Associate Professor Rachel Skinner Sydney University Discipline of Paediatrics & Child Health, at Children’s Hospital, Westmead

Overview what is normal sexual behaviour and what’s risky Understanding why and when young females have their first sexual experience, their use of contraception, and pregnancy decision-making Understanding young males use of condoms and role in pregnancy prevention What does the literature tell us about sexual health promotion in young people? Implications for clinical and public health strategies

Historical changes in sexual development

Trend in age of first intercourse C. Rissel, J. Richters and A. Grulich et al. 2003

What is risky sexual behaviour? Leads to unplanned pregnancy or STI spread High abortion rate, poor outcomes for teen mothers and babies, morbidity of STIs Early age of sexual debut Poor use of condom use/ contraceptives Number of partners over a short time period

Is normal actually risky in adolescence? Reducing age of onset of sexual activity Romantic relationships- shorter duration, shorter between gap Inconsistent condom use Access to methods Biological vulnerability Social vulnerability- Risk taking, impulsivity, social contexts and norms important, low perception of risk, alcohol use

Increasing sexual intercourse, oral sex Majority sexual active in some way from year 10 Condom use stable 40% just happened, 31% trust, knowing partners history (27%) 58% Y12, 37% Y10 use OCP Increasing % with higher number of recent partners (oral and intercourse) HIV knowledge good, other STIs poor but has improved Very few thought they were at risk of STI Perceived risk not associated with condom use, only casual partner Key points SSASH

Unwanted sex in females has increased Drunk/high, partner pressure Mostly “happy” feelings after sexual encounter lower for females, <10% experienced negative emotions, F sl. higher regret or feeling used.

Research- understanding teen sexual behaviour First sexual experience Use of contraception, condoms for STI and pregnancy prevention in females and males Choices around pregnancy outcomes Teenage motherhood- outcomes and repeat pregnancy Smith, Fenwick, Skinner et al, J Adol Health, 2008; J Reproductive Health Care 2010, Sexual Health 2009, Archives of Sexual Behaviour 2010, Journal of Adolescent Research 2011 (in press), Women and Birth 2009

Themes around first sexual experience I was ready for sex- a natural happening, right time- right person I wanted to see what it was all about- unrealistic perceptions about sex Everyone else was doing it- perceptions of peer sexual activity I did it to keep him happy- importance of romantic relationship When you’re drunk you just do it- intoxication

Findings re 1st intercourse Loss of personal control over first intercourse through drunkenness, social norms, peer norms Partner pressure Perceived control influenced how they reflected on their first experience and the meanings Regret was linked to loss of personal control Loss of control tended to be younger age (earlier developmental stage) Control linked with self-efficacy Implications for sexual health education/ promotion

Variation in contraceptive use explained through... Causal-consequence model of PRIORITISING PREGNANCY PROTECTION Bi-causal pathways... Anticipating the impact of motherhood Rejecting teen motherhood Accepting teen motherhood Personalising Pregnancy Risk Accepting pregnancy risk Denying pregnancy risk have fun as a teenager healthy career first stuff up my life lose your friends I couldn’t keep it Change my life for the better more mature than girls my age a new start my mum was a young mum murdering an unborn child scared worst fear expected if it happens it happens I knew I’d fall pregnant paranoid thought I couldn’t get pregnant we’ll be fine just this one time won’t happen to me unprotected sex for a year & it was still a shock

Retracing contraceptive histories 1. Pregnancy ‘avoiders’ (never-pregnant) Rejecting teen motherhood Accepting pregnancy risk HOLDING THE REINS when I went on the Pill we stopped using them I’ll set my alarm for 7 everyday & take it (Pill) & go back to sleep wouldn’t have sex if he didn’t use anything double insurance

Retracing contraceptive histories 1. Pregnancy ‘escapers’ (pregnant-terminated) Rejecting teen motherhood Denying pregnancy risk LOWERING THE GUARD made me stack on weight think I just procrastinated caught up in the heat of the moment too drunk to care couldn’t get into the daily habit

Retracing contraceptive histories 1. Pregnancy ‘embracers’ (pregnant-continued) Accepting teen motherhood Accepting pregnancy risk LETTING NATURE TAKE ITS COURSE we used a couple of condoms then we just stopped & let nature take its course I’m not big on contraception so if it happens it happens we were in love so there was no need (to use condoms) I really wanted to be a mum

Beliefs of teen females regarding contraception use/ pregnancy risk Sexually active girls fall into 3 groups Those who have accurate risk perceptions about fertility, don’t use contraception and are happy to fall pregnant Those who have accurate risk perceptions, use contraception well, and don’t fall pregnant Those who have inaccurate risk perceptions, don’t use protection consistently or effectively, and are shocked when they fall pregnant These 3 groups should have different approaches in education, management

Beliefs of young males regarding condom use Use is linked to the nature of the sexual relationship Pregnancy main concern- condoms used mainly for contraception rather than STI prevention, with regular partner Responsibility for use of hormonal contraception is considered to be the role of female partner No discussion with partner about effective contraception use, or attitudes to hormonal contraception, pregnancy

Reasons for using condoms or not Risk Avoidance Dual methods of protection (very few) Staying safe with casual partners Rationalising condom cessation through assumed safety Reliance on hormonal contraception Clean STI tests Lacking consequential thought Disregarding risk in the immediate context Prioritising sexual satisfaction

Responsibility for birth control Pregnancy as the main concern Compared to STIs Fatherhood as a future event Pregnancy prevention as the girls job Going the extra mile with dual methods of protection Very few had this view

Conclusions from both studies Condoms used when hormonal contraception not being used Condoms considered when STI risk a concern (casual encounters, history) Boys assume that girls are using contraception Barriers to some girls using contraception consistently Similarities in the “heat of the moment” encounter Parenthood not on the agenda for their current life But some girls did not regret Small group who insist on dual protection

Implications for education/ clinical care Don’t assume that all female teens want to avoid pregnancy For some, motherhood a logical choice pregnancy intentions & contraceptive behaviour doesn’t always follow contraceptive attitudes, sexual context & accuracy of risk perceptions, intentions to remain non-pregnant Main concern is pregnancy, risk perceptions regarding STIs may be flawed for both males and females Responsibility for pregnancy prevention in a relationship is left to female partner, with little discussion regarding effective use

Systematic review of STI interventions in Australia Direct access to STI screening in non-clinical setting achieved the highest participation rates More support for STI screening in GP practice is needed School based sexual health education has not been evaluated in Australia Use of new social media technology for education/ promotion and improving access Good media campaigns can influence behaviour

Spreading the message online “A lot of people use the internet now and I guess that’s probably the best place to go because it’s so anonymous too. You don’t actually have to talk to anyone face to face. It might be a lot less confronting for people.”

Providing the groundwork in school “They’re busting to talk about the complexities of things, not just oh it goes in and phfw, and oh oops there’s a baby in nine months, like everyone knows that... any education that goes forward has a lot to do with, a lot broader than sort of facts and figures, you know.”

Making condoms easier to access “For a lot of people it’s a very daunting experience walking up to a counter and putting a packet of condoms on there. I’m not sure how you combat that, perhaps there’s vending machines...” “One of the things we went through high school was about whether we were going to get condom vending machines in the males’ toilets... the school was like oh no we don’t want to do that cause then we’re just encouraging sex. Well isn’t it better to encourage safe sex than just to turn a blind eye to it?”

Aus’s teen fertility rate ↓ over last 3 decades conceals much higher pregnancy & abortion rates Earlier age pregnancy & childbearing → adverse outcomes maternal age or prior disadvantage primary cause?? Up to 90% teen pregnancies ‘unintended’ ‘unintended’... ‘unplanned’... ‘unwanted’?? Overall improvements in contraceptive use in Aus discontinuation, switching & poor compliance common Teenage pregnancy

Teenage mothers in Australia Indigenous Pregnant before Single Living in an area of socio–economic disadvantage Uncertain EDC and fewer antenatal visits A smoker > Perinatal mortality Risk of STI Van der Kliss et al, 2002; Meade & Ickovics 2005; Lewis et al 2009.

Teenage births have poor outcomes Preterm birth, LBW, NND Postnatal depression Domestic violence Abuse Low educational attainment, welfare dependence Children- learning difficulties, emotional and behavioural problems, early pregnancy

Pregnancy outcomes in teenage mothers, preventing repeat pregnancy Lewis, Doherty, Hickey, Skinner et al, MJA 2009, Contraception 2010, MJA 2011 Retrospective review of births at KEMH over a 2.5 year period (<5000 births) Prospective study of 150 teenage mother, recruited in pregnancy followed for 2 years

Main findings Higher obstetric and medical risks associated with teenage pregnancy and birth (anaemia, smoking, HT, UTIs, LBW) Indigenous teenagers need special attention, and there is significant scope for public health interventions around anaemia and smoking in this population Implantable contraceptives should be used postpartum