Pat Lanning has tried everything. She's phoned, written and visited a young mother named Julie to try and get her to bring her children in for checkups at the clinic where Lanning is a social worker.
It's been about six months since Julie has brought her 15-month-old twins and 2 1/2-year-old son to the Western Center for Maternal and Infant Care, and Julie has repeatedly canceled new appointments. It concerns Lanning and pediatrician Carolyn Gould enough that they are trying to get Baltimore's Social Services Department to step in with protective services for the children.
The situation doesn't really surprise them, though, because Julie is only 15 years old.
"Realistically," says Gould, "you can't expect that much from an adolescent."
Although Julie's mother is to a great extent her grandchildren's "caretaker," Gould says, she is not legally responsible for them. That role belongs to Julie because, under Maryland law, adolescent parents are "emancipated minors."
When the law views minors as having the same rights, responsibilities and capacity to consent that adults have, it calls them emancipated. That can mean something as broad as a minor who is living completely independently or something as narrow as a college student who is held responsible for his own credit card bills.
And under a growing number of laws and court decisions, it covers young people who seek medical care and don't want their parents to know about it -- which usually happens, according to speakers and participants at the conference, when they have problems with drinking, drugs or sex.
The sensitive issues surrounding this group of sexually active teens were the focus of a recent conference on "Ethical and Legal Issues in the Health Care of the Emancipated Minor," sponsored by the teen-age pregnancy and parent programs at the Western Center, which is administered by the University of Maryland School of Medicine here.
"We see girls who are 11 and 12 and want abortions and present us with some very ticklish problems," says Angela Holder, counsel for medicolegal affairs and clinical professor of pediatrics at Yale University's School of Medicine. Holder sees numerous 14- and 15-year-olds who come in alone and ask for abortions. And three times as often, she says, pregnant girls come in insisting that they want the baby while the mother insists on an abortion.
"It's now some sign of social status that I cannot understand to have babies," Holder said. A girl who wants to go through with her pregnancy can do so, she added, because "nobody can be aborted without her consent, whether she's 11 or her IQ is 35."
For Holder and many conference participants -- close to 100 doctors, nurses, counselors, administrators and others from the Washington-Baltimore area -- the issues addressed at the conference are daily decisions. In Baltimore, 3,000 teen-age girls become pregnant each year.
At first, Holder says, she had thought education and access to contraceptives would go a long way toward curbing the problem of teen-age pregnancy.
"Never did it dawn on me that they were doing it on purpose," she said. "Never did it dawn on me that when you let them have contraceptives, they would say, 'No, thanks.' "
Nonetheless, the Yale clinic, the Western Center and other organizations across the country are trying to educate adolescents about the whys and hows of contraceptives.
Some of them are glad to be getting the message -- even if late. At the Western Center, 18-year-old Denise (not her real name) held her squirming 3-year-old son, Kevin. She says she loves him but that being a teen-age mother is "not fun. You miss out on a lot of things." Denise had dreams of medical school when her pregnancy "just happened." She is still planning to begin nurse's training after she graduates from high school next year.
Lately, she says, she has been giving advice to a 16-year-old friend who seems uninterested in contraception. "I tell her that if you're going to be sexually active, it's better to be prepared than wait until it's too late and wish you'd done it."
If Denise's friend chooses to follow the advice, she'll probably have no trouble getting contraception. Holder notes that court cases over the past several years have held that "an adolescent girl has a constitutional right of privacy to contraception if she's old enough to get it together to ask for it."
Courts have established that right by throwing out so-called "squeal rules," requiring health care professionals to inform parents, and get their consent, before treating minors.
All 50 states have enacted laws, Holder says, that let health care professionals treat adolescents for venereal disease without getting parental consent or the assurance of payment from the parents. Most states have similar laws regarding treatment for drug or alcohol problems.
Beyond that they vary. In Maryland, for example -- where Denise's friend lives -- minors also may consent to treatment for or advice about both pregnancy and contraception (other than sterilization); they may do the same regarding examination, treatment and obtaining evidence of an alleged rape or sexual offense.
The question of sexual offense is one of the more difficult aspects of teen-age sexuality. Holder says the Yale clinic is particularly cautious and thorough with girls under 14 because "we have not seen an 11- or 12-year-old girl coming into our clinic asking for some kind of gynecological services . . . who has not been the victim of some kind of incestuous or semi-incestuous behavior," such as a rape by a mother's boyfriend.
"A sexually active 12-year-old girl is in trouble . . . and vulnerable to exploitation," Holder said.
Although adolescents may be legally emancipated when they ask for birth control pills, Holder says, "Most of these girls don't want pills, they want help. When they come in, they say, 'I want pills.' What they're really saying is, 'Stop the world and let me off.' "
As those at the conference emphasized, a law on the books is not an answer to everything. "The puzzles are more complex than we thought," says H. Tristram Engelhardt Jr., a bioethicist and professor at Baylor College of Medicine in Houston.
Engelhardt says laws tend to avoid, not endorse, adolescent sexual activity. A state's message in enacting an emancipation law, he says, is not that "it's a neat thing for kids to have autonomy to go down and buy condoms," but rather that "if you can't figure out how to keep them from buying contraceptives, don't come to us.
"The state can't solve all problems of families, and problems of adolescent sexuality in particular. We need to give a place and authority for health care professionals to solve the problems they can solve."