Wednesday, April 27, 2005

Progressive public health policy

Finally schools are getting serious about addressing public health issues: Now in Québec, school nurses can distribute birth control pills (story). So much for la revanche des berceaux....

17 Comments:

Blogger Justin said...

I tend to be a bit squeamish about this sort of thing...

It doesn't make sense to me to say that a medication requires a prescription but that a nurse can hand out the drug without a prescription. Going further, saying that nurses can give out a 3-month supply but then a doctor has to write a prescription after giving a physical seems contradictory. Either the medication is safe enough that it ought to be non-prescription or the medication has sufficient risk that you ought to see a doctor to get a prescription.

As a general rule, it seems like the appropriate thing to do when a teenager has questions about sexuality is to involve the parents in the discussion. In the rare situations where this sort of frank exchange would be dangerous, I can understand circumventing the parents. Generally, though, it seems to me that the average 14-year old is hardly mature enough to make responsible decisions about their sexuality without parental guidance. If you're not mature enough to talk to your parents about taking reasonable and mature steps to mitigate the risks, is seems silly to argue that you're sufficiently mature to make your own medical decisions.

On the other hand, I recognize that, in aggregate, this is probably reduce the rate of teenage pregnancy at least in the short term. I would question how frequently the 3-month supply gets renewed through a doctor and how many nurses will feel pressured to help out a teenager with another 3-month supply off the books.

4/28/2005 08:52:00 PM  
Blogger Vincent said...

You raise a good poing about the health issue. How safe are birth control pills? Is there anyone out there (presumably female) who can address the safety of the pill?

I'm not positive I agree that it's necessary to involve the parents. How many teenage girls would feel comfortable discussing birth control with their parents? Ultraconservative religious parents would strongly disapprove of their daughter's sexuality, and even more moderate parents are stereotypically more protective of the sexuality of their female offspring. The problem for many people is that they see teenage sexuality as a matter of protected sex vs. abstinence, rather than the more realistic protected sex vs. unprotected sex. The issue to weigh is as follows: Would teenage girls opt not to use birth control pills at all if it meant that they had to involve their parents in the decision?

My guess is that from a public health policy perspective, Qu├ębec is making the correct decision. Unfortunately, I don't see how such a program could start in the US. Given the furor that arose when some high schools made condoms freely available, I don't think our society is ready for birth control on demand. Generally, though, it seems to me that the average parent is hardly mature enough to make responsible decisions about their daughters' sexuality without appealing to outdated, misogynistic attitudes rooted less in religious canon than in the historical unenlightened treatment of women as a man's property.

Have I become a feminist? :-)

4/29/2005 12:32:00 AM  
Blogger Mwal said...

Vincent writes: "Even more moderate parents are stereotypically more protective of the sexuality of their female offspring."

Just to be a nuisance, I would like to point out that there is such a thing as a
male contraceptive pill. This policy of Quebec's may be progressive and based on practical considerations, but it is nevertheless sexually discriminatory.

4/29/2005 06:56:00 PM  
Blogger Justin said...

Would the a conversation with parents be enjoyable? Would it be comfortable? Of course not. It shouldn't be a comfortable discussion. Just because it's not pleasant, though, is not a reason to skip it.

If there is a legitimate reason to fear for a teen's safety, I have no problem circumventing the parents and helping the teen make a doctor's appointment. As a general principle, though, parents ought to be given at least the first shot at handling what ought to be a difficult and emotional situation. I'd much rather use this as an opportunity to build trust between parents and children rather than trading a short-term public health good for compromising the ability of parents to guide their children through their formative teenage years.

4/29/2005 08:33:00 PM  
Blogger finou said...

just to add my 2 cents...
First off, birth control pills are relatively safe as long as you don't smoke, are under 35 years old, and don't have a history of blood clots. A lot of teenage girls get them prescribed to help with cramps or acne and not necessarily for birth control. The biggest reason I see that they should be given with a prescription 1. some people have problems with some side effects (it makes you really nauseous, for example) and they typically get different versions 2. you need to monitor to make sure that no complications do occur and 3. (probably most important...) you have to explain throughly to a teenager how you are to take them.
Now, I don't really see how having a nurse do those things is all that much different than the doctor especially since it might easier to see the nurse on a follow up than having to schedule a full blown doctor's visits. The only "problem" I see is that you aren't involving the parent. But as was pointed out if a kid is brave enought to ask the school nurse for birth control pills, she is going to have sex (heck, if she is asking the nurse for birth control pills, she is already having sex. I don't think teenage girls ask for the pill for their first time...). It's not like having the parent there is going to change that. My worry though is that if she has birth control pills now, she might not insist on having condoms and therefore wouldn't be protected against STDs...

5/02/2005 10:26:00 AM  
Blogger Eric said...

Ok, there are a variety of issues here... parental involement, parental notification, parental responsibility, doctors versus nurses, the apparent arbitrariness of 3 months, what will really happen after the first 3 months, etc.. But I'll focus on just one...

In my mind, if the school is distributing birth control, then the school is at least implicitly signaling to students that it's acceptable/ok/normal for kids their age to be having sex. So while there may be some short term benefits, I worry about the potential for this encouraging some students becoming sexually active sooner than they would otherwise. If that happens, then this could end up increasing both health and social problems.

5/03/2005 12:53:00 AM  
Blogger finou said...

Arg boys... 3 months isn't arbitrary.
The pill comes in one month packs (if you can't figure that one out, I'm not explaining it to you! ;). and unless you specifically ask, you usually a 3 month supply at a time. (Anyway, I think 3 months is good initially, it's good to see if there are any bad side effects or not as it takes people a while to get used to it sometime. Also, the pill is not as effective in its first month.)
ok I'm mildly embarassed that I know this stuff but that noone else here seems to...
About your other comment about linking birth control in schools and a tacit ok for kids to have sex or something... I seem to recall (but I could be totally wrong so in that case nevermind!) a study that showed that kids at schools that only have an abstenence based sex-ed program have sex just as much and just as early as those from schools pushing protected sex. However, they tend not to use as much protection. Therefore, I would think that it's better to have condoms and things available than not at all but that's just me...
Personally, I think sex-ed in schools should be to benifit those kids whose parents aren't going to teach it to them. They should know about birth control and where to get it and they should know about the risks associated. This is the type of stuff you should be getting from their parent but I think a lot of parents feel uncomfortable talking to their kids. Regardless of parental upbringing or school programs, some teenagers are going to have sex. I figure the school should try to help by making condoms and things available so that the kids don't do anything stupid.

5/03/2005 09:14:00 AM  
Blogger Eric said...

I suspect that you're referring to a study done in Texas. It sounds to me like they probably demonstrated that the programs weren't an overwhelming success, so there are grounds for questioning how much money you want to spend on such programs.

But studies with real people are very difficult to control for all the variables, and this is no exception. "Pruitt cautioned against drawing overarching conclusions from the study, which is incomplete and does have flaws. For example, the study lacks a comparison group, so researchers can't say whether the teenagers would have shown an even greater increase in sexual activity had they not had abstinence education." The "no comparison group" sounds off a big warning bell to me.

Sorry, Delphine, but 3 still seems arbitrary to me. From the information you gave, it seems like 2 months might be the minimum useful duration for an initial supply of birth control pills. I guess that I wonder if the three months rule was some form of compromise to make it seem temporary, but the liberals will then say that it's arbitary and kids don't stop having sex after 3 months, so they should extend it for a longer/indefinite periods of time.

Another thing I don't get is what people think is going to happen after the first three months? Are the kids supposed to decide to stop after three months? Or are they going to decide now it'll be easy to talk to their parents about such things? Or is the school going to encourage kids to sneak to a doctor without their parent's knowing?

If there's child abuse or something really bad going on with the parents, then I can understand extraordinary measures, but as a general rule I think parents should have some idea of where their 14 year olds are and what they are doing. If I were a parent, I would not appreciate the school saying it was ok for kids to sneak out somewhere (even the doctor) or lie to their parents (even to get birth control).

I guess my initial reactionary suggestion would be to spend less time/money on lecturing to kids about sex ed, and instead try to convince parents that they really need to do it, even when they think their kids are too young. For example, I could see parents receiving a set of statistics each year based on the age and demographics of their children, emphasizing that at least their kids friends will be talking about it. Along with that, the school could provide parents with advice about how to approach and engage their children, as well as multiple sets of information tailored to different audiences (e.g., conservative/liberal, secular/various religions, logical/emotional), in a hope that they'll find one or two of the brochures that they are comfortable sharing with their children, either directly or as a list of issues to include in their discussions.

Of course, I think that all such programs, should first be implemented on a trial basis with honest efforts made to test the effectiveness of the program, as objectively and scientifically as reasonablely possible, given realistic constrains (e.g., ethics and money). Unfortunately, the government often doesn't even try.

5/03/2005 08:53:00 PM  
Blogger acg said...

No, 3 months isn't arbitrary, it's how long it takes to figure out if there are any side effects! Why is this? Remember doing science fair projects in elementary school and the teacher told you that you needed at least three data points for whatever you were measuring? It's like that! Also, I think your idea about the brochures is good, but hopelessly naive. Who's going to make the brochures and agree what goes in them? Some committee -- even if they actually agreed on something, someone would sue them (no matter what the end result, it would surely offend someone). Furthermore, the statistics information thing is useless. Most people don't understand statistics (because so many people lie with them). Many parents assume their kids don't have sex and never ask them about it. As a result, they never give their kids any advice or anything about birth control or anything. I think some of you don't understand how many overworked/apathetic/uninvolved parents are out there. It's not like they would suddenly start telling their kids about birth control, if only they had more information. It's like they'd do it when pigs fly.

5/03/2005 09:57:00 PM  
Blogger Eric said...

If I were to start ingesting some new medicine and got very sick after the first dose, I wouldn't keep taking it for three months just to be sure that it was the medicine's fault. Alternatively, if I go three days eating only deserts, that doesn't prove that there won't be health consequences for continuing to eat only deserts.

Perhaps it is naive, but I'd prefer to think of it as hopeful :).

My idea of distributing multiple sets of information meant to appeal to parents with different beleifs was meant to make it possible to do in a politically/religously neutral way, so reasonable people would simplely choose which to use and which to ignore. I agree that some people will sue no matter what, and don't have a solution to that problem.

I don't see how people can have trouble with a statement such as "According to an anonymous surveys conducted over the last NNN years, XX% of the students in your child's grade and school district answered that they YYYY."

5/04/2005 01:51:00 AM  
Blogger finou said...

Eric, according to your logic in the first paragraph, "1 dose" of the pill is 1 month long (actually to be precise it's 28 days they are talking about when they say 1 month. The exact pill you take changes from day to day for a month to go along with the menstrual cycle and it makes no sense to only take 1/2 a month of the pill). so to try it 3x times would be to do it for 3 months...
It takes a full month for the pill to be completely active. So in the first month or second month on the pill, a lot (if not a majority) of women have some side effects with the pill (usually in the first month but sometimes in the second if it wasn't really working the first month). However, if there are still side effects in the third month then it's something wrong because your body hasn't adjusted and you a different pill or dose.

5/04/2005 04:34:00 PM  
Blogger Vincent said...

I remember hearing some rumours that some people were designing a pill with a seven-week cycle rather than a four-week cycle. Did that ever materialize?

5/04/2005 10:21:00 PM  
Blogger finou said...

not that I know of...

5/04/2005 10:28:00 PM  
Blogger acg said...

I think Vincent is talking about when the woman takes the pill continuously (usually skipping the non-active pills) so she only gets like 4 periods a year. But I think the (active) pills contain the same dosage.
As for the N% of students, I meant that many parents will assume that, surely, THEIR child belongs to the (100 - N)% of students.

5/04/2005 10:50:00 PM  
Blogger Eric said...

Ok, some of my confusion was because I didn't realize that people almost expected there to be negative side effects, and would keep taking it in hopes of the side effects going away as their bodies adjusted. If it's true, that doctors typically reocmmend people try it for three months and let them know how it went, then maybe the three months isn't arbitrary.

5/05/2005 04:07:00 AM  
Blogger Justin said...

There is a variant of the pill called "Seasonale" that is 3 months of active pills along with 1 week of placebo rather than the standard 3 weeks/1 week. Apparently, going much longer than 3 months without a period causes problems with the buildup of tissue in the uterus. I'm guessing that there is no relationship between that 3 month figure and the 3 month figure to see about side effects, but have no idea. Now, if finou was midly embarassed about knowing mechanics of the pill earlier, I should probably be beet red now.

5/05/2005 11:37:00 AM  
Blogger Justin said...

As for Eric's idea on various bis of parental literature, I'd feel a lot more comfortable with the schools being more aggressive about educating kids about sex if they started by being more aggressive about educating parents. I'd find the argument that parents have abdicated their responsibility a lot more effective if parents were being supported in fulfilling that responsibility. I know the extent of my Dad's preparation for "the talk" was a small argument where my Mom told him that he had to have "the talk", double-checking that I knew how babies were created (I was in high school, so I was comfortable with that part of the biology), asking if I had any questions, and then an awkward 5 minutes of silence for show. Now, it might not have been any different if the school had been helping them prepare, but at least they would have been given the chance.

As for acg's comment about lawsuits, if a district can agree on a one size fits all curriculum for every student in the district without getting sued, it would seem far easier to put together a variety of literature. The abstinance-only folks would have a place to put all the information they want to include, other groups would have the opportunity to put together literature that matched their philosophy.

5/05/2005 12:41:00 PM  

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