School nurses are bracing for the hard conversations they may have to have with adolescent students now that the U.S. Supreme Court has overturned the Roe v. Wade ruling on women’s right to an abortion. But those conversations could look very different in different states.
Lisa Ann Kern, a retired school nurse, who currently serves as the director for the Florida Association of School Nurses, said many teenage students turn to school nurses for questions about their sexuality, whether they are sexually active or not.
“We would always point students in the right direction, helping them with those kinds of issues,” she said. “Depending upon the student’s age, we would always give them some time [and] give them resources to go to the health department, and a local health department would assist them with reproductive care.”
Kern predicted the overturning of Roe will, in most cases, hamper the work school nurses do.
“I just think that it’s going to be more difficult for school nurses to provide that counseling service to students, no matter where they are, especially more so in states where [abortion] access is currently being denied,” she said.
In Florida, where a ban on abortions after 15 weeks was recently reinstated, the procedure for getting an early abortion includes the requirement for parental consent if a woman is under 18, and a legal requirement for women of any age to get an ultrasound before the abortion, Kern said.
Currently, abortion is illegal in most cases in nine states, and 13 states have trigger laws which would ban abortion in most instances, when Roe v. Wade was overturned. But it’s not yet clear how many states have separate restrictions in place that would limit what school staff can say to young people on that subject.
Janis Hogan, who worked as a school nurse for 22 years at Camden Hills Regional High School in Maine and currently serves as the state’s director for the National Association of School Nurses, feels fortunate her state still has access to abortion care and comprehensive sex education, but harbors similar fears about the implications of the reversal on the work of school nurses.
“I think school nurses will be limited in those states that have laws that prevent discussion. Their hands will be tied, and students will have very limited options within their own state,” Hogan said. "[Students] may have the option to go to another state, but we know that teens don’t have that kind of access and they don’t have the money ... to seek care.”
She worries this may lead to people opting for unsafe abortions, especially when they’re part of communities that face additional barriers to reproductive care, such as adolescents, people of color, people in rural communities, and low-income groups.
Focus grows on abortion alternatives
But some national nursing and anti-abortion groups said the Supreme Court’s decision last month in Dobbs v. Jackson Women’s Health Organization presents an opportunity for nurses, including those in schools, to talk about alternatives to abortion, such as adoption.
One of those groups is the National Association of Pro-Life Nurses, which has launched a “Shout Your Adoption” campaign where people were encouraged to share their stories of adopting a child or being adopted, to present adoption as “the best alternative to abortion,” according to its mission statement.
“School [nurses] and counselors must be aware of all options, including crisis pregnancy centers, maternity homes, adoption and organizations like Birthright offering baby formula, clothing, etc., in order to provide good advice,” said NAPN spokesperson Nancy Valko, a registered nurse and advanced legal nurse consultant.
Schools could also make students aware of the accommodations they are entitled to receive under the federal Title IX law, should they decide to continue their education through an unplanned pregnancy, said Camille Cisneros, national supportive services director at Students for Life. She runs an initiative called Standing With You that supports women through their pregnancy.
“You can still attend school while being a parent, and there are accommodations your teachers are actually required to provide for you through Title IX,” she said, “if a student has to miss class or a day on campus due to anything related to her pregnancy or parenting status, the campus is required to be able to accommodate and allow her to make up any work that she missed.”
There’s a large variety of ways pregnant students can be accommodated in schools according to Cisneros, from providing comfortable desks to sit in to allowing time for students to breast pump or nurse, if needed.
Need grows for comprehensive sex education
Several other groups, however, said the court’s decision heightens the need for students to have access to sex education to prevent unplanned pregnancies from occurring in the first place.
“It just becomes more important than ever that we are focusing on comprehensive sex education that not only gives people the tools to navigate healthy relationships, but specifically gives them the tools to prevent an unplanned pregnancy,” said Christina Clark, the executive director of the Alabama Campaign for Sexual Health.
Alabama is one of the states that already had some of the most stringent abortion restrictions in place, with a 2019 ban on all abortions from the time of conception, barring pregnancies posing a serious threat to the mother’s life.
But the state also does not legally mandate sexual health education, according to Clark. If sex education is taught, the law says, it has to emphasize abstinence, but should also include the use of contraception and condoms.
“Unfortunately, what we see in practice is that there’s a huge emphasis on abstinence and not so much information about condoms and contraception,” Clark said. That’s because many schools believe that Alabama has an abstinence-only law, even though that is not the case, said Clark.
“What we are concerned about happening is that there’s no legal access to abortion and there’s also no prevention of an unplanned pregnancy,” she said.
While as many as 39 states and the District of Columbia mandate sex and/or HIV education, only 17 states “require program content to be medically accurate,” according to the Guttmacher Institute, which supports sexual and reproductive rights.
The institute found that 39 states and the District of Columbia require abstinence to be part of the curriculum, while 20 states and the District of Columbia require information on contraception to be taught. In 36 states and the District of Columbia, parents are also given the right to pull their child out from instruction if they wish to do so.
According to Leah Jacobson, CEO and founder of the Guiding Star Project, a network of women’s health and family-planning centers, “You need to know how your own body works, before you start to put it with another body, before you add a variable of intercourse and the potential for reproduction. And we’ve skipped that step,” she said.
With or without Roe in place, basic fertility awareness is something students need to be taught early, Jacobson said.
“This is medical information ... anything regarding menstrual cycles, fertility, cervical fluid, all that stuff. These are not shameful things. We need to destigmatize how our bodies work,” she said.
Clark pointed out that without proper education, high schoolers may have many misconceptions about sex.
“What you’re going to run into is young people not knowing how their bodies work, how they get pregnant. Maybe they think they can’t get pregnant the first time, or a condom breaks, so many things can happen, and then they don’t have an option to not have a child,” she said.
With a lack of comprehensive sex education, students don’t just face the challenges of unplanned pregnancies but also of sexually transmitted infections (STIs).
“In Alabama, we have among the highest STI rates [in the country] and young people 20 to 29 have very high HIV rates,” Clark said. “If we can catch them in high school, teaching them about ways to prevent not only unplanned pregnancy, but STIs and HIV, then we can be preventing those into young adulthood as well.”
Teens already face barriers to abortion
Young people may also face other challenges such as a lack of confidentiality and unsupportive parents, according to Rachel Fey, vice president of policy and strategic partnerships at Power to Decide, a nonprofit aimed at preventing teenage pregnancy and unplanned pregnancy among young adults.
She also noted that many states have laws requiring parental notification when it comes to abortion care.
According to the Guttmacher Institute, 37 states require parental involvement in a minor’s decision to get an abortion. Onlytwostates and the District of Columbia provide all individuals, regardless of age, the right to consent to abortion.
“If the young person has valid concerns about their safety in notifying their parents, they have to navigate a really obtuse judicial bypass process,” Fey said. “And now we see all these additional barriers being put in place by them having to navigate bans and potentially have to try and travel out pf state for care.”
In Maine, students 15 and above are not required to get parental consent for abortions and can approach school nurses for help if needed, said Hogan, the director of that state’s school nurses’ group.
Her fear is that in states across the country where abortions will be hard to access, the rate of unintended teenage pregnancies will sharply increase, with students unable to access care in case they do not want to have that pregnancy.
“We have over 12 million teens in this country that are over the age of 15 ... and of those, 40 percent is the most recent statistic of how many of those students are sexually active,” Hogan said.
So what advice can be given to students in states where reproductive options available to teenage students who face unplanned pregnancies are limited?
“As a health-care professional within a school, I would try to counsel those students on what their options are within their state and within the laws of their state,” Hogan said.
She said she had many teens come to her over the years, whom she referred to the local Planned Parenthood and many times helped them access transport to get to the facility.
“It is imperative that students have that information and can be guided,” she said. “[Many] can’t look to their parents, [so] they look to school nurses and look to school counselors, and I am ready with that information for my students.”