Four sets of locked doors slam shut behind Meghan Benson as she marches into the Dane County Juvenile Detention Center lugging a plastic storage container. Teens in maroon jumpsuits wave. Benson is a Thursday night regular. She is here to fight an epidemic that will infect more young people at the center and in the rest of Wisconsin than H1N1, and Benson is one of the few people willing to take it on openly.
After signing in at the security desk, Benson opens the container and pulls out her weapons: condoms, a replica of the female reproductive system, birth control pills and patches, a diaphragm, a dental dam and a wooden model of an erect penis. She has given 20 similar presentations this week to local teenagers in public schools and community centers.
The 25 kids in the detention center’s classroom are giggling and quarreling and gossiping like any other group of teens. Many are accused of crimes ranging from theft to assault. But Benson knows many will end up victims, too, not just of crime but of one of the most serious public health threats facing Wisconsin and the rest of the country. She starts by setting the ground rules — respect and confidentiality — for what they are about to talk about.
Sexually transmitted diseases are reaching epidemic levels in Wisconsin and across the country. The Henry J. Kaiser Family Foundation estimates that there are 253,500 new cases of sexually transmitted infections in Wisconsin each year. A key reason: a surge in infections among teens, according to a Capital Times analysis of state health reports and interviews with local experts.
One in four teenage girls in the U.S. has an STD, according to the Centers for Disease Control. In Wisconsin, the rate of four of the most commonly reported STDs among teens jumped 53 percent between 1997 and 2007. Females and minorities, especially African-Americans, have been hit hard. And these are numbers that have been reported; actual cases may be much higher. But it remains a hidden epidemic, not just because many STDs have no symptoms, but because of the stigma and politics that complicate efforts to fight them.
Benson, an educator with Planned Parenthood of Wisconsin, is among a growing number of local advocates, educators and medical professionals convinced that the best way to fight the spread of STDs is to talk about them and to teach kids to use protections like condoms. A vocal group of others, many of them religious and conservative activists, believe the exact opposite. There is already too much talk about sex and contraceptives, they say, and that’s why the four out of 10 Wisconsin teens who claim to be sexually active face soaring rates of infection. What these kids really need, they say, is to be taught how to abstain from sex completely. “It’s a titanic cultural clash,” says Julaine Appling, chief executive officer of Wisconsin Family Action and a leader of the local abstinence movement.
The presence, or absence, of sexual education — or sex ed, as most call it — is not the only theory for why STDs among young people are on the rise in Wisconsin and elsewhere. There’s a long list of other potential explanations, too. Biology: Children go through puberty earlier thanks to better nutrition, and the immature cervix of teenage girls is especially vulnerable to infection. Psychology: Kids with raging hormones think they are invincible and take stupid risks. Sociology: Children who grow up in the inner city take risks because they can’t imagine a decent future. Technology: Better screening detects more STDs. Poverty: A lack of access to medical care means those infected won’t know they have an STD and will continue to spread it. Culture: Casual high school hookups have replaced the romance of dating. The media: Kids are being sexualized in ads, movies and on the Internet.
But sex ed is what gets people most riled up. The issue erupted in the Legislature this fall after lawmakers introduced a bill that would encourage more comprehensive sex education in Wisconsin schools. Just weeks ago, Milwaukee officials also created a firestorm with their decision to distribute condoms in public high schools. “What if, God forbid, a kid comes in and gets a condom and takes a girl into the school bathroom?” asks Sally Ladky, executive director of the Milwaukee-based Wisconsin Abstinence Coalition. Many say it was a decision born of desperation and embarrassment: Milwaukee County has some of the highest rates of poverty, teen pregnancy, infant mortality and STDs in the entire nation — rates that account for nearly half of some of the state’s sexually transmitted infections.
“The hysteria over this has been mind-boggling,” says Rep. Tamara Grigsby, D-Milwaukee, a co-sponsor of the sex education bill. “We have to deal with reality. Just look at the numbers and how horrible they are. Why wouldn’t we want to protect our kids?”
The numbers are horrible. Yet in all the sound and fury over contraceptives and sex education, they have been mostly — some say even deliberately — ignored. Far more attention and resources and news stories have been devoted to another epidemic sweeping the state and country: H1N1. In Dane County, for example, around two-thirds of the eight public health nurses on the STD-HIV team have been reassigned to fight swine flu. “No state wants to admit it is having an epidemic of STDs,” says Chris Taylor, public policy director with Planned Parenthood Advocates of Wisconsin. This reluctance to deal with sex “as a natural part of growing up” the way many other countries do, Taylor believes, is why the U.S. has some of the worst teen pregnancy and STD rates in the Western world. “If we saw any other infections growing like this, we’d be going totally ballistic,” Taylor says.
Agrees Linda Denise Oakley, a professor of nursing at UW-Madison and a psychiatric nurse practitioner who counsels young adults at risk for sexually transmitted diseases: “We are not taking care of our children.”
Reducing risky sexual behavior, including STD rates, is one of 11 priorities listed in Wisconsin’s public health plan, Healthiest Wisconsin 2010. About a decade ago, health officials broke this priority down into six ambitious goals. The state is failing every single one.
Most numbers are going way up, not down, especially among adolescents. This is a national problem, not just a state problem. One out of five American teenagers today will be infected with an STD, compared with one out of 47 of their parents. “It’s the elephant in the room,” says Mary Jo Hussey, a nurse with the Department of Public Health for Madison & Dane County’s STD-HIV team. Hussey knows from years of trying to track down the partners of people with sexually transmitted diseases just how tenacious these infections can be and how quickly they can spread among young people, who, according to national data, tend to have more sexual partners than other age groups. “This is a population that has been at risk for a long time,” she says.
This keen risk helps explain why the very first sexual health goal of the 2010 plan was to reduce the numbers of Wisconsin youth who report having had sex to 30 percent by 2010. There was initially some progress, based on figures kept beginning in 1999. The number of teens who had sex fell from 42 percent in 1999 to 37 percent in 2003. Then it started climbing again, to 45 percent in 2007 and 41 percent in 2008, the most recent year for which figures are available.
The state also is falling short of the second goal it set for itself: a reduction in the number of unintended pregnancies. Again, a big reason for this failure seems to be the rising pregnancy rates among teens. After a steady decline since 1994, in 2006 and 2007 teen pregnancy rates started inching up again.
But the most sobering differences remain between the targets the state plan set for reducing STDs and today’s reality.
• The state health plan aims to cut the rate of the country’s leading sexual infection, chlamydia, by more half in Wisconsin, from 304 cases per 100,000 people in 2000 to 138 cases per 100,000 in 2010. But rates have been climbing. In 2008 the rate was 371 per 100,000, well more than double the target. More than a third of the 20,767 residents diagnosed with chlamydia infections in 2008 were 15- to 19-year-olds. Another 37 percent were 20- to 24-year-olds, some of whom probably contracted the sneaky infection as teens, since it can take months to show up.
• It’s a similar story with gonorrhea, aka “the clap.” The target was to reduce the incidence to 63 cases per 100,000 in Wisconsin. Rates dipped from 130 in 2000 to 92 in 2005, and then started to climb again. While the rate in 2007, 121, was slightly better than in 2000, it is still nearly double the 2010 target. Teens account for the biggest portion with one-third, or 2,034 cases. Young adults ages 20 to 24 make up another third.
• Public health officials had hoped to finally eliminate the age-old scourge syphilis. Wisconsin came close in 2003, when only 15 victims were counted in the state for a rate of 0.3 per 100,000 cases, just above the 2010 target of 0.2. But the disease is making a comeback in Wisconsin and across the country. In 2007 there were 165 total reported cases in the state for a 2.9 rate — nearly 30 times the target. Forty of the 193 cases reported in 2008 are among those ages 15 to 24.
• Even the dreaded HIV, which can lead to AIDS, is rebounding. In 2007, the rate of infection was nearly three times the target established for 2010. Around a fifth of the 407 cases are among teens and young adults.
Dr. Seth Foldy, state health officer for Wisconsin and administrator of the division of public health, says some of the increase in these rates, particularly chlamydia, is actually a good thing. “There has been an effort to increase testing,” he says, “and so we find more of it.” However, many infections still go undetected, too: Only 11 percent of teens in a recent survey by the Dane County Human Services Department said they had ever been tested for an STD.
Wisconsin is by no means unique. All across the country, state public health programs are battling huge increases in STDs. Several decades ago, there were only two common STDs: syphilis and gonorrhea. Today, there are more than 25. The CDC estimates that there are approximately 19 million new STD infections each year — almost half of them among young people 15 to 24 years of age. And these reported cases are only a fraction of actual cases, since up to 80 percent of infections have no symptoms and remain undetected, meaning that their victims unknowingly continue to spread them to others.
While Foldy insists the state is making progress, he concedes it is not enough. “It would be right to identify sexually transmitted diseases as a problem that is way too common in Wisconsin, absolutely,” he says. “We are not paying enough attention. These diseases put an immense burden on our state. They strike young people at the beginning of their reproductive lives. The consequences are not trivial.”
Not trivial at all. Left untreated, sexually transmitted infections can lead to serious and even deadly complications, including pelvic inflammation, infertility, cancer, kidney problems, infant mortality and disease, ectopic pregnancies, emotional trauma and increased susceptibility to HIV.
They also cost a lot of money. The U.S. spends an estimated $15.9 billion annually on direct medical care for STDs. Wisconsin spends $117 million a year to prevent and treat STD's among teens, according to the state public health department.
Girls bear the brunt of STDs. In 2007 the rate of chlamydia among U.S. females, for example, was almost three times the rate among males, a pattern echoed in state data. In Wisconsin the same year, 7,642 cases of syphilis, gonorrhea, chlamydia and genital herpes were reported among females ages 15-19, compared with 2,049 cases among male teens. Caroline, who requested that we only use her first name because of the stigma surrounding her infection, is one of these statistics. She is a graduate student at UW-Madison.
Caroline contracted herpes after she had sex for the first time with an older partner. She was 16, too shy, too nervous and too unsure of herself to insist that her partner use a condom, which reduces, but not does compeletely eliminate, the spread of STDs. “It just takes one person to make one mistake for one time, and it can change your entire life,” she says.
Three years later, she developed painful genital sores and blisters, and was diagnosed with herpes. She isolated herself from friends and stopped dating. “It was my shameful secret,” she says. “I was in shock and terrified. I felt ugly and filthy, and like nobody would ever want to touch me again.”
Her infection is under control, but there is no cure for herpes. “When I was first diagnosed, I felt like I had this ball and chain around my foot, this bit of ugliness walking behind me,” she says. Since then, she has run into others — many others, she says — who also have STDs, though few of these people are as open about them as she is. She now has a serious boyfriend.
Caroline believes young people need to be taught to use protection, like latex condoms, that can help prevent STDs. “Anybody who preaches abstinence isn’t in touch with real teenagers,” she says. “That’s like putting a young person in the driver’s seat and not teaching them what traffic signs mean or how to drive on the right side of the road.”
The Bush administration spent more than $1.5 billion, or close to $176 million a year, funding programs that taught teenagers to abstain from sex until marriage. Some states — Wisconsin included — eventually rejected that funding after several major national studies found no evidence that such programs actually reduced the rates of STDs and teen pregnancies, which are also on the rise. “We certainly saw the impact of abstinence-only education,” Planned Parenthood’s Taylor says sarcastically. “It doesn’t work. Kids aren’t less likely to have sex, but they are less likely to use contraceptives, so they ended up having sex in a risky way.”
Yet supporters of the abstinence approach aren’t backing down. Appling points to other research she claims is proof that abstinence can work and says those programs which have failed “have been too watered down” in what she calls our “sex-besotted culture.” She points out that comprehensive sexual education, including the use of condoms and other contraceptives, is already taught in Milwaukee and Madison public schools, where Benson makes her presentations. “You’d have to be hiding under a rock somewhere not to know about condoms,” Appling scoffs. “A 10-year-old could get one!”
Appling believes that the sorts of presentations Benson makes are virtual invitations to continue to have sex. “The predominant message that gets to the ears of young people is, ‘We know you’re going to do this. Just run with your hormones. Just be safer,’ ” she says, becoming so indignant that she pounds the table for emphasis. “But we don’t say to a kid about to touch a hot stove, ‘Here, let me show you how to do that safely.’ We don’t say, ‘Just smoke the cigarette with the lowest nicotine.’ We don’t send that mixed message with anything other than sex.”
Many religious organizations, particularly local Catholic churches, share Appling’s views. But not all. “I think that’s just sticking your head in the sand,” says Leslie Ross, director of religious education for the First Unitarian Society of Madison. “Children are sexual beings. It’s a part of who we are.” Ross’ church offers a yearlong course in sexuality and relationships for eighth-graders that tackles everything from happy marriages to discrimination against gays to the use of contraceptives and barrier devices to STDs. “We encourage youth to wait,” Ross says. “But at the same time we know that many of them won’t. So we also give them all the information they need to protect themselves.”
Those who work with the inner-city populations most at risk from STDs say that too often, advocates for one side or the other forget the complex realities and barriers facing people different than them. “It seems like STDs and teen pregnancy should be simple, right? It’s just about having sex or not. Or about using condoms or not. But it’s easier or harder to exercise individual responsibility depending on your context,” points out Dr. Geoffrey Swain, an associate professor of family medicine at the University of Wisconsin School of Medicine & Public Health and chief medical officer for the city of Milwaukee’s Health Department.
“If you live in a suburban family and grew up with lots of resources, and all your siblings went to college and your parents are connected to you and you have a great future in front of you, it’s a lot easier to make good decisions than if you grew up in poverty in a neighborhood where hardly anybody can get a job or goes to college,” Swain says. “This is not an excuse. But it’s a lot harder for people in these neighborhoods to have the kind of hope that leads them to defer gratification and make good decisions for the future.”
Appling is not persuaded by these arguments. “Call me a dinosaur,” she says, “but sex used to be taught as appropriate to marriage, and the result of it is a baby. Were there students having sex back then? Yeah, and everybody knew it. But nobody was handing out condoms in school. We didn’t have sexually transmitted diseases off the charts.”
Could more casual sex among young people help explain the increase in teen pregnancy and STD rates? “The numbers aren’t necessarily there,” says Foldy, the state health officer.
Over the past decade or so, Wisconsin’s Youth Behavioral Risk Surveys have found that the number of kids who say they have had sex has mostly hovered around 40 to 45 percent. (This figure, though, is of kids who self-report their sexual activities, so the actual rates are probably higher, local experts say.)
While there is no hard data to support an explosion in sexual activity among young people, there is plenty of anecdotal evidence to suggest that the nature of relationships is changing, and that this shift could contribute to an increase in more casual and risky sexual behaviors among young people.
In interviews, 10 high school and college students describe a culture in which they felt pressured to just “get it over with,” in the words of one girl, a senior in a Madison area high school.
“By junior year, 90 percent of kids had had sex,” agrees one recent graduate of a Madison high school, who is in college now. “Especially for guys, there was HUGE pressure to have sex. It was a real sore spot for me. I didn’t have sex until the summer after my senior year. I would have been made fun of relentlessly if people knew.”
Instead of dating and going steady, more high school students talk about “hookups,” casual encounters or flings that encompass anything from heavy petting to oral sex to vaginal sex. No longer do relationships progress from flirting to dating to kissing to petting to going steady to sex. These days, sex can happen first, and then maybe a relationship.
“I always wanted to not be a virgin. It just didn’t seem like a big deal,” says one area high school female. “Sexual freedom is great.”
Some public health and school nurses and social workers see the shift, too. “I do agree that among some young people sex seems more casual. It is a different thing,” says public health nurse Hussey. “It is very clear that there is just a sexual hookup. There is no long-term commitment. There isn’t that emotional connection.”
In eight years as a social worker at West High School, Michelle Marking says she, too, has observed this trend. “Nobody talks about STDs or pregnancy or broken hearts,” she says.
Yet some students rave about what they see as one of the perks of this changing culture — “friends with bennies.”
“I’ve had friends with benefits,” says a young man who graduated from a Dane County high school last year. “It’s a sexual relationship with all the good and none of the bad. No emotional phone calls at two in the morning. You don’t have to go out of your way to hang out together. You don’t have the awkward breakups.”
Plus, it’s economical, he says. “A romantic relationship is work and it costs money. There’s Christmas, and Valentine’s, and then a birthday to worry about.”
Several girls report they feel less enthusiastic about the arrangement, mostly because it’s hard for them not to become emotionally involved. “At first I hooked up with him, and it all went according to plan,” says a local high school student who decided to have sex with a friend, no strings attached. “But then I found out he had feelings for me. So I got feelings for him. But then he changed. And it was not so easy for me to change. I have cried so much over this boy.”
Some medical professionals say this trend worries them. “This whole thing about friends with benefits, that’s news and that’s disturbing because it implies that it is casual sex — you don’t have to love someone to have sexual relations. I don’t think young people realize the risks involved, one of which, of course, is STIs,” says Dr. Gregory Landry, a practicing pediatrician and professor of pediatrics and adolescent medicine at UW’s School of Medicine and Public Health.
Among the most serious of these risks are ones health educator Benson was talking about the other night at the Juvenile Detention Center. On a previous visit, the kids had so many questions about HIV and AIDS that Benson decided they needed more information about them — an observation that jibes with a recent state report that found that only 40 percent of teens surveyed in 2007 had talked about the risk of HIV with an adult member of their family; 15 years ago that number was 65 percent.
Benson shows the teenagers, many of whom are minorities, a short movie about a black girl in Chicago who becomes infected with HIV after she has unprotected sex for the first time with a young man who then dumps her. Then she asks the kids what they think about the movie. Many are stunned at the possibility that just one sexual encounter can have such deadly consequences. Their reaction underscores the feeling of invincibility young people have that educators say is a key challenge in getting them to take the risks of sexual activity seriously. In a recent survey, only 8 percent of Dane County high school students said they thought they faced a serious risk of contracting an STD — even though state and federal data now show that at least one out of five Americans will contract at least one infection in his or her lifetime. And many of the kids Benson is talking to face an even higher risk than that: African-Americans represent 12 percent of the U.S. population but half of the syphilis and chlamydia cases, and 71 percent of gonorrhea infections.
Benson demonstrates how the teens can protect themselves by using latex condoms. Surveys show that up to 40 percent of sexually active Wisconsin teens fail to use condoms, and Benson worries that even teens who do use them fail to use them correctly. At each step of the way, she elicits questions from the kids. “Is it OK to keep your condom in your wallet?” (Not for more than one evening, since it could get worn out.) “Is it OK to open the package with your teeth?” (No, because you might rip the condom, too.) She takes the condom out of the box and pulls it over the penile model. “Why do you leave it a little bit loose at the end?” she asks. “So there’s room to ejaculate!” a student correctly responds. Everyone listens and watches intently. There is little snickering.
Questions betray the mix of sexual experiences, naïveté and ignorance that Bohan says is typical of this age, poised precariously between childhood and adulthood. One young man asks if oral sex is safe when it comes to STDs, a common myth among young people. It is not. “If you pee on somebody, will she get AIDS?” another boy asks. “Can’t you just use Saran Wrap for a condom?” asks another. This question and a couple of others reveal another barrier educators say teens face: getting access to and affording protective devices, birth control and medical care. A young man who has been listening intensely raises his hand. After much hemming and hawing, he asks if there are classes where “the dude and the girl who got a baby can go to learn to breathe when she has the baby.” Later, as he leaves the class, he thanks Benson for coming. “I’ll be a lot safer now,” he says.
Benson watches the young man head down the hall to his cell. Nobody really knows if he will be safer in the future, she says, but she sure hopes so.
“I’m very passionate about what I do,” she says. “Young people are going to have sex no matter what we do. We’ve got to protect them. STDs are an epidemic. If we had swine flu at the same rates, we’d be at a stage of national emergency.”