Can the IUD Revolution Come to the Bible Belt?

Free birth control won't work if teens can't find out about it.

J. Helgason / Shutterstock / Paul Spella / The Atlantic

AMARILLO, Texas—In the dimly lit, one-room portable building, Abril Vazquez held up a beige, bulbous model of a human tricep. The high-schoolers had pushed their desks into a circle. Vazquez invited them to pass it around. When they pressed down into the fake flesh, they could feel the rigid shape of a rod about the size of a toothpick.

“What does that do again?” a boy asked. The kids ranged in age from 14 to 16, and some seemed like their minds were in the process of being blown.

“It's birth control,” said Vazquez, who works at a reproductive clinic in town. “It releases hormones into her body in small doses and in even amounts.”

“How does it get in there, Miss?” another boy said.

“It's a small incision,” Vazquez said. “They slip it under the skin, and then they bandage you up. It might be bruised for a while.”

Vazquez is only 25, but she has the stage presence of a seasoned college professor, with a socratic tone and a business-casual sweater. In a neighboring school district, or even a nearby school, the goal of sex ed might be to instill a fear of premarital sex. Here, though, her brass-tacks lecture is about IUDs and implants—devices that would allow the teens to put off having kids until they’re much older.

The school, North Heights, is an “alternative campus” composed of students who, because of pregnancy or some other reason, are finishing their schoolwork independently. Today, she was speaking to a group who had recently been suspended from their regular schools for misbehaving. Most were busted for weed; some had been fighting. One kid insulted his teacher’s mother.

Abril Vazquez speaks to students in a classroom in Amarillo. (Olga Khazan / The Atlantic)

Their punishment, exile in this pre-fab hut behind the main North Heights building, actually awarded them an unusual privilege. Most students in Amarillo don’t get to hear from Vazquez about these long-acting, reversible contraceptives.

For sex education, public schools in this conservative town rely on an abstinence-oriented program called “Worth the Wait.” Vazquez says most high-school principals will not allow her and other workers from her clinic, Haven Health, to come present to the kids about family planning. Her only path into schools, Vazquez said, is through “personal connections” with the teachers or administration, like the kind she has here at North Heights.

Vazquez herself is a former North Heights student. After she gave birth to her son at 16, she came here for two years to catch up on coursework. With the help of scholarships and jobs cleaning houses, she went on to get bachelor’s and master’s degrees in social work. She’s been directing Haven’s educational programs since 2013.

“How much do you think daycare costs for two kids?” she asked the sleepy teens. “My kids are 8 and 6 now. My most affordable option is $647 a month.”

In an ideal world, she tells them, she’d only now be thinking about having children.

Vazquez’s teenage struggle is one that awaits many kids in Amarillo. The surrounding county has a teen birth rate nearly four times the national average. Out of 1,000 Amarillo teenagers, 90 will give birth before the age of 19.

Those numbers inspired Carolena Cogdill, the CEO of Haven Health, to try to offer long-lasting, reversible contraceptives to more of the area’s teenagers. These so-called LARCs, which include IUDs and implants, are by far the most effective forms of contraception, and they’ve been partly credited with bringing down teen pregnancy rates nationwide.

LARCs are set-it-and-forget-it baby-proofing machines. They don't depend on teens using their underdeveloped prefrontal cortices to remember to take a pill each day. They’ve been around since the 1960s, but it wasn’t until 2011 that the American College of Obstetricians and Gynecologists recommended them as the “first line” birth control option for adult women. The following year ACOG said teen girls should get them, too.

Cogdill heard about a project in St. Louis that offered free LARCs to teen girls and cut pregnancy and abortion rates to a quarter the rate typically seen among sexually active teens. Though the devices should be fully covered by most insurance plans, they can cost more than $1,000 for uninsured women or teens who don’t want to use their parents’ insurance plans. Last year, Cogdill secured $130,000 from local foundations to buy LARCs and offer them to Amarillo teenagers for free.

Now, Haven’s problem is finding those teenagers. Haven Health is a Title X clinic, which means that unlike most clinics in the state, it does not require teens to get their parents’ permission to receive birth control. Cogdill is struggling to spread the word; she said only seven moms have brought in their teenage daughters for birth-control advice in the past year—in a town with a population of 200,000.

Route 66 cuts through Amarillo (Olga Khazan / The Atlantic)

Of course, this isn’t the kind of place where families hash out the pros and cons of the NuvaRing over meatloaf. Pro-life protesters still line up across the street every Thursday to proclaim the clinic sinful, even though it doesn’t provide abortions. Kids here have 4G porn in their pockets, but little knowledge of the facts of reproduction, clinic workers say.

“People here are born here, grew up here, they have never lived anywhere else,” Cogdill said. “That really keeps us insulated from the outside world. Your parents didn't talk to you about sex, so you're not talking to your kid about sex.”

When they do come to the clinic, Cogdill’s young patients ask some odd questions. Girls think they can’t get an IUD if they’ve had multiple sex partners, or that they can’t get pregnant if they have sex standing up. A pregnant patient recently asked how many holes she has “down there.”

When it comes to birth control, kids only know about “pulling out and the pill,” Vazquez said. To change that, she tries to bring her reproductive roadshow to as many schools and health fairs as possible.

Middle-schoolers in Amarillo described the birth-control tools they’d like to see. (The Atlantic)

But to hear her describe it, she might as well be trying to sell hot dogs at a vegan convention. Once, she brought cards to a high-school event that provided information about condoms. An abstinence-oriented student group complained, and she was told to put the cards away.

Twice, she’s formally proposed presenting her information in Amarillo schools, and twice, she was denied, she says. That’s not counting all the times she’s tried to entreat individual teachers, also in vain.

“The social worker in me wants to accept and understand their culture,” she said. “But the teen parent in me feels it’s not fair to omit information because of their values.”

Just how, and where, teens should be educated about birth control is still a matter of national debate. Only 24 states require public schools to teach students about sex, and only 20 require that information to be accurate. In Texas, the majority of school districts still teach abstinence as the best and only option.

The Amarillo school district seems to think it’s doing fine without Vazquez’s help. None of the Amarillo principals I contacted replied, but I did get an email response from Tracey Morman, the Amarillo school district’s director of guidance and counseling. She said Worth the Wait does provide information on contraceptives, including IUDs and implants. (Amarillo’s Worth the Wait is a separate entity from the Scott & White Wellness and Sexual Health program, which was previously known as Scott & White Worth the Wait.)

“We give failure rates and recommend students discuss any contraception with a physician and parent/trusted adult,” Morman wrote, adding that any guest speakers in high schools must be approved by a committee of parents and school staff.

Cogdill and Vazquez said this committee rejected them during a meeting several years ago. They also doubt Worth the Wait teaches kids enough about birth control and where to find it. They said that in local public-health meetings, Worth the Wait representatives have aired outdated myths about IUDs, like the idea that they are only for monogamous women. (To this, the school district responded, “Since the 2014-2015 school year … our Worth the Wait educators ensure that they use correct research as put out by the CDC.”)

Mark Leach, the principal of North Heights, allowed Vazquez in that day because he ran into her at jury duty, where she asked him if she could come present. Plus, he thought North Heights kids would be inspired by her story of overcoming adversity. “We’re kind of family here,” he said. “We can always help her out.”

Even when Vazquez has the administration’s blessing, she worries she’s on dangerous terrain. At one point during the presentation at North Heights, a man Vazquez didn’t know entered the classroom. She quickly swept away her IUD models and shifted to a discussion of life goals.

She asked the students how many of them had teen parents. Most hands went up.

How many wanted kids themselves? Every student but one raised their hands.

“But how far apart do you want your children?” Vazquez asked. “And if you were to get pregnant now, how would that change your life?”

The kids seemed genuinely puzzled. A blonde 16-year-old said he loved making potato guns with his friends after school. With a baby in tow, his tuber-firing future looked murky. One girl quietly said she’d probably get kicked out of the house.

Vazquez asked them what they planned to do about it. The stranger had left, so she pivoted back to birth control. There’s always abstinence, she said. But if that’s “not on your radar,” there are also condoms, the pill, and the rhythm method.

Then there’s the gold standard. “For those who want to go to college, this is a really good method,” she said. She held up a plastic uterus with an IUD inside. It lasts up to 10 years—exactly the amount of time between when Vazquez got pregnant the first time and when her 26-year-old self would have conceived, in her ideal world.

“Wait, the strings hang out?” a boy asked, gaping at the IUD’s plastic flagella, which help with insertion and removal.

“Not outside the vagina,” Vazquez said matter-of-factly. (Later, one student wrote in an evaluation that “we were all open; we weren’t afraid to say some things.”)

She tells them they can find all of these contraceptives at the clinic where she works. They don’t even have to ask their parents.

She had more she wanted to tell them, like about different STDs and how they’re prevented. She could describe how a sperm meets an egg and makes a baby. Ideally, she could have more thoroughly explained how to prevent “the poverty and pain” of teen parenthood. She would have asked them, why don’t we see more of you in our clinic?

But it’s not an ideal world. Her time was up, and that had to be all for the kids in the North Heights portable building.