In "Confidential Reproductive Health Services for Minors: The Potential Impact of Mandated Parental Involvement for Contraception" [2004, 36(5):182-191], Rachel K. Jones and Heather Boonstra provide a valuable synthesis of the literature regarding the impact of mandating parental involvement before contraceptives are provided to minors. Their conclusion that such requirements "would likely contribute to increases in rates of teenage pregnancy" is based largely on the results of surveys suggesting that teenagers would be less likely to use contraceptive services if parental involvement laws were in place. Although such evidence is a useful indicator of future behavior, teenagers' actual response and how any behavior change would feed into teenage pregnancy rates are difficult to know.
The strongest evidence is from cases where parental consent has been mandated. In this regard, the authors cite an article that suggests that the proportion of births to women younger than 19 in McHenry County, Illinois, increased relative to that in other counties after parental involvement was mandated in 1998.1 Notably, however, the proportion of abortions that were provided to teenagers decreased significantly more in McHenry County than in other counties between 1996-1997 and 1999-2000. (The decrease was not statistically significant when 1997-1998 was used as the reference period. However, including 1998 in the reference period probably is invalid, as many abortions that year would have ended pregnancies that occurred after parental involvement had been mandated in April.) Also, the significance of the increase in births was not robust to choice of the reference period, and the total teenage pregnancy rate did not increase significantly in McHenry relative to rates in other counties, irrespective of the reference year.2
In addition, Jones and Boonstra omit the only other study that has examined the impact of parental involvement in the provision of contraceptive services on pregnancy rates among minors.3 In late 1984, the Gillick ruling forbade the provision of contraceptives to minors (defined as those younger than 16) in England and Wales without parental involvement. Prior to this, and after the ruling was overturned toward the end of 1985, family planning services were available to minors free of charge, and in most cases with no requirement that parents be informed, in a network of clinics throughout Great Britain.
The Gillick ruling provides a particularly useful natural experiment, as data are available for at least two close comparison groups to whom it did not apply: women aged 16-19 and women younger than 16 in Scotland. Attendance at family planning clinics by women younger than 16 in England and Wales decreased by approximately 30% in 1985, confirming that parental involvement laws are indeed likely to significantly reduce minors' use of services. At the same time, pregnancy rates did not change among women younger than 16 in England and Wales, but increased for both 16-19-year-olds and younger women in Scotland. Formal econometric tests incorporating a range of possible confounding socioeconomic factors confirmed that Gillick did not lead to an increase in either pregnancy or abortion rates among women younger than 16 in England and Wales.
In summary, the available evidence suggests that mandating parental involvement in contraceptive care for minors does not contribute to increases in teenage pregnancy rates. However, the evidence base is limited, and much more research on the question clearly is needed.
David Paton
Nottingham University Business School
Nottingham, UK
Jones and Boonstra reply:
We appreciate Dr. Paton's comments on our article. However, we disagree that the available evidence suggests that mandating parental involvement for contraceptive services would not contribute to increases in U.S. teenage pregnancy rates.
Our article focused on social policies and research in the United States. The context in which adolescents make decisions about sexual activity, contraceptive use and where to obtain contraceptives varies substantially between the United States and England and Wales.1 For this reason, we did not incorporate Paton's study assessing the impact of changes in parental involvement laws on pregnancy among British adolescents younger than 16.2 Furthermore, in the United States, adolescents younger than 18 are minors; parental involvement laws would therefore affect a substantially larger proportion of U.S. adolescents than would the Gillick ruling.
Since the publication of our article, a study by Jones et al. has shown that while one in five female family planning clinic clients younger than 18 say that they would engage in unsafe sex if parental involvement were required, the majority say they would continue to use the clinic for prescription contraceptive services.3 Paton correctly notes that how teenagers think they would react may not correspond with their actual behaviors, and Jones et al. acknowledge this as a shortcoming of the study. However, adolescents may overestimate the degree to which they would engage in protective behaviors under mandated parental involvement. For example, 18% indicated that they would obtain contraceptives from a private doctor, although only 7% had ever been to a private physician for prescription contraception. Furthermore, U.S. minor adolescents typically cannot obtain health services from private-sector providers except through their parents' insurance plan or by paying for services themselves.
Paton criticizes research documenting changes in adolescent pregnancy rates in McHenry County, Illinois, after the implementation of mandated parental involvement for minor adolescents seeking contraceptives.4 The author has published corrected figures, and still finds "a significant...increase in births to young women in McHenry County [relative to births in nearby, similar counties]."5 We agree that these associations, though weaker than originally thought, suggest that a parental consent requirement led to an increase in teenage pregnancies.
To date, there have been limited opportunities to assess the real-life impact that mandated parental involvement has had on adolescent pregnancy (and STD) rates in the United States. We agree with Paton that more research is needed, and it would be worthwhile to monitor pregnancy rates and other sexual health outcomes, should other "natural experiments" occur.
Clinics that receive Title X funds must provide confidential reproductive health care services to all, regardless of age. In addition, 21 states and the District of Columbia explicitly allow all minors to consent to contraceptive services, and another 24 have confirmed this right for certain categories of minors. However, should the federal guarantee of confidentiality disappear and should state laws follow suit, the available evidence suggests that there would be real and tangible harm, in terms of increases in unintended pregnancies, abortions and STDs. Adolescents in all states should have the right to access confidential contraceptive and STD services, regardless of where they obtain care.