Jones RK, Purcell A, Singh S, Finer LB. Adolescents’ Reports of Parental Knowledge of Adolescents’ Use of Sexual Health Services and Their Reactions to Mandated Parental Notification for Prescription Contraception. JAMA. 2005;293(3):340-348. doi:10.1001/jama.293.3.340
Author Affiliations: The Alan Guttmacher Institute,
New York, NY.
Context Legislation has been proposed that would mandate parental notification
for adolescents younger than 18 years (minors) obtaining prescription contraception
from federally funded family planning clinics.
Objective To determine the extent to which parents are currently aware that their
teenage daughters are accessing reproductive health services and how minors
would react in the face of mandated parental involvement laws for prescription
Design, Setting, and Participants A total of 1526 female adolescents younger than 18 years seeking reproductive
health services at a national sample of 79 family planning clinics were surveyed
between May 2003 and February 2004.
Main Outcome Measures Proportions of minor females who reported that a parent or guardian
was aware that they were at the family planning clinic and, under conditions
of mandated parental involvement, proportions of minors who would access prescription
contraceptives at family planning clinics or engage in unsafe sex.
Results Sixty percent of minors reported that a parent or guardian knew they
were accessing sexual health services at the clinic. Fifty-nine percent of
all adolescents would use the clinic for prescription contraception even if
parental notification were mandated. This response was less common (29.5%)
among adolescents whose parents were unaware of their clinic visits and more
common (79%) among those whose parents were aware. Many adolescents gave more
than 1 response to mandated parental involvement. Forty-six percent would
use an over-the-counter method, and 18% would go to a private physician. Seven
percent said that they would stop having sex as one response, but only 1%
indicated this would be their only reaction. One in 5 adolescents would use
no contraception or rely on withdrawal as one response to mandated notification.
Conclusions Most minor adolescent females seeking family planning services report
that their parents are aware of their use of services. Most would continue
to use clinic services if parental notification were mandated. However, mandated
parental notification laws would likely increase risky or unsafe sexual behavior
and, in turn, the incidence of adolescent pregnancy and sexually transmitted
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 1970s6,7 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
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
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
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
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.
Corresponding Author: Rachel K. Jones, PhD,
The Alan Guttmacher Institute, 120 Wall St, New York, NY 10005 (email@example.com).
Author Contributions: Dr Jones had full access
to all of the data in the study and takes responsibility for the integrity
of the data and the accuracy of the data analysis.
Study concept and design: Jones, Singh, Finer.
Acquisition of data: Jones, Purcell.
Analysis and interpretation of data: Jones,
Purcell, Singh, Finer.
Drafting of the manuscript: Jones.
Critical revision of the manuscript for important
intellectual content: Jones, Purcell, Singh, Finer.
Statistical analysis: Jones, Purcell, Finer.
Obtained funding: Jones, Singh.
Administrative, technical, or material support:
Purcell, Singh, Finer.
Study supervision: Jones, Singh, Finer.
Funding/Support: This study was supported in
full by grants from the Annie E. Casey Foundation.
Role of the Sponsor: The sponsor did not participate
in the design or conduct of the study; in the collection, analysis, or interpretation
of the data; or in the preparation, review, or approval of the manuscript.
Disclaimer: The opinions expressed in this
article do not necessarily reflect those of the Annie E. Casey Foundation.
Acknowledgment: We would like to thank Jacqueline
E. Darroch, PhD, of the Gates Foundation and Stanley K. Henshaw, PhD, and
Heather Boonstra, both of the Alan Guttmacher Institute, for their contributions
to this research. The assistance of clinic staff in fielding the survey was
indispensable and greatly appreciated.