Participant Characteristics
Among the twenty cisgender, heterosexual, LGBTQIA+ adolescents (n=20) that participated in the FGs, the mean age was 16.1 years and all participant where currently enrolled in high school. Thirty percent (n=6) identified as LGBTQIA+ and 70% (n=14) as cisgender and/or heterosexual (Table 1). Among the social and health care providers that participated in the IDIs (n=11), 3.6% (n=4) identified as male and 6.3% (n=7) as female. We had a good representation of different services providers including school-based physicians (n=2), social service providers (n=2), school-based nurse (n=1), teacher (n=1), licensed marriage and family therapist (n=2), peer-health educator (n=2) and a community health specialist (n=1) and 72.7% (n=8) had been working with adolescents for 5 or more years (Table 2).
Table 1. Characteristics of adolescents (N=20) seeking sexual and reproductive health services in the U.S. - Mexico border region.
Variable
|
N=20 (100%)
|
Age (mean)
Gender
Male
Female
|
16.1
4 (20%)
16 (80%)
|
Education
|
|
Currently enrolled in high school
|
20 (100%)
|
Speaks another language other than English at home
|
16 (80%)
|
Self-identify as LGBTQIA+
Self-identify as cisgender and/or heterosexual
|
6 (30%)
14 (70%)
|
Table 2. Characteristics of social and healthcare providers in the U.S. - Mexico border region serving adolescents (N=11)
Variable
|
N=11 (100%)
|
Age
18-24 years old
25-34 years old
25-44 years old
45-54 years old
|
2 (22.2%)
2 (22.2%)
2 (22.2%)
5 (45.5%)
|
Sex
Male
Female
Transgender
|
4 (36.3%)
6 (54.4%)
1 (9.0%)
|
Race/Ethnicity
White
Asian
Hispanic or Latinx
|
5 (45.5%)
1 (9.0%)
5 (45.5%)
|
Occupation
|
|
School-based healthcare provider (e.g., physician)
Social services provider
School-based nurse
Teacher
Licensed marriage and Family Therapist (LMFT)
Peer-health educator
Community Health Specialist
|
2 (22.2%)
2 (22.2%)
1 (9.0%)
1 (9.0%)
2 (22.2%)
2 (22.2%)
1 (9.0%)
|
Number of years working with adolescents
<1 year
1 – 5 years
5 – 10 years
10 – 15 years
>15 years
|
1 (9.0%)
4 (36%)
2 (22.2%)
2 (22.2%)
2 (22.2%)
|
Physical Barriers To Accessing Srh
According to providers in the area, SRH services are available but not always readily accessible to adolescents. Nine out of the eleven providers that participated (81%) listed transportation as the dominant physical barrier that makes it challenging for adolescents to access services. When a school-based provider refers a student to services in the area (because they do not have the resources there), the student is responsible for their own transportation to and from the clinic.
“Transportation is one [barrier], because if we do refer someone to the community health center, they’re responsible for providing their own transportation. Even though they can leave campus without their parent’s knowledge and go to the health center, they still have to get there. Unless they’re savvy and know how to use the bus system or have someone take them, it’s pretty difficult to get here.” (IDI, Health and Physical Education Teacher, Male )
“… one of the main barriers was location of wherever they’re getting their services. Uhm, so our clinic was near schools, like it was still hard for them to walk, like it wasn’t next door to a school or anything, it was like a mile away which is, you know, like if they don’t have a car, then it’s hard for them to access, so definitely transportation.” (IDI, Peer-Health Educator, Male)
Given the close proximity of this school district to the U.S.-Mexico border, providers reported serving a large bi-national adolescent population. Providers reported that approximately 30-50% of students are separated from their nuclear family in order to attend schools in the U.S., while other students cross the border on a daily basis. Other students experience homelessness or housing insecurity. Providers described how instability of the home or disrupted living situations contributed to physical barriers in adolescents seeking and maintaining proper SRH care.
“I think the biggest barrier in the population we have is that they are dealing with a lot of chaos in their families. Be it financial problems, be it parents being separated due to being deported” (IDI, Youth Enhancement Services Provider, Male)
“It’s not just as easy as I don’t know where to go?, it’s how am I gonna get there? If I have a kid, who’s gonna watch my kid, how am I going to take off work when I don’t get paid that much anyway because I have to pay this money so that my parents and we can still live here” (IDI, Director of Education and Engagement, Female)
Adolescents collectively agreed that transportation was a factor in attaining SRH services. Some of the concerns included not being able to rely on a relative or older adult without their parent’s knowledge and the costs of public transportation being a barrier for most adolescents.
“There’s no transportation and that’s a big problem and again… like what Beet said [the other participant in the FG], students with conservative parents, they have a hard time going behind their backs or - well, that sounds bad, or just accessing health services without permission.” (FG participant, Female, 16 years old)
Insurance And Cost Of Services
Providers recognized that a majority of the population served in the school district area are low-income or in need of an insurance plan. Families are financially struggling to afford basic necessities, i.e. rent, and oftentimes adolescents find themselves in a position of responsibility to support their family.
“Poverty…putting food on the table and a roof over their heads is a priority or dealing with all of the chaos that’s happening in their lives is a priority so this may not be number one. We get more probably no-shows or non-returning to first services” (IDI, Youth Enhancement Services Provider, Male)
“I think part of it is cost, part of it is going to the store and buying them [condoms]. That could be a barrier” (IDI, Health and Physical Education Teacher, Male)
Some of the school-based providers stated that approximately 90% of the students in schools in the district are living below the federal poverty line. According to providers, a large proportion of families qualify for free or low cost insurance, but do not receive the assistance needed to properly enroll. When providers serve families that have health insurance plans, they often find that a lack of knowledge or awareness prevents adolescents from regularly accessing the SRH services they need.
“Some of the families do have insurance, a small percentage … but when you look at their charts, they’re not very frequent visitors to clinics, teens in general don’t access care unless they have a medical issue very often, they’re generally a pretty healthy population so they might have insurance and they’re often not sure what they have” (IDI, Associate Program Director, Female)
“… they think they’re going to have to pay for it, they don’t understand that insurance will cover the majority, or 100% pretty much, of the services...” (IDI – Director of Education and Engagement, Female)
“What I’ve seen is a lot of students with health insurance…they have to go with their parent to those places and they don’t know how to navigate the confidential services.” (IDI, Associate Program Director, Female)
Providers also noted that adolescents often do not know what type of insurance plan their family is enrolled in or are not aware that they can still use insurance coverage to access services without their parent’s knowledge. Majority of adolescents in the area who access SRH at the clinics qualify for Family Pact (FPACT). However, most of them were unaware and would typically enroll when they would come to the clinic for care.
“So primarily for our adolescent clinic, we almost exclusively use FPACT… that would basically make sure they don’t have to pay anything...I know that sometimes they did use their private insurance, but they would have to have the form that says “okay, this shouldn’t come on the billing because it’s confidential services” Uhm, so kind of make things easier, we would just enroll them into Family Pact” (IDI, Health Educator, Female )
Adolescents agreed that no insurance or low quality of insurance (e.g., limited coverage) makes SRH services such as birth control and hormone replacement therapy (HRT) inaccessible. Additionally, they acknowledged the difficulties in navigating insurance to cover the cost of SRH services without a parent’s knowledge.
“It’s hard for people of economic minority, to buy birth control and things like that because birth control is expensive as is and especially if you don’t have insurance, and if they don’t have insurance, I feel like these people would rather spend their money on other things like paying their bills or food, than on reproductive health.” (FG participant, Female, 15 years old)
“Teenagers don’t have access to their own insurance cards. So I can’t just go to the doctor myself, with my own insurance card and do my own stuff without my parent knowing… They [teenagers] can’t do it on their own, because they don’t know how… like they don’t want anything getting back to their parent, basically.” (FG participant, Female, 17 years old)
Parental Influence On Srh Services Uptake
Many adolescents are unable to talk to their parents about issues related to SRH as they fear they will disapprove. Accessing services without their parent’s knowledge is necessary, however, many spoke about fears that their parents would find out or were not aware that they could access SRH without parental permission. Every provider described parental influence or permission to be a common barrier. When serving adolescent populations, they are frequently asked questions regarding the confidentiality of their visit.
“They think that their parents have to be involved somehow, so one of the main questions that we get when folks reach out for HIV testing, before anything else, is “Do my parents have to know?” (IDI – Youth Services Department Manager, Transgender)
Similarly, perceptions of what parents may allow or not allow often dictated services or prevention methods adolescents might utilize.
“A lot of students don’t want to use contraception because parents aren’t supportive of that…” (IDI, School-based Physician, Female)
“We’ve definitely had a lot of students who haven’t gotten the care they need because they did not want to ask their parents for permission….” (IDI, School-based Nurse, Female)
“I’ve noticed that some of the parents usually say, “you don’t need that” or “you’re not at that age to get any of that”, and they are clearly at that age where they want to know what it’s like and they need to know about protection and everything…” (IDI, Health Educator, Male)
Cultural And Political Climate
Providers reported that some of their patients do not feel comfortable applying for government programs that are low cost or no cost due to immigration status and fear based on the current political climate. This created an additional barrier for adolescents to access care.
“A newer barrier… is a lot of concern around even enrolling in FPACT because immigration status. At one of my other sites… she [client] was in the process of an immigration … and she said, “ I don’t want to get any government [support], is FPACT a government program?” And I said yes, it’s part of Medi-Cal and she said, “I don’t want it, I’ll just pay for it.” And that’s not really realistic to pay for these services, especially if you’re a teen.” (IDI, Associate Program Director, Female)
“… with the concerns around public charge, there is fear in the family because there’s mixed status [immigration status] in the family that’s going to affect someone. (IDI, School-based Physician, Female)
Likewise, participants mentioned there is some fear or stigma in general when engaging in SRH for the first time. Participants noted it was necessary to create a space where adolescents feel comfortable to help eliminate this initial fear.
“So some of our staff will go out to the clinics and make sure it’s youth- friendly. Getting rid of the initial fear of walking through the door is a big deal.” (IDI, School-based Community Service Provider, Female)
“I don’t think they feel comfortable enough to come up to their teacher. So I definitely think there’s a better way to get information. Because I do get students, but I think there’s a lot more students that are just afraid to ask.” (IDI, Health and Physical Education Teacher, Male)
Stigma Experienced By Lgbtqia+ Adolescents
Not surprisingly, providers mentioned that family rejection and peer victimization were common among LGBTQIA+ adolescents. The disclosure of their gender or sexual identity to their family members caused significant interpersonal problems among adolescents and their families such as being kicked out of their homes and becoming homeless.
“Particularly for LGBTQ kids, because of the stigma they face at home, they get kicked out much earlier than their straight and cisgender counterparts, so we have a lot of folks, like who need a place to stay, need a safe house to move into. So a lot of things we do too, is linkage to other agencies that have housing resources.” (IDI, Youth Services Department Manager, Transgender)
“… certainly there’s a group on campus, like an affinity group for LGBTQIA+ students… and the students that I’ve talked to, I ask around safety, and bullying and all of those things and none of them have identified that as a particular issue, but I think that there’s definitely a bias towards heteronormative services. I do have one transgender patient at one of the schools, that I’ve been trying to get plugged in for transgender stuff, but it’s been incredibly challenging.” (IDI, School-based Physician, Female)
Further, LGBTQIA+ adolescents have additional barriers to accessing SRH care in this region. They find it difficult to share access specific LGBTQIA+ care as some clinicians are not well trained in addressing the concerns of members of this community.
“ … If you are transgender and non-binary, walking into any agency even if it’s a healthcare organization, you’re automatically assuming that people are not gonna understand what transgender and non-binary is, they’re not gonna have a place for you to explain what your pronouns and what your chosen name is. Uhm, so you are automatically putting yourself in a situation where you’re either going to be mentally stressed out or physically in danger.” (IDI, Youth Services Department Manager, Transgender)