Teenage Pregnancy Prevention: What Can We Do?
JANET P. REALINI, M.D., M.P.H., San Antonio Metropolitan Health District, San Antonio, Texas
Am Fam Physician. 2004 Oct 15;70(8):1457-1458.
Adolescent pregnancy and its prevention are topics that excite intense controversy. In this issue of American Family Physician, As-Sanie and colleagues1 describe the impact of this public health problem and outline strategies to address it. Despite recent declines, teenage pregnancy rates in the United States still are far higher than rates in comparable countries. Approximately 850,000 American teenagers become pregnant each year.2 Although we are making progress in lowering those rates, we still have a long way to go.
Teenage pregnancy and sexual activity are complex behavioral phenomena, and prevention efforts must do more than provide adolescents with information about the risks and consequences of their behavior. Moreover, focusing exclusively on adolescent girls overlooks the key roles of boys, men, parents, families, and entire communities in teenage pregnancy and its prevention.
Adolescent pregnancy is not just about sex; it is a symptom of young people taking risks. Although sexuality is integral to teenage pregnancy, many nonsexual risk factors and protective factors affect adolescents’ sexual risk-taking. Typically, teenage pregnancy and childbearing reflect low expectations. Young people who see bright futures for themselves, who feel connected to parents and school, and who have many positive factors in their lives take fewer unhealthy risks of any kind and are less likely to experience a pregnancy.3,4 Through research, the Search Institute4 has identified “40 Developmental Assets” that serve as building blocks for healthy development, and that help young people grow up healthy, caring, and responsible.4 Categories of external assets include support, empowerment, boundaries and expectations, and constructive use of time. Internal asset categories include commitment to learning, positive values, social competencies, and positive identity.
One prominent controversy in teenage pregnancy prevention is whether to include positive information on condoms and contraceptives in sex-education programs. American adults and teenagers overwhelmingly favor providing information about contraceptives, along with promoting abstinence among adolescents.5 The evidence that this is not a mixed message is reassuring.6 However, federal abstinence-education funding prohibits positive information about condoms and contraceptives, and many “abstinence-only” programs present highly negative messages. The effectiveness of such an approach has not been proven6 and may increase risks for young people who do become sexually active.7 Encouraging abstinence is a valid priority,8 but caution is needed before we adopt as-yet unproven abstinence-promotion strategies, which potentially could cause harm.
A growing body of evidence tells us what works in preventing teenage pregnancy.6 Well-designed sex-education programs can delay sexual debut and improve condom and contraceptive use—and these programs do not increase sexual activity.6 Condom and contraceptive programs in clinics and schools can improve contraceptive use.6 Media programs also may have an impact by helping to change social norms; one community-based abstinence media campaign may have reduced teenage pregnancy rates.9 The most dramatic results in preventing teenage pregnancy come from youth-development interventions that build “developmental assets,” boost skills, provide healthy activities, and treat young people as resources rather than as problems.10 Importantly, young people can respond to positive messages—healthy “norms”—when they feel connected to the person or group endorsing those norms.11
We have much to learn about other important pieces of the teenage pregnancy–prevention puzzle. Effective programs and strategies are needed to enhance parents’ key role in teaching about sex, relationships, and responsibility. In our modern communities, we are only beginning to ensure that all young people have the developmental assets they need.4 Addressing popular cultural influences in the media, many of which undermine public health messages to teenagers, is another daunting challenge.12
Family physicians and other health professionals can and should do many things to help prevent teenage pregnancy. We should advocate for the use of proven, effective programs—including youth development, sex education, and contraceptive programs—in our schools and communities. We can support research into methods to effectively promote abstinence. We can offer respectful, non-judgmental, and confidential care to adolescents, even as we encourage parent-child communication. Most importantly, family physicians, like all adults in the community, can forge caring connections with adolescents, making our health messages more powerful.
If you are the parent of a middle or high school student, chances are your child is either engaged in, or witness to, online behavior that you would find distressing, if not shocking.
But for many teens, this behavior has become just another challenge of adolescence, and another aspect of their lives that parents either don't know about or feel ill-equipped in how to respond.
The existence of a generational divide between what adults and teens believe is acceptable communication on social media today is one of the findings of an in-depth look at how teens treat each other published last week by the Weekly.
The package of stories reveals the unprecedented struggles facing today's teens as they find their way in the unsupervised world of social media. Teens related stories about the silent suffering many endure when peers they consider friends anonymously post crude, sexually explicit and often completely false comments designed to hurt their feelings and gain social advantage at their expense.
For some, especially those at the top of the social order, it is just another tricky social challenge to navigate. But for those who are more vulnerable, being the subject of online bullying, teasing or gossip can be devastating and lead to depression, alienation and suicide ideation.
It is an environment significantly different and more mean-spirited than faced by teens just a few years ago, and is alarming educators, psychologists and law enforcement as well as parents.
In affluent, highly educated communities like Palo Alto, the dangers may be greater because many teens are very skilled at being polite and engaging with adults when they need to, yet behave very differently on social media when dealing with their classmates away from adult eyes.
As one Paly senior said, "Teens know how to put their best foot forward in front of an adult, especially at school."
That skill, which leads many parents and teachers to a false sense of trust about their teen's behavior, leaves many teens free to let loose, especially in tech-savvy Palo Alto, where kids at an ever younger age are way ahead of their parents' knowledge and understanding of online social media platforms. Often that includes making anonymous online postings, or posts to Facebook pages that carefully avoid identities but that convey a derogatory message or threat to those who recognize they are the intended audience.
When shown some examples of online postings by Paly students, former principal Phil Winston said "Not one of these young people would say anything like that in person. There's such power in not being able to see the person you are hurting."
Jim Steyer, founder of Common Sense Media and Children Now, wrote "We're witnessing the rise of new forms of damaging, destructive interpersonal behavior, like cyberbullying, that are facilitated by digital platforms. It's a lot easier to say or do something truly hurtful to someone else, without considering the consequences, when it requires only a few keystrokes on a computer or cell phone."
Gunn High School Assistant Principal Trinity Klein observed that social media has changed the way students relate to one another. One teen girl told the Weekly she intentionally avoided developing close relationships out of fear that a friend might turn on her and reveal personal information on social media.
Exacerbating the problem is that the social norm for kids who are the victims of online teasing or gossip is not to tell anyone, especially parents, act unaffected and just hope it will pass quickly. Some teens are more resilient than others, and those who are not often have nowhere to turn for support and comfort, leading to isolation and depression.
As the Weekly's stories show, parents, kids and school officials are all struggling to sort out this new environment. With the teens themselves saying that anti-bullying and cyber-education programs are ineffective and not taken seriously, experts believe the focus needs to be on reaching kids when they are younger, before age 12, when they are typically opening Facebook accounts and beginning to use social media. The opportunity to influence social norms of teens closes, they say, during middle school, making the late elementary school years the prime time for parents and teachers to explore these issues with their children.
Lots of efforts are underway in the schools, beginning in second grade, and a small Palo Alto start-up, My Digital Tat2, is currently working with Palo Alto fifth graders and parents on raising awareness about kindness and respect online.
As with so many other things teens are drawn toward that involve potential harm, parents need to walk a fine line between rule-making and understanding the allure. As some of the teens themselves acknowledged, they know when they are crossing the line with their online behavior. The challenge is to make it socially more powerful to stand up and object to such behavior than to engage in it.
Editor's Note: You can access the Weekly's August 16 cover package on social media, entitled "Power to Hurt: How Social Media Impacts Our Kids" here.