Originally published in Children's Hospital of Philadelphia PolicyLab blog.

Editor’s Note: This blog post was written in collaboration with the Guttmacher Institute. The post is part of an effort to use PolicyLab research and expertise to help other researchers, policymakers, program developers, and institutions understand the downstream effects of limiting youth access to comprehensive reproductive health care. For more, read a post on ensuring access to contraception (and view a recording of our virtual conversation on centering youth voices in supporting access to comprehensive sexual and reproductive health services).

Nearly six months after the U.S. Supreme Court overturned Roe v. Wade, we are seeing the profound effects on adolescent health. With states now making decisions about abortion access, more patients are coming into our pediatric practices in southeastern Pennsylvania asking to start contraception or switch to a long-term method in case their right to make reproductive decisions is removed. Our (Dr. Wood) research shows that politically motivated limits on reproductive and sexual health services threatened high-quality service delivery for youth before the Supreme Court decision led to increased state-based restrictions on abortion access. The removal of state protections for abortion care will have far-reaching effects on adolescent health and well-being, with marginalized youth most affected.

Ensuring access to the full range of evidence-based sexual and reproductive health care is a pediatric and health equity policy issue, as stated by the American Academy of Pediatrics and the Society for Adolescent Health and Medicine. In this post, we review the legal framework supporting adolescents’ access to sexual and reproductive services, as well as research on the impact of restrictions on reproductive care for adolescents, particularly racial and ethnic minoritized youth. We conclude with recommended actions that researchers and clinicians can take to improve access and outcomes for youth.

Legal Framework Supporting Adolescent Access to Sexual and Reproductive Health Services

Policies allowing adolescents access to sexual health education and reproductive services have existed for decades and arose in response to public health threats and changing social norms. They notably include:

• Several Supreme Court decisions in the 1970s establishing minors’ constitutional right to due process, privacy rights and access to contraception. The 1977 Carey v. Populations Services International decision made it illegal to prohibit the sale of contraceptives to minors and supported minors’ right to privacy when making reproductive decisions.
• The Title X Family Planning Program, established in 1970, is a pivotal federal funding stream allowing youth access to confidential services without a parent or guardian, including testing for sexually transmitted diseases, contraception and pregnancy counseling.  
• The 1970s marked a rise in the average age of marriage, an increase in the population of unmarried and sexually active youth, a lessening of social pressures for pregnant teens to marry and the legalization of abortion.
• In the late 1980s, the Centers for Disease Control and Prevention began providing funding and technical assistance specifically for HIV education in response to the public health threat presented by the AIDS epidemic.
• In 1990, after decades of activism, SIECUS: Sex Ed for Social Change developed the first guidelines for sexuality education for K-12 schools. See PolicyLab’s issue brief on comprehensive school health education for more current context on the guidelines.

These legal and social changes were felt unevenly across the country. Southern and Midwestern states tended to adopt more restrictive policies, such as abstinence-based sex education programs, and policies that eroded adolescents’ reproductive health care privacy, such as parental involvement laws related to abortion care, among others.

The geographic policy variations were compounded by longstanding racial and socioeconomic inequities and structural racism. Communities where low-income and Black, Indigenous and People of Color (BIPOC) individuals live have historically been more likely to experience chronic underfunding of schools, discriminatory banking, and housing policies, have more low wage jobs, and lack affordable and high-quality health care services. Sexual and reproductive health policies like the Hyde Amendment precluded the use of federal funds to pay for abortions for women insured through Medicaid.

Unequal Access to Reproductive Care Yields Poor Health Outcomes

State variation in restrictions and policies related to access is unsurprisingly accompanied by disparities in outcomes. This is seen in disparities in teen pregnancies and sexually transmitted infections (STI), and is now playing out with state-based variation in abortion restrictions.

PolicyLab research has examined the inequitable impact that restrictive sexual health policies can have on adolescents. In 2020, Dr. Wood and her team studied the impact of the “domestic gag rule” (since overturned), which prohibited clinics receiving federal Title X funding from providing pregnancy options counseling that included abortion. The research found that after the rule change, more than 1.8 million youth aged 15-17 did not have access to legally guaranteed confidential contraceptive and STI-related services due to clinics declining Title X funds rather than comply with these restrictive policies. The loss of access was not uniform, with youth living in rural communities experiencing the heaviest loss of services.

With emerging state abortion restrictions, we will likely see similar trends of vulnerable populations disproportionately affected. States most affected by the loss of abortion services have larger numbers of people of color, other restrictive health policies (e.g., have not expanded Medicaid under the Affordable Care Act), disproportionally high poverty rates, among the highest rurality rates, and the least robust public transportation systems. This means individuals with the least financial means, greatest access barriers, and longer distances to services will face more access challenges or be forced to forgo care. These inequities will be further magnified for young people who face additional challenges traveling and navigating state-varied parental involvement requirements.

Recommendations to Protect Adolescents’ Right to Access Reproductive Care

It is critical that child health researchers, clinicians, and policymakers amplify the importance of access to comprehensive sexual and reproductive health services for adolescents. We recommend the following priorities for action to ensure access to equitable, high-quality services for all youth:

• Support the passage of state and local protections for the right to access sexual and reproductive health services for state residents and/or provide protections for those traveling from restrictive states for care. California, Michigan, and Vermont are examples of states that have enshrined the right to abortion and other pregnancy-related care in their state constitutions.
• Advance multi-sectoral partnerships of clinicians, legal advocates, and grassroots organizations working together to protect youth and providers from vigilante lawsuits, workplace discrimination and to limit the sharing of youth’s confidential reproductive health information.
• Advance youth access to confidential and comprehensive sexual and reproductive health services alongside youth-facing resources so they know their rights and how to access care. More adolescents are likely to access essential care when confidentiality is protected.
• Restore reproductive health services lost following implementation of the domestic gag rule. See PolicyLab’s recent blog post on why this is particularly critical now.  
• Repeal parental notification requirements for youth seeking abortion to align with principles of adolescent autonomy, including expanded definitions of youth-supporting adults to encompass non-parental support figures.
• Invest in health navigators who can guide youth who must undergo the judicial bypass process to receive abortion services.
• Promote innovative, youth-centered strategies for ensuring sexual and reproductive health service delivery to low-resourced areas, including telehealth and mobile health services, financial safety nets, and strategies to create social support for youth who must travel to receive services.

The Supreme Court’s decision to overturn Roe v. Wade threatens a wide array of essential health services for adolescents. While state laws affirm the right of minors to consent to contraception, STI testing and treatment, and pregnancy care, no state requires parental involvement for those services like they do when it comes to abortion care. There is a lot at stake in states across the country, and youth who already face inequitable access to these services could face further losses, which will only be magnified for minoritized youth.

As the landscape of state and federal restrictions on sexual and reproductive health services continues to develop, researchers, clinicians, and policymakers have critical roles to play. By partnering with state and local government, creating innovative service delivery strategies, and studying and amplifying the detrimental impacts of ongoing restrictions, we can counter the growing tide of restrictions and help ensure that all youth sustain access to high-quality and equitable services.

Originally published in Children's Hospital of Philadelphia PolicyLab blog.