Jonathan D. Klein

Many states have laws that require teenagers seeking abortions to notify their parents of their decision or to obtain their consent. In 1999, the Child Custody Protection Act was proposed as a measure that would strengthen such parental consent laws. This measure would punish people who transport girls across state lines in order to avoid consent laws in their home state. In the following viewpoint, pediatrician Jonathan D. Klein argues that such a law would severely limit teen access to safe and confidential abortions. While teens should be encouraged to discuss an abortion decision with their parents, some girls face rejection or abuse if their parents learn about their pregnancies. The possibility of parental disapproval also increases the risk that teens will resort to dangerous methods of terminating their pregnancies, Klein maintains.

As you read, consider the following questions:

1. Why do young people delay seeking help over sensitive health-care issues, according to Klein"
2. According to a survey conducted by the American Medical Association, what percentage of physicians favor confidential treatment for adolescents"

Iam Dr. Jonathan Klein, a practicing pediatrician who has taken care of adolescents for the past 15 years. I am also an associate professor in the Department of Pediatrics at the University of Rochester School of Medicine. In the 15 years that I have engaged in the health care of adolescents, I have been involved with their families, extended families and other caregivers. I have taken care of adolescents in clinical settings and in institutional settings. Within organized medicine and other social service organizations, I have served on numerous national, regional and local advisory and professional committees on many issues regarding adolescent health and conferred with many colleagues across the nation on these very tough issues.

Iam speaking today on behalf of the American Academy of Pediatrics, an organization representing 55,000 pediatricians throughout the nation. In addition, I am representing the Society for Adolescent Medicine, an organization of over 1,500 physicians, nurses, psychologists, social workers, nutritionists and others involved in service delivery, teaching or research on the welfare of adolescents and Advocates for Youth, a national non-profit organization dedicated to helping young people make informed and responsible decisions about their sexual and reproductive health. It provides information, training, and advocacy to youth serving organizations, policy makers and the media in the US and internationally.

It is from these perspectives and perhaps most importantly as a parent that I am here today to express our concerns about the pending legislation, H.R. 1218, the “Child Custody Protection Act.” [As of December 2000, this act had not passed.] I would like to thank the Committee for this opportunity to present this statement as Congress continues to debate this issue of significance to adolescent health care.

The Importance of Communication

The American Academy of Pediatrics firmly believes that parents should be involved in and responsible for assuring medical care for our children. Moreover, we would agree that as parents we ordinarily act in the best interests of our children and that minors benefit from our advice and the emotional support we provide as parents. We strongly encourage and hope that adolescents communicate with and involve their parents or other trusted adults in important health care decisions affecting their lives. This includes those regarding pregnancy and pregnancy termination. We know and research confirms that most adolescents do so voluntarily. This is predicated not by laws but on the quality of their relationships. By its very nature family communication is a family responsibility. Adolescents who live in warm, loving, caring environments, who feel supported by their parents and their parents with them, will in most instances communicate with their parents in a crisis including the disclosure of a pregnancy.

My role as a pediatrician is to support, encourage, strengthen and enhance parental communication and involvement in adolescent decisions without compromising the ethics and integrity of my relationship with adolescent patients.

The stated intent by those who support mandatory parental consent laws is that it enhances family communication as well as parental involvement and responsibility. However, the evidence does not support that these laws have that desired effect. To the contrary, there is evidence that these laws may have an adverse impact on some families and that it increases the risk of medical and psychological harm to adolescents. According to the American Academy of Pediatrics, “[i]nvoluntary 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. Research on abusive and dysfunctional families shows that violence is at its worse during a family member’s pregnancy and during the adolescence of the family’s children.”

Confidentiality of Care

Iwould like to turn my attention to the issue of confidentiality—whether adolescents can access health care services without parental consent. The American Academy of Pediatrics, and other medical and public health groups firmly believe that young people must have access to confidential health care services—including reproductive health care and abortion services. Every one of our states’ laws also provide confidential access to some services for young people, whether for child abuse, STDs, drug addiction or reproductive health care. Concern about confidentiality is one of the primary reasons young people delay seeking health services for sensitive issues, whether for an unintended pregnancy or for other reasons. While parental involvement is very desirable, and should be encouraged, it may not always be feasible and it should not be legislated. Young people must be able to receive health care expeditiously and confidentially.

Most adolescents will seek medical care with their parent or parents’ knowledge. Making services contingent on parental involvement mandatory (either parental consent or notification) however, may drastically affect adolescent decision-making. Mandatory parental consent or notification reduces the likelihood that young people will seek timely treatment for sensitive health issues. In a regional survey of suburban adolescents, only 45 percent said they would seek medical care for sexually transmitted diseases, drug abuse or birth control if they were forced to notify their parents.

Laws That Hurt Teens

Many people who support parental consent to abortion laws do so out of genuine concern for young people. But a closer look at these laws reveals that they hurt rather than help many teens.

Teens who do not seek parental guidance are often physically and emotionally abused, or victims of incest. The story of a 13-year-old from Idaho is one of the many laced with tragedy. Impregnated by her father, this sixth-grader scheduled an abortion in a neighboring state with her mother’s assistance. After learning of his daughter’s intention to terminate the pregnancy, he fatally shot her.

Jennifer Coburn, San Diego Union-Tribune, January 10, 1996.

A teen struggling with concerns over his or her sexual health may be reluctant to share these concerns with a parent for fear of embarrassment, disapproval, or possible violence. A parent or relative may even be the cause or focus of the teen’s emotional or physical problems. The guarantee of confidentiality and the adolescent’s awareness of this guarantee are both essential in helping adolescents to seek health care.

For these reasons, physicians strongly support adolescents’ ability to access confidential health care. A national survey conducted by the American Medical Association (AMA) found that physicians favor confidentiality for adolescents. A regional survey of pediatricians showed strong backing of confidential health services for adolescents. Of the physicians surveyed, 75 percent favored confidential treatment for adolescents. Pediatricians describe confidentiality as “essential” in ensuring that patients share necessary and factual information with their health care provider. This is especially important if we are to reduce the incidence of adolescent suicide, substance abuse, sexually transmitted diseases and unintended pregnancies.

The Opinion of Health Care Organizations

Many influential health care organizations support the provision of confidential health services for adolescents; here is what they say:

The American Academy of Pediatrics. “A general policy guaranteeing confidentiality for the teenager, except in life- threatening situations, should be clearly stated to the parent and the adolescent at the initiation of the professional relationship, either verbally or in writing.”

The Society for Adolescent Medicine. “The most practical reason for clinicians to grant confidentiality to adolescent patients is to facilitate accurate diagnosis and appropriate treatment. . . . If an assurance of confidentiality is not extended, this may create an obstacle to care since that adolescent may withhold information, delay entry into care, or refuse care.”

The American Medical Association. “The AMA reaffirms that confidential care for adolescents is critical to improving their health. The AMA encourages physicians to involve parents in the medical care of the adolescent patient, when it would be in the best interest of the adolescent. When in the opinion of the physician, parental involvement would not be beneficial, parental consent or notification should not be a barrier to care.”

The AMA also notes that, because “the need for privacy may be compelling, minors may be driven to desperate measures to maintain the confidentiality of their pregnancies. They may run away from home, obtain a “back alley” abortion, or resort to a self-induced abortion. The desire to maintain secrecy has been one of the leading reasons for illegal abortion since 1973.”

American College of Physicians. “Physicians should be knowledgeable about state laws governing the rights of adolescent patients to confidentiality and the adolescent’s legal right to consent to treatment. The physician must not release information without the patient’s consent unless required by the law or if there is a duty to warn another.”

The American Public Health Association. APHA “urges that . . . confidential health services (be) tailored to the needs of adolescents, including sexually active adolescents, adolescents considering sexual intercourse, and those seeking information, counseling, or services related to preventing, continuing or terminating a pregnancy.”

Facing a Crisis Pregnancy

Of course, it is important for young people who are facing a health-related crisis to be able to turn to someone dependable, someone they trust, to help them decide what is best. Many, many times that person is a parent. Teenagers facing a crisis pregnancy should be encouraged to involve a parent, and many do so. In fact, over 75 percent of teens under age 16 involve at least one parent in their decision, even in states that do not mandate them to do so. In some populations as many as 91% of teenagers younger than 18 years voluntarily consulted a parent or “parent surrogate” about a pregnancy decision.

All too often, however, young women know that their parents would be overwhelmed, angry, distraught or disappointed if they knew about the crisis pregnancy. Fear of emotional or physical abuse, including being thrown out of the house, are among the major reasons teenagers say they are afraid to tell their parents about a pregnancy. Young women who are afraid to involve their parents very often turn to another adult in times of difficulty. One study shows that, of young women who did not involve a parent in their abortion decision, over half turned to another adult; 15 percent of these young women involved a step-parent or other adult relative. In my own practice, I have had the situation arise in which an adult female sibling or cousin has been the person the adolescent wanted me to call into the consultation based on the fear of anger and rejection from her mother.

H.R. 1218 would harm young women who are most afraid to involve their parents in an abortion decision and who most need the support of other adults in their lives. Instead of encouraging young people to involve adults whom they trust, the law would discourage such communication. The bill would have the unintentional outcome of placing a chilling effect on teenagers’ ability to talk openly with adults— including family members and medical providers—because it sends a message that adults who help young people grapple with difficult decisions are criminals. This disincentive is extremely dangerous for those young people most in need of support and guidance in a difficult time when they cannot involve their parents. . . .

Troubled Teens Need Support

In conclusion, I reiterate a statement previously made by the immediate past president of the Society for Adolescent Medicine: “[C]learly the proposed bill is designed to eliminate this [abortion]option for many adolescents. Adolescents who cannot rely on one or both parents to help them through the trauma of a pregnancy and who, for legal or geographical reasons, may need to go to an adjoining state for termination, are effectively precluded from receiving help from those (such as other relative, health professional, or even the clergy) who would be there to help them. In essence, this law would put adolescents in the position of having to take care of themselves (possibly traveling long distances in the process), without supportive care during a