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during childhood are twice as likely to have gynecological problems, including STDs, compared to women who do not have such a history (Plichta and Abraham, 1996). In addition, women with a history of involuntary sexual intercourse are more likely to have voluntary intercourse at an earlier age (a risk factor for STDs) and to have subsequent psychological problems (Miller et al., 1995).
Transmission of STDs as the result of sexual abuse is particularly salient among prepubescent children and very young adolescents. STDs among children presenting for care after the neonatal period almost always indicate sexual abuse (AAP, Committee on Child Abuse and Neglect, 1991; Gutman et al., 1991; CDC, 1993). Sexually abused children may have severe and long-lasting psychological consequences, may become sexual abusers themselves, and may abuse children (Guidry, 1995). In addition, they may engage in a pattern of high-risk behavior that often puts them at risk for further abuse and subsequent STDs. Guidelines for the clinical management of children with STDs as a result of suspected abuse have been published (CDC, 1993; AAP, Committee on Child Abuse and Neglect, 1991).
Many women who are subjected to sexual violence may not be able to implement practices to protect against STDs or pregnancy (O'Leary and Jemmott, 1995; Plichta and Abraham, 1996). A phenomenon that also may impede protective behaviors among women is the pairing of older men with young women. The age discrepancy between older men and younger, sometimes adolescent, females may predispose to power imbalances in the relationship, thus increasing the potential for involuntary intercourse, lack of protective behavior, and exposure to STDs (Finkelhor and Associates, 1986). In addition, early initiation of sexual intercourse among adolescent males with an older female partner has been shown to increase the number of sex partners later in life (Weber et al., 1992).
STDs Among Disenfranchised Populations
STDs, like most communicable diseases in the United States, disproportionately affect disenfranchised groups and persons who are in social networks where high-risk health behaviors are common. These groups are often of low priority to policymakers since they possess little political power or influence and, without publicly sponsored health services, would not have access to STD-related services. In addition, these groups are difficult to reach, difficult to teach, and difficult to treat (Donovan, 1996). However, they are important from an STD prevention perspective because they represent "core" transmitters of STDs in the population (Thomas and Tucker, 1996). In this section, the committee describes several examples of populations at high risk for STDs that require special attention.