1. Lindberg, Claire E. PhD, RN, GUEST EDITOR

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Three years ago Aimee, then 15-years-old, walked in to the adolescent health center where I practice, asking for emergency contraception. During the visit, she told me that she had already had six sexual partners, had never used a condom or other birth control, was a binge drinker, and smoked cigarettes. A few weeks later when she returned, this time asking for "regular" birth control, I was very pleased. Clearly she had decided to take positive action toward contraception. That same year, I treated Aimee and her boyfriend for chlamydia and taught them how to use condoms. Since then, Aimee has shown up for regular appointments, has stopped smoking, and is controlling her drinking urges. Just before leaving for college she said, "I don't know what would have happened to me if I hadn't come here 3 years ago. I was really messed up then and I didn't even know I needed help. I'm so glad this place is here for kids like me."


Today, although the importance of minors' confidential access to health services is repeatedly reaffirmed by nursing, medical, and public health organizations, this basic tenet is being reexamined at various levels of our government. Many states have passed laws that restrict teens' access to care, and others are debating such limitations. Restrictive bills are repeatedly introduced at the federal level. Major changes in laws related to adolescent health services now seem almost inevitable. Such changes will significantly affect our ability to provide comprehensive care to our young patients. We all need to get involved. Here's why.


Most adolescents are healthy. Teens rarely die of natural causes. Over 70% of all adolescent deaths result from three causes: unintentional injury (including motor vehicle accidents), homicide, and suicide. Most significant morbidity in teens is related to risky behavior. Teen pregnancy remains a significant problem, and sexually transmitted diseases (STDs) affect adolescents disproportionately. Despite overall reductions in the proportion of teens having intercourse, the number of sexually active teens age 14 and younger is increasing. Teens who become sexually active at such young ages are more likely to have unprotected sex and to become pregnant. Natural curiosity and the desire for new experiences lead many teens to experiment with cigarettes, alcohol, and illicit drugs. According national surveys, 33% of high school students smoke cigarettes, 50% consume alcohol, 7 million are binge drinkers, 3 million smoke marijuana, and 2 million use inhalants. Drug use and risky sex increase teens' chances for contracting HIV/AIDS. Currently almost 50% of new cases of HIV occur in individuals younger than age 25.


If there is a group that needs preventive healthcare, it is certainly adolescents! The keys to ensuring adolescent health are careful behavioral risk assessment, individualized risk reduction counseling, and delivery of preventive services including contraception. Yet, despite these documented needs, teens receive relatively little preventive care. When teens go for health services they are often seen by a pediatrician or family practitioner, and might forgo critical services such as STD testing and contraceptive counseling. Why? In my own practice I often ask teens why they have not discussed contraception, dating violence, and substance use with their family doctor. Almost invariably their answer is "Because he/she knows (or will tell) my parents!"


According to Title X of the U.S. Public Health Service Act, adolescent preventive health services must ensure confidentiality. Today, however, teen access to these adolescent clinics is increasingly limited by funding cuts and by legislation aimed at restricting confidential services to teens. "Parental notification" and "Parents' right to know" laws require healthcare providers to notify or obtain consent from parents or guardians prior to providing teens with services. While these laws have a stated aim of supporting family communication, they also create barriers that prevent some teens from receiving critical health interventions.


What can nurses do for the adolescents who cannot (or will not) talk to their parents about sexuality and the attendant need for healthcare? The American Nurses Association's Code of Ethics clearly states that our primary responsibility is to our patients. The code also directs us to try to influence attitudes and structures that negatively impact health. That means we need to be involved in the political arena. Maternal child health nurses understand better than most people the implications of restricting adolescents' access to critical health services. It's time we raise our voices and advocate for access to health services for adolescents who need our help today, and those who will need us in the future.