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Original Contribution |

Effect of Mandatory Parental Notification on Adolescent Girls' Use of Sexual Health Care Services FREE

Diane M. Reddy, PhD; Raymond Fleming, PhD; Carolyne Swain, MS
[+] Author Affiliations

Author Affiliations: Department of Psychology, University of Wisconsin–Milwaukee (Drs Reddy and Fleming); and Planned Parenthood of Wisconsin, Inc, Milwaukee (Ms Swain). Ms Swain is now affiliated with the Midwestern Professional Research and Educational Services, Inc, Milwaukee, Wis.


JAMA. 2002;288(6):710-714. doi:10.1001/jama.288.6.710.
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Context Mandatory parental notification for adolescents to obtain prescribed contraceptives is a controversial issue. Recently, legislation that would prohibit prescribed contraceptives for adolescents without parental involvement was introduced in 10 states and the US Congress.

Objective To determine the effect of mandatory parental notification for prescribed contraceptives on use of sexual health care services by adolescent girls.

Design, Setting, and Participants Girls younger than 18 years and seeking services at all 33 Planned Parenthood family planning clinics in Wisconsin (n = 1118) were surveyed during the spring of 1999. A response rate of 85% was achieved, yielding a sample of 950 girls.

Main Outcome Measures Percentages of girls who reported that they would stop using all sexual health care services, delay testing or treatment for human immunodeficiency virus (HIV) or other sexually transmitted diseases (STDs), or discontinue using specific (but not all) services because of parental notification.

Results Fifty-nine percent (n = 556) indicated they would stop using all sexual health care services, delay testing or treatment for HIV or other STDs, or discontinue use of specific (but not all) sexual health care services if their parents were informed that they were seeking prescribed contraceptives. Eleven percent indicated they would discontinue or delay STD tests or treatment, even though the survey made it clear that mandatory parental notification would occur only for prescribed contraceptives. Analyses comparing girls of different ages and races and from urban vs rural clinics showed that, although the 17-year-olds and African American girls were significantly less likely to stop using sexual health care services with mandatory parental notification, roughly half of the 17-year-olds (56%) and African American girls (49%) indicated that they would stop using all sexual health care services, delay testing or treatment for HIV or other STDs, or discontinue use of specific (but not all) services with mandatory parental notification.

Conclusion Mandatory parental notification for prescribed contraceptives would impede girls' use of sexual health care services, potentially increasing teen pregnancies and the spread of STDs.

Figures in this Article

Mandatory parental notification for adolescents obtaining prescribed contraceptives is a controversial issue. Proponents argue that requiring parental notification would strengthen parents' ability to educate their children and safeguard them from the medical risks associated with prescribed contraceptives. Some proponents also believe that mandating parental notification would encourage adolescents to use condoms rather than prescribed contraceptives, reducing rates of sexually transmitted diseases (STDs).

In 1998, Congress considered the Title X Parental Notification Act requiring written parental consent, a court order, or parental notification 5 business days in advance of providing minors with prescribed contraceptives at all US family planning clinics funded under Title X of the Public Health Services Act. More recently, efforts have been made to bar the use of state matching funds to purchase prescription drugs for minors without parental consent and to deny federal public health and education funds to all school districts offering emergency contraception in school-based health centers without parental consent. In addition, within the last 5 years, at least 10 states have introduced bills to mandate parental involvement in girls' access to prescribed contraceptives. When state law permits or requires parental notification, the new federal medical privacy regulations issued in December 2000 regarding use and disclosure of health information defers to state law.1 Given these parental involvement proposals and recent legislation concerning other reproductive health care issues, other proposals prohibiting prescribed contraceptives for sexually active adolescent girls without parental notification are likely.

Although professional medical organizations strongly encourage and support parental involvement in adolescents' sexual health care decisions, they also recognize the importance of confidential contraceptive services and STD testing and treatment in curbing the high incidence and prevalence of pregnancies and STDs. As far back as 1967, the American Medical Association (AMA) took the position that minors should be able to be tested and treated for STDs without parental notification.2 In the 1970s, 1980s, and 1990s, the AMA opposed legislation requiring parental involvement for adolescents to obtain prescribed contraceptives, and in 1988 the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Academy of Family Physicians, and the National Medical Association concluded that "ultimately, the health risks to adolescents are so impelling that legal barriers in deference to parental involvement should not stand in the way of needed care."3 Furthermore, the AMA National Coalition on Adolescent Health reaffirmed the need for confidential sexual health care services for adolescents,4 and the AMA Council on Scientific Affairs urged members to actively oppose legislation requiring parental consent or notification that would impede health care.5 In sum, professional medical organizations have taken a firm stand against mandatory parental involvement regulations for prescribed contraceptives and STD tests and treatment.

Although research6 examining the general issue of adolescent attitudes about parental involvement in their seeking of health care found that less than 20% of adolescents were willing to seek health care for birth control, pregnancy, or an STD with parental involvement, the only studies to directly assess whether mandatory parental notification would change the behavior of adolescent girls using contraceptive services were conducted more than 20 years ago.7,8 One study was a regional survey (n = 1442), and the other was a national survey (n = 1211). Thirty-six percent of adolescent girls in the regional survey7 and 23% of those in the national survey8 reported that if parental notification were required, they would stop using sexual health care services. These figures may be underestimates. In both surveys, girls were asked whether their parents knew they were seeking prescribed contraceptives before they were asked whether parental notification would cause them to stop using services. Asking the question, "Do your parents know?" may have prompted some girls to say yes out of a desire to make sure they would get prescribed contraceptives, even though their parents might not know. In addition, in the national survey, 5% of girls said they were unsure whether their parents knew they were seeking prescribed contraceptives. What these girls would do if parental notification were required is unaccounted for. Further, in both surveys, whether parental notification would cause girls to stop using family planning services was the only outcome assessed. Other plausible outcomes, such as discontinuing use of specific (but not all) sexual health services or delaying testing or treatment for human immunodeficiency virus (HIV) or other STDs, were not investigated. Therefore, the impact of mandatory parental notification may have been even greater than the estimates provided by these 2 surveys.

Sexually active adolescent girls using family planning services may have become more or less concerned about mandatory parental notification for obtaining prescribed contraceptives throughout the past 2 decades. Consequently, this statewide survey was conducted to investigate whether mandatory parental notification for prescribed contraceptives would cause girls to stop using sexual health care services, delay testing or treatment for HIV or other STDs, or discontinue their use of specific (but not all) sexual health services.

Participants in the Statewide Sample

The data were collected from all Planned Parenthood family planning clinics in Wisconsin (n = 33) in the spring of 1999. All single, sexually active girls who were younger than 18 years and presented to the clinics (n = 1118) were asked to complete a confidential institutional review board–approved survey. Fifteen percent declined, primarily because of time constraints. A total of 950 sexually active adolescent girls voluntarily completed the survey. The participants were a mean 16.8 years of age (SD, 1.06; range, 12-17 years). The sample was 79.9% white, 13.5% African American, 2.6% Hispanic, 2.4% Asian, and 0.9% Native American. The remaining (0.7%) indicated multiple ethnic heritage.

Several steps were taken to ensure that the survey questions were valid. Established principles of survey development9 were used to construct the survey. The survey was extensively evaluated and pilot tested to ensure that the questions were clear, the wording was at a fifth-grade reading level, and the format facilitated completion. To enhance the validity of responses, girls were assured that the survey would not include specific information that could identify them.

Adolescents were asked by clinic staff to complete the confidential survey individually as they waited for their appointments. Clinic staff instructed girls to answer each item honestly and answered any questions the adolescents posed. The completed surveys were returned to a drop box or clinic staff and securely stored away from patient records.

The survey asked girls, "Would you be willing to use Planned Parenthood's confidential services for: pregnancy testing and/or counseling, birth control drugs or devices, health exams, HIV testing and/or treatment, testing and/or treatment for other sexually transmitted diseases (STDs)?" Girls indicated whether (yes or no) they would use each confidential service. After stating that "some lawmakers would like to inform parents in writing that their teens are seeking prescribed birth control pills or devices at family planning clinics that receive federal funds," the survey asked: "Would informing your parents cause you to stop using Planned Parenthood services?" The response format was yes or no. If girls responded that they would not stop using all Planned Parenthood services, they were asked to indicate whether they would continue to use specific services: pregnancy testing or counseling, birth control drugs or devices, health examinations, HIV testing or treatment, and testing or treatment for other STDs. For each service, girls responded yes or no. Those who would not stop using all Planned Parenthood services if their parents were informed also indicated whether (yes or no) they would delay testing or treatment for HIV or other STDs.

Participants in the Additional Sample

Additional data were collected in 2001 from 3 Planned Parenthood family planning clinics in Milwaukee, the most densely populated county in Wisconsin. All single, sexually active girls younger than 18 years (n = 256) were asked to complete a confidential, institutional review board–approved survey. Ten percent declined, primarily because of time constraints. A total of 230 sexually active adolescent girls voluntarily completed the survey. The demographic characteristics of girls in the additional sample were virtually identical to those in the statewide sample. The mean age was 16.5 years (SD, 1.24; range, 12-17 years), and 76.1% were white, 15.2% were African American, 5.2% were Hispanic, and 3.5% were Asian.

The same procedure used for the statewide sample was used to survey the additional sample. The survey stated: "Some lawmakers would like to inform parents in writing that their teens are seeking prescribed birth control pills or devices at family planning clinics that receive federal funds." Girls were then asked: "Would informing your parents cause you to stop using Planned Parenthood services?" The response format was yes or no. If girls responded that they would stop using services with parental notification, they then indicated (yes or no) whether they would "stop having sexual intercourse," "use condoms," "use spermicidal foam or gel," "use the rhythm method," have their partner withdraw or "pull out" before ejaculation, or "have unprotected sexual intercourse." Girls were also given the opportunity to indicate other and specify what they would do if they stopped using family planning services because of mandatory parental notification.

Statistical Analysis

Descriptive statistics computed for the statewide sample included the percentage of girls who would be willing to use all confidential sexual health care services and the percentage who would stop using sexual health care services if parental notification for prescribed contraceptives were mandated. In addition, calculated in the statewide sample among the girls who would not stop using sexual health care services with parental notification were the percentage who would delay testing or treatment for HIV or other STDs and the percentage who would discontinue using specific (but not all) sexual health services if their parents were informed that they were seeking prescribed contraceptives. The effect of mandatory parental notification on girls' use of sexual health care services by clinic site, race, and age was also analyzed with simultaneous logistic regression analysis to control for possible intercorrelations. χ2 Analyses were then performed for clinic site, race, and age to follow up the multivariate analysis.

Statistics computed for the additional sample included the percentage who would stop using services with parental notification. Also, the percentage who would stop having sexual intercourse, use condoms, use spermicidal foam or gel, use the rhythm method, have their partner withdraw, or have unprotected sexual intercourse was calculated among those who would stop using sexual health care services with parental notification. For all analyses, SPSS (SPSS Inc, Chicago, Ill) for Windows (version 10.1) was used.

Eighty-six percent (n = 814) of girls in the statewide sample indicated that they would be willing to use all confidential sexual health care services. The remaining 14% (n = 136) of girls indicated that they would be willing to use one confidential sexual health care service or various combinations of confidential sexual health care services but were unwilling to use all services.

Forty-seven percent (n = 444) of the sample reported that they would stop using all Planned Parenthood services if their parents were notified that they were seeking prescribed birth control pills or devices. An additional 12% (n = 112) reported that they would change their use of Planned Parenthood services if parental notification became mandatory. Sixty-five girls would delay testing or treatment for HIV or other STDs, and 47 would discontinue using specific sexual health care services. Thirty-six girls would discontinue pregnancy testing, 27 would discontinue STD testing and treatment, 9 would discontinue HIV testing, 9 would discontinue health examinations, and 2 would discontinue using services for birth control. Since some girls indicated that they would discontinue using more than one sexual health care service, the total is 83 rather than 47.

The effect of mandatory parental notification on girls' use of sexual health care services was investigated by clinic site, race, and age. An omnibus test of the full model with site, race, and age as predictors indicated that only race and age significantly predicted whether girls would stop using services with parental notification (χ24, 20.8; P<.001). For the 2 other main outcome measures, delay in testing or treatment for HIV and other STDs and for discontinuing use of specific (but not all) services, no site, race, or age differences were found (delay: χ24, 4.5; P = .34; discontinue: χ24, 3.0; P = .56).

Racial differences were investigated by comparing the white girls, the African American girls, and all other girls in the sample combined. There were not enough Hispanic, Native American, and Asian girls in the sample to permit individual comparisons for these groups. Figure 1 shows that there were racial differences in whether girls indicated that they would stop using services (χ22, 9.6; P = .008). Compared with white girls (χ21, 7.7; P = .008) and other girls of color (χ21, 7.1; P = .008), African American girls were significantly less likely to indicate that they would stop using services if their parents were notified. However, the African American girls did not differ from the other racial subgroups in whether they would delay testing or treatment for HIV or other STDs (χ22, 1.8; P = .39) or discontinue using specific (but not all) services (χ22, 0.02; P = .99).

Figure 1. Effect of Mandatory Parental Notification on Girls' Use of Sexual Health Care Services by Race
Graphic Jump Location

Age differences were examined with girls 15 years or younger, 16 years of age, and 17 years of age. Individual comparisons for each age younger than 15 years were impossible because of small sample sizes. As shown in Figure 2, the analysis revealed a significant age difference (χ22, 12.4; P = .002). Girls 17 years of age were less likely than those 15 years or younger (χ21, 10.0; P = .002) and 16 years of age (χ21, 7.0; P = .008) to indicate that they would stop using sexual health care services if their parents were informed that they were seeking prescribed birth control pills or devices. No differences were found between the age groups in whether they would delay testing or treatment for HIV or other STDs (χ22, 2.3; P = .31) or discontinue their use of specific (but not all) services (χ22, 3.6; P = .16).

Figure 2. Effect of Mandatory Parental Notification on Girls' Use of Sexual Health Care Services by Age
Graphic Jump Location

With regard to site, there were no differences between girls seeking sexual health care services at urban clinics vs rural clinics in whether they would stop using services (48.3% urban and 46.9% rural; χ21, 0.2; P = .64), delay testing or treatment for HIV or other STDs (6.5% urban and 6.9% rural; χ21, 0.4; P = .51), or discontinue their use of specific (but not all) services (6.5% urban and 4.9% rural; χ21, 0.4; P = .51) if their parents were informed that they were seeking prescribed birth control pills or devices.

Forty-eight percent (n = 110) of girls in the additional sample indicated that they would stop using services if their parents were notified that they were seeking prescribed birth control pills or devices. Fifty-seven percent indicated that, instead of using services, they would use condoms, 29% indicated that they would have their partner withdraw before ejaculation, 29% indicated that they would have unprotected sexual intercourse, 0% indicated that they would use spermicidal foam or gel, 0% indicated that they would use the rhythm method, and 1% indicated that they would stop having sexual intercourse but would engage in oral sex. (The percentages sum to more than 100% because some girls indicated that they would use more than one method.) Fourteen percent of the girls in this additional sample who said they would use condoms also indicated that they would, at times, have unprotected sexual intercourse or have their partner withdraw before fully ejaculating.

Even though the US courts found that the constitutional right of privacy provides some protection for minors' access to contraceptives (eg, Carey v Population Services International, 431 US 678, [1977]), during the past few years numerous federal and state proposals have been introduced that would mandate some form of parental involvement when minors obtain contraceptives. It is important to know what the impact of such proposals would be if they were enacted. The findings of the statewide study show that 59% of the sexually active girls surveyed would stop, delay, or discontinue using specific (but not all) sexual health care services if parental notification were legislated. Previous regional7 and national8 surveys found that 36% and 23% of adolescent girls, respectively, would stop using sexual health care services with parental notification. More than 2 decades later, we found that 47% of girls surveyed in Wisconsin would stop using sexual health care services with mandatory parental notification. Consistent with previous reports that 96% to 98% of girls would remain sexually active, 99% of adolescent girls in our additional sample who would stop using sexual health care services with parental notification indicated that they would continue having sexual intercourse. Thus, the evidence suggests that requiring parental notification would impede girls' use of prescribed contraceptive services, with the majority of girls continuing to have sexual intercourse despite restricted access to prescribed contraceptives. Given this information, requiring parental notification for obtaining prescribed contraceptives would likely increase unintended pregnancies, abortions, and out-of-wedlock births.

Findings from this statewide investigation also suggest that the effects of parental notification may extend beyond increasing adolescent pregnancies, abortions, and births in that 11% of adolescent girls indicated that if parental notification were required, they would discontinue or delay STD testing and treatment. Every survey question clearly stated that, if legislated, parental notification would occur only for prescribed birth control pills or devices. However, the prospect of parental notification for prescribed contraceptives may have led these girls to question whether HIV and other STD services would be provided in confidence. Consequently, the data suggest that if parental notification were legislated, rates of STDs may increase, not only among adolescent girls who would discontinue using STD tests and treatment, but also among girls for whom STD detection would have occurred during routine gynecological examinations or those related to prescribed contraceptives.

Furthermore, the findings from our additional sample suggest that requiring parental notification for obtaining prescribed contraceptives will not substantially increase consistent condom use. The majority of those who would stop using services with parental notification (56%) indicated that they would at times practice less effective forms of contraception, such as having their partner withdraw or using condoms sporadically. The barriers perceived by adolescent girls (and their sexual partners) to consistently using condoms would have to be addressed before condoms could serve as a feasible substitute for prescribed contraceptives.

Finally, mandatory parental notification was found to be a significant obstacle to girls' use of sexual health care services across all races and ages studied. Almost half (48.8%) of the African American girls and more than half of the white girls (60.3%) and girls classified as other minority (64.2%) would be negatively affected by requiring parental notification. African American girls were less likely to report that they would stop using services with parental notification than were white girls and other minority girls. Greater parental awareness and support of use of contraceptives in African American daughters and greater openness in regard to sexual matters between African American parents and daughters may account for these findings.10 Likewise, greater awareness and support of use of contraceptives and greater independence from parents may explain the finding that girls 17 years of age were less likely than the younger girls to report that they would stop using sexual health care services if their parents were informed that they were seeking prescribed contraceptives.11

Several limitations of this statewide investigation should be kept in mind. The findings of this investigation are by necessity based on reports of what girls would do if parental notification were required. Girls' actual behavior may differ from their projected behavior. Some girls may have responded in ways they presumed the service providers would want or used their responses to voice their opposition to mandatory parental notification. Although biased responses are always possible in any survey, other research examining the general issue of adolescents' attitudes about parental involvement in their seeking of health care6 found results similar to ours when the data were collected in schools rather than family planning clinics. Because 45% indicated that they were willing to seek health care for birth control only if their parents did not know and 47% of girls in our statewide survey indicated that they would stop using sexual health services with parental notification, our findings probably are not the result of the family planning clinic context. Although the data were collected from all 33 Planned Parenthood family planning clinics throughout Wisconsin, and all girls who visited clinics during the study period were invited to participate, yielding a high response rate, the percentage of girls who would stop, delay, or discontinue using specific (but not all) sexual health care services with mandatory parental notification might vary from state to state. However, we speculate that the basic conclusion—requiring parental notification for obtaining prescribed contraceptives would impede adolescent girls' use of sexual health care services—would not differ. Finally, we do not have socioeconomic or clinical information on the adolescents to determine which girls might be more affected by mandatory parental notification.

The findings of this statewide investigation support the hypothesis that requiring parental notification for obtaining prescribed contraceptives would impede adolescent girls' use of contraceptive services and their willingness to seek screening and treatment for STDs.

 Not Available  65 Federal Register.164.502(g) (2000).
Council on Long Range Planning and Development.  AMA Policy Compendium. Chicago, Ill: American Medical Association; 1990.
American College of Obstetricians and Gynecologists.  ACOG Statement of Policy: Confidentiality in Adolescent Health CareWashington, DC: American College of Obstetricians and Gynecologists; 1988.
Gans J. Policy Compendium on Confidential Health Services for Adolescents. Chicago, Ill: American Medical Association; 1993.
Council on Scientific Affairs.  Confidential health services for adolescents.  JAMA.1993;269:1420-1424.
Marks A, Malizio J, Hoch J, Brody R, Fisher M. Assessment of health needs and willingness to utilize health care resources of adolescents in a suburban population.  J Pediatr.1983;102:456-460.
Torres A. Does your mother know?  Fam Plann Perspect.1978;10:280-282.
Torres A, Forrest JD, Eisman S. Telling parents: clinic policies and adolescents' use of family planning and abortion services.  Fam Plann Perspect.1980;12:284-292.
Dillman DA. Mail and Telephone Surveys: The Total Design MethodNew York, NY: John Wiley & Sons; 1978.
Raffaelli M, Bogenschneider K, Flood MF. Parent-teen communication about sexual topics.  J Fam Issues.1998;19:315-333.
Bulcroft RA, Carmody DC, Bulcroft KA. Patterns of parental independence giving to adolescents: variations by race, age, and gender of child.  J Marriage Fam.1996;58:866-883.

Figures

Figure 1. Effect of Mandatory Parental Notification on Girls' Use of Sexual Health Care Services by Race
Graphic Jump Location
Figure 2. Effect of Mandatory Parental Notification on Girls' Use of Sexual Health Care Services by Age
Graphic Jump Location

Tables

References

 Not Available  65 Federal Register.164.502(g) (2000).
Council on Long Range Planning and Development.  AMA Policy Compendium. Chicago, Ill: American Medical Association; 1990.
American College of Obstetricians and Gynecologists.  ACOG Statement of Policy: Confidentiality in Adolescent Health CareWashington, DC: American College of Obstetricians and Gynecologists; 1988.
Gans J. Policy Compendium on Confidential Health Services for Adolescents. Chicago, Ill: American Medical Association; 1993.
Council on Scientific Affairs.  Confidential health services for adolescents.  JAMA.1993;269:1420-1424.
Marks A, Malizio J, Hoch J, Brody R, Fisher M. Assessment of health needs and willingness to utilize health care resources of adolescents in a suburban population.  J Pediatr.1983;102:456-460.
Torres A. Does your mother know?  Fam Plann Perspect.1978;10:280-282.
Torres A, Forrest JD, Eisman S. Telling parents: clinic policies and adolescents' use of family planning and abortion services.  Fam Plann Perspect.1980;12:284-292.
Dillman DA. Mail and Telephone Surveys: The Total Design MethodNew York, NY: John Wiley & Sons; 1978.
Raffaelli M, Bogenschneider K, Flood MF. Parent-teen communication about sexual topics.  J Fam Issues.1998;19:315-333.
Bulcroft RA, Carmody DC, Bulcroft KA. Patterns of parental independence giving to adolescents: variations by race, age, and gender of child.  J Marriage Fam.1996;58:866-883.
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