In this national representative survey, we found that the great majority of Ob/Gyn physicians (94%) are somewhat or very likely to provide birth control pills to a 17-year-old college freshman without notifying her parents. At the same time, half (47%) would encourage her to involve a parent, and half (54%) would advise her to abstain from sexual activity until she is older. Physicians who are more religious are more likely to encourage her to involve her parents, and are more likely to advise her to abstain from sex until she is older, but they are equally likely to provide contraceptives in the end.
Ob/Gyn physicians’ willingness to provide birth control pills to the patient in this case is higher than has been reported for other physicians. Regional data from 1998–1999 suggested that 83% of pediatricians, 85% of family medicine doctors, and 63% of internal medicine doctors provide contraceptive services without parental knowledge [15
]. However, some are unlikely to view this result as progress. Ross [12
] has questioned whether this widespread policy of confidentially supplying contraceptives to adolescents involves physicians in collusion against parents, undervalues parents’ conceptions of the good, and under-appreciates adolescents’ need for parental guidance.
Many factors likely contribute to physicians’ willingness to provide contraceptives in this particular vignette. Adolescence is a period of continuously developing maturity and autonomy, such that as patients grow older and more independent, clinicians are more comfortable providing confidential care [3
]. The Society for Adolescent Medicine has advised physicians to consider the patient’s chronological age, cognitive and psychosocial development, other health-related behaviors, and prior family communication [3
] – each of which might support confidentiality in this case. The American Medical Association is even more open, advising that unless the law requires otherwise, physicians should permit a competent minor to consent to sexual and reproductive medical care and should not notify her parents without her consent [4
]. Additional considerations that could motivate physicians to provide contraceptives include a belief that access to contraceptives may improve public health [8
], or concern that teenagers may not seek contraceptive services if their parents are notified [2
]. Moreover, the patient in this vignette may meet some states’ criteria for not requiring parental notification, since many states have provisions for some minors (e.g., mature minors, emancipated minors, military personnel, or those living independently) to consent for contraceptive services [3
Physicians varied markedly regarding whether they would encourage the patient to involve her parents in the decision, with 47% very likely or somewhat likely to try and persuade her to involve a parent. It is worth noting that many guidelines encourage physicians to persuade adolescents to involve their parents. The American Medical Association says that, “when minors request confidential services, physicians should encourage them to involve their parents” [4
]. ACOG holds that “providers should encourage and, when appropriate, facilitate communication between a minor and her parent” [5
]. Similarly, the Society for Adolescent Medicine states that health care professionals should support (but not mandate) effective communication between adolescents and parents; “helping adolescents to see the potential advantages of increased communication with parents, and offering to facilitate communication with parents in a way that is helpful to the adolescent patient” (p. 162) [3
]. It is possible that physicians who treat adolescents more frequently have greater familiarity and comfort with these guidelines, so are slightly more likely to encourage patients to involve their parents. Even so, that only half of Ob/Gyn physicians would take this approach suggests there is room for reminding physicians that encouraging adolescents to involve their parents is well within professional guidelines.
Roughly half (54%) of Ob/Gyns would advise a 17-year-old patient to abstain from sexual activity until she is older. This is a lower percentage than was found in a 2003 survey of family planning directors at publicly funded family planning clinics, among whom 91% provide routine counseling about abstinence to patients 17 years old and younger during an initial contraceptive visit, and 77% provide abstinence counseling to 18–19 year olds [16
]. This suggests that routine counseling may introduce the concept of abstinence without necessarily promoting it. Pragmatically though, 91% of minors attending publicly funded family planning clinics were already sexually active, and had been active for an average of 20 months (2004 data) [6
], making abstinence a tough sell and perhaps prompting physicians to focus their efforts on sex education and safety.
Religious physicians were more likely to advise abstinence, a trend that is consistent with other literature linking religiosity with the belief that sex should be limited to marriage [24
]. It is possible that religious physicians have a higher percentage of religious patients, and to advise abstinence is to reinforce a value the patient already holds. Alternatively, religious physicians may emphasize best-interest over autonomy-based decision-making paradigms in morally complex situations [18
Advising patients to practice abstinence is somewhat at odds with the clinical model promoted by McCullough and Chervenak [14
]. They recommend that when a patient wants to be sexually active, her decision must be respected, and the physician should explain the techniques of safer sex; in a nondirective fashion (p. 174–5 [14
]). But while this may be standard practice for adult patients, minors are different. Developmentally, socially, and legally minors do not have the same decisional rights and capabilities as adults. Moreover, teenagers are rarely able to take full responsibility if their sexual activity leads to infection or unplanned pregnancy (they rarely pay their own health care bills, and few can raise a child without help from social services). The trends in our data suggest that while physicians recognize adolescents’ emerging autonomy, many believe it is important to offer guidance and direction too.
Our data reveal that physicians who are themselves parents are more likely to advise abstinence to a seventeen year old. Few would deny that the experience of raising a child invites persons to reconsider a number of beliefs. However the findings are unique in suggesting that the experience of parenthood shapes the clinical care physicians provide to adolescents.
A strength of this study is its nationally representative sample. Several prior national studies focused on publicly funded family planning clinics [1
]. However, these clinics provide services for only a minority of women (17% in one survey) [29
]. Additionally, patient populations at government funded family planning clinics do not match the general population, with publicly funded clinics seeing higher percentages of younger, unmarried, minority, less educated, and less insured women compared with private physicians or Health Maintenance Organizations [6
]. Another strength is the high response rate.
Limitations of the study include its dependence on self-report, which may differ from actual practice. Non-responders may differ from responders in ways that bias the results. The vignette involved a 17-year-old college freshman, so we cannot apply the findings to minors in general. Future research directions might include using more vignettes to examine which patient characteristics influence physicians’ decisions the most, conducting qualitative studies to examine whether some counseling techniques are better received than others, and measuring outcomes to determine when counseling is likely to be effective.
In conclusion, this national survey of Ob/Gyn physicians indicates that the vast majority are willing to provide confidential birth control prescriptions to minors in at least some circumstances. Religious physicians are more likely to advise such patients to involve their parents and to delay sexual activity until they are older, but are equally likely to provide contraceptives in the end. While physicians and teenagers should still discuss confidentiality, older adolescents can anticipate that the great majority of Ob/Gyn physicians will provide them contraceptives without notifying their parents.