New York Times
POSTED: 01:30 a.m. HST, Jul 12, 2013
NEW YORK >> She was only 16, with big dreams - too young, she thought, to have a baby. Yet she had had sex without protection, and she could see those dreams evaporating. Terrified, she found her way to the basement of her school, Abraham Lincoln High School in Brooklyn, where the nurse's office was tucked away.
First the nurse weighed her and checked her blood pressure. Then she relayed the information to a doctor and made sure it was all right to give the girl Plan B One-Step, the morning-after pill. The nurse checked to see whether the girl's parents had returned the opt-out form that was supposed to have gone home at the beginning of the year. They had not, so she was free to take the pill.
Taking a pill out of a locked cabinet, the nurse handed it over with a cup of water and waited for her to swallow it, the girl recalled. After that first time, the girl took Plan B at school two or three more times. She said her mother had not signed the opt-out form, because she had wanted to have sex and so had never given it to her. "My mom, she doesn't even know they have this stuff," the girl, a junior from Coney Island, said.
Last month, the Obama administration seemingly changed the landscape of access to emergency contraception across the country when, in a reversal, it agreed to allow the best-known pill, Plan B One-Step, to become available to all ages without a prescription. Until recently, only those 17 and older could buy it over the counter.
But New York City had long ago come to an accommodation with the idea that girls as young as 13 or 14 should have easy access to the pill.
Through a patchwork of nurses' offices and independent clinics operating in schools, students can now get free emergency contraceptives like Plan B One-Step in more than 50 high school buildings, generally in neighborhoods with high teenage pregnancy rates. Girls needing the drug have been able to get it immediately under the supervision of doctors or nurse practitioners with prescribing ability. School clinics began dispensing the pills several years ago, and in the 2011-12 academic year alone, about 5,500 girls received them at school at least once, according to the New York City Department of Health and Mental Hygiene.
"Most teens go to school," Deborah Kaplan, the department's assistant commissioner for maternal, infant and reproductive health, said, explaining the city's decision to make Plan B available in schools, as part of a bigger sex education campaign.
New York is not the only city to take Plan B right to teenagers; similar school-based health centers either prescribe or administer the contraceptives in Baltimore; Chicago; Oakland, Calif.; and all over Colorado, among other places. But New York's ambitious push on Plan B is striking in light of its history with contraceptives in schools. Two decades ago a decision to distribute condoms in schools without parental consent was one of several controversial moves that ultimately cost schools Chancellor Joseph P. Fernandez his job.
Now, Mayor Michael R. Bloomberg has power over schools, and his administration can make such decisions without public debate. Even today, however, providing Plan B to minors remains a sensitive issue. In the 13 schools where the contraceptives are handed out by a school nurse after phone consultation with a doctor, parents must be notified of the program and given a chance to opt out, a provision that originated with a court ruling related to the condom protests in the early '90s. (In 40 schools where an independent provider, which is typically a hospital or local health clinic, provides the pills, no parental consent is required.)
Across the United States, half of all school-based health clinics in the United States are prohibited from handing out any contraception, including condoms, by school, district or state regulations or laws, according to a survey by the School-Based Health Alliance, based in Washington.
Critics of the use of the pill have argued that it encourages sexual activity among teenagers and that parents should thus have a strong say in whether their children should have access to it. "Teens who are otherwise going to think twice about sex are going to say, 'This is always going to be available to me,'" said Anna Higgins, director of the Center for Human Dignity of the Family Research Council.
"The moral and physical consequences to this premature sexual behavior are very real," Higgins added, "and they need to be addressed by the person who knows the child and who loves the child best, which is the parent."
Only 3 percent of parents in the 13 schools sign the opt-out form, according to the health department. Dr. Angela Diaz, director of the Mount Sinai Adolescent Health Center, which runs clinics in three Manhattan high schools (where opt-out forms are not needed) said some parents tacitly condoned the program because it is so hard to talk to their children about sex.
"They wish that their kids would talk to them, but given the reality, they're happy there is a place where they can be helped," Diaz said.
The student at Lincoln, where opt-out forms are required, was one of several who said in interviews that they had not given their parents the form because they wanted access to the pill.
A spokeswoman for the health department said that the city gave parents several opportunities to decline participation. "We made a major effort to inform parents through mail, student backpacks, freshman orientation and parent-teacher meetings," she said. The department did not respond when asked whether any students had needed or received treatment for side effects of Plan B, like heavier menstrual bleeding, nausea and abdominal pain. It also would not give out more up-to-date or detailed statistics on the Plan B program without a Freedom of Information Law request, which is pending. Citing privacy, the health department would not allow a reporter to visit a school clinic.
In interviews outside some schools that offered Plan B, many students described a sort of "don't ask, don't tell" ditente with their parents, and those who said they had received Plan B or other birth control at school asked for anonymity because they did not want their parents to know.
The Lincoln student from Coney Island said she had tried to get birth control from Coney Island Hospital before getting Plan B at school. She saw the gynecologist, and then the hospital told her that she needed to come back again before getting a prescription. "I felt like they were stringing me along," she said. So she gave up.
She did not have money to get Plan B at the pharmacy, and it was free and confidential at school. "After you have unprotected sex, you're thinking about your future: 'I won't be able to go to college. What am I going to do?'" the girl said.
A 17-year-old from Fort Greene, Brooklyn, called the school nurse at Lincoln "my new grandma." She said she had taken Plan B "less than five times" this year. She did not give her parents the opt-out form. She said she had become pregnant twice, after her mother had taken her birth control away. "She's the reason I got pregnant," the girl said.
She said the school nurse had helped her find abortions at a clinic, and had set up an appointment for her to have an intrauterine device implanted.
The new federal rule will not change procedures in school nurses' offices. Under state regulation, they cannot give out any medication, even an aspirin, without a physician's order.
The health department said it did not yet have statistics showing the effect of Plan B on local teenage pregnancy rates, which have been declining in the city and across the country for more than a decade. Based on her observations, the Lincoln student from Fort Greene said she believed the program had reduced pregnancy at her school, but had also made students more likely to have sex.
Most of the scientific evidence, however, suggests that making the morning-after pill available does not increase sexual activity, according to a review of studies by James Trussell, a professor of economics at Princeton, and Dr. Elizabeth G. Raymond, senior medical associate with Gynuity Health Projects, a research organization that supports access to contraception and abortion.
But the pill also does not reduce pregnancy rates, they concluded, mainly because women who take it will often have unprotected sex a short while later and not take the pill. "They give a lot of reasons," Raymond said. "They say 'I forgot.' They say, 'I just didn't think I would get pregnant.' That's a big one."
At Boys & Girls High School in Brooklyn, a 17-year-old junior from Crown Heights said she had taken Plan B at school three times this year. Despite the threat of disease - which is drilled into students during sex education courses - she was less likely to use condoms because she knew she could get the morning-after pill, she said.
Several girls at the school, which has about 1,100 students, were pregnant during this school year - the most commonly cited number in interviews was four. One junior from Brownsville said that fear of pregnancy motivated her to ask for long-term contraception rather than relying on condoms and Plan B. Besides, she said, "School is not all year-round."
She said she had gotten Plan B once from the school nurse. For her, the best part of the program was the confidentiality. Asked what her parents would do if they knew she was sexually active, she said, "I can't even imagine, to be honest."
"I won't say rebellious teens, but for teens who decide to do what they want to do, they have this help," she said. Without it, she added, "The consequences are very extreme."