Strategies to Advance Racial Equity in Adolescent Sexual and Reproductive Health

1. Honor youths’ sexual and reproductive health choices and desires. Work to increase the number of supportive adults who believe in young parents and feel confident in young parents’ abilities to make choices for themselves and their children.
2. Prioritize systemic reforms over efforts focused solely on individual sexual and reproductive health behavior change. Challenge providers, larger systems, and policies to reflect on their roles in ensuring that services are supportive for young people and expand programming and care to address systems-level issues.
3. Value and support expectant and parenting youth. Focus resources on creating appropriate and accessible systems for young parents and their children—not just on preventing pregnancies.
4. Uplift youths’ strengths to achieve their desired goals. Make space for youth to drive discussions about their sexual and reproductive health and goals and use their strengths as a guide.
5. Consider how youths’ multiple identities shape their sexual health experiences. Consider how race, age, geography, disability, poverty, religion, and sexual and gender identity intersect in a young person’s life—and how these factors impact their well-being—to more fully address the young person’s needs.
6. Use accurate language to hold racist systems and policies accountable. Create guidance and a culture on reframing the way we discuss causes and outcomes of adolescent pregnancy and parenting.

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Strategies

Honor youths’ sexual and reproductive choices and desires.

Why honoring youth’s desires is critical for racial equity: Embracing youths’ informed decisions and choices around their sexual and reproductive health fosters reproductive autonomy. Reproductive autonomy—or one’s ability to freely make decisions about one’s own contraception, pregnancy, and childbearing—is crucial to the health and well-being of individuals and the communities in which they live.

Throughout the history of the United States, Black, Brown, and Indigenous people have experienced reproductive coercion rather than autonomy. Members of these communities have been unknowingly or forcibly sterilized, experimented on in health care and research settings without consent, coercively enrolled in research settings without proper consent, pushed into using contraception, stigmatized for their family sizes and pregnancy desires, and prevented from parenting as they wish. These forms of reproductive control are both implicitly and explicitly racist, as they depend on an underlying belief that Black, Brown, and Indigenous people lack the capability to determine their own reproductive health needs—a belief unsupported by research. This perspective has been more prevalent when it comes to the desires and choices that youth—and particularly youth of color—have around their sexual and reproductive health.

Fostering reproductive autonomy in practice: Work to increase the number of supportive adults who believe in young parents and feel confident in young parents’ abilities to make choices for themselves and their children.

In one such program, HealthConnect One and the Ounce provide intensive training and supervision to Chicago-based community doulas in four areas: 1) undoing biases regarding adolescents, 2) confronting stigma and injustice experienced by adolescent parents, 3) valuing all pregnancies and all families, and 4) building adolescent moms’ confidence in their ability to succeed as parents and in life.

Doulas in this program learn to identify and challenge their own biases about expectant and parenting youth and are encouraged to share positive actions that mothers are taking with their supervisors (before noting any challenges) and to encourage mothers themselves to share positive information about their parenting. The program also teaches doulas how to confront the stigma that young people experience within health care settings or with negative family members and how to help young people advocate for themselves. Doulas remain with the mothers throughout their pregnancy, celebrating key milestones and helping them document sentimental moments. Lastly, doulas learn how to inform young people about the options that are available to them, including birth options, without lecturing or trying to influence their decisions.

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Prioritize systemic reforms over efforts focused solely on individual sexual and reproductive health behavior change.

Why systemic reforms are more likely to help: Interventions that address systemic factors have the greatest impact on people’s health. Many evidence-based programs (EBPs) supporting sexual and reproductive health—many of which were created and validated more than a decade ago—focus on changing individual knowledge, attitudes, motivations, and behaviors (e.g., increasing the likelihood that a young person will use a condom during their next sexual interaction), rather than on the factors that influence and determine a person’s decisions and behaviors to begin with (e.g., making it easy and comfortable for youth to receive high-quality, respectful, and youth-friendly health care services and information).

Focusing only on individuals’ attitudes and behaviors overlooks the known systemic inequities that individuals must interact with to achieve their desired sexual and reproductive health outcomes. While programs focused on protective sexual behaviors may have positive impacts, integrating systems-focused interventions could further mitigate inequities and improve outcomes that have otherwise remained unchanged.

Fostering systemic change in practice: Challenge providers, larger systems, and policies to reflect on their roles in ensuring that services are supportive for young people and expand programming and care to address systems-level issues.

In-clued is an evidence-based sexual health education program tailored to the needs of LGBTQ+ youth ages 14 to 19 that has two workshops: one for clinical staff and one for LGBTQ+ youth. The goal of the program is to uplift the voices and experiences of LGBTQ+ youth and take a systems-change approach to sexual health education. The program uses a dual approach in which both adult and youth facilitators deliver content separately to youth and health care providers. Youth receive information on safe sex and on how to access, navigate, and advocate for health services, while health care providers receive information from youth on implicit biases, the pitfalls of thinking of gender as binary (e.g., male or female), and best practices for working with LGBTQ+ youth.

A recent rigorous evaluation of In-clued reported promising results on youth engagement in risky sexual behaviors, sexual health knowledge, and access to and receipt of affirming sexual health care services. Providers also showed significant changes in knowledge of, and comfort in serving, LGBTQ+ youth.

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Value and support expectant and parenting youth.

Why it’s critical to support young parents rather than stigmatize them: Supporting young parents will not only benefit those young parents and their children but also other members of their communities.

Young parents—particularly Black, Brown, and Indigenous parents—are frequently shamed, stigmatized, and villainized for having children. Teen childbearing has been linked to a number of negative consequences, including school dropout, welfare dependency, and health issues for the mom and the child. These consequences have supported the idea that teen childbearing is “a very significant economic and social problem for the United States.”

However, while young parents and their children do experience obstacles, recent research indicates that negative consequences stem more from poverty, a lack of resources, and minority status than from the age at which parents have children. Black, Brown, and Indigenous young people are more likely to live in neighborhoods impacted by redlining and other forms of structural racism that produced high concentrations of crime, limited home ownership, and underfunded school districts.

In Pregnant Girl, Nicole Lewis states, “We begin with pregnancy as the thing that started a cascade of struggles … ignoring all that came before because it allows us to overlook all the ways we have failed them.” Additionally, for some young parents, having a child represents a meaningful transition that enhances their lives; these parents may describe parenthood as a motivation for educational and career goals, an opportunity for self-reflection and transformation, and as something that bestows a sense of maturity and responsibility.

Supporting young parents in practice: Focus resources on creating appropriate and accessible systems for young parents and their children—not just on preventing pregnancies.

Generation Hope drives change by providing direct support to young parents and their children through holistic, two-generation programming. This programming is embedded in an understanding of the systemic stressors that stymie young families’ ability to thrive. Generation Hope collaborates with youth, policymakers, higher education institutions, and other community stakeholders—both locally in the Washington, DC area and nationally.

By calling their participants “Scholars,” Generation Hope prioritizes an assets-based approach to supporting young families’ educational, social, and emotional well-being. Generation Hope provides mentoring, wraparound services, early childhood education, tuition support, career readiness, mental health and parenting support, and a peer community. By illuminating the experiences of young parents and investing in them—both emotionally and financially—Generation Hope has made huge strides in educational growth and development.

Generation Hope’s success is marked by findings showing that participating Scholars are eight times more likely to earn a degree within six years than single mothers nationwide. Additionally, 89 percent of 2021 Scholars reported an income level above the federal poverty line within six months of graduation and 100 percent of their young children scored “on track” on the Ages and Stages Questionnaire-2 Social Emotional development screening tool.

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Uplift youth’s strengths to achieve their desired goals.

Why it’s important to focus on young people’s strengths: Amplifying youth’s strengths can lead to more hope, opportunities, and positive outcomes for them. Youth are well aware of their personal and community-level challenges. Youth-serving professionals who narrowly focus on youth’s challenges—a deficit model—can prevent them from seeing and taking advantage of opportunities or solutions. A deficit model perpetuates a cycle of negative outcomes, wanes enthusiasm for change, and can lead to greater deficits.

Black, Brown, and Indigenous youth are variously viewed as young people who need “saving” or as those who are not worthy of being “saved.” However, neither perspective is true. Despite immense daily challenges, with access to modern technologies and global information, young people possess knowledge, skills, and perspectives that can be leveraged to support their well-being. A strengths-based approach, by contrast, does not deny that serious inequities exist or that certain populations face challenges, but does tap into youth’s strengths as a catalyst for change.

Focusing on youth’s strengths in practice: Make space for youth to drive discussions about their sexual and reproductive health and goals and use their strengths as a guide.

The Adolescent Family Life Program (AFLP) is a strengths-based case management program for expectant and parenting youth. The program’s goals are to increase social and emotional support, build resiliency, improve pregnancy planning and spacing, increase educational attainment and employability, and increase access to services. The program focuses on youths’ self-identified strengths, which are used to help them navigate challenges, build stable and supportive relationships, and achieve their goals. Participating youth drive discussions and activities that identify their strengths, values, and dreams; these are then used as guides to set life plans that focus on self-care, parenting, family planning and safe sex, education, and employment. Using the AFLP Positive Youth Development Model, case managers meet individually with youth twice a month to establish rapport, provide support, and hold youth accountable to their plans.

AFLP recognizes that centering and amplifying youth’s strengths leads to greater positive outcomes. Among AFLP participants, 86 percent of youth either graduated from high school or were enrolled in school; of the high school graduates, 40 percent pursued higher education, 92 percent received an annual medical checkup, and 91 percent of those who were pregnant received prenatal care.

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Consider how youth’s multiple identities shape their sexual health experiences.

Why intersectionality is an important consideration: Every individual has multiple identities or lived experiences, each of which can increase or decrease that person’s power over their circumstances. Systemic disadvantages or inequities in sexual and reproductive health are most deeply felt by youth who experience multiple forms of oppression and discrimination. Many sexual and reproductive health approaches focus on one aspect of identity (e.g., the individual’s race, age, parent status, gender, or sexuality) rather than on how multiple experiences, unique desires, and intersecting identities interdependently create and shape an individual’s experiences in this world.

For example, the sexual and health care experiences of a transgender, English-speaking Hispanic teen are different from those of a cisgender, Spanish-only-speaking Hispanic teen. They both may experience discrimination, but in unique ways. A transgender Hispanic teen may experience bias if providers make incorrect assumptions about their STI risk or pregnancy intention due to their presumed gender, whereas a cisgender, Spanish-only-speaking Hispanic teen may experience confusion, frustration, and poor care because their provider does not speak the same language as them or because the clinic does not provide sufficiently translated materials and clinic signage.

Focusing on race—or another facet of identity—alone might overlook other key dimensions of someone’s experience that nevertheless shape their well-being and inadvertently suggest that all individuals with a common identifying factor are similar (i.e., “all Hispanic teens share the same experiences”). However, intersectionality creates nuance and sheds light on the barriers a person may face in accessing sexual and reproductive health care, their lived experiences that shape their sexual and reproductive health, and their multiple strengths that can promote their well-being.

Focusing on intersectional identities in practice: Consider how race, age, geography, disability, poverty, religion, and sexual and gender identity intersect in a young person’s life—and how these factors impact their well-being—to more fully address the young person’s needs.

The Family Tree Clinic in Minneapolis, Minnesota, recognizes that clients have a range of identities and life experiences and considers clients’ multiple identities (e.g., ability, race, gender identity, body size) by offering person-centered, respectful, inclusive, and safe services. The clinic conducts listening sessions to understand community members’ unique, intersectional needs; trains all staff to work with people who have been excluded and traumatized by the medical system; and provides individualized care options. By understanding the oppressive systems that impact their clients’ sexual and reproductive health and overall health, The Family Tree Clinic goes beyond providing sexual and reproductive health services to also engage in advocacy and community-based initiatives and provide legal, mental health, and financial supports. The clinic also intentionally creates a physical environment in which clients’ multiple identities are acknowledged and prioritized—for example, by arranging furniture in varied ways to accommodate different body types, ensuring that the building is accessible to people of all sizes and abilities, and posting art on the walls that reflects their diverse clientele.

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Use accurate language to hold racist systems and policies accountable.

 Why language matters in advancing equity: Communicating and linking inequities to systems not only inspires change at the systems level but also paints a more accurate picture of the many factors that continue to drive disparities.

The ways in which people describe and discuss populations who have been excluded from safe and accessible sexual health services have implications for programs and policies. This is especially true for sexual and reproductive health programming. People who present data on adolescent sexual and reproductive health often note population health disparities (e.g., “teen birth rates of Black and Hispanic people are twice the rate of White people”) or imply that White people have achieved a standard to which Black and Hispanic people should aspire. This language promotes harmful stereotypical narratives about Black, Indigenous, and Hispanic populations (e.g., that they are irresponsible or promiscuous); undermines non-White populations’ own cultural norms and perspectives around sexual and reproductive health; ignores the variation in experiences of populations, including White populations (e.g., based off of geography, gender, and socioeconomic status); and fails to guide the development of policies and practices that are systems-focused and culturally responsive.

A more appropriate way to describe the experiences of Black, Brown, and Indigenous youth is to link experiences to systemic inequities, such as: “Black and Brown teens still face discrimination and bias from health care providers” or “There are limited employment opportunities for youth under age 18 that provide flexible hours, benefits, and livable wages,” or “Few public schools have strong systems that allow for virtual or remote learning that would accommodate young parents.”

Holding systems accountable through accurate language in practice: Create guidance and a culture on reframing the way we discuss causes and outcomes of adolescent pregnancy and parenting.

The Center for the Study of Social Policy, Linking Systems of Care, and the National Council of Juvenile and Family Court Judges provide guidance on reframing the causes and outcomes of adolescent pregnancy and parenting. Organizations can use this established guidance or create similar guidance to improve the clarity and accuracy of their own messaging.

• Remove stereotypical language about expectant and parenting youth and replace it with affirming, strengths-based language.
• Require anti-bias/anti-racist training and coaching for everyone who interacts with expectant and parenting youth.
• Engage media and other producers of images to partner with systems of care to promote positive images and messages of expectant and parenting youth, such as “Young parents have a desire to be good parents for their children with hopes of creating positive and stable futures for themselves and their children.”
• Invest in improvements to the root causes of inequitable outcomes for young parents and their children.
• Employ practitioners who reflect and maintain the dignity and humanity of expectant and parenting youth.

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Acknowledgements

The authors wish to thank Emma Pliskin for her thought leadership, writing contributions, and expertise on reproductive autonomy. The authors would also like to thank Mavis Sanders, Kristen Harper, Lizy Wildsmith, and Jenn Rogers for their invaluable guidance regarding the overall framing of this product and for reviewing drafts and providing feedback throughout its development; Brent Franklin and Jody Franklin for editorial review and feedback on structure; and Zabryna Balén for an equity review and fact checking.

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