Mobilization is virtually complete. In the civil war between “family planning professionals” and mere families, the professionals — foundation-funded, tightly organized, alight with zeal — have a media blitz in operation to build the “public mandate” needed to market their program. Agents are in place in the helping professions. Beachheads have been secured in some 50 cities across the nation, and in many others strategic assaults are underway. It may be the biggest, best-orchestrated effort since the successful campaign for legal abortion. The adversaries — families and their defenders who might raise “political barriers” to implementation — are only now beginning to organize resistance.
This war pits cultural revolutionaries and social engineers, certain that they offer a better system, against those who hold that the autonomous family in all its untidiness — imperfect parents, rebellious children, the dark-skinned or foreign-tongued as well as models of yuppie achievement — is the irreplaceable natural unit of human society. The current battlefield is the public school; the strategy, establishment of birth control clinics within its walls; the prize, the sexual ethics and practices of American adolescents.
An intense campaign for comprehensive health clinics, operated within schools by non-school agencies, and emphasizing birth control, is underway simultaneously from Connecticut to California. In Chicago last October, a national conference brought together 250 planners from operating or scheduled school-based clinics. Co-sponsored by the Center for Population Options (a spin-off from the Population Institute, which offers training for clinic staffs) and the Ounce of Prevention Fund (an Illinois group that funds the newsmaking clinic at Chicago’s DuSable High School), the conference was described as the starting point of a new national movement.
The movement is not altogether new. The first school-based clinic opened in St. Paul, Minnesota in 1973, and the idea has since then been strongly promoted in family planning publications. But there has been a dramatic multiplication of such programs during the past three years. Joy Dryfoos, chairman of the Center for Population Options and a consultant to the Rockefeller and Carnegie Foundations, told the Chicago conferees that only 12 communities had school-based clinics in the fall of 1984, but during the intervening year the number grew to nearly 50.
The Chicago conference reviewed the advantages such clinics enjoy in habituating high school girls to regular contraceptive use. Because they are operated by outside agencies, they can bypass school regulations which prevent school nurses from giving students any medication, even aspirin, without specific parental permission. Parental consent formalities are dealt with by use of a blanket consent form, in effect transferring control to the clinic, so that parents need not be informed of individual visits. Confidentiality policies allow for prescription of contraceptives, or referral to other agencies, without parental knowledge or consent.
Close links between school administration and clinic staff make intensive client follow-up easy. Staff members are allowed to design curricula for family life and sex education courses, and to make classroom presentations. Restrictions on abortion counseling and referral can be “finessed” by directing girls to outside counseling services, or providing lists of pregnancy-related facilities. One proponent reported that clinics “seem to have been successful in attracting sexually active teenagers,” because “clinic clients surveyed were more likely than young women not enrolled to have had intercourse more than five times (50 percent compared with 30 percent).”
Ann Ricketts, administrator of the St. Paul school-based clinic project, told the group that the student birth rate in the schools involved dropped from 59 per 1,000 students in 1976-77 to 37 per 1,000 in 1984-85. Gerald Kitzi. director of a school-based clinic program in Kansas City, said studies there showed that, while an increasing number of student clients said they used birth control methods “all of the time” (31 percent, up from 24 percent in 1983), the reported pregnancy rate remained “around 10 percent.” The proportion who gave birth, however, dropped from 8 percent to 6 percent. He conceded that “better data” are needed to evaluate the impact of existing programs.
The original school-based clinic, regularly cited as a model for the nation, began operating in 1973 at St. Paul’s inner-city Mechanic Arts Junior-Senior High School, under the direction of obstetricians Laura Edwards and Erick Hakanson. It was a satellite to the teen clinic at St. Paul Ramsey Hospital, as part of the city’s Maternal and Infant Care Project. Initially, the program at Mechanic Arts was presented as a means to keep pregnant students in school, ensure them prenatal care, and provide child development classes and day care after their babies were born. Contraception was introduced as a technique to discourage second pregnancies among the young mothers. Very soon, however, birth control for all sexually active students became the center of the program. Day care, though it is emphasized in approving news features about the program, has in fact dwindled as an element; only one of the four schools presently participating provides it. The program is federally funded, and its services are free to students. Third-party billing is done only if it will not endanger confidentiality. The school principal is described as “responsible for the project,” but program reports make no mention of his duties, while emphasizing the advantages of non-school status.
During its first year, students shunned the clinic, presumably because they were reluctant to identify themselves to their peers as sexually active. Consequently services were expanded to include sports and job physical examinations, weight control, emergency treatment and referral for minor injuries and illnesses, and counseling on a range of issues from “relationship problems” through drug abuse to career planning. Like most imitators, it is described today as a “comprehensive health clinic.”
Its primary function, and the primary argument for similar programs, nonetheless continues to be the provision of contraceptives and the reduction of the student pregnancy rate, or birth rate. Experience has shown that these are not at all the same thing.
Four St. Paul high schools with large minority populations now have such satellite clinics, which also serve feeder junior high schools. Each is staffed by a full-time family planning nurse practitioner, a social worker, and a physician’s assistant. Others who rotate through the clinics regularly include an obstetrician-gynecologist, a pediatrician, a pediatric nurse associate, a nutritionist, and a health educator. All cooperate to keep the clients consistent in their contraceptive use; even the nutritionist reportedly explains to students that the Pill contains not a single calorie.
Spokesmen for the St. Paul program have continually assured skeptics that parental permission is required for students who use the school clinics. In her 1986 report, administrator Ann Ricketts wrote, “Students using a clinic’s services are required to have a consent form signed by their parents.” Nevertheless, the literature of the family planning professionals tends to depict parents as potential troublemakers and consent procedures as an evasive formality. Joy Dryfoos has reported that clinic administrators find that “their major problem has been getting the forms back from the parents.” St. Paul seems to have resolved that problem. During 1986 hearings on the program in the Minnesota legislature, one senator reported that the clinic at his daughter’s high school, St. Paul Johnson, solicited permission with a “negative consent form,” i.e., consent was assumed unless the parent refused permission in writing. Such a system, inadequate for actual legal notice, overlooks the easily imaginable possibility that, for one reason or another, the form might never reach the addressee.
All students who come to the clinic for any reason are asked whether they are sexually active, or plan to be. Those who say yes are encouraged to begin using contraceptives, and individual counseling on sexuality is offered.
The clinic staff functions as part of the school, attends faculty meetings, teaches a three-week curriculum in human sexuality to 2,500 junior and senior high students, and provides other classroom education down to the elementary level. During the 1984-85 school year, 3,187 students used the clinics, 1,127 of them for family planning counseling. These family planners made up 33 percent of the students in the four schools. According to Ricketts’s report to the Chicago conference, 18 percent began using contraceptives before initiating sexual intercourse. On the other hand, cofounder Dr. Erick Hakanson was quoted about the same time as saying, “Eighty-eight percent of the youngsters are sexually active before they come in for birth control.” The two claims total 106 percent, a figure likely to raise some doubts about the accuracy with which program results are reported.
Clinic staffers do not see their role as limited to being “part of the school.” Articles about the program have repeatedly stressed that its effectiveness depends on staff members becoming substitute parents. A 1979 report stated, “The word ‘clinic,’ however, may give the wrong impression of the program. Clinic and day care staff become surrogate parents for many of the students, especially the contraceptive users and young mothers . . . . Students previously ambivalent about contraception and childbearing are now using contraceptives. The programs have accomplished this by bringing the program to the students, by becoming the best friends in the adult world that many of the students have ever had, and by acknowledging that contraception is both permissible and necessary if the student has made a decision to be sexually active” [emphasis added].
The same presumption is echoed in other articles praising the program. In his nationally syndicated column, Neal R. Pierce wrote:
When you consider the broken and disorganized families most of the kids come from, it’s not surprising that the clinic’s counselors and technicians often become the best adult friends these youngsters ever had. The vast majority of girls who become pregnant report alcohol and drug abuse, and often physical abuse, at home. They’re desperate for affirmation, support, and guidance. When they get that kind of substitute family backing, they’re quick to respond . . . . Against these front-line observations, it’s almost laughable that Republicans in a recent U.S. House committee report on teen-age pregnancy said the problem will be solved by increased family responsibility that teaches children correct values and discipline. One has to ask: What family? [Emphasis added.]
Responsible and ethical practice might be expected to consist of reporting criminally neglectful, abusive parents to the appropriate authorities, while guiding such desperate, vulnerable young people toward healthy sexual continence. Instead, the clinics utilize their relationships with students to propel them toward “contraceptive compliance.” While proponents say that one important goal of such programs is “to teach teenagers how to use the health care system,” not even anecdotal evidence is offered to suggest that students learn to take personal responsibility for their treatment, or even learn to recognize professional qualifications in clinic personnel.
Pelvic examinations, birth control instruction, and prescriptions are provided at the school clinics. The prescriptions are filled at Ramsey hospital clinic, where the school staff works after school hours. Follow-up remains the responsibility of the school clinic.
Dr. Laura Edwards has explained how follow-up is done. Student clients, she said, “are located through class schedules and attendance records. . . . The relative effectiveness of the school based clinics is clearly related to the ease with which the young people can be followed up without endangering the confidentiality of the relationship . . . . It is often difficult to follow adolescent patients [at the hospital clinic] who have not informed their parents about their participation, but in the school program, . . . confidentiality of follow-up is maintained since communication need not be made with the student’s home.”
An earlier article described the assiduous process in terms that call to mind those watchful Chinese fertility commissioners who track the menstrual cycles of women assigned to them to make certain no unauthorized pregnancy escapes attention. “The nurse clinician keeps a log of all students on contraception and contacts them at least once a month in the school to discuss any problems related to contraceptive use. Some students have literally been seen on almost a daily basis, dropping in between classes, for example, to report to the nurse clinician, “I took my Pill today, Mary.”
Teaching teenagers how to use the health care system does not extend to teaching them how to recognize professional qualifications in those on whom they depend for medical advice. Another article explains, “the school-based clinic’s strength is in the consistency and availability of its staff. Students want to know that one person will always be available to them; it apparently does not matter what that person’s job classification is . . . . The St. Paul students claim that the clinic attendant is the most important person with whom they have contact. Students in another program are unable to distinguish between professional and nonprofessional personnel.”
One unmeasured factor in the declining student-birthrate is abortion. The program is prohibited from referring for abortion or doing abortion counseling. Students with positive pregnancy tests are instead referred to the central clinic to be counseled by the social work staff at St. Paul Ramsey Hospital, where mid-term abortions are routinely performed. Unlike those who begin taking contraceptives, students considering abortion are classed as “lost to follow-up.” Clinic administrators have said that “the staff believes that very few students received an abortion without their knowledge.” Since they do not know, they can continue to insist piously that the program does not rely on abortion, implying that the decline in births reflects successful contraceptive use.
Extravagant and widely varying claims have been made for the success of the St. Paul program in reducing the birthrate, ranging from 23 percent to 66 percent. A few of those who extol it admit that the reported drop in student fertility rates does not provide an accurate assessment of student pregnancy rates. Joy Dryfoos wrote, “Most of the school-based clinics . . . offer pregnancy counseling and referrals to other agencies for maternity care or abortion . . . . One problem cited by clinic personnel is the lack of public funding for abortion in most states, which severely limits the options of the low-income young people who typically use school health clinics . . . . The issue of abortion is frequently finessed in these clinics.”
Reporting the claim that the St. Paul program reduced the student fertility rate from 59 births per 1,000 students to 37 between 1976-77 and 1984-85, Asta Kenney noted, “whether the decline was due to a decrease in the number of pregnancies or to an increase in reliance on abortion cannot be discerned.”
This is, objectively, an odd time for a wave of hysteria about “children having children.” In both raw numbers and rates per 1,000, adolescent births are lower today than at any time since they peaked in the late 1950s: down 46 percent between 1957 and 1981. The major statistical increase has been in the proportion of births to unmarried women among the declining total, from just under 30 percent in 1970 to about 50 percent in 1983. Even so, statistics from the U.S. Department of Health and Human Services, indicate that in 1983, fewer than three in a hundred unmarried females between 15 and 19 years of age gave birth, and only about one per 1,000 under age 15.
Most teen births are to mothers 18 and 19 years old: 316,613 out of the 1983 total of 499,038 (or 63 percent). These mothers are young adults, not high school students. It is regrettable that some of them become pregnant out of wedlock, but it is hardly a new phenomenon in human behavior, demanding state intervention.
When births to married women under age 20 are subtracted from the total of teen births, the profile of the problem shrinks by more than half, to 249,173, or less than a quarter of the 1982 total of 1,092,645 teen pregnancies. Neither the married women nor the 18- and 19-year olds properly fall within the scope of school-based clinic programs, and their inclusion in the propaganda barrage serves to inflate, not to define, the problem.
A related irony can be noted in the terminology used in the school-based clinic campaign. When family planning professionals talk about providing contraceptives, they refer to “sexually active young women.” But when pregnancy results, the “young women” become “children” again. Perhaps such transparent rhetorical devices are to be expected from those who describe themselves as “family planners,” but who in fact seem more concerned with planning against families.