hey will be more likely to have sex.  This is not true.  What is true, is that school based clinics are helpful in providing information to teens in a not so threatening environment. 

 

Barriers to Care

 

There have been several studies, usually in the form of surveys, demonstrating that adolescents neither seek out nor receive adequate health services.  Some studies have gone further to elucidate reasons for this reality.  Reasons include financial barriers, objectionable rules for parental consent and notification, misinformation, and scarcity in health care providers trained to meet adolescent needs.

            Adolescents are more likely to be uninsured than other populations for reasons not limited to, but highly contingent on financial constraints.  Additionally the rates of uninsured young people continue to increase.  The Office of Technology Assessment in 1991 reported that one in seven teenagers were uninsured; and further, a third of teens eligible for Medicaid remained uncovered.  Quite a few policy changes have attempted to rectify this situation; for instance, the Omnibus Budget Reconciliation Act of 1990 (Public Law 101-58) expanded Medicaid eligibility to all children born after September 30, 1983 in families below the federal poverty level.  Also, the Balance Budget Act of 1997 included the State Children’s Health Insurance program, which was the single largest expansion in public health coverage for children in 30 years able to cover about 5 million more children and adolescents.  Despite all the policy efforts to institute programs that are directed at, and equipped to resolve the issue of uninsured adolescents, why does the problem persist and worsen?  Thoughts are, that uninsured adolescents often lack knowledge of available services or the process of signing on is either too complicated or sophisticated.  Adolescents may consider the effort of obtaining public assistance for health care not worth the perceived benefit of the care.  Financial barriers can be present in the form of not being able to afford any health insurance, and high premiums or co-payment rates that do not offset the assumed worth of the care anticipated (62). 

            Another barrier mentioned was the requirement of parental consent and notification for a minor to receive health care services dictated by common law.  Even though, there are State specific exceptions and federal “emancipation” laws, few teens are aware of these.  An emancipated minor is in the military, lives away from parents and financially supports him or herself; and, can give consent for his or her own medical treatment (25).  Teens are less likely to seek medical care if parents are involved.

            Although parental consent and notification are required, there are still rules on patient confidentiality that apply.  Only a third of adolescents are aware that they have a right to confidentiality and most do not trust that confidentiality will be firmly maintained.  A reasonable assumption, when surveys reveal that 53% of physicians reported discussing confidentiality policies with their teenage patients.  Physician support of confidentiality rights for adolescents is reportedly based on conclusions on maturity of individual patients.  Therefore, it seems as if the distrust is not without grounds.

            Confidentiality concerns in the face of billing, relating to parental positions, insurance company disclosures, may result in providers referring teens to low-cost family planning clinics.

 

 

The Role of Policy

 

Reproductive health policy was defined in the Cairo Programme of Action as “the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as to other methods of their choice for regulation of fertility…”

 

The role of law in reproductive health (RH) is nothing if not controversial.  How much can a government interfere or regulate the sexual health and behavior of its citizens?  Additional complications arise when religious and moral codes of behavior are generalized by legal requirements.  Approaches have ranged from applying general laws of human rights to RH issues, with no specific mention in the constitution or legal documents, to actually outlining detailed provisions under a devoted section.  Other countries have also simply enacted laws to deal with particular aspects of RH.  For instance Ghana enacted a law in 1995 to prohibit Female genital mutilation (WHO website). 

Policy and law regarding issues of RH must be considered very carefully.  An example of well intentioned but ineffective law, was one adopted by several jurisdictions that required HIV testing prior to obtaining a marriage license.  This was meant to protect spouses from HIV by requiring the exchange of status between couples.  The result was that couples got married outside of such jurisdictions or simply postponed marriage plans.  Arising also was the concern that requiring this testing interfered with a persons right to marry and start a family.  Such laws have largely been abolished and replaced with emphasis on education and counseling of couples.  Similarly, laws that have prohibited abortions have served to increase the danger to the health and lives of women seeking abortions from illegal, underground sources or attempting to rid themselves of unwanted pregnancies using unorthodox methods.  Balancing the priorities between the woman, the man, the unborn child, and society as a whole is the challenge the policies on RH must resolve to be effective.  Resolving these priorities is the biggest obstacle to writing policies that are lasting and effective.

            The Urban Institute examined several recent state policies to reduce teenage pregnancies.  Several states have relied on welfare reforms to discourage adolescent pregnancy.  The idea being that the restriction of aid to unwed teenage mothers will serve as a deterrent.  The federal government, in addition to granting funds to states to sponsor abstinence education programs, also gives bonuses to states ranking lowest in unwed teenage pregnancies.  The results of these recent policies are that 28 states in 1999 had official policies on public school based pregnancy education programs compared to 19 states with such policies in 1997.  Furthermore, 23 states in 1999 included contraception education compared to only 14 states just two years earlier.  However, programs on STDs have not seen similar growth.  It is no wonder that pregnancy rates continue to decline, but STD rates remain fairly constant (63).

            Although the recent emphasis on prevention of teen pregnancy seems to have yielded good results, a more global approach to sexual and reproductive health of the adolescent is required.  Education on contraception needs to be included along with abstinence.  The evidence has shown that for every $1 spent on providing contraception education, $4 can be saved on medical expenses (7).

Reproductive health is an issue that has been examined from a policy standpoint by several nations.  Although this may be considered a woman’s issue, it really affects the entire population.

 

Conclusion

 

The evidence is overwhelming that sexual and reproductive health of the adolescent population is a public health concern that needs to be addressed.  Several institutions have addressed this issue with varied levels of success.  The approaches have ranged from national awareness programs to neighborhood and community campaigns.  Some of the key elements for success of a program to address teen pregnancy and spread of STDs are early educational intervention, peer group involvement, access and affordability of confidential healthcare, and trained care givers in a supportive environment. 

            Family planning programs have a role to play.  Without existing services, 386 thousand more adolescents would become pregnant every year and 155 thousand of those would go on to deliver: a 25% increase.  This increase would lead to a 58% projected increase in the amount of abortions performed annually (23).  It benefits everyone including the politically and religiously opposed to increase family planning services to adolescents.

            Adolescent sexuality is a fact that is not changing.  How we as a society choose to participate in this developmental stage of our youth will determine future rates of unintended pregnancies, abortions, STDs, and overall functional sexual and reproductive freedom.

 

 

Links for more information

 

Adolescent Sexuality- Teen and Parents

 

1.      1.        Ask NOAH www.noah-health.org.  York Online Access to Health (NOAH).  City

University of New York, the Metropolitan New York Library Council, the

New York Academy of Medicine, and the New York Public Library.

2.      2.       Go Ask Alice www.goaskalice.columbia.edu.  Go Ask Alice is a source of general

health and sex information maintained by Columbia University health

educators.  High school and college-age people submit most of the answers.

3.      3.        It's Your (Sex) Life www.itsyoursexlife.com.  Sponsored by the Kaiser Family 

Foundation.  Provides sexual information to young adults.

4.      4.      I wanna know www.iwannaknow.org.  Website is to answer questions teenagers may

have about their bodies, sex, and sexual feelings.

5.      5.      Just for You: Teens  http://healthfinder.gov/justforyou/.  HealthfinderKIDS.

HealthFinders Teen Page has multiple links to government-sponsored

information for teens and providers.

For Providers and Professionals

 

6.      6.        Advocates for Youth http://www.advocatesforyouth.org/.   Provides information,

training, and advocacy to youth-serving organizations.  Promotes young adults

to make informed, educated, and responsible choices about their sexual and

reproductive health.

7.      7.        Alan Guttmacher Institute http://www.agi-usa.org/index.html.  The Alan

Guttmacher Institute is a research, policy analysis, and public education

organization dedicated to protecting the reproductive choices of men and

women in the United States and throughout the world.

8.      8.        http://www.cedpa.org. Center for Development and Population Activities includes

the following programs:

1.      1.      http://www.cedpa.org/trainprog/betterlife/betlife.htm.  Better Life

Options for Girls and Young Women.

2.      2.      http://www.cedpa.org/trainprog/ppgyw.htm.  Helps girls in upper

Egypt strengthen vocational literacy skills and increase

understanding of family life issues.

3.  http://www.cedpa.org/trainprog/saharan/subsahaf.htm.  Adolescent and

Gender Project in sub-Saharan Africa.

 

TEENAGE PREGNANCY-Teens and Parents

9.      9.       National Campaign to Prevent Teenage Pregnancy.  http://www.teenpregnancy.org/  

10.  10.   On teen pregnancy.  http://www.plannedparenthood.org/PARENTS/index.html.   

Health Care Professionals

11.  11.   CDC site on teenage pregnancy.  http://www.cdc.gov/nccdphp/teen.htm.  

12.  12.   From the Urban Institute: Involving males in preventing teen pregnancy.

http://www.urban.org/family/invmales.html.  

13.  13.   Department of Health and Human Services (DHHS).

http://aspe.hhs.gov/hsp/teenp/intro.htm.  

14.  14.   The Data Archive on Adolescent Pregnancy and Pregnancy Prevention (DAAPPP).

http://www.socio.com/data_arc/daappp_0.htm.  

15.  15.  Child trends.  http://www.childtrends.org.   Excellent research briefs and facts in

at-a-glance sections.

 

CONTRACEPTION-Health Professionals

16.  16.    American College of Obstetricians and Gynecologist.  http://www.acog.org/.  

17.  17.    Association of Reproductive Health Professionals.  http://www.arhp.org/.

18.  18.    Contraceptive Research and Development Program site.  http://www.conrad.org/.  

 

References and Additional Readings

19.  19.   Devaney B, et al.  The Savings in Medicaid Costs for Newborns and Their Mothers

From Prenatal Participation in the WIC Program, US Department of Agriculture, Food, and Nutrition Service.

20.  20.   Division of STD Prevention: Sexually Transmitted Disease Surveillance, 1997.  US

Department of Health and Human Services, Public Health Service.  Atlanta,

Centers for Disease Control and Prevention (CDC), September, 1998.

21.  21.   Neinstein LS, ed.  Adolescent Healthcare, 4th ed.  Philadelphia: Lippincott Williams

and Wilkins, 2002.

22.  22.    National Campaign to Prevent Teen Pregnancy. (1997).  Whatever Happened to

Childhood?  The Problem of teen pregnancy in the United States.

Washington, DC. 

23.  23.    Child Welfare League of America. (December 1998).  Teen Pregnancy Prevention.

www.cwla.org/cwla/prgeprv/preventionprograms

24.  24.    Orr DP.  “Helping Adolescents towards Adulthood.”  J Contemporary Pediatrics

15(5), May 1998, 55-76.

25.  25.    Greydanus DE, Patel DR.  “Consent and Confidentiality in Adolescent Healthcare”

Pediatric Annals 20(2), February 1991, 80-84.

26.  26.    Greydanus DE et al.  “Contraception in the Adolescent: An Update.”  Pediatrics

107(3), March 2001, 562-573.

27.  27.    Stevens-Simon C.  “Reproductive Healthcare for your adolescent female patient.”

Contemporary Adolescent Gynecology 3(3), 4-18.

28.  28.    Amador L, Eyler AE.  “Adolescent Healthcare.  Diagnosis and Treatment of

Sexually Transmitted Diseases in Adolescents.”  Clinics in Family Practice  2(4), December 2000, WB Saunders Company.

29.  29.    Gold MA.  “Providing emergency contraception in the office.”  Contemporary

Pediatrics 16(3), March 1999, 53-77.

30.  30.    Rayburn WF, ed.  “Treatment of Sexually Transmitted Diseases.”  Journal of

Reproductive Medicine 43(6), June 1998.

31.  31.    Hindelang RL et al.  “Adolescent Risk-Taking Behavior: A Review of the Role of

Parental Involvement.”  Curr Probl Pediatr 31, March 2001, 67-83.

32.  32.    Girardet RG et al.  “Issues in Pediatric Sexual Abuse – What We Think We Know

and Where We Need To Go.”  Curr Probl Pediatr Adolescent Health care 32, 2002, 211-246.

33.  33.    Jaskiewicz JA, McAnarney ER.  “Pregnancy During Adolescence.”  Pediatrics in

Review 15(1), January 1994.

34.  34.    Milligan Renee et al.  “Perceptions about prenatal care: views of urban vulnerable

groups.”  BMC Public Health, November 2002.

35.  35.    Holmes K, Mardin P, Sparling P, et al: Sexually Transmitted Diseases.  New York,

McGraw-Hill, 1999.

36.  36.   Martinez J, Smith R, Farmer M, Alger L, Daniel R, Oupta J, Shah K, Naghashfar Z:

High prevalence of genital tract papilloma virus infection in female

adolescents.  Pediatrics 82(4):604-8, 1988.  Abstract.

37.  37.   Santelli JS, Brener ND, Lowry R, et al: Multiple sexual partners among U.S.

adolescents and young adults.  Fam Plann Perspect 30:271-275, 1998.

Abstract.

38.  38.   Singh S, Darroch JE: Trends in sexual activity among adolescent American women:

                        1982-1995.  Fam Plann Perspect 31:212-219, 1999.  Abstract.

39.  39.   Brown SS, Eisenbery L: The Best Intentions.  Washington DC, National Academy

Press, 1995.

40.  40.   Stevens-Simon C, White M: Adolescent pregnancy.  Pediatr Ann 1991; 20:322.

41.  41.   Stevens-Simon C, Lowy R: Is teenage childbearing an adaptive strategy for the

socioeconomically disadvantaged or a strategy for adapting to

socioeconomic disadvantage?  Arch Pediatr Adolesc Med 1995; 149:912.

42.  42.  Cates W: Teenagers and sexual risk taking: The best of times and the worst of times.

J Adol Health Care 1991; 12:84.

43.  43.    Elster AB, Kuzets N: Guidelines for Adolescent Preventative Services (GAPS).

Baltimore, Md, Williams and Wilkins, 1993.

44.  44.    Frost JJ, Forrest JD: Understanding the inpact of effective teenage pregnancy

prevention programs.  Fam Plann Perspect 1995; 27:168.

45.  45.    Santelli JS, DiClemente RJ, Miller KS, et al. Sexually transmitted diseases,

unintended pregnancy, and adolescent health promotion.  Adolescent

Medicine.  1999; 10:87-108.

46.  46.    Emans SJ, Laufer MR, Goldstein DP.  Contraception.  In: Pediatric and Adolescent

Gynecology.  4th ed. Philadelphia, PA: Lipincott-Raven; 1998: 611-674.

47.  47.    McCann M, Potter L.  Progestin-only contraception: a comprehensive review.

Contraception.  1994; 50(suppl):1-95.

48.  48.    Stubblefield P.  Self-administered emergency contraception-a second chance.  N

Engl J Med.  1998; 339:41-42.

49.  49.    Glasier A, Baird D.  The effect of self-administered emergency contraception.  N

Engl J Med.  1998; 339:104.

50.  50.    Glasier A, Thong KJ, Dewar M, et al. Mifepristone (RU 486) compared with high

dose estrogen and progestogen for emergency postcoital contraception.  N

Engl J Med.  1992; 327:1041.

51.  51.    Darney PD, Klaisle CM, Tanner S, et al. Sustained-release contraceptives.  Curr

Problems Obstet Fertil.  1990; 13:87-125.

52.  52.    Alan Guttmacher Institute: Sex and America’s Teenagers.  New York, Alan

Guttmacher Institute, 1994.

53.  53.    Institute of Medicine: Sexually transmitted diseases: The hidden epidemic, In Eng

TR, Butler WT (eds): Confronting Sexually Transmitted Diseases.

Washington, DC, National Academy Press, 1997, pp 69-117.

54.  54.    Alan Guttmacher Institute.  Why is teenage pregnancy declining: the role of

 abstinence, sexual activity, and contraception.  New York: Alan

Guttmacher, 1999d.  www.agiusa.org/pubs/or_teen_preg_declice.html.  

55.  55.    Furstenberg FF Jr, Brooks-Gunn J, et al.  Adolescent mothers in later life.  New

York: Cambridge University Press, 1987a.

56.  56.    Furstenberg FF, Brooks-Gunn J, Morgan SP.  Adolescent mothers and their children

in later life.  Fam Plann Perspect 1987b; 19:142.

57.  57.    Henshaw SK.  Unintended pregnancy in the United States.  Fam Plann Perspect

1998; 30:24.

58.  58.    Henshaw SK, Van Vort J.  Teenage abortion, birth, and pregnancy statistics: an

update.  Fam Plann Perspect 1992; 24:196.

59.  59.    Center for Disease Control and prevention.  Trends in sexual risk behaviors among

high school students-United States, 1991-1997.  MMWR Morb Mortal

Wkly Rep 1998; 47:749.

60.  60.   Centers for Disease Control and Prevention.  Youth risk behavior surveillance-

United State, 1999.  MMWR Morb Mort Wkly Rep 2000a;49:(SS-5).

61.  61.   Hacker KA, Amare Y, Strunk N, et al.  Listening to youth: teen perspectives on

pregnancy prevention.  J Adolesc Health 2000; 26:279.

62.  62.   Oberg Charles et al.  “Healthcare access, Sexually Transmitted Diseases, and

Adolescents: Identifying Barriers and Creating Solutions.”  Curr Probl Pediatr Adolescent Healthcare 32(9), October 2002, 315-346.

63.  63.    Wertheimer Richard et al.  State Policy Initiatives for Reducing Teen and Adult

Non-marital Childbearing: Family Planning to Family Caps.  New Federalism, The Urban Institute, Series A (A-43), November 2000.