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. .-.-.-:-:-:-:-:-:-:-:-:-.-.-. . .. -:-::::-:-:-:-:-:-:-:-:-::::::::-:-.- ::--- :::-. ~ .-:-:-:-:-:-:-:-:---------------:-:-:-:-:-:-:-:-:-: . -:-:-. .-::-:-:::: ::-: :'::-:-::-. -:-:-:::::::::::::-:- :::-. I-:- : - ~:-: : -- :-: . i.! ~ -I - - I . ~ -:. - . : .. - - - .:.-:-- -: - - .. -:- -.-.- .- ' 2----:-.- -:-:--:-- ::: Health Through the Life Span: The Firsi; Two Decades Carved into the granite lintel over the entrance to the National Archives in Washington, D.C., is a line from Shakespeare's The Tempest: C`What's past is prologue." The Bard intended the phrase to illuminate human nature; the builders of the nation's document repository, to affirm the importance of historical study. But the motto just as aptly encapsulates a central fact about physical and mental health: today's condition derives from yesterday's and affects tomorrow's. To an enormous extent, perhaps even greater than among men, the motto holds true for women. A woman's personal history her weight at birth, the timing of major life events, various choices she makes, the pressures that impinge on her casts a long shadow over her physical and mental well-being throughout her lifetime. Did she develop a taste for athletics in childhood? Did her menarche come early or late? Did she succumb to peer culture during adolescence? Has she had few or many sexual partners? Has she used safe and effective contraceptives? Did she build strong bones during youth? Did she bear children as a young woman, in middle age, or not at all? Did she receive hormone treatment at meno The discussion of the life-span perspective as it applies to women's health derives from the IOM report In Her Lfetime: Female Morbidity and Mortality in Sub-Saharan Africa. 53

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I N H E R O WN R ~ G HT pause? Does she survive her husband? Each of these facts, though seem- ingly minor in itself, nonetheless can influence such large matters as how long she lives, how well she feels at various points in her life, and what ailments befall her. As biographers and novelists have long known, the perspective of a person's entire life span affords a special insight into the ages and stages that compose his or her allotment of individual days. Medical re- searchers, however, have only lately come around to this insight and have only in recent years begun to appreciate fully the power of the long view to clarify health conditions, particularly of women. Until not very long ago, for example, the idea of pregnancy used to distort analyses of women's health even more than the fact of it alters their silhouettes. The capacity to conceive, carry, birth, and nurse healthy babies, or to efficiently avoid doing so, focused interest as an expectant mother's belly draws attention from her arms, legs, even her face on a single, transitory aspect of her being, to the near exclusion of many more enduring features. Unlike the older, pregnancy-centered view, the newer life span perspective regards a woman's experience as happening first and foremost to her, not to or because of or for the benefit of anyone else. Her body, her health, in this view, are first and foremost hers, and only secondarily the fetal environment of her offspring. We can easily recognize this per- son-centered perspective, of course, from the study of the health of men. Historically, very few researchers have considered the male body primarily as a mechanism for producing healthy sperm or providing support for growing children, even though numerous experiences and influences can affect the ability to create or ejaculate viable sperm cells and perform parental duties. Nor have scientists usually evaluated the events that befall a man mainly in relation to their effect on those capacities. Affording him a long and satisfying life has always seemed a sufficient end in itself. In this same spirit, we approach the female life span, especially as lived in the United States in the last years of the twentieth century. In a nation as large and varied as our own, as we've seen, and among a gender undergoing such rapid and far-reaching social change, there can be no "typical" American life. But because, as we noted in Chapter 1, health is the intersection of each person's innate endowment and his or her life 54

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C HA P T E R 4 Con Health Through the Lfe Span: The First Two Decades experience, and because all women share important inborn features, we can expect to find certain characteristic patterns among the vast array of individual experiences. By its nature the female body passes through cer- tain distinctive and distinctively sensitive periods, wherever a woman happens to live. Onto this genetic template, American culture also im- poses its own particular pressures. A second concept, the sensitive period, will also help us illumi- nate the connections in female lives. Every organism goes through a num- ber of such times, during which, because of physical, emotional, develop- mental, or other factors, it is "especially vulnerable to an event such as sensory deprivation, malnutrition, or exposure to toxins," according to an IOM report on child development. To focus on a simple and especially fleeting example, intrauterine infections generally have their severest ef- fects during the fetus's first three months of development; an identical disease striking later in the pregnancy does much less damage. Other such crucial points occur at various stages of the life span. Discovering when, and which, events trigger harmful consequences, 1 1 r ~ 1 ~ 1 1 - and what factors attect the organ~sm-s susceptibility or resistance, and how adverse effects can be overcome today constitutes "one of the key issues for clinicians and researchers," the IOM report notes.) Because the sensi- tive period concept arose first in animal studies, it "has traditionally been associated with the prenatal period and infancy"; experience has proven it "applicable to all stages of development," however.2 As we journey through American women's lives, we will see this concept's explanatory . 1 - power again and again. THE EARLY YEARS For the better part of this century, the great majority of all American lives have begun in hospitals, where the technical ability to cope with complicated births has reached unparalleled heights. Even very small or sick infants now have an excellent chance of surviving birth and the period immediately following. In fact, unless born to a mother who fails to receive adequate prenatal care or who abuses substances, American babies face relatively few dangers, especially as compared to children in developing countries. If she grows up in a family that enjoys emotional 55

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I N H E R O WN R ~ G HT stability, an adequate income, and appropriate medical attention, further- more, a healthy young American girl normally avoids serious medical problems and deprivations. In recent years, though, this all-important "if" has become increasingly problematic for far too many youngsters. Not only do today's children include an unprecedented number living in single-parent homes, they also have, for the first time in American history, the highest poverty rate of any age group.3 Thanks to vaccinations and antibiotics, children who get ad- equate medical attention also escape the many contagions that within living memory were common enough to merit the term "childhood dis- eases." Polio no longer terrorizes swimming pools and summer camps. Measles, mumps, whooping cough, and scarlet fever no longer race through schoolrooms. Rheumatic heart disease no longer condemns kids to months in bed. Ear infections no longer destroy their hearing. But even as infectious disease has been largely conquered, sig- nificant and possibly growing numbers of children still succumb to mental, emotional, and behavioral disorders, including some, like learning disabilities and attention deficits, only relatively recently identified and understood. During the preschool and elementary years, these afflictions strike fewer girls than boys, although girls at every age face a higher risk of sexual abuse at least twice as high, according to studies.4 As if to illus- trate the sensitive period concept, in fact, childhood referrals for psychiat- ric and psychological help peak at certain ages around 4 and then again between 7 and 9. Such times each mark a "transitional stage" in the child's growth, when "accelerations in physical or cognitive development or rapid changes in parental expectation and general societal demands . . . require new adjustments," Conger observes.5 And so, with the major physical threats essentially solved for American youngsters covered by decent health insurance, the big health considerations in the early years now involve more developmental is- sues laying the groundwork, both physical and emotional, for long-term well-being. Habits developed in childhood eating a healthful diet, for example, or practicing good oral hygiene, or getting lots of exercise can bring lifelong benefits. Equally important are the self-image and interper- sonal skills that children acquire. As we have already noted, boys and girls begin segregating themselves as toddlers. By first grade, Maccoby found, 56

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C HA P T E R 4 Cal Health Through the Lice Span: The First Two Decades they are choosing playmates from their own gender 11 times as often as from the opposite one.6 These play groups develop styles that can crucially affect health when kids enter adolescence. Maccoby notes that girls learn to be "recip r~r~1 ~A r - ct~;`r~ ~cr;th hears 1~a~1 "ally l~iJ~llOlV~ VVl~ll VetsThey listen to what a boy says and , , answer him and maybe do what be wants and expect him to do what they want." But boys listen to each other and "are seldom influenced by the response that they get from a girl." For their part, "girls don't like to play with someone they can't reciprocate with." They "back off from play with boys."7 This "backing off" tends to remove girls from the games and playing fields stereotyped as male. "The girls get the territories that are left over from what the boys have grabbed," Maccoby goes on. "The boys get the big areas for their ball games, and the girls are on the edges," jumping rope or skipping across hopscotch boards, or bouncing their small pink balls to counting rhymes.8 Hours and years at the line of scrimmage or in the batter's box or under the hoop teach boys the skills and satisfactions of strenuous physical activity. Many girls, meanwhile, still pass through child- hood convinced that exercise is something that other people do. For the rest of their lives, they are more sedentary than males. Even more important than what their play teaches about exer cise, though, is what each gender learns about the other and about rela- tionships in general. Girls become expert at building friendships around talk, persuasion, and sharing both confidences and leadership. Boys build theirs around shared activities, kidding, and friendly competition for domi- nance. Boys spend much less time talking and almost none sharing confi- dences. Thus, as girls enter a period when their present and future health crucially depends on the influence of males, they come at a very consider- able disadvantage. ADOLESCENCE The passage from childhood to adolescence is among the most complex and variable that Americans make. In the first place, it happens at very different times for different individuals. "Normal" children of the same age can enter puberty as much as two or three years apart. From the 57

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I N H E R O WN R ~ G HT fifth to the ninth grade, any given class includes youngsters at vastly differ- ent points in the transition. In general, girls who develop on the early side experience more stress than their later-blooming classmates. Also crucial to the experience, Conger believes, is a highly variable factor: "how nearly optimal the young person's development has been during earlier age periods." A child who had "trusting, secure rela- tionships with caretakers during infancy and early childhood and who is able to achieve competency in physical, cognitive and social skills and a positive sense of self during middle childhood, will be better prepared to weather the demands of puberty and adolescence than one who has not." But these days, alas, a decent childhood is far from a foregone conclusion. "One of the tragedies of our time," Conger goes on, "is the mounting number of children who have been denied both of these essential psycho- logical building blocks, and who in all too many instances have also been denied basic health and neurobiological integrity, whether as a result of maternal drug use, malnutrition, exposure to toxic environmental agents or physical abuse and neglect."9 But ready or not, girls must face puberty whenever it happens, ushering many of them into a period of turmoil and complex new vulner- abilities. Their bodies change from children's to women's; their images of themselves, and others' images of them, change just as drastically, perma- nently, and fundamentally. They become at first physically, and then, with varying degrees of difficulty, emotionally as well overtly sexual beings. More specifically, in the context of modern American adoles- cence, they become sex objects and sexual actors. Boys are also making a similar shift, if a year or two later. But the impact appears more negative for girls than for boys. Girls of this age "begin to develop an awareness of their inferior social status," both sexually and generally, Frank observes.~ What's more, there is a "profound asymmetry in sexuality it- self," Maccoby notes an imbalance that goes far beyond the obvious fact that only females get pregnant. Adolescent girls find themselves disad- vantaged in a number of other ways. They are physically smaller than boys and headed for a less prestigious adult role. They suffer rape and the constraints on mobility imposed by the fear of rape to a far greater a extent than boys. They come into puberty on average two years earlier than boys, yet are far more focused on and defined by relationships, and 58

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C HA P T E R 4 Cry Health Through the Lfe Span: The First Two Decades far more concerned about popularity, especially with the opposite sex. At the same time, as we have seen, they lack effective means of influencing males especially the older boys and young men interested in romantic relationships. Thus, they may find themselves in potentially exploitative or abusive relationships. And, adding to their emotional distress, Frank notes, "this is that point in development at which girls figure out that sexual abuse is wrong." STAYING SAFE Societies the world over have traditionally erected strong de- fenses around their vulnerable young women. Codes of chastity and chiv- alry, distinctions between "good" and "bad" girls, physical protections ranging from chaperonage to purdah, and elaborate etiquettes of courtship and betrothal all served both to guard girls from male predation and to guide men into commitments providing women security and continuity while raising children. Many of these protective customs child betrothal, arranged marriages, strict taboos, the cult of virginity, the double standard, rules of exclusion and seclusion, intricate rituals of wooing and aff~anc- ing now appear archaic and demeaning. The advent of safe and reliable contraception has also somewhat evened the sexual balance by lessening the risks of unregulated intercourse. "Nevertheless," Maccoby insists, "our modern societies, not just America but other industrialized ones, are probably unique in the whole history of human societies in the lack of protection that we provide young women." Unlike traditional systems that build protections into the very fabric of social life, today "the burden of regulating sexuality is placed primarily on young women. There are very few effective taboos left."~3 And with girls now entering puberty at ages as young as 11, and with the mass media drenching the culture with sexual suggestion, it should come as no surprise that many youngsters find it hard to withstand the new pressures they face. Half of all girls are sexually active by the time they reach 17 and 5 months.~4 Nor should it surprise us that their de- fenselessness lays girls open to emotional crisis. "Early adversity in the form of childhood sexual abuse, coupled with later adversity in the form of stranger rape, date rape, and other kinds of abuse, along with the 59

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I N H E R O WN R ~ G HT apparently universal gender-specific socialization" combine to give girls fewer emotional resources in the face of adversity, Frank believes.~5 Girls used to confront fewer such dangers. A century ago, menarche came at 15 or so and marriage within the next few years. For her brief season of nubility, a "good" girl could count on community norms to respect and defend her virginity and innocence. Even three decades ago, respectable society held decent men responsible for the con- sequences of their sexual conduct, even if that required an involuntary trip to the altar. But the sexual revolution, fueled by the availability of oral contraceptives, changed all that. No single medication has ever had a more sweeping effect on social mores. Nor has any other, among the thousands of tablets and capsules taken by mouth, ever been known sim- ply and universally as the Pill. This epoch-making pharmaceutical fulfilled the ancient dream of freeing women from the fear of unplanned preg- nancy and coincided with the demise of the social restraints that used to . . guarc against it. Today, therefore, although "sexual activity is beginning at younger and younger ages, . . . many girls" stripped of the protection of now-outdated codes and armed only with persuasive powers relatively ineffective on boys "are unprepared to handle the pressure from males." But given that the pressures continue, "it shouldn't come as a surprise to us that adolescence is the time at which we begin to see incidence of depression," Maccoby concludes.~7 Sexual abuse is a very real danger to girls of this age. Most youngsters, of course, still manage a reasonable adjust- ment during this difficult time. Even so, the years from 14 to 16 constitute another peak age for psychiatric referrals; as many as 10 to 15% of adoles- cents suffer from a recognizable psychological disorder in any given year. "When adolescents' own reports are taken into account," Conger adds, "the suffering rate is somewhat higher." In poignant confirmation, each year thousands of youngsters attempt suicide making an estimated 300 tries for every one that suc- ceeds. Some studies cite figures as high as 20% of American teens, but others offer rather lower rates. Six percent of teenagers queried admitted to a Gallup poll that they had tried at least once. So did 5.6% of the boys 60

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C HA P T E R 4 Cal Health Through the Lfe Span: The First Two Decades and 10.9% of the girls at a school enrolling grades 7 through 12. Fortu- nately, few of these youthful efforts succeed. Would-be suicides who fall into the category of"attempters" mostly young females act impul- sively and publicly, using such ineffective means as cutting their wrists. Those in the more dangerous category of"completers" mostly middle- aged men suffering depression or substance abuse generally give few warnings, act in private, and use such effective means as hanging or fire- arms. 19 Still, this youthful anguish reflects something real: the formi- dable developmental challenges that lie between puberty and effective adulthood. Adolescents must learn to manage "increased independence from parents, adjustment to sexual maturation, establishment of new and changing workable relationships with peers . . ., deciding about educa- tional and vocational goals, and the development of some sort of basic philosophy of life . . . and a sense of identity," Conger enumerates.20 For many girls, success in adolescence entails a contradiction, the necessity of attracting male attention while retaining a satisfactory sense of autonomy and dignity, all the while navigating the treacherous currents of a sexual scene devoid of clear boundaries. A generation or two ago, a "good" girl could safeguard her reputation and hold boys at bay by "playing the field" dating a number of people, none of whom could claim sufficient intimacy or commitment to demand sexual favors. In today's much more permissive climate, though, with sexual activity early in a relationship essentially taken for granted, many girls paradoxically feel their "sexual space" much more severely limited than their mothers ever did. They "unwillingly find themselves coerced into exclusive sexual relationships," Maccoby notes. "They don't want to say no entirely and become secluded persons, but they also can't date freely without being considered promiscuous." That venerable defense now im- plies "the risk of getting a bad reputation. So it's safer for them to hook up with one male who then becomes proprietary." The new sexual "free- dom" thus leaves them feeling "coerced and limited."2i IN HER OWN IMAGE This kind of confusion and anxiety over social role and self 61

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I N H E R O WN R ~ G HT image play a major part in many a female adolescence, as a glance at the offerings of any magazine stand makes clear. They also tie directly into all the other big health threats facing teenage girls, smoking, substance abuse, sexually transmitted diseases, pregnancy, and eating disorders. Those at greatest risk for bulimia, for example, "have accepted and internalized most deeply the sociocultural mores of thinness and attractiveness" the fantastical images of svelte perfection pushed relentlessly by the media- according to Conger.22 Bulimia is a subtype of anorexia nervosa, a complex ailment defined by four criteria. Together, they graphically illustrate the close ties among the emotional, physical, and social factors in teens' health. First, the patient refuses to maintain her weight above the minimum normal for her height and age. Second, she (and nearly all anorexics are female) intensely fears gaining weight or becoming fat, despite her actual emacia tion. Third, she perceives her body's weight and shape inaccurately, be- lieving herself much heavier than she is and denying her serious under- weight. She also gives her weight and figure undue importance in her estimate of her own worth. And finally, starvation has stopped her men- strual periods. Bulimics force down their weight by the potentially deadly cycle of Singeing on food and then making themselves vomit it all up. Other anorexics simply starve themselves, and many exercise intensely to boot. Given the teen culture's unhealthy emphasis on thinness, "bu limia unfortunately is a fad," Conger notes, "and occurs frequently, espe- cially on college campuses. Not all people who binge and purge have a psychiatric diagnosis," however. To distinguish mere faddists from the truly disordered, psychiatrists added a final criterion: "A minimum average of two binge eating episodes per week for at least three months."23 This frightening condition is "one of the few psychiatric ill- nesses that in and of its own pathology results in death."24 Sufferers can plunge to a half or even a third of their normal weight. Vomiting can so deplete their bodies' potassium that they go into fatal cardiac arrhythmias. Besides starvation, bulimics die from overdilating their stomachs while Singeing or tearing their esophagus while purging. They take ipecac to induce vomiting, sometimes causing cardiac arrest or irreparable damage that leads to heart failure. Some victims recover or die after a single 62

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C HA P T E R 4 Cal Health Through the Lice Span: The First Two Decades episode. Others relapse and recover again and again. High rates of alcohol and drug abuse and suicide attempts also plague these unfortunate girls. Anorexia peaks at 14, 15, and 18. "I think this is significant as far as stressors are concerned," Conger says. For "anorectic women who do not appreciate or want to develop a normal female body," the years of blossoming breasts and spreading hips can impose serious stress, Conger notes. Leaving home, as so many 18-year-olds do, seriously stresses girls for whom, as is often the case among anorectics, "dependency is a serious problem."25 One in 200 girls between 12 and 18 develops anorexia. Ten years later, 6 to 7% of them have died; 30 years later, death has claimed 18 to 21%.26 Bulimia peaks somewhat later, between 18 and 26 years of age. An estimated 3 to 8% of women between 12 and 40 fall prey, although the death rate is unknown.27 The quest for thinness can lead down another path with its own ramifying risks to long-term health. Can it be coincidental, wonders IOM's Committee on Preventing Nicotine Addiction in Children and Youths, that the late 1960s and early 1970s saw a pair of ominous trends? Cigarette companies began targeting certain brands toward young women, explicitly tying tobacco to both fashionable leanness and feminine inde- pendence. At the same time, the number of girls under 18 who began smoking "increased abruptly around 1967," topping out "around 1973, at the same time that sales of such brands as Virginia Slims peaked."28 Ever since the pre-World War II days when ads encouraged them to "Reach for a Lucky instead of a sweet," women have associated lighting up with lightening up. More than 60% of teenage girls who smoke daily and almost half of those who smoke occasionally report, furthermore, that cigarettes calm them.29 Clearlv. emotional stress also works in nettings swirls to smoke. J ' O O O As smoking lost its "scarlet woman" image over recent de- cades, girls have started puffing at earlier and earlier ages. Since 1955, the average age when white girls begin has fallen more than 5 years, to about 12 or 13.3 (See Table 4-1.) That figure, however, is the only teen smok- ing statistic that has fallen recently. Adult smoking, on the other hand, declined sharply since the Surgeon General's Report in the mid-1960s; among men alive today, fewer are current than former smokers. Teenage smoking rates also dropped in the 1970s but leveled off in the 1980s. 63

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I N H E R O WN R ~ G HT TABLE 4-1 Percentage of Boys and Girls Who Initiate Smoking at Specific Ages Percentage of Age Group Age (years) Girls Boys <9 3.6 6.7 9-10 6.4 8.0 11-12 14.9 16.7 13-14 24.9 24.1 15-16 19.5 19.4 217 4.4 5.0 NOTE: Sample sizes for the various age groups were the same (n = 11,241) because new smokers who emerged from among those who had never smoked for successive age groups were added in- crementally to the numerators of older age groups. SOURCE: Institute of Medicine, Growing Up Tobacco Free: Pre- venting Nicotine Addiction in Children and Youths, 1994, page 44. Data are from the Youth Risk Behavior Survey, 1990, in Luis G. Escobedo, Stephen Marcus, Deborah Holtzman, and Gary Giovino, "Sports Participation, Age at Smoking Initiation, and the Risk of Smoking among U.S. High School Students." Journal of the American Medical Association 17~1 1) :1391-5, 1993. Between 1992 and 1993, however, experts discerned a small but worri some rise.3i Tobacco advertisers have subtly driven home the notion that smoking smoothes the difficult passage to adult status and sophistication, to popularity and social ease. They also exploit the immaturity of young teens' thinking, which is especially plagued by the difficulty of"envision- ing long-term consequences and appreciating the personal relevance of these consequences," notes the nicotine committee. Kids who start smok- ing, the evidence shows, "do not understand the nature of addiction and, as a result, believe they will be able to avoid" its harmful consequences. "They understand that a lifetime of smoking is dangerous, but they also tend to believe that smoking for a few years will not be harmful."32 Teens do not generally start out intending to hurt themselves. Still, "adolescent decisions to engage in risky behaviors, including tobacco 64

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C HA P T E R 4 Cry Health Through the Lfe Span: The First Two Decades use, reflect a distinctive focus on short-term benefits and an accompanying tendency to discount long-term risks and dangers," the committee found. Youngsters often "believe that those risks can be controlled by personal choice." In fact, kids usually choose to smoke because they think that large benefits outweigh small risks. "What is most striking, however, is the nature of the trade-off." Reasons for smoking are "transient in nature and closely linked to specific developmental tasks for example, to assert in- dependence and achieve perceived adult status, or to identify with and establish social bonds with peers who use tobacco."33 But the results, of course, are potentially permanent nicotine addiction and its life-shorten . . . 1ng risks. In addition to all the health dangers that cigarettes entail, both for the girl herself and for any children she might bear or raise while a smoker, they expose her to yet another serious peril. Knowing how to smoke serves as the common gateway to the abuse of illicit drugs. No one can use marijuana, crack cocaine, or other smoke-borne drugs who does not know how to inhale smoke. And once again, the onset of a health-destroying practice re- lates to young females' complex relationship with males. "Male partners play a critical role in women's initiation and progression in drug use," found IOM's Committee on Substance Abuse and Mental Health Issues in AIDS Research. Males tend to pick up drug use from male friends. For females, though, initiation "occurs most often in the context of love or a sexual relationship or friendship with someone of the opposite sex." In- deed, "having a male partner who uses drugs especially heavier drug use places girls at risk of drug use themselves."34 The exact extent of teen drug use is not known, in part be cause surveys tend to study those still in school, a diminishing percentage at the older ages. Both illicit drugs and alcohol are in wide use, however, by boys probably more than by girls. But the female rates of both drinking and drinking to intoxication have been rising faster than the male. Almost 80% of secondary school boys and 70% of girls admit to drinking, one study found, and 23% of boys and 15% of girls to problem drinking. These trends continue upward during the college years. Young people of all ages drink less often than adults, but tend to down much larger amounts when they do.35 65

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I N H E R O WN R ~ G HT Alcohol in particular generally carries more severe physical con- sequences for women than for men. And rather than helping youngsters deal with the emotional burdens of adolescence, mind-altering substances can substantially delay the all-important process of"accomplishing in ado- lescence the tasks necessary to social maturity," the American School Health Association told an IOM panel. These difficult tasks become even harder "if one's perception of self, time and sequence is distorted or if one's interest or ability in evaluative thinking is impaired."36 But beyond exposing girls to the dangers of lifetime addiction and physical and mental deterioration, and beyond retarding their own progress toward maturity, and beyond exposing their fetuses to irreparable mental retardation and other defects, substance abuse opens up the very special perils brought on by choices girls make while in a chemical's grip. Injecting drugs carries risks of HIV and other lethal infections. Unprotected sex carries the twin threats of unwanted pregnancy and dangerous, possibly fatal, sexually trans- mitted diseases. WAGES OF SEX Each year, 2.5 million American teens contract sexually trans- mitted diseases (STDs), running a risk nearly three times that of persons over 20.37 In addition, nearly 1 million American teens are known to become pregnant each year fully 1 out of every 10 girls between 15 and 19. Adding in the presumed number of miscarriages raises the total num- ber of conceptions by another 10 to 15%. Every year 470,000 American teens most of them single, almost half under 18 become mothers. An- other 400,000 obtain abortions.38 In one statistic at least rate of teen pregnancies the U.S. leads all other Western industrial democracies. What explains this sorry distinction? The African American teen pregnancy rate, though consider- ably higher than the white, does not suffice as an explanation. On their own, and despite a continuing fall in overall adult birth rate, white Ameri can teens conceive twice as often as comparable Canadians, citizens of the country closest to our own culturally, geographically, and in terms of pregnancy rates.39 Americans under 15 are at least 5 times as likely to give birth as girls in any other developed country.40 66

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C HA P T E R 4 Cal Health Through the Lfe Span: The First Two Decades "This disparity is all the more puzzling," notes science writer Suzanne Wymelenberg in an IOM publication, when one considers that "U.S. teenagers are no more sexually active than their peers in similar countries."4i The answer lies not in sexuality but in society, not in what randy youngsters do, but in what their cultures teach them to do about it. Compared to Sweden, Canada, England and Wales, France, and the Neth- erlands, American teens make the least use of contraceptives, and when they do use them, they use the least effective kinds. Fewer than half of American girls use any protection at their first intercourse, for example. Of those who do, the condom ranks first, then come the Pill and with- drawal.42 This happens in large measure because, compared to other countries, we make it hardest for young people to get birth control. Sweden, the Netherlands, and England and Wales provide services and supplies cheaply or at no charge. The United States does have a national network of family planning clinics that theoretically provide services to teens in most places, but the clinics' historical association with the poor discourages many better-off people from visiting them. Only about 30% of American adolescents get contraceptives from private physicians, dis- couraged either by the cost or the fear of needing parental permission.43 Many pediatricians and family doctors, but few gynecologists or obstetri- cians, admit that they would in fact refuse to prescribe to teens. Nor does Medicaid cover family planning for childless or nonpregnant poor women. American religious, political, and educational leaders, as well as ordinary citizens, loudly and continually bemoan our nation's dismal record of"children having children." But while their counterparts in other countries "concentrate on preventing teen pregnancy," Wymelenberg observes, the American system "concentrates on preventing teen sex."44 Countries that accept both the existence of teen sexuality and the need to provide effective protection against its likely outcome succeed much bet ter than we do in reducing teenage conception. Properly motivated and properly informed teens, the European experience shows, can successfully contracept. Many conservative French and Dutch physicians initially opposed proposals to provide birth control to teens but changed their opinion when they understood that the alterna- tive was not less adolescent sex but more adolescent abortions. When 67

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I N H E R O WN R ~ G HT Sweden legalized abortion in 1975, the law also made provision for offer- ing birth control to young people, openly acknowledging that, given the realities of teenage behavior, the latter was preferable to the former. American teenagers, on the other hand, "seem to have inher- ited the worst of all possible worlds regarding their exposure to messages about sex," note researchers at the Alan Guttmacher Institute, an author- ity on birth control. "Movies, music, radio and TV tell them that sex is romantic, exciting, titillating; premarital sex and cohabitation are visible ways of life among the adults they see and hear about.... Yet, at the same time, young people get the message that good girls should say no. Almost nothing that they see or hear about sex informs them about contraception or the importance of avoiding pregnancy."45 Beyond media messages, several other features of American culture and society discourage teens from practicing birth control. Reli- gious communities, which are far more influential in this country than in other Western democracies, often reject not only contraception for teen- agers, but even discussions of contraception and sex for teenagers. Our decentralized, locally controlled school system gives such groups greater power than their counterparts have in the centralized, federally controlled educational systems in Europe. Although many people, both within and without the religious community, believe teenage chastity a highly desir- able method of preventing youthful pregnancy, experts agree on neither the feasibility of that goal nor the best way of attaining it. The difficulties that girls have making their wishes known to boys can also contribute, Maccoby believes. Teenage sexual relations are "fraught with possibilities for miscommunication," she observes. "For one thing, it's not uncommon for each member of a pair to expect that the other will take responsibility for contraception. If the young man is more interested in conquest than in protecting the girl, she may find this out too late." Many boys reject condoms as detrimental to pleasure. And, because of their desire for popularity and their weaker skills of persuasion, "many girls will not feel in a position to insist on a boy's using protection if he doesn't volunteer to do it, or, if a girl tries to suggest this, her message may not be received."46 Racism, furthermore, keeps many girls in need of contracep- tion from venturing into facilities or neighborhoods perceived as belong 68

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C HA P T E R 4 Cry Health Through the Lfe Span: The First Two Decades ing to other groups, as, for example, public family planning clinics thought, because of their locations or predominant clientele, as being "for" African Americans or Hispanic Americans. And the United States permits poverty deeper and more widespread than is tolerated in any other Western indus- trial democracy. Thus we have a substantial population of hopeless, alien- ated, poorly educated young people who see no promise of a better future and thus no reason to delay such gratifications as their circumstances af- ford them. The most potent inoculation against early childbearing may in fact be the hope of a better tomorrow, especially in the form of strong educational goals. African American girls with their sights set on finishing their education are likelier than either white girls or other blacks to use effective forms of contraception.47 But even if an American teenager determines to use birth con- trol, she has few options that meet her needs. The most efficacious types, the Pill, the diaphragm, and the intrauterine device, are far better suited to an older woman in a stable, monogamous, predictable sexual relationship than to a young girl whose sexual encounters are likely to be sporadic or unplanned. To be used successfully, each of these methods requires ad- vance planning and special equipment. Each requires its user to under- stand as many youngsters do not that conception can result from any act of intercourse, even extremely occasional ones, even one's first. And each method, perhaps most importantly from an adolescent's point of view, requires a person to acknowledge to herself and others that she is sexually active, that she is "the kind" of person who both expects to sleep with a man and is willing to make preparations for that eventuality. In a nutshell, it requires her to take responsibility for her sexuality. In a culture that teaches that "nice girls don't," however, a youngster's self-respect may depend on believing that sex is not something she plans, but only something that occurs spontaneously, in an unpredict- able burst of passion. Successfully contracepting requires believing that one has the right and the ability to take active steps to take control of her life. "Adolescent pregnancy could be significantly reduced if a safe, rela tively inexpensive, and non-physician-dependent contraceptive were de- veloped for use at the end of the cycles during which intercourse occurs (thereby eliminating the need to plan ahead)," notes Dr. lames Trussell, 69

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I N H E R O WN R ~ G HT assistant professor of economics and public affairs at Princeton.48 For rea- sons we will consider in detail in a later chapter, contraceptive research has slowed to a crawl in the United States. What's more, abortifacients, or substances that cause early abortions, as an "end of the month" pill surely would, remain intensely controversial in a nation still divided over the question of how (or even whether) young girls should be permitted to . . terminate pregnancies. A variety of complicated obstacles therefore stand in the way of American attempts to prevent not only teen childbearing but also teen pregnancy. As statistics on falling ages of menarche and smoking and drinking attest, these issues threaten to become more rather than less . . . . so cent In coming years. LOOKING FORWARD The teen years thus occupy a pivotal place in the health of American women. They represent a true crisis, which, in the original Greek meaning, is an event fraught with both danger and opportunity. If a girl can avoid the snares of adolescence, she can look forward to an adulthood free of some of the gravest threats to a long and healthy life. Almost no one starts smoking or using illicit drugs after age 18 or 20, for example. Avoiding sexually transmitted diseases will safeguard both her fertility and her life. Delaying her first child until her mid- twenties vastly reduces her chances of spending her life in poverty (delay- ing much longer than that, however, somewhat raises her risk of breast cancer). Eating a sound, high-calcium diet and developing the habit of regular exercise will help prevent cardiovascular disorders, the largest killer of women; reproductive cancers; and osteoporosis. Risk of this last disease depends so significantly on the quantity of bone a woman builds up in her adolescence and twenties that, as Charles Chestnut of the National Os- teoporosis Foundation notes, this impairment of old age "may be a pediat- ric disease," whose solution lies in the teen years.49 But, he goes on, "it is obviously very difficult for young women aged 15 to be concerned about a disease that may occur 40 years later,"50 or, even, as experience with teens indicates, to be concerned about dan- gers that lie a day or a week or a month away. For too many American 70

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C HA P T E R 4 cry Health Through the Lice Span: The First Two Decades girls, a turbulent adolescence lays the foundation not for a lifetime of good health but for later bouts of avoidable disorders, both physical and emo- tional. We will watch these forces play out in the chapters that follow. NOTES 1. Research on Children and Adolescents with Mental, Behavioral, and Developmental Disorders: Mobi- lizing a National Initiative, 73. 2. Ibid., 74. 3. Assessing Future Research Needs: Mental and Addictive Disorders in Women (Transcript), 177. IOM 1992 Annual Meeting, 126. Assessing Future Research Needs (Transcript), 151. Ibid., 142. Ibid. Ibid., 143. Ibid., 154-5. IOM 1992 Annual Meeting, 126. 7. 8. 9. 10. 11. Assessing Future Research Needs (Transcript), 148. 12. IOM 1992 Annual Meeting, 126. 13. Assessing Future Research Needs (Transcript), 149. 14. Forrest (1991), 4. 15. IOM 1992 Annual Meeting, 128. 16. Assessing Future Research Needs (Transcript), 149. 17. Ibid., 150. 18. Ibid., 152. 19. Ibid., 192-3. 20. Ibid., 151. 21. Ibid., 149. 22. Ibid., 158. 23. Ibid., 209. 24. Ibid., 210. 25. Ibid., 211. 26. Ibid. 27. Ibid., 212. 28. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths, 116. 29. Ibid., 49. 30. Ibid., 106. 31. Ibid., 8. 32. Ibid., 14. 33. Ibid., 15. 34. AIDS and Behavior: An Integrated Approach, 96. 35. Health and Behavior: Frontiers of Research in the Biobehavioral Sciences, 248. 36. Healthy People 2000: Citizens Chart the Course, 105-6. 37. Ibid., 159. 38. Ibid. 39. Science and Babies: Private Decisions, Public Dilemmas, 70-1. 40. Ibid., 8. 41. Ibid., 70. 71

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I N H E R O WN R ~ G HT 42. Ibid., 57. 43. Ibid., 71. 44. Ibid., 88. 45. Quoted ibid. 46. IOM 1992 Annual Meeting, 88-9. 47. Science and Babies, 76. 48. Quoted ibid., 91. 49. Quoted in Healthy People 2000, 197. 50. Quoted ibid. 72