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Elevating the Needs of Minor Adolescents in a Landscape of Reduced Abortion Access in the United States

Published:September 09, 2022DOI:https://doi.org/10.1016/j.jadohealth.2022.08.007

      The Impact of Reduced Abortion Access on Minor Adolescents

      Abortion is a safe and essential component of comprehensive sexual and reproductive health (SRH) care. Following the United States Supreme Court ruling in June 2022 that struck down Roe v. Wade, the movement to restrict abortion access in many states will severely limit reproductive freedom for pregnancy-capable people [
      ]. Individuals and communities, particularly those marginalized because of race/ethnicity, gender identity, income inequality, immigration status, and/or age, face barriers to reproductive health equity, and these policy changes exacerbate an already unjust reproductive health care landscape [
      • Bryson A.E.
      • Hassan A.
      • Goldberg J.
      • et al.
      Call to action: Healthcare Providers must Speak up for adolescent abortion access.
      ]. This article highlights abortion access barriers specific to minor adolescents (those aged <18 years) and proposes strategic responses adolescent healthcare communities can enact.
      The Society for Adolescent Health and Medicine and six other organizations stated opposition to restrictions on the reproductive rights and care of adolescents and young adults, including access to abortion [
      SAHM News
      Statement on Dobbs v. Jackson. Society for Adolescent Health and Medicine.
      ,
      SAHM News
      SAHM/NASPAG Statement on leaked draft SCOTUS opinion regarding Mississippi v. Jackson Women’s Health. Society for Adolescent Health and Medicine.
      ]. These statements recognize abortion as a basic human right and fundamental to adolescent SRH. They call to normalize abortion as an essential component of comprehensive SRH care, educate policymakers on adolescent developmental capacity to make safe and informed reproductive health decisions, and advocate for improved access to adolescent contraception, sexual health education, and structural initiatives to promote opportunity and health equity among marginalized adolescents.
      Those who provide health care for minor adolescents must understand the great impact restricted abortion access will have on minors and provide strategic responses. Although pregnancy and birth rates declined over the past 30 years, adolescents aged ≤19 years (the standard age range reported by the US Centers for Disease Control and Prevention) account for approximately 9% of individuals who obtain abortions. Although these numbers represent a minority of those seeking abortions, this translates into at least 50,000 adolescents aged ≤19 years needing abortion services annually, with some estimates being nearly double that [
      • Kortsmit K.
      • Mandel M.G.
      • Reeves J.A.
      • et al.
      Abortion Surveillance - United States, 2019.
      ,
      • Jerman J.
      • Jones R.K.
      • Onda T.
      Characteristics of U.S. Abortion Patients in 2014 and changes since 2008, New York: Guttmacher Institute.
      ]. Adolescents have the highest abortion ratio of any age group (851 per 1,000 live births for those aged < 15 years and 332 per 1,000 live births for 15- to 19-year-olds compared with 260 per 1,000 live births for 20- to 24-year-olds). When adolescents do not have access to comprehensive reproductive care, unmet needs lead to negative health and social consequences that may persist across the life course.

      Current Barriers to Abortion Access Among Minor Adolescents

      Minor adolescents face significant barriers to abortion care due to travel challenges, financial constraints, limited access to medication abortion, and parental notification and consent requirements limiting confidentiality [
      • Bryson A.E.
      • Hassan A.
      • Goldberg J.
      • et al.
      Call to action: Healthcare Providers must Speak up for adolescent abortion access.
      ]. Although most adolescents have developmental capacity to make independent health care decisions [
      • Baltag V.
      • Takeuchi Y.
      • Guthold R.
      • Ambresin A.E.
      Assessing and supporting adolescents' capacity for autonomous decision-making in health-care Settings: New Guidance from the World health organization.
      ], they may have less experience navigating reproductive health care decisions than older individuals, potentially needing tailored education and resources when seeking abortion.

      Travel challenges resulting in delayed care

      Without federal protections to abortion, state-specific restrictions will necessitate people in need of abortion to either travel to other states, self-manage in their own states, and face potential legal risks for doing so, or remain pregnant. Minors may face practical and legal barriers to travel for abortion access while maintaining confidentiality. Supportive adults who accompany minors across state lines may be unsure of their legal risk, which could further isolate minor adolescents from their support networks. This is particularly problematic, as adolescents are more likely to have later gestation abortions, and restrictions will cause further delays [
      • Upadhyay U.D.
      • Weitz T.A.
      • Jones R.K.
      • et al.
      Denial of abortion because of provider gestational age limits in the United States.
      ]. Although abortion is safer than childbirth, later gestation abortions entail more medical risks and are more difficult to obtain because of higher expenses and fewer experienced clinicians.

      Cost barriers and limited access to telehealth

      Adolescents face greater costs of care [
      • Ely G.E.
      • Hales T.W.
      • Jackson D.L.
      • et al.
      Access to choice: Examining differences between adolescent and adult abortion fund service recipients.
      ,
      • Leyser-Whalen O.
      • Torres L.
      • Gonzales B.
      Revealing Economic and Racial Injustices: Demographics of abortion fund Callers on the U.S.-Mexico Border.
      ], particularly if they lack confidential insurance coverage. Requirements for diagnostic tests such as ultrasound, abortion procedures, medications, missed school or employment, and other costs may be prohibitive. Many abortion telemedicine programs are restricted to those aged ≥18 years. Another barrier is online payment infrastructure, as minors are not allowed to use some of the common online payment services.

      Parental consent and notification laws

      Major medical organizations have historically opposed laws mandating parental involvement in minors' abortion decisions [
      • Burke P.J.
      • Coles M.S.
      • Di Meglio G.
      • et al.
      Sexual and reproductive health care: A position paper of the Society for adolescent health and medicine.
      ]. Yet, 36 states currently require parental notification or consent before a minor can access abortion services [
      Guttmacher Institute
      Parental involvement in minors’ abortion.
      ]. Adolescents' fear of disclosure around reproductive health care may delay their care [
      • Bryson A.E.
      • Hassan A.
      • Goldberg J.
      • et al.
      Call to action: Healthcare Providers must Speak up for adolescent abortion access.
      ,
      • Davis A.R.
      • Beasley A.D.
      Abortion in adolescents: Epidemiology, confidentiality, and methods.
      ,
      • Braverman P.K.
      • Adelman W.P.
      • Alderman E.M.
      • et al.
      The Adolescent’s right to confidential care when considering abortion.
      ]. Although most minor adolescents make decisions with support from a parent or other trusted adult [
      • Resnick M.D.
      • Bearinger L.H.
      • Stark P.
      • Blum R.W.
      Patterns of consultation among adolescent minors obtaining an abortion.
      ], this support is not always available, and narrowly defined laws often ignore nonparent/guardian supportive adults.
      Minors may pursue judicial bypass to obtain an abortion without parental involvement, but this is a complex and time-consuming process. It is often psychologically traumatic for adolescents to disclose deeply personal information to strangers in court, and it relies on the decision of a judge who may lack expertise in medicine or adolescent development [
      • Braverman P.K.
      • Adelman W.P.
      • Alderman E.M.
      • et al.
      The Adolescent’s right to confidential care when considering abortion.
      ,
      • Coleman-Minahan K.
      • Stevenson A.J.
      • Obront E.
      • Hays S.
      Young Women's experiences obtaining judicial bypass for abortion in Texas.
      ].

      Strategic Responses in Support of Minor Adolescents

      In elevating the unique needs of youth, adolescent health professionals must apply principles of reproductive justice, the basic human right to maintain personal bodily autonomy, to have children, to not have children, and to parent one's children in safe and supportive communities [
      SisterSong Women of Color reproductive justice Collective. Reproductive Justice.
      ]. A recent commentary recommended a series of reproductive justice informed advocacy actions for adolescent health professionals in light of Texas Senate Bill 82. Changes to abortion access will unfold dynamically with state-specific variability. Partnering with local and national professional communities and advocacy groups will enable awareness and responsiveness to evolving reproductive health needs of adolescents. Table 1 provides specific strategies and resources.
      Table 1Barriers specific to minor adolescent abortion access with select approaches and resources
      Barrier specific to minor adolescentsExample approachResources and organizations (hyperlinks included)
      Need for youth-specific education and clinical support
      • -
        Promote comprehensive sexual health education within and beyond schools
      • -
        Create frequent opportunities to discuss healthy relationships, pregnancy intentions, contraception needs and preferences, and specifics of local abortion policy and access considerations
      Advocates for Youth

      Amaze.org

      American Academy of Pediatrics

      ARSHEP curriculum

      Bright Futures

      Planned Parenthood

      Power to Decide

      SIECUS: Sex Ed for Social Change
      Travel challenges
      • -
        Be aware of support resources for legal counseling for adolescents and supportive adults seeking out-of-state care
      • -
        Provide comprehensive information to youth while complying with local legal guidance for providers, minimizing additional barriers through overcompliance
      • -
        Understand practical barriers and be flexible in scheduling whenever possible
      Abortion finder

      Center for Reproductive Rights

      National Abortion Federation

      If/When/How

      Plan C

      Regulatory Assistance for Abortion Providers

      Cost barriers and limited access to telehealth
      • -
        Familiarize oneself and the youth in your care about costs and logistical considerations necessary to access abortion
      • -
        Provide telehealth where legally available
      Center for Reproductive Rights

      National Network of Abortion Funds

      Reproductive Health Access Project
      Parental consent and notification laws
      • -
        Advocate to uphold or develop legislation to ensure minor consent and confidentiality to receive comprehensive reproductive health services
      • -
        Work with legal experts to understand formal requirements and restrictions
      • -
        Educate patients about specific details of local parental notification laws and all options available to patients
      • -
        Support youth who wish to involve parents or other adults
      • -
        Share resources for support through the judicial bypass process
      • -
        Be mindful of the risks of accidental disclosure, especially from health systems and insurance plans that lack infrastructure to protect minor confidentiality
      Guttmacher Institute

      Repro Legal Help

      National Abortion Federation Hotline

      NARAL Pro Choice America

      Individual, Community, and National Efforts are Needed

      On the individual level, health care professionals, parents/guardians, and youth advocates can promote thoughtful, shared decision-making about reproductive health, including frequent opportunities to discuss healthy relationships, pregnancy intentions, contraceptive needs and preferences, and specific local abortion policies and access considerations with young people. On a community level, we can eliminate barriers to and promote comprehensive, accurate sexual health education and youth friendly SRH services. On a national level, we can advocate for health systems, researchers, funding agencies, and policy communities to examine specific impacts of restricted abortion access on youth and form strategic partnerships between clinicians, advocates, operational leaders, and policymakers who understand adolescent development and the health and social prerogative of protecting abortion access for all.

      Funding Sources

      A.J.H. was supported by grant number K12HS026369 from the Agency for Healthcare Research and Quality (AHRQ). J.M. was supported by grant number K01HD091416 from Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The content is solely the responsibility of the authors and does not necessarily represent the official views of the AHRQ or NICHD.

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