Adolescent Reproductive Health Services in the United States

By: Nirmala Trisna Anakagungistri
(For PH7160 course - Spring 2005, Russ Toal, Institute of Public Health, Georgia State University)

Despite the declining incidence of teen pregnancy and the reduction in the number of adolescents who have had sexual intercourse, surveys indicate that almost half of high-school age adolescents are sexually experienced (Manlove et al. 2004, 265). Due to their sexual behaviors and biological vulnerability, adolescents are subject to certain reproductive health risks, such as pregnancy at early age, HIV/AIDS, and other sexually transmitted infections (STIs). Every year, there are about a quarter of 15 million new STI cases in the U.S. occur in adolescents (CDC 2000a), approximately 900,000 numbers of teen pregnancy (CDC 2000b) and girls aged 15-19 have the highest reported rates of chlamydia and gonorrhea infections (CDC 2004). Despite these high rates of health problems, the teen population often faces barriers to reproductive health services. This paper discusses adolescent reproductive health as an important public health issue with focuses on the importance of access to adolescent reproductive health services, the types of access barriers, shape of this issue in the United States today, and recommendations to improve access to adolescent reproductive health services.
I. Adolescents and Reproductive Health

World Health Organization (WHO, 2005a) defined adolescence as “a time of transition from childhood to adulthood, during which young people experience changes following puberty” and it happens between the ages of 10 and 19 (WHO, 2005b). Like adults, adolescents are entitled to the right to access full range of health services as stated by Article 24 of the Convention on the Rights of the Child that States Parties should “recognize the right of the child to the enjoyment of the highest attainable standard of health” and agree to “develop family planning education and services” (UNICEF, 2005). Full range of health services includes reproductive health which implies that people are able to have a satisfying and safe sexual life, and that they have the capability and freedom to decide their reproductive choices (World Bank, 2002).

The Guidelines for Adolescent Preventive Services (GAPS) by American Medicine Association (AMA) provides recommendations that “all adolescents should have an annual preventive services visit”, “physicians should establish office policies regarding confidential care for adolescents and how parents will be involved in that care, “all adolescents should receive health guidance annually to promote a better understanding of their physical growth, psychosocial and psychosexual development, and the importance of becoming actively involved in decision regarding their health care” (AMA, 1997). Sexually experienced adolescents, a group that includes half of all U.S. teens and more than 75% of females and 85% of males at age 19, should be screened for cervical cancer and STIs, and should have access to family planning services and supplies (Gold and Sonfield, 2001: 81).
II. The Importance of Adolescent Reproductive Health

Adolescent reproductive health is a public health issue because of its significant effect to the society. It is a lifelong concern as these young people are the next generation of the nation. According to WHO, “Neglect of this population [adolescents] has major implications for the future, since sexual and reproductive behaviors during adolescence have far reaching consequences for people’s lives as they develop into adulthood” (WHO, 2005a). Adolescents who lack access to reproductive health information and services are more likely to have STIs, unintended pregnancy, abortion, and other health consequences (Kirby, 2002), and over time, those problems tend to reduce an adolescent’s continued education and employment.

It is difficult to endorse teens themselves to deal with their reproductive health and risk factors associated with the health problems. Often, young people engage in risky behaviors because of the misperceptions on sexual issues and the embarrassment to obtain reliable reproductive health information from parents or health professionals. Access to reproductive health services is a crucial component to help adolescents modify their risky sexual behaviors, promote healthy habits, prevent health problems and respond to them.

III. Barriers to Adolescent Reproductive Health Services

Despite the importance of access to reproductive health services for adolescents, teens in the United States are much more likely to encounter barriers to access basic reproductive health services than are their peers in the United Kingdom and other western European countries. The median interval between first sex and first visit for reproductive health care was 22 months for U.S. females younger than 25, much longer than British female adolescents who access the services six months after the first sex (Hocklong et al., 2003). Barriers to access can be categorized into four main categories: psychological, financial, cultural and structural (de Belmonte et al., 2000; Hocklong et al., 2003).

Psychological Barriers. Internal feelings that hinder adolescents to seek reproductive health services include:

- Adolescents are unaware that their sexual behaviors have risks for STIs or pregnancy. This is due to their misperception and the inexistence of early symptoms, if any, of reproductive health problems.

- Adolescents are worried about social stigma associated with STIs or ‘out-of-wedlock’ pregnancy. This feeling makes adolescents disregard any symptoms and the need to seek professional health services.

- Adolescents have insecurity feeling on their relationship that they are worried with their partner’s reactions to the diagnosis of any reproductive health problems.

- Adolescents are afraid of confidential information disclosure to their parents or guardians on their reproductive health problems. For some of the teens, this fear is mostly based on the personal, family and religious values that adolescents are not supposed to engage in sexual relationship and the social stigma attached to it.

Financial Barriers. Access to reproductive health services for adolescents depend upon health insurance coverage, ability to pay for services or costs sharing obligations, or access to federally funded Title X family planning programs (Hocklong et al, 2003). Financial aspects are crucial point to increase teens’ health quality. Analyses have shown that insured adolescents as a group are more likely to receive recommended preventive visits, have fewer unmet health needs, and have a relationship with a primary care physician than their uninsured counterparts. When symptoms and illnesses occur for which visits to health providers are required, insured adolescents are more likely to secure medical attention (Newacheck et al, 1999).

Financial issue also reduces providers’ incentive to broaden access to adolescent reproductive health services. Based on a study on providers’ perspectives in four cities in the U.S., limited insurance reimbursement impede providers to offer routine gynecological examinations and family planning counseling, also STIs screening and contraceptives for sexually active adolescents (McManus et al., 2003).

Cultural Barriers. For certain societies, adolescent sexuality is a sensitive issue so the social norms often bring hostility from parents and other adult caretakers, which impede adolescents to obtain reproductive health information and services (RHO, 2005). Teens who live in communities with low level of education, high rates of unemployment, low income, and high crime rates are more likely to engage in involuntary sexual relationship and risky sexual behavior, also neglect the importance of reproductive health services (Kirby, 2001).

Providers who lack of cultural and linguistic competence create difficulties in reproductive health care delivery (McManus et al., 2003); the same access barrier to health care for the general population of non-English speaking minorities in the United States. Cultural and linguistic differences lead to inadequate health education and poor patient adherence to preventive health services (Aguirre-Molina and Pond, 2001; Lake Snell Perry and Assoc., 2001).

Structural Barriers. This type of barrier is grouped into interim and institutional barriers.

- Interim barriers. Inconvenient location and lack of transportation to the provider’s site are challenges for teens between their needs to seek reproductive health services and their arrival at the site.

- Institutional barriers. Providers who are only open during school hours, long waiting hours and located distant from school sites are institutional barriers for adolescent to access reproductive health services. Many clinics require parental consent for patients under age 18, which reduces service utilization by adolescents (Lieberman and Feierman, 1999). Providers often do not have special training to serve adolescents, who have distinct characteristics; they are not children anymore, but not adult yet. Male teens face peculiar institutional barriers because “many family planning clinics and obstetrician/gynecologist offices have waiting rooms filled with women, which can be very off-putting for the boys” (McManus et al., 2003).

IV. Adolescent Reproductive Health Services in the United States

One important publicly funded reproductive health services in the United States is The Family Planning Program authorized by Title X of the Public Health Services Act of 1970. It is “the only Federal program solely dedicated to family planning and reproductive health with a mandate to provide a broad range of acceptable and effective family planning methods and services”. Adolescent access to confidential reproductive health services is available through this program. Every year, more than four million women, predominantly young, poor, and have never had a child, receive health care services at family planning clinics funded by Title X (OPA/OFP, 2005).

A critical controversy, which has been debated politically and scientifically, is the issue of confidential reproductive health services for adolescents. Some political actions, never been passed into laws, have been attempted to eliminate confidential reproductive health services for teenagers under the Title X family planning program (Lieberman and Feierman, 1999). Restricting adolescent access to confidential reproductive health services would create more burden to the society. This psychological barrier; fear of confidential information disclosure to parent or other adult caregiver, will impede adolescents to seek preventive reproductive health services and teens are more likely to engage in risky or unsafe sexual behavior (Jones et al., 2005). They delay the timing of contraceptive (Lieberman and Feierman, 1999) and preventive screenings services for STIs, which would increase unintended pregnancy and health risks.

Expansion of Medicaid and State Children’s Health Insurance Program (SCHIP). To deal with the growing problem of children without health insurance, Congress created SCHIP, as part of the Balanced Budget Act of 1997. ”SCHIP was designed as a Federal/State partnership, similar to Medicaid, with the goal of expanding health insurance to children whose families earn too much money to be eligible for Medicaid, but not enough money to purchase private insurance”. States have the authority to design SCHIP program best suited to their needs and can include such services as prenatal care and family planning (CMS, 2005). The program offers a significant funding source for family planning services for adolescents. A survey by The Alan Guttmacher Institute (AGI) reported that SCHIP provided relatively comprehensive coverage of reproductive health services, with all state programs covering routine gynecologic care, screening for sexually transmitted diseases and pregnancy testing, but only third of the program offers confidential reproductive health services (Gold & Sonfield, 2001).

Youth-Friendly Health Providers. One possible mechanism to broaden adolescent access to reproductive health services and related health information is the availability and expansion of youth-friendly health providers. Providers are categorized as youth-friendly if “they have policies and attributes that attract youth to the facility or program, provide a comfortable and appropriate setting for serving youth, meet the needs of young people, and are able to retain their youth clientele for follow-up and repeat visits” with special characteristics familiar to adolescents (Senderowitz, 1999). Such characteristics are specially trained staffs who understand adolescent’s needs, separate space for service and convenient operating times and locations for adolescents, short waiting times, low service charges, and wide publication in locations where adolescents are present.

Youth-friendly health clinics are provided by state and local public health departments and school systems that establish school-based or school-linked health services. Such health clinics have high utilization rates by in-school adolescents, and result in improved contraceptive use and decreased rates of pregnancy (Slap 1995). In Atlanta, Grady Health System has a joint program with Emory University School of Medicine called Teen Reproductive Health Services which offers services to teens through contractual relationships with the state and the Atlanta Public Schools (Costello & Henry 2003). In Philadelphia, Family Planning Council, a Title X grantee, administers a Health Resource Center program in selected public schools in which students can drop in for counseling and education on reproductive health. For those who are sexually active, they can receive free condoms or tests for STIs and pregnancy during regular school hours with confidentiality (Hocklong et al. 2003, 146). In San Francisco, the University of California created a free standing clinic named New Generation Health Center, that offers free and confidential reproductive care to everyone ages 12-24 (McManus et al., 2003).

V. Conclusions and Recommendations

Adolescent reproductive health is an important public health issue because the outcome is a continuing concern for the society. Access to reproductive health with affordable costs and quality service are crucial components to help adolescents modify their risky sexual behaviors and respond to their reproductive health problems. The current health care system in the United States does not address access barriers appropriately and adolescent reproductive health service is not fully integrated in the system where social and political perspectives differ on how the services should be administered and financed.
Public health policy should communicate the need to broaden the access to adolescent reproductive health services with highlights on consistent confidential service provision, comprehensive reproductive health education programs for adolescents, increased public awareness, and promotion of adolescents’ involvement in defining the best reproductive health services for their needs. Adolescent reproductive health education programs and comprehensive behavioral interventions should emphasize parent-child communication, responsibility, and informed decision-making with regard to teen bodies and health. Prevention interventions and primary care services can and should be administered by schools system and other establishments where adolescents are present, including juvenile detention centers and community-based service sites. An awareness campaign on adolescent’s need for reproductive health services can be designed according to community culture and values. It is also important to promote adolescents involvement in defining, designing, and implementing their reproductive health services. These public health efforts to increase awareness on the importance of adolescent reproductive health and integrate it to the health care delivery system will extend the individual health benefits to the society in the form of healthier and more productive community.

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