7
Socioeconomic and Cultural Influences on Contraceptive Use

Contraceptive knowledge and access (Chapter 5) are undoubtedly shaped by the surrounding socioeconomic and cultural environment, as are personal attitudes and feelings about contraception (Chapter 6). This observation is consistent with a number of studies—often called a real research—showing that various community attributes, as distinct from individual characteristics, are associated with the likelihood of using contraception (see, for example, Mosher and McNally, 1991; Singh, 1986; Tanfer and Horn, 1985). It is also consistent with data suggesting that the more favorable rates reported by numerous Western European and other industrialized countries on such maternal and child health measures as infant mortality partly reflect the more generous policies and supports that these countries often provide pregnant women and young families (Miller, 1993). Accordingly, this chapter discusses several socioeconomic and cultural factors that, in varying ways, may affect contraceptive use and therefore unintended pregnancy: the large and increasing diversity of the U.S. population (including ethnic, cultural, and religious diversity), conflicting views of sexuality and how such views might influence the use of contraception, economic issues, the roles that racism and violence play in various aspects of reproductive life, selected aspects of gender bias that relate to unintended pregnancy, and how organized opposition to abortion might affect access to contraception.

It is not always clear what the precise relationship is between these factors and the risk of unintended pregnancy. Nonetheless, in the aggregate, they help to form the environment in which individual decisions about contraception and sexual activity occur. Consideration of them must be part of any serious inquiry



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--> 7 Socioeconomic and Cultural Influences on Contraceptive Use Contraceptive knowledge and access (Chapter 5) are undoubtedly shaped by the surrounding socioeconomic and cultural environment, as are personal attitudes and feelings about contraception (Chapter 6). This observation is consistent with a number of studies—often called a real research—showing that various community attributes, as distinct from individual characteristics, are associated with the likelihood of using contraception (see, for example, Mosher and McNally, 1991; Singh, 1986; Tanfer and Horn, 1985). It is also consistent with data suggesting that the more favorable rates reported by numerous Western European and other industrialized countries on such maternal and child health measures as infant mortality partly reflect the more generous policies and supports that these countries often provide pregnant women and young families (Miller, 1993). Accordingly, this chapter discusses several socioeconomic and cultural factors that, in varying ways, may affect contraceptive use and therefore unintended pregnancy: the large and increasing diversity of the U.S. population (including ethnic, cultural, and religious diversity), conflicting views of sexuality and how such views might influence the use of contraception, economic issues, the roles that racism and violence play in various aspects of reproductive life, selected aspects of gender bias that relate to unintended pregnancy, and how organized opposition to abortion might affect access to contraception. It is not always clear what the precise relationship is between these factors and the risk of unintended pregnancy. Nonetheless, in the aggregate, they help to form the environment in which individual decisions about contraception and sexual activity occur. Consideration of them must be part of any serious inquiry

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--> into the reasons that lie behind high rates of unintended pregnancy in the United States. Diversity in U.S. Culture The large and increasing diversity of the U.S. population is unmistakably one of its strengths, celebrated throughout the country with flair and enthusiasm. It is also a factor that makes understanding the determinants of unintended pregnancy more difficult. For example, even the concept of unintended pregnancy may be alien to some groups whose views of pregnancy and childbearing may be based more on fatalism or other value systems than the notion that these events can or should be carefully planned by such artificial means as contraception. Appreciable diversity can also complicate the task of designing culturally competent intervention programs that respect differences in feelings and values regarding unintended pregnancy, contraception, and related topics. This section briefly explores several aspects of diversity: cultural, ethnic, religious, and political. Cultural and Ethnic Diversity The United States is already a diverse mix of cultural, racial, and ethnic groups, and will be even more so in future years. The Bureau of the Census estimates that by the year 2050, non-Hispanic whites will constitute 56 percent of the U.S. population, versus 76 percent in 1990; people of Hispanic origin will be 20 percent of the population in 2050, versus 9 percent in 1990; and the proportion of blacks will grow from 12 to 14 percent over the same interval (Day, 1993). Similarly, some projections suggest that non-white individuals will be the majority in as many as 53 of America's largest cities only 5 years from now, by the year 2000 (Nestor, 1991). The full impact of such diversity is not just a promise for the future, however. School districts in some sections of the country already report that their enrolled children represent many different language groups. One school in suburban Virginia claims that there are more than 36 language groups represented in its student population. Even the terms used to describe the growing diversity of the United States—Asian/Pacific Islander, Middle Eastern, or Hispanic/Latino—fail to capture the full complexity. For example, Asian/Pacific Islanders include Laotians, Cambodians, Vietnamese, Hawaiians, Filipinos, Samoans, Guamanians, Japanese, Chinese, Koreans, and others as well. Moreover, in assessing ethnic, racial, and cultural diversity, it is important to distinguish recent immigrants, such as the majority of Southeast Asians now in the United

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--> States, from native-born Americans such as the vast majority of black Americans. This cultural and ethnic diversity is reflected in widely varying knowledge about and attitudes toward contraception and fertility control. For example, some immigrants arrive in the United States from countries whose systems of family planning services are arguably better organized than those here and whose range of available contraceptive methods is broader. Some bring with them rich traditions of folk medicine (such as reliance on herbal medicines and various folk remedies and use of neighborhood practitioners rather than doctors for health care) that do not always blend easily with U.S. approaches to medicine in general or contraception in particular. Some contraceptive methods available in the United States may be unfamiliar to recent immigrants, and the health care system that one must negotiate in the United States to obtain the more effective methods is certainly different, and often more complicated and inaccessible, than systems in the immigrants' countries of origin. Contraception especially may be associated with images and practices that limit its acceptability. For example, in Thailand, condom use is associated with a vigorous prostitution industry in that country, which may mean that efforts in the United States to encourage greater condom use might be resisted by recent Thai immigrants (Healthy Mothers, Healthy Babies Coalition, 1993). For illegal immigrants, the task of securing contraception may be further complicated because of their general inability to use such programs as Medicaid to help finance primary health care, including contraceptive services. Religious and Political Diversity As fundamental human behaviors, sexuality and family formation represent legitimate areas of concern for most organized religions. Thus, the moral or ethical principles expounded by religious leaders include such issues as the appropriate age of onset of sexual activity, the regulation of non-marital sexual activity, contraception and abortion, appropriate partners, rituals for recognition of marital unions, and responsibilities and obligations for child rearing. As a country historically considered a refuge for those experiencing religious persecution, the United States is characterized by a large number of religious groups quite heterogeneous as to their principles and practices and the historical antecedents of their beliefs. Despite the sometimes quite ancient lineage of these principles and prescriptions, the current entanglement of religious and political groups over issues of sexuality and contraception in the United States reflects a relatively recent effort of religious groups to adapt to events coming to prominence largely in this century (D'Antonio, 1994). As discussed elsewhere in this report, these events include the development of effective and reliable means of contraception,

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--> wider access to safe abortion, a broader and often conflicting array of sources of information on sexual behavior and mores including the media and sexuality education provided in public schools, and an overt recognition of and pressure to accept sexual activities and alternate family configurations not consonant with traditional religious teachings. In addressing the current overlap of religious doctrine and political ideology, it is helpful to consider several separate dimensions, including the appropriate locus for transmission of information and values regarding sexual behavior and family function, the use of contraception both within and outside of marriage, the increased public visibility and wider availability of abortion, the extent to which individuals adhere to the official positions of their religious, and the use of political strategies to assert religious and philosophical positions. Most organized religions transmit values through an alliance with the family, both through formal instruction during or in conjunction with religious services and through modeling of behavior by the family. This traditional mode of transmission has been complicated by the availability of alternative sources of information, especially media. In response to persistently high rates of teenage pregnancy, and more recently the spread of HIV, efforts have been undertaken to provide information and more appropriate models of behavior through the schools. Although most organized religions support such efforts, some individuals perceive the information and values to run counter to their own religious principles. They view these efforts as encouraging premature sexual activity and sexual activity outside the bounds of formally approved unions. Hence, such efforts are perceived as undermining traditional family values. In contrast to issues surrounding the transmission of values that generally involves custom rather than formal principles, many organized religions have formal principles dealing with contraception and abortion. Most religions encourage responsible procreation within the confines of marital unions. Most did not, however, have strong moral or ethical traditions regarding contraception and abortion until this century, and there is only a very limited scriptural background on these issues. In Judeo-Christian traditions, only one Biblical passage can be construed as dealing with contraception (and that interpretation is controversial), and the Koran does not have any clear-cut teaching on this topic. Thus, most religious traditions prior to this century reflected the teachings of religious scholars, often in response to specific questions, events, or heresies. Until this century, most Christian scholars condemned contraception and abortion, with more variability within the Jewish and Islamic traditions (D'Antonio, 1994). In the 1930s, however, this situation changed when the mainline Protestant churches in the United States began to approve contraceptive use by married couples and then later to accept abortion. As is well known, the Roman Catholic Church formally forbids the use of any contraceptive techniques other than

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--> ''natural family planning" or the rhythm method, and any use of abortion for any reason. Other conservative religious groups also proscribe contraception and abortion, including the Lubavitcher Hasidic sect, the Church of Latter Day Saints, and several conservative fundamentalist and evangelical groups (Carlson, 1994; D'Antonio, 1994). Regardless of the formal religious positions on sexual activity and control of fertility, substantial variation in practice occurs among those belonging to specific religious groups. The most dramatic example is the disparity between the position of the Catholic Church and most of its American members regarding contraceptive use. Despite the Church's clear stand against artificial means of birth control, most Catholic women and couples in the United States use a wide variety of contraceptive methods; 75 percent of white Catholic couples practice contraception, and among those couples, 63 percent use sterilization or oral contraceptives (Goldscheider and Mosher, 1991). Not surprisingly, the major predictor of personal practice is the degree of "religiosity," that is, the degree to which religion is seen as important and to which individuals observe other aspects of their religion (D'Antonio, 1994). The considerable diversity of opinion among organized religions and the considerable diversity of personal practice among the membership of these religions, do not, by themselves, explain the vehemence of the current political debate on abortion and family values. The major change over the past decade has been the emphasis on conservative forms of family values and a coalescence of Catholics and the conservative elements within many Protestant denominations into politically active groups. Although certainly initiated among Roman Catholics, this movement now includes a large number of conservative Protestants who share a common vision of a threat to traditional family values. Furthermore, although the National Conference of Catholic Bishops has certainly played a seminal role in bringing its resources to political activity, evangelical Protestant groups such as the Moral Majority are equally committed and also bring substantial resources (Carlson, 1994). Even though people and financing are important elements in attaining political power, another element also contributes to the current political climate. Blendon and colleagues (1993) report that the majority of Americans support the availability of abortion, but they do so conditionally and do not consider it their most important political issue. By contrast, those who strongly oppose abortion view it as a top priority and often vote for candidates on the basis of their expressed positions on abortion. In exploring this phenomenon more carefully, Blendon and colleagues (1993) found that there is no evidence that groups who strongly support abortion vote with the same single-issue orientation as do those who strongly oppose abortion. They also found that the tendency to view political issues through the lens of abortion is directly related to an individual's participation in his or her religion (or to their degree of "religiosity"). One noteworthy aspect of the continuing opposition to abortion is that some of those

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--> who strongly oppose abortion are increasingly engaged in aggressive and organized political activity at all levels of government with abortion as their major, but no longer their sole, focus. This issue is addressed directly later in this chapter under the heading "Opposition to Abortion." The expansion of opposition to abortion into opposition to other aspects of reproductive health, especially contraception and family planning, is a puzzling and distressing development, inasmuch as contraception helps to reduce the need for abortion by reducing the occurrence of unintended pregnancies in the first place. In summary, the availability of effective contraception and abortion and the broader range of sexual behavior considered acceptable in many groups in the United States present a challenge to those espousing traditional family values. Although the majority of Americans profess relatively tolerant attitudes, there is no single shared ethic about what constitutes appropriate family structures or sexual behavior. In response to what is perceived as a threatening liberalization of sexual behavior, conservative elements of many religious denominations have joined in a common cause to protect what are defined as traditional values. The political controversy, in contrast to the moral controversy, reflects the fact that these groups are willing to use the resources of their religious groups for campaigning and lobbying, and they represent single-issue constituencies voting solely on the issues of abortion and family values. Participation in such political activity is less a function of formal religious affiliation than of degree of attachment to religion or religiosity (D'Antonio, 1994).1 Conflicting Views About Sexuality A particularly provocative explanation for the patterns of contraceptive misuse and nonuse (and therefore unintended pregnancy) seen in the United States is that American culture embraces conflicting views and attitudes toward sexual behavior, and that this underlying inconsistency impedes discussion about, and careful use of, contraception (Reiss, 1991). As Rhode (1993–1994:657) has said so bluntly, "Few if any societies exhibit a more perverse combination of permissiveness and prudishness in their treatment of sexual issues." This reluctance—this "prudishness," it is suggested—makes it difficult to disseminate clear, accurate information about contraception, which in turn may limit contraceptive use. Advocates of this perspective cite a wide variety of data, noted below, to support this point of view. The first is that the Victorian ideal of coitus only within marriage and with only one partner lingers in the American consciousness, despite the fact that 1   Appendix B presents additional historical perspectives on the interaction of religion and contraception.

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--> patterns of sexual activity now bear little if any resemblance to that bygone era. As noted earlier, the age of first intercourse has steadily dropped, and the image of virginity until the time of marriage—often a fiction in part—is now significantly out of line with current American practices. For example, among women who turned age 20 between 1985 and 1987, almost three-fourths (73 percent) had had intercourse before marriage and before turning age 20 (The Alan Guttmacher Institute, 1994). But even in the face of large numbers of people having nonmarital sex at all ages and with more than one partner, there is still appreciable support for virginity if one is not married (Haffner, 1994). In a study undertaken by Klassen and colleagues (1989), for example, half of the adult respondents reported that they disapproved of adult women having nonmarital sex with a partner they love, and 41 percent disapproved of men doing so. There are other examples of the mismatch between image and reality as well. Sexual activity in late adolescence has become increasingly common in recent years (Laumann et al., 1944). In the late 1960s, for example, about 55 percent of boys and 35 percent of girls had had intercourse by the age of 18; by the late 1980s, these figures had increased to 73 percent for boys and 56 percent for girls (The Alan Guttmacher Institute, 1994). Nonetheless, a majority of adults disapprove of unmarried teenagers having sexual intercourse (Haffner, 1994). Moreover, although three-fourths of adults believe that unmarried teenagers should have access to contraception, and almost all would want their children to use contraception if the children were sexually involved (Gallup Organization, 1985; Timberlake and Carpenter, 1990), only a third of parents who have talked about sex with their children say that they have included any discussion about contraception (Klassen et al., 1989). Such data suggest that opinions and feelings about sexual behavior may not fit comfortably with contemporary reality (particularly as regards adolescents)—a dynamic that may well limit the ability of individuals and communities to communicate clearly about numerous sexual topics, including ways to reduce unintended pregnancy. The Media Observers of the print and electronic media are especially persuasive in suggesting that mixed messages regarding sex and contraception dominate these pervasive forms of communication, and that the prudishness that Rhode (1993–1994) has referred to impedes clear communication about contraception especially. On the one hand, popular American media (network programming, music videos, advertising, etc.) are filled with sexual material; on the other hand, there is a noted absence of equal attention to contraception, responsible personal behavior, and values in sexual expression. The United States has, in effect, a media culture that glorifies sexual activity (especially illicit, romantic

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--> sex between unmarried people), but is squeamish about contraception. McAnarney and Hendee (1989:78) note, "The print and electronic media are filled with seductive messages, yet [Americans] are given little support or assistance in understanding sexual feelings, defining responsible sexual behavior, and learning respect for themselves and for others." That the media are saturated with sexual material is incontestable. A 1991 study of sexual behaviors on network prime time television (i.e., ABC, CBS, NBC, and Fox) found an average of 10 instances of "sexual behavior" per hour (Lowry and Shidler, 1993). Given that a full 98 percent of American households have a television, many more than one, and that 71 percent of U.S. households are tuned in to a network television program during prime time, the exposure level is clearly very high (Brown and Steele, 1994). Although the overall prevalence of sexual material had declined slightly since a similar study was conducted 4 years earlier, in 1987, decreases in portrayals of prostitution and physical suggestiveness (displays of the body without touching) were almost offset by increases in portrayals of heterosexual intercourse (e.g., mentions or allusions to intercourse, as well as suggestive or actual images). Such portrayals on television increased by 84 percent between 1987 and 1991, from 1.8 to 3.3 behaviors per hour (Lowry and Shidler, 1993). Moreover, the promotional messages for other prime-time programs that surround regular programming include even higher rates of sexual behavior. Lowry and Shidler conclude that the networks "clearly are using sex as bait in promos to attempt to increase their ratings." When the sexual behavior in promos is added, the rate of sexual behaviors per hour increases from about 10 to more than 15 (Lowry and Shidler, 1993:635). With regard to cable television, videocassettes, music rock videos, and movies, the picture is similar. For example, "adult programming" (i.e., X-rated content designed specifically to portray explicit sexual behavior) is cable television's fastest growing segment (Kaplan, 1992). With the advent of a fiber optic infrastructure, a projected 500 channels are expected to include even more such programming. The videocassette recorder (VCR) also provides greater access to sexually explicit material. In 1993 two of the most frequently purchased videos featured Playboy centerfold Jessica Hahn and the "Playmate of the Year" (Billboard Magazine, 1994). Moreover, according to recent content analyses, sex is more frequent and more explicit in movies than in any other medium. Virtually every R-rated film contains at least one nude scene, and some favorites, such as Fast Times at Ridgemont High and Porky's, contain as many as 15 instances of sexual intercourse in less than 2 hours (Greenberg et al., 1993). Despite the R-rating that supposedly restricts viewing to people over 18 unless accompanied by an adult, two-thirds of a sample of high school students in Michigan reported that they were allowed to rent or watch any VCR movie

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--> they wanted, and the movies they most frequently viewed were R-rated (Buerkel-Rothfuss et al., 1993). Such sexual enticement is not balanced by or accompanied by clear messages about avoiding unintended pregnancy or sexually transmitted diseases (STDs) or about managing sexual activity in a safe, caring, and healthy manner. For example, few television programs ever mention the adverse consequences that may result from having sex—rates of mention of pregnancy or disease declined to about one per 4 hours of programming between 1987 and 1991. Thus, a typical viewer would see about 25 instances of sexual behavior for every 1 instance of preventive behavior or comment. Even then, the message may not be constructive—all of the references to STDs coded in the Lowry and Shidler study, for example, were in a joking context (Lowry and Shidler, 1993). The issue of contraceptive advertising on television brings the mixed message issue into sharp relief. Despite the high level of sexual activity in television programming, as just described, the major national networks have adopted the position that contraceptive advertising will not be accepted, although there is more receptivity on cable and independent stations, and some local affiliates as well, mainly to messages about condoms. Lebow (1994) reports, for example, that ABC feels that in catering to a mass audience, contraceptive advertising would be controversial and offend the moral and ethical tastes of a good part of its audience, and the Fox network says that it will possibly accept condom advertisements only if they are designed to prevent disease; messages about preventing unintended pregnancy remain off limits. Similar views constrain the airing of public service announcements (PSAs) that offer general information about contraception, although there were some brief periods of receptivity to selected PSAs developed by the Planned Parenthood Federation of America and the American College of Obstetricians and Gynecologists. By contrast, the print media have been more accepting of contraceptive advertising. Advertisements for birth control now routinely appear in many magazines and some, though not all, newspapers (Lipman, 1986). Interestingly, public opinion appears to favor contraceptive advertising through the media. A Roper organization survey in 1991 found that two-thirds of Americans age 18 or older supported the airing of contraceptive advertisements (Lebow, 1994).2 2   It is important to note that television advertising of such prescription-based methods as oral contraceptives faces restrictions from the Food and Drug Administration, which requires that complete listings of risks and side effects accompany any advertisement—a requirement that is not practical for television in particular. Recently, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Medical Association, and others have urged that new policies and guidelines be developed to allow direct advertising to consumers of these effective methods.

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--> Commercial advertisers may be limited in their ability—and sometimes their willingness—to promote contraception directly, but they often use sexual appeals to sell their products. A study of 4,294 network television commercials found that 1 of every 3.8 commercials includes some type of attractiveness-based message (Downs and Harrison, 1985). Although most advertisements do not directly model sexual intercourse, they help set the stage for sexual behavior by promoting the importance of beautiful bodies and products that enhance attractiveness to the opposite sex. In sum, all forms of mass media, from prime-time television to music videos, magazines, advertising, and the news media, include vivid portrayals of sexual behavior. Sexual activity is frequent and most often engaged in by unmarried partners who rarely appear to use contraception, yet rarely get pregnant. Does exposure to such content contribute to early or unprotected sexual intercourse with multiple partners and high rates of unintended pregnancies among both adolescents and adults? At this point, more is known about what is in the media and how much people are exposed to it, than is known about how the media's content is interpreted or how it affects sexual behavior. According to classic social scientific methods, an ideal test of the effect of sexual content in the media would involve either randomized assignment to different media diets or longitudinal surveys. Such studies would establish whether media exposure or the specific behaviors of interest came first. Unfortunately, the perceived sensitivity of sex as a topic and a focus on adolescents and television to the exclusion of other age groups and other media have restricted the kind of research that has been done. Only a handful of studies has attempted to link exposure to such measures as audience beliefs, attitudes, or subsequent behavior. Moreover, a number of factors, such as gender, cultural background, developmental stage, and prior sexual experience, influence what media are attended to and how images are interpreted. It is reasonable to expect, for example, that individuals who are more sexually active and people who are anticipating having sex will see media content about sexuality as more relevant and thus seek it out. The most likely scenario is that the media's influence is cyclical—individuals who are interested in sex begin to notice sexual messages in the media, may be influenced by and act on them, and then may attend to such messages more in the future (Brown, 1993). In a comprehensive review of the literature in this area covering both correlational studies as well as experimental studies, Brown and Steele (1994:16) concluded that "the few existing studies consistently point to a relationship between exposure to sexual content and sexual beliefs, attitudes, and behaviors." For example, studies of adolescents have found that heavy television viewing is predictive of negative attitudes toward remaining a virgin. Two studies have found correlations between watching high doses of "sexy" television and early

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--> initiation of sexual intercourse (Brown and Newcomer, 1991; Peterson et al., 1991). There probably are useful lessons to be learned from reviewing the large literature on the role of the media in violent behavior. Violence and sex have been used throughout the short history of television, and for a longer time in other media, to attract attention and arouse viewers, keeping them interested enough so that they will attend to the advertising. Both violence and sex are frequently and positively portrayed. Further studies of the impact of the media on sexual behavior may well find patterns of effects similar to those established for violence. More than 1,000 studies have consistently found small positive relationships between exposure to violent content in the visual media (primarily television and movies) and subsequent aggressive and antisocial behavior (Comstock and Strasburger, 1993). Both the 1972 Surgeon General's Report and a 1982 report from the National Institute of Mental Health concluded that exposure to violence in the media can increase aggressive behavior in young people (Brown and Steele, 1994). International Comparisons Cross-national comparisons give added weight to the idea that America's conflicted views and values regarding sexuality contribute to unintended pregnancy. Noting, for example, that in Denmark the proportion of pregnancies estimated to be unintended is far lower than that in the United States, David and colleagues (1990:3) have commented: In Denmark, as in other Nordic countries, the approach to sex is pragmatic, not moralistic. Most Danes deem sexuality as a natural and normal component of a healthy life, similar to eating and sleeping, for which individuals must assume personal responsibility through effective contraception to prevent unintended pregnancies. Sexuality and contraception are openly discussed in the media and the location of contraceptive counselling centers is advertised. Information is provided to children at an early age. There is an entrenched national consensus to limit childbearing to wanted pregnancies. A different set of investigators (Jones et al., 1986) expressed a similar view after studying the factors associated with varying patterns of teenage fertility in the United States and several other industrialized countries. One of their conclusions was that, compared with several other countries with lower rates of teenage childbearing, the United States is far less open about sexuality in general. The authors refer to the "underlying puritanical values" in the United States as limiting effective, easy communication about the importance of using

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--> programs, and research have begun to probe the complicated relationship of men to contraception, pregnancy, and parenthood (Edwards, 1994). Some of this increased attention to men undoubtedly derives from the explosion of STDs, including HIV and AIDS, and the fact that one of the best means of preventing the transmission of STDs is through the male use of condoms. Another factor is the recent increase in nonmarital childbearing and the deepening concern over the number of children in the United States, especially black children, who will spend significant portions of their childhood and adolescence in households without fathers. The passage of the Family Support Act of 1988 also focused attention on men and family formation by developing new procedures to establish paternity and to collect child support payments from fathers, regardless of marital status, through the Child Support Enforcement Program. Current welfare reform proposals put even greater emphasis on establishing paternity. Heightened attention to gender bias in many aspects of American life may also be contributing to the increasing interest in the male role in family planning. Research has also focused attention on men, particularly the accumulating evidence that contraceptive use by women is affected by partner communication and attitudes, as detailed in Chapter 6. Sonenstein and Pleck (1994) have concluded that males are relatively more involved in females' decisions to use female methods than is often realized. As early as 1978, Thompson and Spanier's multivariate analysis in a college sample found that of all the variables examined, male encouragement to use a method of contraception was the strongest predictor of female use of a method. As a general matter, however, males are at the fringes of the nation's complex system of family planning services, in part because many of the most effective methods of contraception are used by females, and also because of the simple biological fact that pregnancy occurs in women, not men, and therefore women have the greatest self-interest in managing contraception. Very few males turn to family planning clinics or health personnel for contraceptive supplies. In the 1991 follow-up interviews for the National Survey of Adolescent Males, for example, only 3 percent of all 17- to 21-year-old males—but 9 percent of black males—indicated that they had obtained the last condom they used from a clinic or a physician (Sonenstein and Pleck, 1994). These low rates of clinic participation by males conform with evidence provided by a recent survey of 421 publicly funded family planning clinics. Eighty-seven percent of these clinics' administrators reported serving no male clients (31 percent) or fewer than 10 percent male clients (56 percent) (Burt et al., 1994). Across all the clinics, the average proportion of male clients served was approximately 6 percent. Similarly, it is estimated that 2 percent of Title X program clients in 1991 and 2 percent of Medicaid family planning recipients in 1990 were male (Ku, 1993). Since Medicaid eligibility is based primarily on participation in AFDC or recent program expansions to low-income pregnant women, it is not surprising that few males receive family planning services

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--> through Medicaid. However, there is nothing in Title X law that forbids the use of these funds for men (Danielson, 1988). Even though most family planning clinics report serving few male clients, they do not ignore condoms. Virtually all of the clinics surveyed by Burt et al. (1994)—99.6 percent—reported that they provide condoms, but it was more often for supplementary protection, not as the primary method. In fact, a recent survey revealed that three-fourths of family planning clinic workers say that they encourage most or all of their clients to use condoms regardless of the primary method chosen for contraception. Although many try, however, only one-fifth think that they are successful with most or all of their clients. Some family planning clinics also do outreach to male clients. Thirty percent of the clinics are reported by their administrators to have recruiting efforts targeted to males (Burt et al., 1994). These various data sets portray a family planning system that for the most part does not serve male clients, although condoms are made available to the female clients. Because various data suggest that men believe contraception is a joint responsibility, future efforts to involve men may well be successful. For example, in the 1988 National Survey of Adolescent Males (aged 15–19), 97 percent of the young men responding agreed that ''before a young man has sexual intercourse with someone, he should know or ask whether she is using contraception," and 95 percent agreed that "if a young man does not want to have a child, he should not have intercourse without contraception" (Sonenstein and Pleck, 1994). Opposition to Abortion The Supreme Court ruling in 1973 that declared abortion legal in all 50 states and the District of Columbia spawned a vigorous movement to restrict access to and the legality of abortion in the United States. Variously labeled the "anti-abortion" or "right-to-life" movement, this force has had a marked presence in local, state, and national political campaigns, including the last few presidential elections, in family planning service programs and funding, and in the process by which funds are appropriated for research and for reproductive health services generally. The movement exists despite the fact that a majority of Americans continue to support the availability of safe, legal abortion, albeit with a variety of restrictions (Blendon et al., 1993), as noted earlier in this chapter. Organized opposition to abortion has led to legislative restrictions in numerous states on access to abortion (National Abortion and Reproductive Rights Action League, 1994), along with efforts to maintain blockades and other barriers at facilities where abortions are performed. In addition, some of those who oppose abortion now extend their opposition to other issues as well, such as school-based sex education, and are increasingly active at the local level,

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--> where they may seek to influence the composition of school boards and to control the content of curricula regarding human sexuality. The increasing stridency and polarization of public debate over abortion, sex education, and other related topics has created an atmosphere that endangers political and public financial support for sex education, family planning, and the provision of legal abortions. The growing intensity even endangers the lives and resources of those providing these services, as the increasingly vehement rhetoric may be seen as a signal to action by those prone to violence. In particular, the movement has been associated with systematic and increasing harassment of abortion facilities and their personnel, including several murders. The National Abortion Federation (1993) reported that between 1977 and 1993, there were more than 6,000 incidents of clinic disruptions, 589 blockades against family planning and abortion clinics, and almost 1,500 acts of violence against abortion providers. Abortion facilities that are not based in hospitals are more likely to be harassed than those that are based in hospitals, as are facilities that perform relatively higher volumes of abortion. More than half of the providers who perform more than 400 abortions annually report that they have been picketed at least 20 times annually as well (Henshaw, 1991). The relationship of abortion opposition to unintended pregnancy centers on three issues: first, because some facilities that provide abortions also dispense contraceptive services and supplies, any restriction on access to abortion facilities may also limit access to contraception; second, the number of unintended pregnancies resolved by abortion rather than childbearing may be affected; and three, the general climate of controversy created around the issue of abortion may spill over into other areas of reproductive services and education, confusing clients about what services are actually available and with what restrictions, affecting the morale and performance of those who work in the family planning field, and encouraging an atmosphere of high emotion on all issues of reproductive and sexual health, not just abortion. With regard to the first issue, data show that only about 85 of the 4,000 contraceptive clinics that receive funding from the federal Title X program perform abortions (using funds other than Title X funds); and about half of these 85 are in hospitals (L. Kaeser, pers. com., 1994). Looked at from the opposite side, however, it is also apparent that many abortion facilities also are a main source of contraceptive services as well. Depending on how one defines a "nonhospital abortion facility," in 1989 somewhere between 83 and 94 percent of such facilities also provided contraceptive care to nonabortion patients. These facilities also offer many other services, including screening and treatment for STDs, general gynecologic care, and infertility services (Henshaw, 1991). To the extent that these facilities and their clients are harassed because of the facilities' abortion activities, access to contraceptive services is compromised, which in turn may contribute to the incidence of unintended pregnancy. Crossing

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--> a picket line to obtain an abortion is undoubtedly stressful; crossing the same picket line for a contraceptive visit—or even worrying that obtaining contraception could require confronting protesters—might be enough to avoid making the trip altogether and cause a couple to rely instead on less effective, nonprescription methods of birth control. With regard to the second issue—that the ratio between unintended pregnancies resolved by abortion rather than childbearing may be affected by opposition to abortion—there are some data to suggest a possible connection. Recently, the number of abortions performed in the United States has begun to decline; in 1992, 1.5 million abortions occurred versus 1.6 million in 1990 (Henshaw and Van Vort, 1994), and a decreasing proportion of all pregnancies, including unintended pregnancies, are now being resolved by abortion (Henshaw and Van Vort, 1994; Henshaw et al., 1991) (see also Chapter 2). It is possible that at least one reason for such trends is the discomfort and fear among both patients and providers caused by the harassment described above. Other factors that may help to explain the decreasing number of abortions include a changing age structure in the population, with more women in the older age groups among whom abortion is less common, and less punitive attitudes towards nonmarital childbearing (Henshaw and Van Vort, 1994). An additional factor that is probably contributing to the decrease is the decline in the number of facilities that perform abortions. Between 1978 and 1992, for example, the number of counties that reported the presence of at least one abortion provider declined by more than 30 percent, such that by 1992 more than 80 percent of all counties in the United States and more than half of all metropolitan counties had no abortion provider at all. Similarly, it is estimated that over the last decade and more, the number of clinics, hospitals, and physician offices that perform abortions has declined by approximately 65 a year (Henshaw and Van Vort, 1994). Again, this may reflect fear among providers, some of whom are understandably reluctant to work at an clinic that provides abortion services. The decline in the number of abortion providers may also reflect the limited training in the procedure that many physicians now receive, particularly as compared to several years ago. Goldstein (1995:A11) recently reported that "in 1975, two years after Roe, all but 7 percent of U.S. medical schools offered training in abortion to obstetrics residents, and 26 percent required it. By 1992, one third were not given any training, even when residents requested it, and 12 percent included it as a requirement." Similarly, Westoff and colleagues (1993) report that most programs training family practice physicians as well as obstetrician-gynecologists do not require competency in this procedure. Although the Accreditation Council for Graduate Medical Education recently revised its requirements for obstetrics-gynecology residency programs to insist that training in abortion be provided (with a few narrowly defined exceptions for religious or moral objections), these new requirements will not

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--> take effect until 1996, and their impact on abortion availability may not be apparent for several more years after that. The third issue—that the general climate of controversy created around the issue of abortion may spill over into other areas of reproductive services and education—is less easily documented, although field reports suggest that this is the case. Some of the more vocal opposition to sex education provided in the schools, for example, is reported to be from anti-abortion groups (Haffner, 1994). Furthermore, Zero Population Growth (1993) reports that "the majority of anti-abortion organizations are also opposed to the use of and access to contraception." In part, this is probably due to the fact that some of these groups are loosely affiliated with, or closely tied philosophically to, the Catholic Church, which has taken a strong stand against all forms of contraception except periodic abstinence. The recent bombings of four contraceptive clinics that perform no abortions at all (located in Pennsylvania, Minnesota, Ohio, and Vermont) suggest that the high level of conflict that surrounds abortion may indeed place those who provide other related services at risk of violence and harassment (C. Glazer, pers. com., 1994). It is also important to note that opposition to abortion, sometimes accompanied by opposition to organized family planning programs as well, has also affected a surprisingly wide variety of basic statistical and research functions related to unintended pregnancy. For example, some state and local systems to collect information on the number of abortions being performed (as well as on their possible complications) have been curtailed. That is, because some object to abortion, fewer abortion-related data are collected—a development that has affected the federal abortion surveillance system operated by the CDC, which relies on these state and local estimates in compiling its own aggregate statistics. Similarly, some systems to collect information on publicly supported family planning programs were shelved for years; research sponsored by such public agencies as the National Institutes of Health has been scrutinized and occasionally reshaped quite directly by abortion opponents; and efforts to increase public information and education about such lethal problems as HIV/AIDS have been stymied as well. The net result of such ideologically-driven developments has been to create a climate in which it has been increasingly difficult to take action to reduce unintended pregnancy, inasmuch as this particular problem can easily get entangled in the "culture wars" of recent years about abortion, contraception, and sexual behavior—wars that appear to be ongoing. Conclusion Many of the factors that may influence contraceptive use and therefore unintended pregnancy touch some of the most controversial and important issues facing contemporary U.S. society. The large number and great complexity of

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--> these forces—cultural values regarding sexuality, racism, violence against women, gender bias, the content of the media, and others as well—suggest that no single or simple remedy is likely to solve the unintended pregnancy problem. Research has not probed how some of the issues noted earlier in this report—contraceptive knowledge and access, as well as personal and interpersonal factors—are affected by the larger social phenomena outlined in this chapter. Nonetheless, it is reasonable to conclude that achieving major reductions in unintended pregnancy will require that socioeconomic and cultural issues be engaged. References Acs G. The impact of AFDC on young women's childbearing decisions. Discussion Paper No. 1011-93: Madison, WI: Institute for Research on Poverty; 1993. The Alan Guttmacher Institute. Sex and America's Teenagers. New York, NY; 1994. American College of obstetricians and Gynecologists. The Abused Woman. ACOG Patient Education Pamphlet No. 83. Washington, DC; 1989. American Medical Association. Graduate Medical Education Directory, 1994–1995. Chicago, IL: American Health Information Management Association; 1994:91. Bates KG. Is it genocide? Essence. September 1990:76–78, 118. Billboard Magazine. Top video sales. January 8, 1994. Blendon RJ, Benson JM, Donelan K. The public and the controversy over abortion. JAMA. 1993;270:2871–2875. Boyer D, Fine D. Sexual abuse as a factor in adolescent pregnancy and child maltreatment. Fam Plann Perspect. 1992;24:4–19. Brown JD. Theoretical overview. In Media, Sex and the Adolescent. Greenberg BS, Brown D, Buerkel-Rothfuss N, eds. Cresskill, NJ: Hampton Press; 1993. Brown JD, Newcomer SF. Television viewing and adolescents' sexual behavior. J Homosex. 1991;21:77–91. Brown JD, Steele JR. Sex, pregnancy and the mass media. Paper prepared for the Committee on Unintended Pregnancy, Institute of Medicine. Washington, DC; 1994. Buerkel-Rothfuss NL, Strouse IS, Pettey G, Shatzer, M. Adolescents' and young adults' exposure to sexually oriented and sexually explicit media. In Media, Sex and the Adolescent . Greenberg BS, Brown JD, Buerkel-Rothfuss NL, eds. Cresskill, NJ: Hampton Press; 1993. Bureau of Justice Statistics. Child Rape Victims, 1992. Publication No. NCJ-147001. Washington, DC: U.S. Department of Justice; 1994. Burt MA, Aron LY, Schack L. Family planning clinics: Current status and recent changes in services, clients, staffing and income sources. In Publicly Supported Family Planning in the United States. Washington, DC: The Urban Institute and Child Trends, Inc.; 1994. Butler J, Burton L. Rethinking teenage childbearing: Is sexual abuse a missing link? Fam Relat. 1990;39:73–80.

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