HIGH STAKES, SILENT SYSTEMS: An Imprint review of 50 state policies and interviews with dozens of current and former foster youth, child welfare experts, officials and legal advocates reveals a troubling lack of critical guidance. Part one of a three-part series; read part two here and part three here.
Foster youth check in with social workers at least once a month. Judges and attorneys track their movements in court reports and databases — from school attendance to visits with parents and siblings. Local, state and federal regulations govern virtually every aspect of their lives.
Yet when tens of thousands of American teenagers move through adolescence and young adulthood, state foster care systems that have stepped in as temporary parents remain notably silent on even the most basic aspects of sexual and reproductive health.
An Imprint review of every state’s publicly available child welfare policy manuals revealed that in many parts of the country there is only scant guidance for caregivers and caseworkers on these vital issues. In dozens of states, there is little or no mention of healthy relationships and sexuality education, the prevention of sexually transmitted infections or the rights of foster youth to access contraception and abortion. In some states, policies have not been updated in decades. In others, rules for foster youth appear to clash with broader reproductive health care rights available to all minors.
“I wasn’t taught about sex growing up in foster care, and I didn’t know to ask — you’re kind of just doing what you think people want you to do, so you have a place to stay,” said Phillisha Kimbles, a 27-year-old California mother, certified nursing assistant and psychology student at Riverside City College.
Kimbles went on to develop a federally funded sex education curriculum for foster youth, and she is a youth leader for the California-based Reproductive Health Equity Project. But she grew up largely self-taught, as she guided three younger siblings through their adolescence.
“I didn’t learn boundaries until I was 19,” Kimbles said, “and even then it was hard to set them and talk about them, and to tell my partner what I’m OK with.”
States such as Minnesota, Delaware, Montana and Colorado exemplify the lacking information in great swaths of the country. In these states, thousands of pages of policies provide detailed requirements and best-practice guidance for child welfare staff and caregivers. Protocols are regularly updated on foster parent training, health care and education.
And while they address how to serve expectant and parenting young people, they are among 10 states with no publicly available policies ensuring all foster youth have received age-appropriate education on sexuality and relationships. Such information is broadly considered “a core developmental milestone for child and adolescent health” and recommended by the American Academy of Pediatrics and other reputable medical associations.
In Rhode Island, the state’s Department of Children, Youth and Families devotes 750 words to “Issues of Sexuality and Pregnancy Affecting Youth in DCYF Care.” But the policy hasn’t been updated since 1988.
The lack of guidance leaves frontline workers and foster parents responding as they see fit — saying nothing, or relying on personal or religious values, even if they conflict with public health guidance or minors’ legal rights.
In states without clear guidance, confusion is commonplace, according to interviews with more than four dozen current and former foster youth, experts, state officials, and legal advocates: Some local officials say schools shoulder the responsibility for sex ed — despite the fact that foster youth often experience spotty attendance or are moved between numerous schools while in the system. Other agencies defend their positions by stating that judges must be consulted when birth parents’ custody rights have not been terminated.
The information void is striking, given who these child welfare systems serve. When compared with the general population, young people in foster care are at higher risk of poor health outcomes, sexual abuse and broken or frayed social relationships.
All too often, silence, coercion and false information from peers and social media fill the knowledge gap, leading to significant consequences.
“Not having policies in place has created a really confusing landscape for social workers, group home workers and for foster parents,” said Elizabeth Aparicio, a public health social work scholar at the University of Maryland who has studied sexual health, pregnancy, and parenting in foster care. “There’s this sense, ‘maybe somebody else is just doing this; I don’t know how to, and I’m not sure if I’m going to harm them.’”
A rare look at foster care policies
To conduct its review, The Imprint searched tens of thousands of pages of publicly available information from websites and policy manuals. Keywords searched in each document included “sex,” “sex education,” “reproductive,” “pregnancy,” “prenatal,” “contraceptive,” “birth control,” “family planning” and “abortion.” The review may have missed some policies or staff training materials in states that have limited publicly available information.
Thirty-nine state child welfare agencies were asked to provide any additional relevant documents or initiatives. New Hampshire, New Jersey, Hawaii, Iowa, Kentucky, South Dakota, Georgia, Kansas and the District of Columbia’s child welfare agencies did not respond to calls and emails. Other states provided some additional material, or confirmed that The Imprint’s analysis relied on all relevant documents.
Some themes stood out from the policy review:
- Too little, too late. In 28 states, there is little or no mention of sexual health education. In those states with brief references, they apply only to youth in group facilities, those aging out, or who have already become pregnant or HIV-positive.
- Confusion reigns. Fewer than half of states mention contraceptive access for minors in foster care, amid widespread confusion about their right to consent to prescription birth control confidentially.
- Unequal standards. Some states describe foster youths’ legal right to contraceptives or abortion services in a manner that is misleading, incomplete or outdated. At least four states impose explicit authorization requirements on foster youth that appear at odds with the rights of all minors, such as needing judicial approval for birth control.
Teenagers make up roughly one quarter of the nearly 400,000 children and youth through age 20 in the nation’s foster care system, according to the most recent federal data. Those numbers include more than 12,000 who remain in foster care past age 18.
Given their numbers and high rates of poor health outcomes, Amy Dworsky, a leading scholar of pregnancy and parenting in foster care with Chapin Hall at the University of Chicago, reacted to The Imprint’s investigation with alarm.
“These findings highlight all the barriers young people in care face to accessing reproductive health care that their peers don’t,” she said. “The situation looks ripe for a lawsuit since, in some states, young people in foster care appear not to have the same rights to reproductive healthcare as their peers who are not in foster care.”
“You grow up in the foster care system, with a caseworker, in a doctor’s care — you might have lots of people in your life — yet you have no idea about your own body and what you are going to experience very soon.”— Sarah Pauter
The outliers: states with detailed guidance
California and New York stand out for having some of the most explicit and detailed requirements in regulations or state statutes. Smaller states such as Connecticut and Tennessee have also issued detailed guidance.
In Arizona, the Department of Child Safety (DCS) requires that foster teens receive “family planning information” within 10 days of being placed in foster care and “in a manner free from coercion or mental pressure.” It is also one of the only states with a policy for expectant fathers who are still in foster care.
Arizona’s policy notes the child welfare agency’s responsibility to these young adults, stating: “DCS Specialists and out-of-home caregivers share with the schools the responsibility of educating and preparing children in out-of-home care to function as self-sufficient, competent adults.”
Unlike the vast majority of states, Kentucky’s sex education policy requires social service workers to document “The type of instruction; Who provided information to the child; and When the instruction occurred.”
Eltuan Dawson of Kentucky grew up in the child welfare system and works as a youth advocate. In his role as a youth development specialist, he trains young people on Love Notes, a curriculum promoting healthy relationships that has shown promising results.
In foster care, “you can carry feelings like, ‘I’m not good enough.’ And that enables exploiters,” the 28-year-old said. “Even when it comes to teenage girls in foster care not being able to choose the tampons or pads that they need — there’s a lot of dominance and control.”
In his adult life, Dawson said he “had to relearn how to love myself the way I did when I was a kid.” But his growing consciousness paid off: “Being able to understand the gravity of boundaries and being able to set them can keep you safe.”
States defend their silence
Child welfare agency officials in states lacking detailed policies for sexual and reproductive health education and services defended their hands-off approach. Their spokespeople argued that schools provided sex ed, or, as in the case of the Minnesota Department of Human Services, stated the agency “does not have the rulemaking authority” to require such programs for county-run child welfare agencies.
Washington’s Department of Children, Youth and Families spokesperson highlighted a significant recent expansion of school curriculum requirements statewide, and guidebooks advising youth of their rights.
Other state agency representatives said one-size-fits-all policies might be harmful to young people who have a wide range of backgrounds, experiences and needs. A Delaware official said the state didn’t “see the need to single out youth in foster care” for more specific guidance on reproductive health care consent laws. Others noted that professional caseworkers may lack the necessary training and expertise to navigate these sensitive topics.
“We are experts in child abuse and neglect, we are not necessarily experts in how to help an adolescent navigate their sexual identity or a pregnancy or any of those things,” said Korey Elger, permanency manager at the Colorado Department of Human Services. “We encourage social workers to have those sorts of conversations, but we don’t mandate them.”
Elger said her agency has improved its approach since adding public health experts to the staff, part of a federally funded teen pregnancy prevention program. But schools, the children’s lawyers, and birth parents also share responsibility, she added, since most families are ultimately reunified after foster care.
Noting how complex the issues can be for even the most caring of caseworkers, Elger described a 13-year-old foster youth seeking birth control, despite a birth parent’s opposition.
“At the end of the day, it’s a constitutional right for a parent to parent their child,” she said. “Even if parents don’t have custody, they still have to be consulted on those decisions.”
Yet in a sign of the double standards that exist for foster youth in some parts of the country, in Colorado, state law allows minors to obtain contraceptives with no adult involvement. Colorado is one of 23 states, along with the District of Columbia, that do not require parental consent or notice for any minor; its law, amended in 2019, makes no exception for foster youth.
Sheri Danz, deputy director of the Colorado Office of the Child’s Representative — which represents foster youth in court — responded sharply to Elger’s remarks.
“The fact that youth have attorneys to advocate for their rights does not provide justification for imposing unnecessary and unauthorized obstacles on access to reproductive health care,” Danz said.
“There seems to be an assumption that parents or schools are handling this, but that’s often not the case.”— Lonnell Schuler, Program coordinator for Black Women For Wellness
High stakes, high risks
“Foster Youth Need Sex Ed Too!” declared a 2018 study in the American Journal of Sexuality Education, which noted their “history of inconsistent relationships, childhood trauma, and broken support systems.”
Among 270 youth surveyed who had been placed in foster families, group homes or detention settings, just 53.5% were “unaware that condom use can decrease their risk of getting HIV/AIDS and other STIs.” And among those stating they’d had sex, nearly 20% reported “forced sex,” or intimate partner violence in the past year.
“A lot of what I’ve been trying to answer is, how do we get our workers and foster parents to engage youth about their sexual and reproductive health as much as their physical health?” said Nadine Finigan-Carr, the study’s lead author and a prevention research scientist at the University of Maryland, Baltimore.
Lonnell Schuler, a former foster youth, sex educator, and program coordinator for the Los Angeles, California nonprofit Black Women for Wellness underscored the concern. “There seems to be an assumption that parents or schools are handling this, but that’s often not the case,” he said. “There’s often this bias: ‘Our babies don’t have to know this.’ Many caretakers haven’t received sex education themselves. How can we expect them to give medically accurate, culturally relevant information?”
Meanwhile, risks abound. Research led by Dr. Kym Ahrens at the Seattle Children’s Hospital has found that foster youth may be at higher risk of coercive or “transactional” sex and sexually transmitted infections. Her research concluded that having a strong relationship with a caregiver or staying in extended foster care past age 18 decreased risks significantly.
“We have lots of great tools that we’re not using to solve the problems of this country’s young people,” she said in an interview, referring to sex ed curriculums that have been tailored for foster youth and caregivers.
What’s more, in one of the most noteworthy demographic trends in recent U.S. history, since the early 1990s, teenage pregnancy rates have dramatically declined. Yet foster youth become pregnant before age 19 at “significantly higher” rates than their peers, according to a compilation of research published in December. Youth who become parents are also far more likely to be investigated by CPS and have their children removed.
Like the overwhelming majority of all parents, foster youth report immense pride, purpose and sense of belonging after having children. Some mothers in foster care surveyed by University of Maryland researchers also cite the child welfare system as a positive source of “material and emotional support.”
But many experience unnecessary hardship during pregnancy, and are not given the health care they need.
A study published in June in the peer-reviewed Child and Adolescent Social Work Journal examined medical records for more than 4,700 female foster youth in Michigan. The study found that among the 39% who became pregnant by age 18 and delivered a baby, “only 64% received adequate prenatal care.”
The lack of policies and guidance is striking, because the stakes are much higher for teens and young adults in foster care than for youth in the general population.
A field increasingly alarmed
The Supreme Court’s historic June decision in Dobbs v. Jackson Women’s Health Organization — which granted states the option to ban abortion — has heightened alarm among some in the child welfare field.
In a December 2022 blog post, five leading social work scholars noted the reversal of Roe v. Wade “will disproportionately impact” youth in foster care — primarily due to low-cost reproductive health clinics closing in response to new abortion bans. The young people, it stated, already have “fewer trusted adults with whom to discuss sensitive topics.” A month later, the federal government published a report declaring foster youth to be “a population at disproportionate risk of poor sexual health outcomes.”
Revealing a contrast in the sense of urgency, nearly two dozen state agencies queried by The Imprint said they had no plans to update their policies for foster youth in the wake of the Supreme Court’s recent ruling in Dobbs.
“Even though there aren’t a lot of folks being very public about it, there is a whole lot of concern for the child welfare profession with regards to what the Dobbs ruling means, and the tragic situations that could emerge,” said one nonprofit executive in a Midwestern state. The source requested anonymity, citing fear of losing foster care contracts with a state that has fully banned abortion.
A prominent national group of legal advocates for kids in foster care shared their concerns at an annual conference last August, addressing an audience that included Aysha Schomburg, the Biden administration’s top child welfare official. During a keynote panel, “A New Era: Reproductive Health Advocacy in a Post-Roe v. Wade World,” attorneys argued that child welfare systems must take greater responsibility for ensuring access to vital services and information.
‘We need real support’
The Imprint’s review of state policies revealed that widespread confusion persists about foster youths’ right to use birth control or have an abortion. It’s also often unclear who’s responsible for providing services when parents have lost temporary custody but retain some legal rights. At times, the issues are complicated by private faith-based foster care providers that follow religious doctrine on matters such as birth control.
In interviews, current and former foster youth in eight states spoke bravely about these deeply personal matters, in the hopes that child welfare professionals would provide clearer guidance and support to their peers.
Rebekka Behr, 25, of Florida said a faith-based foster care agency barred her from taking birth control as a teenager, and sent her to a Bible camp that preached abstinence. Another group home took a less conservative approach, she said, allowing conversations about who was and wasn’t allowed to use birth control.
“When it comes to these intimate issues, or having any conversations about health, let alone reproductive health, it’s extremely hard,” Behr said. “Nobody listened to us, so I stopped talking about the issues I was going through.”
Behr said she was fortunate, because she had received sex education and support navigating relationships from her parents and in school before entering foster care. She added that youth with vigorous advocates — such as caring caseworkers or attorneys willing to argue with judges — are also more likely to get the support and services they need.
Yet foster youth interviewed for this story also pointed to concerns beyond a lack of information and guidance. They said even when the issue of their sexuality did surface, they felt forced to comply with caregivers’ demands, or denied their reproductive rights. That took varied forms, from not being allowed to access contraceptives to feeling pressured to use them.
“Nobody listened to us, so I stopped talking about the issues I was going through.”— Rebekka Behr, former foster youth
After three years in Georgia’s foster care system, Myka’h Blunt recently reunited with her mother. She came home pregnant with her second child. On a call with her mother and a reporter, the 17-year-old said she felt deep frustration that caseworkers and doctors treated her and her peers as if they had no control over their own bodies or their children.
“We need real support,” Blunt said, “real people who are willing to help, and not for a paycheck or a name.” She said her peers in foster care are given informational pamphlets, but they aren’t enough. Instead, young people teach themselves about sex, relationships, reproduction and their rights, mostly through internet searches.
That information brought her relief, she said, during a chaotic journey through the county foster care system that included stints in a group home, a foster home and overnight stays in a county office building — where she and her peers slept in workers’ cubicles.
Blunt described being turned away from more suitable placements because she refused to take birth control.
“That was forced for me. I could only be on it for so long, because of the side effects,” she said. “And that’s very wrong because I want a say-so with my body. I didn’t think it was fair.”
In some instances, teens have been punished for making their own choices.
Seven years ago, five current and former foster youth sued their group home provider, who they alleged had a policy of confiscating contraception and blocking access to reproductive health care, with staffers insisting on being in the room during ob/gyn office visits. The case resulted in a confidential settlement with the group home and an agreement between the state of California and the National Center for Youth Law over changes to sexual and reproductive health care and education policies.
New York University Silver School of Social Work Associate Dean and Professor Linda Lausell Bryant — who for nearly a decade ran a nonprofit with a Manhattan group home for pregnant and parenting foster youth — said foster youth spend their childhoods feeling like they have little control. Then, when they enter adolescence, they may not feel they are able to make choices, because so often, the decisions have been made for them and the injustice can be even more acute.
“What I found is that foster youth struggle to experience a sense of agency over their lives. They hoped, ‘Maybe when I get out of this system, I’ll have some control over my life,’” Bryant said. “So our programming needed to take that into account.”
Where the feds come in
There is some guidance to the states from the federal government, but it is loosely followed, with little accountability. A 1999 federal law includes requirements that older foster youth be taught life skills, which may include pregnancy prevention. Many states have adapted its regulatory language for their policy manuals. But the programming is broadly defined, and could instead involve “first aid” or “smoking avoidance” instruction. Experts agree it has not supported comprehensive education about sexuality and healthy relationships.
States and nonprofits also regularly receive federal funds for sex education programs designed for foster youth, runaway and homeless youth or those in juvenile detention. But scholars who have evaluated these programs note that these curriculums are not yet widely available to all foster youth, nor consistently tailored to their unique experience.
In an interview, Jessica Swafford Marcella, a deputy assistant secretary at the U.S. Department of Health and Human Services, described foster youth as a “priority population,” given broad findings about health disparities they face. Marcella’s office oversees the roughly $100 million Teen Pregnancy Prevention program, which focuses on foster youth in roughly a third of its grants, she said.
“The financial circumstances that many of our agencies find themselves in are challenging,” Marcella said, “and I recognize that the investments made are not enough to meet demand.”
‘No idea about your body’
The Imprint’s inquiry comes nearly 40 years after a group of researchers completed a similar survey. A 1987 review found only four states had mandated training in adolescent sexuality and family planning for caseworkers. Just five states required such training for foster parents.
After years of working with pregnant and parenting foster youth through her nonprofit, Phenomenal Families, Sarah Pauter of San Diego, California, says the continued silence and seeming obliviousness to reproductive health issues makes life even more difficult for young people in the child welfare system.
Pauter, 33, said when she was growing up in foster care, she couldn’t recall a single conversation with a foster parent or caseworker about sex. More recently, young clients she worked with have told her — even on the eve of delivering babies — that they have no idea what to expect. One teen had never heard of a cervix, let alone the contractions she would soon experience during childbirth.
“You grow up in the foster care system, with a caseworker, in a doctor’s care — you might have lots of people in your life — yet you have no idea about your own body and what you are going to experience very soon,” said Pauter, who now works for the nonprofit John Burton Advocates for Youth. “This is the culmination of failures within our education system when it comes to sexual health education, and also in our child welfare system.”
Sarah Seungju Kim assisted with research for this story.