At Planned Parenthood’s family planning clinic in East Austin on a recent afternoon, a young couple sat holding hands in the waiting room. Him: a baby-faced teen in white high-tops and baggy shorts. Her: birdlike, hiding behind her hair. Beside the couple sat the girl’s mother and older, 20-something sisters. Her sisters kidded the young girl, causing the mother, busy signing papers on a clipboard, to snip at them: “Do you want her to go off to college pregnant?” The mother marched the paperwork to the front desk and slipped the clipboard through the glass divide. She wasn’t just there for moral support.
In Texas, teenagers must have their parents’ consent to receive prescription birth control. The girl’s legal guardian must sign a form, which often means coming into the clinic with the teen, before clinicians can dispense contraception. The law went into effect in 1998, prohibiting the use of state funds to provide minors with confidential contraceptive services. Only Utah has the same rule.
But determining which teens must obtain parental permission is complicated. Federal law requires that clinics do exactly the opposite as Texas law. Any providers serving Medicaid clients or using a federal family-planning grant called Title X must guarantee patient confidentiality to everyone, regardless of age. In fact, if a teen’s treatment is paid for with federal funds, then a clinic can’t ask for parental consent without violating federal rules. There are also enough exemption categories within Texas state law, like emancipated minors or those on active military duty, to make clinics anxious that they’re obeying both state and federal regulations.
Those standards are about to get even more muddled. Beginning in September, at least 69 family-planning clinics in Texas will lose federal Title X funding, which means that they will have to comply with state law and start getting parental-consent signatures on file to continue dispensing birth control to minors. Sexually active teens, like the ones in Planned Parenthood’s waiting room, will be forced into frank conversations with their parents. Others, with less supportive parents, could be subject to physical and emotional abuse. From September, those patients must find a new clinic funded by federal dollars so they can get the pill in private.
But that’s not so easy. Jane’s Due Process, a legal aid organization for minors seeking abortions, found in a 2012 survey that many clinics holding the federal Title X grant were erroneously telling teens that they needed parental sign-off. Their confusion may have arisen from uncertainty about who was and wasn’t exempt from the law. Dr. Janet Realini, president of teen pregnancy prevention program Healthy Futures of Texas, said that such legal ambiguity makes physicians nervous. This haziness is unfortunate. Jane’s Due Process notes that the main reason pregnant teens say that they weren’t using birth control is because they thought they needed parental consent to get it. Sometimes parental permission is needed and sometimes it isn’t, but the parental consent law is ambiguous and harmful enough, argues Jane’s Due Process Executive Director Tina Hester, to create major access barriers for teens from unsupportive families.
As Texas’ etch-a-sketch health system for low-income patients rearranges itself yet again, teens trying to access health care have a bewildering task ahead. Texas already has one of the highest teen pregnancy rates in the country. In September, at those 69 clinics that no longer receive Title X funds, about 2,000 young girls will soon be asked to obtain parental permission for contraception where it wasn’t needed before. Not all of them will get it. Some may become pregnant as a result.
Since the Texas Legislature slashed women’s health funds by two thirds in 2011, Texas’ safety net system has been in turmoil. Having lost most of their state funding, family planning clinics hustled for private donations, reduced hours, leveled co-pays and fired staff. About 60 clinics closed. In the 2013 legislative session, family planning advocates convinced legislators to return cash to the health system they’d so devastated two years before. Accordingly, more than $200 million will flow back into the system from state coffers. But each dollar, because it comes from the state, will have the parental consent law attached to it. For this reason, the federal Title X grant is a prized source of money for clinics because only $1 of federal money allows them to cast privacy protection over every patient.
But there’s a problem. Just this spring, the federal government gave control of Texas’s Title X grant to a coalition of family planning providers called the Women’s Health and Family Planning Association of Texas. Previously, the state health department had controlled the grant and got to decide who would get the money (Planned Parenthood affiliates, for example, and rural clinics lost out). To boost their chances of getting the Title X cash, health providers could have signed up to both the health department and the coalition’s bid. But not everyone did. Half of the provider network enrolled only with the state health department. Thus, when the coalition won the award, those who’d cleaved to the state lost a key source of federal money. To comply with a state law they had previously been able to sidestep, each clinic must now start asking for parental consent before dispensing birth control to teenagers. Sixty-nine clinics in all will use their last Title X dollar at the end of August.
Clinics all across the state will be affected, covering 1,996 adolescent girls, by state health department estimates. For example, even though it runs seven specialty teen clinics, the Baylor College of Medicine in Houston chose not to enroll in both Title X bids. Their adolescent clients are now subject to the parental consent law. In Austin, only People’s Community Clinic has Title X which means that all other safety-net providers in the county, including Planned Parenthood, are subject to state laws. Similarly, the largest provider of family planning services in the Hill Country—Lone Star Circle of Care—will start asking for parental consent. Clinics in South Texas, the border region, the Panhandle, the Brazos Valley and the Gulf coast will soon stop providing patient confidentiality for teens.
Patients are shocked but …
Clinicians at Planned Parenthood’s East Austin clinic can imagine what it will be like for patients and providers. Planned Parenthood lost the Title X cash and its patient protection clause in September 2011 when the Legislature determined that the main women’s health provider in Texas was no longer eligible for family planning funds. Clinical nurse specialist Suzy Campbell explained that teens who had had an active birth control prescription were suddenly asked to come back with parental consent to get a refill. “Most are shocked,” Campbell said, “but it gives them the push that they need to talk to their parents.” Campbell emphasized that parental communication is central to healthy adolescent development. Having to gain parental consent for birth control “opens the door for teens to talk about relationships with their parents,” she explained, “and when that discussion comes on the table it usually means that the teens are going to be more informed: They may wait to initiate sexual activity; they are more safe; they are more knowledgeable about birth control.” Dr. Celia Neavel, director of adolescent services at People’s Community Clinic in Austin agrees. “We want parents involved, we love parents involved,” she said, adding that many of her adolescent patients do come in with a guardian. Like Planned Parenthood, Neavel’s clinic lost Title X funding in 2011 and had to ask for parental consent where it wasn’t required before.
Although the debate about parental rights can be divisive, when it comes to teens’ access to contraception, there’s a great deal of common ground. Many parents want to know what health care their teens receive and health professionals want parents involved too. Moreover, the Annie E. Casey Foundation, a child-focused public policy organization, notes studies finding that parents do indeed play a vital role in “protecting their teens from early sexual activity and pregnancy”.
When supportive parents aren’t there
But that’s not where the problem lies. Teen advocates like Tina Hester of Jane’s Due Process, and health professionals like Neavel and Campbell, are concerned about those teens who fall through the gaps. “We don’t know the ones that didn’t come in [for birth control],” said Neavel.
Indeed for the teens that don’t have a supportive relationship with their parents, academic research suggests that they will delay use of contraception, thereby increasing their chances of STD infections and pregnancy. For this reason, legislators in other states that have tried to implement parental consent to contraception laws have been dissuaded by family planning experts. “Maybe once a year we see these efforts but quickly people realize that this is a bad idea,” Elizabeth Nash of the Guttmacher Institute said, speaking most recently of legislative efforts in Maine, Minnesota and North Carolina.
Texas teens are not so lucky. When state Rep. Mary Gonzalez (D-El Paso) filed a bill during the 83rd regular session to allow confidentiality for teen mothers older than 15, it didn’t even receive a hearing in committee. She re-filed the proposal as an amendment to the anti-abortion bill that passed during the second special session. Conservative representatives tabled it.
As a consequence, Jane’s Due Process must deal with the outcome of a health policy that ignores Texas’ most vulnerable. Their attorneys counsel young women who suffer physical and emotional abuse from their guardians, who face rejection if they come home pregnant, whose parents are hostile to the thought of premarital sex. “Minors who call us have a damn good reason not to tell their parents that they were having sex,” said Tina Hester. “One girl had been beaten with a hose. Another hadn’t spoken to her parents for a year because they didn’t like her boyfriend.” Hester said that one of their clients believed her father or brother would kill her if they’d discovered she was pregnant. Clearly, asking an abusive parent like this for permission to use birth control is a dangerous proposition. There is no exception in Texas law for children from abusive families.
Imagining a world where teenagers have healthy relationships with their parents and so make sound decisions about their sexual health, Hester mused: “I’d love to go out of business.” But until vulnerable teens can overcome state barriers to confidential health care, Jane’s Due Process’ caseload may simply continue to climb.