People in the United States have a famously uneasy relationship with sexuality and reproductive health topics, and people younger than 18 often bear the brunt of this discomfort.1 This age-group experiences multiple barriers to sexual and reproductive health care and information, in part because adolescents often lack the financial or logistic resources that older people have. They also face the widespread myth that having access to such services and information will make them more sexually active.2 Many of the barriers adolescents face are even higher for young people in marginalized communities, including Black, Indigenous and other people of color, immigrants, people with disabilities and LGBTQ people.

Sex, sexuality, and sexual and reproductive health care are all parts of adolescents’ lives. For example, nearly six in 10 students in 12th grade have had sexual intercourse, and close to 90% used contraceptives the last time they had sex (see figure).3,4 Policymakers’ inability to accept this reality does not change the experience of millions of young people. Whether or not adolescents are having sex, considering their reproductive future or simply exploring their own sexuality, they deserve policies that support their health and well-being. The Biden-Harris administration and Congress must listen to adolescents and work to ensure that they have access to high-quality sexual and reproductive health information and care. Inherent in this vision is the need to ensure that all adolescents receive high-quality sex education, have unrestricted access to care and are guaranteed confidential care.

 

Ensure Access to High-Quality Sex Education

For many young people, adolescence marks the onset of puberty and new experiences, including sexual activity, romantic relationships and contraceptive use. As adolescents navigate these new experiences, it is critical that they have a comprehensive understanding of their own sexual and reproductive health. High-quality sex education provides young people with the knowledge to make medical, sexual, reproductive and relationship choices that best fit their needs and desires.

Unfortunately, too many U.S. students are subjected to abstinence-only programs, which teach that sex is only acceptable in the context of heterosexual marriage and fail to teach students about contraception, STIs, healthy relationships, gender identity and sexual orientation, among other topics. These programs withhold vital information; promote dangerous gender stereotypes; perpetuate systems of inequity; and stigmatize sex, sexual health and sexuality.5 These types of curricula are particularly harmful to LGBTQ students, as they often frame heterosexual relationships as the norm and either condemn or ignore same-sex relationships.6,7

By contrast, comprehensive sex education (CSE) programs are the gold standard of sex education. Instead of offering students a limited, prescriptive and fear-based perspective on reproduction and sexuality, these programs give students a broad and accurate understanding of these topics. CSE programs trust that when students are equipped with sufficient knowledge, they will make the choices that best fit their needs and circumstances. They teach students about a wide range of subjects, including human development, relationships, communication and decision-making skills, sexual behavior (e.g. abstinence, sexuality throughout life), sexual health, and cultural representations of sexuality and gender.8–11 These types of curricula frame sexuality as a normal part of life—and are medically accurate, LGBTQ inclusive, and culturally and age appropriate. Evidence indicates that CSE programs can reduce homophobia, expand students’ understandings of gender and gender norms, decrease intimate partner violence and improve communication skills, among other benefits.12

State lawmakers and voters in California, New Jersey, Oregon, Rhode Island and Washington have already embraced CSE, and elements of these types of curricula are already being used across the country. For example, more than half of states and the District of Columbia require that sex education be age appropriate, 17 states require the material to be medically accurate, and 35 states and DC require sex educators to discuss skills that help build healthy romantic and sexual relationships.13

Recommendations

President Biden and Congress must work together to:

  • Build off of state support for CSE by passing the Real Education for Healthy Youth Act. This bill would establish the first federal grants for CSE programs and eliminate funding for the harmful Title V abstinence-only-until-marriage program.
  • Zero out the other abstinence-only funding stream in the annual budget bill, so that no federal money would go to these harmful programs, and redirect that funding to the Teen Pregnancy Prevention Program (TPPP) and the Personal Responsibility Education Program (PREP) to expand these programs. This is a bold move that would subvert harmful state policies, and support sexual and reproductive health education for millions of adolescents.

The Biden-Harris administration has several tools to improve sex education:

  • The administration should issue specific program guidance to incorporate elements of CSE into TPPP and PREP, the two federal non-abstinence-only sex education programs. For example, the programs could prioritize funding to state and local applicants that include components of CSE in their curricula.
  • The White House should nominate experienced, dedicated and equity-focused individuals to lead the Office of Population Affairs (which oversees TPPP) and the Family and Youth Services Bureau within the Administration for Children and Families (which oversees PREP). Competent leadership is key to ensure that federal sex education programs are properly envisioned and administered.
  • President Biden and educator Dr. Jill Biden must use their popularity and platform to advocate for CSE as a way to overcome the shortcomings of the U.S. education system as it relates to sex education.

Remove Obstacles to Care

Adolescents face a labyrinth of barriers to sexual and reproductive health care. People younger than 18 are the poorest age-group in the United States, and one in six children live in poverty.14 Though the vast majority of adolescents have health insurance coverage, they and their families may still struggle to afford the out-of-pocket costs that are associated with a trip to the doctor, such as copayments, transportation expenses and missed work.15 The 2019 Title X “domestic gag rule” made care even harder to access for the more than 200,000 young people who rely on the program.16,17

For adolescents who have not developed health literacy skills and are unable to turn to their parents for guidance, even determining where to get care and how to pay for it can be daunting. Furthermore, many clinics keep nine-to-five hours, making clinics hard to reach for adolescents who are in school until early afternoon and have homework, after-school jobs or other responsibilities.

Adolescents without a car or other means of transportation may be entirely cut off from care. Telehealth is one solution to this challenge. As the COVID-19 pandemic has demonstrated, however, the potential of telehealth is limited for people whose health insurance plans do not reimburse for remote services and for those who do not have adequate broadband Internet.18 Privacy is another issue: Even in a state where adolescents are able to obtain confidential, remote sexual or reproductive health care, they may not have a private place at home to talk to a provider.

Adolescents who belong to marginalized groups face all of the aforementioned challenges—and many others. For example, LGBTQ people face disturbingly high rates of harassment and discrimination when they visit providers.19 Understandably, LGBTQ adolescents may be less willing to seek care if they feel that their provider is unwilling to meet their needs.

Black, Indigenous and other young people of color experience provider bias, inequitable health insurance coverage and social determinants of health that are shaped by systemic racism—all of which impact their sexual and reproductive health care and outcomes.20,21 For example, Black (and to a lesser degree, Hispanic, Native American and Pacific Islander) young people are more likely than their Asian and White peers to be living with an STI as a result of social and economic inequities.22

For many young immigrants, the Trump administration’s expanded “public charge” rule forces them to choose between Medicaid-funded care and staying in the United States as permanent residents.23 Nearly 20% of noncitizen women are insured through Medicaid, so this rule effectively blocks many young people from getting the care they need, either directly through the rule itself or via a chilling effect.23,24

Additionally, the U.S. health care system makes minimal accommodations for people with disabilities, including the 2.6 million who are younger than 18.25 Furthermore, eight in 10 women with any disability experience sexual assault, and women and girls with disabilities are more likely than their nondisabled peers to experience reproductive coercion.26,27 Adolescents living outside of permanent homes—including those in foster care and the criminal justice system, and those who are unhoused—also face steep financial and logistic barriers to sexual and reproductive health care.28-30

Recommendations

President Biden and Congress must work together to:

  • Pass the Youth Access to Sexual Health Services Act, which would provide federal funding to sexual health services for people up to age 26 who are disadvantaged as a result of underlying structural barriers or social inequities, including young people of color, immigrants and LGBTQ youth.31
  • Pass the Hallways to Health Act to strengthen the network of school-based health centers (SBHCs). This law would expand SBHC access for people who are eligible for Medicaid and the Children’s Health Insurance Program, and set up a pilot telehealth program.32 Legislators could also strengthen the current version of the bill by including a comprehensive list of sexual and reproductive health services that would be made available and requiring that care be inclusive and accessible regardless of race, ethnicity, immigration status, gender, sexual orientation, or mental or physical ability.
  • Demonstrate support for and respect to people with disabilities by passing legislation to ensure that this community has access to high-quality sexual and reproductive health care, and that individuals with disabilities are not subject to forced or coercive care.
  • Ensure access to affordable and high-quality telehealth care for people of all ages in health reform legislation, including President Biden’s public option plan.33

The Biden-Harris administration has several tools to decrease financial and logistic obstacles to care for adolescents:

  • Federal regulations to expand access to telehealth services would benefit all adolescents, and especially those who do not have access to SBHCs. The regulations should require public and private health insurers to reimburse providers for telehealth services at the same level as in-person services.
  • The administration should revoke the expanded public charge rule and the Title X domestic gag rule, both of which block young people from accessing critical health care.
  • The president’s budget should include generous funding requests for federally qualified health centers, the Title X family planning program and SBHCs, all of which are important sources of high-quality care for adolescents whose families have low incomes.

Guarantee Confidential Care

Privacy is paramount to adolescents’ ability to access sexual and reproductive health care. Several provider groups have issued statements supporting the importance of confidentiality for adolescents and people seeking sexual and reproductive health services.34–38 Confidentiality affects people’s likelihood of obtaining care: Adolescents who are concerned that their parents may find out about their care or who do not have one-on-one appointment time with their provider are less likely to receive sexual or reproductive health care.39–41

For the 66% of adolescents covered through a private insurance plan and the 31% covered through Medicaid,42 confidentiality may be breached when an explanation of benefits (EOB) form is sent to the policyholder (typically, a parent). This document offers a detailed description of services provided to anyone covered under the plan and could indicate that a dependent had sought sexual or reproductive health services.

State laws are another barrier to confidential care. Just 14 states have confidentiality protections for people insured as dependents,43 and many do not explicitly allow adolescents to consent to contraceptive services, prenatal care or abortion without their parents’ involvement.44 In these states, providers may choose to be more conservative than the law, alerting parents to adolescents’ care even when they are not legally obligated to.

Recommendations

President Biden and Congress must work together to:

  • Ensure that health reform proposals, including President Biden’s public option plan, include protections that ensure the confidentiality of sexual and reproductive health services for people younger than 18.
  • Develop a federal version of the Minors and Youth Access to Sensitive Health Services Act, model state legislation developed by Advocates for Youth that would guarantee that people who are insured as dependents (including adolescents) can consent to sexual and reproductive health services, receive those services confidentially, and receive any billing or other communications privately.45

The Biden-Harris administration has several tools to ensure confidential sexual and reproductive health care services for adolescents:

  • The Department of Health and Human Services should issue a rule requiring public and private health plans to send any communication related to sexual and reproductive health care to the person who received that care, rather than the policyholder.
  • The Centers for Medicare and Medicaid Services (CMS) should also send a letter to state Medicaid programs barring them from sending EOBs for sensitive services such as sexual and reproductive health care.
  • CMS should also issue regulations for the Health Insurance Portability and Accountability Act to expand the confidentiality protections for coverage of sensitive services.

Investing in the Future

The best thing that the Biden-Harris administration and Congress can do for adolescents’ sexual and reproductive health is to invest in them. This means defunding dangerous abstinence-only programs and redirecting that money to universal comprehensive sex education. It means removing the financial and logistic barriers that block adolescents—especially those who are marginalized—from getting the care that they need. It also means showing respect to adolescents by ensuring that their sexual and reproductive health care is confidential.

These are three priorities for policymakers to address over the next few years, but adolescents have other sexual and reproductive health issues that deserve urgent attention. The lack of support for pregnant and parenting adolescents,46 unethical and onerous requirements surrounding judicial bypasses for abortion care,47,48 and the unique hardships that the COVID-19 pandemic poses for adolescents49 are some of the additional challenges facing young people.

To address issues related to adolescents’ sexual and reproductive health, the United States desperately needs to reorient its approach. Much of the policymaking in this area has been grounded in a cultural discomfort with sexuality, particularly that of young people. However, discomfort is not—and never has been—a viable policy strategy. Policymakers must trust that adolescents, when equipped with high-quality sexual and reproductive health information and services, will make the best decisions for themselves.