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Long-Acting Reversible Contraception and Condom Use: We Need a Better Message

Long-Acting Reversible Contraception and Condom Use: We Need a Better Message The age-old argument has reared its head again—does giving adolescents access to effective birth control motivate them to engage in more or riskier sex? This time the question pertains to adolescents who are choosing long-acting reversible contraception (LARC), specifically intrauterine devices and implants; are these adolescents less likely to use condoms than users of other contraceptive methods? Many health care professionals who care for adolescents believe that LARC methods are ideally suited to adolescents, given their high efficacy and ease of use. There is good reason to think that more effective contraception will help reduce unintended pregnancy. Almost half of unintended pregnancies occur in the context of contraceptive misuse, rather than nonuse, making the less user-dependent LARC methods appealing.1 However, as more adolescents elect to use LARC and national organizations like the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists support LARC as first-line contraception for adolescents,2,3 a theoretical concern has arisen: once adolescents have intrauterine devices or contraceptive implants, will they stop using condoms? This question is the focus of the investigation by Steiner et al4 in this issue of JAMA Pediatrics. Using the well-known Youth Risk Behavior Survey data set, the authors explore the question of whether LARC users differ in their use of condoms compared with users of other contraceptive methods, namely combined hormonal methods (the birth control pill, the transdermal patch, and the intravaginal ring) and the depot medroxyprogesterone acetate injection, or “the shot.” Steiner and colleagues found that condom use is lower among LARC users than among those using oral contraceptive pills. The authors point out that these data correspond to national data, specifically the 2006-2008 National Survey of Family Growth. Despite the important conclusions of the study, this research question begs for a prospective study. To examine whether condom use is affected by initiation of LARC, it is not enough to look at cross-sectional data that suggest an association between birth control method use and condom use. It is highly likely, as the authors discuss, that LARC users differ in their condom use precisely for the same reasons that they elect to use LARC. Coitally dependent methods like condoms require an organizational and planning ability similar to that which is needed to take birth control pills effectively. Young women who struggle to remember to take a daily birth control pill may be more likely to also struggle with regular condom use, perhaps making a long-acting method more appealing to them. Using the current cross-sectional data set, we cannot tease out directionality of cause and effect. It is interesting to note that condom use among LARC users did not significantly differ from that of those who use the shot, patch, or ring. Additionally, while the authors controlled for demographic differences between the groups of contraceptive users, it is likely that LARC users, a small minority of contraceptive-using adolescents, may differ from users of moderately effective methods in significant ways that are difficult to capture. Only a randomized trial could truly answer this question. Another important consideration is whether LARC users are in fact a higher-risk group of adolescents. It is unfortunate that we do not have information about condom use practices prior to LARC initiation among female adolescents in this study. However, the authors found that participants who reported using long-acting methods had greater odds of reporting 2 or more sexual partners in the last 3 months and 4 or more lifetime partners, suggesting that these adolescents appear to be engaging in higher-risk sexual behavior and are therefore at greater risk for acquiring sexually transmitted infections (STIs). Yet, it is very likely that health care professionals are preferentially recommending LARC to these young high-risk adolescents. It would be interesting to know about the relationship context in which these adolescents were engaging in sex, to better assess their risk potential, and to have data about whether LARC users in this study were subject to a greater burden of STIs. The premise that underlies the hypothesis that teenagers who choose LARC use condoms less than their counterparts is that adolescents—and perhaps women in general—use condoms as a backup for their less effective forms of birth control, a so-called belt and suspenders approach. However, this hypothesis deserves scrutiny. We know from studies assessing condom use motivation that adolescents are motivated to use condoms when they do not trust their partner, do not know their partner well, or have previously had an STI.5,6 It would be interesting to have data from a prospective cohort that looks at shifting condom intention with initiation of LARC compared with other methods. The findings of this study support the need for better public health interventions. With nearly half of new STIs occurring among 15- to 24-year-olds,7 we cannot afford to forget about condom use. However, with pregnancy failure rates for condoms with typical use approaching 18 pregnancies/100 women-years, condoms are by no means highly effective contraception.8 Instead, dual protection is the smartest choice for sexually active adolescents. Dual-protection use rates are dismally low at only 8.8% among adolescents in the 2013 Youth Risk Behavior Survey; adolescents have not yet heard this message clearly or there are barriers to dual-protection use that we do not understand well. A dual-protection approach that addresses both pregnancy and STI prevention should be widely advocated and encouraged. It is encouraging that when health care professionals recommend condoms together with birth control, condom use increases.9 We need to work on crafting a clear message about pregnancy prevention and STI prevention. Withholding LARC—the most effective methods of reversible contraception—owing to concerns about the unintended consequence of decreased condom use is not the answer. Condoms still need to be part of the conversation because STIs are common in the adolescent population. There is no such thing as a “clean” STI bill of health; adolescents need to know that screening for “all STIs” is a fallacy and that STIs can be transmitted by asymptomatic individuals. Dual protection for sexually active adolescents should be encouraged so that adolescents are not exposed to the risk of pregnancy or the risk of STIs as a result of selecting condom use vs effective contraception use. Condoms and LARC complement each other. We need to get the message right. Back to top Article Information Corresponding Author: Julia Potter, MD, Department of Pediatrics, Boston Medical Center, 850 Harrison Ave, ACC-5, Boston, MA 02118 (julia.potter@bmc.org). Published Online: March 14, 2016. doi:10.1001/jamapediatrics.2016.0141. Conflict of Interest Disclosures: None reported. References 1. Guttmacher Institute. Unintended pregnancy in the United States. https://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html. Accessed January 11, 2016. 2. Ott MA, Sucato GS; Committee on Adolescence. Contraception for adolescents. Pediatrics. 2014;134(4):e1257-e1281.PubMedGoogle ScholarCrossref 3. Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group, American College of Obstetricians and Gynecologists. Committee opinion No. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol. 2012;120(4):983-988.PubMedGoogle ScholarCrossref 4. Steiner RJ, Liddon N, Swartzendruber AL, Rasberry CN, Sales JM. Long-acting reversible contraception and condom use among female US high school students: implications for sexually transmitted infection prevention [published online March 14, 2016]. JAMA Pediatr. doi:10.1001/jamapediatrics.2016.0007.Google Scholar 5. Roye CF. Condom use by Hispanic and African-American adolescent girls who use hormonal contraception. J Adolesc Health. 1998;23(4):205-211.PubMedGoogle ScholarCrossref 6. Crosby RA, Milhausen RR, Graham CA, et al. Condom use motivations and selected behaviours with new versus established sex partners. Sex Health. 2014;11(3):252-257.PubMedGoogle ScholarCrossref 7. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis. 2013;40(3):187-193.PubMedGoogle ScholarCrossref 8. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404.PubMedGoogle ScholarCrossref 9. Morroni C, Heartwell S, Edwards S, Zieman M, Westhoff C. The impact of oral contraceptive initiation on young women’s condom use in 3 American cities: missed opportunities for intervention. PLoS One. 2014;9(7):e101804.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Pediatrics American Medical Association

Long-Acting Reversible Contraception and Condom Use: We Need a Better Message

JAMA Pediatrics , Volume 170 (5) – May 1, 2016

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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6203
eISSN
2168-6211
DOI
10.1001/jamapediatrics.2016.0141
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Abstract

The age-old argument has reared its head again—does giving adolescents access to effective birth control motivate them to engage in more or riskier sex? This time the question pertains to adolescents who are choosing long-acting reversible contraception (LARC), specifically intrauterine devices and implants; are these adolescents less likely to use condoms than users of other contraceptive methods? Many health care professionals who care for adolescents believe that LARC methods are ideally suited to adolescents, given their high efficacy and ease of use. There is good reason to think that more effective contraception will help reduce unintended pregnancy. Almost half of unintended pregnancies occur in the context of contraceptive misuse, rather than nonuse, making the less user-dependent LARC methods appealing.1 However, as more adolescents elect to use LARC and national organizations like the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists support LARC as first-line contraception for adolescents,2,3 a theoretical concern has arisen: once adolescents have intrauterine devices or contraceptive implants, will they stop using condoms? This question is the focus of the investigation by Steiner et al4 in this issue of JAMA Pediatrics. Using the well-known Youth Risk Behavior Survey data set, the authors explore the question of whether LARC users differ in their use of condoms compared with users of other contraceptive methods, namely combined hormonal methods (the birth control pill, the transdermal patch, and the intravaginal ring) and the depot medroxyprogesterone acetate injection, or “the shot.” Steiner and colleagues found that condom use is lower among LARC users than among those using oral contraceptive pills. The authors point out that these data correspond to national data, specifically the 2006-2008 National Survey of Family Growth. Despite the important conclusions of the study, this research question begs for a prospective study. To examine whether condom use is affected by initiation of LARC, it is not enough to look at cross-sectional data that suggest an association between birth control method use and condom use. It is highly likely, as the authors discuss, that LARC users differ in their condom use precisely for the same reasons that they elect to use LARC. Coitally dependent methods like condoms require an organizational and planning ability similar to that which is needed to take birth control pills effectively. Young women who struggle to remember to take a daily birth control pill may be more likely to also struggle with regular condom use, perhaps making a long-acting method more appealing to them. Using the current cross-sectional data set, we cannot tease out directionality of cause and effect. It is interesting to note that condom use among LARC users did not significantly differ from that of those who use the shot, patch, or ring. Additionally, while the authors controlled for demographic differences between the groups of contraceptive users, it is likely that LARC users, a small minority of contraceptive-using adolescents, may differ from users of moderately effective methods in significant ways that are difficult to capture. Only a randomized trial could truly answer this question. Another important consideration is whether LARC users are in fact a higher-risk group of adolescents. It is unfortunate that we do not have information about condom use practices prior to LARC initiation among female adolescents in this study. However, the authors found that participants who reported using long-acting methods had greater odds of reporting 2 or more sexual partners in the last 3 months and 4 or more lifetime partners, suggesting that these adolescents appear to be engaging in higher-risk sexual behavior and are therefore at greater risk for acquiring sexually transmitted infections (STIs). Yet, it is very likely that health care professionals are preferentially recommending LARC to these young high-risk adolescents. It would be interesting to know about the relationship context in which these adolescents were engaging in sex, to better assess their risk potential, and to have data about whether LARC users in this study were subject to a greater burden of STIs. The premise that underlies the hypothesis that teenagers who choose LARC use condoms less than their counterparts is that adolescents—and perhaps women in general—use condoms as a backup for their less effective forms of birth control, a so-called belt and suspenders approach. However, this hypothesis deserves scrutiny. We know from studies assessing condom use motivation that adolescents are motivated to use condoms when they do not trust their partner, do not know their partner well, or have previously had an STI.5,6 It would be interesting to have data from a prospective cohort that looks at shifting condom intention with initiation of LARC compared with other methods. The findings of this study support the need for better public health interventions. With nearly half of new STIs occurring among 15- to 24-year-olds,7 we cannot afford to forget about condom use. However, with pregnancy failure rates for condoms with typical use approaching 18 pregnancies/100 women-years, condoms are by no means highly effective contraception.8 Instead, dual protection is the smartest choice for sexually active adolescents. Dual-protection use rates are dismally low at only 8.8% among adolescents in the 2013 Youth Risk Behavior Survey; adolescents have not yet heard this message clearly or there are barriers to dual-protection use that we do not understand well. A dual-protection approach that addresses both pregnancy and STI prevention should be widely advocated and encouraged. It is encouraging that when health care professionals recommend condoms together with birth control, condom use increases.9 We need to work on crafting a clear message about pregnancy prevention and STI prevention. Withholding LARC—the most effective methods of reversible contraception—owing to concerns about the unintended consequence of decreased condom use is not the answer. Condoms still need to be part of the conversation because STIs are common in the adolescent population. There is no such thing as a “clean” STI bill of health; adolescents need to know that screening for “all STIs” is a fallacy and that STIs can be transmitted by asymptomatic individuals. Dual protection for sexually active adolescents should be encouraged so that adolescents are not exposed to the risk of pregnancy or the risk of STIs as a result of selecting condom use vs effective contraception use. Condoms and LARC complement each other. We need to get the message right. Back to top Article Information Corresponding Author: Julia Potter, MD, Department of Pediatrics, Boston Medical Center, 850 Harrison Ave, ACC-5, Boston, MA 02118 (julia.potter@bmc.org). Published Online: March 14, 2016. doi:10.1001/jamapediatrics.2016.0141. Conflict of Interest Disclosures: None reported. References 1. Guttmacher Institute. Unintended pregnancy in the United States. https://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html. Accessed January 11, 2016. 2. Ott MA, Sucato GS; Committee on Adolescence. Contraception for adolescents. Pediatrics. 2014;134(4):e1257-e1281.PubMedGoogle ScholarCrossref 3. Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group, American College of Obstetricians and Gynecologists. Committee opinion No. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol. 2012;120(4):983-988.PubMedGoogle ScholarCrossref 4. Steiner RJ, Liddon N, Swartzendruber AL, Rasberry CN, Sales JM. Long-acting reversible contraception and condom use among female US high school students: implications for sexually transmitted infection prevention [published online March 14, 2016]. JAMA Pediatr. doi:10.1001/jamapediatrics.2016.0007.Google Scholar 5. Roye CF. Condom use by Hispanic and African-American adolescent girls who use hormonal contraception. J Adolesc Health. 1998;23(4):205-211.PubMedGoogle ScholarCrossref 6. Crosby RA, Milhausen RR, Graham CA, et al. Condom use motivations and selected behaviours with new versus established sex partners. Sex Health. 2014;11(3):252-257.PubMedGoogle ScholarCrossref 7. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis. 2013;40(3):187-193.PubMedGoogle ScholarCrossref 8. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404.PubMedGoogle ScholarCrossref 9. Morroni C, Heartwell S, Edwards S, Zieman M, Westhoff C. The impact of oral contraceptive initiation on young women’s condom use in 3 American cities: missed opportunities for intervention. PLoS One. 2014;9(7):e101804.PubMedGoogle ScholarCrossref

Journal

JAMA PediatricsAmerican Medical Association

Published: May 1, 2016

Keywords: oral contraceptives,contraceptive methods,adolescent health services,female condoms,intrauterine devices,pregnancy in adolescence,sex behavior,sexually transmitted diseases,condoms,unplanned pregnancy,risk-taking behavior,young adult

References