Long-acting reversible contraception (LARCs), which include injectables, implants such as the Nexplanon, and intrauterine devices (IUDs), are the most effective contraceptives on the market, partially because they remove most user error. LARCs have been praised by health practitioners and researchers as a first-line choice for pregnancy prevention for adolescents, especially in districts with school-based health centers (SBHCs), as a promising method to reduce adolescent pregnancy. Yet, LARC programs within schools have the potential to exacerbate existing health inequities, causing structural, community, and personal harm, particularly as the majority of SBHCs are located in “underserved neighborhoods”, i.e. Black and Brown and/or lower-socioeconomic status communities.
Black and Brown communities have been disproportionately impacted by historical abuses, including inhumane, nonconsensual testing of sexual and reproductive health-related interventions, such as contraception experimentation on Puerto Ricans, impoverished people, and neurodiverse persons; coercion of Trans and gender non-conforming people into unwanted sterilization procedures; and denial of STI treatment to participants and the exclusion of women who were their partners in the Tuskeegee Syphilis study. Because of this history, LARC programs in SBHCs have the responsibility to employ a reproductive justice lens and present a diversity of contraceptive options, or else they risk alienation of the school’s community, or worse, coercion of the adolescents they serve.
LARCs for Adolescents
Healthcare providers argue that LARCs are the ideal contraceptive choice for adolescents because of their high efficacy rates. Neuroscience provides some evidence that adolescents are less likely to adhere to “perfect use” with shorter-term contraception. A sole focus on this discredits adolescents’ capacities to make and stick with well-thought-out decisions. Additionally, many adults believe providing adolescents with LARCs can help them engage in relationships without an unplanned pregnancy disrupting their education. While early unplanned pregnancy has been associated with a host of short and long-term risks, it is imperative to prioritize an adolescent’s stated values and needs as well as agency in any decision regarding contraceptive methods.
Benefits of Getting LARCs through SBHCs
Schools are where many U.S. adolescents spend most of their time, so SBHCs are ideal providers of reproductive healthcare for young people. SBHCs can decrease contraception delays by offering same-day LARC insertion. They can also reduce time constraints on families, tensions with providers who are typically chosen by parents, or conflicts with practitioners who will not provide adolescents with contraception for religious or moral reasons. SBHCs additionally reduce spending, as many offer reproductive health services at zero out-of-pocket cost, and there are studies demonstrating that the convenience, provider trust, and affordability SBHCs provide are satisfactory to adolescents.
Consequences of Prioritizing LARCs
Although many arguments for adolescent LARC provision are well-intentioned and supported by evidence, we maintain that the impact of prioritizing them, at the expense of methods potentially better suited to students’ circumstances, and without good counseling and consent, disallows adolescents from expressing agency in decisions about their bodies. Unfortunately, some providers may counsel solely on LARCs or dismiss adolescent concerns about LARCs due to their superior efficacy rates. This type of counseling prevents adolescents from making fully-informed decisions, which take into account their own preferences, history with other methods, and concern over side effects. Beyond this, LARC insertion/removal can be particularly invasive compared with oral or barrier contraceptives. Furthermore, many adolescents run into financial or access issues if they need parental insurance or the LARC is not removed before they leave school.
Another important open question regarding LARC provision in SBHCs is whether parents should be included in contraceptive counseling sessions or if they are entitled to final decisions about their adolescents using contraception. Many parents are uncomfortable with the provision of LARCS without parental consultation, especially given the invasive nature of insertion and extraction procedures. Alternatively, some parents strongly prefer LARCs if their adolescents want contraception because of the “certainty” of “set-it-and-forget-it” methods. There is no one-size-fits-all solution to this; adolescents must be given the choice to include/exclude their parents in these decisions.
The Need to Incorporate Reproductive Justice in SBHC LARC Programs
The ethical complexities described above, coupled with a history of reproductive coercion in many communities strongly suggest that SBHCs need to incorporate a reproductive justice lens into their service provision. SisterSong Women of Color Reproductive Justice Collective, co-founded by Loretta Ross, one of the pioneers of the reproductive justice movement, defines reproductive justice as “the human right to maintain personal bodily autonomy, [have/not have children], and parent the children we have in safe and sustainable communities”. Reproductive justice moves beyond the language of access and choice in health and rights-based arguments to uplift the varied lived experiences of historically and currently oppressed communities, centering Black women in particular.
A reproductive justice lens in LARC programs creates space for providers to proactively consider and plan for the impact that prioritizing LARCs might have on adolescents. TORCH, Advocates for Youth, and the Illinois Caucus for Adolescent Health are excellent examples of advocates for an explicit reproductive justice approach to adolescent health, whose work can inform SBHC’s reproductive health practices. They all create space for adolescents, particularly those from Black and Brown communities, to lead, organize, and uplift what is important to their individual and community needs and values around sexual and reproductive health. Furthermore, we believe that SBHCs need to consider goals other than the reduction of unwanted adolescent pregnancy. It is a valid reality that many adolescents welcome parenthood and/or have non-contraceptive reasons for using contraception. What matters most is that adolescents have adequate support and information from those of us tasked with caring for them, so they can make the best decision for themselves.
Reproductive Justice Informed Practices for SBHCs
In proactively planning to reduce the consequences of prioritizing LARCs, SBHCs and adolescent healthcare providers should:
- Check personal biases about different contraceptive methods
- Learn the history of the Reproductive Justice movement
- Honor additional reasons for contraception use
- Provide counseling that centers adolescents’ autonomy
- Ensure that students of all genders and sexualities receive contraception counseling
- Treat adolescents as partners in reproductive health decision making
- Create a plan for LARC removal at insertion that considers breaks and graduation
- Develop contingencies for keeping consistent adolescents’ access to contraception
Prioritize Adolescents First
LARCs work for many people, and they are not the right choice for others. This fact applies to adolescents, regardless of parents, providers, and communities’ values around reproductive health and age-appropriateness. Applying the reproductive justice framework in SBHCs is key to reducing the unintended consequences of LARC prioritization, especially for adolescents from historically and currently marginalized communities. A reproductive justice lens supports the improvement of adolescents’ educational opportunities and health status by enabling them to express their own agency and partner with the adults in their lives to make decisions that best suit their life circumstances. Adolescents deserve that much, at minimum.