Adolescents’ Reports of Parental Knowledge of Adolescents’ Use of Sexual Health Services and Their Reactions to Mandated Parental Notification for Prescription Contraception FREE

Parents generally have the legal authority to make medical decisions on behalf of their children. Because it is often assumed that many teenagers would avoid seeking medical services for contraception or sexually transmitted diseases (STDs) if they were required to involve parents, over the last 30 years many states have passed laws giving adolescents younger than 18 years (minors) the right to consent to a range of sexual health services. All 50 states and the District of Columbia allow most minors to consent to STD testing and treatment.¹ Twenty-one states and the District of Columbia explicitly allow all minors to consent to contraceptive services, and another 14 confirm the right for certain categories of minors, such as those who have had a previous birth.² Where the law is silent, the decision of whether to allow minors to consent to services is left to the discretion of the clinician.³

Clinical sites that are recipients of federal funding from certain sources are required to offer confidential care. Clinics that receive federal funding under Title X of the Public Health Service Act, a program that served 693 000 adolescents younger than 18 years in 2002,⁴ are required to offer confidential family planning services regardless of age. Similarly, family planning services paid for by Medicaid must be provided on a confidential basis to sexually active minors who desire them.

While there are some protections in place, the issue of providing confidential contraceptive and STD services for adolescents younger than 18 years remains controversial. In June 2003, for example, Representative Todd Akin (R-Mo) introduced federal legislation requiring parental involvement for teenagers seeking contraceptives at clinics funded by Title X. Congress did not enact the proposal, but some form of legislation requiring parental involvement for minors seeking prescription contraception in family planning clinics has been introduced in Congress each of the last few years. To date, 2 states and at least 1 county require parental involvement for at least some minors seeking prescription contraception.^1,5

Advocates of mandatory parental involvement for minors seeking family planning services contend that such requirements would deter many teenagers from having sex, but there is little empirical evidence to support this argument. Research on minor females in family planning clinics over the last few decades has found that less than 5% would stop having sex if parental notification were required for contraception.^6- 8 A more common reaction would be to use a nonmedical contraceptive method such as condoms or withdrawal, ranging from 15% to 20% of adolescents accessing services in the late 1970s^6- 7 to approximately one third in 2001.⁸ Additionally, 4% to 14% of teenagers report that they would have unprotected sex.^6- 8 Both of these reactions would place teenagers at greater risk for unintended pregnancy and STDs. This concern is supported by research showing that after an Illinois county began requiring parental involvement for minors seeking contraceptive services, the proportion of births to teenagers younger than 19 years in the county increased while it decreased in nearby counties that had similar racial and economic profiles.⁵

It is likely that many minors seeking contraceptives in family planning clinics would continue to use these services if parental involvement were required. Two recent surveys of minors at Planned Parenthood facilities in Wisconsin found that about one half (48%-53%) would use clinic-based services in the face of mandated parental involvement for contraception, making it the most common response.⁸ One likely reason is that many parents are already aware of their daughters’ contraceptive use. Five studies, most of them dated, have examined parental knowledge of clinic visits among teenagers, and 4 found that about half of adolescents (45%-55%) indicated that a parent knew they were at the clinic.^6- 7,9- 11

Finally, recent research suggests that mandated parental notification for prescription contraceptive services could negatively affect teenagers’ willingness to use other services. Although they would continue to use at least some clinic services, 11% of minors at Planned Parenthood clinics in Wisconsin would not use or would delay accessing human immunodeficiency virus or STD services, and 4% would forgo pregnancy testing in the face of such a law.⁸

We currently lack recent national data about the extent to which the parents of teenagers are aware that their daughters are seeking sexual health services. Research examining how teenagers would respond to parental involvement laws for contraception is dated or limited to a specific geographical area and based on small samples. This study addresses these shortcomings. Using information from a national sample of 1526 minor adolescent females obtaining services at 79 family planning clinics, we examine the extent to which teenagers younger than 18 years report that a parent knew they were at the clinic, their reactions to the possibility of mandated parental notification for prescription contraception, and, among those whose parents did not know they are at the clinic, reasons why they were unable to discuss this issue with parents.

A sample of 80 clinics was selected from a database of all publicly funded family planning clinics in the United States (including non–Title X facilities), which is maintained and periodically updated by the Alan Guttmacher Institute. The universe was restricted to facilities that served 200 or more adolescent contraceptive patients in 2001 to allow for a feasible duration of field work. A stratified, systematic random sample was used; the strata were adolescent caseload (200-399, 400-749, 750-1199, ≥1200 patients), type of facility (hospital clinic, health department, Planned Parenthood, or other), receipt of Title X funding, and whether state law provided explicit protections for minors to access contraceptive services. Facilities in Texas and Utah were excluded from the sample because at least some minors in state-funded family planning clinics in those states were already required to obtain parental consent to receive family planning services. The final universe of 2442 family planning clinics from which the sample was drawn represented 35% of all facilities and 81% of all adolescent contraceptive clinic patients.

Participating facilities distributed questionnaires to eligible adolescents for 2 to 6 weeks, depending on adolescent caseload; the smallest facilities had the longest fielding periods. If a facility declined to participate or did not obtain usable questionnaires from at least 50% of eligible teenagers seen during the study period, it was replaced by the next clinic in the stratified sample, ensuring that the replacement clinic was similar to the original. A total of 97 clinics declined to participate. The most common reasons were understaffing, time and budget constraints, or general lack of interest. An additional 31 clinics agreed to participate, but failed to obtain usable surveys from at least 50% of the eligible female patients. Low response rates typically stemmed from administrative disorganization, inability of facility staff to keep a complete tally of eligible minors, and/or failure to pass out the survey. Because of the time taken to recruit replacement facilities, fieldwork took place over 10 months, from May 2003 until February 2004. The final sample of 79 participating facilities consisted of 28 health departments, 7 hospital clinics, 31 Planned Parenthood clinics, and 13 other clinics providing family planning services. Clinics from 33 of the 48 eligible states participated, including several from each of the 4 major US Census regions.

Data were collected via a self-administered questionnaire, available in both English and Spanish. Clinic staff distributed questionnaires to all patients younger than 18 years seeking reproductive health services, excluding abortion and prenatal and postnatal care. Questionnaires were distributed and filled out on-site. Questionnaires included a statement of informed consent; anonymity and confidentiality were ensured by requesting that teenagers return their questionnaires to clinic staff in a sealed envelope. A pretest was conducted to ensure that the statement of informed consent and survey instrument were at an appropriate reading level and understood by respondents. The survey instrument and fielding protocol were approved by the institutional review board (IRB) of the Alan Guttmacher Institute as well as external IRBs of several study clinics. Parental consent for participation was not obtained. None of the study sites were located in states with laws that require parental consent for minors seeking sexual health services, and the IRB of the Alan Guttmacher Institute determined that minors capable of seeking out and consenting to reproductive health care were also able to consent to participation in survey research that presented minimal risk. Obtaining the consent or notification of parents or guardians for participation in the survey would have been a breach of confidentiality of health care services. However, the instructions to clinic staff indicated that if a clinic required parental consent for adolescents seeking certain types of sexual health services (for example, STD testing for adolescents younger than 15 years), then patients at the clinic for that purpose had to obtain parental consent before filling out the survey.

Participating clinics saw a total of 2038 eligible female patients younger than 18 years during the survey period; we obtained data from 1526 of these patients, for a response rate of 75%. We constructed weights to take into account facilities that had shorter or longer fielding periods than designated and to represent the universe of adolescent women obtaining services from all publicly funded family planning clinics that serve 200 or more adolescent patients annually. We imputed missing values for key demographic variables using a hot-deck procedure in which missing values are replaced with values from similar respondents.¹²

The current analyses focused on 3 outcomes, or dependent variables. The first was parental knowledge of clinic visits, based on the question “Does a parent/legal guardian know you come to this clinic for birth control or other sexual health services?” Teenagers who indicated that a parent knew they were at the clinic were directed to a follow-up item asking how parents found out. We provided 8 response categories, and multiple responses were permitted; the categories included “I told them voluntarily,” “They suggested that I come,” and several “involuntary” situations such as “Another person told them” and “They found my birth control.” Teenagers who indicated that a parent did not know they were at the clinic or who were unsure if a parent knew were directed to a follow-up question asking why they had not informed parents. Ten response categories were provided and multiple responses were allowed.

The second and third outcomes assessed adolescents’ expected reactions to mandated parental involvement based on the following item: “Some lawmakers would like to make clinics tell parents/legal guardians in writing when their teenagers get prescription birth control (such as pills, shots or the patch). If there were such a law for clinics and you wanted to use prescription birth control, what would you do?” Teenagers were provided with 9 response categories and instructed to check as many as applied. Wording and response categories for this item were adapted from the survey of minor females at Planned Parenthood facilities in Wisconsin.⁸ We restricted our analysis of this question to 2 outcomes: teenagers who indicated that they would use the clinic, and those who would engage in unsafe or risky sex in response to mandated parental involvement. We defined unsafe or risky sex as using rhythm, withdrawal, or no contraceptive method. (The questionnaire assessed reactions to parental notification before asking the parental knowledge item to reduce the chance that responses to the latter item biased the former.)

We used t tests to examine subgroup differences and logistic regression analysis to predict the outcomes of interest. We limit the discussion to associations of P<.05. All results presented are weighted and are based on the total sample; however, logistic regression models were also run excluding teenagers who had never had intercourse to ensure that all significant associations were maintained for sexually experienced teenagers. Unweighted numbers are presented in all tables because the actual size or number of respondents in each subgroup or response category is an important factor in interpreting findings. We used the software package Stata 8.0 (Stata Corp, College Station, Tex) to conduct tests of significance that take into account the clustered nature of the sample.

Fewer than 1 in 10 minor adolescent females in family planning clinics were younger than 15 years, 18% were 15 years old, 31% were 16 years old, and 42% were 17 years old. The majority were non-Hispanic white (56%), 23% were non-Hispanic black, 15% were Hispanic, and 7% were some other race. Race and ethnicity were self-reported and based on 2 items: one asking if the respondent was Hispanic or Latina and the other asking her race. We created an “other” group that includes adolescents who indicated they were Asian or Pacific Islander, American Indian or Alaskan Native, as well as adolescents whose only indicated race was “other.” One in 5 respondents had mothers who had not graduated from high school, and the mothers of 20% were college-educated. Similar proportions of adolescents resided with both parents/guardians (43%) or with only a mother or female guardian (44%).

Nine percent had never had sex, and only a small proportion (5%) had ever given birth. The overwhelming majority of sexually experienced respondents (90%) reported using a contraceptive method the last time they had sex, including 45% who had used a hormonal method (the pill, the patch, or the injectable), 37% who had used condoms (25% had used a condom and a hormonal method), and 8% who used withdrawal, rhythm, or some other method. The majority of respondents (58%) had been to a(ny) clinic for contraceptive services in the last 12 months.

Three (60%) in 5 minors reported that a parent or guardian knew they used the clinic for sexual health services (Table 1). Almost all teenagers in this situation either had voluntarily told their parents (39% of all adolescents) or were at the clinic at the suggestion of a parent or guardian (23.5%). For some 5% of teenagers, a parent found out involuntarily (eg, when another person informed the parent). Among teenagers who had made a clinic visit before the current one, 60% had talked to a parent about sex or birth control because of something they learned at a prior clinic visit, and even among teenagers whose parents did not know they were at the clinic, 38% had done so.

One third of adolescents in clinics (36%) indicated that a parent or guardian was unaware that they used sexual health services at the clinic, and 4% were unsure if a parent knew. The main reasons teenagers had not informed parents that they used sexual health services were as follows: did not want parents to know that they were sexually active (25%); taking responsibility for their own health (22%); concerned parents would be disappointed they were having sex (22%); uncomfortable talking about sex (21%); or didn’t want their parents to know the reason they were at the clinic (20%).

A number of characteristics and circumstances were associated with the likelihood that parents knew their daughters were at the clinic (Table 2). Adolescents particularly likely to indicate a parent was aware included those younger than 15 years (76%), non-Hispanic blacks (76%), and those who had made 2 or more clinic visits for prescription contraception in the last year (74%). Adolescents who lived with their mothers or female guardians and not their fathers were more likely than those in other groups to indicate that a parent knew they were at the clinic for sexual health services (70% vs 51%-57%). Levels of parental knowledge were higher for teenagers who used a hormonal method the last time they had sex (71.5%) than for users of other methods and contraceptive nonusers (41%-57%). Most of these bivariate associations were maintained in multivariate logistic regression models (Table 2). For example, teenagers aged 16 years and older were much less likely than those younger than 15 years to indicate that a parent knew they were at the clinic even after controlling for race/ethnicity, mother’s education, living arrangement, prior birth, contraceptive use, and prior clinic visits.

The majority of adolescents younger than 18 years (59%) indicated they would use the clinic for prescription contraception even if parental notification was required (Table 3). This intention was far more common among teenagers whose parents knew they were at the clinic (79%) than among those whose parents were unaware (29.5%). Teenagers whose parents found out involuntarily were significantly less likely to indicate they would continue coming (64% vs 80%, respectively; P = .01).

The second most common reaction to mandated parental notification would be to use an over-the-counter method such as condoms (45.5%), with teenagers whose parents did not know they were visiting a clinic being significantly more likely to indicate that they would rely on over-the-counter methods (63% vs 36%, P<.001). Nearly 1 in 5 teenagers (18%) indicated that they would go to a private physician, although only 7% had ever been to a private physician for prescription contraception. Seven percent of minor females indicated that they would stop having sex, and only 1% indicated this as their only response.

Respondents could give more than 1 response, and more than one third did so. The most common combinations of responses included using an over-the-counter method along with another strategy; for example, 18% of teenagers would adopt this strategy and obtain prescription contraception at a clinic (Table 3).

In the bivariate analyses, several subgroups indicated a greater likelihood of expecting to use the clinic for prescription contraception even if parental notification was required, including those younger than 15 years and non-Hispanic blacks (Table 4). However, logistic regression revealed that parental knowledge was the most important predictor, and once this condition was taken into account, few demographic characteristics were associated with this outcome (Table 4). Logistic regression confirmed that teenagers whose parents did not know they were at the clinic were least likely to expect to use the clinic for prescription contraception if parental notification were required, and those whose parents had been informed involuntarily were also less likely than the comparison group to expect to use the clinic.

Overall, 18% of teenagers would engage in risky sexual behavior if parental involvement were mandated (Table 4). After controlling for age, race/ethnicity, mothers’ education, living arrangement, prior birth, and contraceptive method the last time they had sex, the likelihood that a minor would adopt risky sex as a strategy was much lower among voluntary informers and those whose parents suggested the clinic (Table 4). Teenagers whose parents found out involuntarily were about as likely to engage in risky sexual behavior as teenagers whose parents did not know they were at the clinic. Hispanics and teenagers in the “other” race/ethnicity group were more likely to expect to engage in unsafe sex than black teenagers. Teenagers who were already engaged in unsafe sex, specifically those who had used withdrawal or no method the last time they had sex, were more likely to expect to continue to do so relative to hormonal method users.

Finally, an additional question on the survey revealed that mandated parental involvement for contraception would deter a small proportion of adolescents from using STD services. Immediately following the questionnaire item assessing expected reactions to prescription contraception, respondents were asked to indicate if such a law would prevent them from seeking STD services. The overwhelming majority of teenagers (95%) indicated that they would use the clinic (83%) or a private physician (12%) for STD testing or treatment if parental notification were required for prescription birth control, but 5% would forgo these services.

In 2001, an estimated 917 000 female adolescents younger than 18 years obtained family planning services at federally funded family planning clinics.¹³ Our study adds to prior research by providing a national perspective on questions of great relevance for the ability of teenagers to obtain confidential health care: To what extent are parents aware that their daughters use clinics for reproductive health care, and what would be the impact of mandating parental notification for contraceptive services?

A majority of teenagers indicated that a parent knew they were at the clinic, with almost one quarter reporting that a parent or guardian suggested the clinic. Younger teenagers were more likely to have parents that knew of the visit, and almost one quarter indicated a parent recommended the clinic. These associations suggest that many parents are supportive of their daughters’ use of clinic services.

Consistent with prior research over the last few decades, we found that a majority of females younger than 18 years expected that they would obtain prescription contraception at family planning clinics even if parental notification were mandated. However, 18% would engage in risky sexual behavior, and 5% would forgo STD services.

Our study expands on previous research in several ways. While a majority of all teenagers attending clinics expected that they would use clinic-based contraceptive services in the face of mandated parental involvement, we found that this response was the majority only among adolescents with parents who already knew they were at the clinic. Among adolescents with parents who did not know, 70% would not come for prescription contraception if parental notification were mandated. Adolescents report many reasons for not wanting to inform parents that they are at the clinics, including a desire to be self-sufficient and not wanting to disappoint parents.

Among minors who had voluntarily informed parents, almost 1 in 5 would be deterred from using the clinic if parental notification were required, and this association was even more pronounced if parents had found out involuntarily. It is possible that some parents had not reacted positively on learning that their daughters were receiving sexual health services (and presumably were sexually active), and these adolescents would be unwilling to revisit the experience.

Nationally, just over one half of all teenagers who make family planning visits obtain services from a private physician.¹⁴ Our findings suggest that parental involvement laws for minors seeking contraceptive services from family planning clinics would likely increase this demand and, in turn, the need for physician training in providing reproductive health services to adolescents. More seriously, perhaps, studies have found that 17% to 37% of private physicians are unwilling to or do not provide reproductive health services to minors without parental consent,^15- 18 meaning that this strategy would not be feasible for at least some minors.

Most family planning clinics promote and reinforce responsible sexual behavior. This may be one reason that dual contraceptive use among sexually active minors in our study is substantially higher than is found among the larger population of sexually active females aged 15 to 17 years (25% vs 7%).¹⁹ Similarly, a number of clinics actively encourage adolescents to involve parents and other adults in making decisions about their sexual health. That teenagers who had made prior contraceptive visits were more likely to indicate that a parent knew they were at the clinic (even after controlling for other characteristics) suggests that multiple clinic visits encourage teenagers to inform parents, although it is also possible that parents who know their daughters are at the clinic may encourage them to make follow-up visits. A majority of teenagers who had made a prior clinic visit have talked to parents about sex and contraception because of something they learned at the clinic, including some whose parents were unaware of these visits, suggesting that use of clinic services can encourage parent-child communication without compromising confidentiality.

Our study contains several limitations. While our sample likely represents minors at federally funded family planning clinics that serve 200 or more adolescents annually, it is not nationally representative of all clinics or of all minor female adolescents obtaining sexual health services. Similarly, organizational constraints prevented a number of facilities from participating in the study and from collecting usable surveys from the requisite number of adolescents, and these conditions limit our ability to extrapolate the findings to all adolescents younger than 18 years who visit family planning clinics. The reading level and length of the survey could have deterred some teenagers from participating or caused them to answer items incorrectly. Biased responses are possible if teenagers falsely reported that parents were aware of the visit to maintain access to confidential services. There is no way to know how teenagers’ expected reactions predict how they would actually respond if parental notification laws were implemented. More than a third of teenagers reported multiple responses to this question, which may signify that teenagers are unsure how they would react or that they would adopt multiple strategies, either simultaneously or consecutively. Finally, it is likely that parental knowledge and teenagers’ expected reactions would differ depending on which clinical services they used. We were unable to examine these associations in this analysis, largely due to the fact that many teenagers were at the clinic for multiple purposes, but future research should explore, for example, whether adolescents who use STD services are less likely to indicate a parent knows they are at the clinic.

Parents of a majority of teenagers at family planning clinics are aware that their daughters use sexual health services, and almost one quarter suggested the clinic visits. Nonetheless, this research confirms that parental involvement laws for minors seeking prescription contraception in family planning clinics would discourage few teenagers from having sex and would likely increase rates of adolescent pregnancy and STDs.