Adolescents' attitudes, behaviors, and use of the health care system are linked directly to their health and well-being as adults. To promote understanding of these attributes of adolescent girls, and to determine what health professionals, school systems, parents, and public policy can do to promote girls' health, The Commonwealth Fund undertook a survey of 6,748 adolescents from December 1996 to June 1997. This work was initiated by the Fund's Commission on Women's Health and its recognition that adolescent girls must be included in efforts to improve the health and quality of life of American women.
Adolescence is a critical time for the current and future health of women. In these formative years, experiences of violence or abuse, risky behaviors, access to health care, and supportive relationships can either enhance or undermine teen health, as well as shape the quality of life in years to come.
To explore the current state of girls' health and the challenges they face navigating the often turbulent teenage years, Louis Harris and Associates, Inc., was commissioned to conduct The Commonwealth Fund Survey of the Health of Adolescent Girls.1 From December 1996 to June 1997, 6,748 girls and boys in grades five through twelve completed in-class questionnaires on a range of topics, including abuse and violence, mental health, risky behaviors, access to health care, and communication with providers. In the descriptions below, "younger girls or boys" includes those in grades five through eight, and "older girls or boys" includes those in grades nine through twelve.
The survey found disturbingly high rates of reported abuse, depressive symptoms, and behaviors that can put health at risk and have potential lifelong consequences. Findings also indicate that a significant proportion of adolescent girls do not have access to health care when they need it, and when they do get care, physicians often do not address their concerns.
SEXUAL OR PHYSICAL ABUSE REPORTED BY MORE THAN ONE IN FIVE HIGH SCHOOL GIRLS
Adolescents experiencing abuse or violence are at high risk of immediate and lasting negative effects on health and well-being. Of the high school girls surveyed, an alarming one in five (21 percent) said she had been physically or sexually abused.
Of these older girls,12 percent said they had been sexually abused, and 17 percent said they had been physically abused. Younger girls also reported significant rates of abuse: 7 percent responded "yes" when questioned whether they had been sexually abused, and 9 percent said they had been physically abused. Although boys were far less likely to report sexual abuse (4 percent),their physical abuse rates were high: 12 percent of older boys and 8 percent of younger boys said they had been physically abused.
Most abuse occurs at home, it occurs more than once, and the abuser is usually a family member. Girls who had been physically or sexually abused said the abuse typically occurred at home (53 percent), it took place more than once (65 percent), and the abuser was a family member (57 percent) or family friend (13 percent).
Nearly one in 10 older girls reported abuse by dates or boyfriends. Including date-forced sex, one in four high school girls reported some form of abuse. Eight percent of high school age girls said "yes" when asked if "a boyfriend or date has ever forced sex against your will." When girls who reported date-forced sex were included with those who reported sexual or physical abuse, one in four (26 percent) high school girls said they had been either sexually abused, physically abused, and/or abused by a date or boyfriend.
One in four girls had wanted to leave home because of violence. Both abused and nonabused girls indicated concerns about violence: one in four said there had been a time she wanted to leave home because of it. Nearly three in 10 (29 percent) high school girls reported such a time. Overall, twelve percent of girls and eight percent of boys said that they did not always or often feel safe at home. Fifty-eight percent of abused girls said they had wanted to leave home at some point because of violence, compared with 18 percent of nonabused girls.
Abused girls often did not tell anyone about the abuse, and talking to doctors about it was rare. When asked whether they had told anyone about being abused, 29 percent of girls who had been sexually or physically abused said "no." Abused boys were even less likely to have talked to someone: half (48 percent) said they had not talked to anyone. When girls were asked to whom they had spoken, only 7 percent said a doctor. When girls had talked to anyone about abuse, they were most likely to have talked to their best friend (41 percent) or their mother (38 percent).
MENTAL AND PHYSICAL HEALTH: ONE IN FOUR GIRLS AT RISK
Adolescents' responses to questions related to mental and physical health indicate that the adolescent years are a far more negative time for girls' health than for that of boys. Although the majority of adolescent girls were healthy and showed signs of strong mental health, one in four girls exhibited depressive symptoms—a rate 50 percent higher than for boys. Girls, especially those in high school, were also less likely than boys to be highly self-confident. Black girls appeared be an exception, reporting fewer symptoms of depression or low self-confidence than other groups of girls. Girls with symptoms of poor mental health also indicated that they often lacked a source of support during times when they felt depressed or stressed.
One in four girls exhibited depressive symptoms. Based on a series of 14 questions about feelings in the past two weeks, the survey found that nearly one in four of all girls (23 percent) exhibited depressive symptoms, and one in ten of all girls registered severe depressive symptoms. Rates were higher among girls than boys: 26 percent of older girls had depressive symptoms, compared with 17 percent of older boys. Depressive symptoms included feeling like crying often, thinking about or planning suicide, feeling as though nothing will work out, feeling sad most of the time, hating oneself, feeling alone, not having any fun, not feeling loved, and not feeling as good as others.
Self-confidence and health ratings declined in high school for girls, but not for boys. Based on 10 statements about their feelings of self-worth, the survey found that one in seven older girls registered low self-confidence, a sharp increase compared with the prevalence of low self-confidence among younger girls (14 percent of older girls vs. 9 percent of younger girls). Only 39 percent of older girls were highly confident, compared with 44 percent of younger girls. In contrast, self-confidence improved with age among boys, with more than half (55 percent) indicating they were highly confident by high school years and only 7 percent indicating low self-confidence. Older girls were also more likely than younger girls to assess their health negatively: 19 percent of older girls compared with 13 percent of younger girls rated their health as fair or poor, and only 18 percent of older girls rated their health as excellent, compared with 27 percent of younger girls.
Black girls were least likely to exhibit depressive symptoms or low self-confidence. Black girls were the least likely to have either depressive symptoms (17 percent) or low self-confidence (7 percent). Hispanic and Asian American girls had the highest rates of depressive symptoms (27 percent and 30 percent, respectively), and white girls were in the mid-range, at 22 percent. White, Hispanic, and Asian American girls had similar rates of low self-confidence: 12 percent for white girls, and 11 percent for both Hispanic and Asian American girls.
Abused girls had more than twice the symptoms of poor mental health. About half (46 percent) of girls who had been abused had depressive symptoms, more than twice the rate of girls who said they had not been abused (18 percent). Similarly, abused girls were at least twice as likely to score low on the self-confidence scale: 22 percent of abused girls scored low, compared with 9 percent of nonabused girls.
Many girls had thoughts of suicide. Adolescent girls reported alarmingly high rates of thinking about suicide. Overall, 29 percent said "I think about killing myself but I would not do it." Among high school girls, one in three had thought about suicide in the past two weeks, and another 3 percent responded positively to the statement "I want to kill myself."
Girls with symptoms of poor mental health often lacked sources of support. When asked to whom they turn when feeling stressed, overwhelmed, or depressed, nearly one in three girls with severe depressive symptoms and one in four with moderate symptoms said "nobody." In contrast, only 8 percent of girls with few or no depressive symptoms responded this way.
RISKY BEHAVIORS: SMOKING, DRINKING, USING DRUGS, EATING DISORDERS, LACK OF EXERCISE
The survey found that a significant proportion of adolescent girls were putting their health at risk through frequent smoking and drinking,2 destructive eating patterns, and lack of exercise. The prevalence of risky behaviors doubles among high school girls reporting abuse or showing depressive symptoms.
Smoking, drinking, and using drugs: girls and boys reported similar rates. The survey found that the gender gap between smoking, drinking, and using drugs has closed, with similar rates of high school girls and boys engaging in these behaviors. Fourteen percent of older girls and 15 percent of older boys reported smoking; 15 percent of older girls and 20 percent of older boys reported frequent drinking; and 18 percent of older girls and 20 percent of older boys reported using drugs in the past month. One-third (30 percent) of older girls and older boys (33 percent) reported either smoking, drinking, or using drugs. Fifteen percent of older girls were engaged in at least two of these behaviors.
Many girls reported a lack of exercise. Although girls overwhelmingly indicated that they knew exercise was important to health, by high school years only two-thirds of girls (67 percent), compared with 80 percent of boys, were exercising three times a week or more. Fifteen percent of older girls said they exercised less than once or twice a week or never, double the rate of older boys (8 percent) or younger girls (6 percent) who exercised infrequently.
Eating disorders were a particular risk for girls. The survey found that one in six girls in grades five through twelve said she had binged and purged; 7 percent said they had done so more than once a week. Eighteen percent of high school girls reported that they had binged and purged, and 8 percent said they did so a few times a week or daily. In contrast, only 7 percent of high school boys said that they had binged and purged and 4 percent said they did so a few times a week or daily. These signs of eating disorders were linked to a general preoccupation among girls with their weight and looks. Well over half (58 percent) of older girls said they had been on a diet and one in three thought she was overweight. Compared with older boys, older girls were more than twice as likely to have dieted (58 percent vs. 25 percent) or to think they were overweight (33 percent vs. 16 percent.)
Abused girls and girls with depressive symptoms were at double the risk for signs of eating disorders. One-third of abused girls said they had binged or purged, 13 percent said they did so daily, and 4 percent said they did so a few times a week. Abused girls were nearly three times as likely to binge and purge as girls who said they had not been abused. Abused older girls were also twice as likely to drink or smoke frequently as girls who had not been abused. Frequent smoking and drinking rates were also twice as high among high school girls with depressive symptoms as those without symptoms.
Drinking and smoking were sources of relief for girls, especially for those with depressive symptoms or for those who had reported abuse. When asked why they smoked or drank, 66 percent of girls who reported smoking said they did so to relieve stress, and 36 percent who reported drinking said they did so because it helped them to forget problems. Girls with depressive symptoms or who reported abuse were even more likely to turn to drinking or smoking for relief.
ACCESS TO HEALTH CARE: ONE IN FOUR GIRLS FACE BARRIERS
Access to health care during adolescence can play a key role in shaping a healthy life. The survey, however, found that one in four girls and one in three girls in lower income families reported access barriers.
Many girls did not get care when they needed it, and did not have a regular source of care. One in four of all girls said there had been a time when they did not get needed care, and this rate rose to 29 percent among older girls and 30 percent among all girls from lower income families (measured by mother's education). Although most girls (80 percent) said they had a regular doctor, 16 percent reported not having a usual source of care. Minority girls were particularly at risk: one in five (21 percent) said she had no usual source of care.
Lack of insurance was a major barrier. More than two in five girls (44 percent) who were uninsured said they had gone without care when they needed it. Nearly one-third of uninsured girls lacked a regular doctor, more than twice the rate of those with insurance.
Confidentiality concerns raised barriers. The leading reason adolescents gave for not getting needed care was reluctance to tell their parents about their problem. Two in five older girls cited this concern, as did 36 percent of all girls surveyed.
Nearly half of abused girls and girls with depressive symptoms had gone without needed care. Despite their need for counseling and support, nearly half of abused girls (45 percent) and those with depressive symptoms (44 percent) said they had gone without needed care. Confidentiality was particularly a concern for girls with depressive symptoms or who had reported abuse: more than 40 percent of both groups said they did not get care because they did not want to tell their parents about the problem. Overall, only 22 percent of girls with depressive symptoms said they had seen a psychiatrist, psychologist, or other mental health provider in the past year.
Lack of support, including from parents, was often a problem for those in need. Parents were a major source of support for the majority of girls, with most (55 percent) naming their mother as the person to whom they turned when stressed, overwhelmed, or depressed, or for information about health (76 percent). Thirteen percent of girls, however, said they had no one to turn to. Those with depressive symptoms or who reported abuse were far less likely to say they would turn to their mother as a source of support (34 percent of those with depressive symptoms and 38 percent of those reporting physical or sexual abuse) and more likely to say they had no one to turn to (27 percent of those with depressive symptoms and 18 percent of abused girls).
GIRLS' INTERACTIONS WITH PHYSICIANS: MISSED OPPORTUNITIES
During adolescence, girls typically see physicians infrequently, heightening the need for effective communication and trust. Adolescent girls' reports on their interactions, physician preferences, and comfort in talking about sensitive topics with physicians reveal a discordance between expectations and experiences.
Discussion of sensitive topics with physicians did not occur often, despite adolescent girls' beliefs that physicians should discuss a range of topics with them. Two-thirds or more of adolescent girls said that doctors should discuss drugs, alcohol, smoking, eating disorders, sexually transmitted disease, and pregnancy prevention with them. One in two girls said that doctors should discuss sexual or physical abuse with her. Only one-fourth to one-third of girls, however, said they had had such discussions with their physicians. Rates were particularly low for discussing physical and sexual abuse or safety, violence, or incest: only about one in ten girls or boys said their doctor had ever discussed these issues with them. Instead, physicians appeared to stay with safer topics, emphasizing eating habits, weight control, and exercise.
Embarrassment undermined frank discussions. Although most girls indicated that they were open to discussing sensitive health topics, one-third (35 percent) said there had been a time when they were too embarrassed, afraid, or uncomfortable to discuss a problem with their doctor or health professional. Discomfort increased among girls likely to be in need of care. Half of abused girls and girls with depressive symptoms said there had been a time when they were too embarrassed to discuss problems with doctors.
Girls' preferences for doctors are not always met. Roughly half of girls said they would prefer to have a female physician, and the remaining girls expressed no preference. The survey found, however, that only one-third of girls see a woman physician. One in four girls does not have her preference met.
Girls often lacked the opportunity to speak privately with their doctor. Half of younger girls and a third of older girls said they did not have an opportunity to talk privately with their doctor. One-third of girls who would have liked to talk privately with their doctors said they did not have this opportunity.
The Commonwealth Fund Survey of the Health of Adolescent Girls, Cathy Schoen, Karen Davis, Karen Scott Collins et al., The Commonwealth Fund, The Commonwealth Fund, November 1997