Reproductive Health Needs of Incarcerated Juveniles

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Adolescents in correctional facilities report becoming sexually active at earlier ages and partaking in risky sexual behaviors more frequently than their nonincarcerated peers (Strack & Alexander, 2000). In one study of juvenile offenders aged 14-18, 87% of the sample reported being sexually active. Over one-third reported having sex before they were 12 years old and 57% before they were 13 years old. The median age for first sex was 12 for males and 13 for females. Of those who reported having sexual intercourse, half (49%) had had 6 or more partners in their lifetimes, including 22% with 6-10 partners and 16% with more than 20 partners. Of all the sexually active youth, over half had had sex in the past month and 42% reported having multiple partners in the past 3 months (Strack & Alexander, 2000). In another study of sexual debut among female juvenile offenders, results showed that the mean age of sexual debut was 13. The mean number of sex partners (lifetime) was 8.8 (Crosby et al., 2004).

Though incarcerated juveniles report greater sexual risk-taking behavior, many do not use condoms consistently (Morrison, Baker, & Gillmore, 1994). Strack and Alexander (2000) found that 44% of the youth reported using condoms only about half the time or less and nearly one fifth of the youth indicating that they never use a condom. Among those youth who have had anal intercourse, 70% have had anal sex at least once without a condom. Another study of incarcerated juveniles found that although 96% of female and male respondents were sexually active, only 4% used a condom consistently (Crosby et al., 2004).

Although sexual activity is prohibited within juvenile correctional facilities, it may be occurring either consensually or by sexual assault. The Prison Rape Elimination Act (PREA) was enacted by Congress and will require all correctional facilities, including those serving juveniles, to implement policies and procedures to eliminate prison rape.

Because the majority of detainees have had sex, the discussion of sexual behaviors, including risk and protection, should be included in every preventive medical encounter. Providers should include questions about age at first vaginal, oral, and anal intercourse, current sexual practices, number of partners within the last 3 months, and gender(s) of partners. Though same-sex sexual relations between juvenile detainees are officially prohibited, many detainees may have had same-sex sexual experiences in the past. Additionally, same-sex sexual contact may be occurring within the facility. (See section on Special Populations: GLBTQ Youth.) When questioning all youth about sexual behaviors, it is important to use the word partner and not boyfriend or girlfriend so as not to assume heterosexuality and behaviors. Many youth may be having sex with casual partners or sex work clients who they would not consider as a "boyfriend" or "girlfriend." They may use these terms in reference to a regular partner with whom there may be an emotional attachment.

Additionally, all reproductive health clinical interviews should include discussions on condoms. Though juvenile justice systems often have restrictions on displaying and dispensing condoms within the facility, medical providers and health educators can educate inmates regarding correct and consistent use of condoms so they will be better equipped to protect themselves after incarceration. On release, detainees should either be given (depending on institutional policy) or told where condoms can be purchased or are given out for free.

Due to the high rates of sexual risk behaviors and low rates of condom use, it is not surprising that juvenile detainees experience higher rates of sexually transmitted infections (STIs), including HIV. In one study, 20% of juvenile detainees tested positive for an STI (Crosby et al., 2004). Rates of chlamydia among juvenile detainees range between 2.4, and 27% in females and 1 and 8% in males (Lofy, Hofmann, Mosure, Fine, & Marrazzo, 2006; Kahn et al., 2005; Robertson & Thomas, 2005). Because these rates are so much higher than in the general population, chlamydia screening is recommended for both males and females. Gonorrhea rates are also disproportionately high for juvenile detainees—from 0 to 17% in females and 0 to 18% in males (Kahn et al., 2005; Robertson & Thomas, 2005).

In addition to chlamydia and gonorrhea, other STIs affect incarcerated youth, although these are the most common. A 1996 study assessed the prevalence of genital herpes in a sample of detained juveniles and found that 15% of the males and 20% of the females tested positive (Huerta et al., 1996). HPV prevalence has not been defined in this population, but can be extrapolated as being high, based on the other STI data available, low condom use, early sexual debut, and abnormal Pap smears among female juvenile offenders.

The public health implications of these data are overwhelming. Though statistics demonstrate that incarcerated young men and women are at high risk for STIs, many are still not tested. Recent data are limited, but in 1994, 53% of incarcerated juveniles were screened for STIs. In 33% of the surveyed facilities, nonmedical personnel did the screening (Parent et al., 1994). The detention and confinement period for juveniles is a golden opportunity for screening and treatment of STIs by juvenile justice and public health agencies, which should develop the resources to implement effective screening and treatment programs.

New urine-based tests can improve compliance for testing and may be easily incorporated into the intake process of the juvenile correctional facility. The urine-based nucleic acid amplification tests (NAATs) are highly sensitive and specific. Self-collected genital specimens can be used to accurately diagnose chlamydia and gonorrhea infections. In many cases, use of urine specimens can reduce the necessity for a pelvic examination on females and urethral swabs for males, thus extending the diagnostic capability for detecting these infections in nonclinic screening venues (CDC, 2006).

Public health agencies must consider partnering with juvenile justice agencies to promote and facilitate STI screening and treatment of juvenile offenders prior to their return to the community. Partnerships may be informal with staff communicating regarding treatment and follow up and partner notification or may become formalized with the development of an agreement such as a Memorandum of Understanding (MOU). An MOU can allow sharing of information across agencies and define all parties' responsibilities whether in kind or with some fiscal responsibility.

HIV infection rates are growing among this population based on risk behaviors. Adult correctional populations have at least six times the prevalence of HIV than the general population (CDC, 1996). The prevalence of HIV within juvenile correctional facilities is not documented well, as many juvenile systems do not have universal or mandatory testing. Also, adults may be presenting medically with AIDS while infected juveniles may not be symptomatic yet. Juvenile justice facilities should be encouraged to implement the latest CDC recommendations of opt-out testing for HIV incorporated into the routine health care admission process. However, the agency should be prepared for positive HIV test results and develop a mechanism to provide treatment while the youth is still incarcerated and appropriate follow-up on release into the community.

Young men and women confined in the juvenile justice system are also more likely to have been pregnant or involved in a pregnancy. A 2004 study indicated that 32.2% of juveniles had ever been pregnant (Crosby et al., 2004). Another study found that more half (52.3%) of the sexually active youth in out-of-home care reported that they thought they or their partners were pregnant at one time, but found out that they were not. Twenty-five percent indicated two or more such instances (Strack & Alexander, 2004).

A substantial number of young women are pregnant upon their confinement in the juvenile justice system. A 1995 study of 261 juvenile detention facilities found that 68% of the respondents estimated that they were holding one to five pregnant adolescents on a given day, with a reported yearly census of 2000 pregnant teenagers and 1200 teenaged mothers. Nearly half of the facilities (45%) continue to incarcerate after it is determined that a youth is pregnant. Of those institutions that incarcerate pregnant adolescents, 31% provide no prenatal services and 70% provide no parenting classes. Of these facilities, 60% reported at least one obstetric complication in their pregnant population (Breuner & Farrow, 1995).

Pregnancy testing should be a routine part of medical intake for all females entering juvenile correctional facilities. As more than half of all rapes (54%) of women occur before age 18, juvenile justice health professionals should assess for sexual trauma on diagnosis of pregnancy (Tjaden & Thoennes, 2000). Additionally, detainees should be provided with unbiased and comprehensive options counseling regarding their choices, including parenthood, adoption, and pregnancy termination. Juvenile corrections, public health, and other child serving agencies should partner to provide the best outcome for the young offender whatever her choice. If the pregnancy is continued, prenatal care can be provided through coordination with public health agencies. Many females will be discharged from the facility prior to delivery, so follow up into the community for obstetric care is essential. If the young woman decides to terminate the pregnancy, the detention center, while acting within the confines of state law, should see to it that the termination is obtained at the earliest gestation possible.

Although the juvenile justice system is predominately male, pregnancy prevention interventions are needed in this population. Information on pregnancy prevention, particularly contraception, should be provided to males as well as females in the clinical setting. For instance, many young men and women are unaware of emergency contraception. In the event of forced intercourse or contraceptive failure, emergency contraception provides a second chance to prevent pregnancy. Though commonly referred to as "the morning-after pill," the drug regimen has reasonable effectiveness up to 120 hours after unprotected intercourse. Discussion of emergency contraception should be incorporated into the medical intake process. If the young woman has had unprotected intercourse in the last 5 days, juvenile justice medical personnel should be prepared to administer emergency contraception. Young women and men should be educated regarding emergency contraception before release to prevent future pregnancies.

As noted, young men and women run significant reproductive health risks before incarceration. These risks persist and even increase after release. In a 2003 study of the sexual behaviors of young men on release from incarceration, results indicated that 36% men reported having had risky sex (>two female sex partners and unprotected vaginal sex) in the months following reentry (MacGowan et al. 2003). Therefore, the period of incarceration is an excellent time to initiate pregnancy and STI prevention interventions for both young women and men. In addition to clinical counseling, these can include programs that focus on the antecedents of risky sexual behavior: knowledge of reproductive physiology, condoms, and contraception; and programs that focus on the nonsexual antecedents such as self-efficacy and communication skills.

One final step in public health efforts to reduce pregnancy on release is to partner with juvenile justice agencies in the provision of family planning services during incarceration. Contraception should be provided on release or initiated while the youth is still incarcerated. There are many advantages to the latter. Even though detained young women are not sexually active, initiating a method of contraception will allow for adjustment to the medication and resolution of any related problems while the individual has full access to a medical provider.

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