Philadelphia—If every Hispanic girl in America thought like Sheila, it seems, perhaps they wouldn't have the highest teen birthrate of any ethnic group in the nation.
Sheila preaches the use of condoms. She dreams of a military career and knows that dream can be shattered by having a baby. She regularly visits her high school's health resource center, where youth worker Maureen Comber dispenses sex information, advice and free condoms.
But at 19, Sheila has been pregnant three times.
This strong-willed, outgoing girl epitomizes the struggle facing youth workers like Comber, whose one-room health center on the second floor of Edison High School marks the front line in a battle over one of the nation's most stubborn teen health problems.
Federal officials recently hailed another drop in the teen birthrate, which has declined 18 percent since 1991. The news isn't so great here at Edison and in other Latino communities around the country, where the decline has been slower than for any other ethnic group. In a country that has the highest teen birthrate of any industrialized nation, Hispanic youth have held the top spot since 1994 - and their lead is growing. Pennsylvania bears out the trend: while the rate dropped 24 percent for African Americans and 16 percent for whites from 1991-97, the drop among Hispanic youth was two percent.
"At the national level we are successful, but the disparities [between ethnic groups] are becoming more and more vivid," says Dr. Irshad Shaikh, commissioner of health in the impoverished city of Chester, south of Philadelphia.
The Hispanic teen birthrate is significant not only for Hispanics but for the nation. There are more Hispanic youths in the U.S. than any other minority; that includes 5.5 million Hispanic girls under 18, according to "The State of Hispanic Girls," released this fall by the D.C.-based National Coalition of Hispanic Health and Human Service Organizations (COSSMHO). In the mid-1990s, according to the U.S. Census Bureau, one in 10 U.S. women of reproductive age was Latina. By mid-century, the ratio will be one in four.
That's one reason that Hispanic and government organizations are boosting efforts to reduce unprotected sex among Hispanics youth. Those efforts range from the El Joven Noble Male Responsibility Project, a sexual responsibility initiative aimed at Latino boys in Los Angeles, to increased outreach by the National Latina Institute for Reproductive Health (NLIRH), whose Midwest affiliates last fall named pregnancy and HIV as the top concerns for Latino youth. COSSMHO's new report sounds an alarm about pregnancy as part of a troubling health phenomenon: Hispanic girls lead other ethnic groups in alcohol abuse, drug abuse and suicide.
Why has it been so difficult to reach Hispanic youth? Scarcity of family planning, economics, machismo, American pop culture and traditional Latino culture all get some blame in studies. Generalizations are difficult, especially because "Hispanic" takes in so many different cultures.
But here at Edison, the most striking theme is a lack of passionate long-range life goals that motivate many kids to try to avoid pregnancy. Without big plans for academics or a career, having a baby doesn't really get in the way. Explaining the live-for-today attitude among many of her schoolmates, Sheila says, "You don't know what will happen later today or tomorrow."
The Rubber Room
Edison sits across from a cemetery in a Latino neighborhood of north Philly, a neighborhood so rarely visited by outsiders that a cabbie needs a map from his passenger to find it. It is a poor community of row houses and storefronts; while somewhat disheveled, it is hardly the war zone of many inner cities. St. Christopher's Children's Hospital, its cheerful lobby populated by colorful fake animals, sits a few blocks from Edison. Seventy-eight percent of the 2,400 students are Hispanic (primarily Puerto Rican), and 17 percent are African American.
Once inside, it's easy to find Comber: ask for the condom lady. It's not the nickname that the 25-year-old would have hoped for when she graduated from Shippensburg University with a degree in social work. But she does have a drawer full of Lifestyles condoms which she dispenses for free, one of the reasons her Health Resource Center (HRC) gets heavy foot traffic.
This is one of 10 school-based HRCs established after the Philadelphia School Board voted in 1991 to create a comprehensive program to prevent pregnancy and sexually transmitted diseases (STDs). The Family Planning Council (FPC) administers the centers and provides technical assistance; local health agencies provide staff. (St. Christopher's staffs the Edison clinic.) The Planning Council is a nonprofit that subcontracts with community-based organizations for education and health services in Philadelphia and four surrounding counties. Most of the HRC money comes from federal Title X family planning funds.
Not everyone is happy about it. The HRCs survived a court challenge by parents who objected to the free condoms. The schools must provide space for the centers, but "we have maintained an arm's distance because we don't want people saying there are taxpayer dollars going to hand out condoms to teenagers," says schools spokesman Paul Hanson.
[More typical in Pennsylvania is the nearby city of Chester: high schoolers who want school-based family planning services must get to Smedley Middle School, where funds from Title V of the 1996 Welfare Reform Act restrict the health center - staffed by a local hospital, just like Edison - to providing abstinence-only information.]
No subject appears out of bounds in Comber's office. On display are numerous brochures, such as "101 Reasons to be Abstinent," "What is Safer Sex?" and "Birth Control Facts." One wall sports a chart of birth control effectiveness, from abstinence (most) to withdrawal (least). Comber provides information, she counsels, she addresses classes at the invitation of teachers (about once a week) and she refers students to St. Christopher's adolescent health clinic, where they get pregnancy tests and contraception such as Depo Provera. These services were enough to draw in 559 students last year; most came more than once.
Walking in the first time is the toughest. One ninth grader says her friend strolled around outside the door "until everybody was gone" from the hallway. Once inside, the students get something that Latino youths typically lack: easy access to information about sex and birth control. COSSMHO's recent report cites a scarcity of family planning programs in Hispanic communities, and a scarcity of Spanish-speaking staff in programs that do exist, as major impediments to cutting teen birthrates.
"There are so few curriculums geared especially to that culture," says Lisa Shelby, vice president for education and professional development at Planned Parenthood of Southeastern Pennsylvania. "You're talking about intimate, personal, core stuff. Folks who come from Latino cultures, it's really taboo to have those kind of conversations with someone you don't know or feel comfortable with." In the sex education course that Planned Parenthood runs at a predominately Hispanic middle school in Philadelphia, she says, "the staff is bilingual and bicultural."
But teaching a captive classroom audience is one thing; getting Latinos to seek birth control assistance is especially difficult. "They don't understand family planning," says Iris Caballero, director of health promotions at the Asociacion Puertorrique-os En Marcha, Inc. (APM), a community-based nonprofit that provides health and social services to Hispanics in Philadelphia. In 1993 APM conducted focus groups with Hispanic women, and found that "the lack of information about the availability of family planning services was striking."
APM was running a pilot outreach program to inform Hispanic girls and women about family planning services and to make referrals. The pilot ended when the FPC grant ran out. APM is seeking funds to open a full-service family planning clinic in its Hispanic neighborhood, which is a few miles from Edison. "There are none" in Latino communities now, says Caballero, except hospitals - the kind of large institutions that most people, especially teens, don't just drop into to talk to someone about their sex lives.
How about personal physicians? According to COSSMHO, when compared to whites and African Americans, Hispanic girls are more likely to lack health insurance or a "usual source of health care." They are also less likely to have been taught about HIV in school. "I'm amazed by how many ninth graders don't know about reproduction," says Comber.
To be sure, most kids know something about condoms or AIDS when they walk up the steps as freshmen; the five girls and three boys interviewed at the center all confirmed this. What they get at the HRC is more quality, in-depth access to information and birth control. The question is, how are they using that access?
Wishing for Babies
"I need condoms."
The tall dark boy who zips into the health center between classes is in a hurry; he stands next to Comber shifting his feet as if they're on hot sand, waiting for her to dispense the maximum of four prophylactics. First, she delays him for 20 seconds with questions such as "What's the most common STD?" ("HIV," he says. "Chlamydia," she says.) Does he know that abstinence is the only guarantee against STDs and pregnancy. "Yes." Quiz over, he flees.
"Once you give them the condoms, shoom!" says Deedee, a 14-year-old sitting in the HRC.
Boys, says Comber, typically walk in quickly to get condoms and go. "Girls want to talk about problems, relationships, where they can go for more services," she says. Deedee and her two fellow freshmen friends visited soon after school began because they were involved in relationships that were getting sexually serious, and they wanted to talk to an adult about it. "A lot of girls come in wanting to know if they're pregnant," Comber says. She gives them referrals for testing at St. Christopher's.
What surprises her most is the number of girls "who come to me saying, 'I want to be pregnant.'" It does not surprise Caballero at APM. For many Hispanic women, she says, "the ultimate goal in life is to be a good mother." This, say Caballero and other Latino youth workers, is a significant barrier to cutting teen birthrates.
It's not the motherhood desire itself, but the lack of other life goals strong enough to outweigh it. This was strikingly clear last school year when Comber asked girls to write essays about why they wanted to spend a few days with the HRCs "Baby Think It Over" doll. "The girls really didn't have any other interests," she says. "There wasn't anything they felt they would be missing out on if they had a baby."
School? It's no coincidence that the Hispanic dropout rate, like the teen pregnancy rate, is the highest of any ethnic group in the nation. COSSMHO reports that Latinas who drop out are more likely than whites, African Americans or Asians to get pregnant. Here at Edison, the average daily attendance (67 percent) is the lowest among the 10 HRC schools. The four-year high school completion rate (36 percent) is second lowest.
Careers? Asked where they see themselves after Edison, the girls in the HRC generally shrug. Deedee would like to be a nurse. Sheila, the oldest, displays the strongest burn for a career, the military. If you get pregnant, she says, "your life is not your life anymore."
She speaks from experience. She chalks up her pregnancies to condom failure, or the failure of the guy involved to wear one as promised. Her son, three, lives with her sister.
Sheila and the other four girls at HRC want to avoid pregnancy, but sticking to that objective means overcoming cultural forces that push girls the other way. A study released in September by the American Association of University Women, based on "summits" with 2,100 girls, found that compared to whites and Asian Americans, pressure to have sex is greater on Hispanics and African Americans, who "cite pregnancy as an issue in their lives" more than other girls and "do so at a younger age."
The public abstinence movement that has spread among many teens has not caught fire at Edison; the girls laugh when asked if there is a so-called "virgin club" here. Erica knows a girl who started having sex at 12. Another girl's friend got pregnant at 13. Besides Sheila, one of the other girls, 16-year-old Daniela, has also been pregnant. Several of their mothers had their first babies at around 16.
"If somebody wants to have a baby," says Comber, "you can't just hand them a condom and say, 'Use it.'"
It is impossible to get the three boys sitting in the HRC to talk about sex for more than six seconds without them breaking down in snickers and elbow-in-the-ribs banter about sexual conquests. This is not because they're Latino; it's because they're guys, aged 15, 16 and 17. But many of the forces that impact the Hispanic girls who were sitting here just minutes earlier affect these boys as well.
Consider their economic prospects: 25 percent of Hispanics live below the poverty line, according to the U.S. Census Bureau. (The school district says 91 percent of Edison's students are "low-income," higher than any of the HRC schools.) While 86 percent of whites age 25 and over have at least a high school diploma, only 53 percent of Latinos do. While 26 percent of whites have at least a bachelor's degree, only 9 percent of Latinos do.
Asked where they see themselves after Edison, the boys look a bit blank at first. One wants to be an auto mechanic. (There's a shop at the school.) Another envisions "going to bars, clubs. I'll be having fun. Lookin' for a chlllin' job."
Bill Albert, spokesman for the National Campaign to Prevent Teen Pregnancy, believes that the strong economy of the 1990s has helped to reduce teen pregnancies. "In a lot of focus groups I've been to," he says, "there are teens who say, 'I have a future. I want to go to college. I want to work in computers. I'm not going to get there if I'm pregnant at 17.'"
The flip side is that those with less economic hope might be less motivated to postpone pregnancy. This has long been seen as a factor among young African-Americans. In Chester, which is predominately black, the birthrate among single teens is more than four times the rate for the rest of Delaware County, according to the Pennsylvania Kids Count Partnership. "If the kids have something to look for - scholarships, recreational opportunities, job opportunities - I'm sure they would steer away from risky behavior," says Dr. Shaikh, the city health commissioner.
In both cities, youth workers say many young people don't see sex as risky because they don't envision losing much if they have a baby or contract an STD. Several of the Edison girls say they expect many of the boys to die before getting far into their 20s anyway. They talk about the shooting deaths of several boys in the community, and a widespread feeling that many will die young from violence or drugs.
"I hear a lot of males say they're proud of the fact that they're leaving something behind," Comber says of those who've fathered babies. Sheila talks about a boy who was shot and says, "I wish my friend could have at least had a baby" before he died.
It's a nationwide phenomenon, says Jerry Tallo, director of the National Latino Fatherhood and Family Institute, part of the nonprofit Bienvenidos Family Services in East Los Angeles. "Latinos rarely see themselves in a positive light," he says. "If you're trying to counteract that powerlessness, the easiest and most concrete way to make a stand or be represented is to be sexual and have a baby." The Institute's El Joven Noble Male Responsibility Project teaches boys to take responsibility for their actions, including the creation of life. Among its techniques: channeling creative energy toward other outlets, like dance and theater.
Given such forces, Comber sees the daily depletion of her condom supply as a small victory. For years the most popular contraceptive method among Latinos has been female sterilization. But that step is commonly taken, says Caballero of APM, after a woman has had three babies by 21.
As with young people of many ethnic backgrounds, these youngsters still see birth control as primarily a girl thing. While all five girls at the HRC vow that condoms should be used every time someone has intercourse, only one of the three boys says he always uses condoms. The other two use them sometimes. "I ask the girl, 'You want me to use a condom? It's up to you,' says Ronald.
This puts even more pressure on girls. "Guys, they want to do it raw," says Daniela.
Edison's HRC clearly helps youths such as Daniela grapple with the incredible personal and difficult decisions about sex. A study of the HRCs, published by the Guttmacher Institute in 1997, concluded that they slightly increased condom usage and did not increase sexual activity. But convincing significantly more Latino youth to use condoms or abstain will require more than pamphlets and a friendly youth worker. It will take instilling a stronger sense that they are headed toward a productive, healthy future - a future that they value enough to put babies on hold.
"We can teach them sex ed as much as we want or tell them to say no as much as we want," says Albert of the National Campaign. "Unless they are motivated to choose one method or another, they're not going to do either."