UVMHealth.org/Childrens
Update on Adolescent Sexual and
Reproductive Health
Dr. Erica Gibson
Assistant Clinical Professor of Adolescent Medicine
August 18, 2015
Learning Objectives: Adolescent….
„Brain Development & Communication: 3
key aspects
„LGBTQ youth development: 3 major
phases
„Gender Identity & Sexuality:
Identify the paradigm
„Contraception: 3 key
concepts
Vermont Youth
„
䇾Young people are
not problems to be
solved, but
resources to be
developed䇿
Dr. Michael Resnick
WORLD HEALTH ORGANIZATION
Adolescent development . A critical transition
WHO identifies adolescence as the period in human growth and
development that occurs after childhood and before adulthood,
from ages 10 to19. It represents one of the critical transitions in
the life span and is characterized by a tremendous pace in growth
and change that is second only to that of infancy. Biological
processes drive many aspects of this growth and development,
with the onset of puberty marking the passage from childhood to
adolescence. The biological determinants of adolescence are
fairly universal; however, the duration and defining
characteristics of this period may vary across time, cultures, and
socioeconomic situations. This period has seen many changes
over the past century namely the earlier onset of puberty, later
age of marriage, urbanization, global communication, and
changing sexual attitudes and behaviors.
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MERRIAM-WEBSTER DICTIONARY
The state or process of growing up
It’s a journey…
6
Adolescent Brain Development
UVMHealth.org/Childrens
Brain Development
• Birth: equipped with most
of the neurons our brain
will ever have
• Age 6: 90-95% of its final
adult size
Adolescent Brain Development
• MRI: 2nd wave of neuronal proliferation and pruning
during adolescence
• Until mid 20䇻s: Gray and white matter undergo
extensive structural changes
• Changes affect not the number of nerve cells but the
connections between them
Adolescent Brain Development
FIRST
„ Limbic system: emotions, stress,
“auto responses”
LAST
„ Pre-frontal cortex:
Executive functions: planning,
setting priorities, organizing
thoughts, suppressing impulses,
and weighing consequences
Implications?
• Limited reasoning and planning
• Adolescents 䇾experiment䇿, 䇾test
limits䇿, 䇾push the envelope䇿
• Habits formed during adolescence
may be hard to break
• But, sometimes that exploration has
long-term consequences
It’s Developmental
• Differing timetables in frontal
lobe development
• Ability to connect present
activity (e.g., unprotected sex)
with future outcomes (e.g.,
STI acquisition) is highly
variable
Adolescent Psychological Development
The 䇾Tasks䇿 of Adolescence
„ Undergo cognitive maturation:
– Concrete o abstract thinking
– Present o future orientation in
time
– Causality: single o multiple
cause/effect possibilities
„ Achieve independence from parents
„ Establish identity (sexual, moral,
vocational etc.)
„ Develop and accept body image
UVMHealth.org/Childrens
Adolescent Cognitive and
Social Development
Stages of Adolescent Development
• Early Adolescence
– Females: 9 - 13 years
– Males:
11 – 15
• Middle Adolescence
– Females: 13 – 16
– Males:
14 – 17
• Late Adolescence
– Females: 16 – 21
– Males: 17 - 21
Identity
䇾a search for self among a cast of characters speaking in
different voices䇿
• Who am I?
• Am I normal?
• How do others see me?
• How do I compare to
others?
• What am I good at?
• Where do I fit in?
• What do I believe in?
•What䇻s right and
wrong?
• Where am I going?
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Context of Adolescent Development
„ Individual
„ Family (parents, siblings,
others)
„ Peer group (friends,
classmates)
„ School (academic, social,
recreational)
„ Society (jobs, church,
youth groups)
Adolescent Sexuality
Developmental Issues
• Sexuality is a major part of self-concept
• Individual must clarify
– Gender identity
– Sexual orientation
– Sexual behaviors
Early Adolescence
Cognitive Development
䇾This pimple on my face is HUGE!..
– Ego-centric approach to
the world
– Increased ability to
think about oneself
leads to selfconsciousness;
perception that
everyone is watching
I shouldn䇻t have eaten that Hershey
bar. I just can䇻t go to school today䇿
Early Adolescence
Concrete Thinking
• Reduced capacity to 䇾plan ahead䇿, to
conceptualize potential ramifications of actions
• 䇾I want what I want when I want it䇿
Concrete Thinking
Literal interpretation of facts and events
What brings you here to the
doctor䇻s office today?
The bus…
My mother…
Early Adolescence
Body image concerns…
–
–
–
–
Rapid growth (earlier in girls)
Pubertal changes
Preoccupation with self
Magnified imperfections
• Breast asymmetry
• Gynecomastia
– 䇾Am I normal?䇿
Early Adolescence - Relationships
• Beginning to
separate from
parents
• Socialization in
groups
• Tendency toward
uniformity
Tips for Early Adolescence
• Specific communication tools
• Visual explanations and materials
• Helps to focus on issues important to youth
– Acne, physical appearance, etc
– Early and late maturation
Middle Adolescence
Transition in cognition…
– Beginning sense of future implications of
current actions
– Vacillation between concrete and abstract
thought
Middle Adolescence
Body image concerns…
– Physical development
almost complete
– Becoming comfortable
with 䇾new body䇿
But….
There may be a
䇾disconnect䇿
between a
teen䇻s physical
appearance and
his/her
emotional
maturity level.
Discordance
Middle Adolescence
Independence and peer relationships…
– Major parent-child conflicts
– Testing limits
– Struggle for emancipation
Middle Adolescence
• Peers provide transitional
support system during
separation/individuation
process
• Conformity with peer values
• Importance of feeling
attractive
– 䇾Am I liked?䇿
– 䇾Am I cool (enough?)䇿
Tips for Middle Adolescence
• Friendly relationships create trust
• Avoid 䇾preaching䇿
• Look for the 䇾hidden agenda䇿
• Messages and tools that a teen can relate to
• Focus:
– Supportive adult connections
– Health promotion
– Harm reduction
• Peer counseling can be very
effective
Late Adolescence
Thinking…
– Abstract thinking achieved
– Enhanced memory
– Able to reason logically
Body image concerns…usually resolved!
– Comfortable with and accepting of
physical characteristics
Late Adolescence
Identity development…
– Has developed own
values
– Has realistic vocational
goals
Late Adolescence
Independence and peer relationships…
– Has separated from family (college, work, military)
• …but continues a positive relationship with family members.
– Has re-integrated family values into personal code of
behavior.
– Is financially independent
– Has achieved capacity for intimacy
– Can sustain mature friendships
Tips for Late Adolescence
• More abstract reasoning allows for more
traditional approaches
• Link between behaviors and consequences
better understood
• Provide the option to include close friends
and/or partners for office visits
Adolescent Development and
LGBTQ Youth
• Many developmental challenges
for LGBTQ youth are the same
• Experienced differently because
being LGBTQ doesn’t conform to
the norm
LGBTQ: Early Adolescence
• May start to get a sense that they feel differently than others
but they do not yet understand what feels different
• Development of secondary sexual characteristics and
menstruation can be traumatizing for transgender and gender
non-conforming youth
• Being gender variant may result in teasing and bullying
4. Horberg (2008)
LGBTQ: Middle Adolescence
•
•
•
•
Firming of identity and self-labeling
Coming out concerns
Sexual experimentation may lead to
increased STI/HIV risk
Dating may be difficult because it exposes
same-sex desires and transgender identity
4. Horberg (2008)
LGBTQ: Late Adolescence
• Previous delay in dating may lead to sex-focused relationships
• Independent living potentially increases freedom to come out
4. Horberg (2008)
Vermont Youth Risk Behavior Survey
(YRBS) . LGBTQ Youth
• The 2009 VT YRBS:
– Approx 3,000 LGBTQ students in VT
• 2013 VT YRBS grades 9-12
– Heterosexual 91%
– Bisexual 5%
– Lesbian or Gay 1%
– Not sure 3%
PRCH © 2006
*Asexual, Demi-sexual
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Puberty & Transgender Youth
• Onset of puberty can be very
challenging
• Psychosocial support needed
• Medical treatment possible:
– Hormonal
• Pubertal delay
• Cross-gender hormones and surgery in
future if wanted
• Theme of fluidity and
transformation
42
Gender Identity Disorder
Gender Dysphoria
•
•
•
•
•
Marked difference between the iindividual’s
di id l’ expressed/experienced
d/
i
d gender
d
and the gender others would assign him or her, and it must continue for at
least six months.
In children, the desire to be of the other gender must be present and
verbalized.
This condition causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Manifest in variety of ways, including strong desires to be treated as the other
gender or to be rid of one’s sex characteristics, or a strong conviction that one
has feelings and reactions typical of the other gender.
The DSM-5 diagnosis adds a post-transition specifier for people who are living
full-time as the desired gender (with or without legal sanction of the gender
change). This ensures treatment access for individuals who continue to
undergo hormone therapy, related surgery, or psychotherapy or counseling to
support their gender transition.
General Principles for Counseling
• Recognize developmental stage and interact
accordingly
• Use open ended questions and listen
• Seize every opportunity
• Be up front & genuine
– Express concerns without judgment
– Acknowledge positive steps & successes
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Respect and Rapport are Key
• Respect for the youth䇻s
– Confidentiality
– Preferences
– Choices
– Self-efficacy
– Self-determination
Remember…
Adolescents are good 䇾actors䇿, often appearing
nonchalant. This is frequently a façade…
䇾It䇻s like I䇻m in an airplane 5,000 feet
up in the sky, and the pilot just turned
over the controls to me and bailed out.
How am I supposed to fly this thing and
land safely?䇿
Adult help and support is critical….
ADOLESCENT
CONTRACEPTION TO PREVENT
UNINTENDED PREGNANCY…
Comparing Teen Birth Rates Internationally . 2008
VT 2012 Rate: 16.3
US 2012 Rate: 29.4
When do adolescents seek sexual and
reproductive health (SRH) services?
ƒ
The average teen waits ? months after
becoming sexually active to make her
first family planning visit.
14
months
2013 Youth Risk Behavior Survey (YRBS) Data .
High School Students 15-19yo
YRBS Question
VT
US
% students ever had sex
43%
47%
% students who used a condom at last
sex
62%
59%
% students who used birth control pills
at last sex
2011
36%
19%
% students who used Depo-Provera,
Nuva Ring, Implanon or any IUD before
last sex
2011
6%
5%
Counseling
Ó
Sexual
Orientation
Sexual
Attraction
Paradigm of
Sexuality
Biological
Sex
Sexual
Behavior
Gender
Identity
Facts
¾Using birth control is safer than
becoming pregnant.
¾There are many safe and effective
methods available.
¾Health educators can help young
people understand their choices.
What are the most effective methods of contraception?
Extremely
effective
Very effective
Moderately
effective
Effective
Prevents pregnancy
>99% of the time
Prevents pregnancy
91-99% of the
time
Prevents pregnancy
81-90% of the
time
Prevents pregnancy
up to 80% of the
time
Sterilization
LARCS
Injection
Ring
Patch
Pill
Diaphragm
Condoms
Withdrawal
Sponge
Fertility
Awareness
Spermicide
Implant
IUDs
What are the most effective
methods of contraception?
Extremely
effective
LARCs: Long Acting Reversible
Contraceptives
Implant = Nexplanon
IUDs = Skyla, Mirena, Paragard (Copper)
The American Academy of Pediatrics (AAP) Recommends the
Highly Effective Methods of Contraception as First Line Options
for Adolescents
Specific LARC statements in AAP Contraception Policy
“pediatricians should counsel about and ensure access to a broad range of
contraceptive services for their adolescent patients. This includes educating patients
about all contraceptive methods that are safe and appropriate for them and
describing the most effective methods first such as
contraceptive implants and IUDs.”
“Given the efficacy, safety, and ease of use, LARC methods should be considered
first-line contraceptive choices for adolescents. Some
pediatricians may choose to acquire the skills to provide
these methods to adolescents. Those who do not should identify health
care providers in their communities to whom patients can be referred.”
CONTRACEPTIVE CHOICE PROJECT VIDEO
http://www.choiceproject.wustl.edu/
The
Choices
The
Choices
The Implant: Nexplanon
¾ Thin, flexible single rod implant
with progestin-only. Is inserted by
a medical provider under the skin
of the upper arm. Can be used for
up to three years.
¾ Can result in
unpredictable/irregular menstrual
bleeding is frequent (including
amenorrhea).
¾ Provides no protection against
STI/HIV.
(Hatcher, et al, 䇾A Pocket Guide to Managing Contraception䇿, 8th
Edition, 2005-2007)
Intrauterine Device (IUD)
Paraguard, Mirena, Skyla
¾ Inserted by a clinician into
the uterus through the
cervix.
¾ Increasing use among
adolescents based on new
IUD research.
¾ Provides no STI/HIV
protection.
The Injection: Depo-Provera
¾ Only 1 hormone (progestin).
¾ Injection every 12 weeks.
¾ Very private method.
¾ Irregular bleeding and/or no bleeding is common.
¾ Provides no STI/HIV protection.
The Ring: NuvaRing
¾ Combination of 2
hormones: estrogen &
progestin.
¾ Similar effects to the
pill.
¾ Ring is self-inserted
into the vagina for 3
weeks and removed for
1 week.
¾ Provides no STI/HIV
protection.
The Patch: Ortho Evra Patch
¾ Combination of 2 hormones: estrogen &
progestin.
¾ Similar effects to the pill.
¾ Wear 1 patch a week for 3 weeks,
followed by a patch-free week.
¾ Provides no STI/HIV protection.
Birth Control Pills
¾ Many brands
¾ Combination of 2 hormones:
estrogen & progestin.
¾ Need to remember to take a pill
every day whether or not you have
sex.
¾ Provides no STI/HIV protection.
EC is a safe,
effective way
to prevent
pregnancy
after
unprotected
sex or
contraceptive
failure.
EC…
¾Will not disrupt an established
pregnancy.
¾Will not harm an existing pregnancy.
¾Is not the same as RU-486 (the
abortion pill).
(DHHS, FDA,1997; World Health Organization, 2004)
Emergency Contraception Pills: EC
•
•
•
•
2 Types:
– Levonorgestrel, Ulipristal Acetate
Benefit:
– Use only when needed
– Backup for contraception error
Patient must:
– Always have it on hand
– Take it with each episode of unprotected sex
No role for menstrual regulation
If 100 Females Have Unprotected Sex during the 2nd
or 3rd Week of Their Menstrual Cycle
If No EC: 8/100 (8%) will
become pregnant
(Stewart et al., 2004)
If 100 Females Have Unprotected Sex
during the 2nd or 3rd Week of Their
Menstrual Cycle
With EC: 1/100 (1%) will
become pregnant
(Stewart et al., 2004)
Timing & Use of EC
¾ EC can be used within 5 days (120 hours) of
unprotected sex.
¾ The sooner EC is used, the more effective it is!
¾ Professionals in daily contact with young
people can make a difference by telling them
about EC.
(Von Hertzen et al., 2002)
When Can EC Be Used?
¾If the condom breaks.
¾If birth control was used incorrectly.
¾If birth control was not used.
¾If a teen is forced to have sex against
her will.
Barrier Methods
¾ Male Condom
¾ Female
Condom
¾ Diaphragm/
Cervical Cap
.
Barrier
methods
prevent the sperm
from meeting the egg
by blocking the
passage of semen.
¾ The sponge
Condoms: Dual Protection
Factors affecting contraceptive choice …
Do any of my
friends use it?
Will it
hurt me?
Do I want to prevent
pregnancy?
Will I be able to
afford it?
How will it help me?
What have I heard about it?
Will my parents or partner
find out?
Condoms + Female Birth Control
With EC as Back-up
=
Best Protection
THANK YOU
HELP YOUNG PEOPLE TO
HOLD ONTO THEIR DREAMS
Dr. Al Cohall, Columbia University, Harlem Health Promotion Center
79