Prevention of Adolescent Pregnancy and Sexually Transmitted Disease: A Moral Imperative, a Public Health Imperative or Both?
The issues of adolescent sexuality, teen pregnancy prevention and teen pregnancy are those that are most often framed in terms of morality. Yet, the numbers of teens potentially affected include the majority of the adolescent population of the United States. At the same time, the knowledge, the technology and the skills exist among the health professionals in this country to significantly reduce or nearly eliminate teen pregnancy and sexually transmitted diseases (STDs) as serious risks, if handled from a public health perspective. The combination of parental involvement and comprehensive sexuality education that includes information about pregnancy prevention and protection against sexually transmitted diseases poses an effective means of reducing risks.
The purpose of this article is to suggest that health professionals have an ethical obligation to view the prevention of teen pregnancy and STDs as a public health issue, and the responsibility to apply their skills and knowledge to reduce the public health risks to the nation's adolescents. What is the real story about those risks?
Scope of the Public Health Issue
Despite declining rates of teen pregnancy over the last eight years, more than four in ten teen girls still get pregnant at least once before age 20, translating to approximately 900,000 teen pregnancies per year in the U.S. (Kirby, 2001, p. 2).
Despite a leveling off of sexual activity among teens, about two-thirds of all students have sex before graduating from high school, potentially exposing themselves to pregnancy and STDs (Ibid.).
As a result, about one in four sexually experienced teens contract one or more STDs each year-some of which are incurable, including HIV, which is of course life threatening. This translates to three million teens per year. In some geographic areas the rates are much higher. For instance in one community, 40 % of 14-19 year old girls who came to a teen clinic had an identifiable STD (Kirby, 2001, p. 20).
Among teenagers, a majority of HIV infections occur among girls (56 percent) and may occur through heterosexual contact. In 1999, the numbers of teens with positive HIV tests was over 8,500. Sixty percent of HIV-positive Americans became infected in their teens (Kirby, 2001, p. 21).
When very young girls do have sex, many report that it was either involuntary or unwanted. For example, in 1995, among girls who were 13 or 14 when they first had sex, 8 percent reported that their first experience was involuntary and an additional 31 percent indicated that it was unwanted (Kirby, 2001, p. 14)
Related data indicates that approximately 20 percent of births to 15-19 year-old girls were fathered by males six or more years older than their female partners and 50 percent of births to teens aged 15-17 were fathered by males aged 20 or older (Kirby, 2001, p. 19).
When teens give birth, their future prospects become bleaker. They become less likely to complete school and more likely to be single parents. Their children's prospects are even worse. In particular, children born to teen mothers aged 15-17 in comparison to those born to mothers aged 20-21 have less supportive and stimulating environments, poorer health, lower cognitive development, worse educational outcomes, higher rates of behavior problems and are more likely to become teen parents themselves (Maynard, 1997).
One in three girls who become pregnant have a repeat pregnancy. For teens who experience second (repeat) pregnancies, the likelihood that they will ever finish high school, or be financially independent is reduced dramatically, with even greater impact on the children born to them.
The relationship between sexual abuse, trauma and adolescent pregnancy has long been a concern for those who work with pregnant and parenting teens. Quantification of the issue has been difficult because of the under reporting of abuse and the associated stigma. However, studies in Washington state and Illinois have correlated sexual violence with teen pregnancy. In an Ounce of Prevention study, 61% of respondents reported histories of sexual abuse during childhood (Child,1987). In Washington State, a sample of 535 young women who became pregnant as adolescents found that two-thirds had been sexually abused. They found that the average age of abuse was about 9 years old. More recent studies continue to find similar linkages between teen pregnancy and abuse.
Despite the decreasing rate of teen pregnancy, it is important to remember that each year a new set of teens arrives on the scene, meaning that efforts to prevent teen pregnancy must be constantly renewed.
In addition, between 2000 and 2010, the population of teen girls aged 15-19 is expected to increase by nearly 10 percent, which means that even declining rates will not necessarily mean fewer numbers of teen pregnancies and births.
The Economics of the Public Health Burden
While the above statistics provide a staunch reminder about the emotional, health, and educational impact of teen pregnancy and STDs, the economic costs to society for teen pregnancies and/or STDs are staggering.
After adjustment for other factors related to teen parenthood, the estimated annual cost to taxpayers of births to young women who became mothers when they were 15-17, instead of 20-21, was at least $6.9 billion in 1996. This estimate includes only five categories of costs: lost tax revenues, increased spending on public assistance, health care for the children, foster care, and the criminal justice system (Maynard, 1997).
Increasing health care coverage for adolescents and children through programs such as the Children's Health Insurance Program (CHIP), increases in the numbers of young women in the juvenile justice system approaching those comparable to young men, and increasing costs of living are likely to have impacted these costs in the last five years. The educational needs of the children of teen parents, costs of childcare, increased needs for supportive pro bono legal services to determine custody, for example, and other such concerns have not even been factored into this equation.
The human and monetary costs of STDs are very high as well. STDs other than HIV can lead to infertility, ectopic pregnancy, cancer and numerous other health problems. They can also increase the chances of HIV transmission. The Institute of Medicine estimated that the 1994 monetary costs of STDs, other than HIV, among all people, not only adolescents, exceeded $10 billion per year. Because HIV can still lead to death and because treatment for HIV and AIDS is so expensive, the human and monetary costs of HIV and AIDS are extremely high as well (Kirby 2001).
Current Climate for Reducing the Risks for Adolescents
Several reports have surfaced in recent years that emphasize the complexity of the issues affecting prevention of pregnancy and STDs in the adolescent population. A new report released in May 2001 reviews the research regarding the antecedents of adolescent sexual behavior. The factors (antecedents) in the lives of young people that increase the chances of sexual risk taking and pregnancy are called "risk factors." Those that reduce the chances are called "protective factors" See Doug Kirby's report, "Emerging Answers" published by the National Campaign to Prevent Teen Pregnancy for a full discussion (Kirby, 2001). While the antecedents of sexual behavior are numerous and very complex, the solutions are variable and often focused on moral grounds rather than on knowledge or technology, both of which exist in sufficient quantity to make a positive impact on this issue.
Abstinence-only Education: Most federal money in recent years has been spent to support abstinence-only programs. Early in the 1980s, Congress first delved into the pregnancy prevention issue by passing the Adolescent Family Life Act (AFLA). While funds addressed the value of chastity and self-discipline, support was also provided for pregnant and parenting adolescents. AFLA funds still exist but provide only a fraction of the support given by federal agencies to these issues.
As part of reworking the nation's welfare system, in 1996 Congress enacted a new abstinence education initiative, (Section 510 of Title V of the Social Security Act) projected to spend $87.5 million in federal, state, and local funds per year for five years. The new program was designed to emphasize abstinence from sexual activity outside of marriage, at any age (19 or 29), rather than premarital abstinence for adolescents, which was typical of earlier efforts. The federal tax burden was $50 million per year and the pot has become $20 million richer due to ardent support from individuals in Congress who were distressed that the earmarked funds were being used to deliver messages about contraception and prevention of disease as well.
While early programs trying to win awards for this money included abstinence as part of their message, they also often included information regarding prevention of pregnancy and disease. Certain members of Congress got increasingly agitated that monies in some cases went to agencies that delivered multiple messages or housed both an abstinence-only program as well as a more comprehensive prevention program. The restrictions on the monetary awards have become much stricter, negatively impacting school-based and statewide initiatives that had been comprehensive in nature. The federal funds require state and local governments to match funds according to a formula in order for agencies to receive the abstinence-only federal monies. This has dramatically limited the availability of funds for programs or agencies that believe in providing students with information about contraception and prevention of STDs as well as abstinence. As a consequence, many school districts and even states have redirected already well-established comprehensive sexuality education programs to convert their messages to abstinence-only education, usually against the express wishes of educators and health professionals.
Comprehensive Sexuality Education: The value of providing information and access to both contraception and protective devices has been well accepted in some arenas, yet at times challenged as providing students with mixed messages. The concern was often expressed in the past that giving students information about sexuality and contraception would only encourage sexual activity. However, numerous studies do clearly document that programs that provide access to methods of contraception, i.e. condoms, do not result in increased or earlier initiation of sexual activity (Satcher, 2001). Furthermore, studies have demonstrated that students who had been taught comprehensive sex education rather than abstinence-only sex education were more likely to use contraception when they did become sexually active and in fact were more likely to be prepared to do so.
National studies conducted with both teens and parents of teens have likewise indicated that clearly the majority of parents want their teens to receive education regarding contraception and prevention of disease as well as information about abstinence within the school setting. A 2000 report supported by the Kaiser Family Foundation, "Sex Education in America: A view from inside the Nation's Classrooms" is based on a series of national surveys with more than 4,000 public secondary school students and their parents, sex education teachers and school principals about their experiences with and attitudes toward sex education (Satcher, 2001). The surveys found that most parents look to school sex education programs to provide their children with practical skills that students ad teachers report are not consistently covered. Several states have now conducted similar surveys of parents and have been able to verify that this is true for their state.
Several national organizations have been vocal in support of comprehensive sexuality education. The Sexuality Information and Education Council for the United States (SIECUS) has published "Guidelines for Creating Comprehensive Sexuality Education Programs" and has been instrumental in assisting states in enacting legislation to support such education. The National Organization on Adolescent Pregnancy, Parenting and Prevention (NOAPPP) adopted a policy statement in support of comprehensive sexuality education in 2001 in order to inform the development of state, local and or institutional policies and standards.
A controversial report, "The Surgeon General's Call to Action to Promote Sexual Health and Responsible Behavior" released in June 2001, "encourages open dialogue on sex and supports the notion that sex education must be wide-ranging, begin early and be available throughout life." It recommends that the benefits of abstinence be discussed but points to the importance of instructing teens in how to prevent pregnancy and disease. This report states that more research must be done before conclusions are reached on the efficacy of "abstinence-only" programs, a view echoed and well documented by Doug Kirby in "Emerging Answers". Kirby's work also reviews evaluations of well-documented programs to reduce teen pregnancy and unprotected sexual behavior, with some conclusions about programs that have been found to be successful.
The controversy continues about when teens should initiate sexual activity. The recently released and above identified reports are significant for their insight and review of the research into the complexity of the factors that affect adolescent sexual behavior and the knowledge that has been gained to date about programs that do work to reduce pregnancy and unprotected sexual behavior.
For Health Providers, Must We Take a Public Health Perspective?
It is clear that the impact of unprotected adolescent sexual behavior has severe human and monetary costs for teens, children of teen parents and for society, as well as for the families of the affected teens. What other health issue costs this much in terms of lifelong earning potential, educational success and supportive services for so many individuals, yet has so many resources potentially available for prevention?
The Resources: There is a wide variety of effective contraceptive technologies available to which a teen could have access, and at affordable prices.
There are readily available and comparatively safe methods of protection against disease, also easily affordable.
There are safe and effective measures available for emergency contraception.
There are many well-trained health educators, nurses and physicians who can provide comprehensive education about many aspects of healthy sexuality, pregnancy prevention, STD prevention and development of healthy relationships.
There are overwhelming numbers of parents, teens, school administrators and others who believe that such education belongs in the school environment and wish that their children could receive consistent education about sexuality there.
There are overwhelming numbers of parents who would like to be able to speak more comfortably with their teens about sexuality and teens who want this also.
The Barriers: Federal legislation has provided massive amounts of money to state entities, schools, agencies and programs that are willing to only talk about abstinence.
Minority numbers of parents express negative views regarding the teaching of comprehensive sexuality education.
Teachers and others fear negative repercussions when they talk about methods of contraception and protected sexual activity.
Students obtain information related to risk-taking behavior and prevention from their friends that is often inaccurate.
As Nurses how can you Reduce the Public Health Need, regardless of your own Values?
You, individually and collectively, can educate school administrators, parents and other policy makers about the severity of the public health issues of teen pregnancy, STDs and sexual abuse in your community and in this country.
You can advocate on behalf of more comprehensive approaches for educating teens in your practice settings, your community and your schools.
You can be sure that there are available and affordable and non-punitive resources for teens to obtain contraceptive information and protection in your community.
You can support your community by creating and seeking vehicles to display public service announcements that support and provide information to teens and parents on this topic.
You can provide multiple opportunities for parents whom you serve, to learn more about communicating about issues of sexuality with their children at every age.
You can take every available opportunity to directly educate teens and parents about prevention of pregnancy, STDs and sexual violence in their own lives, as well as about abstinence.
You can support youth development activities that reduce the antecedents of risk-taking behavior and promote protective factors against pregnancy and sexual risk taking.
References
Bayer, Fine, (1992) "Sexual abuse as a factor in adolescent pregnancy and child maltreatment," Family Planning Perspectives 24(1) p. 4-11.
Child Sexual Abuse: A hidden factor in adolescent sexual behavior, The Ounce of Prevention Study, (1987).
Dailard, C (2000) "Reviving Interest in Policies and Programs to Help Teens Prevent Repeat Births," The Guttmacher Report on Public Policy, 3(3), 1-2.
Gold, RB (2000) "Adolescent Care Standards Provide Guidance for State CHIP Programs," The Guttmacher Report on Public Policy, 3(3), 5-8.
Kirby, D. (2001) Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy.
Maynard, R. (1997) The Robin Hood Report: Kids Having Kids: The Economic Costs and Social Consequences of Teen Pregnancy, Washington, DC: The Urban Institute.
NOAPPP Network, (2001) Washington, DC. National Organization on Adolescent Pregnancy, Parenting and Prevention. 21(3) 9-27.
Satcher, D (2001) The Surgeon General's Call to Action to Promote Sexual Health and Responsible Behavior, Atlanta, Ga: The Centers for Disease Control and Prevention.
Sonfield, A. and Gold, RB (2001) States' Implementation of the Section 510 Abstinence Education Program, FY 1999. Family Planning Perspectives, 33(4), 166-171.