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FORUM Physicians Lead Sexual Health Education in Chile Tarayn Grizzard Photo by Jeff Cleary Improved health outcomes and other benefits of CEMERA, a reproductive and sexual health education program at the University of Chile, underscore the importance of physician activism and direct involvement in community health. This success has implications for physicians struggling with similar issues in the United States. In an ideal situation, adolescents receive basic knowledge about reproductive and sexual health in a supportive home environment, and their understanding is reinforced in the educational setting and augmented as needed within the health care system in facilities developed to address adolescent needs. A lack of any one of these factors might be detrimental to health care delivery for this age group and could directly affect outcomes. These factors were a concern in Chile during the mid- to late 1980s, when burgeoning economic success and an increasingly developed infrastructure over the previous 50 years had resulted in a healthier population, earlier menarche, and higher rates of adolescent pregnancy. These rates rose to as high as 14 percent, and the consequences were particularly serious because abortion is illegal. In 1995, for example, more than one third of maternal morbidity among Chilean adolescents was directly attributable to illegal abortion. In the home, due to cultural modesty, families tended to be reticent about discussing sexual topics, and resources outside the home to address sexual issues were sparse. No distinct centers for young persons existed at this time, and as a rule, health centers were not equipped specifically to manage and assist adolescents with sexual health. Serving Adolescents In 1991, the CEMERA (Centro de Medicina Reproductiva y Desarrollo Integral del Adolescente) was established to combat this suboptimal care, particularly for those already pregnant or at high risk for an unplanned pregnancy. The goals of the clinic were to provide excellent care for adolescents seeking reproductive and sexual health and to prevent adolescent pregnancy. The center saw initial success in decreased perinatal morbidity and mortality among the adolescents and increased knowledge about contraception and reproduction in the patients at the clinic. Re-centering physicians in the community may provide better health for patients, better health education, and more effective leadership through physician involvement. --Taryan Grizzard Yet despite the clinic's easily accessible location in Santiago, low patient fees, and strict patient confidentiality, few adolescents proactively sought contraception at the center. The apparent cause of this failure was the clinic's difficulty in promoting and networking its resources within local secondary schools. CEMERA consequently launched a comprehensive reproductive and sexual health program in 1996 aimed at the schools, with the goal of providing reproductive and sexual health education and measuring the impact of the program. More than 4,000 students in greater Santiago were followed over the 33-month intervention, which was approved by the Ministry of Education. Results showed significantly decreased rates of initiation of sexual activity among males and females, a 5.6 percent reduction in pregnancies, and a 13.8 percent reduction in abortion. With these successes as a backdrop, CEMERA has continued to develop its comprehensive reproductive and sexual health education programs and enjoys the trust of local schools, the Ministry of Education, and most importantly, adolescents in the Santiago area. These relationships have enabled CEMERA to forge ahead with programs for teachers and administrators. This trust has also laid the groundwork for promoting and discussing sexuality education, including gay, lesbian, bisexual, and transgender (GLBT) identity issues within the schools, with teachers and administrators being the primary target audience. This topic is particularly controversial in Chile, where the recent shocking addition of an openly gay character on the TV series Machos was discussed on innumerable radio talk shows and major magazines. Better Community Medicine Direct physician service through health education, coupled with appropriately designed and practical outcome measures, enabled CEMERA to build a relationship locally and address topics that otherwise would likely not have been addressed. What is most striking about the CEMERA programs is the impact that health care providers have made as role models for adolescents and community leaders, the utility of using the medical context as a neutral substrate for dealing with controversial issues, and the improved health outcomes. In the United States, this type of direct service and community level intervention has been seen among some physician groups, particularly family physicians whose Tar Wars programs place community physicians in local schools to educate students about the dangers of tobacco use. Such direct service and intervention in U.S. communities might result in improved sexuality education in more conservative areas of the country where such issues are less likely to be discussed openly and the benefits for young people struggling with GLBT issues may be greater. More generally, re-centering physicians in the community may provide better health for patients, better health education, and more effective leadership through physician involvement--not to mention the greater personal satisfaction physicians might find as more visible servants of the community. --Tarayn Grizzard, a fourth-year medical student at HMS The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.