Condom Availability for Youth

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AMERICAN

ACADEMY

OF

PEDIATRICS

Condom

Availability

for

Youth*

Committee on Adolescence

The medical consequences of adolescent sexual

activity are a national health concern, highlighted by

unintended pregnancy and sexually transmitted

dis-eases (STDs), including human immunodeficiency

virus (HIV) infection/acquired immunodeficiency

syndrome (AIDS). Health promotion goals for

teen-agers include postponement of sexual activity until

psychosocial maturity and consistent use of condoms by those who do engage in sexual intercourse.

Although designing effective strategies to

accom-push these goals rethains a challenge, increased

condom use is a realistic, achievable objective. The

national public health agenda to reduce HIV

trans-mission emphasizes the need to facilitate condom

use as a method of disease prevention. Condom

availability programs in schools are receiving

wide-spread attention as a potential strategy to increase condom use by sexually active adolescents.

Pediatni-cians are being asked for advice by school boards

and community groups. This statement reviews the

pertinent issues related to condom availability in

schools and provides recommendations for use in

responding to requests for advice.

Background

Sexual behavior of American adolescents has been

studied for the past generation. Trend analysis

shows increasing rates of sexual intercourse among

young people over the past 20 years.’-3 Middle to late

adolescence is now the average time for initiation of

sexual intercourse. The 1992 Centers for Disease

Control and Prevention national school-based Youth

Risk Behavior Survey (YRBS) of I 1 631 students in

grades 6 through 12 reported that 54% of all high

school students were coitally experienced, with 39%

having had coitus in the 3 months before the

sur-vey.4’ Forty percent of 9th graders reported having

sexual intercourse, a percentage that increased to

72% in 12th graders. The median age of first

inter-course reported by students was 16.1 years for males and 16.9 years for females.

The health consequences of adolescent sexual

be-havior are well known. The United States has the

highest teen pregnancy rate of any developed nation,

This statement has been approved by the Council on Child and Adolescent Health.

The recommendations in this statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.

even though rates of sexual intercourse among US

teenagers are similar to those of other Western

coun-tries.6 One million teenagers become pregnant each

year, and the social and medical risks of adolescent

pregnancy are well documented.7 Of the 20 000 000

cases of STDs reported annually, one third occur in

school-aged youth.8 As many as one in four

adoles-cents contract an STD before graduating from high

school. Adolescents are more likely to have

asymp-tomatic infections than adults and to suffer lifetime consequences such as chronic infection, tubo-ovanian abscess, ectopic pregnancy, infertility, spontaneous

abortions, and infected offspring.9 There has been a

marked increase in mortality from STDs over the

past 12 years with the advent of HIV infection.

Ac-quired immunodeficiency syndrome is now the

sev-enth leading cause of death in the 15- to 24-year age group.’#{176}” The prevalence of AIDS has been increas-ing in teenagers and is expected to steadily increase,

as it is estimated that the number of teens with HIV

infection doubles every 14 months.’#{176}” A recent

sur-vey of over 100 000 disadvantaged youth aged 16 to

20 years documented an HIV seropositivity of 3.2 per

1000 female adolescents and 3.7 per 1000 male

adolescents.’2

The high rates of pregnancy and STDs, including

H1V infection, in part reflect the sporadic use of

con-doms and other contraceptives among sexually active

American youth. The correct use of condoms during

each coital encounter is a well-established prevention

measure. Policy statements of the American Academy

of Pediatrics (AAP) consistently have advised

pediatri-cians to provide anticipatory guidance on safer sex

practices for youth who choose to be sexually

ac-tive.1’6 Unfortunately, condom use by teenagers is

limited. In the national YRBS, 49% of males and 40% of

females reported using condoms with their last coitus.4 Other studies confirm a 38% to 66% rate of condom use

by sexually active youths, with about haM using

con-doms with each coital encounter.9

Various strategies have been proposed to increase

condom use by sexually active teenagers, including

making condoms available in schools.

Condom Effectiveness

A realistic understanding of the benefits and

lim-itations of condom protection is important before

strategies can be planned to promote increased use.

Condoms are recognized as an important measure in

preventing transmission of STDs and pregnancy.

Latex condoms can prevent the transmission of

Neis-seria gonorrhoeae, Chlamydia trachomatis, herpes

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

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plex virus (types 1 and 2), human papillomavirus,

Candida albicans, Treponema pallidum, and others.8”72#{176}

Research (including in vitro studies) has proven that latex condoms offer protection from the transmission of HIV as well,8”927 although this protection may not

be absolute?-28 In contrast, natural membrane

con-doms (made from young lamb cecum) have larger

pores than latex condoms and allow transmission of

HIV and herpes simplex virus and are not

recom-mended for protection from STDs.’9’2#{176}The consensus

of expert opinion concludes that the proper use of

latex condoms can considerably reduce the risk of

transmission of STD agents, including HIV.’7’9 Thus,

latex condoms are recommended for use by sexually

active adolescents.8”728 The effectiveness of condoms

in preventing pregnancy depends primarily on how

consistently and properly they are used. Correct use

can result in 98% effectiveness for birth control,

although failure rates among users average 12%.29

Adolescent Compliance With Condoms

Condoms offer sexually active youths the

follow-ing benefits: (1) highly effective contraception, (2)

reduced transmission of STDs, (3) availability

with-out prescription, (4) minimal side effects, and (5)

encouragement to males to assume responsibility for

contraception and STD prevention.’82#{176}

Several factors influence whether condoms are

used by sexually active teenagers, including access, availability, confidentiality, and cost. Factual

knowl-edge of sexuality issues may be superseded by peer

influences and feelings of not being vulnerable to

the risks associated with not practicing safer

sex. 18,20,27,3032

Behavioral research indicates the complexity of

decision making for using condoms. Although most

adolescents know that condoms can prevent STDs,

an increasing belief in the preventive effect of

con-doms is not necessarily associated with increased

motivation to use them.#{176}Even though a majority of studies have reported that a fear of HIV infection can influence adolescent protective behavior, fear alone does not influence all sexually active teenagers to use

condoms to prevent HIV transmission.3’ Immediate

concerns about self-image may outweigh future

health consequences. Some teenagers are too

embar-rassed to purchase condoms, whereas others remain

ambivalent about their sexual activity and believe

that “spontaneous” sex is more ethically acceptable than “planned” coital encounters. Practical

informa-tion is also lacking regarding how to use condoms.

Printed instructions included in condom packages

require at least a 10th grade reading comprehension level, and over half of these require the reading level of a high school graduate.33

Factors associated with increased condom use by

teenagers have also been identified and include

re-ceiving sexuality education that conveys knowledge

and skills for condom use, actively believing that

condoms can prevent STDs including HIV, being

able to communicate with partners about STDs

in-cluding HIV, overcoming embarrassment to ask for

condoms, perceiving peer norms as supportive of

condom use, and the availability of a discussion with

a physician regarding condom use. Teenagers

who view condoms as acceptable and are confident

that they can convince their partner to use them are

more likely to use condoms.37 Ready availability of a

condom remains a critical practical factor.

Adoles-cents who carry condoms are 2.7 times more likely to

use a condom during intercourse.38

ROLE OF THE SCHOOLS

The ability to practice healthy behaviors requires

three components-knowledge (information, skills,

and beliefs), motivation (positive incentives, peer

ap-proval, and social sanctions), and resources

(equip-ment, supplies, and access to health care). To use

condoms reliably, teenagers must have knowledge

(how to use one correctly), motivation (partner

insis-tence, for example), and resources (an available

sup-ply). Schools have an opportunity to influence all

three of these factors.

School systems have accepted the role of

enhanc-ing knowledge through health education, and yet

currently less than 10% of youth receive comprehen-sive sexuality education.39 Effective educational

pro-grams focus on responsible decision making as well

as on practical skills. Postponing sexual activity (ab-stinence) until psychosocial maturity is emphasized

as a wise choice for unmarried teenagers, and

con-tinuing postponement or renewing abstinence are

the appropriate messages for adolescents.

Compre-hensive information on effective contraception,

in-cluding condom use, is appropriate information for

youth and all sexually active adolescents.”#{176}

Since knowledge alone is not enough to change

behavior, interpersonal skills and motivations for

practicing healthy behaviors need to be addressed in

modern school curricula. Training in life skills

should emphasize interactive communication,

asser-tiveness, negotiation, conflict avoidance and resolu-tion, and refusal skills for negative peer pressure.

These activities may require multiple sessions over

many school grades, the use of multiple media and

activities, and peer support systems for healthy

be-haviors.39 Sexually active teenagers have been shown

to increase their use of condoms if they are involved

in role-playing exercises that teach assertiveness,

de-cision making, communication skills, and correct

contraceptive technique.”#{176}

The third factor in behavior change is having the

necessary resources. The role of schools in making

condoms available to students who want them

re-mains, for some, controversial. School condom avail-ability programs, whether as part of comprehensive health services provided at the school site, or in the

context of a school-based HIV infection/AIDS

pre-vention program, can help remove barriers to

con-traceptive use by teenagers and can help establish

condom use as a norm for expected responsible

behavior, thus encouraging both peer and cultural

acceptance.4’

ROLES OF HEALTH CARE PROVIDERS, FAMILIES,

AND COMMUNITIES

Health care providers have an essential role in

facilitating condom use by sexually active

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cents. Those youths who have discussed HIV infec-tion with a physician are I .7 times more likely to use

condoms than those who have not. Unfortunately,

only 13% of teenagers may actually be counseled on

HIV infection and condom use by a physician.42

Families have a profoundly important influence on

adolescent behavior, resulting primarily from

attitudes, values, and beliefs instilled in earlier

childhood; few teenagers, however, report having

discussions with their family about expectations for

correct, consistent condom use.43 Collaborative

ef-forts involving many individuals, agencies, and

in-stitutions (family, schools, caregivers, media, and

others) are needed to influence behavior changes in

adolescentsfr

Acceptance of School Availability Programs

Boards of education in several school districts

na-tionally have already approved in-school condom

availability programs.4’ A 1991 Roper survey

showed that 74% of adults favor condom availability in high schools and 47% favor condom availability in junior high schools.43 Parental acceptance of condom

availability programs has been high in districts

where programs have been approved. In schools

where parental permission is required, less than 2%

of parents have submitted written denials of

permis-sion. Condoms have also been made available to

students contemplating becoming sexually active

and sexually active students from on-site health care

providers. The Center for Population Options,

Wash-ington, DC, estimates that more than 70 school-based

clinics make condoms available. Nonetheless, this

represents a small proportion of school districts

nationally.

Design of Programs

The design of condom availability programs has

varied considerably, from unrestricted access on

stu-dent’s request, to carefully restricted dispensing by

health care providers only after counseling and with parental permission. School districts have explored the advantages or disadvantages of condom avail-ability programs in their institutions by assembling a broad-based coalition of students, parents, teachers,

health care professionals, school board members,

school administrators, and others. Groups such as

these can more effectively assess community needs

and then set goals and objectives, develop policy,

design program options, address legal issues, build

public support, and provide community guidance.

Legal Issues

Legal issues raised about condom availability

pro-grams often stem from underlying political and

moral debates, rather than from statutory

regula-tions. The United States Supreme Court has

validated a minor’s right to obtain and purchase

condoms.45 Multiple other federal and state

constitu-tional cases have supported this same right. Thus

condom availability through educational institutions is consistent with obtaining a legally accessible

prod-uct. No legal challenge to date has blocked

imple-mentation of a condom availability program. Legal

concerns about these programs may be viewed in the

framework of larger rights issues, such as public

health and safety objectives, adolescent access to

health services, adolescent reproductive rights, and

adolescent rights to consent to confidential health

care. Whether the school district should require

parental permission for such a program on school

grounds is primarily a community rather than a legal

issue.

Promoting Responsible Sexual Behavior

Critics of condom availability programs in schools

believe that such programs send an inappropriate

message to youth and promote rather than postpone

sexual activity. There is no evidence, however, that

condom availability in schools increases the number

of youth who become sexually active. In Europe and

Canada, where comprehensive sexuality education

and convenient, confidential access to condoms is

more common, the rates of adolescent sexual

inter-course are no higher than those in the United States. Research in other countries indicates that students in

schools where clinics provide reproductive health

services are no more likely to be sexually active than peers in schools without clinics, but if they are sex-ually active, they are more likely to use an effective method of contraception.46’47 Similarly, creating

bar-niers to obtaining contraceptives or condoms does

not reduce adolescent sexual intercourse. Public

health evidence supports the need for a national

information campaign that explicitly addresses safer

sex practices and provides practical information on

condom use for individuals contemplating sexual

activity, as well as for those who are already sexually active.

The most successful interventions to promote

healthy adolescent behavior require broad-based

community coordination.48 Effective interventions need to integrate the efforts of parents, families, schools, religious organizations, health departments,

community agencies, and the media. Education

pro-grams should provide adolescents with the

knowl-edge, attitudes, and skills they need both to refrain from sexual intercourse and to use contraceptives

and condoms effectively if they choose to have

intercourse.

The AAP recognizes that no single approach,

whether utilizing sexuality education, abstinence

programs, condom availability programs, or others,

can alone eliminate the high rates of STDs and

preg-nancy among sexually active adolescents. A

compre-hensive, community-based alliance of parents, health professionals, and schools is imperative to positively influence adolescent behavior.

RECOMMENDATIONS

The prevention of HIV infection/AIDS and other

STDs and unintended pregnancy among adolescents

is an AAP strategic goal, as well as a national

priority. Accordingly, the AAP supports the

follow-ing principles:

I. Abstaining from intercourse should be

encour-aged because it is the surest way to prevent STDs, at Viet Nam:AAP Sponsored on September 1, 2020

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including HIV infection, and pregnancy in

adoles-cents; adolescents who have been sexually active

previously should also be counseled regarding the

benefits of postponing future sexual relationships. 2. Pediatricians should actively support and

encour-age the use of reliable contraception and condoms by adolescents who are sexually active or contem-plating sexual activity. The responsibility of male

as well as female adolescents in preventing

un-wanted pregnancies and STDs should be

empha-sized. Pediatricians need to be actively involved in

community programs directed toward this goal.

3. In the interest of public health, restrictions and

barriers to condom availability should be

re-moved.

4. Schools are an appropriate site for the availability of condoms in a community program because

they contain large adolescent populations, and

may potentially provide a comprehensive array of

related educational and health care resources.

5. To be most effective, condom availability

pro-grams should be developed through a

collabora-tive community process and accompanied by

comprehensive sequential sexuality education,

which is ideally part of a K-12 health education

program, parental involvement, counseling, and

positive peer support.

6. Research is encouraged to identify methods to

increase correct and consistent condom use by

sexually active adolescents, and to evaluate

ef-fectiveness of strategies to promote condom use,

including condom availability programs in

school.

COMMIi-rEE ON ADOLESCENCE, 1994 TO 1995

Roberta K. Beach, MD, Chair Suzanne Boulter, MD Edward M. Gotlieb, MD

Donald E. Greydanus, MD

James C. Hoyle Jr. MD I. Ronald Shenker, MD Barbara C. Staggers, MD LIAISON REPRESENTATIVES

Michael Maloney, MD, American Academy of Child

and Adolescent Psychiatry

Diane Sacks, MD, Canadian Paediatric Society Richard E. Smith, MD, American College of

Obstetricians and Gynecologists SEcrnoN LIAISON

Samuel Leavitt, MD, Section on School Health CONSULTANTS

Linda Dannison, PhD, Associate Professor, College of Education, Western Michigan University,

Kalamazoo, Michigan

Guy S. Parcel, PhD, Professor and Director, Center for Health Promotion Research and Development,

School of Public Health; Professor of Pediatrics, School of Medicine, The University of Texas Health Science Center at Houston

Lawrence R. Stanberry, MD, PhD, Professor of Pediatrics, University of Cincinnati Medical Center

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1995;95;281

Pediatrics

Committee on Adolescence