Journal of Pediatric and Adolescent Gynecology
Volume 25, Issue 1 , Pages 2-5, February 2012

Issues in Gynecologic Care for Adolescent Girls in the Juvenile Justice System

  • Ruba Rizk, MD

      Affiliations

    • Corresponding Author InformationAddress correspondence to: Ruba Rizk, MD, Division of Adolescent Medicine, Children’s Hospital at Montefiore, 3411 Wayne Ave, Bronx, NY 10467
    • ,
  • Elizabeth Alderman, MD

Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine, Children’s Hospital at Montefiore

published online 21 March 2011.

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Introduction 

It is estimated that 2.3 million adolescents pass through the juvenile justice system each year. In the year 2000, adolescent girls comprised 28% of these offenders, reflecting a dramatic 35% increase in the number of female delinquents from 1980.1 Recent data shows that on average 14,590 female juvenile offenders are housed in correctional facilities on any given day.2 These adolescent girls have significant health needs. They represent a medically underserved and hard-to-access population who are at high risk of medical, gynecologic, and emotional disorders. A large percentage of these troubled youth have been the victims of child abuse including sexual abuse and neglect.3, 4, 5 They have high rates of learning disabilities and substance abuse and engage in high-risk behaviors.3, 6, 7 With the majority of these juvenile offenders coming from backgrounds of considerable family, social, and psychological turmoil with limited access to medical care,8 incarceration has become a unique opportunity for health care providers to intervene. The striking numbers make health care provision and particularly gynecologic care and counseling critical in optimizing the futures of these incarcerated teens.

A recent national overview of reproductive health care services for girls in residential juvenile justice facilities found that about 70% of facilities, housing at least one girl, offer some form of reproductive health care.9 However, it also found that many facilities are not following the recommendations of the National Commission on Correctional Health Care (NCCHC), American Academy of Pediatrics (AAP), and Society for Adolescent Health and Medicine (SAHM) and are only providing some services as needed rather than to all the resident juveniles in a consistent, well coordinated manner. Health care providers should ensure appropriate counseling and education, as incarceration is a golden opportunity for intervention for this largely medically underserved population.

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Juvenile Justice Facilities 

There are approximately 3500 juvenile justice residential facilities across the United States. They each vary considerably in primary purpose, ownership, size, length of stay, and availability of health services. The seven different types include:

•Detention Center: usually the first facility encountered by juvenile delinquents as they await placement for all types of offences. It is the equivalent of an adult jail.

•Reception or diagnostic center: short stay facility for delinquents who have committed all offences and are awaiting assignment to longer-term facilities pending their diagnosis and classification.

•Boot camps, ranch, forestry camp, wilderness or marine program or farm: usually in rural areas, providing short-term stay with intense programs for delinquents.

•Group homes, halfway houses, community-based facilities or houses that house juvenile delinquents, with less serious offences, for longer periods of time and aid in their transition back to the community.

•Training schools, long term secure facilities: the juvenile equivalent of adult prison. Large facilities with high security for imprisoned youth who are remanded to state custody for long periods of time.

•Residential treatment centers: usually smaller longer stay facilities that provide specific treatment services (eg, mental health, substance abuse treatments).

•Shelter: usually longer stay facilities that house delinquents with minor charges.

With over half a million adolescent girls passing through these facilities yearly, incorporating health and reproductive care services is key to optimizing their lives as they mature into adulthood.

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Preventive Reproductive Healthcare 

Guidelines and recommendations regarding the health status of incarcerated juveniles are available. The NCCHC periodically publishes guidelines, most recently in 2004, on the standards for health services in juvenile detention and confinement facilities that address all facets of care.10 Both the AAP and SAHM have also published policy statements on the health care of incarcerated youth.11, 12 Both statements highlight that all youth should receive preventive health services consisting of complete medical history and physical examination, including testing for sexually transmitted infections (STI) and gynecologic examination. Prenatal services, parenting classes, and substance abuse cessation programs should also be available.

Juvenile justice facilities must ensure that girls have access to reproductive health services that address growth and development and the anxiety stemming from physical maturation. Other services include contraceptive management, treatment of menstrual disorders, sexuality issues and trauma related to physical and sexual abuse and provision of vaccinations. A detailed menstrual history is part of the initial visit in order to identify girls with previously undiagnosed or untreated irregular menses or dysmenorrhea.

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Sexually Transmitted Infections 

Studies have shown that delinquent girls engage in high-risk sexual practices putting them at particularly higher risk for sexually transmitted infections (STIs).13, 14 They initiate sexual activity at much younger ages, usually at 11–14 years, and their partners at coitarche are typically older males, as compared with their non-delinquent counterparts.15, 16 These girls have higher rates of sexual abuse, multiple partners, and are less likely to use contraception, both barrier and hormonal.16 Therefore they are more likely to become pregnant and are at higher risk of acquiring STIs.17 For this reason contraceptive options, including hormonal contraception, and emergency contraception counseling are key discussions.

Combining such high-risk behaviors with a lack of a medical home, STIs emerge as a common problem among incarcerated girls with prevalence rates higher than those seen for adolescent girls in this age group. The prevalence of chlamydia and gonorrhea ranges between 14–22% and 5–6%, respectively.13, 18, 19 HIV seroprevalence, on the other hand, does not seem to significantly differ from those in the community but data is limited.20, 21 It is recommended for all young women within the correctional system to be rigorously and periodically screened for HIV,16 chlamydia, and gonorrhea using urine nucleic acid amplification testing (NAAT), and syphilis regardless of symptoms. Screening for STIs should be done initially, on admission, and then periodically every six months or if there is a new sexual partner or at the teen’s request, regardless of presence or absence of symptoms. Health care providers should have a high index of suspicion for STIs and their sequelae including cervicitis and pelvic inflammatory disease (PID). Patients with positive tests or physical exam findings should be treated according to the 2010 Center for Disease Control (CDC) STI treatment guidelines. Health care providers should provide education and counseling on STIs, PID, and its consequences and on the importance of proper condom use.

Human papillomavirus infection, the most common sexually transmitted infection in adolescents, implicated in changes in cervical cells and cervical cancer, has a high prevalence in adolescent women. Immunocompetent girls generally clear the infection within two years without producing neoplastic changes. However, girls in the juvenile justice system have been found to have higher rates of cervical dysplasia than the general population.22

In November 2009, the American College of Obstetricians and Gynecologists (ACOG) released an updated practice bulletin addressing cervical cytology screening.23 Most notable was their recommendation to delay onset of screening with PAP smears until age 21 years regardless of age at coitarche. The updated guidelines do not provide recommendations for PAP smear screening of HIV-infected and immuno-suppressed adolescents, adolescents who have already been screened and are positive for dysplasia, or those who have undergone excisional procedures. One consideration is to adapt the adult recommendations to adolescents and therefore screen sexually active HIV positive and immuno-suppressed adolescents twice in the first year after coitarche or diagnosis and annually thereafter.

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Concerns for Lesbian, Bisexual, or Questioning Girls 

It is common for girls in the juvenile justice system to identify as lesbian or bisexual. In a study of gender roles in a Berkeley, California, detention center, 35% of the girls interviewed mentioned “involvement or interest in same-sex relationships,” or concerns about family members or other girls in detention being gay.24 It is the health care provider’s responsibility to identify these vulnerable girls using gender neutral and non-judgmental language, ultimately providing appropriate care and counseling, that many have never received.

When caring for lesbian adolescents, it is important to keep in mind that sexual orientation is not synonymous with sexual practice. Most lesbians continue to engage in sexual activity with boys.25, 26 In fact, lesbian and bisexual adolescents are two to three times more likely to get pregnant than heterosexual adolescents.27, 28

Studies have shown that females who are exclusively homosexual have the lowest risk of contracting bacterial STIs29, 30; however, risk does vary depending on sexual practices, sexual orientation, and number of partners. STIs, including trichomonas, can be acquired through heterosexual sex and through the exchange of vaginal secretions using fingers or objects such as sex toys. Studies have also shown that bacterial vaginosis tends to be more prevalent among lesbians31 leading some to suggest that it could be sexually transmitted among lesbian women.32 When counseling it is important to discuss preventive measures such as dental dams during oral sex, washing sex toys between uses, and further stressing the importance of using condoms or plastic wraps when using sex toys and remembering to change condoms between partners. The proper use of condoms during heterosexual sex should be discussed.

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Pregnancy Prevention 

Preventing teenage pregnancy is a national priority.33 Pregnancy prevention counseling is especially important for girls in detention who have engaged in high risk behaviors, have high rates of substance abuse and mental health disorders, and have limited economic and family support resources to depend on. All sexually active teens should be counseled and educated on the importance of safe sex and the various barrier and hormonal contraceptive options available including emergency contraception.

The majority of juvenile justice residential facilities are testing for pregnancy on an “as deemed necessary” basis or at the teen’s request.9 This goes against the current recommendations of both the NCCHC and AAP to screen all teens for pregnancy on initial admission regardless of risk. There should be a low threshold for screening girls for pregnancy in all juvenile justice facilities. Pregnancy testing should be done for all girls with late menstrual periods prior to prescribing teratogenic medications such as some psychiatric medications or antibiotics, and at the teen’s request. Health care providers should keep in mind that these girls are at higher risk of sexual abuse and may not always disclose this abuse.

Many facilities, such as group homes and shelters, allow home visits on the weekends, where these adolescents often engage in sexual activity. As a result, all sexually active teens are encouraged to start a contraceptive method of choice with appropriate medical follow-up. Trained professionals at the facility’s health care center usually dispense all medications, including emergency contraceptive pills when needed. Given that many girls in the juvenile justice system may be on daily medication, such as psychotropics, the issue of compliance with oral contraceptive pills may be moot as girls may be administered all medications at the same time. Long-acting progestin-based contraceptive methods, when available or covered by insurance, are encouraged for girls in whom estrogen is contraindicated, for all medication non-compliant girls, or for girls who need not otherwise visit the health care centers daily for medications.

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Pregnancy 

As the number of female juvenile delinquents rises, so do the numbers of pregnant juvenile delinquents. In 1995, a national survey found that 68% of the 261 facilities surveyed were housing between one and five pregnant teens on any given day. Thirty-one percent of surveyed facilities had no nursing or basic prenatal care, 38% had no obstetric prenatal services, and only 30% provided parenting classes.34 A more recent overview showed that of the 1255 nationwide juvenile justice residential facilities housing at least one girl, 346 facilities reported at least one pregnant teen in their population during the reference month. The authors assumed that if only one girl was pregnant in each facility, then at least 2.1% of teens housed in correctional facilities are pregnant.9 Of the 1255 facilities, approximately 75% provided some form obstetric or prenatal services, mostly outside the facility. For girls who have a positive pregnancy test, prenatal vitamins should be started and options counseling performed. Depending on the teen’s decision, obstetric or termination of pregnancy services should be available. It is important to keep in mind that incarcerated pregnant teens are at increased risk of pregnancy complications secondary to their high-risk health behaviors.35 Again, age-appropriate education and parenting classes should be available during their period of incarceration.

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Vaccinations 

Although acute healthcare needs are usually prioritized, preventive interventions including vaccine updates and PPD testing should not be overlooked when these girls enter the juvenile justice system. Currently there are three vaccine-preventable STIs including hepatitis A, hepatitis B, and human papillomavirus. We shall focus our discussion on the latter two, as Hepatitis A is more common in the MSM population. However, due to the possibility of anal sex, hepatitis A vaccination is also strongly recommended.

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Hepatitis B 

The hepatitis B vaccine is the most effective means of preventing HBV infection and its consequences. All adolescent girls within the juvenile justice system with no vaccination records should be screened for hepatitis B antibodies and hepatitis B surface antigens and those who are either sero-negative or unvaccinated should be offered the Hepatitis B vaccine. A report from 2007 showed that 41 states are vaccinating juvenile delinquents against the hepatitis B virus.36

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Human Papillomavirus 

Human papillomavirus (HPV) is the most common sexually transmitted infection in persons aged ≤24 years in the United States37 with approximately 4.6 million new cases occurring in the year 2000. There are currently two Food and Drug Administration (FDA) approved formulations, a quadrivalent vaccine (Gardasil) for females aged 9–26 years, for the prevention of cervical cancer, precancerous genital lesions, and genital warts associated with HPV types included in the vaccine (HPV 6, 11, 16, and 18), and a bivalent vaccine (Cervarix) (HPV 16, 18) for cervical cancer, approved for girls ages 10–25 years. Adolescent girls in the juvenile justice system are at a considerably higher risk of HPV acquisition because of earlier onset of sexual activity, increased number of partners, and their lack of a medical home as previously discussed.11, 16, 38 As a result, it is highly recommended that the HPV vaccine series be offered during their detention, particularly since full immunization with the vaccine series is a realistic goal in this setting. Girls who began the series prior to incarceration should be offered completion. A recent report stated that HPV vaccine is currently offered by 39 states, to adolescents residing in juvenile justice facilities39 with 11 states not offering. Barriers cited included lack of education among the adolescents regarding HPV and the vaccine, parental consent requirements, lack of consistent health care staff, lack of storage space, fear of needles, and cost. Incarceration is an ideal time, as completion of the series is assured. It is noteworthy to mention that as long as a juvenile justice facility is enrolled as a Vaccine for Children (VFC) provider, then the HPV vaccine can be provided through the Center for Disease Control’s (CDC) VFC program.40

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Summary 

Incarcerated girls represent a captive audience, providing health care providers working in the juvenile justice system with a unique opportunity to intervene in this difficult-to-reach population. Health care providers should promote and encourage healthy lifestyles with the aim of lowering their risk-taking behaviors, promote contraception and screen and treat sexually transmitted infections. For many delinquent girls this encounter represents their first contact with the medical care system as independent young women. It is important to encourage these girls to have a medical home and upon discharge from the facility, it is important to guarantee appropriate follow-up.

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References 

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 Ruba Rizk has no conflict of interest to disclose. Elizabeth Alderman is a Speaker at Merck’s Speaker’s Bureau

PII: S1083-3188(11)00061-1

doi:10.1016/j.jpag.2011.01.060

Journal of Pediatric and Adolescent Gynecology
Volume 25, Issue 1 , Pages 2-5, February 2012

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