New Section publication discusses reproductive counseling and weight-loss surgery

Women of reproductive age often pursue weight-loss surgery; in fact, they account for nearly half of all bariatric surgery patients. The relationship between reproduction and rapid weight loss has been well documented and includes an increased risk of infertility, menstrual irregularities, and changing sexual function. Women who receive bariatric surgery are also more likely to have an unplanned pregnancy. Because of these reproductive risks, the American Society for Metabolic and Bariatric Surgery recommends using effective birth control methods when experiencing rapid weight loss and the American College of Obstetricians and Gynecologists recommends delaying pregnancy one to two years after bariatric surgery.

Yet, according to one survey, 31 percent of female bariatric surgery patients planned to become pregnant after obtaining surgery, and nearly one-third planned to do so within two years. These intentions, as well as contraceptive efficacy following weight loss, warrant close collaboration between bariatric surgeons and women’s health providers.

Section faculty Dr. Julie Chor conducted a national survey of bariatric surgeons to assess perioperative reproductive counseling and contraceptive provision. Her findings were published in Surgery for Obesity and Related Diseases.

http://www.soard.org/

Image courtesy of http://www.soard.org

The study found that 74% of bariatric surgeons preoperatively screen patients regarding contraceptive use more than 50% of the time. The most common method prescribed, however, were oral contraceptive pills, which may have decreased efficacy in the obese and in the postoperative state, depending on the type of surgery.

Most respondents (90 percent) recommended delaying pregnancy 12 to 24 months, yet 84% did not require a gynecologic consultation for female patients of reproductive age and 35% further stated that they did not know how their patients obtained contraception.

One-fifth of respondents did not assess their patients’ pregnancy intentions. This disparity suggests that practitioners should counsel patients preoperatively about reproductive changes that can occur after weight loss from bariatric surgery as well as discuss contraception with all women of reproductive age, whether or not they desire a future pregnancy.

Dr. Chor’s findings suggest implementing a routine gynecology consultation for female bariatric surgery patients prior to an operation. These women would greatly benefit from increased education on fertility changes associated with weight loss and on highly effective methods of contraception, such as intrauterine devices and contraceptive implants.

Read the full article here.

Coercion and Reproductive Justice

An essential piece of the reproductive justice and sexual rights movement is the right of all women to make reproductive choices free from coercion.

According to the Guttmacher Institute, coercion in any form is wrong and compromises choice. Coercion violates women’s right to decide freely if and when to have a child and the right to have the government respect her decision.

The Guttmacher report condemns coercion in the form of U.S. state legislatures passing increasingly restrictive abortion restrictions to keep women from ending an unwanted pregnancy. Parental notification or consent, mandatory waiting periods, and inaccurate and biased counseling exist under the guise of “preventing coerced abortion”. Rather, these TRAP laws aim not so much to inform women about the abortion procedure, as to dissuade them from choosing an abortion in the first place.

Increasingly, these laws prevent women from making decisions about how and when to give birth, posing a risk to all pregnant women, including those who want to stay pregnant.

Roe v. Wade gave women the right to choose abortion. Roe v. Wade also gave women the right not to choose abortion.

In the United States, a dark history of forced sterilization and present day controversies about the rights of the disabled remind us that as much as women have a freedom to abortion, if she chooses to continue a pregnancy, she has the equal right to do so.

Coerced abortion occurs in many forms. In January 2014, a Florida man was sentenced  to nearly 14 years in prison for tricking his pregnant girlfriend into taking Cytotec, a brand-name version of misoprostol, which causes miscarriage. Further complicating the issue, he was initially charged with first-degree murder under the Unborn Victims of Violence Act, punishable by life in prison, but he pleaded guilty to lesser charges of product tampering. The fetus was estimated to be at seven weeks.

In 2013 in Texas, a pregnant 16 year old girl claimed her parents were pressuring her to have an abortion when she wanted to continue the pregnancy and get married. When the pregnancy was confirmed, the teenager’s father allegedly became angry and insisted that she have an abortion and it was his decision.  Texas is one of the states that requires parental or judicial permission for a minor to obtain abortion; in this case, the minor had to obtain judicial permission not to have an abortion.

Coerced abortion compromises reproductive justice and often results from broader issues such as domestic and sexual violence, birth control access and tampering, economic disadvantage, education expectations, and religious convictions. Abortion is not the problem. The prevention of choice is the problem.

Jcr_my_body_my_choice

New Section research promotes parent–daughter communication about abortion before pregnancy occurs

parent_daughters

Press Release

Published: 13 October 2014

 

Discussing sexuality and reproductive health is a complex issue for parents and their daughters. Parents often feel ill-prepared to initiate these talks, and their daughters often fear a negative reaction or perceive judgment for their sexual activity. Yet, numerous studies have shown that, in general, parent-daughter communication leads to positive sexual health outcomes with regards to pregnancy and STI/HIV prevention.

New Section research, published online ahead of print in the Journal of Adolescent Health, discusses the role and potential impact of parent-daughter communication about abortion among non-pregnant adolescents. These conversations, the authors suggest, may decrease pregnancies and abortion and obviate the need for forced communication.

Currently, 38 states legislate communication between abortion-seeking minors and their parents via Parental Involvement (PI) laws, which require minors 18 years old and under to notify or obtain consent from a parent(s) or guardian before obtaining an abortion. PI supporters argue that these laws promote communication and provide young women with family support. PI opponents maintain that forced communication during the time of crisis can harm young women and delay treatment, increasing the medical risk of a procedure. Furthermore, studies show that most adolescents voluntarily involve parents in their decisions about pregnancy resolution, especially when they anticipate support.

Our qualitative study found that only 43 percent of nonpregnant African-American adolescent females had ever discussed abortion with a parent. Almost half were sexually active, and the vast majority stated they would voluntarily tell a parent of an abortion decision “as soon as possible” or “within one to two weeks.” However, nearly 20 percent acknowledged risk and expressed fears of hurt, punishment, and eviction if their parent learned about an abortion.

The study identified several correlates of parent-daughter communication about abortion. Parents who had had talked about other sexual health topics (e.g. birth control and STIs) were more likely to have discussed abortion with their daughter. If daughters perceived parental acceptance of sexual activity, they were more likely to have an abortion communication. A mother’s experience with teenage pregnancy was positively associated with abortion communication, although the study did not assess the positive or negative quality of the communication. Of concern, sexually active adolescents were less likely to communicate about abortion.

Ultimately, this study found that rather than mandating communication at the time of abortion, policies should focus on general parent-daughter communication about sexual health. Policies that force communication at the time of abortion appear misplaced.

Read the full article here.

Reference

Sisco K, Martins S, Kavanaugh E, Gilliam M. Parent-Daughter Communication About Abortion Among Nonpregnant African-American Adolescent Females. Journal of Adolescent Health. Published online ahead of print September 27, 2014: DOI: 10.1016/j.jadohealth.2014.07.010

 

Section study finds young women involve a parent in abortion when they anticipate support

‘Cause it’s like, ‘man what are they going to think’ and ‘are they going to hate me for this?’ That is what goes through your mind.

When a young woman seeks to terminate a pregnancy, how does she decide whether to talk to a parent? A recent study from the Section of Family Planning and Contraceptive Research at the University of Chicago found that pregnant teens will turn to parents and adults who are engaged in their lives and who will offer support, regardless of her decision. Young women will avoid talking with parents who are less involved or may try to prevent them from seeking care.

The study, recently published online ahead of print in the American Journal of Public Health, explored the factors young women under age 18 consider when deciding to involve a parent. Researchers conducted interviews with 30 minors seeking abortion in Illinois, prior to implementation of a parental notice law in 2013. Currently, there are 38 states with laws requiring a parent provide consent or receive notification before a minor can access abortion.

Image courtesy of the Illinois Caucus for Adolescent Health (icah.org)

Image courtesy of the Illinois Caucus for Adolescent Health (icah.org)

“There’s a commonly accepted idea that teens will try to hide their pregnancy or abortion decision. However, pregnant young women actually do turn to parents in the majority of cases. In our study, 70% of the young women involved a parent or guardian. They thought carefully about which parents and adults in their lives they could turn to for help in making their decision,” said Lee Hasselbacher, policy researcher at the Section of Family Planning.

While each young woman’s family circumstance was different, there were several common motivations for involving a parent. Factors in favor included close and supportive relationships, need for help with logistics like travel or payment, or experiences that made discovery of the pregnancy seem inevitable.

I mean, I wouldn’t normally tell my dad but it came to a point where I needed another $50 for the abortion to be done and so I relied on daddy.

Minors expressed a range of motivations for not telling a parent about their abortion as well. Some teens worried that if their parent learned of their decision, it would dramatically change their relationship or feared it would even lead to anger or harm. Young women also discussed the lack of a relationship or presence as a reason they did not want to involve a parent.

To me that [disclosing pregnancy and abortion] would start a whole lot of drama and right now um, our relationship is like- is kind of on good terms but it’s not so for me telling her this um, I think it like would go back down the drain.

One of the strongest findings was that among those young women who did not involve either parent, most were concerned that one or both parents would directly interfere with their decision to get an abortion.

She just told me, like, it’s not right… and she told me like, if I did get pregnant, like, she told me she wouldn’t let me have one. She said it’s my responsibility.

“This study reveals the complicated lives of pregnant young women and suggests that young women, not policymakers, are the ones best able to identify those people in their lives who can help them deal with a pregnancy. This study reinforces the need to listen to these young women and support policies that encourage family communication long before a pregnancy or abortion decision,” said Dr. Melissa Gilliam, Chief of the Section of Family Planning and Contraceptive Research and author on the study.

Reference

Hasselbacher LA, Dekleva A, Tristan S, Gilliam ML. Factors Influencing Parental Involvement Among Minors Seeking an Abortion: A Qualitative Study. Am J Public Health. Published online ahead of print September 11, 2014: e1-e5. Doi:10.2105/AJPH.2014.302116.

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Dr. Melissa Gilliam Featured in AP News Story on Contraception Access

AP Photo

Section Chief Dr. Melissa Gilliam was featured and quoted in an Associated Press news story regarding Illinois’ recent effort to ensure comprehensive and continuous birth control coverage for those with Medicaid.

The story, which has been picked up by outlets nationwide including CBS News, discusses a plan from Illinois Gov. Pat Quinn’s administration to improve access to family planning services for individuals with Medicaid, including long-acting birth control methods, by increasing reimbursement and education. The plan was announced at last month’s Illinois Contraceptive Equity Summit, an event hosted by the Section and EverThrive Illinois. The public is invited to comment on the plan until September 15.

According to the article, the current Illinois Medicaid payment system creates a financial barrier to doctors for offering LARC methods. For example, IUDs cost doctors’ offices between $300 and $800 each to keep in stock. Clinics pay the upfront cost of an IUD and absorb the loss of denied or delayed Medicaid claims. By implementing the Illinois Family Planning Action Plan,  the state would double doctors’ reimbursement rates for inserting IUDs and performing vasectomies, thus alleviating the cost for both patient and provider.

Dr. Gilliam commented on access to contraceptive methods within Medicaid, saying that “for some providers, [the state’s plan] will make a very big difference and will be a very welcome change.”

Photo: M. Spencer Green, AP

Success in School: Efforts to Improve Education for Students who are Pregnant, Parenting or Survivors of Violence

Pregnancy and parenthood does not have to mark the end of education for young men and women. Yet, according to the National Women’s Law Center, nearly half of all female dropouts say that becoming a parent played a role in their decision to leave school, and 33% of female dropouts said pregnancy was a major factor. Additionally, 24% of male say that becoming a parent played a role in their leaving school, and 19% said it was a major factor.

Life becomes increasingly difficult for young parents who drop out of school. Only 51% of women who have a child before age 20 earn a high school diploma before age 22. Education prospects for pregnant or parenting young women become bleaker at the higher-education level. Two percent of women who have a child before age 18 earn a college degree by age 30. This lack of education means that young parents who drop out of school are more likely than their peers to be unemployed or underemployed, and those who obtain work, earn significantly less than their peers who graduate from high school.

These statistics and studies were recently reviewed at a Town Hall held by The Illinois Caucus for Adolescent Health (ICAH) following the national release of the U.S. Department of Education’s recommendations to support the academic success of pregnant and parenting students under Title IX.

Image from ICAH

Image from ICAH

Before Congress passed Title IX in 1972, pregnant or parenting students were often discriminated against and sometimes dismissed from high school. Title IX prohibits sex discrimination, including on the basis of pregnancy, childbirth, and parental status.

The recommendations in the Office of Civil Rights’ June 2013 publication include:

  • A pregnant student must be allowed to remain in her regular classes and school if she chooses. Any alternative arrangement must be comparable to the regular school program in academic, extracurricular and enrichment opportunities.
  • Schools must treat pregnant students in the same way that they treat other students with temporary medical conditions. Thus, any special services and arrangements in place must also be provided to pregnant students, such as at-home tutoring and extensions on assignments.
  • A school must excuse a student’s absences because of pregnancy or childbirth for as long as the student’s doctor deems the absences medically necessary. When a student returns to school, she must be allowed to return to the same academic and extracurricular status as before and have the opportunity to make up missed work. Similarly, parenting students must have excused absences when they need to care for sick children or take them to doctors’ appointments.
  • A school must provide assistant to a pregnant or parenting student, such as providing a larger desk or designating a private room for breastfeeding during the school day.
  • A school must be aware and ensure that their teachers and staff follow Title IX requirements and know their rights. This may involve collaborating with a school district’s Title IX coordinator to provide workshops for administrators on laws related to the provision of services to pregnant and parenting students. A grievance procedure must be in place and adhered to by students, parents, and employees.
  • Schools must work with pregnant and parenting students to create a graduation plan tailored to each student’s needs. This may include an academic credit-recovery option for parents who take time off from school or the option for dropouts to return to school.

Although the recommendations focus on secondary schools, the statues apply to all recipients of federal funds, including post-secondary institutions.

Efforts to pass state-level legislation to ensure these and other protections have also been ongoing — the Ensuring Success in Schools Act was first introduced in 2007. This legislation would promote successful school completion for pregnant and parenting students as well as those affected by domestic or sexual violence by:

  • enabling expectant and parenting students as well as student victims of domestic or sexual violence to succeed in school;
  • providing guidance to school districts in responding to and alleviating the barriers to academic success for students who are parents, expectant parents, or survivors of domestic or sexual violence;
  • encouraging the safe and meaningful involvement of parents of students.

A state-designated Ensuring Success in Schools Task Force issued a report in 2010 which made recommendations for accomodating and supporting pregnant and parenting students, but also made recommendations for policies affecting student survivors of domestic and sexual violence. According to the report:

Students who experience dating violence or sexual harassment have a hard time paying attention in school and often participate less in class or do not go to class at all, whether the violence happened on or off school grounds. Testimony at Task Force hearings indicated that student survivors of sexual violence experienced sharp declines in grades following incidence of violence. Witnesses told stories of schools that refused to respect orders of protection, denied reasonable accommodations requested by the survivor, placed the burden of change and compliance on the survivor and not the perpetrator, forced the survivor to repeat her story several times and in front of other people, denied the survivor basic confidentiality, and punished the survivor for minor offenses related to the violence while overlooking the acts of violence committed by the perpetrator. Students who are survivors of domestic and sexual violence want to stay in school and graduate, but fear for their safety and well-being often forces them into involuntary homeschooling or alternative programs or forces them to drop out entirely.

In response, the authors suggested that schools:

  • waive minimum attendance requirements for students who are survivors of domestic or sexual violence and recognize absences as valid if they are due to safety concerns, to having received victim services, or to recovering from physical or psychological injuries;
  • allow students to make up missed work and provide appropriate academic supports, including the option of homebound instruction;
  • allow in-school accommodations—including changing classes, lockers, lunch hours, or any other appropriate safety measures—as necessary to facilitate school attendance and participation;
  • honor any order of protection and civil no-contact order;
  • allow student survivors of violence to transfer to another school without penalty for reasons of safety and well-being; and
  • place the burden of compliance on the perpetrator whenever possible.

Emergency Contraception Controversy & Gender-Based Violence

Access to emergency contraception (EC) has a storied history in the USA and directly impacts victims of sexual violence. Ci3 and the Section of Family Planning & Contraception Research, along with the Center for the Study of Gender and Sexuality hosted a challenging and informative presentation that explored this intersection. Dr. Susan F. Wood, Associate Professor of Health Policy and Director of the Jacobs Institute of Women’s Health at The George Washington University spoke about her role and observations surrounding over-the-counter EC access.

As Assistant Commissioner for Women’s Health at the FDA, Dr. Wood directed the FDA Office of Women’s Health from 2000 to 2005, at which point she resigned on principle over the continued delay of approval of EC over-the-counter.

Dr. Susan F. Wood

Dr. Susan F. Wood

Dr. Wood’s talk, Controversy over Contraception: From Emergency Contraception to Contraceptive Coverage to the Affordable Care Act, began with the historical context of women’s health and federal funding and ended with the implications of the ACA specifically regarding contraceptive coverage and access.Her talk focused primarily on the ongoing struggle to make EC available to all women over the counter.

In her role at the FDA, Dr. Wood witnessed the agency’s attempts to regulate the practice of medicine and pharmacy when it came to emergency contraception, an unprecedented course of action not only in its role as a government agency but also because of the impact on women’s access to family planning services.

The FDA approved Plan B as EC in 1999 as a prescription product for all women of childbearing potential. The manufacturer sought over-the-counter (OTC) approval in 2003.

At this early stage, it was already known that:

  • EC is safe and suitable for all women.
  • EC does not cause an abortion (“The only relation between EC and abortion is that EC prevents the need for an abortion,” says Dr. Wood.)
  • EC needs to be taken soon after (within hours of) intercourse to be the most effective.
  • EC provides victims of rape the option to prevent an unwanted pregnancy.

Despite these facts and extensive studies on the safety for women of all ages, politics and myths about EC — that it would increase adolescent sexual activity, encourage pedophilia, or cause an abortion — delayed FDA approval.

Not until August 2006 did the FDA approve Plan B over-the-counter (OTC) at pharmacies and health clinics, and this approval was limited to women 18 years and older; younger women would still require a prescription. Between 2003-2006, recommendation for approval had been overruled several times, Dr. Wood resigned, and activists across the country lobbied the FDA to make decisions that reflect good medicine and public interest.

In March 2009, a US district court ruled that the FDA decision to restrict access to women under 18 was “arbitrary and capricious” and ordered the FDA to lift restrictions on 17-year-olds within 30 days. Also in 2009, the FDA approved One Step (a one-dose version of Plan B) and Next Choice (a two-dose generic version), but the age restriction remained at 17. In 2010, with the age restriction still in place, The Center for Reproductive Rights filed for contempt of court citing the delays.

In 2011, Teva (One Step) released new data and filed an application to lift the age restriction. With the age restriction ready to be lifted, the FDA was overruled by Health and Human Services Secretary Kathleen Sebelius, who cited the lack of evidence on 11- to 12-year-olds’ ability to use the product. Although this argument was unprecedented and unfounded, President Obama agreed with Kathleen’s lack of evidence argument and the age restriction remained.

It took until June 2013 for the FDA to approve Plan B One Step OTC for all women without age restriction. That is, it took 10 years for women to have OTC access to a safe medicine approved by the FDA for women of all ages.

Plan B as seen over-the-counter. Image from Dr Wood's presentation 11/19/13.

Plan B as seen over-the-counter. Image from Dr. Wood’s presentation 11/19/13.

How does this history of EC approval, restrictions, stigma, and accessibility relate to gender-based violence and the 16 Days of Activism Against Gender-Based Violence campaign?

  1. EC is an essential contraceptive option for women who experience sexual violence. According to the FDA: “Seven out of every eight women who would have gotten pregnant will not become pregnant after taking Plan B, Plan B One-Step, or Next Choice.” Dr. Wood adds, “There isn’t any difference in efficacy for the use of EC for victims of sexual violence.”
  2. EC potentially prevents the extra burden of an unwanted pregnancy for rape victims.
  3. The cost of EC may be prohibitive; EC costs about $50 OTC in most pharmacies. Under the Affordable Care Act, the cost should still be covered through prescription. According to Dr. Wood, in the cases of rape, specifically for populations who cannot afford the $50, access to EC through family planning clinics may reduce the cost.
  4. If a victim of sexual violence seeks care at an emergency room, EC should be provided as part of her treatment.
  5. Even though EC is available OTC, doctors should continue prescribing and counseling EC, especially for victims of sexual violence. According to Dr. Wood, “Time is of the essence, so provision of information, and advance provision of EC can be helpful for all women. In addition, awareness by providers of other EC methods, such as insertion of copper IUD or use of Ella (a prescription only emergency contraception that is effective for up to 5 days) is important.”

Withdrawal and Unintended Pregnancy

Withdrawal is a widely-used contraceptive method — recent study cohorts report an ever-use between 10 and 60 percent. When used correctly, withdrawal has a perfect use rate comparable to male condoms.

Still, more than half of the unintended pregnancies in the U.S. occur while using a contraceptive method. And withdrawal is less effective at preventing pregnancy than other methods of birth control. Since a high proportion of females use withdrawal, this may contribute to the high rates of unintended pregnancies.

A recent study published in the September 2013 issue of Obstetrics and Gynecology examined the prevalence of withdrawal among U.S. females aged 15-24 years and the correlation to unintended pregnancy. The study describes the characteristics of withdrawal users and concludes that they are at a higher risk of unintended pregnancy compared to those who use other forms of contraception. Researchers from the University of Chicago Section of Family Planning and Contraception contributed to the study.

Increased Risk

The study found a high prevalence of withdrawal use and an association with unintended pregnancy.

Using data from the 2006-2008 National Survey of Family Growth, the study found that of the sample (2,640 sexually active females between 15 and 24 years old), 31 percent used withdrawal as a contraceptive method and of these withdrawal users, 21.4 percent experienced an unintended pregnancy. Comparatively, only 13.2 percent of females who only used other contraceptive methods experienced an unintended pregnancy.

Females in this age group who use withdrawal were also more likely to engage in other risk behaviors such as having multiple sex partners. Withdrawal users were 7.5 percent more likely to have used emergency contraception, a marker for risk of undesired pregnancy.

Withdrawal is rarely discussed as a contraceptive option with reproductive health care providers.

Who uses withdrawal?

The survey data pointed to several characteristics associated with withdrawal use and unintended pregnancy. These women were more likely to have been treated for a sexually transmitted infection in the previous year (24.1 percent), cohabitate with their sexual partner, and live below the poverty line. African American females were also more likely to experience an unintended pregnancy while using the withdrawal method.

Most females in this study did not use withdrawal as their only contraceptive method. As previous studies have indicated, many females use withdrawal because they are dissatisfied with hormonal methods or condoms.

Conclusions  

As with any form of contraception, the key to successful withdrawal is using it consistently and correctly. This requires determination and communication by both partners. Given the contextual factors and fertility status of women aged 15 – 24, withdrawal is not the most effective contraceptive method.

Withdrawal is a common contraceptive method, especially for young women. As this puts them at a higher risk for unintended pregnancy, health care providers should consider their need for emergency contraception while encouraging the use of more effective methods of contraception. Clinicians should routinely ask about withdrawal use even if female patients report using barrier or combined hormonal contraceptive methods.

This study echoes our research about the need for improved access to emergency contraception. Because women often use emergency contraception as a backup when their primary method fails, emergency contraception also contributes to preventing unintended pregnancy. Plan B One-Step is available over the counter to women of all ages, but restrictions still exist to other forms of emergency contraception because of cost, the need for a prescription, or because of religious or conscientious refusal of pharmacists.

Dude A, Neustadt A, Martins S, Gilliam M. Use of Withdrawal and Unintended Pregnancy Among Females 15-24 Years of Age. Obstetrics & Gynecology 2013;  122: 595-600

Contraception & STI Prevention: What Do Young African American Men Think?

This month, researchers from the Section of Family Planning & Contraceptive Research presented results of several ongoing studies at the North American Forum on Family Planning. Dr. Elisabeth Woodhams, now a physician at Thomas Jefferson University Hospital, discussed her findings from a focus group study that sought to understand African American adolescent males’ perceived responsibility for pregnancy prevention. Dr. Woodhams also received the award for the top presentation from an investigator in training.

Dr. Elisabeth Woodhams

Dr. Elisabeth Woodhams

Men, particularly young men, are often left out of conversations about how to improve contraception use, but male partners can have significant influence over the contraceptive and pregnancy decisions of their female partners. Several studies indicate that women are more likely to stick to a chosen method if their partners know they’re using it, or if the partner is involved in the decision to use that method. The reality of this influence drove Dr. Woodhams to wonder how the partners regard this responsibility. Her study included teenaged African American males enrolled in charter schools on Chicago’s South Side. Several compelling themes emerged in Dr. Woodhams’ findings. One theme throughout was that even though the young men reported feeling responsible for the outcome of an unplanned pregnancy, it did not mean they acted to prevent pregnancy.

Focus on condoms, lacking knowledge of non-barrier methods

When asked about ways to prevent pregnancy, the most common answers were condoms, pull out, or don’t have sex. All had heard of pills, some had heard of IUDs or vaginal rings, and none knew about the contraceptive implant. Some had heard of Plan B, but often thought of it as a shot. Several quotes below reflect some of the misunderstandings about methods:

 “…I heard about one where you put it under a layer of skin in your arm. It’s called….Nuvaring.”

“She get the morning after shot and they’ll just kill all the sperm…”

“I also heard of that thing…they take the top off and put it in their vagina or whatever. Like it knock out, it blocks it. It works for years. It’s called… starts with ovulation.”

“All I heard is it goes inside them, but if you hitting it, if you playing bump around, you can knock it out of place.”

Primary role in sex was condom use and provision

Participants did know a lot about condoms, felt responsibility to provide and use a condom, and really only considered condom use when they talked about “protection.”

“…she like grabbin’ me…and just automatically stop and be like ‘you got the rubber?’ and I’m like ‘what?!’ … and most of the time I do because I always carry condoms like in my back pocket or something…”

“I take at least a third of the condoms… and I take ‘em to my girl crib. Cause I might come over there and then, you know, something might happen, I know that if I didn’t bring a condom I got somethin’ over there with her.”

STI prevention greatest motivator in condom use

STI prevention was the greatest motivator for condom use and reflected attitudes about partners.

I’mma need some condoms ’cause. Like, it wasn’t the fear of me havin’ a baby as the fear of me catchin’ something.”

 “You still use a condom. I don’t know what she got.  No matter what. Like, a girl could be on birth control all her life.  She could be on the best birth control. I’m still not gon’ go in raw.”

“Even before you get down to the having sex part you should always ask a girl when the last time she got checked up.”

Partner type, access, and family indirectly impacts condom use

Motivation to use condoms in a specific sexual encounter was indirectly mediated by several things, the most notable being the “type” of girl they’re having sex with, access to condoms, and family influence. The vast majority of the conversations were actually about the various names and terms the teens had for the girls they have sex with. For instance, “thots” were considered “dirty girls” who sleep with anyone, are likely to have an STI, and are not worthy of respect. “Mains” are a more regular partner, although not necessarily a monogamous partner.  Young men behaved differently when they were with casual partners than when they were with more regular partners, who in general they spoke about with more modesty and respect. With regular partners they often would forgo condoms, but several guys mentioned going to get STI testing with their partners before they made that leap. They did not universally mention discussing pregnancy prevention, although some did.

“Mod: If the thot’s like ‘man, come on get down, but you can’t use nuttin’.” Resp: “If we don’t use it then we ain’t doin’ it. Point blank.” Mod: “Okay. But wit’ yo main you not that way.” Resp: “mmm-mmm [MEANING NO]“.

“But, when it comes to like fuckin’ thots …you don’t know who they be fuckin’, you don’t know what they got, so you always wanna be protected.”

Access was also an issue, both in terms of immediate access and terms of cost and availability. As one participant observed, “We in the basement, I know I ain’t got no condoms, they’re upstairs. I’m not about to go to the 3rd floor, leaving a thot downstairs.”

Finally, participants referred to the women in their family as motivators to protect themselves, more from STIs than from pregnancy. They generally felt comfortable telling their family they were having sex, and depended on their mothers/grandmothers/aunts to provide condoms.

 “Like when you first talk to yo’ moms about it, you don’t wanna tell her cause feel like somethin’ bad gon’ happen. But after you tell her it turns out different…she gonna force condoms on you because she don’t want her child to catch no disease…”

Responsible for pregnancy, but not prevention

While the participants did not prioritize pregnancy prevention, when asked directly whose job it is to prevent pregnancy they reported it was a shared responsibility. However, if pregnancy happened, it was mostly the young man’s fault, especially if they weren’t using a condom. They feared unplanned pregnancies and felt a very strong sense of responsibility if pregnancy happened – this often came out within the context of manhood. When they talked about unplanned pregnancy there was a sense of helplessness; they weren’t interested in fathering but there was little they could do about it aside from use condoms.

 “And I shoulda used a condom. And basically, I’mma have to like get two jobs and like I can’t like, I’mma have to finish school so I could get a better job and I’m not even ready yet.  And you thinkin’ all of this, and how your parents is gon’ react. And you havin’ a child. Like how that’s gon’ make you growin’ up so much faster and your life is basically through.”

 “With the guy he has to know that he has two options that he can take.  Face it like a man or basically run away.  Run away and then he has that title saying ‘you a coward, you’re not a man that gon’ step up to the challenge of taking care of a child.’  But if he stays there he knows that he has to be dedicated, committed, make a sacrifice in his life.”

Conclusions

Dr. Woodhams found the young men in the study were much more focused on STI prevention rather than pregnancy prevention, even though they would feel responsibility if a pregnancy occurred. The concern for STIs prompts condom use, but if they believe their partner is low-risk, they will also stop using condoms. Dr. Woodhams suggested that one approach would be to leverage awareness and comfort with condom use among these young men to emphasize that condoms can also be part of pregnancy prevention. While other contraceptive methods may be more effective, young men may respond more positively to education about a method they already use. In addition, Dr. Woodhams observed that the young men perceived their sexual relationships completely based on risk, rather than on the relationship they were in with their partner. In fact, they rarely referred to a relationship at all, but easily categorized the young women they were having sex with into “good” or “bad,” “clean” or “dirty.” She suggested that sex education programs work to emphasize healthy and fulfilling relationship-building and respect as a response to these attitudes and their influence on condom use.