Constance M. Wiemann

Date Rape Among Adolescents and Young Adults

BACKGROUND Adolescents and young adults are four times more likely to be victims of sexual assault than women in all other age groups. In the vast majority of these cases, the perpetrator is an acquaintance of the victim. Date rape is a subset of acquaintance rape where nonconsensual sex occurs between two people who are in a romantic relationship. METHODS We conducted a MEDLINE and Current Concepts search for articles relating to date rape and then systematically reviewed all relevant articles. RESULTS Lifetime prevalence of date or acquaintance rape ranges from 13% to 27% among college-age women and 20% to a high of 68% among adolescents. Demographic characteristics that increase vulnerability to date rape include younger age at first date, early sexual activity, earlier age of menarche, a past history of sexual abuse or prior sexual victimization, and being more accepting of rape myths and violence toward women. Other risk factors include date-specific behaviors such as who initiated, who paid expenses, who drove, date location and activity, as well as the use of alcohol or illicit drugs such as flunitrazepam (Rohypnol). Alcohol use that occurs within the context of the date can lead to: the misinterpretation of friendly cues as sexual invitations, diminished coping responses, and the females inability to ward off a potential attack. CONCLUSIONS Longitudinal research designs are needed to further our understanding of sexual violence among adolescents and young adults and the most effective ways to eliminate it. Understanding and comparing research findings would be easier if consensus regarding the definitions of date rape, sexual aggression, and sexual assault was obtained. Finally, primary and secondary date and acquaintance rape prevention programs must be developed and systematically evaluated.

Use of levonorgestrel implants versus oral contraceptives in adolescence: a case-control study.

OBJECTIVE We compared continuation rates, effectiveness, satisfaction with method, side effects, and condom practices among adolescents using levonorgestrel implants (Norplant, Wyeth-Ayerst Laboratories, Philadelphia) as compared with oral contraceptives. STUDY DESIGN We conducted a case-control study comparing 94 adolescents < or = 18 years old who received Norplant between March 1, 1992, and Nov. 1, 1993 (cases), with 94 age-matched controls who selected oral contraceptives during this same time period. By use of a structured questionnaire, information was obtained on pregnancy status, duration of use, patient satisfaction, side effects, and condom practices 6 months after initiation. Objective measures included weight on Norplant and oral contraceptive users and hematocrit on implant patients. RESULTS Forty (43%) oral contraceptive patients compared with no Norplant patients discontinued their selected method before the 6-month interview (p = 0.00). Six patients prescribed oral contraceptives became pregnant. Ninety-three percent of Norplant users expressed overall satisfaction despite experiencing menstrual irregularity and cramping, amenorrhea, nervousness, abnormal hair growth or loss, rashes, and an increase in appetite more often than oral contraceptive users. Although Norplant patients also reported an increase in the duration of menstrual flow and number of days of spotting more often than oral contraceptive users, evaluation of hematocrits in these patients demonstrated a significant increase over the 6-month period (p = 0.00). Assessment of condom practices since initiation demonstrated that Norplant patients used condoms less often than oral contraceptive users (p = 0.00). CONCLUSION Use of levonorgestrel implants may cause more side effects than oral contraceptives in the early months after initiation but provide superior protection against unintended pregnancy. We concluded that Norplant is a reasonable alternative for adolescents, especially when compliance is an issue.

Contraceptive use among adolescent mothers at 6 months postpartum

OBJECTIVE To assess patterns and predictors of reliable and unreliable contraceptive use among adolescent mothers in the first 6 months following delivery. METHODS We surveyed 462 women, 18 years of age or younger, at delivery and again at 6 months postpartum. Contraceptive behaviors were evaluated among the 359 adolescents who stated they were sexually active and not trying to conceive. RESULTS Method discontinuation and switching were common during the 6-month interval. Only 100 of 189 adolescents (53%) initially prescribed oral contraceptives were still using this method 6 months after delivery; ten of these 100 stated that they had missed at least three pills in the last cycle. Twelve (10%) of the 115 adolescents who initiated depot-medroxyprogesterone acetate failed to obtain a second injection within 4 months of the initial injection or use an alternative method. In contrast nine of the ten women who received levonorgestrel implants were still using this method 6 months after delivery. Overall, 76% of the sample reported using reliable contraception at last intercourse. Multivariate analyses identified seven factors as predictive of reliable contraceptive use: school enrollment, not having failed a grade in school, adequate support, belief that pregnancy is likely without birth control, attendance at postpartum visit, prior abortion, and the adolescents desire to wait at least 2 years before having another child. CONCLUSION Interventions designed to reduce rapid repeat pregnancy during the adolescent years should address emotional, financial, and educational, as well as contraceptive, needs.

Prevalence, Patterns, and Correlates of Voluntary Flunitrazepam Use

Objective.  To determine prevalence, patterns, and correlates of voluntary flunitrazepam use in a sample of sexually active adolescent and young adult women 14 to 26 years of age. Design.  Cross-sectional survey. Setting.  University-based ambulatory reproductive health clinics. Patients or Other Participants.  There were 904 women self-identified as white, African-American, or Mexican-American. Interventions.  None. Main Outcome Measure.  Lifetime, frequency, patterns, and physical effects of flunitrazepam use. Results.  Lifetime use was reported by 5.9% (n = 53) of subjects, with frequency of use ranging from 1 to 40 times. Flunitrazepam was taken most often with alcohol (74%), and 49% took this substance with other illicit drugs. Logistic regression analyses controlling for age and race/ethnicity found that users were significantly more likely than were nonusers to report lifetime use of marijuana (odds ratio [OR] = 3.6) or LSD (OR = 5.2), having a peer or partner who used flunitrazepam (OR = 21.7), pressure to use flunitrazepam when out with friends (OR = 2.7), and a mother who had at least a high school education (OR = 2.6). Finally, 10% of voluntary users reported experiencing subsequent physical or sexual victimization. Conclusions.  Voluntary use of flunitrazepam is becoming a health concern to sexually active young women who reside in the southwestern United States. Young women who have used LSD or marijuana in the past or who have a peer or partner who used this drug appear to be at the greatest risk.

Factors Associated With Recent and Discontinued Alcohol Use by Pregnant Adolescents

PURPOSE To determine easily identifiable risk factors that differentiate pregnant adolescents who report recent (past 30 days) alcohol use and those who discontinue use by their first prenatal visit from those who deny consuming alcohol altogether. METHODS A structured interview was completed by 378 adolescents < or = 17 years of age as part of standard care at our institutions adolescent obstetric clinic between July 7, 1992, and December 28, 1994. Using Chi-square or Students t-tests, unique risk factors associated with recent or discontinued alcohol use in pregnancy were separately identified by comparing demographic, reproductive, behavioral, and environmental factors among recent users (n = 43), discontinued users (n = 48), and adolescents who denied ever using alcohol (n = 108). Significant indicators were then entered into stepwise logistic regression analyses to determine the most efficient models for predicting alcohol use. RESULTS Partner alcohol use and use of alcohol during sexual activities were important risk factors for alcohol use by pregnant adolescents. Recent alcohol users were also more likely to be Mexican-American, to have quit school, and to report recent tobacco use, while adolescents who stopped using alcohol during pregnancy were significantly more likely to have witnessed or been a victim of or known a victim of violence. CONCLUSIONS Screening at the first prenatal visit for these unique and easily assessed factors will help clinicians identify adolescents at greatest risk for alcohol use during pregnancy.

Prevalence and correlates of psychopathology in pregnant adolescents.

PURPOSE To investigate the prevalence and correlates of psychopathology, as measured by the Youth Self-Report Scale, in pregnant adolescents so that interventions during pregnancy may be tailored to treat the psychopathology and thereby improve maternal and child outcomes. METHODS Scores on seven psychologic syndromes (withdrawn, delinquent, aggressive behaviors; anxiety/depression; and social, thought, and attention problems) were compared for groups of pregnant adolescents (n = 185), never pregnant teenagers (n = 126), and previously published normative samples of clinically referred (n = 518) and nonreferred (n = 518) female adolescents using chi-square, Students t-tests, analysis of covariance, or multiple logistic regression. Correlates of psychopathology were identified for the pregnant sample using odds ratios and 95% confidence limits. RESULTS Pregnant adolescents exhibited less serious or lower rates of psychopathology than groups against which they were compared. Correlates of psychopathology included substance use during pregnancy, prior assault, maternal childbirth before age 18 years, ethnicity, > or = 3 sexual partners, and absence of a relationship with the babys father. CONCLUSIONS Although the prevalence of psychopathology was lower among pregnant patients, those who exhibit psychopathology are likely to engage in risky health behaviors that contribute to poor perinatal outcome.

New sexual partners and readiness to seek screening for chlamydia and gonorrhoea: predictors among minority young women

Objectives: To determine (1) level of readiness and (2) demographic and behavioural predictors of readiness to seek chlamydia (CT) and gonorrhoea (NGC) screening in the absence of symptoms after sex with a “new” partner. Methods: Baseline data, obtained as part of a larger randomised controlled clinical trial in young women, were analysed. Readiness to seek screening for CT and NGC after sex with a “new” partner was assessed using the stages of change framework from the transtheoretical model of change—precontemplation, contemplation, preparation, and action. Ordinal logistic regression, using the proportional odds model, was used to determine predictors of being in action for or having already been screened for CT and NGC after sex with a “new” partner. Results: The sample consisted of 376 predominantly African American (67%) young women (mean age 18.5 (SD 1.4) years). The distribution of readiness to seek CT and NGC screening was 4% precontemplation, 11% contemplation, 28% preparation, and 57% action. The best fitting logistic model that predicted being in action for seeking screening after sex with a “new” partner included high perceived seriousness of acquiring a sexually transmitted infection (OR = 2.02, 95% CI 1.05 to 3.89), and having “other” (not steady) partners in the last 6 months (OR = 0.50, 95% C.I. 0.32 to 0.78) Conclusions: Many young women report that they were not getting screened for CT and NGC after sex with a “new” partner and therefore may be at increased risk of an untreated STI. Enhancing level of perceived seriousness of acquiring an STI from a “new” partner may increase a young woman’s readiness to seek screening after initiating a new sexual relationship.

Prevalence and predictors of low sexual assertiveness

Background: Personal beliefs about sexual attitudes and rights likely affect reproductive health behaviors. We examined the prevalence and predictors of low sexual assertiveness (SA) among sexually active females across three age groups (14-17 yo, 18-21 yo, and 22-26 yo).Methods: 904 white, black, and Mexican-American females presenting at community-based family planning clinics in Southeast Texas between April 1997 and February 1998 completed an anonymous self-report questionnaire that assessed demographic and reproductive characteristics, dating behaviors, mental health measures and occurrence of physical and sexual assault. Subjects also completed a sexual assertiveness scale that assessed ones right to make various reproductive health decisions and sexual communications to partners. A total SA score was obtained by summing the 13 items; scores were then dichotomized so those scoring in the lowest quartile could be compared to the others. Data were analyzed using chi-square and logistic regression stratified by age group (244 aged 14-17; 392 aged 18-21; and 268 aged 22-26).Results: 27% of subjects aged 14-17, 22% aged 18-21, and 17% aged 22-26 were identified as having low SA. For 14-17 years olds, logistic regression analyses revealed that those with low SA as compared to adequate SA were significantly more likely to be Mexican American (OR = 4.8) or black (OR = 3.1) than white, to have hand </= 1 dating partner in the last 12 months (OR = 1.8), and to report inconsistent birth control in last 12 months (OR = 2.0). Among 18-21 years olds, low (SA) was related to reporting forced sexual contact in the last 12 months (OR = 5.2), moderate-to-severe depressive symptoms (OR = 3. 0), no history of physical abuse (OR = 2.5), believing that your partner is monogomous (OR = 2.6), married or living with a male partner (OR = 2.1), </= 3 lifetime sexual partners (OR = 1.8), not using alcohol before sex (OR = 1.8), and gravidity >/= 1 (OR = 1.8). Among 22-26 years olds, low SA was associated with gravidity >/= 1 (OR = 2.8), being a high school dropout (OR = 2.1), and inconsistent birth control use in the last 12 months (OR = 1.9).Conclusions: These data suggest that 1 in 4 sexually active women report low SA and for two age groups these attitudes are associated with inconsistent contraception. Among 18-21 years olds, low SA is also associated with forced sexual contact and depressive symptoms. Thus, efforts to prevent unintended pregnancy and unwanted sexual contact may be more effective if individual levels of SA are taken into account.

The rise and fall of levonorgestrel implants: 1992-1996.

Objective To assess shifts over a 4-year period in attitudes of low-income US women regarding use of levonorgestrel implants. Methods An anonymous questionnaire was administered at two different points in time to English-speaking women of reproductive age seeking gynecologic or obstetric care in southeast Texas. The first survey, administered to 762 women in 1992, elicited information on demographic and reproductive characteristics, as well as exposure to information on implants and attitudes regarding use of this method. This same survey was administered again in 1995–1996 to 502 women. χ2, Student t, or Kruskal-Wallis nonparametric tests were used to evaluate shifts in attitudes and perceived barriers to use across the 4-year period. Results Women portrayed less positive attitudes about levonorgestrel implants when surveyed in 1995–1996 as compared with 1992. Most notably, they appeared less appreciative of the convenience associated with implant use and more concerned with potential side effects. Nulliparous and parous women surveyed in 1995–1996 were significantly less likely than those surveyed in 1992 to state that they would consider using this method for birth control (P < .001) and were more likely to state that their partner, friends, and family would object to their use of levonorgestrel implants. Conclusion This study documents the decline in popular perceptions of levonorgestrel implants among low-income English-speaking women over the 4-year period following the introduction of this contraceptive method to the US market.

Employment and Health-Risk Behaviors Among Pregnant Adolescents☆

STUDY OBJECTIVE To compare health-risk behaviors, maternal, and neonatal outcomes of pregnant adolescents less than 18 years old who reported employment more than 15 hours per week with those who did not report working. We hypothesized that working teens compared with nonworking adolescents would report higher rates of health-risk behaviors. METHODS A structured interview was conducted at the first prenatal visit and the medical chart was reviewed to extract pregnancy (pregnancy-induced hypertension, preterm labor with hospitalization, and preterm delivery) and neonatal outcomes (low birthweight, small for gestational age, and admission to the neonatal intensive care unit). The study was conducted at an outpatient maternal and child health clinic at a university teaching hospital. A total of 384 white (n=111), African American (n=151), and Mexican American (n=99) adolescents, aged 12 to 17 years, who initiated care between January 2, 1992, and December 31, 1994, and delivered an infant at our institution were consecutively sampled. A structured interview assessed various health-risk behaviors including age at first intercourse, substance use (tobacco, alcohol, and other illicit drug use), and number of sexual partners. Medical records were reviewed to obtain information on pregnancy complications (pregnancy-induced hypertension, preterm delivery, and preterm labor with hospitalization) and negative birth outcomes (infant birthweight and neonatal intensive care admission). RESULTS Controlling for chronological age, logistic regression analyses found that adolescents reporting employment at their first prenatal visit (n=40) compared with those not employed at this visit (n=331) were more likely to be characterized by school enrollment, higher economic status, partner employment, partner alcohol use, and a longer relationship with the father of their baby. Multivariate logistic regression found that employed females were 4.6 times more likely to deliver a small-for-gestational-age infant. CONCLUSIONS Employment reported at the time of the first prenatal visit does not appear to be associated with an increase in health-risk behaviors or obstetric complications, but a relationship between working more than 15 hours and small-for-gestational-age delivery was detected.