Reproductive and Sexual Health

 

in the Adolescent Population

 

 

Adebola O. Akanbi

 

 

 

OUTLINE

 

CURRENT ISSUES IN ADOLESCENT REPRODUCTIVE HEALTHCARE

 

GROWTH AND DEVELOPMENT

 

CONTRACEPTION

 

PREGNANCY

 

PRENATAL CARE

 

ABORTION

 

SEXUALLY TRANSMITTED DISEASES

 

BARRIERS TO CARE

 

THE ROLE OF POLICY

 

CONCLUSION

 

LINKS FOR MORE INFORMATION

 

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). 

Growth and Development

 

“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.

 

Contraception

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). 

 

Pregnancy

 

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

 

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).

 

Abortion

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

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. 

 

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.