In this statement, the American Academy of Pediatrics reaffirms its position that the rights of adolescents to confidential care when considering abortion should be protected. Adolescents should be encouraged to involve their parents and other trusted adults in decisions regarding pregnancy termination, and most do so voluntarily. The majority of states require that minors have parental consent for an abortion. However, legislation mandating parental involvement does not achieve the intended benefit of promoting family communication, and it increases the risk of harm to the adolescent by delaying access to appropriate medical care. This statement presents a summary of pertinent current information related to the benefits and risks of legislation requiring mandatory parental involvement in an adolescent’s decision to obtain an abortion.

Ensuring that adolescents have access to health care, including reproductive health care, has been a long-standing objective of the American Academy of Pediatrics (AAP).1 Timely access to medical care is especially important for pregnant teenagers because of the significant medical, personal, and social consequences of adolescent childbearing. The AAP strongly advocates for the prevention of unintended adolescent pregnancy by supporting comprehensive health and sexuality education, abstinence, and the use of effective contraception by sexually active youths. For 2 decades, the AAP has been on record as supporting the access of minors to all options regarding undesired pregnancy, including the right to obtain an abortion. Membership surveys of pediatricians, adolescent medicine specialists, and obstetricians confirm this support.2,4 

In the United States, minors have the right to obtain an abortion without parental consent unless otherwise specified by state law. State legislation that mandates parental involvement (parental consent or notification) as a condition of service when a minor seeks an abortion has generated considerable controversy. US Supreme Court rulings, although upholding the constitutional rights of minors to choose abortion, have held that it is not unconstitutional for states to impose requirements for parental involvement as long as “adequate provision for judicial bypass” is available for minors who believe that parental involvement would not be in their best interest.5,6 Subsequently, there has been renewed activity to include mandatory parental consent or notification requirements in state and federal abortion-related legislation.

The American Medical Association, the Society for Adolescent Health and Medicine, the American Public Health Association, the American College of Obstetricians and Gynecologists, the AAP, and other health professional organizations have reached a consensus that a minor should not be compelled or required to involve her parents in her decision to obtain an abortion, although she should be encouraged to discuss the pregnancy with her parents and/or other responsible adults.7,13 These conclusions result from objective analyses of current data, which indicate that legislation mandating parental involvement does not achieve the intended benefit of promoting family communication but does increase the risk of harm to the adolescent by delaying access to appropriate medical care or increasing the rate of unwanted births.

In this statement, the AAP reaffirms its position on the protection of the rights of adolescents to confidential care when considering abortion. 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.8 This statement does not duplicate the extensive analysis in that report but presents a summary of pertinent current information related to the benefits and risks of legislation requiring mandatory parental involvement in an adolescent’s decision to obtain an abortion. This statement does not discuss the philosophical or religious issues related to abortion. Beliefs about abortion are deeply personal and are shaped by class, culture, religion, and personal history as well as the current social and political climate. The AAP acknowledges and respects the diversity of beliefs about abortion. This statement affirms the value of parental involvement in decision-making by adolescents and the importance of productive family communication in general. The AAP is foremost an advocate of strong family relationships and holds that parents are generally supportive and act in the best interests of their children.

In 2009, 705 000 teenagers 15 to 19 years of age became pregnant.14 Of those pregnancies, 25% (176 000) were terminated by elective abortion.14 In 2011, the National Campaign to Prevent Teen and Unplanned Pregnancy reported 553 000 teen pregnancies. In this same year, adolescents (15–19 years of age) accounted for 13.5% of all abortions.15 The absolute number of teen pregnancies may actually be higher if pregnant teenagers undergo illegal or self-induced terminations or experience a miscarriage or a home delivery and never seek pregnancy-related health care. The percentage of pregnancies terminated by induced abortion in minors increased in the 1970s, reached a plateau in the early 1980s, and has decreased since 1985. Postulated explanations for the decline include a shift in attitudes toward abortion among adolescents; increased legal and financial barriers to abortion, particularly for low-income adolescents; and increasing social acceptance of childbearing among unmarried adolescents.

Early childbearing can lead to a range of negative outcomes for the adolescent mother and her child or children, including lower rates of school completion, higher rates of single motherhood, higher rates of preterm birth and low birth weight, increased rates of incarceration among male children, and increased rates of teen motherhood among female children born to adolescent mothers.16 Fewer studies have been conducted in teen fathers, although some studies indicate that teen fathers are more likely to have completed less education and have poorer economic status in terms of income and jobs.17,19 Interestingly, 1 study found that women from an impoverished neighborhood who had been teen parents still experienced negative effects in terms of education and income by age 42, but the same did not hold true for men.19 

Compared with those who choose childbirth, adolescents who choose abortion tend to come from higher socioeconomic backgrounds, have higher educational aspirations and achievements, have mothers with higher educational levels, have higher self-esteem, have greater feelings of control over life, have lower levels of anxiety, and are better able to conceptualize the future.20,22 These findings suggest that young women with a more positive view of their future may choose to have an abortion so that they can pursue that future. One of the only studies that followed teenagers who had an abortion found that young women in New Zealand who had an abortion had higher levels of subsequent educational achievement than those who continued the pregnancy; they were more likely to gain a university degree (26.7% vs 9.7%; P < .05) and more likely to gain postsecondary school training (51.4% vs 30.4%; P < .05).23 

In the landmark case Roe v Wade in 1973, the US Supreme Court ruled 7 to 2 that a right to privacy extended to a woman’s decision to have an abortion.24 This right could be overcome by state interests in regulating abortions and preserving life after the fetus was viable outside the womb. Subsequent Supreme Court decisions affirmed a state’s right to pass laws requiring parental involvement in a minor’s decision to have an abortion, but only if they were accompanied by judicial bypass procedures that also allow a minor to receive court approval for an abortion without her parents’ knowledge or consent.5,6,25,26 In Planned Parenthood v Casey (1992), the Supreme Court upheld several state abortion-related restrictions, including a parental involvement restriction, ruling that the requirements did not impose an “undue burden” on women. These court decisions led to the passage of additional state laws requiring parental involvement for minors. The laws generally take 2 forms: some require a clinic or physician to obtain the consent of 1 or both parents before the teenager’s abortion, and others require the parent(s) to be notified before the procedure. States enacted more restrictions on abortions in the years 2011–2013 than in the entire previous decade,27 reinforcing the need for health care professionals to be fully aware of their state laws to provide the best care for adolescents.28,29 

In 2015, 38 states required parental involvement in a minor’s decision to have an abortion: 21 states required parental consent, 12 states required parental notification, 5 states required both parental consent and notification, and 8 states required the parental consent documentation to be notarized.29 All of the states requiring parental involvement included a judicial bypass procedure, which allows a minor to obtain approval from a court to obtain an abortion.29 Seven states permit a minor to obtain an abortion if a grandparent or other adult relative is involved in the decision.29 Most states that require parental involvement make exceptions under certain circumstances: 36 states permit a minor to obtain an abortion in a medical emergency, and 16 states waive parental involvement and permit a minor to obtain an abortion in cases of abuse, assault, incest, or neglect.29 

Adolescents who are willing to involve parents in their abortion decision will likely benefit from adult experience, wisdom, emotional support, and financial support if the parents’ health insurance policy covers pregnancy termination. The American Medical Association noted that there is a “remarkable degree of consensus that adolescents should have access to confidential health services and that parental involvement, consent, or notification should not be a barrier to care.”30 There is substantial legal consensus that parental consent and notification laws, whether ruled constitutional, run counter to fundamental principles of family law, which ideally seek to protect the privacy of family decision-making from government interference and to protect the best interests of the minor in the circumstances when the government does intervene in family affairs.31 

The concern of competency is naturally questioned when reviewing the need for parental notification. 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 there is no specific evidence to support its use as the point at which individuals become competent decision-makers. Existing research shows that most minors 14 to 17 years of age are as competent as adults to provide consent to abortion, are able to understand the risks and benefits of the options, and are able to make voluntary, rational, and independent decisions.32,41 

Once pregnant, an adolescent, by many state laws, is held responsible for and competent to consent to her own medical treatment during the pregnancy and to the medical decisions regarding her fetus or newborn infant (eg, amniocentesis, genetic testing, life-saving treatment, and circumcision). No state laws require the minor’s parent to consent to the minor’s decision to continue the pregnancy when the parent believes that terminating the pregnancy is in the minor’s best interest, nor do any state laws require a minor’s parent to consent to medical decisions for the infant’s health care or, with few exceptions, to place the infant for adoption.42 It is inconsistent, then, to presume that the minor is not legally competent to make decisions regarding pregnancy termination.35,43,44 The legal issues involved in a minor’s right to confidential abortion care have been well covered in other reviews.45,48 All analyses confirm that confidential care for adolescents is critical to improving their health.

Mandatory parental consent or notification laws do not promote family communication, do not protect the physical or emotional health of young women, and may, in fact, do harm. Judicial bypass procedures also risk causing medical and psychological harm to the pregnant adolescent.

Basic principles of law and society hold that parents should be involved in and responsible for ensuring that their children receive medical care, that parents ordinarily act in the best interests of their children, and that minors benefit from the advice and emotional support of their parents. Legislation mandating parental involvement in abortion decisions is promoted on the basis of its theoretical benefits of strengthening family responsibility and communication. Some who support reproductive choice may be ambivalent about parental notification requirements. Many parents vote for notification clauses, because they hope these laws will increase communication that otherwise might not happen.49 

Research confirms that pregnant minors do not make abortion decisions in isolation; they actively involve adults to whom they feel close. Studies show that adolescents are most likely to disclose pregnancy if their family has a history of warmth, rapport, and involvement of parents in past problem-solving.50,53 Even when not required, most minors seeking an abortion voluntarily involve at least 1 parent in their decisions. A recent review on parent involvement laws and parent-daughter communication showed that in states without parent involvement laws, 34% to 91% of minors told their parents about their pregnancy termination plan.54 A survey of 1519 unmarried pregnant minors in states in which parental involvement is not mandatory found that 61% told 1 or both parents about their intent to have an abortion. The younger the minors, the more likely they were to tell their parents about their intent to have an abortion (90% of those aged ≤14 years, 74% of those aged 16 years).55 A more recent study also showed that younger age increased the likelihood of a minor informing her mother and, conversely, decreased the odds of informing the partner of her intent to have an abortion.52 

Among minors who did not involve a parent in their decision-making about their pregnancy, virtually all involved at least 1 responsible adult other than clinic staff (eg, another relative, teacher, counselor, professional, or clergy). A study in inner-city, black pregnant teenagers younger than 18 years confirmed that >91% voluntarily consulted a parent or “parent surrogate” about pregnancy decisions. The term “parent surrogate” refers to a close adult who is fulfilling a parental role. This parent surrogate was often a grandmother, aunt, or other relative who had “raised” the adolescent or with whom she lived, even if that adult was not the adolescent’s legal guardian.56 The importance of parent surrogates and extended families is significant when assessing the impact of attempts to legislate family communication. Most notification clauses are restricted to traditional definitions of biological parents or legal guardians and fail to address the complexity and diversity of modern family structures and adult support systems relevant to adolescents. For a minor who is willing to involve parents or parent surrogates in her abortion decision, legislation adds no benefit and actually may impede appropriate family communication channels if, for example, a parent is notified before the adolescent has a chance to raise the issue with her parent(s).

Minors who choose not to inform parents about their intent to have an abortion are disproportionately older (16 and 17 years old), white, and employed.55 Very young adolescents almost always agree to voluntary parental involvement. In the unusual instance of resistance by the minor to inform the parent(s), the possibility of incest or abuse should be carefully evaluated. The most frequent reasons minors cite for not telling parents include the desire to protect a vulnerable parent from stress and disappointment, the belief that the knowledge would damage their relationship with the parent, and the fear that disclosure would escalate conflict or coercion.55 Similarly, a study of parents’ attitudes regarding parental notification about minors’ access to contraception showed that parents who were more aware of the negative consequences of notification were less likely to support parental notification laws. The study recommended that more education be provided to parents about the potential negative consequences of parental notification laws.57 

Adolescents who are strongly opposed to informing parents about their intent to have an abortion tend to predict family reactions accurately.58 Involuntary parental notification can precipitate a family crisis characterized by severe parental anger and rejection of the minor and her partner. One-third of minors who do not inform parents already have experienced family violence and fear it will recur.55 For example, in a study in Massachusetts minors who chose not to inform a parent, almost one-quarter feared that they would face family conflict, physical harm, or other abuse if they told a parent about the pregnancy.59 In Hodgson v Minnesota, the majority of the Supreme Court found that mandatory parental involvement can result in family upheaval and can be dangerous for minors in homes in which physical, emotional, or sexual abuse occurs.31,60 Research on abusive and dysfunctional families shows that violence is at its worst during a family member’s pregnancy and during the adolescence of the family’s children.10 Although parental involvement in minors’ abortion decisions may be helpful in many cases, in others it may be punitive, coercive, or abusive.61 The risks of violence, abuse, coercion, unresolved conflict, and rejection are significant in nonsupportive or dysfunctional families when parents are informed of a pregnancy against the adolescent’s considered judgment.55,59,60,62,63 

There is no evidence that mandatory parental involvement results in the benefits to the family intended by the legislation. No studies show that forced disclosure results in improved parent-child relationships, improved communication, or improved satisfaction with the decision about the pregnancy outcome.43,61,64,65 Although a recent study of the 2012 parental notification law in New Hampshire did show more parental involvement after the law went into effect, overall, the percentages of minors who inform parents about their intent to have an abortion are essentially the same in states with and without notification laws.50 In states with such laws, adolescents who are not willing to inform parents use judicial bypass mechanisms,51 go out of state to obtain abortion services,66 obtain clandestine care,67 or delay care.61,68 

The most damaging effect of mandatory parental notification laws is that they can delay and obstruct pregnant adolescents’ access to timely professional advice and medical care.5,10,58,69 Minors generally suspect pregnancy later in its course than do adults.70 Adolescents are often confused about their right to confidential care, and even a perceived lack of confidentiality in health care regarding sexual issues deters them from seeking services.71,74 Once the minor presents for pregnancy counseling, mandatory parental involvement laws can delay medical care further. For example, after enactment of such statutes in Texas, second-trimester abortion rates among 17-year-old adolescents increased by 21%.75,76 Similarly, court proceedings in Massachusetts delayed the termination of pregnancy by as much as 6 weeks.66 In Mississippi, a parental consent requirement resulted in an increase of 19% in the ratio of minors to adults who had an abortion after 12 weeks’ gestation.77 In Missouri, the proportion of abortions occurring past 12 weeks’ gestation increased from 19% to 22% among minors.78 Later-trimester abortions (after 14 weeks’ gestation) increase both the medical risks and financial costs to the patient, and a prolonged delay can eliminate abortion as an accessible option.79 In a recently published study investigating the effect of the 2012 New Hampshire parental notification law for abortion, the abortion rate among minors did not significantly decrease, despite the fact that more parents were involved.80 

Whereas 46.5% of adolescents younger than 15 years and 54.3% of adolescents 15 to 19 years of age who obtained an abortion did so by ≤8 weeks’ gestation, 62.1% to 71.2% of women aged ≥20 years who obtained an abortion did so by ≤8 weeks’ gestation; conversely, 19.0% of adolescents younger than 15 years and 11.8% of adolescents 15 to 19 years of age who obtained an abortion did so after 13 weeks’ gestation, and 6.5% to 8.7% of women aged ≥20 years who obtained an abortion did so after 13 weeks’ gestation.81 It is likely that mandatory parental consent legislation decreases access to abortion by adolescents, although confounding variables (especially the inability to account for abortions obtained out of state) make it difficult to ascertain causal effects on abortion rates.82 The 1 recent study of abortion rates in New Hampshire did not find evidence of New Hampshire minors seeking abortions out of state.80 Both abortion rates and abortion ratios have decreased nationwide in states with and without parental consent statutes.

The medical risks of legal first-trimester abortion likewise are extremely low. The risk of death associated with childbirth is ∼14 times higher than that with abortion,83 and morbidity rates and medical complications from continuing a pregnancy are more adverse than those from abortion at all stages of gestation.81,83 In September 2000, the Food and Drug Administration approved the use of the drug mifepristone to end an early pregnancy.84 This pharmaceutical abortion method has been shown to be both safe and effective for use as an outpatient, especially in the first trimester of pregnancy.85,86 Pregnancies of later gestational ages may be terminated surgically or medically with labor induction if resources are available.86,87 Legal abortion results in fewer deleterious sequelae for women compared with other possible outcomes of unwanted pregnancy. The evidence does not support policies that put barriers in the way of an adolescent’s selection of abortion because of concerns about physical consequences.

There is increasing evidence of the negative effects of delayed or denied abortion on both the emotional health of mothers and the developmental status of unwanted children. Later-stage abortions are associated with a greater risk of psychological sequelae for pregnant teenagers (compared with first-trimester abortions, which are without significant negative sequelae).88 American studies have recently corroborated European research that shows that women who are denied abortions only rarely place their unwanted infants for adoption and may harbor resentment and anger toward their children for years.89,95 Despite strong social pressure not to acknowledge that a child is unwanted, more than one-third of the women confessed to having strong negative feelings toward their children. Compared with the offspring of willing parents, the children of women who did not obtain requested abortions were much more likely to be troubled and depressed, to drop out of school, to commit crimes, and to have serious illnesses.90,91 Compared with peers who terminate their pregnancies, adolescents who bear children are at significantly higher risk of educational deficits and economic disadvantage; children born to teen mothers also have a greater risk of negative health, social, and economic consequences.16,70,96 

Some adults support mandatory parent notification because they believe that it will protect the adolescent from making a decision she might regret later. Most adolescents, however, express satisfaction with their ultimate pregnancy decisions, provided they believe that the decisions were their own. No significant differences in the levels of later satisfaction with their decisions have been found between adolescents who choose abortion and those who bear children or between those who parent as opposed to those who place their infants for adoption; almost all believe that they made the right choices for themselves.96,98 The key determinant of this expressed satisfaction is the sense of “ownership” over the pregnancy decisions and the belief that their choices were not the result of coercion.52,98 In other research, pregnant adolescents who chose not to communicate with parents were as satisfied with their decisions as those who did consult with parents and received support for their decisions.56 Adolescents who communicated with nonsupportive parents were the ones more likely to express dissatisfaction with pregnancy decisions.56 

In 2008, the American Psychological Association published the results of an extensive review of the effects of abortion on women’s mental health.99 Key findings were that some women do experience sadness, grief, and feelings of loss after the termination of a pregnancy, and some experience clinically significant disorders, including depression and anxiety. However, the most well-constructed studies in the review indicated that among women who have an unplanned pregnancy, the relative risk of mental health problems is no greater if they have a single elective first-trimester abortion than if they continue the pregnancy and give birth. Studies in minors have found similar results, and significant negative psychological or medical sequelae to elective, legal, first-trimester abortion among teenagers are not substantiated.99,104 

When facing an unwanted pregnancy, regardless of the ultimate outcome, most women experience a range of normal emotional reactions, including regret, mild depression, and anxiety. Adverse reactions after abortion are rare; most women experience relief and reduced depression and distress.69 Some women may experience feelings of grief and guilt after termination of pregnancies, especially those who consider themselves deeply religious or who were ambivalent about their decisions, and they may benefit from appropriate therapeutic counseling.105 The incidence of diagnosed psychiatric illness and hospitalization is considerably lower after abortion than after childbirth. Psychiatric disorders, when found, have been attributed to preexisting psychiatric illness, undergoing abortion under coercion or pressure, or concomitant highly stressful life circumstances, including abandonment.103,104 A national study that used data from the National Longitudinal Study of Adolescent Health examined whether abortion in adolescence was associated with subsequent depression and low self-esteem within 1 year of the pregnancy and ∼5 years later.106 Abortion was not associated with depression or low self-esteem at either time point. Socioeconomic and demographic characteristics did not substantially modify the relationships between abortion and the outcomes.106 

The option of obtaining a judicial bypass (a court proceeding in which a judge determines whether the adolescent is mature enough to make the decision to have an abortion or whether it is in her best interest not to inform parents) is viewed by some as a reasonable compromise to protect a concerned adolescent from harm while permitting states to impose mandatory parental involvement statutes.10 The Supreme Court ruled in 1990 that judicial bypass mechanisms are constitutionally required if state legislation for parental notification is enacted, and they are ethically essential for adolescents at risk of abuse. However, judges who preside over bypass rulings testify unequivocally that the procedure is of no benefit to minors.60,107,109 It has no effect on the ultimate decision with respect to abortion or on the process by which that decision is made. Of 12 000 petitions in Massachusetts and Minnesota, only 21 were denied, and half of the denials were overturned on appeal.43 The judicial bypass process itself poses risks of medical and psychological harm. Judicial bypass is detrimental to medical well-being, because it causes further delays in access to medical treatment (from 4 days to several weeks), increasing the risk of complications from delayed or second-trimester abortion procedures.61 Qualitative research with adolescents has confirmed these views.59,110 For example, a study in 30 minors presenting for an abortion asked about their attitudes toward judicial bypass. Respondents cited several ways that judicial bypass procedures created obstacles to abortion access, including the need to navigate the court system, travel to the courthouse, confide in a judge, and forfeit privacy.110 Several teenagers suggested that minors might take serious steps to avoid judicial bypass. For example, a 16-year-old who told her father about her pregnancy under pressure explained that some pregnant minors “would probably be afraid and would probably just keep the baby or, you know, do some other crazy stuff to get rid of it.”110 

Judicial bypass is detrimental to emotional well-being, because adolescents perceive the court proceedings as extremely burdensome, humiliating, and stressful.43,108 The pregnant adolescent is required to divulge intimate details of her private life to dozens of strangers (clerks, bailiffs, court reporters, witnesses, and others) to obtain a brief (10-minute) hearing before a judge who has no first-hand knowledge of her case and typically no training in counseling adolescents or developmental issues.31 Many experts disagree with the Supreme Court rulings on judicial bypass, arguing that the process does indeed constitute an “undue burden” for adolescents seeking abortion care.31,43,61 

Judicial bypass may also jeopardize the teenager’s ability to receive abortion services. A 6-state survey comprising a simulated patient call to clinic staff at facilities providing abortion services revealed that only 55.6% of staff in states with parental involvement laws informed the simulated minor patient of her right to a judicial bypass.111 In addition, historically, the court system has been ill prepared to handle the judicial bypass process.112 

  1. The AAP reaffirms its position that the rights of adolescents to confidential care when considering abortion should be protected. Genuine concern for the best interests of minors argues strongly against mandatory parental consent and notification laws. Although the stated intent of mandatory parental consent laws is to enhance family communication and parental responsibility, there is no supporting evidence that the laws have these effects. No evidence exists that legislation mandating parental involvement against the adolescent’s wishes has any added benefit in improving productive family communication or affecting the outcome of the decision. There is evidence that such legislation may have an adverse impact on some families and that it increases the risk of medical and psychological harm to the adolescent. Judicial bypass provisions do not ameliorate the risk and may delay access to safe and appropriate care, making it a later, more complicated procedure.

  2. Concerned health care professionals should strongly encourage that a pregnant teenager receives adult guidance and support when considering all the options available so that she can make the decision that is in her best interest. Adolescents should be strongly encouraged to involve their parents, other family members, or other trusted adults in decisions regarding pregnancy termination, and the majority of them do so voluntarily. The very young adolescent is especially in need of guidance in decision-making. Parents can be encouraged to develop their listening, communicating, and nurturing skills throughout the childhood years. Respecting and valuing the child’s perspective increases the likelihood of family involvement in adolescent decisions. A trusted health care provider may be able to impart the value of family communication skills and supportive behaviors through consistent encouragement and role modeling during visits.

  3. Concern for incest or abuse should be raised when a minor, particularly a younger adolescent, resists parental involvement when seeking abortion services.

  4. Ultimately, the pregnant patient’s right to decide who should be involved and what the outcome of the pregnancy will be should be respected. This approach is most consistent with ethical, legal, and health care principles.

     
  • AAP

    American Academy of Pediatrics

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

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Paula K. Braverman, MD, FAAP, Chairperson

William P. Adelman, MD, FAAP

Elizabeth M. Alderman, MD, FAAP, FSHAM

Cora C. Breuner, MD, MPH, FAAP

David A. Levine, MD, FAAP

Arik V. Marcell, MD, MPH, FAAP

Rebecca O’Brien, MD, FAAP

Margo Lane, MD, FRCPC – Canadian Paediatric Society

Seema Menon, MD – North American Society for Pediatric and Adolescent Gynecology

Julie Strickland, MD – American College of Obstetricians and Gynecologists

Benjamin Shain, MD, PhD – American Academy of Child and Adolescent Psychiatry

Karen S. Smith

James Baumberger, MPP

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.