Children affected by maltreatment and involvement in the child welfare system tend to have an earlier age of first sexual intercourse, have more sexual partners, and are more likely to engage in sex work. This makes them vulnerable to unintended pregnancies and sexually transmitted infections (STIs). Plus, research shows that about half of females in the foster care system report a pregnancy by age 19 years.1
“Pregnancy rates and childbearing rates are very high in the sample,” says Katie Massey Combs, PhD, MPH, MSW, a research associate at the Center for the Study and Prevention of Violence at the University of Colorado Boulder.
Combs and colleagues studied how easily foster youth can access contraception in Colorado, a state that offers wider access to contraceptives for youth than many other states. Previous research had shown that Colorado’s expanded contraceptive access program through the state health department resulted in lower birth and abortion rates and more women obtaining a high school diploma.2
Youth living in urban areas of Colorado should have easy access to contraception. But this group of children in foster care and/or involved in the child welfare system face limitations beyond other adolescents.
“Colorado has done fantastic work in this area,” Combs says. “If they’re going to have contraceptive access anywhere, it should be here.”
The state eliminated financial barriers to contraception, resulting in fewer teen pregnancies and abortions. Adolescents can obtain contraception without parental consent. They can obtain it for free at Title X clinics if they indicate they are low income. No verification is necessary, Combs says. But Colorado’s contraception benefits may not always reach the most at-risk adolescents.
“This is a group so marginalized that even if they live down the street from a facility that has contraception, they don’t know about it,” Combs explains. “They may not know that they can go to a Title X place and get contraception without telling their foster parents or birth parents.”
Combs wanted to study contraception access among this vulnerable group and learn more about their experience. “Even in this area that was rich with contraceptive resources, do these kids know how to get it and where to get it?” she asks. “We asked kids entering eighth and ninth grades and had a representative sample in Colorado. Only one-third said they had ever received information about birth control.”1
The average age of first sexual experience is about 15 years for this marginalized group. The study captured a population at the brink of their first sexual encounter.
“One of the nice things about the study is we surveyed youth about a year before their first sexual experience, on average,” Combs says. “For the general population, the average age is 17 — almost 18 — for first sexual experience.”
Adolescents who are in the child welfare system face many perceived and actual barriers to reproductive health resources. “So much of this is about bodily autonomy, and this is a group that doesn’t have a lot of autonomy,” Combs says. “They’ve experienced violence — physical and sexual mistreatment — and they’re also in care and may not have autonomy about who they live with and where they get to live.”
Children in foster care may not know that they can obtain contraception without guardian consent, and they also may not know who can provide parental consent. “It can be really tricky,” Combs says. “I do trainings for case workers, and in my experience, this is something case workers don’t know, either. A lot of states, like Colorado, don’t have a parental consent requirement for contraception, but many still do.” A foster child might assume they need parental consent, even if it is not required, and they do not know whom to ask.
Primary care providers and reproductive health clinicians can help improve contraceptive access by providing their adolescent patients with a confidential space where they can talk one-on-one with the doctor during a wellness visit. “Doctors need to ask parents or guardians to leave the room to have confidential conversations, and this doesn’t always happen,” Combs says. “It can be a big barrier to these kids.”
Once providers have created a confidential and safe space for the youth, they can ask nonjudgmental questions, such as, “Some kids start having sex around your age, and we can help you make healthy decisions and be prepared, if you think these are decisions you are going to make,” Combs says.
It is not easy for pediatricians and primary care providers to start these conversations, which is why it would help if reproductive health providers offered them information and strategies for having these conversations with youth.
“Nobody’s having these conversations with foster kids,” Combs says. “It’s not something anyone wants to address with them, and foster parents don’t either.”
There are many concerns from the perspective of case workers and foster parents on talking about this sensitive topic. There are a lot of logical reasons why this topic gets buried, Combs says. Foster parents are aware that the children in their care are at risk of becoming pregnant or contracting an STI, and they want someone to talk with the children about it. Doctors are the best and most trusted resources for these conversations, and they can approach the topic in a way that normalizes it and puts adolescents at ease, she adds.
A 2018 study of young people (ages 18-22 years) with histories of foster care revealed they did not view pregnancy positively. Forty-one percent of young people who did want to become pregnant reported inconsistent contraceptive use.3 This points to the need for better contraceptive education and access for this vulnerable population.
There is no specific and universal program that guides sexual and reproductive health discussions with adolescents in foster care. Each state uses its own guidelines. “Even in places where there is really good access to contraceptives, we’ve got to think about contraceptive access for these marginalized groups, and we need to provide support to the professionals working with them,” Combs says. “These professionals are wildly underpaid, overworked, and don’t have all the resources they need.”
Pediatricians, primary care providers, and reproductive health providers can improve contraceptive access for youth in the child welfare system by educating child welfare professionals about these issues. Simply sharing information about Title X clinics can help.
“Title X clinics are very much a part of my vocabulary, but in social work and child welfare, no one knows what a Title X clinic is,” Combs explains. “They don’t tell youths to go to a Title X clinic for confidential testing and STI screening.”
Reproductive health advocates and clinicians can contact state and child welfare departments and let them know what kind of services they offer. Providers can contact faith-based organizations that partner with child welfare groups — which might be more receptive to STI and contraception information for youths than they imagine.
“Even faith-based organizations that are anti-abortion and skittish of contraception understand these sexual health issues are real and impacting youths in real ways, and most will work with you on some level,” Combs says. “The people in the weeds, caring for these kids, see these are real issues. Some of us in the reproductive health world need to see that adversaries on this topic have a good intention; they’re doing good work, and we can work together.”
REFERENCES
- Combs KM, Lee KC, Winter VR, Taussig H. Sexual and reproductive health protective factors among adolescents with child welfare involvement. Child Youth Serv Rev 2022;140:106593.
- Brundin J. CU Boulder study finds that better access to birth control boosts high school graduation rates. CPR News. May 8, 2021.
- Combs KM, Brown SM, Begun S, Taussig H. Pregnancy attitudes and contraceptive use among young adults with histories of foster care. Child Youth Serv Rev 2018;94: 284-289.
Children affected by maltreatment and involvement in the child welfare system tend to have an earlier age of first sexual intercourse, have more sexual partners, and are more likely to engage in sex work. This makes them vulnerable to unintended pregnancies and sexually transmitted infections. Plus, research shows that about half of females in the foster care system report a pregnancy by age 19 years.
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