20. ADOLESCENT SEXUALITY
AND HEALTH CARE REFORM
Adele Dellenbaugh Hofmann
More than half of all adolescents are sexually experienced well before the end of their second decade, leading to such serious consequences as unintended pregnancies, sexually transmitted diseases, and acquired immunodeficiency disease (AIDS/HIV).1 Yet we, as a nation, have not given a high priority to the primary prevention of these outcomes among sexually active youth in terms of either health education or health care itself. Public policy too often has swept teen pregnancy under the rug until after conception has occurred or has limited preventive concerns to seeking universal teen abstinence—an unrealistic goal at best. As a result, we have one million teenagers becoming pregnant each year, equivalent to one out of every nine 15- to 19-year-old girls, or one out of five among those who are sexually active.2 Some 600,000 give birth, becoming parents far too soon and curtailing their future potentials. Rates of gonorrhea, chlamydia, and syphilis among sexually active youth today are higher than among sexually active persons of any other age. While the number of cases of clinical AIDS remains low in the adolescent years, the incidence of HIV seropositivity is rising exponentially and is particularly high among inner-city, homeless, and runaway teens. It also is true that those who manifest AIDS between ages 20 and 26 in all probability become infected as adolescents. The costs to all these young people and to the nation are incalculable.3
Answers are far more complicated than simply telling adolescents to be abstinent until marriage and hoping that will happen—as has been
Cognitive and psychosocial developmental factors also come into play. Younger teens, in particular, are still concrete in their thought processes. It is not until midway in the second decade that they will gain the ability to think in an abstract manner. Concrete thinkers are existential, focused on the here-and-now. They cannot fully appreciate the future consequences of their current acts. At the same time, adolescents are defining their identities and seeking emancipation, processes that, by nature, involve a good bit of experimentation and at least some denial of associated risks.4
Societally, while our basic moral message continues to be one of no premarital sex, we do everything possible to promote it in an exceptionally provocative environment. In 1988, American television viewers were exposed to some 14,000 instances of sexual material, of which more than 9,000 were scenes suggestive of sexual intercourse with varying degrees of explicitness.5 Most such scenes were highly romanticized. Only 1% addressed sex education, sexually transmitted diseases (STDs), birth control, or abortion. In an even more recent study of televised sexual material conducted in the fall of 1996 during the prime-time family hour,6 three out of four programs (75%) on the major networks contained sexual content; 61% showed some degree of sexual behavior (up from 48% in 1986 and 26% in 1976), with 30% featuring scenes with a primary emphasis on sex (up from 23% in 1986 and 9% in 1976.) Further, during the three-week sample period, 15 cases of sexual intercourse were either depicted or clearly implied. Here again, only a handful (6%) had an overall emphasis on sexual risks and responsibilities, such as waiting until a relationship matures before having sex or pursuing efforts to prevent STDs or unwanted pregnancy when sexually active. Further, many MTV rock videos give messages that encourage not only sexual activity but also sexual exploitation—particularly in “heavy metal.”
The clothing industry seems equally bent on turning juniors into
These images create an environment in which there is an extraordinary degree of pressure to be sexually active, to “make out” in the pursuit of autonomy and identity, especially among males. In many respects, we continue to maintain the double standard of old in valuing and encouraging boys to press on and be sexually aggressive while valuing girls who can resist. But major societal changes have occurred in the female role. Prohibitions against sexual activity among unmarried women today are considerably less than in the past. Pregnancy and childbearing no longer need be an invariable outcome—contraception and abortion have changed the odds greatly. Further, single parenthood no longer results in social ostracism.
For many youths, sexual intimacy is something more than an impulsive response to pheromones, passion, or curious experimentation. Teens have a difficult and ambiguous status in our society. We call them “transitional,” which implies that they are neither here nor there but in transit between one place and another—in limbo. They have no significant role or place other than as students. They are not needed either to support the concept of the family, as are little children, or to contribute to society, as are adults. They are segregated away from the societal mainstream in schools and stratified in the classroom according to age. As a result, adolescents today comprise a distinct and separate subculture with powerful peer-group influences and few external ameliorating forces. Sexual activity frequently is perceived as an important marker of this subculture and something that “all kids do.”
Many adolescents who have a negative view of the world are chronically depressed with poor self-esteem and believe that sexual intimacy will provide the love and closeness that they so urgently want. As an added bonus for those teen girls who also are drifting with no sense of the future or personal goals and are doing poorly in school, having a baby often is perceived as providing someone to love and to love them unconditionally, as bestowing instant adulthood, and as ending their “in limbo” status. In a national longitudinal survey of eighth-grade students, more
Other youths are angry and feel deprived, both of which can lead to sexual acting out. Some teens have a self-interested, hedonistic view of life and a belief that they are personally entitled to get their due, including sexual gratification. The new phenomenon of the shrinking “American Dream,” in which young people rightly perceive that they will have less economic opportunity than their parents, may well promote a sense of disappointment and of being cheated by life with little point in delaying sexual activity.
All these societal and developmental factors combine to make it very difficult for adolescents to be fully responsible for their sexual behavior and create a situation that forces intimacy to be clandestine, unintended, and unplanned. Sexual risks tend to be denied by teens who often are both ambivalent about being sexually active and not cognitively mature enough to appreciate the potential risks. Powerful environmental and biological forces often overwhelm even the best of abstinence intentions. Once abstinence intentions give way to action, far less anxiety, fear, blame, and guilt are experienced if the adolescent allows himself or herself to be just swept away by overwhelming emotion, without conscious planning and in denial of risks in the mistaken belief that pregnancy or AIDS “can't happen to me.”
In countering these pressures, parents continue to find it difficult to give guidance to their young about sex beyond prohibition. Few mothers or fathers have open discussions about sexual decision making or sexual responsibility.8,9 Few even know whether their offspring are sexually active or even make such an inquiry. Many parents unwittingly even facilitate sexual activity. It is they who pay the bills for bikini bathing suits and miniskirts. It is they who no longer insist on adult chaperones at teen get-togethers. It is they who are very free with the keys to the family car or even buy their 16-year-old a car of his or her own as a rite of passage. And it is they who often are so self-preoccupied that they demand little accountability from their adolescent.
From another perspective, parental discord and divorce, together with the associated family chaos surrounding such an event, is a major contributor to adolescent health-risk behaviors, including sexual activity.10 The rate of divorce over the past decade has escalated to such a degree
A number of recent popular movies, humorous and good-natured in tone, provide clear models for adolescent sexual freedom by portraying young heroes who monumentally exceed the boundaries of parental permission—and get away with it—while their parents are not at home. In Risky Business, for example, Tom Cruise sets up his home as a bordello for his high school classmates as an entrepreneurial fund-raiser and barely returns the house to normal as his parents walk up the front walk. He does not get caught or suffer any penalty. This is a far different message from teen cult movies of the past, such as James Dean's Rebel without a Cause, so full of anguish and painful consequences for defiant behavior, or the resentful attitudes toward adult authority and adult limit setting expressed by adolescents in The Breakfast Club.
Schools do little better than parents at promoting responsible adolescent sexual behavior. While AIDS education has now been introduced into most secondary school classrooms, relatively few programs employ an approach based on combining social learning, social inoculation, and cognitive-behavioral learning theories, now recognized as the most effective method for modifying behavior (see the section “Modifying Adolescent Sexual Risk Taking”). The vast majority simply provide young people with information about the risks of sexual intimacy and advocate abstinence, an approach that has been found to have only a small effect. Few students are provided answers to all their questions in an honest, straightforward manner; nor are they equipped with the skills and support systems that they need to deal with our highly sexualized society. Moreover, none of these courses reaches the large number of sexually active young people who have dropped out of school. Current conservative political forces also seek to severely restrict sex education to teens. In 1966, the federal legislature appropriated $50 million annually for abstinence-only education in schools, mandating that “sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects” be the only message taught and banning inclusion of any information about other means of pregnancy, AIDS, or STD prevention.12 Such actions totally ignore the fact that abstinence-only education is not very effective for the large numbers of young people who already are sexually experienced.
As far as the health care sector is concerned, with the exception of such specialized programs as family planning and adolescent medicine
THE STATISTICS
Sexual Activity
In 1995, the Centers for Disease Control's (CDC's) national school-based Youth Risk Behavior Survey (YRBS) 13 found that 53% of students in all grades reported being sexually experienced, with 17% having been involved with four or more lifetime partners. By the end of their senior year, nearly three out of every four male students (70%) and two-thirds of all female students (66%) had experienced sexual intercourse at least once, and 7% reported that they either had been pregnant or had impregnated a partner. Nine percent had even initiated sexual intercourse before they were age 13. African-American students (73%) were significantly more likely than White and Hispanic students (49% and 58%, respectively) to have ever had sexual intercourse (Table 20.1). These data were not singularly different from those found in the 1993 YRBS.14
The proportion of adolescent females who report being premaritally sexually experienced not only has increased dramatically over the past two decades but is the culmination of a trend that began at the turn of the 20th century and clearly suggests a fundamental and permanent societal change in teenage girls' sexual behavior. Despite their many statistical flaws and dominantly Caucasian subjects, Kinsey's surveys in the 1940s still provide significant information.15,16 Kinsey found that among women born before 1900, only 3% were premaritally sexually experienced by age 18—and this usually during the period of engagement with their fiancé But for those born just a few years later, or after 1900, the number increased sixfold to 18%, again primarily with a fiancé The incidence of sexual activity among adolescent boys, however, has not changed a great deal. In Kinsey's time, 40% of men reported that they were experienced by age 15 and 60% by age 17. The cardinal difference between past and present patterns of adolescent male sexual activity is
| 1993 | 1995 | |||||
|---|---|---|---|---|---|---|
| Female | Male | Total | Female | Male | Total | |
| SOURCES: Centers for Disease Control (1995 [14],1996 [13]). | ||||||
| Ethnicity/race | ||||||
| White | 47.4 | 49.8 | 48.4 | 49.0 | 48.9 | 48.9 |
| Black | 70.4 | 89.2 | 79.7 | 67.0 | 81.0 | 78.4 |
| Hispanic | 48.3 | 63.5 | 56.0 | 53.3 | 62.0 | 57.6 |
| Grade | ||||||
| 9th | 31.6 | 43.5 | 37.7 | 32.1 | 40.6 | 36.9 |
| 10th | 44.9 | 47.4 | 46.1 | 46.0 | 50.0 | 48.0 |
| 11th | 55.1 | 59.5 | 57.5 | 60.2 | 57.1 | 58.6 |
| 12th | 66.3 | 70.2 | 68.3 | 66.0 | 67.1 | 66.4 |
| Four+partners | 15.0 | 22.3 | 18.8 | 14.4 | 20.9 | 17.8 |
| Total | 50.2 | 55.6 | 53.0 | 52.1 | 54.0 | 53.1 |
There has, however, been a recent modest drop in the proportion of both teens who are sexually active, as evidenced in the CDC's series of high school youth surveys,13,14,19 and females, as seen in the 1995 National Survey of Family Growth (NSFG).20 In the 1990YRBS, 59% of all students reported that they were sexually experienced as compared to 55% in 1991 and 53% in 1995. Over the same period, there was a drop of 3%, from 40% to 37%, in the number of students reporting two or more lifetime partners and a decrease of 6% for four or more partners.
In the 1995 NSFG, the percentage of teenage females aged 15 to 19 years declined to a slightly greater degree (Figure 20.2), with only
Figure 20.1. Percentage of women aged 15, 18, and 20 whohad premarital sexual intercourse by birth cohort. Source: Cates(1990 [17]).
Figure 20.2. Percentage of women aged 15 to 19 years who reported having had premarital sexual intercourse—United States, 1970–1995. Source: Abma et al. (1997 [20]).
Despite the overall drop in the percentage of sexually active youth found in these surveys, a return to universal teen abstinence is highly unlikely. First, taking an overall figure is misleading in not considering the data by both ethnicity and age (Table 20.1). A closer examination of YRBS findings reveals that three-quarters of all Black adolescents continue to be sexually active, that rates among Hispanic girls are increasing, that more 11th-grade females of all ethnicities were sexually active in 1995 than in 1993, and that the percentage of sexually active 12th-grade females has not changed. Second, the trend toward an increasing incidence of premarital sexual intercourse, particularly among teenage girls, has taken place over a span of nearly nine decades and can only be seen as reflecting a major and persistent societal change in normative adolescent behavior. It is clear that a substantial number of teenagers will continue to be at risk from sexual activity and that initiatives promoting abstinence alone will be far from sufficient to meet the task of protecting our adolescents from serious health harm.
The initiation of sexual activity appears to be determined by the interaction of a number of biological, psychological, cultural, and social factors, either singly or severally, including early pubertal onset (particularly in girls), cognitive immaturity, ethnicity, dysfunctional home situations, past physical or sexual abuse, chronic depression, poor self-esteem, absence of future plans, poor schooling, and economic disadvantage.22–33 Most of these studies also show a significant association of an early coital debut, multiple partners, choice of a high-risk partner, and nonuse of protection with a wide range of other problem behaviors, such as alcohol use, marijuana use, school problems, minor delinquent acts, depression, and suicide attempts. Only Stanton 34 showed no such relationship in a survey of African-American youths in a public housing project. These adolescents perceived sex as being in a very different domain.
None of these studies, however, assess the degree to which these other associated risk behaviors are within the experimental or committed range and the degree to which they can be considered truly dysfunctional and deviant. Further, all persons are sexual beings from the time of birth, and the exploration of intimacy in general is a normal behavior for adolescents
Pregnancy
As previously noted, about one million teenagers become pregnant each year.2 In 1990, 11% of all adolescent girls became pregnant, 5% gave birth, 3.3% had an out-of-wedlock birth (although many in-wedlock births were premaritally conceived), 4.6% had an abortion, 1.5% experienced a miscarriage, and only 0.13% gave up their baby for adoption.35 Another way of looking at this epidemic is to state that 43% of the approximately 17 million teen females in the United States will become pregnant at least once before they reach their 20th birthday.36 Further, the vast majority of current teen births are out of wedlock. In 1960, only 15% of all adolescent births were to single mothers, but by 1993 this figure had increased nearly fivefold to 72% (Figure 20.3).37 Rates are highest among teenagers of Mexican, Puerto Rican, and African-American ethnicity, as they are for Mexican, Puerto Rican, and African-American women of all age-groups.38
There has, however, been a recent reversal in the birth rate to teens (Figure 20.3). Although the rate among 15- to 19-year-olds rose by nearly 10% from 53.0 births per 1,000 in 1980 to a high of 62.1 per 1,000 in 1991, the subsequent three years saw a drop of 3% to a rate of 58.9 per 1,000 in 1994.37 This drop, however, was considerably less (only 1%) when 18- to 19-year-olds were excluded, with rates for 1980, 1991, and 1994 among 15- to 17-year-olds being 32.5%, 38.7%, and
Figure 20.3. Birth rates for women aged 15 to 19 years—United States, 1970–1994. Source: National Center for Health Statistics (1996 [37]).
Whatever decrease in adolescent birth rates has occurred is almost exclusively due to more effective contraception (particularly among older teens), not a higher incidence of abortions—which actually has declined—or a reduction in the percentage of sexually active youths, which has only modestly changed. Further, despite this recent decline, the 1994 teen pregnancy rate is still higher than in any year prior to 1990.
California is no exception to high teen birth rates and, in fact, has a substantially higher 15- to 19-year-old rate (68 per 1,000) than the national average (58.9 per 1,000).39 Here too, however, there has been a significant drop of 5.5% from 69.9 births per 1,000 population in 1993 to 64.4 per 1,000 in 1995. These statistics, however, do not reflect the wide geographic variation within the state with singularly high teen birth rates ranging from 92 to 100 per 1,000 15- to 19-year-olds and comprising 18% to 20% of all births reported in Fresno, Kern, Kings, Madera, Merced, and Tulare, all agricultural counties, with the largest number of births (both adolescent and adult) being to mothers of Hispanic ethnicity.40 Nor do these figures represent the true scope of the problem, as California has an even higher adolescent pregnancy rate than reflected in teen birth statistics alone. In 1992, this state had both the highest total number of estimated abortions (338,700) and the highest abortion ratio (564 abortions per 1,000 live births) of any state in the United States.41 As approximately one in five of all abortions are in teenage girls, it can be concluded that California has one of the highest, if not the highest, teen pregnancy rate in the nation.
The cost of births to adolescents alone argues for a greatly expanded program of contraception. Few teen mothers place their babies for adoption (only 2%), and most establish families of their own, often as single parents. In a 1989 study by the Center for Population Options, it cost $21.55 billion to support these young families, or 53% of the public funding spent for Aid to Families with Dependent Children (AFDC), food stamps, and Medicaid (Medi-Cal in California).42 By 1992, this figure had risen to $34 billion,43 with the typical AFDC household receiving $1,426 per month in benefits, or $17,112 per year.44 Effective contraceptive programs could result in substantial savings, particularly in California, where teen births impose a singularly high toll on our financial resources. For every $1 spent on family planning services in this state, $7.70 is saved by averting an unintended birth and its attendant health and welfare costs as compared to an average national savings of $4.40.45 These costs are but the tip of the iceberg when one considers all that is required to support teenage families. In 1992, for example, more than 1,900 kindergarten classes were needed in California to serve just the children born to teen mothers five years earlier and cost the state almost $262 million.46
The United States fares poorly when measured against teen pregnancy and pregnancy outcomes in other developed countries. Rates in this country for 15- to 19-year-olds are twice as high as in England, New Zealand, or Canada; three times as high as in Sweden; and nine times as high as in the Netherlands.2,47 In a detailed comparative study conducted in 1981,48 the average pregnancy rate in selected European countries was 36 per 1,000 adolescent girls, with one-third terminating in abortion and two-thirds resulting in a live birth. In the United States, there were three times as many conceptions, or 98 per 1,000 (Figure 20.4). Moreover, the adolescent abortion rate in the United States alone exceeded the total conception rate of any of the comparison countries. Somewhat more recent data reveal even more dire findings, with 1989 teen pregnancy rates having substantially declined throughout Europe to 13% in Germany, 8.6% in the United Kingdom, and 0.9% in the Netherlands and Denmark49 at a time when the teen pregnancy rate in this country was at a high of 38.7%.19 The primary difference in both studies was not in the incidence of sexual activity—it was similar in all countries—but rather in public policy. The European countries had adopted a vigorous primary prevention approach and provided comprehensive sex education and readily available contraception to all adolescents in need. The United States, on the other hand, approached the issue by promoting abstinence
Figure 20.4. Pregnancy rates and outcomes among adolescent women aged 15 to 19 years in selected western European countries and the United States. Source: Jones et al. (1985 [48]).
Abortion
Between 1980 and 1990, the annual ratio of legal abortions to live births for all age-groups in the United States remained relatively constant at approximately 350 per 1,000. Since 1990, however, this ratio has gradually declined to 321 per 1,000, as has the total number of abortions (from a high of 1,429,577 in 1990 to 1,267,415 in 1994).50 The proportion of all abortions occurring in adolescents 19 years of age or less has decreased from a high of 32.6% in 1972 to 20.2% in 1994, although this latter figure has decreased less than 1% since 1991 (21%) and reflects a lesser effect of prevention efforts in this age-group than in others (Table 20.2). Adolescents aged 15 to 19 years are 1.5 times more likely than adults to terminate a pregnancy, with an abortion ratio of 440 per 1,000. When broken down for each year of age, the ratios for younger adolescents are even higher. In 1992 (the latest date for which detailed data are available), the abortion ratio was 790 per 1,000 for those 14 years of
| Year | All abortions in 10- to 19-year-olds[a] (%) | Total no. of abortions in 10- to 19-year-olds (in 1,000s)[a] | Abortion ratio in 10- to 14-year-olds[b] | Abortion ratio in 15- to 19-year-olds[b] | Abortion rate in sexually active 10- to 14-year-olds[c] | Abortion rate in sexually active 15- to 19-year-olds[c] |
|---|---|---|---|---|---|---|
aFrom Centers for Disease Control, Abortion surveillance: Preliminary data—United States, 1994, Morbidity and Mortality Weekly Report 45(1997), 1123. | ||||||
bNumber of legally induced abortion per 1,000 live births in age-group (from S. K. Henshaw and J. Van Vort, Abortion services in the United States, 1991 and 1992, Family Planning Perspectives 26 [1994], 100). | ||||||
cNumber of legally induced abortions per 1,000 sexually active females in age-group (from A. M. Spitz, P. Velabil, L. M. Koonin, et al., Pregnancy, abortion and birth rates among US adolescents—1980, 1985, and 1990, Journal of the American Medical Association 275[13, 1975], 989). | ||||||
| 1994 | 20.2 | 256.0 | — | — | — | — |
| 1993 | 20.0 | 266.0 | — | — | — | — |
| 1992 | 20.1 | 273.2 | — | — | — | — |
| 1991 | 21.0 | 291.7 | 502 | 379 | — | — |
| 1990 | 22.4 | 320.2 | 515 | 403 | 41.7 | 55.5 |
| 1985 | 26.3 | 349.4 | 624 | 462 | 48.0 | 73.7 |
| 1980 | 29.2 | 378.9 | — | — | 41.2 | 78.3 |
| 1976 | 32.1 | 317.2 | — | — | — | — |
| 1972 | 32.6 | 191.3 | — | — | — | — |
Sexually Transmitted Diseases
The prevalence of STDs among adolescents at risk from sexual activity is higher than among at-risk individuals of any other age. In 1995, the rate of gonorrhea among 15-to 19-year-olds was 665 per 100,000, with rates of 840 per 100,000 for teen females and 498 per 100,000 for teen males (Table 20.3).51 There were striking differences, however, when race and ethnicity was taken into account. Rates in African-American adolescents were more than 20times those who were White or Hispanic. Teen females led all age-groups in reported prevalence; teen males were second only to 20- to 24-year-olds. If these data were modified to include only those individuals who were sexually active and at actual risk, the teenage rate would be even higher; considerably fewer adolescents are sexually active (50%–55%) as compared to older populations (80%–90%).52 It is true, however, that there has been a significant drop in reported gonorrhea rates since 1992 for all age-groups, including adolescents, with a greater decline in males than females.51,53 Nonetheless, inter-age-group gonorrhea ratios remain the same, and teen females continue to have the highest prevalence of this disease even when not factored for at-risk status.
The gonorrhea data parallels the high prevalence of other common STDs in adolescents and often is a comorbid infection. Cervical and vaginal cultures of various sexually active female adolescent populations find an average of 11% (range: 3%–18.3%) positive for gonorrhea, 22% (range: 15%–37%) for chlamydia, 21% (range: 6%–48%) for trichomonas, and 39% (range: 32%–46%) for human papilloma virus as detected by positive cervical cytology or DNA probe. Among urethral cultures in sexually active adolescent males, an average of 6% (range: 3%–9%) are positive for gonorrhea and, in one study, 3% for chlamydia.35
The greater incidence of STDs in sexually active adolescents as compared to older sexually active populations is attributed to a combination of an early coital debut, exposure to a greater number of partners, and a less frequent use of the condom. The highest STD rates are seen in disadvantaged inner-city teens, for whom these behaviors are even more prevalent than in advantaged youths.35 The primary exception is human papilloma virus infection, which has been found to be as frequent in college-age females as in female juvenile detainees.54
Pelvic inflammatory disease (PID) is one of the most serious complications
| 1992 | 1993 | 1994 | 1995 | |
|---|---|---|---|---|
| SOURCE: U.S. Department of Health and Human Services, Public Health Service, Division of STD Prevention, Sexually Transmitted Disease Surveillance, 1995 (Atlanta: Centers for Disease Control, 1996). | ||||
| All races/ethnicities | ||||
| Total | 869 | 733 | 739 | 665 |
| Male | 770 | 616 | 590 | 498 |
| Female | 974 | 857 | 897 | 840 |
| White, non-Hispanic | ||||
| Total | 166 | 137 | 151 | 143 |
| Male | 72 | 49 | 50 | 45 |
| Female | 264 | 230 | 258 | 246 |
| Black, non-Hispanic | ||||
| Total | 4,979 | 4,333 | 4,328 | 3,843 |
| Male | 4,888 | 4,062 | 3,893 | 3,267 |
| Female | 5,073 | 4,611 | 4,772 | 4,433 |
| Hispanic | ||||
| Total | 279 | 280 | 257 | NA |
| Male | 209 | 207 | 180 | NA |
| Female | 359 | 361 | 343 | NA |
From 1981 through 1991, syphilis rates among both male and female 15- to 19-year-olds accounted for 10% to 12% of all primary and secondary cases, with a 1991 rate of 18 cases per 100,000 males and 35 cases per 100,000 females.57 Although rates were highest among 20- to 29-year-olds of both sexes throughout this period, between 1987 and 1990 rates for adolescents rose by 41% among 15- to 19-year-old males and by 112% for 15-to 19-year-old females, contributing significantly to the overall 21% increase in the prevalence of primary and secondary syphilis that occurred during this time. By 1991, the rate for 15- to 19-year-old females (35 per 100,000) was almost twice that of males, reflecting a dramatic increase among women of all ages in the latter half of the 1980s.
Figure 20.5. Annual number of AIDS cases reported in adolescents aged 13 to 19 years by sex—United States, 1984–1996. Source: Centers for Disease Control (1997 [58]).
Acquired Immunodeficiency Disease (AIDS/HIV)
As of December 1996,58 a cumulative total of 2,754 cases of clinical AIDS had been reported in 13- to 19-year-old adolescents; 63% of these cases occurred in males and 37% in females (Figure 20.5). Among 20to 24-year-olds, who most likely became infected as adolescents, there was a cumulative total of 21,097 cases with a male-to-female ratio of three to one. This represents a dramatic increase in total AIDS cases since just 1993, when only 157 cases among 13- to 19-year-olds were reported.59 Data about AIDS cases prior to this time are difficult to interpret, as the diagnostic criteria were greatly expanded in 1993, admitting a far greater number of cases than before. Cumulative 1996 data for HIV seropositivity revealed a total of 3,193 cases in 13- to 19-year-olds for nearly a one-to-one male-to-female ratio, with females predominating (1,563 and 1,630 cases, respectively).
The adolescent age-group is the only one to demonstrate such a high proportion of HIV/AIDS cases occurring in females. All other groups
| 13–19 years | 20–24 years | |||
|---|---|---|---|---|
| Exposure Category | N | (%) | N | (%) |
aIncludes patients pending medical record review; patients who died, were lost to follow-up, or declined interview; and patients whose mode of exposure to HIV remains undetermined. | ||||
| SOURCE: Centers for Disease Control, U.S. HIV and AIDS cases reported through December 1995, HIV/AIDS Surveillance Report 7(2, 1996), 1. | ||||
| Males | ||||
| Men who have sex with men | 501 | (33) | 9,084 | (63) |
| Injecting drug use | 97 | (6) | 1,803 | (13) |
| Men who have sex with men and inject drugs | 77 | (5) | 1,562 | (11) |
| Heterosexual contact | 646 | (42) | 539 | (4) |
| Hemophilia/coagulation disorder | 38 | (2) | 505 | (4) |
| Recipient of blood transfusion, blood components, or tissue | 66 | (4) | 101 | (1) |
| Other/undetermined[a] | 109 | (7) | 802 | (6) |
| Total | 1,534 | (100) | 14,396 | (100) |
| Females | ||||
| Injecting drug use | 132 | (16) | 1,430 | (31) |
| Coagulation disorder | 9 | (1) | 12 | (<1) |
| Heterosexual contact | 440 | (54) | 2,338 | (51) |
| Recipient of blood transfusion, blood components, or tissue | 60 | (7) | 105 | (2) |
| Other/undetermined [a] | 179 | (22) | 674 | (15) |
| Total | 820 | (100) | 4,559 | (100) |
While the incidence of HIV/AIDS infection in adolescents is low compared to older individuals, certain youth populations show an alarmingly high prevalence of HIV infection (Table 20.5). For comparison, the
| Group | Age (Years) | % HIV Positive |
|---|---|---|
| SOURCE: U.S. Congress, Office of Technology Assessment, Adolescent Health—Volume 2 (Washington, D.C.: U.S. Government Printing Office, 1991). | ||
| Military active duty five-year conversions | 17–19 | 0.01 |
| Military applicants | 17–19 | 0.03 |
| College youth | College age | 0.2 |
| Juvenile detainees | 16–17 | 0.2 |
| Job Corps enrollees | 16–21 | 0.4 |
| Youths seen in an inner-city adolescent clinic | 15–18 | 0.7 |
| Adolescents attending an STD clinic | 15–19— males | 2.0 |
| 15–19— females | 2.5 | |
| Runaway and homeless youth | 15–18 | 3.0 |
Risk Taking: Contraceptive and Condom Use
Risks of pregnancy, STDs, and HIV seropositivity are all greater in those sexually active youth who fail to use protection and in those who use protection, but inconsistently. In the CDC's 1995 YRBS,13 slightly more than half of all sexually active high school students (54%) used a condom
Data from the 1995 NSFG shows a similar trend employing somewhat different questions.20 Among 16-year-old females, 57% had used some method of protection at their first coital episode, with 15% relying on the pill and 32% on the condom. For teen women less than 20 years of age, use of any method was lowest among Hispanics (53%) and highest among non-Hispanic Whites and non-Hispanic Blacks (83% and 72%, respectively).
Other studies support a picture of wide variability in contraceptive and condom practices depending on the population studied. Different surveys have found that anywhere from 31% to 80% report that they always use a method, and from 16% to 58% state that they never use one. 21-24,66-69 When adolescents themselves are asked why they do not use protection, two-thirds (65%) state that sex was unexpected, one in four (25%) do not know how to obtain protection or where to go, one in four (24%) fear parental discovery or method side effects or are too embarrassed to seek out services, and one in six (15%) believe that they are safe without birth control and will not get pregnant.70 Although condom and pill use appears to be slowly increasing among sexually active adolescents as a class, a significant number continue to remain unprotected at least some if not all of the time.
Not all teenagers seek to avoid pregnancy, as much as one might think to the contrary. Any efforts to promote contraceptive use among these
Factors that have been found to support contraceptive and condom use include the following: 20,24,–28,61,63,73,74
- Having educational goals
- Doing well at school
- Ability to pay
- Married parents
- An older partner
- Fewer other risk behaviors
- A belief in the efficacy of condom use against HIV infection
- Suburban residence
- Cognitive maturity, older age
- Prior satisfactory contraceptive use
- Higher parental educational level
- Fewer life-time partners
- Friends who use condoms
- A low perception of undesirable aspects of condom use
It is significant to note that HIV knowledge, fear and anxiety about HIV infection, or intentions toward avoiding other risk behaviors were not found to have any substantial effect on sexual risk taking or on contraceptive and condom use.24,25,63,65
MODIFYING ADOLESCENT SEXUAL RISK TAKING
Educational Interventions
Evaluations of educational intervention strategies all show that knowledge alone has little effect on modifying behavior. Simply telling adolescents not to have sex, providing them with information about associated risks, or informing them about protective measures through passive learning methods neither increases nor decreases the age of coital debut, the frequency of sexual intercourse, the number of partners, or the use of protective methods.72,75,76 Even those educational programs that are interactive and focus on building skills only delay the onset of the coital
The health belief model offers an explanation of the complexities of health behavior modification as well as direction for developing effective intervention strategies.27,78 This theory holds that an adolescent will modify his or her behavior only when he or she perceives a clear and personal benefit in doing so. Three separate but interactive elements collectively determine this perception. First, a youth must perceive that his or her sexual risk taking poses an immediate and serious personal threat. Second, the youth must have appropriate knowledge about the benefits of behavior modification (e.g., being abstinent, using effective contraception). That is, he or she must believe in the new behavior's effectiveness, know how to implement it (e.g., resist sexual pressures, obtain and use protection), and have positive attitudes about it. The last element consists of a number of variables that support or undermine these perceptions and beliefs, including sociodemographics, cognitive maturity, motivation, self-esteem, the presence or absence of other risk-taking behaviors, emotional risks, and health-seeking and compliance behaviors. An external catalyst that brings the matter close to home often is required to move intention into actual practice, such as a friend's becoming pregnant or the promptings of a meaningful and supportive person in the adolescent's life.
This health belief model, together with social learning theory, social inoculation theory, and cognitive/behavioral learning theory, has served as the basis for new and innovative sex education programs with the goal of delaying the coital debut and enhancing contraceptive use in cognitively immature adolescents.75,76,79–82 Curricula are narrowly focused on program goals and are participatory in nature. The prediction is that successful enactment of a desired behavior will encourage that behavior in the future (e.g., convincing a partner to delay having sex though rehearsal will lead to delaying in actuality). Course activities closely look at social and media influences and pressures to have sex as well as provide the modeling and practicing of communication and negotiation skills. Abstinence as a positive behavior is strongly supported, as is effective protection for those who are sexually active. Students who participate in these courses are significantly more likely to continue to delay their coital debut for at least 18 months. In one such program, given over 10 sessions to eighth-grade students in Atlanta, only 24% of inexperienced students had become sexually active at the end of the following year as compared to 39% of students in schools that did not offer
Health Care Interventions
Over the past few decades, an increasing number of health programs specifically targeted at adolescents have emerged. The vast majority are school-linked, hospital-based, or community-based clinics.83 All are comprehensive in that they address biological, psychological, and social needs; seek to provide an optimal adolescent health care environment; and offer preventive and early intervention services for health risk behaviors. Many family planning programs also have special programs for adolescents' reproductive health care needs.
Most attention and interest has been given to school-based and school-linked clinics (SBSLCs), which provide a wide range of health services, particularly to disadvantaged and uninsured youth.84–90 The impetus for what has been a rapid expansion of SBSLCs, particularly in relation to a belief in their effectiveness in pregnancy prevention, comes from the initial evaluation of the first such program, which was initiated in St. Paul—Minneapolis in 1977.91 Originally, there appeared to be both a significant increase in contraceptive use with a 93% 12-month continuation rate and a reduction in schoolwide births from 79 to 35 per 1,000 students over the first three years. Subsequent reevaluation of the St. Paul data, however, uncovered significant problems with the first analysis, suggesting that the initial findings were more artifact than real.92 A broader look at longitudinal data, both before and after program implementation, found wide fluctuations in schoolwide birth rates from one year to the next that originally had not been taken into account. When these variations were included in the statistical analysis, there was no significant difference in overall schoolwide birth rates in the postprogram years from those that preceded it.
The reproductive health programs of six SBSLCs in different parts of the country also have been evaluated.93,94 While these clinics demonstrate modest effects on diminishing sexual risk taking, at the same time it is important to note that they did not promote sexual activity in any way, neither hastening the onset of sexual activity nor increasing its frequency. Effects on contraceptive use were varied. Simply providing birth
- A strong school AIDS education program in a community where AIDS was a significant issue
- A school policy and educational program that placed pregnancy prevention as a matter of high priority
- Identification of and focusing on high-risk youth with a strong emphasis on pregnancy prevention
While these strategies definitely increased contraceptive use in those SBSLCs that dispensed them, use remained inconsistent, and none of the six clinics demonstrated a statistically significant effect on schoolwide pregnancy rates, although a small number of conceptions may have been averted.
One SBSLC that has shown dramatic results (not included in the previous study) is linked to a Baltimore school.66,95,96 In the three years following inception of the clinic, there was a 30% drop in the pregnancy rate compared to a 57% pregnancy rate increase in regional schools without SBSLCs during the same time. Factors contributing to this success were thought to be the high priority given to pregnancy prevention as a matter of school policy and curricular objectives; the fact that the clinic was located near but not on the school campus, affording greater privacy; and the fact that the clinic was open during after-school hours, affording greater accessibility.
Community-based programs aimed at adolescent pregnancy prevention also have had mixed success as measured by teen fertility rates.66 One such program, the Multimodal School/Community Program for Sexual Risk Reduction Among Teens, implemented in rural South Carolina, was a comprehensive coordinated approach involving schools, churches, homes, community agencies, and public media. The message to youth was to postpone the onset of sexual activity but, if they were sexually active, to use contraception consistently. A trained school nurse based in an SBSLC provided males with condoms and took females to a local family planning clinic. In the first year, pregnancy rates dropped from 61.7 to 25 per 1,000. A nearby county without such a program showed an increase of 8.5 per 1,000. Reduced rates persisted for three
Earls 97 compared the effectiveness of seven hospital-based adolescent medical clinics funded by the Robert Wood Johnson Foundation to provide comprehensive health care to high-risk adolescents with three similar but nonfunded clinics. Funded clinics detected and treated a substantially wider range of medical and behavioral problems than those that were not funded, but effectiveness was limited. Measures of improvements in lifestyle, risk-taking behaviors, and related medical outcomes showed minimal change.
Studies of family planning clinic effectiveness are mixed. Those clinics with special programs for or special emphasis on adolescents result in greater contraceptive use. Those with less emphasis conduct more teen abortions.66 As a result, both demonstrate similar teen birth rates but, obviously, for very different reasons.
While the ability of special adolescent health care programs to reduce adolescent pregnancies appears to be limited, the model should not be discarded. Overriding factors must be taken into account.
First, given the high-risk nature of many of the adolescents seen in these programs (most are from low-income families and live in disadvantaged environments), any interventions, no matter how well conceived, are likely to be seriously compromised by such central issues as poverty, dysfunctional families, disrupted schools, neighborhood violence, and, for many, limited English proficiency. State and local restrictions on contraceptive and condom distribution in schools and community opposition to dealing openly with the reality of adolescent sexuality also impose substantial barriers.
Second, many young people attending teen clinics have no other source of health care and cannot afford it. Subsidized teen clinics often are the only place they can obtain attention for their health needs.
Third, the highly supportive and comprehensive orientation of SBSLCs, wherever based, and the delivery of care by professionals skilled in working with teens—as opposed to the orientation and care practices found in most private practice offices—are far more likely to promote disclosure of behavioral risks and psychosocial problems and to provide age-appropriate care and counseling to individual youths in need.
Lastly, the adolescent clinic model, wherever based, embodies many of the elements thought to be important for adolescent health care (as discussed in detail in the following) and can well serve as a springboard for further research.
ADOLESCENT HEALTH CARE RESOURCES AND
UTILIZATION BY ADOLESCENTS
Special Adolescent Clinics
A national survey of special adolescent clinics identified 664 such programs.98 Nearly half (45%) were connected with schools (SBSLCs), and one-quarter (22%) were hospital based. One in five (20%) were community or neighborhood centers, and 8% were located in departments of health. More than 90% of these programs provided pregnancy testing, AIDS education, family planning counseling, and STD treatment. Three-quarters (76%) dispensed condoms and provided contraceptive services on site; the remainder had linkages with offsite resources. Confidentiality was regularly afforded, although many SBSLCs required parental permission for the adolescent to use the clinic at all. Young people who attended these clinics averaged 3.6 visits per year and expressed considerable satisfaction with care. Only 44% of the clinics collected patient fees, which were on a sliding scale based on the adolescent's ability to pay. Seventy-two percent received federal funding subsidization, and 75% received state and/or local support. Unfortunately, these special youth programs serve only 5.3% of all 15- to 19-year-olds, meeting the health care needs of only a very few.
Adolescents tend to use family planning clinics more often than private physicians for birth control. In the 1988 NSFG, 30% of all 15- to 19-year-old females reported at least one family planning clinic visit in the previous year. Attracting factors include low cost (private physician fees for similar services are four times as great) and confidentiality. Nearly 9 out of 10 (87%) family planning clinics provided birth control to minors without parental consent.66
The Private Sector
Data from the 1985 National Ambulatory Care Survey and the 1988 National Health Information Survey found that there were 50.216 million visits by 10- to 18-year-olds, an average of 1.6 visits per adolescent
Leading reasons for these visits were general medical and routine physical examinations (10%), symptoms referable to the throat (7%), acne (4%), and routine prenatal care (6%).100,101 The time spent during a physician visit averaged 14 minutes for adolescents compared to the national norm of 16.5 minutes. But nearly half of all visits (48%) were 10 minutes or less, and only 1 in 25 (4%) lasted 30 minutes or more. There is little to suggest that the length of such visits has increased in the intervening years, particularly in light of the expansion of managed care and its focus on lowering health care costs through increasing physician productivity (e.g., seeing more patients in less time).
Only a minority of visits to primary care physicians deal with sexuality issues. A recent survey of more than 1,000 primary care physicians, for example, found that only 40% of respondents routinely inquired about sexual activity among their adolescent patients, only 17% screened for the teenager's number of sexual partners, and only 9% ever provided condoms.102 In a survey of youths themselves, fewer than two out of five (39%) had ever discussed how to avoid getting HIV or STDs with a physician, only 13% had received information about how to use condoms, and only 15% had been asked about their own personal sexual behaviors.103 There does, however, appear to be a positive change in these data from those of the last decade, when a survey of college freshmen revealed that 81% had never received counseling about contraception from a physician, and 79% had never received counseling about STDs.104
Most adolescents (80%–90%) and parents (80%) see physicians as an important resource for discussions about sexuality.103,105 Inquiries of teens themselves, however, find a wide disparity between what they would like to talk to a physician about and what actually does get talked about. In one survey of urban high school students, although the vast majority wanted information about STDs (80%), AIDS (85%), condoms (73%), and safe sex (80%), only 27% reported ever having discussed any of these subjects with their physicians.106 Of particular interest is the finding in this and similar surveys that adolescents find it difficult to initiate a discussion about sexuality issues and look to the physician to do so. At the same time, physicians themselves find this difficult to do. Parents
Confidentiality
Privacy surrounding sexuality issues is an essential ingredient of health care for adolescents.108 There is considerable variation, however, in the degree to which teenagers trust their physicians to keep confidences, depending on the nature of the problem. In one survey,109 most adolescents trusted that their physician would keep it secret if they asked questions about sex (75%), if they were having sex (65%), or if they were using contraception (68%). Only a minority, however, would trust their physician to keep secret the actual presence of an STD (44%) or pregnancy (44%). The level of trust rose among adolescents who knew that physicians in their state do not have to tell parents about either of these conditions, but only to 54%. In another report of 10th-grade students, more than half (58%) would not seek STD care for fear parents would find out, and three-quarters (78%) were afraid that friends would find out. Other perceived barriers were that they did not know where to go (38%), had no transportation (29%), did not think that they could afford care (48%), or were too embarrassed to talk to a doctor (43%).66,108 Among a randomly selected group of adolescents residing in Massachusetts, more than half (58%) had health concerns they wished to keep private from their parents and were concerned about whether a physician would respect their confidences. Of those with a regular source of health care, four out of five (86%) would go to their physician for a physical illness, but only half (57%) would go if there was a question about pregnancy, AIDS, or substance abuse. Three out of every four (77.7%) felt that being sexually active should be kept confidential, 46% felt the same way for STD infection, 55% for pregnancy, and 35% for HIV seropositivity.110
Teenagers generally have poor information about their legal rights to confidential care and the fact that, in all jurisdictions, minors can consent on their own to care for STDs and, in many states, also can consent on their own to contraceptive services, pregnancy diagnosis, and prenatal care. In one study, two out of every three adolescents did not know that they had a legal right to consent to care for STDs. Three-quarters (75%) either believed that STD clinics would tell parents of their visit or did not know whether parents would be notified. Nearly four in five (79%) believed that STD treatment required parental consent.66 Over
This lack of trust of the private sector is not entirely misguided. One national survey of general practitioners and family medicine practitioners—who account for the largest proportion of adolescent visits—found that only 59% were willing to provide contraception to minors without parental consent, and only 57% believed that minor adolescents should have this right.105 An inquiry into physician attitudes about selected ethical dilemmas found that 61% of all respondents would tell a mother of her 15-year-old daughter's pregnancy even against the girl's strongly stated wishes to the contrary and even despite her legal right to confidential care.107 A substantial majority of pediatricians, however, are accepting of the confidentiality option.111 Further, the American Academy of Pediatrics has specifically adopted the position that confidentiality is an important ingredient in adolescent health care, enabling minor youths to seek out early and timely services for sensitive and personal health problems. While strongly encouraging parental participation, the Academy views that mandatory parental consent results only in adolescents maintaining silence about their medical need, unnecessarily delays treatment, and places them at greater risk of health harm.112–114
Competence and Interest
of Private-Sector Physicians
Surveys of physician attitudes toward adolescent patients find that general practitioners, family medicine practitioners, and internists have only a modest interest in this age-group, with only one in four expressing definite interest.115 Even if interested, many are not skilled. Currently, there are insufficient primary care physicians in the United States with the type of training and experience required to provide the nation's 35 million adolescents with age-appropriate care.115,116
Most physicians and other health care providers have limited competence in identifying and treating the health problems of adolescence. Studies have shown that general and family practitioners, pediatricians, and internists all have difficulty identifying adolescents who have behavioral and emotional problems and consider themselves relatively untrained in managing adolescent sexuality, contraception, and psychosocial concerns. Further, only 30% of those who perceive themselves to have such deficiencies have any interest in increasing their competence.115
There may be change among future pediatricians and internists. All approved pediatric residency programs 117 now are required to have a fulltime faculty member trained in adolescent medicine, and all residents must have at least a one-month rotation with teenage patients exclusively as well as additional experience with young people in ambulatory and inpatient settings. Internal medicine residency training requirements also call for specific experience in adolescent medicine, including health-risk behaviors, but without defining the length of time that must be devoted to this discipline.118 Family medicine, on the other hand, has not yet incorporated specific adolescent medicine training requirements into its curriculum,119 presumably because of the view that training residents to provide comprehensive care to families axiomatically includes adolescents as well. The incorporation of adolescent medicine experiences into the resident curricula of pediatrics and internal medicine, however, is a relatively recent event, and it will be many years before all practicing pediatricians and internists will be appropriately skilled.
Financing
Even if all physicians were both interested and trained, providing care to adolescents in a manner that promotes compliance and behavioral modification is time intensive. Public and private third-party reimbursement rates do not reflect this fact and, when adolescents are given the time they need for counseling and anticipatory guidance, do not even compensate for overhead costs. This problem is even further compounded by the increasing emphasis on “productivity” and efforts to decrease health care costs by increasing the volume of patients seen in a given span of time. No specific coverage yet exists for comprehensive adolescent preventive services (see the following discussion of Guidelines for Adolescent Preventive Services). Coverage for mental health and substance abuse problems, often associated with high levels of sexual risk taking, has been substantially cut back in recent years and also is highly limited in availability.
A lack of adequate financing deprives many poor youths of even the most basic services. Yet poor adolescents are the ones at greatest risk of unintended pregnancy, teen parenthood, STDs, and HIV seropositivity. One in every seven adolescents has no public or private health insurance.120 Nearly one-third live in families with incomes at or below 150% of the federal poverty level, and one in three is not eligible for Medicaid/ Medi-Cal. These data do not take into account the ever increasing number
Even when adolescents are insured, they often are reluctant to seek out care for confidential problems out of concern for discovery if payment is dependent on their parents' or family insurance plan. It is virtually impossible to make a private third-party payer claim for a minor without the signature of the insured adult and without the latter receiving notice of claims made and paid. Equal barriers exist in public payment programs (Medicaid, Medi-Cal); a sticker or eligibility card generally must be presented before services can be rendered. These items usually are in the possession of parents, and adolescents do not have independent access to them.
The recent expansion in managed care and health maintenance organizations (HMOs) poses both problems and solutions. In prepaid systems, it becomes possible for adolescents to gain independent access and see a provider without the need for parental payment authorization for each visit. Whether this actually does occur depends on the policies of the particular program in question, and this is a variable matter. Some programs do provide for adolescent confidential care, while others continue to require parental permission for each visit, even though time may be spent with the teenager alone and confidences respected. One of the disadvantages of prepaid and managed care systems is the requirement that all members of a subscribing family receive care at a single location with no reimbursement for services rendered elsewhere. Adolescents may well require services at several sites, such as regular care by their personal physician or HMO and confidential care from a school-based clinic or family planning program. Increasingly, however, public managed care programs for low-income teens are beginning to recognize the unique needs of this age-group and to establish payment linkages between these various types of services.
Summary of Adolescent Health Care Delivery Issues
All in all, the mainstream health care delivery system for adolescents, while making some headway, still has room for considerable improvement. Key issues include inadequate professional training, inadequate reimbursement rates, insufficient visit time allotments to properly evaluate and counsel teens, access difficulties for youths seeking confidential care, and a large segment of economically disadvantaged adolescents who are uninsured.
There is considerable resistance on all fronts to dealing openly with adolescent sexual activity and denial of the fact that sexual intercourse is now a normal behavior on the part of at least half our nation's adolescents today. Nor have we effectively addressed the many problems such as poverty, poor schooling, and community violence that underlie the motives of those teens who see parenthood as a desirable state. Communities tend to resist the overwhelming evidence showing that sex education programs and the availability of contraception to adolescents do not promote an earlier age of coital debut and do not promote greater sexual risk taking.121,122 On the contrary, new sex education programs can, in fact, delay the initiation of sexual activity and, for those already involved, enhance contraceptive use and reduce the number of partners. In the past, policy makers have been all too reluctant to accept these facts and, instead, oppose the formation of services that will best assist adolescents in contending with their own sexuality and with the sexual pressures of the world around them in a responsible manner.
Fortunately, changes are being undertaken in federal administrative policy. In 1997, the U.S. Department of Health and Human Services established the National Strategy to Prevent Teenage Pregnancy and funded two new community grant programs at $1 million per year. The primary target group, however, is 9- to 14-year-olds, with a focus on helping communities to develop horizon-broadening opportunities for youth and experiences that they can say “yes” to. While such initiatives are critical to the solution of teen risk-taking behaviors, this still does not address the needs of those young people who remain at risk and need age-appropriate reproductive health services and effective sex education.
OPTIMAL ADOLESCENT HEALTH SERVICES
In 1992, 15% of the U.S. population (38.4 million) were 10- to 19-year-old youths. Of these, approximately 20% were living below the federal poverty line. Minority adolescents were disproportionately poor, with 43% of African-American teens and 38% of those of Hispanic ethnicity living in poverty as compared to only 15% of White adolescents.123 By the year 2000, the total population of adolescents will have increased by an additional 15%, with more than one-third being members of racial or ethnic minorities.124
We certainly cannot turn back the clock to a time when abstinence among unmarried individuals was the expected norm and governmental
Goals
Realistic goals for managing adolescent sexuality are, first, to foster delay in the initiation of sexual activity, at least until the young person is sufficiently cognitively mature to handle this in a responsible manner; second, to ensure that, when adolescents are sexually active, such activity is consonant with their own personal value codes and is not exploitative of themselves or others; and, finally, to support the consistent use of protection by sexually active youth against the risks of pregnancy, STDs, and AIDS.
The U.S. Public Health Service has established the following specific 10-year objectives relative to adolescent sexuality in its Healthy People: 2000 report: 127
- Reduce the number of pregnancies among girls aged 17 and younger to no more than 50 per 1,000 adolescents. (Objective 5.1)
- Reduce the proportion of adolescents who have engaged in sexual intercourse to no more than 15% by age 15 and no more than 40% by age 17. (Objectives 5.4, 18.3,and 19.1)
- Increase to at least 90% the proportion of sexually active, unmarried adolescents aged 19 and younger who use contraception, especially combined-method contraception that both effectively prevents pregnancy and provides barrier protection against disease. (Objective 5.6)
- Increase to at least 60% the proportion of primary care providers who provide age-appropriate adolescent care and counseling aimed at primary unintended pregnancy prevention. (Objectives 5.10 and 14.12)
Optimal Adolescent Preventive Care
The American Medical Association has developed a set of specific guidelines as a standard for teenage preventive care (Guidelines for Adolescent Preventive Services) calling for annual visits by all adolescents.128 The primary objective of these visits should be to identify both psychosocial and biomedical concerns and to provide anticipatory guidance. In the absence of specific complaints, physical examinations need be performed on only three occasions; once in early, middle, and late adolescence. Services should be age- and developmentally appropriate and sensitive to individual and sociocultural differences. Office policies should be established regarding confidential care and how parents will be involved in that care. Recommendations relating to sexuality include annual anticipatory guidance of all adolescents regarding responsible sexual behavior, including abstinence. All youths should be asked about their involvement in sexual risk-taking behaviors once a year. Those who are sexually active should be screened for STDs, should be given latex condoms for protection, and, if female, should be screened annually for cervical neoplasia. Appropriate methods of birth control also should be made available, as should instruction on how to use them. Adolescents at risk for HIV infection should be offered confidential HIV screening.
Optimal Adolescent Health Care Systems
The U.S. Congress Office of Technology Assessment,31 the Study Group on Adolescent Health of the National Academy of Sciences,129,130 the American Medical Association,128 the National Association of State Boards of Education,131 and the Carnegie Corporation 1 have all examined adolescents' health care needs in depth, are in agreement that these needs have been badly neglected, and call for essential change. Their recommendations have major implications for health care reform and include the following:
- All adolescents should be assured of access to services that provide affordable, accessible, and age-appropriate comprehensive care.
- These services should be located in schools and communities where adolescents live, should be easily reachable by walking or public transportation, should be available on a walk-in basis, and should be open during at least some evening and weekend hours.
- Young people should be able to go to these services by themselves. Confidential care should be provided when the nature of the adolescent's need is such that he or she would not seek out medical assistance otherwise. At the same time, parental involvement always should be encouraged.
- Health care providers who deliver care to adolescents should care about them, be effective in communicating with them, and be specifically trained in meeting young people's health care needs.
- High priority should be given to preventive and early intervention measures for health risk behaviors, including pregnancy, STDs, and AIDS.
- Close linkages and liaisons should exist with schools and other youthserving resources in the community. Integrated multidisciplinary and multimodal programs are particularly important. Educational programs should include a combination of personal skill-building and life-option components and be interactive in nature.
- Health services should be free or based on a sliding fee scale according to the adolescent's own ability to pay.
- Those adolescents who are insured under a family policy should have the ability to secure reimbursement for confidential services without risking disclosure.
- Provider reimbursement rates must be appropriate to the type of specialized services that adolescents need, including preventive anticipatory guidance and intervention counseling.
CONCLUSIONS
Adolescent sexual activity, with its potential consequences of pregnancy, STDs, and HIV infection, is the single largest health problem in this agegroup. Yet for many teenagers our current health care system does not address these problems very effectively, and our health care policies have not, until recently, held primary pregnancy and STD prevention in adolescents as a matter of high concern. Even though the nation is waking up to the problem, current policies primarily seek methods of promoting abstinence and still overlook the needs of the many youths who remain sexually active. Most adolescents are not provided affordable, accessible, and age-appropriate comprehensive care despite compelling arguments in support of this need and despite the recommendations of leading study groups.
Indeed, little attention has been given to adolescents by the health care sector except within the small group of specialized adolescent health care clinics that see only 5% of the nation's youth. The results are unacceptable costs both to the young person who must suffer the consequences of health care's neglect and to society, which must pay for it.
Current health care reform initiatives tend to make matters worse by limiting access to the health care system to a single point of entry where there would be no guarantee that the gatekeeping primary practitioner will have any competence in caring for youth or that confidential care will be an option. If managed care is to be the primary administrative structure for health care delivery in the future, adolescents should be able to choose their own managed care program or, minimally, have access to multiple health care sites. Their choices should include both office-based practices and alternative specialized adolescent health care programs, such as school-linked clinics, hospital-based and community-based adolescent medicine programs, and family planning clinics. All such special services should be covered and should not require referral from a primary care gatekeeper for reimbursement.
Further, there is a clear need for a substantial increase in effective sex education programs and in the number of school-based clinics; both are particularly necessary in reaching teenagers who so far have been underserved and comprise that portion of the adolescent population at greatest risk of pregnancy, STDs, and AIDS. There also is a need for both public and private third-party reimbursement systems that support the young people's comprehensive health care needs. We need to ensure that all primary health care providers are trained in adolescent health—particularly those who will be managed care's gatekeepers—and to develop resources to provide such training. We need to give as much time and concern to preventive interventions for adolescent sexual risk behaviors as we now do for younger children and their immunizations. And we need to establish specific objectives for preventive care interventions and ensure that they are met.
Admittedly, there is limited information about exactly what types of interventions are effective in modifying adolescent sexual risk-taking behaviors. We have some evidence that the initiation of sexual activity can be delayed by educational programs that are based on the health belief model and social inoculation theory and that employ an interactive learning approach. We also have some evidence that sexually active adolescents can be encouraged to be more effective users of protection against STDs and pregnancy when these matters are given high priority and
Research is needed in many areas. First, we need to know much more about adolescent sexual activity, including those factors that contribute to its initiation and what factors can delay it. We also need to know much more about the determinants of condom and contraceptive use. Areas that require additional study include the influence of the media and other aspects of our highly sexualized environment, the role of cognitive maturation on decision making, the role of parents and the nature of parent-adolescent communications about sexuality (not simply whether adolescents have ever talked to their parents about sex), the role of adolescents' perception about power and powerlessness, and the role of negative societal attitudes toward adolescents. We need considerably more research on how the health care and educational systems can effectively reach youth not only to delay their coital debut but also to influence those who are already sexually active to take consistent protective measures. We need more research on how to provide young people with early intervention and prevention counseling in the most cost-effective manner possible. And we need to examine how we can help parents be better communicators with their adolescents about sex. We also need more information on why physicians do not address adolescents' sexuality needs and what it would take to have them provide such services and to feel more enthusiastic about caring for this age-group.
In conclusion, I propose that access to age-appropriate care be provided to all adolescents and that teenage sexuality issues be fully addressed in any health care reforms. In particular, I propose that primary pregnancy prevention become a matter of the highest priority both for those who have not yet engaged in coitus and for those who are already experienced. No adolescent should have to make the choice between having an unintended baby and terminating a pregnancy in abortion, and no adolescent should have to risk STD or HIV infection because of a health care system that fails to provide for these needs. I further propose the establishment of multidisciplinary adolescent health research and training centers to find effective ways of influencing adolescent health risk behaviors and to train primary health care providers in these methodologies.
These initiatives will take commitment and courage in braving the criticism of those who seek only universal teen abstinence and rigorously
NOTE
Prepared for The University of California/Health Net Wellness Lecture Series, 1993.
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