One in Eight U.S. Adolescents Has Considered Suicide

By Kelly Young

    One in eight U.S. teens has seriously considered suicide, and one in 25 has attempted it, according to a study in JAMA Psychiatry (formerly known as Archives of General Psychiatry).

    Nearly 6500 adolescents (aged 13 to 18) were surveyed about their lifetime history of suicidal behaviors and mental disorders. Among the findings:

-A third of those who considered suicide go on to make a plan, and nearly two thirds of those with a plan attempt suicide.

-Most of those who attempt suicide do so within a year of first considering it.

-Roughly 90% of suicidal adolescents had at least one of the 15 mental disorders included in the survey, most commonly depression.

-Between 55% and 73% of suicidal adolescents received some form of treatment before symptom onset.

    Asked to comment, Barbara Geller of Journal Watch Psychiatry wrote: "Because most suicidal teenagers were in treatment, the need for developing effective prevention and intervention is pronounced. Until then, families may benefit from education about the need for vigilance and for sensible precautions such as gun-free homes."

First Published in Physician's First Watch January 10, 2013

Religious Freedom and Women's Health — The Litigation on Contraception

By Timothy Stoltzfus Jost, J.D.

Health policy experts widely agree that health care should not merely be sickness care; rather, it should actively prevent disease and preserve wellness. Not surprisingly, therefore, the Affordable Care Act (ACA) contains an entire chapter dealing with prevention and public health. The ACA also improves private and public insurance coverage of preventive care. One preventive care requirement, however, has caused a major headache for the Obama administration. Indeed, it has provoked charges that the administration is waging “a war on religion.”

The ACA requires private insurers and group health plans (except for “grandfathered” plans, defined as those that existed at the time the ACA became law and have not significantly changed) to cover preventive services without cost sharing by enrollees. This provision does not list the covered services, instead referencing the recommendations of other federal agencies that deal with prevention. It specifically requires coverage of women's preventive care and screening services “provided for in comprehensive guidelines supported by the Health Resources and Services Administration” (HRSA).

At HRSA's request, the Institute of Medicine (IOM) identified women's preventive services that should be covered.(1) On August 1, 2011, HRSA released guidelines based on the IOM's recommendations. Among the services that health plans and insurers must cover are “all Food and Drug Administration–approved contraceptive methods.” Coverage must be available for plan years beginning after August 1, 2012.

Requiring contraception coverage is not a radical innovation. Twenty-eight states currently require insurers (with some exceptions) to cover contraceptives. (2) The Equal Employment Opportunity Commission has also concluded that contraception coverage is required by the Pregnancy Discrimination Act, although federal courts have come to contradictory conclusions on this question. But contraception is considered to be a “grave sin” by the Roman Catholic church, and a number of Protestant organizations object specifically to “morning after” contraceptives and intrauterine devices, which they consider to be abortifacients.

In final rules and guidance issued in February 2012, the Department of Health and Human Services (DHHS) recognized these concerns. First, it excused from compliance with the contraception requirement “religious employers,” defined to include churches and other nonprofit entities that exist for the inculcation of faith and primarily serve and hire adherents to a particular religious faith. Second, it imposed a moratorium until August 1, 2013, on the application of the requirement to “religious organizations” — nonprofit entities such as universities, hospitals, or charities run by religious groups that do not limit the population they serve and employ to adherents to their religion. In March, the DHHS published an advance notice of proposed rulemaking committing itself to finding an approach that would ensure employees of religious organizations (and students in religious universities) access to contraception without requiring the religious organizations to pay for it. Such organizations might, for example, be excused from paying for contraception coverage while the insurers that offer their group plans covered contraceptives using the savings they accrued from not covering unplanned pregnancies.

This approach was not acceptable to organizations that object to contraception. Forty federal lawsuits have been filed challenging the contraception policy.(3) Most have been filed by religious organizations that do not qualify for the religious-employer exception. A number, however, have been filed by for-profit businesses whose owners have personal religious objections to contraception. The governors of seven states joined one lawsuit supporting the religious-organization plaintiffs.

Although the claims in these lawsuits are fundamentally grounded in the right to religious freedom enshrined in the First Amendment, they are not primarily constitutional claims. The Supreme Court decided more than two decades ago that the First Amendment does not prohibit a “neutral law of general applicability” that burdens religious conduct.(4) Rather, the litigation is based primarily on the Religious Freedom Restoration Act, which Congress adopted in response to that Supreme Court decision. This Act prohibits the federal government from substantially burdening the free exercise of religion unless it establishes that a requirement “is in furtherance of a compelling governmental interest” and “is the least restrictive means of furthering” that interest.(5)

To date, district courts have issued decisions in 11 cases (see Federal Court Cases Challenging the Preventive Services Mandate of the Affordable Care Act), with more being decided every week. The courts have dismissed as premature claims brought by religious organizations in 6 cases. These organizations are still protected by the moratorium and have therefore not yet suffered an injury. Because the DHHS has not yet decided how it is going to handle the religious-organization issue, the dispute of these organizations with the agency is not yet timely. They can return to court once the DHHS announces its final rule if they are not satisfied. One court, however, has held that religious organizations are already injured by the rule and can sue.

The cases brought by the secular employers are more problematic. District courts in three of these cases have issued a temporary order prohibiting the federal government from forcing the employer to comply with the contraception requirement while the court considers the case. One other court has dismissed a secular-employer case on the merits, although its decision has been stayed by a federal appellate court. Another court denied a preliminary injunction, holding that the employer was unlikely to succeed on its legal claim.

One issue in the secular-employer cases is whether a private, secular, for-profit corporation can hold protected religious beliefs. The Supreme Court has held that corporations are protected by the First Amendment's freedom-of-speech provisions, but corporations are not protected by other constitutional provisions, such as the Fifth Amendment right against self-incrimination. In one of the contraception cases, the court held that a secular, for-profit corporation cannot hold a religious belief. In other cases, however, the courts have allowed privately held corporations to assert the religious beliefs of their individual owners. These decisions run contrary to the general approach of the law, which refuses to “pierce the corporate veil” separating corporations from their owners.

Another issue is whether the contraception requirement furthers a compelling governmental interest and is the least restrictive means of doing so. The government argues that the requirement promotes a compelling interest in public health, citing the IOM's conclusion that family planning provides health benefits for both women and their children. It also contends that the rule promotes gender equity, freeing women from a significant expense that men do not incur and giving them greater freedom to pursue their life plans. Courts that have enjoined the enforcement of the requirement, however, have asked why, if the interests the law promotes are compelling, it excludes from protection millions of employees who are covered by grandfathered plans or who work for religious employers or for small employers (which are not required to provide health insurance). One court also suggested that the government's goal could be achieved through a public program instead of employer coverage.

Perhaps the most interesting question, however, is whether the requirement substantially burdens the religious beliefs of employers. Two courts have observed that the rule does not require employers to use contraceptives or even to approve of their use. It asks the employer only to make a benefit available, which the employee must then decide whether or not to use. Employers object, however, that they should not have to pay for services that they consider to be morally wrong. The question of whose interests and beliefs — those of the employer or those of the employee — ought to determine access to contraception benefits is one that the courts, and no doubt ultimately the Supreme Court, will have to decide.

1-Institute of Medicine. Clinical preventive services for women: closing the gaps. Washington, DC: National Academies Press, 2011.2-Guttmacher Institute. State policies in brief: insurance coverage of contraceptives. New York: Guttmacher Institute, 2012 http://www.guttmacher.org/statecenter/spibs/spib_ICC.pdf
3-The Becket Fund for Religious Liberty. HHS mandate information central. Washington, DC: The Becket Fund, 2012 http://www.becketfund.org/hhsinformationcentral/
4-Employment Division, Department of Human Resources of Oregon v. Smith, 494 U.S. 872, 879 (1990).
5-42 U.S.C. § 2000bb-1(b).

FEDERAL COURT CASES CHALLENGING THE PREVENTIVE SERVICES MANDATE OF THE AFFORDABLE CARE ACT.

• Courts have dismissed five cases brought by religious organizations that are covered by the current moratorium because their challenge is premature: State of Nebraska v. Sebelius (U.S. District Court for the District of Nebraska, July 17, 2012); Belmont Abbey College v. Sebelius (U.S. District Court for the District of Columbia [D.D.C.], July 18, 2012); Wheaton College v. Sebelius (D.D.C. August 24, 2012); Catholic Diocese of Nashville v. Sebelius (U.S. District Court for the Middle District of Tennessee, November 21, 2012); Zubik v. Sebelius (U.S. District Court for the Western District of Pennsylvania, November 27, 2012).
• One court has permitted claims brought by some religious organizations to proceed: Roman Catholic Archdiocese of New York v. Sebelius (U.S. District Court for the Eastern District of New York, December 4, 2012).
• One court has dismissed a claim brought by a for-profit employer as not stating a legal claim: O'Brien v. United States Department of Health and Human Services (U.S. District Court for the Eastern District of Missouri, September 28, 2012). A federal appeals court has stayed this decision (U.S. Court of Appeals for the Eighth Circuit, November 28, 2012).
• In two cases brought by for-profit employers, the court has granted a preliminary injunction blocking the enforcement of the mandate until the court can give the case full consideration: Newland v. Sebelius (U.S. District Court for the District of Colorado, July 27, 2012); and Tyndale House Publishers v. Sebelius (D.D.C. November 16, 2012).
• In one other case, the court granted a preliminary injunction to a for-profit employer but denied relief to a religious-organization plaintiff that is protected by the moratorium: Legatus v. Sebelius (U.S. District Court for the Eastern District of Michigan, October 31, 2012).
• In one other case, the court denied a for-profit corporation's request for a preliminary injunction, finding that corporations did not have protected rights under the Free Exercise Clause and that the individual plaintiffs did not show a likelihood of success on their legal claim: Hobby Lobby Stores, Inc. v. Sebelius (U.S. District Court for the Western District of Oklahoma, November 19, 2012).

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

This article was published on December 19, 2012, at NEJM.org.

SOURCE INFORMATION From Washington and Lee University School of Law, Lexington, VA.

Developing Women Leaders: Five Essentials

by Lucy P. Marcus

We need to make sure we are investing time and energy to developing future generations of women for leadership. There are five universal factors that make a real difference in encouraging young women to reach success.

We need to make sure we are investing time and energy to developing future generations of women for leadership. As Warren Buffett notes, harnessing the talent of women is key for building strong economies. There are five universal factors that, no matter where people are, where they are from, or what sector they are in, make a real difference in encouraging young women to reach success.

Though successful women are often prone to credit luck for their success, it is mostly hard work and perseverance that brings women to the top of their field, be they artists, scientists, entrepreneurs or academics. These are the women who never settle for the mediocre, are perpetually restless and striving, and who know that real success can only be found by crossing time zones, cultures, and cruising through stop signs.

The most successful women in the world have grabbed every opportunity afforded to them, and have created opportunities for themselves, harnessing their fears and doubts as rocket fuel instead of rocks in their pockets.

The factors that contribute to the development of the next generation of women leaders can be gleaned from their experiences.

Some of the characteristics of successful people, such as motivation, natural curiosity, courage, self-management, enjoying being stretched and rising to a challenge, personal will and fortitude, drive, and flexibility may be innate, but there is no doubt that these characteristics also need to be nurtured and encouraged.

Five factors stand out that help to support developing women leaders. Not particularly costly or demanding, they have proven to be very effective.

1. Basic Skills

There are certain basic skills that everyone should be given access to beyond the standard education. We need to ensure that young women have access to building these skills that help them move to success early in their careers. These include public speaking, writing, negotiation, and effective networking. People might have nature skills in some of these areas, but if not, then seeking out courses and opportunities to practice these skills is worthwhile. Also, some employers will give women access to courses in these areas through career development opportunities, but that can often be in their mid-career, and it is actually more valuable and impactful if it started earlier on. If these are not forthcoming from work, they are worth seeking out independently.

2. International Exposure

Travel brings an invaluable exposure to other cultures and ways of thinking. It is essential for advancement in any profession, even in those that seem local, cloistered, or sheltered. This is particularly the case as the world becomes increasingly globally interdependent and actions that occur in a place that seems far away, inevitably affect, directly or indirectly, everyone. International experiences challenge thinking and certainty in a way that can be very healthy. The skills that come from living and working in unfamiliar settings are valuable in themselves, and so are the experiences that can be gleaned from seeing how other cultures deal with issues. It forces people to think outside the box and challenge them to find, and apply, solutions beyond their comfort zones.

3. Mentoring

Mentoring plays a big role in developing any career. It is important, though, to distinguish what kinds of efforts are most useful at different stages of career development. At different points in a person’s career, they need different types of mentoring. The needs for mentoring change from student years, to the first years out of school, to mid-career, to the most senior career positions.

Student Years

During student years, meeting, shadowing, personal exposure to senior figures in the field all help to inspire young women to aspire to something greater. It helps to be able to see what success looks like in any given field, and to get a sense of accessibility. Seeing the fruits of hard work and hearing the stories of career paths – more often than not, anything but linear ones – can help inspire young women. Access to as many people as possible, in as many fields as possible, helps to open up the vast horizons of opportunity that are available. It can spark the imagination of young people about where their paths can take them. University alumnae networks are useful – and alumnae returning to speak openly about their experiences can make a real difference by making success accessible.

First-Third Jobs

The early period in a person’s career is a time of exploration, of further learning, and of discovering career options, preferences, and interests. During this period, it is most useful to have exposure to a wide array of people in a chosen profession and perhaps to create a group of “go-to” people where a young woman can seek advice and ideas and begin to hone her ideas on her true career path. These mentors can be found many places – speakers who inspire, professionals who are admired, colleagues and managers who they know well. People are often receptive and flattered by emails – it never hurts to try.

Mid-Career

It is helpful to have networks as a means of meeting people in their field and getting to know like-minded and like-skilled people. Equally, if not more important for individual development, is having one or two people who know the individual well and can help to council them directly and specifically about options, choices and direction and concrete ways of achieving goals. This can be a vitally effective means of creating clear paths for career development.

Career Success

The years when women are at the top of their careers are a time of consolidation, solidification and fulfilment. It is a time when women can stretch themselves or get greater depth in areas of interest – for example, in business that can be directorships, in politics it can be senior policy making or influencing positions. Mentoring one another via peer relationships and networks can be very effective and satisfying. Having a close group of trusted friends and peers who can be frank, generous, and root for each other’s success can be the thing that helps bring the goals that seem distant even at this point much more achievable.

4. Role Models

Role models are an extraordinarily fruitful way to inspire women to aspire to great things. Role models can be found close to home or in the people around them, as well as in those at a distance - seen only through the news, even in faraway places.

There are two kinds of role models:

First, those who help us to think about the kind of people we want to be through examples of kindness, fortitude, courage, bravery, integrity, and other admirable characteristics, displayed equally by women and men, in their everyday lives and in the way they conduct themselves in the workplace.

Second, there are those who help us to aspire to roles that perhaps we’ve not thought of before or not encountered personally, particularly for young women – heads of state, heads of multinational corporations, leaders in political, cultural, or social movements. Seeing women in particular, anywhere in the world, succeeding in an ever widening array of roles helps inspire young women to broaden their expectation for their own possibilities.

It is vital to openly and publicly acknowledge and celebrate the work that women leaders do around the world. It is important to recognize the critical roles that women have played in developing societies and economies. By highlighting this work, it begins to help countries, societies, and companies realize that this is not unusual, and that it should be the norm. It also helps to bring to light the ways in which these women have made the journey to their positions and make that journey more accessible. Most importantly, it ensures that young women have the freedom to make different choices if they want to.

5. Starting Early

We need to start early to make sure girls know they are capable of reaching great heights. It starts in the youngest years of their schooling with words of encouragement and aspiration.

Equally important is ensuring that boys and young men absorb these messages both openly and through example. Even the most closed societies and cultures have the ability to make shifts over the generations and if we begin to change the mindsets of girls and boys alike.

***

Creating an environment where women can succeed is vital. Public policy that encourages women to be successful, workplaces that reward those encouraging and advancing women, and education systems that educate women to the highest standards are just some of the things that are needed to help create an environment in which women are prepared and encouraged to rise to leadership.

Never settling, always being driven, and always seeking new experiences – these are the hallmarks of the most successful senior women, and indeed men, in the world. We must all play a part in helping young women succeed, as our countries, economies, and futures depend on their success.

***

First published at LinkedIN, January 01, 2013