Teenage Girls Attending a Dublin Sexually Transmitted Disease Clinic: A Socio-Sexual and Diagnostic Profile C. Fitzpatrick *~, P. McKenna ~, R. Hone*
*Sexually Transmitted Disease Clinic and Departments of ~Gynaecology and +Medical Microbiology, Mater Misericordiae Hospital, Dublin. Abstract Over a 12 month period, 32 teenage girls attended the sexually transmitted disease clinic in the Mater Misericordiae Hospital Dublin for the first time, accounting for 17.8% of all first visits. Their mean age was 18.2 years (range 15-19 years). Twenty-four (75%) were from social class V. Five (15.6%) were abusing drugs. The mean age of first coitus was 16.1 years (range 13-19 years). The mean number of sexual partners was 1.8 (range 1-5). Four (12.5%) had been sexually abused in the past. Fourteen (43.8%) had never used contraception. Twenty-three (71.9%) were nulligravidae: 2 were diagnosed as being pregnant in the clinic. Twelve (37.5%) were unaware of cervical cytology screening. Of 29 having intercourse without condoms, none considered themselves to be at risk of contracting HIV from their present partner. A total of 26 diagnoses were made in 23 patients (71.9%). The most common diagnosis was ano-genital condylomata acuminata (6, 18.8%); Chlamydia trachomatis was located in 2 patients and Neisseria gonorrhoea in one. Mild to moderate dyskaryosis was reported in 4 cervical smears (12.5 %). This data highlights the need for priority targeting of this high risk group. TABLE I Standard microbiological diagnostic techniques used in this study.
Introduction In 1983 Catteralla stated that accurate figures were not available for the incidence of sexually transmitted diseases (STD) in the Republic of Ireland, and furthermore added that the size of the problem was grossly underestimated. Although notification has improved considerably since then, very little has been written to date about the problem of teenagers attending STD clinics in this country. In Northern Ireland, Maw et al 2 reportM that 20.7% of all fem',des attending STD clinics were under 20 years, 1.5% being under 15 years. Due to urbanization, changing sexual mores and early menarche, teenage girls are increasingly promiscuous 3. A rise in the incidence of pelvic inflammatory disease (PIE))4 and CIN s has been reported in this age group.
Site
Organism Wet Prep.
Urethra Neisaeria gonorrhoea
Gram Transport Culture Stain Medium +
Urethra Chlamydia trachomatis
Patients and Methods Over a 12 month period, 180 females attended the STD clinic in the Mater Misericordiae Hospital, Dublin for the first time. Thirty-two (17.8%) were under 20 years of age. A comprehensive genito-urinary and sexual history were obtained from each attender. In addition a genito-pelvic examination was performed. Routine investigations included microscopy of urethral, vaginal and cervical specimens (Table 1), cervical cytology and serological testing for syphilis. HIV testing was performed, if requested and indicated, after fuU counselling. Sexual contacts were traced and treated where appropriate.
+
Vagina Candida
+
Vagina G ardnerella vaginalis Vagina Trichornonas + vaginalis Cervix Neisseria gonorrhoea Cervix Chlamydia traehomatis
+
+ +
Modified New York City Medium Cycloheximide treated McCoy ceils Potato Dextrose Agar Gardnerelta Agar Trichomonas Medium Modified New City Medium Cycloheximide treated McCoy ceils
friends, 2 with other friends; 2 were in residential care, 2 were in prison and one girl lived alone. Twenty (63.5%) referred themselves to the clinic without prior professional consultation; 5 were referred by sexual contacts, 4 by doctors and 3 by social workers. Twenty-five (78.1%) attended the clinic on their own, 4 attended with a female friend, 2 with a boyfriend and one with her mother. Twenty-four (75%) were from social class V. The social classification of the others was: 5 (IV), 2 (III), 1 (fl)." Eight patients were employed; 3 were attending second level
Results The mean age of female teenager attenders was 18.2 years (range 15-19 years); 3 were under 17 years. All were from the Republic of Ireland; 31 (95.5%) were from the Eastern Health Board catchment area; 22 (68.8%) were fi'om Dublin. All were unmarried. Twenty-two (68.8%) lived with parents, 3 with boy460
Vol. 161 No. 7 education and 2 were attending third level education. Nineteen (59.4%) had completed their education and were unemployed. Of these 12 had never bccn employed, 7 had no educational certificates and 6 had no second level education. Twenty-four (75%) smoked cigarettes; 4 smoked more than 10 per day. Twenty-six (81.3%) drank alcohol; 15 said that they had unprotected intercourse at least on one occasion when drunk. Five (15.6%) were abusing drugs: benzediazepines (1), cannabis (3) and heroin (1). All were4~eterosexual and sexually active. The mean age of first'coitus was 16.1 years (range 13-19); eight (25%) were Under 16 years. The mean number of sexual partners was 1.8 (range 1-5); 14 (43.8%) had m o ~ than one sexual partner to date. Four (12.5%) had been sexually abused in the past, it being incestuous in one case. All denied prostitution. Fourteen girls (43.8%) had never used contraception. Contraceptive practices among the others included: confined oral contraceptive pill (8), condoms (3), coitus interruptus (3) and depot progestagen (1). Of these 18, 15 said they had unprotected intercourse on at least one occasion. Six girls (18.8%) objected to condoms: 8 said that their partners objected: this objection was present in 12 couples. Eighteen (56.3%) said that they had never discussed the subject of contraception with their boyfriends: 20 (62.5%) had never discussed the subject with a doctor. Twentyseven (84.4%) had never discussed their sexual activity with either one of their parents. Twenty-three (71.9%) were nuiligravidae; 2 had undergone a previous abortion; 2 were diagnosed as being pregnant in the clinic anal 2 had a single infant each. Seven (21.9%) had previously attended a doctor or nurse for a cervical smear; 12 (37.5%) were unaware of cervical cytology screening. Of 29 girls having intercourse without condoms, none considered themwselves to be at risk of contracting HIV from their present partner. Four (12.5%) had HIV testing in the clinic, the indications being sexual abuse (3), and heroin abuse (1). All tests were negative. A total of 26 diagnoses were made in 23 patients (71.9%), as shown in Table II. The most common diagnosis was ano-genital condylomata acuminata, found in 6 (18.8%). Chlamydia traehomatis was isolated in 2 patients (6.3%) and Neisseria gonorrhoea in 1 patient (3.1%); 2 of these 3 patients were asymptomatic. Candida species and gardnerella vaginalis were isolated in 7 patients; all were symptomatic and were accordingly treated. PID was diagnosed in 1 patient on the basis of history and clinical findings; no causative organism was, however, identified on lower genital tract microbiological sampling. As this patient responded rapidly to appropriate antimicrobial therapy, diagnostic laparoscopy was not performed. Syphilis serology was negative in all cases. Mild to moderate dyskaryosis was reported in 4 cervical smears (12.5%) and colposcopy was arranged in these cases. In addition 4 smears were reported as having inflammatory changes. All had proven microbiological infection and the repeat smears after treat-
Teenage Girls attending a Dublin STD Clinic 461 TABLE Ii Microbiological diagnoses made in 32 teenage girls attending a Dublin STD clinic. Organism
Site
HPV Candida
ano-genital vagina
Gardnarella vaginalis Chlamydia trachomafis Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis Pediculosis pubis
Clinical Presentation
Number 6 (18.8%) 4 (12.5%)
vagina
warts vaginitis/ vulvitis vaginosis
cervix
asymptomatic
2 (6.3%)
urethra
urethritis
1 (3.1%)
cervix
asymptomatic
1
vagina
"~aginitis
1
pubic hair
itch/nits
1
3 (9.4%)
ment were reported as normal. Where appropriate, referrals were made for expert counselling regarding contraception, pregnancy, sexual abuse and drug abuse.
Discussion Mulcahy and Lacey6 studied 210 adolescent girls in residential care in Leeds between 1978 and 1985 (mean age 14.1 years; range 12-16 years). The incidence of Neisseria gonorrhoea, Chlamydia trachomatis and Trichomonas vaginalis was 13.7%, 16.3% and 16% respectively. The incidence of condylomata acuminata and herpes genitalis was 5.7% in each case. Two of the 12 patients with condylomata acuminata were subsequently noted to have dyskaryotic smears. Routine cervical cytology was not performed in this study but was recommended in future for sexually active female adolescents. The incidence of prostitution was 22.4%, the incidence of sexual abuse was 3.3%. The authors concluded that the risk factors for STD were early age of coitarche, poverty and a history of prostitution and sexual abuse. Oar smaller Dublin study differs from the Leeds study in several features; these include: only 3 girls less than 17 years of age, a small minority in residential care or prison, a lower incidence of Neisseria gonorrhoca, Chlamydia trachomatis and Trichomonas vaginalis, no case of herpes genitalis, a higher incidence of condylomata acuminata, a higher incidence of sexual abuse, no ~ecord of prostitution, TABLE Iil Other diagnoses made in 32 teenage girls attending a Dublin STD clinic. Diagnosis
Number
Mildhnoderate cervical dyskaryosis Pregnancy PID - no organism identified
4 (12.5%) 2 (6.2%) 1 (3.1%)
462
Fitzpatrick et al.
and the performance of routine cervical cytology in all patients. As in the Leeds study, the majority of attenders in the Dablin clinic were from low socio-economic backgrounds with the additional disadvantage of poor educational achievement and unemployment. Early age of coitarche, multiple sexual parmers, nonbarrier contraception, cigarette smoking and HPV infection are well recognised aetiological factors for CIN and pose a significant risk for the teenage girls in this study. Although 12.5% had abnormal cytology in this study, 37.5% were totally unaware of cervical cytology screening. In addition there ;,vasa strong reluctance to use condoms by both males and females. In an earlier study of 200 unmarried mothers, many of whom were teenagers, Powell et al7 reported that 131 had no understanding of their menstrual cycle and 110 had never used contraception. In addition 54 females and 69 males were under the influence of alcohol at the thne of conception. A high rate of unprotected and aIcoholrelated coitus was also found in our study. Up to recent years child sexual abuse was rarely reported in Ireland~. In a study of alleged sexual abuse in the Eastern Health Board area during the period 1986-19879, it was found that girls were more likely to be abused than boys at all ages, particularly during their teenage years. This problem may be significantly underestimated in the Irish teenage girls attending STD clinics. No patient in the Dublin study admitted to prostitution. This may represent both a failure of Irish prostitutes to attend STD clinics and their extreme reluctance to discuss their practiceto. Since 1979 there has been an alarming increase in intravenous drug abuse in Dublin with a significant incidence of HIV seropositivity among abusersn.t2. Female abusers may be forced by circumstances into prostitution. To-date this clinic has not succeeded in attracting a significant number of individuals from these high risk categories for screening, treatment and counselling. In a recent study of leaving certificate students in Galway 13, 81% believed that avoiding casual sex could prevent the spread of HIV infection and 78% believed that condoms provided some protection against transmission. The vast majority of attenders in our clinics were unaware of the risk of HIV infection or methods of prevention. This
LJ.M.S. July, 1992
undoubtedly reflected their lower educational achievements and inability or unwillingness to discuss their sexual problems with boyfriends, parents or health professionals. Clearly this high risk group requires priority targeting by STD and allied services. Larger studies involving both sexes are required. As teenager attendanceat STD clinics may represent only a small minority of sexually active teenagers, parents, teachers, health workers and the media must redouble their efforts to educate all adolescents regarding the risks of both casual and unprotected sex. Acknowledgement We wish to acknowledge the technical assistance of Ms. Linda Dyke in this paper. References 1. Catterall, R. D. Sexually transmitted diseases in the Republic of ireland. Br. L Verier. Dis. 1983: 59, 66-7. 2. Maw, R,, Dinsmore, W., Montgomery, H., Eskin, H., Homer, T. Sexually transmitted disease in Northern Ireland. It. Med. J. 1986: 70, 314-7. 3. Zelnik, M., Kartner, J. F. Sexual active, contraceptive use and pregnancy among metropolitan teenagers 1971-1979. Faro. Plann. Perspect. 1980: 12, 230-7. 4. Mardh, P.-A, R~.pa, T., Svensson, L., Westrom, L. Chlamydla ttachomatis infection in patients with acute salpingitis. N. Engl. J. Med. 1975: 296, 137-9. 5. Hein, K., Scheiber, K., Cohen, M., Koss, L. G. Cervical cytology: the need for routine screening in sexually active adults. J. Pediatr. 1977: 91, 123 6. 6. Mulcahy, F. M., Lacey, C. J. Sexually transmitted infections in adolescent girls. Genitoufin. Med. 1987: 63, 119-21. 7. Powell, B., Dockeray, J., Swaine, E. Unmarried mothers: a survey of 200 presenting for antenatal care. Ir. Med. L 1982: 75, 248-9. 8. llensey, O. Child sexual abuse; Cleveland - Irish implications. Ir. Med. J. 1988: 81, 3-4. 9. Hynes, M., Jennings, S. Community notification of child sexual abuse. IX. Med. J. 1989: 82, 115-7. 10. Fitzpatrick, C., Coughlan, B. M., Hamill, R., Colclough, M., Carey, 0. Prostitutes and screening for STD. Ir. Med. J. 1989: 82, 180. 11. Dean, G., O'Hare, A., Kelly, M. G., Kelly, G. The opiate epidemic in Ireland. It, Med. J. 1985: 76, 107-10. 12. O'Btiain, D. S., Jackson, F., Courmey, M. G., O'Malley, F., McDonald, G. S., Mulvihill, E. M., Dinn, L J., Temperley, I. J., Mulcahy, F. The emerging AIDS epid emic in Ireland - Clinicopathological findings in 23 early cases. Ir. Med. J. 1990: 83, 50-3. 13. Fogarty,J. Kn~176176 students' Ix. Med. J. 1990: 83, 19-21.
*Sexually Transmitted Disease Clinic and Departments of ~Gynaecology and +Medical Microbiology, Mater Misericordiae Hospital, Dublin. Abstract Over a 12 month period, 32 teenage girls attended the sexually transmitted disease clinic in the Mater Misericordiae Hospital Dublin for the first time, accounting for 17.8% of all first visits. Their mean age was 18.2 years (range 15-19 years). Twenty-four (75%) were from social class V. Five (15.6%) were abusing drugs. The mean age of first coitus was 16.1 years (range 13-19 years). The mean number of sexual partners was 1.8 (range 1-5). Four (12.5%) had been sexually abused in the past. Fourteen (43.8%) had never used contraception. Twenty-three (71.9%) were nulligravidae: 2 were diagnosed as being pregnant in the clinic. Twelve (37.5%) were unaware of cervical cytology screening. Of 29 having intercourse without condoms, none considered themselves to be at risk of contracting HIV from their present partner. A total of 26 diagnoses were made in 23 patients (71.9%). The most common diagnosis was ano-genital condylomata acuminata (6, 18.8%); Chlamydia trachomatis was located in 2 patients and Neisseria gonorrhoea in one. Mild to moderate dyskaryosis was reported in 4 cervical smears (12.5 %). This data highlights the need for priority targeting of this high risk group. TABLE I Standard microbiological diagnostic techniques used in this study.
Introduction In 1983 Catteralla stated that accurate figures were not available for the incidence of sexually transmitted diseases (STD) in the Republic of Ireland, and furthermore added that the size of the problem was grossly underestimated. Although notification has improved considerably since then, very little has been written to date about the problem of teenagers attending STD clinics in this country. In Northern Ireland, Maw et al 2 reportM that 20.7% of all fem',des attending STD clinics were under 20 years, 1.5% being under 15 years. Due to urbanization, changing sexual mores and early menarche, teenage girls are increasingly promiscuous 3. A rise in the incidence of pelvic inflammatory disease (PIE))4 and CIN s has been reported in this age group.
Site
Organism Wet Prep.
Urethra Neisaeria gonorrhoea
Gram Transport Culture Stain Medium +
Urethra Chlamydia trachomatis
Patients and Methods Over a 12 month period, 180 females attended the STD clinic in the Mater Misericordiae Hospital, Dublin for the first time. Thirty-two (17.8%) were under 20 years of age. A comprehensive genito-urinary and sexual history were obtained from each attender. In addition a genito-pelvic examination was performed. Routine investigations included microscopy of urethral, vaginal and cervical specimens (Table 1), cervical cytology and serological testing for syphilis. HIV testing was performed, if requested and indicated, after fuU counselling. Sexual contacts were traced and treated where appropriate.
+
Vagina Candida
+
Vagina G ardnerella vaginalis Vagina Trichornonas + vaginalis Cervix Neisseria gonorrhoea Cervix Chlamydia traehomatis
+
+ +
Modified New York City Medium Cycloheximide treated McCoy ceils Potato Dextrose Agar Gardnerelta Agar Trichomonas Medium Modified New City Medium Cycloheximide treated McCoy ceils
friends, 2 with other friends; 2 were in residential care, 2 were in prison and one girl lived alone. Twenty (63.5%) referred themselves to the clinic without prior professional consultation; 5 were referred by sexual contacts, 4 by doctors and 3 by social workers. Twenty-five (78.1%) attended the clinic on their own, 4 attended with a female friend, 2 with a boyfriend and one with her mother. Twenty-four (75%) were from social class V. The social classification of the others was: 5 (IV), 2 (III), 1 (fl)." Eight patients were employed; 3 were attending second level
Results The mean age of female teenager attenders was 18.2 years (range 15-19 years); 3 were under 17 years. All were from the Republic of Ireland; 31 (95.5%) were from the Eastern Health Board catchment area; 22 (68.8%) were fi'om Dublin. All were unmarried. Twenty-two (68.8%) lived with parents, 3 with boy460
Vol. 161 No. 7 education and 2 were attending third level education. Nineteen (59.4%) had completed their education and were unemployed. Of these 12 had never bccn employed, 7 had no educational certificates and 6 had no second level education. Twenty-four (75%) smoked cigarettes; 4 smoked more than 10 per day. Twenty-six (81.3%) drank alcohol; 15 said that they had unprotected intercourse at least on one occasion when drunk. Five (15.6%) were abusing drugs: benzediazepines (1), cannabis (3) and heroin (1). All were4~eterosexual and sexually active. The mean age of first'coitus was 16.1 years (range 13-19); eight (25%) were Under 16 years. The mean number of sexual partners was 1.8 (range 1-5); 14 (43.8%) had m o ~ than one sexual partner to date. Four (12.5%) had been sexually abused in the past, it being incestuous in one case. All denied prostitution. Fourteen girls (43.8%) had never used contraception. Contraceptive practices among the others included: confined oral contraceptive pill (8), condoms (3), coitus interruptus (3) and depot progestagen (1). Of these 18, 15 said they had unprotected intercourse on at least one occasion. Six girls (18.8%) objected to condoms: 8 said that their partners objected: this objection was present in 12 couples. Eighteen (56.3%) said that they had never discussed the subject of contraception with their boyfriends: 20 (62.5%) had never discussed the subject with a doctor. Twentyseven (84.4%) had never discussed their sexual activity with either one of their parents. Twenty-three (71.9%) were nuiligravidae; 2 had undergone a previous abortion; 2 were diagnosed as being pregnant in the clinic anal 2 had a single infant each. Seven (21.9%) had previously attended a doctor or nurse for a cervical smear; 12 (37.5%) were unaware of cervical cytology screening. Of 29 girls having intercourse without condoms, none considered themwselves to be at risk of contracting HIV from their present partner. Four (12.5%) had HIV testing in the clinic, the indications being sexual abuse (3), and heroin abuse (1). All tests were negative. A total of 26 diagnoses were made in 23 patients (71.9%), as shown in Table II. The most common diagnosis was ano-genital condylomata acuminata, found in 6 (18.8%). Chlamydia traehomatis was isolated in 2 patients (6.3%) and Neisseria gonorrhoea in 1 patient (3.1%); 2 of these 3 patients were asymptomatic. Candida species and gardnerella vaginalis were isolated in 7 patients; all were symptomatic and were accordingly treated. PID was diagnosed in 1 patient on the basis of history and clinical findings; no causative organism was, however, identified on lower genital tract microbiological sampling. As this patient responded rapidly to appropriate antimicrobial therapy, diagnostic laparoscopy was not performed. Syphilis serology was negative in all cases. Mild to moderate dyskaryosis was reported in 4 cervical smears (12.5%) and colposcopy was arranged in these cases. In addition 4 smears were reported as having inflammatory changes. All had proven microbiological infection and the repeat smears after treat-
Teenage Girls attending a Dublin STD Clinic 461 TABLE Ii Microbiological diagnoses made in 32 teenage girls attending a Dublin STD clinic. Organism
Site
HPV Candida
ano-genital vagina
Gardnarella vaginalis Chlamydia trachomafis Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis Pediculosis pubis
Clinical Presentation
Number 6 (18.8%) 4 (12.5%)
vagina
warts vaginitis/ vulvitis vaginosis
cervix
asymptomatic
2 (6.3%)
urethra
urethritis
1 (3.1%)
cervix
asymptomatic
1
vagina
"~aginitis
1
pubic hair
itch/nits
1
3 (9.4%)
ment were reported as normal. Where appropriate, referrals were made for expert counselling regarding contraception, pregnancy, sexual abuse and drug abuse.
Discussion Mulcahy and Lacey6 studied 210 adolescent girls in residential care in Leeds between 1978 and 1985 (mean age 14.1 years; range 12-16 years). The incidence of Neisseria gonorrhoea, Chlamydia trachomatis and Trichomonas vaginalis was 13.7%, 16.3% and 16% respectively. The incidence of condylomata acuminata and herpes genitalis was 5.7% in each case. Two of the 12 patients with condylomata acuminata were subsequently noted to have dyskaryotic smears. Routine cervical cytology was not performed in this study but was recommended in future for sexually active female adolescents. The incidence of prostitution was 22.4%, the incidence of sexual abuse was 3.3%. The authors concluded that the risk factors for STD were early age of coitarche, poverty and a history of prostitution and sexual abuse. Oar smaller Dublin study differs from the Leeds study in several features; these include: only 3 girls less than 17 years of age, a small minority in residential care or prison, a lower incidence of Neisseria gonorrhoca, Chlamydia trachomatis and Trichomonas vaginalis, no case of herpes genitalis, a higher incidence of condylomata acuminata, a higher incidence of sexual abuse, no ~ecord of prostitution, TABLE Iil Other diagnoses made in 32 teenage girls attending a Dublin STD clinic. Diagnosis
Number
Mildhnoderate cervical dyskaryosis Pregnancy PID - no organism identified
4 (12.5%) 2 (6.2%) 1 (3.1%)
462
Fitzpatrick et al.
and the performance of routine cervical cytology in all patients. As in the Leeds study, the majority of attenders in the Dablin clinic were from low socio-economic backgrounds with the additional disadvantage of poor educational achievement and unemployment. Early age of coitarche, multiple sexual parmers, nonbarrier contraception, cigarette smoking and HPV infection are well recognised aetiological factors for CIN and pose a significant risk for the teenage girls in this study. Although 12.5% had abnormal cytology in this study, 37.5% were totally unaware of cervical cytology screening. In addition there ;,vasa strong reluctance to use condoms by both males and females. In an earlier study of 200 unmarried mothers, many of whom were teenagers, Powell et al7 reported that 131 had no understanding of their menstrual cycle and 110 had never used contraception. In addition 54 females and 69 males were under the influence of alcohol at the thne of conception. A high rate of unprotected and aIcoholrelated coitus was also found in our study. Up to recent years child sexual abuse was rarely reported in Ireland~. In a study of alleged sexual abuse in the Eastern Health Board area during the period 1986-19879, it was found that girls were more likely to be abused than boys at all ages, particularly during their teenage years. This problem may be significantly underestimated in the Irish teenage girls attending STD clinics. No patient in the Dublin study admitted to prostitution. This may represent both a failure of Irish prostitutes to attend STD clinics and their extreme reluctance to discuss their practiceto. Since 1979 there has been an alarming increase in intravenous drug abuse in Dublin with a significant incidence of HIV seropositivity among abusersn.t2. Female abusers may be forced by circumstances into prostitution. To-date this clinic has not succeeded in attracting a significant number of individuals from these high risk categories for screening, treatment and counselling. In a recent study of leaving certificate students in Galway 13, 81% believed that avoiding casual sex could prevent the spread of HIV infection and 78% believed that condoms provided some protection against transmission. The vast majority of attenders in our clinics were unaware of the risk of HIV infection or methods of prevention. This
LJ.M.S. July, 1992
undoubtedly reflected their lower educational achievements and inability or unwillingness to discuss their sexual problems with boyfriends, parents or health professionals. Clearly this high risk group requires priority targeting by STD and allied services. Larger studies involving both sexes are required. As teenager attendanceat STD clinics may represent only a small minority of sexually active teenagers, parents, teachers, health workers and the media must redouble their efforts to educate all adolescents regarding the risks of both casual and unprotected sex. Acknowledgement We wish to acknowledge the technical assistance of Ms. Linda Dyke in this paper. References 1. Catterall, R. D. Sexually transmitted diseases in the Republic of ireland. Br. L Verier. Dis. 1983: 59, 66-7. 2. Maw, R,, Dinsmore, W., Montgomery, H., Eskin, H., Homer, T. Sexually transmitted disease in Northern Ireland. It. Med. J. 1986: 70, 314-7. 3. Zelnik, M., Kartner, J. F. Sexual active, contraceptive use and pregnancy among metropolitan teenagers 1971-1979. Faro. Plann. Perspect. 1980: 12, 230-7. 4. Mardh, P.-A, R~.pa, T., Svensson, L., Westrom, L. Chlamydla ttachomatis infection in patients with acute salpingitis. N. Engl. J. Med. 1975: 296, 137-9. 5. Hein, K., Scheiber, K., Cohen, M., Koss, L. G. Cervical cytology: the need for routine screening in sexually active adults. J. Pediatr. 1977: 91, 123 6. 6. Mulcahy, F. M., Lacey, C. J. Sexually transmitted infections in adolescent girls. Genitoufin. Med. 1987: 63, 119-21. 7. Powell, B., Dockeray, J., Swaine, E. Unmarried mothers: a survey of 200 presenting for antenatal care. Ir. Med. L 1982: 75, 248-9. 8. llensey, O. Child sexual abuse; Cleveland - Irish implications. Ir. Med. J. 1988: 81, 3-4. 9. Hynes, M., Jennings, S. Community notification of child sexual abuse. IX. Med. J. 1989: 82, 115-7. 10. Fitzpatrick, C., Coughlan, B. M., Hamill, R., Colclough, M., Carey, 0. Prostitutes and screening for STD. Ir. Med. J. 1989: 82, 180. 11. Dean, G., O'Hare, A., Kelly, M. G., Kelly, G. The opiate epidemic in Ireland. It, Med. J. 1985: 76, 107-10. 12. O'Btiain, D. S., Jackson, F., Courmey, M. G., O'Malley, F., McDonald, G. S., Mulvihill, E. M., Dinn, L J., Temperley, I. J., Mulcahy, F. The emerging AIDS epid emic in Ireland - Clinicopathological findings in 23 early cases. Ir. Med. J. 1990: 83, 50-3. 13. Fogarty,J. Kn~176176 students' Ix. Med. J. 1990: 83, 19-21.
