Protecting Our Children

Les Willis has what is arguably the most controversial job in all of education. He makes condoms available to high school students.

Willis is a social worker with the Medical College of Pennsylvania and hands out condoms as part of an HIV/AIDS prevention program that began in the Philadelphia high schools in December. He works at Gratz High School and sees about 35 students a day, four days a week. About 65% of them ask for condoms.

Willis knows that controversy swirls around the issue of condom availability in our nation’s schools. He also knows that the controversy is not a big concern to those most affected: the students.

“The students clearly seem to want condoms in their school,” Willis said. “They want the availability. And while students initially come to get condoms, what I’m seeing now is that they are coming more and more for education and counseling.”

At a time when public education is steeped in controversy, perhaps no issue is more inflammatory than proposals to make condoms available at high schools as part of HIV/AIDS prevention programs. In cities and towns from Los Angeles to New York City, from Marin County, Calif. to Chester, Vt., communities have split over the issue. School boards have been bombarded with protests, opponents have packed public hearings, and batteries of lawyers have been hired to debate the programs’ merits in court.

The fact that districts have nonetheless proceeded with condom availability programs speaks to the life and death urgency of preventing the spread of the HIV virus that causes Acquired Immune Deficiency Syndrome (AIDS). For schools, this urgency is even more pressing given the escalating rate of HIV infection among adolescents. Young adults aged 20-29 account for more than 20% of all AIDS cases — and the majority of these young adults probably became infected as adolescents (see story page 8).

“If you look at it from a public health perspective and put aside the political ramifications, it’s hard to come down on any other side than making condoms easily available,” said Devon Davidson, director of the AIDS education project for the National Coalition of Advocates for Students. “We’re talking about saving kids’ lives. That has to be the bottom line.”

Those districts that have passed condom availability programs generally have done so as part of a comprehensive HIV/AIDS education curriculum. While condoms are only a part of the package, they immediately become the center of the controversy. Unfortunately, it is far too easy to predict what will happen when a proposal includes condom availability.

“There will be backlash, absolute backlash,” said Sarah Grambs, spokes-woman for the Family Planning Council of Southeastern Pennsylvania, which helped develop Philadelphia’s condom availability program. “It will happen no matter how inclusive you have tried to make the process, no matter how much you have tried to involve parents, and no matter how public you have been in the discussion.

Once the decision to distribute condoms is made, the backlash is swift and ugly.”

Nationally, there are five district-wide condom programs, according to the Center for Population Options, which monitors condom availability in the schools. These districts are: New York City; Philadelphia; Falmouth and Martha’s Vinyard, Mass.; and Commerce City, Colo. Another 10 districts have approved such programs and are in the process of designing them: Seattle; Los Angeles; San Francisco; Chelsea, Newton, Brookline, Hatfield, Lincoln/Sudbury, and Provincetown, Mass.; and Wachusett Regional High School in Massachusetts. In addition, there are over 40 school-based clinics that make condoms available to sexually active students in cities such as Portland, Ore., Baltimore, and Chicago.

In Washington, Mayor Sharon Pratt Kelly announced a Public Health Department plan this May to make condoms available in the high schools as part of a citywide initiative to combat HIV infection.

In Milwaukee, meanwhile, The Milwaukee AIDS Project (MAP) is finalizing a proposal for a comprehensive HIV/AIDS education plan — including condom availability — for the city’s middle and high schools. MAP will call for a broad-based task force to develop specific guidelines to present to the School Board for approval, according to Doug Nelson, executive director of MAP.

In Canada, three school districts felt so strongly about the need to make condoms available that they installed condom vending machines in the schools. Toronto, one of the districts, has machines in all 32 high schools.

Debates on condom availability raise a number of issues. Why make condoms available to students? Shouldn’t educators be stressing sexual abstinence instead? How does one balance the right of parents who don’t want schools to make condoms available to their kids, versus the right of students to be protected from pregnancy and AIDS and other sexually transmitted diseases? Who should make the condoms available and how?

Issues in the Debate

Opposition to condom availability in the schools generally has been spearheaded by fundamentalist religious groups and representatives of the Roman Catholic Church. Often, the debate mirrors controversies around issues such as the right to abortion, sex education, and support services for gay and lesbian students. Not only are many opponents well-organized, well-financed, and highly vocal, but they couch the argument in uncompromising terms of good versus evil, thus clouding the medical and legal issues involved and often frightening those who don’t agree into silence. Some critics, for example, link condom availability to the “moral decay of society,” perversion, and the promotion of substance abuse and homosexuality. (In general, but not always, staunch opponents of condom availability also view homosexuality as aberrant behavior.)

Virginia Uribe, head of Project 10, a gay and lesbian support program in the Los Angeles schools, said the lesson learned in Los Angeles was that you have to politically organize your supporters and not rely on the overwhelming medical evidence supporting condom availability among adolescents. (A condom availability program narrowly passed, 4-3, in Los Angeles in January.)

“Board members have to be well educated and prepared for the onslaught that is going to definitely take place,” Uribe said. “You need to have your ducks lined up, because the other side will be just awful and they will be relentless.”

While some people are adamantly opposed to condom availability in schools, a number of parents and community people may be unsure what to think because the issue raises complicated questions about substance abuse, adolescent sexuality, and sexual orientation.

Often, people will argue that abstinence is the only correct message, or that schools should not be in the business of making condoms available.

Health educators who advocate condom availability do so as part of what is called the ABC’s of AIDS education: Abstinence, Be monogamous, and Condoms. They stress that the first message they give teens is to remain abstinent if they are not yet sexually active. They also note that abstinence is the only 100% effective way to prevent the sexual transmission of the HIV virus.

The question is, what do you do about the growing number of teenagers who, regardless of what adults might think, are sexually active? And if you want to truly reach young people with the ABCs of AIDS, why would you ignore the one place where they spend a significant portion of their waking day — at school?

“People hate statistics, but just take a look at them,” notes Jennifer Hincks, head of the HIV education program for the Center for Population Options in Washington, D.C. “It’s frightening, there’s no denying that.

But we’re not teaching kids to have sex when we make condoms available. We’re teaching kids to protect themselves.”

For parents who may not think it’s appropriate for their children to have access to condoms, it’s important to note that teenagers already can go to any gas station, convenience store, or drugstore in the country and buy condoms without their parent’s permission. In a 1977 ruling, the U.S. Supreme Court declared that minors have a constitutional right to buy non-prescription contraceptives without adult approval or restrictions.

“There is absolutely no question that teenagers have a legal right to access to condoms, and that right is protected under the constitution,” said Abigail English of the National Center for Youth Law in San Francisco. “The question is, ‘To what extent can that right be curtailed in the school?’”

But there is a difference between having a legal right and exercising that right.

Sexually active teenagers have stressed in various surveys that they don’t use condoms more often because of problems such as embarrassment, objections by a partner, and a lack of perceived risk of pregnancy or infection. They also cite concerns about confidentiality, the cost and problems in getting condoms.

In a 1988 survey of Washington, D.C., drugstores and convenience stores, condoms were kept behind the counter in more than one-third of the stores, according to the Center for Population Options. Only 13% of the stores had signs that clearly marked where contraceptives were kept. Adolescent girls asking for help encountered resistance or condemnation from store clerks 40% of the time.

School-based HIV/AIDS education programs that make condoms available are sensitive to the problems cited by teens.

Perhaps more important, they can also teach the kids how to use the condoms, help foster a climate of peer acceptance of condom use, and refer teenagers for counselling on related social and health issues.

Condom availability programs implicitly tell kids that there are adults who are willing to support them and help them. “It’s showing that we care about these kids,” said Hincks. “To make condoms available in schools is somewhat new and risky. But I think teenagers are getting the message that it’s very important, and it’s so important that we are going to make condoms available wherever we can.”

Barbara Whitney, director of the HIV/ AIDS technical assistance project in the New York City public schools, added that the value of the debate goes beyond the issue of condoms. “What is really important is that we are taking very seriously our students’ right to information and creating a public dialogue about an issue that we never had before,” she said.

Advocates of condom availability note that the issue is one of public health policy

• preventing the spread of the HIV virus
• not one of morality versus immorality. In this regard, the debate over condom availability in schools mirrors problems that have historically plagued the fight against AIDS.

“Perhaps the single most important obstacle to AIDS education is the difficulty in distinguishing a public health agenda from a moral agenda,” Nicholas Freudenberg, professor of Community health education at Hunter College in New York, wrote in a 1989 article published in SIECUS Report, the bimonthly journal of the Sex Information and Education Council of the United States. “This problem shapes every aspect of HIV/AIDS prevention.”

In his article, Freudenberg noted the dangers in watering down what is medically necessary in order to head off controversy. “Any disease involving sex, drugs, and death creates controversy, and almost anything that can be said about AIDS may offend someone,” he wrote. “The danger of education that offends no one is that it may fail in its effort to communicate anything at all to those most in need of the information and resources at the time.”

Support for Programs

Despite the controversy surrounding condom availability in schools, such proposals have wide support. Among the organizations that support New York City’s HIV/AIDS program, which includes condom availability, are the American Medical Association, the American Public Health Association, the American Association of School Administrators, the American Jewish Congress, the National Center for Health Education, the Child Welfare League of America, and the U.S. Conference of Local Health Officers. In addition, a 1991 Roper poll found that 64% of adults say condoms should be available in high schools. Other studies have shown that while many parents may not want their adolescent children to be sexually active, they are equally concerned that they take precautions if they are having sex.

Massachusetts was the first to take action on a statewide level. In August, 1991, the state’s Board of Education issued a policy recommending that high schools consider making condoms easily available to students. As a result, more districts have debated the issue in Massachusetts than in any other state.

Kevin Cranston, director of the AIDS project for the Massachusetts Department of Education, said there have been two key factors in whether a condom availability program passes. One is leadership from the administration or school board (a phenomenon he said was “not the majority experience”). The other is strong grass-roots organizing by parents, community health organizations, and students.

Cranston said he had been particularly impressed by student leadership in the debate. “The students have really driven the agenda on this issue,” he said. “They created the agenda in fact. We at the Department of Ed. weren’t even discussing this [the policy statement] as a possibility until the students pushed for it.”

The students have also been an important factor in countering arguments that making condoms available gives the wrong message to students. “In fact,” Cranston said, “the students are coming to the adults and saying, ‘We know better than you what is at stake and what kind of risk behaviors are going on, and we are protecting our lives.’”

The Massachusetts Board of Education did not tell districts what to do, but recommended that schools discuss all options.

This included making condoms available not only through school officials but through vending machines.

“Students have reported to us repeatedly that they would prefer both options: the vending machines and the nurse’s or counselor’s office,” Cranston said. “Different kids will need different avenues of access.”

NewYork, Philadelphia

Philadelphia and New York City were the first two major school systems to make condoms available on a district-wide basis. In many respects the programs are similar. One major difference involves what is known as parental opt-out.

Almost all condom availability programs allow parents to send in notification that they do not want their children to take part — a procedure known as parental opt-out. But New York City, the first major school system to pass a condom availability program, does not allow parental opt out.

“New York really has to be admired for taking that stand,” said Davidson of the National Coalition of Advocates for Students. “My impression is that most districts that have the parental opt-out did so because that is how they got the program approved.”

“Clearly, kids need free access to condoms regardless of where their parents are on this,” Davidson continued. “It is the child who might end up with the possibly fatal disease, not the parents.”

In New York, parental opt-out was defeated largely as a result of the firm stance taken by Schools Chancellor Joseph A. Fernandez. He argued that allowing parental opt-out would, first of all, water down the plan and deter precisely those youngsters who may have difficulty discussing issues of sexuality with their parents. Second, parental opt-out might jeopardize student confidentiality and trust. A parental opt-out, program, for example, might require school officials to keep lists of students whose parents do not want them to get condoms — thus forcing all students to show an ID to prove they were not on the list.

“It was not a vote against parents,” Erlin Ibreck of the Diamond Foundation that has funded aspects of the New York program said. “It was a vote for these young people who are very much at risk.”

At the same time, New York has promoted parental involvement in the condom availability plan. Every high school must develop an HIV/AIDS education team composed of students, staff, and parents. In addition, no school will be approved for making condoms available until there is a public, school-wide meeting with parents to discuss the program.

“The absence of parental opt-out does not mean that there is not parental involvement in the program,” Whitney stressed.

New York began making condoms available in its high schools in November. By the end of this school year it hopes to have all of the city’s 120 high schools participating, with a combined student population of 261,000.

Under the New York program, condoms are to be made available at least two periods a day, distributed by at least one male and one female volunteer from the school staff who have received special training, or from a professional health advocate at the school. The volunteers and health advocates also offer counseling and guidance services.

School-based health clinics can refer kids to those distributing the condoms, but the clinics themselves do not give out condoms.

Philadelphia began its condom availability program in three schools in December. More schools were added in following months and the goal is to have programs running in all 50 Philadelphia high schools.

In Philadelphia, the condoms are made available through a health resource drop-in center at the school staffed by health professionals. Each school is also linked to a local health care provider such as a hospital or community health center. At Gratz, for example, the drop-in center is linked to the Medical College of Pennsylvania, a major teaching hospital in the city. “The center is also the kids’ entry point into all the services available at the hospital, if they choose to use it,” noted Grambs.

Philadelphia also has a parental opt-out option. Despite the controversy that initially greeted the condom availability proposal, few parents have opted out. At Gratz, only about 36 parents have requested that their child not be able to receive condoms, out of about 2,000 students, according to Willis.

HIV/AIDS Curriculum

While public attention has focused on condom availability, the programs have been approved as part of much more comprehensive HIV/AIDS education programs. In New York, for instance, the program mandates that there be a minimum of five lessons per grade level on HIV/ AIDS in kindergarten through 6th grade, and at least six lessons per grade level from 7th to 12th grade. Likewise, the condom availability program in Philadelphia is accompanied by a revamped K-12 sexuality curriculum, staff training on adolescent sexuality, and parental involvement in implementing the programs.

Generally, comprehensive HIV/AIDS curriculum also include lessons in self-esteem, skills development and decision-making, and general health issues, according to Cranston. In the higher grades, this would also include issues such as contraception, sexually transmitted diseases, substance abuse, pregnancy, and abstinence.

Those involved in HIV/AIDS education programs stress that while lessons must begin in kindergarten, they must be age appropriate. In the early elementary grades, for example, education about AIDS “should principally be designed to allay excessive fears of the epidemic and of becoming infected,” according to the Center for Disease Control. The center has published a guideline for AIDS health education, and several other curriculum guidelines are available (see bibliography, p. 10).

Health educators also note that it is important to be culturally sensitive in discussing HIV and AIDS issues, and to avoid the racism and homophobia that have accompanied much of the public debate on AIDS due to the high numbers of gay men and drug abusers and their sexual partners (who are disproportionately people of color) who have gotten the disease. In addition, a disproportionate percentage of adolescents who have become infected with the HIV virus are African-Americans and Latinos.

Educators underscore that it is important to stop using the term “high-risk groups” when referring to HIV infection and to refer instead to “high-risk behaviors.”

“By focusing on high-risk groups, educators invite the ‘us’ and ‘them’ mentality, and falsely reassure those who would deny their own HIV risk by implying that HIV is someone else’s disease,” write Beverly Wright and Cooper Thompson in the October/November 1990 SIECUS Report. “Speaking about high-risk behaviors neutralizes the issue and is more truthful; it helps people understand that it is what they do that could infect them, not who they are.”

This message is especially important for adolescents, who are notorious for believing that death and disease is something that happens to old people, not kids.

In the 1980s, then Surgeon General and Reagan appointee C. Everett Koop surprised many a liberal — and earned the wrath of many a conservative — when the reality of the AIDS epidemic forced him to advocate a strong education policy around HIV infection. At that time, he made a point about condom education that unfortunately remains all too true today.

“It might offend some people, and I’m sorry about that,” Koop said. “I wish this wasn’t necessary to talk about, but it i , and we can’t let people die in ignorance.”