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Test for Chlamydia, Pap or No Pap

Sex Stories

By Kait Scalisi, MPH

In the continuing saga of patients and healthcare providers communicating poorly about sexual health, a new study shows that chlamydia screening rates dropped after Pap tests became less common.

For decades, Pap smears and chlamydia screening were paired. Once you became sexually active, or in some cases when you wanted birth control, your healthcare provider performed both tests during a pelvic exam. In 2009, the American College of Obstetricians and Gynecologists changed its recommendations around the Pap. As the recommendation still stands, all people with cervices should have a Pap test at age 21, regardless of sexual activity.

At the same time, the CDC recommends yearly chlamydia testing for all sexually active women 25 and under, along with older women with risk factors such as multiple sexual partners.

These recommendations appear to leave a gap: What about the folks who were younger than 25 but having sex? When would they get tested for chlamydia if they didn’t have a Pap done?

The technical answer to this question is simple: there are other ways to test for STDs without a pelvic exam. For example, a healthcare provider use a urine sample or vaginal swab to screen for chlamydia.

The realistic answer is that they aren’t getting tested.

In the study, researchers at the University of Michigan Medical School looked at rates of cervical cancer and/or chlamydia screenings among two groups of female patients: those who made visits before the 2009 change in Pap guidelines, and those who made visits after.

Over 3,000 patients (aged 15-21) visited five family planning clinics in Michigan. Of those who visited before the guidelines changed, about 30% got tested for chlamydia. Afterwards, that number dropped to less than 1%. As expected, the percentage of patients getting Pap smears dropped dramatically too, from 24% to less than 1%.

It’s not that girls and young women were going to the doctor less.  No, in fact the number of visits between the two groups was about the same. The opportunity was there, but not taken.

Chlamydia is curable if detected. So what can clinics and healthcare providers do to close the gap of testing without doing unnecessary Pap exams? An interview with the study’s lead author provides a few ideas.

First, healthcare providers need to shift their mindset and separate out STD testing and cancer screening. They don’t need to happen together and as mentioned above, no pelvic exam is even needed for chlamydia testing. Closely related to this is the need for knowledge about these non-invasive testing methods. If healthcare providers do not know about these options, it is hard to offer them.

Secondly, taking advantage of modern technology. Electronic health records can be formatted to remind healthcare providers when a patient needs a chlamydia testing, maybe even providing information about the noninvasive testing methods.

Lastly, STD testing need not be relegated only to preventative care visits. Here, prompts from electronic health records are particularly helpful. If a patient comes in for a sick or emergency visit, the prompt will pop up no matter what, encouraging the provider to administer the testing along with any procedures relevant to the reason for their visit.

Regardless of whether electronic health record alerts are an option, but especially if they aren’t, this study speaks to the need to better train healthcare providers in talking about sexual health issues. Missed opportunities for testing are not the only reason that STDs continue to spread an go untreated, but they undoubtedly are one factor. And they’re perhaps the easiest to change. After all, people will continue having sex, some of which may be unprotected, and changing the health behaviors of an entire population through community outreach and sex education will take more time and effort than shifting the practices of one group of people who are already dedicated to keeping us healthy.

Other Sexual Health News This Week

Taxpayer Calculator: As Pols Push to Defund Planned Parenthood, How Much Is It Costing You? (Fox News)

Teenage Sex 2015: Sexual Activity Among Teens in US Remains Steady, Reviving Abstinence Debate (International Business Times)

Ruling in Favor of UC Student Accused of Sexual Assault Could Ripple Across US (LA Times)

Calif. Students Now Given Six ‘Gender Identity’ Options on College Admissions (The College Fix)

Women’s Sexual Risk-Taking Focus of New Study (EurekAlert)

Why Aren’t Teens Using More Effective Birth Control?

Sex Stories

By Kait Scalisi, MPH

Earlier this year, the CDC released a new report addressing the lack of long acting reversible contraceptives (LARCs) use by teens (15-19 years old). While teen birth rates are at a historic low, increased use of LARCs would reduce this number even more. Unfortunately, healthcare providers serving teens aren’t always prepared to offer this option.

The CDC brief uses data from the Title X Family Planning Annual Reports compiled between 2005-2013. It offers a lot of good news: Teens are waiting to have sex; they’re reporting more birth control use; and the rate of LARC use has increased 6% over the years studied. Even with this increase, LARC use among teens remains low (about 7% nationally) and there are nearly 300,000 children born to teens each year.

The benefits of using LARCs are plentiful—no remembering to take or change anything, a less than 1% chance of pregnancy, and coverage lasting three to ten years. Unfortunately, so are the barriers, especially for federally-funded clinics like those represented in this report. Three major barriers include:

  • high upfront costs for supplies.
  • providers’ lack of awareness about the safety and effectiveness of LARC for teens.
  • providers’ lack of training on insertion and removal.

These factors inform the recommendations provided in the report. Specifically, providers should:

  • recognize LARCs as safe and effective birth control choices for teens.
  • offer a variety of birth control options to teens, including LARCs.
  • create the infrastructure to support LARCs, such as seeking training on insertion and removal, having supplies available, and exploring funding options to cover cost.

Beyond these barriers, some of the variation in teen LARC use is geographic. Traditionally, “blue” states, such as those in the Northeast and on the West Coast, have above-average rates while “red” states hover at or below average. That being said, there were a few surprises including Iowa, Oklahoma, and Texas. This variation may have to do with the states’ sex education and birth control access policies. It would also be interesting to compare abortion laws and LARC use to see if there is a connection between the two. My hunch is that one exists.

A major limitation of this report is that it only covers teens getting healthcare at a Title X clinic. This means the data is not totally nationally representative; however, it does cover populations that typically have higher rates of unplanned pregnancy. While we need truly nationally representative data, it also is important to ensure there is information about the most at-risk populations. This enables public health policy, education, and communication campaigns to be better tailored and ultimately more effective.

LARCs alone cannot bring the teen pregnancy rate down to zero. For some teens, they won’t be a good fit, either due to the cost or personal preferences related to contraception (e.g., some people don’t like having something in them). Additionally, the larger societal factors which influence teen pregnancy cannot be solved simply through contraception. However, LARCs are an important part of the larger strategy. The recommendations in this report are the next best step towards making them more universal.

Other Sexual Health News

The Evidence on VA.’s Abortion Clinics (Washington Post)

New York Teens FINALLY Get Schooled On Condom Use (Refinery 29)

Oregon Legislature Votes to Expand Access to Birth Control (Fox News) A similar bill also was unveiled in Congress. (USA Today)

Big Study Finds Autism Risk Higher If Teen Mom Or Parental Age Gap (WBUR)

Apple Inc. Updated Health App Will Monitor Sexual Activity (ValueWalk)

The Search for the Best Estimate of the Transgender Population (New York Times)

Existing Same-Sex Marriage Licenses in Ark. Ruled Legal (THV11)

Upcoming Conferences

Center for Research and Education on Gender and Sexuality(CREGS) 2015 Summer School, June 19-26

RSOL National Conference, June 25-28

International Conference on HIV Treatment and Prevention Adherence

Texas Prevention Summit, Jun 29- Jul 1

Becoming a Sexually Permissive Society

Sex Stories

By Kait Scalisi, MPH

Over the last 50 years attitudes towards sexuality have shifted dramatically. A recent study published in the Archives of Sexual Behavior probes the questions of how and why these shifts occurred.

The study uses data from the General Social Survey, a nationally representative survey of over 33,000 American adults. In short, attitudes towards sex have become more flexible. As the study’s authors summarize:

Between the 1970s and the 2010s, American adults became more accepting of premarital sex, adolescent sex, and same-sex sexual activity, but less accepting of extramarital sex.

Most of the shifts in attitudes and behaviors were small but statistically significant.

On the one hand, this feels disheartening because we often need a critical mass of people in order for there to be true societal-level changes. For example, acceptance of adolescent sex remains rather low. This undoubtedly impacts individuals’ attitudes towards comprehensive sex education and, in turn, rates of unplanned pregnancies and STIs. The lack of larger acceptance of this topic may partially explain why Congress recently and quietly sneakily increased funding for abstinence-only sex education.

On the other hand, these shifts offer hope because we already can see some of their impacts. For example, acceptance of sex between adults of the same sex shot up starting in 1993. A few weeks back, we learned that acceptance of same-sex marriage is at its highest rate ever. Though not the same exact measures, they’re related. I certainly wish progress happened more quickly but it is heartening to reflect on the effects of slow and steady change.

Extramarital sex is still a big no-no.

Acceptance of extramarital sex also remained low. In fact, unlike the small increase in acceptance of adolescent sex, this topic saw a small decrease. This is interesting given the recent focus on “monogamish” a term coined by Dan Savage and recently featured in a Tedx Talk by Jessica Reilly as well as the rise of hook-up apps (while marketed towards single people, individuals in relationships likely use them as well).

Our sexual behaviors have also changed.

Adults in the 2000s have had more sexual partners (since age 18) than in past years. They also are more likely to have sex with someone who is not their partner, such as a casual date, hook-up buddy, or acquaintance.

Age, generation, and time period matter.

For all of these factors, there were variations by age, generation, and time period. Generation explains the bulk of this variation. As the researchers noted:

The generational trend was somewhat curvilinear, with the largest difference between those born in the 1900s and Boomers born in the 1940s and 1950s, a slight decline between the 1950s-born Boomers and 1960s-born GenX’ers, and a rise in acceptance between GenX’ers born in the 1960s and Millennials born in the 1980s–1990s

Age also played a role as, generally speaking, older individuals had slightly but significantly less accepting views on all topics. New York Magazine featured an infographic highlighting the significant differences in the last 20 years, showing that even Millennials attitudes and behaviors have shifted.

Gender, race, education level, US region, and religiosity also matter.

Acceptance and behaviors also varied by individual variables. Generally speaking, people are more accepting if they are male, white, from a traditionally blue state, have a college degree, and did not attend religious services regularly. Interestingly, shifts in attitudes and behavior nearly absent for black Americans.

Ultimately, however, these individual characteristics were moderated by generation:

“…generations born later in the twentieth century (compared to those born earlier) held significantly more permissive attitudes toward non-marital sex and had sex with a greater number of partners.”


The authors explored some additional factors that may have influenced this overall change in views and behaviors. They conclude that four societal factors likely played a role. These include:

  • rising cultural individualism
  • rejection of social norms
  • shifting norms around marriage
  • changes in relationship and dating patterns towards sexual relations

Taken together, this research shows us that views on sex are becoming increasingly permissive with the exception of cheating. Many factors come into play from individual to societal to generational differences. The breadth of influences reminds us that we must educate on multiple levels. Each also offers and opportunity to create future impact on sexual attitudes and behaviors.

Other Sexual Health News This Week

Why Caitlyn Jenner’s Transgender Experience is Far From the Norm (CNN)

Bullied Teens Often Become Depressed Adults (MedPage Today)

Groups Wait for SCOTUS Ruling on Same-Sex Marriage (Fox 6)

Permanent Contraception Pushed by Gates Foundation (Baptist Press News)

Minnesota Sex Education Teacher Takes Students to Adult Store (Fox News)

Oregon Women Could Skip Doctor’s Visit for Birth Control (ABC News)

Upcoming Conferences

Center for Research and Education on Gender and Sexuality(CREGS) 2015 Summer School, June 19-26

RSOL National Conference, June 25-28

International Conference on HIV Treatment and Prevention Adherence

Texas Prevention Summit, Jun 29- Jul 1

Eating Disorders: Not Just for Cisgender, Heterosexual Women

Sex Stories

By Kait Scalisi, MPH

Most conversations about eating disorders focus on women, specifically those who are cisgender and heterosexual. This group, however, may not be at the highest risk.  New data from the most recent American College Health Association’s National College Health Assessment (ACHA-NCHA) highlight the intersections of sexuality, gender identity, and eating disorders.

The most recent iteration of the ACHA-NCHA surveyed over almost 300,000 students at 233 US colleges and universities. Data collection took place between Fall 2008 and Fall 2011. All data was collected anonymously. For this analysis/study, only data from the first semester that each institution participated in ACHA_NCHA. This ensured all responses were unique.

To study connections among gender identity, sexuality, and eating disorders, the researches classified individuals into the following seven categories.

  1. transgender
  2. cisgender sexual minority (SM) men
  3. cisgender unsure men
  4. cisgender heterosexual men
  5. cisgender SM women
  6. cisgender unsure women
  7. cisgender heterosexual women (reference)

Individuals in the last category were used as the reference group since most eating disorder research has been conducted on them, providing a rich data set to make comparisons to. “Sexual minority” included individuals identified as gay or bisexual.

Eating disorder status was assessed by asking individuals if they had been diagnosed or treated for an ED in the last 12 months and whether they had vomited, taken laxatives, or taken diet pills in the last 30 days. Covariates assessed included race/ethnicity, smoking frequency, binge drinking frequency, stress level and participation in athletics.

Rates of ED diagnosis or behaviors were highest among transgender individuals and lowest among cis, hetero males. Of the transgender students, those who were unsure of their sexual orientation had the highest rates of eating disorder diagnosis and use of laxatives, diet pills, and vomiting. That being said, rates of these outcomes for all subgroups of transgender folks were higher than any other group. Cisgender SM males also had elevated rates of eating disorder diagnosis.

The authors list several possible reasons for these heightened rates. These include:

    • Using eating disorder behaviors to suppress or accentuate particular gendered feature.
    • Experiencing minority stress.
    • Having a greater likelihood of contact with mental health professionals due to both the heightened rates of mental health issues among SM and the fact that most transgender individuals must receive therapy in order to have gender-affirming surgery.

Most likely, the truth is some combination of the above along with genetic risk factors highlighted in previous research.

One major critique of the study is that it excluded questions about binge eating disorder, a diagnosis only recently added to the DSM but which is thought to affect as many if nor more individuals that anorexia and bulimia. Another limitation is the inability of the researchers to distinguish among the different groups of transgender individuals (e.g. male-to-female, female-to-male, and gender-queer). Like any group, transgender people are not a monolith. They are all individuals with different risk factors and lived experiences, some of which may vary depending on which subgroup of transgender they fall into.

Despite these limitations, this was the first ACHA-NCHA with enough transgender individuals to make statistically significant comparisons to other gender identities. This is hugely important as much research excludes this population due to either low response rates or oversight on the researcher’s behalf. Such lack of representation in the literature means that we cannot create quality health education programs or policy to meet transgender individuals’ unique needs.

Overall this study is groundbreaking in what it adds to our understanding about the intersections of gender identity, sexual orientation, and eating disorders. It provides health educators with new learning objectives for their programs and researchers, a jumping off to point to study additional underlying factors, risk facts, and outcomes for anyone dealing with an eating disorder.

Other Sexual Health News This Week

Newer Types of Birth Control Pills Confirmed to Raise Blood Clot Risk (Los Angeles Times)

Health Buzz: How the Herpes Virus Can Kill Cancer (US News)

New Tuscon Nonprofit Focuses on Women Living with HIV or AIDS (Tuscon News Now)

ACLU Asks Hollywood To Support Gender Equality; Will They? (Forbes)

Lack of Sexual Health Knowledge Among Young Males (PR Newswire)

A Seattle High School is Taking Birth Control Access to the Next Level (Grist)

Upcoming Conferences

AASECT 47th Annual Conference, June 3-8

2015 National Summit on HCV and HIV Diagnosis, Prevention and Access to Care, June 4

Philadelphia Trans Health Conference, June 4-7

Center for Research and Education on Gender and Sexuality(CREGS) 2015 Summer School, June 19-26

RSOL National Conference, June 25-28

International Conference on HIV Treatment and Prevention Adherence

Texas Prevention Summit, Jun 29- Jul 1

Women Targeted on Twitter

Sex Stories

By Kait Scalisi, MPH

Towards the end of 2014, Women, Action, Media (WAM), a nonprofit dedicated to building a robust, effective, inclusive movement for gender justice in media, became an authorized reporter on Twitter. This status allowed them to monitor, report, and follow-up on instances of harassment experienced on the platform. From over 800 reports of harassment, WAM discovered disturbing patterns in online behavior and Twitter’s response. They published their findings and recommendations this week. 

Women experience significantly more and more severe forms of online harassment. WAM sought to quantify this data with a pilot study assessing the types and frequency of harassment. In three weeks, WAM processed over 800 reports and sent over 300 to Twitter. From there, Twitter took action on 161.

Examining the nearly 400 genuine harassment reports led to some interesting findings. These include

  • Bystanders play a huge role in reporting online harassment. Over 50% of reports received were submitted by someone other than the person being harassed. Most of these reports mentioned only one receiver of harassment.
  • Ongoing harassment is a problem. Nearly one-third of reports dealt with on-going harassment and over two-thirds mentioned having reported this problem to Twitter in the past. However, most harassing accounts were reported only once, indicating there’s a lot of jerks out there.
  • Hate speech and doxxing (releasing someone’s private information) were the most common forms of harassment. Together they accounted for nearly half of all reports. An additional 19% of reports did not fall neatly into any category.
  • Twitter took action in 55% of reported cases. In most cases, accounts were suspended. Only one account was deleted.
  • Twitter was more likely to take action on reports of hate speech. Twitter was much less likely to take action for other forms of harassment though they showed no favoritism towards longstanding accounts.
  • The reporting process is complicated. Harassment receivers must provide URLs, not screenshots. This makes it difficult to capture instances of harassment in which the perpetrator “tweets and deletes.” Reviewing reports involves in-depth communication and may be triggering to reviewers.
  • There are four major challenges of proving harassment. These include: context, interpretation, mode, and format of evidence.

Taken together these conclusions highlight the need for more oversight and accountability for alleged harassers as well as updated policies. As a result of the results, WAM also made six specific suggestions.

  • More broadly and clearly define what constitutes online harassment and abuse.
  • Update the abuse reporting interface, using researched and tested trauma-response design methods.
  • Develop new policies which recognize and address current methods that harassers use to manipulate and evade Twitter’s evidence requirements.
  • Expand the ability for users to filter out abusive mentions
  • Hold online abusers accountable for the gravity of their actions.
  • Diversify Twitter’s leadership.

The report itself may not be super surprising if you’ve paid attention to online harassment incidences over the last few years. REgardless, the report is vital as its the first piece of well-researched evidence quantifiying how online harassment is going down- and what to do about it.

Other Sexual Health News This Week

While the FDA recommends lifting the lifetime ban on gay men donating blood (HuffPost Politics), the CDC dedicates $185M to prevent HIV among trans individuals and MSM. (Edge Boston)

Patients More Likely to Get HPV Vaccine After Electronic Health Record Prompts

Millennials More Tolerant of Premarital Sex, But Have Fewer Partners (Time)

Survey Says Teens Skip Birth Control Because They Fear Parental Judgment (CNN)

Military Sexual Assault Claims: 1 in 20 Lead to Jail Time (Military Times)

Illinois Legislature Advances Gender Identity Protection Bill (HRC)

Campus Sexual Assault Rates Are Up, But It’s For a Good Reason: More Victims are Coming Forward (Slate)

Upcoming Conferences

The following conferences take place in May. Click on each name for more information and to register.

2015 Women of Color National Call to Action Summit and Conference, May 20.

American College Health Association 2015 Annual Meeting, May 26-30.

Talking About This One Topic Can Reduce Teen STIs and Pregnancy

Sex Stories

By Kait Scalisi, MPH

Beyond containing complete, medically accurate information and discussing condoms and contraception, comprehensive sex education programs vary widely in their content.  A new review in the journal International Perspectives on Sexual and Reproductive Health sought to determine whether these differences matters. By evaluating 22 programs, the author determined that the inclusion of one specific topic—gender and power dynamics—made a big difference in programs’ efficacy in reducing pregnancy and STIs in adolescents.

Adolescents have a higher risk of both STIs and unplanned pregnancy. When these data are broken down further, vast gender and race disparities emerge. Therefore, to successfully reduce this risk, curricula must address these disparities. While comprehensive sex education has come a long way, there is still room for improvement. Currently, only 13 states require that sex education be medically accurate.  Beyond this, individual programs vary quite a bit in the topics they discuss. Additionally, much of the research conducted on these programs has relied solely on adolescents’ self report, giving less insight than desired into why the program worked.

Any study that provides insight into what makes curricula effective is kind of a big deal. This particular review, inspired by decades of conversations about gender and power, sought to determine whether teaching about these topics is a key component of effective curricula.

The review evaluated 22 programs that:

  • were group- and curriculum-based
  • assessed effects on adolescents 19 or younger
  • were published between 1990 and 2012
  • used rigorous study designs
  • had a sample size of at least 100
  • measured the effect of the intervention on health outcomes including STIs and pregnancy
  • were not abstinence-only
  • were not conducted among special populations (e.g., MSM).

To qualify as addressing gender and power inequalities, curricula had to include at least one lesson, topic, or activity covering an aspect of gender or power in sexual relationships.

The studies varied in location, study design, sample size (n=148-9000), gender, setting where the curriculum was conducted (e.g., school, community, or clinic), and content included in the curriculum. Ten studies showed significant decreases in STIs and/or pregnancy, and eight of them included information on gender and power.

Of the many program characteristics examined, only a few had a clear impact on whether the programs were effective. These included:

  1. being a randomized control trial
  2. follow-up lasting at least one year
  3. being evaluated in 2000 or more recently
  4. being conducted in a clinic
  5. including content on gender and power.

Inclusion of gender and power content led to significant decreases in STIs and/or pregnancy. Of the programs that included this content 80% saw the desired outcomes along with several additional positive effects. On the contrary, of the programs without at least one lesson on gender and power, only 17% led to these outcomes. In a recent article about the study, The Atlantic magazine staffer Julie Beck writes:

Teaching about power and gender roles was a consistent predictor of better health outcomes, even when [researchers]accounted for other variables like sample size and whether the studies were longitudinal. The Atlantic, April 27, 2015

Unsurprisingly, the programs that addressed gender and power and saw positive results had common characteristics. These included:

  • explicit attention to gender or power in relationships
  • fostering critical thinking about how gender norms or power manifest and operate
  • fostering personal reflection
  • valuing oneself and recognizing one’s own power.

Teaching health information alone is not enough. We need to take a more intersectional approach. This shouldn’t come as too big of a surprise. Just a few weeks back we shared two studies examining the various intersections of gender, violence, and contraceptive use. The Atlantic piece links to several more studies looking at HIV and STI rates and condom use. Lastly, we know that pregnancy and STI concerns are not top of mind for adolescents deciding to have sex. Instead, they worry about whether they will get in trouble for having, whether it will feel pleasurable, and what their peers will think of them.

Furthermore, bringing these conversations into sex education curricula opens up space for discussions of sexuality and gender identity. Adherence to gender norms play a huge role in the increased rates of bullying and harassment that LGBTQ individuals experience; therefore, addressing these gives schools one more opportunity to address the bullying and provides further support for bullied students.

Like all systemic reviews, this study has its limitations. Eligible studies could be missed and confounding variables could be overlooked. In my opinion, these don’t make the study any less of a big deal. By unlocking another key to what makes comprehensive sex education programs successful, the study gives educators their next step. The Atlantic‘s Beck puts it best:

There are emotions and social pressures at play, and it seems that when teachers address them, sex ed gets a little closer to being truly comprehensive.  The Atlantic, April 27, 2015

Other Sexual Health News This Week

HIV Prevention Messages for High-Risk Groups Should Target Bars, Street Corners (UT Health News)

PrEP Prompts Shift in Federal Funding Priorities (Gay City News)

Minnesota HIV/AIDS Cases Up Slightly; Rise in Female Cases Concerning (Minnesota Public Radio News)

Poll: American Men Embracing Gender Equality (National Journal)

Google Search Terms Reveal Sexually Transmitted Disease ‘Hotspots’ (Daily Mail)

America’s Gay Corporate Warrior Wants to Bring Full Equality to Red States (Bloomberg Politics)

Less Frequent Cervical Cancer Screening Advised for Women (Fox4KC)

Upcoming Conferences

The following conferences take place in May. Click on each name for more information and to register.

SEXx Interactive: a Journey for the Mind, Heart and Body, May 7-11.

Law, Religion, and Health in America, May 7-10.

2015 Women of Color National Call to Action Summit and Conference, May 20.

American College Health Association 2015 Annual Meeting, May 26-30.