National Partnership for Women & Families

Monthly Women's Health Research Review

Researchers call for increased condom use among adolescent LARC users

Summary of "Long-acting reversible contraception and condom use among female US high school students: Implications for sexually transmitted infection prevention," Steiner et al., JAMA Pediatrics, May 2016.

"Long-acting reversible contraception (LARC) offers a promising strategy for reducing unintended pregnancy among adolescents aged 15 to 19 years in the United States, where teen birth rates remain much higher than many other Western, industrialized countries," according to Riley Steiner of CDC's Division of Adolescent and School Health and colleagues.

However, the researchers noted that while LARC use is increasing among adolescents, some stakeholders are concerned that the trend could result in "the decreased use of condoms for preventing sexually transmitted infections (STIs)." The researchers wrote that few sexually active adolescents report "dual use" -- the use of a highly or moderately effective contraceptive method in addition to a condom -- and several prior studies show "that LARC users may be less likely to use condoms compared with users of moderately effective [contraceptive] methods."

According to the researchers, "Given the evolving context of contraceptive recommendations for and use among adolescents, these associations warrant reexamination among this population particularly at risk for STIs." The researchers used national data on high school students to "compar[e] condom use between sexually active female LARC users and users of moderately effective contraceptive methods." They wrote, "Establishing the relationship between LARC and condom use among adolescent LARC users prior to widespread adolescent uptake will help provide a useful reference point for future monitoring and can ultimately inform STI prevention efforts as LARC is brought to scale."

Methods

For the study, the researchers assessed data from the 2013 Youth Risk Behavior Study (YRBS), which surveyed a nationally representative sample of U.S. high school students in grades nine through 12. The researchers conducted their analysis in July and August 2015.

The researchers examined participants' responses to questions about what type of contraception they used when they last had sexual intercourse and whether they specifically used a condom when they last had sexual intercourse. The researchers also looked at several "secondary outcomes, including number of lifetime partners, number of partners during the past 3 months, age at first sexual intercourse, and use of alcohol or drugs before last sexual intercourse."

The researchers conducted a descriptive analysis using data from the 2,288 female students who reported at least one sexual partner in the last three months. They narrowed the regression analysis to the 619 "sexually active female students who reported using LARC, oral contraceptives, or Depo-Provera, patch, or ring."

Results

According to the researchers, 56.7 percent of sexually active female students in the sample were white and 33.6 percent were in grade 12. Of sexually active female students, "29.8% used LARC or a moderately effective contraceptive method." Specifically, the researchers found that, overall:

  • 40.8 percent of respondents said condoms were their primary form of birth control;
  • 22.4 percent reported using oral contraception;
  • 15.7 percent said they did not use a contraceptive method;
  • 11.8 percent said withdrawal or another contraceptive method was their primary form of birth control;
  • 5.7 percent reported using Depo-Provera injections, the patch or the ring;
  • 1.9 percent said they were unsure about their birth control use; and
  • 1.8 percent reported using LARC.

Regarding race and ethnicity, the researchers found that Hispanic respondents (23.7 percent) and black respondents (21.2 percent) were most likely to report not using a contraceptive method. In addition, they found 30.7 percent of white respondents reported using oral contraception, compared with 7.3 percent of both black respondents and Hispanic respondents.

Regarding respondents' grade, the researchers found that 18.6 percent of sexually active female students in ninth grade reported using LARC or a moderately effective birth control method, compared with 36.4 percent of sexually active female students in grade 12.

When examining condom use in conjunction with LARC or moderately effective contraception, the researchers found that "condom use was highest among oral contraceptive users (37.3%), followed by Depo-Provera, patch, or ring users (26.6 %)." In comparison, among respondents using LARC, the researchers found that "16.4% reported using condoms, which was significantly less than condom use among oral contraceptive users." When the researchers conducted a second analysis, they found that "LARC users were nearly 60% less likely to use condoms compared with oral contraceptive users." Meanwhile, according to the researchers, "No significant differences in condom use were observed comparing LARC users with Depo-Provera, patch, or ring users."

The researchers also assessed respondents' sexual behavior by contraceptive use and found that "LARC users were more than twice as likely" as those using oral contraception "to have 2 or more sexual partners in the past 3 months ... and about twice as likely to have had 4 or more lifetime sexual partners." In addition, LARC users were more likely than those using Depo-Provera, the patch or the ring "to have 2 or more sexual partners in the past 3 months ... and 4 or more lifetime sexual partners," the researchers wrote. The researchers did not find any "significant differences in age at sexual initiation or use of alcohol or drugs before last sexual intercourse between those using LARC and those using moderately effective methods."

Discussion

"Similar to prior studies that have documented low prevalence of condom use with highly or moderately effective contraceptive methods, our findings point to a need to improve condom use among all users of highly and moderately effective methods considered," the researchers wrote.

The researchers noted that the study also "highlights that condom use at last sexual intercourse was even lower among LARC users compared with oral contraceptive users." According to the researchers, the "observed differences in condom use may be due to perceptions of contraceptive effectiveness." For example, they explained that LARC users and users of Depo-Provera, the patch or the ring might be less likely than those using oral contraception to also use condoms because they perceive a lower risk of pregnancy. The researchers also listed other possible explanations for the disparity, including that providers could recommend LARC to "adolescents who report not using condoms or using them infrequently" or that sexually active adolescents using LARC are less concerned about STIs because they believe they are in a committed relationship.

However, "[r]egardless of the reason for the discrepancy, this association between LARC use and condom use is particularly concerning given that STI risk is high during adolescence," the researchers wrote. They noted that as adolescents increasingly use LARC methods, "there is a need to understand health care professionals' perceptions of LARC and how these may influence recommendations in comparison with adults." The researchers highlighted their finding showing that LARC users were more likely to have several sexual partners in the recent past and over the course of their lifetime, which could suggest that providers are offering LARC to more sexually experienced adolescents. "However, multiple partnerships increase risk of STI acquisition, making condom use among adolescent LARC users particularly important," the researchers wrote.

According to the researchers, the study's findings on LARC use and condom use "should not deter adolescent LARC scale-up but rather inform how scale-up occurs." They called for further research "to explore motivations for condom use among adolescents, when used alone and in combination with more effective contraceptive methods," particularly in relation to adolescents' partnership context. They wrote, "Such research can be conceptualized within the framework of dual protection to further distinguish the use of condoms with a highly or moderately effective contraceptive method for 2 potential purposes -- to protect against pregnancy and STIs."

The researchers urged providers to incorporate condom use in counseling and education about LARC use to adolescents, "particularly given that recommendation by health care professionals to use condoms with oral contraception has been positively associated with consistent condom use." Further, they called on providers to "emphasize the importance of using condoms specifically for STI prevention and help adolescents develop strategies for implementing a coitally dependent method." According to the researchers, "[H]ealth care professionals will need training and tools to effectively address both pregnancy and STI prevention and risk assessment within the same clinical visit." Additionally, the researchers called for strategies on how to "retain adolescent LARC users in routine preventive care" and for the implementation of school and community-based programs to teach "the importance of condom use for STI prevention when using moderately or highly effective contraceptive methods."

According to the researchers, "There is a clear need for a concerted effort to improve condom use among adolescent LARC users to prevent STIs, particularly as adolescent LARC use increases." They underscored how lower condom use among LARC users compared with oral contraception users "suggests that it may be beneficial for clinicians to specifically promote condoms for STI prevention," noting that such a strategy would not only address STI prevention as adolescents increasingly adopt LARC methods, but also could "serve to increase condom use with moderately effective contraceptive methods by motivating adolescents to avoid STIs." The researchers concluded, "Regardless of the strategy or combination of strategies used, improving dual protection among adolescents will be key to maximizing both pregnancy and STI prevention goals."