Access to comprehensive reproductive health care is an adolescent health issue

Originally published in the PolicyLab blog at Children’s Hospital of Philadelphia.

Editor’s Note: This blog post was written in collaboration with the Guttmacher Institute. The position is part of an effort to use PolicyLab’s research and expertise to help other researchers, policymakers, program developers, and institutions understand the downstream effects of limiting young people’s access to comprehensive reproductive health care. To learn more, read an article on ensuring access to contraception (and watch a recording of our virtual conversation focus youth voices on supporting access to comprehensive sexual and reproductive health services).

Nearly six months after the U.S. Supreme Court overturned Roe v. Wade, we see the profound effects on adolescent health. States now making decisions on access to abortion, more patients come to our pediatric practices in southeastern Pennsylvania asking to start birth control or switch to a long-term method in case their right to make reproductive decisions is taken away. Our research (Dr. Wood) shows that politically motivated limits on sexual and reproductive health services were threatening the delivery of high-quality services for young people before the Supreme Court ruling led to increased state restrictions on access to abortion. The removal of state protections for abortion care will have far-reaching effects on the health and well-being of adolescents, with marginalized young people being the most affected.

Ensuring access to the full spectrum of evidence-based sexual and reproductive health care is a matter of pediatric policy and health equity, as stated by the American Academy of Pediatrics and the Society for Adolescent Health and Medicine. In this article, we review the legal framework supporting adolescents’ access to sexual and reproductive services, as well as research on the impact of restrictions on reproductive care for adolescents, especially young people from racial and ethnic minorities. We conclude with recommended actions that researchers and clinicians can take to improve access and outcomes for young people.

Legal framework supporting adolescents’ access to sexual and reproductive health services

Policies allowing adolescents to access sexual health education and reproductive services have existed for decades and have emerged in response to public health threats and changing social norms. They include in particular:

  • Several Supreme Court decisions in the 1970s establishing the constitutional right of minors to due process, the right to privacy and access to contraception. The Carey v. Populations Services International of 1977 made it illegal to ban the sale of contraceptives to minors and supported minors’ right to privacy when making reproductive decisions.
  • The Title X Family Planning Program, established in 1970, is a critical federal funding stream for young people to access confidential services without a parent or guardian, including sexually transmitted disease screening, contraception and pregnancy counselling.
  • The 1970s marked a rise in the average age of marriage, an increase in the single population and sexually active young person, reduced social pressure for pregnant teenagers to marry and the legalization of abortion.
  • In the late 1980s, the Centers for Disease Control and Prevention began providing funding and technical assistance specifically for HIV education in response to the public health threat posed by the AIDS epidemic.
  • In 1990, after decades of activism, SIECUS: Sex Ed for Social Change developed the first guidelines for sex education for K-12 schools. See PolicyLab Briefing Note on Comprehensive School Health Education for more current context on the guidelines.

These legal and social changes have been felt unevenly across the country. Southern and Midwestern states tended to adopt more restrictive policies, such as abstinence-based sex education programs, and policies that undermined the confidentiality of adolescent reproductive health care, such as parental involvement laws related to abortion care, among others.

Geographic variations in policies have been compounded by longstanding racial and socio-economic inequalities and structural racism. Communities where low-income and Black, Indigenous and People of Color (BIPOC) live have always been more likely to experience chronic underfunding of schools, discriminatory banking and housing policies, have more low-wage jobs and lack affordable resources and high quality health care services. Sexual and reproductive health policies like the Hyde Amendment prevented federal funds from being used to pay for abortions for Medicaid-insured women.

Unequal access to reproductive care leads to poor health outcomes

State variation in access restrictions and policies comes unsurprisingly with disparities in outcomes. This results in differences in teen pregnancies and sexually transmitted infections (STIs), and now plays with state-based variation of abortion restrictions.

PolicyLab’s research examined the inequitable impact that restrictive sexual health policies can have on adolescents. In 2020, Dr. Wood and his team studied the impact of the “domestic gag rule” (since reversed), which prohibited clinics receiving federal Title X funding from providing counseling on pregnancy options that included abortion. The research found that after the rule change, more than 1.8 million young people aged 15 to 17 did not have access to confidential contraceptives and legally guaranteed STI services due to the fact that clinics were refusing Title X funds rather than complying with these restrictive policies. The loss of access was not uniform, with young people living in rural communities experiencing the greatest loss of services.

With the emergence of abortion restrictions by states, we are likely to see similar trends of vulnerable populations being disproportionately affected. States most affected by loss of abortion services have higher numbers of people of color, other restrictive health policies (e.g., did not expand Medicaid under the Affordable Care Act) , disproportionately high poverty rates, among the highest rates of rurality, and the least robust transit systems. This means that people with the least financial means, the greatest barriers to access and the longest distances to services will face more difficulty accessing or be forced to forgo care. These inequalities will be further amplified for young people who face additional challenges in traveling and navigating varying parental involvement requirements by state.

Recommendations to protect adolescents’ right to access reproductive care

It is essential that child health researchers, clinicians and policy makers amplify the importance of access to comprehensive sexual and reproductive health services for adolescents. We recommend the following priorities for action to ensure access to equitable, high-quality services for all young people:

  • Support the passage of the state and local protections for the right to access sexual and reproductive health services for state residents and/or provide protections for those traveling from restrictive states for care. California, Michigan and Vermont are examples of States which have consecrated the right to abortion and other pregnancy-related care in their state constitutions.
  • Advance multisectoral partnerships of clinicians, legal advocates, and grassroots organizations working together to protect young people and providers from lawsuits, workplace discrimination, and to limit the sharing of confidential health information reproduction of the young.
  • Increase young people’s access to confidential and complete sexual and reproductive health services alongside resources for young people so they know their rights and how to access care. More adolescents are likely to access essential care when confidentiality is protected.
  • Restore reproductive health services lost as a result of the implementation of the household gag rule. See PolicyLab’s recent blog post on why this is particularly critical now.
  • Repeal parental notification requirements for youth seeking abortion to align with principles of adolescent autonomy, including expanding definitions of adults who support youth to encompass non-parental support figures.
  • Invest in health navigators who can guide young people who must go through the legal bypass process to receive abortion services.
  • Promote innovative youth-centered strategies to ensure sexual and reproductive health service delivery in low-resource settings, including telehealth and mobile health services, financial safety nets, and strategies to build support social service for young people who have to travel to receive services.

The Supreme Court’s decision to overturn Roe v. Wade threatens a wide range of essential health services for adolescents. OAlthough state laws affirm the right of minors to consent to contraception, STI testing and treatment, and pregnancy care, no state requires parental involvement for these services as they do when it’s about abortion care. There is a lot at stake in the states of the country, and young people who already face inequitable access to these services may suffer further losses, which will only be magnified for minority young people.

As the landscape of state and federal restrictions on sexual and reproductive health services continues to expand, researchers, clinicians, and policymakers have a critical role to play. By partnering with state and local governments, creating innovative service delivery strategies, and studying and amplifying the harmful effects of ongoing restrictions, we can counter the growing tide of restrictions and help ensure that all young people continue to have access to equitable and high-quality services.

Originally published in the PolicyLab blog at Children’s Hospital of Philadelphia.

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