Remote Contr-aception

Implantable contraceptive devices have been discussed on this blog here. One problem with these devices is that for women who want to come off the devices they must be surgically removed.

A new device created by MicroCHIPS hopes to change that. This device, currently in pre-market saftey and efficacy trials, is theoretically able to have the same contraceptive efficacy as conventional implants. What makes it exciting is it can last for 16 years (most current implants have a 5 year turn around) and most importantly it can be turned on and off using radio waves.

This small device (20x20x7mm) is implanted in the armpit, abdomen or buttock. From here it is able to secrete levonorgestrel, at 30mg/day (a drug currently used in contraceptive devices to prevent pregnancy). It holds the levonorgestrel in small reservoirs surrounded by thin membranes. These membranes are melted by electrical currents resulting in the release of the dose of levonorgrestel into the body.

By turning this signal on and off through a remote control the drug can be stopped or started whenever the woman sees fit, assumedly by her GP.

This would allow women more control over their sexual health. Specifically it would make the decision to become (or not become) pregnant easier, they would not have to visit an outpatient clinic to start trying.

Obviously it's early days but this is another development we will keep our eye on. 

Preventing STI morbidity, a national approach.

There are many varied strategies in place to combat the burden of STIs both globally and locally. As a general point of call the World Health Organisation (WHO) creates and implements global sexual health policy. We have briefly discussed some of their work here. In Australia sexual health (and general healthcare) is controlled by individual state and territory governments. Recently in an attempt to address the growing burden of STIs in Australia there has been a push towards a national approach.

In 2010 the Australian Government Department of Health and Aging published the Second National Sexually Transmissible Infections Stratergy (2010-2013).

"The goal of the Second National Sexually Transmissible Infections Strategy 2010–2013 [was]to reduce the transmission of and morbidity and mortality caused by STIs and to minimise the personal and social impact of the infections."

Aboriginal and non-Aboriginal gonorrhea in WA

More specific aims included: increasing young peoples knowledge of STIs, reducing in the incidence of gonorrhoea, syphilis and chlamydia, whilst increasing the testing for chlamydial infection in high risk populations. The high risk groups identified in this study were: young people (due to the low median age, 16, of first sexual encounters), Aboriginal Australians (as STIs are more prevalent in this population, see graph), sex workers (due to occupational exposure) and men who have sex with men (as they have higher risk of STI transmission)

Priority actions for health promotion and prevention

Prevention is one of the best ways we can stop the spread and thereby the burden of STIs. The importance of prevention is re-enforced by the rising rates of bacterial resistance in common sexually transmitted infectious agents like Neisseria gonorrhea. The widespread extreme drug resistance exhibited by this pathogen is likely to make it untreatable in the foreseeable future. As prevention may soon be the only option we have to prevent STI spread the actions of this strategy are of paramount importance.  I will go through each point with commentary.

Develop a national education framework to implement age appropriate sexual education

Currently sexual education is controlled at the state level. It is incredibly important to deliver a set standard of education across Australia. The three authors of this blog represent three different Australian states/territories: Queensland (rural), WA (metropolitan) and the Australian Capital Territory (metropolitan). Our experiences of sexual education in high school are widely different. A national curricula would take away these discrepancies and ensure that there are high levels of sexual health literacy across the nation. 

Develop and implement targeted prevention and health promotion programs for high risk groups (teenagers, Aboriginal Australian, men who have sex with men)

It is definitely important to target these high risk groups however if the focus is too heavily weighted to these groups people in low risk populations fall through the gaps. Anecdotal experience of the WA education system in rural and metropolitan areas shows this in full effect. In an Albany public school (rural WA) sexual health is taught yearly for years 7-12 in Albany with opportunities to practice putting on a condom correctly. Now compare this with the experience of one of our authors experience in a Perth public school (metropolitan WA) where one sexual education lesson was given in high school. It was provided to year 7 students who watch a video of how to put a condom on properly. 

Whilst I acknowledge the limited application of anecdotes this disparity is provides an interesting point for discussion. It seems plausible that this disparity would leave some adolescents unequipped to make informed decisions about safe sex. Looking at this in context of the massive amount of condom user errors present in sexually active people, it seems that a lot of adults are not equipped with adequate knowledge about safe sexual practice. By looking at high risk groups only we risk leaving low risk people behind. 

Increase amount of health promotion professionals in this area

The more health promotion in this area the better. Due to the pervasive nature of STIs in society it's clear that people need constant reminding about how to practice safe sex. Hopefully by using new and old media we this issue can be kept under the spotlight to promote this discussion. 

Improve access to condoms for high priority groups by improving current interventions and trailing new ones

Access to contraception is incredibly important to stop the spread of STIs but access alone is not enough. As the age old adage goes: give a man a condom and he'll be protected for a day, teach him about sexual health and he'll be protected for life. (sorry) Access to condoms is not enough without both educating about the need for contraception and breaking down the negative stigma around contraception use that is present in some socio-cultural groups. 

Increase access and use of HPV and Hepatitis B vaccine

Vaccination can remove the potential for infection with the HPV and heptatitis B. Whilst this is fantastic it must be remembered that these vaccines don't confer resistance to any other STIs. Now that may be self evident to some people but for many people it is not. This vaccination program would have to go hand in hand with an education program stressing the need for use of barrier protection methods to .

prevent STI transmission. 

Summary

The Second National Sexually Transmissible Infections Stratergy (2010-2013) provides a framework to build a national approach to STI prevention. A national approach is a good first step to reducing the significant burden of STIs on the healthcare system and individuals across Australia. 

Barrier protection methods

Barrier protection methods provide a physical  barrier between sexual partners preventing the transmission of bodily fluids (semen, blood, vaginal fluids) during sexual intercourse. By preventing transmission of these fluids when used correctly these contraceptive methods can prevent most unwanted pregnancies and sexually transmitted infections (STIs). However whilst the use of barrier protection methods is widespread, these devices are often incorrectly used. The most common method of barrier protection is the male condom. Other less common methods are the female condoms and dental dams. The main focus of this article is the male condom but we will quickly overview the other methods.

The Female Condom

A female condom (pictured to the right) is a hollow tube capped at one end consisting containing two flexible rings at each end. The device is inserted into the vaginal canal and covers the external genitalia forming a continuous barrier along the vagina. This barrier protection when correctly used can prevent transmission of STIs and unwanted pregnancy.

This device is not commonly used for several reasons. When used correctly there is still a 5% chance of unwanted pregnancy and STI transmission whereas correctly used male condoms boast only a 2% chance (discussed in more detail below). Additionally they are more expensive than male condoms, can tear, need extensive lubrication and lessen feeling between partners.

However there are several advantages to female condoms. They boast reduced risk of genital warts and herpes transmission as external labia are covered. They give the woman control over contraception, potentially reducing risk taking procedures where the male may not want to use a condom. Furthermore there is some suggestion that when inserted anally they provide protection during anal sex, though more research is needed in this area.

More information about use can be found here and here.

The Dental Dam

The dental dam (pictured right) is a thin sheet of latex that was originally in dentistry to isolate areas of the mouth during dental surgery. It is now used as a barrier protection during performance of oral sex. The rates of oral sex seem to be rising. In NSW in 2006 the majority of genital herpes infection were from herpes simplex virus - 1 (oral herpes) rather than herpes simplex virus - 2 (genital herpes). This indicates a possible decrease in genital-gential sex and an increase in oral-genital sex.

The dental dam is placed over the vagina or anus during cunnilingus or analingus, respectively. It provides protection from transmission of contact STIs such as herpes viridae infection and genital warts. It is not widely used as risk is not often attributed to oral sex and use is often not socially acceptable. Thus in order to get the full advantage of the dental dam people must be educated to the dangers of oral sex and it's use de-stigmatised.


More information here.

The Male Condom

The male condom, usually referred to simply as the condom, is the most commonly used barrier protection device. They're cheap easily available and when used correctly they are 98% effective at preventing unwanted pregnancies and STI transmission. They work by preventing transmission of bodily fluids, preventing transmission of STIs like HIV and hepatitis. They also directly impedes the sperm's path to the vagina, stopping potential pregnancies. Unfortunately it doesn't fully protect against some contact STIs like herpes, genital warts and syphilis.

For a lighthearted look at this contraceptive method I suggest checking out these animations from Loop De Loop, or at least indulge me by having a quick look at my favourite one by sarah and lachlan.

Condoms are only effective when used correctly. No worries, everyone knows how to use a condom properly right? Wrong. There are a huge amount of basic errors people make in putting on and using condoms. Before we take a look at what people do wrong lets quickly revise correct technique.

Putting on a Condom

Firstly there is no shortage of literature on the internet suggesting correct ways to put on a condom. Although some articles like  '25 Sexy Ways to Put on a Condom,' by Cosmopolitan magazine may be tempting, the methods suggested are likely to lead to condom usage errors and pussy genitals aren't so sexy (at least for most people). I suggest getting information from less saucy government sites or this guide from durex is pretty easily digestible.

There are essentially 3 steps to remember:

1. Opening the Packet

Before the packet is opened two checks should be performed. Firstly is it within date? If it is out of date the lubricant may have degraded increasing the chance of the condom ripping. If it is out of date discard the condom.

Is it still air sealed? To check this push one side of the packet, if the other side bulges then the packet is still sealed if not then the condom may have been tampered with. If no air seal is present, discard the condom.

The condom packet should be opened by pushing the condom to one side of the packet. The packet should then be torn from the opposite to the condom BY HAND. Not using teeth, scissors or any other sharp implement as these can damage the condom.

2. Putting it on
 
 Firstly you have to determine the condom's orientation, it will only unroll one way. The teat of the condom should be facing upwards, resembling a sombrero (shown to the right). This allows it roll down the penis nicely.

Next squeeze the teat to remove air in it and place it on the head of the penis. This provides a space for the semen to travel into upon ejaculation. If this teat is full of air on application the condom may rip upon ejaculation due to built up pressure.

Using the your other hand roll the condom down the length of the penis to the base. Don't stretch and pull the condom down. If you find that you have placed it on the penis in an incorrect orientation don't change the orientation and reuse it. This condom has been exposed to the bodily fluids and turning the condom inside out directly exposes your partner to these. Additionally in the incorrect rolling the condom may have been stretched a weakened. Get a new condom and start from step 1 again.

3. Taking it off

Hold the condom at the base and slide it off the penis. Tie it off so the sperm doesn't flow out and bin it. DO NOT put it in the toilet. Condoms can block toilets leading to an expensive (and awkward) visit from a plumber. 

(4.) Lubrication

Lubrication is often overlooked however the un-lubricated condom is prone to ripping, negating it's efficacy. Only WATER-BASED lubricants should be used. Other petroleum based lubricants (like Vasoline) should not be used as these can degrade the condom and lead to leakage. Spit is not an acceptable water-based lubricant, gels like KY jelly are recommended.

Condom Usage Errors

 A 2012 review by Milhausen et al in Sexual Health aimed to discover the frequency of condom use errors world wide. 'Condom use errors and problems: a global view' looked at 50 different studies from 14 different countries and found widespread basic condom use errors were prevalent globally. The major errors are discussed here.

Application errors were the most common error found. Late application of condoms happened in 1.5% to 24.8% of all sexual encounters in which condoms were used. In this instance STIs may have been transferred before the condom was applied. Early removal happened in 1.4% to 26.9% of all sexual events with condom use meaning that these individuals were unprotected from both STIs and unwanted pregnancy. 

Other errors included included incomplete unrolling (1.4% to 26.9%), not leaving space at the tip (24.3% to 45.7%) with the air not being squeezed out in 44.6% of all cases. 4% to 30.4%
of people initially put the condom on inside out before turning it around and putting it on again. 2.1-11.2% of participants exposed the condom to sharp objects before use. Astonishingly 74.5% of
men and 82.7% of females were found to not inspect the condom for damage before use.

These errors were more common than cases of condom failure such as leakage, tearing and slippage. The silver lining here is that if user error is what leads to incomplete protection from condom use then these errors can be corrected by education. It is often assumed that adults know how to use condoms correctly. This data shows this is not so.

Summary 

Barrier protection methods can provide people engaged in sexual activity protection from transmission of STIs and unwanted pregnancies. However these devices are only effective when used properly. Unfortunately they are often used incorrectly and thus education on correct use is essential for these methods to be effective. Furthermore there are many differing attitudes around contraceptive use in differing situations. Particularly the use of contraception must be normalised for oral-genital as well as genital-genital sex to stop increase in oral STIs.