Last week the Centers for Disease Control and Prevention (CDC) released new data which found that fewer babies were born to teens in 2010 than in any year since 1946. The teen birth rate which has been steadily declining for the last two decades (save for an odd blip in 2006) reached an all-time low of 34.3 births per 1,000 women ages 15 to 19. This represents a nine percent decline from just the year before and a 44 percent decline from the peak in 1991 when there were 61.8 births per 1,000 women ages 15 to 19. Moreover, though stark disparities continue to exist between racial and ethnic groups, rates are at an historic low among all racial groups.
The data suggests we averted over 3.4 million additional teen births which would have occurred between 1992 and 2010 had the rates not gone down.
This is good news but while we’re celebrating we also have to be asking ourselves why these rates are coming down, because they are still higher here than in any other industrialized country and there is obviously more work to be done.
The Logic Problem Approach
Sex. Abortion. Parenthood. Power.
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What’s happened here? The initial answer to this question is a simple matter of logic and other data. For the teen birth rate to come down one of two things has to happen: fewer teens get pregnant or more teens who get pregnant have abortions. We know that the teen pregnancy rate is coming down (it is also at a record low as of 2008) and the teen abortion rate is not going up (it is actually down 49 percent since 1988) so the answer to our first question is that fewer teens are getting pregnant.
For fewer teens to get pregnant one of two things has to happen: teens are having less sex or using contraception more effectively. The answer to this one is a little bit of both. Among younger teens 15 to 17 years of age, rates of sexual activity have in fact declined. Teens seem to be choosing to delay sexual intercourse. At the same time, rates of sexual activity among older teens 18 and 19 (who sometimes get forgotten about because their sex lives are less shocking) have remained mostly the same.
For this reason researchers believe that the primary force behind the drop in both teen pregnancy rates and teen birth rates is an increase in the use of contraceptive methods as well the use of more effective methods by teens. One study by economists attributes 35 percent of the decline to less sex and 65 percent to more contraceptives.
While this may not be where we have to stop using logic and data to answer the questions, it is certainly where the answers and even the questions themselves stop being simple. Why are teens having less sex or starting later? Why are they using contraception more? Did the policies we put into place in the last two decades have the desired effect (and if so which ones)? Is sex education working? What role does the economy and the recession have in all of this?
Fewer Young People Are Having Sex
Last year the media jumped all over new data that seemed to suggest more teens were staying “virgins.” This sound bite came from an analysis of the 2006–2008 National Survey of Family Growth (NSFG) data which found that 29 percent of females and 27 percent of males ages 15 to 24 reported never having had sexual contact with another person. This was a small but statistically significant change from 2002 when it was 22 percent for both males and females. While this made for fun headlines, it was a little misleading as the share of never-married teens who had ever had vaginal intercourse in their life (the act we typically, rightly or wrongly, associate with the phrase “losing my virginity”) did not change significantly from 2002.
That said, leading up to 2002 there had been a steady decline in the share of never-married females ages 15 to 19 who had had vaginal intercourse dropping from 51 percent in 1988 to 49 percent in 1995 to 46 percent in 2002. Similarly, for never-married males the percentage that had had vaginal sex dropped from 60 percent in 1988 to 55 percent in 1995 to 45 percent in 2002. Such a drop is echoed by the Youth Risk Behavior Surveillance System (YRBS) which found that 46 percent of high school students reported ever having had sexual intercourse in 2009 compared to 54.1 percent in 1991.
Laura Lindberg, a researcher at the Guttmacher Institute, notes that the changes in sexual behavior are unique to younger teenagers — those 15 to 17. The behavior of 18 and 19-year-olds has not changed. This suggests that teens have chosen to delay sexual intercourse — a message that is in every good comprehensive sexuality curriculum. “There has been no [change] in delaying sex until marriage,” she said.
As Debra Hauser, president of Advocates for Youth puts it, “What we’re really looking at is an increase in the age of initiation, mostly among young men, and a trend that began over 20 years ago.” Hauser points out that declines in teen sex began in the late eighties (before the heyday of the abstinence-only movement) but cautions that there have been no statistically significant declines since 2002. She credits a cultural shift brought about in large part by the AIDS epidemic and notes that there have been a lot of other social changes in the decades since the decline began. For example, as part of the feminist movement and the correlating men’s movement, gender roles became somewhat more flexible for everyone, and men were no longer held to such a strict interpretation of masculinity. This may have had a positive impact on their sexual behavior, allowing them to shed some of the pressure to lose their virginity.
Amy Schalet, a sociologist at the University of Massachusetts‒Amherst, interviewed many young men here and in her native Holland for her book, Not Under My Roof, which compared teen sexuality in both cultures. She feels that young men here are more romantic than they are given credit for and found that many of them were looking for a first experience that they really wanted rather than just for a willing partner.
Hauser agrees that the quality of teen relationships is an important factor that demonstrates young people’s abilities to make responsible decisions. In fact, according to the NSFG 71.9 percent of never-married young women and 56.2 percent of never-married young men ages 15 to 19 had their first experience with a partner with whom they were going steady. Young people in relationships are likely better able to discuss and negotiate sexual behavior and contraception use than those who have sex with an acquaintance or someone they just met.
Elizabeth Schroeder, president of Answer, cautions however, that young men are under a new kind of pressure to prove that they are not gay. Hauser and Schalet both agree. Hauser recalled a focus group a number of years ago during which it became clear just how much of young men’s behavior could be attributed to this kind of social pressure. Young men are constantly considering how to prove that they are not gay to their parents, their peers, and even themselves. And what better way to show it than by having heterosexual sex.
Despite this pressure, young men have been a driving force behind the long-term declines in teen sex. They have also been a driving force behind the increase in contraceptive use.
More Teens Using Contraception
According to the most recent NSFG data, 84 percent of sexually active, never-married female teenagers used contraception at their most recent intercourse. Even more impressive, 93 percent of sexually active, never-married males reported using some method at last intercourse. The most common method for young people is condoms with over 95 percent of sexually active, never-married teenagers reporting having used a condom at some point.
Lindberg points to condoms as key to the long term increase in birth control and the decreases in teen pregnancy and birth that followed. Once again, the HIV epidemic had a tremendous impact. Lindberg says:
“We started talking about HIV and made it more important. We brought boys into the conversation because they need to wear a condom and they’re doing it.”
During this time condoms came out from behind the pharmacy counter. Not only were they now more accessible, they were more acceptable and using condoms became a social expectation. The increase in condom use is certainly impressive. According to the YRBS, in 1991, 53.8 percent of sexually active high school students (defined as those who had had intercourse in the three months prior to the survey) did not use a condom the last time they had sex compared to just 38.9 in 2009, a dramatic increase in reported condom use.
Lindberg says it’s important to look specifically at condom use at first intercourse because there is a great deal of research that shows that young people who use contraception the first time they have sex are more likely to continue using contraception. In fact, Teenagers in the United States, a study based on NSFG data, found that teen females are almost twice as likely to have a birth before reaching age 20 if they did not use a contraceptive method at their first sex. The good news is that use of condom at first intercourse has gone up both over time and in recent years. For example, among sexually active, never-married males this increased from 71 percent in 2002 to 82 percent in 2006–08. Lindberg believes we really did succeed in changing the social norm: “Even if today’s teens aren’t as concerned about HIV—the expectation is that you’re going to use a condom.”
It’s not all about condoms, however, as use of the Pill and other hormonal methods has also increased in both the long and the short term. Pill use rose from 25 percent in 1995 to 34 percent in 2002. In a series of recent articles, economists Melissa Kearney and Phillip Levine, have attempted to use economic modeling and analyses to explain the trends in teen birth. Their analyses suggest that “use of the pill among sexually active teens has the largest effect on the teen birth rate, as compared to use of other forms of contraception.” They go on to say:
“Condom use is also found to be statistically significantly related to a decrease in teen birth rates, but the estimated relationship is about three-quarters (2.64/3.59) the size as that of the pill. This likely reflects the fact that the condom is a less effective method of birth control.”
Schalet notes that in the Netherlands a concerted effort was made to normalize the use of the pill for young woman and routinize the provision of the pill as part of health care for adolescents. On the individual level, this has meant that six in ten young women are on the pill at first intercourse (here it is two in ten). On a societal level it has led to “a sense that we could master unintended pregnancy.”
There have been additional improvements in the use of hormonal methods in recent years. A Guttmacher Institute analysis of NSFG data found that in 2008‒2010 47.5 percent of women who had ever had sex used a hormonal method at last intercourse compared to 37.3 percent in 2006‒2008. Hormonal methods include the pill, the patch, and the ring, as well as injectables and implants— many methods that did not exist in the early 1990s.
Lindberg says that one recent change that may explain these numbers involves new medical guidelines that no longer require young women to have a vaginal exam or pap smear prior to receiving a prescription for hormonal methods. It is easy to imagine these exams serving as a barrier for many young women—those on their parents’ health insurance, those who have no transportation to a family planning provider, or those who get nervous just thinking about stirrups, speculums, and paper gowns, to name a few.
Another important change in medical guidelines involves the use of long-acting reversible contraceptive methods (LARCs) among young women. This term refers to intrauterine devices (IUDs) and contraceptive implants which are among the most effective forms of birth control because of their “insert-em and forget-em” mode of operation. There is essentially no user failure because the user doesn’t have to do anything for between three and ten years. Though these methods were once thought to be unwise for young women and women who had no yet had children, the newest thinking is that they are safe for most women. Last year, the American Congress of Obstetricians and Gynecologists (ACOG) created new guidelines suggesting these methods for young women and adolescents.
The Guttmacher analysis did find an increase in the use of LARC’s between 2006‒08 (1.4 percent of women who had had sex) and 2008‒2010 (4.4 percent). It is too soon to know for sure what impact these changes will have on teen pregnancy and birth rates though some experts expect that they may have already affected subsequent births to teen mothers as post-natal care provides an opportunity for providers to suggest and insert these methods. (In 2008, 19.4 percent of births to teen mothers were second births or higher.)
The availability of new methods to young people and the guidelines making them easier to obtain seem to have had a positive impact on contraceptive use. Another change in accessibility in recent years is the introduction of Medicaid family planning waivers. Twenty-nine states have applied for these waivers which allow them to offer family planning services to low-income women who do not qualify for traditional Medicaid benefits.
Kearney and Levine also compare state data to determine if certain policies have had an impact. They looked at a state’s policies on sex education, state’s acceptance of Title V abstinence-only-until-marriage funds, Medicaid family planning waiver programs, and other aspects of state welfare reform. It is interesting to note that the Medicaid waiver was one of the only policies that their analyses found to affect teen birth rates. Specifically, the researchers concluded that 4 percent of the overall decline in teen birth rates could be attributed to these new state programs.
Most of the experts I spoke to were not surprised by this finding; they agreed that to increase contraceptive use among young people we had to make methods more available and more affordable. This is particularly important when we’re talking about increasing the use of LARCs which, while cost effective over the long run, can require a lot of money upfront —IUDs can be as much as $800 at insertion.
The Role of Education
There was not as much agreement, however, with the implication stemming from Kearney and Levine’s findings on sex education. The economists looked at two decisions on the state level and attempted to measure the impact on teen birth rates.
The first was whether the state took any Title V abstinence-only-until-marriage money and it is not at all surprising that the researchers found this had little impact. Research has consistently found that on an individual level, abstinence-only programs are ineffective at changing attitudes or behaviors among participants. Some of us feared that these programs would have a detrimental impact over time as many provide misinformation and undermine teens’ use of condoms. But as Laura Lindberg said these programs “really did almost nothing.”
To get a sense of the role of comprehensive sexuality education in the state, researchers looked at whether the state mandated any form of sex education and whether it required contraception to be taught. Using these measures, they were unable to find that these programs had made an impact on teen birth rates.
Laura Lindberg says that as always we should approach these policy analyses with caution. “We have to look at which people in which places pick certain policies — the states with more conservative policies have a more conservative population. Whether it’s the policy or the people that make the impact is very hard to distinguish.”
Still, the sexuality educators I talked to were not surprised by this finding. Having a mandate on the books is just a first step. Elizabeth Schroeder explains that mandates give teachers and administrators who may fear controversy a strong place to start when making curriculum decisions but these mandates do not automatically translate into good classroom programs. She also points out that there are things that sexuality education may do that are truly hard to measure. She uses the example of a community that has “awesome self-esteem lessons in grades K-3.” It is logical that these may help set the foundation for young people’s sexual decision-making later in their life but we don’t have the systems in place to quantify that.
Logic also suggests that sex education — both in and out of schools — has played some role in both the decrease in teen sex and the increase use of contraception. Debra Hauser points to the Medicaid waivers: if no one knew they existed, they wouldn’t have helped. Still she says we’re never going to get anywhere if we have to keep fighting, “the belief that providing young people with access and information will cause sexual activity — we are still at this place where we believe umbrellas cause rain.” Almost all of the experts I talked to said we had to get past the disaster-prevention model. Schroeder said: “Until we give as much air time to all of the other issue that are related to sexuality and sexual decision making and relationships, this is going to be an incomplete puzzle.” Schalet added that our conversations around sex have been couched in a “danger discourse” which may have had a detrimental effect. “We have to look at the potential negative outcomes of emphasizing danger. I think it can undermine people’s sense of mastery. If sex is by definition dangerous — it can make people feel that they can’t control the outcome,” she said.
We also have to remember that in the years during which the teen birth rates have been going down the Internet was born and young people now have a new way of accessing information about their sexual health. Schroeder’s organization runs Sex Etc., a website devoted to sexual health that is written by teens for teens. She says that through self-reported data from young people, they’ve seen a significantly positive impact on information and attitudes. The data also shows an increase in the number of teens who see her organization’s site as a credible source of information. Schroeder explains that this has importance beyond just her site because it shows that we are helping young people develop the skills and the savvy both to access information and to assess its value.
It’s the Economy, Stupid
For years there has been a lot of attention paid to the poor outcomes that are commonly faced by young people who become parents while they are still teenagers. We know that teen mothers are less likely to finish school, less likely to get married, and more likely to live in poverty. While many may assume teen parenthood causes poverty, research has found that really it’s the other way around. Kearney and Levine note, in a separate article: “the most rigorous research on the topic has found that teen parenthood has very little if any direct negative economic consequences.” This isn’t good news, however, it is because these young people were already on a “downward economic trajectory” or put another way, stuck in the cycle of poverty.
One need only look at a map of teen birth rates next to one that illustrates poverty in the United States to see the relationship. (Similar maps, by the way, would show the same states to have restrictive policies regarding abstinence-only-until-marriage education and sexuality education, as well as access to contraception and abortion.)
There is a large body of research that suggests that lack of economic opportunity and a sense of hopelessness about the future are at the core of the relationships between poverty and teen parenthood. Kearney and Levine attempt to use economic models to operationalize the notions of “marginalization” and “hopelessness.” They speculate “that the combination of being poor and living in a more unequal (and less mobile) society contributes to a low perception of possible economic success, and hence leads to choices that favor short-term satisfaction—in this case the decision to have a baby while young and unmarried.” They conclude that this is true. They also conclude that income inequality in a geographic area (areas of poverty surrounded by those of wealth) has a large impact on teen births among women of low socioeconomic status. Patricia Quinn, executive director of the Massachusetts Alliance for Teen Pregnancy, put it this way: “You support them in having a viable pathway in opportunity and they will do what they need to protect that opportunity. Absent that opportunity what are they protecting?”
After years of discussing the impact of opportunity, or lack of opportunity, on teen pregnancy and birth rates, I have to confess that I had wondered whether some of the earlier declines reflected the good economic times of the early 2000s and had kind of expected the current recession to cause birth rates to go up. Recessions tend to lower birth rates among all but the oldest women — if they feel they can delay childbirth and wait for more secure times they will. This has been true in recent years. Lindberg says that a Guttmacher survey in the middle of the recession found that women were putting off all major life moves—marriage, childbirth, and migration.
But teens can behave differently than adults when it comes to future planning, and Lindberg had also expected an increase in teen births as economic opportunities went down. She says it’s possible that teens are reacting to the stress in their family situation and to what is happening to their parents. She also says that policies promoting high school graduation and encouraging young people to stay in school may be having an impact.
Kearney and Levine found that the economic downturn actually had little impact on the teen birth rates. They conclude that those teens at highest risk for teen births— those already living in poverty—are not particularly “responsive to short-term labor market conditions.”
A Tale of Two States
Anytime you get good news like a 20-year decline in teen birth rates, the phrase that comes to mind is “that’s great, let’s keep up the good work.” With an issue as complicated as this, however, there are still questions as to what good work we should be continuing. To get some answers, I turned to two women on the front lines. Patricia Quinn who is working in Massachusetts, a state with very low teen birth rates (17.1 per 1,000 young women ages 15 to 19) and Jamie Holcomb Bardwell who is working in Mississippi, the state with the highest teen birth rates in the country (55 per 1,000 young women ages 15 to 19). Both states were among the 16 with the steepest declines since 2007.
Both of them spoke of the need to take a comprehensive approach. Quinn explained that part of the progress made in Massachusetts came simply from an open discourse about the problem. She reminded me of the Gloucester 18 — the group of teens from a fishing community in Massachusetts who got national attention (and became the subject of a Lifetime TV movie) when they apparently made a pact to get pregnant while still in high school. This issue she said put teen pregnancy and prevention on the map and sparked ongoing interest and conversation.
She also says that the state has committed to investing in teen pregnancy prevention and this investment has withstood economic downturns and budget cuts. The state’s interventions focus on providing evidence-based prevention programming as well as making family planning clinics accessible so that even young women who are not on Medicaid can have access to contraception.
Quinn also spoke of the importance of opportunity and a belief in future success and says that teen pregnancy-prevention programs can help young people in other aspect of their lives:
“There is a lot of power in learning to take control of your sexual choices. These are young people learning to take control of their lives in some significant way.”
Bardwell, who is the director of programs at the Women’s Fund of Mississippi, also talked about a multi-pronged approach in her state. Though Mississippi has the highest rate of teen birth in the country, that rate has declined 21 percent since 2007. Bardwell thinks the progress has something to do with the expanded Medicaid waivers and attempts by the Department of Health to make contraception more accessible, though she does say that confidentiality issues are still of great concern to young people, many of whom live in small communities. She says the state is committed to making its services more youth friendly.
Unfortunately, Mississippi has a new sexuality education law that may result in more communities being committed to abstinence-only-until-marriage programs. The new mandate says that by June 30th every school district must choose either an abstinence-plus program or a strict abstinence-only program from a list approved by the state. The abstinence-only list includes Choosing the Best and WAIT Training; two curricula that are based on fear and shame and actively promote numerous gender biases.
Bardwell also focused on the impact of poverty and lack of opportunity as her state has high rates of poverty especially among children. “If both of your parents grew up in poverty — it’s a cycle. A lot of young people simply do not know what is possible. If they knew what is possible they would make certain decisions now to make that happen.”
Both Quinn and Bardwell brought up the need for young people to have adults in their lives who believe in them. Quinn, borrowing a phrase from another educator, said every young person needs at least one adult who is irrationally committed to their success. Bardwell put it this way:
“At the end of the day what you want is for teens to feel loved, and like they have a future in front of them. And that’s the hardest thing especially if they grow up in a family where they don’t hear every day that they are smart and capable and can do anything they want.”
In fact, some teen pregnancy prevention programs really strive to take over this role that might not be filled by parents or other adults in a teen’s life. The Children’s Aid Society’s Carrera Adolescent Pregnancy Prevention Program comes to mind as it gets involved in all aspects of young person’s life in an attempt to prevent teen childbearing.
This program and others like it have been shown to be effective but they are very expensive and require a huge commitment to a small group of teens.
Congratulating Young People
One thing that I found particularly heartening as I was interviewing people for this article was that nearly everyone I spoke to took the time to applaud the young people themselves. Quinn said that she wanted to congratulate young people on “protecting their future.” Debra Hauser started our conversation by saying: “If anyone’s responsible, it’s young people themselves. They deserve the credit for making responsible decisions.”
As I said at the beginning of the article for the teen birth rates to come down (without an increase in abortion rates) one of two things has to happen: fewer teens have to have sex or more sexually active teens have to use contraception effectively. Research suggests that both of these things have happened—and regardless of the policies or the economy, those changes represent laudable decisions made by individual teens. As Hauser put it:
“This is about creating a social contract with young people. If we provide them with the information they need and respect their rights and agency, they will make responsible decisions.”
That said, a lot of the analyses about the declining teen birth rates show the impact of large structural issues in our society—including poverty and vast income inequality. In addition, to providing young people with access to information, education, and reproductive health care it is our responsibility as adults to address the underlying social problems that so dramatically affect the prospects for our teens.