Sex as apple pie.

SEX AS APPLE PIE 

LAST YEAR, three hundred parents thronged the auditorium at the Word of Faith Christian Center in Detroit. They came to hear Detroit school-board president Gloria Cobbin defend the idea of putting "comprehensive health clinics" in two nearby high schools. She talked about teen death rates; she talked about suicide, accidents, and homicide; she talked about everything except what they considered the key issue: contraception. Then a black woman, who had become a single parent at 16 and a welfare-dependent soon thereafter, stood up: "I don't want my girls to make the same mistake I did....But how am I going to teach them what's right if they put this clinic in the school and start passing out birth control?"

For Reverend Keith Butler, the dynamic black pastor of Word of Faith, it was a moment of triumph. The school board's proposal had the support of virtually all the Detroit establishment, including black community groups. But, in the end, Butler's coalition of 105 mostly black pastors won: the school board agreed that the health clinics would not promote birth control.

A similar battle is being re-enacted in many other American cities with as yet unknown results; school-based clinics (SBC), brainchild of the population-control movement, are fast becoming the latest educational craze. At the end of the 1987 school year, there were about 75 such clinics in operation nationally. By the time the school doors swing shut this year, the number will have doubled.

Most of the clinics are going into schools in poor, heavily black or Hispanic, inner-city neighborhoods. That may be, in part, because adolescent pregnancy rates are higher among the poor, but it also reflects a political reality: low-income families frequently don't have the clout to resist them. Birth-control clinics in ghetto schools may even be popular among more comfortable voters who are willing to concede that "those people" need them. But the current school-based-clinic campaign has provoked a powerful backlash among low-income parents who charge that public officials have given up on their children, offering them subsidized sex instead of an education. And it has created an intriguing new phenomenon: an emerging grassroots coalition between New Right activists and black and Hispanic inner-city parents.

In city after city, ghetto residents, generally led by inner-city pastors, have angrily rejected the views of black leaders who gave their imprimatur to school-based clinics. In Chicago's DuSable neighborhood, residents held petition drives and mass meetings (the clinics went in anyway). Parents of children at Chicago's largely Hispanic Orr High School held a mass rally against a clinic. Local politicians vowed to fight the proposal; a few days later the clinic opened for business. In New York City last spring, eight clinics were up and running before parents had even been informed of their existence.

Opponents of school-based clinics are beginning to gather some support from established black leaders. In Boston, Jack E. Robinson, then president of the local chapter of the NAACP, teamed up with Bernard Cardinal Law to defeat a clinic scheme. In New York City, Dr. Gwendolyn Baker, the only black school-board member, strongly opposed the clinics. Dr. Donald Smith, a former president of the National Alliance of Black School Educators, blasted school-based clinics as an effort to "curtail the black birth rate and control the population." Washington Post columnist William Raspberry has opposed school-based clinics.

Money, Prestige, Publicity

BUT MINORITY parents in poor neighborhoods face an uphill battle. School-based clinics are the darling of the population-control movement, which has national prestige, media support, and very deep pockets.

The campaign for SBCs began in 1985 when an organization called the Center for Population Options (CPO) made the establishment of new clinics its top priority. Through its Support Center for School-Based Clinics, CPO put together funding, conferences, publicity, a network of contacts--in short, the wherewithal for waging a major national campaign. Financial support for the clinics is provided by a number of foundations interested in population-control measures. The Robert Wood Johnson Foundation has pledged $16.8 million to the school-based-clinics campaign, dangling start-up grants of up to $600,000 before revenue-hungry school boards. Established clinics go after a wide variety of public monies, from sources ranging from the Maternal and Child Health Block Grant to the Adolescent Family Life Act. At a 1985 conference, clinic directors were urged not to forget to "go after drug and alcohol money." Double-dipping at the public through has important advantages for clinic operators: responsibility for and control over the clinics is diffused in a tangle of overlapping authorities.

A Foot in the Door

SOME CLINICS offer diagnostic services, or nutritional programs, or drug-abuse counseling. A few actually treat minor injuries and illnesses. There is just one service that is universally offered: contraceptive counselling and referral. "We can talk all day about the fact that we want to open up comprehensive services," says Sharon Lovick, director of the Support Center for School-Based Clinics. "But the main focus-the reason people put dollars into it-still turns on the hope, the expectation, that somehow you're going to do something about adolescent pregnancy."

That's not what clinic advocates tell parents, of course. "Most school-based clinics began by offering comprehensive health care, then added family-planning services later, at least partly in order to avoid local controversy," notes CPO Chairman Joy Dryfoos (suggesting that Reverend Butler's victory in Detroit may be short-lived). In Illinois, clinic advocates won state funding by pointing to the high infant-mortality rate. In Alexandria, Virginia, they argued that the clinic was necessary because the city had no physicians specializing in adolescent medicine. In Meriden, Connecticut, the brochure outlining a new clinic at Platt High School did not even mention pregnancy, birth control, or abortion. Clinic advocates are acutely aware that if teen sex becomes an issue, school-based clinics are probably doomed.

So Kathleen Arnold-Sheeran, founder of the National Association of School-Based Clinics, urged SBC activists at a California workshop not to let Planned Parenthood affiliates take a visible role in initial planning: "Be willing to make compromises. Better something than nothing. Do not compromise on being in school. In Kansas City they met with religious leaders and agreed to leave out birth control. Eight months later, birth-control services were added. Get your foot in the door. Be trusted. Total health care means birth control."

Despite the current enthusiasm, there's little evidence that if preventing out-of-wedlock teen pregnancies is the goal, school-based clinics are the answer. Raw data suggest that, at least with respect to teenagers, any pregnancy-prevention strategy that relies on contraception is misguided. In 1981 and 1982, Title X federal family-planning funds dropped from $160 million to $124 million and the number of teens enrolled in birth-control clinics fell from 1.5 to 1.2 million. Teen pregnancy rates, instead of exploding, actually declined slightly. In 1983, when Title X funds started creeping back up, so did the number of out-of-wedlock teen pregnancies. Coincidence? Perhaps, but a similar pattern emerged in a state-by-state multivariate correlation study conducted by Stan Weed and Joseph Olson. They found, on the basis of 1980 statistics, that for every additional one thousand teenagers enrolled in clinic programs there were 77 fewer births to teenage mothers, but 46 more total pregnancies.

Despite major increases in contraceptive use among teens, the percentage of sexually active teenagers who become pregnant has remained remarkably constant. In four separate national studies from 1971 to 1982, the number of young women who had ever been premaritally pregnant was consistently three-tenths the number who had ever had intercourse. Even teenagers who are always-users of the pill have a pregnancy rate of about 7 per cent a year. Apparently, children who receive birth control have sex more often, keeping pregnancy rates about the same.

Not Counting Abortions...

DATA FROM pilot SBC projects tend to confirm this hypothesis. The pioneer St. Paul, Minnesota, clinic program claimed to have reduced the birth rate among students from 59 births per thousand to 37 per thousand. But this widely cited figure counts only live births among students who did not drop out of school. As Dr. Jane Hodgson noted at a 1980 conference of abortion providers: "If you will review the [St. Paul] figures, it was not a 50 per cent reduction in pregnancy rate...it was a 50 per cent reduction in fertility rate, which did not take into consideration, of course, the large number of abortions being performed on those students." The St. Paul program apparently failed to reduce pregnancy rates, even though, at about the same time, Minnesota's statewide rate of teen pregnancy fell by a remarkable 32 per cent-during the years (1981-1984) in which minors could not obtain abortions without parental consent.

The current highly touted success story is a Baltimore program in which pregnancy rates actually did appear to decline from 34 per cent in a baseline group to 25.3 per cent among those girls who completed the three-year program. (Only about one-third of the girls enrolled actually completed the cycle; the rest either dropped out of school or moved, and their pregnancies were not recorded.) The circumstances were unusual-three out of four high-school girls were reportedly already sexually active. More significantly, the average age of first intercourse was seven months later among the study group than among the control group. Postponement of sexual activity was not a program objective and the directors could offer no theory as to why it occurred, but it is obviously the reason for the lower pregnancy rate. Far from demonstrating the success of a contraceptive strategy, the Baltimore study suggests that the best way to reduce unmarried teen pregnancies is to encourage abstinence.

Perhaps the best summary of the evidence was given in March of this year by Douglas Kirby, research director of CPO, at the National Family Protection and Reproductive Health Association Conference. According to Kirby, preliminary findings of a nationwide CPO study of the effects of school-based clinics show, "basically, that there...is no measurable impact upon the use of birth control or upon pregnancy rates or birthrates."

The most surprising opposition to school-based clinics has come from teens themselves. Planned Parenthood commissioned a Harris poll of one thousand teenagers ages 12 to 17. Three out of four of the respondents were virgins. Seventy-nine per cent say most of their peers start having sex too soon; and 61 per cent identify social pressure as the main reason why. Those who have participated in sex-education courses emphasizing birth control and abortion are significantly more likely than their peers to have had sexual intercourse. And by a margin of 8 to 1 they reject school-based clinics.

When asked, "Do you think that clinics where contraceptives can be obtained should be located inside schools, or located close to schools, or located somewhere else?" only 12 per cent said "inside schools" and only 28 per cent said "close to schools." Six out of ten students didn't want clinics anywhere near their schools.

The art in public relations lies in making silk purses out of such sows' ears. When the poll was reported in the New York Times, it carried the headline, "Harris Poll Reports Teenagers Favor Contraception at Clinics." Dr. Michael Kagay, chief analyst for the survey, explained that the reason students wanted the clinics away from their schools was concern over confidentiality. A more likely explanation, based on the poll data, is that students fear that clinics would increase pressure on them to become sexually active.

Colleen Kelly Mast, who developed the chastity-education curriculum Sex Respect, draws a parallel between drug and pregnancy-prevention programs for teenagers. In both cases, the most effective approach is "Just say no." "If we dealt with teen drug abuse the way we deal with teen sex abuse, we would have a whole generation of addicts," argues Mast. "The way we try to help young people deal with drugs is to explain to them how drugs can hurt them, so they can make their own decisions to say no, and then to support that decision by teaching them the skills of saying no. The same basic approach works for dealing with teen sex."

What happens when a birth-control clinic goes into a school? Apparently, its presence encourages more students to become sexually active, creating a larger pool of students at risk for pregnancy. This cancels out the effect of more regular contraception, keeping pregnancy rates the same. More girls will be counseled into abortion, however, so the number of live births will probably decline.

This outcome doesn't necessarily bother clinic proponents. Chicago's DuSable High School clinic was considered a showcase project until neighborhood residents filed a suit to shut it down. Asked how successful the program had been, the clinic's director confessed to a live radio audience that it hadn't kept any statistics on pregnancy. Which tends to confirm the suspicion that some clinic advocates are more interested in sexual liberation than pregnancy prevention. "An implicit assumption in all our approaches is the reality that many teenagers will choose to have sexual intercourse," wrote Planned Parenthood president Fay Wattleton in 1986. "The right to say yes to sex, and to be protected from unintended pregnancy, is as important as the right to say no." Even, apparently, when you are 14 years old.