Americans would seem to have won a big victory for family unity and parental wisdom. At least that's what the U.S. Supreme Court said it was providing last June 25 with its decision to uphold state laws that deny teenagers abortions until their parents are notified. "It is both rational and fair for the state to conclude," wrote Justice Anthony Kennedy, "that, in most instances, the family will strive to give a lonely or even terrified minor advice that is both compassionate and mature." Kennedy was writing for a 6-3 majority that upheld an Ohio law making it a crime for a doctor to perform an abortion on an unmarried minor unless at least one parent is notified first. The law makes an exception if a judge has approved the abortion.
By a 5-4 margin, the Court also upheld a Minnesota law that requires both parents be notified--unless a judge rules otherwise. The Minnesota law without this judicial exemption was struck down by the Court 5-4.
Parental notification laws are on the books of 34 states; and just four days after the Supreme Court acted, Illinois attorney general (and candidate for governor) Neil Hartigan announced that he would take the steps required to activate the 1983 Illinois law, which requires notification of both parents. In 1984, U.S. District Judge Hubert Will blocked enforcement of the Illinois law by issuing an injunction that Hartigan, as attorney general, was never able to remove, despite carrying the state's appeal all the way to the U.S. Supreme Court. The Court, one justice short, deadlocked 4-4, and Will's injunction stood.
Hartigan insists that he is now "committed to preserving the constitutional right of a woman to choose whether or not she would have an abortion"--a position he didn't use to take--but obviously he wants to offer adolescent girls a choice that's not so simple. Hartigan believes it is in "the state's interest" to require a teenager to either notify her parents that she needs an abortion or go before a judge and explain to him why she can't tell her parents.
"We hope that [the law] will reduce the number of abortions," says Ann-Louise Lohr, one of eight lawyers with the Americans United for Life Legal Defense Fund. But she argues for parental notification laws in classically general terms. "The right of a parent to be involved in rearing and guidance and upbringing of an immature, unemancipated dependent child has been well established by the U.S. Supreme Court, not just in the abortion context but back in the 30s and 40s and before that in the area of education, health care, religion," says Lohr. "This is an example of where the Supreme Court has said that if the parents aren't going to be involved, then a judge has to be. It can be beneficial for a minor. If she is being physically or sexually or severely emotionally abused at home and can't tell her parents, this law benefits her because it gets her into the judicial system where she needs to be so that the court system can help her rather than cover up that abuse."
Can any right-thinking American argue with such sentiments? It's hard to. A 1989 Newsweek poll found that 75 percent of the respondents believed that teenagers desiring abortions should get their parents' permission first.
But prochoice groups think they've spotted a Trojan horse. Bryan Howard, associate executive director of Planned Parenthood in Chicago, says, "The antichoice groups have very brilliantly played on a very sensitive issue in our society, the state of the family and the increasing impotence parents feel about the degree to which they can mold their children's lives. The antis very brilliantly have used that issue to get their foot in the door to further restrict abortion. Parents feel more and more impotent, and politicians respond to that with these laws, which don't really get at the issue at all but they can say they're doing something."
The Illinois Parental Notification Act, says Ann-Louise Lohr, is the model on which the laws in other states are based. The Illinois law was written first (though it was not enacted until several years after many other states passed their versions) because its author, Americans United for Life, is based in Chicago. AUL was founded in 1972 to fight Roe v. Wade before the Supreme Court; it has steadily expanded and now has a staff of 30 and is planning further expansion. AUL specializes in writing antiabortion laws for state legislatures and amicus briefs defending these laws once they're enacted and challenged.
The problem with parental notification laws, say Howard and others in the prochoice movement, is that they don't enhance family life and protect teenagers; all they do is what AUL most wants them to do--namely, restrict abortions. Is this true? To find out, we examined records in Minnesota, where a parental notification law more stringent than Illinois' was passed in 1981 and remained in effect until the U.S. Circuit Court declared it unconstitutional in 1985.
The Minnesota law requires a physician who is approached by a minor (under 18) for an abortion to notify both her parents, regardless of the girl's present relationship with them, and then wait 48 hours before performing the abortion. A divorced father living in another state, a father who had abandoned his family years earlier, a father long estranged from his daughter nonetheless must be notified unless the girl chooses to avail herself of the judicial bypass the law provides for.
Early parental notice and consent laws didn't all provide this bypass. But as the laws were enacted in several states and challenged by prochoice groups, it became clear that to survive they would have to accommodate the adolescent who simply cannot talk about abortion with her parents. Judicial permission was the answer. Illinois and most other states gave this girl the option of going before a judge who would determine whether she was mature enough to make her own decisions, and whether going to her parents was truly a bad idea.
On the face of it, this seems like a satisfactory alternative. And in fact, about half of the 7,000 adolescents who had abortions in Minnesota from 1981 to '85 took this route, while only 15 abortions were denied. But other numbers indicate that during those years many more teenagers than before told neither their parents nor a judge; they had babies. Birthrates among teenagers rose and abortion rates fell. For the benefit of the U.S. Supreme Court and to make its case against parental notification laws generally, the American Civil Liberties Union (ACLU) analyzed data from Minnesota and reported a 38.4 percent rise in the birthrate for 13-to-17-year-old girls in the state's largest city, Minneapolis, from 1980 to '84, along with a "significant decline" in the abortion rate in the state as a whole.
AUL, for its part, claims the birthrate fell 12.5 percent among 10-to-17- year-olds in Minnesota and concludes, "The pregnancy rate must have declined . . . supporting the conclusion that the notice law in fact changed adolescent behavior."
Well, which is it? Did the birthrate among teenagers rise or fall while the law was in force? For guidance, I turned to the public Minnesota Center for Health Statistics, the source of AUL's and ACLU's numbers, and also to the Minneapolis Department of Health. (While I was at it I also acquired data for 1986 through '88, the three years after the law was revoked, to see what happened then.) Following are the pregnancy, birth, and abortion rates for 15-to-17-year-olds in Minnesota for 1980 through '88. For every 1,000 girls that age, these figures say how many got pregnant, gave birth, or had abortions.
YEAR 1980 1981 1982 1983 1984 1985 1986 1987 1988
PREGNANCIES 36.9 33.7 31.1 27.7 29.3 29.8 30.2 30.7 29.6
BIRTHS 17.4 17.5 16.6 14.6 16.1 15.1 15.6 15.1 14.7
ABORTIONS 19.4 16.1 14.3 12.9 13.1 14.6 14.5 15.5 14.8
For the state of Minnesota as a whole, pregnancy, birth, and abortion rates for this age group all declined from 1980 to 1985, with a notable drop in abortion rates from 1981 through '84, years in which the law was in effect. After the law was revoked, these rates increased modestly if at all. It would seem that adolescent sexual behavior did change in Minnesota.
But now compare the Minneapolis numbers provided by that city's department of health with those for the state as a whole. Minneapolis is by far the largest of the three urban areas in Minnesota and has the largest minority population, though it's only about 15 percent of the city's population. These figures are for births and abortions only among 15-to-17-year-olds, because the city does not calculate pregnancy rates.
YEAR 1980 1981 1982 1983 1984 1985 1986 1987 1988
BIRTHS 39.1 41.2 42.7 47.3 54.1 58.2 52.2 54.5 53.8
ABORTIONS 43.8 38.6 34.4 34.6 35.9 38.1 45.4 43.0 50.6
Quite a different picture. The birthrate rose steadily from 39.1 in 1980 to 58.2 in 1985, the last year of the law. Then it dropped. (Teen birthrates in most parts of the U.S.--including in Illinois--rose during the 80s, but not as sharply as the birthrate in Minneapolis did.) The abortion rate dropped off sharply in 1981 and '82, and turned up noticeably again in '85.
In a 1989 Supreme Court brief, AUL attempted to explain away the soaring Minneapolis birthrate by ascribing it to an influx of "Asian Pacifics." There was an influx, particularly of Hmong, who have one of the highest birthrates in the world. Even so, in 1988 Asian Pacifics accounted for only 6.7 percent of the births in Minneapolis. They could not have produced all those extra babies by themselves. If parental notification had an effect on adolescent sexual behavior in Minneapolis, the most apparent effect seems to have been on how adolescents reacted to pregnancy when it happened.
Critics of parental notification laws argue that kids who can talk to their parents about sex will do so without being made to, and that for many of the kids who cannot, judicial bypass is no solution.
They raise a class issue. In Minnesota, according to an ACLU brief, 89 percent of the pregnant teenagers who successfully mastered the judicial bypass from 1981 to '83 were 16 or 17. Birthrates among younger girls doubled. Furthermore, "all of them [my emphasis] were white, middle-class, well-dressed, educated, and mature."
Both public defenders who acted for Minnesota youngsters in bypass procedures and six of the judges who heard those cases testified in favor of the suit that brought down the Minnesota law. They said they'd found the experience of going to court difficult even for the white, middle-class, mature girls who went through it. The U.S. district judge who overturned the law wrote, "The experience of going to court for a judicial authorization produces fear and tension in many minors. [They] are apprehensive about the prospect of facing an authority figure who holds in his hand the power to veto their decision to proceed without notifying [their] parents. Many minors are angry and resentful at being required to justify their decision before complete strangers. Despite the confidentiality of the proceedings, many minors resent having to reveal intimate details of their personal and family lives to these strangers."
A Boston judge who has adjudicated as many as 1,000 petitions from teenagers in Massachusetts, which also has a parental notification law in operation, testified in that state, "It just gives these kids a rough time. I can't think it accomplishes a darn thing. I think it basically erects another barrier to abortion. It's just another thing at a very, very difficult time in their lives."
Chicago social worker and attorney Anita Weinberg describes what it would take to get to a judge in Chicago: "She must identify the courthouse where the proceeding will be heard; locate the clerk's office to file a petition form, figure out how to fill in the form, where to file it, where to go to have it heard; learn where a guardian ad litem who is supposed to represent her best interests will be appointed; decide whether she should have an attorney, which the law provides for, and how to get one. Then, she has to find out in what courtroom the case will be heard, where and when it will be heard."
Presumably, if she has an attorney, he or she will help her through the last three steps, but first she has to get that attorney. All this after she has discovered she is pregnant, which is often late in the first trimester for youngsters who still have irregular periods and don't recognize the signs of pregnancy. And most likely after she has consulted with a friend and gone to an abortion clinic where they told her that either they would have to notify her parents or she would have to go before a judge. By the time she navigates all these waters, she may be in the second trimester. What is the likelihood of very many youngsters, let alone minority kids, mastering the Cook County court system before they enter the second trimester, when abortions are more dangerous, more costly, and harder to get?
Add to the hazards of the system the question of privacy raised by the Minnesota judge. An abortion should be strictly one's own business, even if you are only 15 years old. All courts have recognized this and required confidentiality. The Supreme Court, in its June decision, required anonymity. A young girl especially, fearing censure from adults, is likely to want to keep an abortion a secret. Yet in Minnesota, it was estimated by the ACLU that a teenager had to pass by as many as 23 people as she made her way through the courts. Imagine what the number might be in the bureaucratic maze of the Cook County courts.
Ann-Louise Lohr's response to my questions about these problems was: "The Supreme Court has mandated that the judicial bypass has to be expeditious and confidential. Those safeguards are maintained for the minor." Defending parental notification laws, Lohr cited the "immaturity of the minor to make a decision of this magnitude by herself." Wouldn't this same immaturity make a girl unequal to the challenge of the judicial process? Lohr said, "If the statute says these cases are to be given priority over other matters and they have to be handled expeditiously, then we have to assume that will happen. If it doesn't, then they can file an as-applied challenge saying the law doesn't work properly."
Said Bryan Howard, "We're going to have to compile a list of horror stories before we get the law revoked. How many Becky Bells are we going to have before the state comes to its senses?" Howard was referring to the case of 17-year-old Rebecca Bell of Indianapolis, in a state where parents must not only be notified but give consent. Fearing (so a friend now says) that her parents would be disappointed in her, and not wanting to attempt the courts, Rebecca Bell tried to abort herself. Five days after the abortion, she died. Her parents, who had supported Indiana's consent law, have been testifying against such laws in other states since their daughter's death.
Various surveys indicate that about 60 percent of the pregnant teenagers who go to clinics for abortions have already told at least one parent. The younger the teen, the more likely that she's told her mother. The rest of the youngsters who go to clinics say they can't tell their parents, either because the relationship is too distant or because they fear a violent reaction. Some have seen older sisters struck or thrown out of the house. The evidence of the clinics is that many of these girls come from severely disturbed homes.
But probably more common than these girls are the Becky Bells, who are on comfortable terms with their parents but are afraid to "disappoint" them. Despite an increase in sexual activity over the past 25 years, research identifies an enduring population of parents who do not admit that their children, especially their daughters, are sexually active. Many parents and children draw up an implicit pact: "You won't ask and I won't tell."
Then, suddenly, the daughter is pregnant. She understands, in the way kids understand their parents, that they don't approve of her having sex. How can she tell them she's pregnant? Instead, she confides in a friend. Together, they decide she should go to Planned Parenthood, where abortions are safe and inexpensive, or, if there is no Planned Parenthood facility available, they somehow raise the money for a more expensive abortion. Perhaps she has a boyfriend who asks for help from his friends, too.
In many parts of the country, including Minnesota, which has abortion facilities in only two urban centers at either end of the state, the girl might have to travel hundreds of miles. She might lie about the reason for her trip, perhaps not reveal it at all, saying she is staying at her friend's house. She invents an excuse for being away from school and work. She has, in other words, a tough time. But she succeeds in her goal. She has gotten an undisclosed abortion.
This is the girl the notice law is aimed at. Not the girl who can, perhaps with difficulty, tell her parents and get their help (clinics report that many girls arrive accompanied by their mothers). Antis count on the parents the girls don't want to tell--the fathers especially--to prevent abortions. When I asked Tom McCracken, an antichoice Illinois legislator from the western suburbs, whether he would be willing to amend the Illinois law to allow single-parent notification, considering the fact that as of 1988, 22.5 percent of the children under 18 in this country were living with only one natural parent, he asked, "Which parent would that be?" The custodial parent, obviously, I said. "Oh no, I couldn't go for the custodial parents. They'd probably be for abortion." Mothers, that is.
Fathers, McCracken apparently believes, would be less likely to condone abortions. He's not alone in thinking that. Many wives and girlfriends have abortions secretly, not telling their male companions, fearing the consequences. One young woman, discussing her own experience, said, "This law is just a license for fathers and boyfriends to beat up the girls."
Notice laws are grounded on the assumption that teenagers are not mature enough to make what Lohr calls "a decision of this magnitude." Yet she's mature enough to bring a pregnancy to term healthfully and care for a baby? No, that's not true, says Tom McCracken. "We're not saying she's mature enough to have the baby. We're just saying that she's going to have the baby. The child will have the child regardless of whether the parents consent. The decision to abort is one that is affected by the one who is making the decision. Once a girl is pregnant, going to term will just happen. That's not true of abortion. That's going to happen when a decision is made after the pregnancy. The law can't affect pregnancy, but it can affect abortion."
Maturity, then, is only selectively the issue. Supporters of notification laws question whether teenagers are prepared to deal with the consequences of abortion, but not the consequences of birth. Abortion's consequences on the young mother must be largely presumed. According to all available evidence, abortions are much safer than childbirth, especially for teenagers. Teens--particularly young ones--run a two and a half times greater risk from pregnancy and childbirth than adult women do, according to the Minnesota Department of Health and the Alan Guttmacher Institute, a New York City-based organization that does reproductive policy research. As for the psychological consequences, although it was not singling out teenagers, the World Health Organization did report in 1978 that "there is now a substantial body of data reported from many countries, after careful and objective follow-up, suggesting frequent physical benefit and low incidence of adverse psychological sequelae" due to abortion. Third, the evidence from many studies is that abortion does not affect subsequent ability to get pregnant.
Consider the personal motives that might lead a pregnant teenager to seek an abortion: she believes she's too young to be a mother; she has ambitions for a career that would be severely damaged by having a baby; she doesn't want to be as dependent on her parents as having a baby might make her; she doesn't want a baby conceived in incest or rape. Are these considerations necessarily signs of immaturity?
The ACLU contends that research shows teenagers to be as capable as adults of making decisions about their own health care, and as able to relate their own physical histories to their doctors. Psychologist Lawrence Kohlberg of Columbia University has written that by the age of 14 adolescents have developed a personal sense of conscience and morality.
As if sensing all this, the ACLU has argued, many states accord minors some authority over their own medical treatment. Idaho, for instance, gives minors 14 and over the right to make all medical decisions. In California and some other states, minors 12 and over can authorize treatment for sexually transmitted diseases. In Illinois, a law passed in 1961 and amended in 1969 permits doctors to forgo parental consent for youngsters 12 and over in need of emergency care, or in need of treatment for venereal disease, assault or sexual abuse, or drug or alcohol abuse, or in need of psychiatric care. Compare this expansive 60s law, which declares, "A married person who is a minor, a pregnant woman who is a minor . . . is deemed to have the same legal capacity to act and has the same powers and obligations as has a person of legal age," with the encumbering (and superseding) '83 law.
Parental notification laws have received almost no support from medical groups, psychologists or psychiatrists, youth advocates, women's associations, advocates against child abuse, or any other organizations traditionally associated with helping teenagers and their families. The only amicus briefs received by the Supreme Court in favor of the Ohio or Minnesota laws were filed by AUL and the avowedly antiabortion Association of American Physicians and Surgeons. Antiabortion advocates have written the legislation, organized their followers to support it, lobbied the state legislatures, and, when the bills were challenged, helped the state attorneys general defend them.
Because the tabled Illinois law, requiring either the notification of both parents or a judicial bypass, meets the new U.S. Supreme Court standards, Attorney General Hartigan is beginning the process that will make the law operational. It can't be enforced yet because Illinois isn't in a position to follow the set of rules governing the judicial bypass that were written last year by the state Supreme Court. Says Deputy Attorney General Michael Hayes, "We are prepared to tell [Judge Will] that the court system is not at this point ready to implement these rules in a fashion consistent with the Supreme Court's directives, namely quick and confidential with anonymity. And that we will take steps, governmentally, to see that they are ready. We want to make sure that there is no room for people to come in and say the application of the law doesn't fit the Supreme Court directions."
Not yet in place, Hayes explains, are any of the administrative tools or personnel to make the rules work. There are no clerks, no judges, no courtrooms, no public defenders, no guardians required to carry out the rules. Hayes can't say whether the bypass cases will be handled by present court employees after they've received special training, or whether additional personnel will be needed. "The judiciary has to figure that out," he says, "and if money is needed, the court will have to order it."
But Hayes emphasizes, "We know the courts aren't ready yet, so we don't want the injunction lifted yet." There is some question whether the state's rural counties with their tiny courthouses will ever be able to meet the Supreme Court's requirement of anonymity, and whether the bureaucratic maze of the Cook County court system will ever permit the speedy dispensation of these cases.
But there is a more fundamental question being raised by prochoice activists. Is Hartigan truly required by law to revive this law, now that the Supreme Court has indicated it is constitutional, or can he let the law lie dormant? Hayes said, "One reason we can't just let it lay is because the Seventh Circuit Court [of Appeals] told us to bring back a set of rules." That was back in 1984, when Hartigan was appealing Hubert Will's injunction against the state law, and when Hartigan was on record as opposed to the right of a woman to choose an abortion. He reversed himself last year when he declared his candidacy for governor.
The second reason that Hartigan must take the 1983 law back into the courts, Hayes says, is that "the office has a constitutional duty to uphold the statutes passed by the legislature." True enough, but as professor Mary Becker of the University of Chicago Law School pointed out, "There are lots of laws on the books that the attorney general never enforces. He makes prosecutorial decisions about which matters he will push." Becker cited an Illinois statute, last revised in 1975, that forbids fornication "between a person and another who is not their spouse, if the behavior is open and notorious." (The earlier law forbade all fornication outside marriage.) Here is a modern law that certainly doesn't enjoy the weight of the attorney general behind it.
Becker said that Hartigan "could clearly take the position that he won't take up this law, considering how difficult it will be to follow the Supreme Court's directions to ensure speed and anonymity in these cases. But it's a political decision."
Albert Alschuler, a professor of law at the University of Chicago, agrees with Becker that prosecutors have a lot of discretion about which laws they will enforce. "They can even let burglars go free if they think it will best serve the public interest," Alschuler said. But, he added, "Hartigan might be naturally reluctant to take upon himself the option in this case. He's in a legitimate position to pursue this and might feel compelled." One of Hartigan's people says the attorney general is under heavy pressure from the antichoice legislators to move quickly to lift the injunction. Having infuriated the antis by settling Ragsdale last fall before it reached the Supreme Court, where it might have led to the overthrow of Roe v. Wade, Hartigan is now on the horns of a dilemma. He is running for governor and behind in the polls. Does he drag his feet on the parental notification act and lose antichoice votes or does he move promptly and risk prochoice votes? Hartigan's opponent, Secretary of State Jim Edgar, is strongly prochoice but nevertheless supports the parental notification act. If Hartigan's position is indistinguishable, he could lose both antichoice voters and prochoice voters more impressed by Edgar's long prochoice history than by Hartigan's Johnny-come-lately support. Michael Hayes's strong statement that Hartigan must uphold the law but doesn't want the injunction lifted until the courts are truly able to offer speedy and anonymous access seems sensitive to the feelings of both sides.
While the whole prochoice population was upset by the possibility that Ragsdale might go to the Supreme Court, and while polls have indicated that the prochoice position enjoys a wide margin of support among voters, other polls indicate heavy support, obviously reaching into the prochoice ranks, for parental-notice laws. It isn't clear what pressure, if any, prochoice activists will put on Hartigan to let the law sleep, or how significant they can make the issue in November. It seems probable that Hartigan will follow the polls and hope for the best. It is entirely possible that by moving with deliberate speed, he will see to it that the Illinois law is still in limbo in November.
But at some point in the not-too-distant future, Illinois is apt to have in effect a law under which a physician could be found guilty of a Class A misdemeanor, carrying a penalty of up to one year in jail and a $1,000 fine, for failing to notify the parents of a patient's intent to have an abortion. Doctors say they will not take the risk, according to Bryan Howard. So more unwanted babies will be born. "If this law could work anywhere at all, it could work in Minnesota," said Howard. "Minnesota is a much more rational state that has a greater sensitivity to many social issues than most states, especially Illinois. And the judges in Minnesota testified that it didn't work. The possibility that our young people are going to be able to access the courts is much smaller."
The Alan Guttmacher Institute surveys teenage pregnancy and abortion rates of several countries. The disparities between the U.S. and other countries are dismaying. Here are 1987 figures for some selected countries:
COUNTRY PREGNANCIES ABORTIONS
Canada 45.4 14.2
Great Britain 53.4 18.5
Sweden 33.2 17.4
Netherlands 15.0 5.3
U.S. 109.9 43.5
(per thousand girls 15 to 17)
Why are so many American teenagers getting pregnant? Or should we ask, why are teenage pregnancies so much more uncommon in other industrialized countries? A Guttmacher study said, "One reason for the more successful experience [of limiting teen pregnancy and birth] may be that public attention [in other Western countries] was not generally focused on the morality of early sexual activity but rather was directed to a search for solutions to prevent increased pregnancy and child-bearing. In the U.S., sex tends to be treated as a special topic and there is much more ambivalence. Sex is romantic but also sinful and dirty. It is flaunted but also something to be hidden." This study suggested that "openness about sex may be an especially important factor in lowering adolescent fertility." America's teenage population finds itself bombarded with sexual symbolism and explicit sexuality in movies, television, and advertising, while confronted with either silence or hostility at home, in the church, and often in school.
Public opinion polls show many American parents wanting sex education classes in the schools--classes that talk about contraceptives, abortion, and homosexuality, even to 12-year-olds. These parents admit they have trouble discussing such matters with their kids. On the other hand, a recent survey by the Guttmacher Institute showed that the biggest problem that teachers face in teaching sex education is opposition from parents, community groups, and public officials. Only half of the teachers surveyed said that parents and the community support their efforts. The opposition to sex education is very vocal and influential, just like the opposition to legalized abortion during the last 15 years. Oddly, opponents of one often oppose the other. When I asked Ann-Louise Lohr if her law firm did anything to promote birth control as one way to avoid abortion, she replied, "That's a separate issue."
Some sex education does get taught--according to the Guttmacher Institute, four-fifths of the states require an average of about six and a half hours a year to be taught to American students in the 12-to-17-year-old age range, with less than two of those hours devoted to contraception, even in those communities that support sex education. Virtually all the teachers surveyed said they taught about the negative consequences of sex for teenagers. Only 13 state curricula specifically cover pregnancy prevention, and just 2 of those discussed contraceptives along with abstinence. Not even one included information about where to get them. Nevertheless, the Institute has found that sex education does lead some teenagers to use contraceptives; incidentally, it does not encourage more teens to engage in sex.
So much for sex education in the U.S. How about access to contraceptives? All of the countries that have low pregnancy and birthrates among teenagers have some kind of national health plan that includes free contraceptive information and distribution. The Guttmacher surveys revealed that in most other Western countries the main source of contraceptives was also the main source of health care, whether a public clinic where contraceptives are free or a family physician; and in five of the seven countries where the family physician was the main source the government paid for the contraceptives.
Compare that with access in the U.S. Take Chicago. There are about 40 Department of Public Health clinics in the city that dispense free condoms, and there is a handful of not-for-profit clinics, the largest of which are Planned Parenthood's, that give contraceptive information and suitable devices free or at low cost. Far and away the most common providers of contraceptive information and devices other than condoms are gynecologists, who charge hefty fees and are not particularly accessible to teenagers.
Teenagers--and adults--can get free condoms in the public clinics and in two public schools in the city, or they can buy them in the drugstore for slightly under a dollar apiece. Whatever one may think of condoms, their use among teenagers has greatly increased. According to a national survey by Freya Sonenstein and Joseph Pleck, published in Family Planning Perspectives last September, 58 percent of sexually active males aged 17 to 19 and living in metropolitan areas said they used condoms. The reason was not pregnancy prevention, however. It was fear of AIDS.
With condoms so easily available and reasonably cheap, that 58 percent figure for boys in what may be their most sexually active period could seem dismayingly low. But in 1979, only 21 percent of boys in this age group used them. What's really dismaying is that when condoms are the only easily accessible contraceptive, control over the consequences of sex is left to the male. In all other Western nations, young women have access to a wide variety of birth control devices, and thus more control over their lives. According to Guttmacher, "The proportion of all women of reproductive age who use one of the three modern, highly effective methods of contraception [the pill, the IUD, and sterilization], is lower in the U.S. than in many other Western countries . . . and the proportion of women not using any method is highest in the U.S."
This study also showed that "use of the most effective contraceptive methods is likely to be high where general and family practitioners are the usual source of primary health care, including contraceptive services. . . . On the other hand, use of effective methods is likely to be relatively low where the usual source is specialist physicians . . . as in the United States."
Choice is further limited by the lack of public and private funding for research in new contraceptive methods. While the federal government never spent a great deal in this area, funding fell from $12 million a year in the early 80s to $8 or $9 million in the last few years, while the inflation rate for medical research rose 7.5 percent, according to Lisa Kaeser, who is the senior associate for policy analysis at Guttmacher. Even more important, the number of pharmaceutical houses doing research has dropped from 8 to 1 since the 70s, Kaeser said. With the drying up of research funds has come the exit of scientists working on contraceptive research. "In the early 70s, this was a hot area of research for young scientists. Now with politics and funding as they are, they're going into other areas," Kaeser said.
For the first 65 years of this century, Americans in many states were denied legal access to contraceptives. As Malcolm Potts, president of Family Health International, wrote in 1988, "Birth control has had a more bitter history in the United States than in any other industrialized country." Nevertheless, in 1957 the U.S. produced the most significant breakthrough in contraceptive knowledge--the pill. Its development has led, in other countries, to a variety of contraceptives that use the same basic technology but provide more efficacious methods than the ingestion of a daily pill, and it is the favored method of contraception throughout the Western world. Only in the U.S., Canada, and Switzerland is sterilization more widely practiced than the pill.
In the pill's early years, a variety of side effects were reported, but over the past ten years or so research has refined the pill to make it quite safe for almost all women (smokers are the main exception). Continued research has also established that some of the original dangers were overstated. Malcolm Potts wrote, "The original estimates of cardiovascular risk were probably overstated, even for high-dose formulations. One study showed that while pill use climbed in the late 60s and 70s, deaths due to cardiovascular disease fell among women 15-44."
The pill apparently tends to reduce the danger of ovarian or endometrial cancer, while there is some evidence that it may increase the risk of breast or cervical cancer. Potts pointed out that much of the research so far done on the pill has been with animals, which have very different reproductive systems than humans. "In some cases," he wrote, "the rigid application of animal tests [by the Food and Drug Administration] may have actually prevented the use of safe and effective contraceptives."
Unfortunately, in the U.S., there is still widespread fear of the pill's side effects. Its current level of safety and effectiveness has been inadequately publicized in the political atmosphere that has prevailed in recent years. Even many physicians continue to use the restrictive 1970 guidelines that no longer apply.
Making matters worse, access to the pill in the U.S. is limited to a few not-for-profit clinics and to gynecologists, who are normally beyond the reach of teenagers, especially poor ones. The fact that the pill costs about $20 a month is no small deterrent, either, considering that this is one health care measure many teens won't ask their parents to pay for. The pill, as it is offered in this country, is not the best method of contraception for teenagers. Their secretive and sporadic sex lives make them less likely to adhere to the daily regimen required for the pill to be effective. Methods available in other countries include a postsex pill, an injection effective for three months, an implant that lasts five years, and the controversial RU 486, the French abortion pill. But the political atmosphere surrounding the FDA, and that agency's rigid procedures, have contributed to preventing any of these alternatives from reaching the U.S. In addition, the pharmaceutical houses, threatened with right-wing boycotts and fearing the kind of liability suits that arose several years ago over the Dalkon Shield, have largely stayed away from new contraceptives.
There is one notable exception. The Population Council of New York, a not-for-profit research organization that conducts health-science research programs in developing countries and develops contraceptives, is expecting FDA approval this year for Norplant, a new product already tested in 44 countries with 55,000 women. Norplant consists of slowly diffusing progestin encapsulated in linguinilike strands that are placed under the skin of the upper arm with a needle. A six-capsule implant lasts five years and can be easily removed. It is now licensed for sale in 16 countries. A large pharmaceutical house, Wyeth-Ayerst Laboratories of Philadelphia, will distribute it in the U.S.
But while Norplant promises to be a major step forward in American birth control, it will be yet another method out of the reach of the poor and the young. That's partly because of its cost --an estimated $1,200, comparable to a two-year supply of the pill--and partly because it requires a surgical procedure, though very simple, that probably will be performed mostly by gynecologists (although the FDA is expected to allow health-care professionals other than physicians to perform the procedure, a Population Council spokesperson said). In countries where Norplant is now available, says Population Council spokesperson Julia Lave, the procedure is often performed by nurses and clinicians.
There are a number of other contraceptive devices on the market in the U.S., namely the diaphragm, sponges, foam, the IUD (in very limited use), and the cervical cap (also limited); but most are less effective than the pill and none are recommended for use by adolescents, for reasons having to do with their age and the nature of their sexual lives.
But the most effective barrier to effective birth control among Americans isn't a lack of choices. It's cost, a lack of access to providers, and a lack of basic information. Until the influence of the right wing on sex education and the dissemination of contraceptive information is effectively countered, until more funds are available for contraceptive research to find a suitable device easily available to teenagers, the likelihood is that the teenage pregnancy rate will rise steadily in the U.S. More and more teens are becoming sexually active, despite the efforts of moralists to prevent it. No comparable figures for girls are available, but the Guttmacher Institute reports that while about two-thirds of boys 17 to 19 were sexually experienced in 1979, that figure rose to three-quarters by 1988.
In 1988, almost 19 percent of all births in Chicago--10,660 of them--were to girls 19 and under, 89 percent of them unmarried. Of those births, 363 were to girls under 15. These figures continued a steady rise from previous years. According to the Illinois Caucus on Teenage Pregnancy, many of these girls had no prenatal care. Many had babies of low birth weight; many babies were seriously ill. Many of the girls live on welfare. Of single girls between 15 and 17 who had babies, 73 percent were on welfare within four years--a figure exactly the same for black and white teenagers. Most teen mothers do not finish high school. Much of the child abuse reported in the city is committed by them. Many of these mothers and their children end up in shelters.
And not all these young girls are from poor homes or minorities. During 1988, births to unwed teenagers rose by 8.1 percent in Chicago's suburbs, in McHenry County alone by 22.2 percent. The rise in the city was 5.7 percent. The social problem represented by poor, uneducated, frustrated, depressed, young single mothers is not a small one. The refusal of the federal government to fund contraceptive research, the refusal of the pharmaceutical companies to test and market new methods from abroad, and the success of the right wing in limiting teenage abortion with consent and notification laws must inevitably increase the number of such women, at great cost to their own lives and to the lives of many of their children, thus increasing the financial and social burden on the state.
Art accompanying story in printed newspaper (not available in this archive): illustration/Robert Goldstrom.