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Glenn D. Braunstein, M.D.

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Let's Immunize Boys Against HPV and Educate Them About Sexual Responsibility at the Same Time

Posted: 04/02/2012 11:07 am

Human papillomavirus (HPV) is one of the most common sexually transmitted diseases in the United States and the main cause of cervical cancer, which kills more than 4,000 women a year. HPV also can lead to anal cancer and genital warts, in both women and men, as well as penile and oropharyngeal cancers in men.

We now have a vaccine against HPV and its considerable harms. The Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics, American Academy of Family Physicians and Society for Adolescent Health and Medicine all now advise that, in addition to girls, boys ages 11 and 12 get these safe and effective shots. The three-shot vaccine is recommended for preteens because the levels of antibodies against HPV are higher than those achieved when the vaccine is given to older adolescents or adults.

The vaccine not only gives us the opportunity to decrease the spread of the HPV virus, but it provides us with an important opportunity to teach boys about sexual health and responsibility. Historically, boys have been given inadequate attention regarding these issues.

Teenage males are more likely to initiate sex, have sex at an earlier age and have more partners than their female counterparts. But they are less likely to receive comprehensive education about sexual health and contraception and less likely to use reproductive health services than girls. In the 2006-2008 National Survey of Family Growth, 55 percent of males reported having received formal education about contraception prior to first having sexual intercourse, versus 66 percent of females.

Routine Doctor Visits Decline for Teen Boys

Boys also are less likely to be guided about their sexual health by physicians. During adolescence, the number of routine health visits typically declines for males, particularly among older male youths, whereas females generally receive bundled sexual-reproductive health care as part of gynecologic examinations, birth control visits and prenatal care. Adolescent males also are less likely than females to talk with their parents about birth control, sexually transmitted diseases or as they are known in short-hand STDs or "how to say no to sex."

Despite these gaps, teen pregnancy has decreased by over one third since the early 1990s. During 2009 and 2010, the rate decreased by 9 percent, the largest drop recorded in a single year since 1946-1947. Still, with 750,000 or so teen pregnancies each year, America has some of the major challenges in this area in the developed world.

Teens here have a similar level of sexual activity as their Canadian, English, French and Swedish peers, but are more likely to have shorter and less consistent sexual relationships, and are less likely to use contraceptives.

Teenagers in the United States also have higher rates of sexually transmitted diseases compared to those in Western Europe and Canada. Roughly nine million new cases of STDs are diagnosed among teens and young adults a year. Rates of syphilis, gonorrhea and chlamydia among teens here continue to rise and adolescent males and young adult men are at greater risk than females for both. In 2007, the most recent year for which statistics are available, the CDC reported a 14 percent increase in the prevalence of chlamydia and a 4 percent increase in gonorrhea in males aged 15-19 years.

Adolescent Males Don't Know As Much As They Think They Do

If you've ever tried to give a young fellow important advice, however, you know it's not easy. And teenage boys don't know as much as they think they do about sexual health and preventing pregnancy. In a recent study, the vast majority said they're not confused at all about preventing pregnancy -- but one-third didn't know that two condoms aren't better than one, 15 percent didn't know that certain sexual positions don't eliminate the risk of pregnancy and more than one in 10 didn't know that a girl can get pregnant the first time she has sex.

Adolescent male hormones are a force to be reckoned with. Nearly one-third of teenage boys say they would have sex even if they didn't have a condom handy. And in a recent study, 82 percent of males ages 12 to 19 said they have felt pressured by friends to have sex; among those who were sexually experienced, 55 percent wished that they had waited longer before having sex for the first time. Among ninth- to 12th grade adolescents, 4.5 percent of boys reported that they were forced to have intercourse (compared to 11.3 percent of girls).

Some of the most significant deterrents to teenage boys becoming sexually active include their having future goals, peer role models and religion, though religion also may be a factor for not using birth control among boys who are sexually active.

Most of us want our sons to wait until they're in a committed relationship to have sex, as well as being emotionally and practically mature enough to handle all that comes with it. Certainly, the best place to start advocating that message is at home. Parents underestimate their influence. But studies show that teens who discuss sex with their parents become sexually active at later age and use condoms and birth control more often if they do have sex. They also report having better communication with romantic partners and have sex less often.

So what does the research tell us? We need to talk to both young women and men, not once but early and often about sexual health and responsibility. Talk to boys before there is a specific girl in the picture and keep at it when they're teens and older. As parents, you've got a built in advantage over other sources of information young men might turn to: You can keep at the discussion and, we hope, you know what you're talking about.

A Teen Boy's Catch-22

Boys typically feel more comfortable talking to their mothers about their feelings (how to treat girls, their feelings about girls). But they want to talk with their dads about sex and protection. These teens often find themselves in a Catch-22, though. Fathers are less likely than mothers to discuss such issues, while mothers are less likely to talk to their sons than to their daughters. Fathers' role in discussing sexuality is frequently discounted, but they are in a position to offer their son's a different and vital perspective, including their own knowledge of the male sex drive.

Should any parent need more incentive to step up, consider this: Adolescent boys rank porn equally with sex education when boys were asked to rate their influences when it comes to sex.

Physicians often neglect boys' sexual and reproductive health needs, as well. Even after the release of the American Medical Association's Guidelines for Adolescent Preventive Services and Bright Futures, which recommended preventive health services for adolescents, few improvements have been observed in counseling of male teens in the prevention of STDs or HIV infection. Data from outpatient ambulatory medical records also show that primary-care providers are three times more likely to take sexual health histories from female than male patients and twice as likely to counsel female patients on the use of condoms. The new recommendations that boys be vaccinated for HPV offer a key point of contact to better serve young male patients in these areas. [If you must argue the issue of vaccination safety, I've posted on this topic and the bad science that misleads many.]

Oh, so if physicians aren't great at taking care of business, you'd like to punt over to your local schools this possibly red-face causing, continued conversation with your son about responsible sex?

Well, sex education in schools is an all too often controversial and mixed effort. Twenty states and the District of Columbia now require sex and HIV education; one state mandates sex education alone; another 13 states mandate HIV education. Only 18 states and the District of Columbia require that sex education programs include information on contraception. California schools long have been among the most progressive. Schools here must provide students in grades 7 to 12 with HIV/AIDS prevention education. Sex education is optional but schools that have programs, as most do in Los Angeles, must include information about contraception as well as abstinence.

The curriculum matters: Males who received instruction on AIDS prevention and comprehensive sex education at school are more likely to have fewer sexual partners, engage in fewer sex acts and use condoms more consistently than those who did not receive such information. Abstinence-only-until-marriage education programs have not been shown to delay teen sexual activity and, may in fact, deter contraceptive use when the teens are sexually active, increasing the risk of an unintended pregnancy.

Websites and Text Services Fill Gap

It would be ostrich-like to think that schools alone can take on a burden like getting young people to be more sexually responsible, just by education. Shrinking budgets and competing academic subjects have helped diminish sex education as a priority. In response, some health organizations and school districts are developing websites and texting services as cost-effective alternatives. In California, for example, Hookup enables teens to text their ZIP codes to a number and receive locations for health clinics.

More than half of those in grades 7 through 12 have looked up health information online to learn more about an issue affecting themselves or someone they know. But not all such Internet help is created equal. In fact, much of it is inaccurate. Of the 177 sexual health websites examined in a recent study, 46 percent of those addressing contraception and 35 percent of those addressing abortion contained inaccurate information.

Several community-based pregnancy prevention programs, such as the Wise Guys Male Responsibility Curriculum, a weekly classroom program that has been used in 350 communities, successfully target teenage boys in educating and shaping values about sexual responsibility and behavior.

Other efforts, like Concerned Black Men of Los Angeles, have culturally tailored approaches and employed mentors to help at-risk boys to make better choices. In Houston, the Fifth Ward Enrichment Program uses a multiple approaches to tackle problems that hit hard young inner-city African-American men, including HIV/AIDS and the persistent devaluation of women. Utilizing mentors, the program combines career development activities such as goal setting, college preparation, male hygiene and entrepreneurship, with plays with dialogues on safer sex in realistic high-risk situations.

Prevention of HIV and teen pregnancy have been designated as top priorities and winnable battles by the CDC. To that end, no strategy should be underestimated. Nobody gets an STD or pregnant by themselves. And as grown-ups and physicians, we can neither burden only young women with the responsibility to be sexually safe and wise, nor can we ignore that young boys - to be true men - must carry their share, too. So, moms and dads, uncles and aunties, cousins, older sisters and brothers, teachers and physicians, let's not abdicate our responsibilities and get those young guys vaccinated and educated!

 
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