Reproductive
and Sexual Health
in
the Adolescent Population
Adebola O. Akanbi
OUTLINE
CURRENT ISSUES IN ADOLESCENT
REPRODUCTIVE HEALTHCARE
REFERENCES AND ADDITIONAL READINGS
Reproductive
and Sexual Health in the Adolescent Population
Adebola O. Akanbi
“In spite of the sound arguments – based on public health concerns, human rights, equity, and social justice – calling for a strong focus on sexual and reproductive health, in many countries the concept of comprehensive reproductive health care is still insufficiently understood and applied” Paul Van Look, Director, WHO, RHR
This chapter will cover the current issues in the
reproductive and sexual health facing the adolescent in the United States. Adolescence refers to the period between 11
and 20 years of age when puberty occurs and youth obtain social and sexual
maturity. The focus will be on defining
the public health burden of teenage pregnancy and sexually transmitted diseases
and further explore solutions. Certain
issues of sexual health and development will not be discussed in detail, such
as homosexuality, sexual development, and pathology. The last section will delve into public health policies and
approaches to confront the issues identified.
In 1998, there was an
estimated 38.8 million adolescents (10 –19 years old) in the United
States. Twenty-six percent of teens
surveyed admitted to having voluntary sexual intercourse prior to their 13th
birthday. United States has a teenage
pregnancy rate that is twice that of England, Canada, and nine times greater
than the rate in Japan and the Netherlands.
Each year in the United States, 800 to 900 thousand teenagers get
pregnant (37).
Fifty percent of teenage
mothers complete high school by the age of 18 versus 97% of their peers. The public assistance program, Aids to
Families with Dependent Children (AFDC), estimates that 55% of their funds go
to families with or who were teenage mothers. This results in majority of
families with teen moms having lower economic status. Although the decade from 1991 to 1999 saw a 15% steady decline in
the birthrate of 15 to 19 year old girls, the economic and social burden of
unintended teen pregnancies and the prevalence of STDs remain a serious problem
with a lot of progress still to be made (21).
Current Issues in Adolescent Reproductive Health
Adolescents are becoming
sexually active at alarmingly younger ages.
Sexually active teenagers are at increase risk for unintended
pregnancies and sexually transmitted diseases.
Out of the greater than one million teenage pregnancies each year, about
82% of these are unintended (27). The
burden of unwanted pregnancies rest not only on the adolescent, but also on
society as a whole: likewise the burden of sexually transmitted diseases. Aside from the cost of treatment, delivery,
and well being, the psychosocial burden on development cannot be ignored.
An interesting point to
consider is that while the rates of pregnancy and STDs have increased in
American teenagers as they become more sexually active, the same has not been
the case for teens in other countries such as Japan and Europe. Some experts have blamed this fact on the
lack of education and open discussion about sexuality, especially regarding the
adolescent. Many Americans believe,
contrary to evidence shown, that discussing sexuality with teenagers condones
and encourages them to engage in sexual behavior (27).
“Children now love luxury.
They have bad manners, contempt for authority. They show disrespect for elders and love chatter in place of
exercise. Children are now tyrants, not
the servants of their households.” -
Socrates
The developmental task of the
adolescent period centers on the definition of personal identity. This definition involves resolving value
systems, issues of independence, and attaining sexual and social maturity. In addition to the physical and emotional
evolution during adolescence, cognitive changes from concrete to abstract
reasoning occur. All these changes have
an impact on teen behavior and understanding the evolution may be key to
implement effective interventions. It
is important that any information given to adolescents be presented in a clear
and concrete manner to ensure global understanding despite any individual stage
of development (34).
Despite popular belief, most
parents remain the primary influence and role model for adolescent behavior
(31). Therefore the involvement of
parents and caregivers are paramount to successful interventions. Events affecting the family and the
environment of the teenager become important.
Several studies have shown an increase in risky behaviors within teens
from broken homes, poor homes, and those who have experienced violence,
physical, emotional, or sexual abuse (32).
In some cases of pediatric sexual abuse, which directly interrupts
aspects of normal sexual development, the long-term outcomes suggest increase
in promiscuity, depression, and other psychosomatic problems. For that reason, adolescents with a history
of abuse are particularly vulnerable and warrant special attention to ensure
normal development.
In 1999, the CDC reported
that 39% of 9th graders had sexual intercourse. The majority of 9th graders are
between 14 and 16 years of age. With so
many adolescents being sexually active, it is imperative to educate this age
group on contraceptive methods and safe sex practices. The use of contraception prevented an
estimated 1.65 million pregnancies in teens 15-19 years old in 1945 (58). These programs are effective, but the
message needs to reach the adolescent earlier.
Improving contraception use in the adolescent population should
begin with education. Society needs to
move away from the taboo of discussing sexuality, its significance, and
consequences with teenagers. Who is
qualified to teach sex education?
Recent surveys have discovered the need to educate the teachers on the
topic. When 1300 sex educators were
asked a series of True or False type questions, only 72% knew that pregnancy
during adolescence was riskier than taking the pill, 30% were aware that the
pill does not have adverse effects on later fertility, and a mere 23%
recognized that the pill does not need to be stopped periodically to give the
body a break (23)! The amount of
misinformation existing within those responsible for teaching adolescents about
their sexuality is appalling, and discouraging for the resolution of the
current crisis.
Considerations when deciding
on contraceptive method for adolescents should include convenience,
reliability, reversibility, inexpensiveness, and safety. Keep in mind that any contraceptive method
is safer than pregnancy, there is no perfect method, and STD prevention should
be dealt with as a separate issue. The
Urban Institute is a non-profit research and education program that provides
help and assistance for educators to develop well-structured and effective
programs. Visit the web site www.urban.org for more information.
The introduction of sex
education programs within schools was met with lots of resistance from certain
groups. Most of the resistance stemmed
from the idea that teaching sex to teenagers would encourage sexual
activity. Studies have shown that this
idea has no basis in reality and that educating youth on sexuality better
equips them to handle the pressures of their environment. These pressures to participate in risky
sexual behaviors at an early age are perpetrated by the media and society at
large. The media portrays the idea that
sex is cool and should be plunged into with abandon and no thought of
consequences. When was the last time
the question of either abstaining or using a condom was brought up before,
during, or after a movie sex scene.
Music videos do not discuss the topic of birth control as they do
unplanned children, child support, and dead-beat dads.
Public attitudes need to be
changed to support making contraception widely available to teens that wish to
practice birth control. An example of
changing public perception is spreading knowledge of emergency contraception. Emergency contraception, also known as the
“morning after pill,” is a concept that has been around since 1969 when high
dose estrogens were given to rape victims to prevent pregnancy. However, it was not until 1997 that the FDA
approved a combination estrogen and progestin pill for emergency
contraception. The latest method is a
progestin only morning after pill to be taken within 72 hours after episodes of
unprotected intercourse to prevent pregnancy.
This method has a 75% efficacy but this is excellent when combined with
the fact that 85% of the time unprotected sex will lead to pregnancy. Nevertheless, unless the adolescent is aware
of this option and how to get this pill, the efficacy is zero. In a recent survey, only 34% of teenage
girls reported being aware of emergency contraception (29).
There are 15 million births
accredited to teenage mothers every year around the world. About 1 million of the adolescents who live
in the United States become pregnant annually and half of them go on to give
birth (US accounting office). The
public health burden of pregnancy during adolescence comprise the increased
risk of mortality and morbidity among teenage moms and the ensuing
socioeconomic disadvantages that they face.
These disadvantages include the fact that adolescent pregnancy can limit
educational opportunities, restrict skill development, and affect overall
quality of life. Children born to teenage mothers perpetuate the legacy. A study done in a comprehensive maternity
program in Baltimore following children of adolescent mothers found that nearly
50% had repeated a level and nearly 61% reported academic performance at or
below the average (56). In essence the
social impact of teenage pregnancy was perpetuated to the following generation.
Early diagnosis is key in
cases of teenage pregnancies. The
earlier the diagnosis, the sooner appropriate intervention can be
established. There are basically three
choices for the pregnant adolescent: to deliver and raise the child, to give the
child up for adoption, or terminate the pregnancy. Several factors work to delay diagnosis in this population. These factors include, but are not limited
to, denial, history of irregular menstrual cycles, vague symptoms, fear of
discovery, and difficult access to confidential and affordable health care
services. Proper referral and
management choices rely heavily on timing.
For adolescents who choose to deliver, early institution of prenatal
care can reduce the risk of morbidity and mortality. Likewise, timing is critical for teens that decide to terminate
their pregnancies. Most of the
termination procedures have defined gestational age limits to ensure maximum
safety.
The first approach to solving
this problem is to prevent it.
Prevention is the ideal solution to the problem of teenage pregnancy and
therefore is the ultimate goal.
Examples of programs include Oklahoma states’ local teen pregnancy
initiatives like businesses sponsoring marquees stating, “Babies cost $474 per
month. How much is your
allowance?” Other programs have schools
make signs supporting abstinence, distributing flyers in pizza boxes, and so
on. The idea being that the community
should get involved in preventing teenage pregnancy. Oklahoma communities are also sponsoring other programs like
“Postponing Sexual Involvement” and “Dads make a Difference.” What is particularly great about these
programs are that they target middle school aged youth and are taught by
trained high school students. The
message coming from other students is more powerful because the generation gap
is less and the younger teens are more apt to listen. Oklahoma saw a 12.1% drop in pregnancy rates from 1991-1996 (www.siecus.org/school/preg/preg0006.html.)
The California Wellness
Foundation has a Pregnancy Prevention Initiative that focuses on supporting
organizations aimed at reducing teen pregnancies. The goal is to reduce the incidence of teen pregnancies by encouraging
teenagers to delay sexual activity or to use effective contraception. Minnesota also has an organization on
Adolescent Pregnancy that advocates prevention and parenting skills (www.moappp.org)
Prenatal care (PNC) is the
medical supervision and monitoring of a pregnancy from conception until the
onset of labor. PNC visits are every
2-4 weeks for the first seven months, every 2 weeks for the eighth month, and
every week during the ninth month.
During this time, intervention and education can influence the outcome
of the pregnancy and decrease the public health burden. Understanding the barriers and facilitators
to obtaining prenatal care can help to determine methods to increase
utilization by women and especially adolescents.
Adolescents are twice as
likely not to receive prenatal care or present for care in the third trimester
when compared to all pregnant women.
Some studies claim only one-third of teenage moms receive prenatal care
and their babies are more likely to be hospitalized and have low birth weights
(19). High infant mortality rates have
been reported, in some instances, to be correlated with the lack of prenatal
care. Routine prenatal care often
consists of a minimum of seven clinic visits in which screening tests,
ultrasounds, monitoring of fetal growth and development, and preparation for
labor and delivery are performed.
Obviously access to health care, affordability of health care, and
knowledge of the importance of care are major factors and challenging obstacles
for the adolescent, especially those who have no parental or adult
support.
Most teens are not aware
of “emancipation” laws that enable them
to see a physician without the consent of their parents under certain
circumstances, including pregnancy. For
those who do know that they can see a physician, lack of trust in the
confidentiality of the visit and fear that their parents will find out keeps
them away. There are also a number of
public assistance programs designed for the uninsured or poor pregnant woman to
receive free prenatal care.
In 1998, Washington D. C.
reported an infant mortality rate almost twice that of the national average
(13.8 infant deaths / 1000 live births compared to 7.2 nationally). A particular study using focus groups around
the Washington, D.C. area identified three main deterrents: drug lifestyle,
role of father, staff or provider attitudes.
Although this study was not focused on adolescents, the issues identified
can be generalized to gain insight into their analogous situation (34).
The pursuit and use of drugs
by an addict dictates their entire lifestyle and does not allow the reliable
attendance of appointments. Some women
however, stated that during pregnancy they were able to halt drug use due to
concern for their child, but often went back to the drugs once the child was
born. The pregnant adolescent needs to
be screened and counseled regarding drug abuse and resources made available for
rehabilitation.
An involved father or partner
seemed to have a positive effect on women getting prenatal care. The accountability to someone else and being
reminded to keep appointments encouraged them to make and keep more prenatal
appointments. In reproductive health
education, the male is often left out and the focus is placed on the
female. However, more and more programs
are focusing on the adolescent male: their role in the process cannot be
ignored. The Urban Institute has a male
health initiative that lists the following goals: promote young men's sexual
health and development, promote healthy intimate relationships, prevent and
control STDs, including HIV, and promote responsible fatherhood. Through programs such as this, the male
adolescent will be called into account and receive the focus they deserve with
respect to the issue of reproductive health (12).
Additionally, staff or
provider attitudes could deter or facilitate the pursuit of care. If the providers were not judgmental or
showed them more respect, more adolescents may get PNC. There is sometimes shame and guilt that
accompanies teenage pregnancy and the physician is seen as an adult figure that
will criticize and scold as a parent might.
Both providers and educators need to be mindful of their approach to the
adolescent. Pediatricians,
Obstetricians and Gynecologist, should obtain special training for the care of
the adolescent patient. They are indeed
a unique patient population. Some
Pediatric practices recognize this and have separate adolescent clinics with a
trained physician supervising. More
practices need to follow suit.
The government realized the
cost saving benefits of prenatal care and has funded programs to provide more
access to care for low-income expectant mothers and their children. The Women, Infants, and Children (WIC), a
federally funded program, was established in 1972 as a part of Medicaid. The main purpose of this program included
providing healthcare and social services to low income, pregnant women and
children less than 5 years of age. A
large public health program serving about 2 million women with $750 million, it
grew substantially in a decade, and by 1990 was serving 4.5 million with $2.1
billion! Current legislation mandates
that all pregnant women and children who make below 133% of the poverty level
should be insured.
There is data showing that
the risk of premature birth increases 2.8 times in women who do not receive
prenatal care. Premature newborns
increase hospital cost and spending. A
study was performed to compare the cost of Medicaid providing PNC through WIC
to the benefits of this additional coverage.
These benefits were measured in terms of healthcare cost accrued by the
newborns and their mothers within the first 60 days of life. Five States were included in the study over
the period of a year (19).
Results: The savings in mother and newborn Medicaid
expenses during the first 60 days of life for participants in the WIC program
ranged from $277 to $598. When newborn
expenses were isolated the range was from $573 to $744. Calculated benefit-cost ratios for the PNC
component of WIC to savings ranged from 1.77 to 3.13 for mothers and newborns
and from 2.84 to 3.90 when newborns were isolated (19).
It was apparent by this study
that the savings in Medicaid expenses were more than the cost of providing the
PNC component of WIC and therefore was worth continuing. The cost-saving effects of PNC were more
pronounced when participation in the program was adequate. Adequate participation was found to be more
than four PNC visits and the study showed that considerable savings were
coupled with the level of participation (19).
About 30% of teenage
pregnancies result in abortions. The
rate of abortions in the adolescent population has been declining as well. There was a 24% reduction in rates between
the years 1990 and 1996 (57). At least
one parent is aware in an estimated 61% of cases (58). Most parents actually support the adolescent
decision to terminate the unintended pregnancy. In the United States, unlike some other nations, has a mortality
rate of less than 1 in 100,000 (21).
This low mortality rate is the result of departure from unsafe,
underground methods that women were driven to in the past and the advent of
newer, safer, and regulated methods.
The unsafe methods of termination account for vast amounts of maternal
deaths in developing countries.
The close to 40% of all
pregnant women who opt for therapeutic abortions, do not have the socioeconomic
difficulties as their counterparts that deliver. However, information on the psychosocial and physical
implications of abortion is limited.
More research studies and long term follow-ups are needed to draw
concrete conclusions (33). However the
political and religious debate on the ethics and morality of abortion continues
in the United States.
Sexually transmitted diseases
(STDs), unfortunately, are not negligible within the adolescent
population. The CDC reports that the
“rates of many STDs are highest among adolescents”. In 1998, teenage girls, age 15-19, had the highest rates of
chlamydia and gonorrhea. Younger teens
(less than 15 years) are not only at higher risk due to riskier behaviors, but
are also more biologically susceptible, have obstacles to health care access,
and partnerships are of shorter duration.
Young adults are at highest risk for HPV infection. Some studies of urban young women have
reported rates of 24% prevalence of HPV (36).
Providers need to pay particular attention if adolescent has been in a
detention facility, uses injected drugs, has previous history of infection, or
is a homosexual male. These statistics
are not surprising when you consider surveys that report 31% of 21 year old
women and 45% of the same age males have had six or more sexual partners!
(37)
Most adolescents can consent
to treatment of STDs without parental knowledge. Many states even include HIV testing and counseling. The disease burden of STDs in the adolescent
population is a public health issue that will not simply go away. STDs vary in clinical presentation with many
infections remaining asymptomatic though still leading to complications. Some of the public health issues include the
high prevalence in adolescents, in urban youth, coinfection rates, emergence of
drug resistant gonorrhea, and increasing asymptomatic infections. Comprehensive screening, diagnosis, and
efficient treatment protocols are necessary to reduce the prevalence of these
diseases.
2002 CDC Practice Guidelines
The
CDC publishes practice guideline for the diagnosis and treatment of STDs in any
population. Some of the recommendations
in the latest publication include the following preventive methods.
Prevention
Methods
- Only
reliable prevention is abstinence.
- Male
condoms when used correctly can prevent CC, GC, and trichomonas. Basically infections transmitted through
mucosal fluids. Condoms do not
guarantee protection when transmission is through skin-to-skin contact (e.g.
HSV, HPV, syphilis, and chancroid)
- Latex
has the least breakage / slippage rates (2 out of 100)
Brief overview of the most common STDs in the adolescent population
Evaluation of
a patient
History: Vaginal discharge (trichimonas, bacterial
vaginosis, and candidiasis, pain, dyspareunia, dysuria, burning, itching, odor,
systemic symptoms like headache, fever, rash, arthritis.
Physical: Complete physical and pelvic exam
Clues to
diagnosis include high temperature, malaise, lymphadenopathy, localized versus
generalized pain, rash, swollen joints, genital or perianal ulcers or erythema,
abnormal lesions or warts, characteristics of discharge, cervical motion
tenderness, uncustomary discomfort during pelvic exam.
Laboratory
test:
Wet mount – looking for clue cells, white blood cells, motile
protozoans, kOH whiff test, hyphae and pseudohyphae. Also, DNA probe for gonorrhea and chlamydia, non-treponemal test,
HIV testing, CBC with differential.
Assessment
and Plan:
Diagnosis/differential, Treatment, Partner notification (CC, GC,
trichomonas, HIV, syphilis, HSV), Co-infection (Chancroid, Syphilis, HSV),
pregnancy and education.
Chlamydia
Infections Chlamydia has 10% prevalence among teenage girls and 5% among
teenage boys. It may be asymptomatic in
both males and females. Annual screening
should be provided for sexually active females. The rate of infection has been shown to respond positively to
interventions such as large-scale screening and education, and community family
planning clinics.
Therapy –
Azithromycin 1gm orally x1 or Docycline 100mg orally BID x 7days
Gonococcal
Infections The past twenty years has seen a decline in the rate of gonorrhea
infection in almost all age groups.
However the rate in youth 15-19 years of age has remained high and constant. Symptoms can often be absent or more delayed
in women and therefore infection leads to more complications such as PID.
Therapy
- Dual therapy to cover presumptive co-infection with chlamydia is
recommended. Alternatives include,
Cefixime 400mg orally x1 or Ceftriaxone 125mg IM x1 plus chlamydia therapy as
above. Be advised that quinolone
resistant N. gonorrhoeae is increasing, but Cipro and others may be used, as
well as Spectinomycin.
Trichomoniasis Mostly asymptomatic in most men, or may
present as non-gonococcal urethritis.
In women, look for a malodorous yellow green discharge accompanied with
vulvar irritation. Also, a strawberry
looking cervix and visualization of motile protozoan on wet mount. This infection has been associated with a
2-4 fold increase in HIV transmission.
Therapy
- Metronidazole 2gm orally x1
STDs involving genital ulcers (Herpes, Syphilis, Chancroid)
Genital Herpes The typical painful multiple ulcers are
actually absent in many cases. Look for
recurrence and exposure history.
Transmission is through skin-to-skin contact and condoms may not
necessarily offer protection. The virus
establishes latency within peripheral nerve root ganglia. Prognosis and natural history vary dependent
on the serotype, therefore clinical diagnosis should be confirmed and serotype
determined.
Therapy
varies depending on episode and there are lots of alternatives.
Syphilis In primary syphilis the
ulcer is not painful and is at site of infection, secondary stage consist of
rash, lymphadenopathy, and the tertiary stage has gummatous lesions, cardiac,
ear and eye complications. Diagnosis is
made by visualization of Treponema pallidum by darkfield microscopy.
Therapy -
Benzathine PCN G 2.4 million units IM x1
All
patients who have syphilis should be tested for HIV.
The
availability of condoms to the adolescent population has reduced the incidence
of STDs in certain subsets. However,
promoting safe sex through sex education classes and community programs to
youth at younger ages could make more progress. Most of the sex education programs in schools start at the high
school level when it is already too late for some adolescents. Programs should be started in middle school
and youth should be encouraged to deal with their sexuality in an open,
healthy, and age appropriate way.
Practical ways of saying no, delaying sexual activity despite the social
and peer pressures should be taught along with the consequences of sexual
activity. Young teens should know about
STDs, how to protect themselves, and where to go for confidential and
affordable health care.
School based
clinics have been tried with some success.
The major drawbacks are that teens still require permission of parents
to participate and parents are concerned that if their children have access to
this service, they 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.
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.
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.
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.
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.