Confidential reproductive health services for minors: the potential impact of mandated parental involvement for contraception

CONTEXT: Recent legislative efforts to implement mandated parental involvement for minor adolescents seeking family planning services threaten the rights of adolescents younger than 18 to access reproductive health care. METHODS: State and federal laws and policies pertaining to minor adolescents' rights to access services for contraception and sexually transmitted diseases are reviewed, and research examining issues of parental involvement among adolescents using clinic-based reproductive health services is synthesized. RESULTS: Attempts to mandate parental involvement for reproductive health care often focus on contraceptive services and are typically linked to federal or state funding. Studies of teenagers using clinic-based family planning services suggest that slightly more than one-half would obtain contraceptives at family planning clinics even if parental notification were required. Mandated parental involvement for contraception would discourage few teenagers from having sex, but would likely result in more teenagers' using the least effective methods, such as withdrawal, or no method at all. Family planning clinics encourage teenagers to voluntarily talk to their parents, but relatively little information is available about the extent to which activities to promote parent-child communication have been adopted. CONCLUSIONS: Mandated parental involvement for teenagers seeking contraceptive care would likely contribute to increases in rates of teenage pregnancy. Research that will help clinics implement and improve efforts to encourage voluntary parental involvement is urgently needed.     

Factors Influencing Parental Involvement Among Minors Seeking an Abortion: A Qualitative Study

Objectives. We explored factors that influenced whether minors involved or excluded a parent when seeking an abortion.Methods. In the summer of 2010, we conducted interviews with 30 minors who sought an abortion in a state that did not require parental involvement at the time. Interviews were coded and analyzed following the principles of the grounded theory method.Results. The majority of minors involved a parent. Commonly cited factors were close or supportive parental relationships, a sense that disclosure was inevitable, a need for practical assistance, and compelled disclosure. Motivations for not wanting to involve a parent, although some minors ultimately did, included preservation of the parent–daughter relationship, fear or detachment, and preservation of autonomy.Conclusions. Minors were motivated to involve parents and other adults who were engaged in their lives at the time of the pregnancy, particularly those who supported them in obtaining an abortion. Motivations to exclude a parent were often based on particular family circumstances or experiences that suggested that involvement would not be helpful, might be harmful, or might restrict a minor’s ability to obtain an abortion.Nationally, nearly one third of pregnant women aged 18 years or younger seek an abortion.1 Currently, 38 states have parental involvement laws that require a parent provide consent or receive notification before a minor can access abortion. States do allow some exceptions in cases of abuse, assault, and medical emergencies.2 Courts have upheld parental involvement laws when an alternative for adolescents unable or unwilling to involve parents exists. In most states, this means a judge determines if the adolescent is sufficiently mature to waive parental involvement requirements, a process called “judicial bypass.” Although the majority of parental involvement laws have been in place since the 1990s, lawmakers have recently passed a new wave of legislation, including new parental involvement laws in states that lack them and stricter mandates for existing laws. Efforts to make parental involvement laws more restrictive include requiring parental consent instead of notification, mandating involvement of both parents, notarization of consent documents, heightened evidentiary requirements for judges to find a minor mature, and jurisdictional limitations on where minors can seek judicial bypass.3–5Previous studies, published in the 1980s and 1990s, found that parents were often involved in a minor’s decision regardless of the law. Those minors who did not wish to involve a parent often cited fear of negative parental reactions, lack of or fragile relationships with parents, and desire to avoid parental pressure in the decision-making process.6–10 The legal landscape has changed since these seminal studies, with a shift toward increasingly strict laws. There is limited current research exploring minors’ experiences and the factors influencing their decisions to involve or exclude parents when seeking an abortion.11States without parental involvement laws provide an opportunity to examine minors’ experiences involving adults in their abortion-seeking process in the absence of a legal requirement. In Illinois, the Parental Notice of Abortion Act was passed in 1995. The law requires physicians to give notice to an adult family member (defined as a parent, legal guardian, grandparent, or cohabiting step-parent) 48 hours before providing abortion services to a minor.12 However, because of legal challenges, the law was not implemented until August 2013. Previously, Illinois was the only state in the Midwest that did not enforce a parental involvement law. Our aim in this study was to explore the factors in abortion-seeking minors’ motivations regarding parental involvement. This snapshot before implementation of a new parental involvement law provided a rare opportunity to understand its potential impact.     

The Child Custody Protection Act: a "minor" issue at the top of the antiabortion agenda

By a 276/159 vote, the US House of Delegates approved a "Child Custody Protection Act" that would make it a federal crime to transport a minor across state lines to obtain an abortion unless the parental involvement requirements of her home state were met. This legislation was promoted by social conservatives within the Republican party and would only affect a small portion of abortion-seekers. The proposed legislation would criminalize anyone (grandparents, siblings, members of the clergy, or medical professionals) who helps a minor travel to another state to avoid parental involvement. Thus, young women will more likely be forced to deal with a crisis pregnancy on their own. The legislation also raises a number of constitutional and "federalism" issues beyond the abortion debate. In the US, teenagers account for 20% of all abortions, but minors for less than 10%. Parental involvement proponents argue that parents of minors have a right to decide what medical treatment their daughters can access, but no state requires parental consent before a minor obtains contraceptive services, prenatal care, sexually transmitted diseases services, or treatment for alcohol or drug abuse. Only a few services require parental permission for a minor to carry a pregnancy to term or to offer a baby for adoption. Also, many minors voluntarily involve their parents in abortion decisions. Opponents to the bill argue that it fails to strengthen families because it targets extended family members. The President will veto the bill as written.     

Impact of parental consent and notification policies on the decisions of adolescents to be tested for HIV.

Restrictions have been placed on the ability of adolescents to obtain human immunodeficiency virus (HIV) testing independent of their parents. Although some states have given adolescents the right to consent to HIV testing independently, many states have remained silent on the issue or have compromised these rights by providing for parental consent or notification when adolescents seek testing. This article examines existing policies and explores whether policies that require adolescents to obtain parental consent, or that permit or mandate parental notification, may deter them from obtaining needed HIV testing.     

CDC suspends testing of newborns. Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) has announced the suspension of their anonymous HIV testing program for newborn infants. The announcement came on the heels of legislation introduced by Gary Ackerman, D-N.Y., requiring states to tell parents or other legal guardians if their newborn babies test positive for HIV antibodies. CDC officials said the survey was useful in tracking the epidemic, but it was time to reevaluate whether the $10 million annual cost could be better spent preventing HIV infection among women and newborns. The CDC advocates the implementation of their proposed guidelines, for physicians to counsel all pregnant women about their HIV risks and offer, but not require, testing. Those who test positive for HIV antibodies should be given nonjudgmental information about the risks and benefits of taking AZT. The CDC cites a recent study which shows that pregnant women may reduce by two-thirds the risk of transmitting HIV to their babies if they take the antiviral drug AZT during pregnancy, labor and delivery. If the decision to suspend the survey becomes final, activists are concerned that Ackerman might change the legislation to mandate testing of all pregnant women. The CDC plans to convene a panel of outside experts to evaluate its guidelines for counseling and voluntary testing.     

Adolescent Pediatric Decision-Making: A Critical Reconsideration in the Light of the Data

Adolescents present a puzzle. There are foundational unclarities about how they should be regarded as decision-makers. Although superficially adolescents may appear to have mature decisional capacity, their decision-making is in many ways unlike that of adults. Despite this seemingly obvious fact, a concern for the claims of autonomy has led to the development of the legal doctrine of the mature minor. This legal construct considers adolescents, as far as possible, as equivalent to adults for the purpose of medical decision-making. The movement to support independent decision-making by adolescents through providing information to them and securing their consent apart from their parents is encouraged by those legal understandings that hold that unemancipated minors should generally be considered as possessing effective decisional capacity. Such legal structures, however, do not adequately take account of the wide variations in adolescent capacities, the immaturity of most adolescent decision-makers, or the important contributions made by parents to the development of their adolescents through parental partnering in the adolescent’s decision-making. The data available indicate that in general adolescents should be regarded as apprentice decision-makers who should make decisions in collaboration with their parents until at least the age of 18. Steps should not be taken pre-emptively to isolate adolescents from the guidance of their parents. As a general rule, what Piker has referred to as “collaborative paternalism” appears most likely both to protect adolescents from their own untoward choices, while also very importantly helping them with parental guidance to develop into mature decision-makers with the capacity to make medical choices on their own.     

Adolescent Pregnancy Options

The range of pregnancy options available to adolescents each have significant ramifications for future educational and economic achievement. The changing societal context of adolescent pregnancy decision-making are described, and the characteristics of adolescents who choose to terminate their pregnancy, parent their child, or place for adoption are examined. The role of significant others in decision-making and the implications of mandatory parental involvement in pregnancy decision-making is discussed, as well as the roles of schools in promoting the well-being and potential of adolescents considering pregnancy decisions.     

Parent-child relations among minor females attending U.S. family planning clinics

CONTEXT: Relatively little is known about parent-child relations among minor females who use family planning clinics. Such information could inform the debate on parental involvement legislation and help clinics develop effective strategies to promote positive parental engagement. METHODS: Self-administered surveys were completed in 2003-2004 by 1,526 women younger than 18 attending 79 U.S. family planning clinics, providing measures of parent-child relations, perceived parental attitudes toward sex and birth control, and parental knowledge of the clinic visit. Associations between relationships with parents and parental knowledge of clinic visits were examined using t tests and logistic regression. RESULTS: Many adolescents had talked to parents about sexual issues (50-80%, depending on the topic) and reported high levels of connectedness with parents (68%). A substantial minority (19%) perceived that parents disapprove of their both having sex and using birth control. The majority (60%) reported that a parent knew of their clinic visit; such reports were most common among those who had high levels of connectedness to parents and communication with parents about sexual issues, and those who did not perceive parents to disapprove of sex and birth control. Adolescents aged 15 and younger were more likely than 17-year-olds to indicate that a parent knew they were at the clinic and to report that a parent suggested the clinic. CONCLUSIONS: Overall, minors attending family planning clinics have good relations with parents. The youngest adolescents may be at family planning clinics specifically because parents are involved in their reproductive health decisions.     

Misclassification bias and the estimated effect of parental involvement laws on adolescents' reproductive outcomes

Objectives. We evaluated the presence of misclassification bias in the estimated effect of parental involvement laws on minors’ reproductive outcomes when subjection to such laws was measured by age at the time of pregnancy resolution.Methods. Using data from abortion and birth certificates, we evaluated the effect of Texas''s parental notification law on the abortion, birth, and pregnancy rates of adolescents aged 17 years compared with those aged 18 years on the basis of age at the time of pregnancy resolution and age at conception.Results. On the basis of age at the time of the abortion or birth, the law was associated with a fall of 26%, 7%, and 11% in the abortion, birth, and pregnancy rates, respectively, of 17- relative to 18-year-olds. Based on age at the time of conception, the abortion rate fell 15%, the birth rate rose 2%, and the pregnancy rate remained unchanged.Conclusions. Previous studies of parental involvement laws should be interpreted with caution because their methodological limitations have resulted in an overestimation of the fall in abortions and underestimation of the rise in births, possibly leading to the erroneous conclusion that pregnancies decline in response to such laws.Over the past 2 decades, 22 states have passed laws restricting minors’ access to abortion, and 36 states now enforce laws requiring parental involvement in minors’ decisions to obtain abortions.¹ The popularity of such laws stems in part from the belief that these laws reduce abortion and pregnancy rates among adolescents. This belief is supported by previous studies that have reported that after the passage of a parental involvement law, there was a fall in abortion rates among minors that was unaccompanied by a rise in births.^2–6However, most previous analyses have used the pregnant adolescent''s age at the time of the birth or abortion to classify adolescents as either affected or unaffected by the parental involvement law, and this may have biased estimates of the effect of such laws on the reduction in minors’ abortion rates and the lack of increase in their birth rates. These biases have significant implications for policy. If after a parental involvement law, abortion rates fall less than legislators expect and birth rates rise, then the increase in unintended childbearing by minors may dampen enthusiasm for such statutes.A recent analysis of Texas''s parental notification law found that many 17-year-olds who are contemplating having an abortion will, if feasible, wait to do so until their 18th birthday to avoid having to notify their parents.⁷ Some of them are willing to wait even if it leads to a riskier second-trimester abortion. Such behavior introduces a misclassification bias into the estimated impact of the law on minors’ abortion rates.The canonical research design for the evaluation of parental involvement laws is a pre–post analysis with a comparison group, in which changes in abortion or birth rates among minors are compared with changes among older adolescents or changes among minors in a similar state without a parental involvement law. The delay in the timing of abortion by older 17-year-olds causes a decline in the number of abortions obtained at age 17 years and a rise in the number of abortions obtained at age 18 years, which leads researchers to overestimate the effect of the law on the abortion rate of 17-year-olds, if exposure to the law is determined based on the adolescent''s age at the time of abortion rather than age at the time of conception.Misclassification bias will be more notable if the comparison group is older adolescents in the same state, because the delay of abortions by 17-year-olds will spuriously reduce the number of abortions performed on 17-year-olds and at the same time increase the number of abortions performed on 18-year-olds. If minors in states without a parental involvement law serve as the counterfactual, the bias results from excluding the delayed abortions from the analysis altogether.The way exposure to the law is determined also affects inferences about the effect of the law on minors’ birth rates. By exposure we mean adolescents are subject to the law on the basis of their age. After the introduction of a parental involvement law, adolescents younger than 18 years are subject (exposed) to the law, regardless of whether or not they are aware of the law before they become pregnant. Adolescents 18 years and older are not subject to the law (are not exposed), because the parental involvement requirement does not apply to them.Approximately three fourths of all minors who conceive as 17-year-olds give birth when they are 18 years of age. Thus, a pregnant 17-year-old who carries to term because of a parental involvement law will most likely give birth when she is aged 18 years. In all but 1 previous analysis of parental involvement laws, the mother''s age has been measured at the time of delivery. Thus, births to 18-year-olds who may have been affected by the law during pregnancy will not be counted if comparisons are between 17-year-olds in different states, or such births will be included among the controls if changes among 18-year-olds within the state serve as the counterfactual. This form of misclassification bias drives estimates of the law''s impact on birth rates toward the null and may even lead to the erroneous inference that birth rates have declined or remained unchanged in response to the law.We sought to evaluate the extent of misclassification bias in estimates of the effect of parental involvement laws if exposure to the law was determined on the basis of the pregnant adolescent''s age at the time of abortion or birth rather than her age at the time of conception. We were able to accomplish this objective because of unique data from abortion and birth certificates from Texas, which enacted a parental notification law in January 2000. The Texas data provide precise information that allowed us to determine the adolescent''s age at the time of conception as well as her age at the time of pregnancy resolution (abortion or birth). Initially, we followed previous work and used age at the time of abortion or birth to classify adolescents as affected and unaffected by the law. We evaluated the effect of the Texas parental notification law on the abortion, birth, and pregnancy rates of 17-year-olds using 18-year-olds as the comparison group. We then repeated the analysis but used age at conception to define exposure and contrasted the 2 sets of estimates.     

Decisionmaking Regarding Unwanted Pregnancy among Adolescents in Mexico City: A Qualitative Study

Adolescents in Latin America and the Caribbean confront difficult decisions when faced with unwanted pregnancies, especially given the region's legal restrictions on and widespread cultural opposition to abortion. Little research has been conducted on pregnancy decisionmaking among young people in this region. This study examines the role of peers, partners, family members, and health‐care providers in adolescents' decisionmaking regarding pregnancy continuation or termination in Mexico City shortly after abortion was legalized in 2007. Qualitative in‐depth interviews and focus group discussions were conducted in 2009 with participants aged 13–17 who experienced an unwanted pregnancy. Although participants were able to formulate preferences regarding pregnancy resolution, parents' wishes usually prevailed when their wishes conflicted. Peers were generally found to be supportive, whereas the role of partners varied. Results indicate the need for comprehensive sexuality education to promote adolescents’ autonomy, mechanisms other than legal mandates to encourage constructive parental involvement, and confidential counseling from health professionals offering options and supporting adolescents' ability to act on their decisions.     

Parental involvement in minors' abortion decisions.

In a 1991 study based on a nationally representative sample of more than 1,500 unmarried minors having an abortion, 61% of the respondents said that one or both of their parents (usually the mother) knew about the abortion. Only 26% of the respondents said their father knew about the abortion; furthermore, 57% of the mothers who knew about their daughter's pregnancy did not tell her father. In this study, which was conducted in states without parental involvement laws in effect, about 75% of the parents who knew about the pregnancy had been told by the daughter herself, and the great majority supported their daughter's decision to have an abortion. Among the minors whose parents found out without being told by the minor, 18% said their parents were forcing them to have an abortion and 6% reported physical violence, being forced to leave home or damage to their parents' health. Minors who did not tell their parents were disproportionately older (aged 16 or 17), white and employed. The minors' most common reasons for not telling their parents were wanting to preserve their relationship with their parents and wanting to protect the parents from stress and conflict. Of those who did not tell their parents, 30% had experienced violence in their family, feared that violence would occur or were afraid of being forced to leave home. Among minors whose parents were unaware of the pregnancy, all consulted someone other than clinic staff about the abortion; most frequently, they consulted their boyfriend (89%), an adult (52%) or a professional (22%).     

Impact of Parental Involvement in Life-Support Decisions: A Qualitative Analysis of Parents' Adjustment Following Their Critically Ill Child's Death

A retrospective, qualitative, preliminary study examined if parental involvement in a life-support withdrawal (LSW) decision impacts the perceptions and adjustment of parents whose child died in a pediatric critical care unit. Participants were parents whose child died following an LSW decision (11 mothers, 7 fathers) and parents whose child died without an LSW decision (5 mothers, 4 fathers). At 6 to12 months after their child's death, the two groups of parents were interviewed and asked to reexamine their perceptions of the following categories: understanding of child's medical condition, staff communication, support, and feelings of closure. Content analysis of the interview data indicated that in comparison to parents whose child died without an LSW decision, a significantly greater number of parents whose child died following an LSW decision were certain about their child's future health; believed that their child's quality of life would have been unacceptable; and reported less dissatisfaction with time spent with their child, fewer negative changes in family functioning, and more positive changes in feelings toward staff.     

Mandatory parental involvement/judicial bypass laws: do they promote adolescents' health?

Laws mandating parental involvement in the abortion decisions of pregnant adolescents exist in contrast to "medical emancipation" laws permitting competent minors to consent to their own care. Mandatory parental involvement laws have been the subject of extensive litigation. The Constitution of the United States requires states mandating parental consent or notification to offer the option of a "judicial bypass." In court proceedings, mature minors must be permitted to make their own decisions. Parental involvement/judicial bypass laws, when implemented, have failed to promote family consultation and have had adverse consequences for the pregnant adolescents they affect. States are permitted but not required by the federal Constitution to enact parental involvement/judicial bypass laws. Courts have prevented some of these laws from taking effect based on privacy guarantees in state constitutions. A few states have enacted alternative laws to ensure careful decision making and appropriate family or adult guidance and support.     

Legal authority for HIV testing of adolescents

Human immunodeficiency virus (HIV) infection in adolescents has been reported in a number of studies, but little attention has been given to the potential for an epidemic spread among inner city adolescents. Voluntary HIV testing and counseling without parental consent should be available to all adolescents, especially those at high risk of infection. Although physicians may fear legal liability as a consequence of testing and counseling adolescents without parental permission, legal authority to do so exists in most jurisdictions in the United States. The sources for that authority differ from state to state. This article analyzes these sources. Requirements for confidentiality or the disclosure of test results to parents vary from state to state, but in most instances there is no authority to disclose the confidences of a minor patient who has independently consented to his or her own treatment.     

Legislation on contraception and abortion for adolescents

The serious health and social consequences of adolescent pregnancy call for the examination of the laws that affect adolescents' access to contraception and abortion. The general law of any country relating to the availability, sale, or distribution and financing of contraceptives affects adolescents. Similarly, a country's general law on abortion applies to adolescents faced with unwanted pregnancy and affects them accordingly. In addition, special legislation relating to adolescents, particularly legislation or court decisions concerning parental consent for contraception or abortion for a minor, has an important influence on the access that sexually active young people have to services.     

Lifetime parental smoking history and cessation and early adolescent smoking behavior

BACKGROUND: Associations are examined between parental smoking and smoking onset by their children. Smoking parents are more likely to have children who start smoking in their teenage years; however, less is known about whether parental quitting is related to adolescent smoking. METHODS: A cross-sectional national sample of 2,206 adolescents, ages 10-14 years, living in two-parent households were interviewed for the DEFACTO annual report on Dutch youth smoking behavior. Adolescent smokers reported that they have tried smoking, even one puff. Respondents indicated whether their parents were never, former, or current smokers, and provided, in the case a parent had quit, their age at that time. RESULTS: Logistic regression analyses revealed that likelihood increased gradually: adolescents with both parents being current smokers were four times more likely to be a smoker compared to adolescents with parents who had never smoked. Additionally, within the group of adolescents whose parents quit smoking, the findings demonstrated that the earlier the parents stopped smoking in the life of their offspring, the less likely their children were to start smoking in adolescence. CONCLUSIONS: Parental smoking history is associated with smoking initiation in early adolescence. Parental cessation at an early age of their offspring reduces the likelihood of adolescent smoking initiation. Preventive efforts, therefore, should focus on the benefits of parental cessation as early as possible.     

Parental involvement laws and fertility behavior

This paper considers the impact of the introduction of laws requiring parental involvement in a minor's decision to abort a pregnancy. State-level data over the 1985-1996 period are used to examine abortion, birth, and pregnancy outcomes, while microdata from the 1988 and 1995 National Surveys of Family Growth (NSFG) are utilized to examine sexual activity and contraception. Quasi-experimental methods are employed that examine whether minors' fertility outcomes were affected in those locations that introduced these laws following their introduction and occurred for minors but not other women. I find that parental involvement laws resulted in fewer abortions for minors resulting from fewer pregnancies; there is no statistically significant impact on births. The reduction in pregnancy seems to be attributable to increased use of contraception rather than a reduction in sexual activity.     

Minor women obtaining abortions: a study of parental notification in a metropolitan area.

Data were collected from 141 women under age 18 attending an abortion clinic that did not require parental notification. Most of them informed their girl friend but not their parents of the plans for abortion. Younger minors and those who perceive their parents to hold positive attitudes toward abortion were more apt to inform parents. Reasons for not informing parents included fears of physical retaliation. Implications for parental notification legislation are discussed.     

Parents’ Perspectives About Adolescent Boys’ Involvement in Biomedical HIV Prevention Research

Research on the use of pre-exposure prophylaxis (PrEP) among adolescents at high risk for HIV is urgently needed, and parents’ perspectives on these studies are essential for guiding the responsible conduct of adolescent PrEP research. We conducted interviews with 30 parents of adolescent boys (50% known/presumed heterosexual; 50% sexual minority) to understand their views of research risks and benefits and parental permission regarding their son’s involvement in a hypothetical PrEP adherence trial. Parents identified several health and educational benefits of the study and expressed that waiving parental permission would overcome barriers to accessing PrEP, particularly for youth who may benefit most. Among their concerns were medication non-adherence and risk compensation. Parents provided suggestions to facilitate informed, rational, and voluntary participation decisions and protect youth’s safety if parental permission was waived. These findings can inform ways to increase parental trust in PrEP research and create adequate protections for adolescent participants.     

The Role of Parents and Partners in Minors' Decisions to Have an Abortion and Anticipated Coping After Abortion

PurposeDespite the prevalence of laws requiring parental involvement in minors' abortion, little is known about the effect of parental involvement on minors' abortion decision making and anticipated coping after abortion.MethodsWe analyzed data from medical charts and counseling needs assessment forms for 5,109 women accessing abortion services at a clinic in 2008, 9% (n = 476) of whom were minors aged 17 years and under. We examined differences in abortion characteristics, including parental and partner involvement, between minors and adults, and used multivariate logistic regression models to examine predictors of parental involvement and support, confidence in the decision, and anticipated poor coping among minors.ResultsMost minors reported that their mothers (64%) and partners (83%) were aware of their abortion. Younger age was associated with increased odds of maternal awareness and reduced odds of partner awareness. Compared with adults, minors were more likely to report external pressure to seek abortion (10% vs. 3%), and mothers were the most common source of pressure. Minors overall had high confidence in their decision and anticipated feeling a range of emotions post-abortion; minors who felt pressure to seek abortion were less likely to report having confidence in their decision (odds ratio = .1) and more likely to report anticipating poor coping (odds ratio = 5.6).ConclusionsMost minors involve parents and partners in their decision making regarding abortion, and find support from these individuals. For a minority, experiencing pressure or lack of support reduces confidence in their decision and increases their likelihood of anticipating poor coping after an abortion.