Tag: sexual health

Making the Cut: Is It Time to Put the Circumcision Debate to Rest?

Circumcision is not a new practice – it is most notably well known as a religious practice in many communities. But its implementation for public health purposes has been controversial. Raising ethical concerns and questions of tractable population health impact, the procedure has gained increasing attention in the past couple of years as it treads on unprecedented ground—surgery for the prevention of infectious disease.

Research in support of circumcision as a protective measure against the spread of HIV and other sexually transmitted diseases is mounting, countering concerns of its potential risks. [Most recently, the American Academy of Pediatrics officially articulated that the health benefits outweigh the risks – though the decision should be left to parents, as those benefits aren’t marked enough to warrant a blanket recommendation.]

The circumcision debate turns largely on biological, behavioral, and relational factors – and these are the elements to keep in mind when thinking of [voluntary male medical] circumcision in the context of HIV. Particularly in developing countries.

Biologically speaking, the foreskin is the ideal environment for bacterial and viral infections to flourish. Heat and lack of oxygen facilitate the growth of pathogens. When the inner foreskin is retracted during heterosexual intercourse, for example, it is exposed to the vaginal secretions of a female partner, which if carrying HIV and other sexually transmitted infections easily fosters transmission. A 2009 study indicated that the greater the size—and therefore surface of—the foreskin, the higher the incidence of HIV in an infected male, underscoring how it can be a breeding ground for the virus.

A recent study conducted by Dr. Ronald Gray of Johns Hopkins University, in which researchers followed Ugandan adult study participants after a circumcision intervention, showed that the subsequent risk of acquiring HIV was reduced for the 40-month follow-up period. In addition, circumcision decreased the viral load of high-risk human papillomavirus—the strains that can cause penile, cervical and anal cancers—in men.

Other studies have shown significant reductions in bacteria after circumcision, which also benefits the female partners of the men. Adverse events or complications appear to be rare in both HIV-positive and HIV-negative men who undergo the procedure, with one study documenting moderate-to-severe complications occurring between 3-4 percent of men regardless of HIV-status.

Behavior change also features prominently in the circumcision debate. Opponents of circumcision express concerns that the procedure may contribute to a perception of immunity against HIV and result in the reduction of condom use. Additionally, there is a question of whether or not it may increase the number of sex partners one has, for the same reason of rationalizing post-surgery invincibility.

Many circumcision interventions studies are not so cut and dry, so to speak. A number contain significant education components, which makes the procedure’s contribution to HIV risk reduction less clear.

One study examined the length of time men who had undergone circumcision waited before engaging in sexual activity. If a man HIV-positive, the risk of infecting a partner is notably higher if he engages in sexual activity before the wound heals, highlighting the importance of the quality of the surgery to minimize healing complications and the importance of concurrent education to delay sexual activity. Since a 2008 study showed that after 30 days, 73% of HIV-positive men had healed wounds, compared to 83% of HIV-negative men (the discrepancy owing to greater time HIV-positive individuals may take for any kind of wound healing), this is of particular importance.

It seems that being married, not single, might diminish concerns about the length of time it takes wounds to heal. There was no statistically significant difference in time waited to engage in sex post-surgery between HIV-positive and HIV-negative men who were married; nearly 28 percent and 29 percent, respectively, engaged before the wound healed, which is the single greatest cause of post-procedure complications. However, among single men, roughly 13 percent of HIV-positive men resumed sex before their wound was fully healed, compared to about 6 percent of HIV-negative men did.

The significant difference between the single HIV-positive men and the single HIV-negative men underscores the potential for altered beliefs about post-circumcision HIV transmission. However, HIV-positive men reported more sexual partners and less consistent condom use than the HIV-negative men throughout the study—itself underscoring the difficulty of risky behavior change. Encouragingly, condom use among HIV-positive men increased over the course of the study.

The relational impacts of circumcision have also been examined. Researchers have assessed the perceptions and opinions of the women in relationships with those who have undergone the surgery. A 2009 study indicated that women whose male partners were circumcised were either more sexually satisfied than they had been previously, or felt no difference. Thirty-nine percent of women indicated more satisfaction, 57 percent noted no change, and less than 3 percent said they were less satisfied than they had been when their partners were uncircumcised. The greater satisfaction, according to the women, was primarily attributed to better hygiene.

These results are important, as one of biggest issues around circumcision is “the sell.” The best way to make that sell, researchers argue, is to have the female partners articulate their preference for and encouragement of circumcision to their male partners. It appears that there may also be a generational difference in the acceptance and uptake of the procedure. Dr. Gray and his colleagues have found that adolescent males disproportionately access circumcision procedures. Even some fathers who encouraged circumcision in their sons refused the procedure themselves.

Precautions are of course essential. Research has shown that it takes practitioners approximately 100 circumcision procedures before they can be considered adept at performing the surgery.

And not all the research being done has produced promising results, specifically for women. While some studies suggest that HIV-discordant couples—HIV-negative woman and HIV-positive man—benefit from circumcision and the procedure prevents infection of the woman, other studies have produced conflicting results.

Biologically, the circumcision seems to benefit primarily men, in preventing the contraction of HIV from an HIV-positive female partner. The same is not necessarily true for HIV-negative women whose male partners are HIV-positive. This biologically higher risk of infection for women is well known among public health researchers. Of course, decreasing the prevalence of HIV-positive men will ultimately, in the long run, help to lower the HIV incidence in women.

Indeed, population health benefits are already emerging. Dr. Gray and colleagues showed earlier this year that in Uganda, 37 percent of the reduction in HIV incidence could be attributed to circumcision, since there was no change in risk behaviors. The impact was not observed in women.

Circumcision seems to make economic sense. The male circumcision procedure costs $30-$60 in adults, and $5-$10 in infants. For each HIV infection avoided due to five to 15 male circumcisions performed, the savings reach well into the billions of dollars with the assumptions of a $150-$900 cost per infection (depending on HIV incidence in a specific region) over the next ten years.

Critics of course remain, and most vocally claim that other strategies, like education and behavior change, are viable solutions that should be championed. Regarding the sustained HIV epidemic and the hopeful strategies of condom use, testing, and treatment, Dr. Gray himself remarked, “I don’t know how to change behavior, I wish I did.”

So while behavior change strategies are perhaps the most important intervention to counter the HIV epidemic, they are not the only effective HIV interventions. The evidence seems to indicate that voluntary circumcision also makes the cut as a contender in the global fight against HIV.

Originally published by The 2×2 Project.

The Health Implications of Sex-Selective Abortion

Anyone paying attention to the election this past year—or, frankly, even those who tried to avoid it—has at least a superficial understanding of what the abortion rights argument looks like in the United States.

But the long-term population health outcomes of abortion are generally not considered as part of the argument. That’s because when a woman terminates a pregnancy in America, the decision is rarely made based on the sex of the fetus. However, in many developing and growing countries, that is at the crux of a woman’s decision—and the significant shift in gender representation is changing their population health status, and perhaps even the picture of the burden of disease. One of the countries in which this is most evident is China.

Interestingly, and likely unsurprisingly for those invested in a woman’s right to choose, we see that sex selection is itself a manifestation of the gender inequities in economic and social standing in many of these countries—not so different than many of the reasons cited by women in the U.S. seeking abortions. So while the outcomes of sex-selective abortion abroad may pose different problems, it should be acknowledged that the need for abortion is rooted in similar circumstances around the globe.

This issue is addressed by one of the few research studies to explore the ramifications of China’s one-child policy, published in the New England Journal of Medicine (NEJM). China is a prime example of the increase in the male population due to women terminating pregnancies that were discovered to be female, a practice deemed illegal but nonetheless carried out widely.

The ratio of male to female live births in industrialized countries generally ranges from 1.03 – 1.07 (103,000 – 107,000 boys born for every 100,000 girls born). In China, since the inception of the one-child policy, the ratio has risen from 1.06 in 1979, to 1.11 in 1988, to 1.17 in 2001 (117,000 boys born for every 100,000 girls). Some regions show even higher numbers, with the Anhui, Guangdong, and Qinghai provinces reaching ratios as high as 1.3 (meaning that for every 130,000 boys born there are 100,000 girls born).

There are distinctions between urban and rural areas as well, since couples in rural provinces are generally allowed to have more than one child. The sex ratio comes in high at 1.13 for the first birth in urban regions, since one child is usually all a couple will be allowed. It peaks at 1.30 for the second birth (130,000 boys born for every 100,000 girls), which if couples are allowed to have, the preference is clearly male. This contrasts markedly with rural areas, in which the ratio for the first child is normal at 1.05 (105,000 boys for ever 100,000 girls), indicating that sex-selection is not a huge issue since rural couples are allowed a second child. However, the ratio sharply increases at second births, reaching 1.23 (123,000 boys for every 100,000 girls).

(Recently, China has noted that their thinking may be changing in regards to the one-child policy, with the possibility of extending the two-child allowance to everyone.)

This has unsurprising impacts on the health of the population. Some of the more pressing concerns noted by researchers that they articulate as a result of there being fewer women to marry and partner with include mental illness and socially disruptive behavior issues in men. Recently, studies have begun to document these trends, underscoring the significant long-term consequences of this gender imbalance. One recent study showed that even after adjusting for age, education, and income level, unmarried men in China were more likely to have lower self-esteem, higher depression, higher aggression, and more likely to have suicidal thoughts or actions than married men—at statistically significant levels.

The findings of another study, comprised of interviews conducted with people in China born just before and just after the implementation of the one-child policy showed similar results. Researchers found that the policy itself had created a less trusting and less trustworthy population, who are more risk-averse and less competitive, more pessimistic, less conscientious and even more neurotic. The impact of anti-social behaviors in a predominantly male population seems to be shifting the mental health profile of the entire nation.

More concerning as a result of sex-selective abortion and a decrease in the number of women available for marriage is the increased in trafficked women, and the subsequent increase in the number of commercial sex workers. Researchers note that a broad range of high-risk sex behaviors are often demanded by the surplus male clients, increasing the incidence of HIV and other sexually transmitted infections. This alone has been noted as having a likely significant affect on the spread of HIV throughout China, posing a major national public health threat for the country.

The health implications aren’t limited to reproductive health and mental illness. If it is in fact accurate that most of the children living in China’s orphanages are girls, it is unclear how the future healthcare needs of these girls as they age into women will be handled and by whom, with a rapidly growing aging population already relying heavily on the significantly less populous younger generation.

Critics of abortion—sex-selective or not—often cite mental health issues and resulting regret as major reasons why women should not get abortions. So what about the health status—physical and mental—of the women who have these procedures?

Recently, public health researchers have worked to create the first body of scientific literature answering these very concerns. A group of University of California, San Francisco researchers at the group Advancing New Standards in Reproductive Health (ANSIRH) recently presented some of the findings of their longitudinal research known as the Turnaway Study. They found that women who were seeking abortions and who were denied were more likely to have slipped into poverty a year later, more likely to be on public assistance, and less likely to have a job. There was no correlation between abortion and drug use, or abortion and depression.

Abroad, given that sex-selective abortion is usually a procedure performed by private providers due to legal restrictions, tracking this kind of information is extremely difficult. And while this research was limited to the experiences of American women, the results showing decreases in economic status and increases in reliance on some form of public assistance, if available, certainly seem like potential outcomes in countries with worse statistics in terms of gender equality and economic growth.

Is there a solution? The gender imbalance, and therefore the changing prevalence of certain diseases, will not balance out unless sex-selective abortion is essentially made impossible, but it is imperative that the issue of sex-selective abortion not become a rallying cry to end the right to the procedure overall for women. As seen by the work done by researchers in China and the findings by UCSF researchers, the issues surrounding the choice to have an abortion, whether in the United States or abroad, are complex and inextricably linked to the economic and social circumstances of the women.

To tackle the burgeoning disease differences emerging from the sex-selective abortions, the work must begin by tackling the fundamental issues regarding the reasons why women seek these abortions in the first place.

Originally published at The 2×2 Project.

Can the Pill Alleviate Depression?

The use of oral contraceptives for purposes other than birth control is by now a normal practice. The pill is frequently prescribed to those suffering from severe and persistent acne, for the alleviation of severe cramping and endometriosis, and for soothing the symptoms of premenstrual dysphoric disorder and premenstrual syndrome.

In fact, when asking women for the reasons they began using the pill, 82 percent cited non-contraceptive reasons as a major factor, and one third of teens use the pill solely for reasons other than preventing pregnancy.

Of course, the use of the birth control pill at all—for the prevention of pregnancy or other reasons—has unnecessarily become the center of heated political and social debates, despite the fact that millions of American women rely on it. The ability for women to access oral contraception has become increasingly contentious in recent years, with legislators working to outlaw them entirely. So, the mention of another potentially promising side effect of the pill may be immediately—and unfortunately—rebuffed.

And yet, it seems there may be another non-contraceptive reason for using oral contraceptives—the prevention of incident depression and suicidal ideation in young women. While opponents of birth control may claim that there are existing medications for the treatment of depression, the findings of this new research detail even more compelling reasons why oral contraception may benefit the health of women.

According to a study published in this month’s American Journal of Epidemiology by researchers at Columbia University’s Mailman School of Public Health, the steady hormone levels provided by the pill may reduce the risk of depression and suicide attempts in young women. Only a handful of studies have explored this relationship in the past. Two studies in the past decade and half showed no positive or negative effect of hormonal contraceptives on depressive symptoms, while another showed that those using oral contraceptives had reduced depressive symptoms.

“We have long believed that sex-linked hormones such as estrogen are important predictors of mood problems, but little research has addressed how [external] estrogen regulation through hormonal contraceptives may or may not be associated with mental health outcomes,” says Katherine Keyes, Ph.D., lead author of the study and assistant professor of epidemiology at Columbia.

The study authors used a longitudinal—meaning the young women were followed over a period of time—nationally representative sample called the National Longitudinal Study of Adolescent Health (known as Add Health). The Add Health study began in 1992, with a total of 90,000 girls being surveyed about health behaviors in school. Subsequently, 20,000 of these girls were randomly selected for in-depth home interviews, and were given follow-up interviews in 1996 (known as Wave 2), 2000-2001 (Wave 3), and 2007-2008 (Wave 4).

A total of 6,654 young women, now between the ages of 25-34, who completed these interviews and indicated using contraception were used in this study’s analysis. The interviews assessed depression symptoms and previous suicide attempts among the women. At each wave, women were asked about symptoms of depression in the previous week and the symptoms were given a score based on their severity. They were also asked how many times they had attempted suicide in the previous year.

The findings produced compelling results. First, women who used hormonal contraception (birth control pill, the ring, or the patch) were more likely to be younger and have a college degree, less likely to have children, and more likely to engage in other protective health behaviors—like exercising, visiting the dentist, not smoking, and maintaining a lower body mass index.

Second, the women using hormonal contraception had lower scores of past-week depression symptoms, lower odds of high depressive symptoms, and lower odds of having attempted suicide in the last year. This was true even after the authors accounted for previous depressive symptoms among the women. When exploring the data longitudinally—that is, examining the association between contraceptive use and depression over the course of two waves of data to see if there were differences depending on the age of the women—the findings held true. Users of the pill, patch, or ring had lower odds of having high depression scores between the ages of 18-28, with even lower odds of a high depression score between the ages of 25-34.

Interestingly, hormonal contraception was not protective against a suicide attempts between the ages of 18-28, but it was between the ages of 25-34.

Dr. Kim Yonkers, professor of psychiatry at the Yale University School of Public Health and an expert on women’s reproductive and psychiatric health, praised the study.

“It’s certainly in line with what data are out there with regard to oral contraceptives, and I think the researchers did a nice job using the information that’s available,” she says.

There are limitations to the study. The authors acknowledge that women who perceive there to be negative side effects in their mood due to hormonal contraception are less likely to maintain its use, and these women may be more prone to depressive symptoms, potentially accounting for some of the findings and partially explaining the link.

As Yonkers says, “it could be a healthy observer effect. They’re talking to a group of women [who were using oral contraceptives] who are more likely to be healthy, to be psychologically healthy, to attend medical appointments; so it’s impossible to assign causality,” which she notes the authors are accurately not doing.

There are also a range of personal factors—like relationship status and sexual comfort—that contribute to a woman’s decision to use the pill, patch or ring, as opposed to using a barrier method such as a condom on its own, or no protection at all.

Hormonal contraception, as noted by the authors, is most commonly used among educated, cohabitating and unmarried white women. This is likely due to a few factors. College educated individuals are more likely to be fully employed and therefore have better health insurance, making the pill more affordable. There are racial disparities due to insurance as well, as white women are more likely to have health coverage than women of color. Funding for public and non-profit organizations that offer oral contraceptives at affordable and sliding scale prices for women without insurance are constantly under threat of—and actually victim to—major cuts in funding. It is unlikely that evidence for protective effects on mental health will ameliorate these differences since they are rooted in access and economics, but the implications of the study are still wide.

For example, Yonkers also points out the influence this study could have on regulations for prescription drugs.

“I think this adds to the body of literature questioning why oral contraceptives have to have this labeling that their compound increases the risk of depression. I don’t think we see that at a population level very strongly. No [older, randomized control] trials have found that oral contraceptives, even at a much higher dose, increase the likelihood of depression, let alone suicidal ideation or suicide,” she says.

This labeling may deter some women from using the birth control pill if they are particularly wary of its influence over their mood stability, when in fact it seems it may benefit mood or at minimum have no effect. The Federal Drug Administration notes that they label drugs based on data derived from human experience wherever possible.

As Yonkers says, “the FDA keeps mandating that this labeling be included on oral contraceptive agents—as a class labeling—despite the fact that we don’t see it in clinical trials. So I think it’s something that has to be taken up more carefully with the FDA.”

Whether data or politics will determine FDA labeling remains to be seen, but this study adds to the mounting evidence that the former should be more greatly weighed.

Originally posted at The 2×2 Project.

Teens + Smart Phones = More Sexual Activity?

A new study by researchers at my alma mater, University of Southern California, found that young people with smart phones were 1.5 times more likely to be sexually active than those without. Results were presented at this week’s American Public Health Association annual conference. I’ve written before about the relationship between media and imagery and its particular impact on healthy human development, so I found this study particularly interesting.

The lynchpin is the internet access, obviously, since that’s where smart phones differ from regular cell phones. The key findings pulled from the study are:

  • young people with smartphones are two times as likely to have been approached online for sex — and more than twice as likely to be sexually active with an Internet-met partner;
  • 5 percent of high school students used the internet to seek sex; and
  • non-heterosexual high school students were five times more likely to seek sex online — and more than four times as likely to have unprotected sex during their last intercourse with an online-met sex partner.

The odds of having unprotected sex with a casual and perhaps anonymous partner are of course the most troubling to public health professionals. It’s not surprising that non-heterosexual students were five times more likely to seek sex online than heterosexual teens, since those findings have been seen before and highlight the difficulty that many non-heterosexual students may have come out, the lack of social support they may feel, and the isolation that coming out may have brought on.

The researchers used a sample of 1,839 Los Angeles high school students between the ages of 12-18, and they controlled for age, race, gender, and sexual orientation. Since this is the first study to really explore this,  I’d be really interested in follow-up studies looking at other markers of sexual behavior in teens in relation to these findings. I’m also fascinated by the fact that 5% of high school students used the internet to seek sex, and am really interested in seeing how that number changes as smart phones become ubiquitous even in high school.

Lots of Rest Can Prevent STD Transmission! At Least, That’s What Fresno is Telling Kids

In case you wanted to read something today that will make make you fume, check out ThinkProgress’ report about an abstinence-only education program in Fresno (for shame, California). It is massively, massively irresponsible.

Did you know that getting a lot of rest can prevent you from getting STDs? And that HIV can be spread by kissing? Let that marinate for a bit, because that’s what kids in Clovis, CA, are going to come out of school thinking.

Condoms? Not addressed. Contraception? Not covered.

This curriculum is actually against California law, which requires medically accurate sexual health education to be delivered to students. The ACLU is suing.