Sexuality Research and Social Policy

https://doi.org/10.1007/s13178-021-00591-w

Sexual Behavior: Challenges for Prevention and Control Among

Medical Students in Mexico
Juan Carlos Ibarrola‑Peña1 · Roberto Carlos Miranda‑Ackerman1 · Yolanda Lorelei Almanza‑Mena1 ·
Francisco José Barbosa‑Camacho2 · Martín López‑Zendejas1 · Maura Patricia López‑Reynoso1 ·
Miguel Ángel Bonaparte‑Pimentel1 · Francisco Javier Warren‑Cano1 · Rafael Zaragoza‑Organista1 ·
Ana Olivia Cortés‑Flores1 · Clotilde Fuentes‑Orozco2 · Alejandro González‑Ojeda2 

Accepted: 13 May 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Introduction  In Mexico, sexually transmitted diseases (STDs) are the fifth-leading reason to seek medical guidance. Among
people aged 15–44 years, STDs are ranked among the top 10 causes of general morbidity.
Methods  This was a descriptive cross-sectional study conducted at a private university in Mexico from December 2019 to
January 2020. A total of 519 surveys were completed by medical students aged 18–24 years (mean age, 19.9 years). The
questionnaire asked whether students considered that they had adequate knowledge about STDs, age at sexual intercourse
onset, sexual behavior, sexual orientation, use of condoms and contraceptives, and reasons for not seeking STD screening.
Results  About one-third (169, 32.7%) reported having insufficient knowledge about STD prevention, 373 students (71.8%)
were sexually active; of those, 61.7% (230 students) had never had STD screening, and 116 female students (52.5%) had never
had a cervical smear. Most students with an active sexual life (229, 61.4%) reported using condoms for all sexual intercourse.
Conclusions  These findings show that half of the young adult population in Mexico becomes sexually active in their teens.
A large percentage considers that they have insufficient knowledge about STDs.
Policy Implications  In Mexico, a large sexually active population does not seek STD screening. Educators should be encour-
aged to include information about sexual activity in early education courses to ensure healthier sexual outcomes in coming
generations.
Trial Registration  ClinicalTrials.gov identifier NCT04417426

Keywords  Epidemiology · Medical students · Public health · Sexual intercourse · Sexually transmitted diseases

Introduction (Céspedes Gamboa et  al., 2017). STDs strongly affect

The classification of sexually transmitted diseases (STDs)
follows the method of transmission as acquired through sex-
ual contact: vaginal, anal, or oral. STDs have been a serious
global public health concern, as acknowledged since ancient
times by writers such as Plato, Aristotle, and Hippocrates
* Alejandro González‑Ojeda
avygail5@gmail.com
1
Hospital San Javier, Jalisco, Guadalajara, Mexico
2
Unidad de Investigación Biomédica 02, Hospital de
Especialidades, Centro Médico Nacional de Occidente,
Instituto Nacional del Seguro Social, Belisario
Domínguez Avenue #1000. Col. Independencia,
Jalisco 44340 Guadalajara, Mexico
emerging countries that lack a solid health program, such
as most Latin American countries, where the health of the
young population can be affected by the lack of information,
resources, and interest.
STDs should be a topic of special interest for preventive
medicine and epidemiology because these diseases spread
rapidly and have high rates of mortality and complications;
in addition, a high percentage of infected people are asymp-
tomatic (Nelson et al., 2010). Most types of STDs can be
treated, and their complications prevented with early diag-
nosis and treatment. However, the prevalence remains high
in Latin American countries such as Mexico. The conse-
quences of STDs can include infertility caused by chlamydia
infection, regional disfigurement caused by lymphogranu-
loma venereum, secondary or tertiary manifestations of

13
Vol.:(0123456789)

syphilis, and the devastating effects of the human immuno-
deficiency virus (HIV) on individuals and their communities
(Subramanian et al., 2020). According to the 2012 UNAIDS
Report on the Global AIDS Epidemic, more than 34 million
people living with HIV worldwide, half of whom do not
know their actual serological status. In addition, as of 2019,
2.5 million people have been diagnosed, and 32.7 million
people have died of AIDS (UNAIDS, 2020).
STDs are often spread through condomless sexual contact
(i.e., no use of a barrier protection method). However, STDs can
spread even with the use of barrier protection because areas not
covered by a condom can still become infected, for example,
with herpes and syphilis, through skin-to-skin contact. Con-
doms are known not to protect the lower part of the penis, scro-
tum, and labia from these infections (Sánchez-Saldaña, 2014).
In Mexico, STDs are the fifth-leading cause for medi-
cal consultation in primary health care. Among people aged
15–44 years, STDs are ranked among the top 10 causes of
general morbidity (Mexico: Secretaria de Salud, 2009)⁠
Although few epidemiological studies have reported on
STDs in Mexican teenagers, small studies have estimated
the national incidence of STDs. For example, a study of
people aged 15–18 years from marginalized semiurban areas
in Mexico reported the prevalence of herpes simplex virus
type 2 as 9% in men and 4% in women (Cuenca et al., 2013).
In Mexico, an estimated 30% of people aged 18–30 years
are diagnosed with or treated for an STD throughout their
lifetime.
Given these high rates, it is crucial to provide adequate
information and promote preventive measures and screen-
ing awareness to prevent STDs (GeSIDA, 2017). In recent
years, biological and physiological aspects of human sexu-
ality have been incorporated into textbooks. The National
Health System supports most high schools in Mexico to
incorporate sexual orientation into the curriculum. Recent
public policies include the General Law on Girls, Boys, and
Adolescents Rights, approved in 2014, which requires the
inclusion of comprehensive sex education within national
education, as well as the New Educational Model of the
executive summary of the law mentioned above, which was
introduced in early 2017 (Tapia Fonllem, 2018).
A study aiming to identify the current challenges required to
increase university students’ awareness of screening for STDs
found that young people report a lack of parental guidance
about their sexuality (Montes de Oca, 2013), probably because
of notions of “respect” or “shame” within the context of
contemporary culture and social norms. Teenagers and young
adults are at high risk of acquiring STDs because of their early
onset of sexual intercourse, multiple partners, and insufficient
knowledge about STDs (Villafañe-Ferrer & González-Navarro,
2017). In Latin America and the Caribbean, the onset of
an active sex life occurs before age 15 years in 17% of girls,
although this percentage may be higher in some countries;
13
Sexuality Research and Social Policy
for example, one study reported that 84% of adolescents had
initiated sexual activity before age 15 years in Venezuela (Rios-
Becerril et al., 2016). These results are consistent with a Mexi-
can study of medical students at a public university in Mexico
City. The mean age of initiation of sexual activity was 16 years
(Aburto-Arciniega et al., 2020). Therefore, to develop suitable
intervention strategies, it is vital to understand risk behavior and
improve the use of resources to prevent, control, and reduce the
risk of STD acquisition.
Education about family planning to avoid unwanted pregnan-
cies and the prevention of STDs are aspects encompassed within
sex education. However, there seems to be a tendency for young
people to be more likely to take action to prevent pregnancy than
a sexually transmitted disease. In Mexico, the 2012 National
Health and Nutrition Survey, which addressed reproductive
health, reported that 90% of adolescents were aware of contra-
ceptive methods (Aburto-Arciniega et al., 2020). Nevertheless,
according to the Organization for Economic Co-operation and
Development (OECD), Mexico has the highest rate of teen-
age pregnancy: one in five pregnancies in the country involves
young parents aged 15–19 years (Cifuentes et al., 2010). This
suggests that a sizable proportion of young people may lack
understanding of sexual health care. Teachers should be sup-
ported to acquire the knowledge, skills, and confidence to teach
students about sexual health. An Australian study that assessed
sex education programs in middle school (Burns & Hendriks,
2018) emphasized the importance of professional development
and the need for teaching strategies to address developmental
changes, social norms, and new technologies. The authors of
that paper noted that teacher training should also consider the
need for tailored strategies and training to combat the lack of
information in the population.
The objectives of this study were to identify the factors
that motivate students to seek STD screening, describe the
sexual behaviors of Mexican university students, and identify
possible risks and epidemiological challenges to achieving
adequate prevention and control of STDs in this population.
Our ultimate aim is to provide information to Mexican insti-
tutes to help them develop policy recommendations for health
education and promotion among young people. It is important
to increase awareness of the risk of contracting STDs and their
consequences among the general population and to encourage
the regular use of tests for STDs to ensure the effectiveness of
sexual health education in Mexico.
Methods
Study Design
This was a cross-sectional study conducted at a private
university in Guadalajara, Mexico, from December 2019
to April 2020.
Sexuality Research and Social Policy

Sample survey also included questions about the students’ sexual

behavior, such as whether they thought they had sufficient
Convenience sampling was conducted among the total knowledge about STDs, age at sexual intercourse onset,
population of students in their first to the sixth semester number of sexual partners in the past year, the total number
of medical school. A total of 650 students were recruited. of sexual partners, sexual orientation, use of condoms and
Our strategy was to prepare physical copies of the survey contraceptives, exclusive or nonexclusive sexual relation-
and deliver them to the students at the end of lectures ships (e.g., monogamous or non-monogamous sexual rela-
and examinations. To maintain the students’ privacy, we tionships), frequency of STD screening, and whether they
invited them to complete the survey anonymously and knew the location of STD testing centers. The survey was
leave it in a locked black box located at the back of the completed wholly and voluntarily anonymously and was
classrooms. A total of 535 surveys were completed and approved by the university’s ethics committee. The survey
submitted, giving a response rate of 82.3%. We excluded can be found in Supplementary Material A.
16 surveys because of incomplete information and
included 519 surveys in this analysis. The demographic Statistical Analysis
characteristics of the participants are presented in Table 1.
The data were analyzed using IBM SPSS for Windows (ver-
Inclusion and Exclusion Criteria sion 23). Descriptive analyses included percentages, means,
and standard deviations. Inferential analysis was performed
University students currently enrolled in their first through using the Χ2 test, Fisher’s exact probability test, or analy-
the sixth semester in medical school were included. We sis of variance as appropriate for categorical variables, and
excluded young adults who were not attending medical Student’s t test was used to analyze continuous variables. A
school, students not in their first through the sixth semester, p value < 0.05 was considered to be significant.
students who decided not to participate, and those who did
not fully complete the survey.
Results
Survey Instrument
The sample was classified into three groups according to
The survey comprised a questionnaire that included demo- sexual activity and number of partners: 146 students (28.1%)
graphic data such as sex, age, religion, and semester. The with no sexual activity, 183 (35.2%) with < 3 sexual partners
during their lifetime, and 190 (36.60%) with ≥ 3 partners. In
Table 1  Participant demographic information
response to whether students felt they had sufficient informa-
Demographic characteristics tion about STDs, 504 students (97.1%) responded having
Age (years) (mean ± SD) 19.94 ± 1.36
this knowledge, and 15 (2.9%) responded that they were not
Sex, n (%)
informed. In the groups classified according to sexual activ-
Female 325 (62.6%)
ity, 141 students (96.5%) in the no sexual activity group, 181
Male 194 (37.4%)
(98.9%) in the < 3 sexual partners group, and 182 (95.7%)
Semester, n (%)
in the ≥ 3 partners group responded as having sufficient
1st Semester 65 (12.5%)
information.
2nd Semester 50 (9.6%)
In response to whether students felt they had sufficient
3rd Semester 243 (46.8%)
knowledge about STDs to have a responsible sex life, 349
4th Semester 98 (18.9%)
students (67.2%) answered positively and 170 (32.8%)
5th Semester 60 (11.6%)
negatively. This percentage did not differ significantly
6th Semester 3 (0.6%)
between groups classified according to the sexual activity:
Religion, n (%) 91 students (62.3%) in the no sexual activity group, 121
Catholic 435 (83.3%) (66.1%) in the < 3 sexual partners group, and 137 (72.1%)
Atheists 68 (13.1%) in the ≥ 3 sexual partners group responded positively to
Christians 5 (1%) this question.
Others 14 (2.6%) When asked about their sexual activity, 373 students
Sexual orientation of sexually active students, n (%) (71.8%) reported that they were sexually active, and 145
Heterosexual 350 (93.8%) (27.9%) had never had sexual intercourse. Of those who had
Bisexual 14 (3.8%) experienced sexual activity, 221 (59.2%) were women, and
Homosexual 9 (2.4%) 152 (40.8%) were men. The mean age at the time of their
first sexual intercourse was 17.2 ± 1.6 years. The sample

13

was classified into students who had their first sexual inter-
course before or after age 18 years. Men were significantly
more likely to have had their first sexual activity before age
18 years (p = 0.001): 107 (70.3%) had their first sexual activ-
ity before and 45 (29.6%) after age 18 years. In women, 90
(40.7%) had had their first sexual activity before and 131
(59.2%) after age 18 years. Other differences between male
and female respondents are shown in Table 2. Students had
an average of 1.8 ± 1.7 sexual partners in the survey year
(range 0–18) and an average of 4.1 ± 4.8 total sexual partners
during their lifetime (range 1–49).
Sexually active students were asked further questions
about their sexual behavior. When asked about their current
sexual relationship status, 318 students (85.3%) reported
having monogamous sexual intercourse, and 55 (14.7%)
reported having nonexclusive sexual intercourse. Students
were asked whether they had ever had casual sex, to which
156 (41.8%) answered positively and 217 (58.2%) answered
negatively. Students were also asked whether they had
ever had group sexual intercourse, to which 359 (96.2%)
answered they had not, and 14 (3.8%) answered that they
had. Finally, students were asked whether they had ever had
sexual intercourse with sex workers, to which 362 (97.1%)
replied they had not and 11 (2.9%) replied that they had.
When asked whether alcohol or drugs had influenced
their decision-making about using or not using any protec-
tion method against STDs, 88 students (23.6%) reported hav-
ing had sexual intercourse without using a condom while
being under the influence of alcohol and 22 (5.9%) while
under the influence of drugs. Additionally, when asked
whether they would notify their sexual partner if they were
diagnosed with an STD, 352 students (94.4%) responded
they would inform any partner, 20 (5.3%) only a stable part-
ner. One student would not mention the disease at all.
Protection Methods Against STDs
Sexually active students (n = 373) were asked how often they
used any protection method against STDs such as a con-
dom, contraceptive diaphragm, female condom, or another
method. Most of the students (229, 61.4%) reported using
some kind of protection method against STDs in all of their
intercourse: 95 (25.5%) used it for at least 80% of inter-
course, 21 (5.6%) for at least 50%, 18 (4.8%) for 20%, and 10
Table 2  Age at first sexual Sex Age at first sexual
intercourse and total number intercourse
of sexual partners for male and
female students Female 17.6 ± 1.4
Male 16.6 ± 1.7
Values are presented as mean ± standard deviation; p values were obtained using Student’s t test
13
Sexuality Research and Social Policy
(2.7%) never used a protection method. Most of the respond-
ents (363, 97.3%) used male condoms.
Contraceptive Methods
Only sexually active female students were asked about con-
traceptive methods (n = 221). When asked about the use of
any contraceptive method, 79 students (35.7%) reported
using one method, and 142 (64.3%) reported not using
any method. Of those who used contraception, 46 students
(58.2%) used oral contraceptives, 11 (13.9%) used a subder-
mal contraceptive implant, nine (11.4%) used an intrauterine
device, six (7.6%) used a transdermal contraceptive patch,
five (6.3%) used a contraceptive vaginal ring, and two (2.5%)
used a once-a-month injectable contraceptive.
Laboratory Tests
STD Screening
More than half of the sexually active students (230, 61.7%)
had never been screened for STDs, 69 (18.5%) had been
screened at least once or twice in their lifetime, 39 (10.5%)
once per year, 26 (7%) every 6 months, and nine (2.4%) only
after having condomless or high-risk sexual intercourse.
The population sample was divided according to the
regularity of STD screening: 65 students (17.4%) reported
being screened regularly and 308 (82.6%) irregularly. In the
irregular screening group, 126 (82.8%) were men, and 182
(82.3%) were women. In the regular screening group, 26
(17.1%) were men, and 39 (17.6%) were women; this differ-
ence was not significant (p = 1.0). However, when comparing
the groups of the number of partners, the two groups differed
significantly. Not having regular STD screening was reported
by 161 students (87.9%) in the group with < 3 sexual part-
ners and 147 (77.3%) in the group with ≥ 3 sexual partners.
By contrast, having regular STD screening was reported
by 22 students (12%) in the group with < 3 sexual partners
and 43 (22.6%) in the group with ≥ 3 sexual partners; this
difference was significant (p = 0.005, odds ratio: 2.14, 95%
confidence interval: 1.22–3.74). The two groups also dif-
fered significantly in the total number of sexual partners in
the past year and during their lifetime. The mean numbers of
partners in the past year were 2.54 ± 2.65 and 1.71 ± 1.43 in
p Number of sex partners p Lifetime number of p
in the past year sex partners
0.041 2.2 ± 1.7 .001 2.8 ± 2.5 0.001
1.5 ± 1.6 5.9 ± 6.5
Sexuality Research and Social Policy
the groups receiving regular screening and irregular screen-
ing, respectively (p = 0.018). A similar pattern was seen for
the number of partners over the lifetime: 6.29 ± 7.89 versus
3.65 ± 3.83 sex partners, respectively (p = 0.010).
Papanicolaou Smear (Pap Smear)
When asked how often female students received a pap smear,
116 students (52.5%) responded that they had never had a
pap smear, 87 (39.4%) once a year, and 18 (4.8%) had not
had a pap smear in the past year.
When asked why they did not have serological tests, the
most prevalent reasons were to be due to them being in a
monogamous relationship (123 students (33%)), followed
by 65 students (17.4%) that referred they believed that they
were unlikely to have an STD, and “disinterest” in 60 stu-
dents (16.1%). Similarly, when asked our female students
why not having a pap smear in the last year, 46 students
(34.3%) answered that they were in a monogamous relation-
ship, 40 students (29.9%) due to disinterest, and 18 students
(13.4%) answered to have a fear of positive results. The rest
of the reasons why these students do not have a serological
test and pap smear are shown in Table 3.
STD Screening Centers
When asked about whether they knew the location of STD
detection centers, 311 students knew (83.4%), and 62 (16.6%)
did not know where to obtain screening. When asked whether
they had ever had an STD, 356 (95.4%) answered no, and 17
(4.6%) reported that they had had an STD at an unspecified
time. Of these 17 students, six had acquired human papil-
lomavirus (HPV), two herpes virus type 2, one molluscum
contagiosum, one pelvic inflammatory disease, one HIV, and
six preferred not to mention the type of STD.
Table 3  Reasons for not seeking Reasons
STD screening and a cervical
pap smear
Fear of positive results
Disinterest
Lack of resources
Belief that she/he is unlikely that I have an STD
I am in a monogamous relationship
Do not know where to get an STD test
Do not know what an STD test is
Sexual Behavior According to the Number
of Partners
Students were asked about the frequency of condom use for
every sexual intercourse, and the responses were analyzed
for two groups: those with < 3 sexual partners (183 students,
49%) and those with ≥ 3 partners (190 students, 51%). In
the group with < 3 sexual partners, 125 students (68.3%)
reported using condoms 100% of the time, 40 (21.8%) 80%
of the time, five (2.7%) 50% of the time, eight (4.3%) 20% of
the time, and five (2.7%) never used condoms. In the group
with ≥ 3 sexual partners, 104 students (54.7%) reported
using condoms 100% of the time, 55 (28.9%) 80% of the
time, 16 (8.4%) 50% of the time, 10 (5.2%) 20% of the time,
and five (2.6%) never used condoms.
When asked whether they had adequate information
about STDs, 121 (66.1%) of those with < 3 partners and
137 (72.2%) of those with ≥ 3 sexual partners responded
positively. We divided the sample into those who always
use condoms during their sexual encounters (229 students,
61.3%) and those who do not always use condoms (144 stu-
dents, 38.6%). When comparing the use of condoms in sex-
ual partner groups, we found that the group with < 3 sexual
partners always uses a condom during their sexual encoun-
ters (125, 68.3%). In comparison, 104 students (54.7%) in
the ≥ 3 partners group answered that they always use a con-
dom. This difference was statistically significant (p = 0.008).
Additionally, when comparing the frequency of STD screen-
ing and the number of sexual partners groups, 43 students
(22.6%) of the students in the ≥ 3 sexual partners group and
22 (12%) of the students in the < 3 partners group answered
to have a regular STD screening. In contrast, 147 (87.9%)
students of the ≥ 3 sexual partners group and 161 (77.3%) in
the < 3 partners groups reported not having regular screen-
ing. This difference was statistically significant (p = 0.009).
STD screening (n = 308) Cervical
pap smear
(n = 134)
32 (8.6%) 18 (13.4%)
60 (16.1%) 40 (29.9%)
9 (2.4%) 3 (2.2%)
65 (17.4%) 15 (11.2%)
123 (33%) 46 (34.3%)
18 (4.8%) 10 (7.5%)
1 (0.3%) 2 (1.5%)
13

Discussion
We note that our study sample included only medical stu-
dents. The numbers and percentages observed here would
likely be higher in the general university population than in
our medical student sample because we assume that medi-
cal students would have greater knowledge, interest, and
access to precise and verified information on STDs than the
general university population. One possible consequence of
misinformation about STDs is a high rate of visits to emer-
gency departments; for example, one study found a 39%
increase in the number of visits to emergency departments
that included an STD diagnosis in the USA from 2008–2010
to 2011–2013 (Pearson et al., 2017).
Two-thirds of our sexually active population affirmed that
they had sought STD screening, but 82.6% did not seek regu-
lar screening. When asked about the motivation influencing
their decision to seek screening or not, the main reasons
were, “I am in a monogamous relationship,” “unlikely that
I have an STD,” and “disinterest.” This finding may pro-
vide evidence of the lack of knowledge about STDs among
these students. These results are similar to those reported in
a study of sexually experienced teenagers and young adults
in the USA who had never been tested. That study reported
that 41.8% did not seek testing because they felt they were
not at risk of STDs and that males (60.1%) were significantly
more likely than females to avoid testing for confidentiality
reasons (Cuffe et al., 2016)⁠. We believe that the reasons why
our university students do not seek STD screening (“unlikely
that I have an STD,” “disinterest,” and “fear of positive
results”) may reflect the lack of complete knowledge about
STDs and risk awareness, as discussed earlier in this article.
We emphasize the importance of providing truthful, timely,
and relevant information to young people.
The main reason why our students do not seek STD
screening is that they are in a monogamous relationship.
However, it is important to reiterate that being in a com-
mitted monogamous relationship is not a sound reason for
avoiding screening tests or refraining from using condoms.
Multiple factors, such as intravenous drug use, exposure to
blood or fluids, accidental needle stick in a healthcare set-
ting, and sexual infidelity by one’s partner, can lead to an
STD, which can put both members of a relationship at risk.
Given these possibilities, we believe that even those involved
in a monogamous relationship should get tested for STDs.
In Mexico, 21.7% of the HIV-positive population is
female. Females are the most affected group, and their preva-
lence is similar to those who have condonmless sex. Eighty
percent of females who contract HIV say that they are “in a
monogamous relationship.” According to the National Center
for Prevention Control of HIV and AIDs, there were 210,931
HIV cases registered in 2019 in Mexico (CENSIDA, 2019).
13
Sexuality Research and Social Policy
Only one-third of our sexually active female sample had
at least one pap smear annually, and more than half men-
tioned they had never had a pap smear. The main reason
stated by these women for not seeking STD screening was
because they were in a monogamous relationship. How-
ever, cervical cancer is the second leading cause of cancer
death in women, and STD screening should not be avoided
even if one is in a monogamous relationship. Cervical can-
cer is a growing global burden, both for developing and
industrialized nations. According to GLOBOCAN 2012,
cervical cancer caused 266,000 deaths, and 528,000 new
cases were recorded (Vu et al., 2018). HPV has oncogenic
potential in the cervix uteri and can cause other anogenital
lesions such as vulvar, penile, or anal cancer (Uken et al.,
2016)⁠ . The documented risk factors for cervical cancer
include early sexual intercourse initiation at age 18 years,
HPV infection, age < 30 years without having had any pap
smear test, STDs, and multiple sex partners (México: Sec-
retaría de Salud, 2010). These risk factors, along with the
findings of our study, indicate a need to implement effec-
tive educational and prevention programs for the general
population.
Understanding why university students refuse to use con-
doms was not one of the aims of our study. Alcohol or drug
use can lead partners not to use condoms, and we found that
about 25% of these students did not use a condom when
under the influence of alcohol or drugs. A study at a univer-
sity in Mexico City reported that 8% of the students had sex
when under the influence of alcohol and 1.5% when under
the influence of drugs (Aburto-Arciniega et al., 2020). Alter-
natively, multiple studies have found that at least 40–60% of
the studied sample did not use condoms during sexual inter-
course while under the effect of drugs or alcohol (Gleton
et al., 2019; Hamilton et al., 2019; Wang et al., 2018; Zule
et al., 2018). This behavior may explain why Mexico has the
highest rate of teenage pregnancies according to the OECD:
one in five pregnancies in the country involves young parents
aged 15–19 years (Cifuentes et al., 2010).
Our data on the sexual behavior of our medical student
population show the challenges for the prevention and con-
trol of sexually transmitted diseases. In our study, these
students lacked understanding of the risk, prevalence,
signs and symptoms, and consequences of STDs. These
students also lacked information about where to obtain
information about prevention methods and their limita-
tions and the importance of sexual health beyond prevent-
ing an unwanted pregnancy. It is important to review the
national policies that promote sex education at an early age
and the objectives of these programs to determine whether
they meet the needs of Mexican youth.
Well-designed health campaigns or promotion programs
delivered by physicians in Atlanta, GA, USA, have been
Sexuality Research and Social Policy
reported to promote STD prevention and testing behaviors
in at-risk populations and complement other public health
programs (Friedman et al., 2016). Health communication
campaigns may fill a gap in STD prevention efforts when
there are known social or behavioral contributors to the
STD problem. Such programs may help change a defined
population’s attitudes, norms, or behaviors if that popula-
tion is not otherwise reached by STD prevention programs
(Céspedes Gamboa et al., 2017). It is also important to
raise awareness among students, parents, teachers, and the
rest of the population. Health promotion campaigns are
needed to inform students about how and where they can
access tests for STDs and the possibility of being tested
within the medical service of their university. It is impor-
tant to provide information to students already infected by
an STD about treatment options or the inability to obtain
a complete cure (for example, if infected with HIV) and
direct students to associations where they can receive sup-
port and information about the disease. It is also important
to do a thorough review of the Mexican health agencies
and whether and how they address these diseases beyond
treatment, for example, by offering preventive strategies.
Guaranteeing the sexual health of the Mexican falls on the
family, the society, and the entire nation. This information
must reach everyone to allow all to make informed deci-
sions based on accurate information.
We asked whether the sexually active students sought
STD screening and found that three-quarters did so; these
students were identified as the more sexually active group
with the highest rate of STD screening. Similar results
were reported in a study conducted in Washington, DC,
USA, in which the study offered STD screening to 533
adolescents. That study found that participants who
were sexually active and young people who affirmed that
they had high-risk sexual behavior were more likely to
accept STD screening (Céspedes Gamboa et al., 2017).
The authors concluded that this high rate indicated that
these young people were well informed or feared acquir-
ing an STD. Fear of acquiring an STD seems to be related
to high-risk behavior, increasing the risk of exposure to
STDs. This was also observed in our study, which found
that only half of the participants with multiple sex part-
ners used condoms for every intercourse and one-fifth used
them for less than half of their intercourse. The observa-
tion that only half this population used condoms for each
intercourse raises concerns about the susceptibility of
acquiring and transmitting STDs. This was also observed
in a study conducted in the UK that showed that refusal to
use condoms explained the 2–4-times increased incidence
of STDs in their region over the past 10 years (Céspedes
Gamboa et al., 2017).
It is important to pay close attention to students with
multiple sex partners. We classified the students in our
study according to the number of sexual partners in their
lifetime (< 3 and ≥ 3 partners). One in four students in the
group with more sexual partners group considered that
they have insufficient knowledge about STDs; this propor-
tion was similar between the two groups classified accord-
ing to the number of sexual partners in their lifetime.
Conclusion
Young adults in Mexico are having their first sexual
intercourse at increasingly early ages. However, the
efforts of multiple programs of sex education and guid-
ance for having a healthy sex life do not appear to be
effective. Many sexually active students are having
sexual intercourse without using any barrier methods
against STDs or contraceptive methods and are not
regularly screened. This sexual behavior and the high
prevalence of risk factors for acquiring an STD indicate
a failure of public health programs and epidemiological
surveillance. If these trends continue, the risk of acquir-
ing STDs will increase in the population. The students
in our study may be healthy at present, but an increase in
their incidence of STDs would represent a severe public
health concern. The results obtained in this population
of medical students may be significantly different from
those in the general university population, assuming that
they have greater knowledge, interest, and access to pre-
cise and verified information on STDs than the broader
university population. This is relevant for establishing
contingency planning and STD awareness and screening
campaigns. In Mexico, few studies have taken an epide-
miological approach to understand the frequency of STD
screening and treatment in the general population. Such
an approach is needed to understand the facts related to
STDs.
Supplementary Information  The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 13178-0​ 21-0​ 0591-w.
Author Contribution  JCIP, RCMA, MLZ, and AOCF conceived the
idea for the study. All the authors contributed to the study’s concep-
tion and design. YLAM, RCMA, and MLZ prepared the material, and
MABP, MPLR, FJWC, AOCF, and RZO assisted with the student
recruitment and distribution of the surveys. Data management and
analysis were performed by FJBC, JCIP, AOCF, CFO, and AGO. The
first draft of the manuscript was written by JCIP, YLAM, FJBC, and
AGO. All the authors commented on previous versions of the manu-
script, and all the authors read and approved the final manuscript.
13

Data Availability  The datasets used and/or analyzed during this study
are available from the corresponding author upon reasonable request.
Declarations  ated with condom use among African American and Hispanic/
Ethics Approval and Consent  This study was designed not to affect the
physical or moral integrity of the participants. This research protocol
is registered in ClinicalTrials.gov with the identifier NCT04417426.
Written consent was obtained from each research participant before
the study, and all the participants were ensured of the protection of
their privacy, confidentiality, and anonymity. The authors state that
all interventions complied with the ethical standards of the relevant
national and institutional committees on human experimentation and
were in accordance with the Declaration of Helsinki of 1975, as revised
in Fortaleza, Brazil 2013, and the Mexican Health Guidelines.
Informed Consent  All the participants signed free and informed con-
sent forms online before proceeding with the questionnaire.
Conflict of Interests  The authors declare no competing interests.
References
Aburto-Arciniega, M. B., Escamilla-Santiago, R. A., Díaz-Olavarrieta,
C. A., Fajardo-Dolci, G. E., Urrutia-Aguilar, M. E., Arce-Cedeño,
A., Mota-Sánchez, A. A., & Guevara-Guzmán, R. (2020). Educa-
tional intervention on sexual health in medical students. Gaceta
Medica de Mexico, 156(2). https://​doi.​org/​10.​24875/​gmm.​20005​587
Burns, S., & Hendriks, J. (2018). Sexuality and relationship education
training to primary and secondary school teachers: An evaluation
of provision in Western Australia. Sex Education, 18(6), 672–688.
https://​doi.​org/​10.​1080/​14681​811.​2018.​14595​35
CENSIDA. (2019). Vigilancia Epidemiológica de casos de VIH/SIDA
en México Registro Nacional de Casos de SIDA Actualización al
Cierre de 2019 [Epidemiological surveillance of HIV/AIDS cases
in Mexico. National registration of AIDS cases. Update 2019].
Secretaria de Salud, 23.
Céspedes Gamboa, L. R., PupoCejas, Y., del Céspedes Gamboa, M.,
& P., Ramírez Castillo, R. A., & Ballester Real, R. F. (2017).
Sexually transmitted diseases and medicine students. Multimed,
21(1), 70–85.
Cifuentes, E., Trasande, L., Ramirez, M., & Landrigan, P. J. (2010).
A qualitative analysis of environmental policy and children’s
health in Mexico. Environmental Health: A Global Access Sci-
ence Source, 9(1), 14. https://​doi.​org/​10.​1186/​1476-​069X-9-​14
Cuenca, L. C., Atienzo, E. E., SuárezLópez, L., Prado, B. H., & Vil-
lalobos Hernández, A. (2013). Sexual and reproductive health
among adolescents in Mexico: Evidence and proposals. Gaceta
Médica De México, 149(3), 299–307.
Cuffe, K. M., Newton-Levinson, A., Gift, T. L., McFarlane, M., &
Leichliter, J. S. (2016). Sexually transmitted infection testing
among adolescents and young adults in the United States. Journal
of Adolescent Health, 58(5), 512–519. https://​doi.​org/​10.​1016/j.​
jadoh​ealth.​2016.​01.​002
Friedman, A. L., Kachur, R. E., Noar, S. M., & McFarlane, M. (2016).
Health communication and social marketing campaigns for sexu-
ally transmitted disease prevention and control: What is the evi-
dence of their effectiveness? In Sexually Transmitted Diseases
(Vol. 43, Issue 2, pp. S83–S101). Lippincott Williams and
Wilkins. https://​doi.​org/​10.​1097/​OLQ.​00000​00000​000286
GeSIDA. (2017). Documento de consenso sobre diagnóstico y tratami-
ento de las infecciones de trasmision sexual en adultos, niños y
adolesecentes [Consensus of diagnosis and treatment of sexually
13
Sexuality Research and Social Policy
transmitted infections in adults, children and adolescents]. Socie-
dad Española De Enfermedades Infecciosas Microbiología, 1,
1–87.
Gleton, B., Jahanfar, S., Inungu, J., & Latty, C. (2019). Factors associ-
Latino Youth. European Journal of Environment and Public
Health, 4(1), em0033. https://​doi.​org/​10.​29333/​ejeph/​5954
Hamilton, K. M., Falletta, L., Fischbein, R., & Kenne, D. R. (2019).
Nonmedical use of prescription drugs during sexual activity as
a predictor of condom use among a sample of college students.
Journal of American College Health, 67(5), 459–468. https://​doi.​
org/​10.​1080/​07448​481.​2018.​14868​43
Montes de Oca, A. (2013). Estudiantes universitarios frente a las infec-
ciones de transmisión sexual: un estudio de audiencia desde la
comunicación para la salud [University students against sexually
transmitted infections: A study of audience from communication
to health]. Correspondencias & Análisis, 3, 367–381. https://​doi.​
org/​10.​24265/​cian.​2013.​n3.​16
Nelson, D. E., Van Der Pol, B., Dong, Q., Revanna, K. V., Fan, B.,
Easwaran, S., et al. (2010). Characteristic male urine microbiomes
associate with asymptomatic sexually transmitted infection. PLoS
One, 5(11), e14116. https://d​ oi.o​ rg/1​ 0.1​ 371/j​ ourna​ l.p​ one.0​ 01411​ 6.
Pearson, W. S., Peterman, T. A., & Gift, T. L. (2017). An increase
in sexually transmitted infections seen in US emergency depart-
ments. Preventive Medicine, 100, 143–144. https://​doi.​org/​10.​
1016/j.​ypmed.​2017.​04.​028
Rios-Becerril, J., Cruz-Bello, P., Becerril-Amero, P., & Maldonado-
Gonzalez, V. (2016). Educational nursing intervention on sexual
and reproductive health in adolescents. Revista De Enfermería Del
Instituto Mexicano Del Seguro Social, 24(1), 51–54.
Salud., Mexico: Secretaria de. (2009). Enfermedades de transmisión
sexual en el adolescente y adulto que producen úlceras genitales:
Herpes, Sífilis, Chancroide, Linfogranuloma venereo y granuloma
inguinal [Sexually transmitted diseases in adolescents and adults
that cause genital ulcers: Herp.
Salud, México: Secretaría de. (2010). Diagnóstico y Tratamiento del Cáncer
Cérvicouterino [Diagnosis and Treatment of Cervical Cancer].
Sánchez-Saldaña, L. (2014). Condiloma acuminado [Condyloma
acuminatum]. Revista Dermatología Peruana, 24(2).
Subramanian, A., Mohan, A., Nandi, P. K., & Rajeshwari, K. (2020).
Perceived social support, depression and their impact on quality of
life of people living with HIV in India. AIDS Care - Psychological
and Socio-Medical Aspects of AIDS/HIV. https://d​ oi.o​ rg/1​ 0.1​ 080/​
09540​121.​2020.​18106​20
Tapia Fonllem, M. E. (2018). Educación sexual para todas y todos: la
asignatura urgente para el logro de la igualdad en méxico [Sexual
education: The burning subject to achieve equality in Mexico].
Cotidiano - Revista De La Realidad Mexicana, 14(212), 23–28.
Uken, R. B., Brummer, O., von Schubert-Bayer, C., Brodegger, T.,
& Teudt, I. U. (2016). Oral HPV prevalence in women positive
for cervical HPV infection and their sexual partners: A German
screening study. European Archives of Oto-Rhino-Laryngology,
273(7), 1933–1942. https://​doi.​org/​10.​1007/​s00405-​016-​3953-1.
UNAIDS. (2020). Global HIV & AIDS statistics — 2020 fact sheet.
https://​www.​unaids.​org/​en/​resou​rces/​fact-​sheet
Villafañe-Ferrer, L. M., & González-Navarro, R. M. (2017). Risk
behaviors and level of knowledge about sexually transmitted infec-
tions in university students. Duazary, 14(2), 160–168.
Vu, M., Yu, J., Awolude, O. A., & Chuang, L. (2018). Cervical cancer
worldwide. In Current Problems in Cancer (Vol. 42, Issue 5, pp.
457–465). Mosby Inc. https://​doi.​org/​10.​1016/j.​currp​roblc​ancer.​
2018.​06.​003
Wang, S. C., Lui, J. H. L., Vega, G., Waldrop, M., & Garris, J. (2018).
The moderating effect of alcohol use on protective and risky sex
behaviors among college students in the Southeast United States.
Sexuality Research and Social Policy
Journal of American College Health, 66(7), 546–552. https://​doi.​
org/​10.​1080/​07448​481.​2018.​14319​16
Zule, W. A., Speizer, I. S., Browne, F. A., Howard, B. N., & Wechsberg,
W. M. (2018). Condom use, multiple rounds of sex, and alcohol
use among south african women who use alcohol and other drugs:
An event-level analysis. Sexually Transmitted Diseases, 45(12),
786–790. https://​doi.​org/​10.​1097/​OLQ.​00000​00000​000881
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
13