Thursday, May 24, 2018

Marin Medicine

The magazine of the Marin Medical Society

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FEATURE ARTICLE
An Atypical Clinic for Typical Teens

Jaclynn Davis, MPH, MSW

It was one month into the academic year when Jonathan, Dominique and Raquel walked through the door of Huckleberry Youth Program’s Teen Tuesday Clinic in San Rafael. They entered the clinic together with smiles and waves, recognizing me sitting at the reception desk. Between giggles and teen gossip, they filled out their intake forms. Today, they would start with the basics: an STD test, a pregnancy test, and a method of birth control. 

As one of the leading youth service agencies in Marin and San Francisco, Huckleberry has served over 150,000 youth since its incorporation in 1967. In a typical year Huckleberry provides services to over 4,000 Marin youth. Of all those young people, these three stand out in my mind. 

Jonathan, Dominique and Raquel (not their real names) were all students in my Huckleberry sexual education and prevention workshop series. All three had been involved in a complex examination of the interplay between their own knowledge, risk behavior, and community contexts. And all three had emerged from intensive health education workshops deciding to make a change.

A typical Huckleberry workshop sends a health educator into a middle school or high school serving high-risk Marin youth to talk, quite simply, about sex. For eight hours spread over several weeks, students engage in a highly participatory course that encourages them to step far beyond knowledge acquisition. The facts of sexual health are important, of course, but what distinguishes Huckleberry’s workshops from others is the focus on process.
 
{{222}} 
Huckleberry Clinic staff include (left to right) Samantha Ramirez, Jaclynn Davis, 
Maribel Cabrera-Borloz and Tyler Holmes.

Make no mistake about it, eight hours is a process. It starts with discomfort, denial, silence. (What? We’re gonna have to talk about that?) It eases into giggles, sideways glances, notes passed between desks. (Oh my gawd, she said penis.) There is a moment when Raquel’s single brave voice breaks through the awkwardness, just a small break, and then it is practically uncontrollable, the desperation to talk, to be heard, to question. Then come the real guts of the workshop: the self-examination, the recognition of relevance, the assessment of one’s own risk, the moments of Uh oh, like the day Jonathan lingered after the bell to ask all the questions he couldn’t in class. Eight hours is a process. 

In a typical workshop, we talk about our values, goals and visions for ourselves. We talk about anatomy, our bodies and how they work, and how cool they are. We talk about STIs, about risk and protection, pregnancy and birth control, about all the reasons to have sex and all the reasons not to have sex. We talk about relationships, how they feel and how they should not feel. 

Questions spark like wildfire when we talk about abuse and control, as if these young people have just been waiting for someone to stumble upon the issue that no one wants to talk about. We talk about how to talk—to parents, peers, and intimate partners. About how to say no, and how to decide you want to say no. Or maybe you plan to say yes, in which case, may I offer you some birth control and a condom, please?

By the end of eight hours of curriculum rooted in health education and behavior-change research, those teens are thinking. They are not simply passive receivers of information. They are part of the process, and as they start to examine their own values and behaviors, the information holds salience. 

Jonathan, Dominique and Raquel all participated in the workshop. All three decided to cross the myriad of barriers established to marginalize young people from health care. They overcame the embarrassment and the paradoxical stigma against sexuality despite its grotesque hype in the media and teen social networks. They overcame confusing gender messages: the voices that told her she shouldn’t protect herself or she’d be considered a whore; the voices that told him that a real man doesn’t wear condoms. They overcame cultural and religious norms that they saw as contradictory to the reality of their lives: the mandate that she not use birth control, the necessity that he stay on the down-low and not acknowledge that he is a man who has sex with other men. They overcame linguistic barriers, questions of identity and empowerment, fear, cash flow, acknowledging that there is even a problem to be addressed … the list goes on. They somehow managed to surmount all those barriers as they walked into clinic that day. 

Started in 1995 in response to a lack of services for teens, Teen Tuesday Clinic is a vital access point for teen health care both for the services it provides and also for the manner in which those services are delivered. When we talk about teens, it isn’t enough for health care to just exist—it has to be tailored to meet their needs, their developmental stage, and their level of health literacy. Teen Tuesday Clinic is designed to defy everything that teens think they know about health care. Services are delivered without cost to the teen, attendance is confidential, and both Huckleberry staff and our Marin Community Clinic (MCC) medical partners are distinctly “teen friendly.” 

The waiting room is filled with educational games (Shoots & Ladders transformed into substance abuse trivia; Jenga reinvented with STI questions). The television displays a steady stream of films based on stories written by teens for teens. The issues are relevant: eating disorders, domestic violence, and sexual decision making, all explored through the teen mind and teen voice. Reading materials come from sources evaluated specifically for use with adolescents. MCC medical personnel know how to speak to teens so they’ll listen, and more importantly, how to listen to teens so they will talk. On some days, a stranger wouldn’t know if this was a clinic or a really cool youth hang-out spot. That’s the point. 

After 15 years of Teen Tuesday, we’ve learned some lessons:

Health care access for teens is complex. Access is more than just existence. Access means it is safe and confidential. There is trust and respect. Otherwise, your service might as well not exist in the eyes of teens. 

Ask questions. Teens don’t often offer up that vital piece of information unless you ask for it.

Give permission to admit missteps. The missteps are clues to what a teen needs, and if we don’t allow them to admit those faults in a safe space, we won’t ever learn about the underlying issues.

Teen communication networks are key. Jonathan, Dominique and Raquel were three students in three separate classes. But they knew each other, they talked about what was going on in their workshop, and they came to clinic together. 

Social norms are powerful. They are one of the most influential impacts on adolescent behavior. If we want teens to take care of themselves and make healthy decisions, we have to create an entire teen culture that ascribes to that value. “Teen friendly” access points bring in more teens, and more teens start shaping new social norms. 

Confidentiality is a lot more than a buzz-word. We seldom know the full story, and confidentiality can be the difference in physical and emotional safety when an abusive partner or parent is involved. 

Teens do not exist in a vacuum. Nor do their health behavior choices. They are influenced by family, friends and romantic partners. They are impacted by the neighborhoods they live in, the environment they are exposed to, and the education they receive. If we don’t recognize the wider contexts of their lives, we can’t help them make changes. 

Amid the wisdom gained, there are still challenges. We operate on Tuesday afternoons in San Rafael, and we collaborate with the Novato Youth Center and MCC to operate another teen clinic on Monday afternoons in Novato. But what happens on a Wednesday when a teen needs unexpected reproductive or sexual health services, or is looking for primary care from a medical provider who speaks a teen language?

In an economic climate where public funds are being slashed and foundation funds are steadily decreasing, adolescent access to health care is endangered. This lack of access is devastating for an already vulnerable youth population. On the brink of adulthood, just as they are preparing to emerge as positive and contributing members of our community, they are also walking a tightrope. In the delicate balance between childhood and independence, teens are susceptible to risky behaviors and complex emotional and mental states. How can we expect to foster a community of healthy adults when we neglect the youth who stand on the brink?

Jonathan, Dominique and Raquel are typical. They are typical in their classes at school and the places they hang out. They are typical youth who come to clinic for the typical reasons: a bag of condoms, a pregnancy test, and Plan B. And yet they always skid to the forefront of my memory. Was it because of the progress made, the success? A method of birth control, a session or two with a therapist, a strong adult mentorship formed? Is it because one is now an empowered young woman who is getting all A’s in the 10th grade? 

Really, I remember them because they weren’t all success stories. One I’ve never seen again: Jonathan. Truth is, I couldn’t remember his face or his real name if I tried. He only came to clinic that one time and no progress came from follow-ups on a substance use referral. I see Dominique sometimes, though I worry about her. She returned to Huckleberry to meet with a therapist after an assessment indicated depression, though she stopped coming after a while. She didn’t want a method of birth control, and now we see her for the occasional pregnancy test. 

The third, however, is soaring: Raquel. She comes in every 12 weeks for her Depo shot. She usually brings her boyfriend for “moral support,” as they say, laughing. He chats with me about whatever subject he’s picked for the day while Raquel sees her nurse practitioner. Raquel glows when she tells me how well she’s doing in school, how communicative she’s become with her parents, how she’s balanced strong female friendships with a developing romantic relationship. 

Some successes, some failures, and a lot of in-betweens and unknowns: three typical teens in a sea of Marin adolescents. And yet they are so very atypical, so very unique in their needs and dreams, and so very worth being cared about, for the individuals that they are, and for the future they will create.


Ms. Davis is the community health coordinator for the Huckleberry Teen Health Program in San Rafael.




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