History of contraception

 Idea is ancient  Egypt ○ Douched with wine and garlic after sex ○ Soaked crocodile dung in sour milk and inserted in vagina  Greeks and Romans ○ Placed absorbent materials within vagina to absorb semen   Penile sheaths as far back as 1350 BC in Egypt Term condom in 18 th ○ century Originally made of animal intestines ○ Casanova used condoms ○ Rubber condoms in late 1840s

Selecting a method of contraception

 Convenience  Moral acceptability  Cost  Sharing responsibility  Safety/side effects  Reversibility  Protection from STDs  Effectiveness

History of fight against contraceptives

  Anthony Comstock ○ Secretary of NY Society for the Suppression of Vice ○ Lobbied for passage of 1873 federal law (Comstock Law) Margaret Sanger ○ ○ Proponent of contraception and information 1 st started magazine called “The Woman Rebel” in 1914 ○ Founded birth control clinic in 1916, which was shut down by police  She appealed  In 1918, courts ruled in favor of MDs being able to disseminate information that might prevent disease ○ Today, critics of Sanger persist   Eugenics Racism

Need for contraceptives

 

Worldwide over 100,000,000 acts of intercourse per day

 910,000 conceptions ○ 50% planned, 25% unwanted  356, 000 sexually transmitted bacterial and viral infections

Mythical contraceptives

 Nursing an infant    Withdrawal Douching Teens —all sorts of ideas

Contraceptives around the world

    Japan ○ Oral contraceptives approved in 1999 ○ ○ About 3% of women take them (compared with 18% in US) 70% don’t want them ○ Strategy was to discourage sterilization, IUDs and diaphragms to encourage condom use to decrease STDs Brazil ○ Had a trial of a male contraceptive —still refining ○ Impressive because until 1979 it was illegal to advertise contraceptives ○ ○ 60% of men express a willingness to take a contraceptive Sterilization was illegal until 1997 —now 40% of married women have undergone this China ○ One child policy implemented in 1978 ○ Expected to remain in place until at least 2020 ○ Induced abortion is one of the forms of birth control ○ Requires abortion of a fetus with any abnormality because kids are supposed to care for aging parents France ○ French Catholic Bishops —approved of condoms due to STDs

Contraceptives around the world

 United Nations World Contraceptive Use 2003  61 per cent of all women of reproductive age who are married or in a consensual union are using contraception.     More developed regions--69 % Less developed regions-- 59 % Africa —27% Nine out of every 10 women using contraception rely on modern methods.  Traditional methods are more popular in developing countries than in developed countries The most commonly used traditional methods are: rhythm (periodic abstinence) and withdrawal. At the world level, these methods are used by 6 per cent of women who are married or in union.



The biggest obstacle to contraceptive use in US: Effective planning

The pill

     Combination pill —synthetic estrogen and progesterone —steady dose, some multiphasic and vary through the month Mini pill —progestin pill Pills are used by 28% of women who use reversible contraception Works by preventing ovulation —fakes pregnancy ○ ○ Artificially increases estrogen, which prohibits FSH production and inhibits ovulation Progestin is a backup —keeps cervical mucus thick more difficult implantation  hard for sperm to get through and changes lining of uterus for a ○ When pill is withdrawn, menstruation Failure rate (pregnancy rate over year) ○ Perfect user .1%, typical user 3%

Side effects

     Side effects  Slight increase in diseases of circulatory system —DVT, stroke, heart attack, high bp  No evidence of increase in cervical, uterine, or breast CA   Actually a protectant from endometrial and ovarian CA Increases susceptibility to vaginitis, gonorrhea, Chlamydia 20% of users report increased irritability, depression —become worse with time used. Groups who should not use BCP Antibiotics may decrease effectiveness  Pill may make some drugs more potent (anxiolytics) Research on effects on sex interest   There is already research on how male contraceptives affect sex interest, but very little on female contraceptives Not Now Darling I’m on the Pill ○ ○ ○ Began with uncontrolled, retrospective study Then did prospective study Results —BCP decrease breast pain and bloating but decreases sexual interest

The mini pill



Good for women who can’t take combo pill for estrogen reasons

 Women with a history of clotting problems  

Creates irregular periods Not sure why they work —40% continue to ovulate



Progestin also fosters male secondary sex characteristics

 Acne, facial hair, vaginal dryness, thinning of scalp hair, decreased breast size

Morning after pill

      Stops fertilization or implantation Take within 72 hours New York Times poll —65% consider this birth control, 20% abortion High dosage of estrogen and progesterone —not tested long term As of 2002, France —girls under 18 are eligible for free pills, must speak with pharmacist, no script necessary In US, costs $10-$70 —over 17, no script, under need prescription

The patch

      2010 Ortho Evra patch approved It is a transdermal estrogen/progestin drug system It is applied to the lower abdomen, buttocks, or upper body every week for 3 weeks. The fourth week is patch-free to allow menses. Risks and effectiveness are similar to oral combination contraceptive pills. Less than 2% of these patients discontinued the patch due to effects, less effective in those weighing over 200 lbs Costs about $30/month, just like pill

Vaginal ring

        2010 NuvaRing approved It is a flexible polymer 2.1” ring that is colorless and transparent —releases estrogen and progesterone The patient inserts the ring in the vagina on day 5 of her cycle and leaves it in place for 3 weeks. Effectiveness takes 7 days, requiring abstinence or a backup contraceptive method. The ring is removed to allow menses (1 week hormone-free similar to the pill and patch Efficacy and side effects are similar to oral contraceptives Compliance rates of about 91% The ring may accidentally be expelled if not inserted correctly Cost for is about $45

Other hormonal methods



Monthly shots —Depo Provera, Lunelle--progesterone



Implanon —implantable, in arm

 Estrogen, progesterone  Good for three years  Costs $400-$800 for implantation  Highly effective —failure rate of less than 1%

IUD

         Both hormonal (Mirena-progesterone) and non hormonal (ParaGard) methods Small t-shaped piece of plastic or copper Left in place for 1 to 5 years Common in China (1/3 of married women) —only about 3% here Not exactly sure how non-hormonal method works Mirena also decreases menstrual flow and can be used to treat excessive menstrual bleeding Quite effective —1-2% failure rate—usually due to expulsion Major side effect —PID—pelvic inflammatory disease  Others —menstrual cramps, irregular bleeding, increased menstrual flow in 10-20% of women Initial cost--$175-$650

Diaphragm and cervical cap

      Diaphragm  Fewer than 5% of married women use  Circular, dome-shaped piece of thin rubber with rubber covered rim of flexible material  Contraceptive jelly on edge Can be inserted 6 hours before sex. Must be there 6 hours after Typical user failure rate —18%, perfect user 6% Fit is key —refit after birth, abortion, weight gain or loss or more than 10 lbs Few side effects   Cost $10 plus office visit, should last 2 years No effect on hormones Cervical cap     Newer Fits snugly on cervix Used with spermicide 18% for nulliparous, 36% for parous

Spermicides



Use no more than 60 minutes before sex



Jellies, foams, creams, suppositories, film

 

Work by coating cervical opening Typical user failure rate —as high as 21%

 Foams are better than creams or jellies  Better when combined with condom or diaphragm

Male condom



Old idea

 

New one for every act of intercourse Must be put on before intercourse



pre ejaculate contains sperm



Typical user failure rate 12%, perfect user 3%

 

FDA regulates only US made condoms Animal skin —not as effective in preventing STDs

Female condom



Can be inserted as much as 8 hrs before sex



Typical user failure rate of 21%, perfect user failure of 5%



Early material made lots of crinkling noise, but newer materials do less of this



$2.50 to $5 each

Non-contraceptives



Douching

 40% failure rate 

Withdrawal

 20% at best

Fertility awareness

        Major advantage —sanctioned by RCC Involves abstaining from sex around ovulation Calendar method —based on ovulation day 13 15 Basal body temp —good only after ovulation Cervical mucus Home ovulation kits  Saliva ovulation test Sympto-thermal —both mucus and temp Effectiveness  Typical user —20% typical user ○ Perfect user 1% home ovulation, 9% calendar

Sterilization

   39% married women under 45, 15% of men    Vasectomy  Severs vas deferens  Takes 20 min in drs office No physical changes that interfere with erection .1% failure 50% pregnancy rate after reversal Female sterilization  Tubal ligation   Takes 10-20 min in hospital Doesn’t interfere with ovaries  .4% failure rate  45-80% pregnancy rate after reversal

Abortion

     Each year, nearly 1 million girls 15-19 get pregnant  About 30% end in abortion, 50% live birth, rest miscarriage  27% white teen girls, 35% black teen girls report no contraceptives 37 million abortions worldwide each year 90% during first trimester In US, rates range from about 3 per 1000 (Idaho) women to 37 per 1000 (DC) Average of about 14.1 per 1000 women overall per year

Abortion around the world

    Canada ○ All remaining restrictions struck down in 1988 ○ ○ No reporting requirements, but about 19% of all known pregnancies 90% are in the 1 st trimester ○ 2/3 on young, unmarried China ○ 13 million annually (China Daily) (Compared to 20 million births each year) ○ 62 percent of the women who have abortions are between 20 and 29 years old, and most are single ○ Additional 10 million abortion pills are distributed yearly ○ 70% are due to contraceptive failure Ireland ○ Abortion is completely illegal ○ Estimated that over 125,000 have traveled to England for abortions since 1985 Iran ○ Abortion is only legal if mother’s life is in danger

Abortion around the world

   Egypt ○ Abortion is illegal unless mother’s life is in danger ○ Commonly performed by midwives Sweden ○ ○ ○ Up to 12 weeks upon request 12-18 weeks on consult with MD and counselor After 18 weeks with approval of Nat’l Board of Health and Welfare ○ ○ Free One of the lowest abortion rates in the world US ○ ○ 90% in first 12 weeks States can regulate in 2 nd   2 nd 3 rd to assure safety may prohibit and 3 rd trimester

US Attitudes

      Majority support Roe v. Wade  22% say should be allowed under all circumstances   18% say should never be allowed 1998 Poll —32% said that abortion is murder, but still sometimes the best option 2009 —Gallup Poll—47% describe selves as pro-life, 46 as pro-choice  Other polls show more of a spread —52 to 41 Republicans more pro-life Those for whom religion is more important are more pro choice, but not all religions Younger more pro-choice (64% of college students) % of obstetricians willing to perform abortions is dropping — 33% in 1995  Since 1980, about 550 hospitals have stopped performing them

Methods

  Vacuum aspiration  Up to 14 weeks gestation  90% of abortion   Outpt with local, takes 10 min Dilate cervix, tube is inserted, and the other end is attached to suction  Complications are rare D&C —Dilation and Curettage  8-20 weeks  Dilate cervix, scrape uterus  Hospital with general  Rare for abortion  More common now for gynecological problems

Methods

     D&E —Dilation and Evacuation  2 nd trimester  Similar to vacuum aspiration, but then uterus is scraped Induced labor by amniotic infusion —saline  2 nd trimester  1% of abortions Hysterotomy    Essentially a c-section from 16-24 weeks More complications Expensive —over $1000 Intact Dilation and Extraction  Partial birth abortion .17% of all abortions

Mifeprestone

       RU-486 Within 49 days of LMP Blocks progesterone, thus not allowing ovum to implant Requires physician’s script Requires 3-4 drs visits Nausea, vomiting, diarrhea, headache, dizziness, and fatigue may occur. Bleeding and cramping are expected ○ Bleeding and spotting may last up to 30 days, and may be greater than a normal, heavy period. In a very few cases, this bleeding will need to be stopped by performing a surgical procedure

Psychological consequences of abortion

 Major et al 2000  72% were satisfied  69% would do it again  All of these women had agreed to be contacted 2 yrs post ○ What about the 15% who didn’t?

 300,000 women per year would not do it again   Hollander 2001  16% regretted decision  67% would do it again  20% met criteria for depression Fergussen et al 2009  High rates of both positive and negative emotions   90% believed it was necessary But —rates of mental illness 1.4-1.8 times higher than those not having abortion   Distress is related to being younger, unmarried, not given birth previously, culture, religion What about those denied an abortion?

 Studies from 1960s and 1970s suggest increased risk to the children —poor social adjustment, etc  However, others argue that these studies did not control for other factors (SES, etc) and when these are controlled, those risks are diminished

Physical consequences



Rates of mortality and complications

 .4 -1 per 100,000 abortions —mortality rate  10x more likely to die from childbirth than abortion  97% have no complications 

Long term effects

 1 st trimester —no effect on later childbearing  Later abortions might

Conception



Egg is released at day 14

 Makes its way to uterus  Disintegrates in 48 hours if not fertilized  Otherwise takes 5 days  Propelled by cilia

Sperm

 Sperm   5 micrometers long (1/5000 th in) Made up of head (chromosomes and acrosome —provides energy for tail), midpiece, and tail   Majority of sperm never make it close to egg ○ 300 million sperm ○ ○ Some flow out of vagina, some die in vagina due to acidity, some go up wrong fallopian tube About 2000 reach tube with egg ○ 100-200 reach egg Arrive at egg after 1 1 ½ hrs ○ Conception occurs in fallopian tube ○ ○ Egg secretes chemical to attract sperm Egg is surrounded by gelatinous layer called zona pellucid. Sperm secrete enzyme hyaluronidase to dissolve zona pellucid and allow one sperm to penetrate  Capacitation —sperm become able to penetrate ova after entering uterus/tubes. This is a chemical change ○ Sperm bearing X are more durable, Y are smaller and faster

If you could pick sex of your child, would you?

   Recently been separating sperm to get male or female ○ Success rate is around 80% Wilcox et al 1995 ovulation —no association between gender and timing of intercourse in relation to Shettler’s Technique ○ ○ ○ Given assumptions about speed/durability of Y and X, try these.

Claim 80% success. Others say this is too high.

Boy  Sex at ovulation  Decrease acidity ○ Girl   Sex before ovulation Increase acidity

When conception isn’t easy

 Infertility —when failure to conceive has persisted for more than a year    About 15 % of couples have infertility problems ½ of these will eventually succeed Infertility is on the rise —in part due to rise in later childbearing   Primary vs secondary Pregnancy wastage —able to conceive, but unable to carry to term   Attributed to man 40% of time Attributed to woman 40%  Attributed to both 20%

Male infertility

        Low sperm count ○ ○ Azoospermia —no sperm production Oligospermia —low sperm production  Most common causes Low sperm motility Irregularly shaped sperm Chronic or infectious diseases —diabetes, STDs Injury to the testes Pituitary imbalance, thyroid disease Autoimmune response Enlarged prostate —body kills own sperm

Female infertility

 Irregular ovulation ○ Most common cause  Obstructions of the reproductive tract  Endometriosis  Low estrogen and progesterone that prevent egg from being fertilized or staying implanted  Chemically hostile cervical mucus   High or low body mass Fibroid tumors —associated with miscarriage

Treatment

       Artificial insemination Fertility drugs to increase ovulation ○ 43% of triplet or higher births due to drugs ○ Multiple births account for 3.3% of all births In vitro fertilization Donor in vitro Embryonic transfer aka ovum transfer (father’s sperm in surrogate, flushed and implanted) Surrogacy (artificial insemination of a gestational host) Adoption

Adjustment

   VanDenAkker (1997)   105 infertile respondents ¾ devastated by diagnosis   64% women, 47% men could never be happy without a child ¼ ultimately sought adoption Peterson et al 2003  Couples who perceived the stress of infertility at similar levels adjusted better Daniluk and Tench 2007  A 33-month longitudinal of 38 infertile couples –unsuccessful treatments  Increased self-esteem and decreased sexual satisfaction were evident over time.   Poorer adjustment was related to having none or few available options, little social support, poor emotional and physical health, and reliance on emotion-focused coping. Participants who adopted demonstrated better adjustment

Fertility services

 Of 6.7 million women with fertility problems ○ 42% received some fertility services ○ Most of these were low tech  Advice (60%)  Diagnostic testing (50%)  Medical intervention to reduce miscarriage (44%)  Ovulation inducing drugs (35 %) ○ Those receiving services tend to be older, more educated, more income than those not receiving services

Pregnancy

    Zygote —fertilized egg—travels down fallopian tube After 36 hours, cell division begins 1 st 8-10 weeks called embryo, after that called fetus Early signs of pregnancy   Basal temp stays up for 2-3 weeks Missed periods   Tenderness of the breasts Morning sickness —related to lower rates of miscarriage and stillbirth   Fatigue Frequent urination

Pregnancy tests

 Lab —98-99% accurate after 7 days— urine tests; 1-2% false negative ○ Blood —more accurate and more expensive  In home —less accurate ○ Perhaps 25-38% false negative, 16% false positive

Miscarriage

   

Up to 40%

Miscarriage is the spontaneous loss of a pregnancy before the 20th week. About 10 to 20 percent of known pregnancies end in miscarriage. But the actual number is probably much higher because many miscarriages occur so early in pregnancy that a woman doesn't even know she's pregnant. Most miscarriages occur because the fetus isn't developing normally.

Adjustment to miscarriage

         Not much literature relating grief to miscarriage Reactions that typically are similar to the affective and behavioral reactions after other types of significant losses.

Different, too: emphasis on times ahead rather than remembered No clear percentage of how common this is  As low as 12%  As high as 96% Abates after about 6 months or after subsequent pregnancy Less intense and enduring in men Some evidence for gestational age being related to grief Grief doesn’t seem to be related to maternal age Prior psych problems are related to increased risk

Sex during pregnancy



Old fear of causing infection, miscarriage, early delivery —now known to be unfounded



Sex until 4 weeks before delivery is ok



Some say until delivery



Generally drops in frequency in 1

st

3

rd

trimesters and



One study found 90% having sex at 5 months

Psychological changes

       Genevie and Margolies —35% love pregnancy, 8% hated it, 40% mixed Physical discomfort influences happiness  Fatigue and nausea prominent in 1 st trimester  1 st Fatigue and heartburn prominent in 3 rd trimester —turbulent—many moody, irritable 2 nd —maternity clothes, movement, happier 3 rd —impatient Routh, 2000 —20% experience significant depression Striegel-Moore, 1996 —no huge psychological issues assoc with pregnancy

Fathers

  Couvade —Brennan et al, 2007  Industrialized countries  Range of phys and psy sx with no phys basis ○ ○ Usually in male partners Other cases (eg., a twin sister) have been reported  Conner and Denson, 1990 ○ 3 main groups of sx ○ 1) Nausea, heartburn, abdominal pain, bloating and appetite changes ○ 2)Upper respiratory disturbances ○ 3) Psychological symptoms   U-shaped pattern: present in the first trimester, temporarily disappear in the second and reappear in the third trimester In serious cases in Asia and parts of North and South America — men take to bed, feel all pains of labor, moan, groan Seeing ultrasound helps fathers feel more involved

Prenatal development

    During embryonic stage, major organ systems are formed  Inner part of ball of cells differentiates into 2 layers with 3 rd layer forming between them  Ectoderm  Endoderm  Mesoderm  Developmental is cephalocaudal Another group of cells becomes the trophoblast, which will be placenta  Placenta provides cushioning and nourishment  Circulatory system of mother and child are separate  Placenta also secretes estrogen, progesterone, and hcg Umbilical cord forms in 5 th week, attaches to placenta Amniotic fluid —cushions baby

1

st

Trimester

      By 3 rd week, baby is 1/12 in long During 3 rd and 4 th week  Head develops  CNS forms  See eyes and ears  Backbone by end of 4 th week  Heart beats —4 th week From 4 th -8 th week —eyes, ears, arms, hands, fingers, legs, feet, toes End of 7 th week —liver, lungs, pancreas, kidneys, intestines, gonads —all present with limited function 10 12 th th week —fingernails week —looks like small infant, 10cm long

2

nd

Trimester

    

End of 14

th

detected

 Woman should feel movement between 16 and 20 weeks

18

th

week —physician can hear heartbeat with stethoscope Week 20 —opens eyes Week 24 —sensitive to light and sound



week —movement can be

Alternates between wake and sleep

Wrinkled skin, downy hair at end of trimester

3

rd

trimester



Fat deposits from under skin —chubby



Downy hair lost



Rapid growth



About 7

th

month —turns to be head down

Weight gain



Should be 22-27 lbs



7.5 baby



1 placenta



2 amniotic fluid



2 enlargement of uterus



1.5 enlargement of breasts



8 additional fat and water retained by mother

Environmental influences

   Mother’s diet—both malnutrition and obesity are risks Teratogens —substance producing defects in a fetus  Antibiotics  Antihistamines  Accutane  X-rays  Smoking  Alcohol ○ Fetal alcohol syndrome 70 —growth deficiencies, small brain, small eyes, joint, limb, heart malformations, 85% have lower IQ below Maternal age  In 2000, 5000 women between 45-49 gave birth  Risk of fetal defects ○ 2.6/1000 before 30 ○ 5.6/1000 at 35 ○ ○ 15.8 at 40 53.7 at 45

Labor and delivery

  Average for first births —20 hours Only 10% begin with rupture of membranes   Lose mucus plug a while before 3 stages  First stage ○ ○ ○ Regular contractions of muscles of the uterus This causes necessary changes in the cervix  Effacement  Dilation--must be 10 cm (4.5 in) First stage is divided into 3 stages    Early —contractions 15-20 minutes apart Late —dilation 5-8 cm—shorter than 1 st stage Transition —final dilation from 8-10 cm—short and difficult

Labor and delivery

○ Second stage —Delivery ○   Begins with crowning, urge to bear down Episiotomy —baby’s head pressing on pelvic floor provides a natural anesthetic —controversial— biggest predictor is whether physician usually does it Third stage —delivery of placenta  Easy, important

Caesarean section



1/5 of births here, 3% Europe



Research says can deliver vaginally after c-section



Women with c-sections are less satisfied with birth process, less likely to breast feed, interact less with newborn baby

Baby blues



50-80% of women



Lasts about 48 hours



Thought to be a normal response to hormonal and psychological changes

Postpartum depression

     9.3% of 1,033 married, middle-class mothers, <1% psychotic depression Some estimates up to 15% Marked by extreme sadness or despair, apathy, changes in sleep or appetite, decreased self-esteem, difficulty concentrating    Related to hormonal changes, but these women were already predisposed to experience depression. More likely to be prolonged in women who feel helpless to meet demands around home.

Greatest risk: 1 st time mother Single mothers Mothers lacking social support

Breast vs. bottle

    47% of 1wk old exclusively breast fed (2002) 10% of 6 mo old Breast feeding  Decreases risk of infections, allergies  Delays resumption of normal menstrual cycle  Uterine contractions while breast feeding help uterus return to normal size  Weight loss!

  Not related to attachment Disadvantages ○ ○ Breast soreness Lower levels of estrogen (thus decreased lubrication) Cigarettes decrease milk production

Resumption of sex

   

6 weeks recommended or after end of lochia (3-4 weeks) 7 weeks average Those who enjoyed good sex lives before resume earlier 1997 study

   Before pregnancy, 38% report sexual problems 1 st three months postpartum —80% 6 months postpartum —64%  Only 15% discuss these problems with OB

Infancy

    

Many boys are born with erections Erections are found in ultrasound Historically believed no urges until puberty until Freud But…sensual with mother—breast feeding, cleaning diapers, toilet training Masturbation

  Don’t know how aware they are, but must feel good Rocking on things —no rhythmic manipulation until 2 ½ -3

Early childhood

    Masturbation  Reports of incidence are speculative —parents don’t answer or present kids as little ladies and gentlemen  Friedrich (1998) reports, among 2-5 yo, 60% boys and 44% girls touch private parts at home ○ For those 6-9, 40% boys, 21% girls Heterosexual beh —3-4 yo—kissing; 6-10 yo— playing doctor, playing house Homosexual beh —more common than hetero  Showing others, handling others’ genitals, urinate for distance Sex knowledge  By age 7, 30% understand difference between boys and girls

Preadolescence

    Latency Masturbation   Kinsey reported 45% boys, 15% girls masturbated by age 13 Recollective study of college students —32% women, 49% men Heterosexual behavior  Heterosexual parties begin between 10 and 13, kissing games emerge Homosexual beh  Most boys and 30% of girls —some homosexual behavior  Homosocial behavior

Sex knowledge

     Our kids don’t know much In studies, 5-20% admit lying about behavior Some kids change answers later about what happened before —in some cases because of changing knowledge In a study of preschool kids 6-9 (Larson & Svedin, 2002)  Parental and staff attitudes toward child sexuality were quite open  67% of the parents and 41% of the teachers never spoke to the children on sexual matters  One fifth of the adults used no term for genitals at all, and even fewer had a name for girls’ genitals Our 9 yo do worse at knowing physical differences of babies, correct names for genitals, length of gestation, and that one purpose of intercourse is fun than Australians, British and Swedes

Sex education

        Perhaps lack of knowledge is related to training for sex ed instructors  40% of districts provide no training for sex ed instructors  In the other 60%, training averages 3 hours Nightline poll —53% of adults say they learned about sex from friends Today’s teens report 83% from friends Fewer than 10% receive comprehensive (meaning good quality) sex ed Kids say they want to learn about sex from parents, but only 23% say they have As far back as 1986, fully 86% of US adults in favor of sex ed in school Majority favor sex ed for 12 yo with topics like AIDS, STDs, premarital sex, contraceptives All states mandate some sex ed   Over 50% of districts report that sex ed is comprehensive About 35% report that sex ed is abstinence-only

Goals of sex education

 Information  Exploration and clarification of attitudes, values, and insights  Relationships and interpersonal skills  Responsibility

Effective programs

 Focus on decreasing risk-taking behavior  Based on social learning theory  Teach through experiential activities that personalize the message  Address media and social influences  Reinforce clear and appropriate values  Enhance communication skills

Condom programs

     Brown et al looked at 431 programs in 21 states Available through sex ed programs, nurses’ offices, vending machines Denver —85% parents approve, NYC 69% approve  ½ of parents think that should be able to stop kids from getting condoms Seattle —condoms in all schools—48% of kids said that they got condoms from school. Prefer nurses office to vending machine (privacy). Teens wanted sex ed with condoms Kirby, 1992 —appear to decrease births, but not change rates of sex

Adolescence

 Begins with puberty  Female ○ ○ Breast buds as early as 8 or 9 and enlarge during 10 th year When girls reach critical weight (critical fat hypothesis) — around 103-109 —menarche can occur ○ Other changes    Growth of uterus Pubic and underarm hair Estrogen stimulates growth of vagina and uterus, but also slows height and growth  Male ○ Growth of genitals —testes, scrotum, penis ○ Secondary sex characteristics     Growth of facial, body, pubic hair Deepening of voice By 13 or 14, frequent erections Spermarche —as early as 8, as late as 20. Usually 13

Adolescence

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Masturbation

 46% boys, 24% girls  Only 1/3 of teens feel no guilt over masturbation  Most report defensiveness or embarrassment  Girls start later. Not related to early sexual activity

Homosexual behavior

 Coles and Stokes —5% report homosexual experiences ○ 9/10 are between peers

Influence of the media

      Kaiser Family Foundation (1997)  Among kids 10-15, most freq named source of info about sex was mass media Over half of kids have a tv in bedroom 1 in 7 prime time shows portray sexual intercourse About 10 portrayals of sex/hr/avg in prime time. Most unmarried Bersamin et al, 2010  Sexually inexperienced youth watched more television overall than sexually experienced youth, but less adult, premium and music television on cable networks. Brown and L’Engle (2009)  Two-thirds (66%) of males and more than one-third (39%) of females had seen at least one form of sexually explicit media in the past year  Early exposure for males predicted less progressive gender role attitudes, more permissive sexual norms, sexual harassment perpetration, and having oral sex and sexual intercourse two years late  Early exposure for females predicted subsequently less progressive gender role attitudes, and having oral sex and sexual intercourse

How many teens have sex?

        Most studies show greater than 50%--most accurate Men younger across the board Nearly one fifth (17%) of sexually active females 15-19 and 9 percent of males the same age said they used no method of contraception the last time they had sex (KFF) Most (74%) sexually active females aged 15-19 have partners who are the same age or 1-3 years older; for a quarter of girls, their first partners were 4 or more years older. One third (33%) of sexually active teens 15 didn’t really want to do.” 17 reported “being in a relationship where they felt things were moving too fast sexually”, and 24 percent had “done something sexual they More than one in five (21%) reported having oral sex to “avoid having sexual intercourse” with a partner More than a quarter (29%) of teens 15-17 report feeling pressure to have sex Nearly one in 10 (9%) 9-12th grade students report having been physically forced to have sexual intercourse when they did not want to at some point.

Why do teens have sex?

      Girls are more likely to mention love and affection Boys are more likely to mention physical pleasure NHSLS  Wedding night (7% men, 21% women)  Curiosity/readiness (51% men, 24% women)  Wanting to get pregnant (<1%) Reasons for abstaining  Religious or moral  Family influence  Fear of being caught  Fear of getting pregnant  Fear of disease For males —big predictor—testosterone Factors related to lower sexual activity  Teens with higher educational goals  Two-parent households  Religion  Later dating  Good quality relationship with parents  Parents who set rules

First intercourse

  Thoughts on sex   Zabin et al 1984 ○ ○ Inner city youth 83% gave an ideal age for 1 than they were and 25% of sexually active teens said premarital sex st intercourse that was older More recent studies have shown similar things First intercourse    Males report more pleasure, less guilt Males and females who experience orgasm report sex is better Females —Peggy Lee Syndrome—Is that all there is?

Teen pregnancy

 The U.S. teen pregnancy rate (the number of pregnancies per 1,000 females aged 15-19) decreased 28 percent between 1990 and 2000    From 117 pregnancies per 1,000 females aged 15-19 in 1990, to 84 per 1,000 in 2000 (KFF, 2005) Among sexual active teens, rate has also declined (from 211.8 per 1,000 in 1995 to 197.1 per 1,000 in 1998) Rate is roughly 1/5 sexually active girls    African Americans (154 per 1,000) and Latinas (140 per 1,000) have higher rates of than whites The teen abortion rate (the number of abortions per 1,000 women aged 15-19) has declined in recent years, from 34 per 1,000 in 1994 to 25 in 2000; the biggest abortion rate decline occurred among 15-17-year-olds, from 24 in 1994 to 15 in 2000 Approximately one in four sexually active teens contracts an STD every year  White US teens are 2x as likely as Canadians, 4x as likely as Swedish

Teen pregnancy

  Big reason for becoming pregnant: lack of knowledge about reproduction/contraception Negative outcomes        More likely to be in poverty, receive welfare Lack of hope for future Earn ½ as much as those who give birth in 20s Among teens who become pregnant, 1/5 will be pregnant again in a year Increased medical complications Kids are at increased risk ○ ○ Aggressive Impulsive ○ ○ Worse in school More abuse and neglect Outcomes are better for teen parents if ○ Better educated parents who have more income ○ ○ Competence and motivation at school Intervention programs

Teen fathers

    Low SES boys are more likely to view paternity as a source of self-esteem ○ More likely to say that having baby would make them more of a man and they’d be pleased ○ Low SES less likely to use effective contraception during most recent encounter Teen fathers —more school problems—both behavioral and academic, more likely to have pessimistic ideas about future.

Steady dating increases risk of teen fatherhood Study of 46,511 marital and unwed pregnancy of high school girls in California ○ ○ ○ 71% of fathers were post high school Mean age of 22.6 Average of 5 years older than girls

Sex and the single person

     1963 —83% women 25-55 were married. In 2000, 65% Median age at first marriage in 2007 27.7 men, 26.0 women  Increase of 5 years since 1950 Among single women, report missing companionship (75%) more than sex (4%) Serial monogamy is the most common pattern Sexual values of college students (Richey, Knox, & Zusman, 2009)    62% relativism —sexual decisions made in context of relationship 25% hedonism —If it feels good, do it 13 % absolutism —abstinence until marriage  Men more hedonistic than women  Older students (over 19) more hedonistic than younger  Those in relationships, less hedonistic

Cohabitation

           As of 2005, just under 5 million couples 25% of people 19-24 and 42% of 25-29 have cohabited at least once 1/3 last less than a year, only 1/10 last 5 years About 60% marry About 56% of marriages are preceded by living together More common among less well-educated, less affluent, less religious About 40% will divorce —higher rate than non-cohabiters 40% have kids in the household Spouses who cohabited before marriage--more negative and less positive problem solving and support behaviors (Cohan & Kleinbaum, 2002) Less committed to values traditionally associated with marriage Some studies show more sex in cohabiting couples

Marriage

     In US, 65% men, 60% women are married and living with spouses 80% who divorce remarry    Why marry?

 Legitimizes sexual relationships and provides legal sanction for committed relationships  Children socialized and supported  Home maintenance Transmission of wealth Emotional and psychological security Companionship and intimacy Married people, especially men, are happier, less depressed than singles Who do we marry?

 Birds of a feather flock together or opposites attract?

 Homogamy ○ Practice of marrying people who are like us in social background and standing ○ Age homogamy ○ 9/10 are same religion ○ 1-2% are different ethnicity

Marital sexuality

    Average married couple has sex 2-3 times per week, declining with frequency with age (still happens, though) Why does sex decrease with age?

○ Less easily aroused by someone familiar ○ Hectic pace ○ Arrival of children Newlyweds in Mangaia —5-6x night Inis Beag, a small island off the coast of Ireland, is among the most naive and sexually repressive societies in the world. The islands abhor nudity, with adults washing only the parts of the body that extend beyond their clothing.

Marital sexuality

  Techniques ○ Duration —most people report between 15 minutes and 1 hour ○ Orgasmic consistency has increased since Kinsey ○ ○ Increased popularity of mouth-genital techniques since Kinsey 63% men, 42% women (NHSLS) reported masturbating in past year Satisfaction ○ Varies with frequency of sex ○ Overall, 40-50% are physically satisfied ○ ○ 40-50% are emotionally satisfied Enjoy sex a great deal (Primetime, 2004)   70% of those married >10 years 87% of those married <3 years ○ ○ Sex life very exciting (Primetime, 2004)  58% married less than 3 years  29% married more than 10 years Doesn’t change with age ○ Children may decrease marital satisfaction if (Cowan & Cowan, 2009)

Extramarital sex

      NHSLS  >90% women   75% married men faithful Best estimates —75-80% men, 87% women New York Times poll —86% “absolutely certain” partners were faithful Rate of infidelity has been slowly decreasing since 1948 Higher levels of testosterone (in men) related to more affairs Reasons for affairs   Men —sex (75% cite sexual excitement as justification) Women —love (77%) say love is justification) Attitudes     75% Americans say it is always wrong 9/10 always or almost always wrong 1% not at all wrong One of the best predictors of extramarital permissiveness is premarital sexual permissiveness

Divorce

       Divorce rate of 50% is true, but misleading Rate increased steadily through 20 th 80s century then leveled off in People hold higher expectations for marriage than in past  expect fulfillment and happiness Over 1/3 of divorces happen in less than 5 years of marriage Women are more likely to end marriage until age 55. Then men are more likely to end marriage.

Common reasons given for divorce   Communication Lack of understanding Key predictors of divorce  Husband’s criticism     Defensiveness Contempt Stonewalling Women’s tendency to be overly compliant and agreeable  Facial expression research

Remarriage

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Most remarry

  These marriages are more likely to end in divorce ○ Selected subgroup ○ Stressors from kids, alimony, etc But —marital satisfaction is about the same in 2 nd marriages  Women with high incomes or high education are least likely to remarry  Men with high incomes or high education are most likely to remarry

Adjustment to divorce

  Kalmijn & Monden , 2006  Divorce following more unfair marriages is less negative than following marriages that are less unfair  Significant increase in depression following divorce, esp for women According to divorced people  Advantages ○ ○ Nothing (15 % of men) Increased freedom  Wives from husbands’ control  Husbands from wives’ demands ○ Increased self-esteem due to self-sufficiency  Disadvantages ○ Loneliness ○ Separation from kids ○ ○ Lower standard of living for women Not knowing how to do gender atypical chores

Sex and senior citizen

        Changes physically over time, but both men and women remain capable Takes longer Sexual daydreaming , sex drive, and sexual activity decrease with time Women  Reduced estrogen  reduced vaginal lubrication  Reduced myotonia  Reduced elasticity of vaginal walls  Reduced intensity of muscle contractions at orgasm Men  Longer time to erection and orgasm  Less semen during ejaculation  Longer refractory period Leary, 1998  74% men, 70% women over 60 who were sexually active were as satisfied or more satisfied than when younger Sample of 82-102 yo —62% men, 30% women—still have sex 2 factors to maintain sexual capacity   Good physical and mental health Regularity of sexual expression

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American sexual behavior and attitudes

Sex outdoors Sexually adventurous First date sex Paid for sex (men) 57% 42% 29% 15% Currently in sexual relationship (under 65) Satisfied with marriage or committed relationship 64% 97%   Think about sex every day Enjoy sex a great deal Men 70% Men 83% Women 34 % Women 59%  Women report an average of 6 sex partners in lifetime, men 20

Autoerotic behavior

     Religious attitudes —negative for centuries (ie ., St. Augustine)  Chinese religious thought —need balance between yang (male) and yin (female)  Today, attending religious services and seeing oneself as devout are associated with lower levels Kinsey, 1948  92% men reported masturbation Gender —men > women cross culturally  Men younger than women Higher levels of education more likely to report Does not necessarily decrease in committed relationships

Sexual fantasy and cognition

  Reynaud & Byers, 2001   Most + cognitions ○ Intercourse with loved partner 31% ○ ○ Intercourse with someone known but have not had sex with 10% Most – cognitions ○ Kissing passionately 17% Incest 11% ○ Embarrassed by failure of performance 10% ○ Contrary to sexual orientation 7% ○ Sexual victimization 7% Gender  Both men and women experience sexual cognitions, but men > women ○ # of different people in fantasized encounters is > for men ○ ○ Men do, women have done to them in fantasy Men —more explicit and visual imagery ○ Men more likely to fantasize about multiple partners ○ Men more likely to fantasize about being dominant

Cross-cultural attitudes

 24 countries   Fairly similar attitudes Premarital sex —Scandinavian countries are more permissive ○ Non-Western (China, India, Indonesia, Iran, Taiwan) more conservative  Big variation in the West ○ Attitudes about sex explicit material, public nudity, condom advertising —Sweden vs. Ireland  Extramarital sex attitudes ○ % always wrong    43 80 51 Czech Republic Ireland Bulgaria   80 36 USA Russia  Authors also asked questions about teen sex, homosexual sex, premarital sex  Clustered countries together in terms of attitudes ○ Teen Permissiveness ○ Sexual conservatives ○ ○ ○ Homosexual permissiveness Moderate —Australia, Great Britain, Hungary, Italy, Bulgaria, Russia, New Zealand, Israel 2 countries didn’t fit