About half of U.S. states do not allow minors to obtain contraception without parental approval. For adolescents and teens younger than age 18 years, their only confidential option is to visit a Title X clinic, where a federal ruling from decades ago gives them a right to contraception and privacy.1
But how does this work in practice? Researchers say that it does not work very well — and it is only getting worse. The study found that minors faced a range of barriers, including inconvenient clinic hours, Title X staff without knowledge of minors’ rights, and the lack of transportation.1
Since conducting the study, things changed in Texas for the worse. A recent lawsuit, which is being challenged in court, was filed to prevent minors from accessing contraception at Title X clinics.2 They can obtain only over-the-counter contraception, but the IUD, patch, pills, and other prescription-only methods are not accessible to minors in Texas without parental involvement, says Brooke Whitfield, MA, lead study author and a doctoral student in the department of sociology at The University of Texas at Austin. Emancipated youth or those with their own Medicaid plan are the only exceptions.
Whitfield and colleagues interviewed 28 minors, ages 15 to 17 years, in Texas between September 2020 and June 2021. They found the participants had faced a range of barriers to finding accurate information and obtaining confidential contraceptive services — and the COVID-19 pandemic made everything even worse.1
“Many minors are unable to obtain parental consent for myriad reasons — not just because their parents are disapproving,” Whitfield says. “Because of that, they could only obtain contraception at those Title X clinics.”
Funding Is a Barrier
One barrier was that many teens did not know what a Title X clinic is. The only Title X clinic in Texas with name recognition was Planned Parenthood, but the state had defunded Planned Parenthood a decade earlier by cutting the organization from state funding and refusing federal money for it.
“That was a move to kick Planned Parenthood out of family planning funding,” Whitfield says. There are some Title X clinics in Texas, but they are less well known, she adds. Without federal funding and the Title X umbrella, Planned Parenthood cannot provide confidential contraception to underage patients.
Older teens may be willing to obtain fake IDs for attempting to buy alcohol, but none of the teens interviewed by researchers talked about doing something like that to bypass the parental approval rule. They also did not fake their parents’ signatures on consent forms or attempt other workarounds.
“There is a lot of fear around doing something that is not compliant with the medical system, and they’d say, ‘I wouldn’t want to lie about that,’” Whitfield says. “They feared there would be real repercussions. While that could happen for some of these clinics, where someone takes the parental consent home and signs their parent’s name, we don’t know about that.”
The teens told Whitfield and colleagues that they were trying to access contraceptives without their parents and wanted to visit a Title X clinic. This was challenging because, for some teens, the closest Planned Parenthood was an hour away.
“That makes it inaccessible,” Whitfield says. “Especially if you’re not trying to involve your parents, how do you explain, ‘I’m going to leave for three to four hours’?” Even minors who lived in one of the state’s larger cities would find transportation an obstacle if the clinic was more than a mile from where they lived because Texas has poor public transit, she adds.
For most of the teens interviewed, their problem was that their parents did not want to talk about sex and reproductive health. “These minors say, ‘Our parents have never had a conversation about this with me, and anytime I talk about relationships and contraception, they get visibly uncomfortable and shut it down,’” Whitfield says. “One minor said her mom gave her the uncomfortable talk when she was younger, and then said, ‘If you ever have sex, use contraception.’ A few years later, she told her mom she wanted contraception, and her mom said, ‘We’ll schedule an appointment for you,’ and [the mother] never set it up.”
The girl tried to discuss this with her mother three times before giving up. “That left them in a tough spot. Where do you turn for information if your parent is not an available source?” Whitfield asks. “To compound that, a lot of minors in our study said they had never had alone time with a healthcare provider. There wasn’t a time when the provider asked the parent to step out, so there was no time to ask the provider about birth control.”
One-third of the young people interviewed were able to visit a Title X clinic, but the process was difficult even then. “They talked about how often the clinic schedules were incompatible with school schedules,” Whitfield notes.
Budgets were slashed for family planning centers. This led to clinics closing or drastically reducing their hours. “Evening and weekend appointments are not common anymore,” she says.
Even those who found the time and transportation to visit a Title X clinic noted that clinic staff were not trained in how to interact with minors. The teens encountered Title X workers who were unaware that minors do not need parental consent at Title X. Or the staff would ask teens how they were going to pay for the visit when staff are not supposed to ask those questions of minors — only adults.
“It’s a stressful and anxiety-producing experience for minors. If they are told to list their phone number or address, they’re afraid it will be disclosed,” Whitfield says. “One minor showed up, and [staff] asked for a Social Security number and finances. [The minor] said, ‘I didn’t have that information on me, so I had to leave.’”
By the time researchers interviewed her, the girl still had not returned to the Title X clinic. “She had missed out on an appointment because she was asked for information that she did not need to provide, and the staff were not trained on handling minors,” Whitfield says.
The only exception to the rule requiring minors to obtain consent is when the teen is emancipated from his or her parents or is on Medicaid. “Those enrolled in Medicaid can access contraception without parental consent, but there are few of them, and they may not be guaranteed confidentiality because their parents may be informed through billing procedures,” Whitfield notes.
It is tough for a teen to prove he or she has been living separately while underage, and Medicaid requirements are stringent in Texas, Whitfield notes. Texas has a Medicaid-equivalent program that is one of a few in the United States that does not offer contraception. These rules and barriers leave minors with almost no options.
“If you’re in a situation where it’s awkward to have that conversation with your parent, it’s fine. But if you’re afraid of the parent finding out, that’s a barrier,” Whitfield says.
When Texas eliminated the option of confidential contraceptive access without parental consent in Title X programs, it obliterated access for minors, Whitfield says. “Fake IDs may be prolific,” she adds. “But there’s a fear because it seems scarier to do something medically related, like uploading a fake ID to a platform for a medical service. If the Texas decision stands, minors will remain stripped of their ability to control their reproductive lives, and that’s very upsetting.”
In interviews with researchers, minors said they did not want to become pregnant and were trying to be responsible and take care of their health, but they did not receive the information or resources they needed.
“Even when they have resources, Texas has made it so difficult to access them,” Whitfield says. “The minors are trying to be proactive and responsible for their health, and they’re getting pushback at every step along the way.”
The teens participating in the study fell into two camps concerning obtaining parental consent for contraceptives:
• First: “Even if their parents were OK with [contraception], they found it hard to get them to act on it,” Whitfield says. “Their parents face the same barriers they do — they work a normal 9-to-5 job, and the clinic is only open from 9-to-5. It’s really hard for low-income minors to take several hours or a half-day off to go to the clinic, and it’s asking a lot of the parent, too.”
Limited clinic hours proved frustrating for some minors. “They didn’t have anything after 4 p.m.,” one participant noted. “They didn’t have any days to go on the weekend. I was very frustrated with that because I was like, ‘I go to school, so I won’t have time to go to a clinic.’”1
• Second: Some parents were anti-contraception even if it was for non-sexual reasons, such as treating acne or managing the teenager’s menstrual symptoms.
“For one minor, her mom was into this idea of natural, nonhormonal holistic medicine. Her mom said, ‘No, these hormones are bad for you, so you shouldn’t use them,’” Whitfield recalls. “She wasn’t anti-sex but was anti-birth control.”
One minor reported that when she brought up the topic of contraception, her “mom was shutting it down saying how it was unnatural, so that’s why I can’t go to her about any of these questions.”1
Other parents feared that even if their child obtained contraception for a health concern apart from preventing pregnancy, the contraceptive would make the child sexually active.
Study participants offered these suggestions for how contraception access could improve:
- Repeal parental consent laws;
- Require parents to leave the room during appointments;
- Provide teen-friendly services, including extended hours, transportation, telehealth appointments, delivery services, social media sources, and staff trained in working with teens.
As of January 2024, there was no word on how the first over-the-counter birth control pill, Opill, would be received in Texas and whether minors could obtain it.
“People over 18 will buy it over the counter, which is a huge win. That’s awesome for people, but it won’t be something accessible to minors,” Whitfield predicts. “I think they’ll still require parental consent to buy it.”
The efforts to get Opill approved took many years, so it may take longer to ensure minors also can access the medication in every state, she adds.
“Even though it will be another long, hard-fought battle, I think we can get it over the counter for minors, but it will take a little bit of time,” Whitfield says. “Minors are fully capable of acting in their best interest when they are acting to improve their reproductive health. These laws create unnecessary barriers to contraceptive care, and they violate their rights. [Texas lawmakers] just want to control people’s reproduction.”
REFERENCES
- Whitfield B, Vizcarra E, Dane’el A, et al. Minors’ experiences accessing confidential contraception in Texas. J Adolesc Health 2023;72:591-598.
- Deanda v. Becerra. Dec. 8, 2022. https://law.justia.com/cases/f...
About half of U.S. states do not allow minors to obtain contraception without parental approval. For adolescents and teens younger than age 18 years, their only confidential option is to visit a Title X clinic, where a federal ruling from decades ago gives them a right to contraception and privacy. But how does this work in practice? Researchers say that it does not work very well — and it is only getting worse.
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