Music, Math, and Mirena

Published July 6, 2015

NEWS:   Various news outlets report that Seattle sixth graders can obtain IUDs without parental consent but cannot buy soda at school.

On 1 July 2015, published an article titled "Seattle 6th Graders Can’t Get a Coke at School, But Can Get an IUD," about Seattle-area school-based health clinics that offer reproductive care. That article began by stating that 13 Seattle-area clinics offered long-acting reversible contraceptives (LARCs) to "students in sixth-grade and above," adding that students in all included schools "can't get a Coca-Cola or a candy bar at 13 Seattle public schools, but they can get a taxpayer-funded intrauterine device (IUD) implanted without their parents' consent":

School-based health clinics in at least 13 Seattle-area public high schools and middle schools offer long-acting reversible contraceptives (LARCs), including IUDs and hormonal implants, to students in sixth-grade and above at no cost, according to Washington State officials.

LARCs are associated with serious side effects, such as uterine perforation and infection. IUDs, specifically, can also act as abortifacients by preventing the implantation of a fertilized egg.

The state and federally funded contraceptive services are made possible by Take Charge, a Washington State Medicaid program which provides free birth control to adults who are uninsured, lack contraceptive coverage, have an income at or below 260 percent of the Federal Poverty Level — or, in this case, to teens who don’t want their parents to know they’re on birth control.

That article produced a good deal of outraged and surprised reaction from readers by presenting an extreme, hypothetical scenario that its author did not document had ever occurred (or was even likely to occur), along with a healthy helping of misinformation.

Much of the topic the article addressed isn't unique to the Seattle area, the state of Washington, or even the United States as a whole. As the Guttmacher Institute (a non-profit organization that works to advance reproductive health) noted in a July 2015 brief, over half the states in the U.S. allow all minors 12 and older to consent to contraceptive services:

The legal ability of minors to consent to a range of sensitive health care services — including sexual and reproductive health care, mental health services and alcohol and drug abuse treatment — has expanded dramatically over the past 30 years. This trend reflects the recognition that, while parental involvement in minors’ health care decisions is desirable, many minors will not avail themselves of important services if they are forced to involve their parents. With regard to sexual and reproductive health care, many states explicitly permit all or some minors to obtain contraceptive, prenatal and STI services without parental involvement.

In most cases, state consent laws apply to all minors age 12 and older. In some cases, however, states allow only certain groups of minors — such as those who are married, pregnant or already parents—to consent. Several states have no relevant policy or case law; in these states, physicians commonly provide medical care without parental consent to minors they deem mature, particularly if the state allows minors to consent to related services.

26 states and the District of Columbia allow all minors (12 and older) to consent to contraceptive services. 20 states allow only certain categories of minors to consent to contraceptive services. 4 states have no relevant policy or case law.

Moreover, under Washington state law, minors may obtain or refuse birth control services at any age without the consent of a parent or guardian. The King County (where Seattle is located) web site advises that reproductive services are available to teens beginning at the age of 12 and are offered on a confidential basis:

Teen Health Clinics and school-based clinics provide education and services for pregnancy prevention, contraception, pregnant and parenting teens, physical exams, STD education, alcohol, drug and mental health services just for teens aged 12-20.

In Washington state, all health care services offered at family planning clinics are confidential. This means that you don't need written permission from your parent or guardian to get services like birth control, annual exams, STD tests, and pregnancy tests. It also means we will not tell anyone about your visit unless you ask us to.

We always encourage teens to talk with a parent or trusted adult about their care with us. However, it is ultimately the teen's decision who to involve.

So, the CNS article provided little information that was new or newsworthy, other than highlighting that some minors in Seattle-area schools can get free birth control (and thereby presumably avoid their parents' finding out about it) and can obtain long-acting reversible contraceptives (LARCs) such as IUDs that "are associated with serious side effects."

As to the first point, Planned Parenthood of the Great Northwest offers the Take Charge program throughout the state of Washington, "a state and federally funded program providing family planning services (including free birth control) to women and men in Washington state who do not have insurance or whose coverage does not include contraception." So, if any minors want to avail themselves of birth control services but have no way of paying for them other with than their parents' money, Take Charge is a program that allows them to obtain those services without their parents' necessarily knowing about it. But that's the whole point of the law allowing minors access to birth control services on a confidential basis, without the need for parental consent.

As for CNS's suggestion that sixth graders are getting "IUDs implanted without parental consent," they didn't offer any evidence documenting that such a thing had been taking place (or was even likely to take place); they merely cited a non-specific answer from Take Charge about whether it was hypotically possible:

When asked if a sixth grader could get an IUD implanted without parental consent, Take Charge told “We encourage all Take Charge providers to offer long-acting reversible contraceptives (LARCs) in their clinics. A young person does not need parental consent to obtain a LARC or any other contraceptive method ... If the young person is not choosing abstinence, she would be able to select a LARC and have it inserted without parental consent.”

IUDs were previously not recommended for women under 25 who had not yet carried a pregnancy to term due to concerns about IUD expulsion and pelvic inflammatory disease. However, studies have since indicated that IUDs are safe and effective for women of all ages.

In 2012, the American College of Obstetricians and Gynecologists issued a committee opinion saying that adolescents exploring contraceptive options should be encouraged to consider IUDs as well as the implant, which it called "the best reversible methods for preventing unintended pregnancy" in young women.

Despite a growing body of scientific support, concerns about IUD safety persist. Fears date back to the 1970s, when hundreds of thousands of women in the U.S. testified about serious harms caused by the Dalkon Shield — an IUD that caused infection and even death, but has long since been removed from the market.

"I think that myth is still out there, that IUDs are going to cause infection and future infertility," [Dr. Casey Petra, an associate professor of obstetrics and gynecology at the Mayo Clinic] said, "but the perception is changing."

"This [new study] adds to our evidence that IUDs are safe and effective, as well as acceptable to women of all ages, including adolescents," she said.

An October 2012 study from the American College of Obstetricians and Gynecologists stated:

Intrauterine devices are safe to use among adolescents.

Current evidence demonstrates the safety of modern IUDs. Although few studies have focused exclusively on adolescents who use currently available IUDs, good evidence suggests that the relative risk of pelvic inflammatory disease (PID) is increased only in the first 20 days after IUD insertion and then returns to baseline, while the absolute risk remains small (15–17). Bacterial contamination associated with the insertion process is the likely cause of infection, not the IUD itself.

Long-acting reversible contraception (LARC) — intrauterine devices and the contraceptive implant — are safe and appropriate contraceptive methods for most women and adolescents. The LARC methods are top-tier contraceptives based on effectiveness, with pregnancy rates of less than 1% per year for perfect use and typical use.

As for CNS's statement that "IUDs, specifically, can also act as abortifacients by preventing the implantation of a fertilized egg," the Association of Reproductive Health Professionals categorizes that claim as a myth:

Myth: IUC works by causing an abortion.

Fact: IUC does not cause abortion.

IUC prevents pregnancy. ParaGard, Mirena, and Skyla work by keeping a woman’s egg and a man’s sperm from meeting. With ParaGard, copper repels sperm, so they don’t have a chance to fertilize an egg. The hormone in Mirena and Skyla thickens the mucus in the cervix, and that keeps sperm from reaching the uterus.

Multiple medical sources (such as WebMD)document that IUDs work by preventing fertilization or implantation, not by inducing abortion (i.e., the termination of an existing pregnancy):

Both types of IUD prevent fertilization of the egg by damaging or killing sperm. The IUD also affects the uterine lining (where a fertilized egg would implant and grow).

Hormonal IUD: This IUD prevents fertilization by damaging or killing sperm and making the mucus in the cervix thick and sticky, so sperm can't get through to the uterus. It also keeps the lining of the uterus (endometrium) from growing very thick. This makes the lining a poor place for a fertilized egg to implant and grow. The hormones in this IUD also reduce menstrual bleeding and cramping.

Copper IUD: Copper is toxic to sperm. It makes the uterus and fallopian tubes produce fluid that kills sperm. This fluid contains white blood cells, copper ions, enzymes, and prostaglandins.

The Seattle school board didn't actually prohibit students from consuming candy bars or soda at school; they enacted a ban on the sale or distribution of junk foods (including sugared sodas) at area schools beginning in 2005. Students can still bring those items with them from home in their lunches.

It's possible that the repeated comparison between schoolkids obtaining LARCs and buying Coca-Cola originated with a 27 May 2015 Grist article titled "A Seattle high school is taking birth control access to the next level":

Now, it’s as easy for a Chief Sealth student to get an IUD as it is to get a Coke — actually, easier, because pop is banned in Seattle schools.

I met with Katie Acker, health educator with Neighborcare, in the Chief Sealth clinic, which is fully outfitted with counselors’ offices, exam rooms, and even a kitchen. Katie is so bubbly, enthusiastic, and kind that talking with her made my teenage self a little jealous. Why didn’t I have such a great resource to talk to about birth control when I was growing up?

However, Chief Sealth High School comprises grades 9-12, so its student body is unlikely to include any 12-year-olds (unless they're extremely accelerated in their studies). Grist did not suggest than many (or any) sixth-graders were patients of the Seattle-area school-based clinics, but the site did offer numbers not provided in the article:

Since LARCs were made available to students in 2010, Acker tells me that Neighborcare has placed 500 of them in six schools in Seattle. There were approximately 10 placed the first year; by the 2013-2014 school year, that number had jumped to 170.

The number of pre-teens receiving LARCs wasn't offered in that article; but neither was any evidence supporting the idea that girls as young as 12 were regularly seeking out such forms of contraception.

The CNS article closed with a quote from an unspecified healthcare provider who "reportedly commented" (i.e., CNS didn't actually talk to this person):

Researchers found that “school-based health providers often cited their lack of formal training not only in inserting or removing IUDs and contraceptive implants, but also with the procedures in general.”

One health care provider who was interviewed reportedly commented: “It’s still scary to begin putting them in. Scary meaning that we know the biggest complication risk come with the least experienced providers. So how do you take that leap and just go for it?”

However, public health information from an official Washington State source clarified that, contrary to what claimed, schools themselves are not "offering" and "inserting" LARCs to students. The students are referred by schools to outside health care providers, and "IUD/IUS insertion is done by a specially trained doctor or health care provider," not by "school-based health providers" with a "lack of formal training."

An April 2015 article citing the Centers for Disease Control and Prevention (CDC) reported that IUD usage rates in teens (aged 15-19) has increased dramatically in recent years:

Specifically, the CDC found that the use of long-acting reversible contraception among 15-19-year-old females seeking contraceptive services from Title X sites increased from 0.4% in 2005 to 7.1% in 2013 — an increase by more than 15 times.

"Given the estimated 4.4 million sexually experienced female teens in the United States, and the high effectiveness, safety and ease of using [long-acting reversible contraception], continued efforts are needed to increase access and availability of these methods for teens," the CDC suggest.

The New York Times reported in July 2015 that a Colorado state program providing free intrauterine devices and implants to women, including teenagers, had a dramatic effect on decreasing the teenage birth rate in that state:

Over the past six years, Colorado has conducted one of the largest ever real-life experiments with long-acting birth control. If teenagers and poor women were offered free intrauterine devices and implants that prevent pregnancy for years, state officials asked, would those women choose them?

They did in a big way, and the results were startling. The birthrate for teenagers across the state plunged by 40 percent from 2009 to 2013, while their rate of abortions fell by 42 percent, according to the Colorado Department of Public Health and Environment. There was a similar decline in births for another group particularly vulnerable to unplanned pregnancies: unmarried women under 25 who have not finished high school.

“Our demographer came into my office with a chart and said, ‘Greta, look at this, we’ve never seen this before,’” said Greta Klingler, the family planning supervisor for the public health department. “The numbers were plummeting.”

The changes were particularly pronounced in the poorest areas of the state.

Kim LaCapria is a former writer for Snopes.

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