Pediatricians treating teenaged girls should consider writing just-in-case prescriptions for the morning-after pill,  the American Academy of Pediatrics (AAP) said on Monday.

It’s the second recommendation in a week from a major doctor’s group that would make contraception more widely available to women. Last week, the American College of Obstetricians and Gynecologists recommended making all birth control pills available over the counter.

The Food and Drug Administration says emergency contraception – the so-called morning after pill – should be available to any woman who needs it without a prescription. But Health and Human Services Secretary Kathleen Sebelius overruled the FDA a year ago. Now, federal policy says girls under 17 need a prescription to get it.

AAP says many teenaged girls need emergency contraception, and their pediatricians should help make it easy for them to get it. “Studies have shown that adolescents are more likely to use emergency contraception if it has been prescribed in advance of need,” the group said in a policy statement.

“Despite significant declines over the past two decades, the United States continues to have teen birth rates that are significantly higher than other industrialized nations,” it added.

Morning-after pills can prevent pregnancy -- they don’t cause abortions -- if they are used within five days of intercourse.

Dr. Susan Wood, who resigned her job as assistant commissioner for women's health at the FDA in 2005 in a dispute over the then-Bush administration’s handling of the birth control issue, called the decision a significant one. “It's not often you see physician organizations saying that their patients are better off without the physician involvement,” Wood told Reuters.

"We do hope that pediatricians read the policy statement and follow the recommendations," said Dr. Cora Breuner, a pediatrician at Seattle Children's Hospital who led the AAP panel that produced the recommendations. "The Academy prides itself on a devoted membership."

Emergency contraception for adolescents has been one of the most politically fraught areas in health care for almost a decade.
 
In 2005 the FDA declined to approve any over-the-counter sales of the Plan B morning-after pill, overruling its own advisory panel, as well as its own scientists. Last December the FDA reversed  its stance when it approved over-the-counter sales with no age limits. When Sebelius overruled the decision, it meant many women must present proof of age to get the pills.

Virtually every medical organization with expertise in the area supports making emergency contraception available for sale to girls and women of all ages who might need it. The American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, and the Society for Adolescent Health and Medicine joined forces to denounce Sebelius’s action last year.

“The decision to continue restricting access to this safe and effective product is medically inexplicable,” AAP president Dr. Robert Block said in a statement at the time. One of the reasons Sebelius gave for her decision was the worry that girls as young as 11 might get the pills and might not understand the consequences. But the pediatricians have said they do not share that worry.

Arthur Caplan, head of the division of medical ethics at NYU Langone Medical Center and an NBC News contributor, calls it a "remarkable and innovative idea." 

"Having emergency contraception readily available will surely lead to fewer young women getting pregnant and fewer abortions.   The battle over abortion should not hinder making this sort of safe and reliable emergency pill easily available especially to those who may be coerced into sex, forget to take their birth control or have a partner whose birth control method fails," Caplan said. "Improvements in medicine are shifting the arena for discussing reproductive ethics from abortion clinics and surgical procedures to choices made by individual women talking to their doctor, nurse, pharmacist and others whom they trust.  Those on all sides of contraceptive availability need to come to terms with this new moral reality."

The most common form of emergency contraception is a high dose of a regular birth control pill such as Plan B and Plan B One-Step from Teva Pharmaceutical Industries Ltd or Next Choice from Watson Pharmaceuticals Inc. They generally sell for $10 to $80 and are most effective in the first 24 hours.

All work by preventing ovulation, not by stopping the implantation of a fertilized egg. "These are not abortifacients," said Breuner.

A 2006-08 survey found that 14 percent of sexually experienced girls had used emergency contraception, up from 8 percent in a 2002 survey. The most common reason given was condom failure, but 13 percent of the girls said it was because of rape.

A 2010 analysis of seven randomized studies of emergency contraception found that teens who had a morning-after prescription in were not more likely to have sex or less likely to use contraceptives.

"It's just common sense that requiring a prescription is a barrier," said Bill Alpert, chief program officer of the National Campaign to Prevent Teen and Unplanned Pregnancy. "If an august and respected medical group like AAP is suggesting providing emergency contraception to minors is OK, that is a big deal."

That is especially so when teens face other obstacles to getting emergency contraception. For instance, a 2012 study that had 17-year-olds telephone pharmacies asking about morning-after pills found only 57 percent of them correctly told the caller that she could get the drugs without a prescription.

Also, some physicians refuse to provide the prescriptions to teenagers, while others do so only in cases of rape, AAP's research shows, suggesting that the refusal "may be related to the physician's beliefs about whether it is OK for teenagers to have sex."

There are no good data on how many physicians write prescriptions ahead of time for emergency contraception. "But we do know that pediatricians don't even talk about it, let alone offer advance prescriptions," said Breuner. "We tend not to like bringing up stuff that's controversial."

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No Plan B for young teens, HHS says

A new report on teen sex contradicts a popular notion that teens are turning to oral sex as a way to delay “real” intercourse. The government study shows fewer teenage girls are having oral sex, compared to a few years ago.

The study, based on in-depth interviews with 6,300 young men and women aged 15 to 24, shows two-thirds in that age group have had oral sex, and just about the same proportion have had vaginal intercourse. But just about 42 percent of 15 to 19-year-old girls have given or received oral sex, down from 45 percent when the last survey was done in 2006-2008.

This is good news, the researchers say, because the earlier young people start any sexual activity at all, the more likely they are to get a sexually transmitted disease or to get pregnant.

The bad news is that teenagers and young adults are still highly likely to get sexually transmitted infections or STIs. “Despite the decline in the percentage of teenagers who ever had vaginal intercourse and increases in condom use, the rate of STIs has not decreased, particularly among teenagers 15–19 and young adults aged 20–24 years,” says the report, from the Centers for Disease Control and Prevention’s National Center for Health Statistics.

“In 2010, about one-half of all new STIs occurred among people aged 15–24.”

The report shows that only 7 percent of girls aged 15 to 19 had had oral sex without ever having had vaginal intercourse. By age 22 to 24, just 2.7 percent of young women said they had given or received oral sex but not had vaginal intercourse.

“This new CDC analysis debunks many myths about when young people are initiating oral sex, and underscores the need for the kind of sex education that Planned Parenthood provides, which emphasizes not only pregnancy prevention, but sexually transmitted disease prevention as well,” said Leslie Kantor, vice president for education for Planned Parenthood Federation of America.

“Although there has never been data to support it, there has been the perception that many teens engage in oral sex as a ‘risk-free’ alternative to intercourse. But the CDC analysis shows that sexually active young people are likely to engage in both activities.”

Planned Parenthood advocates for comprehensive sex education, and the Obama administration does too. The CDC researchers who did the study declined to comment on what it might mean, policy-wise, and said they were simply gathering statistics.

But the researchers also noted that teenagers often don’t understand the risks associated with sexual activity. “Research suggests that adolescents perceive fewer health-related risks for oral sex compared with vaginal intercourse. However, young people, particularly those who have oral sex before their first vaginal intercourse, may still be placing themselves at risk of STIs or HIV before they are ever at risk of pregnancy,” they wrote.

 “The risk of sexually transmitted infections (STIs), including human immunodeficiency virus or HIV, the virus that causes AIDS, is lower for oral sex than for vaginal intercourse or anal sex,” the report adds. “However, several studies have documented that oral sex can transmit certain STIs, including chlamydia, genital herpes, gonorrhea and syphilis. Teenagers and young adults engaging in sexual activity are at increased risk of STIs or HIV.”

Kantor said this calls for more sex education. “We need to make sure that young people have the skills to negotiate what they do and don’t want to do in sexual relationships, as well as education about and access to condoms and birth control so that they can protect themselves from STDs and pregnancy and remain healthy,” she said.

The study, based on hour-long, in-person interviews done from 2007 to 2010, also demonstrates racial disparities. Black girls and women aged 15 to 24 were far more likely than similar white girls to have had intercourse. The survey found that 74 percent of African-American females had vaginal intercourse at least once, compared to 68 percent of Hispanic females and 66 percent of whites.

And the study, meant to shed light on sexual practices, suggests that different types of sexual contact go together. “Among females aged 15–24 years, 26 percent had first oral sex before first vaginal intercourse; 27 percent had oral sex after first intercourse; 7.4 percent had oral sex on the same occasion as first intercourse; and 5.1 percent had oral sex, but no vaginal intercourse,” says the report.

But fewer girls were having oral sex than before. “About the same percentage of girls aged 15–19 years reported giving or receiving oral sex (41 percent and 43 percent, respectively),” the report says. This compares to 45 percent in 2006-2008.

“A higher percentage of  boys aged 15–19 years had oral sex (49 percent) than had vaginal intercourse (44 percent),” it adds. This was about the same as 2006-2008.

Related links:

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Giving credit to sex education

More teens are using condoms

Chris Vanek paid attention in middle school sex education classes. When he first had sex at the age of 16, both he and his partner used condoms, even though both were virgins. Vanek, now 26, credits an open attitude about sex and frank talk about protection.

Vanek is a living example of one success story being reported at the 19^th International AIDS Conference in Washington -- an improvement in the number of U.S. high school students who are having risky sex.

CDC data presented on Tuesday show just 47 percent of high school students have ever had sex, down from 54 percent in 1991 and holding steady since about 2001. Much progress has been seen among black students: in 1991, 82 percent of black high school students had started having sex but this plummeted to 60 percent by 2011. Just 15 percent of all students have had more four or more sex partners, down from 19 percent in 1991.

And 60 percent of those who are sexually active used a condom, which can protect against pregnancy and sexually transmitted diseases including the human immunodeficiency virus that causes AIDS.

“I knew from a very young age that I was gay. I knew gay men were more at risk from HIV and AIDS than maybe the heterosexual population,” Vanek told NBC News in a telephone interview. “I guess I always just knew that I had to protect myself and the risks of being sexually active.”

Those risks later caught up with Vanek, a road manager and make-up artist for the singer Macy Gray. He learned he was infected with the AIDS virus in 2011 and is now a spokesman for a new Centers for Disease Control and Prevention campaign against HIV stigma. 

“I think I took sex education two or three times,” says Vanek, who grew up in Los Angeles. “It was definitely a topic in school. I even went to a Catholic high school. We would talk about it in religion class. We would talk about it in PE and health. While the schools in California are not the best schools, I definitely think they did a good job of educating me about sex and sexual health and puberty.”

Even Vanek’s conservative blue-collar parents took on the uncomfortable subject, he said. He remembers when he was 13 and learned an older teenaged cousin was pregnant. “They said, ‘Obviously, we would rather you not have sex but we know you are at an age where you are curious. We want you to protect yourself’. And they gave me a package of condoms. It was a really awkward conversation with them.”

The CDC’s Dr. Kevin Fenton says it’s the frank talk about sex that works. “The more comprehensive an education you provide, the better,” Fenton said in an interview. But he noted there is variation across the country, with some school districts choosing abstinence-only education while others offer a full curriculum that includes discussion of lesbian gay and transgender themes as well as how to respect one another in a relationship.

Budget cuts aren’t helping. “Data show that fewer schools provide the comprehensive HIV education needed to ensure that this trajectory continues,” Fenton said. Another barrier: socially conservative movements that reject sex education. Fenton is diplomatic when he is asked about school districts and parents who fear that sex education teaches poor morals.

“Part of what we are committed to doing is to provide evidence,” he said. “We try to make our recommendations on the best available evidence.” Studies show that a comprehensive sex education program can influence sexual behavior more than a limited approach.

It worries Fenton that the numbers of high school students having sex, having unprotected sex, and having multiple partners have leveled off. “The challenge that these data highlight is the need for us to sustain our efforts,” he said.

And CDC and other public health agencies are now looking for better ways to reach young adults after they leave high school. Young, gay men like Vanek are a particular target. Men in his demographic are by far the most likely Americans to become infected with HIV and CDC is acutely aware of the need to keep the momentum going after they leave those middle school sex education classes.

Vanek says he made just one mistake. “I met a guy and we hit it off and we did have sex without a condom,” he said. “We had talked about it. He said he had just been tested, and I had just been tested and we thought we were safe.”

Related links:

The female face of HIV: 'Everyone's at risk'

HIV rates soar in black, gay men

AIDS turns researchers into activists

By Christopher Wanjek
LiveScience

Sex education is failing to reduce adolescent birthrates in conservative states, according to a new study.

Perhaps paradoxically, states with a majority conservative population and higher degree of religiosity tend to have higher teen birthrates. The findings suggest that the social structure of the state, such as the degree of conservatism, can undermine the effect of the sex curricula.

The researchers, from Washington University in St. Louis (WUSL), do not recommend abstinence-based education, but rather crafting sex education curricula that take into account the influences of a state's sociopolitical composition. The study appears today (Feb. 6) in the Archives of Pediatrics & Adolescent Medicine.

The U.S. adolescent birthrate is by far the highest among industrialized nations. The birthrate among girls ages 15 to 19 was 39.1 per 1,000 teens in this age group in 2009, the most recent year for which statistics are available. The rate in Western Europe ranges from about 24 per 1,000 teens in the U.K. (slightly lower than the U.S. white non-Hispanic rate) to four in the Netherlands.

Broken down by race, the U.S. rate ranges from 70.1 among Hispanic Americans to 14.6 among Asian Americans, according to the Centers for Disease Control and Prevention (CDC).

The rate is falling, however, and is at its lowest point since recordkeeping began 70 years ago. Health experts cannot fully explain the cause for the decline after a recent peak in the 1980s, nor do they know the reason for disparity from state to state. Thus, there is an ongoing debate over the efficacy of comprehensive sexuality-based programs, which teach about both abstinence and condom use to reduce the risk of pregnancy and sexually transmitted diseases, compared with abstinence-based programs, which exclude information about birth control and safe sex.

Researchers led by Patricia Cavazos-Rehg of WUSL narrowed their analysis to birthrates among girls ages 15 to 17 in 24 U.S. states during years of steady decline from 1997 to 2005. (The national birthrates climbed slightly in 2006 and 2007 before declining again in 2008 and 2009.) They found what many researchers have stated previously — that an increase in comprehensive sex education in school is associated with lower adolescent birthrates. [ 10 Surprising Sex Statistics ]

The association disappears, however, when the researchers controlled for state characteristics, such as religiosity and abortion policies. The apparent irony is that states with higher religiosity rankings and greater political conservatism had higher adolescent birthrates.

That much was not a total surprise. Researchers at Drexel University reported a similar finding in 2009 in the journal Reproductive Health. The latest findings provide the added twist that a state's level of conservatism might compromise the value or quality of sex education.

The WUSL researchers postulate that girls living in conservative states or counties either get a watered-down version of the sex education curriculum, disregard the lesson, or are less willing or able to have an abortion, all leading to higher statewide teen birthrates.

"State adolescent births vary widely, and these disparities across states should be acknowledged as a major public health concern," Cavazos-Rehg told LiveScience. She noted the difference in birthrates among girls ages 15 to 17 in Arkansas and New Hampshire. Arkansas, with high conservatism, had the highest birthrate in this study, 34.8 per 1,000 girls in this age range. New Hampshire, with high liberalism, had the lowest birthrate, 9.7. [ Teen Pregnancy: A 'Winnable' Public Health Battle? ]

Yet the analysis failed to consider pregnancy rates, which Cavazos-Rehg said are more difficult to obtain than birthrates. Could it be that, despite sex education, girls in both conservative and liberal states are getting pregnant at about the same rate, and that the girls in Arkansas are carrying their babies to term, perhaps as a result of higher religiosity, a lack of access to abortion services, or both?

The analysis also assumed that statewide data faithfully represented all schools within the state. But states are large geographic entities with many different school districts and schools, which individually make choices about what to offer in terms of sex education. Policies are made primarily at the local and individual school level.

"The study shows the difficulty of mounting an intervention at the state level that would be sufficient to shift teenage birthrates," said Freya Sonenstein, director for the Center for Adolescent Health Promotion and Disease Prevention at Johns Hopkins Bloomberg School of Public Health. "But at the local and school levels, there is plenty of other evidence that implementing particular curriculums can produce improvements in students' risk-taking behaviors."

Cavazos-Rehg said she hopes to conduct a follow-up study with data on pregnancy and sexual behavior. Yet for now, she added, "though it still remains unclear as to what 'truly effective' sex education is, what we now know is that any future evaluations of sex education must consider the effects of sociopolitical characteristics in comprehensive analyses."

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• 10 Facts Every Parent Should Know about Their Teen's Brain  

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