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TECHNICAL REPORT

Barrier Protection Use by Adolescents During Sexual Activity Laura K. Grubb, MD, MPH, FAAP, COMMITTEE ON ADOLESCENCE

Rates of sexual activity, , and births among adolescents have abstract continued to decline during the past decade to historic lows. Despite these positive trends, many adolescents remain at risk for unintended Departments of Pediatrics and Public and Community Medicine, Floating Hospital for Children at Tufts Medical Center, Boston, and sexually transmitted (STIs). This technical report discusses the Massachusetts new data and trends in adolescent sexual behavior and barrier protection use. Technical reports from the American Academy of Pediatrics benefit Since 2017, STI rates have increased and use of barrier methods, specifically from expertise and resources of liaisons and internal (AAP) and external use, has declined among adolescents and young adults. external reviewers. However, technical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the Interventions that increase availability of or accessibility to barrier methods organizations or government agencies that they represent. are most efficacious when combined with additional individual, small-group, Dr Grubb, along with the Committee on Adolescence, researched, or community-level activities that include messages about safer . Continued conceived of, designed, analyzed and interpreted data for, drafted, and revised this technical report and approved the final manuscript as research informs interventions for adolescents that increase the submitted. consistent and correct use of barrier methods and promote dual protection of The guidance in this report does not indicate an exclusive course of barrier methods for STI prevention together with other effective methods of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. contraception. All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

This document is copyrighted and is property of the American TRENDS IN ADOLESCENT SEXUAL ACTIVITY AND CONSEQUENCES: THE Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of AMERICAN ACADEMY OF PEDIATRICS BRIGHT FUTURES Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Pediatrics has neither solicited nor accepted any commercial Adolescents, Fourth Edition provides guidance for adolescent visits for ages involvement in the development of the content of this publication. 11 to 21 years, and in this report, we will provide information that DOI: https://doi.org/10.1542/peds.2020-007245 1 includes this age range. Despite recent data indicating sexual activity has Address correspondence to Laura K. Grubb. E-mail: lgrubb@ declined among adolescents, the current rates of sexual activity and health tuftsmedicalcenter.org consequences of sexually transmitted infections (STIs) and pregnancy PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). indicate that these remain significant public health concerns. The Centers Copyright © 2020 by the American Academy of Pediatrics for Disease Control and Prevention (CDC), through its Risk Behavior FINANCIAL DISCLOSURE: The author has indicated she has no financial Surveillance System, reports sexual behaviors in a nationally relationships relevant to this article to disclose. representative sample of high school students surveyed biannually. In the FUNDING: No external funding. most recently available Youth Risk Behavior Survey (YRBS) from 2017, 40% of high school students reported they had ever had (defined as penile-vaginal penetration), 29% reported they To cite: Grubb LK, AAP COMMITTEE ON ADOLESCENCE. Barrier were currently sexually active, and 10% had sexual intercourse with 4 or Protection Use by Adolescents During Sexual Activity. Pediatrics. 2020;146(2):e2020007245 more partners in their lifetime.2

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 146, number 2, August 2020:e2020007245 FROM THE AMERICAN ACADEMY OF PEDIATRICS In 2017, the year for which the most An estimated 50 900 youth had HIV from making copies of itself in recent data are available, 456 000 in 2016, representing 4% of the body), and concern exists for adolescent and young women all people with HIV infection. Of extensive -resistant strains if younger than 20 years became those, an estimated 56% were aware these youth are not taking pregnant; 448 000 of those of their infection, and people 15 to combination antiretroviral therapy pregnancies were among 15- to 19- 24 years of age were the least likely consistently.16 In a prospective cohort year-olds, and 7400 were among to be aware of their infection study of the of those 14 years of age and younger.3 In compared with any other age group.9 sexually active female adolescents 2017, the US pregnancy rate among Young people (13–24 years of age) with PHIV, the cumulative incidence 15- to 19-year-olds was at its lowest accounted for an estimated 21% of all of pregnancy at 19 years of age was point in at least 80 years3; however, new HIV diagnoses in the United 21%, and incidence of STIs was the for US teenagers States in 2018, totaling 7891 people, 26%.17,18 Several studies have remains higher than that for other of whom 87% were natal male youth revealed that adolescents with PHIV industrialized nations, with marked and 13% were natal female youth.10 have higher rates of sexual activity, disparities by race and/or ethnicity The CDC attributed 80% of new HIV multiple partners, and unprotected and geographic area.4 diagnoses among youth to male-to- penetrative intercourse compared male sexual contact and 20% to other with noninfected peers; more New cases of STIs increased 31% in means (vaginal-penile sexual contact, adolescents frequently tested positive the United States from 2013 to 2017, intravenous drug use, dual male-to- for multidrug-resistant HIV and with half of the 2.3 million new STIs male sexual contact, intravenous drug rarely disclosed their HIV status to reported each year among young use, and other). Among young women partners.19,20 people 15 to 24 years of age.3,5,6 The who received an HIV diagnosis, the Adolescents with intellectual and CDC does not publish specific data on CDC attributed 85% of those physical disabilities are an STI rates by modes of transmission. infections to vaginal-penile contact overlooked group when it comes to The rate of reported cases of and 15% to other transmission sexual behavior, but they have similar , , and 10 methods. There is a paucity of data rates of sexual behaviors when increased for both sexes in both the for transgender adolescents, but the compared with their peers without adolescent (15–19 years of age) and results from the National HIV disabilities.20 These youth receive young adult (20–24 years of age) age – Surveillance System 2009 2014 limited sexual education from their groups between 2012 and 2016. For revealed that youth 13 to 19 years of parents and pediatricians because chlamydia and gonorrhea, rates are age accounted for 8% of new HIV many assume they will not engage in consistently highest among diagnoses among transgender sexual behaviors.21 The American adolescent and young women 15 to 10–12 people. The study also revealed Academy of Pediatrics clinical report 24 years of age; however, the rate of that 25% of transgender women were “Sexuality of Children and reported chlamydia in male patients living with HIV infection and that the Adolescents With Developmental increased, whereas the rate in female percentage of transgender people Disabilities” provides additional patients decreased from 2012 to who received a new HIV diagnosis 22 3 information. 2016. Reported cases of syphilis was more than 3 times the national have been consistently higher among average in 2015.13 In 2018, 1252 This information concerning adolescent and young adult men youth received a diagnosis of AIDS.14 adolescent pregnancy, STIs and/or compared with women, and between HIV, and minority youth is provided 2012 and 2016, rates of reported In discussing barrier methods and to emphasize the need for syphilis cases increased substantially risks, it is important to include comprehensive barrier method in both adolescent and young adult information about youth living with counseling and education for all men and women.6 Because HIV acquired through perinatal youth, regardless of stated sexual (Trichomonas transmission (PHIV). The CDC does orientation, behaviors, gender, or vaginalis infection) is not a reportable not report specific adolescent data, intellectual and/or physical disease, it is difficult to determine the but at the end of 2016, 1814 children differences. prevalence among adolescents. In the were living with PHIV, and 10 101 United States, there are adults and adolescents (13 years of BARRIER METHOD USE approximately 7 million new cases of age and older) were living with Recent Trends in Adolescent Barrier trichomoniasis each year, and PHIV.15 Youth with HIV infection Method Use prevalence rates range from 3% in generally receive combination a nationally representative sample of antiretroviral therapy (a combination The external condom remains the women to 14% in adolescents.7,8 of 3 or more that stops the most popular contraceptive method

Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS among adolescents. Most reported female students (50%).23 In one Family Growth, the authors found, for barrier method use data are for the study, approximately one-third of adolescents and young adults 15 to external condom because there is transgender female youth reported 24 years of age, that 58% of male a paucity of current available data for not using barrier methods participants and female participants other barrier methods. The 2017 consistently during receptive anal reported having at least 1 oral YRBS data refer to external intercourse with casual and opposite-sex partner in the last 12 and vaginal-penile sexual activity.23 commercial partners; less than half months. Condom use at the last oral Although overall sexual activity consistently used them with a main sex was 8% for female participants decreased among high school partner.24 and 9% for male participants. Black students, barrier method use male participants (adjusted odds The National HIV Behavioral (referred to as condom use in the ratio [aOR] 3.46), Black female Surveillance interviewed individuals YRBS) also declined among sexually participants (aOR 2.65), and female in 23 cities, and among HIV-negative active adolescents. Among sexually participants of other races and/or males who have sex with males active high school students, 54% ethnicities (aOR 2.40) were more (MSM) 18 to 24 years of age, 10% reported condom use during their likely to use a condom at the last oral reported having condomless vaginal last sexual encounter, a decline from sex. Women 20 to 24 years of age sex with female partners, 3.5% 62% in 2007.2 Among 12th-grade (aOR 0.31), women whose mothers reported having condomless students, 57% reported ever being had a college education or more (aOR with female partners (3.5%), and sexually active, but they had the 0.43), and men and women who 73% reported having condomless lowest use of condoms among all reported no intercourse experience anal sex with male partners. Among grades.23 The prevalence of having were less likely to use a condom at HIV-positive MSM, 7% reported used a condom during the last sexual the last (aORs 0.46 and 0.20, having condomless vaginal sex with intercourse was higher among male respectively).27 female partners, 3% reported having than female students, and use rates condomless anal sex with female Factors That Influence Barrier were as follows: white male students, partners, and 74% reported having Method Use 62%; Black male students, 58%; condomless anal sex with male Hispanic male students, 62%; white Several factors, including individual, partners.25 Rates of actual barrier female students, 47%; Black female family, cultural, sociodemographic, method use in surveys also may be students, 46%; and Hispanic female attitude, education, relationship, and lower than reported because of the students, 47%. Use rates declined partner-related factors, influence uncertain or questionable validity of with increasing grade level.23 Among barrier method use28 (Table 1). In the self-report of this and other sexual currently sexually active students, most current national study of male behaviors that are prone to bias. For 56% of self-identified heterosexual adolescents,29 factors associated with example, in a clinic-based sample of students; 40% of self-identified gay, greater consistency of barrier method Black female participants 15 to lesbian, and bisexual students; and use included Black race or ethnicity, 21 years of age in Atlanta, Georgia, 44% of questioning students used more positive attitudes toward 186 young women reported 100% a condom during the last sexual barrier methods, and more discussion condom use via an audio computer- intercourse.23 The prevalence of of health topics with parents. assisted self-interviewing having used a condom during the last Adolescents who did not have formal technique.26 In these young women, sexual intercourse was higher among were half as likely to 34% had a positive biological marker heterosexual (56%) than sexual- use a barrier method at first for unprotected vaginal sex (a Y minority (40%) students. Among intercourse and even less likely to use chromosome polymerase chain female students, the prevalence of barrier methods consistently. A lower reaction assay) in the past 14 days. As having used a condom during the last rate of barrier method use at first a possible explanation of these sexual intercourse was higher among sexual intercourse was associated findings, participants may have used heterosexual students (50%) than with older age, an older or casual first condoms inconsistently or incorrectly, lesbian and bisexual students (37%), , and a partner using or youth might have provided socially and among male students, the another method of contraception. desirable answers. prevalence was higher among These factors were also associated heterosexual students (62%) than gay The rate of barrier method use is with a lower rate of barrier method and bisexual students (53%). The significantly less for oral intercourse. use at last sex, except for having prevalence of having used a condom Using data collected from 3816 a casual sexual partner, which was at last sexual intercourse also was cisgender female participants and associated with a higher rate of higher among heterosexual male 3520 cisgender male participants in barrier method use.29 In a large study students (62%) than heterosexual the 2011–2015 National Survey of of rural adolescents,30 authors found

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 146, number 2, August 2020 3 TABLE 1 Factors Influencing Barrier Use Among Adolescents who communicated with their Personal Factors Environmental Factors Behavioral Factors mothers about barrier method use Age Parental Barrier method use history before onset of sexual activity, as 40 Barriers Perceived social support Sexual history compared with after initiation. In Sex Social norms Substance use the most recent longitudinal study of Goals parents and their children regarding Knowledge the timing of parent and child Personal standards Self-efficacy communication about sexual Self-esteem behaviors, more than 40% of the Worry children had intercourse before there were discussions about STI symptoms, barrier method use, birth that sexually active students who use. Relationship duration was control, or partner barrier method used barrier methods had negatively associated with consistent refusal.41,42 significantly higher levels of barrier method use.31 Another study In a randomized of knowledge about sexual risk, self- revealed higher rates of barrier Hispanic and Black mother- esteem, personal standards for method use in youth who perceived adolescent (11–14 years of age) barrier method use, self-efficacy (an their partners as wanting to use dyads, mothers waiting in a pediatric individual’s belief in his or her barrier methods and in those able to clinic received a parent-based capacity to execute behaviors communicate their desire to use intervention. The intervention group necessary to produce specific barrier methods with their demonstrated significantly reduced performance attainments) for barrier partners.32 Lack of barrier method rates of transitioning to sexual method use, self-efficacy for partner use by adolescents is also associated activity and frequency of sexual communication, self-efficacy for with perceptions that barrier intercourse, with decreases in oral refusal of unwanted intercourse, methods reduce sexual pleasure and/ sex nearly reaching statistical barrier method use goals, and or that partners disapprove of barrier significance (P , .054), compared perceived norms and lower levels of method use. This perception was with controls. Specifically, sexual worry about pregnancy compared supported by one large study that activity increased from 6% to 22% with students who did not use barrier revealed that perceptions about how for adolescents in the standard of methods. Adolescents using barrier barrier methods reduce sexual care control condition, although it methods reported significantly higher pleasure were more strongly remained at 6% among adolescents in levels of perceived support from their associated with not using a barrier the intervention condition at the 9- family, and the perceived level of method.33 Other factors associated month follow-up.42 The media also support received from friends or from with increased barrier method use may influence adolescent sexual significant others did not differ include receiving comprehensive sex behavior.43,44 Exposure to sexual between those who used barrier and HIV education programs,34 content in music, movies, magazines, methods and those who did not.30 attending schools where barrier television, and the Internet may play methods are available,35,36 and an important role in adolescent Relationship factors play an perceived risk of getting STIs.34 sexual activity. Despite the important role in barrier method use increasingly sexually explicit material among adolescents. In the Toronto In several studies, authors have in media and programming, there are Relationship Study,31 authors found examined the role of parent- rare messages promoting responsible that negative relationship dynamics adolescent communication about sexual activity, such as contraception (conflict, control, mistrust, jealousy, sexual risk and the association with use (including condom use).35 In perceived partner inferiority) and increased adolescent use of barrier – primetime television, 77% of positive qualities (love, enmeshment, methods.37 39 Parental programs have sexual content, but salience, self-disclosure) were communication about sexual risk and only 14% reference risks or associated with consistent barrier barrier method use is associated with responsibility of sexual behavior.44 method use. Teenagers who scored increases in adolescents’ use of highly on both positive and negative barrier methods, especially at first Substance use also affects sexual qualities had the least consistent intercourse. Timing of the discussion behavior and barrier use. In studies of barrier method use. Conversely, is important; in one study, the highest young adult and adolescent sexual teenagers in relationships with low rates of barrier method use at first behavior after use of , positive and negative qualities had and last sex, as well as for regular use, marijuana, or other illicit substances the most consistent barrier method were found among adolescent girls (including nonmedical use of

Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS prescription drugs), authors found Barrier use was slightly more partners and first-time partners and associated increases in risky sexual prevalent in the context of genital associated higher perceived pleasure behavior and lower rates of barrier stimulation with a , with with condom use.57 Participants’ – protection use.45 47 62.1% and 63.4% of respondents condom use was less likely if their reporting that they never used partners did not ejaculate, when they Barrier availability may significantly barrier protection when performing had sex in a location other than affect use among adolescents. and receiving this type of stimulation, a residence, or with higher levels of External condoms, dental dams, and respectively.54 preintercourse arousal or barrier sheets are available over the difficulty. In a study of Black MSM, counter in all states but may still be In a qualitative study of lesbian and authors found that participants used difficult for adolescents to access. bisexual female participants 14 to perceived masculinity of potential Many stores stock condoms in 18 years of age, reasons participants partners to assess HIV-related risk, in physically inaccessible places that did not use barriers (external which masculine men were presumed require a store attendant to assist the condom or ) during sex low risk and effeminate men were customer.48 Barrier methods can be with female partners included presumed high risk, thus contributing expensive, and private insurance does pleasure, risk perception based on to condom use behavior.58 not pay for them, but some states’ sex of sexual partner, lack of Medicaid plans do.49 Barrier methods knowledge of sexual risk or of barrier Dual Protection are less available in poorer use for female-to-female sexual Nonbarrier contraceptive methods neighborhoods,50 rural areas, activities, and use of STI testing as offer pregnancy protection but no American Indian or Alaska Native a prevention tool.55 One 17-year-old protection against STIs. Dual-method communities,51,52 and certain faith- girl shared, “they [other girls] use, the use of barriers in based communities or colleges or probably don’t think [about barriers] combination with other universities.53 since condoms are seen as a way to contraceptive methods to protect prevent pregnancy, and when two Sexual-minority youth may have against STIs and unwanted girls have sex they can’t get pregnant different patterns of barrier use, but pregnancy, is the ideal contraceptive so we forget that there’s still a chance there are limited data on their habits. practice for adolescents. The 2017 of STDs.” Additionally, participants Sexual-minority youth may not use YRBS revealed that 9% of all male cited greater trust with female barriers during sexual activity for and female high school students partners, no concern for pregnancy, similar reasons as their reported dual contraceptive use lack of awareness of importance, and heteronormative peers, but they often (defined as external condom use lack of inclusive sexuality education. have unique explanations. In a study with another contraceptive method) of women who have sex with women Among MSM, there are a variety of with the last intercourse.23 The (40% of participants were 24 years of reasons for barrier use behaviors. In overall percentage of dual usage age or younger), the percentage of a survey of adolescent MSM,56 most increased with age, up to 10% women who reported never using received sexual education from among 12th-graders, and was barrier protection was significantly parents and school, but they lacked highest among white (12%), Black higher among those in monogamous information on specific or explicit (6%), and Hispanic (4%) students. relationships than among those in information concerning male-to-male Studies have revealed beliefs that nonmonogamous relationships sexual activity (eg, types of male-to- positively correlate with dual (78.6% vs 27.4%, respectively; P , male sex, how to safely and contraceptive use, including .01).54 Women who reported always comfortably have anal sex). For MSM, perceived benefits of protected sex, using barrier protection were relationship to partner correlates positive attitudes about birth significantly more likely to be in with condom use. For HIV-negative control, and higher perceived risk of nonmonogamous than monogamous MSM 18 to 24 years of age, 52% STI and pregnancy consequences.59 relationships (14.3% vs 3.5%, reported condomless anal sex with Additionally, predictors of dual- respectively; P , .01). Of note, 27.7% a main male partner, compared with method use are similar to predictors of nonmonogamous women reported 44% with casual male partners. In the of adolescent barrier use (Table 1). using barrier protection with their same survey, 55% of HIV-positive Younger age at first coitus, older secondary partners only. Overall, MSM reported condomless anal sex partner age, history of , most of the study population with a main partner, compared with lower self-esteem, and obesity are (83%–88%) reported never using 41% with a casual partner.25 In predictive of inconsistent use and barrier protection when performing a large Internet study of adolescent nonuse of barrier methods. Longer and receiving digital sex or when MSM, participants reported increased relationship duration is also performing and receiving oral sex. likelihood of condom use with casual predictive of lower barrier-only or

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 146, number 2, August 2020 5 dual-method use but not of overall Preexposure Prophylactic Therapy that nonlatex synthetic condoms were contraceptive use, even after and Barrier Use linked with higher rates of clinical 60 controlling for age. Adolescents For individuals at increased risk for breakage than their latex 74 with main and regular partners tend HIV acquisition (sexually active counterparts. The synthetic (AT-10 to discontinue use of barriers MSM, individuals with an HIV- resin, polyisoprene, polyethylene, or quickly, especially if they are using positive partner, those engaging in ) condoms still provide other pregnancy prevention anal intercourse, those engaging in an acceptable alternative for methods. frequentsexwithoutabarrier,or individuals with allergies, those with a high number of sexual sensitivities, or preferences that Because adolescents have increased partners), the CDC recommends might prevent the consistent use of their use of long-acting reversible preexposure prophylaxis (PrEP) to latex condoms. The polyurethane contraceptive (LARC) methods, there reduce HIV acquisition and condom is not as effective as the latex are concerns about their effects on transmission.63 The US Food and external condom for pregnancy 75 adolescent use of barrier protection. Drug Administration (FDA) has prevention. Synthetic barrier LARCs are considered the best form approved both emtricitabine and methods are compatible with both of contraception for adolescents tenofovir disoproxil fumarate and oil- and water-based lubricants, and wishing to avoid pregnancy, but they emtricitabine and tenofovir although not extensively studied, offer no protection against STIs. An alafenamide for PrEP in adults and synthetic external condoms are analysis of YRBS cross-sectional data adolescents who weigh at least 35 believed to provide STI protection revealed that among 2288 sexually kg.64 TheCDCWebsiteprovides similar to external latex condoms; active female participants, 2% used HIV risk behavior assessment, PrEP however, FDA labeling currently LARCs; 6% used depot clinical practice guidelines, patient restricts their recommended use to medroxyprogesterone acetate and provider education, and tool latex-sensitive or latex-allergic – 76 , the ethinyl estradiol and kits.65 68 PrEP can reduce the risk people. In the United States, the norelgestromin patch, or the of HIV acquisition by 90% when FDA regulates external condoms and and ethinyl estradiol people use it consistently. With the barrier methods (dental dams) ; 22% used oral increase in PrEP use, researchers marketed to prevent STIs as medical contraceptives; 41% used condoms; have documented significant devices, and stringent manufacturing 69–71 12% used withdrawal or another declines in barrier use and standards exist to ensure testing of increases in STIs among MSM each barrier for holes or weak spots method; 16% used no contraceptive 77,78 61 before sale. method; and 2% were not sure. (cisgender males and transgender LARC users were approximately 60% females), suggesting that PrEP users External condoms can be effective less likely to use barriers compared may be engaging in risk against when with oral contraceptive users. compensation. used consistently and correctly. fi fi Authors did not nd signi cant External condom failure rates have differences in condom use between EFFECTIVENESS OF BARRIER METHOD declined significantly since 1995, USE LARC users and depot injection, from 18% to 13% with typical use, patch, or ring users, but LARC users Most studies of barrier method according to the National Survey of were more than twice as likely to effectiveness involve external Family Growth (2006–2010).79 have 2 or more recent sexual partners condoms. External condoms consist Researchers estimate that the compared with oral contraceptive, of 3 types of materials: most (.80%) failure rate of the external condom 61 depot injection, patch, or ring users. are latex (), a small for pregnancy is 2% in 12 months of In a secondary analysis of the percentage (less than 5%) are natural perfect use (ie, 2 pregnancies per Contraceptive Choice Project, authors membrane (lamb cecum), and 100 woman-years).79 The most found that LARC use was associated approximately 15% are synthetic (eg, important noncontraceptive benefit with increased acquisition of an STI polyurethane).72 The CDC only of external condom use is the within the first 12 months after recommends latex and synthetic additional protection against placement compared with no use of condoms for prevention of STIs and acquisition and transmission of LARCs.62 These findings suggest that HIV because natural-membrane STIs, including HIV. If the user adolescents using other contraceptive condoms contain small pores that places the external condom on the methods besides barriers may be may allow for passage of , before genital, oral, anal, or engaging in , the including HIV, virus, and skin contact and uses it throughout adjustment of behavior in response to virus.73 In a recent activity, this should prevent contact perceived level of risk. Cochrane review, authors concluded with , vaginal secretions,

Downloaded from www.aappublications.org/news by guest on September 24, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS saliva, , skin and mucosal intercourse, incomplete use (late Affordable Care Act’smandatefor lesions, and infectious secretions. application and early removal), contraceptive coverage.96 There are External condoms greatly reduce improper use, barrier breakage and no published data on the effects of the risk of STI transmission to or slippage, not using a new barrier this change. from the penile , including when switching from one form Data regarding contraceptive gonorrhea, chlamydia, of sex to another, barrier effectiveness of FC1 internal trichomoniasis, , method–associated erection – condoms suggest that estimated and HIV.80 88 Barrier methods also problems (either during application rates of pregnancy during the first provide protection against STIs or during intercourse), and problems 12 months of perfect use and typical transmitted via skin-to-skin contact with the fit or feel of barriers, use are 5% and 21% respectively; or contact with mucosal surfaces in including problems related to the these pregnancy rates are slightly those covered areas, including size or shape of the barrier or higher than those of the external simplex virus, human discomfort or interference with condom. Although available data papillomavirus, syphilis, and sensation.92,93 suggest that internal condoms may ; all published studies – provide similar degrees of protection refer to the external condom.89 91 The internal condom (formerly against pregnancy and STIs as do The latex condom effectively ) is a loose-fitting latex external male condoms alone, blocked passage of the smallest polyurethane (nitrile) sheath with 2 this conclusion has not been sexually transmitted , flexible polyurethane rings and is the demonstrated, and thus comparative hepatitis B virus, according to only FDA-approved nonpenile research is needed.61 Overall in vitro studies.91 In most studies on barrier method for STI prevention internal condom use accounts for external condom effectiveness, currently available in the United 94 less than 1% of US barrier use vaginal-penile sexual activity is States. The FDA regulates the overall.97 evaluated. Adolescents can also use internal condom as a level III either a latex or synthetic barrier product, on par with medical devices Adolescents may also use dental during anogenital and orogenital such as pacemakers, thus making dams, latex sheets, or improvised intercoursetoreducetherisk manufacturing and distribution more barriers to protect against STIs and of STIs. challenging in the United States. The pregnancy. Published data on the FDA approved the original device effectiveness of these barrier Well-designed epidemiological (brand name FC1) in 1993 and the methods are unavailable, but the CDC studies and those of couples with revised product (brand name FC2) in does provide proper-use information discordant HIV infection status have 2009. In September 2018, the FDA on its Web site.98 revealed that external condoms are petitioned to reclassify the female highly effective against transmission condom as a level II device and of HIV. Researchers conducted renamed it the internal condom.95 EFFORTS AIMED AT INCREASING a meta-analysis of studies comparing BARRIER METHOD USE This proposed change would seroconversion rates among couples increase access to internal barrier In a review of the literature, authors who regularly used external condoms methods in the United States and found contradicting evidence on the and those who used them broaden use, especially when it effectiveness of community- and inconsistently to determine their use comes to the lesbian, gay, bisexual, behavioral-level barrier method and/or effectiveness in preventing transgender, and questioning promotion programs, highlighting the HIV transmission. Results of the community, because an increasing need for further evaluation of analysis revealed that external number of people have begun to use program effectiveness.63,64,99,100 One condoms were 90% to 95% effective this method for nonvaginal large-scale review revealed concern in preventing HIV transmission when intercourse. The FC2 device is the that these programs might hasten the opposite- and same-sex partners used only internal condom available in the initiation of sex, but this concern them consistently.80 United States. Recently, the FC2 appears unfounded.65 In the 52 Given the coital-dependent nature of manufacturer, Veru, decided to take studies measuring timing of initiation barrier methods, the degrees of the FC2 off of pharmacy shelves and of sex, 42% found that sexual consistency and correctness of use make it available exclusively through initiation was significantly delayed influence effectiveness against both prescription with the rationale that for at least 6 months after unintended pregnancy and STIs. by doing so, they would ensure that participation in such a program, and Factors associated with decreased women with health insurance 55% found no effect. There are few effectiveness include failure to use can access them free of charge programs promoting enhanced sexual a barrier with every act of under the Patient Protection and pleasure as a motivating factor, which

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 146, number 2, August 2020 7 has led to increased uptake of barrier barrier methods are most parent or caregiver disproval (66%), methods and safer sex efficacious when combined with potential of upsetting or offending – behaviors.101 103 additional individual, small-group, patients (28%), possibility of or community-level activities. The preventing adolescents from In 2017, the Society for Adolescent intervention effects were significant developing self-reliance (11%), and Health and Medicine published across target participant potential of promoting sexual activity “ apositionstatement, Condom characteristics (youth, adults, (7%). Of those who did not distribute Availability in Schools: A Practical commercial sex workers, STI clinic condoms, the most cited reasons Approach to the Prevention of populations, or male participants). included unsure and had not thought Sexually Transmitted Infection/HIV In a large systematic review of the about it (45%), inconvenience (31%), and Unintended Pregnancy,” literature, authors found that and concern for parent or caregiver recommending increased barrier interventions using constructs of disproval (27%). Ninety percent of method availability at schools.35 the information, motivation, and providers endorsed that they would Theevidenceontheimpactof behavioral skills model were or may be willing to consider office- availability of barrier methods in associated with significant increases based condom distribution if they had schools is inconsistent.104–107 In in condom use or condom-use help with organizing and funding this themostrecentstudyofprograms 115 intentions. Additionally, service. in Massachusetts high schools, interventions that included modules adolescents attending schools to increase self-efficacy for condom To enhance safer sex and proper where barrier methods were use and that taught participants barrier usage, it is important for availableweremorelikelyto where to obtain condoms and how adolescents to receive receive barrier method use to negotiate condom use with comprehensive, evidence-based, and instruction and less likely to report partners or elicit positive medically accurate sexual education lifetime or recent sexual associations (feelings) toward that includes barrier method intercourse, and adolescents who condoms were associated with instruction. A review of states’ were sexually active were twice as increased condom use or intention sexuality education programs likely to use barrier methods at the to use condoms. revealed that 16 states require most recent sexual encounter.108 instruction on barrier methods or Studies have revealed that school Social networks may promote contraception with sexuality or HIV condom programs do not increase barrier use as well. In a study of and/or STI education.122 Additionally, sexual activity, the number of homeless youth, those who had adolescents need affordable access to sexual partners, or risk a condom-using peers reported barrier methods without behaviors.109,110 increased condom use and reduced risky behavior.116 In a large review discrimination or other barriers. Most Likewise, clinic-based interventions of network-based condom barrier methods are sold over the have been effective in increasing intervention strategies, authors of counter in all 50 states and barrier method use and decreasing all studies reported substantial territories, but obstacles persist, 111,112 STIs. The CDC publishes improvement in condom use for the including barriers displayed behind a summary: “Compendium of intervention groups compared with counters or in locked cabinets, store Evidence-Based Interventions and the control groups.117 Social media or pharmacy personnel refusing to Best Practices for HIV platforms also provide information sell to adolescents of certain ages, 113 Prevention.” and promote safer sexual practices, cost, and poor availability in some including barrier use.118 Study neighborhoods. In a recent meta-analysis of high- authors reported small short-term quality US and international studies gains in condom use or of structural-level barrier method consumption but mixed long-term CONCLUSIONS distribution interventions, authors behavioral effectiveness.117,119,120 found significant effects on Recent trends in adolescent and increased barrier method use, Availability of barrier methods in the young adult sexual behavior reveal increased barrier method pediatrician’soffice may reduce that adolescents and young adults acquisition, increased barrier obstacles to use for adolescents, but remain at risk for unintended method carrying, delayed sexual a survey of primary care providers pregnancies, STIs, and HIV. When initiation of youth, and reduced revealed that most do not distribute adolescents and young adults use incidence of STIs.114 The condoms in their practices.121 barrier methods consistently and interventions that increase Providers cited the following risks to correctly, these methods are excellent availability of or accessibility to distribution of condoms: potential for means to reduce the risk of many

Downloaded from www.aappublications.org/news by guest on September 24, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS PAST COMMITTEE MEMBERS STIs, including HIV, and prevent ABBREVIATIONS pregnancy. Cora C. Breuner, MD, MPH, FAAP Laurie L. Hornberger, MD, MPH, FAAP aOR: adjusted odds ratio CDC: Centers for Disease Control and Prevention LEAD AUTHOR LIAISONS FDA: US Food and Drug Laura K. Grubb, MD, MPH, FAAP Anne-Marie Amies, MD – American College Administration of Obstetricians and Gynecologists LARC: long-acting reversible Liwei L. Hua, MD, PhD – American Academy of Child and Adolescent Psychiatry contraceptive COMMITTEE ON ADOLESCENCE, 2019–2020 Seema Menon, MD – North American Society MSM: males who have sex with Elizabeth M. Alderman, MD, FSAHM, FAAP, for Pediatric and Adolescent Gynecology males Chairperson Ellie E. Vyver, MD, FRCPC, FAAP – Canadian PHIV: HIV acquired through peri- Richard J. Chung, MD, FAAP Paediatric Society natal transmission Laura K. Grubb, MD, MPH, FAAP CDR Lauren B. Zapata, PhD, MSPH – Centers PrEP: preexposure prophylaxis Janet Lee, MD, FAAP for Disease Control and Prevention Makia E. Powers, MD, MPH, FAAP STI: sexually transmitted infection Maria H. Rahmandar, MD, FAAP YRBS: Youth Risk Behavior STAFF Krishna K. Upadhya, MD, FAAP Survey Stephenie B. Wallace, MD, FAAP Karen S. Smith

POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 146, number 2, August 2020 13 Barrier Protection Use by Adolescents During Sexual Activity Laura K. Grubb and COMMITTEE ON ADOLESCENCE Pediatrics 2020;146; DOI: 10.1542/peds.2020-007245 originally published online July 20, 2020;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/146/2/e2020007245 References This article cites 87 articles, 6 of which you can access for free at: http://pediatrics.aappublications.org/content/146/2/e2020007245#BI BL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Current Policy http://www.aappublications.org/cgi/collection/current_policy Committee on Adolescence http://www.aappublications.org/cgi/collection/committee_on_adoles cence Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 24, 2021 Barrier Protection Use by Adolescents During Sexual Activity Laura K. Grubb and COMMITTEE ON ADOLESCENCE Pediatrics 2020;146; DOI: 10.1542/peds.2020-007245 originally published online July 20, 2020;

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