Dispensing Birth Control in Public Schools

This article focuses on the controversial practice of dispensing birth control in public schools. Minors' constitutional right to contraception is described. This article explores the way in which the federal government frames teen pregnancy as a public problem with a public policy solution. The differences in state laws governing the practice of dispensing birth control in public schools are described. The history, funding, and scope of school-based health centers is explored. The debate over promoting the Title V abstinence education program versus dispensing birth control in public schools is included.

Keywords Abstinence; American Civil Liberties Union; Birth Control; Comprehensive Sex Education; Public Policy; Public Problems; Public Problem Solving; Public Schools; School-Based Health Centers; Supreme Court; Values

Overview

Adolescents are a population at high risk for pregnancy and sexually transmitted disease. The Guttmacher Institute, a reproductive health advocacy group, reported that in 2008, there were nearly 750,000 pregnancies among women younger than 20 in the United States. The pregnancy rate among women aged 15 to 19 was nearly 68 pregnancies per 1,000 women — a decline of 42 percent from its high of nearly 117 in 1990 (Kost & Henshaw, 2012, p. 2). Researchers associate the decline with teenagers' decision to delay sex and an increase in contraceptive use. Despite declining teen pregnancy rates, the United States still has one of the highest teen pregnancy rates among major industrialized nations. In addition to the high risk and likelihood of pregnancy resulting from sex between teenagers, sexually transmitted diseases are common. In 2003, the American Civil Liberties Union reported that approximately half of all new HIV/AIDS infections in the United States occur in teenagers. In the United States, three million teenagers contract a sexually transmitted disease annually. Possible consequences of sexually transmitted diseases include infertility, infection, and death. Legal and medical advocates argue that limiting students' access to contraceptives puts students at risk for disease and pregnancy.

Society debates the role that public schools should play in dispensing birth control to students. Health and sex education became common in public schools in the 1960s. School-based health clinics began to appear in public schools in the 1970s. Pregnancy and sexually transmitted diseases among teens became recognized as a public problem in the 1970s. The first school-based comprehensive health clinics, which included family planning services, were established in St. Paul, Minnesota, in 1972. Schools began teaching and advocating abstinence decades before discussing and promoting contraception. While state, federal, and church-funded abstinence education programs continue, numerous public schools now dispense contraceptives to sexually active teens. Supporters of the practice of dispensing birth control in the public schools cite studies that illustrate how schools that dispense or prescribe birth control lower their student pregnancy rates significantly. Opponents of the practice of dispensing birth control in the public schools argue that providing birth control to students promotes promiscuity (Ruby, 1986).

In the United States, federal and state governments approach teen pregnancy as a public problem with a public policy solution. When teen pregnancy is recognized as a public problem, birth control becomes official public policy. Government-funded contraceptive programs, in schools, community clinics, and throughout society, provide and promote contraception to avoid unwanted pregnancy and to lower the risk of contracting sexually transmitted diseases. A limited number of school-based health centers dispense birth control, such as condoms, oral contraceptives, patches, and emergency contraceptives, to students. Despite the relationship between dispensing birth control in the public schools and lowered teen pregnancy rates, significant religious, legal, and moral opposition remains against this practice.

The following section provides an overview of minors' constitutional right to contraception. This section serves as a foundation for later discussion of the way in which the federal government frames teen pregnancy as a public problem with a public policy solution. The differences in state laws governing the practice of dispensing birth control in public schools are described. The history, funding, and scope of school-based health centers is explored. The debate over promoting abstinence versus dispensing birth control in public schools is included.

Minors' Constitutional Right to Contraception

The U.S. Supreme Court has ruled that minors do not need to get permission from parents to attain contraceptives. In 1977, the court heard Carey v. Population Services International. In this case, the Supreme Court overturned a New York law that forbade the sale of nonprescription contraceptives to adolescents under 16. The Supreme Court found that both minors and adults have a right to privacy in situations that affect procreation.

In 1983, a U.S. District Court heard Planned Parenthood Association of Utah v. Matheson. In this decision, the U.S. District Court overturned a Utah statute that required parents or guardians to be notified before contraceptives could be dispensed to a minor. The District Court found that the Utah law was unconstitutional in that it infringed on the right of a minor to decide whether to bear children. Minors and adults alike have a constitutionally protected right to determine whether they want to have a child or use contraceptives. Ultimately, the federal government protects the constitutional rights of minors and does not require minors to attain parental consent and notification for contraceptive services. Title X and Medicaid, the two major sources of federal family planning funds in the country, provide contraceptive services to all teens in these programs without parental permission or notification.

Teen Pregnancy as a Public Problem

Teen pregnancy is a religious, ethical, social, and economic problem for stakeholders in society. The financial and social costs of teen pregnancy affect everyone in society. As a result, the federal government treats teen pregnancy as a public problem with a public policy solution. Public problems, such as teen pregnancy, are characterized as undesirable conditions that impinge on a society. All undesirable conditions within society do not become classified as public problems. Citizens and their elected officials establish their public problem agendas based on their levels of tolerance for specific adverse conditions. Theoreticians use decision or choice theory, which studies how real or ideal decision-makers make decisions and how optimal decisions can be reached, to explain how public problems are solved in ideal circumstances. In reality, historical, social, and economic variables make many public problems difficult to solve if not intractable. Declining teen pregnancy rates suggest that teen pregnancy is not an intractable public problem.

The U.S. government addresses public problems, such as teen pregnancy and teen parents, through multiple means and strategies. In government, public administrators and politicians are responsible for solving many types of public problems. A common, generally applied problem-solving or decision-making model includes the following steps:

• Determine whether a problem exists;

• State decisional objectives, alleviations, or solutions;

• Identify the decision apparatus and possible action options;

• Specify alternatives;

• State recommendations;

• Ascertain ways to implement recommendations.

Public problems may be routine, out-of-the-ordinary, small-scale, or large-scale. Teen pregnancy is a large-scale public problem that occurs in each geographic sector of the nation. Systematic decision-making processes may or may not be used in their entirety to solve or alleviate the public problem. Factors influencing the formal adoption and use or a problem-solving process or model include agency or department regulations, personal preference of public administrator, and the variables of the public problem at hand (Hy & Mathews, 1978).

While teen pregnancy rates are declining, the public problem of teen pregnancy still requires multiple types and categories of problem-solving techniques. Problem solving strategies are often situation or condition-specific requiring carefully selected problem-solving strategies and techniques such as the multiple criteria decision making model (MCDM), consensus or group decision making, ethical decision-making, and finance-based or budget-maximizing decision making. The federal government's problem-solving process involves activities such as intergovernmental collaboration, public budgeting, public policy, public education, and regulation (Andranovich, 1995). Important trends in public problem solving include increased community participation in government decision-making and collaborative public decision-making (Irvin, 2004). The political economy of public problems, and closely related public policy, is a long-established area of study and interest. The federal government uses economic tools of analyses to determine the economic effects of public problems and their solutions. The economic problem of teen pregnancy, possibly more than any other factor, drives the federal government to promote contraceptive and abstinence programs and policies in public institutions such as schools.

State Laws & Birth Control in Public Schools

State and federal governments work cooperatively on education and health policy for minors. States differ significantly in their laws and guidelines for sex education, health services, and contraceptives in the public schools. As of 2013, according to the Guttmacher Institute, twenty-one states and the District of Columbia explicitly allowed all minors to receive contraceptive services, and twenty-five states allowed it in limited circumstances ("Minors' access," 2013). The following are examples of state actions to dispense birth control in the public schools as a means to address the problem of teen pregnancy:

• Minnesota: In 1972, Minnesota became the first state to have school-based comprehensive health clinics which included family planning services. In Minneapolis, Minnesota, many high school students can access free contraception directly from clinics at their schools. Prior to 1998, high school students received birth control vouchers that they could redeem for free at community health clinics. The Minneapolis Department of Health and Family Support found that the majority of students did not use the vouchers. In 1998, school-based health clinics, which operate under the assumption that making contraceptives more accessible does not lead to increased sexual activity among adolescents who were not already sexually active, started dispersing birth control directly to students (Ham, 2003).

• Maryland: In the 1970s, Maryland passed a law that allows a minor confidential access to contraception. School clinics in Maryland have been distributing contraceptives on a limited basis since 1988. In 1992, Baltimore public health officials decided to offer Norplant to public school students. The controversial decision was made to address the high rate of teen pregnancy. Baltimore has one of the highest teen-age pregnancy rates in the nation. In Baltimore, one in ten young women, from 15 to 17 years old, gave birth in 1990 (Lewin, 1992).

• New York: In 1986, the New York State Health Department provided funding for eight school-based health clinics. These eight clinics joined the 71 other school-based clinics that were opened in schools around the country in the early 1980s. Two of the eight New York City school-based clinics dispensed birth control to students. The school board allowed the schools to dispense birth control because they recognized that family planning was a part of comprehensive health care. The schools' decision to dispense birth control to students was challenged by the New York Catholic Diocese, United Parents Organization, and African People's Christian Organization. In 1985, the New York City Board of Education banned the distribution of contraceptives at high school health clinics in the city citing the fear of increased promiscuity among students (Ruby, 1986). In 2011, however, a pilot program was launched to distribute morning-after pills and other contraceptives to students in selected schools; parents were given the choice to opt out of having contraceptives made available to their children, but only 1 to 2 percent did so (Hartocollis, 2012).

• Washington: In 1993, Planned Parenthood, in cooperation with the school board, put condom-dispensing machines in Seattle public high schools.

• California: In 2005, Santa Rosa City Board of Education passed a plan to dispense low- to no-cost contraceptives. The Elsie Allen High School clinic was authorized by the school board to prescribe and distribute the contraceptives to students from the entire school district. The school district continues to face strong opposition from religious organizations such as the Eagle Forum of California. The Eagle Forum, a pro-family advocacy organization founded in 1972, is demanding that the Santa Rosa City Board of Education to stop dispensing birth control and teach abstinence education.

• Maine: In 2007, the Portland school board, in cooperation with the Portland Division of Public Health, approved a plan to allow middle-school students to obtain prescription birth control medications without parental notification. The Portland school board is creating independently operated health care centers at middle schools and high schools that provide services such as immunizations, physical checkups, birth-control medications, and counseling for sexually transmitted diseases. The district's three middle schools, which teach kids from 11 to 13 years old, had 17 reported pregnancies among students since 2003. The district saw a need for contraceptives in the school body.

• Virginia: In 2010, the Alexandria school district installed an adolescent health center in T. C. Williams High School with a full-time primary care physician and nurse practitioner; previously, the clinic, which dispenses contraceptives in addition to other health services, had been three blocks down the street. The year before the move, there were 50 pregnancies in the school; the year after the move, there were 35, and the number was set to continue to decline in the 2011–12 school year (Welsh 2012).

Ultimately, state stakeholders, including state governments, school boards, communities, parents, and students, debate whether or not dispensing birth control at public schools promotes sexual activity. These interested stakeholders use their values and mores to determine whether or not contraceptives should be dispensed in their schools.

Applications

School-Based Health Centers

School-based health centers began appearing in public schools in the 1970s. School-based health centers, found in urban, suburban, and rural locations across the country, are generally dedicated to reducing teen pregnancy, incidents of sexually transmitted diseases, and overall student health. In poor or rural locations, school-based health centers may provide primary or preventive medical care for some students. There is debate throughout the United States about the scope of care that school-based health centers should provide their students. Sexually active teenagers may have family planning and contraceptive needs. Who is responsible for helping teens meet those needs? Some states and school boards limit the ability of school-based health centers to distribute contraceptives on school grounds. Some school-based health centers are independent operations and some are sponsored by larger health agencies such as a hospital, medical school, health department, or school system.

Funding sources for school-based health centers include state, federal, and private sectors. Federal money for school-based health centers comes mainly from the maternal and child health block grant program. In some instances, school-based health centers may seek third-party reimbursement from Medicaid. States provide competitive block grants to clinics and school districts as well as funding Maternal and Child Health Block Grant under Title V of the Social Security Act. States have also allocated tobacco taxes to fund school-based health clinics. Increased state funding has been a major factor in the development of school-based health centers over the course of the past decade (Whitman, 1987). Private sources of student health funding come from foundations such as the Robert Wood Johnson Foundation. The foundation created a national grant program, called Making the Grade, to assist states in raising the finances necessary to grow their school-based health centers.

The funding sources of school-based health centers significantly influence a clinic's ability to dispense birth control. For example, in 2007, the Mathis, Texas, school district opened the first school-based health clinic in the coastal bend. The clinic's funding was tied to limitations. The grant that the clinic receives prohibits the clinic from offering family planning services.

School-based health centers are usually have a multidisciplinary staff including nurse practitioners, physicians, and mental health providers. School-based health centers provide a selection of the following types of services: Treatment for chronic and acute illnesses; prescription services; lab tests; sports physicals and general health assessments; vision and hearing screenings; and mental health services. Reproductive health services may include pregnancy testing, HIV/AIDS counseling, sexual transmitted disease testing and treatment, contraceptive counseling, gynecological examinations, pap smears, sexual orientation counseling, contraceptive dispensing, and prenantal care.

Despite the fact that the practice, in some areas, of dispensing birth control in school-based health clinics is decades old, significant opposition and controversy remains. In 1994, a report by the U.S. General Accounting Office (GAO) found that the controversy regarding school-based family planning services limited and hindered the capability of school-based health centers to meet some important health needs. In 2000, approximately 75 percent of school-based health centers, located in middle or high schools, were stripped of the ability to dispense contraceptives. Stakeholders recognize that any increased willingness to allow birth control in the public schools may be related to HIV/AIDS. The prevalence and danger of the HIV/AIDS virus convinced numerous parents and school communities that students needed to be able to protect themselves with readily-available contraceptives. Hundred of student clinics opened in high schools in the 1980s. The Roman Catholic Church, and numerous other religious groups and sects, condemned these clinics and the practice of dispensing birth control to students (Whitman, 1987).

In 1999, the National Assembly on School-Based Health Care (NASBHC) reported that the number of school-based health clinics across the country had grown to 1,135 (Dallard, 2000). Since then, the number of school-based health centers has grown over the following decade to approximately 1,700. The Center for Health and Health Care in School reported that the number of school-based health centers across the country grew from 607 in 1994 to 1,498 in 2002. As of 2002, school-based health centers were located in forty-three states as well as the District of Columbia. The top ten states with the most school-based health centers are New York, California, Arizona, Florida, Connecticut, Massachusetts, Texas, Maryland, Louisiana, and Michigan.

Issues

Promoting Abstinence versus Dispensing Birth Control in Public Schools

Sex education, in some form, is almost universal in U.S. public schools. Schools vary in the scope and content of their sex instruction. Topics of instruction include abstinence, sexually transmitted diseases, birth control, and gaining access to sexually transmitted disease and contraceptive services (Landry, 2003). School districts and communities debate abstinence-only versus comprehensive approaches to sex education. Comprehensive sex education refers to instruction, provided in partnership with parents and teachers, which gives correct, comprehensive, and age appropriate information on human sexuality. It includes risk reduction strategies such as abstinence, contraceptives, and sexually transmitted disease protection. Comprehensive sex education works in concert with other educational programs to promote the steady development of important personal and interpersonal skills (Constantine, 2007).

While the type and scope of sex education provided in the schools would seem a community choice based on values and mores, sex education curriculum and policy is increasingly tied to school funding. The "no sex outside of marriage" policies of public schools in the United States are largely a result of the federal Title V abstinence education program (Lippman, 2000). In 1996, President Bill Clinton's welfare reform package included nationally instituted abstinence-only programs. The Title V abstinence education program was a central part of the original 1996 welfare reform act officially called the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). Title V distributes money to states that adhere to certain requirements such as prohibiting teachers from discussing contraceptive methods and requiring all public school teachers to say that sex is only socially acceptable within marriage.

Despite the control that the Title V abstinence program exerts on sex education in public schools across the country, the federal government does provide funds for all types of sex education and contraception. According to the Heritage Foundation, contraceptive programs are currently supported federally through eight different programs: Medicaid; Temporary Assistance for Needy Families; Title X Family Planning; Indian Health Service funding; the Division of Adolescent School Health of the Centers for Disease Control and Prevention; the Social Services Block Grant; the Community Coalition Partnership Program for the Prevention of Teen Pregnancy; and the Preventive Health and Health Services Block Grant.

Conclusion

In the final analysis, the United States is only one of many industrialized countries debating the role of public schools in student health and family planning. In November 1999, France became the first country to permit public school nurses to dispense post-coital contraception pills. The French Council of State overturned the decision in June 2000. Despite the constitutional right of minors in the United States to make their own family planning decisions in private, stakeholders continue to debate how and when minors should have access to contraceptives.

Terms & Concepts

Abstinence: Refraining from sexual intercourse.

Birth Control: Any method used to prevent pregnancy.

Comprehensive Sex Education: Instruction, provided in partnership with parents and teachers, which gives correct, comprehensive, and age appropriate information on human sexuality. It includes risk reduction strategies such as abstinence, contraceptives, and sexually transmitted disease protection.

Public Policy: The basic policy or set of policies that serve as the foundation for public laws.

Public Problems: Undesirable conditions that impinge on a society.

Public Problem Solving: The approaches and strategies that citizens and their elected representatives undertake to solve or alleviate public problems.

Public Schools: The elementary or secondary school system in the United States supported by public funds.

School-Based Health Centers: Clinics in schools dedicated to reducing teen pregnancy, incidents of sexually transmitted diseases, and overall student health.

Values: Personally and culturally specific moral judgments.

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Suggested Reading

Benda, B., & Corwyn, R. (1999, June). Abstinence and birth control among rural adolescents in impoverished families: A test of theoretical discriminators. Child & Adolescent Social Work Journal, 16, 191-214. Retrieved November 26, 2007 from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=2242915&site=ehost-live

Haley, T., Puskar, K., Terhorst, L., Terry, M., & Charron-Prochownik, D. (2013). Condom use among sexually active rural high school adolescents: Personal, environmental, and behavioral predictors. Journal of School Nursing, 29, 212-224. Retrieved December 17, 2013 from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=87479602

Hansen, H., Stroh, G., & Whitaker, K. (1978). School achievement: Risk factor in teenage pregnancies? American Journal of Public Health, 68, 753-759. Retrieved November 26, 2007 from EBSCO Online Database Business Source Complete. http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=5675224&site=ehost-live

Joyce, T. (1988). The social and economic correlates of pregnancy resolution among adolescents in New York City, by race and ethnicity: A multivariate analysis. American Journal of Public Health, 78, 626-631. Retrieved November 26, 2007 from EBSCO Online Database Business Source Complete. http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=4692902&site=ehost-live

Perry, R. W., Braun, R. A., Cantu, M., Dudovitz, R. N., Sheoran, B., & Chung, P. J. (2014). Associations among text messaging, academic performance, and sexual behaviors of adolescents. Journal Of School Health, 84, 33–39. Retrieved October 3, 2014 from EBSCO Online Database Education Resource Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=92776127