News Contraception

Pediatric Academy Encourages IUDs and Implants for Sexually Active Teens

Martha Kempner

Intrauterine devices (IUDs) and implants are highly effective at preventing pregnancy and safe for women of all ages. Many think they are the ideal contraceptive method for adolescent girls. The American Academy of Pediatrics weighed in this week.

In new recommendations released Monday, the American Academy of Pediatrics (AAP) suggests intrauterine devices (IUDs) and contraceptive implants over other pregnancy prevention methods for sexually active teenage girls.

The policy statement, which was published in the October issue of Pediatrics and replaces a statement written in 2007, notes that pediatricians have an important role to play in reducing teen pregnancy and promoting contraceptive use.

The AAP has made recommendations on contraception to its members since 1980 and suggested that pediatricians become familiar with all contraceptive methods as well as the negative consequences of unintended teen pregnancy. This is the first time, however, that the organization has recommended that pediatricians consider long-acting reversible contraceptive methods (LARCs), including IUDs and implants, for their patients before other methods.

The recommendations note that pediatricians should encourage correct use of condoms for every sexual act, even for those adolescents using a LARC method. This is particularly important because neither the IUD nor the implant prevent the transmission of sexually transmitted infections, including HIV.

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IUDs are small, T-shape devices that are inserted into the uterus by a physician. They prevent pregnancy primarily by interfering with the path of the sperm toward the egg.

Two of the IUDs on the market—Mirena and Skyla—release hormones similar to those in some birth control pills, which thickens the cervical mucus (creating a barrier to sperm) and may also prevent ovulation. The other type of IUD, called ParaGard, releases copper, which is thought to create an environment that is toxic to sperm.

ParaGard lasts for ten years, Mirena for five, and Skyla for three years, but any of them can be removed if a user wishes to become pregnant.

Contraceptive implants, sold under the brand name Nexplanon, are flexible plastic devices about the size of a matchstick that are inserted under the skin on a woman’s upper arm.

LARC methods are highly effective in large part because users can “set them and forget them.”

All contraceptive methods have two efficacy rates: the perfect use rate, which shows how well they can work if used consistently and correctly, and the typical use rate, which shows how well they do work for average couples during the first year.

The typical use rate for most contraceptive methods is lower than the perfect use rate because people make mistakes, from forgetting to refill a pill prescription to leaving the condom in the night table drawer. For LARC methods, however, the perfect use rate and the typical use rate are essentially the same; if the method is properly inserted by a physician, users can’t make mistakes.

IUDs have a failure rate of less than 1 percent. Implants have a failure rate of 0.05 percent, meaning that out of 100 couples who use these methods as their primary form of birth control, fewer than one couple will experience an unintended pregnancy in the first year of use.

Though IUDs were once thought to be safe only for older women or women who had already had children, research in the past decade has found that they are safe for women of all ages, including adolescents. Implants have also been found to be safe for women of all ages.

Given the safety and efficacy of these devices, many experts believe that they are the ideal birth control method for young women.

In 2012, the American Congress of Obstetricians and Gynecologists recommended that LARCs be considered the first-line contraceptive method for adolescents. That opinion read, in part:

When choosing contraceptive methods, adolescents should be encouraged to consider LARC methods. Intrauterine devices and the contraceptive implant are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.

The AAP recommendations released this week are similar but focus more on the role the pediatrician should play.

Pediatricians should be able to educate adolescent patients about LARC methods including progestin implants and IUDs. Given the efficacy, safety, and ease of use, LARC methods should be considered first-line contraceptive choices for adolescents. Some pediatricians will choose to acquire the skills to provide these methods to adolescents. Those who do not should identify health care providers in their communities to whom patients can be referred.

Commentary Sexual Health

Fewer Teens Are Having Sex, But Don’t Pop the Champagne Yet

Martha Kempner

The number of teens having sex may be less important than the number having protected sex. And according to recent data from the Centers for Disease Control and Prevention, condom use is dropping among young people.

Every two years, the Centers for Disease Control and Prevention’s Division of Adolescent and School Health (CDC-DASH) surveys high school students to gauge how often they engage in perceived risky behaviors. The national Youth Risk Behavior Surveillance (YRBS) is wide ranging: It asks about violence, guns, alcohol, drugs, seat belts, bicycle safety, and nutrition. It also asks questions about “sexual intercourse” (which it doesn’t define as a specific act) and sexual behaviors.

Started in 1991, this long-running study can provide both a picture of what high school students are doing right now and a historical perspective of how things have changed. But for more than a decade, the story it has told about sexual risk has been the virtually the same. Risk behaviors continually declined between 1991 and 2001, with fewer high school students having sex and more of them using condoms and contraception. But after the first 10 years, there has been little change in youth sexual risk behaviors. And, with each new release of almost unchanging data, I’ve reminded us that no news isn’t necessarily good news.

This year, there is news and it looks good—at least on the surface. The survey showed some significant changes between 2013 and 2015; fewer kids have ever had sex, are currently sexually active, or became sexually active at a young age. More teens are relying on IUDs and implants, which are virtually error-proof in preventing pregnancy.

In 2015, 41 percent of high school students reported ever having had sexual intercourse compared to 47 percent in 2013. The researchers say this is a statistically significant decrease, which adds to the decreases seen since 1991, when 54 percent of teens reported ever having had sexual intercourse.

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Another change is in the percentage of students who had sex for the first time before age 13. In 2015, 4 percent of high school students reported this compared to almost 6 percent in 2013. This is down from a full 10 percent in 1991. As for number of overall partners, that is down as well, with only 12 percent of students reporting four or more partners during their lifetime compared to 15 percent in 2013 and 19 percent in 1991. Finally, the percentage of students who are currently sexually active also decreased significantly between 2013 (34 percent) and 2015 (30 percent).

These are all positive developments. Delaying sex can often help prevent (at least temporarily) the risk of pregnancy or STIs. Having fewer partners, especially fewer concurrent partners, is frequently important for reducing STI risk. And those teens who are not currently having sex are not currently at risk for those things.

While I want to congratulate all teens who took fewer risks this year, I’m not ready to celebrate those statistics alone—because the number of teens having sex is less important to me than the percentage of teens having sex that is protected from both pregnancy and sexually transmitted infections. And that number is lower than it once was.

Among sexually active teens, there were no significant positive changes in measures of safer sex other than an increase in the number of sexually active high school students using the IUD or implant (up to 4 percent from 2 percent in 2013).

Moreover, some results indicate that today’s teens are using less protection than those who were teens a decade ago. The most telling finding might be the percentage of teens who used no method of contraception the last time they had sex. This decreased between 1991 and 2007 (from 17 percent to 12 percent), inched up to 14 percent in 2013, and stayed the same in 2015 (14 percent). There was also little to no change in the percentage of high school students who say that either they or their partner used birth control pills between 2013 (19 percent) and 2015 (18 percent) or those who say they used the contraceptive shot, patch, or ring (5 percent in 2013 and 2015).

For me, however, the most distressing finding is the backward progress we continue to see in condom use. The prevalence of high school students who used a condom at last sex went up from 45 percent in 1991 to 63 percent in 2003. But then it started to drop. In 2015, only 57 percent of sexually active high school students used condoms the last time they had sex, less than in 2013, when 59 percent said they used condoms.

It’s not surprising that teens use condoms less frequently than they did a decade ago. In the 1990s, the HIV epidemic was still front and center, and condoms were heavily promoted as a way to avoid infection. As this threat waned—thanks to treatment advances that now also serve as prevention—discussions of the importance of condoms diminished as well. The rise of abstinence-only-until-marriage programs may have also affected condom use, because these programs often include misinformation suggesting condoms are unreliable at best.

Unfortunately, some of the negative messages about condoms inadvertently came from public health experts themselves, whether they were promoting emergency contraception with ads that said “oops, the condom broke”; encouraging the development of new condoms with articles suggesting that current condoms are no fun; or focusing on teen pregnancy and the use of highly effective contraceptive methods such as long-acting reversible contraceptives (LARC). The end result is that condoms have been undersold to today’s teenagers.

We have to turn these condom trends around, because despite the decreases in sexual activity, young people continue to contract STIs at an alarming rate. In 2014, for example, there were nearly 950,000 reported cases of chlamydia among young people ages 15 to 24. In fact, young people in this age group represented 66 percent of all reported chlamydia cases. Similarly, in 2014, young women ages 15 to 19 had the second-highest rate of gonorrhea infection of any age group (400 cases per 100,000 women in the age group), exceeded only by those 20 to 24 (489 cases per 100,000 women).

While we can be pleased that fewer young people are having sex right now, we can’t fool ourselves into believing that this is enough or that our prevention messages are truly working. We should certainly praise teens for taking fewer risks and use this survey as a reminder that teens can and do make good decisions. But while we’re shaking a young person’s hand, we should be slipping a condom into it. Because someday soon (before high school ends, for more than half of them), that teenager will have sex—and when they do, they need to protect themselves from both pregnancy and STIs.

News Contraception

After Relying on Private Donors, Colorado Lawmakers Fund Teen Contraception Program

Jason Salzman

“Ensuring women have access to the most effective methods of birth control enables them to create the best future for themselves and support a healthy start for their children,” said Erin Miller, vice president of health initiatives at the Colorado Children’s Campaign.

Colorado Gov. John Hickenlooper (D) signed a budget bill Tuesday that included $2.5 million for a program that has reduced both teen births and abortions by 48 percent.

Republican lawmakers last year blocked funding of the Colorado Family Planning Initiative, which had been supported by $25 million from private donors during an initial five-year pilot project. The $2.5 million included in the budget bill will be combined with $1.6 million already allocated for the program, along with federal Title X funding and “local contributions,” from contractors, said Jody Camp, family planning unit section manager for the Colorado Department of Public Health and Environment (CDPHE).

The initiative has been “a game changer—successful beyond our dreams,” Camp wrote in an email to Rewire.

Asked for details on the initiative’s impact, Camp pointed to, among other metrics, Medicaid savings of $79 million over three years, a 58 percent drop in repeat teen births (teens having multiple babies), and 36,000 long acting reversible contraceptives (LARCs), such as intrauterine devices (IUDs), provided at no cost or low cost to low-income women.

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The $2.5 million in state funds will allow the program to run without private contributions next year, Camp explained.

The initiative provides LARCs, which work for up to 12 years but are expensive at the outset, as well as training for health-care providers.

“It is extremely important for our teen moms who are sexually active to have a full understanding of the health choices available, including birth control,” Lisa Steven, executive director of Hope House of Colorado, which offers free self-sufficiency programs to teenage mothers, said in an email to Rewire. “And, the more we can reduce the rate of secondary teen pregnancies, the more likely a teen mom is to become self-sufficient.”

Anti-choice activists have opposed the initiative for a variety of reasons. Some incorrectly believe that contraception leads to promiscuity, that Obamacare covers the program, or that IUDs, as one Colorado GOP lawmaker put it last year, prevent “a small child from implanting” in the uterus.

Gualberto Garcia Jones, vice president of the anti-choice Personhood Alliance, said one reason he opposes the state’s LARC initiative is what he describes as the negative effect it has on public perception of pregnancy.

“It is also concerning that when society treats children as something to be avoided, pregnancy begins to be seen as a disease,” Garcia Jones wrote in an email to Rewire. “The argument that children are a burden is only encouraged by these public policies, leading to a culture of abortion and barrenness.”

Backers of the initiative counter that the program creates stronger families.

“Ensuring women have access to the most effective methods of birth control enables them to create the best future for themselves and support a healthy start for their children,” Erin Miller, vice president of health initiatives at the Colorado Children’s Campaign, told reporters.

Lisa VanRaemdonck, executive director of the Colorado Association of Local Public Health Officials, told reporters, “When women have access to the family planning method that works best for themselves and their families, our financial investment is returned through better short and long-term outcomes for women and their families.”

Officials from the state’s health department are trying to improve the Family Planning Initiative by offering LARC training to a wider variety of health-care providers, such as pediatricians and school-based health center clinicians who work outside of the family planning network.

The department is sponsoring a LARC Symposium June 6 and 7 in Denver.