My Dear Daughter,

It is still dark and chilly outside as I stepped out of the house for my morning run. The cold air nibbles my thumb, as it is the only portion on my hand exposed to the weather. I love this time in the early morning and hardly anything will stop me from going out to enjoy it. I can feel the cold air nudging on my face, opening my sinuses and making my nose run. The dawn is trying to break out, waking up the birds into their chirping, all priceless. Without fail, I can see the sun trying to come out a few minutes into my run. It starts with a little peep on the other side of the mountain. The red glow then turns into orange, yellow, bathing my surroundings with the most beautiful mixture of red, orange, and yellow. It’s the perfect time of the day. I feel so lucky to be able to watch and enjoy it all. Every time it’s perfect and precise. Makes me wonder, why is our life not like that? With that question lingering on my mind, I get ready and get to my work. After picking up my stethoscope, I am ready for my first patient.

As I head to my room, I have to pass through a waiting room. I noticed a young lady and slightly older lady sitting in the lobby. I noticed the girl is fidgety, the legs moving in rhythmic motions back and forth. She might be nervous being here. The lady next to her is on her phone. They are clean and well dressed. I grabbed the first chart and called Mary into my room. A very young looking, beautiful girl, as tall as you are, gets up from the chair. For a second, I wonder if she is here for immunizations instead of family planning and STD testing. She looks too young to be coming to this side of the building. No, I was wrong, they both get up and follow me. The older lady must be her mother, because mothers are concerned for their teenagers. She wants to be part of the planning and treatment plan involving her child. I invite this mother in for the initial plan of care that happens behind my closed doors.

Mother takes a seat on my exam bed and Mary in the green chair that sits in front of me. I always sit my patient in front of me so I can look into their eyes, while I am trying to figure out what’s going on and understand them. I can watch their fidgetiness, their constant back and forth motion, that helps me to assess their behaviour and understand them better. It helps me to ascertain the reasons for coming to my clinic. As they say, body language is the doorway to unspoken words. Their constant effort to avoid my eyes, the twirling of their thumbs, the sighs between unfinished sentences tells me a lot about them. Sometimes the rolling of tears down their eyes and even unstoppable wailing are common emotions behind my closed doors. But unlike others, Mary is sitting still, obediently in that chair. Like a good, little, well mannered child.

I looked at her and asked my first question. What’s your date of birth? The paperwork said thirteen years. Mother spoke first – “She is thirteen years old. She needs to be tested for STDs and started on a birth control method. Can you tell us more about them?” Mary kept quiet. I wanted Mary to hear all about birth control options and make an informed decision. There are several options for birth controls and most effective would be something she will not have to take or think about every day. Just to list them, there are pills to take daily, Depo Provera, which is an injection for every three months. There are rings that you change every three weeks, patches that you change every week, and other long term options. After going over all of them in a concise method, her mom wanted Mary to have Depo Provera. Mother and Mary agree to the plan of care for this visit. Depo Provera, STD testing and education, and then her mother stepped out of the room. I wanted Mary to myself so she can open up and tell me about herself.

Mary is a beautiful teenager. Her hair is long and curly. She is in jeans and a sweater. While her mother was talking, she played with her fingers — twirling them, picking at her nails. They are not painted, but are clean and short. She looked like any other teen that I see, she is wondering why in the world she got dragged into this clinic? She didn’t seem to be too concerned about the graveness of the situation. If she was concerned, she didn’t express it. She is a child, trying to copy and adopt adult behavior too early in her life. While mother expressed her concern for STDs and early pregnancy, Mary was quietly watching her mother and I with those innocent eyes of hers, trying to soak it all in and make sense of it all.. Obviously, she does not realize the risk she has taken being sexually active so early in life. The loss of childhood innocence, the simplicity, are not in her worry list yet.

This is not a scene of a movie or any television drama. It is a very common scenario at my work these days. Everyday, the age of my patients seeking birth control options and STD testing is getting younger and younger. The teenage girls that barely have started their menses or boys barely any stubble on the upper lip line are coming to the clinic. Sometimes they don’t even meet the criteria for hormonal birth control methods yet. To treat them for STDs, we have to take extra measures to ensure their physical and home safety, along with it the responsibilities of making them understand the risk they are taking by adopting such behavior so early in life.

I ask Mary, what is your story? Mary is thirteen years old, in middle school, and started menses one years ago. She started dating a few months ago and is sexually active. According to her, the relationship was mutually consensual. Whenever I come across a young patient, I want to make sure that they are not being forced into the relationship. Listening to her tells me that she does not realize that with giving consent for a relationship, she has made herself vulnerable to STDs and early pregnancy. Every sexual encounter is a risk for STIs there are some that can be cured with antibiotics like gonorrhea, chlamydia, and trichomoniasis, but there are some that are going to stay in her system forever like HIV, HPV, Syphilis and Herpes. She is a child herself, will she be able to handle the physical and emotional involvement that would be required to maintain the relationship and raise a child? She gave me a blank stare.

I can tell, she had never thought through all that. Nobody would in her age. All the words that were coming out of my mouth were very foreign to her. She didn’t know about STDs and didn’t know about the risk she is taking so early in her life. Nobody has taken time to explain them to her. I try to be as plain as I could while explaining it to her. If you contract syphilis, HIV, HPV, or herpes, they will stay in your system and you are always going to test positive for it. We have tested you today and if anything comes positive, we will ask you to come back to get treatment. If you do not take antibiotics for positive STDs, you will have severe consequences on your health. As I was explaining all of this, I felt bad for her. At her age I was playing with my friends, life was carefree and full of wonder. There was no worry about contracting STDs or having a baby. Shouldn’t all childhood be that way?

We went  over all the birth controls options for her. With my experience, I can tell that her mother’s choice is the best option for her at this time. Once she receives birth control today, she will be back in three months. We will schedule her for next visit considering her availability and good days to come within the time frame to get the next shot. I want her to be fully aware of the risk factors and side effects of hormonal birth control methods. It is very important to me that she makes informed consent for birth control. I want her to realize that she is adding hormones in her body. It can take away her periods, increase risk of depression, and any of the other side effects that come with hormonal birth control methods. I can feel that she’s  overloaded with information. She barely can understand her every day routine yet. If she was educated and informed about all these options early enough, she might have chosen a different route. Maybe she wouldn’t end up in my office today.

It makes me wonder if she is a victim of parents like us? A mother, who has good intentions of wanting safety and wellbeing of their child, but is novice on the topic. A mother or father who could never muster enough courage to start the conversation of sex and emotional safety in an early age. I understand that parent very well. She had a desire for her child to be equipped with all the information. She wants her to learn, master, and then implement the emotional involvement in relationships. But could never be strong enough to start the conversation at home because she never grew up hearing about it. Well, if you are one of those parents that is not equipped with the knowledge about all the STIs and birth control options, please talk to your sons and daughters about abstinence. That is what I did.

I grew up in a culture where sex and pregnancy are adult topics. Children were never invited or entertained on the topic. Children are not even educated about their bodies. I knew nothing about my body until I started going through the experiences myself. The menses were not talked about. I grew up with no information about STDs and Birth Control options. Only knowledge I had was abstinence. I encouraged and emphasized abstinence for you and your brother through high school. I also believe that teenage years are for growing and learning and making friends. It is the time to carve the future. It’s time to enjoy and master worldly etiquette.

I am a firm believer of Ashrama texts. The Ashrama is a medieval Hindu text in Hinduism. It divides human life into four stages. According to the text, human life up to early twenties is considered time to learn and grow. Children are not considered to be mature — emotionally, physically, and mentally. Therefore, any kind of relationship that requires emotional, physical, and mental maturity needs to be put on hold until such caliber is attained.

Mary’s mother is worried that Mary will end up pregnant and drop out of school like herself. She wanted her daughter to finish school and have a career before she had a child. A child raising a child is a very common scenario with my patients. The years that they would be flowering into womanhood, those precious years when you form your identity and lay the foundation for your future, these girls are forced to quit and become fully involved in raising younger versions of themselves. Having a child at an early age will affect young life in so many ways. Her mother did not want Mary to have to go through this and brought her to us. It was a good decision on her part.

Why is Mary sexually active so early in life? It could be due to multiple reasons. Peer pressure, social media, or just the lack of confidence made her give in, just as it is for so many teenegers that sit in my green chair and try to justify their actions. As parents of teengeers, it is very important that we guide our children from their early years. We want to introduce the self-confidence, feelings of belonging, and role model to grow up into. The focus should shift from encouraging intimate relationships in high schools into focusing on education, self growth and adoration of early years. The rest will fall into place.

Most important of all we parents need to talk to our children, before social media, the peers take over their young minds. The research has shown that if children are talked to about abstinence and STDs, they are less likely to be sexually active too early in life. The principle of abstinence is the best option. If abstinence is not going to be your option, then there are many options for birth controls. Educate them on use of condoms to prevent STDs. They are vulnerable to HIV, HPV, syphilis, and herpes, once infected will possess lifelong threats.

My research on the topic about school involvement in sexual education was very disappointing. And you have told me all along that they don’t talk about anything at all. And the concept of abstinence is so foreign to all the girls. If the schools are not informing them, then parents need to step up and take that responsibility. If you are shy about it, guide them to an authentic information site like CDC or your local Health Department.

Abstinence needs to be the choice of birth control until they are mature enough emotionally and physically. Social maturity has to be reached to be able to handle the emotional aspects of intimate relationships. For those that choose to have intimate relationships early on, they should be informed about all aspects of relationships. Besides the social and emotional aspects of relationships, they need to be informed about birth control options and the use of condoms as double protection. Birth control should be made easily available and girls need to know about the side effects of them. They should be taught the importance of condom use for self protection and make them available easily. Unlike popular belief, the research indicated that providing condoms will not increase the incidence of sexual promiscuity, if the service is combined with the education of abstinence and STDs.

Mary, like so many teenagers, is the backbone of this nation. Education and self safety should be the priority for that group of children. The life of a thirteen year old is to enjoy and be carefree. It is not the time to be handling the side effects of hormonal birth control methods. It is not time to be stressing about the emotional aspects of a relationship or worry about catching lifelong STDs. Mary’s beautiful face was so engorged with all the information that was provided today. “Do you have any questions?,” I asked. “No, I am going to think about all the information you provided today.” The answer filled me with hope.

Mary was open to the education and options she had. She is picking the options that would work for her for right now. She was excited about the idea of being able to come off birth control if she decided abstinence as her method. She got her injection. Mary picked up her bag full of condoms, birth control options material, information on STIs, and was ready to be checked out. I walked her to her mother. Now, they are going to check themselves out and schedule her to come back in three months if she decides to do that. I will see her back in three months. It will give her enough time to contemplate on the material we went over today.

Mary is not a real patient — although, I do regularly see many teenagers with similar stories to hers. It is deeply concerning for me and I am sure, with you being involved in social awareness programs, it would add more reason and urgency in your work. Your work of guiding and empowering the younger generation is a necessity in our society today.

With Love,

Mamu