The Prevention of Teenage Pregnancies.  Ellen Rome

I am honoured to be here and I am grateful to each of the prior presenters for outlining the issues so eloquently. The statistics have been so well laid out already this morning by Gail Slap and everybody else who’s spoken. Sexual activity is a problem in teenagers in that there is too much of it without adequate contraception. We’ll talk a little bit about why this is going on and we’ll talk about the medical model or one-on-one in the office and also the public health model, how to prevent pregnancy on a more global front.

First of all I come from the United States where we are not doing that well. Our teen pregnancy rate is appalling when you look, at the UK, France, Netherlands, Canada, Sweden, we are just way worse on this front. It’s not that our teens having sex more than other developed countries, it’s that we are not adequately contracepting, we are not teaching them to choose abstinence and we are not teaching the use contraception effectively when they are choosing to have sex. We also have better access to services and supplies than other countries by just as Gail Slap’s example with the person with HIV our teens are not necessarily choosing to use those services or access those supplies. We also unfortunately are very behind on the sex education end of things. Sex education in many other countries such as Switzerland and in other developed countries is mandatory. Ours is theoretically happening in every school but every school requires it.

Why our kids getting pregnant is more theoretical  it’s not so easy to put one finger on one thing and say, That’s it. Three quarters of the births are unintended. But it’s really a nebulous number because if you really press many of those teens they very intentionally did get pregnant but they don’t necessarily want their mother to know that they were planning so or their partner, or whoever. And it is a sharp contrast in the United States at least between a society which promotes sexuality through our media and TV and MTV and everything else and yet resists access to contraception and family planning services. So it’s kind of a schizophrenic message, sexuality is pervading society yet when we don’t want to talk about it with our kids. And physicians and patients both overestimate the risk of contraception. The risks to a pregnant mum far outweigh the risks of taking oral contraception, or Depoprovera or using a condom or whatever else. But we overestimate the problems that go hand in hand with using contraception.

What are the developmental factors that forces, pushes kids to get pregnant? First, there is a delay in obtaining contraception, kids in the United States at least will start sex and not access contraceptive services for up to one year and in one study it was 24 months. In that first year if they are starting sex below age 14-15 or by age 14-15 they are likely to have three or more partners and the longer they wait the more likely they are to use contraception. We have a lot of patients who feel that they are immune to pregnancy, can’t happen to me. In that planning to use contraception and planning to use sex implies that you are thinking to have sex and in our schizophrenic environment, if I don’t think about it then I am not guilty of doing it, it’s kind of happened. It’s basically an adolescent mind set, “If I don’t think about it - it’s not my fault”. And also the lower the self image the harder it is to access contraceptive services and again a pill every day or getting your Depoprovera shot or buying the condoms or all of the above requires motivation on the girls and the boys’ part.

We also have this disclosure, many people do not access health care because they are afraid that in the neighbourhood clinic Daisy is going to be behind the counter and their confidentiality is going to be breached. They also may not even understand the concept of confidentiality and that can be a very big obstacle. We also have a lot of people who don’t seek access to care because they are afraid of the pelvic exam and we know those who hold teens hostage and will not give them birth control pills now without first pelvic exam, it’s not absolutely that they have to have that first exam to get those pills started and then that gives you a little more time to educate and help them to get over the fear of the pelvic exam just as we hopefully get them over the fear of going to the dentist, something that kind of a necessary part of life and shouldn’t be a big deal.

How do we change teen’s behaviour? First of all we need knowledge, information skills, beliefs,  but it’s not enough, so we also need resources, supplies, alternatives, access to care, adolescent centres of providers. That’s not enough, we also need to help them with motivation, meaning positive incentives for healthier choices. Peer approval for healthier choices and social sanctions and then also helping them build the skills so that they can practice it and I remind my patients if they come and say, Oh yeah, I have another partner, that they did not  learn to ride a bicycle overnight, they had training wheels to help them practice, they may not learn to build their own self-esteem overnight, it may take a little bit of time to figure out how to say “no” time after time or to figure out how to get a condom used between kid and a partner every single time, this goes for the boys as well as for the girls.

How to identify adolescents at risk? We look for the hidden symptoms, in the hidden agenda, that is, Oh by the way, at the end of your visit with them. School problems, anyone who’s had a lag in grades, or if you have somebody who is 17 and in a lower grade, where did they miss those years, what’s going on. School failure and what we call push-aways or throw-aways, it’s no longer dropping out of school, society pushing them out somehow. If you have an older sibling who’s had a kid you are much more likely to do so and the more partners the more risks and if they are using drugs and alcohol the likelihood of condom use decreases significantly as well.

Why do they say they are not using condoms? Common lines that we hear is, I am a virgin so I didn’t need one; My partner is a virgin; I don’t use drugs, assuming that HIV is the only thing they have to worry about and that if they are not using drugs they are not at risk; I am on the pill, and we are telling them they need belt and suspenders, they need two methods to keep those pants up which we like to have them doing literally of course but the pill or Depoprovera or a barrier method spemicidal jelly, spermicidal foam, local barrier method plus a condom, so that they are preventing disease and pregnancy, we are making sure that kids are not relying on condoms alone whenever possible. I’ve been tested for other diseases and I am clean, or You don’t trust me.

So how do we prevent teen pregnancies? The classic medical model is on-in-one in the office setting, but the public health model is in the community, including schools, health centres, through religious organisations, through family environment, use of the media proactively and other causes. And now in the 90s it’s worthwhile combining both: getting access to patients in your office and also being an activist in the community and helping all the grass-root community initiatives get on their feet and running. An example is ‘Ask Doctor Whoopee’, tonight’s topic is Teens in Turmoil, in this age of promiscuity what you kids really know about the risks, we are getting answers from some actual teens, look Andrea here, Andrea! And she says, Well like I know AIDS is a totally bad thing to get and so my parents are like paranoid and it’s like my life, you know, also like, I don’t know, but I heard sex is totally excellent, my friend Jennifer …, and he cuts her up and saying, Remember, these are actual teenagers.

Communicating with the adolescents you have to get past that sense of invulnerability, it can’t happen to me, and the concrete thinking that teens have. If you talked to them about AIDS and being sick or dead about ten years from now, that’s irrelevant, that’s like talking about lung cancer and the risk of smoking. They are much more likely to relate to the here and now. And you want to get them thinking as far as opening the lines of communications. And if they are thinking about sex or considering sex  what are their views on contraception and abstinence, how you even ask the questions becomes crucial. For instance, in the United States if you ask a teen, Are you sexually active? Dealt with concrete facts they say, Oh no I just lay there, my partner is active. True statements, that my residents have gotten these responses, you have to ask, Have you ever had sex? And are you intending to have sex? Make sure you are asking them in a way that they can answer. As far as the concrete thought process, we also have teen who also will take your word literally, I had a partner who had made sure that her patient appropriately named Surry was condoms every time she had sex with her boyfriend. Sure enough Surry became pregnant. Doctor Collin said, But Surry I thought you were going to use condom every time you had sex with your boyfriend, she said, But I did, Doctor Collin, I did, and my partner said, What happened? And she said, I wasn’t with my boyfriend. Concrete thinking.

We have something called the Heads exam, popularised by Richard Mackenzie who is another one of our speakers this week and we ask these questions confidentially, that means without a parent in the room having defined confidentiality for patient in care and parent if they are both coming to your visit together. Who lives at home? What happens when there is an argument at home? Oh, it’s fine except when my mum drinks. Oh, and what happens when mum drinks? Well, she beats up my brother and I. Taking the questions to the level where you need to know what’s going on in the home. Education, what grade are they in, what’s their level of functioning, do they have a learning disability. Again markers for low self esteem can be a pathway to sex. Activities and attitudes, do they have any friends, do they carry on in a gang, which has been a risk, and in some of the female gangs in the United States you have to have sex with at least three people in the male gang to get in, in one gang in Cleveland a couple of years back you had to have sex with somebody with HIV, known HIV without a condom. They are taking willing risks to be part of a certain peer group sometimes.

Do they carry a weapon? If they do, are they carrying it now and can they not bring it into your office for their next visit. Do they use drugs, cigarettes, alcohol? How much, how often? And an easier way to get to this is to ask, do your friends use? And if they say, yes, do you use, no, oh, and what do you do when your friends are gonna use, you are getting a chance to use a little role-play without telling them, OK we are going to do a little role-play now, you’re giving them a chance to practice refusal skills. And then sex. Do they have a history of physical or sexual abuse, if they are using condoms, are they using them sometime, most of the time or all the time, and have they ever traded sex for food, clothes, drugs, shelter, we call that survival sex in the United States in adolescent medicine circles, it’s not really prostitution in their minds, it’s staying relatively safer than they think they are, than where they think they are.

Yeah, I just think making these decisions is hard, there is not one to discuss them with, How about your folks? No way, they live in a dream world, Are you sure? Have you and your parents ever sat down to discuss sexual responsibility? Well, yeah, once when I was about 14, And? They just weren’t ready. Maybe you are rushing them, some parents need more time.

So helping the parents to communicate with the child is very very important. And that should start at birth and that should be continued on and new as roles as a care provider doing anything in the home of adolescents can help parents find the words. Help them to organise their own thoughts first and then to share those with kids. And this reflects the heart problem we have with these messages says, Let me get this straight, mum, sex is healthy, natural and lots of fun, but at the same time it’s frightening, dangerous, upsetting and potentially life-threatening. We are giving them tough messages right here.

So what’s a physicians’ role, you could substitute nurse practitioner, clinician, school nurse, psychologist, etc. As an educator we are perceived by teens as being a very authoritative source on HIV yet only 13% of them counsel on AIDS at a last visit in United State data. Encourage abstinence, but tamper with practical tips, for instance, I’d prefer all my patients to choose not to have sex but if you are going to choose sex I’d love you to use a condom as a second method. When prescribing contraception to your patient, if you have somebody who does not use tampons the odds of them to be using an insertible method are going to be very low. If you have somebody who is afraid of needles Depoprovera is probably not going to be a good option.

Now how do you expand the medical model to the pelvic health realm?  Ryan Howard did a study looking at 8^th and 9^th graders using peer leaders just as A PAUSE does and found that at the end of the 8^th grade those who’s had the programmes were 4 times less likely to be sexually active than those who had not had the programme. The programme worked, it decreased the risk of those having sex and at the end of 9^th grade a year and half after the programme they were still a third less likely to be sexually active if they’d been on the programme, and if they were given both contraceptive and abstinence counselling they were more likely to use protection when they initiated sex. In the same way Kingston found that if teens were more likely to use a condom if they thought that it decreased the risk of HIV, if they thought that is does not reduce their pleasure, if they thought that they themselves were at risk for HIV, and if they were not  embarrassed accessing them or using them. If they discussed it with the doctor they were twice as likely to use condoms, and 50% less likely if they were simultaneously using alcohol and marihuana.

Clementi in San Francisco looked at junior high school students and found a two fold increased use of condoms if they thought they would prevent HIV and lower social class and more partners less likely to use. Those at most risk with more partners were using condoms the worst or the least. So have them accessible. Again found that talking about sex goes not make kids do it. This is a message that at least in the United States parents need to hear over and over. They’re afraid that if they are talking about it they’re condoning it. Family planning counselling does not promote sex, it actually will delay sexual initiation and get them using condoms more effectively when they start.

So what do you do in school? First generation programmes - the goal was to increase the knowledge, that was just done, just know, k-n-o-w. And we found no behaviour change. So the next generation we decided to increase the knowledge, plus role clarification, decision-making skills, communication skills. That still didn’t work. So next they tried a regression, they decided to go to just say “no” in a Reganesque view of things and not only there was no delay in onset and frequency of sexual activity but there actually was kind of  con-committant flurry of more activity than anything. So then the fourth generation the goal was really to delay sex as a healthy delay, postponing sexual activity is now a good goal, as a short-term goal and if you can’t delay sex have them using a condom.

The fourth generation is based on two theories: the health belief model where a teen acquires a belief about personal vulnerability either through their own action or through vicariously watching their friends experience and incorporate this belief as something they need to worry about or change their behaviour. We also use a social learning theory, that you learn from yourself and other’s experiences and this requires knowledge, motivation and skills. Michael Carrera at Hunter College guarantees his students that he picks up between 6^th and 8^th grade and follows them through high school, teaches them how to do a bank account, teaches them skills like squash and tennis and golf where they,  as he says, don’t succeed by throwing around their weight but succeed by skill and guarantees them a four-year college tuition if they finish the programme. And he said the best birth control we can provide is to make a young person feel they are something special. The programme was called The Pregnancy Prevention Programme, but it it’s a substance abuse prevention programme, it’s a drop-out prevention programme.

And how do you prevent teen pregnancy?  Educate early and often. Build self-esteem from birth onward and over and over again. Help instil a sense of hope. And re-enforce the messages diffusely and everywhere that means at home, in the religious organisations, at school, through the media, in the doctor’s office, anywhere. And help them improve access to medical services it’s clearly that there’s a barrier to teens health care. When you are talking to a teen ask them about their feelings on pregnancy and address each teens individual needs and myths, so you’re counselling them in contact. For instance the kid that feels that he’s never gonna live beyond 19 may very well like to father a child, so helping them take care of themselves so that they can live beyond age 19, help them to make healthier choices. Again that gets back to the fathers as well as the mothers. And then never underestimate the strength of a individual relationship between an adult and a kid. You are one of those factors that can help them instil hope and continuity of care really helps. Just to keep it in perspective here, if there are 600 million women reproductive age and 39 trillion numbers of acts of intercourse at any minute in time given 12,000 ejaculations per second and 60 million sperm per ejaculate we are combating a total world-wide sperm release of 720 trillion sperm per second. This is global and magnificent problem. I am going to end there and leave it to he next speaker, thank you very much.

Adolescent Pregnancy, Sexuality and the Welfare Debate  Peter Selman

Thank you very much. I’m going to move on to rather different level of discussion in that I want to talk about the politics of teenage pregnancy following on what Ellen was saying I am going to be talking about how not to be effective at preventing teenage pregnancy which I think what her government and my government have tended to do over the last ten to fifteen years. So although we heard words about the high rates of teenage pregnancy in America I think it’s worth starting by remembering that this is not so very different in Britain. Yes the level in America is the highest of the developed world but the bold figures in there for England and Wales since 1971 show that we share with America phenomenon having had rising teenage birth rate in the 1980s, in the Thatcher - Reagan years as we like to think of them, and that we are now about 4 times higher than the level for example in the Netherlands.

It’s less often that we compare these figures in relation to other parts of Europe and what I’ve done here it just remind us that in England today and America we are more like Eastern Europe than the countries of Southern as well as Northern Europe shown before. And this is pleasing to find that the whole solution to this was summarised very nicely by a former Prime- Minister while visiting United States yesterday. So some of you have seen this. Mrs. Thatcher sums up all this long British-American approach to this problem, the obsession with sex: the belief in chastity is the answer and the way of getting people off welfare. This is not just Mrs. Thatcher, this is a theme that ran through British politics for the last 7 or 8 years, here are some example I’ve taken from the Tory party conference of 1992: these are yesterday’s people repeatedly have these lively idea of young ladies seeking council houses, the minister of housing explaining that we really have to stop helping people who didn’t get married first to have housing and that was the source of most of our problems. And that is the theme I want to come back to, the way in which Britain and America uniquely in my experience have blamed the welfare system as the main reason for their high rate of teenage births.

We in Britain have also been obsessed with the idea that its a symptom of all that’s wrong with society, so I will show you how we have handled the teenage birth issue in the last few years.

An article in the Daily Express seeing the end of the family due basically to teenage birth. The extraordinary thing about this story was that although it did indeed pick up some issues about changes in marriage and divorce if you have a closer look Scandal of teenage mothers, this was based on story taken place seven years earlier of a school master who remembered as he thought that all his 15-year olds when they left school immediately got pregnant in order to get a council house and that’ s the way we subscribed completely virtuously to part of a theme. Inside the same issue the point was made that they had cynically by these teenagers that to get a better life rely on the dole and the portrayal of teenage parents was typical of what was happening at that time.

Worst of all was the picking up of people who were very very exceptional as being the norm. So here is Sue Simco who has got five children by three fathers who is pregnant again with the fifth and she’s going to go on ripping off the welfare state like mad and she started as a teenage mother. That quite extraordinary panorama actually maintained that the whole theme of welfare dependency was dominated by teenage mothers who went on to have 6 or 7 children, these are very very rare indeed. The extraordinary thing however is coming back to why we’ve been so obsessed in the last few years about this particular problem. This incidentally is theme that’s also true as I recall it of much of the American figures.

The greatest concern about teenage births has arisen when actually the level of such births is much lower than it was in the past. OK, so 1966 - 86 thousand, 1995 - 42 thousand. So half a level, twice the fuss. Partly that’s a distortion of numbers of teenagers, there are now relatively few teenagers in comparison with the number there were ten years ago, because of the rise and fall in birth rate. But actually when you look at it the real issue of course being that the growth of births outside marriage and in particular the proportion of births outside marriage which of course is as much a picture of the reduction of births inside marriage most of which were forced births resulting form pregnancy that was unwanted. So in the past we accepted this because pregnancy was solved, quotes, by early marriage followed by divorce or it was solved by adoption or it was solved in ways that didn’t cost the state. Therefore we’ve come on to the theme I want to end on which is looking at this question of why we have become so obsessive over the cost of teenagers that we actually, it should be welfare as the cause, that is unique in my experience to the thinking of Britain and America.

So let’s have a look at that particular theme. The argument goes like this: we in America and Britain have introduced benefits that enable people not to starve and die if they are teenage unmarried mothers therefore lots of young people are saying, wait, if we become a teenage mother we needn’t starve, that’s living a life of Riley and there is a mechanism of thinking there which I find so inherently implausible that I find it almost a waste of time to have to argue against it, but argue against it we have to do because everybody will find one person who will come forward and say, That’s why I did it, in which case the question we should be asking is, and what on earth is the social situation that can cause people to have that mode of completely absurd thinking.

Let’s have a look at what’s happening at the moment. The issue in America has gone on for many years, talk about the epidemic of teenage pregnancy, the concern over the perverse incentives cause by issues like the introduction of FDC and yet when we look at this rationally America of course stands out of all countries as being the least generous in term of welfare support and therefore the last place where one be in any sense taking this as an incentive to have children. But even with the move from the Thatcher-Reagan years which I’d hoped we’d see a change in attitudes things are not that different. So I am going just end by looking at a few features of new America and New Labour.

This is President Clinton by-passing Congress to impose reform which would slash welfare payments to teenage mothers. So whole series of changes have been brought in by individual States as a result of presidential wave in the United States which are putting burdens on to encourage teenage mothers or force them really to live at home, to continue school and to defy them of basic role of benefits, the argument is that is will not only save the state money but it will also revive a new approach that will be rational that people not have perverse incentives and therefore teenage births will go down. What a marvellous solution. But this is not one put forward only to America. Here is New Labour deciding also that they are going to get tough on single mothers. And the Home Secretary putting out again the belief that the benefit system created an environment in which what he calls natural checks the checks of stigma, of blame, of shame I suppose are now gone. The image there is of two things: first of all it seems that this is encouraging people to have children but also the words “and keeping them”, and so the theme that hovers around  comes back to the one of would we not be going back to the 1960s when one in 5 of all births outside marriage ended up in adoption. Now I work in adoption much of my life and I am a believer in adoption but I’ve also worked with mothers of that generation who gave up their children and believe me it’s one of the most tragic things to hear somebody who pressured into that. Which brings us back to Mrs. Thatcher. We used to have things called mother and baby homes and mothers would go there and they would earn their keep and they would then be persuaded to give their child up. So there may be a further agenda. We made a mistake back in the 60s because we started giving them money so they didn’t sort of die, we gave them housing so that the children could be kept warm, you know, what a bloody mistake. If only we’d thought, so there it is. Now the sadness and I will end up in the next few minutes, about it is that of course to some of us even if we accept all this concern we say, well there is an answer and it lies in what we’ve been talking about most of today, better sex education, better  access to contraception, right to abortions but I am afraid like America we share it seems at least at the press and government level a complete inability to get our act together on this.

This story was reported in the Sun a few years ago - the story that shook Britain is interesting but of course what is most interesting is that the real issue is sex at 11 rather than at 12. Incidentally at the moment at 12 one is not going to get welfare as a matter of interest but I mean different stories at different times. So when we try to move forward on sex education what do we find? A few years back and I thought possibly that was something that was changing, the Health Education authority came out with a fairly explicit but rather readable book for youngsters on contraception and sex education, absolute outrage. And the government adviser said that it was unacceptable. You see who the government advisers are: Ester Ransen and Chris Acabusi. Absolute shock at this. And it did a world of good, actually, because the government minister banned it, Penguin promptly published it and they sold many more copies, you know, we learn this back in the 19^th century the Riddle of Bizantiles but that was the absolute classic, well I thought that was fading out and then I picked up the Scottish Sunday Post this Sunday, we’ve been here before I remember the nurse who was sort of castigate for going in to a school and talking about oral sex and lots of dreadful things like this. This was not even, you know, tea talk as they say, this was emergency contraception which it seems to me to be one thing that was really very important, the variability of this further opportunity to make a decision. But no, absolute outrage that this should possibly be suggested.

This brings me on to my two final points and then I will stop. And that’s OK, I am being very negative, I am saying that we are very bad  at sex education, we’ve got it wrong about the welfare, so you know, what about this, what are you going to do instead? Well, I want to end my two points and one is to go back to actually look at the situation in this country in regional terms. This nice, if everybody has got time go and see there is a nice poster display from Sheffield on the teenage pregnancy programme, is anybody  representing that here? Anyway, it was jolly good, go and have a look at it. But what struck me when I looked at it was that actually the figures that were concerning Sheffield were far lower than some of the extremes here. So first of all there is variation across regions.

So what happens when you get down to really small areas. Two points quickly, one is when you get down to areas Sunderland and Manchester we are talking about the level of births that are twice the national average. And the range across the country is much wider than the range we are seeing within Europe that causes concern. So there are big problems in Britain in particular areas, most of those areas are areas of considerable deprivation. And the arguments that most of us will put forward is that you cannot explain that in terms of welfare access nor can you actually explain that in term of quality of provision of birth control services. What is also interesting is almost an iron law here, that those areas with the highest conception rates also have the lowest abortion rates. So where there are most pregnancies more are going on to keep the child, and takes me back to my final point which is about thinking about the motivation and what is it that people are looking for.

I come from the North East and believe me the abortion access up there is pretty good. There is NHS access and that is not the key thing, it’s not that they are being denied abortion. But of course abortion before I go on to the final point  is not one something that we can dismiss, because we in America and Britain do have much lower use of abortion in relation to teenage pregnancy than the countries of Northern Europe. I was pretty struck by this that in Denmark in 1991 there were 2 births to women under 15. I was talking here, I don’t know whether he is here, to a colleague from Switzerland at lunch and he said that they just discovered a young teenage birth in the hospital, so there are some countries for whom this is seen so unusual that it’s permeating the whole culture. So that’s very striking. But coming back to theme that I want to end on, I am simply saying that I think governments have got it wrong again and again, that the media that we were talking about at lunch time has distorted and represented a very antagonistic approach to many of the rational solutions, but in the last resort we have to come back and ask about what it is that leads so many people, so many young people in Britain and America especially in poor areas to feel that there is something to gain for them in going on. And I feel that it is rooted often in the sort of situation we left them in, in another words that the high rate of teenage pregnancy in Britain and America reflect two things: one is our totally confused position of sexuality and secondly the fact that we have especially in the Thatcher - Reagan years develop more social inequalities than any other developed country.

I’d like to end up with a quote from my favourite book on teenage pregnancy which many of you may know and that’s Christine Lucas book “Dubious Conceptions”, where she says one thing which I think can be applied equally to my country as to America that we shouldn’t be going on about epidemics of teenage pregnancy, but start thinking of the social context within which these arise. This does not mean we don’t need also to go on to provide the best contraception services we can and so on. And then reminder that we are not in that category in England of most European countries, we share with America a very real problem in terms of some aspects of out society and I believe that that’s the key reason behind our continuing high birth rates.

Christine Ferron: I want to thank all of our speakers for their really brilliant presentations..