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Remaining patient : a critical analysis of British Columbia health discourse on teen mothers Creighton, Genevieve 2007

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Remaining Patient: A critical analysis of British Columbian health discourse on teen mothers B y Genevieve Creighton B A , University of Victoria, 2001 B A , Simon Fraser University, 1.997 A THESIS S U B M I T T E D I N P A R T I A L F U L F I L M E N T OF T H E R E Q U I R E M E N T S F O R T H E D E G R E E OF M A S T E R O F A R T S in T H E F A C U L T Y OF G R A D U A T E S T U D I E S ( A D U L T E D U C A T I O N ) T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A August, 2007 © Genevieve Creighton, 2007 ABSTRACT Since the early 1970s the issue of teen pregnancy and parenthood has been the subject of vigorous public policy debate. Literature reports that becoming a teen parent increases the risk of abbreviated education, poverty, isolation, low self-esteem and economic dependency. Discourses within the health care system conceive of these adolescents as presenting health risk to themselves and their future child by choosing to proceed with their pregnancies. These stated risks include greater frequency of pre and post-natal complications, poor maternal diet resulting in foetal underdevelopment and increased risk of child maltreatment. While there is very little literature that solicits the experiences of teen mothers, research attests to the fact that they are reluctant to access the health care system because of the judgement and stigmatization they experience in these interactions. The ways in which the identities of teen mothers are constituted within the health care system, through the discourse of health promotion and the attitudes and practices of some health care providers, negatively impact upon health outcomes for this population. To further explore this issue engaged in discursive analysis of texts which centralized a discussion of teen pregnancy and motherhood in health care. M y approach to research was grounded in a feminist, post-structural approach to discourse analysis, paying particular attention to power, authority in the process of creating subject positions for young mothers. I found that, despite relatively progressive government health policy regarding youth and sexuality, stigmatizing stereotypes of teen mothers continued to inform the ways that health care providers and researchers spoke about the teen pregnancy and motherhood. I argue that this is due to an interplay between the encroachment of American media representations of teen mothers, the presence of neo-liberal political ideologies and the lack of mandate for local sites to implement national policy. There was a strong tendency, within public health interventions, to de-contextualize teen mothers from social locations of class, race and gender in discussions about so-called risky lifestyles. Health interventions concentrated on improving diet, substance abuse and social practices, without consideration of the complexities behind these issues. TABLE OF CONTENTS ABSTRACT . i TABLE OF CONTENTS ii ACKNOWLEDGEMENTS v CHAPTER ONE: CULTURAL INSEMINATIONS Introduction .'. 1 Teen mothers: Discursive Dances 1 Who are teen mothers? 2 Historical constructions of adolescent childbearing 4 Current perspectives of teenage pregnancy 7 Research questions and methodology 8 What will this research contribute? 8 Reflexivity in research ; 9 Motivation/Location 10 Thesis structure 12 CHAPTER TWO: AN APPROACH TO DISCOURSE ANALYSIS Introduction 13 Why discourse analysis? 13 Conceptualization of discourse 14 Textual analysis 17 Specific texts 19 Conclusion 19 CHAPTER THREE: HOW SHALL I JUDGE THEE? Pathways into the problem of teen motherhood 21 Moral Panic 22 Teen pregnancy as moral panic 25 Needs Interpretation 26 Healthism ; 28 Conclusion 30 CHAPTER FOUR: FRAMING THE RESEARCH Who says teen mothers are a problem? 31 The Health Care debate 32 Health is science and science renders the truth 32 Teen mothers are a problem for the health care system 34 Being considered a 'problem' is a barrier to health care 35 Sexual health education to prevent teen pregnancy 37 The "prevention" discourse 38 Do teen mothers ever plan their pregnancies? 39 Cultural Rationali sm 41 Sex Education and Male Hegemony 42 Promoting a 'discourse of desire' 45 The power house marriage between health and psychology 46 Teenage mothers and the low self-esteem discourse 48 Teen mothers w i l l be bad mothers 49 Teen mothers must need therapy 50 Teen mothers are a problem for the economy 52 Neo-liberalism 52 The shifting discourse of social assistance 54 Mothers as welfare 'dependents' 56 Teen mothers are not the cause of poverty. 57 Beyond the Macro-analysis 58 Canadian aboriginal teen mothers 60 Silences in the Literature: Fathers 62 Conclusion 63 CHAPTER FIVE: THROUGH A MIRROR DIMLY: THE BIFURCATION BETWEEN POLICY AND PRACTICE Introduction 65 Health Canada on Teen Mothers 66 Canadian Guidelines for Sexual Health Education 66 Consultations on a Framework for Sexual and Reproductive Health 68 The Opportunity o f Adolescence: The Health Sector Contribution 69 Two paths diverge 71 American 'family values' 73 Policy not practice: the evolution of Health Promotion in Canada 74 Downloading Responsibility 79 The Media 80 Conclusion 81 CHAPTER SIX: REDUCING AND ENABLING DISCOURSES Introduction 82 Coding 84 Citations 86 Problematizing Discourses 86 Psychologizing Motherhood 86 The healthy lifestyle 89 The demon cigarette 90 Teen moms drain the economy 91 Moral Panic 92 The "Bad Mother" 93 Supportive Discourses 95 Advocating Discourses 96 Conclusion 97 CHAPTER SEVEN: KEY FINDINGS AND RECOMMENDATIONS Summary 98 Key Findings 99 Not a Pretty Sight: Good mothers don't smoke 99 It's all about you 101 Implication for Practice 103 A Critical Approach to Health Promotion 103 A Cautionary Note 105 Limitations of Study 105 Future Research 106 InClosing 106 REFERENCES 105 v ACKNOWLEDGEMENTS To my supervisor, Shauna Butterwick, for the thoughtful and careful guiding of my writing. I deeply appreciate all of your insight, humour and patience during this, occasionally overwhelming, journey To Deirdre Ke l ly whose critical and creative research on the construction of teen mothers had a major impact on the direction of this thesis. To Jim Frankish who has opened so many doors for me in the academic world and taught me most of what I know about Health Promotion. To Marina Niks who is approachable, wise and persistently committed to the work of social justice. Y o u made academia human to me. To John Egan, a wonderful mentor, who generously shared his time and expertise. To Trish Graham, a born teacher and editor. To Lee Weinstein for believing that education belongs to everybody and leading me into adult education To Gordon Campbell for throwing me out of a really good job so I could go to Grad school and for so profoundly contributing to the marginalization of young mothers that this thesis was made relevant. To the teen moms at Learning Together who really inspired this thesis. I am grateful for the way that you shook up my worldview. To my Hemispherians- Chris, Tracy, Bronwyn and Laura- to whom I owe a lifetime of debt for carrying me through 13 years worth of crises and celebrations. I have been profoundly shaped by the privilege of knowing you. To my really smart friends Jenny Matthews and Al l i son Campbell who showed me new ways of looking at things, introduced me to all sorts of theory and assured me that a tool is a weapon (if you hold it right) To my parents who have been there every single time I needed them, who inspire me with their lives and who regularly go well beyond the call of duty to rescue me from myself. To Kiera and Zoe who gracefully endured 10 months of me yelling at the computer and continually reminded me (thank goodness) that teenagers are not just a theoretical construct. To endlessly patient Emma who asks great questions and, as she finishes off grade four, may possibly know more about this topic than I do. A n d to Maya who has moved me with her grace during unimaginable crisis. v i To Barbara for being my very best friend. Thank you for all the hundreds of ways that you energize me, make me laugh (and laugh at my dumb jokes), inspire me to be a better person and f i l l me up when there is nothing left and temper my craziness. Thank you for the road trips, the nefarious eating of junk food, the retail therapy and the "What Not to Wear" marathons that got me through writing this thesis. / salute you for your courage and I applaud your perseverance and I embrace you for your faith in the face of adversarial forces that I represent CHAPTER ONE: CULTURAL INSEMINATIONS Introduction Talk is powerful and teen mothers are spoken about at every turn. They are repeatedly blamed for their poverty and stigmatized for their youth. They are alternately accused of actively presenting health risks to their children and indicted for their passive neglect. This thesis is an exploration of the discursive constructions of teen mothers within Canadian health promotion and public health literature. Central to this study is the premise that the way that teen mothers are constructed in health promotion strategies has bearing on the quality of health services that they are provided with and are able to access and that authorized talk about the problematic nature of adolescent motherhood deeply impacts upon relationships with health care providers. Moreover, uncritical health promotion discourses serve to reproduce hegemonic understandings of gender, sexuality, motherhood and class. Alternatively, supportive and advocating discourses taken up by health care providers serve to challenge the social order that perpetuates poverty and stigma in the lives of young mothers. Teen parents: Discursive Dances Cherrington and Breheny (2005) argue that there is no such thing as a bounded discourse when it comes to teenage pregnancy and parenting. A s teen mothers pass through multiple discursive spaces of health, education, social services, the political arena, the media, culture, family and peer groups, the images presented of them both meld together and shift away. A married nineteen year old is conceived of much differently than a single sixteen year old. A white middle class pregnant adolescent finds her life constructed and mapped out in ways that are dissimilar to a young aboriginal woman living on reserve. To the health community they are biologically compromised. To social services they are another 'at risk' person on the caseload. The popular media vacillates between disapproval of teenage pregnancy, seeing it as acceptable within the confines of marriage, and inevitable within certain cultural 1 contexts. Celebrity, 16-year-old Keisha Castle-Hughes' (Whale Rider) pregnancy was all but ignored by the media aside from a brief highlighting of her Maori background. Hit TV show, The OC, used Navi Rawat's character, Theresa, to show the horrendous experience of being a teen mother, destined as she was to be poor and alone. "One Tree Hi l l " , another TV program popular with teens, portrayed 17 year old white, married, upper-middle class Haley's pregnancy as disappointing, but cradled in moral . righteousness of her marital status and financial stability. A review of Canadian bestseller, "Lullabies for Little Criminals", extracts this learning from the story, ".. . i f anyone has doubts about the problems that occur when children have children, this novel demonstrates them emphatically." (Vancouver Sun, February 24 t h, 2007) Who are teen mothers? In 1999, the average number of teens who became pregnant in Canada was 42.7 out of every 1000 with 24 of those teens giving birth. Canada's teen pregnancy rate sits in the middle of Western industrialized countries. A l l of the Scandinavian countries and Japan have lower rates of pregnancy, the United States and Russia have higher rates and Iceland, England, Wales and New Zealand have rates that are comparable. (Dillon, 2001) There were much higher pregnancy rates at ages 18 to 19 than at ages 15 to 17: 68.9 versus 25.5 per 1,000, likely reflecting the levels of sexual activity within these respective groups. For the first time, in 1997, more pregnancies ended in abortion than in a live birth. In BC the number of those young women choosing abortions was particularly high, second only to Ontario. (Drysburgh, 2000) . Adolescent childbearing is not equally distributed across geographic and economic regions in British Columbia and Canada. Alex McKay, the research coordinator of the Sex Information and Education Council of Canada notes that in Vancouver, for example, there were only 0.8 births per 1,000 women under 19 on the city's affluent west-side while the rate was more than twenty times higher in the downtown eastside. (Ince, 2004). Ross, Kelly and Scott (1996) found that 18% of teens from low-income families became pregnant in contrast to 4% of young women from higher income families. According to Statistics Canada, the poverty rate of young 2 families with children increased by 56% between 1981 and 2001. 38.1% of young families with children currently live in poverty. (Planned Parenthood Toronto, 2003) According to a community based participatory research study done by Silvia Olsen (2005) up to 70 percent of new First Nations families on southern Vancouver Island, British Columbia are starting with teenaged mothers, most between the ages of 15 to 17. Thirty to forty percent of status First Nations babies born each year are mothered by women less than nineteen years of age. From 1991-1999, 25 % of teenage mothers in the province of British Columbia were First Nations, despite the fact that Aboriginal people only account for 3-5 percent of British Columbia's population. The realities faced by low income, single teen mothers, are harsh. The past five years have seen cuts to shelter allowances for people on social assistance which, when combined by a high cost of l iving and very low levels of affordable housing, means that young mothers are often living in unsafe, substandard housing or are rendered homeless (Ince, 2004). School-based programs for young mothers have been compromised or forced to close by restrictions to child-care subsidy eligibility, cut backs to education and a lack of sustained funding for operations. (Forer and Holden, 2004) The current political climate, while hard on all poor people, is particularly amplified in the lives of teen mothers. The face of the adolescent mother is not white and wealthy, like the young women glamourized on teen soap operas. The majority of teen mothers in Canada live below the poverty line and many are aboriginal. (Public Health Agency of Canada, 1999) Some are with partners but most are parenting alone. It is on these economically disadvantaged young women rests stereotypes, stigmas and the surveillance of the health and social welfare system. It is these teenagers that society considers to be problematic, deviant and a threat to the social order. So, while teenage pregnancy and parenting is present in every socio-economic group, for the purpose of this thesis I am limiting my discussion to those who live below the poverty line, as designated by Statistics Canada. 3 Historical Constructions of Adolescent Childbearing The main thing at the time was to conceal it, the scandal was so intense. A daughter could do nothing more disgraceful. It ruined you in a social sense. You have no idea what the stigma was. Joni Mitchell speaking about her "out of wedlock" pregnancy in the 1960s (Petrie, 1998, p. 44) While sometimes constructed as a new phenomenon, "youthful pregnancy" did not come about in recent decades. Women have always had babies in the time period that we now consider to be adolescence. While there is little research done on the history of adolescent pregnancy within Canada, we can follow the discursive threads as they have been produced in the United States and Great Britain. In the 17 th century, during colonial times, babies born to single teenagers were considered to be morally problematic, not because of the age of the mother, but because of her marital status. During this Puritanical time, having a baby "out of wedlock" was considered to be a sin against God and, because babies born out of wedlock became a public charge, they placed economic burden on communities. Due to these factors, "bastardy" was punished harshly through public lashings and fines. Despite the colonial community's aversion to and chastisement of unwed motherhood, historical records demonstrate that it was not unusual in American society. (Luker, 1996) So determined were the Quakers arid the Puritans to protect the moral and economic interests of the community, they relentlessly sought out the fathers of bastard offspring. Midwives were compelled to question a labouring mother as to the parentage of their child, as this type of cross-examination was deemed to yield factual information. A man who was convicted of fathering an illegitimate child was often fined and expelled from his community. Amongst the Quakers, such fathers were not allowed to testify in court nor were they permitted to hold public office. Children born to slaves or to mixed race couples during this time period were necessarily considered to be bastards due to a legal prohibition on marriage. These children were born with no rights and were the property of the master of the household. 4 In the 18 century, the economic burden on communities of "fatherless children" was more the issue of concern than the moral question of illegitimacy and extra-marital sex. Rather than punish the offspring of single mothers, however, it became public policy to support and protect children in this situation. Local governments saw it as a priority to search out men who had abdicated responsibility for their offspring and go after their finances. Common law marriage was created and all children were considered to be legitimate rather than being held responsible for the "mistakes" of their parents. (Luker, 1996) In Britain, single mothers were seen as "feeble minded women producing feeble minded off-spring". (Carabine, 2001) In order to protect the purity of the British race, as well as the well being of the mother, many women who bore children out of wedlock were incarcerated. (Carabine, 2001) In some Canadian provinces out of wedlock pregnancy was seen as a criminal, chargeable under the Juvenile Delinquency Act. (Petrie, 1998) Over the late 19 t h and early 20 t h centuries the moral and the economic understandings of unwed motherhood merged into a new conceptualization of a "social" problem. The women's movement advocated a new discourse about "women in trouble" (whose categories included prostitutes, abandoned mistresses and single mothers) where, rather than being seen as morally transgressive, these women were seen as victims of the social and economic problems that had befallen them. Feminists of the time indicted the men who were using and taking advantaged of these vulnerable women, leaving them "ruined" at the end of their exploits. Luker (1996) notes that, homes which had been opened in the 1880s for the homeless, alcoholic and sex trade workers were, by 1900, almost exclusively transformed into homes for unwed mothers. In Canada, in the 1950's and 60's, young single pregnant women were sent away to 'homes' run by religious institutions until they had given birth. A t the end of the 1960s there were over 50 of these homes in various places across the country. In her book, a retrospective of her own and other women's experiences in maternity homes, Anne Petrie writes that the shame of being a unwed mother was so great that it was often determined that they needed to be hidden away from society and their community. A common notion was that women had evil within them that needed redeeming through hard work and 5 religious conversion. Life in the homes, therefore, often ranged from dreary to punitive as staff attempted to transform these fallen members of society. (Petrie, 1998) B y the 1920's, Freud's psychoanalytic framework of the unconscious began to inform how unwed mothers were characterized. In the 1950s it was more common to see such phrases such as "un-wholesome parent-child relationship" and "sexual delinquency" to describe the aetiology of the women in trouble, rather grounding the phenomenon in social and economic situations. The "Out of Wedlock" conference held in Toronto in 1964 presented the unwed mother as having a deficient ego and an unresolved Electra complex. In her book of the same name, Leontine Young described unwed mothers as being generally characterized as having a dominating mother and/or a dominating father, a lack of capacity to communicate and desire to self-punish. (Petrie, 1998) The conceptualization of unwed mothers was re-situated from a woman victimized by men to a woman who was a victim of herself. Lone motherhood was identified as a pathological state, interpreted in psychological terms. Children born to unwed mothers were newly conceptualized as being "at-risk" for future social and emotional problems. The onus was placed on government to help and protect these children as well as to target the issue of the "breakdown of the family", in order to facilitate the end of poverty, delinquency and other social ills. While, previously, the aid of women and children in trouble had been the domain of the social reformers and the religious the helping profession (in the form of newly professionalized social workers, counsellors and researchers) were engaged to solve these problems. It was very common during this time for children born into poor families of single mothers to be adopted by middle class families. (Petrie, 1998; Luker, 1996) In Quebec, during the 1950s, only 14.6 per cent offilles-meres (girl mothers) left the hospital with their babies. (1998) Curren t Perspectives of Teenage Pregnancy For the past four decades, teenage pregnancy has been thrown into the political spotlight. While adolescent childbirth, per se, is not a newly emerged problem, since the 1970's the formulation of the problem has been differently inflected and ideas about how 6 to deal with the problem have taken a new shape. It was during this time period that the age of the mother, as distinct from her martial status, became a social concern (Kelly, 2000; Luker, 1996; Wilson and Huntington, 2005). This occurred in a transitional period, at a time when a number of social and political discursive events were taking place. Legal reforms made safe abortions available to young women. Contraception became more widely available to women of all classes. A s the feminist movement advocated for economic independence for women, growing numbers of middle class women began to delay childbirth until their education and career were established. Despite a decline in the actual numbers of teenagers becoming pregnant, there was a rise in very young mothers choosing to keep and parent their children. (Clark, 1999) A significant proportion of these teenaged mothers were also choosing not to marry and, instead, to remain in school. It was then that "teenaged childbearing- that is early and unmarried parenthood- became a prominent and socially disturbing trend." (Furstenburg, 1991, p. 129) In the United States, the publication "Eleven M i l l i o n Teenagers: What Can Be Done about the Epidemic of Adolescent Pregnancies," published by the research arm of the Planned Parenthood Federation, was one that established teenaged pregnancy as an "urgent problem" that required intervention. (Wong & Checkland, 1999) A critical reading of the literature exposes the cracks in the central argument that teenage pregnancy is, in itself, a problem for the health and wellbeing of the individual and society. This assumption, however, is firmly embedded in commonsense as being one of the root causes of poverty, illiteracy, child abuse and i l l health. A s some authors assert, this strong tendency to conceptualize teenaged pregnancy as a social problem has led to an overstatement of negative outcomes and a lack of attention paid to the factors that can ameliorate them. (Bunting and McAuley , 2004; Geronimus, 1997)) Research Questions and Methodology A common response to research that challenges commonsensical notions of teen motherhood is to accuse the author of encouraging and promoting adolescent childbearing. While it is clear to me that such allegations attempt to be a form of 7 censorship in the bid to maintain hegemony, I state at the outset that this thesis is not intended to render an opinion about whether teen pregnancy and childbearing is right or wrong. Its purpose is to critically analyse the premises underpinning the indictment of teen motherhood and to thereby take issue with its material effects. This analysis will be guided by the following research questions: What are the dominant discourses, within the health promotion, that intersect to create definitions of teen mothers? What power relations, between health care providers and teen mothers, are constituted by these definitions? I will engage these questions through the process of discursive analysis of a collection of texts that speak about teen mothers from the perspective of public health professionals. By examining the various policies, programs and interventions directed at young mothers, this study will seek to discern what Foucault termed the 'authorized talk' about young moms and define the various themes present in the conversations that take place. 1) 2) What will this research contribute? By critically taking up the question of how teen mothers are represented within the health promotion literature I hope to contribute to a re-thinking about healthcare services for young mothers. While it is clear that 'discursive emancipation' does not replace the issues of redistribution of resources and power that are subjugation, to understand language used to perpetuate the status quo and examining how discourse produces identities can be a useful first step. In doing this I aim to provide some direction to policy makers and curriculum developers regarding creating supportive environments within health care for teen mothers. My second purpose is to contribute to the body of literature that takes issue with the term "at-risk" as a blanket descriptor for all youth who find themselves outside of what is considered to be socially adaptive behaviour and development. I want to interrupt the notion that youth have eccentric or individual traits that cause transgressive or "sick" 8 behaviour. Instead I w i l l examine the basis of a social order that actively marginalizes youth for deviating from hegemonic ideas about gender, sexuality, work and citizenship. Reflexivity in Research Discursive analytic methods are unavoidably reflexive, in no small part because of the strong social constructivist epistemology that forms its foundation. A feminist, critical, post-structural approach to research demands that I be self-reflexive about the role that my own social location, politics and life experience play into my data collection and conclusions. In this discursive analysis I w i l l be relying only on what has been written about teen mothers. I w i l l not be including their voices as part of my data and therein lies the danger of divorcing text from subject. It is even more essential, then, that I am fully transparent about my standpoint and my intentions. Whether doing empirical or textual research, particularly with populations who are marginalized, one must take into account ethical cautions and moral dilemmas. I must negotiate the reality that there are sometimes fundamental power differences between researcher and study participants, dictated by the differentials in education, race and socioeconomic status. A s Lincoln notes "the dark side of research, the fact that most of our research is written for ourselves and our own consumption, and it earns us the dignity, respect, prestige and economic power in our own worlds that those about whom we write frequently do not have." (2002, p.340) This thesis w i l l earn me a graduate degree that w i l l add to my status and power. The current era of academic research promotes ideals that take into consideration the impact that the researcher has on the subjects of research. There is an acknowledgement that extractions of information in ways that promote harm are no longer acceptable methods of investigation. Kvale likens the post-modern researcher as being closer to a traveller rather than a miner; an investigator who walks through territory and engages with it rather than extracting information and leaving, bell hooks, however, poses a challenge to the notion that the footprints left by travellers are innocuous. She 9 expresses these journeys as acts of terror, which have been made part of the memory of marginalized people. Rather than a simple focus on those who journey there should be thought given to those whose "bodies, territories, beliefs and values have been travelled through." (Smith, 1999 p. 78) While this research wi l l not directly deal with real bodies it w i l l still be an act of representation. It is important, therefore, that I am explicit about the values I bring to this project, my intentions and my location. The following section deals with my motivation for engaging in this research as well as my political standpoints. M o t i v a t i o n / L o c a t i o n M y decision to focus on the issue of pregnancy and parenting teen mothers and health care is personally and politically motivated. M y critical analysis is partially a reflection on and a critique of my own work with this population, informed as it was by the dominant discourses that I w i l l deconstruct. I take up this issue with a feminist political agenda, believing that subject identities conceived of for teen mothers are not politically innocent. Like many of the researchers engaged in work related to marginalized youth in the system, I do not have a great deal of personal experience. I come from the social location of a white, middle-class, educated woman who has had very few doors closed to me as I have negotiated my life. M y interest in the topic arose from my experiences working with pregnant and parenting teens, and, over the past ten years, as a social worker, community developer and as an educator. After getting my degree in Chi ld and Youth Care, I focused on female adolescents considered to be at high risk for suicide, pregnancy, drug addiction and street involvement. I worked in the Ministry for Children and Family Development, in child and youth mental health, and spent two years working at the Victoria Birth Control Cl inic as an educator and pregnancy counsellor. A s a community worker in Surrey, I was part of developing a literacy program for teen mothers and their children. In my formal and informal roles as a sexual health educator for teens I attempted to equip young people with the information regarding contraception and relationships that 10 would give them agency in their decision making. It wasn't until I worked with teen mothers in a poor neighbourhood in Surrey that I truly became aware of my middle-class, liberal bias regarding the role of education in making future choices. I discovered that young women weren't always choosing to have babies because of a failure of birth control or a wrong-headed idea about creating love in their lives. I began to recognize that early pregnancy and parenthood was complicated by a myriad of issues and life situations that had nothing to do with who forgot the condom. Upon reflection, I began to see the ways that my role as an educator was informed by a well-intentioned but judgemental attitude toward pregnant and parenting teens and how this impacted upon my ability to be effective. Despite a professed feminist analysis, I had not let women's voices and experiences truly disturb my preconceptions of what they needed. In August of 2006,1 worked on a research project with Partnering in Community Health Research that investigated the health literacy of marginalized youth in North Vancouver. Through a variety of focus groups with youth and interviews with youth workers and health care professionals, I heard the extent to which youth outside of the mainstream feel alienated by the health care system. These young people had experienced such judgement and condemnation from doctors and some nurses that they were reluctant to seek medical care for even very severe medical issues. I heard stories about very young teenaged girls being refused the 'Morning After P i l l ' until they came up with the $50 to pay for it, the implication being that they should pay for the 'mess' they had gotten themselves into. This experience led me to understand the urgency of the issue of the access of youth to quality health care. Despite many lofty policy statements and bn-going lip service paid to making clinics and Doctor's offices "youth friendly", there remains a disjuncture between these assertions of inclusivity and what actually transpires in the day-to-day experience of youth in the health system. In a world where the young and the poor are given fewer resources to keep themselves physically and mentally healthy, these barriers to accessing services are serious. This thesis begins from this starting place: that there is a serious injustice being perpetrated when those most economically and socially powerful can subjugate those 11 least powerful by restricting their access to health care. The spin offs of negative conceptions of marginalized youth, such as teen mothers, within the health care system perpetuate structures of domination that repress those who do not fit into categories of 'white', 'middle class' and 'male'. M y approach to the process of research, therefore, is informed by and grounded in my political commitment to contribute to changing structures that marginalize and dominate young women and my interest in health promotion strategies that are supportive and liberatory rather than stigmatizing. I stand in opposition to the increasing encroachment of the neo-liberal ideological practices within the health care system, which manifest in the ideals of competitiveness and productivity above human rights and fair wages. Thesis Structure The thesis is divided into seven chapters. In this chapter, I introduced my research by discussing my purpose, outlining my research questions and methodology and providing a look at the terrain of teen motherhood, past and present. In Chapter Two I wi l l describe my methodology and outline my process of textual analysis. In Chapter Three I w i l l define three critical theories relevant to discerning the operating discursive formations. In Chapter Four, I w i l l review the key ideas, debates, and critiques in the theorizing of teen motherhood present in the intersecting discourses of health, the economy and psychology. In Chapter Five, I w i l l look at how teen motherhood is perceived in federal and provincial health policy and examine the impact of the political landscape on this formation. Chapter Six wi l l be an analysis of the texts and, in Chapter Seven I w i l l summarize my findings and recommendations. 12 CHAPTER TWO: AN APPROACH TO DISCOURSE ANALYSIS Introduction This research study uses a process Of discursive analysis to explore the ways in which teen mothers are constructed in the health care system. Specifically, it looks at the way in which Canadian public health care workers and researchers 'talk' about teen mothers through newsletters and targeted journal articles. In this chapter I w i l l locate my theoretical approach to discourse analysis and provide a rational for the texts I w i l l be examining. Why Discourse Analysis? M y interest in analysing discourse came about in 2001, the year that the Liberals came into power in British Columbia. While it may not have represented a major transition of political ideology it was a pivotal moment for the shift of language about the marginalized and poor. The B C Liberals and their supporters used a proliferation of talk about accountability, personal responsibility and fiscal management to alter thinking about the role of government and the role of the public. This discourse created subject positions for poor people as undeserving, irresponsible, and burdens which, in turn, had an impact on how the public was encouraged to conceive of social programs. This neo-liberal discourse in British Columbia produced, in the words of Foucault, "authorized talk" about the poor and the marginalized. To speak of the welfare state, equality and social support systems, in current times, is to risk sounding outdated, idealistic and naive. This neo-liberal discursive shift, of course, is not simply a theoretical conception but also a legitimization for a differential mobilization and distribution of material resources. A s a report from the Canadian Centre for Policy Alternatives notes, recent years have seen the growth of extreme disparities between rich and poor within Canada ( C C P A . 2007) In planning for this thesis, I gave serious consideration to interviewing teen mothers. From a feminist perspective, one of the primary cautions in doing a discourse 13 analysis of text in documents is losing sight of the multiplicity of experience that individuals have living in the real world. A s Dorothy Smith (1990) theorizes, text can serve to abstract women, obscuring their everyday/everynight experiences as profound ways of knowing. Because discourse analysis potentially conceptualizes subjects as theoretical representations, Smith (1999) cautions researchers to be cognizant of the bodies that inhabit the constructs, using as a starting point what is real and actual. Smith (1990) also makes an important contribution in demonstrating how texts play a critical organizing and mediating role between people and the ruling relations. It is the text, which is read and used by people in their local contexts, that organizes and coordinates their encounter with the state. She argues that dominant discourse enters the local contexts of people's lives through various texts and it is through the analysis of text that one can find a point of entry into understanding the workings of the institutional processes. In their uniformity across diverse situations, texts can reveal the 'relations of ruling' of dominant institutional structures such as hospitals and schools. C o n c e p t u a l i z a t i o n o f D iscourse The concept of discourse cannot be universally defined nor located in a single theory. It is referred to in multiple disciplines, which include linguistics, sociology, anthropology and the humanities, each with its own epistemology and ontology. I have chosen a definition that has evolved from feminist and post-structuralist theoretical perspectives which pays particular attention to how discourse defines and positions human subjects and to the way in which both are constituted and impacted by access to cultural, economic, symbolic and material resources. Discourse analysis from a post-structuralist perspective, in contrast to non-critical conversational or textual analysis, is based on the assumption that language is neither transparent or simply functions to reflect the world back to itself (Carabine, 2001; St.Pierre, 2000; Luke, 1995-1996, Phillips and Hardy, 2002) "Language does not simply point to pre-existing things and ideas, but rather helps to construct them and, by extension, the world as we know it. In other words we word the world." (St. Pierre, 2000 p. 483) According to Derrida, words, as signifiers, are relational rather than entities 14 containing intrinsic meaning. The word "water" gains significance, not in itself, but in opposition to that which is not water. Women and girls are defined by an absence of characteristics that are attributed to men and boys. The term "ethnic" is all that is not white. In this way, language becomes a collection of binaries, that which is and that which is not, presence and absence, subject and object. Drawing on the work of post-structuralists such as Foucault, St. Pierre argues that, to ease the difficulty in producing enough words to reflect the many variations and permutations presenting the world, language functions to gather together entities with seemingly common attributes. (St. Pierre, 2000) Categories such as woman and man, able and disabled, schooled and illiterate are created that both encompass and subsume difference. These categories, over time, lose their distinction as umbrellas and gain status as unified subjects with stable and essential qualities. Through operations of hegemony, the unified subject comes to represents all of the attributes of the dominant culture in terms of race, class, gender, ability and socio-economic status. On the one hand, this categorization creates false universalism and, on the other, it establishes groupings for people based on deficit. Anyone falling outside of the unified subject becomes the colonized other. (Luke, 1995-1996) It becomes apparent that, while language is revealing of and demonstrative of discourse, it does not encompass all of its complexity. Discourse analysis, is then, not simply the study of language, but is a study of patterns of language in use. (Taylor, 2001) In the words of Foucault, discourse is the way that language "gathers itself together" to produce and represent a socially and institutionally specific structure of statements, terms, categories and beliefs. (Hardy and Phillips, 2002) Said another way, discourse is a group of related statements that cohere to build up a picture or representation of a topic in a way that produces meanings and effects in the real world. (Carabine, 2001) Discourse manifests itself in texts, which can take the form of written documents, spoken words, pictures, symbols, and artefacts. (Philips and Hardy, 2002; Luke, 1995-1996) When looked at individually, texts are not meaningful in the creation of discourse. One cannot determine the intent of an individual or policy document by examining it in isolation. Where it becomes significant is through its interconnection with other texts, 15 repeated and reiterated words, statements and themes that appear in a number of texts. Kristeva (1996 as cited in Van Dijk, 1998) calls this dialogical relationship between texts "intertexuality". I agree with Carabine who suggests that a critical discursive study begins with the notion that discourse cannot be separated from the systems of knowledge and power that it produces and is produced by. Whereas the dominant discourses in contemporary society represent power relations and social formations as natural, Foucault suggests that all knowledge and truth is socially situated and constructed by those in positions of authority. (Luke, 1995-1996) Power, knowledge and discourse are continually implicated in one another (Carabine, 2001; Van Dijk, 1998) Foucault's methodology of "genealogy" demonstrates the ways in which the discourse/knowledge/power triad has historically operated and to what effects. Beyond a history of ideas, which would trace the development and evolution of discursive content and practice, his methodology examines the discontinuities in discourse and practice that emerges in succession, over time. (Fraser, 1989) Genealogy looks at historical documents to understand how phenomena become objects of knowledge about which truth can be spoken. It examines the ways in which each discursive system is supported by its own matrix of institutional, economic, social and legal policy. Foucault's History of Sexuality, for instance, looks at the way that sexuality has been produced in completely different ways at various moments in history. Each manifestation is accompanied by "regimes of truth", embedded knowledge and practices of power that prop up the current discursive formation of sexuality. While all discourses make truth claims, all discourses are not equally authoritative nor effective in their ability to embed themselves in our consciousness as representative of reality. The most powerful discourses are ones that hook into existing ideas about what constitutes common sense. Discourses about teenaged motherhood, for example, interact and are mediated by other dominant discourses about family, femininity, morality, gender, race, ethnicity, sexuality and class. (Carabine, 2001) These dominant discourses use their authority to give unquestioning passage to new discourses in ways that do not jar our assumptions about the world. 16 W h i l e l i v i n g under and w i t h i n its regime, discourse can seem unchanging and ahistorical . D i s c o u r s e is , however , by its nature, unstable. D i s c u r s i v e formations about adolescent motherhood have changed according to their locat ion against the background o f beliefs about acceptable reproduct ion, e c o n o m i c and p o l i t i c a l ideologies and v i e w s about what is m o r a l . It is an interesting project to note the different ways that the p r o b l e m o f u n w e d mothers and then 'teenage mothers ' has been produced as w e have m o v e d through different p o l i t i c a l and social eras. W h i l e I w i l l pay some attention to the evo lut ion o f the constructions o f teen motherhood, I w i l l not endeavour to engage i n a f u l l F o u c a u l t i a n his tor ica l examinat ion o f soc ia l p o l i c y documents. Instead I w i l l u t i l i ze Carabine ' s n o t i o n o f a genealogical 'snap shot' that w i l l l o o k at the specif ic issue o f teenaged motherhood as constituted through health p r o m o t i o n and socia l p o l i c y , and the material effects o f this constitution. W h i l e this approach w i l l not y i e l d an in-depth examinat ion o f h o w the p h e n o m e n o n has been produced over t ime, it w i l l provide a r i c h picture o f the impact o f health promot ions o n the current construct ion o f teen motherhood. Textual Analysis P h i l l i p s and H a r d y (2002) identify four different approaches to discourse analysis that vary i n the degree to w h i c h they focus o n l inguist ics , soc ia l context and power. W h i l e the approaches are not m u t u a l l y exc lus ive , the issues that each one takes up provide a specif ic lens for discursive research. Rather than choose a single approach to discourse analysis , I have chosen to c o m b i n e two o f the methodologies: cr i t i ca l l inguist ics and cr i t i ca l discourse analysis. A cr i t i ca l l inguist ic approach is conducive to an analysis o f documents because it a l l o w s a closer l o o k at h o w rhetorical devices and strategies w o r k to construct the identities o f teen mothers w i t h i n the discourse o f health p r o m o t i o n . W h i l e this discursive analysis w i l l stop short o f a detai led analysis o f l inguist ics , I w i l l be e x a m i n i n g the w a y that textual devices, metaphor and patterns o f language occur w i t h i n texts. A s H e p w o r t h 17 (1999) queries: what are the "regularly occurring systems of language" about teen pregnancy and parenting? A critical linguistic approach reveals the way that key words and phrases used repetitively throughout text creates what Nancy Fraser refers to as 'doxa' , or taken for granted understandings about teen mothers. It points to the way that silences and exclusions in the texts, what is left out in the discourse about teen moms, also works to construct our common sensical notions. To avoid a myopic analysis of the documents I am going to examine, I w i l l analyse linguistics in reference to critical discourse analysis ( C D A ) . Van Dijk (1998) defines C D A as examining "the role of discourse in the (re)production and challenge of dominance... defined as the exercise of social power by elites, institutions or groups, that results in social inequality, including political, cultural, class, ethnic, racial and gender inequality." (p. 250) He states, as does Fairclough (2001) and other theorists, that critical discourse analysis is primarily concerned with the discursive dimension of power abuse and the injustice and inequality that results from it. For my research I w i l l examine the ways in which authorized discourse about teenaged childbearing creates advantaged and disadvantaged groups and its role in serving a social, political and economic agenda. M y discursive analysis w i l l pay attention to which texts and practices are deemed official in creating the dominant discursive formations, where they come from and how they are supported by other discourses to gain authoritative status. I w i l l also look for the silences that occur within the discourse and, whose voices are absent or constructed as "unofficial". I w i l l question the points at which discourse is masking power dynamics based on race, class, gender and sexuality. Specific Texts Firstly, I w i l l be analysing articles in the magazines directed at public health practitioners in Canada, specifically the Canadian Nurses Association, Nursing BC and Canadian Nurse. I have chosen to focus on nurses, rather than other health care providers, because they have, by far, the most 'face to face' interaction with teen 18 mothers. They are also largely responsible for the implementation of public health promotion campaigns regarding sexuality, substance use and pre-natal care- issues associated with teen mothers. The articles are largely written for nurses by other nurses in the field, describing various programs and interventions that have been implemented with teenage mothers. These documents are relevant because of the way that they elucidate the conversations and priorities within public health about the population. Secondly, I w i l l be analysing a collection of newsletters put out by the B C Alliance Concerned with Early Pregnancy and Parenthood from 1990-2003 when it ceased to exist due to issues of funding. The Alliance was initiated and supported by the Y W C A and was intended to be a body that provided advocacy, support and resources for teen mothers and those who worked with them. The editorial board was made up of people representing various perspectives including frontline workers, academia, people involved in program and community organizers. Each issue of this newsletter includes a message from the board that reviews the primary issues faced by teen pregnancy/parenting support agencies and includes perspectives from teen mothers themselves. Also incorporated in the newsletter are a variety of articles, reports, announcements, reviews and personal story telling. It is a forum for practitioners and support workers to talk to each other and, embedded in these conversations, are the dominant discourses about the population with whom they work. C o n c l u s i o n In this chapter I described a version of discursive analysis and the methodological approach I w i l l take to this textual analysis. Discourse analysis is a way for researchers to make explicit the assumptions and ideas present within the dominant forms of talk about individuals and groups of people. Critical forms of discourse contextualize authorized talk within power relations, demonstrating the ways in which hegemonic notions are held in place by the discursive strategies of institutions. Dominant discourse can have powerful material effects, not only in its ability to stigmatize and marginalize people but also in its influence over the distribution of society's resources and authority. I have identified the texts I w i l l be investigating and discussed my rational for selecting the texts 19 that I did. In Chapter Three, I w i l l investigate three approaches that can be used to situate the power relationships that exist between teen mothers and the institution of health. 20 CHAPTER THREE: HOW SHALL I JUDGE THEE? Pathways into the problem of teen motherhood Few would dispute the notion that teen mothers are stigmatized within Western society. They are educated in portables lodged in the back of schools where they are out of the sight of the general population; they experience judgement and condemnation at health care facilities; they are held up in the media as examples of young women who made poor life choices; and, by the very fact that they have become pregnant in their teens, they are assigned social workers. The argument for why teen mothers are stigmatized is not, however, structured in a unitary fashion. It is refracted very differently depending on the political and ideological stream in which it is lodged. While there are multiple sub-themes, the major perspectives on the problem of teen motherhood are framed by neo-conservative, neo-liberal and social welfare perspectives; all three of which I w i l l briefly define. A neo-conservative perspective is overtly and intentionally stigmatizing adolescent childbearing as a purposeful bad act. The marginalization is thought to act as a discouragement to choosing a life that appears to reject the principles of what is traditionally right and good. Teenage pregnancy and parenting is equated with a decline in 'family values' and sexual morality (defined as sex within the context of marriage, often for the explicit function of procreation), as well as a challenge to traditional notions of citizenship, work, family and education. This view can be equated with the Christian Right, embodied by governments such as the U S Bush-led Republicans. A neo-liberal perspective characterizes teen mothers as problematic, not because of issues of morality, but because of their lack of economic independence. The welfare state is considered to be complicit in this problem in its support for choices that result in dependence on the state. Teen mothers are stigmatized as an outcome of political discourse that frames women on welfare as burdens on taxpayers. A s this perspective has great salience within our current political climate, I w i l l explore these perspectives in greater detail in this chapter. 21 A social welfare perspective can purport to be against stigmatization, but may end up producing it through disempowerment and pathologization. Embodied by social workers, psychologists, teachers and centrist politicians, this discourse conceptualizes teen mothers as victims of their circumstances who require specialized assistance. The social welfare perspective formulates the solution to the problem of teen pregnancy as meeting unmet needs or deficits within young women. In the following section of this chapter, I propose three models that can serve to elucidate how these perspectives enact themselves through different ways of formulating the 'problem' and the solution to teenage pregnancy and parenthood. First, I w i l l explore the notion of 'moral panic' as being demonstrative of a neo-conservative stance. Second, I w i l l look at 'needs interpretation' as a way in which the social welfare perspective interacts with teen mothers. Third, I w i l l discuss 'healthism' as a primary vehicle of neo-liberal health promotion strategies. M o r a l Panic People have been afraid of teenagers for a long time. The way they moon around in perpetual lovesickness, the way they threaten to erase themselves from the picture- die from drugs, permanently defy curfew, wrap their cars around telephone poles. Society fears teenagers because of the chaotic element they represent: the point after the law of the father has worn off but before the law of the land has been internalized. It is the period when everything is being questioned and everything is up for grabs- a moment of limbo during which anything could happen. (White, 2002, p. 15) A classical understanding of moral panic describes the way in which the dominant social order, through the use of emotive and rhetorical language, creates a sense of emergency about the deviance of a specific group of people. (Cohen and Young, 1973) While not singularly, moral panics often revolve around movements or actions initiated by youth. While moral panic is related to the dominant discourses about all young people, 22 not every body of authorized talk rises to the emotional level of moral panic. Moral panic can be recognized by its portrayal of a group of youth or the behaviour of a group of youth as dangerous, harmful and/or out of control, producing subjects that are the focus of fear. There is a subsequent call for 'something to be done about this'. Following the lead of this 'public outcry', the government convenes to work out legislative strategies to address this problem. A key aspect of moral panic is the idea that a particular misbehaviour of young people is fundamentally connected to the breakdown of social norms and values. For the creation of successful moral panic, conditions must include a clear separation between 'us' and 'them'; one which amplifies the nefarious nature of the other. In this separation, 'us' represents all that is normal and good. 'They', meanwhile, represent danger and all that stands in opposition to the social norms established by, and in the best interest of, 'us'. Whoever the majority designates as the 'other' is portrayed as being distinct and separate from those who are positioned to make such distinctions. Importantly, the separation relies on dominant discourses of class, gender, race, drug use and religious morality (as discussed by Cohen and Young, 1973, Hal l , 1979; Pearson, 1983). In addition, the distinction between 'us' and 'them' is taken for granted as something that is self-evident. In order for a moral panic to be successful, the idea must seem self-evident that 'we' are at risk of losing something valuable to 'us': social values, material assets, a way of life or a predictable future. "The power of moral panics comes from their ability to create imaginary positions that redefine and rearticulate popular common sense." (Roman, 1996) This belief / notion in turn maintains a constituted belief that the current system is serving the general population well , no matter how much evidence exists to the contrary. This belief is itself necessary in order to maintain existing power relations and social norms. The implicit message is always that, i f the issue, which is the subject of the moral panic, is not dealt with firmly and decisively, c iv i l society w i l l surely disintegrate into anarchy. Critical sociologists argue that the orchestration of moral panic is a way by which those in power maintain their own hegemony. To mask perpetual social inequities, the 23 dominant society utilizes tools such as moral panic to create public consent. B y creating a sense that the average, law-abiding citizen is at risk from deviant behaviour, permission is granted for laws that suppress alternative voices that challenge the economic, gender and racial injustices. Moral panic also legitimizes the alienation of young people, poor people and people of colour from communities, justifying cuts to social supports. Critics also point out that a fundamental tenet of moral panic, nostalgia for days gone by, does not hold up when examined from a historical perspective. Ideals of a 'golden age' are constituted by declarations that young people are undisciplined, unruly, and immoral with too much free time compared to their counterparts of the previous generation. In contradiction, the work of moral panic theorists such as Pearson (1993) and Hal l , (1979) shows a series of moral panics about the rise of leisure time and the contribution of Hollywood cinema to the disintegration of the British way of life. The 1940s were morally panicked by the Bl i tz kids and 'cosh boys', the 1960's by the criminality of African Americans. Roman (1996) gives a contemporary and Canadian example of moral panic in the construction of the phenomenon of "youth-at-risk" for pregnancy, suicide, gang involvement and delinquency. She focuses, in particular, on the National Stay-in-School Initiative as a focal point for situating youth who drop out of school as problematic within the global economy. Roman quotes Barbara McDougal l , Minister of Employment and Immigration in 1990 as she defines the crisis of youth who drop out of school, defining them as "illiterate," "ill-educated," "largely untrainable," and "mostly unemployable" (1996, p. 16). Youth are represented as a spectacle that are not only educationally deficient, but are placing the nation at risk by their disregard for the national economy. McDougal l invokes the "we" construct of the 'caring nation' which w i l l strategize to save youth and the country from the moral depravity of dropping out of school. The naming and deconstruction of moral panic has been helpful in understanding the ideological role of the media and its influence in constructing subject positions. Conceptual models of moral panic have been demonstrative of the way in which labelling 'deviant behaviour' is interactive rather than absolutist, arising from a complexity of representations and positioning. However, McRobbie and Thornton (1995) suggest that 24 the concept of moral panic has evolved as a greater number of voices, including pressure groups, lobby groups, self-help and interest groups, have access to technology to create media space for themselves. The once steadfast division between media professionals and 'media punters' has begun to be eroded. On the one hand current social and technological realities provide a challenge to a discourse analysis because of the sheer range of sources that potentially contribute to creating a representation of teen mothers. Counter discourses that once had very little voice in public debate can find ways to be credible and contest the line between deviant and normal. On the other hand, the level of cohesion in the dominant discourses attests to the fact that access to power and resources continues to play a central role. Teen pregnancy as a Moral Panic It is useful to look at ways in which dominant discourses have constituted teen childbearing as a moral panic and the effects of this construction. Both conservative and well as a few who have deemed themselves liberal policy makers have overtly used teen pregnancy as a measure of the strength of the moral fabric of their nations. A survey cited by a national website entitled "The National Campaign to Prevent Teenage Pregnancy" reported that 87% thought that there was something fundamentally wrong with America's moral condition and 79% named the "spread of teenage pregnancy" as the primary social i l l . The United States, British, and Scottish governments have declared a "war" on teenage pregnancy (Males, 1996; Horton, 2G02), calling it a shameful condition of a civilized society. (Social Exclusion Unit, 1999) Canadian politicians and media utilize language that is not as overtly aggressive but no less impactful. Deirdre Ke l ly speaks of the ways in which the term "teen mother" has become a condensation symbol; "the image draws its intensity from the associations it represses" (Edelman,T988 as cited in Kel ly , 1999, p. 52). Teen motherhood, as a condensation symbol, represents rebellion against adult authority, an apathetic attitude towards work, an inflated sense of entitlement to public resources, the breakdown of the family and adolescent sexuality out of control. (Kelly, 1999) 25 To strengthen the urgency of the moral panic, teen parents are conveyed as contributing to the disintegration of society, not only because of their morally objectionable sexual activity, but because of the stress they place on the social system. They are considered to be a drain on health, education and welfare programs due to adverse pregnancy and birth outcomes, higher rates of poverty and abbreviated education, lower rates of employment, higher rates of welfare, and poor developmental, educational and social outcomes for their children. (Wilson and Huntington, 2005; Kel ly , 2000; Cherrington and Breheny, 2005; Hoffman et al, 1993; Hanna, 2001) The moral panic created over teenage pregnancy has legitimized the view that it is the result of individual failings of poor young women, contextualized by the corrupt and loose social norms of the group, broken families and an overly progressive school system. Blame is placed on social mores that support this 'deviant behaviour', such as sexual education, which encourages its reproduction. The solution to this 'problem' is to condemn teen pregnancy and find ways of encouraging these adolescents to rejoin the mainstream. (Philip, Shucksmith, Tucker, yan Teijlingen, Immamura, and Penfold, 2006) While moral panic is a common framework from which to stigmatize adolescent mothers it is inadequate, in itself, to describe the way that they are conceptualized within the social service system. Within this discipline, there is another layer of complexity as 'experts' and 'workers' attempt to determine practical solutions to the problems presented by teenage mothers. Needs I n t e r p r e t a t i o n A second point of entry to the problem of teenage parenting has emerged as a challenge to the social welfare system's construction and de-politicization of the needs of the marginalized. Through her analysis of'needs interpretation' Nancy Fraser (1988) problematises the welfare system as a site that delivers survival benefits to the poor at the cost of reproducing structural inequities. The process, informed by 'expert' discourses and re-privitization discourses, identifies, defines and interprets needs of those served by the system without regard for their voices and experiences. Needs interpretation, while highly political, is portrayed as a natural response to a perceived deficit. 26 Fraser challenges the notion that needs are self-evident, shifting the discussion from asking "what are the needs?" to inquiring into the discourse about needs and the politics surrounding them. She identifies four components of thought that serve to depoliticize needs interpretation: 1) The notion that the interpretation of needs is simply a given and unproblematic, 2) The lack of critique regarding who is interpreting the needs in question, 3) A failure to evaluate the means that various groups have to create their own needs discourse and finally, 4) A failure to account for the processes by which needs interpretation is authorized, (p. 164) Two of the primary discourses associated with a needs assessment are the discourse of the expert and the discourses of re-privitization. The third discourse identified by Fraser, opposing discourses, w i l l be examined in chapter five. The discourse of the expert is primarily associated with social service professionals, law and medicine as well as academia and research in the field of social science. The vocabulary of the expert discourses evokes notions of people as cases rather than members of social groups. It depoliticizes needs interpretation by abstracting people from the context of race, class and gender to individuals without location. (Fraser, 1989) Teen mothers are individualized and pathologized within expert needs talk. According to this discourse, adolescent pregnancy has come about due to disruptive and insufficient homes, the trauma of sexual abuse and a profound lack of love in their lives. (Kelly, 2000) It is up to the experts to help the teen mother to rectify her mistake, not through punishment, but through a myriad of support services that can provide therapy, education and direction. Experts associated with social policy issue a call to society to address the problem of teen pregnancy in order to break the cycle of intergenerational poverty and abuse that is going on. Teen pregnancy is not condemned as a contravention of a moral code within expert discourse, but these adolescents are constructed as having 27 inadequacies that warrant actions to keep them 'safe' from their families and their partners. (Kelly, 2000). Re-privatization discourses attempt to remove needs out of the political arena by insisting that they are rightly situated in the realm of the family, the personal and the economy. Embodied primarily by the political right, this discourse comes the closest to matching the ideas of moral panic in its reference back to the heterosexual family unit and conservative notions of education and human rights. (Fraser, 1989) Re-privatization discourse is dismissive of the oppositional discourses, but primarily seeks to contest the talk of the expert. They oppose all of the support services conceived of by the welfare state including social assistance, education, abortion and sexual health education, believing that all of these interventions undermine the traditional structure of the family and c iv i l society. Teen pregnancy is caused by over indulgence of young people by the system. The need is for child rearing to be taken out of the public sphere and placed within the private sphere of the family. Gender roles need to be reconstituted to align with traditional attributes of masculinity and femininity. The power to interpret needs is unevenly distributed. Those who have power and resources in society are those who have no immediate need for the system to change. Consequently, there is no rational need for the social welfare system to be interrupted by those who are constricted and oppressed by the system that they are tied into and dependent on. Discourses that challenge or go against the official versions of needs interpretation are presented as subversive or unimportant. Healthism A third point of entry into the critical analysis of the discourse about teen motherhood draws from the tenets of both moral panic and needs interpretation as well as highlighting neo-liberal conceptualizations of risk and individualism. "Healthism", as deemed by critics of traditional health promotion, is a widely accepted idea that individuals are largely responsible for their own health and making healthy choices. Individuals make "rational" choices to achieve desired standards of health. If one's health 28 "decision" does not fall within the realm of what is considered to be "healthy", the cultures imbues the individual with moral obligation and blame. (Rich & Evans, 2005) The body is centralized in the discourse of healthism. Powerful dictates in the school system and in the media reinforce 'correct' pathways to follow, regarding physical activity, diet and other bodily practices that w i l l result in the attainment of health. Health is then measured and evaluated through standards of shape, size and weight according to age. (Wright and Burrows, 2004, p. 215). If one is judged to be transgressing the 'rules' by choosing not to conform to the standards of what is healthy (eating too much fat, not exercising enough, smoking, not getting enough sleep, etc) she/he is seen as irresponsible. One is blithely putting her/his own body at risk and risking the health of others by taking valuable resources from the health care system. The notions of responsibility and. risk that characterize healthism are consistent with Beck's theory of the 'risk society'. According to Beck, individualization within reflexive modernism is "the requirement.. .that individuals must produce their own biographies, in the absence of fixed, obligatory and traditional norms and certainties and the emergence of new ways of life that are continually subject to change." (Beck, 1994 as cited in Lupton, 1999, p. 69) In other words, identities that were previously considered to be shaped by one's position at birth, family, culture and society are now determined by one's own decisions and choices. Because of the conception of an individual's agency, one's lifespan is thought of as having a great deal of flexibility. Couched within the discourse of decision making and self-determination is the assumption that everyone possess an equal opportunity to shape their biography and has a common responsibility to avoid the kind of risk that w i l l cost the economy. Because individuals have been 'liberated' from their context and provided with knowledge and some resources, any failure to succeed can be attributed to a lack of motivation to make good choices. Healthism is not simply about health education or information, but about the ways in which the person is decontextualized from social, economic and political contexts in the uniformity of the health message (Rich & Evans, 2005). There is little attention paid to the complexities that lie behind notions of "healthy food", "exercise" and the consumption of alcohol, tobacco and drugs. Health curriculum does not draw on ideas 29 that are meaningful to cultural groups other that the white middle class, nor does it take up broader notions of health which would prioritize other aspects of health such as connectedness to the community and respect for elders. There is an exclusive preoccupation with personal health issues. (Wright and Burrows, 2004, p. 226) While very few escape the surveillance of healthism, teen mothers are the subjected to a particularly intense focus. This is demonstrated in the proliferation of health programs specifically directed at them. Because they are conceived of as being at 'high risk' for pre and post-natal health problems, a young mother's health curriculum includes a variety of topics that presumably wi l l help to mitigate these risks. Young mothers groups often focus on strategies for adjusting one's lifestyle so that it becomes aligned with what is conceived of being healthy including smoking cessation, diet and nutrition, breast-feeding and exercise. Virtually no attention is paid to the contextual reason for 'unhealthy lifestyle choices'; there is a simple and uniform message to change. C o n c l u s i o n In this chapter, I looked at the basis of stigmatization of teen mothers as viewed from three different but associated discourses: A conservative stance that looks at teen motherhood through the lens of moral panic, an institutional social service discourse that assesses needs through a presumed knowledge of what marginalized people require and a discourse of healthism that draws on 'science' to assess the components of a health lifestyle, situating adherence or non-compliance within a moral framework. The commonality of these discursive strains is the way that they provide the groundwork for totalizing narratives about adolescent mothers. They serve to decontextualize teenage mothers from intersections of race, class and gender conceiving solutions to the problem in the absence of the experiences of young mothers themselves. In chapter four, I turn to a review of the literature as it relates to teenage mothers. 30 C H A P T E R FOUR: FRAMING T H E R E S E A R C H W h o says teen m o t h e r s are a p r o b l e m ? While attempting to find a category that represents 'teen mother' can be frustrating for those engaged in policy making, for researchers engaged in critical analysis these slippery representations are demonstrative of the constructive nature of discourse. Conceptions of motherhood are re-situated for young parents, wrapped up as they are in multiple intersections of power and power relationships. Given that there are powerful and numerous negative understandings and stereotypes about teen mothers in Western society, there is little space for articulations of the realities of these young women themselves. Health discourse powerfully shapes the identities of teen mothers. This discourse intersects, however, with other institutional discourses that contribute notions of how the 'problem' of teen motherhood is understood and how solutions are best formulated. The health care system, for example, concerns itself not only with bio-medical issues, but also with determinants of health, particularly those related to 'lifestyle choices' and their impacts. In these moments, discussions about teen motherhood merge with other discourses about poverty, gender, class, sexuality, adolescence, and race. Health discourse comes together with a therapeutic discourse in defining how the 'problem' of teen motherhood is understood, and then formulates potential interventions to prevent it in the future. It is contextualized by economic discourses that ascribe blame and responsibility and then assesses needs. There has been a vast amount of research produced in the industrialized world, over the past thirty years that has formed the building blocks for the current conception of teen motherhood. In this chapter I w i l l review and examine key ideas, debates and critiques that exist within the literature, particularly how they exist in relationship to the discourses of the health care system. The final section of this literature review looks specifically at qualitative research that has intentionally sought out the stories of young mothers themselves in a way that grounds data in experience. 31 T h e H e a l t h C a r e debate While teenaged mothers pass through multiple discursive spaces, it could be argued that it is health and health promotion 'talk' that most powerfully constitutes their identities. A n extensive literature review reveals that research conducted on teen pregnancy is either located directly within health related journals or draws its conclusions based on health research. This gives authority and societal acceptability to the health care system's positioning of teen pregnancy among major social problems such as sexually transmitted diseases, substance abuses and suicide. (Cherrington and Breheny, 2005, Lawlor and Shaw, 2002; Huntington and Wilson, 2005). 1 Health is science and science renders the truth Now, I maintain that there is as much reason in the works of Montaigne or Verlaine as there is in physics or biochemistry, and reciprocally, that often there is as much unreason scattered through the sciences as there is in certain dreams. Reason is statistically distributed everywhere; no one can claim exclusive rights to it. (Serres, 1995, 1990 as quoted in St. Pierre, 2000, p. 486) While health discourse does not go uncontested, its formations carry particular weight within our culture. The roots of this authority can be traced back to the Enlightenment. Comte, considered to be the father of positivism and sociology, believed ' It has not always been the case that a pregnant woman was seen to be worthy of health care intervention, and therefore the subject of institutional health discourse. For most of recorded history and in most cultures the management of reproduction has been the concern of women, not medical science. It is only since the 17* century in the industrialized world, that the "science of child birth" has come under the regulation and control of men. (Oakley, 1984) Concurrent with the location of obstetrics as a male domain was the rise and dominance of the discourse of pregnancy as illness, Medical writings exemplify the low regard that the medical profession has for women through their general characterization as slaves to their biology. Freud based his theories of the inferiority of women on the presence of the womb. "(T) hrough its ideological construction of the uterus as the controlling organ of womanhood, it effectively demoted reproduction as woman's unique achievement to the status of pitiful handicap." (Oakley, 1984, p. 171). This subjugation then justified the need for the control. 32 that true knowledge of the world could be based only on observation. He proposed that observation could provide unmediated access to the world and, through it, reality and truth could be discovered. The work of scientists was to further investigate, examine and contribute to these laws by the testing of hypotheses. Comte conceptualized positivism as being a totalizing narrative, applicable to both the social and natural world. Reason became the basis of the scientific method and any kind of rationality not formed by science was considered irrational and therefore suspect. (St. Pierre, 2000) Through to this day, science and ideas yielded from scientific methodology are considered to exemplify rationality and reason and often gain unquestioned authority. This authority can serve to obscure underlying political and ideological interests. I was reminded of this recently while listening to the C B C radio program "The Current" where they were discussing Canada's decision to veto a proposal at a Geneva Convention that would ban the international sale of asbestos. (November 6 t h , 2006) Despite full knowledge of its health hazards (two M P s are currently suffering from asbestos related illnesses), Canada had refused to support placing them on the dangerous substance list, ostensibly because of a major Quebec corporation's role in its manufacture. Time and again the interviewer attempted to ask of Gary Lunn, the Minister of Natural Resources, why the Canadian government refused to support health and environment activists in halting the export of asbestos. Repeatedly, the Minister used the phrases "scientific evidence" and "medical evidence" to back up his claims that the substance posed no major health risk. When the interviewer pointed out that the evidence he was citing came out of Quebec's Chrysotile Asbestos industry studies and was likely biased, Lunn responded that, "we w i l l continue to work with the scientific community to ensure that asbestos is safe." Lunn was basing his argument on an epistemological view that scientists come to research without bias or inclination and without motivation to find evidence that supports their own conjectures and that "truth" can be discovered through the formation and testing of hypothesis. While educators, sociologists and environmentalists using qualitative research to yield data are regularly accused of manipulating information to suit their own purposes, scientists stand fortified by their location within positivism. 33 Teen mothers are a problem for the health care system Teen pregnancy creates a myriad of health complications for the girl and her baby. Individual Canadians, and society at large, pay a significant price for teenage sexual and reproductive problems. (Dillon, 2001, p. 20) The current body of research looking at pregnancy and childbirth during the period of adolescence describes the elevated levels of jeopardy considered to be present both pre and post-natally. During maternity, for example, teen mothers make an average of six visits to a health care professional in contrast with older mothers who make an average of twelve visits. Teen mothers are more likely to spend longer in the hospital post-partum and have babies with low birth weight and other complications. The children of teen mothers become i l l with greater frequency than older mothers and suffer from episodic and chronic diseases. (Scholl, Hediger & Belsky, 1994; Berenson, Wiemann & McCombs, 1997; Maskey, 1991; Fraser, Brockert & Ward, 1995). The literature is not in agreement as to the aetiology of these health risks. In her meta-analysis of literature examining the health issues of teenage pregnancy, Cunnington (2000) notes that most of the studies which make claims about the hazards of teenage pregnancy and childbirth have serious methodological flaws. The characteristics of adolescent biology, such as early gestational bleeding and irregularity of menstruation, were frequently not accounted for in the dating of birth. Very few studies employed ultra-sound or newborn assessment. Because most studies employed a retrospective cohort that began with the birth records of women and worked backwards through recorded complications, they did not account for terminations. N o studies controlled for factors such as whether or not the pregnancy was planned or wanted or i f teens terminated to the same degree as older women of low socio-economic status. (Cunnington, 2000) Other authors challenge these findings by citing sample size and opportunistic sampling, (Macintyre and Cunningham-Burl ey, 1993), a focus on only very young teenagers (Lamb and Elster, 1986) and the lack of a control group (Coley and Chase-Lansdale, 1998). 34 Geronimus (1991) argues that poverty and other hardships that preceded the pregnancy are the primary predictors of the future disadvantage of the young mother and her children. She maintains that the medical practice community has been overly reliant on simple correlations between teenaged childbearing and health and social risk to the detriment of their strategies of intervention. To investigate this phenomenon, Geronimus, Hillimeire and Korenman conducted a program of research that compared outcomes among sisters who became mothers at different ages. The researchers applied a longitudinal approach to the study of socio-economic outcomes, (Geronimus & Korenman, 1991a) infant health (Geronimus & Korenman, 1991b) and children's socio-cognitive development (Geronimus, Hillimeire & Korenman, 1991). Their findings demonstrated that age was not a determining factor in life trajectory post-pregnancy. Being considered a 'problem' is a significant barrier to health care Underpinning the critiques of the research is the notion that, i f the science can be improved with better sample sizes, better controls and a better methodological plan, then truth about teenaged mothers can be elicited. "It is very likely (however) that such determination to produce rigorous knowledge about teenaged mothers compounds the pathologization of these young women which some of these very researchers appear to condemn." (Wilson and Huntington, 2005, p. 64) A disproportionate focus on issues of the health risks of teen mothers also contributes to constituting a bigger problem than actually exists. This has implications for social policy that increasing draws its foundation from evidence-based health research. (David, 2001) The multiple discourses which focus on the pathologization of adolescent child bearing has filtered down to affect the way that health care practitioners relate to young mothers. In their study of young mothers and the health care system in Scotland, Philip Shucksmith, Tucker, van Teijlingen, Immamura & Penfold (2006), found that young people experience traditional health care as overly medicalized and are particularly cold and unfriendly towards marginalized youth. They are perceived as places where the confidentiality of youth wi l l not be respected and their anonymity w i l l be compromised. "It is clear that in the eyes of many commentators the determination by some parties to 35 use sex education and sexual health services to dampen moral deviance has often served to exclude young people from access to appropriate services." (Philip et al, 2006, p. 618) Australian research demonstrates an aversion, among young mothers, to accessing support services from health and social services because of their perception that they were being watched and judged. (Hanna, 2001) Unlike older, middle-class clients, young mothers felt that nurses patronized them, behaved in authoritarian ways toward them and offered unsolicited advice about childrearing. This supports British research in which teen mothers perceive health care workers to be dismissive and unsympathetic. (Jewell, Tacchi & Donovan, 2000). A focus group conducted by Planned Parenthood in Toronto (PPT) indicated that most of the teen parent participants felt that health care practitioners were reluctant to discuss sexual health issues with them. They reported that they were not made aware that services were confidential which discouraged them from accessing care. Young mothers spoke of the way in which they felt discouraged by an inability to develop a trustworthy, comfortable and confidential relationship with doctors and nurses. (PPT, 2005) In her ethnographic study of a pregnant teen school-based program in the United States, Wendy Luttrell (2003) employed a theatre activity in which teen mothers 'performed' their social experience of being pregnant. In this process, the young women described real life experiences, which their classmates subsequently acted out. According to Luttrell, the most commonly chosen and most emotionally laden scenarios were interactions played out between pregnant adolescents and medical providers. These scenes were full o f judgement and condemnation on the part of the nurses; challenging the young person's knowledge, moral fibre and intelligence with patronizing and insulting questions. The girls described these scenes as "nurses talking down to a patient," often citing their own experiences of this. Other times a nurse would be cold and distant as i f the girl were "just one more person bothering her." Performances of nurse mistreatment were so routine and some were so unsettling to me that 36 I found myself asking, "Is this how you are treated at the cl inic?" (Luttrell, 2003, p. 118) A common 'nurse' phrase repeated by the teens in Luttrell's study was 'you've gotten yourself into a mess'. The transgressive act of 'getting into a mess' seemed to legitimize any subsequent bad treatment in the health care system; the underpinning assumption being that each girl had the tools to avoid her pregnancy. In a neo-liberal/social welfare state, the 'tools' to avoid pregnancy presumably emerge from a combination of sexual health education, individual psychological stability and a sense of citizenship. Each of these constructs and strategies are potentially problematic when examining their gendered, racist and classist formations. Sexual health education to prevent teen pregnancy Dominant discourses of health promotion arise from public health research that examines population-level sexual health outcomes by using statistical measures of individual characteristics and risk-taking behaviour. Much of public health education is designed with the aim of altering risky behaviour and lifestyles that propagate illness or result in "bad outcomes" such as sexually transmitted infections, obesity, drug addiction, suicide or teenaged pregnancy . (Shoveller and Johnson, 2006) The assumption of this epidemiological framework is that, i f a population is well educated about the risks associated with various behaviours and given the tools to make healthier choices, then health care issues wi l l be resolved. While few would dispute the value of health education and specifically sexual health education, it is clear that information about reproduction and the technologies of contraception do not provide a clear path to the prevention of teenage pregnancy. In a study done by Susan Clark (1999), out of the 80% of young women who stated that their pregnancies were unplanned, only 35% said that they lacked the necessary information about birth control. Another study by Ralph, Lochman and Thomas (1984) found that 2 By discursively associating teenage pregnancy with health issues such as sexually transmitted infections it reinforces 'common sense' that it is necessarily a bad outcome. 37 86% of adolescent parents knew about birth control prior to becoming pregnant. Dawson, (1986); Marsiglo & Mott, (1986) and Kirby, (1985) suggest that traditional sex education demonstrates no impact on teenage pregnancy rates. Researchers such as Fine (1988), Shoveller and Johnson (2006) and Holland, Ramazanoglu, Sharpe and Thomson (1998) contend that the ways in which traditional sexual health education is transmitted constitute the identities of individuals and groups in ways that is counter productive to their sexual health. Shoveller and Johnson (2006) note that, implicit in most sex education, there are versions of authorized and unauthorized sexual behaviour. This binary construction places young people in subject positions of either those who make positive and healthy choices or those who make decisions that are counter-culture and unhealthy, intimating that individuals on the wrong side of the duality should be shamed, punished and improved. The "prevention" discourse Risk-factor epidemiology and psychosocial models of prevention are framed by the assumption that teens make good choices or bad choices about how they express their sexuality. Depending on the religious and social context of the educational site, good/safe choices might include abstinence, heterosexual sex, monogamous sex and safer sex practices. Bad/risky choices encompass all the variances outside of the "good choice" including sex at a young age, multiple partners, homosexual sex and sex without contraception. Those who make "good choices" are lauded while those make "bad choices" are deemed to be problematic. (Shoveller and Johnson, 2006) Through pedagogies that espouse fear of death or grave illness, lives of poverty and lack of direction or physical disfigurement, educators seek to mitigate the potential for risky sexual behaviour amongst young people. Some educators give extreme and inaccurate portrayals of what w i l l happen to individuals who deviate from authorized sexual behaviour. They state, for example, that all people who contract H I V / A I D S w i l l die (Fielden, 2006), and teenagers who have children wi l l live in poverty. With tenets borrowed from "Scared Straight", the U S model that attempts to divert young people 38 from the criminal justice system, this approach is intended to reveal the worst possible results of practicing unsafe sex. Other models take a more moderate approach, speaking of the benefits of putting off sex and fulfilling educational and career goals. The discourse is consistent, however, in expressing the bounds of socially desirable and undesirable behaviour. Young people who engage in activities considered to be risky and experience a "bad result" (contracting an STI or becoming pregnant) are then seen as fully confronting the educator and the dominant society's sex discourse. The supposition is that, i f information has been presented about contraception and been disregarded, the youth has either made a conscious choice to be problematic or does not have the intellectual ability to make a good choice. In a health promotion framework of good choice/bad choice, the deviant young person must then be held up as a bad example to her peers. The prevention message would be weakened i f the negative choice were ever to be construed as acceptable so considerable efforts are made to locate her as "other". (Shoveller and Johnson, 2006) Do teen mothers ever plan their pregnancies? Critics of the prevention discourse contend that there remains a disjuncture between the proposed behaviour changes and what young people experience as the real possibilities in their lives. Basic issues related to gender, race, class and sexuality are obscured in simplistic notions of'just say no'. (Williams, 2003; Bay-Cheng, 2003; Holland, Ramazanoglu, Sharpe, & Thomson, 1998). A number of authors including Hanna (2001); Coleman and Cater (2006); Philip, Shucksmith, Tucker, van Teijlingen, Immamura, and Penfold, (2006); Polit and Kahn. (1986); Phoenix, (1991) Geronomus (1997), contend, some with great caution, that larger than reported numbers of adolescents who get pregnant and proceed with child birth are doing so with some degree of purposefulness, ranging from not using available contraception to having prior discussions with their partners. Philip et al (2006), states that 39 .. .an assumption that teenage mothers simply 'fall into parenthood' may be misleading and may obscure understanding of the range of processes at work. For some young women, continuing a teenage pregnancy may be a deliberate decision and in some cases may offer a career move that may be preferable to other options, (p. 617) In a longitudinal study based in four U S inner cities, Polit and Kahn (1986), looked at 789 adolescent parents in order to discern the variables that would predict a repeat pregnancy amongst the participants. The researchers discovered that 20% of adolescents who became pregnant before the age of 17 had a repeat pregnancy within 12 months and 38 percent became pregnant again within 24 months. They found that, while most of the young women did not state that their pregnancy was planned , few took measures to prevent them. The authors report that education regarding contraception did not appear to be a factor as virtually every study participant had experienced multiple incidents of birth control counselling. The researchers concluded that repeat pregnancies occur because of a general lack of opportunities for young, poor women. "Three years of studying these teenagers suggest to us that they were not motivated to have a second pregnancy, but were insufficiently motivated to avoid one." (Polit and Kahn, 1986, p. 170) In the United States, they state, there are few high paying jobs that women can access even with a high school diploma. Advanced training is a prospect that only a few can afford. It seems likely that until mechanisms are developed that offer real and accessible rewards and life options (e.g., a permanent job with a decent wage) for avoiding another pregnancy, the rate of early subsequent births in this population w i l l remain high. Unt i l that time, we can expect that health, education, and other community organizations wi l l continue to be taxed by 3 Interviews with 82% of the participants after their first pregnancy indicated that, i f they wanted another child, they intended to space the pregnancies an average of five years. 40 the heavy need for ameliorative services by these young women. (Polit and Kahn, p.171) Another study done by Coleman and Cater (2006) studied 41 teen mothers who stated that they had planned their pregnancies. The majority of these young women chose to become pregnant for highly rational reasons: changing their life course from volatile to stable, escaping negative experiences in the school system, normative experiences of family and friends, gaining a new identity and role in life and desiring the experience of mothering. While a minority of the teens are regretful of having a child, the majority cite benefits that include increased confidence and self-esteem, improved relationships with their parents and increased self worth. A Canadian study also found young women who planned their pregnancy for similar reasons. (PPT, 2005) Cultural Rationalism Lawlor and Shaw (2002) pose the question: "What public health impact would we achieve i f we could successfully intervene and change a women's age at first birth and nothing else about her at this point?" (p. 45). Geronimus (1997) argues that there is some degree of cultural rationalism involved in teen childbearing in poor black communities in the United States. She bases her conclusions on her research that showed that among African Americans, first-time mothers above the age of 23 had higher rates of neonatal mortality than most black or white teen mothers. Further research showed that, among sisters, black mothers in their 20s are more likely to give birth to low birth weight babies, and to smoke and drink during their pregnancy than are mothers who gave birth in their teens. These older mothers are less likely than teen mothers to breastfeed or utilize well-child health care in the first 6 months of life. Pregnancy risk factors such as hypertension become more prominent among women in their 20s. This pattern was opposite to the one found in white communities. From the perspective of social support, Geronimus finds that the kinship network is stronger for teen mothers than for older mothers, suggesting that this increases the likelihood that the children of teen parents w i l l ultimately form stronger family attachments and have greater resilience. Lastly, Geronimus concludes 41 that her findings point to a larger reality that, due to the effects of poverty and racism, the social and physical health of poor black women declines more rapidly than that of white women. The timing of fertility at a young age in these communities might actually be considered to be a culturally rational decision in the interest of maintaining best possible health outcomes. (Geronimus, 1997) Sex Education and Male Hegemony According to Furstenburg (1991), the primary reasons for the failure of teens to use contraception are: the unpredictable and sporadic nature of sexual activity, a belief among younger teens that they have little control over sexual encounters, a dislike of contraception because of its role in transforming sex into the realm of rationality, and teen culture's low regard for contraception. Feminists provide a critique of this ungendered analysis of contraceptive use among teens by claiming that it ignores notions of power and cultural learning and thereby contributes to the reproduction of male hegemony. Holland, Ramazanoglu, Sharpe and Thomson (1998) and Fine (1988) argue that traditional sex education contributes to hegemonic constructions of masculinity and femininity that creates a gendered dynamic within sexual relationships which make it even more difficult for young women to exert control over their own sexuality. Connell and Messerschmitt (2005) define masculinity and femininity as "configuration(s) of practice organized in relation to gender." (p. 843) Research by Connell and, others have examined gendered behaviour and practices through the lens of hegemonic masculinity. Supported by multiple and intersecting discourse, normative ideas about what it means to be a man or a women have deeply impacted social thinking. There has been a concerted effort to naturalize hegemonic gender relations by expressing the idea that men and women are 'different yet equal'. Underpinning this notion is the conception that men and women perform gendered functions that neutrally complement each other without reference to power. It is conceived as biologically determined that women provide care and men provide protection; women are intuitive nurturers and men provide financial stability, women are demure while men are vocal. 42 Women are naturally imbued with feminine qualities that harmonize with a man's natural masculine qualities. Although constructs of masculinity and femininity are neither global, transhistorical or uncontested, they continue to have a powerful impact on the way that people conceptualize ideal gender behaviour. The concept of hegemonic masculinity has evolved over the past 10 years from an understanding that hegemonic masculine qualities are universal to an acknowledgment of way that they are shaped by the local culture. Australian hegemonic masculinity, for example, is represented differently in San Francisco. There is, what Demitriou (2001 as cited in Connell and Messerschmidt, 2005) calls "dialectical" pragmatism, by which hegemonic masculinity appropriates from other masculinities whatever appears to be pragmatically useful for continued domination. Connell maintains, however, there remains a social rigidity about gender roles that is punitive towards those who transgress them. He gives the example of a study that showed the very high rates of suicide among male to female transsexuals, presumably due to social censure. (Ruby, 1995 as cited in Connell and Messerschmidt, 2005) In their major study that investigated constructions of masculinity and femininity among youth in Great Britain, Holland, Ramazanoglu, Sharpe and Thomson (1998) proposed that the formal and informal ways in which young people are taught about sexual health is deeply gendered. Holland et al (1998) and Fine (1988) contend that much of formal sexual education confirms hegemonic masculinity and emphasized femininity and, by doing this, constitutes an unsafe sexual identity for women. Sex education is profoundly complicit in reproducing gender roles in which male power over women is seen as acceptable. Ironically, this course of education perpetuates what it aims to prevent: unprotected sex. Within the confines of hegemonic masculinity, for example, to be conventionally feminine is to be naive and unknowing about sex. Young women are instructed by the dictates of femininity to, 'just let it happen', to aspire to and centralize a relationship with a man, to work for the fulfillment and happiness of their male partner and to trust the veracity of male sexual decision-making. Masculine young men are assumed to be all knowing about sexual expression, gaining prestige and strength with each conquest. While potentially equally inexperienced, men and women come to a sexual relationship 43 from very different subject positions. The way that they have learned about sex from school, family, their peers and popular culture is situated differently in relation to this inexperience. (Holland et al, 1998) In the gendered learning about sex, young men are sexually empowered by their masculinity while women are disempowered by their femininity. Because of this unequal relationship, Holland et al (1998) argue that heterosexuality is not a simple construction of masculine and feminine traits situated as opposite yet equal. Heterosexuality is masculine, privileging male freedom, thoughts, desires and perspectives. Holland et al refer to the surveillance mechanism that holds men and women to strict gender conventions as the "male in the head." M e n are held to masculine identities by a male audience as are women acting out feminine behaviours under a male gaze. This version of masculine heterosexuality, however, is not a simple equation imposed by men onto women. More current literature demonstrates the ways in which young men and women collaborate in promoting this patriarchal social arrangement. One can see this in the ways that both genders police each other's sexual reputation in ways that are differently inflected. Sexually active men are seen to be successfully masculine, called "players" or "real men". Conversely, women have tainted their feminine purity by having sex with men are often labelled "sluts" or "whores." (Holland et al, 1998) The fact that gender roles are collaborative, however, does not negate the ultimate imbalance of power present in the relationship. "Young men are caught in a contradiction in which they suffer pressure to conform to a narrow and constraining conception of masculine sexuality but, through acquiring this version of masculinity, can take advantage of social arrangements which systemically privilege the male over the female." (Holland et al, 1998, p. 9) Throughout extensive interviews with young men and women from a variety of different cultures and socio-economic statuses, the Holland et al.(1998) found pervasive evidence of a "protective discourse" within sexual education that is designed to warn young women of the dangers of sex and men. The protective discourse instructs young women to defend themselves against "being used" in ways that w i l l cause disease and pregnancy. Curriculum advises teachers to lead girls in role plays in which they can practice saying 'no' to sexual advances by men. (Fine, 1988) 44 Young men, on the other hand, are instructed about male pleasure through the teaching about 'wet dreams' (as the onset of puberty for men), erection and ejaculation. Masturbation is constructed as normal and natural; as practice for future pleasurable sexual experiences. (Fine, 1998 p. 36) In opposition to the disembodied sex education taught to young women, sex education for men is embodied. Discourse on sexuality is based on the male in search of desire and the female in search of protection. Fine is suspicious of the claim that the protective discourse in sex education is organized out of a concern for women's victimization. If this were truly the case, victims of rape, incest and sexual harassment would experience social compassion rather than suspicion and blame. If sex education was intended to prevent victimization but not designed to silence discussion of desire, it would make sense that there would be more exploration of non-risky expressions of sexuality such as lesbian relationships, protected intercourse, masturbation and fantasy. She believes that the protective discourse in sex education has far more to do with silencing the discourse of desire than helping women to be safe within the context of sexual relationships (Fine, 1988) Promoting a 'discourse of desire' In her review of the U S sexual health curriculum, Bay-Cheng (2003) argues that there is such a focus on the negative outcomes and consequences associated with teen sex that any discussion about the positive aspects of sexuality or the capacity of teens to manage their own sexuality is obscured. Ironically, there is evidence to support the notion that adopting a sex-positive attitude accomplishes more effectively the goals that public health wants to achieve in terms of healthy and safe choices. Michelle Fine's seminal work on 'the missing discourse of desire' articulates the ways in anti-sex rhetoric in education denies subjectivity to teen girls and hampers the development of sexual responsibility. She contends that, far from promoting safer sex, these practices actually lead to increased victimization, teenaged pregnancy and dropout rates. (Fine, 1988). Conversely, Fine argues that sex positive education can delay the inception of heterosexual sexual intercourse and "may enable females to feel that they are sexual agents, entitled and 45 therefore responsible, rather than at the constant and terrifying mercy of a young man's pressure to 'give in ' or a parent's demand to 'save yourself." (p. 46) Other research supports the notion that a positive approach to discussion of sexuality and desire promotes the kind of safe behaviour that is advocated by health care professionals. A study that compared women who received sex-negative, cautionary parental messages with women who received sex-positive, instructional messages found that the former group was more likely to engage in high-risk sexual behaviours. (Ward and Wyatt, 1994) A study done by Fisher et al (1983) determined that adolescents who expressed sex-positive views were more likely to use contraception. The Netherlands provides students with a non-moralistic sexuality curriculum that promotes discussion on many different topics. This country also has the lowest teen pregnancy rate of all Western, industrialized countries. (Luker, 1996) T h e p o w e r house m a r r i a g e between hea l th a n d psycho logy A s one might discern from the sexual health promotion strategies reviewed above, there are as many discursive intersections in health, with psychology as there are with bio-medics. This is demonstrative of the functional co-existence of the two disciplines. It has been generally assumed that, for example, in order to promote the health of a particular population, one must understand why they might resist changing their behaviour. (Oakley, 1984) This has been particularly true in examining the health issues of marginalized groups such as women, aboriginals, people of colour and poor people. A constellation of physical health issues is listed concurrently with psychological and social concerns, underscoring the pathological nature of the group. Health care providers are encouraged to consider not only the physical risks of teenage pregnancy and motherhood, but the psychological ones as well . (Luker, 1996; Cherrington and Breheny, 2005; Lawlor and Shaw, 2003; Shoveller and Johnson, 2006). Understanding the urgency of the problem of teenage pregnancy and parenting w i l l , presumably, spur on health care providers in the cause of pregnancy avoidance as well as preventing them from making the mistake of treating teen mothers as i f they were 'normal.' The following quote from the Journal Nursing Clinics of North America is a 46 typical characterization of teenage mothers provided by mainstream research to doctors and nurses. Childbearing adolescents are susceptible to a myriad of health-related problems. For these youth, health-related problems include both physiological and psychological disease states that negatively impact both their own and their children's lives. Suicide attempts, parenting problems (including child abuse), domestic violence, poor birth outcomes, and sexually transmitted diseases (including H I V ) are just some of the problems encountered. (Lesser, 1999, p. 28) Teen mothers are often distinguished from their non-parenting peers by psychological traits such an oppositional/defiance toward social norms or, more commonly, low self-esteem and a desperate yearning for love. A common understanding is that they come into the pregnancy with pre-existing deficits, which are amplified by a decision to parent. Other discursive streams are concerned with the psychological state of the teen mother as being compromised due to a myriad of factors that include a lack of love as a child, sexual abuse, neglect and a broken home. (Kelly, 2000) In a study conducted in 1976, three factors were attributed to early pregnancy. The first was a supposition that the mother of the teen mother was an inadequate role model. The second was a seductive father-daughter relationship that excluded the mother. The third was a distant and unaffectionate relationship between the parents (Thomas, Mitchell and Devlin, 1990). The same study also decided that the root of the problem was an ineffectual or unemployed father. Serious mental health problems were also cited as being part of the problem. It argued that delinquent behaviour increased the possibility of getting pregnant by 20 times when compared with what they call 'normal females.' It is commonly believed that teen mothers are in a state of deprivation that requires society to respond with psychological interventions. While psychological discourses surrounding teen motherhood may, at first glance, appear to be more sympathetic than punitive, they have powerful implications for where teen pregnancy is situated within the 47 health and social welfare system and how it is conceived. These 'psychological risk' discourses also prevent health care workers, and ultimately the young women themselves, from seeing this birth as a positive event. In the following section, I w i l l review some of the literature that examines the underpinnings of the psychological discourse. Teenage mothers and the low self-esteem discourse Shoveller and Johnson (2006) contend that it is widely assumed that youth who engage in ' r isky' sexual behaviour (i.e. unprotected sex resulting in pregnancy or an STI) are doing so because they have low self-esteem. This discourse presents the assumption that youth with high self-esteem wi l l be less likely to engage in risky sexual behaviour because they care about themselves and their future while youth with low self-esteem do not have these protective factors. Adults working with youth, particularly those working with youth considered to be 'at risk' for unauthorized sexual behaviour, are instructed to intervene to increase the self-esteem of these young people. While the authors acknowledge that there is nothing wrong with enhancing self-esteem, they make the case that the 'self-esteem' discourse is problematic in the way that it is differently inflected according to gender and class. G i r l s with lower social status (not considered to be popular) or who come from lower socio-economic statuses, for example, are assumed to be engaging in risky sexual behaviour because they have low self-esteem. This is not the case for boys of higher social and economic standing. Popular and wealthy boys gain more social status (and consequently, higher esteem) by having random sex with multiple women because it confirms their masculinity. The association of low self-esteem with other marginalized attributes of gender, poverty and lack of popularity leads to an implicit conclusion that girls who engage in risky sex have a character flaw or personality deficit. (Shoveller and Johnson 2006) In their literature review focused on the impact of self-esteem, Baumeister et a l . (2005) note the lack of evidence for the notion that low self-esteem is related to high-risk sex. They argue that, i f there is any correlation, it is that those with high self-esteem are more likely to have fewer inhibitions about engaging in sexual behaviour. If low self-esteem is indeed detected in teen mothers, Baumeister argues, one might question when it 48 came about. It could be argued that low self-esteem is a result of the way that teen mothers are blamed and stigmatized after they become pregnant and must face the world. Teen mothers w i l l be bad mothers Ke l ly (2000) argues that many of the negative stereotypes about teen mothers: immorality, immaturity, selfishness, thoughtlessness and/or irrationality, come together to form the stereotype of a bad mother. The prevailing wisdom is that single, teenage mothers act without thought for the child that they are bringing in to the world; a child who wi l l likely to be brought up in poverty and have numerous disadvantages in the future. According to psychological developmental theory they are considered to be essentially self-centred and they are thought to be at high-risk for abusing or neglecting their children. The assumption that teen parent is synonymous with 'inadequate' parent is at the root of the proliferation of abuse avoidance parenting classes for young mothers. A systematic review of the literature (Kelly, 2000; Geronimus, Korenman and Hillemeire, 1994; Phoenix, 1991) shows that it is a lack of social support, isolation and insufficient material resources that interplay to create situations in which mothers abuse and neglect their children, not young age. Researchers contend that many of the negative factors listed by researchers and policy makers (poor parenting, substance abuse during pregnancy, welfare dependency, lack of direction, failure to complete high school) can be ameliorated by proper emotional and material support systems. (Bunting and McAuley , 2004; Macleod & Weaver, 2003; Waller, Brown & Whittle, 1999; Coletta & Hunter, 1981). In their study that investigated the link between social support and teen pregnancy and birth outcomes, Macleod and Weaver (2003) identified four support systems that have a positive impact: buffering support, esteem support (the person feels loved and wanted), instrumental support (practical aid) and social companionship. These forms of support precipitated a positive attitude toward pregnancy and resulted in positive behaviour changes during pregnancy (i.e. cessation of drug and alcohol use, maintaining good nutrition). They identified social support by doctors and nurses as being connected 49 to improvement in birth weight, feelings of well being after childbirth and lower number of hospital admission post birth (Macleod and Weaver, 2003) Strong support networks put in place during pregnancy were associated with a reduction in stress levels (Coletta and Hunter, 1981) and a reduction of child mal-treatment post birth. Where strong support was implemented initially, less support (emotional and financial) was required over time. (Bunting and McAuley , 2004) Teen mothers must need therapy Nancy Fraser (1989) proposes that, along with the judicial and administrative bodies of social welfare that handle issues of eligibility and distribution, there is a "therapeutic moment" that occurs in the feminine subsystem.4 Because social welfare system discourse has created subject positions for female recipients as having essential character flaws, workers are charged with the duty of providing services to deal with mental health and social skil l development. In addition to prenatal care, programs for unmarried teenaged mothers include mothering instruction, tutoring and counselling sessions with the psychiatric social worker intended to "bring girls to acknowledge what are considered to be their true deep, latent and emotional problems, on the assumption that this w i l l enable them to avoid future pregnancies." (Fraser, 1989, p. 155) Adolescents who do not submit to the therapeutic interventions of workers are often interpreted to be 'resistant' or 'non-compliant'. A study done at the University of Victoria examined the attitudes and practices of social workers working with adolescent mothers and the experiences of these mothers receiving service. The report concluded 4 In her feminist analysis of the US social welfare, Nancy Fraser (1989) notes that the system can be separated into those components geared to serve mostly men and those geared to serve mostly women. Men and women fall into the respective categories for reasons that are largely circumstantial: women's lower participation in the workforce and women's over-representation in the informal and "irregular" workforces (paid household workers, part-time workers, pregnant workers, babysitters and home typists). The "masculine" component of the system, therefore, includes services such as social security, Unemployment Insurance, Medicare and Supplementary Security. Because these are benefits that individuals are considered deserving of, by virtue of having paid in, they position recipients as "rights-bears". They have 'earned' this money and thereby are free to apply for it and use it as they choose without too many constraints or moral judgements. The "feminine" component of system includes relief programs such as Aid for Families with Dependent Children, food stamps, Medicaid and public-housing assistance. They are positioned as dependent clients, recipients of undeserved help and individuals who failed to live up to social standards of achievement. 50 that, while workers were not unaware of the financial need of the young women, they tended to focus most strongly on trying to connect them with resources intended to develop and enhance parenting skills. This was in direct contrast with the women's stated need, which was for material support. (Ross, 2004) This disjuncture between the adolescent's expressed need for material resources and the worker's offer of other resources may contribute to the ambivalence regarding the use of the resources; ambivalence which caused distress among social workers. (Ross, 2004) Cherrington and Breheny (2006) argue that there is very little research that lifts the issue of teen motherhood out of the 'individual psychopathology' analysis. Even literature that purports to position teen pregnancy as a social issue generally fails to lift it out of an individualistic perspective. This discursive stream tends to equate teen pregnancy with the 'under resourced conditions' of economic background, education, family composition and peer experiences. The research queries why only some teens with these 'risk factors' end up pregnant and imply that it is due to individual's inability to cope with such conditions. Cherrington and Breheny (2006) state that such literature is concerned with the young person's failure to adjust to and rise above their situation. Pregnant teenagers are conceptualized as being in opposition to more resilient teens who have the psychological fortitude to adapt to their surroundings without falling prey to a bad outcome. A health psychology approach to teen motherhood, while often framed in a way that is sympathetic, promotes similar patterns of disempowerment to that of institutional medicine. It denies agency by homogenizing the variety of reasons for becoming pregnant and amplifies the notion that teens who become pregnant are always in need of psychological assistance. What is even more salient, however, is the way that the psychological discourse masks the systemic issue of poverty. It is presented as psychologically adaptive to 'overcome' the hardships of a capitalist system and grow up to be citizens who contribute to it. There is profound irony in this construction, as this a system that has essentially failed poor, young women in the first place. 51 Teen m o t h e r s a re a p r o b l e m f o r the economy With the advent of population health approaches, talk of the health care system is inextricably linked with discussions about the economy and citizenship. It is common to hear politicians talk about the cost of the public health care system "spiralling out of control," the implication being that this is largely due to the burden placed on it by those who require specialized care. The young, the poor, and single mothers are viewed as a serious drain on state resources and, consequently, on taxpayers. It is unremarkable that the constitution of teenaged pregnancy as problematic for economic reasons coincided with the rise of neo-liberalism in the west. It occurred almost simultaneously with the move from traditional social welfare notions of equality and redistribution of wealth to a neo-liberal model that privileges economic growth and independence. (Wilson and Huntington, 2005) With this move came major discursive shifts regarding the role of welfare, the place of women and the primacy of work. Neo-liberalism O f course, late capitalist societies are not simply pluralist. Rather they are stratified, differentiated into social groups with unequal status, power and access to resources, traversed by pervasive axes of inequality along lines of class, gender, race, ethnicity and age. (Fraser, 1989 p. 165) It can be substantively argued that most of the developed world currently governs itself under the tenets of neo-liberal economic theory. While an economic analysis is more evident in some dominant discourses about teen mothers than in others, most can be deconstructed in a way that reveals a basis in neo-liberal theoretical assumptions. While a definition of neo-liberalism continues to evolve, it essentially asserts the following conditions: 1) A belief in the market as an equalizing force; without intervention supply w i l l naturally meet demand. 52 2) A commitment to removing welfare benefits which could act as deterrent to market participation. 3) A belief that the use of private finances in public projects w i l l more efficiently serve the market assessed public good. 4) A n assurance that the market is the best mechanism for the allocation of scarce resources. 5) A confidence in the functionality of a global regime of free trade and free capital mobility. (Hay, 2004) Neo-liberal theory rests on the notion that every individual is an economic actor who is free to engage equally in the labour market. One's financial success is the market's reward for making 'good choices': decisions in tune with the current demands of the economy. Failure to thrive financially is the market's response to the individual in order to correct 'poor choices' which are at odds with the economic climate. The assumption is that, when individuals become aware of the fact that different choices w i l l result in greater material wealth, they wi l l shift their behaviour accordingly. Left to its own devices, the market w i l l produce conditions of optimal economic growth. To interfere with market forces by financially rewarding poor choices (in the form of social assistance for example) is to the ultimate detriment of c iv i l society. A neo-liberal discourse conceptualizes teen mothers as calculating, knowing, rational actors who are using the system for their own advantage. "The teen mother coolly assesses the costs of having a baby, analyzes the benefits of welfare and "invests" in a course of action that w i l l get her what she wants. 5" (Luker, 1996, p.4) When the young mother is conceptualized as an individual making a choice to become pregnant in order to garner resources, the articulated solution is to deny social assistance that w i l l reward her and support a cycle of teen pregnancy through the next generation. Within the neo-liberal framework, though often seen as contesting it, is the social welfare state. Social welfare discourse concedes that, while teen mothers are problematic, 5 It was an accepted, though unsubstantiated, view in Britain, that adolescents were becoming pregnant specifically to jump the queue for Council Flats (Carabine, 2001) 53 they are victims who are either hapless products of circumstance or too young to appreciate the consequences of their actions. A s discussed in chapter two, they are subject to the 'needs assessment' that w i l l presumably prevent long-term dependency on state resources. Neo-liberal claims are based on a variety of assumptions that are essentially problematic. They are ahistorical in the sense that they do not recognize the original function of social assistance, they present contradictory expectations for women as mothers and as 'workers' and they do not recognize the systemic nature of poverty within a capitalist system. The shifting discourse of social assistance In the U.S . , Great Britain and New Zealand, welfare benefits were initially put in place so that the sole parent did not have to work. 6 Scientific and psychological discourse of the time claimed that optimal development was supported by the parent (almost always the mother) staying home to care for children. (Bowlby, 1951) While working class women often had to work outside the home to support their family's income, middle class women generally acted as homemakers. (Wilson and Huntington, 2005) Middle-class women who did choose to work were considered to be compromising the good health of their family. Graham and McDermott (2005) note that the past fifty years has brought a sequence of transitions in how we conceptualize the transition from youth to adulthood, situated in the context of post-industrialism. During the 60's, the transition from youth to adulthood was stable and largely consistent throughout the lower and middle classes. The majority of young people (two-thirds) left school at the minimum age and went directly into the work force. Over 60 % of women born in the 1940's were married and more than 50% had their first child by the age of 23. The 1970's brought great changes to the labour market with industries, which had employed inexperienced 16 year olds at a l iving wage, 5 Canadian welfare benefits were initiated for different reasons. Tommy Douglas helped put this assistance in place because of the dire unemployment following World War Two. The subsequent discursive shift regarding the subject position of welfare recipients, however, followed a similar path to that of the US and Great Britain. 54 collapsing. To address the problem of persistent low wages, government introduced youth training programs and expanded post secondary education, the result being longer educational careers and a deferral into full-time employment. (Graham and McDermott, 2005) While middle class youth were likely to take advantage of the extra education that would launch them into higher paying jobs, youth from lower classes often did not have the cultural capital to do so. This created a fast and slow track to adulthood with middle class young people delaying marriage and childbirth and working class young people starting families early. Middle class youth were more likely to reproduce their family earnings while lower class youth often entered a cycle of under-employment and low wages (Graham and McDermott, 2005) In the eighties and nineties, the education and career path became normative for women, rendering young mothers who stayed at home, particularly those on welfare, as transgressive. While benefits had originally been put in place to encourage women to stay home, as both a constructive and reflective mechanism, social discourse changed to stigmatize these women. A new discourse emerged that implicitly and sometimes explicitly implied that state benefits only encouraged women to become pregnant, presumably because they were too lazy to work. To discourage this "laziness", mothers were required to return to school or to participate in work programs in order to collect benefits. (Carabine, 2001; Fraser, 1989; Wilson and Huntington, 2005) Mothers as welfare 'dependents' For every dollar spent on preventing teenage pregnancy, $10 could be saved on the costs of abortion services and the costs of income maintenance to support adolescent single mothers (Orton and Rosenblatt, 1986). Overall, many studies suggest that teenage motherhood can result in a loss of educational and occupational opportunities and increase the likelihood of diminished socioeconomic status of young women (Wadhera and Strachan, 1991; Wadhera and Mil la r , 1997). 55 Neo-liberal economics demand that benefits be removed to eliminate intervention by the state into the market. Teen mothers who do go back to work, however, often find that the wages which they are able to earn are insufficient to support their family. The Canadian Research Institute for the Advancement of Women reports that the poor wages are still a major contributor to women's poverty, regardless of parental status. Female high school graduates make only 71% of the earnings of a male with the same academic qualifications. Even in the female dominated professions, such as teaching, nursing and clerical work, men still averaged a much higher salary. In the lowest paid sectors, sales and services industry, women made only 55.7% of what men made for full-time, full-year work. Since the cutbacks to Employment Insurance in the 1990s, fewer women than men qualify, especially women who are young and/or lower income. Women working part-time, as most mothers do, were the hardest hit by these adjustments, remaining obligated to pay into EI while finding it exceedingly difficult to qualify for maternity and sick leave as well as employment insurance. ( C R I A W , 2006) Considering that teen mothers are much less likely to have completed high school, their prospects for making a l iving wage, within this market system, are minimal. To complicate matters, research done in New Brunswick and British Columbia now points to a lack of parental supervision as a factor in children's substance abuse, risky behaviour and intergenerational transmission of teenage parenthood. A t the same time that women are being blamed for being on social assistance and forced back to work, Ontario's workfare program as a prime example, women are being accused of not paying sufficient attention to their children. (Langille, Flowerdew and Andreou, 2004) Neo-liberal discourse places teen mothers in an untenable position. B y situating career and education preceding childbirth as the only normative option for women, by privileging the economy over care giving, by constructing social assistance as undeserved, reprehensible and humiliating, and by providing few viable economic opportunities for them to support themselves, there seem to be no acceptable options. According to Fraser, current policies about social assistance are paradoxical in the way 56 that, rather than providing it to mothers as an income equivalent to a family wage, it humiliates and stigmatizes them. "In effect, it decrees simultaneously that these women must be and yet cannot be normative mothers". (1989, p. 153) British policy equates social inclusion in terms of access to work and employment, regardless of family status. To be "dependent" on social welfare is seen as the ultimate failure to reach the market valorized status of an economically contributing citizen. (David, 2001) Framing social welfare for mothers in a way that constructs it as " shameful, points to the neo-liberal discourse that valorizes participation in the labour market more highly than caring for children. While under valuing women's work is not a new phenomenon, a neo-liberal context spawns new levels of oppression. Teen mothers are not the cause of poverty Despite all o f the discourse stating that teen motherhood causes poverty and places long-term strain on the welfare rolls, this is not born out by research. Furstenburg, Brooks-Gunn and Morgan's (1987) longitudinal study on teenage mothers determined that many women do not remain in poverty but go on to achieve educationally and attain employment. A Statistics Canada report cited in Ke l ly (2000) showed that only 6.4% of families on welfare were headed by young women (age 15-24). Savings to social assistance payments by the removal of teen parents off its rolls would make a negligible impact. Finally, as many researchers, including Geronomus (1997) and Grindstaff (1988), state, teen mothers tend to come from disadvantaged background and there is no substantial evidence to support the notion that they would not require social supports regardless of their motherhood status. Geronomus suggests that, instead of continuing on with the current direction of pregnancy prevention, " . . .that earnest consideration be given to redirecting intervention efforts meant to reduce poverty and minimize its negative effects on the health and wellbeing of infants, children and families." (Geronomus, 1997, p. 470. 7 Welfare benefits for a mother and a child are currently $650 per month in British Columbia 57 Beyond the 'Macro' analysis Responding to a question from an audience member "So, what do you think is the underlying reason these girls have babies?" researcher Wendy Luttrell replied, "I've worked with fifty girls and there are at least fifty reasons." (Luttrell, 2003, p. 6) As Luke (1995-1996) and Smith (1999) postulate, the danger in analysing the discourses of institutions is that lived experience can be obscured. Given the social location of teen mothers, on the wrong side of binary of gender and most often race and class, it is perhaps unremarkable that there is a paucity of literature that centralizes their voices. Luttrell notes that, in the race to 'understand,' judge and stigmatize teen mothers, their individual identities and articulations of self are obscured. Research that does solicit the views, perspectives and reflections of teen mothers reveals the presence of the full range of experiences of motherhood; throughout the population and within the individual herself Themes of joy, despair, stigmatization, growing maturity, poverty, isolation, support and fulfillment are all evidenced in the. stories told by young mothers. It is these very stories that contest and begin to dismantle the dominant discourses. Kirkman, Harrison, Hillier and Pyett, (2001) discuss the contrast between teen mothers' awareness of society's 'canonical narrative' of teenage childbearing, in which they are condemned, and their own autobiographical narratives in which they perceive themselves as good mothers who are acquiring skills. They spoke about the hostility and discrimination that they have experienced from others, which led some to publicly 'prove them wrong,' and others to internalize negative images of themselves and to retreat to the safety of their private spaces. (Frith, 1993; Kirkman et al., 2001) Other teen mothers expressed deep resentment at having their right to motherhood questioned and invalidated while older mothers were given such support. (Olsen 2005; Kirkman et al, 2001) Joanne Lipper's (2003) book "Growing up Fast" is an ethnographic study of six teen mothers living in the depressed town of Pittsfield. Her research demonstrates how statistics that describe the "typical" teen mother mask the diverse and complex experiences of parenthood. The young women articulate the way that being a mother both held them back from achieving life goals and propelled them forward to build lives 58 with new purpose and meaning. The relationships they have with men were characterized by a child-like desire for love and acceptance as well as mature sense of realism about the capacity of these men to provide for themselves and their children. When these men proved themselves to be abusive or poor role models, the teen mothers eventually prevented them from entering their houses or their children's lives. A l l the young mothers were poor and yet each had a strong sense of resourcefulness. While a few of the mothers went on social assistance for a time, all of them showed a strong desire to find work that would release them from the burden of the surveillance of the state. Many researchers discover, to their surprise in some cases, that teen mothers did not hesitate to list the positive aspects of being a young mother. Included in their narratives were ideas such as: young mothers have more energy than older mothers, young mothers w i l l have freedom in the future because they have gotten parenting over with at an early age, there are benefits to growing up with your children, having a child can bring the extended family together and being young is an advantage to looking after children. (Kirkman et al, 2001; Hanna, 2001, Frith, 1983; Lipper, 2003) A number of teen moms expressed the way that motherhood had changed how they thought about life and responsibility. Motherhood gave them an opportunity to nurture and care for a child, demonstrate adult skills and attempt to be better parents than their own. (Hanna, 2001) Some spoke of the way that becoming a mother led them to adopt healthier life choices such as getting out of abusive relationships, ceasing to drink and do drugs and focusing on graduating from high school. (Olsen, 2005) " I f I didn't get pregnant I would have continued on a downward path, going nowhere. They say teenaged pregnancy is bad for you, but it was good for me. I know I can't mess around now. I got to worry about what's good for Tiffany and for me." (Fine, 1988 p. 37) Teen moms also spoke of the intense difficulties present in attempting to parent in the midst of poverty, isolation and often without the support of a partner. This hardship is intensified by a common experience of negative public criticism directed at them, on the streets, on buses, in supermarkets and in public facilities. (Hanna, 2001; Olsen, 2005) They also noted a loss of social interaction with friends and money to go out with friends. (Jewell et al, 2000) While there was often an attempt by family members to be 59 supportive, many were engaged in their own life difficulties and did not have the time or energy to be there in the way that the young mothers would have liked. (Lipper, 2003) Canadian aboriginal teen mothers A s previously stated, aboriginal teens have a far greater incidence of pregnancy and childbirth. Some equate this with the finding that sexual activity occurs at earlier ages within this population. A n Ontario Federation of Friendship Centers' study reported that almost half of Aboriginal youth 16 years and under are sexually active. O f this group, over one-quarter (28 percent) began having intercourse at the age of 13 or less. (OFIFC, 2002). This compares with rates 23 percent of boys and 19 percent of girls, in the general population, who reported having sexual intercourse before age 16. ( P H A C , 2003) While many Aboriginal teen mothers share the conditions of African American teen mothers in the United States, such as poverty and lack of economic opportunity, Olsen (2005) asserts a lack of material resources alone does not account for high rates of childbearing. She frames her community-based research in historical terms, recounting the shameful history of colonization and cultural genocide initiated by the European settlers that came into Canada in the late 18 t h century and continued on by Canadian church and state. This subjugation of First Nations played a major role in the attempted destruction of health, culture, language, traditions and family systems of aboriginal people. (Olsen, 2005) The residential school movement resulted in a tragic breakdown in social order which led to a much higher incidence of sexual abuse, sexually transmitted diseases, alcoholism, violence, suicide and drug addiction among young aboriginals. Aboriginal children represent upwards of 50% of children in care in B C (Olsen, 2005). The loss of aboriginal children, through removal or death, has been profound. Citing K i m Anderson, a Cree/Metis author and educator, Olsen argues that part of the reason for high levels of reproduction among young First Nations is an effort to sustain and rebuild their culture. Olsen concludes that First Nations communities are caught between old ways and modern practices in regard to dealing with teen pregnancy. Traditionally, all birth was considered sacred within First Nations Communities. Babies were honoured and mothers 60 were given an elevated position and cared for within the communities. Over time, the realities of First Nations communities have changed. Economic, historical and social forces have contributed to drastically changing the make up of the population on reserves, with the proportion of very young mothers needing care overwhelming the capacity of communities to provide sufficient attention to them. Abortion is unacceptable within the context of a belief that the spirit of the child emerges at conception. The elders only tolerate sex education if it is non-explicit and done in a moral framework that decries reproductive freedom. "What's left of the old way is a deep belief that a woman's purpose is to have children; what's missing is the support that mothers need, especially when they are teenagers." (Olsen, 2005, p..39) Many within aboriginal communities do not see teen pregnancy as an unmitigated disaster, but view it with pragmatism. Research participants in a study done on teen pregnancy in an Inuit community expressed the view that, in some cases, becoming a parent at a young age could protect the young woman from substance abuse and lead her to choose better ways for her and her child. Others indicated that the pregnancy itself was not problematic, but became negative if the young woman did not have sufficient social supports, i f she lacked the skills to care for the child, if she became depressed and overwhelmed, if she did not have the financial resources to buy the necessities or i f she was forced to drop out of school. (Archibald, 2004). Teen mothers at the Ontario Friendship Centre noted that, while early motherhood give teens a sense of accomplishment, it also creates stress, added complications, and demands. Although the responsibility could be scary, they also noted that raising a child could be a catalyst to change a life trajectory. Others within aboriginal communities conceptualize teen pregnancy as a major social problem on reserves in that it is related to substance abuse, youth staying out too late and a general lack of parental supervision and guidance. (Archibald, 2004) A First Nations support worker in Olsen's study sees it as related to a lack of respect for themselves and each other. Some attribute teen pregnancy to young people's uncritical consumption of media's glorified and unrealistic version of what it means to be in a relationship. Olsen contends that Internet pornography has much greater distribution 61 among teens and has a larger impact on young people's sexuality than is generally reported. Similar to the teen mothers in other literature, young moms in Olsen's studies speak of a dichotomy between feeling accepted and marginalized, comfortable in their new role as mother and deeply regretful and hopeless about their future. Many expressed the perception that teen parenthood was so normalized within their communities that they were the only ones surprised at becoming pregnant at a young age. (Olsen, 2005) Silences in the Literature: Fathers A n obvious gap in the literature surrounding teenage pregnancy is the very limited attention paid to the role of the father of the children of adolescent mothers8. While there is a small amount of research on this topic the tenor of the discussion and the situating of the issue diverges significantly from that of the literature on teen mothers. Like teenage mothers, fathers are portrayed negatively in terms of individual psychological traits and negative school experiences. (Weinman, Buzi & Smith, 2005) In contrast to the construction of teenage mothers as the center of an epidemic, however, fathers are sidelined as one of many variables in a teen mother's life that include family, peers and education. (Parra-Cardona, Wampler, & Sharp, 2006) Nowhere in the literature is there an equation of young fatherhood with negative health outcomes. There is no resounding call to rein in the sexual behaviour of young men. A s discussed in Chapter one, historically fathers were held responsible for 'bastard' offspring. While unwed mothers were pressured to reveal the father of their child, the weight of responsibility and moral condemnation was placed on the man who failed to marry the mother of his child. Local governments and churches went after fathers who could or would not economically support women and children. A s the current lack of attention paid in the literature to the role and meaning of young fatherhood demonstrates, it is single teen mothers who are now cause for a moral panic. It is According to Millar and Wadhera (1997), the majority of men who father the children of adolescent mothers are at least 4 years older and generally not adolescents. 62 adolescent mothers who are negated for their inability to finance parenthood without state assistance. Conclusion Dominant discourses from health, psychology and neo-liberal economics constitute teenage pregnancy and motherhood as problematic. Adolescent childbearing is considered to be physically unhealthy for mother and child, presents barriers to career and education, confirms a condition of long term poverty and places undue pressure on the public system. Teen pregnancy occurs in youth with low self-esteem who engage in risky sexual practices, who are morally corrupted and who are attempting to get free money and housing. Those who contest dominant discourses provide evidence that teen mothers are caught up in interlocking oppressions of race, class and gender with few opportunities in their lives other than that of motherhood. Others support the notion that teen pregnancy is culturally rational, given optimal times for childbirth, or individually rational, given a desire to turn one's life around. The dominant discourses and those contesting them elucidate the many complexities that exist at the heart of the debate surrounding teen pregnancy. The question of planned or unplanned pregnancies raises issues about agency and determinism, where they overlap and where they contradict each other. Can it be said that young women without economic resources living in the context of a racist society can , make a free choice to become pregnant? On the other hand, to say that free choice is not possible is to make a claim that young women are not the subjects of their own lives, an assertion that would be abhorrent to most. It would also contradict and further subjugate the positive discourses about teen pregnancy. A related dilemma for policy makers, educators and health care professionals who examine the subjugated discourse regarding adolescent child bearing is whether or not to define teenage pregnancy as problematic. To declare teen pregnancy acceptable presents pragmatic difficulties for those trying to secure funding for sexual health education and support for young mothers. As Furstenberg (1991) asserts, it leaves policy makers in a quandary about whether health dollars are well spent on vulnerable youth. To continue to 63 state that teen pregnancy is deviant, however, perpetuates divisions between teen mothers and the mainstream ideals of motherhood. A s adolescent mothers report, this attitude only delays or prevents them seeking needed health support. The next chapter w i l l look at the political and health policy environment in Canada and British Columbia that is currently shaping how institutions respond to teen motherhood. 64 CHAPTER FIVE: THROUGH A MIRROR DIMLY: THE BIFURCATION BETWEEN POLICY AND PRACTICE The increasing influence of conservative political, religious and cultural forces around the world threatens to undermine progress made... and arguably provides the best example of the detrimental intrusion of politics into public health. (Georgia Straight, November 14 t h, 2006) Introduction It can be confusing to try to discern a coherent Canadian position on the issue of teen motherhood. One might assume, initially, that there would be a strong connection between the government policy statements, regarding this issue, and the way that it is taken up by practitioners on the frontline. This is certainly true when one examines the official US government regarding teenage pregnancy9 and the individual experiences of teen mothers in that country, (see Luker, 1995; Luttrell, 2003 and others) In Canada, however, this issue of teen pregnancy and parenthood is far more complex. Our legacy of social democracy and progressive values around health issues are at odds with local conservativism and intolerance. Globalization has ensured that media conceptualizations of teen mothers often trump our national values and ideas regarding health promotion. Regionalization minimizes the impact of Health Canada's statements and recommendations regarding sexual and reproductive health. This chapter will explore these dynamics as they manifest themselves in, what Dorothy Smith (1999) refers to as, the everyday/everynight experiences of women. 9 In 1996 the Personal Responsibility Act was brought into legislation, directly implicating single, teenage mothers for the poverty of the nation. 65 Health Canada on Teen Mothers Canadian federal government policies related to teen pregnancy/parenting are largely articulated through reports and documents associated with health, sex and sexuality. I have chosen to review three documents Canadian Guidelines for Sexual Health Education (CGSHE), Consultation on a Framework for Sexual and Reproductive Health (CFSRSH) and The Opportunity of Adolescence: The Health Sector Contributions as a representative sample of statements originating out of the federal health sector. I selected C G S H E because of the window it provides into both the epistemological and pedogological stance of Health Canada on issues of sexuality and education. C F S R S H is an example of a Canadian consultation on various topics related to sex and sexuality, especially related to access to services and resources. The Opportunity of Adolescence is a broader study on the health of youth in Canada, examining both strengths and challenges. In the latter two reports I have given particular focus to the discussion of teenage pregnancy/parenting. Canadian Guidelines for Sexual Health Education The Canadian Guidelines for Sexual Health Education ( C G S H E ) , updated in 2004, is a reference document that summarizes the federal policy on educating around issues of sexuality and gives instructions for how stakeholders might go about developing programs and practice. The purpose is introduced by stating, "This document proposes a framework that outlines the philosophical and guiding principles for the development, delivery and evaluation of sexual health education." The text defines key terms such as 'health', 'health promotion', 'sexual health' and 'sexual education'. It includes strategies for the development of sexual health education that is intended to provide a 'path' to 'enhance' sexual health and avoid negative health outcomes. C G S H E provides direction for future program and policy development on sexual health, tools for evaluation of 66 sexual health education, and includes current research that can be utilized for updating and improving current programming. C G S H E appears to be a document that is both critical and inclusive. The authors begin by acknowledging the constructivist nature of the concept of sexual health, governed as it is by expert and professional discourse. They state that the dominant and authoritative medical ideas about health and what is healthy are not necessarily encompassing of the perspectives of those from non-dominant cultures, socio-economic statuses and religious institutions. It encourages educators to be considerate of the multiplicity of beliefs and experiences that people have in regards to sexual health and to adopt pedagogical approaches that are non-ideological, non-personal and non-judgemental. C G S H E urges educators to remain aware of their own values and standards that they are promoting and instructs them to be cognizant of the specific needs of the audience they are charged with educating. The section of C G S H E that describes the philosophy of sexual health education expands upon the notion that human sexuality is experienced and expressed in a variety of different ways throughout the life span. It involves interplay between an individual's personal desires, the autonomous needs and rights of others and the 'requirements and expectations of society'. Sexual health education should affirm the individual's self worth and dignity, equip individuals with tools to communicate their own needs and develop an awareness of the impact of their behaviour on others. Educators should be responsive to the specific sexual health needs of children, youth, adults and seniors and recognize the different requirements for doing education for marginalized groups such as Aboriginal people, gay, lesbian, bisexual, transgendered people, the mental and physically disabled and street youth. C G S H E proposes five guiding principles that should characterize sexual health education: accessibility, comprehensiveness, effectiveness of educational approaches and methods, training and administrative support, and planning, evaluation, updating and social development. It advocates formalized funding sources for staff training and resource to ensure that sexual health education is universal and for the location of sexual health education within a number of disciplines to ensure coverage of a broad base of relevant subject matter. It calls for the creation of an educational environment that 67 supports acquisition of skills and the development of critical thinking about sex and sexuality. C G S H E stresses the importance of remaining cognizant of the best practices regarding sexual health education and updating programs as appropriate. Consultations on a Framework for Sexual and Reproductive Health In 1999 Health Canada released a report from Consultations on a Framework for Sexual and Reproductive Health. This document was the result of a national dialogue on issues related to values about sex and sexuality, the need for services and access to sexual and reproductive health services and which actions should be taken to maintain, protect, and promote sexual and reproductive health. The report recognizes the impact of social location in determining access to health care, situating an individual's sexual health within the context of the social, economic and physical environment. Poverty, gender, race, ethnicity and sexual orientation were acknowledged as factors that can marginalize people from mainstream health services and compromise physical and emotional health. The report presents eight principles that the authors state, reflect the fundamental values of Canadian society and are consistent with factors that influence sexual and reproductive health. The principles cover a wide range of topics that include the lifelong nature of sexual development and expression, the right of the individual to have autonomy in sexual health care decision making, the preference for prevention and promotion of health strategies, a desire for health interventions that are safe, effective and evidence-based approaches that utilize simplest and least invasive techniques possible, the necessity of informed consent, the obligation to provide sexual health services that are responsive to diversity and not limited because of discrimination, the responsibility to protect individuals from conditions and environments that negatively affect sexual health and, finally, the need for families and communities to share the task of creating a positive milieu for optimal sexual and reproductive health. The report introduces a discussion of teen pregnancy as problematic by making the point that " in Canada, we have unacceptably high levels of sexual and reproductive health problems", (p. ii) The authors state that the rates of teen pregnancy are higher than in other Western, industrialized countries due to a number of factors including access to 68 sexuality education and contraceptive services as well as poverty and marginalization. It is situated alongside other issues considered to be sexual and reproductive problems such as sexually transmitted diseases, low birth weigh babies, sexual abuse and family violence. Teens who become pregnant, the report states, have lower lifetime earnings and other social difficulties that w i l l complicate their lives. Teen pregnancy places a burden on health system through the cost of abortion or on income support to single, adolescent mothers. According to the report, teen pregnancy is caused by a failure of the health system to engage in proper prevention strategies with marginalized youth and the structures of society that inadequately address social and economic issues. Youth who come from families with lower socio-economic status, for example are more likely to have an early initiation into sexual activity and engage in 'riskier sexual practices' "Teenagers whose parents have lower educational levels are more likely to be sexually active, and those who live with a single parent are more likely to have had multiple sex partners."(p. 14) The authors argue that health intervention to prevent teen pregnancy must include a critical analysis of gender. "[Teen pregnancy] is most often seen as a problem for young women, not for young men, with most of the onus for preventing pregnancy falling on the young woman rather than emphasizing the sexual behaviour and responsibilities of both." (P-16) The Opportunity of Adolescence: The Health Sector Contribution The Opportunity of Adolescence, released October 2000, reports on health issues for adolescents in Canada. It describes the health status of Canadian youth and paid particular attention to issues of health literacy; areas where youth have needs for information and greater support to access services. The report contextualized the health issues of youth with consideration to gender, race and cultural differences. Health, the report argues, is an interplay between determinants of health such as the health system, social support networks, the education system, personal health habits and coping skills, the socio-economic environment, the physical environment, and biological and genetic factors, (p. 13) It identified places for the health sector to take action to foster the healthy 69 development of adolescents, building on the commitments made to health in early childhood. The paper devotes some space to establishing benchmarks for healthy adolescent development. Healthy adolescents, according to the authors, are equipped to enter adulthood with the knowledge and skills to: • Manage their personal health and well-being by making healthy decisions related to nutrition, exercise, tobacco, alcohol, drugs and sexuality; • Develop intimate relationships and family life because of positive self-esteem, good decision making skills, autonomy and a sense of emotional commitment; • Participate in the workforce and; • Participate in community life. The report characterizes adolescents as a period of life that presents both opportunities and challenges. Developmentally, adolescents are beginning to become more independent, they are making decisions on their own, and they are trying out new behaviours and developing a sense of self outside of family. They are increasingly self-reliant and are often participating in their communities in ways that are meaningful. The Opportunity of Adolescence asserts that, while most youth are healthy, some adolescents are vulnerable to conditions that are less than optimal. "Youth who are growing up in adverse conditions, such as poverty, in adequate parental support and/or social environments that promote alcohol/drug use, unprotected sex and violence, need effective intervention to 'beat the odds.'" (p. 1) The report state that there is a disjuncture between the knowledge that youth have about health and the degree to which they are engage in healthy practices which suggests that educational strategies should be improved. Access to health services within the school system has also been seriously eroded in past years with health care professionals providing tertiary care rather than prevention services. There is a brief discussion of sex and sexuality and only a scant mention of teenage pregnancy. Interestingly the report designates parents as 'the primary educators of their adolescents regarding healthy sexual development", (p. 24) It goes on to say that youth have expressed "frustration with the narrow scope of sexuality education that they 70 receive" (p. 29) and that sexual health education can be obscured in the myriad of competing curriculums and issues. Adolescents identified access to birth control and confidentiality as concerns. The report states that many adolescents talk about unprotected intercourse occurring while under the influence of drugs and alcohol. Unplanned pregnancy and STIs must be prevented through programs that are accessible and available to youth. Among the report's many recommendations for action is a call for the removal of legislative, regulatory and practice barriers that restrict access to health services and supports because of age or issues of consent. It recommends that sex education programs be developed, in collaboration with parents and communities, which are culturally appropriate. The report proposes that affordable sexual and reproductive health care services (including contraceptives, planned parenting services and prenatal counseling) be made available to young people In order to address the reality that the most marginalized youth are unable or unwilling to access mainstream services, the report advises that more sexual health services and supports be developed for this population. T w o paths d ive rge Government health policy regarding adolescents is consistent with so-called mainstream Canadian values concerning the separation of church and state and liberal attitudes toward sexual health. Each of these reports provides a broad analysis of the social determinants of health and do not engage in the blaming of individuals for i l l health. The health reports are echoed by government social marketing campaigns, such as the Canadian Health Network (CHN) , that promote safer sex for teens in a tone that is explicitly non-judgemental. The use of birth control is promoted along with factual information about the variety of methods available. (Public Health Association of Canada, n.d.) While, predictably, none of the policies engage in truly challenging discussions about sexual health, i.e. encouraging discourses of pleasure or an analysis of male hegemony in heterosexual relationships, neither do the reports construct adolescent sexual expression or teen pregnancy as a symbol of m o r a l bankrupcy. The problematic 71 nature of teen pregnancy and motherhood is strictly related to so-called health risks and economic instability. If there is no explicit moral condemnation of teen parenthood within the context of documents produced by Health Canada, is it expressed by government leadership? Stephen Harper, a self-professed evangelical, right wing Christian, might realistically be expected to have a great deal to say about teenage sex. According to E G A L E , at least 10 cabinet members in the Harper government have identified themselves as social conservatives with ties to the Christian right. These include David Sweet (former head of the Promise Keepers) and Maurice Vellacott (Focus on the Family). These movements are vocally against broad distribution of birth control to young people, sexUal health education in the schools as well as access to abortion and birth control. A n extensive internet search for interviews, speeches, statements or public policy in which any representative of the conservative government comments on the issue of adolescent sex or sexuality came up with no hits. There was virtually no evidence to indicate that Harper or his government has an opinion about adolescent sexual health and teen pregnancy. Likewise, neither has the conservative government made any obvious moves to adapt health policy to reflect the values of his political counterparts to the south. The provincial government in B C is also relatively silent on the issue of teen pregnancy. Adolescent childbearing is not considered acceptable- the one available document focussing on this issue reproduces the dominant discourses about teen pregnancy (negative impact on health, education and economic security)- but mentions are brief, suggesting that teen pregnancy is not a central concern of the Ministry. (BC Ministry for Children and Families, 2000) Other discussions of sexual health on the B C Government Ministry of Health website are reproduced from the B C Health Guide. The text, which includes a section on "Talking With Your Teen About Sex" and "Adolescent Sexual Development", does not speak to the multiplicity of cultural or class experiences potentially present in its audience but there is a primary message that encourages a discussion about sex rather than a mandate of abstinence. 72 Talking about sex does not encourage sexual activity in teens; in fact, some studies show that talking frankly and honestly about sex can prevent teenage pregnancy and delay intercourse. Having an open, honest relationship with your teen wi l l largely depend on the quality of the relationship you have built to this point. (BC Ministry of Health, n.d.) Why then, with official Health Canada and British Columbian Ministry of Health policy articulating a relatively progressive stance on adolescent sexuality (advocating open discussions about sexuality with teens), do these messages fail to filter down into action in the local jurisdictions responsible for delivering services to young mothers? Why do pregnant and parenting teens persistently have negative experiences within the Canadian health system? American 'family values' The Canadian discourse of sex and sexuality contrasts sharply with discourse promoted by the United States government. A n examination of American political talk about teen motherhood demonstrates that it is remarkably consistent with the actual experience of teen mothers in the health care system. Government administrations in the United States, be they Democratic or Republican, have consistently positioned teen pregnancy as a moral panic, only to be remedied by stronger family values. The 1996 passage of the Personal Responsibility Act (PRA) , spearheaded by Newt Gingrich, underscored the assumption that teen mothers are centrally responsible for poverty and other social ills. (Kelly, 2000) Sex education is conceptualized as being complicit in the rise of young, single motherhood, encouraging youth to randomly and prematurely engage in sexual relationships. A s expected, teen mothers experience these condemning and exclusionary attitudes against them when they walk into American clinics to access services. (Jewell et al 2002; Hanna, 2001; Luttrell, 2003) Deirdre Ke l ly writes of a telling statement made by the former leader of the reform party, Preston Manning. Despite a similar political ideology concerning a neo-liberal economy and "family values", Manning intuited that to align himself too closely 73 with radical conservative Newt Gingrich would unsettle the Canadian public. In an attempt to differentiate himself from Gingrich he stated, " A revolutionary should neither look like one nor act like one to get ahead in our country." (Newt's axis, 1996 as cited in Kel ly , 2000, p. 17) While there is a faction within the Canadian public that would identify themselves as socially conservative (pro-life, anti-gay, pro-capital punishment) there is not the same vitriolic discourse about morality to draw from when condemning adolescent sex and teenage pregnancy and parenthood. Right-wing governments in Canada must rely on other, less overt, ways of accomplishing conservative objectives. I observe that there are three factors at work which allow a conservative element to thrive at the local level, effectively marginalizing teen mothers in the health system. While there are a host of other complexities, the factors that I w i l l elucidate below are: social policy with little influence, the downloading of sexual health education to the schools and local clinics, and the influence of American values through media. These dynamics interplay to create scenarios that are not reflective of 'official ' health policy at the federal level. Policy not practice: the evolution of Health Promotion in Canada To most accounts, Canada has provided a leadership role for many other countries in health promotion. The World Health Organization relies heavily on Canadian intellectual resources to form policies on global health. (Raphael & Bryant, 2002). While there has been a series of 'evidence-based', well-articulated models that are intended to promote the health of Canadians, some research argues that there is actually a very tenuous link between official policy and the initiatives which end up with funding and a mandate. (Pinder, 2007) This next section wi l l explore, in greater detail, the various approaches and their subsequent impact. I w i l l pay particular attention to the 'Population Health Approach', as it reflects the neo-liberal assumptions that inform the current political climate. The past fifty years in Canada has seen a number of shifts in discourses that speak to health and the determinants of health. The period following World War II, a time when 74 there was great focus on re-building, asserted the importance of accessibility to health care as a way of ensuring people's good health. It was during these years and into the 1960s that the country's program of universal health care was put into place and became an integral part of Canadian identity. The early 1970s brought a challenge to the notion that accessibility to care was the most important determinant of health. The government policy document, known as the Lalonde Report (1974), introduced an explanatory model of the factors that can influence physical wellbeing. These factors include lifestyle, human biology, genetics and the environment. This "lifestyle" discourse, that articulated individual level behaviour as the primary way of maintaining good health, remained dominant throughout the 1970s and into the 80s. The federal government's approach to improving the lifestyle of Canadians was comprehensive, including a focus on issues, target groups and countrywide strategies. The four levels of intervention were: 1) informing and equipping the public to deal with lifestyle issues; 2) promoting a social climate supportive of healthy lifestyles; 3) supporting self-help and citizen participation; and 4) promoting the adoption of health promotion programs within health care and social welfare. (Pinder, 2007) The programs, while lofty in their goals, were so under-resourced that many of the strategies never got traction across the country. (Pinder, 2007) The mid-eighties saw the beginnings of a serious critique to the notion that change on a personal level could widely determine health outcomes. This model, the critics argued, neglected to provide sufficient analysis of the social, economic and political contexts in which individuals exist. Analysing health outcomes from the individual sphere could only result in blaming the victim. A n alternate discourse emerged that would soon become known as the N e w Health Promotion or "social determinants of health". This new set of policies were widely supported, finding international voice in documents such as the World Health Organization's Ottawa Charter and Health and Welfare Canada's Achieving Health for All: A Framework for Health Promotion (Epp, 1986). It centralized the notion that health outcomes are impacted by factors outside of the individual, namely poverty, unemployment, poor housing and other inequalities. 75 These health issues needed to be dealt with through engaging the communities through development and empowerment. The strength of the Health Promotion model was in its coordination of the sectors that facilitated working relationships between local, provincial and federal levels. Social marketing efforts set a non-judgmental, positive tone and research cast a wide net, exploring many aspects of living and working conditions. Funds were distributed by regional offices to community action groups who were responding to locally defined needs. (Pinder, 2007) A s integrated as the new health promotion policies were however, a social determinants approach never received high-level support of politicians. Efforts to obtain sufficient resources and a mandate to address a broader vision of health were unsuccessful. The majority of resources were, instead, directed to programs which focused narrowly on drug and alcohol abuse, tobacco use, nutrition and A I D S . (Pinder, 2007) It soon became, in the eyes of its critics, merely a social marketing campaign that addressed lifestyle issues. The next discursive shift was to come in the early 1990s following a paper by Evans and Stoddard through the Canadian Institute for Advanced Research (CIAR) . It was an important document in the way that it brought into alignment a health approach that was consistent with the neo-liberal tenets of the economy. The authors of this report, Evans and Stoddart, entitled Producing Health, Consuming Health Care, contended that the health care system has been over resourced when measured against its ability to produce health in the population. They argued that this is problematic given the "spiraling" health care costs, measured by its proportion of the G N P . Spending excessively on 'curative' health care prohibits investment in the economy. A s Evans and Stoddart assert, " A society that spends so much on health care that it cannot or w i l l not spend adequately on other health-enhancing activities may actually be reducing the health of its population" (Evans and Stoddart, 1990, p.55). Continuing to maintain current levels of expenditures on health care w i l l , at the very least, produce diminishing returns and, more ominously, negatively impact the general health of the population. The 'population health approach', as proposed by the C I A R , shared with the social determinants of health approach a belief that health is impacted by factors beyond 76 the biomedical condition of the individual. It also privileged socio-economic status as a central influence on the overall well-being of people. Where a population health approach becomes problematic, critics argue, is in its basis and faith in the neo-liberal economic notion that wealth wi l l necessarily 'trickle down' to those most marginalized in society. (Coburn et al, 2003) A n affinity towards a positivistic analysis of health determinants- a belief that the problem of human needs can be solved by rational means outside the realm of the social and political- blinds population health approaches to the larger structural factors that maintain poverty and disempowerment. From an epistemological and ontological position, they argued, there is acceptance of the scientifically produced data regarding socioeconomic status and health without asking how poverty came to be and what can be done about it. Raphael and Bryant (2002) deem the 'desituating and depoliticizing' of health determinants to be "context stripping", with little consideration of how such models and statistics can be connected to real people and groups in actual life circumstances. This positivist approach seeks to name causes and effects and to understand how risk and protective factors manifest themselves generally in the population. The complexities within an individual or community's environment.are obscured, rather than indicative of the larger social structures that are manifesting themselves in health concerns. This top down approach precludes the community development and empowerment models espoused by the social determinants health promotion. Opponents of the population health approach charge that, even as the approach claims to be non-ideological, it is in fact deeply political. They make the case that the rise of population health intentionally displaced the social determinants of health approach's call for social justice as a vehicle for improving health. (Raphael & Bryant, 2002; Coburn et al, 2003; Robertson, 1998) B y adopting an approach that regards intervention (aside from the stimulation of the economy through neo-liberal means) as undesirable, policy makers are released from the obligation to institute corrective measures within the local context. There is no obligation to align health promotion with the underlying moral economy of the welfare state. (Robertson, 1998) Seeing the shortcomings of population health, policy researchers, including Evans and Stoddard, proposed an integration of population health and health promotion. This 77 combined approach would attempt to re-orient the top-down nature of population health and re-engage communities (Health Canada, 1996). Health Canada, however, had committed to the ideals of population health and was not prepared to shift gears. This, combined with the major cutbacks of the 1990s ensured that recommendations from this report would not materialize. (Pinder, 2007) The ' S A R S crisis', West Ni le Virus and Mad Cow disease initiated the most current shift in discourse on health promotion. The media frenzy surrounding these three health issues stimulated a public desire for health care that addressed other health determinants and systems that worked in tandem with communities. Public health, as a primary vehicle for health promotion, gained primacy on the federal stage. The Public Health Agency of Canada ( P H A C ) now functions as Health Canada's way of facilitating integration between population health approaches, health promotion and community engagement strategies. Its mission reads "to promote and protect the health of Canadians through leadership, partnership, innovation and action in public health." ( P H A C , 2006, introduction section) The commonality among all of the various incarnations of health policy is the reality that, unless there is solid direction and proper resources to substantiate stated goals and objectives, they become immaterial. A s Pinder (2007) argues: .. .introducing new policy ideas is not too difficult. Gaining acceptance is possible but taking action is not so easy. Each in its turn- the Lalonde Report, the Epp Report (1986), the Ottawa Charter (1986) and Strategies for Population Health (1994) was thought to be the turning point. Proponents promised a great deal and were able to deliver very little. In fact, there is remarkable similarity in the results of each new wave- changes in language, reorganization, a host of excellent programs but little actualization of the policy, (p. 18) Bureaucrats within governments can commission reports and studies that form the basis of policy but, ultimately, it is the administration of the government in power that 78 determines the agenda. Governments, like the current ones, do not have to make public statements about controversial issues in order to implement their ideological leanings. Initiatives can be allowed to slip under the radar and programs can be under resourced to the extent that they slip away. Downloading Responsibility While the recommendation of Health Canada's commission reports and consultations are many, it is largely left up to local schools and health clinics to deliver them. In 2004, based on wide consultations with schools across the province, Options for Sexual Health (OPT), reported that sexuality education in schools and public health is produced very differently in different communities. They pointed out that the curriculum: competes with other issues for attention in schools; does not have clear and achievable goals; and there is a lack of general accountability to governing bodies. OPT argues that the Ministry of Education, school districts and principals have different understandings about whether or not sexuality education is mandatory within health promotion programming. (OPT, 2004) The Surrey School District in British Columbia is a good example of how the politics of a local board can deeply impact the curriculum provided to students. Conservatism on the part of board members resulted in a series of actions designed to restrict the degree to which students had access to sexual health information. In 1994, despite the results of a district-wide referendum indicating a desire on the part of parents for condoms to be made available in school washrooms, board members voted to abandon this initiative. During that same year, the board voted to cut funding to the Chi ld Abuse Research Education ( C A R E ) training for teachers. C A R E , a program aimed at teaching children, from kindergarten to grade three, skills to protect themselves from sexual abuse (proper names for body parts, stranger safety and assertiveness training), is widely used and respected across the province for its efficacy. Money saved in the cuts to this program was directed to starting up the Surrey Traditional School. ( E G A L E , 2007) In 1994, public health nurses were stopped from teaching about STDs in the Surrey schools and, in 1.996, Planned Parenthood was banned from acting as a resource or 79 making presentations in the schools. A s trustee Robert Pickering was quoted as saying "Planned Parenthood and some public health coordinators continually push the boundaries of common decency as it relates to sex education." ( E G A L E , 2007) Other sexual health educators such as Youth Co. and the A I D S society were similarly excluded. The school board decided that any outside speaker on Family Life topics must apply for board approval before being considered for the classroom. In 1997 it approved 'Chastity '97 ' - student presentations in high schools on the merits of abstinence and chastity. The Surrey School Board is, perhaps, best known for its discriminatory acts against gays and lesbians. In 1996, it voted to remove the phrases "a form of discrimination based on sexual orientation" and "Any form of expression of bias on the basis of sex or sexual orientation including derogatory comments" from the definition of outline of the practices that constituted sexual harassment. In 1997, the Board attempted to ban from classrooms and school library three books portraying gay and lesbian parents. While the Supreme Court ultimately overturned this ban, the school board maintained its position that the 'traditional family' is still the normative standard. ( E G A L E , 2007) While the Surrey School Board has taken up the issue of sex and sexuality in a way that is atypical for an urban centre on the West Coast, the latitude it was able to express in terms of sexual health education is, however, reflective of other, more rural areas in British Columbia. The values of sexual health education, including an acknowledgement of the diversity of sexual expression, are in no way being taken up uniformly across the province. A n y individual not fitting into, what has been deemed, 'authorized sexual behaviour' (i.e. gays and lesbians and sexually active adolescents) are explicitly shunned and marginalized. The Media There is scant.research on the role of media as a determinant of health. The very large body of research that demonstrates the function of media in discourse production, however, indicates that there is a profound connection between the way that media conceptualizes teen mothers and general public perception of this population. (Kelly, 2000) Ke l ly (2006), citing a U S study done by Gi l lam and Bales (2001) speaks of the 80 w a y that pervasive ly negative m e d i a images o f youth, part icular ly those because o f those m a r g i n a l i z e d because o f i m m i g r a n t status, race, gender, ab i l i ty and sexuality, impact o n the w a y that adults conceive o f youth. E v e n adults w h o have had posi t ive experiences o f y o u n g people discounters these encounters i n favour o f popular notions o f y o u t h as delinquent. H e a l t h care providers , w h i l e ostensibly educated regarding the ' factual i n f o r m a t i o n ' about teen motherhood (as opposed to an exc lus ive rel iance o n stereotype and myth) are not untouched b y the media-generated discourse about them. T h i s discourse is far closer to the n o t i o n o f A m e r i c a n f a m i l y values than the C a n a d i a n government statements regarding adolescent sexuality. A s discussed i n chapter three, the mul t ip le negative discourses directed at teen mothers, are f u l l y present i n the popular m e d i a that makes its w a y into Canada. B r i e f l y , this includes teen mothers as destined to l i v e l ives o f poverty and desperation, abusing their c h i l d r e n and perpetually dependent o n welfare. T e e n mothers, according to the discourse, must be treated i n punit ive ways that discourage rather than encourage another pregnancy. H e a l t h care providers w h o do not choose to engage i n a cr i t i ca l analysis o f this discourse or do not have access to alternative forms o f i n f o r m a t i o n about teen motherhood and health care are l i k e l y to treat teen mothers i n w a y s that are reflective o f popular discourse. C o n c l u s i o n There is a disjuncture between government 's ' o f f i c i a l ' analysis and p o l i c y about teen pregnancy and parenthood and the realties o f a cont inued m a r g i n a l i z a t i o n w i t h i n mainstream health systems. U n l i k e the consistency found between A m e r i c a n p o l i t i c a l rhetoric and service p r o v i s i o n , there is a differential between what p o l i c y advocates as a f o r m u l a t i o n and response to adolescent sexuality and pregnancy and what occurs i n the loca l context. In this chapter, I have explored some o f the reasons for this bi furcat ion: p o l i c y that is not backed up w i t h a mandate, the d o w n l o a d i n g o f sexual health education to i n d i v i d u a l districts without accountabi l i ty to nat ional standards and the impact o f m e d i a discourse o n health care providers. 81 In the next chapter I w i l l take a closer look at what transpires in the discourse of public health, through the textual conversation between the health care providers who deal with pregnant and parenting teens. 82 CHAPTER SIX: REDUCING AND PRODUCING DISCOURSE Introduction In this chapter, I w i l l provide an overview of the data and the themes that emerged from it. The materials analyzed in this study were collected with the intent of representing the conversations which health care providers, specifically nurses, in B C are having regarding teen mothers. To determine which publications were the most relevant, I asked four nurses (two public health nurses, one nurse working in the hospital and one who is serving as the associate dean of a Lower Mainland College) to refer me to publications that were both widely read and included discussions regarding current issues in health care. They referred me to: the Canadian Nurses Association, Nursing BC and Canadian Nurse. A t the Canadian Nurse's Association's Helen Randall Library, I accessed an on-line database of these three publications. I typed the keywords 'teen pregnancy', 'adolescent pregnancy' and 'adolescent childbearing' into the search engine in order to find articles specific to my topic. Because there were very few articles that made mention of the topic of teen pregnancy (or adolescent sexuality) I searched as far back as 1988.1 found 12 articles that, in some way, made mention of adolescent pregnancy and/or childbearing. While it is not exclusively directed at health care practitioners, I chose to analyse the tri-annual newsletter of the B C Alliance Concerned with Early Pregnancy and Parenting ( B C A C E P P ) from 1990 to the newsletter's final publication in 2003. Under the larger umbrella of the Y W C A , B C A C E P P was the provincial network of all organizations - school, health and social service based- dealing specifically with parenting and pregnant teens. The purpose of the newsletter was to provide a forum for those working with young mothers to discuss issues, share resources, advertise and evaluate programs. It contained program updates, conference announcements and reviews, reflections on adolescent childbearing by practitioners and teen mothers, articles focusing on advocacy and justice (including issues of housing and social assistance) and peer-reviewed articles on teen pregnancy and parenthood. 83 Over the course of the 12 years of newsletters that I analysed, the leadership of the B C A C E P P underwent a series of changes and the political climate in British Columbia shifted significantly. Both of these factors had an impact on the ways that the newsletter took up its role of representing young mothers and advocating for them. One noteworthy change occurred in the mid-nineties when the Alliance's coordinator, Kathy Johns, died of cancer and the leadership changed hands. Instances in which the voices of teen mothers were present in positive ways occurred with less frequency when others took over her post. A second transition happened in 2001 at the beginning of serious government funding cuts to social programs. Passing on specific "tool-based information" replaced the inclusion of research articles. In the newsletter's final year of publication an action plan to "increase the visibility of young parents" was in the process of being implemented with the intention of equipping service providers to advocate for funding. A s an outsider to the organization it was not always easy to determine an editorial position on the issue of teenage pregnancy and motherhood. The newsletter included the multiple perspectives of service providers in the form of reports and submissions, reprinted newspaper articles and a wide selection of research articles. The majority of these submissions were included without editorial comment. It appeared that the newsletter was attempting to be inclusive of a diversity of beliefs, ideologies and practices regarding young motherhood and because of the varied nature of the voices on the topic; a reflective sample of discourses can be discerned. Coding Following on my research questions (as stated in on page 8) and informed by my findings within a review of the literature, I posed the following questions to guide my analysis of the newsletters and the journal articles: 1. What are the key words, phrases, themes and metaphors, assumptions and silences in the text? 2. H o w do the different discourses rely on, contradict and/or mediate one another? What other dominant discourses do they rely upon/are mediated by? 84 3. H o w are teen mothers positioned by the dominant discourses in these texts? After an initial reading of the journal articles and several of the newsletters I identified three primary discursive themes to code for: problematizing or reductive discourses, supportive discourses and advocating discourses. I repeated my reading of the articles and the newsletters, coding for themes, key words, metaphors and phrases that I considered to reflect one or more of the themes. The first, problematic or reductive discourses, articulated assumptions that teenage pregnancy and parenting is an inherent problem that requires health intervention to correct. These discourses presented images of teen mothers as psychologically deficient, irresponsible about the health of their babies as well as being of economic and moral concern to society. I took notice of where, in the text, 'teen mothers' were spoken of in ways that lifted them out of their context - ignoring issues of poverty, class, race and culture. More specifically, I examined the places where this lack of attention to context led to 'needs assessment' as discussed by Fraser (1989) (i.e. talking about parenting skills without reference to material support.) In contrast, supportive discourses situated teen mothers as 'real ' mothers facing the challenges and joys of parenthood. While not obscuring the very real hardships produced by poverty and isolation, the guiding notion of these discourses was that teen mothers have the opportunity to thrive, given the appropriate supports. Supportive discourses did not homogenize the category of teen mother but allowed space for individual experiences of pregnancy and parenting while refraining from moralizing or judging. Advocating discourses paid attention to the broader issues that perpetuate marginalization of teen mothers and promoted systemic solutions that included housing, social assistance, better medical care and opportunities for community building. They made mention of the necessity of changing social structures that perpetuate injustice, not simply changing the teen mother in order that she might fit in to these systems. Some of the data fit easily into the categories that I had created. Other pieces of data I found to be deeply nuanced. Talk about parenting support, for example, ostensibly supports a teen mother in her interactions with her child. It also carries unspoken assumptions about what 'good' mothering entails; generalizations gleaned from white, 85 middle-class research and traditions. With these multi-layered pieces of data, I found it helpful to look at where the teen mother was constructed without reference to positions of race, socio-economic status, culture and geography. Citations When referencing journal articles I have used typical A P A internal citations. In the places in which I am referencing content from the newsletters I use two different formats. When citing or quoting directly from a peer-reviewed, scholarly article that has been re-printed within the body of the newsletter, I reference the article and then make reference to the newsletter in which it can be found, i.e. Maracek, 1987 as quoted in 1993, Summer/Spring, B C A C E P P , p. 17. In the places in which I am citing or quoting portions of the newsletter that originate from editorials, organizational reports or reader submissions I cite the newsletter in which it is located, i.e. 1993, Summer/Spring, B C A C E P P , p. 17. Problematizing Discourses Psychologizing teen motherhood One of the most prevalent discourses in the material was one that focused on the psychology of the teenage mother. A central assumption within this discourse is that teen pregnancy and motherhood throws a wrench into the works of 'normal adolescent developmental goals" that results in subsequent pathology. (Krishnamoni, 1992) Psychological discourses are utilized to determine why an adolescent would become pregnant, the reasons why an adolescent is a poor mother and how to design an intervention that would improve a teen's ability to parent and prevent a future pregnancy. Within the psychological discourse, there were three primary theoretical approaches: a cognitive stream, a humanist approach, and a psychoanalytic approach. These streams often overlapped producing eclectic psychological formations. 86 According to cognitive theory, which focuses on development of the brain in relationship to processing of information, an adolescent has an inability to comprehend messages about preventing pregnancy and the use of contraception because of immature thinking patterns. The capacity to determine the consequences of actions, which occur with formal operational thinking, is not fully developed in the adolescent. This prevents teenagers from truly being able to understand future consequences and thereby act on prevention messages. (1993, Winter, B C A C E P P , p. 17) They do not understand the importance of planning for the future nor can they envision the impact of one event (having a baby) on the rest of their lives. (Fedak, Pearl, Connolly, 1996) There was a stated assumption that, because adolescents are in the early stages of development themselves, they are less knowledgeable about children and unprepared to provide for their baby's needs. (2001, Fall , B C A C E P P , p. 15-16) "It is those who are least well-prepared to nurture and raise a child who are most likely to become parents." (1999, Fal l , B C A C E P P , p. 23) Humanism is a branch of psychology that centralizes the concepts of the 'whole human' development in the context of work, relationship, and individual fulfillment. Gaining positive self-esteem is considered a necessary step in the process of moving forward to becoming an adult who is self-actualized. Within psychological discourses present in the texts, low self-esteem is presented as being either a cause or result of adolescent child bearing. How a teen feels about herself is a primary factor in how she chooses her life. A s an antecedent to teen pregnancy, girls engage in 'high risk' sexual activity in order to maintain a relationship. Sexual intercourse isn't experienced as an intimate act; nor is it found enjoyable. Despite this, teenage girls often submit to having intercourse, partly hoping to gain intimacy and partly to hold on to their boyfriend. When pregnancy occurs, neither aim is achieved. (Krishnamoni, 1992, p. 21) Deciding to proceed with a pregnancy contributes to low self-esteem because the adolescent is unable to properly fulfill the normal stages of development such as 87 completing educational goals and moving on towards a career. A teen mothers sees herself through the eyes of family and friends as a failure; someone whose process of self-actualization has been arrested by the birth of a child. The perceived judgements of others lead the teen mother to develop (or continue to develop) a self-concept that is one of disempowerment and disappointment. A psychoanalytic perspective pays attention to the unconscious- motivations and desires of which the individual acts on without reflection. The adolescent, according to this theoretical model, is in a stage of intense ego development in which 'consideration of others before self is not a well-established characteristic.' (Fedak, Pearl, Connolly, 1996 p. 51) When weighing the advantages and disadvantages of becoming pregnant they are considering only themselves. A n adolescent's decision to raise a child, for example, is often determined by such egocentric desires as the wish to get married and leave home, assert autonomy and adult status or receive unconditional love from a dependent object. In this case, the baby. (Maracek, 1987 in 1993, Spring/Summer, B C A C E P P , p. 17) In the article Speaking for the Baby: A Therapeutic Intervention with Adolescent Mothers and their infants (Carter, Osofsky & Hann, n.d. in 1993, Fal l , B C A C E P P , p. 10), the authors spoke about the necessity of protecting babies from their potentially dangerous mothers. They argued that, because of their own unmet developmental requirements, teens at best do not bond with and at worse, mal-treat their infants. There is an inherent conflict in the child's need to be fully focused on and the adolescent's conception of the world as focused around themselves. Multiple texts articulated the message that the adolescent's egocentricity causes her to compromise the health of the baby. The pregnant teenager, in an attempt to restrict weight gain to maintain body image, might not take in sufficient nutrition to facilitate the healthy development of the fetus. The teen mother's desire to smoke and 'party' creates a 88 poor environment for lung development and wastes resources that could be spent on healthy food. Teen mothers can be 'helped' by interventions that address their psychological issues. Working on self-esteem, teaching appropriate social skills and conflict resolution techniques, facilitating responsibility for self by 'tough love' and engaging the adolescent in intensive counseling are all conceived of as appropriate responses to adolescent pregnancy. One article suggests that, because teen parents come from troubled families who model substance addiction, an effective strategy would be one that is modeled after Alcoholics Anonymous. "The road to health starts with breaking through the denial, after this comes the anger and then grieving the loss. The clients have to do the work themselves. We cannot rescue them because in so doing the client is just substituting their dependency of alcohol, etc, to us." (1990, Winter, B C A C E P P , p. 3) The healthy lifestyle "Teenagers presented a higher percentage of possible risk factors, such as low educational level, low socio-economic status, living alone and smoking." (Kelen, Hunt, Siebeko-Stones and Varga, 1991, p. 22) A s discussed in Chapter Two, 'healthism' is not simply the dissemination of health information, but education done with the implicit assumption that individuals are deemed largely responsible for their own health and for 'making healthy choices'. The focus of this discourse on individualism constructs the "person" as i f independent of structural and social constraints. It was entirely predictable that, within a field whose entire mandate is to improve the health of the population, there was a proliferation of health promotion messaging. While evident to some degree in the B C C E P P newsletters, healthism was particularly prevalent in the nursing journals Health interventions are most commonly conceived of with an assumption that adolescent mothers are unhealthy because of personal lifestyle choices rather than contextualizing individual conditions within systemic or structural frameworks. , 89 Most program descriptions include a diet and nutrition component, citing concerns about the health of mother and child. Teen mothers are assumed to have a lack of knowledge about a healthy lifestyle: i.e. eating well and avoiding smoking, drugs and the consumption of alcohol. One program talked about the general lack of knowledge that teens tended to have about the 'proper' running of a household and the necessity of providing them with the training to do so. "The young women are expected to participate in the day to day operation of the house, i.e., menu planning, grocery shopping, cooking and cleaning." (1995, Fal l , B C A C E P P , p. 17) Another program spoke about leaving "healthy baby recipe" magnetic cards at grocery stores, pregnancy testing clinics and hospitals. (1991, Winter, B C A C E P P , p. 16) The notion of authorized and unauthorized health behaviour is underscored in three articles that describe 'health games' as a conduit for 'creative and fun' ways for pregnant and parenting teens to learn about health. In the contexts of these activities, the young women compete in answering questions about nutrition, smoking, drinking, alcohol, tobacco and exercise. " Y o u walked to the mall, move ahead two spaces. Y o u had coffee and doughnuts for breakfast. Go back three spaces". (Kelen, Hunt, Siebeko-Stones, Varga, 1991, p. 22). In a "pregnancy fair", participants are challenged to 'guess' the price of healthy snack foods and distinguish between types of beans in order to win prizes. (Curry, 1988) In the game, 'Sexual Jeopardy', girls learned about behaviour that 'causes' STDs and pregnancy. (Griffiths, 2005) B y learning and practicing problem solving skills, they were better able to deal more effectively with the choices and decisions that determine their own health and well-being, that of their baby and ultimately that of their family. (Fedak, Peart & Connelly, 1996, p. 51) The demon cigarette There was a great deal of attention paid in both the articles and the newsletters to the 'risk' that smoking presents to the unborn baby and to the infant. The 'teen mother who smokes' is part of a larger representation of the chaotic lifestyle led by the young 90 mother that includes staying up late, drinking, and partying. One Canadian Nurse article spoke of an advertisement directed at young mothers that depicted a rocket ship with the phrase underneath " M o m at Controls" which "symbolized the youth mother taking control and making healthy choices for herself. (Curry, 1988, p. 27) Around the rocketship were 'space invaders' in the form of smoking and alcohol. Health promoters utilize discourses about good and bad mothering in order to convince the young woman to stop smoking (i.e. the 'good mother' does not put her baby at risk by selfishly consuming tobacco). Within the discourses on health, it was interesting to note the ways in which the larger 'determinants of health', originally intended as a way of lifting bio-medical conditions out of an individual analysis, were re-situated and de-politicized. One newsletter included the statement: Adolescent childbearing is a public health concern because of the significant medical, psychological and social risk to the mother and her infant. Poor outcomes have been attributed to inadequate prenatal care, low socio-economic status, nutritional deficiencies, lifestyle, ethnic background and marital status. (Roth, 1993 as quoted in 1993, Winter, B C A C E P P , p. 17) Rather than discussing inadequate pre-natal care and nutritional deficiencies in the context of poverty and discrimination, low socio-economic status and ethnicity are deemed to be lifestyle choices with poor health outcomes. Rather than contextualize the reasons why ethnic background and marital status are associated with poor health outcomes they are simply listed as risky. Instead of addressing poverty by rectifying economic injustices they are 'solved' by instituting individual health interventions. Teen moms drain the economy A persistent theme in the literature, a problematization of teen motherhood in relation to the economy, is woven into the talk about health. The teen mother is a burden 91 on the economy, not only because of the money spent through the social welfare system, but because of the long term costs of caring for infants facing complications. Studies have shown that the social cost of teen pregnancy shows up in other ways. If babies are born and the mothers keep them, some of the.mothers surrender the potential earning power they could have achieved. Not only that but an unusually large proportion of babies born to teenaged mothers are sickly and in need of expensive health care. (Mitchell, A . 1998 as quoted in 1998, Spring, B C A C E P P , p. 14) To mitigate the impact on the economy there were numerous references made to job skills programs for teen mothers that would increase their chances of finding employment. (1999, Winter, B C A C E P P , p. 16) These employment training programs generally focused on the creation of a resume, what to wear to a job site, how to behave during interviews, communication skills and the use of word processing computer programs. These skills would presumably help the young mothers to get off of social assistance and take up the role of contributing citizen. Moral Panic Discourses of 'moral panic' about adolescent pregnancy tended to be expressed indirectly through other discourses, often couched in tones of concern about health and future well-being. There was, however, evidence of a conservative and moralistic interpretation of teen motherhood sprinkled throughout the journal articles. The newsletters reproduced mainstream newspaper articles that articulated concerns about teenage pregnancy as a threat to the moral health of the nation. This strain of conversation expressed notions of adolescent childbearing that are more typically seen in American media, underscoring the fact that Canadian 'liberal ' views about sex and sexuality are not universally accepted. Some authors expressed nostalgia for the 'o ld days' when teenage pregnancy was a cause of shame and embarrassment for young women and their families. Adolescents 92 who choose to remain in school and mother their children exhibit a rebelliousness that challenges traditional ideas about gender roles. "Hidden behind these concerns is that, for many, the phenomenon of teenaged pregnancy- now much more visible than in the 1950's, when teens gave up their babies for adoption- is a proxy for the state of the nation's moral health" (Mitchell, A . 1998 as quoted in 1998, Spring, B C A C E P P , p. 14) Another point of entry for a moral panic discourse is sex education in the schools. Sexual health education is conceptualized as leading to uncontrolled expressions of sexuality among teens. For these social conservatives, even the acknowledgement that youth are sexual is seen as a de facto acceptance of teen pregnancy. A B C A C E P P newsletter re-printed a Globe and M a i l article that quoted David Curtin, spokesman for the anti-abortion group Campaign Life Coalition in Toronto. According to Curtin, the rise in the teen pregnancy rate is evidence of a failure to maintain standards of morality in the schools and to act as the gatekeepers of adolescent sexuality. ' M r Curtin said it is clear to him that the rate is rising because of sex education that promotes sexual activity. What they need instead of that is education about chastity." (1998, Spring, B C A C E P P , p. 15) The "Bad Mother" Teenagers are notorious for shunning prenatal care with potentially negative health consequences for mother and baby. Many young mothers become single parents and are sustained by the social services system; it can easily become a way of life. Education is often interrupted and rarely resumed, at least not immediately. Without educational qualifications to improve their situation, many of these teenagers become trapped in a poverty cycle from which escape is difficult. (Krishnamoni, 1992) Encompassing elements of the psychological, healthism, economic and moral discourses, a 'teen mothers are bad mothers' assumption underpins the problematization of adolescent childbearing. Teen mothers are inadequate because they smoke, they spend money unwisely, they do not think of future consequences because they are only 93 considering themselves, they don't take their education seriously, they take health risks that endanger their children and they go on social assistance without thought for tax payers. "Teen mothers take on negative identities and revel in the attention that it brings." (1999, Spring/Summer, B C A C E P P , p. 24) In the very act of choosing to give birth and keep her baby, the teen mother is a poor role model to her child. The child of a teen mother w i l l not have an example of good health or good citizenship. (1995, Fal l , B C A C E P P ) One newsletter (2001, Spring/Summer, B C A C E P P , p. 21) printed an article from the National Post (Saturday, Apr i l 14, 2001) that reported on a study by researcher Tom Arnold that showed that "teen mothers were likely to have bad boys". Arnold claimed that the association between adolescent mothers and delinquency in boys was due to undue care and attention. He states that, while his intention was not to stigmatize young mothers, this find was important "because it highlights the need for new programs to help teen mothers gain the parenting skills necessary to raise their children". Many programs focus on trying to 'break the cycle' of teenage motherhood by offering corrective interventions in the form of 'parenting skil ls ' . It is implicitly and explicitly stated that pregnancy is an opportunity to draw the marginalized young women into health programs and give them the knowledge and skills necessary to bring up a generation that w i l l be less compromised. Equipping young mothers with parenting skills w i l l , presumably, give the children of teen mothers a better chance of success in life. The very clear assumption of the majority of parenting programs is that, in contrast to older mothers who presumably have innate knowledge regarding childrearing (irony intended), young mothers do not instinctively know how to care for their child. Teen mothers must be taught and moulded into the vision of a 'good mother' that is held by facilitators. What it means to be a good mother and what one needs to become one, of course, is defined by those who design the programs. They speak of methods of discipline, how to make routines, how to pick out safe toys and how to help the baby to eat well . (1998, Fal l , B C A C E P P , p. 12) These white and middle-class perspectives rarely make reference to the difficulty of parenting in a society in which the teen mothers are discriminated against because of age or ethnicity. There is no mention of the near impossibility of providing for themselves and their children on a very limited income. 94 Supportive Discourses While in the minority, there was evidence of discourses within the text, which suggested different interpretations of teen motherhood. In some cases these discourses presented a direct critique to dominant assumptions about the capacity of teens to mother. There were a few instances in which researchers and practitioners challenged hegemonic constructs of youth. Targeting youth as uniquely contributing to the disintegration of c iv i l society was seen as myopic and deeply problematic. One contributor wrote that the portrayal of teenage sex as deviant or radically different from adult sex is completely unwarranted. "The behaviour and value systems are, at the individual and societal levels, the same". (Males, 1994 as quoted in 1995, Summer, B C A C E P P , p. 15) Another writer took issue with the assumption that a trend towards single motherhood was somehow associated with this particular generation of young people because of a lack of value placed on commitment and responsibility. "The national obsession with teen parents as a symbol of declining morality is a sad example of denial and projection by adults in a 'blame the vict im' distortion." (1997, Spring, B C A C E P P , p. 14) In contrast to the healthism discourses that concentrated on prevention of future pregnancy through abstinence and contraception there were a few advocates for an affirmation of youth sexuality. (Carrera, 1995 as quoted in 1995, Fal l , B C A C E P P , p. 17) This discourse took a critical approach to the forms of education that silenced young women by pathologizing sexual expression. (1993, Winter, B C A C E P P , p. 5) In addition to the confrontation of 'youth bashing', the assumption that teen mothers are necessarily inadequate mothers was contested. This opposing discourse conceived of teen mothers as a heterogeneous group, embodying all of the strengths and weaknesses, insecurities and confidence of all mothers. It presented the notion that the experiences of mothers varied according to cultural background, sexuality and socio-economic status as much as they did to age. "Stereotypical and contradictory perceptions of youth are one of the main reasons why young people are denied access to information, health services and other resources that might enable them to protect and enhance their sexual health." (Campbell & Aggleton, 1999 as quoted in 2000, Fal l , B C A C E P P , p.20) 95 Three newsletters presented research that challenged the imposition of middle-class ideas about motherhood on to working class young mothers. In a chapter reproduced from a book entitled Education for Social Change, Susan Victor states that "Curriculum based on what I think is important cannot reflect their experiences as a culture; rather, it is an imposition of my life experiences and formal education (and perhaps my desire to promote social and psychological change) on the 15 adolescent mothers in the group." (Victor, 1998 as quoted in 1998, Fal l , B C A C E P P , p. 21) Conceptualizing teen mothers as mothers generally resulted in program ideas that promoted the strengths of age, gender and culture. Peer education and community empowerment sessions drew on the existing power and creativity of youth in the programs. Teen mothers were encouraged to talk about the positive experiences of motherhood rather than repeatedly being instructed to hold up their lives as a cautionary tale. (1999, Spring/Summer, B C A C E P P , p. 21) (1998, Fal l , B C A C E P P , p. 18) A feminist approach in one program encouraged the deconstruction of gendered attitudes among support workers. In another program, elders were regularly invited in to a First Nations young mothers group to ensure contact with cultural roots. Advocat ing Discourses Several issues of the B C A C E P P included advocating discourses that were contextualized by the understanding that teen mothers exist within a matrix of racism, classism, sexism and ageism. There was an understanding that so-called health risks were caused by these structures of oppression rather than simply an individual's lifestyle considerations. These articles provided a critique to the injustice that is perpetrated on teen mothers, as it is committed on all poor people, through inadequate housing, a lack of day care, inaccessible programs and poverty sustaining frameworks of social assistance. (1997, Summer/Fall, B C A C E P P , p. 13) (1998, Fal l , B C A C E P P , p. 2) (1996, Summer, B C A C E P P , p. 8)They also issued a call for the funding and re-funding of programs targeting mothers with young children. (2000, Fal l , B C A C E P P , p. 6) Advocating discourses encouraged support workers to take up action against poverty by writing to the government and supporting the causes taken up by the 96 B C A C E P P . The Alliance called for the dismantling of the social stigma against teen mothers that result in the population being ignored on the social priority list. (W 1999 3) There was strong protest against the cuts to housing and to social services. "We lack transition houses in the city.. . there are no transition houses geared towards teenage mothers... we need transition houses specifically for teenage mothers." (1992, Fal l , B C A C E P P , p. 4) Young mothers were encouraged to become advocates for inclusion and against stigmatization. The B C A C E P P ' s steering committee developed two training components that programs and communities could potentially incorporate in their work with young mothers. "One module w i l l focus on how to assist young parents to be better self advocates and the other w i l l be on how to assist young parents to be advocates for young parents as a population in the community." (1999, Fall , B C A C E P P , p. 2) Letters were included to demonstrate the way that a young mother acted on her own behalf for better government assistance. (1999, Fal l , B C A C E P P , p. 10) C o n c l u s i o n In this chapter I reviewed some of the discursive themes that emerged from a critical discursive analysis of two bodies of text encompassed in some of the 'talk' that nurses have about teen mothers. The analysis was based on the notion that discourses are reflective of the subject positions offered to teen mothers as well as the power relationships that are potentially created between health care provider and the adolescent. Within the text, I found three primary discourses: discourses that problematized or reduced teen mothers by way of totalizing narratives, discourses that were supportive of them by challenging assumptions about age and class, and advocating discourses which situated stigmatization, poverty and racism as fundamental social injustices. In the final chapter I w i l l summarize my key findings and explore some of the implications for practice arising from these findings. 97 C H A P T E R S E V E N : K E Y F I N D I N G S A N D R E C O M M E N D A T I O N S Summary This research began with the premise that the way in which marginalized people are constructed within health promotion has a significant impact on the services that they are able to access. I chose to focus my study on teen mothers, partially because of my ongoing experience of working with this population arid also because the vast majority of pregnant young women have some engagement with the health care system and often this connection (or surveillance) carries on into their experience of early parenting. Teen mothers and their children are targeted by the public health system as a population "at risk" for physical health concerns as well as a constellation of other potential factors such as child-maltreatment, psychological vulnerabilities, family chaos and repeat pregnancies. There is a widespread assumption that families headed by adolescent mothers are problematic and require intervention in order to prevent harm. M y research was guided by the questions: what are the dominant discourses within the health care system, how do they intersect to define teen mothers, and, what power relations between health care providers and teen mothers are constituted by these definitions? I investigated these questions through a process of critical discourse analysis, theoretically informed by tenets of feminism and post-structuralism which looked closely at the issues of the subject positions offered to teen mothers, the differential distributions of power and the operations of 'regimes of truth'. The body of texts analysed were articles and newsletters that originated from or were directed to, specifically British Columbian and, more generally, Canadian public health providers. To provide context to these texts, I also examined Canadian health policy documents that spoke, in some way, to the issue of teenage pregnancy and parenting. 98 Key Findings Some of the conclusions of this research reassert the findings of previous literature regarding the way that the 'matrix of oppression' 1 0 constitutes teen mothers within literature, popular culture and the major social institutions. Because of the multiple discourses about motherhood, youth, the economy, gender, and race, teen mothers have been positioned in ways that restrict their ability to articulate their own needs, advocate for themselves and find their own way into motherhood. Dominant discourses about teen mothers, originating from institutions of health, psychology, social services and the economy weave together and mutually reinforce a notion of teen mothers as problematic. What emerged from the data was a repeated tendency for health care providers, through accepted strategies of health promotion, to reinforce negative stereotypes about teen mothers. These seemingly uncritical health promotion discourses serve to reproduce, not only unequal power relations between health care providers and young mothers, but hegemonic understandings of gender, sexuality, motherhood and class. While there were several examples of such strategies, the two that were particularly outstanding were discourses about anti-smoking and empowerment. Not a Pretty Sight: Good mothers don't smoke The anti-smoking campaign is particularly poignant because of the passion with which health workers focus on teen mothers who smoke, with more vehemence than the preaching of the average evangelical pastor. Through efforts to find the most effective pathways into a 'healthy lifestyle', public health promotion has played on the insecurities that young women have about measuring up as an ideal female and all that this role entails. It reinforces the notion that women are only concerned about health as it is expressed through how it impacts on physical perfection (and, by extension, their attractiveness to men) and how it impacts on 1 0 K e l l y (2000) 99 their family. Through their roles of girlfriend, wife and mother, women are seen as the purveyors of healthy eating, good hygiene, clean houses and the implementation of positive medical practices for the partner and children. 1 1 For the general population, anti-smoking messages are framed by the notion that the act of smoking is reprehensible and socially unacceptable. Smokers themselves are portrayed as 'distasteful', dirty people who selfishly disregard their own health and the health of others. These individuals are considered to be weak in their lack of discipline and wi l l power to resist the draw of nicotine. (Lupton, 1999). Because of research that points to adolescent females as a population in which smoking is becoming more prevalent, teen girls are targeted with great fervour for prevention messages. In order to get the message across to girls, health promotion strategies utilize discourses of heteronormativity and emphasized femininity- the primary notion being: "Smoking wi l l make you ugly". The strategy takes up the notion that young women have greater preoccupation with a body ideal than with personal health benefits. The teen girl is consumed with looking well put together and 'nice' . A s a way of discouraging smoking 'the girl who smokes', is represented in health promotion campaigns as ugly with prematurely aged skin, bad teeth, bad breath and dry hair. Maintaining youth and 'prettiness' by not smoking is conceptualized as way to ensure that they are still attractive to the opposite sex and their peers. While boys are told that smoking w i l l inhibit breathing, girls are informed that cigarettes w i l l make them'disgusting'. A teen mother who smokes is not only failing to live up to notions of a pretty girl, but is constructed as being unsuccessful as a mother. Added on to the idea that smoking makes young women unattractive is the key message that "Smoking creates health risks for your child". B y ignoring the fact that cigarette smoke could potentially create the conditions for long-term harm to her children, the teen mother is eschewing the womanly role of being the 'guardian of health' for her family, a position so essential in health promotion. Transgressing this fundamental tenet of public health consequently 1 1 There is much evidence in the data that this discourse is repeated within Canadian public health interventions on young mothers. The focus on life skills, learning how to shop for groceries and plan a menu, cook and clean reproduces the understanding that an important role the teen will take on as a mother is that of housewife. Her success as a mother will depend on the extent to which she is able to fulfill this role. 100 legitimates drastic and intensive intervention ranging from public humiliation to child apprehension. Anti-smoking campaigns garner even more intensity when gender runs into class. The additional message: "Smoking is expensive" is added on with the implication that the teen mother should not be wasting her money on cigarettes. B y spending her limited finances on cigarettes for herself, the teen mom is conceived as literally taking food out of her baby's mouth. If she is on social assistance, she is committing an act of aggression against taxpayers by using her benefits to selfishly serve her own addiction. With the good intention of promoting optimal health outcomes for infants, health care providers reproduce gender relations that are ultimately restrictive and oppressive. Poverty is conceived of as a lifestyle choice produced by irresponsible choices about allocating finances. There is seemingly no inquiry into the role that cigarettes play in the lives of young women despite research that note that, for poor women, smoking may symbolize the only break that they have in a day and the only money they spend on themselves. Women report that smoking brings calm and relief and reduces the level of conflict in their homes. Typical anti-smoking campaigns do not address the issue of the lack of pleasure in the lives of teen mothers and the implications of this. It's all about you. . . Consistent with health promotion's preoccupation with the lifestyle choices of the individual, interventions are generally focused on personal transformation. While the individual is conceived of as facing personal barriers such as poverty, poor nutrition and violence, these obstacles can be overcome by a stronger psychology, more efficient use of resources and a more extensive 'tool box' of life skills. The prevalence of the discourse that interprets teen pregnancy and motherhood in psychological terms is indicative of the foundational belief of health promotion that, i f something can be modified in the psyche and behaviour of the individual, outcomes wi l l somehow be different. The adolescent that receives sufficient counselling regarding the issues arising from her deprived background can overcome them. 101 Therapeutic interventions are almost invariably linked to a mandate to 'empower' the adolescent to be a better mother to her child. In contrast to more traditional version of public health, which utilized overt forms of social control to accomplish its aim, the health promotion of today draws on the language that denotes less of a top down approach. The goal of 'empowerment' is to engage people in a way that facilitates discussion and the building of skills through group activities. Phrases such as 'community development', 'participation', 'leadership training' and 'dialogue' elicit notions of freedom and egalitarianism. The role of health professionals is to 'nurture' health promotion by helping people to develop 'personal skills ' to make 'healthy choices' by providing information and education, thus 'enabling' people to 'exercise more control over their own health and over their environments'. (Lupton, 1995, p. 58) The language of empowerment was very present in the texts, as it is in the more general discourse of marginalized youth work. It is based on research that states that adolescents are more likely to respond to health messages when they are implemented in ways that are non-authoritarian and validating of youth experience. Empowerment techniques included various brainstorming activities, the acting.out of scenarios, sessions on personal decision-making and activities on value clarification. Firstly, what became clear was that the language of empowerment denoted equality and democracy that served to mask the power differential between client and public health worker. It obscured the intervention and real investment of public health workers in instructing people to develop skills and exercise control. The 'ski l ls ' that people are intended to develop are, to a large extent, predetermined by globalized notions of what is healthy and unhealthy. It also masks a moralism that is associated with interrogating people's lives for the reasons they choose to eat certain foods in certain quantities, smoke and engage in sexual activity. Secondly, an empowerment discourse is only empowering when it is accompanied by interventions that address the underlying issues of social injustice. 102 Decontexualizing the individual and psychologizing their concerns is a limited approach that does not address structural aspects of racism, classism and sexism that contexualizes their lives. To be instructed to 'exercise control over the environment' and choose healthier lifestyles when being faced daily with confounding factors of poverty, isolation and stigma can often result in an overwhelming sense of failure i f one does not succeed. According to Michelle Fine (1987), the depoliticizing and psychologizing of young people's lives only serves to reinforce alienation, something that health promotion is presumably hoping to prevent. Implications for practice A critical approach to health promotion Because of its close link to biomedical sciences and positivistic forms of data collection, health promotion has largely excluded itself from critical, theoretical and interpretive criticism. According to Lupton (1995), while health promotion is subjected to internal and external political critique, the debate tends to be narrowly conceived as balancing the rights of the individual and society's measures to improve the standard of public health. A t its most conservative, health promotion is seen as a way o f reducing the financial burden on the economy by directing individuals to take personal responsibility for their own health. A t its most radical, health promotion is conceptualized as a vehicle for social change by shifting the relationship between the state and citizens, moving 'health' out of institutional medical care back into the hands of the community. What is missing is a genuine contest of the epistemology and ontology at the foundations of health promotion. There is no meaningful attempt to question whose voices are being heard and privileged, what body of expertise is cited in support, what counts as official knowledge as well as how it is authenticated, controlled and disseminated, who has access to this knowledge, and who decides how it is taken up and used by health practitioners. (Lupton, 1995) I propose that, in order for the institutions of health promotion and, by extension, health care providers, to engage with teen mothers more effectively it requires a 103 fundamentally self-reflexive and self-critical approach to examine the process and impacts of interventions. One point of entry could take up Fraser's (1989) critical analysis of needs interpretation; where the health needs of teen mothers have been constructed as self-evident and depoliticized by the health care system. Critical reflection on the way that the interpretation of the needs of teen mothers reinforces inequities between health care providers, health promoters and teen mothers and whose version of 'needs' is deemed to be authoritative is urgently needed. The media is dominated by discourses of the expert and non-hegemonic discourses about the needs of teen mothers are exceptionally difficult to find. A critical re-evaluation of health promotion would seek to validate, what Fraser calls, oppositional discourses that present contesting interpretations of needs that "challenge, displace and/or modify hegemonic ones." (Fraser, 1989, p. 166) These discourses could be explicitly feminist and anti-racist, taking up positions that centralize the political nature of needs, and critique the nature of a capitalist system in which single young women are impoverished, revealing how the welfare system inappropriately judges teen mothers, reinforcing their isolation. The right to choose for all people and the way that this right has been unequally applied to wealthy women (Kelly, 2000) is also part of this oppositional discourse. One oppositional discourse, whose thread is seen woven through the analysed documents, is the notion that adolescent mothers are mothers who are very likely to thrive when the larger, systemic issues in their lives are addressed. Like all mothers, they require appropriate social support. Statistically they come from and live in poverty, therefore they should be provided with sufficient financial resources and proper housing in which to raise their child. These discourses could link the child poverty initiatives to the needs of mothers. L ike all youth, they should have the chance to finish high school without feeling shamed. Like all those who have been silenced and marginalized, teen mothers should be advocated on behalf of and supported in their self-advocacy. A cumulative reading of the policy and research documents published by Health Canada in the past ten years indicates that the Canadian government is well-informed about the multiple levels of intervention needed to take up the cause of teen pregnancy 104 prevention and support for teens when they become pregnant. There is general acknowledgement that the issue of teen pregnancy should not be framed it as a moral issue, a 'problem' solved by implementing abstinence-only sexual health education programs. There is a disjuncture, however, between the suggestions and directives o f the various studies and reports printed at a federal level, and what filters down to the primary sites of education, the individual schools, and bodies primarily responsible for the policy regard and allocation of social assistance for young parents. Good policy must be followed up by a critical approach to health promotion, one that does not reduce adolescent parenting to a series of unhealthy lifestyle choices. A cautionary note A s a former employee of a non-profit agency, I am always aware of the short sightedness o f holding public health providers and social service workers personally responsible for the inadequacies of health promotion strategies. Workers and programs, especially in recent years, are profoundly constrained in what they are able to offer in terms of services. While health care providers might have an awareness of the larger issues at play in the lives of teen mothers, they are severely restricted in the amount of time, energy and resources they can dedicate to social transformation. In the era of 'accountability', granting agencies and governments require that a number of deliverables be produced; deliverables that are far more concerned with the numbers of teen mothers that programs can deposit in the job market, the number who quit smoking, etc. Limitat ions of Study This research is limited primarily by the number of texts I was able to analyze given time and resources as well as the scope of my research. While I attempted to seek out texts that were widely read and that spoke to the topic I was concerned with, I acknowledge there are many other sites in which nurses engage in knowledge exchange. Because I made the decision to look primarily at 'mainstream' health promotion, for example, I did not engaged in the analysis of publications that took alternative perspectives of nursing practices with young people. The other body of text that I chose not to include, due to its inaccessibility, were nursing electronic list-serves. Future Research A s this critical discourse analysis of teen mothers in the health care system indicates, health promotion focuses on women as being responsible for the health of men and of children. The health promotion discourse has been powerful in creating women, especially young women and especially mothers, as disembodied subjects who should be solely concerned with the impact of so-called risky activities on others. Future discourse analysis is needed to more deeply investigate health promotion campaigns (anti-smoking, sexual health) campaigns directed at young women and the material effects. A follow-up study to this discursive analysis of teen mothers within the Canadian health system could take an approach of ethnography, one that asks questions of health care providers and adolescents about their lived experience. It would look at the meaning behind various activities and different understandings of health policy. This research would delve into the contradictions present in the 'data' and provide a rich description of the interaction between institutions and those that pass through its space. In Closing This research has been an opportunity to critically reflect on my practice with teen mothers and all of the young people with whom I work. I had the chance to consider the process of marginalization and the factors that exacerbate and mitigate it. Through this learning I have transformed my ideas about what it means to be part of giving teen mothers a better chance at fulfillment and happiness. Being in solidarity with young mothers and acting as a political ally is more important than teaching lifeskills. I have been inspired to spend more time listening to what young mothers think about, and their own articulations about what they need. 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Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-24 1997, Winter. B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-24 1998, Spring. B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1.-26 121 1998, Fall . B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-24 1999, Winter. B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-17 1999, Spring/Summer. B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-27 1999, Fall . B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-25 1999, Winter. B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-29 2000, Spring/Summer. B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-24 2000, Fal l . B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-23 2000, Winter. B. C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-28 2001, Spring/Summer. B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-22 2001, Fal l . B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-18 2002, Spring/Summer. B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-25 2002, Winter. B.C. Alliance Concerned with Early Pregnancy and Parenthood (BCACEPP), 1-22 122 

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