FIGO position statement on comprehensive sexuality education.

Now is a pivotal moment in the fight for reproductive health and justice internationally. Well-established research has recognized the benefits of comprehensive sexuality education for youth and adolescents-including vast reproductive health benefits, decreased interpersonal violence, and improvements on measures of academic success and well-being. Despite these established benefits, challenges to the implementation of culturally sensitive and holistically framed sexuality education are intensifying across the globe. The International Federation of Gynecology and Obstetrics (FIGO) stands firmly in its support of comprehensive sexuality education and re-emphasizes the importance of the implementation of scientifically accurate, age-appropriate, culturally relevant, and inclusive education. Successful implementation relies on active youth leadership, physician involvement, and a renewed focus on high-quality monitoring mechanisms to assess impact and accountability at all levels. Most importantly, future efforts to improve and scale comprehensive sexuality education must emphasize the importance of an inclusive curriculum that addresses previously marginalized youth, such as LGTBQ+ and disabled individuals, through a reproductive justice lens. FIGO commits, and encourages the international healthcare community, to provide continued advocacy for the rights to health, education, and equality, in order to achieve improvement in health outcomes for young people across the globe.

Common teratogenic medication exposures-a population-based study of pregnancies in the United States.

BACKGROUND: Risk mitigation for most teratogenic medications relies on risk communication via drug label, and prenatal exposures remain common. Information on the types of and risk factors for prenatal exposures to medications with teratogenic risk can guide strategies to reduce exposure. OBJECTIVE: This study aimed to identify medications with known or potential teratogenic risk commonly used during pregnancy among privately insured persons. STUDY DESIGN: We used the Merative™ MarketScan® Commercial Database to identify pregnancies with live or nonlive (ectopic pregnancies, spontaneous and elective abortions, stillbirths) outcomes among persons aged 12 to 55 years from 2011 to 2018. Start/end dates of medication exposure and pregnancy outcomes were identified via an adapted algorithm based on validation studies. We required continuous health plan enrollment from 90 days before conception until 30 days after the pregnancy end date. Medications with known or potential teratogenic risk were selected from TERIS (Teratogen Information System) and drug monographs based on the level of risk and quality of evidence (138 with known and 60 with potential risk). We defined prenatal exposure on the basis of ≥1 outpatient pharmacy claim or medical encounter for medication administration during target pregnancy periods considering medication risk profiles (eg, risk only in the first trimester or at a certain dose threshold). Sex hormones and hormone analogs, and abortion and postpartum/abortion hemorrhage treatments were not considered as teratogenic medications because of challenges in separating pregnancy-related indications, nor were opioids (because of complex risk-benefit considerations) or antiobesity medications if their only teratogenic mechanism was weight loss. RESULTS: Among all pregnancies, the 10 medications with known teratogenic risk and the highest prenatal exposures were sulfamethoxazole/trimethoprim (1988 per 100,000 pregnancy-years), high-dose fluconazole (1248), topiramate (351), lisinopril (144), warfarin (57), losartan (56), carbamazepine (50), valproate (49), vedolizumab (28 since 2015), and valsartan (25). Prevalence of exposure to sulfamethoxazole/trimethoprim decreased from 2346 to 1453 per 100,000 pregnancy-years from 2011 to 2018, but prevalence of exposure to vedolizumab increased 6-fold since its approval in 2015. Prenatal exposures in the first trimester were higher among nonlive pregnancies than among live-birth pregnancies, with the largest difference observed for warfarin (nonlive 370 vs live birth 78), followed by valproate (258 vs 86) and topiramate (1728 vs 674). Prenatal exposures to medications with potential teratogenic risk were most prevalent for low-dose fluconazole (6495), metoprolol (1325), and atenolol (448). The largest first-trimester exposure differences between nonlive and live-birth pregnancies were observed for lithium (242 vs 89), gabapentin (1639 vs 653), and duloxetine (1914 vs 860). Steady increases in hydralazine and gabapentin exposures were observed during the study years, whereas atenolol exposure decreased (561 to 280). CONCLUSION: Several medications with teratogenic risk for which there are potentially safer alternatives continue to be used during pregnancy. The fluctuating rates of prenatal exposure observed for select teratogenic medications suggest that regular reevaluation of risk mitigation strategies is needed. Future research focusing on understanding the clinical context of medication use is necessary to develop effective strategies for reducing exposures to medications with teratogenic risk during pregnancy.

Contraceptives and teens: what are the options?

PIP: This article focuses on the contraceptive options of adolescents to prevent unintended pregnancy. Based on the Contraceptive Technology Update 2000 Contraceptive Survey involving health care providers, 90% of the respondents will provide injectable depot medroxyprogesterone acetate (Depo-Provera or DMPA) to young teens. Meanwhile, in surveying providers¿ practices with regard to the possible link between DMPA use and diminishing bone mass, about half of the providers inform patients of such an effect and about 30% use other methods, such as counseling on calcium supplementation and weight-bearing exercise. However, just-released research revealed that DMPA's impact on bone density might be a short-term or current-user effect, apparently without long-term implications. On the other hand, when providers were asked for the treatment of severe dysmenorrhea in women who are not sexually active and have no plans to engage in such activity, 45% of respondents said they would prescribe an oral contraceptive and a prostaglandin inhibitor.^ieng

Teaching refusal skills to sexually active adolescents.

Refusal skills training was extended to sexually active handicapped female adolescents who lacked an effective refusal strategy. Role-plays for assessment and training were developed using the who, what, when and where of situations which resulted in unwanted intercourse. Refusal skills were trained following the format of rationale, modeling, rehearsal, feedback, and reinforcement. Baseline rates of most target behaviors were quite low. High frequencies of target behaviors were observed as each behavior became the focus of training. Generalization across staff and time was also observed. The skillfulness and effectiveness of the subjects' refusal skills were judged to be improved as a function of training. One-year follow-up showed decreased sexual activity for each girl.

PIP: In an attempt to curtail adolescent pregnancy, refusal skills were taught to 2 sexually active and handicapped female adolescents. The goal was to surpass the just say no philosophy by 1) socially validating each girl's effectiveness and skill, and 2) extending refusal skills training to special populations, where skill deficits may be more prevalent and the need the greatest. One child Amy, 16 years) was dead and was being treated for sexual disorders, and the other (Karen, 14 years) was developmentally delayed and sexually precocious. Both desired refusal skills. Training was designed to teach skills to effectively refuse sexual advances when they deemed it necessary and desirable to do so. An assessment was made for each girl. A role play vignette was developed for each girl which relied on her past experiences. The performance of the role play was videotaped in order to identify the particular deficits in refusal assertion. Refusal, specification, leaving the situation, and eye contact were situations that were categorized as either an occurrence or nonoccurrence for the pre- and postassessments. Skills were taught based on rationale, feedback, modeling, behavioral rehearsal, and reinforcement. 8 randomly ordered play roles were analyzed by 2 observers to evaluate social perception of client refusal skills and effectiveness. Reliability was evaluated using Cohen's Kappa (K). The K for eye contact was .84; refusal , .85; leaving the situation, 1.0; and specifying objectionable behavior, .90. The deaf child, Amy, initially showed only eye contact skills, while Karen used only verbal refusal before skills training. The intervention created long and shortterm effects, i.e., use of target behaviors posttraining, at a 2-week follow up with nonintervention staff, and a 1-year telephone follow up which indicated decreased sexual activity for each girl. Significant differences were found in the baseline and posttreatment performance ratings for both refusal and effectiveness (F=103.02, df=27.3, p=.001; and F=243.7, df=27.3, p.001). For Karen only refusal skill rating was significantly changed (F=22.06, df=27.3, p=.001). There is a need to provide additional research to verify the actual effectiveness of refusal skills packages and their impact on the occurrences of unwanted sexual behavior. Refusal components, developmental factors, societal norms, familial and peer pressure that are most critical need to be determined. Generalizability is limited.

Adolescent pregnancy: an interpersonal skill training approach to prevention.

The research literature reports numerous negative consequences of adolescent pregnancy. Unfortunately, contemporary approaches to preventing teenage pregnancies have been largely unsuccessful. Recent evidence, however, suggests that interpersonal communication skill training may represent an important step in helping adolescents deal with their sexual and contraceptive behavior. This describes a pilot study of an interpersonal skill training model for sexually active inner-city teenagers. Results show that this training model is a feasible and attractive approach to modifying the youths' communication patterns. Findings indicate that such training is a fruitful direction for future pregnancy prevention research with the adolescent target population.

PIP: The research literature reports numerous medical risks associated with teenage pregnancy, including increased incidence of infant mortality, prematurity, and neurological impairments linked to prematurity. Teenage pregnancies also heighten the risk of maternal mortality and morbidity. Furthermore, early childbearing often initiates a rapid sequence of subsequent pregnancies, each with increasing obstetrical risk. In addition to medical risks, pregnancy in adolescence is associated with untoward social and psychological consequences, namely, the interruption or termination of the parent's education, usually accompanied by loss or reduction in earning power. This cycle often culminates in dependence on public assistance and the social welfare system. Unfortunately, contemporary approaches to preventing teenage pregnancies have been largely unsuccessful. Such approaches can be characterized as either reductionistic, stressing a single underlying explanation; or developmental, emphasizing normal adolescent maturational processes, and multiple causal factors. The literature reports adolescent pregnancy prevention as requiring more knowledge and access to contraceptive methods. New skills as well as new knowledge are necessary to cope with bodily changes and changing societal expectations. Available data suggest that interpersonal communication may play an important role in determining sexual activity and contraceptive use among adolescents. This paper describes a pilot study of an interpersonal skill training model for sexually active inner-city teenagers enrolled in a public school's continuation program for school-age parents and parents-to-be. Results of this pilot study, generated by group leaders' observations and students' evaluations, suggest that the group sessions represented a viable and attractive approach to interpersonal communication training. This training approach appears germane for the adolescent target population. Furthermore, the interpersonal skill model represents an economical and portable training approach. Public schools, family practice outpatient clinics, public health agencies and family planning centers are particularly suited for this approach. Future research should build upon results of the presnet study and findings of other investigators, suggesting the efficacy of a personalized and peer-supported adolescent pregnancy prevention approach, using role playing and peer assistance as educational techniques.