It was a delayed reaction, but the uproar was predictable as news spread that New York City public schools are providing free birth control pills (including Plan B, the so called morning-after pill) to teenagers without their parents’ consent. The program had been running since last year (and parents do have the right to opt out,) but timeliness and accuracy come secondary with stories that have all the ingredients for controversy and moral judgment-flinging: parental rights denied, unnecessary intrusion into the sanctity of the family; medical concerns (some factually incorrect) about the risks and mechanisms of hormonal contraception.
Of course, we rarely hear the reverse arguments: that pregnancy poses a huge burden on government resources; that teenagers have legal rights and protections, too; that the health risk of using birth control pills is surely outweighed by the much greater medical risks of adolescent pregnancy and childbirth; that this latest disproportionate — and even shaming — focus on the sex lives of girls over boys seems more of a piece with recent headlines about “forcible rape.”
Behind the atmospherics, this is an old story: school-based health centers, the vast majority of which provide pregnancy testing, contraceptive counseling and treatment for sexually transmitted infections, numbered more than 1,300 even back in the late 1990s, and teenagers’ have seen steady gains in legal recognition of their privacy rights over the last 30 years. Currently, 21 states and D.C. allow all minors to obtain contraception without parental knowledge and another 25 states allow consent for specified categories of minors, such as those married, already pregnant or a mother, or who meet other conditions.
Granted, it seems like common sense that parents who sign permission slips for Tylenol should have the authority to make serious moral and medical decisions for their own children. Except when they shouldn’t. School-based contraceptive services are designed precisely for the kids who don’t have alternatives at home, including the one-third of American teenagers who receive no information whatsoever about pregnancy prevention. It’s easy to make policy prescriptions based on normative scenarios; it’s the people who fall outside the norm — including kids who have no relationship with their parents, who fear them, who are sexually or physically victimized by them — who need special exceptions. The public health safety net is there for a reason: to protect the most vulnerable.
We can strengthen the safety net for these at-risk kids with a better continuum of care in an environment where they feel safe. In 2006, only 5% of high schools made condoms available, while all 50 states allow minors to consent to treatment services for sexually transmitted infections. If we don’t require consent for treatment, why do we balk at consent for prevention? Interestingly, in one study, school-based health centers operating for more than a decade were twice as likely to provide contraceptive services as newer school-based health clinics. According to the authorities, parents and community members needed time to become comfortable with the health center’s mandate. Trust grew over time, and with it an expanded range of acceptable (and desired) and services. This suggests that open dialogue between schools and families is critical if we want to make a dent in bringing pregnancy rates down.
Public policy rarely comes down to black-and-white solutions; more often, we’re faced with imperfect choices from which we must pick the least sub-optimal. With or without parental consent, many feel that Plan B doesn’t “belong” in schools. But surely neither do pregnant 15-year-olds. Which one do you prefer?