What is the exception among the following risk factors for sexually transmitted infections (STIs) among adolescents and young adults: living in a detention facility, mental health disorders, substance misuse, or later initiation of sexual activity?

Risk Factors for STIs in Adolescents and Young Adults

The correct answer is D: Later initiation of sexual activity is NOT a risk factor for sexually transmitted infections—in fact, it is protective, while earlier sexual initiation significantly increases STI risk.

Understanding the Risk Factors

Early Sexual Initiation (The Protective Factor When Delayed)

Earlier age of sexual initiation is a well-established risk factor for STIs, making later initiation protective:

• Early sexual activity among US adolescents creates substantial risk for pregnancy and STIs, with 46% of high school seniors reporting sexual intercourse and 14% having 4 or more partners 1
• Adolescents and young adults (ages 15-24) account for only one-quarter of the sexually active population but contract nearly half of all new STIs annually 1
• Earlier sexual initiation is directly linked to higher numbers of lifetime sexual partners and increased STI risk 2, 3
• Males who had their first sexual experience before age 11 reported significantly larger numbers of sexual partners throughout their lifetime 2
• The relationship between early sexual initiation and substance use disorders, poor physical health, and obesity is partially mediated through sexual consequences including STIs 3

Living in Detention Facilities (Confirmed Risk Factor)

Incarcerated youth demonstrate markedly elevated STI rates compared to the general adolescent population:

• Among juvenile detention facilities, chlamydia positivity rates reach 14.8% in females and 6.6% in males 1
• Gonorrhea positivity rates are 3.9% in females and 1.0% in males in detention settings 1
• Incarcerated youth report higher rates of sexual activity, are more likely to have 4 or more lifetime sexual partners, and demonstrate much lower contraception/condom use at most recent intercourse compared to general high school populations 1
• Despite high STI risk, only 18.5% of juvenile facilities offer STI testing for all adolescents on admission, and 8.3% don't even have STI testing available 1

Mental Health Disorders (Confirmed Risk Factor)

Mental health disorders, particularly depression, significantly increase STI risk:

• Patients with depressive disorder exhibit a 54% increased risk (HR 1.54,95% CI 1.34-1.76) for subsequent STIs including HIV, syphilis, genital warts, gonorrhea, chlamydia, and trichomoniasis 4
• People with severe mental health problems are likely to engage in high-risk sexual behavior for multiple reasons, putting them at elevated risk for sexually transmitted diseases 5
• Detained adolescents with mental health disorders demonstrate earlier onset of criminal behavior and substance use, more lifetime substance use problems, and increased impulsivity—all factors associated with higher STI risk 1

Substance Misuse (Confirmed Risk Factor)

Substance use is strongly associated with increased STI risk through multiple pathways:

• There is a clear relationship between substance use and physical fights, weapon use, and gang membership among youth—all markers of high-risk behavior patterns 1
• Detained adolescents with histories of substance use demonstrate more previous-year criminal acts and lifetime substance use problems 1
• The association between early sexual initiation and marijuana disorders is partially mediated through sexual consequences including STIs 3

Clinical Implications

Chlamydial infection is especially prevalent among adolescents, and PID occurs more commonly after chlamydial infection among adolescent females than older women, making prevention efforts critical for young populations 1

• All sexually active adolescents and young adults are at high risk for chlamydia, with infection broadly distributed geographically and socioeconomically 1
• Rates of many STDs are highest among adolescents, with gonorrhea rates peaking in the 15-19 age group 1
• Clinic-based studies demonstrate that chlamydial infection prevalence is highest among adolescents 1

Key Pitfall to Avoid

Do not confuse the timing of sexual initiation with sexual activity status: While being sexually active is a risk factor for STIs, later initiation of sexual activity (when it does occur) is protective compared to earlier initiation. The question specifically asks about timing, not activity status itself 1, 2, 3.