Sexual Health Update

1. Sexual Health Update Lynnan Svensson, RN, BSN, PHN Supervising Public Health Nurse MCAH Program Director Heather Orchard, PHN, MSN, FNP Supervising Public Health Nurse STD Controller El Dorado County Health & Human Services

2. Learning Objectives • Define sexual health • Describe current trends of sexual activity in the 12-18 year old age grouping • Identify factors that influence sexual health • Describe current trends in contraception technology

3. Learning Objectives • Brief overview of STDs • Explain current STD screening recommendations • Describe the general epidemiology of current HIV epidemic • Give examples of risk reduction messages

4. What is Sexual Health?

5. Sexual Health • More than sex -Feelings -Behaviors • More than intercourse -Attitudes -Relationships **UNDERSTANDING SEXUAL BEHAVIOR IS CRITICAL FOR DESIGN**

6. Adolescent Sexual Behavior • Is puberty reached earlier today? • Is marriage delayed longer today then past generations? • Are teens having sex earlier or later then past generations? • What are the most common reasons for delaying a sexual relationship?

7. Adolescent Sexual Risk Behavior • 47% never had sexual intercourse San Francisco 26% • 6% had sexual intercourse for the first time before age 13 years San Francisco 4% • 15% had sexual intercourse with four or more persons San Francisco 7% Centers for Disease Control and Prevention, MMWR. Youth Risk Behavior Surveillance, United States, 2013

8. P % of Adolescents Who Have Had Sex by Age

9. 34% had sexual intercourse with at least one person during the 3 months before the survey 41% did not use a condom during last sexual intercourse. LGB youth are more than twice as likely to have attempted suicide as their heterosexual peers. Centers for Disease Control and Prevention, MMWR. Youth Risk Behavior Surveillance, United States, 2013 Adolescent Sexual Risk Behavior

10. Adolescent Sexual Risk Behavior • 22% drank alcohol or used drugs before last sexual intercourse • 7% were physically forced to have sexual intercourse males – 4% females – 11% • 10% experienced physical and sexual dating violence males – 7% females – 13% Centers for Disease Control and Prevention, MMWR. Youth Risk Behavior Surveillance, United States, 2013

11. Yes Means Yes • Gov. Jerry Brown signed a bill into law that makes California the first in the nation to have a clear definition of when people agree to sex. The law goes further than the common "no means no" standard, which has been blamed for bringing ambiguity into investigations of sexual assault cases.

12. Adolescent Sexual Risk Behavior • In 2012, 2/3 of all youth 15-24 had experienced oral sex (1) • Nearly half of 19 million new cases of STDs each year are among the ages of 15-24 (2) • More than 400,000 girls 15-19 years old gave birth in 2009 (2) (1) National Center of Health Statistics, CDC 2012 (2) Centers for Disease Control and Prevention, MMWR. Youth Risk Behavior Surveillance, United States, 2011

13. Role of Abstinence • First Choice Contraception • Better Have a Back-up Plan • Little Significant Difference

14. Teen Pregnancy • Nearly 1 in 4 female teens at risk for unintended pregnancy were not using any contraceptive method at last intercourse.(1) • In 2006–2010, one in five sexually active female teens (20%) and one-third of sexually active male teens (34%) reported having used both the condom and a hormonal method the last time they had sex.(2) (1) Mosher WD and Jones J, Use of contraception in the United States: 1982–2008, Vital and Health Statistics, 2010, Series 23, No. 29. (2) Martinez G et al., Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2006–2010 National Survey of Family Growth, Vital and Health Statistics, 2011, Series 23, No. 31.

15. Teen Pregnancy • In 2011, there were 31 births per 1,000 women aged 15–19; this rate marked a 50% decline from the peak rate of 62 reached in 1991.(1) • Most births among teen mothers are first births. Eighteen percent are second or higher-order births. • In El Dorado County things are improving! (1) Hamilton BE, Martin JA and Ventura SJ, Births: preliminary data for 2011, National Vital Statistics Reports, 2011, Vol. 61, No. 5,.

16. Teen Pregnancy Teen birth • Births per 1,000 females ages 15 to 17 in 2009-2011 are lower than the State (County = 5.6vs. CA = 16.8), HP2020 Objective achieved • Births declined in County from 10.8 per 1,000 females ages 15 to 17 in 2000-2002 to 5.6 in 2009-2011 • Births per 1,000 females ages 15 to 19 in 2009-2011 are lower than the State (County = 15.3vs. CA = 31.6) ElixhauserA, Steiner C, Palmer L. Clinical Classifications Software (CCS), 2013. U.S. Agency for Healthcare Research and Quality

17. What can affect our sexual health?

18. What can affect our sexual health? • Sexual relationships with people who are infected, even when they don’t know they have an STD • Having multiple partners increases chance of infection • Difficulty or discomfort in talking about sex and STDs • Myths and misinformation about who is at risk for STDs and how STDs are passed (“My partner’s clean!”)

19. What can affect our sexual health? • Sexual experiences we have without fully thinking through the consequences of unprotected sex. • Not getting tested regularly for STDs. • Re-infection by untreated partners is common. Sex partners must be treated even if they have no symptoms. • Physically or emotionally abusive relationships where people feel unable to say “no” to their partners.

20. Alcohol and Other Drugs:Sex under the influence (SUI) Emotional and Psychological Issues: • discomfort with sober sex • decreases inhibitions • affects choice of sexual partners • less condom use • increased sexual appetite • do not remember sexual behavior (i.e. blackouts) • increased sexual assault and intimate partner violence

21. Alcohol and Other Drugs (cont.): Physical Effects: • Stimulants may prolong sex and increase trauma • “Sextacy”: Viagra & Ecstacy (or meth, deadly combo) • Sharing drug equipment (needles, cocaine straws) • Dehydration and decreased pain sensation can lead to dryness and increases trauma

22. Alcohol and Other Drugs (cont.): • Prevalence of Stimulant Use: • 6% of HS Students have used cocaine in their lifetime • 3% of HS Students have used meth in their lifetime 4% in San Francisco Centers for Disease Control and Prevention, MMWR. Youth Risk Behavior Surveillance, United States, 2013

23. Alcohol and Other Drugs (cont.): • Trading sex for drugs is associated with increased risk of infection • Drug users (who don’t use needles) still have higher HIV rates than people who don’t use any drugs Resource: http://www.cdc.gov/healthyyouth/alcoholdrug/index.htm Centers for Disease Control and Prevention, MMWR. Youth Risk Behavior Surveillance, United States, 2013

24. Resources

25. Contraceptive Technology

26. Potential for Pregnancy Less than1 per 100 2-9 per 100 15-24 per 100 25 per 100

27. Correct and consistent use Low risk still implies a high risk of cumulative risk Simultaneous use of methods Half of all pregnancies are unintended Contraception Essentials

28. Prescription Oral Contraception“pill” Ortho Evra “patch” Nuva Ring “ring” Depo Provera “shot” Implant “Implanon” Cervical Cap Diaphragm Non-prescription Female Condom Male Condom Spermicidal Foam Spermicidal Film Natural Family Planning Abstinence Methods

29. Oral Contraception: Hormonal Description: • Estrogen and Progestin • 1 pill is taken daily • Time sensitive, the pill is to be taken at the same time every day

30. ADVANTAGES Regulates menses Decreases blood loss/ menstrual cramps No disruption at time of intercourse Decrease risk of ovarian/endometrial cancer Treatment for acne DISADVANTAGES Mood Changes, depression, anxiety Daily pill taking may be stressful No Protection against STI (Sexually Transmitted Infections), including HIV Nausea, breast tenderness, especially in the first few cycles Weight gain Oral Contraception: Hormonal

31. Ortho Evra: The Patch Description: • Estrogen and Progestin • 1 Patch a week, for 3 weeks • 4th week patch free, Menstruation • Usually worn lower abdomen or buttocks

32. Advantages: Menstrual (Similar to the Pills) Nothing to do on a daily basis No disruption at time of intercourse Change once a week 3 week on one week off Disadvantages: Mood Changes, depression, anxiety No Protection against STI (Sexually Transmitted Infections), including HIV Nausea, breast tenderness, especially in the first few cycles Weight gain Cannot use if breastfeeding Ortho Evra: The Patch

33. Nuva Ring Description: • Combined estrogen and progestin • Thin flexible transparent ring • Left in place in the vagina for three weeks and removed for a week to allow a menstrual period the fourth week • Maintains a steady low release rate while in place

34. Advantages: Only two tasks: Insertion/Removal 1x month Steady even hormonal levels in blood are achieved Privacy/No visible patch or pill packages 95% of women say they cannot feel device Disadvantages: Some women dislike placing/removing objects into/out of their vagina Adverse side effects similar to the pill Possible devise expulsion Nuva Ring

35. Depo Provera Description: • Injected intra-muscularly into the deltoid or gluteus-maximums every 11 to 13 weeks • Progestin only

36. Advantages: Less menstrual blood loss and anemia After one year 50% of users will develop amenorrhea 80% will develop amenorrhea in 5 years Only need to remember 1x every three months Disadvantages: Irregular menses during first several months Unpredictable spotting and bleeding Possible weight gain Patient fear of pregnancy or build up of menses in uterus if not explained well Decreased libido Fear of needles Return to fertility is long average 10 months from last injection Depo Provera

37. Implanon Description: • Progestin only • Thin, flexible, plastic implant about the size of a matchstick • Inserted under the skin by the bicep muscle • Implanted in the arm for 3 years

38. Advantages: Insertion only takes a few minutes Protection against pregnancy is immediate if you get the implant during the 1st five days of your period Ability to get pregnant is immediate after removal Gives continuous long-lasting birth control without sterilization No medicine to take every day Disadvantages: Irregular bleeding is the most common side effect Periods become lighter and may stop altogether or periods may become heavier and last longer Some women will have longer heavier periods Acne, change in appetite, or sex drive Pain at the site of insertion Implanon

39. Cervical Cap Protection 48 hrs intermittent use Professional fitting Diaphragm Protection 6 hrs intermittent use Professional fitting Barrier by RX

40. Female Condom Description: • Inserted into vagina with the moveable ring inside the vagina creating an internal sheath. The large ring externally covers the labia. • Disposable single use sheath made of polyurethane • Shelf life: 3-5 years

41. Advantages: Can be inserted up to 8 hours before sex to allow more spontaneity Woman can make sure she is somewhat protected against STDs No medical visit required, available over the counter Can be safely used with individuals who have latex allergies Disadvantages: Requires careful sexual practices during intercourse Noise made during intercourse can be distracting, if occurs add more lubricant In one study, 88% of females disliked using the female condom Somewhat difficult for new users Possible increase risk of UTI Possible difficulty inserting and removing device Female Condom

42. Male Condom Description: • Made of latex, polyurethane or natural membranes • Available in at least 2 different sizes and a variety of textures and thickness • May come with or without spermicidal coating • Reduces risk of pregnancy and contracting sexually transmitted infections • Natural Skin condoms do not protect against HIV transmission

43. Advantages: Some men maintain erections longer with condoms If the partner puts the condom on it can increase the pleasure Makes sex less messy by catching the ejaculate Intercourse may be more pleasurable because of the fear of pregnancy and STDs Cost effective Opportunity of couples to improve communication and negotiating skills Disadvantages: Use may be perceived as interrupting love making Requires discipline to resist impulse to progress to sexual act after erection May cause loss of erection Decrease the sensation Male Condom

44. Spermicidal Foam

45. Vaginal Film

46. Advantages: Can be used when no other method is available No medical or hormonal side effects No prescriptionnecessary Disadvantages: Not for men who don’t know when to pull out or ejaculate prematurely Not recommended for teens and sexually inexperienced men Requires great self-control, experience, and trust Withdrawal

47. Birth Control Updates: • IUD: • Can insert on females who have not given birth • Can be used as Emergency Contraception (an option for those looking for long-term protection) • Plan B: • Available over the counter without a prescription for those 15 years and older without a prescription • Available to teenagers of all ages over the counter with a prescription

48. Quick Start