The Adolescent’s Right to Confidential Care When Considering Abortion

In this statement, the American Academy of Pediatrics (AAP) reaffirms its position on the protection of the rights of adolescents to confidential care when considering legal medical and surgical abortion therapies. This statement presents a summary of pertinent information on the impact of restrictive abortion laws, including mandatory parental involvement, on minor adolescents. Parental involvement laws refer to state laws that require either parental notification or consent for an adolescent to receive abortion care. The judicial bypass procedure allows an adolescent to request court approval to access abortion services confidentially. The AAP supports the recommendations presented by the Council on Ethical and Judicial Affairs of the American Medical Association in its report on mandatory parental consent to abortion.¹  This statement does not include philosophical or religious issues related to abortion because these beliefs are deeply personal. The AAP acknowledges and respects the diversity of opinions about legal abortion therapies. Although this statement supports adolescent access to confidential reproductive health care, the AAP is an advocate of strong family relationships, acknowledging that parents act in the best interests of their children, and their involvement is generally supportive and valuable. The AAP advocates for comprehensive health and sexuality education and the use of effective contraception as effective primary strategies to prevent unintended pregnancy during adolescence.^2,3  Promoting adolescents’ access to confidential sexual and reproductive health care has been a longstanding objective of the AAP. Membership surveys of pediatricians, adolescent medicine specialists, and obstetricians confirm their support of this position.^4–6 

Laws regulating abortion in the United States are increasingly restrictive, profoundly impacting the ability to receive legal abortion therapy.⁷  After the Roe v Wade (1973) decision, which established that an individual’s right to privacy extends to choosing abortion services, the United States Supreme Court ruled on several cases involving mandatory parental involvement and the judicial bypass process shaping minors’ rights to confidential abortion services.^8–12  The decision in Dobbs v Jackson Women’s Health Organization likely weakens or overturns the federal right to abortion, allowing a significant number of states to immediately enforce restrictive abortion laws that were suspended during the Roe v Wade era.^13,14 

Parental involvement laws generally consist of 1 of the following 2 formats: requiring the consent of one or both parent(s) before a minor adolescent’s abortion, or requiring preprocedure parental notification. Most notification laws require written parental notification from a medical provider 24 to 48 hours before the abortion.¹⁵  The majority of states require parental involvement. Most states provide a judicial bypass procedure and allow a minor to consent during a medical emergency. A minority of states waive parental involvement in situations of abuse, assault, or neglect. The Guttmacher Institute maintains an up-to-date reference on parental involvement laws accessible online.¹⁶ 

The AAP, the American Medical Association, the Society for Adolescent Health and Medicine, the American Public Health Association, and the American College of Obstetricians and Gynecologists agree that minors should be encouraged to discuss pregnancy with parents and/or other responsible adults and may look to health care providers to facilitate this.^1,17–21  However, adolescents should not be required to involve parents in the decision to obtain an abortion because legal abortion therapies are safe and most adolescents are capable of medical decision-making.^1,17–21  Additionally, mandating parental involvement does not promote positive family communication, potentially delays or restricts access to appropriate medical care, and creates an unsafe family atmosphere for some adolescents.²² 

The health risks of legal medical and surgical abortion therapies are extremely low.²³  Legal abortion therapies result in fewer deleterious sequelae for individuals compared with other possible outcomes of unwanted pregnancy.^24–27  Although the absolute risk of pregnancy-related mortality is low, some studies have found that adolescents experience pregnancy complications at a higher rate than adult women.²⁸  The risk of death associated with childbirth is approximately 14 times higher than that with abortion, and morbidity rates and medical complications from continuing a pregnancy are more adverse than those from abortion at all stages of gestation.^29–31  The complication risk of abortion procedures increases with gestational age; therefore, laws that increase the time between an adolescent seeking and receiving abortion services are not best practice.²³ 

Studies have found legal, first-trimester abortion to have no significant negative psychological or medical sequelae among adolescents.^32–41  Similarly, evaluation of abortion regret in minor adolescents receiving confidential services have found that most express satisfaction with their pregnancy decision regardless of whether they chose abortion therapy, parenting, or adoption.^42–44  When facing an unwanted pregnancy, regardless of the ultimate outcome, most experience a range of normal emotional reactions.⁴⁵  Adverse emotional reactions after legal abortion therapies are rare; most individuals experience relief and reduced depression and distress.⁴⁶  In contrast, decades of evidence support that delayed or denied care is harmful to the emotional health of individuals seeking legal abortion therapies.^32,36,37 

Multiple professional societies support involving parents in medical decision-making while recognizing the right of adolescents to receive confidential reproductive health care.^47–49  The capacity of an adolescent to make medical decisions is an important consideration when determining the appropriate person to provide consent. There is a growing body of knowledge regarding adolescent cognitive development related to decision-making. The age of 18 years is a convenient legal dividing line, but does not accurately identify when an individual develops decision-making capacity.⁵⁰  Research demonstrates that most adolescents are capable of medical decision-making by age 14, are as competent as adults to provide consent to abortion, and are able to make voluntary, rational, independent decisions.^51,52  Adolescents may require more time to make a medical decision compared with adults but ultimately make decisions grounded in logic.^53,54 

Adolescents seeking abortion therapy consistently cite not being ready to financially provide for a baby and future opportunity limitations as reasons for proceeding with pregnancy termination, suggesting rational decision-making based on future life planning.^55,56 

Once pregnant, an adolescent, by many state laws, is held responsible for and competent to consent to their own medical treatment during the pregnancy and to the medical decisions regarding the fetus or newborn infant. Therefore, it is inconsistent to presume that a pregnant adolescent is not competent to make decisions regarding abortion therapies.^57–59 

There is substantial legal consensus that parental involvement laws run counter to fundamental principles of family law, which seek to protect the privacy of family decision-making from government interference and to protect the best interests of the minor in circumstances when the government does intervene in family affairs.⁶⁰  Parental involvement laws do not impact adolescent pregnancy rates or birth rates.⁶¹  The impact of parental involvement laws on adolescent abortion rates is unclear because studies have produced mixed findings.^61–63  Previous evaluations of parental involvement laws found considerable variability in adolescent abortion rates and second-trimester abortion rates between states and different time periods.^61,63  Recent studies have found judicial bypass to significantly delay the receipt of abortion care, which may lead to ineligibility to receive medication abortion, best demonstrated by a study involving 2063 minor adolescents.^{55,61,64–68} 

Polling suggests the widespread support for parental involvement laws is rooted in the hope that family responsibility and communication will be strengthened.^22,69  Support for such laws is based on the belief that adolescents make better decisions after discussion with parental figures.²²  Although this belief is well-accepted, supportive evidence is lacking.^22,58–72  A 2012 parental involvement law in New Hampshire did show more parental involvement after the law went into effect; however, most studies find the percentage of minors who inform parents about their intent to have an abortion is similar in states with and without notification laws.^72,73  In states with parental involvement laws, adolescents seeking confidential abortion services use judicial bypass mechanisms, go out of state to obtain abortion services, obtain clandestine care, or delay care.^{64,68,71,74–76}  Studies confirm that most pregnant minors, especially those of younger ages, actively involve parents regardless of parental involvement laws.^{22,73,74,77,78,80}  Pregnant minors often involve trusted adults such as other family members, teachers, coaches, and parents of friends, dispelling the characterization that adolescents make abortion decisions in isolation if not mandated to involve a parent.^55,56,22,80 

Involuntary parental notification may precipitate a family crisis characterized by severe parental anger, possible violence, and rejection of the minor and their partner. Studies over the past 3 decades found that adolescents are motivated to seek confidential services for a variety of reasons, such as wanting to protect a vulnerable parent from stress and disappointment, belief that the relationship with the parent would be damaged, fear of losing housing and financial security, and fear that disclosure would escalate conflict or coercion to continue the pregnancy.^55,56,79,81  Adolescents who are strongly opposed to informing parents about their intent to have an abortion tend to predict family reactions accurately.^56,82  One-third of minors who do not inform parents have already experienced family violence and fear it will recur.⁷⁹  Seminal research on tumultuous family environments shows that violence is at its height during a family member’s pregnancy and during adolescence.¹⁸  Although parental involvement in minors’ abortion decisions is helpful in many cases, it is important to recognize that mandating parental involvement, despite an adolescent’s desire for confidentiality, increases the risk of violence, abuse, coercion, and rejection in families with financial or relationship instability.^{40,79,81,83,84} 

Legal precedent has upheld that judicial bypass is a reasonable alternative to parental notification in the interest of protecting an adolescent from harm.¹⁸  Many experts, however, disagree with Supreme Court rulings on judicial bypass, arguing that the process constitutes an “undue burden” for adolescents seeking abortion care.^58,60,70  Judges who preside over bypass rulings testify that the procedure is of no benefit to minors.^64,85–88  For the judicial bypass process to be effective, the adolescent has to be aware of this right, have a basic understanding of the court system and procedure to retain an attorney, be prepared for school and home absences, and have access to transportation.¹⁵  Minor adolescents are vulnerable to receiving inaccurate or incomplete information regarding the judicial bypass process. A multistate, “mystery-caller” study of abortion clinics revealed that only 55.6% of staff in states with parental involvement laws informed the simulated minor patient of their right to a judicial bypass.⁸⁹ 

As the judicial bypass process has become more restrictive, denials have increased.^58,90  Since 2010, 11 states restricted judicial bypass by limiting the number of courts able to grant permission, amending the request procedure, and changing the type of evidence the minor must present to prove the ability to consent and why parental notification is not possible.⁹¹  Texas introduced legislation in 2015 requiring most minors to seek bypass in their home county.⁹¹  In 2014, Alabama enacted legislation allowing the district attorney to defend the interest of the fetus in cases of judicial bypass.⁹¹  Adolescents pursuing judicial bypass experience challenges, with some reporting feeling shame, intimidation, and physical symptoms of anxiety.^91–93  Inconsistency in the timing of proceedings, with some cases not proceeding on the scheduled day, and inconsistency in the reasoning behind judicial bypass denials have significant negative impact on adolescents.⁹³ 

Reproductive justice recognizes that the decision to parent or not parent in a safe space is a basic human right.⁹⁴  This principle has been embraced by the AAP and other professional societies.^95,96  Restrictive abortion policies directly conflict with this principle. The AAP strives to attain optimal health and well-being for all children, adolescents, and young adults, and recognizes the negative impact structural drivers of inequity have on health.⁹⁷  Restrictive abortion laws disproportionately impact people of color in the United States, with studies identifying a higher reduction in abortion rates among individuals identifying as Hispanic and those living in rural counties after passage of restrictive abortion laws.^98–100  Black and Hispanic individuals are more likely to live in states with restrictive state abortion laws, and because of complex structural inequities, have slightly higher abortion rates compared with non-Hispanic, White individuals.^98,101,102  Structural inequities have led to racial and ethnic disparities in poverty-related factors such as transportation, lack of expendable finances, and health insurance, all of which contribute to inequitable access to health care, including abortion care.^101,103,104  Restrictive state abortion laws not only exaggerate existing racial and ethnic abortion access inequity, but also disproportionately impact adolescent access to care, especially if travel to another state is required.¹⁰⁴ 

Parental involvement laws that strictly define “parent” or “legal guardian” discount the complexity of family structures in the United States, especially because minors from various racial, ethnic, and socioeconomic background are more like to live in family structures that may not include, or include more than, both biological parents.^105–108  It is important to note that the impact of parental involvement laws is unknown on families recently immigrating to the United States in which parents and their adolescent children may hold significantly different religious or cultural beliefs, leading to different standards related to sexual relationships. Parents with undocumented residence status is another significant barrier to an adolescent seeking abortion services in states with restrictive parental involvement laws because ∼ 6% of infants born in the United States had a parent without legal residence status.¹⁰⁹ 

Parental involvement laws fail to recognize the added stress that an adolescent pregnancy may bring to the family. To preserve parent well-being, adolescents in families experiencing complex stressors such as recent death or significant illness, financial trouble, recent divorce, or threats of deportation are likely to pursue judicial bypass rather than involve a parent in the decision to proceed with legal abortion services.^55,56  Again, because of structural inequities, adolescents of color are more likely to experience some of these family stressors and may be more negatively impacted by parental involvement laws.⁹⁸  Special family circumstances may be driving the decision to maintain confidentiality. Parental involvement laws do not account for these special circumstances and contribute to the inequitable impact of barriers facing adolescents seeking confidential abortion services.

Recent studies show that, although abortion rates decrease in states with restrictive laws, abortion therapy in neighboring states and gestational age at the time of abortion therapy increases.^{99,100,110–113}  If there is no federal protection to abortion, it is estimated that, on average, 39% of the national population would need to travel an additional 249 miles to receive legal abortion services.¹¹⁴  Adolescents are particularly negatively impacted by geographic restrictions to legal abortion services when considering transportation access, cost, and absence from both home and school.^55,115 

The coronavirus disease 2019 pandemic accelerated advances in delivering health and legal services using virtual technology. Telehealth services to deliver medication abortion care have been used since the United States Food and Drug Administration allowed the mailing of abortion pills in April 2021.¹¹⁶  Medication abortion by telehealth is safe, effective, and acceptable.¹¹⁷  In recent years, the practice of self-managed medication abortion has gained acceptance and traction as restrictive abortion laws have reduced access to these services in traditional medical settings.¹¹⁸  Trauma related to self-instrumentation in an effort to end pregnancy may be reduced by teaching self-administration of misoprostol, reducing morbidity and mortality.¹¹⁹  Limited evidence suggests that self-managed medication abortion is safe, but concerns over the ability to accurately self-identify as an appropriate candidate for medication abortion and the ability to access urgent medical care support the need for legal abortion.¹²⁰  It is important for health care professionals to be aware of the availability of self-managed abortion and to be able to provide accurate information to adolescents who desire abortion services in states with highly restrictive laws. The relationship between restrictive abortion laws, high-risk pregnancy outcomes, unsafe abortion, and maternal mortality emphasizes the importance of ensuring that adolescents have access to confidential legal abortion.²⁵ 

1. The AAP reaffirms its position that the rights of adolescents to confidential care when considering abortion should be protected. Although the stated intent of mandatory parental involvement laws is to enhance family communication and parental responsibility, there is no supporting evidence that these effects are achieved. There is evidence that such legislation may have an adverse impact on some families and pose medical and psychological harm to some adolescents. Similarly, judicial bypass provisions do not ameliorate risks and may delay access to safe and appropriate care.

2. Because of the harms of restrictive abortion laws and the dangers associated with unsafe abortions, adolescents should have access to legal abortion services.

3. When safe and appropriate, health care professionals should encourage adolescents to seek adult guidance and support when considering their pregnancy options. It should be recognized that most adolescents do involve a parent or trusted adult when making the decision to proceed with legal abortion therapy. Ultimately, the pregnant adolescent’s right to decide whom to involve in the decision to seek abortion care should be respected. This approach is consistent with basic ethical, legal, and health care principles.

4. Health care professionals should understand state and regional laws regulating abortion services, including restrictions on health care professionals’ counseling about or referring adolescents for abortion therapy. For more information on laws in your state, contact AAP State Advocacy at [email protected].

5. Health care professionals should be aware of structural inequities within US society and understand that adolescents from marginalized communities are likely to experience more negative impacts from restrictive abortion laws, including mandatory parental involvement and judicial bypass requirements.

Elise D. Berlan, MD, MPH, FAAP Seema Menon, MD

Elizabeth M. Alderman, MD, FSAHM, FAAP, chairperson Elise D. Berlan, MD, MPH, FAAP Richard J. Chung, MD, FAAP Michael D. Colburn, MD, MEd, FAAP Laura K. Grubb, MD, FAAP Janet Lee, MD, FAAP Stephenie B. Wallace, MD, MSPH, FAAP

Anne-Marie Amies, MD, American College of Obstetricians and Gynecologists Liwei L. Hua MD, PhD, American Academy of Child and Adolescent Psychiatry Seema Menon, MD, North American Society for Pediatric and Adolescent Gynecology Maria H. Rahmandar, MD, FAAP, Section on Adolescent Health Ellie Vyver, MD, Canadian Paediatric Society Lauren Zapata, PhD, MSPH, Centers for Disease Control and Prevention

Karen S. Smith James Baumberger, MPP

AAP

American Academy of Pediatrics