And doctor makes three: A push for shared decision-making in adolescent contraceptive use

Introduction

In 2022, Representative Kathy Manning introduced the “Right to Contraception Act,” designed to protect both a person's ability to access contraceptives and a provider's ability to provide contraceptives in the United States. ^a In the Act, accessing contraception is recognized as a fundamental human right and a critical component of sexual and reproductive health. This right is “central to a person's privacy, health, wellbeing, dignity, [and] liberty” and is affirmed for all Americans. ¹ Exercising this proposed right often entails interactions with a medical provider, as any birth control which is not available over the counter (OTC) (everything except condoms, Opill, sponges, and emergency contraceptives, i.e. the morning after pill) requires physician interaction and a prescription.

This presents a challenge for a population that is largely not in control of their own medical decisions in the United States: adolescents under the age of 18. While minors are explicitly permitted to access contraceptive services through their care providers without a requirement of parental consent or notification in more than half of our nation's states, minors in the remaining states may not be permitted to do so, with exceptions for those who are married, pregnant, parents, or emancipated. Obtaining parental consent may understandably be uncomfortable, tense, or land teenagers in trouble, as Anna, a 17-year-old explains, “Mentioning birth control to my mom would be, in her mind, saying that I’m having premarital sex, that I’m openly sinning, so it's not something I broach with her.” ² It seems on the surface that allowing teenagers like Anna to privately access contraception through their provider is a benefit: she is able to practice sex safely and prevent an unwanted pregnancy without having to broach the topic with her mother, thanks to the help of her physician. This idyllic picture of beneficial confidentiality is easily interrupted, however, by any number of factors: if the contraceptive is billed through Anna's mother's insurance, her mother could discover that her daughter has been acting against her wishes, leaving her feeling upset and betrayed. Anna's secrecy about her sexual relationship could leave her open to coercion and manipulation if the relationship is unhealthy. Anna's mother's determination of her daughter's best interests in the realm of sexual activity is not only undermined, but disregarded altogether by not giving her a say in the situation, distancing the parent from the child. Should Anna experience any negative consequences as a result of being sexually active, whether it be physically, mentally, or emotionally, her mother must either tend to her with an incomplete understanding of the situation or continue to be excluded from the care of her child.

In this paper, I will argue that providers should facilitate a process of shared decision-making between parents and their adolescent children when decisions about contraception are to be made, if such a process is determined to be possible. Although the public health argument has been used to justify confidential adolescent access to care, it poses its own risks, undermines parental authority, and prevents parents from fulfilling the responsibilities of their roles as providers and educators. Parental involvement and open parent–child communication is an ideal to strive for in the realm of sexual health decision-making. If the parent is deemed supportive, the clinician can prescribe contraception with parental involvement in the decision-making process, empowering the parent to promote adherence as well as the sexual and emotional well-being of their child. If the provider determines that the parent is unsupportive, the provider can proceed with confidential prescription of contraception in states where it is legal if this is determined to be in the child's best interests. If the patient does not desire a prescription, or in states where contraceptives cannot be confidentially prescribed, the provider can direct the minor to OTC birth control methods. In either case, the provider should have a serious conversation about the child's sexual health and well-being, as well as the patient's values and goals in the realm of contraception.

To make this argument, I will begin by outlining the various forms of birth control which are currently available, specifying those which require provider intervention and those which can be obtained OTC. Then, I will present the current legal landscape of pediatric medical decision-making in the United States and how, in many states, minors accessing contraception through their providers serves as an exception to the rule. I will outline the benefits of parental involvement in contraceptive decision-making and the harms posed when the parent is not involved. Finally, I will propose changes in practice that facilitate parental involvement in order to promote sexual well-being for pediatric patients.

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Figure 1.

Clinician flowchart for shared decision-making process.

An overview of age of consent laws and available birth control methods

In this section, I will briefly outline the legal landscape concerning the age of consent in the United States, as well as the currently available contraceptives, in order from most to least efficacious. In the United States, there is no uniform age at which a minor can legally consent to sexual activity. The unrestricted age of consent is different from the age of majority—the age (18) at which a person is legally considered an adult—and varies on a state-by-state basis, with the majority of states designating 16 as the age of consent. ³ In states such as Texas and New York, the age of consent is 17, and in states such as California and Florida, the age of consent is 18. ³ Depending on the state and the nature of the interaction, those above the age of consent who engage in sexual activity with individuals under the age of consent in their state can be prosecuted, although several states, such as Texas, outline exceptions which are often dubbed “Romeo and Juliet laws.” These laws target teenagers and young adults who engage in sexual activity with those under the age of consent but are close in age to their sexual partner; in Texas, for example, there must be no more than a three-year age difference between partners if at least one of them is under the age of 17. This provision “keeps these would-be offenders from being classified as sex offenders.” ³ Although adolescents are in the process of developing decision-making skills and capacity, this process of evolution is not accounted for in the law; legally, there is a bright line at which minors gain the capacity to consent to sexual activity. This occurs on their birthday, marking the surpassing of the age of consent threshold.

With a notable recent exception, the most effective methods of birth control require a prescription. Note that “perfect use” statistics for all forms of birth control—the rate of pregnancy within the first year if the method is utilized perfectly each time—are higher than “typical use” statistics, which consider the probability of pregnancy in the first year of use with user error—missed pills, unchanged patches, and forgotten condoms. ⁴

The two most effective forms of contraception are the birth control implant and the intrauterine device (IUD). These two are referred to as long-acting reversible contraceptives (LARC). The birth control implant is an etonogestrel-containing rod inserted into the upper arm. IUDs are T-shaped uterine devices that must be surgically inserted and removed. Both the birth control implant and the IUD have failure rates of less than 1% and nearly eliminate the concern of non-adherence, because they require no maintenance except for removal. Next are progestin injections, given every 13–15 weeks, with a failure rate of 4%.^4,5

The most popular contraceptive method among adolescents is the combined oral contraceptive (COC) pill. The pill has a failure rate of 7%; adherence is complicated by a pill that must be taken at the same time on a daily basis.^4,5 Adolescents must also be informed of the correct course of action should they miss one or more pills, as well as when emergency contraception is needed in the case of missed pills and sexual activity. In addition to combined contraceptives, there also exist progestin-only pills, most notably, Opill, which was approved by the FDA in 2023. Opill is the first daily contraceptive pill sold OTC. ⁶ It is noteworthy because of its presence on pharmacy shelves, meaning that anyone can access it without a prescription, and it has a similar failure rate to the COC pill (9%). ⁶

The contraceptive vaginal ring is an estrogen and progestin-releasing silicone ring that is placed inside the vagina. ⁴ Adherence in young people has not been found to be any better than that of those on COCs, with one study of college students demonstrating adherence rates for both methods below 30% after six months. The transdermal contraceptive patch, similar to the ring, is used in a three-weeks-on, one-week-off pattern. The simple patch regimen was initially believed to promote adherence among adolescents, but in a study of adolescent women who chose their contraceptive method, nearly half discontinued the patch after one year, which was significantly fewer women than those who decided to continue the pill. ⁴

Importantly, none of the methods listed above provides protection against sexually transmitted infections (STIs), so they should all be used in combination with a barrier method—male condoms being the most popular choice—to prevent the spread of disease. Despite their ease of access, education is needed for consistently correct condom use. “Many adolescents do not use condoms effectively or at all,” with condom use frequently declining in the context of relationships. ⁴ Other barrier options which are less commonly used today are female condoms, spermicides, diaphragms, cervical caps, and contraceptive sponges. Individuals may also use periodic abstinence—abstaining from sex during the fertile days of one's cycle—or withdrawal, in which the penis is “pulled out” or “withdrawn” prior to ejaculation.

Although rates of adolescents who have had sexual intercourse have declined in recent decades, as of 2017, more than half of teenagers in the United States have had sex before the age of 18. ⁷ Although sexual activity cannot be legally consented to by those aged 15 and under, approximately 30% of those aged 15–16 have had sex. ⁸ According to the CDC, 99% of female teens who had experienced sex utilized some form of contraception, most commonly condoms (97%), withdrawal (60%), and the pill (56%). ⁷ Adolescents have the “lowest level of contraceptive knowledge and use” of any age group, and are subsequently at higher risk of unwanted pregnancy and STIs; many do not utilize contraception at first intercourse or fail to use it consistently. ⁹ The methods most commonly elected by adolescents are less reliable and have higher failure rates than other contraceptive methods, as detailed above. A report by the CDC investigating LARC use in adolescents found that barriers to use include “unfounded concerns about safety, high upfront costs, and lack of awareness about LARC” among family planning clinic directors and staff. ¹⁰ In a nationwide survey, fewer than half of the nearly 1200 publicly funded family planning facilities discussed LARC methods with younger clients due to the aforementioned barriers. ¹¹ On the patient side, adolescents may be less likely to pursue LARC methods due to a fear of pain associated with insertion and removal, as well as the potential for adverse effects. ¹² One study investigating the acceptability of the pill, the shot, the implant, and the IUD among young women found that fewer overall participants had heard of the IUD and the implant, and that for all methods, knowing someone who had become pregnant while utilizing that method or knowing a friend or family member's dislike of the method was a predictor of low acceptability. ¹³ Considering the lack of education surrounding LARC methods, the education and adherence necessary to utilize condoms correctly every time, the high failure rate of the withdrawal method, and poor adolescent adherence to oral contraception, it is clear that providers “have an important role to play in ensuring that adolescents have access to high-quality and non-judgmental reproductive health care services.” ⁹ What remains in question is if and how parents should be involved in decision-making regarding their children’s use of contraception.

Adolescent contraceptive use and parental involvement

As is evident in the section above, the majority of available contraception in the United States, and certainly LARC methods, which are the most efficacious, require interaction with a provider in order to access. In the section that follows, I will briefly detail typical medical decision-making for adolescents, the history behind why contraceptive access functions as an exception to the rule in certain states, and what is regarded by many providers to be the most desirable scenario for minor decision-making with regards to contraception.

Children under the age of 18 have traditionally been excluded from medical decision-making due to their classification as non-autonomous. ¹⁴ There has been a recent emphasis on child involvement in healthcare decision-making to the degree they are capable. This participation occurs in proportion to the child's “developmental capacity to understand the nature and consequences of their medical problem as well as to reasonably foreseeable risks and benefits of the treatment proposed,” but ultimately, the child's parents legally have the final say in medical decisions until the child gains decisional authority at the age of 18. ¹⁵ This is because “parents have a long-standing right to control the rearing of their children”; parental rights are not solely legally codified but culturally assumed, as the family serves as the basic social unit. ¹⁶

There is an exception for mature minors and emancipated minors. The former is a rare, judicially granted status that partially emancipates the minor to make medical decisions contrary to the wishes of their parents. The latter is a designation that an individual under the age of 18 is no longer a child under the law; they are no longer under the custody of their parents and are legally and financially responsible for themselves.

Although many minors may be determined to have decision-making capacity on an individual basis, it is important to note that there is no threshold age at which all minors are determined to have this capacity. This is because brain development is nonlinear, that the onset of adolescence alters decision-making patterns, and genuine competence cannot exist without accurate and adapted information. ¹⁷ Shared decision-making can still take place despite these challenges, with physicians, parents, and children working together. Providers must determine the patient's capacity, give the child all relevant information in a developmentally-appropriate manner, and determine that the decision is free of coercion (challenging in a pediatric population because of limited experience and dependence on parents). ¹⁵

Decision-making about accessing contraception differs drastically from other forms of medical decision-making for minors. There is no federal law guaranteeing universal confidential contraceptive access for adolescents. ¹⁸ Currently, 27 states allow all minors to explicitly consent to contraceptive services, and 19 states permit access in one more specific circumstances: if a minor is married, a parent, is or has been pregnant, if a physician determines that lack of access would constitute a health hazard, and if a specific requirement is met, such as an age minimum, graduating high school, holding mature minor status, or receiving referral from a physician or clergy member.^5,19 The former is justified via a public health exception, and the latter as a result of a belief that “certain minors have attained a level of maturity or autonomy which makes it appropriate for them to make their own medical decisions.” ²⁰ This means that in more than half of the states in the United States, minors do not need to obtain parental consent to access contraceptive services.

Some teenagers do involve or notify parents when they seek reproductive care; one study from the 1980s indicates that 41% of first-time minor clinic users’ mothers knew they were accessing these services, with the percentage increasing to 58% and 72% at 6- and 15-month follow-up points. ²¹ A 2005 study of nearly 80 family planning clinics reports that 60% of minors had a parent or guardian who knew they were accessing the clinic's services. ²² More recent data collected from parents of female emergency department patients between the ages of 14 and 19 showed that although many parents accepted confidential prescription of contraception for their children (57%), many more (81%) preferred prescription with their involvement as opposed to a confidential prescription without their involvement. ²³ While this process of confidential prescription stands in opposition to the legal determination of parents as medical decision-makers and the process of shared decision-making described above, an examination of the history of adolescent reproductive care and legal rulings in the 1970s and 1980s elucidates the reason for this distinction.

In the 1970s, the average age of marriage rose, leading to greater numbers of unmarried and sexually active teenagers; there was less social pressure for pregnant teenagers to get married, and abortion was legalized. Universities provided contraception, women were offered greater sexual freedom, and control over reproduction was widely regarded as not only a moral good, but a moral imperative. As Barina and Bishop explain, “failure to master the female body becomes irresponsible; autonomy attains normative primacy for adult female sexuality. The transformations in norms of adult female sexuality trickled down to unemancipated adolescents.” ²⁴ These adolescents too were called to become the “ideal woman” by exercising this increased control. With the knowledge that teenage pregnancy often led to poor outcomes for mothers and their children, the state's goal became to provide care that sexually active teenagers would feel comfortable accessing. In 1976, the Supreme Court ruled that parental consent was an unconstitutional condition for the provision of contraception. ²⁴ The 1983 case Planned Parenthood v. Matheson affirmed this ruling by finding mandated parental notification to infringe upon a minor's constitutional right to “decide whether to bear or beget a child using or not using contraceptives.” ²⁵ Minors can access OTC contraception as a result of the 1977 Carey v. Populations Services International decision, which determined that prohibition of the sale of contraceptives to minors is illegal and designated sexual maturity (the ability to become pregnant) as the factor which should determine access. ²⁶ Using the Fourteenth Amendment, the Court found that minors had a right to choose “whether to bear or beget a child.” ²⁵

Thus, minor access to contraceptives is justified under a public health exception: minors may access services for certain health issues, such as contraception and family planning (but also including STI diagnosis and treatment, as well as mental health and substance abuse treatment), because of the state's interest in “having citizens, of whatever age, receive treatment.”^27,28 The state does not uphold this exception to make “a normative statement about the relative value of the autonomy of adolescents.” ²⁶ Instead, it seeks to promote the health of the public and of the individual under this exception, because the consensus is that if parental consent or notification is mandated, the child is less likely to seek out this treatment, leading to undesirable outcomes of unintended pregnancy and the spread of STIs.^16,26 The state intervenes to limit parental rights in this instance because of the “potential for significant social burdens.” ¹⁶ In the aforementioned study of adolescent females accessing contraceptive services at family planning clinics, the authors found that 79% of respondents whose parents knew they accessed the clinic's services said they would continue to use the services if parental notification were required, but of those whose parents did not know, only 29.5% would continue to obtain prescription contraceptives. When asked to respond to mandated parental involvement, 46% would use an OTC method, and one in five would use no contraception or rely on withdrawal as one potential response. ²² While mandated parental involvement may lead to more teenagers having parents who are informed about their contraceptive use, there is no assurance that this would “broaden communication about sex and contraception [or] positively affect the quality of relationships.” ¹⁸

Confidentiality is evidently a necessary assurance for many teenagers in these sensitive conversations. One study found that confidentiality concerns reduced the likelihood that sexually experienced girls have received a contraceptive service in the past year from a healthcare provider. ²⁹ Another study found that a third of adolescents who were insured would not use insurance to cover family planning center visits because of confidentiality concerns. Despite this importance, confidentiality may be difficult to maintain, with a study on the provision of LARC services to adolescents demonstrating that practices surrounding electronic health records and billing often lead to confidentiality breaches. ³⁰ Parents may have unfettered access to their children's medical records. ²⁶ In many states, physicians have discretion regarding parental notification; they may limit confidentiality if it is determined to be in the best interests of the patient. This makes it difficult for these services to be provided confidentially to minors, even when state laws permit confidential prescription. These challenges remain despite the work of organizations like the Title X Family Planning Program—a federal grant program designed to provide family planning assistance, especially to low-income individuals—which do not send a detailed bill of services to parents or guardians whose children access contraception through healthcare providers. ³⁰ The mandatory status of parental consent for Title X services was proposed and ultimately voted against thrice in the House of Representatives. ¹⁸ Ironically, this provision of confidential services, largely to low-income women and teenagers, occurs in clinics that have a mandate to encourage adolescents to involve their parents in their reproductive decision-making. ¹⁸

While the public health exception raises important points regarding the spread of disease and prevention of unplanned pregnancies, permission through this justification argument may expose adolescents to other harms, leading to opposition from organizations like the United States Conference of Catholic Bishops (USCCB). The USCCB advocates for parental involvement laws on the basis that confidential care “undermine[s] parental authority and family values” and “condon[es] early sexual activity.” ¹⁸ Most teenagers initiate sexual activity at a younger age than they themselves think is best, and they become fertile before they are “mentally, socially, and morally mature.” ³¹ Adolescents of this age may not be prepared to embrace the consequences, both physical and emotional, which accompany the initiation of sex. One risk, for example, is adolescent relationship abuse (ARA), which is highly prevalent (lifetime report rate of 69% among adolescents who have dated in the past year) and most common among female adolescents aged 15 and above. ³² Abuse of this sort may entail sexual, psychological, and cyber abuse, as well as reproductive coercion, which is defined as “power and control over a partner's reproductive choices.” ³² Clinicians are called to address ARA by providing education about healthy relationship behaviors, increasing resilience factors, and decreasing risk factors. A protective factor against ARA is parental monitoring; when parents have conversations with their children about dating, set limits, and maintain awareness around their child's dating activity, they are able to protect their children and act in their best interests. ³²

The American Medical Association (AMA) claims that most clinicians, even those who strongly advocate for the provision of confidential care, “agree that the active involvement of a concerned and capable parent is the best possible situation of sexually active teens.” ²⁶ The AMA's reasoning is that parents know the emotional needs of their adolescents best, are presumed to be competent decision-makers—unlike their children—and are most likely providing consistent love and care. Furthermore, parents are legally and financially responsible for their children. Salter takes up this point when explaining why we do not allow adolescents to make medical decisions for themselves. While it is unknown but theoretically possible that a child of this age has decision-making capacity, she does not yet have the authority to make medical decisions because the child does not have legal, financial, and moral responsibility for herself. ²⁷ This means, of course, that parents must provide food, shelter, education, supervision, and medical care for their children, but also that parents are “often heavily implicated in the health care decisions made for children” because they “absorb the impact of these decisions, sometimes even more so than the child him- or herself.” ²⁷ Parents may be able to promote adherence to contraceptive methods which require maintenance, like the birth control pill, with a Pediatrics article proposing “support from a family member” to facilitate compliance with the required daily regimen. ⁴ If the adolescent who has been prescribed contraceptives experiences adverse effects or failure of their contraceptive method, it is their parents who will have to provide care by virtue of being responsible for their children. If the child has kept their use of birth control secret, the parent is not able to fully enact their naturally protective role because they are missing information about their child's medical care. It appears that parents need to be fully informed about the medical interventions taking place in their child's life, because they are responsible for the adverse effects of contraception and the consequences of unsafe sexual behavior, whether it be contraction of STIs, unwanted pregnancies, or the emotional effects of navigating sex for the first time as an adolescent.

Furthermore, parents have a right “to direct the moral and spiritual upbringing of children.” ²⁶ Salter also echoes this point by alluding to the “moral significance of parental responsibility” which extends beyond legal and financial providence; a parent is “an educator, shepherd, nurturer, and guide.” ²⁷ Decisions about health care cannot be taken out of the wider context of parenthood and the responsibilities which accompany this role: “protecting, instructing, listening, disciplining, modeling, and loving.” ²⁷ Included in the parental obligation to educate and guide one's child is to familiarize her with her sexuality, impart sexual mores onto her, and allow her to maximize her potential for moral rationality. The parent, in providing for the child's long-term good, should provide her with values for sexual decision-making.

Barina and Bishop argue that the prescription of contraceptives to minors without parental consent constitutes an “omission of the family's moral commitments with regard to pregnancy or sexual activity.” ²⁴ They contrast the “thin commitment of the polis to promote public health by reducing teen pregnancy” with the “thick metaphysical moral content surrounding sex” which ought to be provided by the child's family. ²⁴ Not only do the child's parents seek to foster their present and long-term physical good by inculcating them with sexual morality, but they also prepare their children for the emotional reality of sex, such as the vulnerability experienced, the importance of enthusiastic consent, and the potential for coercion or manipulation. Adolescents lack a full understanding of the moral content behind the meaning of the body, which parents have largely provided for them by meeting and understanding bodily needs, such as good hygiene, the physical changes experienced in puberty, and the needs of intimacy. Adolescents also lack fully developed frontal lobes, making them more impulsive and less able to prioritize long-term goals over short-term goals; this means they may not be capable of integrating this moral content into sexual decision-making. ²⁴ The public health exception dislodges parental authority in favor of “the presumed higher sexual morality of the state.” ²⁴ If parents do not want their children to be sexually active, they should clearly explain their reasoning and answer the child's questions so children can understand what underlies the prohibition. This responsibility is especially critical for parents to uphold in states such as Texas, which have no sexual health education requirements in schools. ² The background knowledge and capacities gained through thoughtful discussions between parent and child about sex allow the child to make decisions which promote her long-term life plans.

As Salter explains, “It is the parent's role and responsibility to guide his or her child's moral and cognitive development while at the same time absorbing the impact of the real world, to varying degrees depending on the situation.” ²⁷ This justification, as well as the assumption that parents act in the best interests of their children and the legal reality of parental responsibility for their child, grounds our current legal framework of parental decision-making for their pediatric patients and provides a strong rationale for parental involvement in contraceptive decision-making contexts. When possible, a parent must be invited into contraceptive decision-making in order for them to fulfill their duties to their child. If the goal of the public health exception is to serve the best interests of minors, it appears as though the exclusion of parents undermines this goal.

Rethinking the role of the provider through a shared decision-making framework

“Asking adolescents to make independent choices about such high-risk issues as sexual behavior, reproductive health, addiction, and mental health is no one's idea of an optimum safety net. It is pragmatic, it is necessary, but it is rarely satisfactory.” ²⁶

The AMA acknowledges that our current system for adolescent access to contraceptives is unsatisfactory. Before introducing my procedural framework, I will provide a brief overview of the recommendations made by the American Academy of Pediatrics (AAP) surrounding contraception for adolescents and parental involvement in this realm. The AAP advocates for the protection of adolescent confidentiality and the support of adolescent self-consent for contraception, with best practice identified as “offer[ing] contraception as a confidential service when legally able to do so, allowing the adolescent the choice to involve parents, caregivers, or another trusted adult.” ⁵ As one substep in the framework outlined, the clinician is called to reflect upon whether parents, among others, may be able to help adolescents “follow through on reproductive care goals.” ⁵ If the adolescent brought an adult with them to seek contraception, the clinician may provide “anticipatory guidance and educational materials” about contraceptive care, confidential provision of services, and emerging adolescent autonomy. ⁵ Confidentiality is heavily emphasized in these practice guidelines, and although there will certainly be adolescents who will require confidential prescription due to parental unwillingness or lack of support, this document neglects the role and responsibility of parents as caregivers and guides discussed at length in the previous section. This framework appears to prioritize confidentiality over the benefits offered by parental involvement. Under AAP guidelines, caregivers are only involved when adolescents wish to involve them, excluding parents whose children feel uncomfortable or hesitant to involve them, but who may desire to take part in decision-making with their children.

To ensure the best outcomes for adolescents, we should strive for open communication and shared decision-making “guided by a supportive parent and an assessing clinician.” ²⁶ The pediatrician's long-term relationship with the patient and family “can provide the trust and accessibility needed for private conversations about sensitive topics such as sexuality and contraception.” ⁵ Open communication about sex has been shown to delay first-time sex and promote the use of contraceptives; one study showed that daughters who spoke to their mothers about contraception were three times more likely to have used effective contraception at last intercourse than those who had not. ³¹ As adolescents are developing autonomy and decision-making capacity, the physician can help by “encouraging teens to take an active role in medical communication and decision making and helping parents learn to yield authority.” ²⁶ The model I will outline below operates in inverse to the current schema by which children under the age of 18 are able to participate in their medical decisions. Instead of evaluating whether and to what extent children are capable of being involved in medical decision-making, I propose that the clinician begin by evaluating the child's parents. When parents appear to be receptive to involvement in decision-making about their children's use of contraception, then the clinician, parent, and child can have a conversation together about contraceptive options and safe sexual practice. This fosters trust among all three parties, will likely facilitate adherence and foster the emotional well-being of the child, and allow the guardian to fulfill their parental obligation as caregivers and educators. While involvement of a willing and capable parent is a best-case scenario, if parents are unwilling or unable, the provider can provide a confidential prescription of one of the more efficacious methods, with direction to OTC methods as the least ideal option which remains preferable to reliance on withdrawal or no method at all.

A burden of the current system of contraceptive access is that if the child wants their parent to be involved in contraceptive decision-making or lives in a state in which they cannot self-consent, they must approach a parent and say, “Mom, I’m having sex. Can we talk about me starting on birth control?” It is unfair to require adolescents to initiate what is often perceived to be a tremendously uncomfortable conversation with their parents alone, especially if they believe that they will not be listened to or supported. In a study of minors accessing confidential contraception in Texas, one 17-year-old girl reported, “I brought [contraception] up and my mom was shutting it down saying how it was unnatural, so that's why I can’t go to her about any of these questions.” ² This participant reported that her mother “believes a lot of myths about birth control,” presumably making it difficult for her daughter to challenge her mother's beliefs about and current understanding of contraception. Another 17-year-old girl explained, “I have conservative Asian parents, so talking about birth control methods was awkward… because it's taboo to have sexual intercourse at my age.” On the other hand, “parents often have difficulty discussing sexual activity with their children on a practical and meaningful level,” but this does not imply that parents have no desire to respond to their children's questions regarding sex. ³³ The aforementioned study reported that of 28 participants, 25 had never had a conversation with their parents about contraception, or had only had one conversation which the child had to initiate. ² Many parents were described as unreceptive or reproachful when their children attempted to initiate a conversation about contraception, despite the increase in safe sex behavior in adolescents as a result of parental communication. A clinician is uniquely empowered to ameliorate the awkwardness of this encounter, enhancing knowledge and promoting healthy communication. Jones and Boonstra identify activities that providers use to facilitate parent–child communication: creating pamphlets or launching media campaigns encouraging parents to talk to their children about sex, providing tips online, or hosting open houses. ¹⁸

I propose that physicians implement an upstream, routine practice (Figure 1) by which parents and children can be evaluated separately and, if the clinician deems it to be in the best interests of the patient, brought into conversation about contraception. Jones and Boonstra support this interpersonal counseling approach, as it occurs one-on-one, allows patients to ask specific questions, and permits the provider to ask whether the child would like to invite the parent to talk about sex. ¹⁸ This process can begin with a brief one-on-one conversation between physician and parent in order to evaluate the parent's knowledge about birth control, attitude about their child's use of contraceptives, and willingness to participate in decision-making concerning their adolescent's sexual activity. At the beginning of the conversation, the physician's questions should be emphasized to be routine and standard practice and are asked before the clinician speaks to the patient independently to assuage the concerns of teenagers who may fear that broaching the topic with parents would indicate the occurrence of sexual activity. The clinician can inform the parent that many adolescents of their child's age engage in potentially risky behaviors such as drinking, smoking, drug use, and unsafe sexual behaviors. The clinician gauges attitude and knowledge by asking questions like, “How would you feel about your child being sexually active? How would you feel about your child using birth control? What do you know about different birth control methods? What questions do you have about the available contraceptive methods for teenagers?” The clinician should offer their expertise, answer questions, and correct misconceptions so parents can have complete and accurate information about adolescent sexual habits, the risks of sex without contraception, and the efficacy of and adverse effects associated with different birth control methods. There will be instances in which the parent does not clearly indicate support or opposition, or seems reluctant or unwilling to have this conversation. Determination of parental support is ultimately a subjective judgment made by the physician, but the parent's responses to the questions asked should provide enough insight for the physician to parse out whether the parent has moral or religious objections to the use of contraception.

As Jones and Boonstra note, clinicians can benefit from knowing parental willingness to support their children in accessing birth control and their interest in obtaining information and enhancing communication with their children. ¹⁸ The following step is taken only if the parent has indicated support of their child accessing contraceptives. The physician would explain that she is going to have a brief one-on-one conversation with the patient and ask, “If your child indicates to me that she is sexually active, can I invite you into the room to have a conversation with us about contraception and safe sexual practice?” If the parent agrees, the process of shared decision-making can proceed following the patient disclosure of sexual activity. If the parent presents discomfort or unwillingness to participate in this conversation, the physician can explain the importance of and benefits offered by the shared decision-making process and can assure the parent that they will be there to guide the conversation and process, should the need arise. If the parent ultimately agrees, they will be welcomed to participate; if they do not, the physician will discuss options and may prescribe contraception confidentially without parental involvement. One could argue that the conversation is moot and has wasted the provider, parent, and patient's time if the child is not sexually active or does not disclose sexual activity. However, the high prevalence of sexual activity in minors and the benefits offered by this shared decision-making framework make these conversations worthwhile, and information gathered about parental attitude can be documented in the record if sexual activity is disclosed at a later visit.

Following parental evaluation, the provider will have a conversation with the patient in which she can ask about the child's sexual activity and the child can feel comfortable responding in their parent's absence. Some children report never having the opportunity to speak privately with their doctor, as indicated in the study response: “[My mom] is always in the room, so it's not like I can tell my pediatrician, ‘Can you make my mom step out?’ If I were to do that, she would for sure know what was going on.” ² Another 17-year-old study participant reported, “I never get any alone time with my doctors.” ² Her response indicates the need for a private opportunity for the adolescent to speak with their healthcare provider, which is echoed by another study which showed that among male and female adolescents, those who had spent time alone with their providers at their most recent visit were more likely to have received sexual and reproductive health services when compared with those who did not have any alone time. ²⁹ The clinician, considered by adolescents to be “a trustworthy source of medically accurate sexual health care information,” is “well-positioned to address adolescents’ unmet contraceptive needs with developmentally tailored approaches.” ⁵

The physician proceeds depending on the obtained parental response. The parent could have indicated support or lack thereof; in the latter case, the provider's response varies depending on whether or not a confidential prescription is permissible under state law. If the parent indicated support, the clinician has a clear path forward, as the parent and child can be brought into conversation with one another. After notifying the child that the parent will be brought into the room and explaining the parent's willingness to support the use of contraception, the clinician can initiate a conversation in which contraceptive options are explored based on goals and preferences, concerns are expressed, and questions are answered. In addition to the AAP, the AMA also notes that confidential care may be necessary for teenagers who are not supported by capable parents. ²⁶

When parents appear unwilling to participate or incapable of being involved due to a lack of support or an explicit prohibition of their child utilizing contraception, the clinician can proceed by having a confidential conversation with the patient. In states where confidential prescription is legal as a result of the public health exception, the provider can educate the patient about the benefits and harms of available options, explain the potential for confidentiality concerns, and engage in shared decision-making with the patient as she spells out her goals, preferences, and life circumstances. If, following this conversation, the adolescent does not wish to proceed with a prescribed method—or if she lives in a state in which the provider cannot prescribe contraception without parental involvement—the physician should still engage in an educational conversation with the patient about safe sexual activity to prevent harm from befalling the adolescent by facilitating coercion or manipulation. This conversation should include guidance and cautioning regarding safe sexual practice, how to identify and respond to abusive behaviors from one's partner, and potentially emotional health and well-being following the initiation of sexual activity. The provider should explain that the use of OTC methods is not the most desirable outcome by virtue of being generally less efficacious, but that the use of these methods is preferable to reliance on withdrawal or condoms alone. As a final option, providers can direct the child to OTC options like Opill, the daily oral contraceptive with failure rates comparable to the prescribed oral contraceptive pill, if they decide not to proceed with provider-prescribed contraception. Whether the adolescent receives a prescription or not, the provider should emphasize the importance of utilizing contraception consistently and correctly, as well as the need to use barrier methods to prevent the spread of sexually-transmitted infection. The clinician can invite the teenager to continue to consider options if they desire a more efficacious method or feel as though they can involve a parent in decision-making to obtain a prescribed method in the future.

In states where adolescents cannot self-consent to contraception, physicians can initiate the same conversation and direct the child to OTC methods of contraception, as mentioned above. This grants the child incapable of obtaining parental consent an accessible, private, and safe option to protect against unwanted pregnancy and STIs. All of these recommendations are made with the caveat that if the physician determines that the child is at risk of serious harm as a result of sexual activity or the use of contraception, they retain the ability and responsibility to notify the child's parents if they deem it to be in the patient's best interests.

Placing these evaluations and conversations into the hands of the clinician may raise concerns of paternalism. One could argue that allowing the physician to determine the parent's capability to participate and exercise their judgment regarding the risks and benefits of contraceptive use for each patient restricts autonomy. However, the clinician's obligation to operate under a best interests standard to care for the patient and their unique position of medical authority, requisite with clinical expertise, places them in a uniquely beneficial position to mediate between parent and child and foster a shared decision-making environment or assist the minor in making decisions which require responsibility, maturity, and good judgment.

Conclusion

Access to contraception constitutes one of the few exceptions to parental medical decision-making for minors. Despite inconsistencies in state law across the United States, many minors are legally protected in confidentially accessing contraception under the public health exception to parental authority. However, this exception may undermine one of the goals it sets out to achieve—the best interest of the child—by preventing parents from exercising their responsibility to protect, provide for, and educate their children, who are not fully decisionally capable. While parental involvement in a process of shared decision-making is widely encouraged and believed to foster good outcomes, it is difficult for children to initiate these conversations. Enter the clinician, who has the knowledge and resources to bring more parents and children together into conversation about contraceptive use. If inquiring about parental capacity for involvement in these decisions becomes standard medical practice, adolescents will be equipped to practice sex safely, and parents will continue to be able to uphold their responsibilities to their children, facilitating the flourishing of the family as a whole.