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BIRTH CONTROL ISSUES IN FOSTER CARE
In a perfect world, there is an orderly sequence to life events. As the old saying goes, “First comes love, then comes marriage, and then comes Susie with a baby carriage.” Most of us know that foster care denies the perfect world syndrome. After all, if this was a perfect world, there would be little or no need for foster care. That being said, “Here comes Susie with a reality carriage.” Many teens are sexually active. An even higher percentage of teens in foster care have been exposed to explicit sexual content and/or sexual abuse, thus leading to a high percentage of teens that are or have been sexually active or sexually abused.
A generation ago, the biggest concern for the parents of the sexually active teen was the fear of an unplanned pregnancy. Today, the fears run from the life-long effects of sexually transmitted diseases to the stark reality of acquiring HIV. This article is intended to inform foster parents of the medical advancements in birth control, testing for sexually transmitted diseases, and advances in the prevention of sexually transmitted diseases. Hopefully this article, written in cooperation with a board certified OB-GYN, will help foster parents to discuss the issues with their foster child, their caseworker, and the child’s health care provider.
Honest open communication with a teen is the best prevention that any parent can offer. However, many foster parents may feel that discussing disease prevention, birth control, and sexual topics is tantamount to condoning sexual activity. If a foster parent is not comfortable with discussing the wide range of topics that focus on sexuality activity, the foster parent may opt for discussing abstinence, and working with a health care professional to discuss topics that aren’t abstinence-based. One of the recent ads on television focused the first part of a parent/teen conversation about abstinence, with the second part of the conversation focusing on protecting the child unconditionally. (The conversation somewhat reminded me of the time a year ago when I announced to my mother that I had decided to try skydiving. She was adamantly against the idea and preached abstinence from sky diving. However, when that failed she did indeed want me to read the manual, watch the video, and wear a good parachute.)
That being said, how can a foster parent talk with some comfort level to a teen about sexual activity? It is important for a foster parent to emphasize that having sexual activity is a choice that the teen has control over. A person never has to have sex. Sexual favors are not something that is owed because they bought you dinner, and anyone who is going to break up with you because you won’t sleep with them isn’t someone you should be dating in the first place. It’s a choice to say “yes” to sex, and it’s also choice to say “no”. Likewise, teens need to understand that just because they have been sexually active before, does not mean that they have to continue to be sexually active. Teens also need to hear and understand that their brain is the most important sex organ. A teen needs to be empowered to use their brain to be informed, aware of risk factors, transmission methods, symptoms, and methods of prevention. They can also use their brain and good judgment to pick partners sensibly, and decide on what level of activity is right for them. Foster parents should reinforce that making irresponsible decisions about having sex are heightened with the use of drugs and/or alcohol. It’s difficult to make responsible choices about your sex life if you start out impaired by drugs or alcohol. When teens are under the influence of chemical substances, they are more likely to choose to have sex with someone, and equally less likely to have safe sex. Mixing the possibility of sexual activity and chemical substances can almost certainly lead to irresponsible choices. Talk honestly with your teen about the use of alcohol and drugs as it relates to sexual activity. Teens also need to know about setting their limits with their significant others before their date on Saturday night. It can be very difficult to use the brain once the kissing and petting begins. The heavy petting session is not the time to start thinking about how far you want to go with your partner that evening. Teens need to hear good advice from people that they trust and know have their best interest at heart. Talking openly and honestly to your teen about responsible choices in sexual activity is responsible parenting.
Foster parents and teens need to understand basic information about the transmission of diseases and conception. In a world where information is literally at your fingertips, there is still a great deal of misinformation. Many teens believe that HIV and AIDS are only found in the homosexual population, thus not affecting them. The majority of HIV infections are acquired through HYPERLINK “http://en.wikipedia.org/wiki/Bareback_(sex)” \o “Bareback (sex)” unprotected sexual relations between partners, one of whom has HIV. The primary mode of HIV infection worldwide is through sexual contact between members of the opposite sex, not homosexual activity. Teens need to understand that HYPERLINK “http://en.wikipedia.org/wiki/Condom” \o “Condom” condoms can reduce the chances of infection with HIV and other STDs and the chances of becoming HYPERLINK “http://en.wikipedia.org/wiki/Pregnant” \o “Pregnant” pregnant. The best evidence to date indicates that typical condom use reduces the risk of HYPERLINK “http://en.wikipedia.org/wiki/Heterosexual” \o “Heterosexual” heterosexual HIV transmission by approximately 80% over the long-term. Teens also need to understand that oral contraceptives are effective means to prevent pregnancy, but are not effective in preventing HIV and other STD transmission.
Many teens are aware of AIDS and HIV, but are very limited in knowing about the sexual transmission of herpes and hepatitis. Many teens confuse the two different types of herpes viruses. Genital herpes caused by the herpes simplex virus, is estimated to be present in 20 percent of the general population. The majority of these infected people may be unaware they even have it. Studies show that more than 500,000 Americans are diagnosed with genital herpes each year, and the largest increase is occurring in HYPERLINK “http://www.herpes.com/news.shtml” young teens. There is no cure for herpes to date. Consequently, acquiring herpes as a teen becomes a life long medical problem. Nationwide, 45 million people ages 12 and older, or one out of five of the total adolescent and adult population, is infected with HSV-2. HSV-2 infection is more common in women (approximately one out of four women) than in men (almost one out of five). Most people infected with HSV-2 are not aware of their infection. Most people diagnosed with a primary episode of genital herpes can expect to have several symptomatic recurrences a year, averaging four to five episodes per year. As with protection with AIDS, consistent and correct use of latex condoms is the best protection. However, condoms do not provide complete protection, because a herpes lesion may not be covered by the condom and viral shedding may occur.
Dramatic advancements in the past 10 years have decreased the number of unplanned pregnancies significantly. It is important for a foster parent and caseworker to understand the new advancements and assist in the selection of the available birth control options depending on the special needs of the young lady. The initial visit for birth control does not always require a pelvic exam, if the adolescent is young. As one can imagine the pelvic exam can be a deterrent to many adolescents seeking birth control. Birth control options can now be divided into short acting options and long acting options.
SHORT ACTING OPTIONS
Birth control pills have been the most popular method of contraception for adolescents in the past 20 years. Birth control pills are highly effective when used correctly and consistently. Some brands of the pills contain estrogen and progestin, while some versions contain only progestin. The combination pills have the side effects of headaches, breast tenderness, nausea, missed periods, irregular bleeding, depression and cardiovascular issues. The progestin-only pills have the same side effects coupled with acne, hirsutism, weight gain, depression, and anxiety and are less forgiving of missed or delayed pill taking. The emotional side effects of the progestin-only pills may exacerbate the depression and anxiety that may already exist in some adolescents.
Honest discussions about the possible side effects of the birth control pills can assist the adolescent with finding which combination is best for her. It should be noted, however, adolescents are not always reliable about taking the pills correctly and consistently. Teens with ADHD, teens who have been known to run away or are prone to running away, and/or teens who may be in and out of different foster homes and residential settings have the greatest likelihood of not taking the pills on a consistent basis, thus increasing the chances of an unwanted pregnancy.
Another short acting option for birth control is the transdermal patch, which releases the hormones estrogen and progestin. The patch is applied once a week for three weeks. Week four is patch free. Side effects can include cramps, allergies to the patch, breast tenderness, nausea and cardiovascular problems.
The vaginal ring is another short acting birth control option, but requires pelvic insertion on a monthly basis. The pelvic insertion component makes this form of birth control a less favorite option for most adolescents, but the least frequent application can be a plus and avoids the “missed pills problem.” Vaginal discharge, infection, weight gain, along with nausea and cardiovascular issues are unwanted side effects.
LONGER ACTING OPTIONS
Longer acting options may be a good choice for adolescents in foster care based on their Attention Deficit Hyperactivity Disorder diagnosis, frequent moves from one foster home to another, and special medical issues and the vulnerability of some adolescent females. The progestin-only injection has a high rate of effectiveness and only has to be administered every three months. In addition to the three month coverage, the return to fertility can be delayed on the average 9 to 10 months. The length of coverage and noninvasive application is positive. However, side effects such as irregular bleeding, headache, weight gain, worsening of depression, acne, hirsuitism, dizziness, and slowing of bone growth are side effects to consider with the physician.
An even longer option is the progestin implant that is placed just under the skin. The implant is changed every three years and is considered 99 percent effective. As with most birth control, irregular bleeding, mood swings, weight gain, acne and depression are possible side effects. Contradictions to all hormonal forms of birth control can include liver disease, blood clotting issues, and breast cancer. Intrauterine devices are also long acting options. The Progestin-only intrauterine system can remain in place for five years, while the copper intrauterine device can be in place for 10 years.
Extensive discussion with the doctor, foster parent and caseworkers should take place when looking at the needs of an adolescent who may be non-ambulatory and non-verbal. The high degree of venerability for sexual abuse and hygiene issues need to be discussed and options explored for a foster child with these severe needs.
Foster parents also need to be aware of emergency contraception in the event of sexual abuse, forced sex or other unforeseen circumstances such as missing two or more birth control pills, starting a pill pack two or more days late, a broken condom, or the lack of any birth control. Emergency contraception must be taken within 72 hours of intercourse. The emergency contraception prevents the fertilization and implantation of the egg. Adolescents should understand that this is not a form of regular birth control, but an emergency plan that requires a prescription from a doctor.
Sexually transmitted diseases are a major health issue for adolescents. In fact, adolescents account for more than 25 percent of all new cases of STDs. Chlamydia and gonorrhea are the most prevalent STDs in the adolescent population. The good news in medical advances is that both of these STDs can be detected with a simple urine test, thus eliminating the fear of an invasive exam for girls and boys. Likewise, both sexually transmitted diseases can be cured with antibiotics.
Another good piece of medical news in the fight against STDs is the vaccination for the human papilloma virus, or HPV. The vaccination can prevent some of the viruses that cause most cases of cervical cancer and genital warts. The vaccination should be considered for girls who are between the ages of 11 and 25. In fact, many pediatricians are discussing this vaccination with parents as a part of their daughter’s well-child checkups. It is important to note that the HPV vaccinations only cover some of the viruses. Consequently, girls who are diagnosed as positive with one of the viruses should still be vaccinated for others.
At the current time, an adolescent infected with herpes will live with a management issue for the rest of his or her life. The diagnosis of herpes is more invasive than the one for Chlamydia and gonorrhea and is best preformed by a culture taken from an active lesion or may also be done with blood tests. It is also important to note that if a younger non-sexually active child makes a disclosure about sexual abuse, he or she should be tested for STDs.
A good male role model is essential when talking with sexually active adolescent males. The male role model or physician needs to stress that just because a partner is taking precaution about birth control, it is not the same as protection against STDs. One doctor stated that a picture of an infected male with an STD is truly when “a picture is worth a thousand words.”
When talking to sexually active teens it is crucial that we are honest, open and unafraid to discuss sexual information in an accurate manner. The day of “let them hear it in health class at school” is gone. Many foster children have already been sexually active or sexually abused by the time they are in the sixth grade. Helping foster children understand the ramifications of sexual activity and the warning signs that they may be infected with a STD can help prevent others from becoming infected and in the case of AIDS — could save a life. Providing accurate and non-judgmental access to birth control could prevent a new life born into foster care and the abrupt end to a childhood, strained by an unplanned pregnancy.
ABOUT THE AUTHOR: June Bond earned a bachelor of arts in psychology and a master of education in early childhood education from Converse College. She is the executive director of Adoption Advocacy of South Carolina. She has published numerous articles that relate to adoption, education, and family issues and speaks nation-wide on adoption-related issues. She was South Carolina Adoption Advocate of the Year in 1995. She has most recently worked with the Presbyterian Church of the United States to develop a portion of the nation-wide curriculum — We Believe. She is also the 2006 Congressional Angel of Adoption recipient. She is the mother of six children, ranging in age from 16 to 29. She resides in Spartanburg with Bill, her husband of 30 years.