Help teens stay safe: Identify barriers to prevent pregnancy, STD infection

Privacy issues, insurance coverage, lack of education put teens at risk

What are the odds that your first-time adolescent patients are sexually experienced? Have they used protection to prevent pregnancy and sexually transmitted diseases (STDs)? A national survey shows those odds are good: More than 90% of sexually active teen girls ages 15 to 19 reported using a contraceptive method,1 but teens don't always use contraceptives consistently or correctly,2,3 a finding confirmed by a recent random-sample survey by the Kaiser Family Foundation in Menlo Park, CA, and YM Magazine, a popular teen publication.4

The survey, which polled 650 teens ages 13 to 18, found that by the time teens have sex for the first time, many aren't adequately prepared. More than half (58%) who are sexually experienced report not using contraception every time they have sex, and more than a third have never spoken with a sexual partner about preventing pregnancy or disease. About one in five who did talk about contraception or STDs did so only after having sex.

"Teens do know about the birds and the bees, and they do know generally about contraception and preventing pregnancy and STD," says Felicia Stewart, MD, director of reproductive health programs for the Kaiser Foundation. "What they don't know is enough detail, such as information about the various method options, how to use them, where to get them, and symptoms to watch for STDs."

And details count when it comes to contraception and STD prevention. In a single act of unprotected sex with an infected partner, a teen-age girl has a 1% risk of acquiring HIV, a 30% chance of contracting genital herpes, and a 50% chance of contracting gonorrhea, according to information released at a recent briefing series on teen sexuality data by the Kaiser Foundation, the Alan Guttmacher Institute in New York City, and the National Press Foundation in Washington, DC.

While parental involvement is desirable, federal and state lawmakers have long recognized that confidentiality can play a crucial part in encouraging teens to seek pregnancy prevention and STD diagnosis and treatment. Teen access to such confidential services came under attack in 1997 on the federal and several state levels, according to the Guttmacher Institute.5 While the parental rights movement has seen limited success in promoting its proposals, there is concern that a change in confidentiality laws would hinder teens from seeking needed care.

Confidentiality plays a large role when it comes to such issues as HIV testing. A survey of sexually active Massachusetts teens found that only 22% had sought voluntary HIV testing.6 About one-third of those surveyed didn't believe or didn't know that HIV test results would be kept in confidence. In a separate study, 12 months after Connecticut eliminated a parental consent requirement for minors seeking HIV counseling and testing, the number of youths ages 13 to 17 who visited publicly funded facilities to receive such treatment jumped 44%, and the number obtaining HIV tests doubled.7

A randomized controlled trial of teen-agers in three California public high schools found that when adolescents are assured of physician confidentiality, they are more willing to disclose sensitive information on sexuality and other issues and return for future health care.8

Teen patients need to be assured that their information remains confidential, says Paula Hillard, MD, professor of obstetrics and gynecology at the University of Cincinnati College of Medicine and chairwoman of the Committee on Adolescent Health at the American College of Obstetricians and Gynecologists in Washington, DC.

Many young women are accompanied by their mothers for the initial OB/GYN visit, and Hillard takes that moment to let mother and daughter know that discussions between provider and patient remain confidential. She repeats the statement during the exam so the patient fully understands her rights. "I do have to go on and say there are some exceptions," Hillard tells the patient. "If there are concerns about you hurting yourself or others, or if there are concerns about abuse, those are things I legally have to report. Beyond that, the things you and I talk about are just between us."

Financial coverage for teens

Teens are the most vulnerable when it comes to financial coverage for contraceptive/STD care, Stewart says. "The issue of financial coverage for contraception is especially critical for teens and young adults. Teen-agers and young adults are now in the United States the group least likely to have health insurance coverage - period."

Publicly funded family planning clinics are a key source of contraceptive services for teens. Thirty percent of Title X clients are younger than 20, according to a Guttmacher Institute report.9

A study co-authored by Stewart examined the medical care cost savings afforded through adolescent contraceptive use.10 The study examined costs and savings in the private and public sectors and compared use of 11 methods with those associated with the consequences of using no method: unintended pregnancy and STDs.

Using the most conservative estimates, the cost of pregnancy and STD health care for each at-risk, unprotected teen-ager results in an average cost of $1,267 in the private sector and $677 in the public sector. In contrast, the cost of condom use in the first year of use is only about one-fourth that of using no method.

Legislative activity is under way to expand private insurance coverage for contraceptive serv ices. (See Washington Watch, p. 82.) Such efforts recently were vetoed in California, however, and may preview of what's in store for the federal bill. Title X services for adolescents were challenged when some legislators raised the issue of parental consent but remained intact after a substitute amendment was passed requiring Title X grantees to certify that they encourage family participation. (See Contraceptive Technology Update, December 1997, pp. 153-155.)

Studies have shown programs led by trained teachers who provide information about abstinence and contraception are effective in delaying the onset of intercourse and aid use of contraception and STD protection in sexually active teens.11

Nineteen states plus the District of Columbia mandate that schools provide sex education, but the scope and nature of these programs vary, according to information presented at the joint meeting of the Kaiser Foundation, Guttmacher Institute, and National Press Foundation. Ten states require sex education programs to teach abstinence but do not mandate inclusion of information on contraception, while 13 states require programs to teach abstinence and provide contraceptive information.

As of fiscal year 1998, the federal government is allocating $50 million annually for abstinence-only education. States must match every $4 in federal funds with $3 in state funds for the new program. All states have applied for and received abstinence-only funds, according to the New York City-based Sexuality Information and Education Council of the United States. Twenty states are targeting people under age 14, while four are focusing programs for those under 17. Seven are directi ng programs to those under 19, while one is aiming at those 20 to 24 and another at those 20 to 25. (For more on abstinence-only funding, see CTU, July 1997, pp. 81-84.)

Providing solid information on contraceptive choices should begin early to dispel myths, says Catherine Stevens Simon, MD, associate professor of pediatrics at the University of Colorado Health Sciences Center in Denver and director of the Colorado Adolescent Maternity Program. Knowledge about birth control options and how they work helps young people overcome misinformation often offered by family members or peers.

Young people have no problem accepting the safety of Tylenol but may have culturally ingrained fears about birth control, Stevens Simon explains. When they receive early education on birth control methods and how they work, they can counter those fears. The misinformation surrounding Norplant safety is a case in point.

"They have to already know that Norplant is a safe method before they start hearing the rumors, so that it sounds just as silly as someone telling them that a Martian landed in their backyard," Stevens Simon says. "Unless we reach them at that early level, we won't get behind the problem." (For counseling tips, see p. 72. For details on how to support teens who choose to delay intercourse, see p. 73.)

References

1. Piccinino LJ, Mosher WD. Trends in contraceptive use in the United States: 1982-1995. Fam Plann Perspect 1998; 30:4-10.

2. Peterson LS, Oakley D, Potter LS, et al. Women's efforts to prevent pregnancy: Consistency of oral contraceptive use. Fam Plann Perspect 1998; 30:19-23.

3. Kaiser Family Foundation. The 1996 Kaiser Family Foun dation Survey on Teens and Sex: What They Say Teens Today Need to Know, and Who They Listen To. Menlo Park, CA; June 1996.

4. Kaiser Family Foundation. The Kaiser Family Foundation/ YM 1998 National Survey of Teens: Teens Talk about Dating, Intimacy, and Their Sexual Experiences. Menlo Park, CA; March 27, 1998.

5. The Alan Guttmacher Institute. Teen-agers' Right to Consent to Reproductive Health Care. Issues in Brief October 1997.

6. Samet JH, Winter MR, Grant L, et al. Factors associated with HIV testing among sexually active adolescents: a Massachusetts survey. Pediatrics 1997; 100(3 Pt 1):371-377.

7. Meehan TM, Hansen H, Klein WC. The impact of parental consent on the HIV testing of minors. Am J Public Health 1997; 87:1,338-1,341.

8. Ford CA, Millstein SG, Halpern-Felsher BL, et al. Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care. A randomized controlled trial. JAMA 1997; 278:1,029-1,034.

9. The Alan Guttmacher Institute. Title X and the U.S. Family Planning Effort. Issues in Brief February 1997.

10. Trussell J, Koenig J, Stewart F, et al. Medical care cost savings from adolescent contraceptive use. Fam Plann Perspect 1997; 29:248-255.

11. Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: A review of effectiveness. Public Health Rep 1994; 109:339-360.