Are adolescents mature enough to make their own decisions when it comes to their medical care? If so, should those decisions be kept confidential from the adolescent’s parents or guardians?
When it comes to answering this question, the lines are blurred. Thus far, public policy in the United States says both yes and no, with laws differing based on the type of medical care that is involved. For example, all states allow minors to consent to STI services, but not all states allow them to consent for mental health care. Although parents and guardians are encouraged to involve teens in their own health care decisions, final consent is often still left up to the parents to the extent that current state and federal law allows. Adolescent consent and confidentiality become particularly controversial when it comes to some reproductive health care services, with contraceptive use and abortion being particularly hot-button topics.
Significant stigma has created a barrier to adolescent reproductive health care for decades. Before the 1950s and 1960s, teenage pregnancy was thought to have “social invisibility;” it wasn’t discussed or acknowledged, particularly because many older teens were already married and thought to be ready to bear children by that point in their lives. The shame surrounding unmarried teen pregnancy also contributed to society’s ignorance of the issue, with many pregnant teens being sent away by their families to maternity homes in the 1950s and 1960s. As the marriage age for girls started to rise in the 1970s, teenage pregnancies were more commonly occurring in unmarried women, rendering them more visible in the eyes of society. In a 1996 address, President Bill Clinton referred to teen pregnancy as “our most serious social problem,” increasing the visibility of the issue nationally. Clinton’s address resulted in the push to ensure accessible reproductive health care for teens, who traditionally have the lowest rates of prenatal care and disproportionately poor maternal and infant health outcomes.
However, not everyone shared the same view on reproductive health care accessibility for adolescent mothers. Conservatives have tried many times to limit both sex education and the ability of adolescents to seek reproductive health care without parental consent, including an attempt in 2005 to impose or strengthen parental involvement requirements for adolescent abortions and an attempt in 2012 to force teens to obtain parental consent for contraceptives.
Currently, state laws vary on the extent to which physicians need to obtain parental consent for issues regarding the reproductive health of their adolescent patients. This varies from issue to issue, with much greater flexibility for teen patients on some health matters than others. STI services are the most accessible area of reproductive health, with all 50 states allowing adolescents to independently consent to testing and treatment. In contrast, teens trying to access contraception, such as birth control pills, can do so on their own in 26 states, while those trying to access prenatal care can do so without parental consent in 33 states. Abortion is the most restrictive area of reproductive health, with just two states, Connecticut and Maine, allowing adolescents to independently consent to an abortion. States in which they cannot access certain reproductive care on their own may have laws requiring that parents consent to procedures, be informed before they happen, or both.
Based on extensive research done over decades, the reality is that requiring parental consent or parental notice for adolescents to obtain reproductive health care services can negatively affect teen reproductive health as a whole. An ACLU publication detailed the detriments of requiring parental consent or parental notice for adolescents to obtain contraceptives. The publication includes a reference to a study that showed that young women in the United States were sexually active for nearly two years on average before they first received reproductive health care, illustrating that the common fear that easy contraceptive access will increase the likelihood of sexual activity in teens is unfounded. The publication also references a study that states that nearly half of teenage girls would stop accessing all reproductive health care services – including STI testing – if they were told by a clinic that their parents would be informed before they could receive contraceptive services. When one in four sexually active adolescent females has an STD, this presents a serious implication for their reproductive and sexual health as a whole. By reassuring teenagers that they will have full autonomy and confidentiality when it comes to obtaining contraceptives, physicians can help ensure that they will continue to seek reproductive health care for other issues as well.
Similarly negative effects on reproductive health exist when parental consent is required for adolescents to obtain an abortion. When teenagers are forced to obtain parental consent before having an abortion, it may delay the abortion or even prevent it from actually taking place. The decision to have an abortion is extremely personal and presumably challenging to discuss with parents or guardians who may already have their own ideas of how the situation should be handled. This lost time could be critical, as second-trimester abortions are considered to be both physically and psychologically more dangerous than first-trimester abortions. Additionally, adolescents who choose not to discuss their decision to have an abortion with their parents may have reason to believe that involving their parents would prove to be unhelpful or harmful in some way. These teens may fear being forced to continue with the pregnancy, being kicked out of the house and rendered homeless, and/or being physically or emotionally abused. In any of these cases, forced parental involvement would prove to be much more harmful to the reproductive health of the adolescent than allowing them full consent and confidentiality for the procedure. It is worth noting that several prominent and credible medical groups have taken a stance against forcing adolescents to involve their parents in abortion decisions.
When adolescents have a disproportionately high risk for poor maternal and fetal outcomes, we should be striving as a society to make reproductive health care more accessible for them, not less. Forcing them to involve their parents in their decisions related to reproductive health care only drives them away from seeking reproductive health care at all, which could increase their risk of going undiagnosed and untreated with an STI or other serious condition. Requiring parental consent may also cause needed reproductive health care to be delayed, as it may take the adolescent some time to discuss sensitive topics with parents or find a way to avoid involving them. This could put them in a situation with higher medical risks. Teenagers may also have legitimate reasons for leaving their parents out of decisions related to their reproductive health care, such as fear of abandonment, abuse, or forced continuation of pregnancy. Any of these situations would prove to be far more dangerous to the teen’s health than allowing them to give full informed consent and maintain complete confidentiality for any reproductive health care they receive. In the interest of nonmaleficence and patient autonomy, adolescents seeking reproductive health care should be granted the ability to provide full informed consent for themselves without being forced to involve parents or guardians in any way.