Abortion sucks

The chief complaint listed next to her name was, "wants to know if she is pregnant." At first, it didn't seem like she wanted to know that badly--she barely looked up from her cell phone when I walked into the room for the first time. She answered questions the way fifteen-year-olds often do--briefly--and held out one skinny hand for the urine sample cup without turning her eyes away from the keypad of her phone.

I imagined the exchange:

"@ drs ofc 2 chk f nokd up"
"wnt 2 mt l8r @ mall 2 mk sum bad choicz?"
"abt fashn or sex?"
"OK, f my boyfrnd cn come"

She looked up the second time I walked into the room, then looked back down after I told her the pregnancy test was positive. It wasn't the first time she'd heard news like this; she'd been pregnant twice before, and had had abortions to end both pregnancies. She cried even as her fingers flew over the keypad. "I'm gonna have another abortion," she said. "That's fine," I said, "but you need to put down the phone so we can talk."

According to her records, she'd never taken birth control--never even been counseled on it. And she'd missed her past three well-child checks, which suggested some instability in her home situation.

I asked why she was crying. "Having an abortion kind of sucks," she said. She talked--again, briefly--about loneliness, shame, and having to tell her mother (not by law, but because she felt she needed to).

Her alternatives to abortion--completing the pregnancy and giving the newborn up for adoption, or raising the child herself--were significantly less acceptable to her than dealing with these "side effects." I sent her home with a plan for her to follow up the next day with a local family planning clinic, where she would be further counseled, offered an abortion (if she continued to want one), and offered birth control for afterward.

I don't mean to get into a discussion of whether abortion should be legal or not. What I mean is to point out that the nuances that seem completely absent from the national debate on abortion are all over the actual interactions that health care providers have with the women who get abortions. Yes, abortion sucks. It carries risks risks of minor physical and major emotional side effects. But the alternatives--unwanted children at an unprepared age, and the sheer indignity of not having reproductive choice--suck ever so much more.

Our national abortion policy just got decided by an organization whose main goal is to communicate that abortion sucks without telling the rest of the story. It's likely that the reason this organization had as much of an impact as it did was because the abortion-rights side thought the organization's argument was too inane to be worth responding to in court.

They were wrong, of course. It's hard to overestimate the distance between most lawmakers and the fifteen-year old girls with skinny hands and ruined lives. And it's hard to underestimate their interest in getting closer.

More like this

Hell, this child doesn't need to make any adoption plan for a fetus; she needs to be adopted herself! Fifteen and pregnant for the third time!

As a family doctor who believes that abortion is an important, and potentially very empowering (not sucky at all), part of comprehensive health care, I was quite glad to read that your article was more nuanced that the title might have suggested. I often have women tell me how grateful they are to have abortion as an option, and how it can be quite the positive experience for various and sometimes complicated reasons. In fact, this happened just a few hours ago!

I would also argue that with your point that our "national abortion policy" has something to do with the fact that the lawmakers think abortion sucks for women. They think it sucks for themselves and their faith and don't care about women. That is quite clear, as evidenced generally by their attitudes and misguided opinions, and specifically by the lack of a health exception for the women in regards to second-trimester abortion procedures.

And Elf Eye, that's an awful judgmental thing to write, isn't it?

This is unbelievable! How, how, HOW can you say that murdering this girl's THIRD child is better? If your mom had gotten pregnant with you when you were 14 or 15, would YOU have rather been murdered?

Abortion is better than the indignity of not having reproductive choice?!?! WHAT? She DID have reproductive choice. She chose to get pregnant! She chose to have sex without birth control. She did choose.

The TRUE INDIGNITY is that this innocent child - who is in no way responsible for the way in which it was conceived - is being forced to pay the price with its very own life! A life it will never get to have.

I really do not understand how doctors who take a pledge to protect life can be so fine with routinely allowing the killing of unwanted babies. That is the true indignity!

Deb, it's not murder, and it is most definitely not a child! Even though a blastocyst or embryo have the capability of becoming a child, in those stages they are as independent and different from the woman carrying it as, say a tumor or even a skin cell that's had some UV damage and thus has different DNA. In those stages it has not developed yet a nervous system and, much more significantly, a brain. Our human brain is what gives us our personality and sense of self, without it we are not human. Should removing a parasitic twin, invariably anencephalic and dependent completely on its host (the "other" twin) be considered murder then? In what way is this twin any different from an embryo?

Brigit -
It IS different than a tumor or a cell with mutated DNA - that child has DNA that is its own DNA. A tumor cell has no capability of becoming a life. A tumor or mutated cell still has the same DNA as the mother plus or minus a few mutated tumor suppressor genes or oncogenes. Even the DNA it received from its mother is not entirely the same due to recombination. That baby has DNA that is a unique combination NEVER seen before on earth! It is absolutely ridiculous to compare the two! It shows how little you know about genetics and shows what little respect you have for life.

It is a unique life. BTW, no abortion is ever done (except for the morning after pill) during the blastocyst stage. Pregnancy can't even be confirmed until after implantation.

Do you really think that this abortion or most abortions, for that matter, are done before the nervous system begins development? Yeah, right... most women don't even know they're pregnant until 6 weeks or so. That's why there's spina bifida - women don't know they're pregnant until after the neural tube has closed. Then, it's too late for them to start taking their folic acid.

Let's say that we think there are too many kindergardener's in Dodge county - the schools are crowded. Not enough teachers that want to teach them. Nobody wants all these kindergardners! So, we're going to kill all the 1 year olds. They're not 5 year olds yet ANYWAY - what's it matter. At one year of age, they won't even know what's happening. They can't tell us to stop. They can't put up a fight really either. They don't have the brain of a 5 year old. Their nervous system isn't even hardly developed - they just lost they're primitive reflexes anyway.

Isn't that a ridiculous idea! We shouldn't do that because if we just left them alone, they would become 5 year olds! That 1 year old didn't do anything wrong. Someone just thought there were too many kindergardeners. Someone didn't want the hassle. I'm sure there are lots of other counties that would be willing to help out if they heard the alternative was killing them! Why is it OK to kill that baby - it's heart has likely been beating for weeks! If we'd just leave it alone, it would be a viable human life. Right now, yes, it's not viable. But that doesn't mean it's not a human life! That 1 year old would likely not survive on its own either - it needs the care of adults. Just like these unborn babies need the care of adults. They need the care of their mother most.

America today is sooo caught up with themselves. The only person that matters to most people is themselves! They are number one! I think that is at the root of why so many support abortion. They think that they would like the choice. They turn a blind eye to the facts because the facts might mess with their conscience, and they want to do what they want to when they want to and how they want to.

It shows how little you know about genetics and shows what little respect you have for life.

Well, this definitely seems to show how comfortable you are with personal attacks. 'Classy', to say the least.

Do you really think that this abortion or most abortions, for that matter, are done before the nervous system begins development?

Of course not. Maybe I didn't explain myself enough in my previous post. The brain is not a fully functional organ until synaptic connections are formed among neurons. This does not happen until mid or late second trimester. In this stage only pregnancies that threaten the life of the mother are terminated. And yes, after this point I consider the fetus to be a human being.

Your next three paragraphs are just an illogical tirade against a strawman that stems from your hypothesis of an embryo being equal to a child. Given that a functioning brain is formed in the second trimester it's just an useless argument.
So, I think I answered your questions. How about you now answer mine?

Should removing a parasitic twin, invariably anencephalic and dependent completely on its host (the "other" twin) be considered murder then? In what way is this twin any different from an embryo?

Chances are that if youre reading this blog (unless you stumbled upon it by some miracle of randomly pounding the keyboard), you are intelligent and well-educated enough to have formed an opinion about abortion. Hopefully most of the readers are also intelligent enough to realize that people on both sides of the debate are going to have vastly different, yet well-informed, views on this subject that are influenced both by science and personal ethics. While Jerry Springer may be a great forum for the arguments of both Deb and Brigit, theyre really not going to convince anyone of anything here. Deb, while you and many people may believe it to be so, calling abortion murder is certainly not a cutting-edge argument that is going to do anything except get people pissed off at you for being inflammatory. The definition of murder is the unlawful taking of a human life. Abortion isnt illegal Deb so it isnt murder. Pick a better word. And did you really ask would you have rather been murdered? Im sorrylet me quote more accuratelywould YOU have rather been murdered? Has that argument really changed anyones mind? No seriously, has ANYONE ever been convinced that abortion is wrong by asking if they would rather have been murdered? Seriouslyanyone? And Brigit, I would hope that you realize that the argument its not a life is pretty lame and easier and easier to refute as medical advances decrease the age of viability. Where will your debate go when medicine finally does create a test tube baby and we watch a blastocyst develop into a human without a human womb? When does life start then? Life will be irrelevant then and the debate will focus solely on choice at that point. Even if youre convinced beyond all doubt that its not a life, if you cant comprehend the difference between a blastocyst (which is genetically goal-driven into becoming a human infant) and UV-damaged skin (which can and will never ever grow into a fully functioning human being), then you should probably go to back to school. And DrRobert, for you to blindly say that lawmakers dont care about women and then turn around and call Elf Eyes comments judgemental (even if they are) is so hypocritical that its sickening. You have to understand that many people in the anti-choice camp truly believe that an embryo is a life and that abortion is ending that life and is therefore wrong. You may disagree and think science backs you, but if you dont understand that thats where theyre coming from and that they can have that deep-seeded opinion and still care fervently about the health of women as much as you fervently believe that abortion positively impacts womens health, then you are too blinded by your own politics/beliefs to see reality.

Though I think most of us understand these points. I sure hope in 2007 that most of us understand these points. Thus, Signouts goal in this blog was specifically not to discuss whether or not abortion should be legal. She, in fact, clearly stated What I mean is to point out that the nuances that seem completely absent from the national debate on abortion are all over the actual interactions that health care providers have with the women who get abortions. Do you all really think that the arguments its not a life, its murder, or they dont care about women are the nuances which have been excluded from the debate? I doubt it. Is it possible to have a debate about a blog that mentions abortion without spiraling down into the same old counter-productive, emotionally-charged, and childish arguments hurled back and forth by most elementary schoolers when arguing about abortion on the playground? Bring something worthy of discussion to the table peopleor shut the fuck up.

Slander, I never stated that an embryo was not "life", rather humanity. My argument was that it is not a person (child), therefore it has no human rights and the termination of a pregnancy cannot be considered murder. If you cannot clearly read what other people have written, then you definitely should go back to school. The the main concerns regarding pregnancy termination should be the health and well-being of the woman . Women are definitely able to analyze their situation according to their beliefs and choose accordingly. However, their decisions and, in many cases, their own moral values, are questioned by people that have no idea under what circumstances they came to the doctors office. Thank you for contributing absolutely nothing to this discussion, so if you have nothing to say about abortion issues or doctor-patient relationship and counseling STFU and stop you bitching.

You didn't do her any favors, Doc. If she is 15 and pregnant, for the third, second or even first time- she is not being adaquately supervised. A 15-year-old does not have the ability to legally consent to sex. She is a child, and needs to be protected from diseases, heartbreak, exploitation...(how much do you want to bet that at least one of her the fathers was over 18?).

Referring her for an abortion was a neglectful thing to do. She needs to be referred to a social service agency that will protect her.

Why is it okay to continue giving this girl abortions so she can continue engaging in self-destructive behaviors?

By JacqueFromTexas (not verified) on 08 Jun 2007 #permalink

Jack from Texas
-why is it ok? because he's a doctor, she's a patient. That's how it goes. That's his job. That's the reason doctors in war zones treat whoever is in front of them. that's why cops shoot bank robbers and murderers and rush them to the hospital. why save a criminal who may be a criminal again? because the doctor doesn't make that choice. s/he treats whoever is in need of treatment.
-second, you say the girl isnt being adequately supervised. probably. but that happens to a lot of 15 year olds from troubled homes. and it doesnt mean theyll be better off if taken away from their families. maybe, maybe not. you just dont know. the doc did what he was supposed to do - refer her to people who are supposed to help her get help. counseling, education, etc. if they fail - they fail. but not Signout.

I, personally, am deeply offended by sloughing skin. We could take the DNA from those skin cells, inject it into an egg with its own nucleus removed, and get a whole new human being! Who are we to judge that this potential human being should not be given its chance at life?

Yes! And, I'd add, what about the men?

But seriously. Jacque, although I don't agree that referring her for an abortion was neglectful, I do agree that it's not enough to "fix" her. And I think involving a social worker and/or some kind of social service to help her change some of her risky behaviors is a great idea.

Suggesting that we shouldn't give her an abortion because it encourages destructive behavior is like saying we shouldn't treat a smoker's bronchitis, a type-II diabetic's foot ulcer, or an obese person's hypertension. My guess is that around 80% of my patients did it to themselves, but that doesn't mean we don't treat them--why should we see a woman with an unwanted pregnancy any differently?

A patriarchy says what?

I'd also like to point out, in response to Jacque's comment, that all of us--myself included--are expecting the doctor in this case to turn this woman's life around. I think it's worth just being aware of the new paradigm in which primary care docs working with high-risk patients now operate: we feel that if we don't connect them with every social service they need, we haven't done our jobs. As doctors. Discuss.

As ever, many thanks to the folks willing to take this discussion away from the usual yes-it-is-no-it's-not.

I am a social worker- and involving us is not just a good idea, it's the law. 15, in any state in the U.S., is not a legal age for consent to have sex. Her 3 pregnancies are a result of neglectful supervision at best, statuatory rape or sexual abuse at worse. So, yes, doctor, you just sending her to an abortionist so that she can continue to have sex (which is illegal at her age for good reason) is absolutely in all ways NEGLECTFUL. Certain conditions can't be "fixed" with a quick referral to an abortionist. When she comes back to you with HIV because you didn't fufill your role as a mandatory reporter, what do you intend to do then?

I am not suggesting that you deny people treatment because they are the cause of their own maladies. I never implied that at all- and this summarizes the misconception that pro-lifers are patriachal assholes that want to punish women for having sex. If the person in question was an adult, nothing I have said would matter- because adults can consent to sex: A 15-year-old child can not. What I'm saying is that the abortion referral simply enables her to continue this dangerous lifestyle unchecked whereas the right referral would have been to social services who can help this girl be safer. I don't expect you to practice social work on her, just pick up the phone and report the situation to social services! It's that easy. It's much easier than making fun on this poor child on a blog!

I don't expect you as a doctor to act as a social worker and "turn this woman's life around." I expect you to be an adult. Adults have an obligation to children to protect them and you failed miserably. Instead, you make fun of her bad and dangerous choices rather than getting her the proper attention. Adults that have a suspicion of child abuse and fail to report it have broken the law. Any pregnant child under the age of consent is an abuse victim. So perhaps it's not that I expect a doctor to be a social worker, but simply a law-abiding adult.

You still have the opportunity to do the right, responsible thing. Make a phone call: 1-800-4-A-CHILD.

By JacqueFromTexas (not verified) on 08 Jun 2007 #permalink

1. I did not make fun of her situation--I made fun of her texting. If you find this inappropriate, you do not have enough of a sense of humor to be reading this blog.

2. Sending a patient to a doctor who will perform an abortion does not determine whether she will have sex or not.

3. I referred her to a clinic that, like most clinics that provide abortions, also provides social services, counseling, contraception, and other supportive services. It was an illness clinic visit--a one-off visit--so involving social work in the clinic seemed less helpful than having her be followed by the OB/GYN social worker longitudinally. What do we say about assuming?

4. Even if we are mandatory reporters of underage sexual activity, doctors don't report every kid who's sexually active and not of age. There's some consideration of a kid's maturity and decision-making ability before reporting to Child Protective Services, which is essentially what you're talking about. CPS referrals are often far less helpful than a different kind of intervention in cases when you think a kid is making his or her own choices, such as they are.

5. Before commenting again, please review the "about" section of this blog. I am learning to be a doctor. I make mistakes (although I don't think I made one in this case). So, like, be nice.

JacqueFromTexas - easy on the finger pointing! In order to get her abortion, this girl has to see more doctors and nurses... more mandatory reporters. And mandatory reporters who deal with this kind of this every day, as opposed to Signout who, as a resident, is still learning. Watch where you put your ALL CAPS.

As for you, Dr. S, "...we feel that if we don't connect them with every social service they need, we haven't done our jobs. As doctors. Discuss." Guh. That's why I'm going in to Critical Care (or other such specialty - don't worry - no decisions made yet!) I can't handle the GUILT :)

Oh! Signout! You beat me to the post! Dammit. And it was so proud of my carefully worded can of whoopass. Oh well. Bedtime for this on-call resident.

Ah look- 5 excuses and you're still legally liable. You didn't make the phone call did you?


1. It's not that I found your making fun of her innappropriate so much as the neglect coupled with the making fun of her. I do have a sense of humor, but not so much when it comes to child abuse.

2. Sending her to have an abortion does not mean she won't continue to have sex, absolutely, but it does mean that she can continue to do so with no one in authority over her aware to her problem behavior. You don't see 3 pregnancies at 15 to be a problem? Or is it as long as she keeps aborting, everything's okay?

3. Abortion clinics are not social services. Abortion clinics sell abortions- period. They make a killing, no pun intended, on irresponsible repeat customers like this little girl. Just like doctors can't be expected to be social workers, abortion clinics "counselors" who hold limited to no credentials in counseling are in no position to deal with social issues. Social workers at Child Protection have the legal authority to intervene- abortion clinic workers do not. They certainly also do not discourage teen sex, as that's because contrary to their ideology and their profits. Just because they might give her the pill, which will not protect her from sexually transmitted diseases, doesn't mean that the proper authorities have been alerted to her neglect.

Think about it: She's had other abortions, so these clinics have also neglected to call the proper authorities to address this problem. It's nigh impossible to leave any abortion clinic without a prescription for a hormonal contraceptive, and this hasn't worked for this child thus far- and you really think that your referral is going to make a difference this time?

And, passing the buck on reporting child abuse ("Oh, the clinic will report") is perhaps what the clinic did also. Perhaps the clinic said, "Someone else has reported this" or, like so many clinics- maybe they just don't care.

91% of clinics fail to mandatory report much like you did. A study of 800 taped phone conversations with clinics that said that they were going to ignore the law on statutory rape. It was a pro-life organization that conducted this study, but the tapes don't lie:


So you can't assume that the clinic will pick up where you left off. Reporting is your responsibility.

4. You're wrong. Doctors don't have the latitude to make those judgement calls, just like I am not allowed to make the judgement call for my child to forego treatment for strep throat. I'm not a doctor and you're not a social worker, but the law is the law. You have to report. Yes, often times, the case worker will choose not to pursue a neglectful supervision case because our case loads are ridiculously overwhelming with children with more serious needs, but that's the caseworkers' judgement to make, not yours or mine.

And, in your professional opinion, in this case, you think this 15 year-old who is pregnant for the 3rd time who couldn't peel herself away from texting to speak with you fits the bill as having maturity and decision making ability?

5. You don't have to be a doctor to do the right thing. You don't have to be a doctor to follow the law. It's relatively straightforward. If you had made some mistake as learning resident: you are learning, I am not in any position to criticise as I have never been to medical school- but it's the fact that you continue to rationalize your breaking the law at this child's expense.

Instead of defending yourself, how about, "Oops. You're right. I'll make that phone call. I guess I made a mistake. I am learning to be a doctor" rather than putting your patients in peril by being incorrigible? I'd be considerably nicer if you're step up to the plate and do your legal duty.

By JacqueFromTexas (not verified) on 08 Jun 2007 #permalink

Signout: If the place you sent her has the resources to handle someone her age, then that's where she should go. Their social workers will help to determine why at 15 she has had 3 abortions, who she is having sex with and what they can do to help her. This is indeed a girl crying out for help.

While providers had reporting requrements for child abuse, those requirements assume you have some evidence or suspicion of abuse. At this point, I'm not sure that is in evidence here. Bringing in the police is not what is needed - but bringing in social work is. They have the skills to work with this girl and to hopefully determine if there is any child abuse going on, or if her partners are her peers. I do agree that if this kid has managed to get herself pregnant 3 times by age 15, thngs at home are not what they should be.

I would have taken that cell phone number, since clearly that is the way to communicate with her. Maybe IM her over the next few days to see how she is doing, and to be sure she is hooked in with the social services she needs..

By tbtam@rcn.com (not verified) on 09 Jun 2007 #permalink


It seems that you won't be happy until you prove that I'm a neglectful, uncaring, and incorrigible (!) doctor. I also continue to dislike your condescending semi-shriek of a tone. So I'm not going to engage you any more. I'll take the lesson of involving social work when an underage kid is having a lot of sex, but I still won't be reporting every case of underage sex I see. And I'll still be sending women who want abortions to abortion providers.

It seems that you won't be happy until you prove that I'm a neglectful, uncaring, and incorrigible (!) doctor

I don't care about you- this isn't about you. I'm trying to explain that by law and by all the factors involved, that this is a case that needs to be reported. But the law apparently doesn't apply to you, which certainly suggests that you are neglectful and incorrigible. I mentioned that this girl needed to have social services alerted to her self-endangerment. You agreed, but continued to explain why you did not rather than simply doing what you know should be done. Seriously- this girl obviously needs to be reported. This isn't a girl at 15 who got pregnant for the first time- this is someone who has been pregnant 3 times and continues to expose herself to danger.

Proving anything negative about you is the least of my concerns- getting you to report this case so this child can get some real help rather than more diseases and abortions is my concern. But apparently it's not yours.

By JacqueFromTexas (not verified) on 09 Jun 2007 #permalink

You obviously think, with your extensive knowledge of this individual girl's case based on a 9 paragraph blog entry, that Signout's lack of reporting was illegal...because you keep telling us all it was illegal. It's pretty obnoxious to keep asserting that a physician did something illegal when you really don't know what you're talking about. What mandatory reporting law are you referring to? Are you referring to the one in the state in which Signout practices that "requires mandatory reporters to notify the police when they suspect that any person in a position of authority with a minor has committed an offense against the minor"? Because if you are, Signout has indicated that she didn't think that anyone in a position of authority has committed an offense. What factual information from this case do you have otherwise? You made an assumption that at least one of the men was over 18. You made a lot of assumptions. What are these based on? Do you regularly make assumptions without any knowledge of the facts involved with your patients? I'd caution you to stop doing that. It would make for bad medicine and I'm pretty sure it makes for bad social work as well.

From the very little Ive read about this case, I think social services probably should have been called and I fear that this patient may be lost to follow-up...but I wasn't there. I also know as a doctor and regular old human being that there is NOTHING you as a social worker can do to stop a 15 year old from having sex if she wants to short of locking her up. Is this necessarily the parents' fault? Do you really believe that the parents of a 15 year old girl can stop her from having sex if she wants to? Is it possible that she had sex with her 15 year old boyfriend...the boy being neither older than her or in a position of authority? Is it possible that maybe 15 year old kids are having sex these days? I know it's a stretch but I think it's possible. I dont know though cause I wasn't there. I guess I could jump to the conclusion that it was an adult...but I'm gonna choose not too. Im pretty sure I could have found a way to get out of the house and knock up a 15 year old when I was that age. Does that make my parents at fault? I'm pretty sure you too, if you really stretch your imagination, could have managed to get knocked up at that age? Would it be your parents' fault? Would anyone in a position of authority be at fault?

It's also possible that this child was raped repeatedly by her 30 year old teacher and her dad at the same time. But I'm not gonna make that assumption because I wasn't there. You know who was there? Signout was there. Signout's attending was there. The nurses working with Signout were there. They were all there. I'm pretty sure you, Jacque...from Texas...were not there. Signout has acquiesced that, in retrospect, she maybe should have called social services. She has also stated that she did not feel at the time that the child was in danger and mandated a social services call. Therefor it was not a legally mandated call Jacque. It was a judgement call. In this case, I'm gonna trust Signout's clinical judgement as opposed to your just plain judgement...from afar...in Texas.

Sounds like folks here need to take a deep breath, a step back and get their facts straight. And also, quit hi-jacking Signout's comments section!

TBTAM's comment is tempered and well-taken. The most important thing here is to ensure that this teen has access to confidential and appropriate care. It sounds as if Signout has done this.

JacqueFromTexas: Adolescents have rights when it comes to reproductive health care. You are wrong. A 15 year old CAN legally consent to sex, despite whatever moral objections you may have. Only 12 states have single age of consent in regards to statutory rape. The rest are more nuanced. These ages of consent have nothing to do with engaging in sexual activity in general. In Texas, the penal code states that as long as the sexual partner is not more than 3 years older, a child as young as 14 can consent to sex (Texas Penal Code � 22.011(a)(2)).

Once this 15 year old is sexually active, she has rights and considerations. I would refer you to the two quotes below from the AAFP and the AAP and the following website for a comprehensive article on teenager's access to reproductive health care services. As a social worker, you should be familiar with the pertinent legal and ethical issues.


American Academy of Family Physicians: "Concerns about confidentiality may discourage adolescents from seeking necessary medical care and counseling, and may create barriers to open communication between patient and physician. Protection of confidentiality is needed to appropriately address issues such as...unintended pregnancy." (Adolescent Health Care, 2001)

American Academy of Pediatrics: "Health care professionals have an ethical obligation to provide the best possible care and counseling to respond to the needs of their adolescent patients...This obligation includes every reasonable effort to encourage the adolescent to involve parents, whose support can, in many circumstances, increase the potential for dealing with the adolescent's problems on a continuing basis....At the time providers establish an independent relationship with adolescents as patients, the provider should make...clear to parents and adolescents [that]...confidentiality will be preserved between the adolescent patient and the provider. (Confidentiality in Adolescent Health Care, 2004)


Has anyone ever heard of the phrase "You catch more flies with honey than with vineager?" Jacques - I strongly suspect that you would have gotten closer to acheiving your ultimate goal ("getting you to report this case so this child can get some real help rather than more diseases and abortions") if you had gone with a nice, little "Wow. This girl seems to need a lot of help. Have you referred to her to a social worker?" instead of calling Signout neglectful (and other things in screaming CAPS).

And Cherry - putting something on her A** (assuming that A** is her ASS) wouldn't really do much for stopping pregnancies, now would it? (But removing the CAPS LOCK from your keyboard would go a long way for people wanting to read your posts).

Thanks, GirlMD, for bringing out the Teen Sex confidentiality laws that I knew were there but was too tired to look up.

I'm pro-choice (as you know). That is not to say that this patient doesn't need guidance on birth control in addition to making a choice (which PATIENT makes, not Signout) about an abortion. Also, Signout is in training, so big decisions about most situations are supervised. It is up to the supervisor to guide her, not you, Jacque. If you had ever been through a residency, then maybe you'd know that. I assume that you haven't received this level of training to be aware of the number of folks who make decisions together.

Although, I will say that I am surprised that there is not a social worker on staff at the hospital for situations like this.

GirlMD, thank you, thank you for bringing the facts! I learned more from your comment than from any other single comment ever posted on this blog. And it looks like I'm not the only one. You get a cookie.

Yeah, BDF, who knew a post on abortion would attract a bunch of angries?

EGM, Slander, big up. Cherry, I am sorry for all you have been through. Please turn off your caps lock. And K2, of course there's a social worker on staff! But it was illness clinic and therefore an acute visit, and the social worker there is swamped with Medicab and temp Medicaid paperwork. We thought she'd better benefit from longitudinal follow-up from the family planning clinic social worker.

A patriarchy says what, indeed! I think some seeds of the nuance Signout was looking for in posting this piece are embedded deep, deep, deep within JacqueFromTexas'emesis. To wit: Is a 15-year-old on her third unwanted pregnancy a victim of abuse, or is she an agent of abuse (for continuing to "expose herself to danger")?

Which is she, Jacque? You say that "this girl obviously needs to be reported," but you seem torn about why. Does she need to be saved, or does she need to be stopped?

Oh, yeah -- discuss! ;)

What do we think about the fact that, in each pregnancy, this patient had voluntarily notified her mother? This is not some child out alone in the wilderness as some might have us believe; she is making life-altering decisions with the assistance (or at least awareness) of a parent who clearly may not be the best source of information. "Victimizing" the patient does her no good; it would let her assume that a) someone else is responsible for the mess she's in and b) someone else has to save her. Neither of these assumptions bring the patient to a place of personal accountability. If she's sexually active, then accountability had better start being part of the mix.

Let us lift the blame from our physician friend, who simply directed the patient toward the expressed preferred treatment, and start expecting responsibility from both patient and parent. Would a social worker help? Almost indubitably. Is it the panacea? Nope. Mom (evidently) and patient (definitely) are hobbled by an inability to link behavior with consequences. Unfortunately, that sounds like something that would take years of psychotherapy and/or incarceration to hit on the head.

Is a 15-year-old on her third unwanted pregnancy a victim of abuse, or is she an agent of abuse (for continuing to "expose herself to danger")?

Do you not understand the difference between a child and an adult? She's a child. Adults are obligated to protect children from danger. Think "baby gates" and "outlet covers." While you can't protect children from everything- they'll inevitably have trips and falls, you don't ignore a child that continues to hurt themselves. A 15 year old can not be supervised 100% of the time so that she will not have sex, but 3 pregnancies do not suggest that she is properly supervised at all. A toddler that continues to get under the sink and drinks the citrus flavored household cleaning products because he likes the taste, and inevitably gets sick, is not "self-abusive." He's a child. Put a latch on the cabinet for his protection. Likewise, a 15 year old who has a ton of sex because it's fun, and inevitably creates 3 babies and could easily contract any number of STD's, needs to be properly supervised, properly educated, properly cared-for.

Do you not understand that 15 years old is not an adult? So, yes, a 15 year old is a victim of abuse, like an unsupervised child that burns themselves repeatedly on a hot stove is a victim of abuse because he isn't properly supervised. Children can't self-abuse. They lack the capacity. Even for children that self-mutilate or hurt themselves, the responsible adults are expected to restrain the children from such behavior. We put scratch mittens on infants and pad the walls of the cribs for infants who bang their heads.

This is relatively straightforward: Adults are responsible for children.

P.S. The youngest age of consent I am aware of is 16, typically 17. Feel free to prove me wrong. If the age of consent for sex in the state where Signout practices is 15, then she hasn't broken the law. (We'll not mention that most likely all 3 of these pregnancies haven't occured in this past year, and this child has been sexually active younger than 15).

By JacqueFromTexas (not verified) on 12 Jun 2007 #permalink

Actually, JFT, most of the people reading this blog probably understand more than you give credit for.

I think the phrase "expose herself to danger" -- which I quoted from one of your posts -- is really interesting and salient to the discussion. It suggests that she does, in fact have the capacity to exercise some degree of control. If she does not, the next logical step -- given your infant-care analogy and the fact that her mother has not yet been willing or able to "restrain [this] child from such behavior" -- is a chastity belt. Right?

As someone who has known a fair number of 15-year-olds (and not like THAT, so don't go calling any social workers!), I can say that I think it's a beautiful age. While they are still kids in many, many ways, they are also learning how to be adults, and trying out their many possible selves.

This is part of an extended practice period -- raise your hand if you're STILL practicing (hello!) -- and there are lots of mistakes to be made (especially given the incomplete brain development and the hormome cascade). However, that doesn't mean that people this age aren't actively testing, thinking, planning, or dreaming. It ALSO doesn't mean that once they reach the magical Age of Consent, they will suddenly be paragons of good judgement and self control.

Do I think it's a good thing that this girl is on her third pregnancy? Absolutely not. Do I think it makes sense to argue that right now she requires immediate adult intervention and that next year she won't? Absolutely not. Birth control is not rocket science, but it's not foolproof, either, and people of all ages are fallible, impulsive, and sometimes just plain stupid. Maybe if you'd been there you could have pulled her off the railroad tracks and properly fitted her with new scratch mittens, but looping over and over about calling in the calvary (especially after Signout has explained pretty clearly why they were not immediately called) disregards any possibility of nuance in the situation. And who is going to call the social worker for this girl's partner(s?), who apparently doesn't know how to wrap it?


NRS 200.364 Definitions. As used in NRS 200.364 to 200.3774, inclusive, unless the context otherwise requires:
1. "Perpetrator" means a person who commits a sexual assault.
2. "Sexual penetration" means cunnilingus, fellatio, or any intrusion, however slight, of any part of a person�s body or any object manipulated or inserted by a person into the genital or anal openings of the body of another, including sexual intercourse in its ordinary meaning.
3. "Statutory sexual seduction" means:
(a) Ordinary sexual intercourse, anal intercourse, cunnilingus or fellatio committed by a person 18 years of age or older with a person under the age of 16 years; or
(b) Any other sexual penetration committed by a person 18 years of age or older with a person under the age of 16 years with the intent of arousing, appealing to, or gratifying the lust or passions or sexual desires of either of the persons.
4. "Victim" means a person who is subjected to a sexual assault.
(Added to NRS by 1977, 1626; A 1979, 572; 1991, 801; 1995, 700)

NRS 200.368 Statutory sexual seduction: Penalties. Except under circumstances where a greater penalty is provided in NRS 201.540, a person who commits statutory sexual seduction shall be punished:
1. If he is 21 years of age or older, for a category C felony as provided in NRS 193.130.
2. If he is under the age of 21 years, for a gross misdemeanor.
(Added to NRS by 1977, 1627; A 1979, 1426; 1995, 1187; 2001, 703)

These are the actual statutes for my state, Nevada, and forgive me for not including those of the other 49 but in South Carolina the age of consent for females is 14. Suffice it to say it looks like statutory rape laws are a little more challenging and subtle than "you must be this tall to ride this attraction." So let's hop off the legal train and start talking about the medical map--how do we as providers get this girl some help that doesn't involve a lawyer?

PS: credit due to http://www.leg.state.nv.us/NRS/


Here's http://www.avert.org/aofconsent.htm a table of the ages of consent around the world, to and including each state in the U.S. of A. Please also note the discrepancy between male ages of consent and female ages.

As an aside, if you are going to say that putting this girl in foster care is a better choice than what she has now, I strongly disagree.

How many kids stay in ONLY ONE FOSTER HOME during their "time in the system?"

Yes, that, and then the other question of "Where's the love?" Her newest boyfriend or pimp, that's where. This "Where's the love?" argument can also be applied to many teen girls in seemingly stable homes with parents and family intact.

In conclusion, Signout is absolutely correct. Abortion sucks, but sometimes the only person there to listen and counsel is the physician because, as you pointed out, the parent(s) or fosters are obviously very, very absent.

Wow! The age difference thing is BIZARRE! Isn't it generally accepted that as a set, girls "mature" earlier than boys? If that's the case, what's the reasoning behind the higher age of consent? "Boys will be boys"?

I came across this randomly... but I think that Signout wrote a very good post on a tricky situation.

Not to get into the abortion debate... my 2 cents is this. How has a young woman had three unwanted pregnancies by the time she is 15. Where is the sexual education for this young woman? Was she taught abstinence only? Has she been taught about birth control and options accessible to her? Some teens are going to have sex. It is nothing new, and unlikely to change. Knowledge is the best power, and for her to learn how she can protect herself from pregnancy and diseases if she chooses to have sex is her best defence.

Even if we are mandatory reporters of underage sexual activity, doctors don't report every kid who's sexually active and not of age.

I tried to skim all the comments to ensure that this wasn't mentioned, but a mandated reporter is only supposed to report sexual activity of an teen girl if it is believed that the person she had sex with is someone who is in a position of power over her (father, uncle, adult neighbor, teacher, father's friend, etc) or if there is other evidence of neglect by the parents. Even if the 15 year old's boyfriend was 19 or 20 years old, it still wouldn't require a mandated report. If doctors reported all teens who were having underage sex, these teens would not confide in doctors about their activities.

In my ER, nurses always give discharge instructions (or reiterate MD's d/c instructions) to patients, and I'd probably decline to tell a 15 year old to follow up at a "family planning"/abortion clinic. I'd tell the MD she had to say that herself if she thought that was more appropriate than an OB/GYN clinic.


It's kind of hard to teach children about sex and all of its consequences when schools are mandated by our current theocratic administration to teach abstinence is the only choice.

Not all parents are equipped to teach everything about sex.

And 15 year olds are not children. Or maybe they are experienced children and inexperienced adults?

15, in any state in the U.S., is not a legal age for consent to have sex.

Actually, fifteen-year-olds can have sex perfectly legally in many places in the US (I don't know if it's all) - as long as their partner isn't past a certain age.

By Caledonian (not verified) on 19 Jun 2007 #permalink

Wow...It's sad that in this day and age we're still arguing over whether or not a human being is produced when two humans have sex...What else could be produced?
God's Judgment will be interesting! These poor pro-choice people...

I really wish Christians would act more Christian. It's funny to see people revel in the idea that their fellow humans will burn in eternal flame someday. Sickos.

Signout, interesting post. Thanks much. :)

JacqueFromTexas - easy on the finger pointing! In order to get her abortion, this girl has to see more doctors and nurses... more mandatory reporters. And mandatory reporters who deal with this kind of this every day, as opposed to Signout who, as a resident, is still learning. Watch where you put your ALL CAPS.

As for you, Dr. S, "...we feel that if we don't connect them with every social service they need, we haven't done our jobs. As doctors. Discuss." Guh. That's why I'm going in to Critical Care (or other such specialty - don't worry - no decisions made yet!) I can't handle the GUILT :)

It's kind of hard to teach children about sex and all of its consequences when schools are mandated by our current theocratic administration to teach abstinence is the only choice.