Pregnancy Prevention and Sexual Health Education: Considering the Complex Needs of Teens in Foster Care
May is National Teen Pregnancy Prevention Month and there is no better time to talk about the complex landscape of sexual and reproductive health for teens. Pregnancy in adolescence can create challenges for youth, including delays in education, fewer job opportunities and decreased familial, social and economic stability. These challenges are often even greater for teenagers who are involved in the foster care system.
Exploring one's sexuality and navigating intimate interpersonal relationships is a developmentally appropriate aspect of later adolescence and emerging adulthood. Further, what exploration and navigation is developmentally appropriate for an 11 year old will rarely be appropriate for a 17 year old. The balance between delaying the age that someone is first sexually active or becomes pregnant and recognizing the role of healthy sexual development and exploration are often framed as being in direct conflict with one another. But by pathologizing sexuality exploration and expression with a sole focus on risk reduction and problem behaviors, we miss the opportunity to empower youth to make safe and healthy decisions. The significance of this missed opportunity may be even more relevant for marginalized and under-resourced groups, including teens who are involved in the foster care system.
While overall teen pregnancy rates have been decreasing, the same is not true for youth in the foster care system. Adolescent women involved in foster care are more than twice as likely to get pregnant than their non-system-involved peers, and many of these women have another pregnancy before age 19. Approximately 30 percent of youth in care have been pregnant more than once, and one-third of youth in care give birth before the age of 16. In fact, an alarming 20 percent of youth in foster care report having consensual sex for the first time before the age of 13, compared to 8 percent of their non-system-involved peers.
Two Big Issues for Youth in Foster Care: Trauma and Transience
Youth in the foster care system often experience high rates of trauma and adversity. There is clear evidence of the negative impact that early, chronic, traumatic stress can have on decreased health and wellness in adulthood. These adverse childhood experiences can also influence sexual health and decision-making. The more exposure to adversity and trauma an individual has early in life, the more likely they are to experience a pregnancy in adolescence. Many young women entering pregnancy and motherhood early are doing so while also experiencing physical and behavioral health challenges—health challenges that often relate directly to trauma-exposure. An awareness of the role that trauma might play in a young person's life is critical to providing them with appropriate and comprehensive support services. However, we must ensure that trauma awareness is followed by a focus on resilience if we are to truly support all youth.
Adding another layer of vulnerability for youth in foster care are the frequent changes, transience and resulting instability of placements within the foster care system. Over a one and a half year period, it is possible that an individual may have as many as 15 different foster placements, meaning they’re moving from school to school and not receiving consistent sexual and reproductive health education. Stable parent-teen relationships, family connectivity and stability are protective factors for delaying adolescent sexual activity and pregnancy. For youth in the foster care system, these protective factors are often absent.
The Current State of Sexual Health Education in the United States
While there is consensus that being sexually active or becoming pregnant before the age of 13 is problematic, there is less agreement on how best to support youth in their quest to safely arrive at adulthood. The literature supports the concept that comprehensive, evidence-based, medically-accurate, developmentally appropriate, trauma-informed, empowerment-focused sexual and reproductive health programs provide youth with the range of tools they need to make informed decisions and maintain their health and safety. This includes information about sexually transmitted diseases, the full range of available contraceptive options, education around navigating healthy relationships and risk reduction.
The terms "sexual risk reduction and avoidance" are often affiliated with an exclusive focus on cessation, which promotes elimination of all sexual activity in adolescence. The singular focus in messaging proves problematic for many adolescents, particularly those with experience in foster care. Youth who have experienced adversity, particularly in the context of familial disruption with placement in the foster care system, often have ambivalence around pregnancy and parenting. They may seek to recreate their own families or see sexual activity and parenthood as a way to more swiftly enter into adulthood. They may also seek to build close relationships with partners, via sexual intimacy, to account for an absence of other close, healthy relationships. Narrow messaging focused solely on abstinence without also equipping young people with the tools needed to navigate the complexity of the adolescent landscape does youth a disservice. For adolescents in foster care and those who have experienced trauma and adversity, the disservice may contribute to disparities in health outcomes.
Federal Funding for Sexual and Reproductive Education and Prevention Programming
In recent weeks, there have been multiple judicial decisions petitioning the U.S. Department of Health and Human Services’ (HHS) decision to prematurely terminate grant funding for the Teen Pregnancy Prevention Programming. The TPPP program, a national program focusing on pregnancy prevention that has largely enjoyed bipartisan support in the past, has been credited with a reduction in rates of unwanted pregnancies in the past decade. The U.S. District Court for the State of Maryland obtained a favorable court ruling, which will prevent the HHS from prematurely terminating grant funding. At present, it appears that grant funding will remain in place.
Federal funding devoted to evidence-based, medically accurate, developmentally appropriate sexual health education, TPPP and reproductive health services that are guided by science are essential in ensuring equitable health outcomes for all youth. For foster care-involved youth, who may experience higher rates of pregnancy, have more children, be younger when they become sexually active and experience greater rates of trauma and transience, equitable access to sexual health education must be a national priority. Supporting healthy and positive sexuality development and equipping youth with the knowledge they need to engage in sound decision making and navigate intimate relationships is essential for all young people, especially those who are most vulnerable.
Kirby Wycoff, PsyD, NCSP, is a school psychologist and assistant professor at Worcester State University in Worcester, Massachusetts, where she teaches graduate students in the School Psychology Program. Dr. Wycoff is also earning her Masters of Public Health from Dartmouth College and serves as a Leadership and Education in Adolescent Health (LEAH) Fellow at the Children's Hospital of Philadelphia and the University of Pennsylvania.