Abstinence and abstinence-only education

Educational interventions for promoting sexual and reproductive health in school counselors: a three-arm, randomized control trial comparing lecturing, buzz group and role-play

BACKGROUND AND OBJECTIVE

School-based sexual and reproductive health (SRH) education is often reported as being inadequate and/or inconsistent. This study aimed to investigate the educational interventions for promoting SRH in school counselors and compare the results in three groups: lecturing, buzz group and role-play.

MATERIALS AND METHODS

An intervention quasi-experimental design was employed to evaluate the usefulness of educating SRH topics by using interactive teaching methods for 120 school counselors. Changes in the participants' knowledge, attitudes and self-efficacy toward SRH education were evaluated by each group using a pretest and a posttest.

RESULTS

The results of this study revealed that 75% of counselors deemed SRH training vital and felt that the best SRH educators are health care providers and the reason might be their lack of educational skills. They also stated that the most significant barriers to education in schools include concerns about parental feedback and lack of appropriate abilities.

CONCLUSION

The present study showed that the use of all three methods (lecturing, buzz groups and role-play) in SRH training improves the level of knowledge, attitude and self-efficacy; although role-play could have been more effective than lecturing in improving counselors' knowledge.

Advancing healthcare equity through dissemination and implementation science

OBJECTIVE

To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity.

DATA SOURCES AND STUDY SETTING

This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees.

STUDY DESIGN

This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees.

DATA COLLECTION/EXTRACTION METHODS

We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations.

PRINCIPAL FINDINGS

We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers.

CONCLUSIONS

Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.

Reproductive Rights and Women's Mental Health

Reproductive rights, including access to comprehensive reproductive health care, are essential to the well-being of women and society. The Dobbs decision of the US Supreme Court has greatly exacerbated the confusion, the stress, and the loss of services. Psychiatrists need to know and communicate the strong scientific evidence of the advantages of sex education, contraception, abortion, and bodily autonomy and to help patients process their feelings and make informed decisions about their own care.

Leveraging Comprehensive Sexuality Education as a Tool for Knowledge, Equity, and Inclusion

BACKGROUND

Sexual education programs in the United States are rooted in inequitable structures and are often inadequate at educating marginalized student groups such as students of color, Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+), women, and disabled students.

CONTRIBUTIONS TO THEORY

Current sexual education is irregularly implemented and often excludes or misrepresents the experiences of students with marginalized identities. This theoretical paper specifically discusses ways that sexual education has been harmful or exclusionary for marginalized student groups and how a shift toward making sexual education inclusive and equitable will improve outcomes for students of all identities.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

This paper discusses several recommendations on improving access to equitable sexual health education for all students including reviewing and improving sexual education curriculum and delivery, as well as the need for additional research focused on this topic.

CONCLUSIONS

This article provides an overview on the current sexual education system, its inadequacies, and how comprehensive sexuality education programs can be leveraged as a tool for equity for students of all backgrounds, but particularly those who are underrepresented in sexual education curricula.

Assessment of Jordanian pharmacists' knowledge and perception regarding sexual and reproductive health and their practice in providing sexual counseling to patients

Objective

In this quantitative study, we intended to explore sexual/ reproductive counseling between Jordanian pharmacists by addressing pharmacists' knowledge regarding sexual/ reproductive health and their perception and practice in providing counseling to patients.

Method

This study adopted a survey methodology using a self-completed validated and administered unnamed survey. Participants were asked to fill-out the electronic survey after providing their electronic consent. Social media was utilized to extend the survey to facilitate contact multiple parts of pharmacists' community.

Results

In this study, 200 pharmacists agreed to participate in this study. Most of the pharmacists knew that depression (n= 182, 91%) and alcohol (n=171, 85.5%) were among the main factors that my decrease sexual performance. Also, only 38.5% of the pharmacists (n= 77) agreed that discussing sexual issues is the responsibility pf pharmacists, and only 55% of them (n= 110) felt comfortable discussing patients' sexual matters as any medical issue. Moreover, more than two-third of the pharmacist (n= 146, 73%) reported that if they were consulted about sexual problem, they may explore patients' problem. On the other side, only half of pharmacists (n= 102, 51%) revealed that they may discuss the side effects of prescribed drug if it might affect sexual performance.

Conclusion

Education on sexuality/ reproduction is the key to help Jordanian pharmacists to advance patients' sexual/ reproductive health. In general, research on sexual/ reproductive health in conservative societies is limited. Therefore, additional surveys that include the perspectives of both patients and pharmacists on sexuality/ reproduction to augment this normally ignored aspect of health are necessary.

Factors influencing the integration of comprehensive sexuality education into educational systems in low- and middle-income countries: a systematic review

BACKGROUND

Comprehensive sexuality education (CSE) plays a critical role in promoting youth and adolescent's sexual and reproductive health and wellbeing. However, little is known about the enablers and barriers affecting the integration of CSE into educational programmes. The aim of this review is to explore positive and negative factors influencing the integration of CSE into national curricula and educational systems in low- and middle-income countries.

METHODS

We conducted a systematic literature review (January 2010 to August 2022). The results accord with the Preferred Reporting Items for Systematic Reviews and Meta-analysis standards for systematic reviews. Data were retrieved from the PubMed, Cochrane, Google Scholar, and Web of Hinari databases. The search yielded 442 publications, of which 34 met the inclusion criteria for full-text screening. The review is guided by an established conceptual framework that incorporates the integration of health innovations into health systems. Data were analysed using a thematic synthesis approach.

RESULTS

The magnitude of the problem is evidenced by sexual and reproductive health challenges such as high teenage pregnancies, early marriages, and sexually transmitted infections. Awareness of these challenges can facilitate the development of interventions and the implementation and integration of CSE. Reported aspects of the interventions include core CSE content, delivery methods, training materials and resources, and various teacher-training factors. Reasons for adoption include perceived benefits of CSE, experiences and characteristics of both teachers and learners, and religious, social and cultural factors. Broad system characteristics include strengthening links between schools and health facilities, school and community-based collaboration, coordination of CSE implementation, and the monitoring and evaluation of CSE. Ultimately, the availability of resources, national policies and laws, international agendas, and political commitment will impact upon the extent and level of integration.

CONCLUSION

Social, economic, cultural, political, legal, and financial contextual factors influence the implementation and integration of CSE into national curricula and educational systems. Stakeholder collaboration and involvement in the design and appropriateness of interventions is critical.

The Need for Earlier Implementation of Comprehensive Sexual Education Within a Formal Classroom Setting and Beyond Based on the Influences of Technology

Abstinence-only education taught predominately via formal classroom instruction has continuously been emphasized throughout history and in classrooms today. Although abstinence-only methods are often stressed, contraceptive education is occasionally but not consistently implemented in school curricula. A variety of other instructional delivery methods include student-peer education, education outside of the formal classroom setting, community youth service programs, education via telehealth, educational videos, self-study websites and social media. Providing comprehensive sexual education utilizing multiple instructional delivery methods could close the gap in sexual education for adolescents.

The age at which sexual education instruction is introduced has remained relatively unchanged throughout history. Adolescents are being formally educated within classrooms as early as grade five, although they are often exposed to informal and potentially misleading information regarding sexual education much earlier than this. In part, this is due to the relatively recent emergence and subsequent influence of technology such as social media. Thus, given the influence of technology such as social media in recent history we need to reevaluate the age of formal sexual education and increase comprehensive sexual education resources.

Additionally, it is important to note that sexual education instruction provided solely in formal classroom settings may not provide sufficient information for youth to make informed decisions. Thus, sexual education information including abstinence and contraceptive methods should be provided through additional means via utilizing differing instructional delivery methods in conjunction with formal classroom instruction. For example, comprehensive sexual education should also be provided in healthcare offices including pediatric and obstetrics and gynecology (OBGYN) offices. Sexual education could include discussing/providing external resources such as pamphlets that incorporate social media and other links to online resources that provide a more inclusive, accurate educational experience within a safe environment. This would allow healthcare professionals to provide a better targeted and engaging educational experience to adolescents as well as proactively allow for exposure of younger adolescents to helpful educational resources.

Sexual and reproductive health-related knowledge, attitudes and support network of Italian adolescents

Objectives

What is the state of sexual and reproductive health (SRH) knowledge among teens? What about adolescents’ attitudes toward SRH and the available supporting network?

Study design

A cross-sectional study conducted between April and May 2018.

Methods

An anonymous 36-item questionnaire on SRH knowledge, behaviors, and networks was developed, revised and validated by a multidisciplinary health professional team, then distributed to high school students in Udine (Italy).

Results

747 questionnaires were collected in five high schools; respondents were predominantly male, mean age 14.8 years; 48% of students have sufficient SRH knowledge (considered as above the mean value). Factors associated with higher knowledge levels were female sex, age, SES according to father's profession, first SRH information at age 11–13, Italy as country of origin, and attendance at a technical school.

Conclusions

Students’ knowledge on SHR resulted relatively poor. Sex, school type and previous experience of sexuality education were the most important factor associated with SRH knowledge.

A scoping review of de-implementation frameworks and models

BACKGROUND

Reduction or elimination of inappropriate, ineffective, or potentially harmful healthcare services and public health programs can help to ensure limited resources are used effectively. Frameworks and models (FM) are valuable tools in conceptualizing and guiding the study of de-implementation. This scoping review sought to identify and characterize FM that can be used to study de-implementation as a phenomenon and identify gaps in the literature to inform future model development and application for research.

METHODS

We searched nine databases and eleven journals from a broad array of disciplines (e.g., healthcare, public health, public policy) for de-implementation studies published between 1990 and June 2020. Two raters independently screened titles and abstracts, and then a pair of raters screened all full text records. We extracted information related to setting, discipline, study design, methodology, and FM characteristics from included studies.

RESULTS

The final search yielded 1860 records, from which we screened 126 full text records. We extracted data from 27 articles containing 27 unique FM. Most FM (n = 21) were applicable to two or more levels of the Socio-Ecological Framework, and most commonly assessed constructs were at the organization level (n = 18). Most FM (n = 18) depicted a linear relationship between constructs, few depicted a more complex structure, such as a nested or cyclical relationship. Thirteen studies applied FM in empirical investigations of de-implementation, while 14 articles were commentary or review papers that included FM.

CONCLUSION

De-implementation is a process studied in a broad array of disciplines, yet implementation science has thus far been limited in the integration of learnings from other fields. This review offers an overview of visual representations of FM that implementation researchers and practitioners can use to inform their work. Additional work is needed to test and refine existing FM and to determine the extent to which FM developed in one setting or for a particular topic can be applied to other contexts. Given the extensive availability of FM in implementation science, we suggest researchers build from existing FM rather than recreating novel FM.

REGISTRATION

Not registered.

Association between First Sexual Intercourse and Sexual Violence Victimization, Symptoms of Depression, and Suicidal Behaviors among Adolescents in the United States: Findings from 2017 and 2019 National Youth Risk Behavior Survey

The objective of this study was to investigate the association between first sexual intercourse and sexual violence victimization, symptoms of depression, and suicidal ideation among sexually active adolescents in the United States. Data for this study came from the U.S. 2017 and 2019 iterations of the National Youth Risk Behavior Survey. An analytic sample of 6252 adolescents aged 14–18 years old (49.5% female) who reported ever having sexual intercourse was analyzed using Poisson regression. The outcome variables investigated in this study were sexual violence victimization, symptoms of depression, suicidal ideation, a suicide plan, and suicide attempts, and the main explanatory variables were age at first sexual intercourse and forced sexual intercourse. We also analyzed differences by gender and race. Of the 6252 adolescents who reported ever having sexual intercourse, 7.1% had their first sexual intercourse before age 13, and 14.8% experienced forced sexual intercourse. About 16% of adolescents experienced sexual violence during the past year, 42.6% reported symptoms of depression, 23.9% experienced suicidal ideation, 19.3% made a suicide plan, and 11.1% attempted suicide during the past year. In the regression analysis, early sexual intercourse was significantly and positively associated with suicidal ideation (relative risk (RR) = 1.15, 95% Confidence Interval (CI) = 1.02–1.30), suicide plan (RR = 1.18, 95% CI = 1.00–1.38), and suicide attempts (RR = 1.36, 95% CI = 1.15–1.61). Controlling for the effects of covariates, history of forced sexual intercourse was positively associated with the five outcomes examined with the relative risk ranging between 1.59 and 6.01. Findings of this study suggest that history of early or forced sexual intercourse is associated with poor mental health outcomes among adolescents and underscores the importance of developing interventions that offer psychological support in reducing the adverse impact of early sexual intercourse and forced sexual intercourse on adolescent health.

Reproductive Rights and Women's Mental Health: Essential Information for the Obstetrician-Gynecologist

Reproductive health care is crucial to women's well-being and that of their families. State and federal laws restricting access to contraception and abortion in the United States are proliferating. Often the given rationales for these laws state or imply that access to contraception and abortion promote promiscuity, and/or that abortion is medically dangerous and causes a variety of adverse obstetric, medical, and psychological sequelae. These rationales lack scientific foundation. This article provides the evidence for the safety of abortion, for both women and girls, and encourages readers to advocate against restrictions.

Epistles of dyspareunia: storying Christian women's experiences of painful sex

Dyspareunia is painful attempted or completed vaginal-penile intercourse, and vaginal pain from other forms of touch. Because there is a persistent underlying message of shame and taboo surrounding female sexual pleasure in some Christian-informed cultural contexts, we sought to examine how self-identified Christian women in the Midsouthern USA conceptualise and experience dyspareunia. Data were collected through initial surveys and semi-structured interviews and analysed using incident-to-incident and in-vivo coding. Creative Analytic Practice was used to create composite character narratives from the data, storying five aspects of participants' experiences: (1) ignorance and abstinence at home, church, and school; (2) socially-informed expectations of sex and painful realities; (3) making sense of, coping with, and seeking help for painful sex; (4) validation, diagnosis, and treatment; and (5) sex mis-education and desire for a different future. Findings suggest that participants' understandings of and coping with their sexuality and the accompanying painful sex are shaped by implicit and explicit religious messages they encountered in their family upbringing, schooling, social and religious circles, and interactions with healthcare providers. Health professionals are urged to pre-screen women for symptoms of dyspareunia and include sexual wellness checks as routine procedure, and subsequently refer patients to pelvic health physical therapy when appropriate.

Experiences of teachers and community health workers implementing sexuality and life skills education in youth clubs in Zambia

Zambia, like other low- and middle-income countries, faces numerous adolescent sexual and reproductive health challenges such as teenage pregnancies. This study aimed at understanding teachers' and community health workers' (CHWs) implementation of comprehensive sexuality education (CSE) as part of a comprehensive support package for adolescent girls to prevent early childbearing. Data collected using in-depth interviews [n = 28] with teachers [n = 15] and community health workers [n = 13] were analysed using thematic analysis. The teachers and CHWs reported that the use of participatory approaches and collaboration between them in implementing CSE enabled them to increase girls' and boys' participation youth clubs. However, some teachers and CHWs experienced practical challenges with the manuals because some concepts were difficult to understand and translate into local language. The participants perceived that the youth club increased knowledge on CSE, assertiveness and self-esteem among the learners. Training and providing a detailed teaching manual with participatory approaches for delivering CSE, and collaborative teaching enabled teachers and CHWs to easily communicate sensitive SRH topics to the learners. However, for the adoption of CSE to be even more successful, piloting of the curriculum with local facilitators and translating the manuals into the local languages before they are implemented, is recommended.

La sexualité pendant la pandémie COVID-19 – de l’importance d’Internet

Le coronavirus est une maladie infectieuse qui a affecté de nombreux pays. Pour les couples, les contacts physiques ont diminué et la vie sexuelle en a été altérée. Une sexualité sans risque implique de savoir comment éviter la transmission du virus. La distance physique crée de l’irritabilité, de la peur, et menace la vie sexuelle : il est raisonnable pour un couple vivant sous le même toit d’avoir des relations sexuelles sauf si l’un d’entre eux présentent un risque d’infection. Tous les couples confinés séparément n’ont pas nécessairement envie d’avoir des relations sexuelles en ligne et pour les personnes qui ne sont pas en couple, il est difficile de s’engager dans des relations sexuelles récréatives. En dépit de cela, la pandémie permet d’envisager une nouvelle intimité sexuelle utilisant des sex toys et de la technologie. L’utilisation d’internet pour maintenir une activité sexuelle active semble avoir été une excellente alternative pour pallier la distance physique entre les partenaires. Le conseil le plus couramment donné aux membres de couples confinés seuls était de maintenir un contact électronique constant pour atténuer la nostalgie et compenser le manque d’activité sexuelle. Ceci entraîna l’essor des sextos, des rencontres par webcam ou des appels téléphoniques érotiques contribuant à la désinhibition des couples. L’utilisation de la webcam, associée à l’utilisation de sex toys, permet également d’enrichir le répertoire sexuel. La pratique du sexe en ligne avec le partenaire stable ne vivant pas sous le même toit a aidé certaines personnes à maintenir leur désir et à le satisfaire et préserver celui-ci intact en vue de la fin de la pandémie. L’objectif de ce travail est de passer en revue les données disponibles sur la sexualité pendant les pandémies COVID-19 et de fournir des recommandations pour aider la population à vivre et préserver sa sexualité dans cette période critique.

Sexuality during the COVID-19 pandemic: The importance of Internet

Coronavirus is an infectious disease that has affected many countries, changing daily life. For many individuals, sexual activity has decreased, physical contact within couples has been reduced. Obviously, to maintain a safe sex life, it is essential to know how to avoid the virus transmission. Distance creates irritability, fear, anxiety, endangering sexual life: it is reasonable to have sex between cohabiting partners unless one or both are at risk of infection. Despite this, the pandemic allows us to think of new sexual intimacies mediated by sextoys and technology. Not all distant couples are willing to have sex online, and it is difficult for singles to engage in casual sexual relations, so after the pandemic there will be many couples who will have to remodel and many singles who will seek a partner. Using the Internet to maintain active sexual activity appeared to be an excellent alternative to diminish the distance between partners or to increase online knowledge. The most common advice for separated couples was to maintain constant digital contact to alleviate nostalgia and lack. This was the springboard to use sexting, meeting via webcam or making a hot call that make the couple more uninhibited. Using the webcam, also sometimes with the possibility to use sex toys, could create also the opportunity to enrich the future sexual repertoire. Practicing online sex with the stable partner far from home has helped some to keep their desire active and to satisfy it in order to be able to realize it once the pandemic has ended. The purpose of this narrative review of available evidence on sexuality during COVID-19 pandemics is to provide recommendations to help people facing their sexual life in this critical period.

Early sexual debut: A multi-country, sex-stratified analysis in sub-Saharan Africa

This study examined outcomes associated with early sexual debut in five sub-Saharan African countries for males and females, separately. We employed Violence Against Children Surveys (VACS) from Kenya, Malawi, Nigeria, Tanzania, and Uganda, restricting samples to males and females age 18-24 years. Early sexual debut was defined as having one's first sexual intercourse before 15. Logistic, Ordinary Least Squares, and Poisson regressions were utilised to estimate associations between early sexual debut and outcomes across four ecological domains: individual, family, peer/partner, and community. Regressions were stratified by sex. The prevalence of early sexual debut ranged from 8.6% in Tanzania to 17.7% in Malawi. Males were more likely to report early sexual debut in Kenya (16.3%, compared to 6.7% for females; P < 0.001) and Uganda (15%, compared to 10.4% for females; P = 0.037). In Nigeria, 14.5% of females reported early sexual debut, compared to 5.4% of males (P < 0.001). Early sexual debut was associated with only one outcome in the individual and family domains, and was most consistently associated with outcomes in the peer/partner domain. Differences in these relationships for males and females suggest programs and policies working to reduce early sexual debut and promote healthy sexual relationships among young adolescents should thoughtfully consider framing messaging through a gendered lens.

Sexual Health in the SARS-CoV-2 Era

Sexual contact carries some risk for exposure to infection with severe acute respiratory syndrome coronavirus 2 during the coronavirus disease 2019 pandemic. This commentary provides clinicians with guidance on how to address sexual health and activity with patients in this context.

Changes in Sex Life among People in Taiwan during the COVID-19 Pandemic: The Roles of Risk Perception, General Anxiety, and Demographic Characteristics

This study used data collected from an online survey study on coronavirus disease 2019 (COVID-19) in Taiwan to examine changes in sex life during the pandemic and the factors affecting such changes. In total, 1954 respondents were recruited from a Facebook advertisement. The survey inquired changes in sex life during the pandemic, including satisfaction with the individual’s sex life, frequency of sexual activity, frequency of sex-seeking activity, and frequency of using protection for sex. The associations of change in sex life with risk perception of COVID-19, general anxiety, gender, age, and sexual orientation were also examined. For each aspect of their sex life, 1.4%–13.5% of respondents reported a decrease in frequency or satisfaction, and 1.6%–2.9% reported an increase in frequency or satisfaction. Risk perception of COVID-19 was significantly and negatively associated with frequencies of sexual and sex-seeking activities. Higher general anxiety was significantly and negatively associated with satisfaction of sex life and frequencies of sexual and sex-seeking activities. Sexual minority respondents were more likely to report decreased satisfaction with sex life and frequencies of sexual activity and sex-seeking activities during COVID-19. Health care providers should consider these factors when developing strategies for sexual wellness amid respiratory infection epidemics.

Sexuality, sexual well being, and intimacy during COVID-19 pandemic: An advocacy perspective

The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome (SARS)-CoV-2, has emerged as a global public health threat. The implications are much beyond just health crisis, and it has long-lasting psychosocial and economic implications. Although the psychological offshoots such as depression, anxiety, posttraumatic stress, and sleep disturbances are being studied in-depth, there is a dearth of literature on the sexual well-being and sexual practices during this pandemic. Considering the physical distancing; travel restrictions; the high human-human transmission rate; misinformation and uncertainty about the sexual routes of transmission for SARS-CoV-2; and fear about intimacy, sexuality, and safe sexual practices have increased significantly. This is more prominent in newly settled or distanced couples and the frontline health workers, with increased risk exposure to the virus. For them, guilt and distress associated with sexual relationships might increase primary psychiatric and sexual disorders. This, in turn, impacts relationships and emotional bonding in couples and affects healthy coping during the pandemic crisis. Although sexual abstinence is the safest practice to prevent transmission, it is not practically feasible in all cases. Risk reduction counseling, sex with quarantined partners, and digital sex are other options that are worth exploring. There are additional concerns of digital safety, unhealthy use of technology, cyber-crimes, and online extortion. Keeping this in the background, this advocacy article glances through the effects of past outbreaks on sexuality, reviews the current recommendations, and proposes methods and approaches for sexual well-being during the COVID-19 pandemic, which is vital for overall public health.

The Impact of Sociosexualization and Sexual Identity Development on the Sexual Well-Being of Youth Formerly in the Foster Care System

PURPOSE

Youth in the child welfare system experience disproportionate rates of negative sexual health outcomes as well as increased engagement in risky sexual behaviors. This study explored the impact of sociosexualization and sexual identity development on the sexual well-being of youth formerly in the foster care system.

METHODS

Two hundred and nineteen youth formerly in the foster care system completed an Internet-based survey, including measures of the level of sexuality-related topics discussion, relationship quality with the individual with whom the topics were discussed, adverse childhood experiences, severity of sexual abuse history, sexual identity development, and sexual well-being. Hierarchical regressions examined the impact of youths' sociosexualization experiences and four domains of sexual identity development on their sexual well-being.

RESULTS

Sexual Identity Commitment was the strongest positive predictor of youths' sexual well-being (β = .428) followed by Sexual Identity Synthesis/Integration (β = .350) and Sexual Identity Exploration (β = .169). Sexual Orientation Identity Uncertainty negatively impacted sexual well-being (β = -.235), as did adverse childhood experiences (β range = -.150 to -.178) and sexual abuse severity (β range = -.208 to -.322). Sexuality-related discussions with foster parents negatively impacted youths' sexual well-being, whereas discussions with peers were a positive predictor.

CONCLUSION

Enhancing youths' sexual identity development and reducing the impact of traumatic experience are critical to improving sexual well-being. The influence of sexuality-related discussions on sexual well-being requires further analysis as impacts varied widely. Public policies should provide guidance to professionals on what services should be provided to enhance youths' sexual development.

Variable Implementation of Sexuality Education in Three Nigerian States

In 2003, Nigeria adopted the Family Life and HIV Education (FLHE) sexuality education curriculum. Our analysis interrogates variation in sub-national implementation. We conducted 52 interviews with persons knowledgeable about the curriculum in three states-Kano, Lagos, and Niger-and reviewed publications on FLHE. In Kano, the socio-cultural context impeded implementation, but the persistence of innovative local champions resulted in some success. In Lagos, the cosmopolitan context, effective champions, funding by international donors, and a receptive government bureaucracy led to successful implementation. In Niger, despite a relatively conservative socio-cultural context, state bureaucratic bottlenecks overwhelmed proponents' efforts. In summary, the interaction of socio-cultural context, domestic champions, adaptive capacity of state bureaucracies, and international funders explains variable implementation of FLHE. The Nigerian experience highlights the need for sexuality education proponents to anticipate and prepare for local opposition and bureaucratic barriers.

State-Mandated (Mis)Information and Women's Endorsement of Common Abortion Myths

PURPOSE

The extent that state-mandated informed consent scripts affect women's knowledge about abortion is unknown. We examine women's endorsement of common abortion myths before and after receiving state-mandated information that included accurate and inaccurate statements about abortion.

METHODS

In Utah, women presenting for an abortion information visit completed baseline surveys (n = 494) and follow-up interviews 3 weeks later (n = 309). Women answered five items about abortion risks, indicating which of two statements was closer to the truth (as established by prior research) or responding "don't know." We developed a continuous myth endorsement scale (range, 0-1) and, using multivariable regression models, examined predictors of myth endorsement at baseline and change in myth endorsement from baseline to follow-up.

RESULTS

At baseline, many women reported not knowing about abortion risks (range, 36%-70% across myths). Women who were younger, non-White, and had previously given birth but not had a prior abortion reported higher myth endorsement at baseline. Overall, myth endorsement decreased after the information visit (0.37-0.31; p < .001). However, endorsement of the myth that was included in the state script-describing inaccurate risks of depression and anxiety-increased at follow-up (0.47-0.52; p < .05).

CONCLUSIONS

Lack of knowledge about the effects of abortion is common. Knowledge of information that was accurately presented or not referenced in state-mandated scripts increased. In contrast, inaccurate information was associated with decreases in women's knowledge about abortion, violating accepted principles of informed consent. State policies that require or result in the provision of inaccurate information should be reconsidered.

Timing of First Sexual Intercourse and Young Adult Health Outcomes

PURPOSE

To examine how age of onset of sexual intercourse is associated with past-year and lifetime sexually transmitted infections (STIs) and depression in young adulthood.

METHODS

We examined how occurrence of a lifetime and past-year STI, lifetime diagnosis of depression, and past-week depressive symptoms differed as a function of age of onset of sexual intercourse using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health; N = 8,938 individuals). Time-varying effect models were used to examine how age of onset, measured as continuous age, was associated with these outcomes in young adulthood, with all analyses stratified to examine gender differences.

RESULTS

Individuals who engaged in first intercourse before age 16 reported higher than average rates of all outcomes studied; for example, an estimated 35% of women and 12% of men who initiated at age 14 years reported a lifetime STI, compared with about 5% of those who initiated at age 24 years. Timing of first intercourse past the mid-twenties was associated with lower than average rates of STIs and lifetime depression diagnoses but was associated with a somewhat higher level of past-year depressive symptoms. Patterns were similar by gender, although there was little difference in men's depression diagnoses by age of onset.

CONCLUSIONS

Results suggest that sexual intercourse before age 16 years may be associated with higher rates of STIs and depression. Findings provide support for comprehensive programs that both promote delay of first intercourse and provide safe sex and psychological support for those who initiate early.

Timing of First Sexual Intercourse and Young Adult Health Outcomes

PURPOSE

To examine how age of onset of sexual intercourse is associated with past-year and lifetime sexually transmitted infections (STIs) and depression in young adulthood.

METHODS

We examined how occurrence of a lifetime and past-year STI, lifetime diagnosis of depression, and past-week depressive symptoms differed as a function of age of onset of sexual intercourse using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health; N = 8,938 individuals). Time-varying effect models were used to examine how age of onset, measured as continuous age, was associated with these outcomes in young adulthood, with all analyses stratified to examine gender differences.

RESULTS

Individuals who engaged in first intercourse before age 16 reported higher than average rates of all outcomes studied; for example, an estimated 35% of women and 12% of men who initiated at age 14 years reported a lifetime STI, compared with about 5% of those who initiated at age 24 years. Timing of first intercourse past the mid-twenties was associated with lower than average rates of STIs and lifetime depression diagnoses but was associated with a somewhat higher level of past-year depressive symptoms. Patterns were similar by gender, although there was little difference in men's depression diagnoses by age of onset.

CONCLUSIONS

Results suggest that sexual intercourse before age 16 years may be associated with higher rates of STIs and depression. Findings provide support for comprehensive programs that both promote delay of first intercourse and provide safe sex and psychological support for those who initiate early.

Sexuality Education for Children and Adolescents

The purpose of this clinical report is to provide pediatricians updated research on evidence-based sexual and reproductive health education conducted since the original clinical report on the subject was published by the American Academy of Pediatrics in 2001. Sexuality education is defined as teaching about human sexuality, including intimate relationships, human sexual anatomy, sexual reproduction, sexually transmitted infections, sexual activity, sexual orientation, gender identity, abstinence, contraception, and reproductive rights and responsibilities. Developmentally appropriate and evidence-based education about human sexuality and sexual reproduction over time provided by pediatricians, schools, other professionals, and parents is important to help children and adolescents make informed, positive, and safe choices about healthy relationships, responsible sexual activity, and their reproductive health. Sexuality education has been shown to help to prevent and reduce the risks of adolescent pregnancy, HIV, and sexually transmitted infections for children and adolescents with and without chronic health conditions and disabilities in the United States.

Barriers to HIV Testing Among Young Men Who Have Sex With Men (MSM): Experiences from Clark County, Nevada

Clark County, Nevada had a 52% increase in newly diagnosed HIV infections in young people age 13-24 with 83% of the new diagnoses in this age group being men who have sex with men (MSM). HIV testing and counseling is critical for HIV prevention, care and treatment, yet young people are the least likely to seek HIV testing. The purpose of this study was to identify barriers and facilitators to HIV testing experienced by young MSM in Clark County, Nevada. We conducted a qualitative focus group discussion to identify barriers and facilitators to HIV testing among eleven young MSM in March, 2015. The primary barrier to HIV testing identified by the group was a lack of awareness or knowledge about testing for HIV. Other barriers within the person included: fear of results, fear of rejection, and fear of disclosure. Barriers identified within the environment included: access issues, stigma, and unfriendly test environments for young people. In addition to increasing awareness, intervention to increase HIV testing among MSM young people should incorporate access to testing in environments where the adolescents are comfortable and which reduces stigma. HIV testing sites should be convenient, accessible and young person/gay friendly.

Do State-Based Policies Have an Impact on Teen Birth Rates and Teen Abortion Rates in the United States?

OBJECTIVES

The United States has one of the highest teen birth rates among developed countries. Interstate birth rates and abortion rates vary widely, as do policies on abortion and sex education. The objective of our study is to assess whether US state-level policies regarding abortion and sexual education are associated with different teen birth and teen abortion rates.

METHODS

We carried out a state-level (N = 51 [50 states plus the District of Columbia]) retrospective observational cross-sectional study, using data imported from the National Vital Statistics System. State policies were obtained from the Guttmacher Institute. We used descriptive statistics and regression analysis to study the association of different state policies with teen birth and teen abortion rates.

RESULTS

The state-level mean birth rates, when stratifying between policies protective and nonprotective of teen births, were not statistically different-for sex education policies, 39.8 of 1000 vs 45.1 of 1000 (P = .2187); for mandatory parents' consent to abortion 45 of 1000, vs 38 of 1000 when the minor could consent (P = .0721); and for deterrents to abortion, 45.4 of 1000 vs 37.4 of 1000 (P = .0448). Political affiliation (35.1 of 1000 vs 49.6 of 1000, P < .0001) and ethnic distribution of the population were the only variables associated with a difference between mean teen births. Lower teen abortion rates were, however, associated with restrictive abortion policies, specifically lower in states with financial barriers, deterrents to abortion, and requirement for parental consent.

CONCLUSION

While teen birth rates do not appear to be influenced by state-level sex education policies, state-level policies that restrict abortion appear to be associated with lower state teen abortion rates.

HIV testing and linkage to services for youth

Introduction

HIV testing is the portal to serostatus knowledge that can empower linkage to care for HIV treatment and HIV prevention. However, young people's access to HIV testing is uneven worldwide. The objective of this paper is to review the context and concerns faced by youth around HIV testing in low- as well as high-income country settings.

Discussion

HIV testing is a critical entry point for primary and secondary prevention as well as care and treatment for young people including key populations of vulnerable youth. We provide a framework for thinking about the role of testing in the continuum of prevention and care for young people. Brief case study examples from Kenya and the US illustrate some of the common barriers and issues involved for young people.

Conclusions

Young people worldwide need more routine access to HIV testing services that effectively address the developmental, socio-political and other issues faced by young women and men.

Does state-level context matter for individuals' knowledge about abortion, legality and health? Challenging the 'red states v. blue states' hypothesis

Recently, the hypothesis that state-level political context influences individuals' cultural values--the 'red states v. blue states' hypothesis--has been invoked to explain the hyper-polarisation of politics in the USA. To test this hypothesis, we examined individuals' knowledge about abortion in relation to the political context of their current state of residence. Drawing from an internet-survey of 586 reproductive-age individuals in the USA, we assessed two types of abortion knowledge: health-related and legality. We found that state-level conservatism does not modify the existing relationships between individual predictors and each of the two types of abortion knowledge. Hence, our findings do not support the 'red states' versus 'blue states' hypothesis. Additionally, we find that knowledge about abortion's health effects in the USA is low: 7% of our sample thought abortion before 12 weeks gestation was illegal.

School based sex education and HIV prevention in low- and middle-income countries: a systematic review and meta-analysis

OBJECTIVES

School-based sex education is a cornerstone of HIV prevention for adolescents who continue to bear a disproportionally high HIV burden globally. We systematically reviewed and meta-analyzed the existing evidence for school-based sex education interventions in low- and middle-income countries to determine the efficacy of these interventions in changing HIV-related knowledge and risk behaviors.

METHODS

We searched five electronic databases, PubMed, Embase, PsycInfo, CINAHL, and Sociological Abstracts, for eligible articles. We also conducted hand-searching of key journals and secondary reference searching of included articles to identify potential studies. Intervention effects were synthesized through random effects meta-analysis for five outcomes: HIV knowledge, self-efficacy, sexual debut, condom use, and number of sexual partners.

RESULTS

Of 6191 unique citations initially identified, 64 studies in 63 articles were included in the review. Nine interventions either focused exclusively on abstinence (abstinence-only) or emphasized abstinence (abstinence-plus), whereas the remaining 55 interventions provided comprehensive sex education. Thirty-three studies were able to be meta-analyzed across five HIV-related outcomes. Results from meta-analysis demonstrate that school-based sex education is an effective strategy for reducing HIV-related risk. Students who received school-based sex education interventions had significantly greater HIV knowledge (Hedges g = 0.63, 95% Confidence Interval (CI): 0.49-0.78, p<0.001), self-efficacy related to refusing sex or condom use (Hedges g = 0.25, 95% CI: 0.14-0.36, p<0.001), condom use (OR = 1.34, 95% CI: 1.18-1.52, p<0.001), fewer sexual partners (OR = 0.75, 95% CI:0.67-0.84, p<0.001) and less initiation of first sex during follow-up (OR = 0.66, 95% CI: 0.54-0.83, p<0.001).

CONCLUSIONS

The paucity of abstinence-only or abstinence-plus interventions identified during the review made comparisons between the predominant comprehensive and less common abstinence-focused programs difficult. Comprehensive school-based sex education interventions adapted from effective programs and those involving a range of school-based and community-based components had the largest impact on changing HIV-related behaviors.

Discussions of adolescent sexuality in news media coverage of the HPV vaccine

Given the sexually transmitted nature of human papillomavirus (HPV), some worry the HPV vaccine will create a false sense of security and promote adolescent sexual activity. Media coverage of vaccines can influence social norms, parental attitudes, and vaccine acceptance; in this paper we examine U.S. news media messages related to sexuality and HPV vaccination. Drawing on a structured analysis of 447 articles published during 2005-2009, we qualitatively analyzed a purposive sample of 49 articles discussing adolescent health behaviors related to HPV vaccination. Commonly, articles discussed vaccination in the context of abstinence-only versus comprehensive sexual health education; cited research findings to support vaccination or sex education; argued against connecting vaccination to promiscuous behavior; but included fear-inducing messages. Media messages concerning health behaviors related to HPV vaccination tended to support government and parental involvement in sex education, and dismiss concerns linking vaccination to sexual activity, while also presenting the vaccine as lifesaving.

The evolving sexual health paradigm: transforming definitions into sexual health practices

Sexual health is an evolving paradigm that integrates a positive approach to sexuality with existing public health policy and practice for reducing the burdens of sexually transmitted infections, including those due to HIV. The sexual health paradigm rests in commitment to sexual rights, sexual knowledge, sexual choice, and sexual pleasure, as well as key elements of sexuality addressed by sexual desire, sexual arousal, and sexual function, and sexual behaviors. The sexual health paradigm offers new approaches to supporting general health and well being while reducing the burdens of sexual diseases and their consequences.

Puberty and adolescent sexuality

This article is part of a Special Issue "Puberty and Adolescence". Sexuality emerges as a major developmental element of puberty and the adolescent years that follow. However, connecting the sexuality that emerges with puberty and elements of adult sexuality is difficult because much adolescent sexuality research addresses the transition to partnered sexual behaviors (primarily coitus) and consequences such as unplanned pregnancy and sexually transmitted infections. This review proposes a framework of an expanded understanding of puberty and adolescent sexuality from the perspective of four hallmarks of adult sexuality: sexual desire; sexual arousal; sexual behaviors; and, sexual function. This approach thus addresses important gaps in understanding of the ontogeny of sex and the continuum of sexuality development from adolescence through the adult lifespan.

Combination prevention: new hope for stopping the epidemic

HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, "treatment as prevention" for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

The HIV Epidemic: High-Income Countries

The HIV epidemic in higher-income nations is driven by receptive anal intercourse, injection drug use through needle/syringe sharing, and, less efficiently, vaginal intercourse. Alcohol and noninjecting drug use increase sexual HIV vulnerability. Appropriate diagnostic screening has nearly eliminated blood/blood product-related transmissions and, with antiretroviral therapy, has reduced mother-to-child transmission radically. Affected subgroups have changed over time (e.g., increasing numbers of Black and minority ethnic men who have sex with men). Molecular phylogenetic approaches have established historical links between HIV strains from central Africa to those in the United States and thence to Europe. However, Europe did not just receive virus from the United States, as it was also imported from Africa directly. Initial introductions led to epidemics in different risk groups in Western Europe distinguished by viral clades/sequences, and likewise, more recent explosive epidemics linked to injection drug use in Eastern Europe are associated with specific strains. Recent developments in phylodynamic approaches have made it possible to obtain estimates of sequence evolution rates and network parameters for epidemics.

Obstetrician-gynecologists' beliefs about safe-sex and abstinence counseling

OBJECTIVE

To examine obstetrician-gynecologists' beliefs about safe-sex and abstinence counseling.

METHODS

Between October 2008 and January 2009, a survey was mailed to a national randomized sample of 1800 practicing US obstetrician-gynecologists. Study variables were agreement with 2 statements. (1) "If physicians counsel patients about safe-sex practices, the patients will be less likely to engage in risky sexual behaviors". (2) "If physicians counsel patients about abstinence, the patients will be much less likely to engage in sexual activity". Covariates included demographic, clinical, and religious characteristics of the physician.

RESULTS

The response rate was 66% (1154/1760 eligible physicians). Most respondents somewhat (62%) or strongly (25%) agreed that counseling patients about safe-sex practices makes patients less likely to engage in risky sexual behaviors. Fewer agreed strongly (3%) or somewhat (28%) that counseling patients about abstinence makes patients less likely to engage in sexual activity. The belief that safe-sex counseling reduces risky behaviors was less common among males (odds ratio [OR] 0.6) and more common among immigrants (OR 2.0). Religious physicians were more likely to believe that abstinence counseling reduces sexual activity (OR 2.2-5.3).

CONCLUSIONS

Most obstetrician-gynecologists believed that counseling about safe sex is effective, and a significant minority endorsed abstinence counseling.

Obstetrician-gynecologists' views on contraception and natural family planning: a national survey

OBJECTIVE

The objective of the study was to characterize beliefs about contraception among obstetrician-gynecologists.

STUDY DESIGN

National mailed survey of 1800 US obstetrician-gynecologists. Criterion variables were whether physicians have a moral or ethical objection to, and whether they would offer, 6 common contraceptive methods. Covariates included physician demographic and religious characteristics.

RESULTS

One thousand one hundred fifty-four of 1760 eligible obstetrician-gynecologists responded (66%). Some obstetrician-gynecologists object to intrauterine devices (4.4% object, 3.6% would not offer), progesterone implants and/or injections (1.7% object, 2.1% would not offer), tubal ligations (1.5% object, 1.5% would not offer), oral contraceptive pills (1.3% object, 1.1% would not offer), condoms (1.3% object, 1.8% would not offer), and the diaphragm or cervical cap with spermicide (1.3% object, 3.3% would not offer). Religious physicians were more likely to object (odds ratio, 7.4) and to refuse to provide a contraceptive (odds ratio, 1.9).

CONCLUSION

Controversies about contraception are ongoing but among obstetrician-gynecologists, objections and refusals to provide contraceptives are infrequent.

Modeling early sexual initiation among young adolescents using quantum and continuous behavior change methods: implications for HIV prevention

Behavioral research and prevention intervention science efforts have largely been based on hypotheses of linear or rational behavior change. Additional advances in the field may result from the integration of quantum behavior change and catastrophe models. Longitudinal data from a randomized trial for 1241 pre-adolescents 9-12 years old who self-described as virgin were analyzed. Data for 469 virgins in the control group were included for linear and cusp catastrophe models to describe sexual initiation; data for the rest in the intervention group were added for program effect assessment. Self-reported likelihood to have sex was positively associated with actual initiation of sex (OR = 1.72, 95% CI: 1.43-2.06, R² = 0.13). Receipt of a behavioral prevention intervention based on a cognitive model prevented 15.6% (33.0% vs. 48.6%, OR = 0.52, 95% CI: 0.24-1.11) of the participants from initiating sex among only those who reported 'very likely to have sex.' The beta coefficients for the cubic term of the usp assessing three bifurcating variables (planning to have sex, intrinsic rewards from sex and self-efficacy for abstinence) were 0.0726, 0.1116 and 0.1069 respectively; R² varied from 0.49 to 0.54 (p < 0.001 for all). Although an intervention based on a model of continuous behavior change did produce a modest impact on sexual initiation, quantum change has contributed more than continuous change in describing sexual initiation among young adolescents, suggesting the need for quantum change and chaotic models to advance behavioral prevention of HIV/AIDS.

Reasons for and challenges of recent increases in teen birth rates: a study of family planning service policies and demographic changes at the state level

PURPOSE

After declining for over a decade, the birth rate in the United States for adolescents aged 15-19 years increased by 3% in 2006 and 1% again in 2007. We examined demographic and policy reasons for this trend at state level.

METHODS

With data merged from multiple sources, descriptive analysis was used to detect state-level trends in birth rate and policy changes from 2000 to 2006, and variations in the distribution of teen birth rates, sex education, and family planning service policies, and demographic features across each state in 2006. Regression analysis was then conducted to estimate the effect of several reproductive health policies and demographic features on teen birth rates at the state level. Instrument variable was used to correct possible bias in the regression analysis.

RESULTS

Medicaid family planning waivers were found to reduce teen birth rates across all ages and races. Abstinence-only education programs were found to cause an increase in teen birth rates among white and black teens. The increasing Hispanic population is another driving force for high teen birth rates.

DISCUSSION

Both demographic factors and policy changes contributed to the increase in teen birth rates between 2000 and 2006. Future policy and behavioral interventions should focus on promoting and increasing access to contraceptive use. Family planning policies should be crafted to address the special needs of teens from different cultural backgrounds, especially Hispanics.

Introducing abortion patients to a culture of support: a pilot study

Currently in the United States, women who have abortions face a societal culture in which disapproval, stigma, and misinformation about the risks and sequelae of abortion are common. The purpose of this study is to pilot test an intervention that introduces abortion patients to a "culture of support" by providing validating messages and information about groups and services that support women in their reproductive decisions, addressing stigma, and providing information to help women identify and avoid sources of abortion misinformation. Twenty-two women who completed their post-operative exam after abortion were enrolled to take part in the study intervention. In-depth interviews were conducted to explore patient experiences and responses to the intervention. All (22/22) participants responded that they believed that interventions like the one studied could help women avoid letting the judgmental actions and attitudes of others "get to them so much". All (20/20) participants felt that the intervention was personally helpful to them. An intervention that introduces women having abortions to a "culture of support" was well-received. This study provides a framework for future research about the content, strength, and effect of societal and cultural influences on women having abortions and for additional research about interventions to promote resilience after abortion.

Research on adolescents and microbicides: a review

Adolescents are an important target for microbicide research, as they are disproportionately affected by sexually transmitted infections and currently are underrepresented in the microbicide research literature. Furthermore, adolescents are psychosocially and biologically different from adults, and findings from adult research cannot be assumed to apply universally to adolescents. Adolescents, to date have rarely been included in clinical trials and acceptability research for microbicides, in part because their participation requires attention to unique developmental issues, including parental consent and confidentiality. Despite these challenges, adolescents should be included in microbicide clinical research. If adolescents are ultimately expected to use microbicides, it is essential that we understand the developmental, contextual, and relationship variables that may influence use and acceptability. Accordingly, the goal of this paper was to examine the issues affecting the inclusion of adolescents in microbicide clinical research as well as review the existing adolescent-specific microbicide research, which highlights the various factors that may influence use and acceptability. It is hoped that this review can provide guidance for future work with this important, specialized population.