European Approaches to Adolescent Sexual Behavior and Responsibility: Executive Summary & Call to Action [PDF]

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The health care system in the United States is cumbersome and complex and varies from state to state. Approximately 85 percent of U.S. residents have health care coverage through either public or private health insurance. About 15 percent of the population—some 37 million people—have no form of health care coverage. These people tend to be ages 18 to 24, nonwhite, or unemployed.²⁶ Young, unemployed, and uninsured people who lack financial resources may also have reduced access to effective contraception.

Reproductive health care is among the services least likely to be covered in the U.S. health care system, particularly for teens. Although no U.S. health care policy is known to pay for condoms, many health maintenance organizations (HMOs), family planning clinics, and school-based health centers provide free condoms. While 97 percent of employer plans cover prescription drugs, only 51 percent pay for prescription contraceptive methods, and only 15 percent pay for all five of the most common, effective, and reversible forms of contraception—IUD, diaphragm, Depo Provera, Norplant and oral contraceptives. Only about 33 percent pay for oral contraceptives, the most widely used form of female contraception other than sterilization.²⁷

Teens have access to reproductive health services through private organizations and school-based services. Planned Parenthood Federation of America provides education and reproductive health services but targets older teens and young adult women for services. School-based health centers, partly funded through Maternal and Child Health Bureau grants as well as by private foundations, provide health services for more than half a million teens in the United States; however, only 26 percent of the school-based health centers that serve teens provide access to condoms or contraception.²⁸

Abortion is legal in the United States, and women may choose the outcome of their pregnancies during the first trimester. States regulate second trimester abortions and impose a variety of laws to reduce the demand for abortion, including mandatory waiting periods and parental consent requirements.

Emergency contraception—'morning after' contraception—has been legal for over 20 years, but has been relatively unknown and unused by women in the United States. Slightly more than 28 percent of U.S. teenagers have heard of emergency contraception.²⁹ Many teens in the U.S. are unaware of and fail to seek appropriate reproductive health services in a timely manner, and a pregnancy or STD often drives U.S. teens to seek reproductive health services.

In 1969, the Netherlands legalized selling contraceptives and providing condoms in vending machines. By 1971, national health insurance included coverage for the pill. In 1981, the Netherlands legalized abortion although high levels of contraceptive use had already begun to drive abortion rates lower than in surrounding countries. In the early 1980s, the Dutch government funded the Rutgers Foundation to provide special services for adolescents, reproductive health care to the public, and sexuality education. The Rutgers Foundation currently runs seven sexual and reproductive health centers ³⁰ and employs a multidisciplinary staff of doctors, nurses and psychologists who provide contraception and emergency contraception, test for pregnancy and STDs, diagnose fertility problems, and provide sexual abuse counseling.

Because the Netherlands has many port cities, controlling STDs has been a major health concern. Easily accessible STD clinics, fully funded by the government, provide testing, treatment, and education. Walk-in clinics are strategically located and easily accessible for target populations. Clinics provide early STD diagnosis, rapid STD treatment, and free HIV testing. Clinics also offer free pre- and post-test counseling, contact tracing, and treatment of infected partners as well as examinations and counseling for sexual assault. Finally, clinics provide safer sex outreach and education. Treatment is offered to everyone at no cost.³¹

National Public Health Insurance funds all reproductive health services—contraceptive pills and devices, emergency contraception, abortion, testing for pregnancy and HIV/ STD, prenatal care, delivery, and all drug therapy associated with the early diagnosis and treatment of STD, HIV, and AIDS. Only condoms are not funded. Over 99 percent of the Dutch population have full health coverage.³² Dutch teens have excellent access to the best methods of protecting themselves. Sexually active teens encounter nonjudgmental attitudes and strong adult convictions that young people must be sexually responsible. Services are confidential and free or low cost. While the Netherlands has a minimum age of consent, it is waived when a doctor or clinician believes waiver to be in the young person's best interest.

The German government regulates insurance, and 90 percent of households have compulsory health insurance. Private insurance is available for the remaining ten percent of households with very high incomes. Even though patients must meet co-payment fees, these fees remain substantially lower than those in the United States. In addition to subsidizing health care for almost all of its residents, the German government provides generous support for sexuality education, family planning, and contraceptive services.³³ Most Germans believe that sexual expression is a basic need and a normal, healthy part of personality development. Germans believe that sexuality is to be handled responsibly. German residents enjoy access to condoms and contraception with few barriers.

Oral contraceptive pills, IUDs, barrier methods, and sterilization are covered by insurance and are free of charge to women ages 20 and under.³⁴ Adolescents need not visit a physician to get contraception.²³ Germans view contraceptive use as indispensable to sexual intercourse,³⁴ and many German adolescents effectively use contraceptive methods. Some 63 percent of German teens use oral contraceptives and 57 percent use condoms.⁴ Condoms are widely available in pharmacies, grocery stores, restaurants, clubs, and in vending machines in most public rest rooms. In general, Germans view contraceptive use as the way to avoid abortion.³⁵ Parents, schools, and communities support teens' use of protection when they become sexually active.

In 1996, Germany legalized abortion within the first trimester and with "proper counseling" which emphasizes the life of the fetus but leaves the final decision to the woman. Second trimester abortion is not permitted unless pregnancy endangers the mother's life. Abortion is also covered by the national health plan and counseling is required three days prior to the procedure.³⁶ German law requires parental consent for abortions in women under age 18, but doctors may perform abortions for women as young as 14 who fully understand the ramifications of the procedure.³⁵

The French health care system faces rising costs; yet, the country remains committed to national health insurance coverage.^37,38 About 99 percent of French residents are covered by health insurance.³⁹ National health insurance covers all reproductive health services. In 1967, the French government revoked a 1920 law restricting access to contraception. In 1974, Parliament permitted family planning clinics to dispense condoms and contraceptives and required that services be confidential and free to those ages 18 and under.³⁹ The age of consent is 15.

The main reason for providing low cost to no cost protection is to reduce the demand for abortion. Abortion is legal and free through the tenth week of gestation, but women seeking abortion must wait 10 days. Second trimester abortions are legal only when the pregnancy endangers the life of the mother, as determined by two consulting physicians. Approximately 18 percent of abortions are accomplished through administration of RU-486 (mifepristone), which is legal until the fifth week of gestation. Minors seeking an abortion must have the consent of at least one parent although doctors ignore this requirement when they think it is in the best interest of the young woman.³⁹

The French use innovative strategies to make contraception more accessible for adolescents. One successful approach is Mercredi Libre, or "Free Wednesday." Students in French schools have Wednesday afternoons off, and family planning clinics cater to teens on those days. Clinics permit walk-in appointments and also set up educational programs to entice teens to visit, alone, in couples, or in groups. The French increase access to contraception through condom vending machines, located throughout the country in places frequented by teens.

France has many STD and family planning clinics which provide education, counseling, condoms and contraception, STD testing, and gynecological exams. Overall, teens seeking reproductive health services encounter few barriers in France. Services are free, conveniently timed, and promoted by adults. Condoms are cheap, contraception is free, and both are widely available. Abortions are free and legal, though not condoned. The focus, in this predominantly Catholic country, is on preventing abortion through responsible sexual behavior.

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Source/Citation:
Berne L and Huberman B. European Approaches to Adolescent Sexual Behavior & Responsibility: Executive Summary & Call to Action. Washington, DC: Advocates for Youth, 1999.