A decades-old practice of dispensing birth control to students in Baltimore is generating new debate as schools are again offering a long-acting hormone implant as an option.
After Baltimore schools became the first in the nation to provide Norplant to students more than 20 years ago, city leaders say they continue to be pioneers in adolescent reproductive health. The school birth control program now offers an array of contraceptives and has been credited with reducing the city's teen pregnancy rates to a record low.
But the ability of city students to obtain contraceptives on their way to class — including condoms, birth control pills and the morning-after pill — remains controversial.
This school year, the city began offering the hormone implant Nexplanon, which is implanted under the skin and lasts up to three years. Such an option hasn't been available since Norplant was taken out of schools several years ago amid public controversy and lawsuits over its side effects.
Eight health centers in city schools that are run by the Baltimore City Health Department offer birth control to students in elementary through high school, though no grade-schoolers and only a handful of middle-schoolers obtained contraceptives through the program this school year. By state law, students don't need parental consent to obtain contraceptives, no matter their age.
Baltimore City Health Commissioner Dr. Leana Wen said student access to birth control helped to cut the city's teenage pregnancy rate by one-third from 2009 to 2014. Wen said that providing access to contraceptives is part of comprehensive reproductive education.
"You can give people all of the education you want, but unless they can access the treatment, where they are, in their schools, in their communities, then we're not really giving people much of a choice at all," Wen said. "It's not education to just say, 'Teen pregnancy is a problem.'"
But ministers and City Council members say they are concerned that students don't need parental permission and that younger people have access to it.
At its worst, opponents see the contraception program as targeting poor, black populations. Other major cities such as New York and Chicago offer contraceptives in school, but none of the five suburban school districts in the Baltimore area do.
City Councilman Carl Stokes compared offering Norplant and Nexplanon to a "social engineering experiment" like the Tuskegee trials that studied untreated syphilis in rural African-American men in Alabama.
"I'm just as opposed as I was to it then," said Stokes, who was on the City Council and opposed Norplant when city officials introduced it in schools in the early 1990s. "They need parental permission to take children to the zoo, but they can surgically implant such a thing into a child's arm. I don't think so. It's social engineering at its worst."
Former Health Commissioner Dr. Peter Beilenson stepped up efforts to provide birth control in schools during his 13-year tenure. He recalled in a recent interview how his introduction of Norplant created "a political firestorm." He said that he received death threats and that police were stationed at his home for a week.
Beilenson, who is now CEO of Evergreen Health Cooperative, which has offices in the Baltimore region, said the continued pushback against contraceptives in schools is akin to "sticking your head in the sand." He said the program has been embraced by the students and parents whose lives it affected.
"Anything we can do to get kids through high school, to college and on to a career … by providing contraception and not an abortion, we should be doing it," he said. "I think it's very clear that we planned and allowed for young women to get their education under their belts before they had a planned pregnancy."
Beilenson said that the young girls who received the Norplant implant — he personally inserted 11 — didn't experience adverse effects, nor were they at increased risk of sexually transmitted diseases, as critics feared.
He lauded the return of a long-acting reversible contraceptive, or LARCs, like Nexplanon, to the city school birth control program. LARCs are recommended by the American Academy of Pediatrics for teens who aren't abstinent.
Nexplanon replaces the Depo-Provera shot as the longest-acting option offered to students. Depo-Provera, which is still being offered, is effective for three months.
Wen acknowledged that such contraceptives may be more controversial because of how long they last and the invasive procedure used to implant them, but she said they have the biggest impact in reducing teen pregnancy.
LARCs are 20 times more effective than the average use of birth control, she said, in part because they eliminate the need to remember to take a pill every day at the same time.
"We do believe that access to LARCs, just as we believe that access to all contraception, is critical to the rate reduction, which was unprecedented."
For nearly 30 years, Baltimore's Health Department has been offering contraceptives at school-based health centers, at no cost. Only students in those schools are eligible.
The Health Department spent about $60,000 on contraceptives for its health centers this year.
Another seven school-based health centers run by the Baltimore Medical System, a nonprofit that serves medically underserved communities, also provide birth control. In addition, teenagers can access birth control at a number of health clinics in the city.
Baltimore's teen pregnancy rate stands at 43.4 pregnancies per 1,000 female teens. That's a dramatic decline from decades ago but still twice as high as the state's and significantly higher than the nation's.
Students in schools where birth control is offered praised the program for its convenience and practicality.
Once every three months, one 11th-grader at Digital Harbor High School heads to the school-based health center instead of the cafeteria at lunchtime. There she'll get her Depo-Provera shot sometime in the 30-minute window before fourth period.
"You don't have to wait on a doctor appointment because it's right there at school," said the girl, whom The Baltimore Sun is not naming to protect her privacy. "I think it's a good thing to help people who want to be on birth control."
Digital Harbor 11th-grader Tamaria Miller said that while she doesn't use birth control, she's glad the health center offers it to her peers.
"There's a lot of people here having sex, and they're going to need to get their birth control from somewhere," she said. "It makes students more safe knowing they can come to the school for it if they can't get it from anywhere else."
Through April of this school year, students made 537 visits to the eight school-based health centers for contraceptives. Last year, the city recorded 1,700 such visits. Officials said the number of visits recorded at city-run health centers declined because the Baltimore Medical System, with grant funding, took over some health services in schools.
Most of those students were high-schoolers, as only five in grades six through eight were administered a contraceptive this school year.
Wen said she understands that offering birth control to an elementary school student may be disconcerting to some but that the Health Department believes "reproductive health education extends the entire life course."
She also noted that health practitioners in school centers are responsible for determining whether a minor has the capacity to consent to treatment with contraceptives and to receive information about them. In cases where practitioners suspect abuse, they are required to notify authorities.
Several parents said they weren't aware of the birth control program and expressed dismay about it.
Larry Linton, the 46-year-old father of a 10th-grader at Digital Harbor High, criticized the center for offering birth control without parental consent.
"It concerns me that my daughter has that access," he said. "I feel like that's something that should be handled at home. ... I'd like to know if my daughter is having sex or not."
Ericka Hester, the 29-year-old mother of a sixth-grader and fourth-grader at City Springs Elementary and Middle School, said she had no idea the health center made birth control available to her children. She's reconsidering sending her children to the school.
She said the medical implications that come with birth control are serious enough that parents should be involved.
"If they give children birth control without parents' consent, anything could happen," she said. "They don't know my child's health problems, how this could affect her."
A Maryland law dating back to the 1970s allows minors to seek reproductive, mental health and substance abuse services confidentially. Such laws are common in states across the country.
Baltimore school officials said they send parents forms, which they must sign to allow their children to be seen by a school-based health center and to access their services. On the form, officials said, parents are told that the state allows a minor to get treatment or advice about birth control without their consent. School officials didn't take a position on the long-standing birth control program.
"There are major consequences for kids, probably greater than anything else in the health world, for sexual activity as a teenager," Beilenson said. "So it's really crucial that they get services to get reproductive health under the consent law."
John Schlitt, president of the School-Based Health Alliance, which tracks services provided by school health centers, said birth control in schools has become more widely accepted over the years.
Urban districts are more likely to offer contraceptives, he said. He said many districts haven't adopted such policies because they "would not want to ignite that kind of controversy."
In 1998, 77 percent of school health centers surveyed by the group said they were prohibited from providing contraception. That declined to 50 percent by 2010.
Schlitt credits "visionary leaders" in Baltimore and in other districts that offer birth control for allowing health centers to take on a broader role in schools.
"They're focusing on school success in a way that was not so much front in mind for school-based health providers in the past," Schlitt said. "We have to be full-on partners who are working toward the goal of having every student graduate and succeed."
In addition to reproductive services, the city's school-based health centers provide a range of services, such as physicals and immunizations.
A health practitioner would need parental consent to treat a student for an ailment like ear pain in a school center, officials said.
The Rev. Gregory B. Perkins of St. Paul Community Baptist Church was among a group of pastors at the forefront of the controversy in Baltimore over access to birth control in schools in the 1990s.
Perkins took particular exception with Norplant, because he felt that poor, black students were being targeted in ways their white suburban counterparts never would be.
"Why do you target African-American girls? Why not other communities? I think the answer is racism," Perkins said in a recent interview. "They bring that garbage to the black community because we're supposed to just take it."
Perkins, who now belongs to the Interdenominational Ministerial Alliance, thinks the same is true today about all birth control and points out that counties still aren't offering access to any contraceptives in their schools.
Wen acknowledges that the city is unique in the state, but says so are its challenges with high teen pregnancy and infant mortality rates, problems exacerbated by a lack of prenatal care and poverty.
"We have to be seen as different than other jurisdictions," Wen said. "Our demographics are so different, and our needs therefore are so different."
Perkins rejects that notion.
"A teenager's a teenager," Perkins said. "We live in a promiscuous society. The same challenges for a young person in terms of sexual activity is the same in Baltimore City as it is in Montgomery County."
Birth control dispensed at health centers in schools:
•Oral contraceptives: 51
•Ortho Evra (patch): 52
•Depo-Provera (shot): 100
•Hormonal implantation, Nexplanon: 38
•Plan B ("morning-after pill"): 85
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Figures are for the 2015 school year through April 30