Missed Opportunities and Racialized Surveillance: Rethinking STI Testing for Adolescent Males

In this issue of Pediatrics, Rolin et al present a timely examination of sexually transmitted infection (STI) testing practices among male adolescents, a group often overlooked in sexual health research.1 Using emergency department (ED) data, the authors found that a substantial proportion (>60%) of symptomatic youth were not tested for chlamydia or gonorrhea, while non-Hispanic Black male adolescents were significantly more likely than white male adolescents to be screened. These findings expose a dual problem: both missed clinical opportunities for adolescents and disproportionate screening of Black male adolescents. The authors highlight how, in the absence of universal guidance, racial and gendered biases may shape screening and testing practices.STIs are one of the most common and preventable public health concerns, affecting millions of adolescents and young adults across the United States.2 EDs serve as a critical safety net for early detection and treatment of STIs to prevent long-term complications and reduce community transmission.3 Youth who seek care in the ED are often less likely to have access to or engage in regular primary care and are disproportionately affected by STIs, underscoring the importance of ED-based screening and intervention strategies.4,5In regard to STIs and other adolescent health screening strategies, an urgent shift in practice is needed, from seeing risk as an individual choice to understanding that it is rooted in structural conditions such as poverty, racial and gender discrimination, lack of access to confidential health care, and community disinvestment.6 Clinician biases that assign higher risk based on race while overlooking broader social drivers of health such as access to care, structural racism, and criminalization create a harmful paradox: Black male adolescents are simultaneously hypervisible and underprotected in health systems.7 Racialized perceptions of Black adolescents as more sexually active reflect broader forms of adultification bias, in which Black youth are seen as older, less innocent, and more accountable for behaviors than their white counterparts.8 In pediatric contexts, adultification bias has been linked to disparities across multiple domains of health care delivery.9,10These inequities in STI screening exist within a broader developmental context, as adolescence is a period of rapid cognitive, emotional, and social growth in which affirming, bias-free care can foster lifelong health engagement—or conversely, entrench mistrust and disengagement.11 For Black male adolescents in particular, being framed as inherently "at risk" rather than as adolescents in need of guidance and support may reinforce societal stereotypes while failing to meet their developmental needs.8 Collectively, these intersecting biases contribute to institutional practices that disadvantage all youth, simultaneously neglecting some while disproportionately surveilling others.Beyond the striking disparities in who receives STI screening, the authors underscore another sobering concern: Many symptomatic youth are not tested at all. This finding signals missed opportunities for early diagnosis, timely treatment, and prevention of ongoing transmission, not only for individual patients but also for adolescent public health more broadly. Without universal, guideline-driven protocols, clinical decision-making may default to subjective assessments of perceived risk, shaped by both implicit bias and structural racism. Such patterns mirror long-standing disparities seen across multiple domains of adolescent health, including pain management, mental health assessment, and reproductive care.6,7,12,13Advocating for universal STI screening protocols, particularly in high-prevalence, resource-limited settings such as EDs, offers a pathway to mitigate both undertesting and biased oversurveillance. Universal screening would shift clinical practice away from assumptions about who is presumed "at risk," ensuring that all symptomatic youth are appropriately tested and empirically treated, regardless of racialized perceptions of behavior. It also provides an opportunity to protect male adolescents' health more broadly and to disrupt long-standing gendered surveillance practices that disproportionately target girls under the guise of pregnancy prevention or reproductive morbidity from pelvic inflammatory disease while neglecting male reproductive health entirely. In fact, in the United States, individuals assigned male at birth are nearly 2 times more likely than those assigned female at birth to become infected with HIV. Failure to screen them for other STIs, which are a marker of HIV risk, leads to critical missed opportunities for HIV testing and diagnosis, prevention education, and HIV preexposure prophylaxis.14Ultimately, addressing these disparities requires a shift from individual-risk frameworks to models that recognize structural vulnerability, hold systems accountable, and acknowledge how racism, bias, and inequity harm all youth. It also requires intentional investment in clinician education, institutional accountability, and partnerships with communities to reimagine what equitable adolescent care should look like. We must move beyond simply documenting disparities to actively dismantling the structures that sustain them.As health professionals, we must recognize how these early experiences shape both health outcomes and adolescents' trust in health systems over time. For Black male adolescents in particular, being treated as adults accountable for presumed "risky behaviors" rather than individuals deserving protection, guidance, and developmentally appropriate care can erode trust and deepen health inequities. Implementation of universal, evidence-based testing protocols through quality-improvement and research activities is critical to not only reducing bias but also ensuring that all adolescents, across racial and gender groups, receive comprehensive care and developmentally appropriate guidance that supports their growing autonomy in healthy sexual relationships and overall long-term health and well-being.