Barrier Protection Use by Adolescents During Sexual Activity

This policy statement updates the 2013 American Academy of Pediatrics (AAP) statement on condom use.¹  Sexually transmitted infections (STIs), including new HIV infections, and unintended pregnancies among adolescents remain significant public health problems. Although abstinence from sexual activity is the most effective way to reduce pregnancy and STIs, it is important for young people to be prepared for the time when they will become sexually active. The prevention of STIs in adolescents involves abstinence or safer sexual practices by those who are not abstinent. The accompanying technical report²  provides new information concerning adolescent pregnancy, STIs and HIV, and minority youth to emphasize the need for comprehensive barrier method counseling and education for all youth, regardless of stated sexual orientation, behaviors, gender, or intellectual and/or physical differences. For this statement, the age range for adolescent visits, as defined in the AAP’s Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition, is 11 to 21 years of age.³  Detailed information forming the basis of the recommendations in this policy statement is found in the technical report.² 

Preventing HIV, STIs, or pregnancy involves more than traditional condoms, and sexual practices of adolescents consist of more than penile-vaginal penetration. Therefore, this policy statement has been expanded to include all barrier methods and multiple types of sexual activity.⁴  Adolescents and young adults may use a variety of barrier methods to reduce the transmission of STIs or prevent pregnancy by reducing or preventing the transmission of bodily fluids, skin-to-skin contact, or skin-to-mucous membrane contact. The external condom, commonly known as the male condom, is a latex, synthetic, or natural material shield designed to fit over the male penis and is available over the counter. The internal condom (formerly the female condom) is a loose-fitting polyurethane (nitrile) sheath with 2 flexible polyurethane rings and is the only US Food and Drug Administration–approved nonpenile barrier method for STI prevention currently available in the United States. Users may place it inside the anus, vagina, or mouth. The internal condom is only available in the United States with a prescription. Another over the counter barrier method is a dental dam, or a latex, synthetic (nitrile or polyurethane) sheet (usually square shaped) that users may place over the penis, vulva, vagina, mouth, anus, or any part of the body. Although not evidence based or advised, adolescents may also improvise using plastic wrap or plastic bags to act as barriers.

Pediatricians are encouraged to address adolescent sexual and reproductive health on a routine basis, including with youth who have developmental or physical disabilities,^5,6  by taking a sexual history, discussing healthy sexuality, performing an appropriate examination, providing patient-centered and age-appropriate anticipatory guidance, and delivering appropriate screenings and vaccinations.⁷  The HEADSS (home, education and employment, activities, drugs, sexuality, and suicide and depression) interview provides an excellent structure for discussing a variety of issues that may affect sexual health and barrier use.⁸  Key AAP publications provide a framework to assist pediatricians in incorporating various aspects of sexual and reproductive health care into their practices and provide guidance on overcoming obstacles to delivering this care routinely while maximizing opportunities for confidential health services delivery in their offices.^9,10  The AAP Adolescent Sexual Health Web site also provides significant resources (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/adolescent-sexual-health/Pages/Assessing-the-Adolescent-Patient.aspx).

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition, outlines how pediatricians and other providers can support parents and adolescents in promoting healthy sexual development and sexuality, including discussion of the use of barrier methods to protect against STIs, including HIV.⁹  Multiple studies reviewed in the technical report²  suggest increased efforts are needed by pediatricians, educators, and those in public health to encourage parents to talk about these issues. The implication for pediatricians is that providing parents with accurate information about adolescent sexual behavior, risks, and use and effectiveness of barrier methods can improve communication with their adolescents.

Pediatricians and other physicians may provide barrier education and free barrier methods within their offices and support efforts to increase availability within their communities. The World Health Organization offers instructions on proper external barrier method use (Table 1).¹¹  Table 2 provides a list of resources for pediatricians. In addition, the District of Columbia and the state of New York have condom distribution programs that may serve as models for health care providers and organizations.^12,13  Many states have Web sites that offer free mail delivery of barrier methods (Table 2).¹⁴  Most local or state public health departments offer low-cost or free barrier programs that pediatricians may contact for assistance. Additionally, to enhance safer sex and proper barrier usage, it is important for adolescents to receive comprehensive, evidence-based, medically accurate sexual education that includes barrier method instruction.

The AAP has published a policy statement on refusal to provide information or treatment based on claims conscience.¹⁵  According to the policy, pediatricians and physicians have a duty to inform their patients about relevant, legally available treatment options to which they object and have a moral obligation to refer patients to other physicians who will provide and educate about those services.

When adolescents and young adults use barrier methods consistently and correctly, these methods are an excellent means to reduce the risk of many STIs, including HIV, and prevent pregnancy. Pediatricians are uniquely suited to provide screening and anticipatory guidance around sexual behaviors, prevention of adverse consequences, harm reduction, and availability and appropriate use of barrier methods. Pediatricians should advocate for increased education, availability, and reduced obstacles to barrier methods for adolescents in their practices and communities.

1. Discuss abstaining from sexual intercourse as the most effective way to prevent genital STIs, as well as HIV infection, and unintended pregnancy.

2. Support and encourage the consistent and correct use of barrier methods as well as other reliable contraception as part of anticipatory guidance during visits with adolescents who are sexually active or contemplating sexual activity, including emphasis on the responsibility of all genders in preventing unintended pregnancies and STIs.

3. Use the recommendations in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition promoting communication between parents and adolescents about healthy sexual development and sexuality and supporting education programs that help parents develop communications skills with their adolescents regarding the prevention of STIs and proper use of barrier methods.

4. Remove restrictions and obstacles to barrier method availability to encourage and promote barrier method use among adolescents. Beyond retail distribution of barrier methods, the provision of free or low-cost barrier methods is a priority for adolescent-friendly health services. Pediatricians and other clinicians are encouraged to provide barrier methods within their offices and support availability within their communities.

5. Advocate for barrier method availability programs through a collaborative community process and the provision of comprehensive sequential sexuality education. This is ideally part of a kindergarten-to-12th-grade health education program with parental involvement, counseling, coaching, and positive peer support.

6. Support school barrier method educational programs, especially because these programs reach large adolescent populations and may potentially provide a comprehensive array of related educational and health care resources.

7. Actively communicate to parents and communities that making barrier methods available to adolescents does not increase the onset or frequency of adolescent sexual activity and that use of barrier methods can help decrease rates of unintended pregnancy and acquisition of STIs.

8. Monitor adolescents who use preexposure prophylaxis or nonbarrier contraception, are bisexual or lesbian, and/or are in established relationships closely for risk compensation (the adjustment of behavior in response to perceived level of risk) leading to decreased use of barrier methods. Pediatricians can assess risk during acute or routine visits to determine the need for additional counseling regarding barrier methods or STI testing. Engage and support additional research to identify strategies to increase continued barrier method use for populations that may engage in risk compensation.

9. Advocate for engagement and support of additional research regarding barrier use (and safer sex practices) for higher-risk youth and those living in areas with lack of access to barrier methods.

AAP

American Academy of Pediatrics

STI

sexually transmitted infection

Laura K. Grubb, MD, MPH, FAAP

Elizabeth M. Alderman, MD, FSAHM, FAAP, Chairperson

Richard J. Chung, MD, FAAP

Laura K. Grubb, MD, MPH, FAAP

Janet Lee, MD, FAAP

Makia E. Powers, MD, MPH, FAAP

Maria H. Rahmandar, MD, FAAP

Krishna K. Upadhya, MD, FAAP

Stephenie B. Wallace, MD, FAAP

Cora C. Breuner, MD, MPH, FAAP

Laurie L. Hornberger, MD, MPH, FAAP

Anne-Marie Amies, MD – American College of Obstetricians and Gynecologists

Liwei L. Hua, MD, PhD – American Academy of Child and Adolescent Psychiatry

Seema Menon, MD – North American Society for Pediatric and Adolescent Gynecology

Ellie E. Vyver, MD, FRCPC, FAAP – Canadian Paediatric Society

CDR Lauren B. Zapata, PhD, MSPH – Centers for Disease Control and Prevention

Karen S. Smith