Earlier this month, the Centers for Disease Control and Prevention (CDC) released a study that found more people ages 15-to-19 are using long acting reversible contraceptive (LARC) methods than in the past. That rate among young people, however, is still relatively low. The authors of the report join a chorus of public health experts in suggesting that further efforts be taken to increase access to and use of these methods throughout the country.
I worry that in our excitement to promote LARCs as an effective means of preventing teen pregnancy, we will overlook the importance of sex education and the need for condoms—both as an alternative, short-term form of contraception and to prevent sexually transmitted infections.
Contraceptive methods that are safe and highly effective are vital for preventing unwanted pregnancies, but there is more to sexual health than that.
IUDs are small, T-shaped devices that are inserted into the uterus by a physician. They prevent pregnancy primarily by interfering with the path of the sperm toward the egg. Two of the IUDs on the market—Mirena and Skyla—release hormones similar to those in some birth control pills, which create a barrier to sperm by thickening the cervical mucus and may also prevent ovulation. The other type of IUD, called ParaGard, releases copper, which is thought to create an environment that is toxic to sperm. ParaGard lasts for ten years, Mirena for five, and Skyla (which is smaller and was introduced with young women in mind) for three, but any of them can be removed sooner if a user wishes to become pregnant or switch methods.
Contraceptive implants, sold under the brand name Nexplanon, are flexible plastic devices about the size of a matchstick that are inserted under the skin on a woman’s upper arm. Nexplanon releases hormones similar to those in birth control pills, which prevent ovulation and thicken cervical mucus. Nexplanon also lasts three years but can be removed earlier.
LARC methods have the highest efficacy rates against pregnancy, in large part because users can “set them and forget them,” so to speak. Unlike the birth control pill, which a woman has to take every day regardless of whether she has sex, or a condom, which couples must use each time they have sex, these methods work with no effort on the part of the user. This means that the typical-use efficacy rate (the one that shows how well the method usually works for a couple during the first year of use) is very similar to the perfect-use efficacy rate (the one that shows how well the method can work if used consistently and correctly).
IUDs have a failure rate of less than 1 percent; implants have a failure rate of 0.05 percent. In other words, out of 100 couples who use these methods as their primary form of birth control, fewer than one will experience an unintended pregnancy in the first year of use. In comparison, typical use rates for the pill suggest that nine couples out of 100 will experience an unintended pregnancy that first year.
Though IUDs were once thought to be safe only for older women or women who had already had children, research in the past decade has found that they are safe for women of all ages, including adolescents. Implants have also been found to be safe for women of all ages.
Given the safety and efficacy of these devices, it’s easy to see why so many experts feel that LARCs may help prevent teen pregnancy in the United States. After all, if a 16-year-old gets an IUD, there’s almost a guarantee that she won’t get pregnant until she’s 19 at the least.
As Rewire has reported, both the American Congress of Obstetricians and Gynecologists (ACOG) and the American Pediatric Association (APA) have suggested that LARC methods should be a first choice for young women.
When choosing contraceptive methods, adolescents should be encouraged to consider LARC methods. Intrauterine devices and the contraceptive implant are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.
The APA recommendations are similar:
Pediatricians should be able to educate adolescent patients about LARC methods including progestin implants and IUDs. Given the efficacy, safety, and ease of use, LARC methods should be considered first-line contraceptive choices for adolescents. Some pediatricians will choose to acquire the skills to provide these methods to adolescents. Those who do not should identify health care providers in their communities to whom patients can be referred.
And, this month’s CDC report will likely add to that excitement. The report looked at IUD and implant use among 15-to-19-year-old women who receive health care through Title X clinics. The Title X program provides family planning and related preventive health services for low-income individuals; it serves approximately one million teens nationwide each year.
The report found that among teens who sought contraceptive services at Title X sites, use of LARCs increased from less than 1 percent in 2005 to more than 7 percent in 2013. In 2013, roughly 3 percent of teens who sought contraceptive services used an IUD and 4 percent an implant. Teens older than 18 were more likely than 15-to-17-year-olds to use these methods.
The study also found that the use of LARCs varied widely across states. In Mississippi, for example, less than 1 percent of women ages 15-to-19 used LARCs, but in Colorado that percentage was up to over 28 percent. This finding is not surprising, as Colorado has implemented an initiative designed to improve LARC use among Title X clients.
The authors of the CDC study suggest that more programs like this are needed:
Given the estimated 4.4 million sexually experienced female teens in the United States, and the high effectiveness, safety and ease of using LARC, continued efforts are needed to increase access and availability of these methods for teens.
This month, the CDC also released a Vital Signs document about the key role that the government, health-care providers, and parents can take in helping teens prevent pregnancy. The document points out that about 43 percent of teens ages 15-to-19 have had sex and that four out of five used birth control the last time they had sex—but only 5 percent used “the most effective methods.” (This differs from the CDC study mentioned earlier because that study was limited to teens who sought contraceptive services through Title X providers.) The CDC suggests adults encourage teens to be abstinent, but also encourage the use of LARC methods when they become sexually active. It also suggests the government can help by funding programs, such as Colorado’s, to make such methods affordable and accessible.
While this push toward LARCs is indeed exciting, many public health experts and sexuality educators, myself included, worry that in our rush to promote them we will forget to discuss condoms—or worse, suggest that condoms are not good at preventing pregnancy. We have seen the manufacturers of other birth control methods, such as emergency contraception, throw condoms under the bus by suggesting they break easily. Similarly, the infographics accompanying the Vital Signs document depict the efficacy of various methods—LARC methods are at one end, with few pregnancies, and condoms are at the other, with many.
Though the information is not inaccurate, it does not contain the nuance needed to remind young people that condoms can work very well to prevent pregnancy but have a low typical use efficacy rate because people often make mistakes using condoms: Most notably, they don’t use one every time.
We know that young people often use condoms as their first method of birth control and that those who use them the first time are more likely to do so going forward. We also know that many people rely on condoms when they are in between relationships or in between other methods. This is encouraging for individual and public health reasons, and emphasizing condom failure runs counter to the goal.
And perhaps most importantly, condoms are the only birth control method that provide protection from STIs, for which we know adolescents are at high risk. Adults concerned about teens’ health need to stress dual use for young people: “Even if you or your girlfriend has a LARC, you should still be using condoms.” This will not only protect them from STIs now; it will help ensure their future fertility, as untreated STIs can compromise the ability to become pregnant later in life.
Deborah Arrindell of the American Sexual Health Association (ASHA) explained to Rewire:
LARC are a fantastic addition to the pregnancy prevention [resources]. But unless we are very intentional about promoting dual use of condoms and LARC, we leave young people at risk for HIV and other STIs. In fact, what young women do to prevent pregnancy now, may leave them exposed to complications from STIs that may prevent pregnancy when they want it. Maintaining good sexual health can be challenging, and we need to do everything we can to promote comprehensive messages.
As a sexuality educator, I must also say that I fear LARCs will be seen as a substitute for teaching young people about sex. Sexuality education is already controversial and undervalued. Even educators, advocates, and elected officials who support contraceptive-inclusive sexuality education often sell it primarily as a way to prevent teen pregnancy, because that is more politically expedient than arguing for knowledge for the sake of knowledge. But programs that start and stop with pregnancy prevention—or even STI prevention—don’t help teens understand the characteristics of healthy interactions, examine their own values around sexuality, and think critically about issues such as consent, gender roles, and sexual orientation.
As Debra Hauser, president of Advocates for Youth, told Rewire:
There are no magic bullets. Young people who wish to use LARC should have confidential, low or no cost access. But LARC will not help reduce sexual assault or young people’s risk for STDs. Nor will LARC, in and of itself, promote healthy relationships. Enthusiasm for the effectiveness of LARC and its ability to prevent unplanned pregnancy should not usurp the importance of helping young people acquire the information and skills they need to develop agency and take personal responsibility for their sexual health and well-being.
Knowledge for the sake of knowledge is important if we want young people to grow up sexually healthy—to understand how their bodies work, have the skills they need to create and sustain good relationships, and make responsible decision about pregnancy and disease prevention. LARC methods can prevent pregnancy, but they can’t do anything else.
We can and should be enthusiastic about LARCs for teenagers. They are safe and highly effective and can help our young people prevent pregnancy in their teen years and beyond. But as we promote these methods and increase access to them, we have to remember to look at the whole picture of sexual health and make sure we do not sell our young people short.