Position papers on reproductive health care for adolescents

JOURNAL OF ADOLESCENTHEALTHCARE 1983;4:205-10

Position Papers on Reproductive Health Care for Adolescents SOCIETY FOR ADOLESCENT MEDICINE

Introduction Sexuality is an integral, multifaceted part of being human; reproduction represents only one aspect of human sexuality. Most of our professional attention in the past has focused on the reproductive adolescent instead of the sexual child, adolescent, and adult. Our professional focus has been directed primarily toward disease prevention, rather than health promotion. The reproductive health needs of adolescents are best served through a broad approach to sexuality as a life-long responsibility of the individual. This" is nurtured by promoting the availability and delivery of excellent medical services and health education programs directed toward general and psychosexual adolescent development. In this position paper, we shall present pertinent background data and briefly discuss three major, current challenges. We shall then state the position of the Soc/ety for Adolescent Medicine on adolescent sexuality, sex education, contraception, adolescent childbearing and cl~ildrearing, abortion, and sexually transmitted diseases.

Background Data Ado!escent pregnancy* remains a problem of major proportion in the United States. Recent data indicate that adolescents and their infants do equally ~~.well

Address requests Jar reprints to the Business Office of the Society for Adolescent Medicine. *The focus of this position paper is the reproductive health care of the adolescent who has not yet reached legal majority and/or who is biologically, cognitively, and/or psychosocially immature. "Adolescent pregnancy" refers to conception occurring in adolescents who are cognitively, emotionally, and/or legally immature, it encompasses those-becoming pregnant before 13

as adults perinatally if there is adequate and consistent prenatal care [1,2]; many pregnant adolescents still do not receive such care and thus are medically at high risk. The young adolescent who bears a child is likely to repeat pregnancy during adolescence and to have increased medical risk with subsequent pregnancies. At any age, she is likely to remain a single parent or to experience unsuccessful marriage. Both she and her male partner ultimately receive fewer years of formal education and vocational opportunities than adults who have not become adolescent parents [3,4]. Despite a relative increase in the number of adolescents who use contraception, pregnancy rates remain high, even though the bh'th-rate has decreased in recent years, largely due to the increased availability of abortion services. In 1970, women less than 20 years of age bore 656,460 children, the largest number in recent years. In 1978, by contrast there were 554,179 births to adolescents (10,772 to 12-14year-olds; 202,661 to 15-17-year-olds; 340,746 to 1819-year-olds) [5,6]. The most dramatic recent change in fertility statistics has not been in births, but in abortions. The number performed on teenagers has increased yearly since the procedure became legalized nationwide in 1973. In 1978, there were 357,028 teenage abortions (12,754 for 12-14-year-olds; 139,156 for 15--17-yearolds; 205,118 for 18--19-year-olds). The numbers and

eafs of age as well as those who are 18 years old or older who

l ave not completed the process of adolescence. Our concerns

apply to adolescent males as well as females, those who are married as well as unmarried, and those who already are parents. The assumption is made that the earlier conception occurs in an adolescent's life, the more likely it is to be associated with negative sequelae for the youth and offspring and this risk is not lessened by marriage.

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rate of abortion have stayed relatively stable since 1975 for those less than 15 years of age. The abortion ratio (abortions/1000 live births) provides a good indicator of the percentage of unplanned pregnancies. In 1978 there were 644 abortions for every 1000 live births to teenagers overall (1183 for 12-14-year-olds; 687 for 15-17-year-olds; 602 for 18-19-year-olds). Abortion is not without morbidity, especially for the adolescent who frequently delays the procedure until later in gestation [7]. Most health professionals agree that abortion should not be a form of birth control. Therefore, prevention of unwanted pregnancy must be stressed. This is especially true since between 1976 and 1979, the percentage of 15--19-year-old, never-married women who reported they ever had premarital intercourse increased from 43.4% to 49.8%. Of males 17-21 years of age 70.3% reported having had premarital intercourse according to 1980 report by Zelnik and Kantner [8]. Even though there has been considerable improvement in the use of contraception by sexually experienced, never-married adolescent women (from 45% at last intercourse in 1971 to 63% in 1976 in one study), adolescents as a g r o u p are still less-thaneffective contraceptors. Between 1971 and 1976, the percentage of adolescents who never used contraceptives increased from 17% to 26% [9]. Zelnik and Kantner have noted a decrease over time in the utilization of effective methods such as oral contraceptives or intrauterine devices and an increased utilization of less-effective methods such as withdrawal and rhythm [8]. The rhythm method, for example, requires a regular menstrual cycle and the teenager's knowledge of her ovulatory cycle. Adolescents often have neither. One large survey found that only 37% of 1517-year-old females and 49% of 18-19-year-old females knew the time in the cycle of greatest fertility. Having had a sex education course did seem to make a difference in this knowledge, especially among the younger women. Only 27% of the 15-17-year-olds who did not have a sex education course knew the time of greatest risk, compared with 41% of those who did have such a course [10]. Conception is but one potentially harmful consequence of adolescent sexual activity. Sexually transmitted diseases increasingly threaten the health and well-being of millions of adolescents. Males and females between the ages of 15 and 24 years of age account for about 75% of all reported cases. More

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important, an estimated 75,000 women of childbearing age become sterile each year as a result of pelvic inflammatory disease caused by sexually transmitted infection [11]. There is also reason for concern about future neoplasia in the sexually active female adolescent. Women taking oral contracepfives [12], women using no contraceptives [13], even women whose partners use condoms consistently [14], all appear to have an increased risk of developing a gynecologic neoplasm compared to virgins [7]. This risk is increased with earlier age of first sexual intercourse, with frequency of intercourse, with number of partners, and with number of endocervical infections. A more difficult to study consequence of premature sexual activity is the associated psychological morbidity. Cvetkovich and Grote [15] suggest that persons who remain virginal during adolescence formulate their gender identity at an earlier age than nonvirgins. They also note that the sexually active group of adolescents whom they studied appeared "to be liberal, but not liberated." Many research questions still need to be answered. For example is social immaturity a cause, or a consequence, of adolescent sexual activity? Can sexual assertiveness training result in more positive consequences and responsible sexual behavior [16]? Based on reviewing the decade of the 1970s, we face several dilemmas: More adolescents are sexually active; a substantial number become pregnant; fewer in actual numbers bear children, but a substantial number have abortions; more unmarried adolescent women use contraception but are more likely to use less-effective methods; and a substantial number still do not know when in the menstrual cycle a woman is most likely to become pregnant. Health providers face immense challenges with regard to adolescent reproductive health. We have chosen three issues of particularly pressing concern to emphasize the scope of these challenges (parental notification, sex education, and the adolescent father.)

Current Challenges Parental Notification More than 50% of adolescents currently involve parents in the decision to seek contraception or to have abortions, or both, according to a recent survey [17]. Of adolescents attending family planning clinics, 55% stated that their parents knew. When the 45% of teens whose parents did not know were asked what

September1983

they would do if parental consent were required, more than one-half said they would stop attending. Of these, the majority would change to nonprescription methods. Only 2% of the total said they would stop having sex. Studies show that services requ/ring parental consent for adolescents tend to provide less care to teens than services lacking such requirements. Thus, adolescents are more likely to obtain necessary medical services if they are not forced to obtain parental consent, although many will voluntarily discuss this issue with parents [18]. Many services today strongly encourage, but do not require parental involvement. This is a more acceptable, and undoubtedly more effective policy in maximizing the number of youth who will be serv_-,d. Legal requirements of parental consent, consultation, or notifications suggest that adolescents are unwilling to talk with their families and that parents will not participate in their children's decisions unless required by law--a situation far removed from truth in most cases. Health professionals need the flexibility to make individual judgements about the best interests of adolescents and their families. Some adolescents must be assured of confidentiality in the patient-professional relationship if they are to seek medical assistance at all and not forego, or withdraw from, needed care. Legal requirements to involve parents in all cases, however well-intentioned, not only are mmecessary but are potentially detrimental. They can result in increased rather than decreased rates of unintended pregnancy and out-of-wedlock childbearing or abortion. They risk increasing the medical complications of abortions and unwanted births to adolescents by delaying the receipt of services through fear of disclosure. In some cases, forced and possibly premature involvement of the parents may promote irreparable fracture of the family unit, the very consequence proponents of mandatory parental involvement seek to prevent. Implicit in this argument is an acknowledgement of a minor's fight to consent to reproductive health care as determined by his or her level of maturity. Otherwise, as noted by Hoffman, "parents, adolescents and health providers become adversaries and the unique developmental status of the adolescent is overlooked, i.e., he is treated inappropriately either as a dependent child or as a wholly autonomous adult during his emancipation" [19]. Once one acknowledges the right of an adolescent t O reproductive health care, "'who will pay" must be addressed. A t present, there is n o universally acceptable response to this question because prepaid

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health plans and free clinics are available to only a minority of adolescents. Sex Education

Sex education appears to improve adolescents' sexual knowledge, but many questions remain about whether sex education alters sexual responsibility. Historically, it is believed that adolescents should be taught about fertility, contraception, sexually transm i r e d diseases, sexuality, and parenthood, and that with this knowledge their behavior will be modified toward greater responsibility. There are no data to either prove or disprove this assumption. Concerns are often voiced that discussing sexuality with adolescents only encourages sexual activity. Most sex education research has found that increasing an adolescent's sexual knowledge does not increase his or her sexual activity [20]. Further, on their own, adolescents tend to obtain sexual information, although often inaccurate and from unreliable sources [21]. Reliable sex education in the schools and at home presently may be a utopian goal. One study found that 98% of parents reported needing help in talking to their teenage children about sex [22]. Another study revealed that only 45% of the mothers questioned knew the fertile period of their menstrual cycles, and only 18% realized that intercourse 2 days after.ovulation could lead to pregnancy [22]. Although parents need to be involved in the sexual training of their adolescents, parents themselves need to become knowledgeable in sexual matters. A family life program in San Bernardino, California has been established to provide such education, enabling parents to consider their teenager's sexuality [23]. In support of such programs is the finding by Lewis that "rather than stimulate coital experimentation, sex information given primarily by parents seems to contribute to more restrictive premarital sexual behavior" [24]. As of 1978, only three states (Kentucky, Maryland, and New Jersey) and the District of Columbia require sex education in the schools. Another seven states (Minnesota, Iowa, [lllnois, Pennsylvania, Delaware, Utah, and Kansas) encourage sex education; the latter two states discourage the discussion of birth control in sex education classes, however. Thus, approximately 80% of our junior and senior high age youth live in states where the decision to offer family life and sex education is left to the jurisdiction of the local ,~,l~ooldistrict [25]. This is deafly unacceptable

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if we are to enhance the awareness of all our youth. In addition, sex education within the schools does not reach those youth who have dropped out or who are truant frequently. One national survey of high school principals in 1978 found that only 36% of high schools offered a separate sex education course. Much instruction on sexuality and reproduction takes place only in the context of health or biology classes. One must question the effectiveness of all this instruction in light of some of the previously discussed data. The Adolescent Father

The welfare of the unmarried adolescent father and his importance in decisions regarding the outcome of the pregnancy are significant but often neglected issues. As suggested by Pannor and others, the active involvement of the male partner can be of considerable emotional benefit to the pregnant teenager [26]. There is still insufficient information regarding the psychosocial morbidity the teenage male suffers for fathering an unwanted child. There is similar need to study the adolescent male who is not yet a father, as well as the adolescent male who has not become sexually active. As pointed out in the study by Cvetkovich and Grote, the three groups--fathers, sexually active nonfathers, and virg i n s - m a y differ sufficiently with respect to variables such as self-concept, sex-role concepts, family

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orientation, and religious orientation to permit identification of important determinants of responsible sexual behavior by a systematic examination of various components of sexual as well as nonsexual identity.

Summary There are no simple solutions to the problems associated with adolescent sexual activity. As a Society dedicated to "promoting the development, synthesis, and dissemination of scientific and scholarly knowledge unique to developmental and health care needs of adolescents," we encourage continued scientific focus on the issues related to adolescent reproduction. The positions of the Society of Adolescent Medicine on reproductive health care for adolescents follow and represent the views of the membership. Obviously, unanimous concurrence on such sensitive issues is impossible and the differing opinions by some of the membership are recognized and respected.

The Ad Hac Committee on Reproductive Health Richard E. Kreipe, M.D. Catherine MacDonald, M.D. Elizabeth R. McAnarney, M.D., Chairman The Committee"would like to extend its gratitude for Adele D. Hofmann, M.D. who assisted the Committee in the final wording of the Position Statements.

Positions Papers on Reproductive Health Care for Adolescents Adolescent Sexuality The Society for Adolescent Medicine hereby resolves to support and encourage the development of responsibility toward sexuality, on tlie part of all adolescents; to support and encourage an awareness and acceptance by adults of sexuality in all children and adolescents; and to support and encourage an

approach to adolescent reproductive health care that promotes health as well as prevents disease.

Sex Education The Society for Adolescent Medicine hereby resolves that all States should mandate the teaching of Health and Sex Education from kindergarten through the