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Summary of ReCAPP Forum: Advances in Reproductive Health,
Contraception, and STI Prevention On
November 26, 2002, Sharon Myoji Schnare, RN, FNP, CNM, MS, joined moderator
Lori Rolleri for a ReCAPP forum on advances in reproductive health, contraception,
and STI prevention. More than 140 participants from a variety of organizations
and countries shared information, resources and common concerns and questions
regarding reproductive health and puberty education. The
forum not only explored general issues about trends and approaches in
the field of reproductive health and education but also provided information
and answers to very specific questions about particular types of birth
control and STD preventative measures. The moderators fielded questions
and comments about the following topics:
Resources discussed during the forum are listed at the end.
Abstinence
Only Versus Holistic Education Ms. Schnare agreed that abstinence can work, but she pointed out that the data shows it works best in conjunction with all options discussed and available to young women and men. She noted that there is now heightened sensitivity to parts of the world where women are kept in the dark about their bodies, sexuality, and contraception. Ms. Schnare's goal is to have children love and respect their entire bodies because we are less likely to be unsafe with our bodies when we view ourselves positively. Honest information with use of scenarios that enhance children's positive sense of self and ability to make good decisions is one good approach. A program coordinator for an abstinence-based program agreed that all sex education must be holistic. While her program supports those teens who want to stay abstinent, the staff does not hesitate to provide information on other options that are available for those teens who are not going to take the abstinence route. Ms. Schnare elaborated on her approach, adding that she asks teens to share steps they plan to take to change from a current (unsafe) behavior to safer or more healthy behaviors and then she listens to THEIR plans. Teens respond best when they create their own solutions, she said. Merely giving advice to teens (according to research) has little impact and may actually make teens more resistant to change. Creative Educational Activities & Resources Many of the forum participants work with teens and even younger children and sought creative ideas for educating them about STDs and contraception. Many suggestions were contributed by forum participants, including a Jeopardy-like game created by a nurse for high school students (available by contacting her — Debbie Gold — at cre8tiv@erols.com) and an activity called "Sweetly Transmitted Infections," in which students trade different kinds of candy to illustrate the transmission of STDs (available by contacting Magda Permut at mpermut@ymca.org). Another participant described one of her favorite activities, which involves marking craft/popsicle sticks with the letters "I" and "C" (about half as many as the letter "I" sticks) and handing them to teens as they arrive. She has all the teens shake hands and asks those with the "I" sticks to stand. She explains that the "I" stands for "infection" and anyone with whom they shook hands should also stand. She then tells those with the letter "C" sticks to sit and explains that their sticks stand for "condoms." They were therefore protected during "intimate contact." Robert Becker, with Planned Parenthood of New York City, suggested ordering curricula (ETR Associates publications are available for sale at www.etr.org/pub/index.html) or accessing activities on-line (the ReCAPP site and the Planned Parenthood Federation site at www.ppfa.org/education/index.html). Co-moderator Lori Rolleri agreed with Mr. Becker's recommendations and also provided a list of interactive activities/ learning formats that would work well. These include:
Ms. Schnare recommended reading material related to the motivational interviewing technique based on behavior change theory by Prochaska and DeClemete and books by Miller and Rollnick. In response to a query about sources of information on sexual response and sexual communication, Ms. Schnare recommended contacting the Sex Information and Education Counsel of the U.S. and the Center for Health Training in Seattle (206-447-9538; ask for Joan Helmich), which would be able to provide information on some wonderful sexuality education programs that have been developed and tested in educational settings. Co-moderator Lori Rolleri noted that some basic information about the human sexual response cycle can be found at the following web sites: www.engenderhealth.org/res/onc/sexuality/response/pg2.html; test.bagus.org/sex/women/anatomy/female_sex_response; and test.bagus.org/sex/men/anatomy/male_sex_response. Several suggestions were also made in response to a query about STD photographs and color pictures to show to middle and high school youth. The Centers for Disease Control and Prevention (CDC) has a web site as well as a Powerpoint presentation on STDs, which includes graphic and powerful STD clinical slides www.cdc.gov/nchstp/dstd/dstdp.html). ETR Associates also makes a display and STD flipchart with color drawings rather than actual photographs. There are also several good puberty and STI activities on ReCAPP. Do a search for "puberty" and "STIs." Another suggestion was to check out the Our Whole Lives curriculum, which covers sexual health K-12. Call (617) 742-2100 or go to: www.uua.org/owl/facts.html. One participant inquired about models or ideas on wellness programs and healthy lifestyle classes for teens and middle school students. She noted that her interest stemmed from the fact that several of her students weigh over 300 pounds. Elaine Ellers, an MSW in Sacramento, CA responded by saying that Sutter Medical Center in Sacramento offers a "Healthy Lifestyles" program for kids who are overweight. Parental Involvement A participant who conducts parent workshops on how to talk to children about sexuality asked for suggestions on resources and recommended approaches, noting that many parents see the topic of sexuality as taboo. Co-moderator Sharon Schnare agreed that many parents are uncomfortable with the topic of sexuality, and they communicate this discomfort to their children. She believes that all such information should be provided in a positive, accurate and non-shaming way. Children's questions (all questions) must be answered honestly. Folks who teach these courses need to know the material and feel comfortable discussing the body, its functions and the miraculous, positive aspects of our bodies, including genitals. Ms. Schnare noted that in the U.S., our society has tremendous ambivalence about genitals and sexuality. Even though television and other media have explicit pictures of sexual activity, people are woefully ignorant about sexual response, sexual communication, contraception, and STD prevention. She asked why it is that we are comfortable using sex to sell objects but uncomfortable actually discussing reproduction, sexuality, and body functions. When we inhibit exploration, Ms. Schnare said, we give children the idea that their genitals are not their own, that they are ugly or dirty or somehow bad. Then we wonder why we have so much sexual dysfunction and unhealthy attitudes about our bodies and sexuality especially. Ms. Schnare suggested setting up a parent group and discussing puberty, sexuality issues, and reproductive physiology, which she has found to be an effective way to help parents (especially mothers) "buy-in" to a course for their children. She shared a story about a nurse who had a tea for the mothers of the children she was going to be teaching in a rural community. At first, the mothers were dubious about the course but once they began to share how they first learned "the facts of life," they realized how poor the information was that they had received as adolescents, and they appreciated the need to do better with their own children. Co-moderator Lori Rolleri recommended purchasing a newly released monograph from SIECUS (noting that it is the best research synthesis and overview of programs that she has seen) titled "Innovative Approaches to Increase Parent-Child Communication about Sexuality: Their Impact and Examples from the Field." (Available for approximately $20 from www.siecus.org or 212-819-9776.) Male Involvement In response to a request for ideas on encouraging male involvement, co-moderator Sharon Schnare referred participants to Rob Becker at Planned Parenthood of New York (a forum participant). She noted that Mr. Becker is an expert in male involvement and one of the best in the field. Co-moderator Lori Rolleri encouraged participants to check out the summary of the Male Involvement Forum (and the list of resources) that Mr. Becker moderated in the 2001 as well as ReCAPP's Male Involvement section under Theories and Approaches. Contraception & Depression Co-moderator Lori Rolleri inquired about the use of contraception in depressed teens and the interactions of antidepressants with contraception. Co-moderator Sharon Schnare noted that this is a great question and concern because teens are increasingly being evaluated for depression, and medical management with antidepressants along with counseling is essential. She said that there are no contraindications to hormonal contraceptive use with any of the antidepressants on the market, but there has been variable data on the impact of hormones on mood. Depro Provera has been known to increase depression in some susceptible young women. Ms. Schnare evaluates all women for depression and if a young woman has had a history of depression, she considers using another method other than Depo Provera. All the newer methods discussed (contraceptive ring, patch, oral contraceptives and the new implants) are safe to use with antidepressant agents. Teens using anticonvulsant medications (except valproic acid) and rifampin or griseofulvin (antifungal and antituberculosis meds) should not use oral contraceptives (or they should use them with a condom to increase efficacy) as they can significantly reduce the efficacy of the contraceptive pills. St. John's Wort should also be avoided with hormonal contraceptives as it theoretically can reduce the contraceptive efficacy. St. John's Wort is sold in health food stores for use as an antidepressant. Ms. Schnare noted that whether St. John’s Wort works for depression is under debate, so she usually suggests patients avoid using it and instead use medications that are known to be effective and have undergone clinical trials for safety and quality. Ms. Rolleri followed up on the St. John's Wort discussion, noting that it is important for health care providers to ask patients about all medications — both prescription AND over the counter — that they are taking since many people may not consider St. John's Wort to be a medication. Sexual Health Needs of LGBTs A participant who runs a Planned Parenthood male involvement program sought information on how to respond to the sexual health needs of LGBTs (lesbian, gay, bisexual and transgender). Several participants responded, including one who said that, on a personal level, she recommends treating them no differently than other teens. She pointed out that teens grappling with their sexuality still need nurturing, respect and current, correct information to prevent the spread of STIs and foster strong, healthy bodies and relationships. She also noted that any work with teens who have chosen to pursue "alternative" lifestyles also has to have some sort of support built in. Co-moderator Sharon Schnare agreed, noting that often gay teens are isolated and need support. She added that while she encourages assessing all teens for depression, it is particularly important to do so with gay teens. As for providing a supportive environment, Ms. Schnare said that she urges all the health care providers she teaches to never assume the orientation of their patients. Using terms like "partner" in not only history-taking but, more importantly, on forms helps develop an accepting and supportive environment. She suggests posting non-discrimination policies in clinics and offices and providing educational material that is not sexually biased. She also avoids sensitive sexual issues or behaviors in her charting because charts are available to insurance companies and they can be requested in court matters. Co-moderator Lori Rolleri asked for advice on counseling female patients who identify as lesbian. She noted that according to research, lesbian youth are actually more likely than straight girls to have an unintended pregnancy. Does this, she wondered, make counseling lesbian women tricky in that they could simply respond, "Well, my sexual relationships are with other women, so therefore I do not need contraception?" Ms. Schnare agreed that there is an increase in unintended pregnancies in teens who identify themselves as lesbian. A participant suggested that one explanation is that the youth are thinking, "It's only this one time," or they are in an altered state (seeking physical closeness due to depression, or under the influence of drugs or alcohol) and therefore might not be using their full faculties. Ms. Schnare stated that approximately 2/3 of women who identify themselves as gay report having had sex with a man at some time. This means that gay teens may be at risk for STDs and HPV infection, including cervical dysplasia from HPV. Adolescent women identifying themselves as lesbian need to be aware that they may have the same health risks as heterosexual teens, which includes contracting STDs. Lesbian women can also transmit HPV and herpes to their partners and need to be aware of safe sex practices to keep each other safe. Finally, Ms. Schnare noted that contraception may be indicated for therapy in gay teen women for a variety of reasons:
There is also data that lesbian girls may have more mental health risks due to ostracism, violence against gays, and role confusion. Ms. Schnare cautioned everyone to encourage gay teens to seek support groups. She also recommended obtaining a copy of an OrthoMcNeil video (in which she participated) on lesbian women and their health care needs (available by contacting an Ortho representative).
STIs
Versus STDs Co-moderator Sharon Schnare agreed that STD and STI are used interchangeably. She said STI is more commonly used in Europe, and STD is more common in the U.S. She believes that STI is the more accurate term because STDs are really infections, not diseases. She also thinks the term "disease" is a little stigmatizing. Microbicides A participant asked for the latest, most promising information about the availability of microbicides in the U.S. because he is often asked about the prevention of STIs in teen pregnancy prevention programs. Co-moderator Sharon Schnare explained that microbicides are gels or adherent fluids that contain spermicidal ingredients and/or provide a protective coating to the vagina to inhibit transmission of bacteria or a virus. Ms. Schnare added that Canada is currently researching the "Invisible Condom," a female condom which contains sodium lauryl sulfate in a thermo-reversible gel. This is a liquid at room temperature that becomes a gel at body temperature. This gel covers both the vagina and the cervical tissues and seeps into the smallest tissue folds. Researchers in Canada are developing a special applicator for this microbicide and are now moving into clinical trials. The tests on the invisible condom in vitro have shown it to be an inactivator of HIV-1 infectivity in cultured cells. The sodium lauryl sulfate is a detergent and dissolves the viral membranes. It has also been shown (in vitro) to inactivate Herpes Virus 1 and 2. Ms. Schnare cautioned, however, that studies in tissue cultures in the lab may not be reproducible in real clinical trials with people. She noted that Nonoxynol-9 looked good too until it was shown to actually increase transmissibility of HIV infection. More information on microbicides can be found at www.microbicide.org or www.itg.be/micro2002. BufferGel Co-moderator Lori Rolleri, in responding to a question about macrocodes, shared an article from the 11/12/02 Los Angeles Times about a microbicide called BufferGel. The article, entitled "Potential AIDS Preventive Doubles as a Contraceptive," begins with, "[o]ur best weapon against the spread of AIDS may turn out to be a common gel that's been used for years in drugs and cosmetics." The article goes on to describe how a Johns Hopkins research team developed a microbicide called BufferGel and that, if all goes well, it could be on sale in the U.S. within two years. Unlike the much touted microbicide Nonoxynol-9, which was approved by the FDA as a contraceptive but was then found to promote, rather than prevent, HIV transmission (because it irritated the cells lining the vagina, providing viruses with an entry point through the damaged tissue), BufferGel preserves the acidity of the vagina, thus killing off such sexually transmitted microbes. If it's effective, it will provide an alternative for women whose partners refuse to use condoms. Nonoxynol-9 A participant asked specifically about Nonoxynol-9 (N-9) and wondered if there would be anything on the market in the near future to help in the fight against STIs. Co-moderator Lori Rolleri also requested specific information about N-9, asking if it is still on the market and if young people still use it as a spermicide. She asked Ms. Schnare if she recommends N-9 and if there are any other spermicidal foams, jellies, creams that are available in the U.S. market. Other participants asked if there was a consensus on recommendations for N-9's use. There appears to be some disagreement in the field as to whether or not N-9 should be recommended for contraceptive use. Co-moderator Sharon Schnare agreed that there are differences in clinical practice based on data about Nonoxynol-9. While noting that she does not recommend the use of N-9 at this time, she added that she is conservative in her approach. She pointed out that other clinicians who suggest that N-9 may not be a problem for those at low risk for STD/AIDS are simply interpreting the available data less conservatively than she does. She then shared the recommendations from the 2002 Centers for Disease Control and Prevention (CDC) STD Guidelines:
Ms. Rolleri added that the CDC's official statement about Nonoxynol-9 (which includes a "Dear Colleague" letter recommending that N-9 not be used as an effective means of HIV prevention) can be found at www.cdc.gov/hiv/pubs/mmwr/mmwr11aug00.htm. Jennifer Galbraith, who works at CDC, Division of Adolescent and School Health, responded that N-9 should be recommended for contraception but not for prevention of HIV, and women should be advised to consider their risk for HIV when deciding upon contraceptive methods. She suggested the following web site for obtaining more information on N-9: Nonoxynol-9 Spermicide Contraception Use United States, 1999 www.cdc.gov/mmwr/preview/mmwrhtml/mm5118a1.htm Ms. Rolleri also recommended the quarterly publication of the Association of Reproductive Health Professionals (ARHP) — Health and Sexuality — which put out a great issue on microbicides in their third quarter, 2002 publication (Volume 7, No. 3). The publication describes the lead microbicides and their clinical research status. (ARHP's web site: www.arhp.org; ARHP email: arhp@arhp.org). Participants asked Ms. Schnare what she recommends for teens to use if not foam with Nonoxynol-9 in it. Instead of N-9 products (such as foams, creams, film), Ms. Schnare recommends condoms (both male and female condoms) and back-up emergency contraception. Spermicides alone are not very effective for contraception but are better than not using anything. Ms. Schnare also recommends condom use with every act of intercourse, no matter what other contraceptive method is used concomitantly. She uses the following scenario when counseling teens who use condoms inconsistently: "At the times that you use condoms, what makes you so successful? And when you don't use a condom, what is different about the situation? It sounds like you are more secure when you have used a condom; how do you plan to be more successful next time?" This style of counseling avoids giving advice. Instead, it helps the teens think through their own situations and come up with their own solutions. Ms. Schnare added that this style is more effective and kinder than telling teens what to do. "When I tell a teen how to live their life," she concluded, "they don't like it any better than we do, and they are more likely to be resistant to change." HPV Vaccine Co-moderator Lori Rolleri asked her fellow moderator to share what she knows about a new vaccine for HPV, the virus associated with cervical cancer. Ms. Schnare responded by saying that Merck pharmaceuticals is developing a vaccine to immunize against certain DNA serotypes of HPV (human papilloma virus). There are over 60 different subtypes of HPV. Currently Merck has a monovalant vaccine, i.e., a vaccine for one DNA serotype of HPV. They are working on a polyvalant vaccine. The issue of vaccination against certain subtypes of HPV is that high risk serotypes of HPV are strongly implicated in cervical cancer. In fact, cervical cancer has been called an STD because of the association with HPV. Approximately 5600 women die each year in the U.S. from cervical cancer; the vast majority of these women either had never had a PAP smear or had not had one for over seven years. Worldwide, the total numbers of women dying of cervical cancer is in the hundreds of thousands. This is a totally preventable cancer, Ms. Schnare said, yet millions of women worldwide have NO access to health care, such as PAP smears. It is estimated in the U.S. that 20% of adults have HPV. The DNA serotypes most associated with cervical cancer are 16 and 18. Subtype 16 is responsible for about 50% of cervical cancer. Ms. Schnare then referred to a New England Journal of Medicine (Nov. 21, 2002, No 21, Vol. 347:1645-1651) double-blind, randomized study of 2392 young women (16-23 years) who received either a placebo vaccine or HPV-16 virus-like particle vaccine. The study's conclusion was that the vaccine would protect 50-70% of women against cervical cancer. As for when the vaccine will be ready, Ms. Schnare cautioned that there is still more to do, and it may be another three to five years before a product is available.
The
Patch Co-moderator Sharon Schnare said that the patch actually stays on very well; you really have to pull to detach it. Only 2-4% of patches either partially or completely detach. The patch was tested with women wearing it while swimming, in saunas, exercising, bathing etc., and it worked great. The researchers also looked at pull force studies to see how much strength was necessary to detach a patch. She added that the adhesive in the patch contains the hormones, and this adhesive is NOT like the adhesive in the typical band aid. A participant provided the following data regarding the patch’s adhesive record: out of 70,000 patches applied worldwide, 3% partially lifted and less than 2% fell off.Ms. Schnare encouraged anyone who had not yet seen a patch to get sample patches from OrthoMcNeil reps and try one on, as she did, to see firsthand how well they work. The patch can result in side effects similar to oral contraceptives (OCs) — spotting, nausea and breast tenderness, said Ms. Schnare. (There is more breast tenderness than with OCs, but this goes away in two to three months.) Precautions for use of the patch are the same as the contraindications for OCs. Ms. Schnare is frequently asked about using the patch continuously, i.e., without a patch-free interval. She thinks women will experiment with this, but there is currently no data on the effects of continuous use of the patch. As for teen use of the patch, Ms. Schnare assured the forum that teens do like it. Teens enjoy the novelty and the fact that they do not have to take a daily pill, although they have discovered that it is not thong-friendly (nowhere to hide it) and therefore not good for summer bathing suit weather. She noted that the efficacy rate is that of OCs; however, the patch may actually be more effective for two reasons:
Ms. Schnare agreed with several participants who wondered why the patch isn't being more effectively marketed to teens. She even asked the company that produces the patch about putting designs on it, but she was told that covering the top of the patch may alter the absorption of the hormones. A discussion about the pros and cons of making the patch more attractive ensued. One participant thought that wearing birth control as decoration was, in effect, flaunting one's sexual activity. Another participant noted that different packaging selections are now available for birth control pills, which she thought was good. However, she saw a difference between hip and exciting packaging and something that "kind of throws" a person's personal birth control choice in other peoples' faces. Yet another participant responded that she liked the idea of tattoos/decorations on the patch because she would rather work on educating folks about sexual consent (e.g., how do you know for sure that someone wants and agrees to have sex with you?) than limiting personal expression. She also pondered the bigger question of why birth control methods aren't packaged in a greater variety of styles so that they appeal more broadly (e.g., pill containers in different designs, diaphragm containers that look more like a make-up compact, etc.) She suggested that thinking creatively and keeping diversity in mind when marketing contraceptive methods would increase correct and consistent contraceptive use among those who don't want to get pregnant right now. Co-moderator Lori Rolleri suggested checking out the following resources for more information about transdermal contraception:
Side Effects One participant stated that, as more and more birth control methods become available, she tries to group methods according to their similarities for various types of presentations. She has grouped the hormonal methods with estrogen: bcp, Lunelle, patch, ring and she wondered how comparable the common side effects of Lunelle, the patch and the ring are to side effects of combined birth control pills. After noting that it was an excellent question, co-moderator Sharon Schnare provided the following information about side effects:
Emergency Contraception Several questions arose regarding strategies for increasing youth access to emergency contraception (EC). One participant wondered how to get more doctors to issue advance prescriptions for their patients, noting that many doctors are getting better about giving patients free condoms during visits, but they do not currently include EC information as well. In response, forum participant Andrea Gerber said that she completely agrees that it should be easier for teens, adult women, and their partners to access emergency contraception. Her organization's EC guidelines, which are research-based, enable providers to use their discretion in offering emergency contraception. To download a Microsoft Word version of these guidelines, go to: www.metrokc.gov/health/famplan/clinicguide/ec.doc. Co-moderator Lori Rolleri asked her fellow moderator what she knows about the current status of over-the-counter availability of EC. She noted that California and Washington are now making EC available at selected pharmacies, which means that pharmacists need to receive some training to properly counsel/educate women who request it. Ms. Schnare believes that EC pills should be over-the-counter because they are very safe and effective when given for such a short period of time. The progestin-only ECs have an efficacy of 85% or more when used within 72 hours following unprotected intercourse, and they may still be effective after 72 hours. For women with contraindications to OCs, Ms. Schnare recommends using the progestin-only EC (Plan B). In the state of Washington, pharmacists may dispense EC under written agreement with a nurse practitioner or physician, which is akin to a standing order. The Pharmacy Board provided excellent training programs for the pharmacists about EC dispensing. The pharmacists must refer the woman to her health care provider after she has been given the EC. This program has worked so well that many more states are adopting the process. Ms. Schnare concluded by saying that EC saves lives because when it prevents pregnancy, it also prevents ectopic pregnancies. Ms. Rolleri told the forum about several helpful web sites which provide information about educational approaches used to teach teens about EC:
Ms. Rolleri then asked the participants to share any EC social marketing campaigns that they had either developed or seen. One participant said that Advocates for Youth, along with selected state partners, launched a social marketing campaign about EC in the last couple of years. More information is available through their site, which features PSAs, fact sheets, lesson plans, and other related resources: www.advocatesforyouth.org/news/Feature/ecps.htm. Forum participant Robert Becker noted that Planned Parenthood of New York City ran a social marketing campaign on emergency contraception and is about to launch another campaign. A sample of their EC campaign is available on their web site at: www.ppnyc.org/services/factsheets/emergency.html. Contraceptive Samples A marriage and family therapist who volunteers with teens asked how she can get information and samples of the newest birth control methods. One participant suggested contacting the pharmaceutical companies and telling them about her educational outreach to teens. Typically, if you put a request on letterhead and contact their sales department, they are pretty good about sending samples along. The participant noted that this method has proven successful for her; she has been able to obtain pills, the patch, the ring, depo, norplant and diaphragms this way. Another suggestion was to borrow a kit from a Planned Parenthood or Health Department or purchase a complete kit (Planned Parenthood of Greater Northern NJ and Planned Parenthood of Philadelphia sell complete kits for $100 or less). Co-moderator Sharon Schnare applauded the use of contraceptive supplies in seminars and consultations, noting that it is important for men and women (especially teens) to touch and play with various contraceptive methods. When her patients touch various devices and look and play with different pill packs, they become desensitized and less fearful or cautious of methods. A very common reaction she gets from women who touch intrauterine devices is "Gee, this is so small...it's kinda cute!" Ms. Schnare recommended using outdated pill packs for "Show and Tell" and going to the drug stores periodically to buy a female condom and various spermicides to show. She also noted that one can obtain free condoms for display from most Title X Family Planning Programs and Planned Parenthoods. In addition, both moderators provided the following contact information for obtaining samples of different birth control methods:
Condom Use One participant shared several concerns — hormone birth control leads teens to think that because they can't get pregnant, they also won't get an STD. Teens are not using condoms consistently and/or correctly. Cases of STDs (including HIV) are on the rise. And many schools are still promoting abstinence only, which has been proven ineffective after six months. She asked about initiatives to teach children at an earlier age (prior to high school) about all of their options. Co-moderator Sharon Schnare is also concerned that many teens erroneously think that oral contraceptives protect them from STDs; however, she noted that more and more teens are using condoms consistently. They are getting the message because reproductive health educators are out there and teaching them. She recommended the following approach with a teen who is thinking of starting condom use: "How do you see yourself talking with your girlfriend/boyfriend about using condoms? What do you think their reaction might be? How do you plan to creatively use the condoms? You are a bright young man/woman and I'm sure you will come up with more creative ideas about using these than I could." She emphasized that such a motivational counseling style works great. Ms. Schnare then shared a study done by Linda Goldman, RN, NP, MSN, who has worked at Harbor/UCLA NP Program. She asked men in an STD clinic what they thought women's reactions to condoms were. Then she asked women the same question about men. Ms. Goldman found that men and women thought members of the opposite sex were more negative about condoms, while their own reactions were relatively positive. This study suggests that we need to focus our counseling on helping folks feel comfortable talking with each other. New Methods A participant working with an adolescent pregnancy prevention program in North Carolina asked for more information about newer birth control methods, particularly Lunelle, and whether Medicaid or Title X clinics are able to offer these newer methods. Co-moderator Sharon Schnare provided a brief description of several new birth control methods (Lunelle, the patch, and the ring) and stated that they are all similar in price. She cautioned participants to remember that generic oral contraceptives (OCs) are equally as effective as brand named OCs, and they are cheaper. Inexpensive OCs can be purchased through Canadiandrugstore.com for about half the price of OCs marketed in the US. She added that most of these new methods can be obtained at Planned Parenthood and Title X agencies/clinics. Lunelle is medication injected monthly that contains an estrogen and a progestin (like OCs). Lunelle is as effective as OCs and probably more effective because women do not have to remember to take a daily pill. Lunelle usually results in very regular cycles after the first two to three months of use, Ms. Schnare explained. Teens in her practice like injectable contraceptive methods like Lunelle and Depo Provera. Many pharmacies in her area will give women contraceptive injections for a nominal fee (approximately $7). This works well when a teen can't get to the clinic before her next shot is due but can go to a pharmacy (many of which are open 24 hours). Ms. Schnare strongly advises the preemptive use of emergency contraception because it clearly decreases unintended pregnancies and abortions. Ms. Schnare provided more information about the patch. She said that it should be applied to a clean, dry, lotion-free area of skin once each week for three weeks; the fourth week is patch-free so the user can have a menses or withdrawal bleed. A new patch is applied seven days later, and the cycle begins again. The ring is placed in the vagina for three weeks at a time and removed the fourth week. A new ring is inserted at the seventh day of menses. The ring does not need to be "fitted;" it comes in one size. Few rings expel. The ring is comfortable to wear, and most male partners are not bothered by it during intercourse. Co-moderator Lori Rolleri pointed out that Norplant has been taken off the market. For more information, see a press release from the company dated 7/26/02 at www.wyeth.com/news/Pressed_and_Released/pr07_26_2002.asp. She then asked Ms. Schnare if she was aware of any new method coming out that is similar to Norplant. She asked specifically about Jadelle (two-rod system also by Wyeth) and Implanon (single rod system by Organon). Ms. Schnare said that contraceptive implants have been the most effective contraceptive methods on Earth. Norplant had a 0.2% failure rate, and the newer products are expected to be as effective or better. The two-rod implant Jadelle uses levonorgestrel and has a first-year failure rate of 0.2%. The rods have a total of 75 mg of levonorgestrel and release the hormone slowly in small amounts. The rods are very small (2.5 mm x 4.3 cm). There is a five-year clinical trial underway. Jadelle side effects have been similar to Norplant, although insertion and removal are much easier. The single rod Implanon is also very exciting. Implanon contains 60 mg of 3-keto-desogestrel (etonorgestrel). The hormone is released at 60 mcg/day and decreases to 30 mcg/ day after two years of use. The rod is 4 cm long. Implanon is designed to provide contraception for three years. There have been NO pregnancies with Implanon in over 53,000 cycles! This implant has similar side effects to Norplant except for a higher rate of amenorrhea.
Creative Educational Activities and Resources
Parental Involvement
Male Involvement
Preventative Measures for STDs/STIs
Pregnancy Prevention/Birth Control
Emergency Contraception
Contraceptive Samples
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