Ensuring Access to Confidential Reproductive Care

For almost 50 years, teenagers in the United States had access to confidential reproductive care and contraceptives even if they did not have their parents’ permission. Changes to Title X regulations, however, could prevent adolescents from receiving confidential reproductive services, unless they obtain parental permission first.

In a recent article, Naomi Schapiro of the University of California San Francisco School of Nursing argues that the Trump Administration’s Title X regulations could place adolescents at greater risk for STDs and unintended pregnancies by gutting their access to confidential reproductive care. Schapiro explains that requiring parental permission for contraceptives does not deter adolescents from engaging in sexual activity—but instead it actually makes them less likely to seek out reproductive care to protect themselves from STDs and unintended pregnancies.

Title X of the Public Health Service Act has funded confidential family planning and preventive health services for low income communities since 1970. Although most patients use Title X-funded clinics for contraceptives and reproductive care counseling, clinicians also test patients for sexually transmitted diseases, offer primary care, and provide cervical and breast cancer screenings. For many young adults, Title X clinics are their only reliable sources of affordable and confidential reproductive services.

Schapiro suggests that Title X’s success is attributed to its confidentiality provision. Historically, the program “extended confidentiality protections to adolescents who did not wish to involve their families,” explicitly prohibiting providers from notifying parents of patients without their consent. Many states have laws allowing providers to contact parents about contraception and family planning related visits, Schapiro explains. Title X, however, guaranteed confidentiality for patients by superseding state restrictions.

But the Trump Administration’s changes to Title X regulations compromise confidentiality for adolescents, Schapiro argues.

Under the changes, clinicians are required to encourage minors to involve their families in their health care decision making, and must document efforts to do so in their medical records. Without documentation of family involvement, clinicians have the discretion to deny adolescents access to essential Title X services and contraceptives, according to Schapiro. Although these changes appear harmless on their face, critics argue that they are unnecessary and may be a signal of the government’s future intent to require parental involvement and insert itself into the practice of medicine.

The changes also impose what critics call a “gag rule,” which prevents physicians from providing the full range of reproductive services and alternatives for pregnant patients. Schapiro explains that pediatric health care providers who perform counseling for pregnant adolescents are now barred from providing referrals to abortion clinics or even mentioning abortion—even if patients request that information themselves.

These changes go against Title X’s longstanding legacy, Schapiro suggests. Changes to Title X regulations under previous administrations, she argues, always maintained “a balance between protecting the conscientious objections of those opposed to abortion or contraception while honoring the rights of Title X recipients to access their choice of legal health services.”

Although the Trump Administration claims that the purpose of its Title X reforms is to “protect life and conscience,” the changes fail to provide physicians and adolescent patients any other choice. This shift is particularly troubling, Schapiro claims, because Title X no longer protects health care providers “whose own conscience and ethics impel them to give trustworthy answers to client questions about contraceptive and pregnancy options.”

Although it may be too early to forecast the full impacts of the Trump Administration’s changes to Title X regulations, Schapiro warns that adolescent access to confidential care is already dwindling.

Because the regulations require providers to deprive patients of the full range of reproductive health options, more than 20 percent of clinics funded by Title X have announced their intentions to decline future funding and disassociate from the program. Although some states have promised to help bridge gaps in funding, Schapiro notes that “it is unclear how much and for how long they will be able to contribute.”

This exodus of providers will disproportionately affect young adults who are often already living below the federal poverty line, Schapiro claims. Up to 40 percent of Title X patients could lose access to confidential preventive and primary care.

According to Schapiro, several lawsuits have since been filed against the Trump Administration arguing that the changes infringe upon physicians’ ability to communicate honestly with patients, especially those intending to terminate their pregnancies.

It is unclear what the status of Title X will be under the incoming Biden Administration. As legal challenges to the changes continue, health care providers have a critical role to play in advocating for continued access to comprehensive, confidential health care, Schapiro argues. Pediatric health care providers “should educate themselves about the history and current changes in Title X regulations, and advocate for access to a full range of reproductive health services to improve adolescent health outcomes,” she concludes.