possible indicator of behavior that will increase the risk of contracting an STD.

Studies of the sexual behavior of adolescents in the general population also suggest that foster teens are at high risk. For example, 67% of women and 76% of men in this country have had sexual intercourse by age 18 (Centers for Disease Control,1993). The number of teenage women reporting having more than one sexual partner has grown from 39% in 1971 to 62% in 1992 (Kost & Forrest, 1992), with those reporting four or more partners more than doubling (Donovan, 1993). Kost and Forrest (1992) report that "because of the high proportion of adolescents already infected with an STD, a teenager's likelihood of encountering a partner carrying an STDeven if he or she has had only one partner-is higher than that of most groups of adults" (p. 245). In a study of condom use for disease prevention, Weisman, Plichta, Nathanson, Ensminger, and Robinson (1991) found only 16% of 382 sexually active adolescent females used condoms consistently, even though 30% had sequential or concurrent multiple partners. Another study by Soskolne, Aral, Magder, Reed, and Bowen (1991) found similar results: only 17% of girls who had had sex with a casual partner during the previous year used condoms consistently. This extremely infrequent condom use is consistent with research done by the Centers for Disease Control (1993), which found that only 9.5% of women 15-44 years of age reported using condoms.

By themselves, these data suggest that foster children may be at high risk for HIV exposure as well as for contracting other, more common STDs. Several other factors, however, also contribute to the importance of addressing this health problem in foster children: the increasing rates of many STDs among adolescents; the consequences of having an untreated STD, especially for females; and the fact that many of those infected with an STD do not manifest symptoms (i.e., are asymptomatic). Last, and perhaps most important, having certain types of STDs can increase the risk of contracting AIDS (Cates & Hinman, 1991; Centers for Disease Control,1993).

Female Focus

This article deals primarily with the consequences of certain STDs for females. This restriction is not intended to diminish the importance of preventing and treating STDs in males. The focus on females was chosen because the incidence of some STDs is rising more rapidly among them than among males (Cates & Toomey, 1990; Chambers, 1990) and because STDs are more easily transmitted to and often harder to diagnose and treat in females (Donovan, 1993; Handsfield, 1982). For example, women are twice as likely as are men to contract gonorrhea or chlamydia through a single act of unprotected sex with an infected partner, and teenage women may be even more susceptible (Donovan, 1993). Sexually transmitted diseases left untreated also have more serious consequences for females than for males (Aral & Guinan, 1984; Donovan, 1993; Noble,1990).

Among the known STDs, only AIDS is not currently considered intrinsically gender biased. Handsfield (1982) noted that for other STDs, "not only are clinical manifestations more subtle and diagnosis more difficult in women than in men, but complications are far more frequent and serious in women" (p. 102). For example, 10% to 15% of women with gonorrhea will develop pelvic inflammatory disease (PID), which has no equivalent in men (Guinan, 1985). This disease is a major cause of infertility in women; it is related to the occurrence of ectopic pregnancies (a potentially lifethreatening pregnancy that develops outside the uterus, usually in a fallopian tube) and can result in death if left untreated (Noble,1990).

In addition, pregnant women with an STD can infect their babies before or during birth. Miscarriage, low birth weight, blindness, and death are just a few of the possible outcomes for infected babies (Derman, 1983). In 1984, it was estimated that 300,000 infants die or suffer birth defects every year because of STD infections that they contract from their mothers (American Social Health Association, 1984). In terms of their importance to public health in the United States, the top six STD syndromes and their consequences affect women and their babies primarily (Handsfield, 1982).

The extremely low use of condoms and the increase in STDs among adolescent females, coupled with the difficulty of diagnosis, the severity of complications, and the inadvertent transmission of the disease to babies, make the problem of STDs very critical, particularly for young women. However, because STDs are more likely to be asymptomatic in females than in males, women are less likely to receive treatment and more likely to experience complications. Mosher and Aral (1991) found in their study of women of reproductive age that only 43% with a history of STDs received an STD test in the year prior to the study. Although STD rates are higher for teens, they found that teen women, overall, were no more likely to be tested than were older women. African American teen women were even less likely to be tested. This suggests that teen women are not being tested at a rate proportional to their risk.

Social and cultural norms and values also decrease the attention paid to the problem of STDs and the likelihood that people, especially females, will obtain diagnoses and treatment. Although the past two decades have brought significant changes in the status of women, many of the values and attitudes related to women's sexuality have not kept pace: "Having an STD is still doubly stigmatizing for a woman because of the socio-historical implications and their related connotations, especially of promiscuity" (Aral & Guinan, 1984, p. 87).

The reader should note that although the statistics cited here refer to adolescent females, many younger females are sexually active and therefore at risk. A review of my own data on the health status of 1,910 foster children revealed that some children as young as 10 years of age reported being sexually active (RisleyCurtiss, 1995). Preadolescence is also usually the age of onset for sexual abuse. Consequently, the risk of contracting an STD is not limited to adolescents or adults-female or male.

Incidence and Consequences of STDs

With more adolescents having sexual intercourse and an increase in the number of their sex partners, teens', especially girls', risk of contracting an STD is increasing. The following presents incidence rates and consequences for females as well as symptoms of five of the most common STDs: syphilis, gonorrhea, chlamydia, genital human papillomavirus (HPV), and genital herpes. All of these diseases are potentially disabling or life threatening (see Table 1).

It should be noted that the majority of females who are infected with an STD are asymptomatic (e.g., up to 75% of chlamydia cases in women are without symptoms). Thus, although symptoms of each disease are presented, screening for STDs should not depend solely on the presence of such symptoms. Additional risk factors, as discussed below, should be taken into consideration.

Reportable STDs

Reportable STDs are STDs that the medical community are required to report to the Centers for Disease Control and Prevention (CDC). Traditionally, only two diseases have been reportable, syphilis and gonorrhea. However, physicians are now required to report the diagnosis of AIDS.

Syphilis. The introduction of penicillin in the late 1940s helped bring about a dramatic decrease in the number of syphilis cases in the United States. More recently, however, incidence trends have followed a roller-coaster pattern, with 33,613 cases of infectious syphilis reported in 1982, 27,131 in 1985, and 35,955 in 1988 (Centers for Disease Control, 1993). Although currently the national incidence of infectious syphilis appears to be decreasing, 50,233 cases were reported in 1990, representing the highest levels in 40 years (Donovan, 1993). Many states in the Midwest and South continue to experience large increases (Centers for Disease Control, 1993).

Increases that occurred in the 1980s were greatest among heterosexual and inner-city minority populations, especially African American and Hispanic persons (Cates & Toomey, 1990; Chambers, 1990). "Syphilis rates are 31 times higher among Blacks than Whites and 11 times higher among Hispanics than hites" (Centers for Disease Control, 1990a, p. 216).

Syphilis is often hard to detect because its early symptoms, which may not be noticed in women, tend to disappear without treatment (Zamula, 1986). The disease can remain undiagnosed for years. Although syphilis can now be cured at any time during the course of the disease, the damage that is done before it is diagnosed, including blindness, impairment of the brain, heart defects, and bone deformities, cannot be reversed (Zamula, 1986). The disease also can be fatal (Grimes, 1986). Finally, a strong association between syphilis and HIV infection suggests that syphilis increases the risk of acquiring HIV and facilitates its transmission (Centers for Disease Control, 1993).

If a woman who is unaware that she has syphilis becomes pregnant, her baby can acquire the disease before birth and go undiagnosed after birth. Syphilis that remains untreated during pregnancy results in the stillbirth, premature birth, or neonatal death (death of a live-born infant younger than 28 days) of approximately 50% of babies who are exposed (Noble, 1990) and in congenital syphilis in the other exposed 50% (Cates & Alexander, 1988). Babies who are born alive with congenital syphilis may have deformities or they may seem healthy at birth only to develop symptoms later in childhood (Derman, 1983).

Not surprisingly, past increases in the incidence of syphilis have been coupled with an increase in the incidence of congenital syphilis for children younger than one year (Centers for Disease Control, 1990a). "The incidence of congenital syphilis generally reflects [the] incidence of . . . syphilis among women of child bearing age, as well as the diagnosis and treatment of syphilis in prenatal care programs" ("Congenital Syphilis," 1986, p. 625). Thus, although some of the increase in congenital syphilis may have been due to changes in reporting, much of it reflected the rise in heterosexual syphilis and the failure to control the disease in prenatal cases by diagnosis and treatment of mothers (Cates & Toomey, 1990; Centers for Disease Control, 1990a).

Syphilis is most commonly acquired through anal, vaginal, or oral sex with someone who has an active infection. It progresses through three infectious stages: primary, secondary, and early latent. In its first stage, symptoms include a painless ulcer (Donovan, 1993). Although these sores can appear anywhere on the body, they usually occur on the genitals. In women they may occur on the cervix or inner vaginal walls and therefore are not visible (Chemiak & Feingold, 1977). The sores usually appear 10 days to 3 months after exposure and disappear in a few weeks, even without treatment. If untreated, the disease progresses to a secondary stage, which is characterized by a systemic illness that usually occurs within six to eight weeks and includes a generalized skin rash (Chambers, 1990). These symptoms may also disappear spontaneously. During the third stage, symptoms may recur within the first two years but then disappear and remain completely hidden.

Gonorrhea. Gonorrhea continues to be the most frequently reported communicable disease in the United States (Spence, Adler, & McLellan, 1990), with more than one million cases annually (Donovan, 1993). After years of decline, total reported incidence of gonorrhea increased 1.5% in 1989 (Centers for Disease Control, 1990a). Although rates are again declining for many groups, they remain high among African Americans, adolescents, and young unmarried adults (Centers for Disease Control, 1993). Among adolescents, reported rates are higher among females than among males (Spence et al., 1990).

A problem inhibiting attempts to control gonorrhea is that the disease frequently does not manifest early symptoms (Cates & Alexander, 1988; Rullan, 1987). In the past, many experts believed that only infected women were asymptomatic; more recently, however, it has been found that as many as 50%-75% of both men and women do not experience early symptoms (Derman, 1983), which means that many people are unknowingly passing on the disease (Carlton & Mayes, 1982).

Untreated gonorrhea can lead to sterility (damage to the sperm ducts in men and to the fallopian tubes in women), arthritis, heart disease, eye infections that result in blindness, meningitis, and, in women, PID (Derman, 1983). Evidence also suggests that having gonorrhea increases the risk of HIV transmission almost threefold (Centers for Disease Control, 1993). Finally, untreated gonorrhea in pregnant women can lead to prematurely born and low-birth-weight babies (Cates & Alexander, 1988). Infants can acquire gonorrhea from their mothers during delivery and, if the disease is untreated, they can become blind (Derman, 1983).

The number and percentage of strains of gonorrhea resistant to standard treatment, primarily penicillin, is rapidly increasing (Centers for Disease Control, 1990b). For example, in 1986, 16,608 cases of one such strain, commonly referred to as penicillinase-producing neisseria gonorrhea (PPNG), were reported to the CDC. This represented a 90% increase over the 8,724 cases reported in 1985 and 1.8% of all reported gonorrhea ("PenicillinaseProducing Neisseria Gonorrhoea," 1987). More than 62,600 cases of resistant gonorrhea were reported in 1989, a 62% increase over 1988 figures. Resistant gonorrhea now represents more than 10% of all gonorrhea cases reported (Cates & Hinman, 1991), and, unfortunately, "once antibiotic-resistant gonorrhea becomes endemic, eradication is extremely difficult [and] expensive" ("Penicillinase-Producing Neisseria Gonorrhoea," 1987, p. 108).

The data show that, in general, groups at high risk for resistant gonorrhea are similar to those for other STDs-young, unmarried, heterosexual persons, especially ethnic minorities (Curran, 1980). In one sample, 54% of those infected were women, 48.4% of whom were asymptomatic (Rullan, 1987). Patients with inadequately treated PPNG infection are at high risk for complications; for women, PID represents the greatest risk.

The symptoms of gonorrhea infection are often mild or absent (especially in women). When they do occur, it is usually within 2-10 days. Symptoms include discharge from the penis, vagina, or rectum and pain or burning during urination (Chemiak & Feingold, 1977).

Nonreportable STDs

Nonreportable STDs are STDs that the medical community is not required to report to the CDC. They include chlamydia, HPV, and genital herpes.

Chlamydia. Although gonorrhea is considered the most common "reportable" STD, chlamydia is now recognized as the most common bacterial STD in the United States, with approximately four million new cases per year (Centers for Disease Control, 1993). The highest incidence is among young, unmarried, sexually active women living in poor socioeconomic conditions (Schachter, 1987), especially nonwhites younger than 20 years of age (Braverman et al., 1990).

Strong evidence suggests that chlamydial infections represent a substantial threat to the reproductive health of sexually active women. For example, chlamydial infections in women can be clinically mild and still result in infertility (Schachter, 1987), and a history of chlamydial infection appears to double the risk of ectopic pregnancy (Witwer, 1990). Chlamydia also accounts for about 40% of the one million recognized cases of PID in the United States each year (Centers for Disease Control, 1993).

The majority of women infected with chlamydia are asymptomatic (Winter, Goldy, & Baer, 1990). Being asymptomatic means that many infected women do not seek medical treatment for chlamydia, thereby exposing themselves to the longer-term consequences of the disease. The absence of symptoms also leads to the inadvertent transmission of the disease to others, particularly one's offspring. More than 155,000 babies are born each year to mothers who are infected and approximately 60%-70% of those babies who pass through a chlamydia-infected birth canal will contract the disease (Loucks, 1987). These infants are at risk of being born prematurely (Witwer, 1990) and of developing serious eye and respiratory infections, such as pneumonia (Handsfield, 1982). They also exhibit increased risk of fetal or neonatal (i.e., perinatal) mortality (Loucks, 1987).

The symptoms of chlamydia resemble those of gonorrhea: an abnormal genital discharge and a burning sensation during urination (Loucks, 1987). However, the incubation period for chlamydia is longer: 7-28 days versus 2-10 days (Marvin & Slevin, 1987).

Genital herpes. The national fear during the early 1980s about contracting genital herpes (Handsfield, 1982) has been eclipsed by concern about the spread of HIV/AIDS. Yet it is estimated that more than 30 million adults in the United States are actively infected with the herpes virus (Cates & Toomey, 1990), and the incidence of new cases ranges from 400,000 to 600,000 a year (Handsfield, 1982). The prevalence of genital herpes continues to increase primarily because of the absence of symptoms (Cates & Toomey, 1990) and because the disease, though treatable, is incurable. More than three quarters of genital herpes infections are transmitted by people who are unaware that they have the disease (Centers for Disease Control,1993).

African Americans are more likely than whites, and women of both races are much more likely than men, to contract genital herpes (Cates & Toomey, 1990). Genital herpes is generally more debilitating for women than for men (Noble, 1990). Women who are infected have a seven times greater risk of developing cervical cancer than do those who do not have the disease (Aral & Guinan, 1984). Genital herpes in pregnant women can cause spontaneous abortion and stillbirth (Noble, 1990). It also can be transmitted to infants as they pass through the birth canal, especially when the mother has a severe primary infection (Noble, 1990). Because normal delivery may be fatal in such cases, a cesarean section may be recommended (Aral & Guinan, 1984). Even babies who are born alive through vaginal delivery may die shortly afterward or may have severe physical or mental damage, such as impairment of the central nervous system, blindness, and mental retardation (American Social Health Association, 1984). "Neonatal herpes is a serious disease with a mortality of 65% in untreated patients" (Noble,1990, p. 179).

Genital herpes is spread through skin-toskin contact with the infected site. It can be transmitted even when the infected person has no symptoms. Symptoms, which are often very mild, include an itching or burning sensation; pain in the legs, buttocks, or genital area; or vaginal discharge. Swollen, tender, very painful sores resembling fever blisters or cold sores may also appear within a few days. Although the sores heal after several weeks, many people suffer recurrences (Donovan, 1993).

Genital human papillomavirus infections. Genital human papillomavirus (HPV), perhaps the most common STD in the United States (Rosenfeld, 1991), causes what is familiarly known as genital warts. It is estimated that approximately 24 million to 40 million people are infected with HPV (Donovan, 1993). Infection rates as high as 38%-46% have been reported among populations of adolescents and young adult females (Rosenfeld, 1991).

When genital warts are visible, they are easily detected in both male and female patients. However, as many as 90% of those infected may be asymptomatic (Cates & Toomey, 1990). Treatment of HPV is often problematic, with troublesome side effects and frequent treatment failures (Donovan, 1993; Rosenfeld,1991).

The key consequence of HPV infection is the association of several strains of the virus with cervical cancer as well as cancer of other parts of the genitalia (vulva, vagina, and anus in women; penis and anus in men) (Donovan, 1993). In addition, babies exposed to HPV in the birth canal can develop warts in the throat (Cates and Alexander, 1988). While the probability of this occurring is low, the consequences of obstruction of the air passages can be life threatening (Donovan, 1993).

The genital warts that sometimes occur as a result of HPV infection are soft, pink, or red and cauliflower-like in appearance. They can appear on or inside the genitals and can be transmitted to others even when they are not visible (Cherniak & Feingold, 1977).

Pelvic inflammatory disease. Pelvic inflammatory disease (PID) is the most common and one of the most serious complications of STDs (Handsfield, 1982; Washington, Amo, & Brooks, 1986). It occurs when infections of the vagina and cervix spread to other areas of the pelvis, including the uterus, other reproductive organs, and the abdominal cavity. Pelvic inflammatory disease, which can be caused by several different organisms, often results from untreated gonorrhea or chlamydia (Curran, 1980). The fact that many cases are attributable to more than one organism makes PID especially difficult to treat (Handsfield,1982).

The annual incidence of PID is approximately one million cases (Washington et al., 1986). This disease is considered a direct cause of increased female infertility and ectopic pregnancy (Chambers, 1990), each of which more than tripled in incidence from 1970 to 1980. In 1971, 19,000 cases of ectopic pregnancies were reported, whereas in 1984 the figure increased to more than 70,000 (Cates & Alexander, 1988). Ruptured ectopic pregnancies are one of the major causes of maternal deaths in the United States, especially among African American women (Guinan, 1985). Additional consequences of PID include chronic pelvic pain, pelvic adhesions (tissues abnormally united by fibrous tissue resulting from an inflammatory process), tubo-ovarian abscesses, chronic recurring infections resulting in hysterectomies, and great emotional stress (Noble,1990; Spence et al.,1990; Washington et al., 1986). Furthermore, PID accounts for most STD deaths (Grimes,1986).

Besides the physical and emotional damage it causes, PID is estimated to incur more than $2.6 billion a year in direct and indirect costs (Washington et al., 1986). For example, PID results in the hospitalization of approximately 300,000 women, more than 2 million visits to physicians, and 118,000 surgical procedures each year (Curran, 1980).

Pelvic inflammatory disease occurs most often in young, sexually active women between the ages of 15 and 20 (Spence et al., 1990). Additional risk factors include having more than one sex partner and using an intrauterine device (IUD) (Chambers, 1990). In one study of PID in adolescents, Spence et al. (1990) found that only 25% of adolescents with PID reported a single partner and none of the adolescent patients reported using a barrier method of contraception.

Conclusion

Annually, approximately one in four teens 13-19 years of age who have sexual intercourse contract an STD (Donovan, 1993). This rate is even higher among poor minority adolescents living in urban areas. Thus, given their social characteristics, many children entering foster care are likely to be at high risk for having or contracting an STD. Unfortunately, it is also likely that many of these children are not being screened or treated for such diseases. The consequences of having an untreated STD, especially for girls, are extremely serious.

The most immediate and traditional line of defense against STDs is medical screening and treatment. With early detection, most STDs can be cured or controlled. The major resources needed for medical treatment are already in place. The federal government supports the prevention and control of STDs primarily through the Centers for Disease Control and Prevention, an arm of the U.S. Public Health Services. The CDC provides financial and technical assistance to state and local agencies to support STD screening and treatment. Approximately 4,000 STD clinics are in operation nationwide, ranging from freestanding clinics to programs within state and local health departments (Donovan, 1993). Although clients are usually charged for screening and treatment services, these services are provided free if the patient is unable to pay (personal communication, Centers for Disease Control, September 28, 1993). Medical screening and treatment are also available through public family planning and Planned Parenthood clinics.

Treatment for STDs is usually confidential, and teenagers may, in many states, receive services without parental permission or notification. The best way to locate these clinics and to find out about the laws and policies regarding confidentiality and parental involvement (e.g., bottom-age limits may vary) is to contact one's state health department.

To insure utilization of these resources, child-service agencies need to develop and implement policies and protocols that require routine screening of sexually active foster children. However, unless health care and childwelfare personnel understand the need for such screening and treatment, implementation of such policies and procedures will not be successful. In a study of public child-welfare agencies in 48 states, only 9 states had formal written policies for meeting the sexual-development and family-planning needs of the teenagers they served (Polit et al., 1987). Although 19 states offered training in adolescent sexuality to caseworkers, only four states required workers to attend. Twenty-nine states offered such training to foster parents, but only five states mandated attendance. Finally, some of the state officials responding to the survey admitted not having given these issues much thought (Polit et al., 1987).

Social workers can help fill this service gap by educating themselves about adolescent sexual development in general and STDs in particular and participating in the education of others who are involved in providing services to foster children. Social workers can advocate for screening and treatment policies and participate in their creation. Implementation of screening policies will, of course, necessitate assessing whether children are sexually active. For example, the author has been affiliated with a health care screening unit of one child-welfare agency that included questions regarding sexual activity in their preplacement examination of foster children (Risley-Curtiss, 1993). This agency also instituted an automatic referral protocol for any child entering foster care who was determined to be sexually active. Training on the risk factors and consequences of STDs and on how to discuss sexuality issues sensitively with children is needed for all child-caring staff, including caseworkers, foster parents, group-home and residential-care providers (including health care providers), and supervisors. Social workers, with their knowledge and skill in discussing difficult issues with clients, can participate in the development and delivery of such training.

In addition, social workers need to understand that many physicians receive only minimal medical training on STDs (Centers for Disease Control,1990b) and therefore are not always experts in this area. They are even less likely to be trained to deal with the psychosocial aspects and reactions of those infected. Thus, social workers in both health care and child-caring agencies may have to become strong advocates for foster children in order to get their health needs met.

Sexually transmitted diseases can be prevented through life-style changes such as abstaining from sex or from unsafe sexual contact, using condoms, and limiting the number of sexual partners. However, unlike other riskreducing changes in life-style (e.g., exercise, diet, quitting smoking), many sexual-behavior changes involve the consent of at least one other individual (e.g., agreement of partner to use a condom). This interpersonal factor makes changing one's sexual life-style difficult, especially for an adolescent.

Unfortunately, few intervention strategies are effective in reducing unprotected intercourse (Kirby, Barth, Leland, & Fetro, 1991). Traditionally, STD primary-prevention efforts have focused on education in the form of media messages and sex education (e.g., in the schools). Although this line of defense has accelerated with the advent of HIV/AIDS, the evidence clearly suggests that many teens are not receiving sex education in school (Centers for Disease Control, 1990b). Moreover, increasing knowledge alone often does not change sexual behavior (Althaus, 1990; Cooper, 1993; Kirby et al., 1991).

More recent prevention efforts have focused on multicomponent programs that emphasize theory-based skill-building strategies and community and parent involvement (Cooper, 1993; Kirby et al., 1991; Schinke, Orlandi, Forgey, Rugg, & Douglas, 1992). These programs, however, appear to be more effective in postponing the initiation of intercourse than in increasing the use of condoms, especially among persons who are already sexually active (Kirby et al., 1991). Although simple solutions do not exist, social workers can stay informed about prevention efforts and continue to develop and test such programs.

A lot of attention has been focused on the physical and medical aspects of STDs; far less attention has been directed at the psychological and emotional responses of infected persons (Carlton & Mayes, 1982). Diagnosis of an STD can result in such problems as anxiety, depression, insomnia, and feelings of guilt, cheapness, self-anger, humiliation, and shame (Wright & Rodway, 1988). It can cause conflict, blaming, accusations of unfaithfulness, and loss of trust between sexual partners. Social workers in health and child-caring agencies need to be prepared to assist foster children in understanding the meaning of an STD diagnosis and in coping with their mental and emotional reactions to both the disease and its implication for their lives. For example, information should be provided about the symptoms, prevention, and treatment of the STD and about how it is transmitted. Although this information may be provided at the time of diagnosis, the young person may have been too upset to absorb it, or the information may not have been presented in an age-appropriate manner. Social workers can encourage youth to discuss their feelings about having an STD. They can also use modeling, demonstration, and rehearsal techniques to teach them strategies for disclosing to partners and asserting their needs in interpersonal relationships. They may even be able to reduce perceived stigma by helping people see beyond the STD diagnosis.

Because foster children are an identifiable population generally in the custody of the state, the human service system has an obligation as well as an opportunity to address the serious problem of sexually transmitted diseases among adolescents. A comprehensive program that includes STD prevention efforts, screening, and medical treatment would greatly reduce the risk of these children contracting an STD. Social workers can and must act as advocates and resources in promoting such programs.

Christina Risley-Curtiss is Assistant Professor, School of Social Work, Arizona State University, Tempe, Arizona.

Copyright Family Service America Feb 1996
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