The Best Contraceptive

During the 1960s War on Poverty, I ran a small Community Action Agency family planning clinic in one of Baltimore's most impoverished neighborhoods. At the corner of Ashland and Eden streets near Hopkins, it was the first U.S. clinic ever to receive federal funds for contraception. Women would often enter quite tentatively, but one day an 18-year-old bounded in with a smile. "I need 'a birth control,'" she said. "I got my letter from the Job Corps today. Nothin's gonna stop me now!" Possibilities, maybe even a future, were in her grasp. For the first time, I saw, personified, that great expression: Hope is the best contraceptive.

Four decades later, I still treasure that indelible moment. I wish every one of the world's 1 billion young people could have her confidence and motivation.

I often shock adults when I say that sex is normal starting at puberty. I quickly have to reassure them: Yes, I know it's not socially normative, but it is biologically normal. Millennia of strict social customs—pubertal rites, gender separation, chaperonage and even very early marriage—acknowledged this biological reality and bound young people to traditional norms. But today, as those rules weaken, what can prevent a young person from giving in to the "normal" pressures of hormones within and the daily barrage of the media without?

My young Job Corps friend knew: an expectation of future rewards.

In the U.S. today—as in most Western countries—sex in mid-teens is almost universal. It is common in all economic, social, ethnic, racial and geographic sectors and across most religious groups. Here, more than 70 percent of youth are sexually active by age 19. European teens start sex at the same ages, but U.S. rates of infection, unintended pregnancy and abortion are much higher. If we had comprehensive sex education that really taught our teens how to prevent infection and pregnancy, and accessible services without political interference, we might do better. In the 1980s, for example, my colleagues and I showed that pregnancy rates could come down in a school that had good, accessible counseling and a caring clinic close by—even when similar schools had soaring pregnancy rates. We have demonstrated that such programs can help most teens; we just need to implement them.

However, in many pockets of poverty and deprivation, sex starts even younger and teen motherhood is common. It's not just that services are lacking in the neediest neighborhoods. For many adolescents, even the best sex education and medical service are only a start. These girls may not actively want to have a child—they tell us they don't—but pregnancy happens if you don't care enough, or feel empowered enough, to prevent it. Without hope for their futures, too many young people have nothing to lose.

If they see no future, they see nothing at risk. High aspirations are characteristic of youth. It's adolescents' realistic expectations—not their dreams—that we need to change. Programs can only alter their vision of the future if they're powerful enough to change that reality—and to give our young people a credible reason to hope.

After a lifetime in the field, I see family planning playing an exciting role in meeting this challenge. In urban ghettos at home or in the rim cities of the developing world, adolescents—in fact, women of all ages—have limited control over their lives. Into that circle of frustration, control of their own reproduction can bring a sense of empowerment that may, and often does, spill over into the rest of their lives.

Knowing that hope provides such empowerment keeps those of us in the field going strong. Maybe, hope is our best incentive.