Sexual Health

The National Academy of Sciences recently celebrated its 150th birthday by, among other things, conferring membership on Ben Barres, MD, PhD. Additional NAS admittees from Stanford were sleep scientist Emmanuel Mignot, MD, PhD, and bioengineer Steve Quake, PhD.

A distinguished scientist by anybody’s yardstick, as well as the chair of Stanford’s ironically named neurobiology department, Barres is a leading light in the study of glial cells (collectively known as glia), the 90 percent of all the cells in the brain that aren’t nerve cells.

The term”glia” is derived from the Greek word for glue. Like Rodney Dangerfield, glial cells once got no respect. They were thought of, in fact, as not much more than “brain glue”: mere structural scaffolds for the organ’s much more revered nerve cells.

Barres’ research has proved that hypothesis incorrect, to say the least. (For details, click here.) Discoveries coming out of his lab include, to name one example, glial cells’ crucial role in determining exactly when and where nerve-cell connections in the brain are made, tweaked to strengthen or weaken them, or destroyed.

You don’t get much more respectable than that: Those connections pretty much define the thoughts we have, the emotions and sensations we experience and the actions we take.

The man who, as much as anyone, has brought a set of unsung cells a newly elevated status would like to see another group get more respect: the estimated 0.3 percent of Americans who are transgender.

“I’m the first transgender scientist to make into the National Academy of Science,” says Barres, who began life under another first name: Barbara.

“We don’t know if other members past or present are or were transgender,” demurs an NAS representative. And after all, how would they? What kind of statistics could be compiled by an organization that doesn’t ask or track the sexual orientations, much less the gender identities, of its membership? Who would have even considered asking such a question 20 or 30 years ago, much less running sex-chromosome tests on cheek swabs from prospective, current or posthumous members?

But it’s a pretty safe bet that if any previously admitted NAS member were openly transgender, we’d have heard about it. (Transgendered computer scientist Lynn Conway was admitted to the National Academy of Engineering in 1989.)

One is tempted to compare Barres to Jackie Robinson, who broke the Major League Baseball’s color barrier in 1947 - except that the latter had to put up with a whole lot more grief from his fellow major-league ballplayers than Barres is likely to encounter from his peers.

“We heartily congratulate Prof. Barres on his election,” says NAS spokesperson Bill Skane.

In science, if anywhere, diverse perspectives drive innovation. ”Don’t ever let anyone make you feel bad about being different,” Barres tells young scientists. “Your difference is your greatest advantage.”

Previously: Malfunctioning glia - brains cells that aren’t nerve cells - may contribute big time to ALS and other neurological disorders, Neuroinflammation, microglia, and brain health in the balance and Unsung brain-cell population implicated in variety of autism

When we think of the AIDS epidemic, many of us turn to the developing world, overlooking the fact that HIV is very much a problem here in the United States. Every year some 50,000 people in this country are newly diagnosed with HIV, and many of these individuals previously had no idea they were infected with the virus.

To help prevent further spread of the disease, which affects an estimated 1.2 million Americans, the U.S. Preventive Services Task Force has issued (.pdf) a final recommendation that every adult between 15 and 65 be screened for the virus. Younger adolescents and older adults considered at risk also should be screened, as well as all pregnant women in labor whose HIV status is not known, the task force suggests.

“Treatment for HIV has advanced remarkably, helping people live longer and healthier lives, and reducing HIV transmission,” Stanford professor Douglas K. Owens, MD, one of the members of the task force, told me last week. “Treatment is most effective when offered early in the course of HIV disease, typically well before people have symptoms, and screening enables people to learn they have HIV in time to get the full benefit from treatment.”

“Screening is especially important because up to quarter of people who have HIV do not know they have it,” Owens added.

Studies have shown that people who are infected with the virus are significantly less likely to pass it along if they are receiving ARV treatment, which reduces the amount of virus circulating in the blood. Moreover, people who are infected are more likely to do better - suffering fewer opportunistic infections - if they receive treatment early on, rather than wait until symptoms occur and the disease becomes more advanced. For these reasons, identifying infected individuals through universal screening makes good public health sense.

The task force’s latest recommendation, published in the new issue of the Annals of Internal Medicine, is in keeping with the guidelines of the American College of Physicians, the American Academy of Pediatrics and the federal Centers for Disease Control and Prevention. Owens talked more about this issue with me last fall, after the task force’s draft recommendations were released.

Previously: Stanford expert discusses recommendation for universal HIV screening, Task force issues draft recommendation for universal HIV screening and National HIV screening and testing could be very cost-effective

A large body of scientific research supports the safety and effectiveness of intrauterine devices and other forms of long-acting, reversible contraception (LARC) for adolescents, and physicians should offer these birth control methods to young women in their care. That’s the message behind a series of review articles published this week in a special supplemental issue of the Journal of Adolescent Health.

Stanford ob/gyn expert Paula Hillard, MD, who edited the supplement, explained to me that doctors are missing a great opportunity to prevent unwanted pregnancies by not offering young women the LARC birth control methods, which include IUDs and hormonal implants. Not only are the LARC methods very safe, the rate of unintended pregnancy with typical use of these techniques is 20 times lower than for alternate methods such as the Pill or a hormone patch.

But a design flaw in one specific IUD used in the 1970s - the Dalkon Shield - increased women’s risk for pelvic infections and gave all IUDs a bad rap. Use of IUDs among adult American women has been low ever since; it’s even lower in teens.

“Long after it was proven that the Dalkon Shield was particularly bad and newer IUDs were much safer, women were just scared,” Hillard said. “Not only did women stop asking for for them, many doctors also stopped using IUDs.”

The new review articles that Hillard edited are targeted at physicians but contain some interesting tidbits for general readers as well. The article titled “Myths and Misperceptions about Long Acting Reversible Contraception (LARC)” provides scientific evidence to refute several common myths, concluding, for instance, that IUDs don’t cause abortions or infertility, don’t increase women’s rates of ectopic pregnancy above the rates seen in the general population, and can be used by women and teens who have never had children.

And, as Hillard put it for me during our conversation, “These birth control methods are very safe and as effective as sterilization but completely reversible. They work better than anything else, and they’re so easy to use.”

Previously: Will more women begin opting for an IUD?, Promoting the use of IUDs in the developing world, and Study shows women may overestimate the effectiveness of common contraceptives
Photo, by ATIS547, shows a public sculpture on the campus of the University of California, Santa Cruz that is affectionately known as the “Flying IUD”

Last week, I wrote about efforts to boost IUD use in developing countries. This form of birth control, despite its benefits, isn’t widely embraced here in the United States, either - with surveys showing that less than 10 percent of women of reproductive age use it. But, as reported earlier this week by Kaiser Health News, the recently enacted Affordable Care Act might change that:

IUDs and the hormonal implant — a matchstick-sized rod that is inserted under the skin of the arm that releases pregnancy-preventing hormones for up to three years — generally cost between $400 and $1,000. The steep upfront cost has deterred many women from trying them, women’s health advocates say, even though they are cost-effective in the long run compared with other methods, because they last far longer.

Under the Affordable Care Act, new plans or those that lose their grandfathered status are required to provide a range of preventive benefits, including birth control, without patient cost-sharing. Yet even when insurance is covering the cost of the device and insertion, some plans may require women to pick up related expenses, such as lab charges.

Long-acting reversible contraceptives (LARCs) require no effort once they’re put into place, so they can be an appealing birth-control option for teens and young women, whose rates of unintended pregnancy are highest, experts say.

Via Our Bodies, Our Blog
Previously: Promoting the use of IUDs in the developing world, For many women, no more co-pay for birth control and A look at the federal mandate to cover contraceptives

IUDs, despite being safe, effective and relatively inexpensive, aren’t widely embraced by women in the developing world. There are likely several reasons why, including, as Stanford’s Paul Blumenthal, MD, tells me, “myths and rumors about the IUD, uncertainty or inadequate information about where a woman could get one, and an inadequate number of providers trained and ready to provide a quality service.”

Many women face challenges in obtaining other forms of birth control, as well, and a group of researchers recently launched a two-year initiative to increase women’s contraceptive options and improve reproductive health in 13 developing countries.

[Our] experience with promoting a contraceptive previously believed to be unsuitable… should encourage both public and private providers

I describe the effort, which was led by the nonprofit Population Services International, in a press release:

The initiative focused on both creating demand and improving service delivery. A group of community “mobilizers” conducted outreach in many of the countries, going door to door or gathering in group settings to educate women on family planning options and linking them with local providers. Media activities, including radio and TV spots, printed educational materials and billboards, were also done in many areas to address misconceptions about reversible contraceptives and to educate women on the potential benefits of using them.

Project leaders also improved access by training local clinic staff on counseling, complication management, side effects, removals and referrals, and by offering IUD insertion at a variety of clinics throughout each of the countries. Outreach clinic event days were held in six countries, during which IUD insertions were offered to local women over a one- to three-day period.

Between January 2009 and December 2010, 575,601 women across the 13 countries were provided with IUDs. The typical woman who received an IUD was in her 20s, married, had at least one living child and was primary-school educated. Twenty-four percent of women who received an IUD said they previously had been using no modern birth control method.

Blumenthal, who worked with PSI on the project and is lead author of a study appearing in Contraception, told me that a “success at this scale has not been previously reported.” And the researchers, who are continuing their project and expanding to other countries, wrote in the paper that their “experience with promoting a contraceptive previously believed to be unsuitable for these contexts should encourage both public and private providers.”

Previously: Using family planning counseling to reduce number of HIV-positive children in Africa, Access to contraceptives best way to cut maternal and newborn deaths in developing world, advocates argue and Africa and the pill

Several cancers associated with human papillomavirus (HPV) infection are on the rise in the U.S., but the country’s HPV vaccination rates remain dismally low, according to the just-published Annual Report to the Nation on the Status of Cancer.

This year’s report, which focuses on cancer data from 1975 to 2009, includes lots of good news, such as ongoing declines in the nation’s overall cancer death rate and in the incidence of many kinds of cancer. But the HPV-associated cancers, highlighted in a special section of the report, present a less rosy picture.

When the first HPV vaccine was introduced in 2006, physicians welcomed the opportunity to protect patients against cancers linked to HPV, the most common sexually transmitted infection. But doctors have faced an uphill battle convincing parents to give their kids the vaccine, which is now recommended for all 11- and 12-year-old boys and girls.

“Some parents are under the mistaken impression that ‘if I give my kids the vaccine, I’m giving them license to have sex,’” said Packard Children’s adolescent medicine specialist Sophia Yen, MD, when I asked for her opinion of the reason for low U.S. vaccination rates.

As the new report describes, by 2010, only 32 percent of U.S. girls aged 13 to 17 had received the entire three-dose series of injections. (The vaccine has been recommended for boys only since 2011, so vaccination rates among boys are even lower.) In contrast, more than half of Canadian girls in the same age group have completed the vaccination series, as have more than 70 percent of teen girls in Australia and the U.K.

Meanwhile, in the U.S., the incidence of HPV-associated cancers of the mouth, throat, anus and vulva increased between 2000 and 2009, the new report says. Cervical cancer, which is also associated with HPV, declined over the same period, but still accounts for more than half of HPV-associated cancers in women.

When she’s talking with parents about the HPV vaccine, Yen has some favorite talking points:

• The HPV vaccine is a safe and effective way to protect against many HPV-associated cancers and genital warts.

• HPV vaccination elicits a stronger immune response in younger kids, so it’s best to give children the series of shots at the recommended age of 11 or 12 instead of waiting for them to make their own decision about receiving the vaccine at age 18, as some parents say they want to do.

• If you’re uncomfortable discussing it with your pre-teen, you don’t have to tell your child the vaccination has anything to do with sex.

Continue Reading »

Yesterday my colleague wrote about a task force’s draft recommendation for universal HIV screening. Today, in a 1:2:1 podcast, task force member Douglas K. Owens, MD, discussed the proposed guidelines and the importance of screening. He believes the recommendation, if implemented, could have a substantial impact on the course of the epidemic in the United States.

Previously: Task force issues draft recommendation for universal HIV screening

New pediatricians in California need better training in treating sexually transmitted diseases among teens, according to a Stanford/Packard Children’s study published today in Pediatrics.

In the study (subscription required), researchers examined pediatric residents’ knowledge of state laws governing treatment of their patients’ sexual partners and found the physicians have spotty knowledge of an important method for preventing teens from suffering multiple bouts of STDs. The method, called “expedited partner therapy” (EPT) lets doctors prescribe antibiotics for the sexual partner of a gonorrhea or chlamydia patient without seeing the partner.

Even after receiving antibiotics to clear their infections, 40 percent of teenage gonorrhea and chlamydia patients are diagnosed with a second bout of the same illness within a year.

EPT, which has been legal in California since 2001 and is now permitted in more than 30 states, isn’t the only way that doctors can reach patients’ sexual partners for STD treatment. But prior research has shown that EPT improves the rate of STD treatment among partners in comparison with other methods. Our press release on the new study explains why treating teens’ sexual partners is so important:

“Unless you treat the partner, your patient gets re-infected,” said Neville Golden, MD, an adolescent medicine specialist at Packard Children’s and professor of pediatrics at Stanford. “We call this the ‘ping-pong effect.’”

Indeed, even after receiving antibiotics to clear their infections, 40 percent of teenage gonorrhea and chlamydia patients are diagnosed with a second bout of the same illness within a year. About half of all sexually transmitted infections in this country occur in teenagers.

The study by Golden and colleagues focused on young doctors completing specialty training in pediatrics in California and asked whether they knew about California’s expedited partner therapy law. Though about half of the pediatric residents had used EPT, 87 percent said their knowledge of the law was shaky and that this lack of knowledge was a barrier to their use of EPT. Less than a quarter of the residents had ever been educated about EPT, suggesting a large opportunity for teaching pediatricians about the practice.

EPT isn’t perfect, and the residents’ responses also reflected valid concerns with the method. For instance, 78 percent of respondents worried about missing opportunities to address the partners’ health care needs and 69 percent were concerned that partners would not take the medication as directed. But given how common STDs are among teenagers, and how useful EPT can be, the study’s authors conclude that it’s important to ensure new pediatricians are better informed about it.

Previously: Experts weigh in on recommendation that boys be given HPV vaccine; Only one-third of teenage girls get HPV vaccine to prevent cervical cancer.

This will be certainly be discussed elsewhere, but I couldn’t let the morning pass without acknowledging that it’s a big day in women’s health. As of today, many private insurance companies will begin providing contraceptives and other reproductive health services, including well-woman visits, without co-pay. Katherine Harmon has written a terrific Observations blog entry on the news - which comes thanks to a provision in the Affordable Care Act - and why it’s important.

I feel like running to my Walgreens and celebrating!

Previously: A look at the federal mandate to cover contraceptives, Government advisors call for free contraception for women, Another birth control revolution? New health law could provide free contraceptives to women and Women’s health groups launch campaign for no-cost prescription birth control

More news from the International AIDS Conference: Stanford researchers have presented findings showing that family planning counseling could be a cost-effective way to help minimize the number of children born HIV-positive in sub-Saharan Africa. The study involved 98 HIV-positive women - two-thirds of whom attended three 90-minute group courses on family planning, sexual negotiation, and self-esteem building. My colleague Ruthann Richter, who has been reporting from the conference, writes:

According to [Clea Sarnquist, DrPH, MPH, a senior research scholar in pediatrics] and her colleagues, about 40 percent of pregnancies in sub-Saharan Africa are unplanned. Such unwanted pregnancies could be prevented if women relied on long-acting forms of contraception — such as the intra-uterine device, or IUD, or hormonal implants — rather than birth control pills or diaphragms. Indeed, the researchers found that [three months] after receiving group counseling almost 90 percent of the HIV-positive women in the study chose a long-acting form of contraception.

The women in the study, which was conducted in a suburban region of Zimbabwe, also said they felt a greater sense of power in negotiating sexual activity, including condom use, and were more open with their partners about their HIV status, the researchers reported.

Sarnquist, who is hoping to expand the study to a larger population of women who could be followed over a longer period of time, said of the significance of this work, “If you can help prevent HIV-positive women from having unplanned children, obviously you’re going to prevent unnecessary HIV transmission.”

Previously: International AIDS Conference Day Four: Focusing on a vaccine, International AIDS Conference Day Three: Daring to talk about a cure, International AIDS Conference Day Two: Hillary Clinton envisions AIDS-free generation, International AIDS Conference: Day One, WHO’s new recommendations on contraceptive use and HIV and New book shows the pain and hope of AIDS orphans