California's Parental Notification Initiative, Prop. 85

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Testimony of Norma Jo Waxman, MD Member of Physicians for Reproductive Choice and Health Presented to the Joint Informational Hearing on Proposition 85: Assembly Committee on Health, Senate Heath Committee September 12, 2006
Thank you to members of the Assembly Committee on Health and the Senate Health Committee for allowing me to appear before you today. My name is Dr. Norma Jo Waxman. I have been a family physician for 18 years. I am a Professor of Family and Community Medicine at the University of California San Francisco (UCSF), and teach medical students and residents. I am part of the core faculty at the UCSF Family Medicine Residency program, where I care for underserved, culturally diverse, inner city patients of all ages at San Francisco General Hospital. I lecture professionally about contraception and how to decrease unintended pregnancy, and on other adolescent and women’s health issues, such as intimate partner violence. Previously, I taught and practiced adolescent medicine at Children’s Hospital Oakland and was a child and adolescent sexual abuse examiner. I am the loving and proud mother of two young daughters, Zoe, age 4½, and Isabella, age 6. I am submitting testimony today as a concerned resident of the State of California, an experienced healthcare provider, and as a member of Physicians for Reproductive Choice and Health, or PRCH. PRCH is a national nonprofit organization with staff and projects in California. PRCH exists to ensure that all people have the knowledge, access to quality services, and freedom to make their own reproductive health decisions. I submit this testimony to you today on behalf of the PRCH Board of Directors, as well as our physician members nationally and here in California, to express our opposition to the proposed amendment to the Constitution of the State of California, entitled “Waiting Period and Parental Notification Before Termination of Minor’s Pregnancy,” also known as Proposition 85, that is on the ballot for the election on November 7. I speak in strong
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opposition to this initiative because it is a threat to public health—and particularly threatens the health of California’s young people. As you know, the proposition would ban abortions for women younger than 18 years old until 48 hours after a parent or guardian was informed about the intended abortion, except in the case of a medical emergency or judicial bypass. As a physician and reproductive health expert, I will explain why Proposition 85 would create profound obstacles to healthcare access and thus impose health risks on adolescents. Mandatory parental notification and consent laws will cause frightened young women who are dealing with unintended pregnancies to delay seeking healthcare. Doctors know the most important thing a pregnant young woman can do is seek prompt medical counseling to help her choose whether to continue or terminate the pregnancy and then obtain that care, be it abortion or early prenatal care. This initiative would delay, discourage and restrict initiation of healthcare. Timing is critical when a young woman is pregnant. Parental notification laws have been demonstrated to delay and obstruct the access of pregnant adolescents to timely professional advice and medical care. i ii iii Mandated parental involvement may lead to delays in decision-making or convince minors to travel to out-of-state facilities.iv A 1997 study of a parental consent requirement in Mississippi showed that the number of teens having abortions did decrease in Mississippi, but this decrease was offset by an increase in the number of teens having abortion in surrounding states, along with an increase in later, more medically complicated second trimester abortions in young women.v Adolescents are already more likely than older women to delay obtaining abortions for a variety of reasons, including the fact that many have irregular periods and so some do not realize that they are pregnant. Adolescents living in rural California and in counties with poor access to reproductive health services face additional challenges to gaining access to care, which have been documented to result in adverse effects on mental health.vi This notification law would compound delays and the potentially ensuing anguish, anxiety and depression. As a physician, my first priority is my patient’s health. I fear this initiative would interfere with this, and would put the relationship between me and my patient into a complex legal web, jeopardizing trust and confidentiality, which are key to the physician-patient relationship. Adolescents are often confused about their right to confidential care, and even the perception of the lack of confidentiality regarding sexual issues may deter them from seeking advice and services.vii Studies show that laws requiring parental involvement for contraception have the potential to decrease adolescents’ use of contraception, without decreasing sexual activity, and deter them from seeking the advice of health professionals.viii
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Physicians have the same priorities as parents—we want young women to have access to safe medical care. Parents ideally should be—and usually are—involved in healthcare decisions regarding their children. Parents, like physicians, first and foremost want to ensure that their daughters are safe and healthy. However, Proposition 85 does nothing to promote such communication or keep young women safe and healthy. Instead, it places burdens on the most vulnerable young women and infringes on their rights and privacy and thus puts their health at risk. Despite its best intentions, the government cannot mandate healthy family communication. In fact, one published study shows that the proportion of minors who inform parents about their intent to have abortions are about the same in states with and without notification laws.ix I want to clearly state that there are no studies that demonstrate that parental involvement laws increase communication between a young woman and her parents. I want to emphasize that physicians regularly encourage our young patients to involve their parents in major health decisions, and most young women do talk with their parents. According to a large national survey, the majority of parents (61%) are aware of their daughters’ decision to have an abortion, and 75% of those are told by their daughters themselves. The likelihood that parents know about their child’s abortion rises with decreasing age, from 74% of parents of 16-year-olds to 90% of parents of those 14 years old or younger.x Most of those who do not involve a parent have good reasons for not doing so. Close to one-third of minors who do not inform parents of their pregnancies fear physical violence or being forced to leave home.xi Studies show that when parents are informed of a pregnancy against the adolescent’s judgment, there is an increased risk of conflict, a coerced decision, or rejection of the daughter by the family.xii, xiii And, unfortunately, as we know, some young women become pregnant as a result of rape or incest. One of the most heart-wrenching patients I have cared for was a 12year-old girl, pregnant by the boyfriend of her crack-using mother. Her aunt, who was not the legal guardian, brought her to my clinic for a referral for an abortion. How would notifying this patient’s mother have helped? We also know from other studies that more than 80% of young women do rely on other trusted adults, including aunts, grandparents, teachers, siblings and clergy when they cannot talk with their parents about their pregnancies.xiv, xv Under this proposed law, who does the physician notify if the parent is in jail, on drugs, or doesn’t live in this country? Some of our most at-risk teens are not being raised by a parent or legal guardian, but by loving grandparents, aunts and uncles. This initiative would undermine those caring relationships. That’s just not right. This proposed law will adversely affect those young women who are already in the appalling position of not being able to consult with their parents because their families are unsupportive, unavailable, dysfunctional or abusive. The proposition undermines the goals it claims to promote—healthy family communication and the well-being of young women—by forcing some
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young women to risk abuse or abandonment if they tell their parents. In some cases, young women in risky situations will keep their pregnancies a secret, which in turn may mean they forego prenatal care, or delay and have a more risky and distressing later-term abortion or, worst of all, seek to terminate the pregnancy outside of the medical establishment. We all recall the tragic story of a young, pregnant woman in Michigan who had her boyfriend beat her abdomen with a baseball bat. The proposed initiative does provide an exception to parental notification through a procedure called judicial bypass. Some may view judicial bypass as a reasonable compromise. I believe the bypass process, rather than alleviating the burdens imposed by this law, is detrimental to the medical and emotional well-being of teens. Judicial bypass has been shown to delay access to medical care from four days up to six weeks, increasing the risk of complications from second trimester abortions,xvi as well as absenteeism from school. And keep in mind that the delay caused by the judicial bypass process compounds the young woman’s initial delay in accessing healthcare related to the pregnancy. I also worry about the psychological harm and lack of confidentiality created by judicial bypass. Often in rural settings the teen is known by someone at the court. As the American Academy of Pediatrics argued, the “pregnant teen is required to divulge intimate details of her private life to dozens of strangers (clerks, bailiffs, court reporters, witnesses and others) to obtain a brief (ten minute) hearing before a judge who has no firsthand knowledge of her case and typically no training in counseling adolescents on developmental issues.” Adolescents see the court proceedings as extremely burdensome, humiliating and stressful, and therefore detrimental to their emotional wellbeing.xvii, xviii This is on top of the fact that negotiating the judicial process is daunting and embarrassing enough for adults. Can you imagine an unsupported, pregnant young woman navigating our current judicial system by herself in a timely fashion? Can you imagine an anxious young women providing detailed information about her pregnancy and her reasons why she needs a judicial bypass all in front of room full of adults? Doctors are scientists, healers and caretakers. We are not police officers. We are trusted by our patients to provide medical care and to put their interests first. This initiative would cause physicians to betray our patients’ trust and would make us participate in enforcing a law that we know is harmful to our patients. As a doctor, I have been trained to act in the best interest of my patients. I should not be required to do the opposite—to act in a way that data show is detrimental to the health of my patients. Leading medical organizations concur on this issue. The American Academy of Family Physicians, the American Academy of Pediatrics, the American Medical Association, the American College of Obstetricians and Gynecologists,
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the American Medical Women’s Association, the American Public Health Association, the National Medical Association and the Society for Adolescent Medicine all oppose mandatory parental-involvement laws because they endanger the health of adolescents and pose undue burdens on physicians. In California, the American Academy of Pediatrics, California; the American College of Obstetricians and Gynecologists, District IX; the California Academy of Family Physicians; the California Primary Care Association; and the California Medical Association all oppose Proposition 85. As a physician, I must use my professional expertise to act in the best interests of my patient. Medical judgment is based on scientific facts, as well as our professional decisions on what works, not on what doesn’t work. It is not appropriate for those without medical training to interfere with the practice of medicine. As doctors, we should put our patients and their health first, and not have to fear legal reprisal for doing so. Both the doctor-patient and parent-child relationship should be based on trust and the assumption that we all want our children to grow up healthy, happy and able to fulfill their dreams. This initiative invades that trust, allowing politicians to dictate medical practices that will be dangerous to the health of young women. As a mother, I hope that my daughters would turn to me if they had an unintended pregnancy. However, my highest priority would be their health and wellbeing. If my daughters didn’t feel comfortable coming to me, I would want to know they got excellent, expedient, safe and supportive care from the medical system. As a physician, I believe that Proposition 85 represents bad medicine. Clinical experience and scientific evidence concur: this legislation would hurt the health of young women. It is for this reason that I appear here today in opposition to Proposition 85. Thank you for allowing me to appear before you today.
i Joyce T, Kaestner R, Colman S. Changes in abortion and births and the Texas parental notification law. N Engl J Med. 2006; 9;354(10):1031-8. ii Ellertson C. Mandatory Parental Involvement in Minors’ Abortions: Effects of the Laws in Minnesota, Missouri, and Indiana. Am J Public Health. 1997;87:1367-1374. iii Henshaw S. The impact of requirements for parental consent on minors’ abortions in Mississippi. Fam Plann Perspect. 1995;27:120-122. iv Ellertson C. Mandatory Parental Involvement in Minors’ Abortions: Effects of the Laws in Minnesota, Missouri, and Indiana. Am J Public Health. 1997;87:1367-1374. v Henshaw S. The impact of requirements for parental consent on minor’s abortions in Mississippi. Fam Plann Perspect. 1997;27:120-122. vi American Medical Association National Coalition on Adolescent Health, Gans JE, ed. Policy Compendium on Confidential Health Services for Adolescents. Chicago, IL: American Medical Association; 1993. vii Jones R, Bonstra H. Confidential Reproductive Health Services for Minors: The Potential Impact of Mandated Parental Involvement for Contraception. Perspectives on Sexual and Reproductive Health. 2004;36(5). viii Ibid.
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ix Blum RW et al. The impact of parental notification law on adolescent abortion decision making. Am J Pub Health. 1987;77:619-620. x Henshaw SK, Kost K. Parental involvement in minors' abortion decisions. Fam Plann Perspect. 1992;24(5):196-207. xi Ibid. xii David HP, Dytrych Z, Matejek Z, Schuller V, eds. Born Unzonnted: Developmental Effects of Denied Abortion. New York, NY: Springer Publishing Co; 1988. xiii American Academy of Pediatrics, Committee on Adolescence. Counseling the adolescent about pregnancy options. Pediatrics. 1989;83:135-137. xiv Henshaw SK, Kost K. Parental involvement in minors’ abortion decisions. Fam Plann Perspect. 1992;24:196-207,213. xv Zabin LA, Hirsch MB, Emerson MR, Raymond E. To whom do inner-city minor talk about their pregnancies? Adolescents’ communication with parents and parent surrogates. Fam Plann Perspect. 1992;24: 148-154, 173. xvi Donovan I. Judging teenagers: how minors fare when they seek court authorized abortions. Fam Plann Perspect. 1983;15:259-267, Crosby 1991. xvii AAP, Committee on Adolescence. Pediatrics; 1996:746-751. xviii Crosby MC, Englist A. Mandatory parental involvement/judicial bypass laws: do they promote adolescents’ health? J Adolesce Health. 1991; 12: 143-147.
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