Slide 1:Steamy Hot Topics In Teen Sexuality: Behavior, Disease, and Prevention 2008 Jonathan Fanburg, MD, MPH Daniel Summers, MD


What you will learn :What you will learn Trends in Teen Sexuality Diseases – Chlamydia, Gonorrhea, Hep C, HPV Prevention – HPV Vaccine, Pap recs Pregnancy – New Trends, Birth Control, and Abstinence Data Gay, Lesbian Relationships


A Trendy Question :A Trendy Question When you ask a 13 year old if they started having sex, they stare off for a second and then say yes, just recently. Which is most likely to be true? A. The 13 year old is female. B. They had oral sex, not intercourse. C. They had been smoking pot before hand. D. They used a condom and birth control. E. All of the above.


TV causes pregnancy? :TV causes pregnancy? Teens who watch high levels of sexual content on TV are twice as likely to get pregnant as teens who watch low sex content. (Compared 90th%ile with 10th%ile. Pediatrics, 11/4/08)


Slide 7:Males – treat sex as objects Females – submission is part of sex Results: eating disorders, anxiety, self esteem, sexual violence


Slide 8:Lingerie Barby Sexual expression is a matter of accessorizing. Sexualizing products – results in passion for the products, not partnership. (Jean Kilborne, AAP NCE 10/08)


The Good News :The Good News Sex improves self-esteem Teens who had sex greater than 2.3x/wk had increased alertness, happiness, and sense of well being (Society for Adol Med, 5/05)


Trends :Trends Serial Monogamy One night stands/non-romantic sex is up Teen Pregnancy is Down Oral Sex is Up (M=F)


Trends – oral sex :Trends – oral sex 15-50% of teens have oral sex prior to initiating intercourse (Society for Adolescent Medicine, 5/05) Amongst California 9th graders, 20% reported having oral sex, whereas 14% reported having vaginal intercourse. Perceived less chance of pregnancy and catching chlamydia or HIV, as well as less chance of jeopardizing their relationship or their reputation, getting into trouble or feeling guilty about their behavior (Perspectives on Sexual and Reproductive Healtholume. 37, Number 3, September 2005)


Casual Sex :Casual Sex Casual sex occurs in 20% of college students Casual sex (n=695, ages 18-24yrs) Associated with fewer depressive symptoms and better emotional health among males Was not seen in females Physical health (STD’s) may have the opposite correlation and wasn’t studied in this study. (SAM, 3/08)


STI’s: The Bedtime Story :STI’s: The Bedtime Story TONIGHT 10,960 Americans get Chlamydia TONIGHT 3,835 Americans get Gonorrhea TONIGHT 89 Americans get AIDS 50% of sexually active teens will get an STI by age 25yrs.


Local STI’s :2005 MCMH Lab Teens (10-18); 19,733 visits 156 gon/chlam tests 8 had Chlamydia (5.1%) 1 had Gonorrhea (0.6%) Among all ages 1110 gon/chlam tests 18 had Chlamydia (1.6%) Local STI’s Source: Maine CDC, Sept. 2006. Deb MacGown, Lab, Jan 2006. Maine CDC - Chlamydia (total population) [Cases (Incidence)] MCMH Lab (tested patients) [Cases (prevalence)] 3% of the teen population has chlamydia. 5-7% of those tested will be positive. Bottom Line - Fact #2


Fact #3: Chlamydia and Gonorrhea have Unique Propertieswhich are hints in how they present :Fact #3: Chlamydia and Gonorrhea have Unique Propertieswhich are hints in how they present


Chlamydia / Gonorrhea :Chlamydia / Gonorrhea No Symptoms (days or months) Discharge (“The Drip”) or Burning with Urination or pain with intercourse Females more than Males


Slide 17:(Adapted from Merk slide kit).


Mucous Membranes are at Greatest Risk of Transferring Infection :Mucous Membranes are at Greatest Risk of Transferring Infection Endometrial Tissue Exocervix and Vaginal wall


“Road Side Assistance” :“Road Side Assistance” IUD - ladder effect and local inflammation Sperm - taxi effect Trichomonas - taxi eff. PMN’s - ?taxi effect Surg.Instr.- bulldozer effect Hx PID - entrapment effect and loss of cilia ?BV - buddy system theory Menses Young age - Ectropia -open door policy


“Road Block” :“Road Block” OCP’s - protect against gonorrhea ?also chlamydia Nonoxnol 9 - breaks down cell wall of infectious agent


Gonorrhea/Chlamydia :Gonorrhea/Chlamydia No Symptoms Discharge or Burning Abdominal Pain and/or (PID) Fever Vomiting Systemic Spread Blood Joints Liver Skin Eyes Heart Brain Pelvic Inflammatory Disease (PID) Tubo-ovarian Abcess (TOA) Long Term Risks Sterility (1x=13-21%, 2x=35%, 3x=55-75%) Ectopic Pregnancies Chronic Abdominal Pain (1x=18%) (42%) (99%) (40%)


How Do You Test? :How Do You Test? 16 year female who started sexual activity 1 year ago comes for well physical. How do you test her for an STI? A. I don’t. She only had one partner. B. I don’t. She says she doesn’t need it. C. Pelvic exam and DNA probe. D. Urine molecular amplification (LCR/SDA) E. I refer her to GYN.


Testing Accuracy :Testing Accuracy Culture DNA Probe LCR/SDA Urine Combined urine maintains sensitivity at ratio of 10:1 Chlam/Gon (sens) (spec) Cx 56-93 100 DNA 50-81 88-99 LCR 95 99.9 Study: Among those who claim abstinence, 3% were positive for chlamydia, as compared to 7% of those who admitted to intercourse. Home test is coming. Screening Recs ??


Treatment :Treatment Inpatient if really bad or not tolerating medications Outpatient: (almost 100% effective) Ceftriaxone 125mg IM x1 or Cefixime 400mg PO x1 or Ciprofloxacin 500mg PO x1 or (Ofloxacin 400mg PO x1) or (Levofloxacin 250mg PO x1) (quinolone resistance exists) Azithromycin 1gm PO x1 or Doxycycline 100mg BID x7d or EES or Ofloxacin or Levofloxacin Consider anaerobic coverage: Metronidazole Chlamydia Gonorrhea Anaerobes


Expedited Partner Therapy :Expedited Partner Therapy 8% of Chlamydia persists when one rechecks. (NEJM 2005: 352:676-85) Expedited Partner Therapy Treating unseen partner is becoming more common of a practice. Legal? Vs Smart medicine?


Question #3 :Question #3 Which is more common in young adults? A. Hepatitis B B. Hepatitis C


Hepatitis C (ages 10-24, 2003-2005) :Hepatitis C (ages 10-24, 2003-2005) Hancock Penobscot 15-19yo 7 positive 16 positive 20-24yo 21 positive 41 positive Rate is 0.2-0.9 percent Maine CDC, Sept 2006.


Hepatitis C :Hepatitis C Most are associated with IVDA Current Treatment – rapidly changing Watch for up to 6 months plus Many acute hepatitis patients will self resolve Treat if persistent or signs of liver involvement Interferon has its own problems


WARTS (HPV)Human Papilloma Virus :WARTS (HPV)Human Papilloma Virus 70% of sexually active teenagers acquire HPV within 5 yrs Most cervical HPV is caused by strains 16+18, and genital warts are from strains 6+8. HPV accounts for 93% of cervical cancer HPV Cervical Pathology


Most LSIL Goes Away in Teens :Most LSIL Goes Away in Teens Among study of 200,000 females, No patients under age 21 progressed to cancer Most LSIL reverted to normal within 2-3yrs The most rapid progression of LSIL to HSIL was 3yrs Among 21-24 year olds, 2 people developed cervical cancer. (SAM Annual Meeting 2004) Among study of 899 young females (13-22yo) 91% LSIL regressed to normal over 3 yrs 3% LSIL progressed to HSIL over 3 yrs (Moscicki. Lancet. 2004:364:1678-83.)


2002 American Cancer Society and ACOG Guidelinesfor Cervical Cancer Screening and Prevention “Get less aggressive” :2002 American Cancer Society and ACOG Guidelinesfor Cervical Cancer Screening and Prevention “Get less aggressive” Most teens get rid of HPV on their own 1st Pap Smear should occur within 3 years of initiating sex, or by age 21 if virgin Birth control is not a reason for PAP smears Watch LSIL for up to 2-3 years, before further intervention. Repeat PAP smears 6-12mo? Consider Colpo if high risk HPV DNA and CIN1 persists for 1yr Aggressive colposcopy, freezing, conization is not indicated in most adolescents and only weakens the cervix for future pregnancy. (ACS 2002. ACOG Committee on Adol Health Care. ObstGyn 2004:104:885-889.)


HPV Vaccine – 2006 :HPV Vaccine – 2006 Effective Prevention 100% for CIN 2/3+ (strains 16,18) 95% for CIN 1+ (strains 6,8,16,18) 99% for genital warts (strains 6,8,16,18) 93% of cervical cancer is from HPV 80% of cervical cancer is caused by strains 6, 8, 16, and 18 (which are found in HPV vaccine) Sexually Naive DISCLOSURE (Ref. Merck)


HPV Vaccine – 2006 :HPV Vaccine – 2006 46% effective for CIN 1+ (strains 6,8,16,18) 68% effective for genital warts (strains 6,8,16,18) CDC/FDA Recs: Give Vaccine to ages 11-12yo Can give vaccine to ages 9-26yo What about >26yr old? Males? Infants? How long will vaccine last? All Comers – General Population (Ref. Merck)


Legislative Task Force on Cervical Cancer - 2006 :Legislative Task Force on Cervical Cancer - 2006 Increase Public Awareness Increase Provider Knowledge Guidelines, Screening, and Vaccine Increase Cancer Screening Adhere to CDC Vaccine Guidelines Appropriate funds for HPV vaccine Q2yr report on vaccination rates to legislature 2010 assess potential school mandate of vaccine Invest in Prevention Efforts


Prevention Trends :Prevention Trends Abstinence Only Education Multiple studies have demonstrated that this is not effective. Virginity Pledges One study demonstrated that pledging virginity in 7-12th graders resulted in delayed sex, yet equal rates of STD’s. Pledgers were less likely to use condoms at sexual debut, less likely to seek testing/treatment for STD’s, more likely to have anal only sex, and more likely to be married earlier than non-pledgers. (Bruckner, J.Adol.Health. 336(2005)271-8.) (SAM, 3/2005)


New Birth Controls :New Birth Controls Patch + Nuvo Ring presently available 90 day pill (Seasonale) Yasmin (anti-androgenic effects – facial hair, acne, ect; hyperkalemia side effect) Pills with low dose estrogen instead of placebo Progesterone 3 year implants 24day pack, quick start, Yaz, Yasmin