Chapter 5: Teen Sexuality and Pregnancy

EARLY SEXUAL ACTIVITY
CONTRACEPTIVE USE
SEXUALLY TRANSMITTED DISEASES
TEEN CHILDBEARING TRENDS
TEEN ABORTION
HOMOSEXUALITY
STD AND PREGNANCY PREVENTION PROGRAMS FOR TEENS

EARLY SEXUAL ACTIVITY

Many teenagers are sexually active. Danice K. Eaton et al. of the Centers for Disease Control and Prevention (CDC) report in “Youth Risk Behavior Surveillance—United States, 2007” (Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf) that 47.8% of high school students surveyed in grades nine through 12 have had sexual intercourse. (See Table 5.1.) Girls (45.9%) were slightly less likely than boys (49.8%) to have had intercourse. African-American students (66.5%) were more likely than Hispanic (52%) or non-Hispanic white students (43.7%) to be sexually active.

The proportion of students who had intercourse rose with age; 32.8% of ninth graders, 43.8% of 10th graders, 55.5% of 11th graders, and 64.6% of 12th graders had ever had intercourse at the time of the survey. (See Table 5.1.) A number of youth were sexually active before age 13; 7.1% had had intercourse at age 12 or younger. This early sexual activity is of concern, especially among young girls. According to studies such as Sonya S. Brady and Bonnie L. Halpern-Felsher's “Adolescents' Reported Consequences of Having Oral Sex versus Vaginal Sex” (Pediatrics, vol. 119, no. 2, February 2007), among sexually active young teens, boys tend to feel good about themselves and experience popularity as a result of sexual activity, whereas girls are more likely to feel used and bad about themselves. In addition, Denise D. Hallfors et al. report in “Which Comes First in Adolescence—Sex and Drugs or Depression?” (American Journal of Preventive Medicine, vol. 29, no. 3, 2005) that being sexually active puts adolescents, particularly girls, at risk for depression.

Risk Factors for Early Sexual Activity

In “Early Adolescent Sexual Activity: A Developmental Study” (Journal of Marriage and the Family, vol. 61, no. 4, November 1999), Les B. Whitbeck et al. note that “the main predictors of early intercourse were age, association with delinquent peers, alcohol use, opportunity, and sexually permissive attitudes.” Cami K. McBride et al. indicate in “Individual and Familial Influences on the Onset of Sexual Intercourse among Urban African American Adolescents” (Journal of Consulting and Clinical Psychology, vol. 71, no. 1, February 2003) that family conflict is also linked to early sexual activity among poor urban African-American adolescents. In “Parental Influences on Adolescent Sexual Behavior in High Poverty Settings” (Archives of Pediatrics and Adolescent Medicine, vol. 53, no. 10, 1999), another study of poor African-American children, Daniel Romer et al. find that those who reported high levels of monitoring from parents were less likely to have sex before adolescence (at age 10 or earlier) and had lower rates of sexual initiation in their teen years as well. John S. Santelli et al. report in “Initiation of Sexual Intercourse among Middle School Adolescents: The Influence of Psychosocial Factors” (Journal of Adolescent Health, vol. 34, no. 3, March 2004), a study of inner-city seventh graders, that peer norms about refraining from sex were strongly correlated with seventh and eighth graders abstaining; on the contrary, drug or alcohol use increased the risk of early sexual activity. Other studies, such as S. Liliana Escobar-Chaves et al.'s “Impact of the Media on Adolescent Sexual Attitudes and Behaviors” (Pediatrics, vol. 116, no. 1, July 2005), find a correlation between exposure to sexual themes in mass media and adolescent sexual activity.

Reasons Given for Not Delaying Sex

A number of studies report that both sexes consider social pressure the major factor in engaging in early sexual activity. Peer pressure and a belief that “everyone is doing it” have often been cited as explanations. However, in “Adolescent Girls' Perceptions of the Timing of Their Sexual Initiation: ‘Too Young’ or ‘Just Right’?” (Journal of Adolescent Health, vol. 34, no. 5, May 2004), Sian Cotton et al. indicate that most female adolescents (78% of the studied group) felt that they had been “too young” at their first sexual experience.

In addition, some research challenges the theory that social pressure is the strongest influence on teenagers' sexual decisions. The press release “Study Offers Parents New Insights into When and Why Teens Choose Drinking, Drugs, and Sex” (October 29, 2002, http://www.sadd.org/teenstoday/teenstodaypdfs/study.pdf) discusses the Teens Today survey, which was commissioned by Students against Destructive Decisions and the Liberty Mutual Group. Students in grades six through 11 were asked what factors had most influenced their decisions about sexuality. The most common reasons 11th graders gave for engaging in sexual activity were boredom, curiosity, and to please one's partner. The most commonly mentioned reasons not to have sex were fear of pregnancy, fear of sexually transmitted diseases (STDs), and not being in a relationship or in love.

The Media and Teen Concepts of Sexuality

In Sex on TV 4 (November 2005, http://www.kff.org/entmedia/upload/Sex-on-TV-4-Full-Report.pdf), the Kaiser Family Foundation and Dale Kunkel et al. of the University of Arizona discuss the results of a study of sexual messages on television. The report finds that the percent of shows with sexual content had increased from 56% in 1998 to 70% in 2005. In addition, in those shows that included sexual content, the number of sexual scenes per hour had risen from 3.2 in 1998 to 5 in 2005—and in the top teen programs, there were on average 6.7 sexual scenes per hour. Of the 20 shows most popular with teenagers, 70% included some sexual content, and 45% included sexual behavior. More than one out of 10 (11%) episodes included scenes in which sexual intercourse was depicted or strongly implied. Only 10% of shows most popular with teens that contained sexual content included a reference to sexual risk or responsibility.

The study's authors note that the portrayal of sex on television does not have wholly negative consequences. In fact, even though references to sexual risk or responsibility are still low, they have increased in recent years. Furthermore, these references can have a big impact. The study's authors state, “New research over the past several years has documented the powerful positive impact television can have on young people—whether it is learning about HIV from an episode of Girlfriends or about condom efficacy from an episode of Friends. Indeed … for many young people, exposure to a higher proportion of shows referencing sexual risks or responsibilities can promote healthier sexual decision-making.”

Sexual Activity and Substance Use

Over the years, a number of studies have suggested a link between substance use and sexual activity. Researchers find that both sexual activity and a history of multiple partners correlate with some use of drugs, alcohol, and cigarettes. However, Eaton et al. indicate that among sexually active students, only 22.5% reported in 2007 they had used alcohol or drugs at the time of their last sexual experience. (See Table 5.2.) Males (27.5%) were more likely than females (17.7%) to report this behavior; African-Americans (16.4%) were less likely than Hispanics (21.4%) or non-Hispanic whites (24.8%) to report using alcohol or drugs during sexual activity.

Jie Guo et al. of the University of Washington note in “Developmental Relationships between Adolescent Substance Use and Risky Sexual Behavior in Young Adulthood” (Journal of Adolescent Health, vol. 31, no. 4, 2002) that there is a link between adolescent binge drinking and marijuana use and risky sexual behavior. Young people

who used marijuana or binge drank in high school were more likely at age 21 to have had more sexual partners and to use condoms inconsistently. In “Trends in Sexual Risk Behavior and Unprotected Sex among High School Students, 1991–2006: The Role of Substance Use” (Journal of School Health, vol. 78, no. 11, November 2008), John E. Anderson and Trisha E. Mueller of the CDC find that adolescents who use drugs or alcohol are more likely to engage in risky sexual behaviors. The researchers report, “In spite of favorable trends in recent years for both sexual risk and drug use among adolescents, the [Youth Risk Behavior Survey] data show that a high percentage of youth are at risk and that many youth remain at dual risk from substance abuse and sexual behaviors.”

Voluntary and Nonvoluntary Experiences

The 1995 and 2002 National Survey of Family Growth asked women whether their first sexual experience was voluntary. In “A Demographic Portrait of Statutory Rape” (2005, http://www.childtrends.org/Files/ConferenceonSexualExploitationofTeensPresentation.pdf), Kristin Moore and Jennifer Manlove find that 18% of girls whose first sexual experience occurred at age 13 or under said it was non-voluntary, compared to 10% of 15- and 16-year-olds and 5% of 17- and 19-year-olds. In addition, Elizabeth Terry-Humen, Jennifer Manlove, and Sarah Cottingham report in “Trends and Recent Estimates: Sexual Activity among U.S. Teens” (June 2006, http://www.childtrends.org/Files//Child_Trends-2006_06_01_RB_SexualActivity.pdf) that survey respondents were asked to state which of three statements most closely described how much they wanted their first sexual intercourse experience: “I really didn't want it to happen at the time,” “I had mixed feelings—part of me wanted it to happen at the time and part of me didn't,” and “I really wanted it to happen at the time.” Only 34% of adolescent females said they really wanted it to happen at the time, compared to 62% of adolescent males who felt that way. More than one out of 10 (13%) females, compared to 6% of males, reported that they really did not want their first sexual intercourse to happen at that time.

Additionally, Anita Raj et al. find in “The Relationship between Sexual Abuse and Sexual Risk among High School Students: Findings from the 1997 Massachusetts Youth Risk Behavior Survey” (Maternal and Child Health Journal, vol. 4, no. 2, June 2000), that almost one-third (30.2%) of the girls and one-tenth (9.3%) of the boys reported having been sexually abused. Sexually abused females were twice as likely to engage in early sexual intercourse and other risky sexual behaviors as girls who had not been abused. Several studies corroborate evidence of the increased sexual risks taken by sexually abused youth, such as Elizabeth M. Saewyc, Lara Leanne Magee, and Sandra E. Pettingell's “Teenage Pregnancy and Associated Risk Behaviors among Sexually Abused Adolescents” (Perspectives on Sexual and Reproductive Health, vol. 36, no. 3, May–June 2004); Regina Jones Johnson, Lynn Rew, and R. Weylin Sternglanz's “The Relationship between Childhood Sexual Abuse and Sexual Health Practices of Homeless Adolescents” (Adolescence, vol. 41, no. 162, 2006); and Jonathan G. Tubman et al.'s “Abuse Experiences in a Community Sample of Young Adults: Relations with Psychiatric Disorders, Sexual Risk Behaviors, and Sexually Transmitted Diseases” (American Journal of Community Psychology, vol. 34, nos. 1–2, September 2004).

Saewyc, Magee, and Pettingell indicate that teenage pregnancy is also strongly linked to sexual abuse.

According to Child Trends, a nonprofit research organization dedicated to improving the lives of children, early sexual initiation for teenage girls has been linked to several adverse outcomes. The Child Trends publication Facts at a Glance (January 1, 1997) indicates that more than half (54%) of females 14 or younger at first sexual intercourse reported experiencing nonvoluntary sex at some point during their teen years. Brent C. Miller, Bruce H. Monson, and Maria C. Norton report in “The Effects of Forced Sexual Intercourse on White Female Adolescents” (Child Abuse and Neglect, vol. 19, no. 10, October 1995) that early sexual initiation has also been linked to domestic violence and verbal abuse later in life and to depression and low self-esteem. In “Associations of Dating Violence Victimization with Lifetime Participation, Co-occurrence, and Early Initiation of Risk Behaviors among U.S. High School Students” (Journal of Interpersonal Violence, vol. 22, no. 5, May 2007), Danice K. Eaton et al. of the CDC link early sexual intercourse with dating violence victimization among female students. Erin Schelar, Suzanne Ryan, and Jennifer Manlove argue in “Long-Term Consequences for Teens with Older Sexual Partners” (April 2008, http://www.childtrends.org/Files//Child_Trends-2008_05_06_FS_OlderPartners.pdf) that many girls with an early sexual initiation have partners three or more years older; the combination of early sexual initiation with older sexual partners puts girls at a higher risk for contracting STDs. In “Long-Term Health Correlates of Timing of Sexual Debut: Results from a National U.S. Study” (American Journal of Public Health, vol. 98, no. 1, January 2008), Theo G. M. Sandfort et al. link early sexual initiation to increased sexual risk behaviors and problems and sexual functioning for both males and females.

CONTRACEPTIVE USE

Too Few Use Contraceptives

Eaton et al. find that in 2007, 61.5% of sexually active teenagers reported that they or their partners used condoms during their last sexual intercourse. (See Table 5.3.) Young African-Americans reported the highest condom use (67.3%) among sexually active youth, Hispanic students reported a rate of 61.4%, and non-Hispanic white students reported the lowest rate of 59.7%. Males (68.5%) were significantly more likely than females (54.9%) to report condom use. However, the use of condoms decreased from the ninth grade (69.3%) to the 12th grade (54.2%), a period during which the frequency of sexual intercourse increased, probably because older adolescents turned to alternative methods of birth control, such as oral contraception.

Among sexually active students nationwide in 2007, 16% reported they or their partners used oral contraceptives, or “the pill.” (See Table 5.3.) Even though this form of contraception protects against pregnancy, it does not protect against STDs. Twice as many non-Hispanic white students (20.8%) reported using birth control pills than did Hispanic (9.1%) or African-American students (9.1%). This disparity may be due to the need for a prescription for birth control pills; white students tend to have greater access to medical care than minority students do. Birth control pill use increased between ninth (8.7%) and 12th grade (23.5%).

Drawing on a national survey of male adolescents, Erum Ikramullah and Jennifer Manlove find in “Condom Use and Consistency among Teen Males” (October 2008, http://www.childtrends.org/Files/Child_Trends-2008_10_30_FS_CondomUse.pdf) that even though 71% of male teens reported using a condom the first and most recent time they had sexual intercourse, only half of male teens reported consistent condom use with their most recent sexual partner.

REASONS FOR USE OR NONUSE OF CONDOMS. There are many factors involved in adolescents' decisions to use or not use condoms. The November 2000 SexSmarts (http://www.kff.org/entpartnerships/upload/SexSmarts-Survey-Safer-Sex-Condoms-and-the-Pill-Toplines.pdf), a survey of 519 adolescents aged 12 to 17 by the Henry J. Kaiser Family Foundation and Seventeen magazine, highlights teens' fairly casual attitude toward condom use. The survey shows that teens do not completely understand the importance of using condoms consistently to avoid STDs, including HIV and acquired immunodeficiency syndrome (AIDS). Eleven percent agreed with the statement “having sex without a condom every now and then is not that big of a deal,” and 9% believed that “if you don't have a lot of partners you don't need to use condoms.” One out of four (25%) teenage females agreed with the statement “condoms break so often they are not worth using.” In “Gender Roles” (November 2002, http://www.kff.org/entpartnerships/upload/Gender-Rolls-Summary.pdf), a follow-up survey, SexSmarts finds that girls face more negative attitudes than boys do if they carry condoms with them; 70% of boys and 75% of girls agreed with the statement, “If a girl carries a condom people might think she is ‘easy’,” whereas only 43% of boys and 36% of girls agreed with the statement, “If a boy carries a condom people might think he is ‘easy’.”

Research indicates that adolescents' attitudes and beliefs about their relationships with their partners influence whether or not they will use condoms. Celia M. Lescano et al. of Brown Medical School find in “Condom Use with ‘Casual’ and ‘Main’ Partners: What's in a Name?” (Journal of Adolescent Health, vol. 39, no. 3, September 2006) that adolescents were more likely to use a condom with a partner that they perceived as a casual one. However, even when partners were casual ones, teens reported using condoms only about half the time. Therefore, teens were not adequately protecting themselves against STDs even with partners they perceived as more risky. Condom use with partners perceived as main partners was even lower. Lescano et al. state, “Perhaps adolescents overestimate the safety of using condoms ‘most of the time’ with a casual partner and underestimate the risk of unprotected sex with a ‘serious’ partner.”

Cynthia Grossman et al. find in “Adolescent Sexual Risk: Factors Predicting Condom Use across the Stages of Change” (AIDS and Behavior, vol. 12, no. 6, November 2008) that teens who consistently used condoms reported a greater understanding of the importance of using condoms, had better communication about condom use with their partners, and were less likely to perceive themselves as immune to the human immunodeficiency virus (HIV) than their peers who reported inconsistent condom use.

In “Condom Use among High-Risk Adolescents: Anticipation of Partner Disapproval and Less Pleasure Associated with Not Using Condoms” (Public Health Reports, vol. 123, no. 5, September–October 2008), Larry K. Brown et al. note that they surveyed 1,410 adolescents and young adults between the ages of 15 and 21 who had unprotected sex in the previous 90 days. The researchers find that nearly two-thirds of adolescents did not use condoms at the time of last intercourse. Teens who did not use condoms were significantly more likely to believe that condoms reduce sexual pleasure. They were also less likely to discuss condom use with their partners, but were more concerned that their partners would not approve of condom use.

According to Tricia Hall et al., in “Attitudes toward Using Condoms and Condom Use: Differences between Sexually Abused and Nonabused African American Female Adolescents” (Behavioral Medicine, vol. 34, no. 2, Summer 2008), there is some evidence that teens who have been sexually abused are less likely to use condoms and more likely to have unprotected sex than their nonabused peers.

SEXUALLY TRANSMITTED DISEASES

Adolescents and young adults have a higher risk of acquiring STDs than older adults. Female adolescents may have an increased susceptibility to chlamydia, a bacterial infection that can cause pelvic inflammatory disease and is a contributing factor in the transmission of HIV. In Child Health USA 2007 (2008, ftp://ftp.hrsa.gov/mchb/chusa_07/c07.pdf), the Maternal and Child Health Bureau states that in 2005 chlamydia was the most common STD among adolescents. It was also more common in adolescents and young adults than in any other age group, with 1,621 cases among every 100,000 teens aged 15 to 19. This group also had the highest rates of gonorrhea infection. As Figure 5.1 shows, non-Hispanic African-American teens had much higher rates of both chlamydia and gonorrhea than non-Hispanic white teens.

Kathleen J. Sikkema et al. emphasize in “HIV Risk Behavior among Ethnically Diverse Adolescents Living in Low-Income Housing Developments” (Journal of Adolescent Health, vol. 35, no. 2, August 2004) that half of all new HIV infections in the United States are diagnosed in people under 25 years old. Most of these young people become infected through sexual activity. The researchers find that the risk of HIV infection was highest among older adolescents who did not see a need to practice safer sex because they were with steady partners and among teens who abused drugs and alcohol. Sikkema et al. suggest that their

study results could be used to design prevention programs for those adolescents most at risk.

In “Does Parental Involvement Predict New Sexually Transmitted Diseases in Female Adolescents?” (Archives of Pediatrics and Adolescent Medicine, vol. 158, no. 7, July 2004), Julie A. Bettinger et al. test whether parental involvement had any impact on the rates of STDs among low-income African-American adolescent girls. The researchers find that when these high-risk teens perceived their parents as exercising a high degree of supervision over their activities, they had lower rates of both gonorrhea and chlamydia infection. Anne M. Teitelman, Sarah J. Ratcliffe, and Julie A. Cederbaum find in “Parent-Adolescent Communication about Sexual Pressure, Maternal Norms about Relationship Power, and STI/HIV Protective Behaviors of Minority Urban Girls” (American Psychiatric Nurses Association Journal, vol. 14, no. 1, 2008) that racial and ethnic minority adolescent females who communicated with their parents about sex were better able to be consistent in condom use.

Human Papilloma Virus Vaccine

One STD, the human papilloma virus (HPV), can cause genital warts and cervical cancer in women. At least half of sexually active people will get HPV; most of the time, it resolves on its own. However, sometimes it lingers and causes cell changes that can lead to cervical cancer. In “What Are the Key Statistics about Cervical Cancer?” (March 26, 2008, http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_cervical_cancer_8.asp), the American Cancer Society estimates that in 2008

about 11,070 women will be diagnosed with cervical cancer, and about 3,870 women will die from it. A large proportion of cervical cancer cases are caused by HPV, perhaps in combination with other factors. Clinical trials for a new vaccine against certain strains of the virus, given in three doses over a six-month period, show that the vaccine is nearly 100% effective. In August 2006 the CDC recommended in “HPV Vaccine Information for Young Women” (http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine.htm) that the new vaccine be given to girls before they become sexually active, around age 12, to prevent the transmission of HPV.

However, such recommendations stirred up controversy, which heated up in February 2007, when Rick Perry (1950–), the governor of Texas, issued an executive order making the state the first to require that girls entering the sixth grade be vaccinated as a condition for enrolling in public school. Liz Austin Peterson reports in “Texas Gov. Orders Anti-cancer Vaccine” (Associated Press, February 2, 2007) that conservative groups feared that such a requirement undermined abstinence education and would condone premarital sex. In “Virginity or Death!” (Nation, May 12, 2005), Katha Pollitt explains that others argued for mandatory vaccination because young girls would not abstain from sexual activity due to fear of cervical cancer, HPV cannot be prevented by condom use, and 70% of cases of cervical cancer could be prevented by this vaccine.

TEEN CHILDBEARING TRENDS

Brady E. Hamilton, Joyce A. Martin, and Stephanie J. Ventura of the CDC report in “Births: Preliminary Data for 2006” (National Vital Statistics Reports, vol. 56, no. 7, December 5, 2007, http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_07.pdf) that birthrates for women aged 15 to 19 rose in 2006 for the first time in many years. (See Figure 5.2.) Among girls aged 15 to 17, the birthrate dropped from 38.6 per 1,000 women in 1991 to 21.4 per 1,000 women in 2005, but rose to 22 births per 1,000 women in 2006. Among young women aged 18 to 19 years, the birthrate dropped from 94 per 1,000 in 1991 to 69.9 in 2005, but rose to 73 births per 1,000 in 2006. Most teens who give birth are unmarried. (See Table 5.4.) Childbearing by unmarried women jumped to record high levels that year, to 1.6 million births.

According to Hamilton, Martin, and Ventura, available data by race show that the greatest percentage increase in teen births in 2006 was among African-Americans, whose rate rose 5% to 63.7 births per 1,000. Births to Native American teens increased 4% to 54.7 per 1,000, 3% for non-Hispanic white teenagers to 26.6 births per 1,000, and 2% for Hispanic teens to 83 births per 1,000. The only ethnic group whose birthrate did not see an increase was Asian and Pacific Islanders. In “Births: Final Data for 2006” (National Vital Statistics Reports, vol. 57, no. 7, January 7, 2009), Joyce A. Martin et al. of the CDC explain

that New Hampshire, Vermont, and Massachusetts had the lowest teen birth rates in 2006, whereas Mississippi, New Mexico, and Texas had the highest rates.

Consequences for Teen Mothers and Their Children

Teenage mothers and their babies face more health risks than older women and their children. Teenagers who become pregnant are more likely than older women to suffer from pregnancy-induced hypertension and eclampsia (a life-threatening condition that sometimes results in convulsions and/or coma). Teenagers are more likely to have their labor induced, and an immature pelvis can cause prolonged or difficult labor, possibly resulting in bladder or bowel damage to the mother, infant brain damage, or even death of the mother and/or the child.

Even though most health risks are similar for children born to teenage and older mothers, teenage mothers may have a higher prevalence of certain risk factors. For example, the CDC notes in Health, United States, 2007 (2007, http://www.cdc.gov/nchs/data/hus/hus07.pdf) that in 2004 teenagers had very high rates of smoking during pregnancy (10.5% for 15- to 17-year-olds and 16% for 18- to 19-year-olds) and that smokers were nearly twice as likely to have low-birth-weight babies as nonsmokers. In the fact sheet “Preventing Infant Mortality” (January 13, 2006, http://www.hhs.gov/news/factsheet/infant.html), the U.S. Department of Health and

Human Services indicates that teenagers in general are at a higher risk of having low-birth-weight babies. Michael Klitsch finds in “Youngest Mothers' Infants Have Greatly Elevated Risk of Dying by Age One” (Perspectives on Sexual and Reproductive Health, vol. 35, no. 1, January–February 2003) that babies born to adolescents have a greater risk of dying between one and 12 months after birth.

Few teenage mothers are ready for the emotional, psychological, and financial responsibilities and challenges of parenthood. Becoming a parent at a young age usually cuts short a teenage mother's education, limiting her ability to support herself and her child. According to Sandra L. Hofferth, Lori Reid, and Frank L. Mott, in “The Effects of Early Childbearing on Schooling over Time” (Family Planning Perspectives, vol. 33, no. 6, November–December 2001), women who gave birth as teens in the early 1990s had only a 65% probability of graduating from high school, and only a 29% probability of completing some college. David M. Fergusson, Joseph M. Boden, and L. John Horwood report in “Abortion among Young Women and Subsequent Life Outcomes” (Perspectives on Sexual and Reproductive Health, vol. 39, no. 1, March 2007) that educational attainment is lower among teen mothers than among teens who had an abortion. Additionally, Susheela Singh et al. note in “Socioeconomic Disadvantage and Adolescent Women's Sexual and Reproductive Behavior: The Case of Five Developed Countries” (Family Planning Perspectives, vol. 33, no. 5, November–December 2001) that 40% of American women aged 20 to 24 who gave birth before age 20 had an income of less than 149% of the federal poverty guideline.

The children of teen mothers face consequences as well. In Playing Catch-up: How Children Born to Teen Mothers Fare (January 2005, http://www.teenpregnancy.org/works/pdf/PlayingCatchUp.pdf), Elizabeth Terry-Humen, Jennifer Manlove, and Kristin A. Moore examine data on kindergarteners to determine the relationship between the age a woman has a child and how her child does in several key areas: cognition and knowledge, language and communication skills, approaches to learning, emotional well-being and social skills, and physical well-being and motor development. The researchers find that children born to mothers aged 17 and younger had lower general knowledge scores and language and communication skills, compared to children born to mothers aged 20 and older. Children's approaches to learning, physical well-being, and emotional development, as well as their social skills and emotional well-being, were relatively unaffected by maternal age. In sum, Terry-Humen, Manlove, and Moore state, “Children born to mothers aged 17 and younger began kindergarten with lower levels of school readiness.… The children born to mothers in their 20s clearly outperformed those whose mothers were still teenagers at time of birth, and the most consistent and pronounced differences were observed when comparing children born to mothers aged 17 and younger to those children born to mothers aged 22–29.”

Greg Pogarsky, Terence P. Thornberry, and Alan J. Lizotte come to similar conclusions in “Developmental Outcomes for Children of Young Mothers” (Journal of Marriage and Family, vol. 68, no. 2, May 2006). The researchers note that boys born to young mothers had elevated risks of drug use, gang membership, unemployment, and early parenthood, whereas girls had elevated risks of becoming young mothers themselves.

Adolescent Fathers

According to the Child Trends Databank, in Teen Births (January 2007, http://www.childtrendsdatabank.org/pdf/13_PDF.pdf), in 2005 15- to 19-year-old males had a birthrate

of 16.8 per 1,000, down from a high of 24.7 in 1991. This rate was substantially lower than the 2005 rate for teenage girls of 40.5 per 1,000. The rate was higher for African-American male teens (32.2) than for white male teens (14.2); data for Hispanic male teens were unavailable. The difference between male adolescent and female adolescent birthrates is due in part to the fact that many teen mothers have older partners, as well as to the underreporting of information about fathers on birth certificates. In Facts at a Glance (November 2003, http://www.childtrends.org/Files/FAAG2003.pdf), Child Trends reports that 38% of births to mothers aged 18 and younger were to fathers four or more years older than the mother. In some cases teen mothers have been sexually abused by their older partners.

Such studies alert officials who design programs for the prevention of pregnancy and STDs to the need to pay attention not only to preadolescent and adolescent males but also to older males who are partners of teenage girls. Because these men are typically out of the public school system, officials agree that programs must be broader in scope.

TEEN ABORTION

The CDC reports that in 2004, 839,000 abortions were performed; the year before, 848,000 had been performed. (See Table 5.5.) The Guttmacher Institute conducted a survey and estimated that a much higher number of abortions had been performed in 2004—over 1.2 million. The rate of abortions per 100 live births has decreased from a high of 35.9 in 1980 to 23.8 in 2004. Girls under 15 years old had the highest rate of abortions (76.2 per 100 live births) in 2004, followed by teens aged 15 to 19 (36.2 per 100 live births). All other age groups had lower rates of abortion. For all age groups, African-Americans had the highest abortion rate of any race or ethnic group (47.2 per 100 live births), followed by Hispanics (21.1 per 100 live births) and non-Hispanic whites (16.1 per 100 live births).

As Table 5.5 shows, the abortion rates for teens have declined dramatically since the late 1980s, as have the pregnancy and birthrates.

States have varying laws on parental involvement in minors' abortion decisions. In “An Overview of Abortion Laws” (January 1, 2009, http://www.guttmacher.org/statecenter/spibs/spib_OAL.pdf), the Guttmacher Institute reports that 16 states and the District of Columbia required no parental involvement in minors' abortions. Thirty-four states required some parental involvement, 22 required parental consent, and 10 required parental notification.

HOMOSEXUALITY

In Just the Facts about Sexual Orientation and Youth (2008, http://www.apa.org/pi/lgbc/publications/justthefacts.pdf), a pamphlet for school personnel, the American Psychological Association (APA) stresses that sexual orientation is one aspect of the identity of adolescents—not a mental disorder. According to the APA, sexual orientation is developed across a lifetime and along a continuum; in other words, teens are not necessarily simply homosexual or heterosexual, but may feel varying degrees of attraction to people of both genders. The APA explains that gay, lesbian, and bisexual adolescents face prejudice and discrimination that negatively affect their educational experiences and emotional and physical health. Their legitimate fear of being hurt as a result of disclosing their sexuality often leads to a feeling of isolation. All these factors account for lesbian, gay, and bisexual adolescents' higher rates of emotional distress, suicide attempts, risky sexual behavior, and substance use. The APA underscores the need for school personnel to be as open and accepting as possible to support these adolescents.

STD AND PREGNANCY PREVENTION PROGRAMS FOR TEENS

Abstinence

In response to the growing concern about out-of-wedlock births and the threat of AIDS, several national youth organizations and religious groups began campaigns in the early and mid-1990s to encourage teens to sign an abstinence pledge—a promise to abstain from sexual activity until marriage. According to the National Institutes of Health, in the news release “Virginity Pledge Helps Teens Delay Sexual Activity” (January 5, 2001, http://www.nichd.nih.gov/news/releases/virginity.cfm), 2.5 million teens had taken the “virginity pledge” by 1995. Debra Hauser of Advocates for Youth indicates in Five Years of Abstinence-Only-until-Marriage Education: Assessing the Impact (2004, http://www.advocatesforyouth.org/publications/stateevaluations.pdf) that in 1996 the federal government committed $250 million over the following five years to fund state initiatives to promote abstinence as Title V of the Social Security Act. Even though only 11 states made the results of their evaluations of the effectiveness of these programs public, Hauser states that Advocates for Youth examined these evaluations and found that the programs “showed few short-term benefits and no lasting, positive impact.… No program was able to demonstrate a positive impact on sexual behavior over time.”

The administration of U.S. president George W. Bush (1946-) placed a new emphasis on abstinence among teens. According to the White House report Working toward Independence (February 2002, http://www.whitehouse.gov/news/releases/2002/02/welfare-reform-announcement-book.pdf), an overview of Bush's suggested plan for welfare reform, “the goal of Federal policy should be to emphasize abstinence as the only certain way to avoid both unintended pregnancies and STDs.” In 2007, the U.S. government provided $176 million for abstinence-only programs, but no federal funding for comprehensive sex education programs. Title V, the state abstinence-only education program, provided states with federal funding for abstinence-only sex education programs, but in 2007, 25 of 50 states refused to take the money because they did not want to offer such programs.

Despite the federal funds spent on such programs, Eaton et al. find that in 2007 over one-third (35%) of high school students were sexually active at the time of the survey—35.6% of females and 34.3% of males. Younger students were less likely to be currently sexually active than were older students. Even though 47.8% of all students had ever had sexual intercourse; 64.6% of high school seniors had. (See Table 5.1.)

In this context, abstinence-only education will do little to prevent teen pregnancy or the spread of STDs. As John S. Santelli et al. state in “Abstinence and Abstinence-Only Education: A Review of U.S. Policies and Programs” (Journal of Adolescent Health, vol. 38, no. 1, January 2006), “Although abstinence is a healthy behavioral option for teens, abstinence as a sole option for adolescents is scientifically and ethically problematic.… We believe that abstinence-only education programs, as defined by federal funding requirements, are morally problematic, by withholding information and promoting questionable and inaccurate opinions. Abstinence-only programs threaten fundamental human rights to health, information, and life.”

In 2007, the Department of Health and Human Services released Impacts of Four Title V, Section 510 Abstinence Education Programs (April 2007, http://aspe.hhs.gov/hsp/abstinence07/report.pdf) by Christopher Trenholm et al. The researchers conclude that the youth in the abstinence-only programs were no more likely than youth who were assigned to the control group to have abstained from sex. Those who reported having sex had similar numbers of sexual partners and had initiated sex at the same mean age. In September 2008, several articles about abstinence-only programs were published in a special issue of the journal Sexuality Research and Social Policy (vol. 5, no. 3). Douglas B. Kirby states in “The Impact of Abstinence and Comprehensive Sex and STD/HIV Education Programs on Adolescent Sexual Behavior” that such programs fail to change sexual behavior in teenagers. Other articles concluded that the programs provide inaccurate information about condoms and that they violate human rights principles.

The fate of abstinence-only education was unknown when Barack Obama (1961–) was sworn in as president of the United States in January 2009. Many considered Obama to be in favor of more comprehensive sex education programs. The HHS states in Budget in Brief, Fiscal Year 2009 (2008, http://www.hhs.gov/budget/09budget/2009BudgetInBrief.pdf) that in fiscal year 2009, $191 million in grant money was available for abstinence education, up $28 million from the previous year. The White House explains in A New Era of Responsibility: Renewing America's Promise (2009, http://www.whitehouse.gov/omb/assets/fy2010_new_era/A_New_Era_of_Responsibility2.pdf) that President Obama's 2010 budget proposal not only continued funding for abstinence education but also provided funding for “medically-accurate and age-appropriate information to youth who have already become sexually active,” signaling a potential change of direction in the new administration.

Sex and STD/HIV Education in Schools

As of November 2008, 35 states and the District of Columbia required schools to provide education on HIV/AIDS and other STDs, although in all cases parents were allowed to remove their children from sex education classes. (See Table 5.6.) Twenty-six states required schools to stress the importance of abstinence in STD and HIV/AIDS education, and 11 states required abstinence to be covered. Seventeen states required schools to teach students about contraception, but none required that it be stressed.

According to Eaton et al., 89.5% of all students had been taught about AIDS or HIV in school, compared to 91.5% in 1997. (See Table 5.2.) As HIV/AIDS is increasingly common among young people, the declining percentages of students who learn about the disease in school is problematic.

Chapter 5
Teen Sexuality and Pregnancy

EARLY SEXUAL ACTIVITY

Many teenagers are sexually active. The Centers for Disease Control and Prevention (CDC) reports that in 2005 almost half of high school students (46.8%) had had sexual intercourse, down from the 54.1% who were reported as sexually active in 1991. (See Table 5.1.) One out of seven (14.3%) had had sex with four or more partners. Girls (45.7%) were slightly less likely than boys (47.9%) to have had intercourse. African-American students (67.6%) were more likely than Hispanic (51%) or non-Hispanic white students (43%) to be sexually active.

The proportion of students who had intercourse rose with age; 34.3% of ninth graders, 42.8% of tenth graders, 51.4% of eleventh graders, and 63.1% of twelfth graders had ever had intercourse at the time of the survey. (See Table 5.1.) A number of youth were sexually active before age thirteen; 6.2% had had intercourse at age twelve or younger. This early sexual activity is of concern, especially among young girls. Sonya S. Brady and Bonnie L. Halpern-Felsher of the University of California at San Francisco, in "Adolescents' Reported Consequences of Having Oral Sex versus Vaginal Sex" (Pediatrics, February 2007), find that among sexually active young teens, boys tend to feel good about themselves and experience popularity as a result of sexual activity, whereas girls are more likely to feel bad about themselves as well as feeling used. In addition, the article "Risky Adolescent Behavior Leads to Depression, Not Vice Versa" (NeuroPsychiatry Reviews, December 2005) notes that being sexually active puts adolescents, particularly girls, at risk for depression.

Risk Factors for Early Sexual Activity

In "Early Adolescent Sexual Activity: A Developmental Study" (Journal of Marriage and the Family, November 1999), Les B. Whitbeck et al. note that "the main predictors of early intercourse were age, association with delinquent peers, alcohol use, opportunity, and sexually permissive attitudes." Cami K. McBride et al. of the University of Illinois, in "Individual and Familial Influences on the Onset of Sexual Intercourse among Urban African American Adolescents" (Journal of Consulting and Clinical Psychology, February 2003), indicate that family conflict can also be linked to early sexual activity among poor urban African-American adolescents. In "Parental Influences on Adolescent Sexual Behavior in High Poverty Settings" (Archives of Pediatrics and Adolescent Medicine, 1999), another study of poor African-American children, Daniel Romer et al. of the University of Pennsylvania find that those who reported high levels of monitoring from parents were less likely to have sex before adolescence (at age ten or earlier) and had lower rates of sexual initiation in their teen years as well. John S. Santelli et al., in "Initiation of Sexual Intercourse among Middle School Adolescents: The Influence of Psychosocial Factors" (Journal of Adolescent Health, March 2004), a study of inner-city seventh graders, report that peer norms about refraining from sex were strongly correlated with seventh and eighth graders abstaining; on the contrary, drug or alcohol use increased the risk of early sexual activity.

Reasons Given for Not Delaying Sex

A number of studies report that both sexes consider social pressure the major factor in engaging in early sexual activity. Peer pressure and a belief that "everyone is doing it" are often cited as explanations. However, in "Adolescent Girls' Perceptions of the Timing of Their Sexual Initiation: 'Too Young' or 'Just Right'?" (Journal of Adolescent Health, May 2004), Sian Cotton et al. of the Children's Hospital Medical Center in Cincinnati, Ohio, indicate that most female adolescents (78% of the studied group) felt that they had been "too young" at their first sexual experience.

In addition, recent research challenges the theory that social pressure is the strongest influence on teenagers'

sexual decisions. In Teens Today (October 29, 2002, http://www.sadd.org/teenstoday/teenstodaypdfs/study.pdf), a survey commissioned by Students Against Destructive Decisions and the Liberty Mutual Group, students in grades six through twelve were asked what factors had most influenced their decisions about sexuality. The most common reasons teenagers gave for engaging in sexual activity were boredom, curiosity, and to please one's partner. The most commonly mentioned reasons not to have sex were fear of pregnancy, fear of sexually transmitted diseases (STDs), and not being in a relationship or in love.

Media and Teen Concepts of Sexuality

In Sex on TV 4 (November 2005, http://www.kff.org/entmedia/upload/Sex-on-TV-4-Executive-Summary.pdf), the Kaiser Family Foundation and Dale Kunkel et al. of the University of Arizona report the results of the latest biennial study of sexual messages on television. The report finds that the percent of shows with sexual content had increased from 56% in 1998 to 70% in 2005. In addition, in those shows that included sexual content, the number of sexual scenes per hour had risen from 3.2 in 1998 to 5 in 2005—and in the top teen programs, there were on average 6.7 sexual scenes per hour. Of the twenty shows most popular with teenagers, 70% included some sexual content, and 45% included sexual behavior. More than one out of ten episodes (11%) included scenes in which sexual intercourse was depicted or strongly implied. Only one out of ten shows most popular with teens that contained sexual content included a reference to sexual risk or responsibility.

The study's authors note that the portrayal of sex on television does not have wholly negative consequences. In fact, even though references to sexual risk or responsibility are still low, they have increased in recent years, and these references can have a big impact. The study's authors state, "New research over the past several years has documented the powerful positive impact television can have on young people—whether it is learning about HIV from an episode of Girlfriends or about condom efficacy from an episode of Friends. Indeed … for many young people, exposure to a higher proportion of shows referencing sexual risks or responsibilities can promote healthier decision-making."

Sexual Activity and Substance Use

Over the years, a number of studies have suggested a link between substance use and sexual activity. Researchers find that both sexual activity and a history of multiple partners correlate with some use of drugs, alcohol, and cigarettes. However, the CDC finds that among sexually active students in 2005, only one-fourth (23.3%) reported they had used alcohol or drugs at the time of their last sexual experience. (See Table 5.2.) Males (27.6%) were more likely than females (19%) to report this behavior; African-Americans (14.1%) were less likely than Hispanics (25.6%) or non-Hispanic whites (25%) to report using alcohol or drugs during sexual activity.

In "Developmental Relationships between Adolescent Substance Use and Risky Sexual Behavior in Young Adulthood" (Journal of Adolescent Health, October 2002), Jie Guo et al. of the University of Washington note a link between adolescent binge drinking and marijuana use and risky sexual behavior. Young people who used marijuana or binge drank in high school are more likely at age twenty-one to have more sexual partners and to use condoms inconsistently.

The Kaiser Family Foundation, in Substance Abuse and Risky Sexual Behavior (February 2002, http://www.kff.org/youthhivstds/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14907), reports on a survey of almost a thousand teens and young adults from November 2001 through January 2002. More than a quarter (29%) of sexually active fifteen- to seventeen-year-olds surveyed said that alcohol or drugs had influenced their sexual decisions. More than one out of ten (12%) sexually active fifteen- to seventeen-year-olds reported having had unprotected sex while under the influence of drugs or alcohol. Two out of five of these (41%) said their peers drank or used drugs before having sex "a lot" of the time.

Voluntary and Nonvoluntary Experiences

The 1995 and 2002 National Survey of Family Growth asked women whether their first sexual experience was voluntary. In "A Demographic Portrait of Statutory Rape" (2005, http://www.childtrends.org/Files/ConferenceonSexualExploitationofTeensPresentation.pdf), Kristin Moore and Jennifer Manlove find that 18% of girls whose first sexual experience occurred at age thirteen or under said it was nonvoluntary, compared with 10% of fifteen- and sixteen-year-olds and 5% of seventeen- to nineteen-year-olds. In addition, Elizabeth Terry-Humen, Jennifer Manlove, and Sarah Cottingham report in "Trends and Recent Estimates: Sexual Activity among U.S. Teens" (June 2006, http://www.childtrends.org/Files//Child_Trends-2006_06_01_RB_SexualActivity.pdf) that they asked survey respondents to state which of three statements most closely described how much they wanted their first sexual intercourse experience: "I really didn't want it to happen at the time," "I had mixed feelings—part of me wanted it to happen at the time and part of me didn't," and "I really wanted it to happen at the time." Only 34% of adolescent females said they really wanted it to happen at the time, compared with 62% of adolescent males who felt that way. More than one out of ten (13%) females, compared with 6% of males, reported that they really did not want their first sexual intercourse to happen at that time.

Additionally, Anita Raj et al. of Boston University find in "The Relationship between Sexual Abuse and Sexual Risk among High School Students: Findings from the 1997 Massachusetts Youth Risk Behavior Survey" (Maternal and Child Health Journal, June 2000), a study of four thousand high school students, that almost a third of the girls (30.2%) and a tenth of the boys (9.3%) reported having been sexually abused. Sexually abused females were twice as likely to engage in early sexual intercourse and other risky sexual behaviors than girls who had not been abused. Elizabeth M. Saewyc, Lara Leanne Magee, and Sandra E. Pettingell corroborate in "Teenage Pregnancy and Associated Risk Behaviors among Sexually Abused Adolescents" (Perspectives on Sexual and Reproductive Health, May-June 2004) evidence of the increased sexual risks taken by sexually abused youth.

Moreover, according to Child Trends, a nonprofit research organization dedicated to improving the lives of children, early sexual initiation for teenage girls has been linked to a higher risk of becoming the victim of rape or sexual assault at some later time during their adolescence. The Child Trends publication Facts at a Glance 1997 (January 1, 1997) indicates that more than half (54%) of females age fourteen or younger at first sexual intercourse reported experiencing nonvoluntary sex at some point during their teen years. Vaughn I. Rickert et al. note, in "The Relationship among Demographics, Reproductive Characteristics, and Intimate Partner Violence" (American Journal of Obstetrics and Gynecology, October 2002), that early sexual initiation is linked to domestic violence and verbal abuse later in life. Furthermore, in "The Effects of Forced Sexual Intercourse on White Female Adolescents" (Child Abuse and Neglect, October 1995), Brent C. Miller, Bruce H. Monson, and Maria C. Norton of Utah State University find that early sexual initiation can lead to depression and low self-esteem.

CONTRACEPTIVE USE

Too Few Use Contraceptives

The CDC finds that in 2005, 62.8% of sexually active teenagers reported that they or their partners used condoms during their last sexual intercourse, up from 46.2% in 1991, when the CDC began tracking condom use. (See Table 5.1.) Young African-Americans reported the highest condom use (68.9%) among sexually active youth. Hispanic students reported the lowest rate of condom use (57.7%). Males (70%) were significantly more likely than females (55.9%) to report condom use. However, the use of condoms decreased from the ninth grade (74.5%) to the twelfth grade (55.4%), a period during which the frequency of sexual intercourse increased, probably because older adolescents turned to alternative methods of birth control, such as oral contraception.

Among sexually active students nationwide in 2005, 17.6% reported they or their partners used oral contraceptives, or "the pill." (See Table 5.1.) Even though this form of contraception protects against pregnancy, it does not protect against STDs. More white students (22.3%) reported using birth control pills than either Hispanic (9.8%) or African-American students (10%). This disparity may be because of the need for a prescription for birth control pills; white students tend to have greater access to medical care than minority students do. Birth control pill use increased between the ninth (7.5%) and twelfth grades (25.6%).

REASONS FOR USE OR NONUSE

Research indicates that adolescents' attitudes and beliefs about their relationships with their partners influence whether they will use condoms. Celia M. Lescano et al. find, in "Condom Use with 'Casual' and 'Main' Partners: What's in a Name?" (Journal of Adolescent Health, 2006), that adolescents are more likely to use a condom with a partner that they perceive as a casual one. However, even when partners are casual ones, teens report using condoms only about half the time; therefore, teens are not adequately protecting themselves against STDs, even with partners they perceive as more risky. Condom use with partners perceived as main partners is even lower. Lescano et al. state, "Perhaps adolescents overestimate the safety of using condoms 'most of the time' with a casual partner and underestimate the risk of unprotected sex with a 'serious' partner."

The November 2000 Sexsmart (http://www.kff.org/entpartnerships/upload/SexSmarts-Survey-Safer-Sex-Condoms-and-the-Pill-Toplines.pdf), a survey of 519 adolescents aged twelve to seventeen by the Henry J. Kaiser Family Foundation and Seventeen magazine, also highlights teens' fairly casual attitude toward condom use. The survey shows that teens do not completely understand the importance of using condoms consistently to avoid STDs, including the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS). Eleven percent agreed with the statement "having sex without a condom every now and then is not that big of a deal," and 9% believed that "if you don't have a lot of partners you don't need to use condoms." One out of four teenage females (25%) agreed with the statement "condoms break so often they are not worth using."

SEXUALLY TRANSMITTED DISEASES

Adolescents and young adults have a higher risk of acquiring STDs than older adults. Female adolescents may have an increased susceptibility to chlamydia, a bacterial infection that can cause pelvic inflammatory disease and is a contributing factor in the transmission of HIV. In 2003 chlamydia was the most common STD among adolescents. According to the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services (HHS), in Child Health USA 2005 (2005, http://www.mchb.hrsa.gov/mchirc/chusa_05/pages/pdf/c05.pdf), it was also more common in adolescents than in any other age group, with 1,524 cases among every 100,000 fifteen- to nineteen-year-old girls. This group also had the highest rate of gonorrhea infection, at 443 per 100,000. Syphilis was far less common in teens, with only 1.6 cases per 100,000 reported in 2003. As Figure 5.1 shows, African-American non-Hispanic teens had much higher rates of STDs than non-Hispanic white teens.

The study "HIV Risk Behavior among Ethnically Diverse Adolescents Living in Low-Income Housing Developments" (Journal of Adolescent Health, August 2004) by Kathleen J. Sikkema et al. of Yale University emphasizes that half of all new HIV infections in the United States are diagnosed in people under twenty-five years old. Most of these young people become infected through sexual activity. Sikkema et al. find that the risk of HIV infection was highest among older adolescents who did not see a need to practice safer sex because they were with steady partners and among teens who abused drugs and alcohol. The researchers suggest that study results could be used to design prevention programs for those adolescents most at risk.

Furthermore, Julie A. Bettinger et al., in "Does Parental Involvement Predict New Sexually Transmitted Diseases in Female Adolescents?" (Archives of Pediatrics and Adolescent Medicine, 2004), examine whether parental involvement had any impact on rates of STDs among low-income African-American adolescent girls. They find that when these high-risk teens perceived their parents as exercising a high degree of supervision over their activities, they had lower rates of both gonorrhea and chlamydia infection.

HPV Vaccine

One STD, the human papillomavirus (HPV), can cause genital warts and cervical cancer in women. At least half of sexually active people will get HPV; most of the time, it resolves on its own. However, sometimes it lingers and causes cell changes that can lead to cervical cancer. The American Cancer Society estimates in Cancer Facts and Figures 2005 (http://www.cancer.org/downloads/STT/CAFF2005f4PWSecured.pdf) that in 2005, 10,370 women were diagnosed with cervical cancer and 3,710 died from it. In "HPV Vaccine Questions and Answers" (August 2006, http://www.cdc.gov/std/hpv/hpv-vaccine.pdf), the CDC's Advisory Committee on Immunization Practices states that up to 70% of these cases are caused by HPV. Clinical trials for a new vaccine against certain strains of the virus, given in three doses over a six-month period, show that the vaccine was nearly 100% effective. The advisory committee recommends that the new vaccine be given to girls before they become sexually active, at around age twelve, to prevent the transmission of HPV.

However, such recommendations stirred up controversy, which heated up in February 2007 when Rick Perry, the governor of Texas, issued an executive order making the state the first to require that girls entering the sixth grade be vaccinated as a condition for enrolling in public school. Conservative groups feared that such a requirement undermined abstinence education and would condone premarital sex. Others argued for mandatory vaccination because young girls would not abstain from sexual activity due to fear of cervical cancer; HPV cannot be prevented by condom use; and 70% of cases of cervical cancer could be prevented by this vaccine.

TEEN CHILDBEARING TRENDS

Joyce A. Martin et al. of the CDC report in "Births: Final Data for 2004" (National Vital Statistics Reports, September 29, 2006) that even though birthrates for unmarried women had risen in recent years, the birthrates among unmarried teens had dropped from a high of 45.8 per 1,000 women in 1994 to 34.7 per 1,000 women in 2004. Among girls aged fifteen to seventeen, the birthrate dropped from a high of 31.7 per 1,000 women in 1994 to 20.1 per 1,000 women in 2004. (See Figure 5.2.) Among young women aged eighteen to nineteen years, the birthrate dropped from a high of 69.1 per 1,000 in 1994 to 57.7 in 2004. In "Can Changes in Sexual Behaviors among High School Students Explain the Decline in Teen Pregnancy Rates in the 1990s?" (Journal of Adolescent Health, August 2004), John S. Santelli et al. find that both later ages at first intercourse and improved contraceptive practice contributed equally to the decline in pregnancy rates over the period.

According to Martin et al., available data by race show that the greatest percentage decline in births between 1991 and 2004 was among African-American teens aged fifteen to nineteen, down from 118.2 births per 1,000 in 1991 to 63.1 in 2004. (See Table 5.3.) The Hispanic rate in this age group in 2004 was higher, at 82.6 births per 1,000, even though it had declined from the 1991 rate of 104.6. Non-Hispanic white teens fifteen to nineteen years old had a birthrate of 26.7 in 2004, down from 43.4 in 1991. The rate for Native American teens dropped from 84.1 in 1991 to 52.5 in 2004, and for Asian and Pacific Islander teens, from 27.3 in 1991 to 17.3 in 2004.

Consequences for Teen Mothers and Their Children

Teenage mothers and their babies face more health risks than older women and their children. Teenagers who become pregnant are more likely than older women to suffer from pregnancy-induced hypertension and eclampsia (a life-threatening condition that sometimes results in convulsions and/or coma). Teenagers are more likely to have their labor induced, and an immature pelvis can cause prolonged or difficult labor, possibly resulting in bladder or bowel damage to the mother, infant brain damage, or even death of the mother and/or child.

Even though most health risks are similar for children born to teenage and older mothers, teenage mothers may have a higher prevalence of certain risk factors. For example, in Health, United States, 2006 (http://www.cdc.gov/nchs/data/hus/hus06.pdf), the CDC notes that teenagers had high rates of smoking during pregnancy (10.5% for fifteen- to seventeen-year-olds and 16% for eighteen- to nineteen-year-olds) in 2004 and that smokers are nearly twice as likely to have low birth weight babies as nonsmokers. The HHS finds in the fact sheet "Preventing Infant Mortality" (January 13, 2006, http://www.hhs.gov/news/factsheet/infant.html) that teenagers in general are at a higher risk of having low birth weight babies. Furthermore, in "Youngest Mothers' Infants Have Greatly Elevated Risk of Dying by Age One" (Perspectives on Sexual and Reproductive Health, January-February 2003), Michael Klitsch indicates that babies born to adolescents have a greater risk of dying between one and twelve months after birth.

Few teenage mothers are ready for the emotional, psychological, and financial responsibilities and challenges of parenthood. Becoming a parent at a young age usually cuts short a teenage mother's education, limiting her ability to support herself and her child. According to Sandra L. Hofferth, Lori Reid, and Frank L. Mottj, in "The Effects of Early Childbearing on Schooling over Time" (Family Planning Perspectives, November-December 2001), women who gave birth as teens in the early 1990s had only a 65% probability of graduating from high school, and only a 29% probability of completing some college. Additionally, Susheela Singh et al., in "Socioeconomic Disadvantage and Adolescent Women's Sexual and Reproductive Behavior: The Case of Five Developed Countries" (Family Planning Perspectives, November-December 2001), note that 40% of American women aged twenty to twenty-four who gave birth before age twenty had an income of less than 149% of the federal poverty guideline.

The children of teen mothers face consequences as well. In Playing Catch-Up: How Children Born to Teen Mothers Fare (January 2005, http://www.teenpregnancy.org/works/pdf/PlayingCatchUp.pdf), Elizabeth Terry-Humen, Jennifer Manlove, and Kristin Moore examine data on kindergarteners to determine the relationship between the age a woman has a child and how her child does in several key areas: cognition and knowledge, language and communication skills, approaches to learning, emotional well-being and social skills, and physical well-being and motor development. The researchers find that children born to mothers aged seventeen or younger had lower general knowledge scores and language and communication skills, compared with children born to mothers aged twenty or older. Children's approaches to learning, physical well-being, and emotional development, as well as their social skills and emotional well-being, were relatively unaffected by maternal age. In sum, Terry-Humen, Manlove, and Moore state, "Children born to mothers aged 17 and younger began kindergarten with lower levels of school readiness…. The children born to mothers in their 20s clearly outperformed those whose mothers were still teenagers at time of birth, and the most consistent and pronounced differences were observed when comparing children born to mothers aged 17 and younger to those children born to mothers aged 22-29."

In 1996 President Bill Clinton signed into law the Personal Responsibility and Work Opportunity Reconciliation Act, which abolished the sixty-year-old Aid to Families with Dependent Children program and created the Temporary Assistance for Needy Families (TANF) block grant program. To be eligible for TANF benefits, unmarried minor parents are required to remain in high school or its equivalent and to live with a parent or in an adult-supervised setting. One provision in the law allows for the creation of second-chance homes for teen parents and their children. These homes require that all residents either enroll in school or participate in a job-training program. They also provide parenting and life-skills classes, as well as counseling and support services.

Adolescent Fathers

According to the Child Trends Databank, in "Teen Births" (January 2007, http://www.childtrendsdatabank.org/pdf/13_PDF.pdf), in 2004 fifteen- to nineteen-year-old males had a birthrate of 17 per 1,000, down from a high of 24.7 in 1991. This rate was substantially lower than the 2004 rate for teenage girls of 41.1 per 1,000. The rate was higher for African-American male teens (32.7) than for white male teens (14.3); data for Hispanic male teens was unavailable. The difference between male adolescent and female adolescent birthrates is due in part to the fact that many teen mothers have older partners, as well as to the underreporting of information about fathers on birth certificates. In 2003 Facts at a Glance (November 2003, http://www.childtrends.org/Files/FAAG2003.pdf), Child Trends reports that 38% of births to mothers aged eighteen and younger were to fathers four or more years older than the mother. In some cases teen mothers have been sexually abused by their older partners.

Such studies alert officials who design programs for the prevention of pregnancy and STDs to the need to pay attention not only to preadolescent and adolescent males but also to older males who are partners of teenage girls. Because these men are typically out of the public school system, officials agree that programs must be broader in scope.

TEEN ABORTION

The CDC reports that in 2003, 848,000 abortions were performed; the year before, 854,000 had been performed. (See Table 5.4.) The Alan Guttmacher Institute conducted a survey and estimated that a much higher number of abortions had been performed in 2003—almost 1.3 million. As Table 5.4 shows, the rate of abortions per 100 live births has decreased from a high of 35.9 in 1980 to 24.1 in 2003. Girls under fifteen years old have the highest rate of abortions (83 per 100 live births) followed by teens aged fifteen to nineteen (37.4 per 100 live births). All other age groups have lower rates of abortion. For all age groups, African-Americans have the highest abortion rate of any race or ethnic group (49.1 per 100 live births), followed by Hispanics (22.8 per 100

live births) and whites (16.5 per 100 live births). As Figure 5.3 and Figure 5.4 show, the abortion rates for teens have declined dramatically since the late 1980s, as have the pregnancy and birthrates.

States have varying laws on parental involvement in minors' abortion decisions. In "An Overview of Abortion Laws" (April 1, 2007, http://www.guttmacher.org/statecenter/spibs/spib_OAL.pdf), the Alan Guttmacher Institute reports that sixteen states and the District of Columbia require no parental involvement in minors' abortions. Thirty-five states require some parental involvement: twenty-four require parental consent, and thirteen require parental notification (Oklahoma and Utah require both parental involvement and consent).

HOMOSEXUALITY

Just the Facts about Sexual Orientation and Youth: A Primer for Principals, Educators, and School Personnel (2007, http://www.apa.org/pi/lgbc/publications/justthefacts.html), a pamphlet for school personnel put together by several organizations, including the American Academy of Pediatrics, the American Psychological Association, and the National Education Association, stresses that sexual orientation is one aspect of the identity of adolescents—not a mental disorder. According to the publication, sexual orientation is developed across a lifetime and along a continuum; in other words, teens are not necessarily simply homosexual or heterosexual, but may feel varying degrees of attraction to people of both genders. The pamphlet emphasizes that gay, lesbian, and bisexual adolescents face prejudice and discrimination that negatively affect their educational experiences and emotional and physical health. Their legitimate fear of being hurt as a result of disclosing their sexuality often leads to a feeling of isolation. All these factors account for lesbian, gay, and bisexual adolescents' higher rates of emotional distress, suicide attempts, risky sexual behavior, and substance use. The publication underscores the need for school personnel to be as open and accepting as possible to support these adolescents.

STD AND PREGNANCY PREVENTION PROGRAMS FOR TEENS

Abstinence

In response to the growing concern about out-of-wed-lock births and the threat of AIDS, several national youth organizations and religious groups began campaigns in the early and mid-1990s to encourage teens to sign an abstinence pledge—a promise to abstain from sexual activity until marriage. According to the National Institutes of Health news release "Virginity Pledge Helps Teens Delay Sexual Activity" (January 5, 2001, http://www.nichd.nih.gov/news/releases/virginity.cfm), by 1995, 2.5 million teens had taken the "virginity pledge." Debra Hauser, the vice president of Advocates for Youth, indicates in Five Years of Abstinence-Only-until-Marriage Education: Assessing the Impact (2004, http://www.advocatesforyouth.org/publications/stateevaluations.pdf) that in 1996 the federal government committed $250 million over the next five years to fund state initiatives to promote abstinence as Title V of the Social Security Act. Even though only eleven states made results of their evaluations of the effectiveness of these programs public, Hauser states that Advocates for Youth examined these evaluations and found that the programs "showed few short-term benefits and no lasting, positive impact…. No program was able to demonstrate a positive impact on sexual behavior over time."

The Bush administration placed a new stress on abstinence among teens. According to the White House report Working toward Independence (February 2002, http://www.whitehouse.gov/news/releases/2002/02/welfare-reform-announcement-book.pdf), an overview of President George W. Bush's suggested plan for welfare reform, "the goal of Federal policy should be to emphasize abstinence as the only certain way to avoid both unintended pregnancies and STDs." According to the HHS's 2008 Budget in Brief (2007, http://www.hhs.gov/budget/08budget/2008BudgetInBrief.pdf), $191 million was allocated for abstinence education in fiscal year 2008, an increase of $28 million over fiscal year 2007.

Regardless, the CDC finds that in 2005 approximately one-third of high school students (33.9%) were sexually active at the time of being surveyed—34.6% of females and 33.3% of males. (See Table 5.1.) Younger students were less likely to be currently sexually active than were older students. However, almost half of all students (46.8%) had ever had sexual intercourse; 63.1% of high school seniors had.

In this context, abstinence-only education will do little to prevent teen pregnancy or the spread of STDs. As John S. Santelli et al. state, in "Abstinence and Abstinence-Only Education: A Review of U.S. Policies and Program" (Journal of Adolescent Health, January 2006), "Although abstinence is a healthy behavioral option for teens, abstinence as a sole option for adolescents is scientifically and ethically problematic…. We believe that abstinence-only education programs, as defined by federal funding requirements, are morally problematic, by withholding information and promoting questionable and inaccurate opinions. Abstinence-only programs threaten fundamental human rights to health, information, and life."

Sex and STD/HIV Education in Schools

As of July 2007, thirty-five states and the District of Columbia required schools to provide education on HIV/AIDS and other STDs, although in all cases parents were allowed to remove their children from sex education classes. (See Table 5.5.) Twenty-two states required schools to stress the importance of abstinence in STD and HIV/AIDS education, and ten states required abstinence to be covered. Fourteen states required schools to teach students about contraception, but none required that it be stressed.

According to the CDC, in "Youth Risk Behavior Surveillance—United States, 2005" (Morbidity and Mortality Weekly Report, June 9, 2006), 87.9% of all students were taught about AIDS or HIV in school in 2005, compared with 91.5% in 1997. As HIV/AIDS is increasingly common among young people, the declining percentages of students who learn about the disease in school is problematic.

chapter 7
TEEN SEXUALITY AND PREGNANCY

EARLY SEXUAL ACTIVITY

The Centers for Disease Control and Prevention (CDC) reported in its 2003 Youth Risk Behavior Survey that almost half of high school students (46.7%) had had sexual intercourse, down from the 54% who were reported as sexually active in 1991. (See Table 7.1 and Figure 7.1.) Almost one in seven (14.2%) had had sex with four or more partners. Girls (45.3%) were slightly less likely than boys (48%) to have had intercourse, and African-American students (67.3%) were more likely than Hispanics (51.4%) or white students (41.8%) to be sexually active.

The proportion of students who had intercourse rose with age; 27.9% of ninth graders, 43.1% of tenth graders, 53.1% of eleventh graders, and 62.3% of twelfth graders had had intercourse at the time of the survey. (See Table 7.1.) Many youth were sexually active before age thirteen; 7.4% had had intercourse at age twelve or younger.

Risk Factors for Early Sexual Activity

In "Early Adolescent Sexual Activity: A Developmental Study," Les B. Whitbeck and his colleagues noted that "the main predictors of early intercourse were age, association with delinquent peers, alcohol use, opportunity, and sexually permissive attitudes" (Journal of Marriage and the Family, November 1999). Family conflict has also been linked to early sexual activity among poor urban African-American adolescents (Cami K. McBride et al., "Individual and Familial Influences on the Onset of Sexual Intercourse among Urban African American Adolescents," Journal of Consulting and Clinical Psychology, February 2003). Another study of poor African-American children found that those who reported high levels of monitoring from parents were less likely to have sex before adolescence (at age ten or earlier) and had lower rates of sexual initiation in their teen years as well (D. Romer et al., "Parental Influences on Adolescent Sexual Behavior in High Poverty Settings," Archives of Pediatrics and Adolescent Medicine, 1999). A 2004 study of inner-city seventh graders found that peer norms about refraining from sex were strongly correlated with seventh and eighth graders abstaining; drug or alcohol use, on the other hand, increased the risk of early sexual activity (John S. Santelli et al., "Initiation of Sexual Intercourse among Middle School Adolescents: The Influence of Psychosocial Factors," Journal of Adolescent Health, vol. 34, March 2004).

Reasons Given for Not Delaying Sex

A number of studies have reported that both sexes consider social pressure the major factor in engaging in early sexual activity. Peer pressure and a belief that "everyone is doing it" have often been cited as explanations. But a recent study found that most female adolescents (78% of the studied group) felt that they had been "too young" at their first sexual experience (Sian Cotton et al., "Adolescent Girls' Perceptions of the Timing of Their Sexual Initiation: 'Too Young' or 'Just Right'?" Journal of Adolescent Health, vol. 34, May 2004).

Figure 7.2 shows that in the 1990s both adults and teens overestimated the percent of teens who were sexually experienced by age fifteen. In addition, some more recent research has challenged the theory that social pressure is the strongest influence on teenagers' sexual decisions. A survey commissioned by Students Against Destructive Decisions (SADD) and the Liberty Mutual Group in January 2002 (Teens Today) asked students in grades six through twelve what factors had most influenced their decisions about sexuality. The most common reasons teenagers gave were to feel good, to have fun, and to please one's partner. The most commonly mentioned reasons not to have sex were fear of pregnancy, fear of sexually transmitted diseases, and not being in a relationship or in love.

The Media and Teen Concepts of Sexuality

In February 2003 the Kaiser Family Foundation released the results of its latest biennial study of sexual

TABLE 7.1

messages on television (Dale Kunkel et al., Sex on TV 3: Content and Context). Of the twenty shows most popular with teenagers during the 2000–01 television season, five out of every six episodes (83%) included some sexual content, as compared with the average of 64% for television programs overall. One-fifth (20%) of the episodes reviewed included a portrayal of sexual intercourse, but nearly half (45%) of those included a reference to sexual risk or responsibility. The study's authors noted that while "the effect of viewing sexual content is not thought to be direct and powerful, with a single exposure to a particular program leading a viewer to think or act in any given way," television clearly does influence teenagers' decisions about sex, or their "sexual socialization."

Sexual Activity and Substance Use

Over the years, a number of studies have suggested a link between substance use and sexual activity. Researchers have found that both sexual activity and a history of multiple partners correlated with some use of drugs, alcohol, and cigarettes. However, the 2003 Youth Risk Behavior Survey found that among sexually active students, only one-fourth (25.4%) reported they had used alcohol or drugs at the time of their last sexual experience. (See Table 7.2.) Males (29.8%) were more likely than females (21%) to report this behavior; African-Americans (19.5%) were somewhat less likely than Hispanics (24.1%) or whites (26.8%) to report using alcohol or drugs during sexual activity.

A 2002 report in the Journal of Adolescent Health (J. Guo et al., "Developmental Relationships between Adolescent Substance Use and Risky Sexual Behavior in Young Adulthood," vol. 31, no. 4) noted a link between adolescent binge drinking and marijuana use and risky sexual behavior. Young people who used marijuana or binge drank in high school were more likely at age twenty-one to have had more sexual partners and to use condoms inconsistently.

In Substance Abuse and Risky Sexual Behavior (February 2002), the Kaiser Family Foundation reported on a

FIGURE 7.1

survey of almost a thousand teens and young adults from November 2001 through January 2002. More than a quarter (29%) of sexually active fifteen- to seventeen-year olds surveyed said that alcohol or drugs had influenced their sexual decisions. (See Figure 7.3.) More than one in ten (12%) sexually active fifteen- to seventeen-year-olds reported having had unprotected sex while under the influence of drugs or alcohol. Two out of five of these (41%) said their peers drank or used drugs before having sex "a lot" of the time.

voluntary and nonvoluntary experiences. The 1995 National Survey of Family Growth asked women whether their first sexual experience was voluntary. Nearly one out of every ten women ages fifteen to twenty-four (9%) reported that their first premarital inter-course was nonvoluntary (reported as either "not voluntary" or "rape"). The first experience for 24% of females who had sexual intercourse by age fourteen was described as not voluntary, compared with 10% of women whose first sexual experience occurred at nineteen to twenty-four years of age (Family Planning Perspectives, January/February 1998). Frequently these girls were coerced into having unwanted relations by a date. Other girls were raped, either by an acquaintance or a family member.

Additionally, in a study of four thousand high school students, almost a third of the girls (30.2%) and a tenth of the boys (9.3%) reported having been sexually abused. Sexually abused females were twice as likely to engage in early sexual intercourse and other risky sexual behaviors as girls who had not been abused (A. Raj et al., "The Relationship between Sexual Abuse and Sexual Risk among High School Students: Findings from the 1997 Massachusetts Youth Risk Behavior Survey," Maternal and Child

FIGURE 7.2

Health Journal, vol. 4, 2000). A study published in 2004 corroborated evidence of the increased sexual risks taken by sexually abused youth (Elizabeth M. Saewyc et al., "Teenage Pregnancy and Associated Risk Behaviors among Sexually Abused Adolescents," Perspectives on Sexual and Reproductive Health, vol. 26, May/June 2004).

Moreover, according to Child Trends, a Washington, D.C.-based nonprofit research organization dedicated to improving the lives of children, early sexual initiation for teenage girls has been linked to a higher risk of becoming the victim of rape or sexual assault at some later time during their adolescence. The October 1997 publication Facts at a Glance indicated that more than half (54%) of females fourteen or younger at first sexual intercourse reported experiencing non-voluntary sex at some point during their teen years. Early sexual initiation has also been linked to domestic violence and verbal abuse later in life (Vaughn I. Rickert, "The Relationship among Demographics, Reproductive Characteristics, and Intimate Partner Violence," American Journal of Obstetrics and Gynecology, October 2002) and to depression and low self-esteem (B. C. Miller, B. H. Monson, and M. C. Norton, "The Effects of Forced Sexual Intercourse on White Female Adolescents," Child Abuse and Neglect, vol. 19, 1995).

CONTRACEPTIVE USE

Too Few Use Contraceptives

In its 2003 Youth Risk Behavior Survey the CDC found that almost two-thirds of sexually active teenagers (63%)

TABLE 7.2

reported that they or their partners used condoms during their last sexual intercourse, up from 46.2% in 1991, when the CDC began tracking condom use. (See Table 7.1.) Young African-Americans reported the highest condom use (72.8%) among sexually active youth, up from 48% in 1991. Hispanic students reported the lowest rate of condom use (57.4%), but this was still significantly higher than the 1991 rate of 37.4%. Males (68.8%) were significantly more likely than females (57.4%) to report condom use. The use of condoms decreased from the ninth grade (69%) to the twelfth grade (57.4%), a period during which the frequency of sexual intercourse increased.

Among sexually active students nationwide in 2003, 17% reported they or their partners used birth control pills ("the Pill") prior to their last sexual intercourse. (See Table 7.1.) More white students (22.3%) reported using birth control pills than either Hispanic (11.2%) or African-American students (7.9%). This disparity may be due to the need for a prescription for birth control pills; white students tend to have greater access to medical care than minority students do. Birth control pill use increased between ninth (8.7%) and twelfth grade (22.6%).

A Decade of Tracking Teen Condom Use

CDC researchers noted in 2002 that an increase in condom use among teenagers at last intercourse from 1991 to 2001 was mirrored by a decrease in the percentages of high school students who had ever had intercourse or who had had multiple sex partners. Such safer sexual behaviors in turn corresponded to a decrease in gonorrhea, pregnancy, and birth rates among adolescents. The

FIGURE 7.3

CDC added that these "improvements in health outcomes probably resulted from the combined efforts of parents and families, schools, community organizations that serve young persons, healthcare providers, religious organizations

FIGURE 7.4

the media, and government agencies to reduce sexual risks among young persons."

Reasons for Use or Nonuse

Research indicates that adolescents' attitudes and beliefs about condoms determine whether or not they will use them. In 2000 the Henry J. Kaiser Family Foundation joined together with Seventeen magazine on a campaign called SexSmarts, which was designed "to provide young people with information and resources on sexual health issues." As part of the program, a survey of 519 teens ages twelve to seventeen was conducted in September 2000 on safe sex, including condoms and the Pill. Students were asked how important various factors were in choosing a method of birth control or protection. The three highest-ranking factors were pregnancy prevention (92%), HIV/AIDS and sexually transmitted disease prevention (88%), and "what my partner wants to use" (83%).

The survey also showed that teens did not completely understand the importance of using condoms consistently to avoid sexually transmitted diseases including HIV/AIDS. Eleven percent agreed with the statement "having sex without a condom every now and then is not that big of a deal," and 9% believed that "if you don't have a lot of partners you don't need to use condoms." More than one in five teens (22%) and one in four teenage females (25%) agreed with the statement "condoms break so often they are not worth using."

SEXUALLY TRANSMITTED DISEASES

Adolescents and young adults have a higher risk of acquiring sexually transmitted diseases (STDs) than older adults. Female adolescents may have an increased susceptibility to chlamydia, a bacterial infection that can cause pelvic inflammatory disease and is a contributing factor in the transmission of HIV. In 2002 chlamydia was the most common sexually transmitted disease among adolescents. It was also more common in adolescents than in any other age group, with 2,619.1 cases among every one hundred thousand fifteen- to nineteen-year-old girls. This group also had the highest rates of gonorrhea infection, although the rate of gonorrhea among fifteen- to nineteen-year-olds had decreased from 542.4 per one hundred thousand in 1998 to 476.4 per one hundred thousand in 2002. Syphilis was far less common in teens, with only 2.3 cases per one hundred thousand reported in 2000. As Figure 7.4 shows, African-American non-Hispanic teens had much higher rates of STDs than white non-Hispanic teens.

A 2004 study emphasized that half of all new HIV infections in the United States are diagnosed in people under twenty-five years old (Kathleen J. Sikkema et al., "HIV Risk Behavior among Ethnically Diverse Adolescents Living in Low-Income Housing Developments," Journal of Adolescent Health, vol. 35, 2004). Most of these young people become infected through sexual activity. The authors found that the risk of HIV infection was highest among older adolescents who believed their partners did not see a need to practice safer sex and among teens who abused drugs and alcohol. The researchers suggested that study results could be used to design prevention programs for those adolescents most at risk.

Another 2004 study in Archives of Pediatrics and Adolescent Medicine tested whether parental involvement had any impact on rates of STDs among low-income African-American adolescent girls (J. A. Bettinger et al., "Does Parental Involvement Predict New Sexually Transmitted Diseases in Female Adolescents?"). Researchers found that when these high-risk teens perceived their parents as exercising a high degree of supervision over their activities, they had lower rates of both gonorrhea and chlamydia infection.

TEEN CHILDBEARING TRENDS

The 2003 Youth Risk Behavior Survey found that 4.2% of students had been pregnant or had gotten someone pregnant. (See Table 7.1.) African-Americans (9.1%) were more likely than Hispanics (6.4%) or whites (2.3%) to have been pregnant or gotten someone pregnant. Pregnancy reports increased with grade level, with 2.6% of ninth graders and 6.2% of twelfth graders reporting having been pregnant or gotten someone pregnant.

Teen Birth Rate Falling

The National Center for Health Statistics (NCHS) reported that birth rates among American girls aged fifteen to nineteen dropped from 61.8 per one thousand girls in 1991 to 43 per one thousand in 2002. (See Figure 7.5.) A 2004 report, "Can Changes in Sexual Behaviors among High School Students Explain the Decline in Teen Pregnancy Rates in the 1990s?" in the Journal of Adolescent Health (August 2004), found that both later ages at first intercourse and improved contraceptive practice contributed equally to the decline in pregnancy rates over the period.

Available data by race show that the greatest percentage decline in births between 1991 and 2002 was among African-American teens ages fifteen to nineteen, down from 118.2 births per one thousand in 1991 to 68.3 in 2002, although the 2002 rate remains high. (See Figure 7.6.) The Hispanic rate in that age group in 2002 was even higher (83.4 births per one thousand), even though it had declined from the 1991 rate of 104.6. Non-Hispanic white teens fifteen to nineteen years old had a birth rate of 28.5 in 2002, down from 43.4 in 1991. The rate for Native American teens dropped from 84.1 in 1991 to 53.8 in 2002, and for Asian/Pacific Islander teens, from 27.3 in 1991 to 18.3 in 2002.

Trends in Marital and Nonmarital Births

According to the CDC, the number of marital births (babies born to parents married to each other) dropped dramatically during the 1980s, while the number of non-marital (out-of-wedlock) births rose steadily to a record high of 44.1 per one thousand unmarried women in 2000. That rate dropped to 43.7 births per one thousand unmarried women in 2002.

The rate of nonmarital births among teens has risen dramatically. In 1960 15.3 babies were born to every one thousand unmarried fifteen- to nineteen-year-olds. In 1994 that rate had risen to 46.9 births per one thousand before declining to 35.4 in 2002. However, births to unmarried teens have risen even more sharply when taken

FIGURE 7.5

as a percentage of all births to teenage women. Among teenage mothers fifteen to nineteen years old, the proportion of nonmarital births rose from 14.8% of all teen births in 1960 to 80% in 2002. Since the mid-1980s the majority of births to teens at every age have occurred outside of marriage.

Health Consequences for Teen Mothers and Their Children

Teenage mothers and their babies face more health risks than older women and their children. Teenagers who become pregnant are more likely than older women to be anemic and malnourished and to suffer from pregnancy induced hypertension and eclampsia (a life-threatening condition that sometimes results in convulsions and/or coma). An immature pelvis can cause prolonged or difficult labor, possibly resulting in bladder or bowel damage to the mother, infant brain damage, or even death of mother

FIGURE 7.6

and/or child. CDC data show that in nearly one-third of live births to women under twenty in 1997, the mother received delayed (30.2%) or no (2.1%) prenatal care. Poor prenatal care can increase the risk of undetected complications of pregnancy that can lead to illness and/or death.

While most health risks are similar for children born to teenage and older mothers, teenage mothers may have a higher prevalence of certain risk factors. According to the CDC, for example, teenagers had the highest rates of smoking during pregnancy (17.5% for those ages fifteen to nineteen) of all pregnant women (12.3% among all ages) over the period 1990–99, and smokers were nearly twice as likely to have low-birthweight babies as nonsmokers. Researchers have also found that babies born to adolescents have a greater risk of dying between one and twelve months after birth (M. Klitsch, "Youngest Mothers' Infants Have Greatly Elevated Risk of Dying by Age One," Perspectives on Sexual and Reproductive Health, vol. 35, January-February 2003).

Consequences of Early Motherhood

Few teenage mothers are ready for the emotional, psychological, and financial responsibilities and challenges of parenthood. Becoming a parent at a young age usually cuts short a teenage mother's education, limiting her ability to support herself and her child. According to an article in Family Planning Perspectives (Sandra L. Hofferth, "The Effects of Early Childbearing on Schooling Over Time," November-December 2001), women who gave birth as teens in the early 1990s had only a 65% probability of graduating from high school, and only a 29% probability of completing some college. Another Family Planning Perspectives report in the same issue (Susheela Singh et al., "Socioeconomic Disadvantage and Adolescent Women's Sexual and Reproductive Behavior: The Case of Five Developed Countries") noted that 40% of American women ages twenty to twenty-four who gave birth before age twenty had an income of less than 149% of the federal poverty guideline.

In 1996 President Bill Clinton signed into law the Personal Responsibility and Work Opportunity Reconciliation Act (PL 104–193), which abolished the sixty-yearold Aid to Families with Dependent Children (AFDC) program and created the Temporary Assistance for Needy Families (TANF) block grant program. In order to be eligible for TANF benefits, unmarried minor parents are required to remain in high school or its equivalent and to live with a parent or in an adult-supervised setting. One provision in the law allows for the creation of second-chance homes for teen parents and their children. These homes require that all residents either enroll in school or participate in a job-training program. They also provide parenting and life-skills classes, as well as counseling and support services.

ADOLESCENT AND NONADOLESCENT FATHERS

Adolescent fathers were more likely than their childless peers to perform poorly in school, to drop out, to have few financial resources, and to have poor employment prospects. They were more likely than teen mothers to have more than one child and less likely to have an ongoing relationship with the mother of the first child.

In 2002 fifteen- to nineteen-year-old males had a birth rate of 17.4 per one thousand males in the age group, down from a high of 24.7 in 1991. This rate was substantially lower than the rate for teenage girls of 43 per one thousand. The rate was higher for African-American teens (33.3) than for white teens (14.8). The data suggest that many teen mothers had older partners (National Vital Statistics Reports, vol. 52, no. 10, December 17, 2003). In "Adolescent Pregnancy—Current Trends and Issues: 1998" (Pediatrics, 1999), the American Academy of Pediatrics Committee on Adolescence reported that nearly two-thirds of teen mothers had partners older than twenty. In its publication 2003 Facts at a Glance, the organization Child Trends reported that 38% of births to mothers age eighteen and younger were to fathers four or more years older than the mother. In some cases teen mothers have been sexually abused by their older partners.

Such studies have alerted officials who design programs for the prevention of pregnancy and STDs to the need to pay attention not only to preadolescent and adolescent males, but also to older males who are partners of teenage girls. Because these men are typically out of the public school system, officials agree that programs must be broader in scope.

TEEN ABORTION

According to an article in Perspectives on Sexual and Reproductive Health, 1,313,300 legal induced abortions were performed in 2000, representing an 11% reduction in the abortion rate since 1994. About 18.6% of those legal abortions were performed on women under the age of twenty. (See Table 7.3.) Although the number of abortions for U.S. teens rose from 1975 to 1980, the number has decreased dramatically since 1988. (See Figure 7.7.)

In 2000 the overall abortion ratio (number of abortions per one thousand live births) was 232. The younger the pregnant woman, the higher the abortion ratio. (See Figure 7.8.) Although less than 1% of all abortions were obtained by teenagers younger than fifteen years of age, their abortion ratio (708 per one thousand live births) was the highest. This finding shows that while the actual number of abortions in this age group was small, a significantly large proportion of adolescents younger than fifteen who got pregnant chose abortion. Women ages fifteen to nineteen and women over age forty had the next highest ratios of abortions to live births. Since not all states require reporting the age of women who obtain legal abortions, however, complete data for adolescents are not available.

States have varying laws on parental involvement in minors' abortion decisions. According to the Alan Guttmacher Institute, as of July 1, 2004, seventeen states and the District of Columbia required no parental involvement in minors' abortions. Thirty-three states required some parental involvement; nineteen required parental consent and fourteen required parental notification. All of these states except Utah have an alternative judicial process for minors seeking an abortion.

HOMOSEXUALITY

Just the Facts about Sexual Orientation and Youth, a pamphlet for school personnel put together by several organizations, including the American Academy of Pediatrics,

FIGURE 7.7

FIGURE 7.8

the American Psychological Association, and the National Education Association, stressed that sexual orientation is one aspect of the identity of adolescents—not a mental disorder. According to the publication, sexual orientation is developed across a lifetime and along a continuum; in other words, teens are not necessarily simply homosexual or heterosexual, but may feel varying degrees of attraction to people of both genders. The pamphlet stressed that gay, lesbian,

TABLE 7.3

and bisexual adolescents face prejudice and discrimination that negatively affect their educational experiences and emotional and physical health. Their legitimate fear of being hurt as a result of disclosing their sexuality often leads to a feeling of isolation. All of these factors account for lesbian, gay, and bisexual adolescents' higher rates of emotional distress, suicide attempts, risky sexual behavior, and substance use. The authors stress the need for school personnel to be as open and accepting as possible in order to support these adolescents.

STD AND PREGNANCY PREVENTION PROGRAMS FOR TEENS

Abstinence

In response to the growing concern about out-of-wedlock births and the threat of AIDS, several national youth organizations and religious groups began campaigns in the early and mid-1990s to encourage teens to sign an abstinence pledge—a promise to abstain from sexual activity until marriage. In January 2001 researchers at Columbia and Yale universities released a study finding that by 1995 2.5 million teens (10% of adolescent boys and 16% of girls) had taken a "virginity pledge" ("Virginity Pledge Helps Teens Delay Sexual Activity," National Institutes of Health News Release, January 5, 2001). The analysis showed that, on average, teens who took the pledge delayed having sex about one-third longer than teens who had not pledged. However, the effectiveness of pledging depended on the student's age. Among teens aged eighteen and older, pledging had no effect. Among sixteen and seventeen year olds, pledgers delayed sex about eighteen months longer than those who did not pledge. Among the youngest teens, the effect of pledging depended on the social environment of the teen's school.