Selected Podcast
STDs and Birth Control
Mary Fournier, MD, MPH, discusses the current state of STDs and birth control in the millennial generation. She shares what has changed, any new methods available and how pediatricians can help frame this conversation for parents and patients.
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Learn more about Mary Fournier, MD, MPH
Mary Fournier, MD, MPH
Dr. Mary Elizabeth Fournier is a physician based out of Saint Louis, Missouri and her medical specialization is Pediatrics. She practices in Saint Louis, Missouri and has the professional credentials of MD.Learn more about Mary Fournier, MD, MPH
Transcription:
STDs and Birth Control
Melanie Cole (Host): Recent survey data shows that many young sexually active women do not undergo routine screening for sexually transmitted infections because they don’t see themselves at risk, even though less than half reported using a condom the last time they had sexual intercourse. Here to tell us about this today, is Dr. Mary Fournier. She’s a Washington University Adolescent Medicine physician at St. Louis Children’s Hospital. Dr. Fournier, tell us about the current state of STIs in the millennial generation. What have you been seeing?
Mary Fournier, MD, MPH (Guest): Well, we definitely see a large portion of adolescent and young adults, both men and women presenting with the wide variety of sexually transmitted infections. The biggest concern of course, would be the bacterial STIs, the chlamydia and gonorrhea. The unique thing about this population, generally patients between the ages of 15 and 24; they compromise about 25 to 27% of the sexually active population in the United States, but they actually, especially for the bacterial sexually transmitted infections; they carry a huge burden of those infections, so about 75% of those particular chlamydia and gonorrhea; those particular STIs, are diagnosed in this age population. And overall, the 15-24-year olds account for about 50% of all STIs including the viral ones.
Host: Do you feel there’s a gap in STI awareness among clinicians, because we know that the media has been really pushing some of the awareness in the last maybe 15 years or so; or do you think clinicians are also – there’s a lack of use of the screening guidelines for one reason or another?
Dr. Fournier: Well, I think there’s a couple of different things to think about. I think most physicians are aware that adolescents are at risk for sexually transmitted infections and they generally know that they probably should be screened; but there’s – especially with the younger adolescents, the under 18-year-olds who still have parental involvement. There is some concern about how do we provide some of these services, some of the STI screening and treatment to an adolescent population when you want to maintain confidentiality. Because there’s some issues around do we do the testing or offer the testing if the parents might find out through insurances or other means. And I think that makes some of the pediatricians out there or primary care providers a little reluctant to go down that road especially with the younger adolescents.
Host: So, then how do you work with your patients in this regard and what would you tell other providers about that issue with confidentiality, with discussing it with their patients, even with the involvement of the parents?
Dr. Fournier: Well, definitely STI screening and risk and how it’s done and what needs to be done, should be part of every encounter particularly the preventive health care maintenance encounters, those well-child exams, starting right at the very beginning of adolescence, kind of talking about the risks. And generally, one of the things that we talk about with confidentiality is that while providers maintain confidentiality, a lot of the parents are aware of what’s going on with their teenagers, want to be aware and so when I talk to my teenagers about getting screening for their STIs and confidentiality comes up; we sometimes talk about the fact that letting your mom and dad know might not be the end of the world, if they do find out about it through insurance as they might not be as happy. Now some teenagers prefer to go ahead and do the screening without talking to their parents. If their parents find out through insurance, they take more of a attitude such as I’d rather ask forgiveness than permission if it comes out, it comes out and I’ll deal with it. If they want to maintain confidentiality, there are ways that we can do that. There are clinics around the St. Louis area that can provide confidential services and we talk about getting screening through those clinics.
Host: In your opinion Doctor, do you think that at the time when Gardasil is first discussed and the HPV vaccine, because some parents have concerns about that opening that conversation and opening that door to their teens. Would that be a good time, in your opinion, to discuss with the teen or preteen, sexually transmitted infections and the damage that they can do?
Dr. Fournier: Absolutely. I think starting in the preteen years, discussing sexual activity, birth control, consent, the risk of STDs and what they can do and how to screen and treat them, should absolutely start right around the time that kids are starting to think about sex which generally happens around puberty. I would recommend perhaps separating the conversation between HPV vaccination and the rest of the sexual health encounter. I think this concern that parents have at times with if I vaccinate my child against HPV; this is basically allowing them, saying I’m okay with them having sex and that’s really not the message we are endorsing here. We know that at some point during their life, during their whether it’s young adult life or beyond; they are going to become sexually active. Obviously, it’s just part of a normal health life.
But the reason we screen at the age we do is to try to get them fully vaccinated before exposure becomes an issue. And the data has actually looked into it. There’s been multiple studies kind of looking at if we vaccinate adolescents against HPV or other STDs like hepatitis B; does this give the teens – does it change their behavior? And the answer is no. We know that teens who have been vaccinated against HPV, do not initiate sexual activity at an earlier age if they have not already been sexually active. And for those teens who are currently sexually active and become vaccinated against HPV; does it encourage them to use sort of riskier sexual practices? Are they less likely to use condoms, etc.? And the answer to that is no. So, really, the data is very clear that the vaccination doesn’t change their sexual activity at all. So, we really want to keep the vaccination message as this really should be a preventative recommendation for your entire life, much like we would vaccinate you against meningitis or T-DAP, the tetanus and pertussis, because that’s really where it is. It’s not really relating to their sexual activity during adolescence at all.
Host: Are there any new innovative treatment options for STIs or are we mostly looking at prevention or even STI prophylaxis?
Dr. Fournier: Well, what we really want to recommend is maintaining an appropriate screening guidelines. We want to definitely assess our adolescents and young adults for their STI risk factors. So, adolescents who have new sexual partners, have multiple sexual partners, have inconsistent or incomplete condom use outside of a mutually monogamous sexual relationship; these are all patients who would generally benefit from STI screening and if you do diagnose one particular STI in an adolescent; that definitely puts them at higher risk or likelihood of having another STI, so we want to make sure we are doing comprehensive screening looking at gonorrhea, chlamydia, syphilis, HIV and in patients who have been diagnosed with any particular STI.
And as far as treatment goes, we want to make sure that once we do diagnose it, we get the patients treated, we get their partners treated. Talking to patients about letting their partners know and how you can do that. Through the Public Health Department there’s ways of letting partners of patients know confidentially so they don’t really know where the information is coming from, just that they should get themselves screened and then expedited partner treatment is this idea where for instance, if a patient is diagnosed with chlamydia, which we generally treat with oral antibiotics, there are a couple of different protocols for that; we can provide the patient with prescriptions for those treatments that the patient then can provide to their sexual partners and that can really decrease the risk of spreading the infection or reinfecting a patient that has already been treated.
Host: So, as we are talking about STIs and we don’t have a lot of time Doctor, just give us a little overview of birth control these days and what you are seeing in the millennial population and with their providers. Are they feeling comfortable to ask their providers for this type of birth control? What’s going on in the field today?
Dr. Fournier: Well, adolescents and young adults, their first contact with the medical community for birth control generally is through their primary care physician. So, this is really where we want to get the accurate and complete information going. So, both the American Academy of Pediatrics and the American College of Obstetrics and Gynecology have really come out and very strongly recommended that the long acting reversable contraceptive methods such as the hormone implant or the various IUDs should be first line in this population. So, really this is what we should be recommending. We want to do comprehensive counseling so talking about all of the hormonal options, whether it’s birth control pills, patch, ring, the progesterone – the long-acting progesterone shot and then the long acting reversable methods. And while many primary care providers may not have training or expertise to provide the implants and IUDs, knowing what their referral networks are and getting the patients to those referrals if that is what an adolescent prefers to have, and we have seen increased numbers over the last five or ten years of increased uptick of these IUDs and implants in this population.
But when you are referring out to those providers, making sure that you offer sort of a bridge method. Maybe you prescribe birth control pills in the interim before they are able to get to the gynecologist or adolescent specialist to actually get the implant or IUD.
Host: As you summarize, and this is a very comprehensive topic Doctor, so, we really- there’s a lot we could talk about. But where do you want providers to frame this conversation? How do you want them to frame it for parents and for patients and what should a pediatrician know about referring to a specialist when necessary?
Dr. Fournier: Well, I think a lot of these conversations are going to happen both with the teen during your confidential portions when you are talking just to the teen themselves trying to give them the education and the information that they need, that they might not be getting from any other place, like school or home. And helping them make their own informed choices and supporting those choices and trying to get them the screening and the medications that they need. And with the parents, generally, I talk to the parents, not breaking confidentiality, but just more in general terms, encouraging parents to talk to their kids about sexual activity, their views on sexual activity, trying to help and support whatever choices the teens make and trying to just encourage open communication between the teens and the parents. Of course, you want to give the same information to the parents that you are providing to the teen, so everybody is on the same page as far as the current risks and the current statistics and safety information about the medications.
As far as referring from a primary care provider to a specialist. I think that really varies from provider to provider. Some providers are extraordinarily comfortable doing the screening and the testing of STIs or providing birth control and some really aren’t. And I think it really depends on your comfort level and if it’s beyond what you are wanting to do; then I think referring is absolutely appropriate.
Host: Thank you so much Doctor, for coming on today and for explaining the current state of STIs and birth control in the millennial population and really giving pediatricians a voice to discuss and primary care providers to discuss these with their patients and their parents and get that discussion going. Thank you again for being with us. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to www.stlouischildrens.org, that’s www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.
STDs and Birth Control
Melanie Cole (Host): Recent survey data shows that many young sexually active women do not undergo routine screening for sexually transmitted infections because they don’t see themselves at risk, even though less than half reported using a condom the last time they had sexual intercourse. Here to tell us about this today, is Dr. Mary Fournier. She’s a Washington University Adolescent Medicine physician at St. Louis Children’s Hospital. Dr. Fournier, tell us about the current state of STIs in the millennial generation. What have you been seeing?
Mary Fournier, MD, MPH (Guest): Well, we definitely see a large portion of adolescent and young adults, both men and women presenting with the wide variety of sexually transmitted infections. The biggest concern of course, would be the bacterial STIs, the chlamydia and gonorrhea. The unique thing about this population, generally patients between the ages of 15 and 24; they compromise about 25 to 27% of the sexually active population in the United States, but they actually, especially for the bacterial sexually transmitted infections; they carry a huge burden of those infections, so about 75% of those particular chlamydia and gonorrhea; those particular STIs, are diagnosed in this age population. And overall, the 15-24-year olds account for about 50% of all STIs including the viral ones.
Host: Do you feel there’s a gap in STI awareness among clinicians, because we know that the media has been really pushing some of the awareness in the last maybe 15 years or so; or do you think clinicians are also – there’s a lack of use of the screening guidelines for one reason or another?
Dr. Fournier: Well, I think there’s a couple of different things to think about. I think most physicians are aware that adolescents are at risk for sexually transmitted infections and they generally know that they probably should be screened; but there’s – especially with the younger adolescents, the under 18-year-olds who still have parental involvement. There is some concern about how do we provide some of these services, some of the STI screening and treatment to an adolescent population when you want to maintain confidentiality. Because there’s some issues around do we do the testing or offer the testing if the parents might find out through insurances or other means. And I think that makes some of the pediatricians out there or primary care providers a little reluctant to go down that road especially with the younger adolescents.
Host: So, then how do you work with your patients in this regard and what would you tell other providers about that issue with confidentiality, with discussing it with their patients, even with the involvement of the parents?
Dr. Fournier: Well, definitely STI screening and risk and how it’s done and what needs to be done, should be part of every encounter particularly the preventive health care maintenance encounters, those well-child exams, starting right at the very beginning of adolescence, kind of talking about the risks. And generally, one of the things that we talk about with confidentiality is that while providers maintain confidentiality, a lot of the parents are aware of what’s going on with their teenagers, want to be aware and so when I talk to my teenagers about getting screening for their STIs and confidentiality comes up; we sometimes talk about the fact that letting your mom and dad know might not be the end of the world, if they do find out about it through insurance as they might not be as happy. Now some teenagers prefer to go ahead and do the screening without talking to their parents. If their parents find out through insurance, they take more of a attitude such as I’d rather ask forgiveness than permission if it comes out, it comes out and I’ll deal with it. If they want to maintain confidentiality, there are ways that we can do that. There are clinics around the St. Louis area that can provide confidential services and we talk about getting screening through those clinics.
Host: In your opinion Doctor, do you think that at the time when Gardasil is first discussed and the HPV vaccine, because some parents have concerns about that opening that conversation and opening that door to their teens. Would that be a good time, in your opinion, to discuss with the teen or preteen, sexually transmitted infections and the damage that they can do?
Dr. Fournier: Absolutely. I think starting in the preteen years, discussing sexual activity, birth control, consent, the risk of STDs and what they can do and how to screen and treat them, should absolutely start right around the time that kids are starting to think about sex which generally happens around puberty. I would recommend perhaps separating the conversation between HPV vaccination and the rest of the sexual health encounter. I think this concern that parents have at times with if I vaccinate my child against HPV; this is basically allowing them, saying I’m okay with them having sex and that’s really not the message we are endorsing here. We know that at some point during their life, during their whether it’s young adult life or beyond; they are going to become sexually active. Obviously, it’s just part of a normal health life.
But the reason we screen at the age we do is to try to get them fully vaccinated before exposure becomes an issue. And the data has actually looked into it. There’s been multiple studies kind of looking at if we vaccinate adolescents against HPV or other STDs like hepatitis B; does this give the teens – does it change their behavior? And the answer is no. We know that teens who have been vaccinated against HPV, do not initiate sexual activity at an earlier age if they have not already been sexually active. And for those teens who are currently sexually active and become vaccinated against HPV; does it encourage them to use sort of riskier sexual practices? Are they less likely to use condoms, etc.? And the answer to that is no. So, really, the data is very clear that the vaccination doesn’t change their sexual activity at all. So, we really want to keep the vaccination message as this really should be a preventative recommendation for your entire life, much like we would vaccinate you against meningitis or T-DAP, the tetanus and pertussis, because that’s really where it is. It’s not really relating to their sexual activity during adolescence at all.
Host: Are there any new innovative treatment options for STIs or are we mostly looking at prevention or even STI prophylaxis?
Dr. Fournier: Well, what we really want to recommend is maintaining an appropriate screening guidelines. We want to definitely assess our adolescents and young adults for their STI risk factors. So, adolescents who have new sexual partners, have multiple sexual partners, have inconsistent or incomplete condom use outside of a mutually monogamous sexual relationship; these are all patients who would generally benefit from STI screening and if you do diagnose one particular STI in an adolescent; that definitely puts them at higher risk or likelihood of having another STI, so we want to make sure we are doing comprehensive screening looking at gonorrhea, chlamydia, syphilis, HIV and in patients who have been diagnosed with any particular STI.
And as far as treatment goes, we want to make sure that once we do diagnose it, we get the patients treated, we get their partners treated. Talking to patients about letting their partners know and how you can do that. Through the Public Health Department there’s ways of letting partners of patients know confidentially so they don’t really know where the information is coming from, just that they should get themselves screened and then expedited partner treatment is this idea where for instance, if a patient is diagnosed with chlamydia, which we generally treat with oral antibiotics, there are a couple of different protocols for that; we can provide the patient with prescriptions for those treatments that the patient then can provide to their sexual partners and that can really decrease the risk of spreading the infection or reinfecting a patient that has already been treated.
Host: So, as we are talking about STIs and we don’t have a lot of time Doctor, just give us a little overview of birth control these days and what you are seeing in the millennial population and with their providers. Are they feeling comfortable to ask their providers for this type of birth control? What’s going on in the field today?
Dr. Fournier: Well, adolescents and young adults, their first contact with the medical community for birth control generally is through their primary care physician. So, this is really where we want to get the accurate and complete information going. So, both the American Academy of Pediatrics and the American College of Obstetrics and Gynecology have really come out and very strongly recommended that the long acting reversable contraceptive methods such as the hormone implant or the various IUDs should be first line in this population. So, really this is what we should be recommending. We want to do comprehensive counseling so talking about all of the hormonal options, whether it’s birth control pills, patch, ring, the progesterone – the long-acting progesterone shot and then the long acting reversable methods. And while many primary care providers may not have training or expertise to provide the implants and IUDs, knowing what their referral networks are and getting the patients to those referrals if that is what an adolescent prefers to have, and we have seen increased numbers over the last five or ten years of increased uptick of these IUDs and implants in this population.
But when you are referring out to those providers, making sure that you offer sort of a bridge method. Maybe you prescribe birth control pills in the interim before they are able to get to the gynecologist or adolescent specialist to actually get the implant or IUD.
Host: As you summarize, and this is a very comprehensive topic Doctor, so, we really- there’s a lot we could talk about. But where do you want providers to frame this conversation? How do you want them to frame it for parents and for patients and what should a pediatrician know about referring to a specialist when necessary?
Dr. Fournier: Well, I think a lot of these conversations are going to happen both with the teen during your confidential portions when you are talking just to the teen themselves trying to give them the education and the information that they need, that they might not be getting from any other place, like school or home. And helping them make their own informed choices and supporting those choices and trying to get them the screening and the medications that they need. And with the parents, generally, I talk to the parents, not breaking confidentiality, but just more in general terms, encouraging parents to talk to their kids about sexual activity, their views on sexual activity, trying to help and support whatever choices the teens make and trying to just encourage open communication between the teens and the parents. Of course, you want to give the same information to the parents that you are providing to the teen, so everybody is on the same page as far as the current risks and the current statistics and safety information about the medications.
As far as referring from a primary care provider to a specialist. I think that really varies from provider to provider. Some providers are extraordinarily comfortable doing the screening and the testing of STIs or providing birth control and some really aren’t. And I think it really depends on your comfort level and if it’s beyond what you are wanting to do; then I think referring is absolutely appropriate.
Host: Thank you so much Doctor, for coming on today and for explaining the current state of STIs and birth control in the millennial population and really giving pediatricians a voice to discuss and primary care providers to discuss these with their patients and their parents and get that discussion going. Thank you again for being with us. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to www.stlouischildrens.org, that’s www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.