Missed Opportunities for STI Care in Adolescent Males

Source: Rolin A, Badolato G, Boyle M, et al. STI testing in adolescent males presenting to an emergency department. Pediatrics. 2025;156(4):e2024068574; doi: 10.1542/peds.2024-068574.Investigators from Children’s National Hospital, Washington, DC, conducted a retrospective study to assess rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) testing and screening during emergency department (ED) visits by adolescent males, and to compare rates among those in different racial and ethnic groups. For the study, they identified visits by males 13–21 years old to a large, urban, freestanding children’s hospital or satellite campus ED between January 2021 and February 2023. Data on age, race and ethnicity, presence of genitourinary symptoms, possible CT/GC exposure, and CT/GC testing or screening and results were abstracted on study patients. Separate analyses were conducted to determine rates of screening and testing. Patients presenting with genitourinary symptoms and/or a GC/CT exposure were eligible for testing, and those without symptoms or exposure were included in the screening analysis. Rates of screening and testing were calculated in all adolescent males in the corresponding group, and in those from different racial or ethnic groups. After controlling for possible confounders, logistic regression was used to compare rates of testing or screening among patients in different racial and ethnic groups, with non-Hispanic White used as the referent group.Data were analyzed on 17,244 ED visits by 11,139 unique adolescent males; 65.1% of visits were by non-Hispanic Black patients. Overall, CT/GC testing or screening was performed at 643 (3.7%) visits, with 188 (29.2%) positive results. There were 473 visits by patients with a mean age of 16.3 ±2.3 years who were symptomatic and/or had a CT/GC exposure. Testing was performed at 187 (39.5%) visits, with 57 (30.5%) positive results. CT/GC testing was performed during 50% of visits by non-Hispanic Black males, 26.4% by Hispanic patients, and 11.8% by non-Hispanic White youths. The rate of testing was significantly higher in non-Hispanic Black patients than in non-Hispanic White males (adjusted odds ratio [aOR], 3.3; 95% confidence interval [CI], 1.3, 8.3). There was no significant difference in testing rates between Hispanic and non-Hispanic White males (aOR, 2.0; 95% CI, 0.7, 5.8). GC/CT screening was conducted at 456 of 16,771 visits (2.7%) by asymptomatic males with no exposure, with 131 (28.7%) positive results. Rates of screening during visits by non-Hispanic Black, Hispanic and non-Hispanic White adolescent males were 3.5%, 1.4%, and 0.8%, respectively. Compared to non-Hispanic White males, screening was significantly more frequent during visits by non-Hispanic Black males (aOR, 3.1; 95% CI, 1.6, 5.9). There was no significant difference in rate of screening in non-Hispanic White and Hispanic patients.The authors conclude that rates of CT/GC testing and screening during ED visits by adolescent males were low.Dr Raphael has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Adolescents and young adults account for nearly 50% of the 2.2 million CT and GC infections in the United States.1 Despite the risk posed by these infections, there are gaps in sexual and reproductive health services for adolescents. (See AAP Grand Rounds. 2024;52[6]:68.)2 Adolescents, especially males, are less likely to seek preventive health visits. A 'no-missed-opportunities paradigm,' wherein every health care encounter, including an ED encounter, is viewed as an opportunity to address gaps in care, could decrease inequities.3Previous studies indicate that both adolescents and ED providers report positive attitudes toward sexually transmitted infection (STI) testing and screening in the ED.4,5 However, the current study researchers found that among asymptomatic males, this almost never occurs. Of equal concern are the markedly low testing rates in symptomatic males. Unfortunately, consistent with studies in other settings,2 racial/ethnic bias in STI testing and screening was evident in this ED setting as well. Symptomatic non-Hispanic Black male adolescents had a 7.5-fold higher rate of CT/GC testing, and asymptomatic non-Hispanic Black males had a 3.1-fold higher rate of screening compared to their non-Hispanic White counterparts. Inherent to the retrospective nature of the current study, there were some confounders that the researchers could not account for. For instance, factors such as confidentiality concerns, patient preference, prior screening, sexual activity, and clinical findings may have influenced STI testing/screening rates.As highlighted in the accompanying editorial, missed opportunities and disparities in CT/GC testing can increase the risk of complications for the individual, for partners, and perpetuate the ongoing public health impact of CT/GC.6 Besides implicit biases, lack of clear CT/GC screening guidelines for adolescent males exacerbates variable care.7 The findings of the current study underscore the need for system-based improvements to address the low rates of STI screening and testing and race/ethnicity bias in STI care.Adolescent males are rarely screened for CT/GC in pediatric ED settings, and testing rates among symptomatic adolescent males remain suboptimal.The similar proportion of positive results among adolescent males 'tested' or 'screened' (30.5% and 28.7%, respectively) suggests many of those in the screening group were actually not at low risk.