Making Sexual Health a Part of the Health Discussion

Jamille Fields, Resident Blogger (’13, St Louis University School of Law)

The health care provider’s office is intended to be a confidential space for health discussions. It should be a place where all can discuss personal health issues as they arise, or practices to prevent health issues from arising. Conversations on sex and sexuality should be among these health discussions throughout youth. Education on sexuality has been shown to increase contraception use, reduce adolescent pregnancy rate, and reduce the risk of sexually transmitted diseases. But sadly, sexual health often is not discussed with youth in the provider’s office.

Earlier this year, the Journal of the American Medical Association published a study, documenting–perhaps for the first time–sexual health discussions occurring in physicians’ offices.  The study observed adolescent patients’ visits and found nearly one-third of physicians did not discuss sexual health. For those that did have sexual health discussions, the conversations lasted only 36 seconds. Now, count out 36 seconds and see how much of a “discussion” you can have.

In 36 seconds, one certainly cannot have a discussion that includes the full range of topics recommended. The American Academy of Pediatrics’ Bright Futures Guidelines for Health Supervisions of Infants, Children, and Adolescents recommends that sexuality education be provided from infancy to 21 years old. These recommendations include teaching the proper name of genitalia to young children. As children grow older, the discussions should include hygiene, privacy, and sexual development. By adolescence, these conversations should advance to counseling on contraceptives, HIV and STD prevention, and counseling against domestic violence. Notice, these conversations do not start in adolescence – the ground work should have been laid since infancy.

Failure to provide children and adolescents education on sexual health can also violate Medicaid and some Children’s Health Insurance Program (CHIP) rules. Specifically, the required benefit for those younger than 21 years old enrolled in Medicaid and some CHIPs includes medical screenings. And health education is a required component of each medical screen. This education must encourage a healthy lifestyle, be forward-looking and age-appropriate. As the Bright Futures recommendations indicate, age-appropriate health education must include sexuality education.

Unfortunately, children and adolescents are not receiving screenings as the law requires. A 2010 report from the Department of Health and Human Services notes that 76% of youth did not receive the required screening. And even when the screening did occur, it often failed to include any health education (over 20% screened did not receive any health education). So clearly changes must be made.

Thanks to the Affordable Care Act (ACA) sexuality education is also now a clear requirement for children and adolescents enrolled in Marketplace (Exchange) plans. The ACA requires most individual and group health plans to cover certain preventive services. One such service is sexuality education as Bright Futures recommends.

The explicit coverage requirements are an important first step to ensure that sexuality education and counseling are included in health care delivery. However, efforts should not stop there. Changes in the health care system must be made to ensure this actually occurs. To encourage these conversations, I offered recommendations in an issue brief and on a webinar LSRJ and American University hosted.


Threats to Youth Healthcare Privacy, the ACA, and SB 138

Kaitlin Morrison, LSRJ Summer Intern (’15, Columbia Law School)

The expansion of healthcare brought by the ACA is much-needed and certainly a net positive. Dependents may now remain on insurance until the age of 26. With this expansion however, the pre-existing gaps in privacy protections have been exacerbated. Consider the case of a young adult who goes to the doctor for a routine STD screening (the responsible thing, right?), only to have this private information relayed to the primary policy holder – usually the parents! The right to healthcare should not be conditional upon a relinquishment of doctor-patient confidentiality.

The basic conflict is between two important policies: maintaining appropriate communications between insurer and policy holder to ensure billing and payment transparency versus protecting patient confidentiality for insured dependents accessing “sensitive services:” sexual and reproductive health care, mental health services and drug and alcohol abuse treatment.

Many negative consequences are likely to result from this administrative quagmire. Minors and adults on another’s insurance may simply choose not to seek medical care for STD testing and treatment, contraception, and drug and mental health services, for fear of this information being shared. Alternately, dependents on private insurance may seek public clinics for STD testing and similar services to avoid the possibility of parental notification, shifting the cost to the state. Victims of domestic violence will face a difficult decision: seek treatment and risk the possibility of their location being known by their abuser (if they share a policy), or not seek medical care.

The patchwork of laws and regulations protecting privacy are incoherent in a model in which young adults remain on their parents’ insurance. By law, adult patients in California have a right to keep all health information confidential and decide whether and when to share that information with their partners and parents, regardless of whose insurance plan they are covered under. Adolescent patients in California have a right to keep certain health information confidential and decide whether and when to share that information with parents, including information about “sensitive services.” However, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) made an exception to the general confidentiality rules above, allowing providers and insurers to use and disclose information for payment and health care operations purposes. “Reasonable efforts” are required to limit disclosure to the “minimum necessary” to accomplish the intended purpose of the disclosure. This unclear standard is insufficient to protect privacy.

A solution to this problem has arisen in the form of SB 138, authored by state Senator Ed Hernandez, which aims to bring clarity to the myriad state and federal statutes and regulations related to the sharing of patient information in order to protect patient confidentiality for insured dependents. At the heart of the bill are two provisions: If the patient is a dependent on another’s policy, and is less than 26 years old, all such communications would be barred unless the patient authorizes them. If the patient is not a dependent and under 26, there is no automatic barring of sensitive communications, but if that patient submits a nondisclosure request, the insurer will have to honor it.

The most recently amended form of the bill will go to the appropriations committee after recess. Consider contacting your state Senator to show your support.

Moving Backwards: Silver Screen Portrayal of Teen Sexuality

Rosie Wang, Resident Blogger (’14, Columbia Law School)

A week or so ago, my classmates and I were arguing one of the most pressing questions of our nostalgia-obsessed generation: What is ultimate high school movie – Clueless or Mean Girls? (Answer: Neither, it’s obviously Heathers.) Amid the heady discussion and subsequent teen movie marathon planning, I started thinking about how high school movies have portrayed teen sexuality, contraception, and pregnancy over the years. In so many of the teen movies I grew up watching, sex was something that characters are obsessed with and defined by, and pregnancy is the ultimate horror. But is this moralizing cast on teen movies a modern thing? Maybe so.

One of my favorite teen movies is the cult classic, Fast Times at Ridgemont High (FTaRH). For a film that came out in 1982 – smack dab between two landslide election wins for Reagan – it’s shockingly open-minded. One of the main characters, Stacy, is a 15 year old freshman. She has sex for the first time with a 26 year old man and then initiates an encounter with a classmate, Mike Damone, from which she gets pregnant. She decides to get an abortion and tells Damone that he owes her half of the fee and a ride to the clinic. When Damone turns out to be a flake, Stacy’s brother deduces what has happened. He picks her up from the clinic, agrees to keep it a secret from their parents, and takes her out for lunch. Her best friend get revenge by vandalizing Damone’s car and locker in a classic act of high school public humiliation. Stacy, rather than being ostracized or shamed, is shown as being supported by her social circle and loved ones. It is Damone who is ridiculed for shirking his responsibilities, not Stacy for being sexually active. Stacy shows no signs of trauma and the abortion is never brought up again. Instead her narrative becomes one of her blossoming romance with Rat, a boy who has long harbored a crush on her. Rat angrily brushes aside Damone’s veiled insult that Stacy is “a very aggressive girl” (undertones of slut-shaming fully in force). Stacy continues to be assertive by giving Rat a picture of herself with her phone number on it and kissing him. Her reputation, as well as her confidence in herself and her sexuality is unshaken and unpunished.

I can only imagine the outcry such a story line would cause now. It’s a testament to how much we’ve gone backwards to imagine the complaints that would hound FTaRH for giving teens license to have wild, unprotected sex because the movies told them there’d be no penalties! The climate we live in today even mistakenly accused Juno, a movie in which the young woman chooses adoption rather than abortion, of glamorizing teen sex without consequences. In reality, teen pregnancy and teen moms face a great deal of stigma that is racially charged and makes it difficult to continue their education.

Turning to a classic of the aughts, Mean Girls is a film that has people endlessly quoting and referencing it eight years later. It was written by Tina Fey who promisingly said last week, “If I have to listen to one more gray-faced man with a two-dollar haircut explain to me what rape is, I’m going lose my mind.” And Mean Girls does have some golden reproductive justice moments. For example, it makes fun of a health curriculum that tells students that they’ll die if they have sex (taught by a teacher later revealed to be in a relationship with an underage student no less). And yet it leaves some things to be desired. When arch-Mean Girl Regina is in her bedroom with her boyfriend, her mother pops in and asks, “You guys need anything? Some snacks? A condom? Let me know!” It’s part of a larger characterization of Regina’s cold personality resulting from a dysfunctional family in which her mother sets no boundaries because she wants to be a “cool mom.” But is it really being a bad mother to make sure your daughter is equipped to deal with her sexual decisions rather than trying to control her sexuality? Not according to the way many families treat teen sexuality in the Netherlands. Apparently acknowledging that teens have sex, having open communication about contraceptives, and allowing sleepovers actually encourages trust and responsibility rather than the opposite.

Even if Hollywood is unlikely to portray teen sexuality in this way anytime soon (because of both conservative backlash and the lack of narrative drama), hopefully the actual experiences of American teenagers can begin to approach it.


Back to Reality: Why Abstinence-Only Education Needs an Upgrade

In a scene from the most recent Twilight movie, Bella tries to convince Edward that she wants him and wants to take the next step in their relationship by having sex.  While Edward makes it clear that he definitely wants her back, he tells her that in his time, there would be a whole process before any of this could take place.  He would have wooed her, they’d hold hands, he’d get permission from her father to marry her, they’d get married, then they’d do the deed.  Bella informs him that it’s now her day in age, and that’s definitely not the way it works.  Who knew that Twilight would have such a brilliant metaphor for why abstinence-only education doesn’t work?

The problem with abstinence-only education is not so much that it wants teenagers to prolong sexual activity until they are married, but more that it’s completely out of touch with today’s modern teenager.  Suporters of ab-only education seem to believe that sex should only occur during marriage, and anything outside of that concept is morally wrong.  They suggest that comprehensive sex education that teaches students about condoms and other forms of contraception is what causes teenagers to engage in sexual behavior.  As if saying, well if kids don’t learn about condoms and contraception from their sex-ed teacher at school, then they will magically never be curious about sex or have any idea what it is.  Apparently, they’ve never turned on their TV.

The simple truth  is, teenagers are exposed to sex on a regular basis, whether their parents want to accept it or not.  It’s on TV.  It’s in music videos and song lyrics.  It’s in magazines and print ads for their favorite clothing store.  And on that little thing called the internet.  Sex is a part of our society and our culture, plain and simple.  Sexuality is part of the human condition.  And it’s complicated. Continue reading