Consent Stressed at L.A. Clinics : School District Program Could Serve as Model Here

A student dashed into the nurse’s office at Los Angeles High School the other morning and asked for an aspirin to relieve his headache.

Sorry, the aide said, but the nurse’s office cannot dispense medicine. But why not try the school health clinic on the other side of the counter, which offers a complete menu of medical services?

So the student moved to the other side of the waiting room and asked the clinic receptionist for an aspirin. Are you a member of the clinic? Have your parents filled out the consent form? she asked.

No Matter How Simple

No, he wasn’t a member, but he was 18 years old. Sorry again, but, even if you’re an adult, all students who use the clinic must have written permission from their parents in advance, no matter how simple or complex the medical problem. The student walked away in disappointment.

That brief tableau illustrates a key point that Los Angeles city school administrators emphasize over and over to critics of their clinics, which could serve as a model for San Diego should the Board of Education approve the concept today: that the centers are intended not to usurp parental authority, but to provide medical care that, for economic and other reasons, the parent or legal guardian cannot.

“We see this as a consent program,” said Pam Wagner, the Los Angeles school district’s nurse coordinator. “Parents have the right to tell us what services they want their child to have,” or even to forbid use of the clinic altogether.

Wagner said state law that allows minors to receive pregnancy-related treatment without parental consent applies only when a clinic has agreed to provide it.

The first of three health clinics on Los Angeles high school campuses opened in September, 1987, with a complete range of medical offerings, including pregnancy testing, contraceptives and counseling--for diet and weight control, drug and alcohol use, pregnancy prevention and mental health.

Too Many Pregnancies

The Los Angeles city school board, despite strident opposition from the city’s Catholic diocese and right-to-life pressure groups, authorized the pilot projects, saying that too many teen-agers ignore their health and that too many girls become pregnant and drop out.

Each clinic is operated under contract by a non-district medical organization, which carries the required medical liability insurance.

The Watts Health Foundation runs the Jordan High School clinic in Watts, the first to open; UCLA’s schools of medicine and public health, in conjunction with a private health corporation, run the clinic at San Fernando High School, and Children’s Hospital of Los Angeles operates the Los Angeles High clinic. Funding comes from a variety of private foundations--half from the Robert Wood Johnson Foundation of Princeton, N. J., which supports 23 clinics nationwide.

The district’s latest data shows that parents or legal guardians of 51% of all eligible students have given consent to use the clinics, and 92% of those agree to all services, including reproductive medicine. Of those students with parental permission, 63% have used the clinics at least once.

Forty-eight percent of clinic visits have been for basic acute or chronic medical problems, 19% for mental health problems, 16% for reproductive-related matters and 16% for health education information.

Once parents have signed the consent form, they usually are not told of the visits, except in cases where their child has a life-threatening illness or condition, Wagner said.

“We didn’t think we’d have as much usage as quickly as we did,” said Socorro Macias, who coordinates the clinic at Los Angeles High.

Used by 42%

That clinic opened in January, 1988, as the last of the district’s three pilots, but already has attracted 42% of all eligible students, a mix of blacks, Latinos and Koreans, many of them immigrants and a third of them who have English as a second language.

The clinic at predominantly Latino San Fernando High has the lowest rate of parent approval, at 41%, mainly because of continued organized opposition by Catholic and right-to-life groups who ask parents to boycott use by their children. The clinic opened in November, 1987.

The clinics differ somewhat depending on the specific needs of students, but all three have either a full-time physician assistant or nurse practitioner, a part-time medical doctor and a part-time psychologist and psychology interns.

A student can either come to the clinic directly or be referred by the school nurse, who still treats minor injuries and first-aid matters.

Most students use the clinics by appointment. At Los Angeles High, scheduling is in 45-minute slots, with certain times set aside for walk-ins or emergencies.

On their first visit, students are given an in-depth evaluation to detect any underlying problems behind symptoms such as a headache or earache, Macias said.

Make Them More Aware

“We probe so that we can elicit all information,” she said, adding that the specialty of adolescent medicine has only recently been recognized for its importance in treating teen-agers as a group distinct from adults and children.

“And when we need to make referrals to outside agencies, we have sat down with the students, explained to them why we are making an appointment to another doctor and make them more aware of things so they will be more likely to keep” the appointment, Macias said. “Remember, these kids don’t have a lot of health consumer experience.”

Los Angeles High nurse Barbara King calls the school’s clinic a godsend.

“I know my students can now get immediate treatment, whereas before I had to make an outside referral for any type of care, and the parent would have no way to get the kid there or have no money . . . and I would never know if they went or not,” King said. “Now I can spend a lot more time making certain that all students have up-to-date immunization records and other requirements.”

Figures from districtwide clinic coordinator Michael Godfrey show that, of the 360 students now using the clinics for contraceptive purposes, 183 are receiving birth control pills and 177 are receiving barrier devices, including condoms. Only 17 students, or 4.7%, have become pregnant while using contraception.

“We believe that is an excellent compliance rate,” Godfrey said.

Dramatic Difference?

The district has no firm data to show whether its program has cut the number of pregnancies because it has no figures on how many girls were becoming pregnant before the clinics opened.

But Godfrey and King believe there has been a dramatic effect. “I’m certain I’d be seeing more pregnant women otherwise,” King said.

A harder question to answer is whether fewer teens are sexually active.

“My gut feeling is that we certainly aren’t promoting teen sex,” Godfrey said, referring to criticism from opponents who say the availability of contraceptives encourages students to become sexually active.

The clinic staff talks at length with students who come in for reproductive services, trying to gauge their concerns.

“We talk with them, try to give them accurate information and find out if there is a way to make them see the consequences” of sexual activity, Macias said.

Counseling Encouraged

If the students are sexually active, they are encouraged to come to the clinic with their partner for counseling, as well as to talk with a parent, she said. The latter is often a difficult proposition, especially when many of the teen-agers come from broken families or have a parent in another country whom they have not seen for several years.

“Yes, we try to get them to say no, or at least delay a decision to become active,” Godfrey said. “But look, these kids don’t plan ahead, like coming in on Friday afternoon before a Friday night date, and talk about what they should do.”

The neighboring Culver City School District has established a clinic as well, operated under contract with UCLA and with guidelines similar to those in Los Angeles. The difference is that it does not dispense or prescribe contraceptives.

The clinic serves all teen-agers from ages 12 to 18 living in Culver City, whether or not they attend school in the city.

“Our clinic did not start for reasons of coping with adolescent pregnancy,” said Vera Jashni, assistant superintendent for educational services. “We were seeing primary health care problems and, while people do not think of our city as disadvantaged, we have 36% of our students with no health insurance.”

Jashni said that 54% of all visits are for illnesses and injuries, with another 15% for immunizations and about the same for counseling. About 5% are sex-related.

Referred to Agencies

“I think we have found emotional and stress problems to be greater than originally thought,” she said.

The clinic does test for pregnancy, but then refers students to outside social service agencies for intensive counseling if they are unwilling to talk with their parents or church.

“We try to do some counseling at the clinic and get some changes in attitude,” Jashni said. “And we stress abstinence in group counseling--where we have as speakers girls who have had children--to bring a greater sense of reality to (being a teen-age mother) than you might get from just a sex education class.”

But the clinic still faces opposition from right-to-life groups, who denounce the referrals because social-service agencies include discussion of birth control and, in some cases, abortion.