Easy access to emergency contraception does not appear to encourage women to engage in risky behavior.1 In a study conducted in 2001-2003 in four California clinics, 2,117 women aged 15-24 were randomly assigned to either have access to emergency contraception from a pharmacy without a prescription, receive a supply of the pills to have on hand or be instructed to return to the clinic if they needed emergency contraception (the control group). Six months later, 29% overall said they had used emergency contraception since entering the study. The proportion did not differ between the pharmacy access and control groups (21-24%), but was significantly higher in the advance supply group (37%). No differences were found between controls and the other groups in frequency of unprotected intercourse, contraceptive use patterns, number of partners or consistency of condom use; however, reports of condom use at last intercourse were less common among women who had received pills in advance than among controls (47% vs. 54%). All three groups had similar rates of pregnancy and sexually transmitted disease during the study period. In the researchers' view, "it seems unreasonable" to require a clinic visit for the provision of emergency contraception.
1. Raine TR et al., Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial, Journal of the American Medical Association, 2005, 293(1):54-62.
JUST BETWEEN US WOMEN . . .
Evidence suggesting that women may contract bacterial vaginosis through sexual activity with female partners is growing.1 Between 1992 and 1995, some 708 new patients at two London sexual health clinics for lesbians and bisexual women completed surveys eliciting information on sexual risk factors. After undergoing genitourinary screening, 31% received a diagnosis of bacterial vaginosis, an often asymptomatic condition that may lead to infection, pregnancy complications and poor birth outcomes. In a multivariate analysis, women who had had more than 10 female sex partners had 60% higher odds of bacterial vaginosis than those who had had 1-5 female partners. The researchers conclude that the female partners of women being treated for bacterial vaginosis should be screened for the condition.
1. Bailey JV et al., Bacterial vaginosis in lesbians and bisexual women, Sexually Transmitted Diseases, 2004, 31(11): 691-694.
MEETING ICPD GOALS (OR NOT)
Ten years after the International Conference on Population and Development (ICPD), the extent to which the wealthiest donor countries have met their financial commitments to help achieve the goal of assuring access to basic reproductive health care for all men and women worldwide by 2015 varies widely.1 Four countries (Denmark, Norway, the Netherlands and Luxembourg) have met their assistance goals for 2005, but others have a long way to go. The fair share for 10 countries is about 2-7 times their current funding levels. Spain and Portugal would need to contribute at least 60 times their 2002 levels to meet their commitments. Together, donor nations need to triple their population assistance to meet ICPD's goal for 2005. More generally, when graded on a scale reflecting a variety of measures of financial and policy commitments to population assistance, 13 of 21 donor countries scored A's and B's, and the rest scored C's and D's. The United States makes a poor showing: It needs to triple its funding to pull its fair share, and its overall grade has slipped from B to C.
1. Population Action International, Progress & Promises: Trends in International Assistance for Reproductive Health and Population, Washington, DC: Population Action International, 2004.
ALMOST COMPLETE GUIDELINES
The Justice Department has issued the first-ever national guidelines aimed at helping state, local and tribal jurisdictions to respond "in the most competent, compassionate, and understanding manner possible" to individuals who have experienced sexual assault.1 Among other points, the guidelines stress the importance of victim-centered care that includes assessment of individuals' needs for immediate medical attention. They go into some detail about steps health care providers should take to address the risk of sexually transmitted diseases, including encouraging individuals to accept prophylactic treatment when appropriate. As regards pregnancy, however, they are less comprehensive: The guidelines recommend that providers discuss the risk of pregnancy and encourage women of reproductive age to undergo pregnancy testing. They also suggest discussing "treatment options . . . , including reproductive health services," but nowhere mention the provision of emergency contraception. Predictably, the omission is seen as a major flaw by victims' advocates and many medical professionals, but has won praise from some conservative groups.2
1. Office on Violence Against Women, A National Protocol for Sexual Assault Medical Forensic Examinations: Adults/Adolescents, Washington, DC: Department of Justice, 2004.
2. McCullough M, Sex-assault treatment guidelines omit pill, Philadelphia Inquirer, Dec. 31, 2004, <www.philly. com/mld/inquirer/1053638.htm?1c>, accessed Jan. 10, 2005.
WATCH YOUR MOUTH
Fourteen percent of men and women with primary or secondary syphilis interviewed in Chicago in 2000-2002 reported that the only type of sexual contact they had had during the period in which they likely acquired the infection was oral sex.1 Among men who have had sex with men, the proportion of infections attributable to oral sex was above the average—20%. By contrast, only 6-7% of women and of men reporting exclusively heterosexual behavior appear to have become infected through oral sex. The total number of syphilis cases in Chicago has been stable since the 1990s, but the population affected has shifted dramatically: In the 1990s, infections were almost exclusively among heterosexual men and women; in 2001 and 2002, nearly three in five were among men who have sex with men. Some of the men interviewed believed that oral sex carries no risks and had been surprised to learn that they were infected. The researchers stress that "persons who are not in a long-term monogamous relationship and who engage in oral sex should use barrier protection."
1. Ciesielski C, Tabidze I and Brown C, Transmission of primary and secondary syphilis by oral sex—Chicago, Illinois, 1998-2002, Morbidity and Mortality Weekly Report, 2004, 53(41): 966-968.
COST OF NO CONFIDENTIALITY
Laws that restrict the confidentiality of Texas teenagers who wish to obtain reproductive health services could exact substantial health and economic costs.1 Using data from the state health department and publicly funded family planning clinics, analysts projected the effects of teenagers' loss of confidentiality resulting from two laws implemented since 2001, one of which requires those younger than 18 to get parental consent to obtain prescription contraceptives. Assuming that 37% of clinic clients younger than 18 would forgo reproductive health care if they had to tell their parents, the analysts estimate that each year, an additional 5,372 births and 1,654 abortions would occur in this population; medical costs associated with these outcomes would exceed $44 million. Teenagers' failure to seek care also would result in increases in untreated cases of chlamydia (2,243), gonorrhea (521) and pelvic inflammatory disease (501); treating the consequences of these diseases would cost $708,000. A reduction in visits owing to the loss of confidentiality would somewhat offset these costs; still, the state's tab would run $43.6 million.
1. Franzini L et al., Projected economic costs due to health consequences of teenagers' loss of confidentiality in obtaining reproductive health care services in Texas, Archives of Pediatrics and Adolescent Medicine, 2004, 158(12):1140- 1146.
INFANT DEATHS IN THE 'HOOD
Infant mortality varies more by neighborhood in New York City than it does in Paris, London or Tokyo.1 In 1988-1992, the infant mortality rate in high-income neighborhoods of Manhattan was 56% lower than the rate in low-income neighborhoods; the difference grew to 61% in 1993-1997. By contrast, in the later period, high-income neighborhoods in London had a 19% lower rate than low-income ones, and rates in Paris differed only marginally by neighborhood. In Tokyo, rates did not differ by neighborhood income level in either period. According to the analysts, "reducing disparities among neighborhood infant mortality rates will require intense targeting of high-rate neighborhoods."
1. Rodwin VG and Neuberg LG, Infant mortality and income in 4 world cities: New York, London, Paris, and Tokyo, American Journal of Public Health, 2005, 95(1):86-90.
Women and, to a lesser extent, men attending a Seattle sexually transmitted disease (STD) clinic in 2002-2003 were more apt to tell a computer about sensitive behaviors than they were to tell a live interviewer.1 A total of 609 men and women between the ages of 14 and 65 agreed to take an audio computer-assisted self-interview before having their sexual history taken by a clinician. Higher proportions of women told the computer than told the clinician that they had recently had a female partner (20% vs. 12%) or engaged in oral sex (67% vs. 50%), had used amphetamines (5% vs. 1%) or had engaged in transactional sex (21% vs. 10%); a lower proportion reported STD symptoms to the computer than to the clinician (55% vs. 64%). Among men, only reports of ever having had a male partner were more common in the computerized interview than in a face-to-face situation (37% vs. 29%). Fifty-six percent of participants preferred the computerized to the clinician interview, and 49% would favor answering sexual history questions on a computer and then reviewing their answers with a clinician. The researchers conclude that computerized self-interview could help to "expand and enhance behavioral surveillance in STD clinics, standardize sexual history-taking, and...decrease costs associated with clinic visits."
1. Kurth AE et al., A comparison between audio computer-assisted self-interviews and clinician interviews for obtaining the sexual history, Sexually Transmitted Diseases, 2004, 31(12):719-726.
ACCOUNTING FOR ABSTINENCE
In two interviews 18 months apart, sexually inexperienced young adolescents in Missouri expressed increasingly positive views toward having intercourse. On average, the 422 youth who reported in both 1997 and 1999 that they had not had sex gave eight reasons for abstaining at baseline, but only seven at follow-up. Significant declines were seen in the proportions reporting that they were not ready for sex (71% vs. 62%), they were waiting until they were older (69% vs. 61%) or married (59% vs. 51%), or they considered premarital sex wrong (59% vs. 51%). Additionally, parents' reactions were cited less frequently in 1999 than in 1997 (5% vs. 60%), as were embarrassment about sex (14% vs. 21%) and about the use of birth control or condoms (5% vs. 9%). Fear of pregnancy or AIDS was a motivation for eight in 10 respondents at each interview. In logistic regression analyses, teenagers with conservative attitudes toward premarital sex, males and youth who did not drink had an elevated likelihood of remaining sexually inexperienced over the study period. According to the researchers, antidrinking messages targeted to young adolescents are essential, as are booster sessions to reinforce messages about HIV and pregnancy.
1. Blinn-Pike L et al., Sexually abstinent adolescents: an 18-month follow-up, Journal of Adolescent Research, 2004, 19(5):495–511.