Sexual activity among adolescents continues to be a prevalent issue, although some data suggest that there has been a decline in sexual activity among certain age groups. Since 1991, the number of high school teenagers who engaged in sexual intercourse decreased from 54% to 46% (MMWR, 2011a). There is some evidence to suggest that teens are delaying the age at first intercourse; however, the rate of sexual intercourse increases with age. Approximately 13% of teens have had their first sexual encounter before the age of 15 years. By age 17 years, only 27.7% of girls and 28.8% of boys have engaged in sexual activity; by the time they reach 18 to 19 years of age, 59.7% of girls and 65.2% of boys have engaged in sexual activity (Abma et al., 2010). The Healthy People 2020 objectives (U.S. Department of Health and Human Services [USDHHS], 2010) have identified priorities associated with teenage sexual activity, including the following (see also the Healthy People 2020 box on page 605):

Abma and colleagues (2010) conducted a study on teens and their first sexual intercourse. Seven percent of girls reported that their first sexual intercourse was not voluntary. In addition, 10% of girls and 5% of boys reported that they did not want their first intercourse to happen when it did, and 47% of girls and 34% of boys had mixed feelings about the timing of their first intercourse. This suggests much ambivalence about initiation of sexual activity. Educational programs and counseling should continue to stress techniques to handle pressure from peers and potential partners related to initiation of sexual activity.

The practice of oral sex is now as common as intercourse in the teen population. Approximately 25% of teens substitute oral sex for intercourse. In one survey, half of the teens did not consider oral sex to be a sexual activity. Half of all college students who pledged to remain virgins reported that they engaged in oral sex (Dailard, 2003). One-third of teens reported having oral sex with someone who was not the right partner for intercourse or someone with whom they wished to delay initiation of intercourse (Chandra et al., 2011; Dailard, 2006). Most were unaware of the risk for STDs associated with oral sex.

The most current comprehensive comparative study (United Nations, 2008) shows little difference in sexual experience or age at initial sexual intercourse among teenagers in developed countries (Figure 24-1). There are, however, differences in contraceptive behaviors and pregnancy rates. Teenagers in the United States are less likely to be aware of contraceptive methods, to know or to explore how to obtain and use contraceptives, and to initiate action to protect themselves from unwanted pregnancies either before or just after their first sexual experience (Abma et al., 2010; Albert, 2010). The reason for such sexually risky behavior is at least partially the way in which sexuality and sexual behaviors are addressed in the United States.

In other developed countries, information about sexual intercourse and birth control is regularly provided to teenagers. Government-sponsored sex education programs in the school systems are common. Programs include health teaching on contraceptive methods, encouragement of responsible sexual activity, and easy access to contraceptives and service is generally provided in a nonjudgmental fashion (GI, 2006a). Sexuality and contraception education is mandatory in public schools in England, Wales, France, and Sweden and in most Canadian schools.

The United States provides little information on contraceptives, and contraception is not an emphasized element in most school-based sex education programs. One-third of high school students have had no formal education on contraceptives, and 24% of students received abstinence education without any information on birth control (GI, 2011b; Martinez et al., 2010). The United States has also been ambivalent about providing contraceptive services to teenagers. In some instances, federal or state funding for clinics serving large numbers of young disadvantaged females has been reduced or discontinued (see Chapters 4 21 and 27). A significant number of U.S. teenagers and their families have no health insurance and find access to any kind of health care services (including contraceptive services) difficult (Gold et al., 2009; MMWR, 2011b). Some federal programs have actively attempted to restrict rather than increase access to reproductive services.

Formal sexual education programs for adolescents are closely monitored. Parental involvement and permission requirements and abstinence-only programs are two methods supported at the federal level. Federal funding for abstinence-only sex education programs increased by 157% between 1997 and 2005 (Lindberg et al., 2006a) but has since been reduced, pending results of the efficacy of such education programs.

In 2011, 37 states required parental involvement in sex education programs, and 3 states required parental consent before a child could attend a sex education program (National Conference of State Legislatures [NCSL], 2011). The type and manner of “parental involvement” varies by state. In addition, 37 states and the District of Columbia allow parents to opt out of sex education programs for their children. By contrast, the majority of states (73%) required education about STDs and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). No program that takes federal funds is allowed to provide information about the positive effects of contraceptive use.

Early onset of sexual activity increases the risk for multiple sex partners, unprotected sex, and STDs (Abma et al., 2010; USDHHS, 2000). Each year, approximately 9 million adolescents contract an STD (Guttmacher Institute, 2006b; USDHHS, 2000). Of the top 10 infectious diseases, 5 are STDs: chlamydia, gonorrhea, AIDS, syphilis, and hepatitis B. In 2008, a Centers for Disease Control and Prevention (CDC) study reported that 26% of girls between the ages of 14 and 19 years (3.2 million girls) were infected with at least one of the most common types of STD (human papillomavirus [HPV], chlamydia, genital herpes, trichomoniasis) (CDC, 2008). This study did not include syphilis, HIV infection, or gonorrhea, and it did not include young males. Incidence rates can be expected to be higher if the excluded STDs and young males were included in the study.

The rates of chlamydia, gonorrhea, genital herpes, and syphilis among sexually active teens are higher than the rates in the general population. Abma and colleagues (2010) reported that 15- to 24-year-olds acquired nearly 50% of all STDs each year. Table 24-1 provides information on selected STDs actually reported to the CDC; not all STDs are reportable. In 2009, there were over 1.2 million cases of chlamydia, of which approximately 600,000 occurred among teens and young adults (MMWR, 2011c). HIV/AIDS is a growing problem in the adolescent population. Infections are often contracted in the teenage years and remain undetected until the infected persons reach their twenties or thirties (see Chapters 7 and 8). The rates of STDs are higher among racial and ethnic minority groups and adolescents living in poverty than among adolescents in other racial groups or teens living in families with higher socioeconomic levels (see Chapters 78, and 21). As the differences among racial and ethnic groups disappear, differences in STD rates will also disappear.

The rates of chlamydia and gonorrhea are higher among females than among males. Much of that difference might be due to the greater extent of screening and detection provided to females by reproductive health care services. Males, who are largely asymptomatic, do not generally seek reproductive health care services, and the infections are more likely to remain undetected (ACOG, 2009; Abma et al., 2004; Chesson et al., 2004;). Females are also more likely to experience health complications from STDs, such as pelvic inflammatory disease, cervical cancer, infertility, and ectopic pregnancy (Mayo Clinic, 2011; USDHHS, 2007).

Contraceptive use among teenagers has steadily increased since the 1980s. Approximately 12% of teens do not use protection during intercourse (Abma et al., 2010; MMWR, 2011a). Birth control use generally starts after sexual activity has already begun. Teenagers use birth control sporadically and tend to switch methods without taking the proper precautions (Abma et al., 2010; Santelli et al., 2006b).

Condoms are the most common type of contraception used at first intercourse. More than 95% of sexually active teens reported using condoms (Abma et al., 2010). Teens who engage in sexual activity on an ongoing basis switch to more effective methods such as birth control pills, injectable Depo-Provera, and intrauterine devices. About 52% of adolescent females reported using birth control pills. Concern about HIV and STDs have led to an increased use of barrier methods (condoms) in conjunction with other birth control measures. Although dual contraceptive use in teens has increased, only 35% of teens report using two methods of birth control (Abma et al., 2010).

Poverty is associated with less access to and less successful use of reversible contraceptive measures. Poor people have difficulty obtaining contraceptive health care services and paying for birth control products. Frost and colleagues (2001) reported that poor teens are less likely to use birth control pills than those who are more economically advantaged. The price of one cycle of pills averages $30 per month. Teens who are not well off must rely on public programs to obtain contraceptive services. Public program services are financed by federal and state monies, primarily Medicaid and Title X monies. Approximately 30% (5 million) of women serviced at public-funded centers were younger than 20 years (GI, 2010a). The importance of subsidized family planning services has been stressed, but these services are likely to see additional funding cuts as both the federal and state governments deal with the current economic recession.

Preliminary figures through 2009 point to a sharp decline in pregnancy and a more moderate decline in birth and abortion rates among adolescents. Tabulation and publication of national data comparisons of pregnancy, birth rates, and abortion rates among teens are delayed by 4 or more years. Figure 24-2 shows the most current information for all three categories. In 1991, the birth rate for teens (15 to 19 years) was 62.1 per 1000. In 2009, the birth rate was 39.1 per 1000 (MMWR, 2011a). Nevertheless, both the pregnancy rate and teen birth rate remain high.

Approximately 14% of the decline in pregnancy rates is attributable to delaying sexual activity, and 86% is related to the use of highly effective contraceptive methods among sexually active adolescent girls (Santelli et al., 2007).

Most teen pregnancies (82%) are unintended (Ventura et al., 2011). Whether intended or unintended, adolescent girls who become pregnant and choose to continue the pregnancy are more likely to come from low socioeconomic circumstances, live on their own or with one parent, have lower educational and career aspirations, and have older sexual partners (Abma et al., 2010; MMWR, 2011a).

An unintended pregnancy is an unplanned or accidental pregnancy and is accompanied by increased risks for the pregnancy, the mother, and the baby. Unintended pregnancies are more likely to result in premature or low-birth-weight babies, little or no prenatal care, abortion and miscarriages, and pregnancy complications (MMWR, 2011a; Ventura et al., 2011). Unintended pregnancies have a social cost to young mothers. These young women are at great risk for limited educational and employment opportunities, the consequences of which can last a lifetime.

Approximately 60% of pregnancies result in birth, and one-fourth of pregnancies end in abortion (see Figure 24-2). Most single mothers keep their infants rather than place them for adoption. Therefore, there is a greater demand for adoptions than there are infants placed for adoption.

Older teens have a higher pregnancy and birth rate compared with younger teens, perhaps because more of the older adolescents engage in sexual intercourse compared with younger teens. The pregnancy rate for females 15 to 17 years of age is 41.4 per 1000, and for females 18 to 19 years of age, it is 118.6 per 1000 (MMWR, 2009). The older the teen’s sexual partner, the more likely it is that an adolescent female will become pregnant.

In general, teens do not delay sexual activity or pregnancy until marriage. Marriage because of pregnancy used to be common in the past; today, few teenagers opt for marriage if they become pregnant. Approximately 84% of pregnant adolescents remain unwed (CDC, 2009). Pregnancy is, however, still the main reason for teenage marriages.

There are differences in pregnancy and abortion rates among racial and ethnic groups. The highest rates of birth are among black and Hispanic adolescents, and the lowest are among Asian American and Pacific Islander adolescents (Figure 24-3). The pregnancy rates in all racial and ethnic groups have declined in the past decade, with the sharpest decline in African American pregnancy rates. Abortion rates are lowest among white adolescents, perhaps because they have a lower pregnancy rate. African American adolescents chose abortion at twice the rate of Hispanic American teens. The pregnancy rates for other ethnic groups have not been as widely published. Birth rate data provide some indication of pregnancy rates. American Indian and Alaska Native teens have the third highest birth rate, non-Hispanic whites the fourth highest, and Asian Americans and Pacific Islanders have the lowest birth rate.

A common public perception is that among teenagers, most pregnancies and births occur in those from racial minority groups. This is not true. In 2007, white teenagers accounted for the largest percentage of births (56%), followed by black (34%) and Hispanic (4%) teens (Martin et al., 2010a). Hispanic and black teenagers have a higher proportional rate of adolescent pregnancy, but because they are fewer in number, the largest number of teenage births occurs among white teenagers.

Among adolescent females, there is a link between pregnancy rate and socioeconomic status. Teens from lower-income families start sexual intercourse at an earlier age, which increases their risk for pregnancy. Teens from lower-income groups are more likely than those from middle-income or upper-income groups to become pregnant and, once pregnant, to choose to have the baby (Abma et al., 2010; Young et al., 2004). Of teens aged 15 to 19 years, 19% of those with family income at or below 150% of the poverty level have a child, compared with 2% of teens with family incomes at or above 300% of the poverty level (Frost et al., 2001).

With advances in birth control, increased sexual activity does not necessarily mean an increased risk for pregnancy. Why, then, are teenage pregnancy rates so high? There is no single, clear-cut answer. Teenage pregnancies occur due to a variety of reasons. Any effort to reduce the rate of adolescent pregnancies must begin with a clear understanding of the conscious or unconscious reasons and motives behind teenage pregnancies. Knowledge about the motives and reasoning of sexually active teenagers helps the community health nurse identify teens at particular risk for pregnancy. Some of the factors associated with pregnancies in the teenage population are enumerated in Box 24-1. Many teens who become pregnant do not do well academically and have few expectations for the future (Albert, 2010; Manlove et al., 2004). A study of pregnant teens in California found that 44% had dropped out of school prior to pregnancy and that many lived in chaotic family situations. Approximately 25% could not identify any future life goals. Many of the girls reported that in their social circles early childbearing was common, and almost 70% identified an adolescent friend or sibling who was either pregnant or already had a child (Frost & Oslake, 1999; Raneri & Wiemann, 2007).

The United States leads most developed nations in the rate of teenage pregnancy (Albert, 2010; GI, 2006b). A comparison of eight countries indicates that the U.S. pregnancy rate is two or more times higher than the rates in all other comparable countries, except the Russian Federation (Figure 24-4).

Teenagers appear to run a greater risk for pregnancy at an earlier age in the United States than in other countries (Santelli et al., 2008). A comparison of the five industrialized countries shows that in all of them, contraceptive services are more readily available and in greater use than in the United States (Figure 24-5). This disparity in availability and use can be explained partly by the different types of health insurance available in each country. The four other countries—France, Sweden, the United Kingdom, and Canada—all have national health care systems. In those countries, contraceptive services and supplies are provided free or at reduced cost; contraceptives are advertised in the media; and contraceptive methods are included in the sex education programs provided to adolescents (GI, 2006b; Santelli et al., 2008). In the United States, many teens and their families lack health insurance coverage (see Chapters 4 and 21). Furthermore, birth control supplies are not advertised in print or television media, and many sex education programs restrict information to abstinence-only approaches (NCSL, 2011).

When teenagers become pregnant, many choose abortion, with some variations seen among countries. As with pregnancy rates, the abortion rate is higher in the United States than in four of the comparable countries (see Figure 24-4). The abortion rate in the Russian Federation is partly the result of poor access to contraceptives due to cost. The abortion rate is very similar in the United States, Sweden, and the United Kingdom. In Sweden and Denmark, the rate of abortion (as a chosen alternative) among pregnant teenagers is higher than that among pregnant teenagers in the United States.

In all the comparison countries, access to abortion is less problematic, and there is little or no controversy about abortion compared with the United States. Abortion is provided by government health services or funded by national health insurance. In the United States, abortion might be covered under health insurance for those whose families have insurance, but some policies specifically deny coverage—for example, federal insurance programs and some state Medicaid programs (GI, 2006b, 2011c). Abortion services are provided by separate providers, not the teen’s or family’s regular physician or health care practice. Some states have made it more difficult for teens to have abortions, requiring parental consent, judicial reviews, waiting periods, and mandatory counseling sessions (see Chapter 6). Advocacy groups are attempting to further restrict service availability through boycotting or protest campaigns and are attempting to secure the passage of state regulations or legislation that restricts clinic operations. These efforts have met with some success.

Families headed by young females have a greater chance of being poor compared with other families (Hoffman, 2006; NCPTP, 2010b). The child of a teenage mother who did not get a high school diploma or GED has a nine times greater risk of growing up in poverty compared with a child whose mother delayed having children until she was older (NCPTP, 2010c). More than 30% of single women with children live in poverty (U.S. Census Bureau, 2010). Poverty is accompanied by many quality-of-life problems for teenage mothers and their children, including an increase in health problems and limited access to health care services (see Chapter 21). Teenage pregnancy is viewed as the hub of the poverty cycle in the United States because teenage mothers are likely to rear children who repeat the cycle (Abma et al., 2010; Elfenbein & Felice, 2003; Hoffman, 2006).

Pregnancy affects educational achievement. Only 66% of women who become mothers in adolescence complete high school compared with 94% of women who delay childbirth until age 20 to 21 (Perper et al., 2010). Many teenagers who became pregnant were not doing well in school and had dropped out even before they became pregnant. Shearer and colleagues (2002) compared adolescent females’ test scores and found that teens with lower cognitive scores initiate sex earlier and have a higher rate of pregnancy compared with girls with higher test scores. Others drop out of school because of the demands of pregnancy and child rearing. The younger the teenager at the time of pregnancy, the greater is the danger that she will not complete high school. Teen mothers are also less likely to attend college. Only 2% of women who become pregnant before 18 years of age go on to college (Hoffman, 2006).

It is important for the community health nurse and others involved with pregnant teens to encourage the girls to remain in school, if possible. Lack of education hampers the mother’s prospects in the job market. The income of young mothers is only half that of women who delay childbearing until after 25 years of age.

A third of pregnant teens receive inadequate prenatal care (Chen et al., 2007). Many pregnant teenagers delay seeking prenatal care or do not receive regular care. Although the number of young women who receive first-trimester care has increased over the past 10 years, more than 33% have had no prenatal care at the end of their first trimester (NCPTP, 2010b; Philliber et al., 2003). The same teenagers at greatest risk for pregnancy—those from poor families—are also at greatest risk for poor prenatal care. In general, this group tends to be more oriented to treatment rather than prevention of illness in its health practices (see Chapter 4). Delays in seeking prenatal care might also be influenced by denial of the pregnancy and an orientation toward concrete, present-centered reasoning.

Ethics in Practice

Distributing Community Resources Fairly

Gail A. DeLuca Havens, PhD, APRN, BC

“It seems like coercion to me,” says Eileen. “Like we are being vindictive and punishing a teenager for getting pregnant and electing to carry the baby to term. Teenagers are babies themselves in many respects. This doesn’t solve the problem; it hides it so the community doesn’t have to confront the underlying reasons for the high incidence of teenage pregnancy that prevails here. This proposed regulation is nothing more than a cop-out.”

Cynthia disagrees. “In this day and age, getting pregnant is a choice. If a teenager with no means of financial support chooses to get pregnant, especially when she already has one child, then she should expect to have to decide whether she wishes to practice birth control in the future or have the aid for her dependents decreased if she has additional children. We can’t afford to keep supporting all these young mothers and their babies in this city, particularly when so many of our other health and social services are significantly underfunded. Consider the dollars we spend per capita on programs for the learning disabled in our city, for example. Or the percentage of the city’s budget allocated to programs for older adults. Both are significantly underfunded in comparison to the dollars spent for similar programs in cities of comparable size throughout the state.”

On the way home, Eileen and Cynthia continue the debate over the Department of Social Services’ proposed regulation requiring that females in the community younger than 18 years of age who are receiving benefits under Temporary Assistance to Needy Families (TANF) must show evidence of practicing birth control to continue the aid. The proposal includes provision of free birth control counseling and products as well. Eileen and Cynthia are both community health clinical nurses employed by the community. Eileen practices in the Pediatric Service and Cynthia in the Council on Aging’s Geriatric Intervention Program. They have just attended the last of the public hearings sponsored by a joint task force created by the Departments of Health and Social Services and the school board to hear opinions from members of the health care professions and the community at large regarding the proposal, which is intended to address the problem of teenage pregnancy in the community. Now the task force will deliberate on the issue and make recommendations to the departments and the board. If you were a member of the task force, how would you go about the decision-making process? What would be your decision? Why?

The problem appears to be just distribution of resources. The community has a finite budget allocated for multiple social services that serve many different populations. It is being argued that a disproportionate amount of the community’s social services budget is being spent on aid to the dependent children of teenage mothers. A plan intended to ensure a more equitable distribution of social service resources across the community’s populations has been proposed as a solution. Theoretically, limiting the number of people covered by the TANF program ought to make a greater percentage of the city’s budget available for other social services programs targeted at underserved populations.

The plan’s defenders believe that although the solution does not include all the choices to which a teenage mother might be accustomed, it does offer reasonable options considering the overall needs of the community. Detractors of the plan argue that it violates the autonomy of teenage mothers in the community because it coerces them into not becoming pregnant to have the means they need to care for the children they presently have. Coercion has been characterized as an extreme form of influence that entirely compromises one’s autonomy (Beauchamp & Childress, 2009).

If the proposal is adopted, it would be a step toward a more equitable distribution of resources, and thus if the planning has been accurate, it ought to have some short- and long-term effects on the social services programs for the community. A plan such as this is grounded in the ethical theory of utilitarianism, which seeks to maximize the positive consequences of an action by achieving the greatest good for the greatest number (Beauchamp & Childress, 2009). Services in need of resources ought to be targeted, monitored, and measured to see if they benefit. Adopting the proposal has the potential to jeopardize the health and well-being of a population of children already at risk, namely, the children of teenage mothers.

If teenage females continue to have children, their ability to care for those children already dependent on them will be diminished because of a lack of resources. The short-term consequences might be a rising incidence of children who fail to thrive, are afflicted by disease, or are disabled by developmental and psychological problems. The long-term consequences might be a generation of children who would overburden the community’s social services. Such an action would contradict the ethical principle of nonmaleficence (i.e., avoiding harm), contained in the Code of Ethics for Nurses (American Nurses Association, 2001). In addition, it would go against the value of promoting autonomy and self-determination through the achievement of health and well-being, as expressed by the code.

Not adopting the proposal is an alternative. However, this changes nothing for the community and for its teenage mothers. Another alternative attempts to address the issue of teenage pregnancy in the community by seeking ways to discover the underlying causes of the increased incidence of teenage pregnancy. One strategy that has been successfully introduced in a growing number of communities is school-based clinics. Decreased fertility rates, decreased pregnancy rates, and later sexual activity are evidence of the success of school-based clinics. Outcomes directly attributable to school-based clinics include improvements in students’ health, lowered birth rates, increased use of contraceptives, and improvements in school attendance (Santelli et al., 2006).

References

American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: Author.

Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics (6th ed.). New York: Oxford University Press.

Santelli, J. S., Morrow, B., Anderson, J. E., et al. (2006). Contraceptive use and pregnancy risk among U.S. high school students, 1991-2003. Perspectives on Sexual and Reproductive Health, 38 (2), 106-111.

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