The Importance of Access to Contraception

Various methods of contraception are available to adolescents, including:

• Abstinence.
• Emergency contraception.
• Progestin, progestin implants, and progestin injections.
• Combined oral contraceptive pills.
• Transdermal contraceptive patch.
• Progestin-only pills.
• Internal and external condoms.
• Other barrier methods.
• Fertility awareness and other periodic abstinence methods.
• Withdrawal.
• Vaginal ring.
• Cooper intrauterine device (IUD).

Contraceptive counseling conversations should emphasize a patient-centered framework, taking place before adolescents are sexually active and include discussions about contraception, consent, and sexually transmitted infections (STIs). Bright Futures outlines clinical considerations for promoting healthy sexual development.

Key elements relevant to taking a sexual history that involves discussions about contraception include creating a safe environment and taking a sexual history.

Creating a safe environment

Establish rapport:

• Normalize the discussion. State that all patients are asked the same questions.
• Minimize note-taking, particularly during sensitive questions.
• Screen for broad risk assessment which involves issues relating to home, school, and substance use.
• Provide assurances of confidentiality and establish limits of confidentiality. Patients are more likely to disclose sensitive information if consent and confidentiality are clearly explained. Clarify laws and limits of confidentiality, including how it will be maintained throughout the billing process.

Avoid assumptions of heteronormativity or behaviors:

• Understand the difference between gender and sexuality and how it may apply to your patients.
• Use gender-neutral language.
• Be familiar with colloquial terminology that patients may use.
• All clinicians and office staff should be nonjudgmental and supportive.
• Offer open-ended encouragement, such as “Tell me your story.” When seeking to understand a youth’s current situation.
• Ask developmentally appropriate questions.
• Ask open-ended questions.
• Avoid the surrogate parent role. Instead, look for opportunities to offer relevant and appropriate risk reduction information.
• Be concrete and specific with your questions.
• Describe how screening tests and results will be delivered.

Taking a Sexual History – adapted from A Pediatrician’s Guide to an LGBTQ+ Friendly Practice

While contraceptive education is associated with clinical settings, it can and should be simultaneously delivered in other complementary settings:

• Schools:
  • Schools can incorporate content on contraception into comprehensive sex education curriculum.
  • The Sexuality Information and Education Council of the United States (SIECUS) provides guidelines for providing developmentally appropriate education on contraception as part of its Guidelines for Comprehensive Sexuality Education.
• Community and Faith-based Settings:
  • Community and faith-based settings can provide safe and nonjudgmental spaces to educate youth on contraception methods.
  • Education and health service delivery programs can be tailored to the populations served.
• At Home:
  • Parents and caregivers can provide developmentally appropriate contraceptive information to their children.
  • Many factors impact the sex education that youth receive at home, including parent/caregiver knowledge, skills, comfort, culture, beliefs, and social norms.
• Online
  • Online resources that provide evidence-based information on contraception options and effectiveness exist.
  • Few websites offer up-to-date, accurate information on effective contraception options, including long-acting reversible contraception (LARC). This could present a barrier to promoting its utilization among youth, especially those who are part of historically franchised or underserved communities.

Access to contraception allows adolescents to maintain:

• Personal bodily autonomy.
• Healthy decision making.
• Self-management of their own health care.

There are many demonstrated benefits of contraception, including improved health and well-being and reduced global maternal mortality. A large and growing body of literature explores the social and economic benefits of a person’s ability to use reliable contraception:

• Improved health and well-being.
• Reduced global maternal mortality, which disproportionally affects people who are non-Hispanic Black and American Indian/Alaskan Native.
• Health benefits of pregnancy spacing for maternal and child health.
• Educational attainment.
• Female engagement in the work force.
• Economic self-sufficiency.
• Pregnancy prevention, particularly after sexual abuse.
• Regulation and shorter, lighter menstrual periods.
• Treatment of menstrual cramps, which relates to menses and quality of life for many people who menstruate throughout the world.
• Suppression of painful ovarian cysts.
• Treatment for endometriosis.

Nearly half of all pregnancies in the United States are unintended – with a higher rate (75%) unintended for those 15-19yrs old – and individuals who have lower incomes are disproportionately affected. Healthy People 2030 focuses on reducing unintended pregnancy by increasing use of birth control and family planning services to those who want it, including among adolescents.

A person’s ability to avoid unintended pregnancy is related to their perceived level of risk for unintended pregnancy, the strength of their motivation to avoid pregnancy, and their pattern of contraceptive use. These factors, in turn, are often associated with:

• Demographic and socioeconomic background.
• Characteristics of their sexual partnerships.
• Confidentiality.
• Their STI concerns and risks.
• Their experiences with and attitudes towards pregnancy and contraception.
• Access.
• Affordability.

Although unintended pregnancy occurs among people of all backgrounds, levels are highest among those who:

• Have lower incomes.
• Have not completed high school.
• Are members of racial or ethnic minority groups.
• Are aged 18-24.
• Are unmarried (particularly those who are cohabitating with a partner).

The most effective way to prevent unintended pregnancy is by improving access to improving access to patient-centered reproductive health care that includes access to comprehensive and affordable contraception.

When adolescents lack access to patient-centered care, including comprehensive and affordable contraception, they lack the tools they need to make informed, healthy decisions about their bodies, lives, relationships, and behaviors.

Several trends in sexual health in the US highlight the need for increasing access to contraceptive services for all youth.

National data indicate that adolescents under-use effective methods of contraception:

• 55% of US high school students report having sexual intercourse by age 18.
• Self-reported condom use has decreased significantly among high school students.
• Only 9% of sexually active high school students report using both a condom for STI-prevention and a more effective form of birth control to prevent pregnancy.

Adolescents and young adults are disproportionately impacted by STIs:

• Cases of chlamydia, gonorrhea, and syphilis are rising rapidly among young people.
• When left untreated, these infections can lead to infertility, negative pregnancy and birth outcomes, and increased risk of acquiring new STIs.

Contraceptive access can support prevention of unintended pregnancy among adolescents:

• Overall US birth rates among adolescent mothers have declined for 3 decades.
• There are significant geographic disparities in adolescent pregnancy rates, with higher rates of pregnancy in rural counties and in southern and southwestern states.
• Social drivers of health and systemic inequities have caused racial and ethnic disparities in adolescent pregnancy rates.
• Eliminating disparities in adolescent pregnancy and birth rates can increase health equity, improve health and life outcomes, and reduce the economic impact of adolescent parenting.

Access to contraception across the US varies widely.

Ensuring access to contraception is important for supporting reproductive autonomy, preventing unintended pregnancies, and promoting equitable reproductive health. There is significant variation in contraception access and use across the US, leading to disparities in health information, methods used, and outcomes.

One example of the many steps that an adolescent must manage in order to access prescribed contraception via a traditional primary clinic is outlined by Tracey A. Wilkinson, MD MPH:

Access to comprehensive contraceptive care and methods are impacted by the following factors:

• Health insurance: Disparities in same-day access to health insurance and variations in individual plan coverage of all FDA-approved contraceptives without cost sharing can impact access.
• Adequate funding: Programs to offset the cost of contraceptives can support access for low-income individuals.
• Ability to access tools (such as a reliable phone or internet access) required for telehealth visits.
• Comprehensive sex education: Youth education around methods and use can encourage use of contraception.
• Confidential care: Dedicated confidential time during a clinical visit and legislation mandating parental involvement can dissuade some youth from seeking contraception.
• Partnerships with alternative providers and method: Partnerships with healthcare providers who have specialized training in various methods of contraception (eg, long-acting reversible contraceptives, or LARC) can increase access for youth seen by providers who do not have this training.
• Public and health care provider education: Requiring education about guidelines for contraceptive care can increase access for youth seen in medical settings.
• Institutional and systematic changes: Inclusion of all contraceptive methods on all payer and hospital formularies and payment policies that support immediate postpartum and postabortion provision of contraception can increase access.

State laws also impact a minor’s access to contraceptive services. According to a report from the Guttmacher Institute:

• 23 state and the District of Columbia explicitly allow all minors to consent to contraceptive services
• 24 states explicitly permit minors to consent to contraceptive services in one or more circumstances:
  • 2 states allow minors to consent to contraceptive services if a physician determines that the minor would face a health hazard if they are not provided with contraceptive services.
  • 19 states allow a married minor to consent to contraceptive services.
  • 5 states allow a minor who is a parent to consent.
  • 5 states allow a minor who is or has ever been pregnant to consent to services.
  • 10 states allow a minor to consent if they meet other requirements, including being a high school graduate, reaching a minimum age, demonstrating maturity or receiving a referral from a specified professional, such as a physician or member of the clergy.

Contraception is starting to become available via new avenues, including mail order (MO) purchasing, pharmacist-prescribed prescriptions (also known as pharmacy access), over-the-counter (OTC) sales, and telehealth. Each method is described in more detail below:

Mail order:
Mail order contraception is a new avenue made possible by a range of companies including Pandia Health, Nurx, Plush Care, The Pill Club, and Lemonaid. To place an order: 1) the individual must fill out an online health profile and answer questions regarding their medical history, 2) the company’s medical team will review the health history and work with the patient to select the best option, and then 3) contraception is prescribed and delivered to the patient’s door (with options for automatic refill available). MO contraception consult/prescription fees vary by company, as do the available methods, telemedicine visit requirements, and age qualifications (which are impacted by state law).

Pharmacy prescribed contraceptives:
“Pharmacy access” laws authorize pharmacists to prescribe contraceptives, which can make contraceptive care more accessible and affordable by eliminating the need for a separate visit to a health care provider to obtain a prescription. Importantly, pharmacist prescribing of contraceptives has been proven to be safe and effective.

Guttmacher reports that there are over 15 states and the District of Columbia allow pharmacists to provide contraceptive care and 3 states that explicitly allow pharmacists to refuse to prescribe contraceptives. Several national medical and public health organizations, including the American College of Obstetricians and Gynecologists, the American Public Health Association, and the American Pharmacists Association, support pharmacist-provided contraception to increase access to contraception, with over-the-counter access to hormonal contraception being the ultimate goal.

Over the counter (OTC) sales:
OTC access to hormonal contraception is available without a prescription in over 100 countries globally. In the US, emergency contraception is available OTC but can be cost-prohibitive and difficult to find in-stock. More than 100 organizations, including those that serve youth, have voiced their support. Furthermore, data show that 3 in 10 teens have interest in OTC access and 1 in 4 teens not already using a birth control method would consider an OTC contraceptive pill. These youth could be reached via the provision of school-based health centers, which already play an important role in expanding access to contraceptive services. Lastly, the evidence suggests that OTC contraception patients are capable of self-screening, and users continue to access preventive care while taking an OTC pill. To help bring such affordable, available, insurance-covered OTC to the US, the Oral Contraceptives OTC Working Group – a coalition of advocates, researchers, and health care providers – has been collaborating since 2o04, and two companies are pursuing the necessary research to provide the FDA the data needed to approve the OTC transition.

Telehealth:
The COVID-19 pandemic has greatly expanded the adoption and use of telehealth. Many states expanded telehealth access and coverage during this time to allow access to medical care while reducing people’s exposure to COVID-19. Both telephone and video platforms have shown to be well suited to delivering contraceptive counseling, and provision and maintenance of regular and emergency contraception. Resources are available that describe high-level information about the telehealth policies in each state.

School-based programs:
Access to sexual and reproductive health care services at school-linked programs residing in high schools, colleges and universities, and vocational settings, play a critical role in meeting the health care needs of youth. Many school-based health services provide a limited range of prescription contraceptive methods on-site, including oral contraceptive pills. There have been examples of expanded access to contraception at schools via adding long-acting reversible contraceptive methods (LARCs) to health services provided and university student organizations setting up vending machines to dispense emergency contraception. Providing prescription contraceptive services on-site can reduce common barriers to contraception for students, including limited knowledge of off-campus locations for health service clinics and clinicians, lack of trust in clinicians, and lack of time or transportation to access a clinic.

AAP and other national medical associations support access to contraception for youth.

Given the evidence outlined above, AAP and other national medical organizations endorse counseling and access to a broad range of contraceptive services for their adolescent patients. This includes education about safe and effective contraceptive methods.

National medical and public health associations supporting contraception education, counseling, and access include:

• American Academy of Pediatrics.
• American Academy of Family Physicians.
• American College of Obstetricians and Gynecologists.
• American Osteopathic Association.
• American Medical Association.
• American Public Health Association.
• Society for Adolescent Health and Medicine.

Pediatric clinics provide a unique opportunity for contraception counseling and access.

Pediatricians and other pediatric health clinicians are a trusted source of sexual health information and typically have long-term care relationships with their patients and families, and thus have unique opportunities to address contraception with their adolescent patients.

Pediatric health clinicians have the opportunity to deliver care with a reproductive justice approach, which means to explore patients’ priorities and trust young people’s decisions when it comes to their bodies. While prescribing contraception to adolescents is an important form of reproductive health advocacy, a reproductive justice mindset recognizes the socio-economic and cultural inequalities that provide some people with “easier access to self-determination and bodily autonomy than others.”

The clinical visit is an opportunity to counsel about and ensure access to a broad range of contraceptive services for adolescent patients in a way that is caring and nonjudgmental. Contraceptive needs, expectations, and concerns should be discussed routinely. It can also serve as a useful adjunct to support other sources of sexual health information.

AAP policy and Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents provide recommendations for addressing contraception in clinical settings, including:

• Clinicians having their own working knowledge of contraception options and effectiveness for adolescents.
• Regularly assessing adolescent patients’ sexual history.
• Incorporating confidentiality and consent into contraceptive care.
• Counseling about and ensuring access to a broad range of contraceptive services, describing the most effective methods first.
• Educating adolescent patients about all safe and effective contraceptive methods or identifying clinicians in the community to whom patients can be referred for these services.
• Addressing contraceptive needs using a patient-centered approach.
• Following up to support adherence and monitor adverse effects and complications.
• Being aware of programs and community clinics that provide confidential and free or low-cost reproductive health care services and supplies, including contraception.

Many adolescents do not have access to contraceptive serves they want or need. Despite declines in recent decades, rates of unintended pregnancies in the US remain high.

Barriers to accessing contraception include:

Knowledge deficits, misinformation, mistrust:

• The emphasis on abstinence-only sexuality education may contribute to misperceptions around contraceptive effectiveness, a lack of understanding of how various methods of contraception work, and incorrect concerns about safety that can influence contraceptive use and method selection.
• Few websites offer up-to-date, accurate information on effective contraception options, including long-acting reversible contraception (LARC). This could present a barrier to promoting its utilization among youth, especially those who are part of historically franchised or underserved communities.
• People with periods of contraceptive nonuse report misconceptions about pregnancy risk.
• One study found gender queer participants experienced a lack of self-concept and a fear of stigma from both queer and health care communities as contraceptive users.
• Historical coercive contraceptive practices, rooted in systemic racism, and related policies designed to restrict childbearing in specific populations have led to misinformation and mistrust of the healthcare system.
• Individuals who are LGBTQ2S+ are often not provided with medically accurate education materials that address their sexual health needs.

Bias:

• Pediatric health clinicians may have knowledge deficits or attitudes and biases that can limit their ability to offer appropriate contraceptive methods to their patients.
• Contraceptive counseling can be based on clinician assumptions about a patient’s sexual behavior (eg, a mistaken belief that women who have sex with women do not need contraception), and as a result, non-contraceptive benefits of birth control may not be taken into consideration.
• Some practices may require or pressure youth to agree to other sexual and reproductive health services, like STI screening, when trying to access contraception.

Legal and legislative climate:

• While the Affordable Care Act (ACA) mandates that private insurance cover all contraceptives approved by the FDA without excessive cost-sharing, regulations allow employer exemptions from the contraceptive coverage rules.
• Rulings like the US Supreme Court’s Burwell v Hobby Lobby state that corporations can exclude contraceptive coverage from workers’ insurance benefits based on the company owner’s religious beliefs.
• Some states that require insurance plans to cover prescription drugs do not specify or cover prescription contraceptives.
• Measures that define life as beginning at fertilization assert that most methods of contraception act as abortifacients because they may prevent a fertilized egg from implanting and therefore assert that these methods are illegal.
• Despite national organizations recommending confidential care to adolescents, legislation requiring parental involvement for minors who receive contraceptive care provide legal barriers to access.

Cost and insurance:

• High out-of-pocket costs, deductibles, and copayments for contraception limit contraceptive access – even for those with private health insurance.
  • Out-of-pocket costs for contraception are nearly double that of out-of-pocket costs for non-contraceptive drugs.
• Individuals who have private insurance from employers who do not cover contraception or who are uninsured may not be able to afford the cost of the most effective methods, such as IUDs.
• While access to an extended supply of contraceptives is cost effective and has been shown to increase adherence and continuation rates, insurance plans restrict many individuals’ abilities to receive more than a single month’s supply of contraception at a time.
• Some insurers, clinic systems, or pharmacy and therapeutics committees require people to “fail” certain contraceptive methods before the cost of a more expensive method, such as an IUD or implant, will be covered.
• The majority of unintended pregnancies in the US care caused by gaps in contraceptive use, most often due to interruptions in insurance coverage or inability to cover co-pays.

Objection to contraception:

• Health systems sponsored by religious institutions often provide limited access to reproductive health services, including contraception.
  • It is estimated that 30-37% of hospital admissions statewide are to religiously affiliated hospitals, and 40% of hospital beds are in religiously affiliated hospitals.
• Reports of pharmacies refusing to fill contraception prescriptions or provide emergency contraception are increasing.
• Six states have laws or regulations that specifically allow pharmacies or pharmacists to refuse medication dispersion for religious or moral reasons without critical protections for patients, such as requirements to refer or transfer prescriptions.
• Areas where health care options are limited, such as rural areas, may be exacerbated by these barriers.

Repetitive clinical visits:

• Requiring a clinical visit that includes a pelvic examination prior to initiating hormonal contraception is not evidence-based and may deter an adolescent from seeking a more effective form of contraception and facilitate use of over-the-counter methods.
• Requiring multiple clinical visits:
  • For use of long acting reversible contraception (LARC).
    • STI testing can occur on the same day as LARC placement and people do not require cervical preparation for insertion.
    • For use of non-LARC methods, such as only dispensing 1-2 months of contraception for repeated, frequent visits.

Institutional and payment barriers:

• Variable compensation for contraceptive services may disincentivize clinics from providing the full range of contraceptive options.
• Healthcare providers face inadequate reimbursement for LARC devices in certain settings.

Health care inequities:

• Rates of adverse reproductive health outcomes are higher among people who are low-income and who live in under resourced communities.
• Individuals who are low income, historically disenfranchised, and underserved have higher rates of nonuse of contraceptives and are more likely to use less effective reversible methods such as condoms.
• Individuals who are low income face health system barriers to contraceptive access because they are more likely to be uninsured, a major risk factor for nonuse of prescription contraceptives.
• Many people who are eligible for publicly funded contraception live in contraceptive deserts.
• Publicly funded programs that support family planning services, including Title X and Medicaid, are increasingly underfunded and cannot bridge the gap in access for vulnerable people.

A 2021 report from the Guttmacher Institute indicates that the COVID-19 pandemic has impacted fertility preferences and access to care. Key findings indicate that the pandemic:

• Has shifted fertility preferences with 15% of respondents wanting fewer children or to have children later.
  • Pandemic-related shifts in fertility preferences were more likely to be experienced by respondents of color, LGTBQ2S+ respondents, respondents who are low-income, and those who experienced financial and employment difficulties in the past year than by their counterparts who are white, straight, cisgender, and financially better-off or employed.
• Impedes access to sexual and reproductive health care, including contraceptive services.
  • Respondents of color, LGTBQ2S+ respondents, low-income respondents, and those who experienced financial and employment difficulties in the past year were more likely than others to experience COVID-19–related barriers to SRH care.
  • Respondents who were higher-income Hispanic (23%) and Black (22%) were more likely than respondents who were lower-income white (15%) to report difficulty obtaining SRH care in the previous 12 months.
• Has disproportionate effects on the SRH of those already experiencing systemic social and health inequities.
  • Respondents who were Hispanic and Black were more likely to report financial or employment challenges, such as financial instability and job loss, than respondents who were White.

Disparities in access to contraception.

The barriers listed above limit access to full contraceptive options. While these barriers impact youth across the US, there are some populations who are less likely to have access to contraception. One significant limitation is the disparity in racial and ethnic representation in research studies: most studies recruit predominately white populations, which leads to a lack of understanding about tailored sexual and reproductive health care for specific communities and identities.

Youth who are LGBTQ2S+ face added barriers to contraception:

• One study found people who are queer and can get pregnant are more likely than their counterparts who are straight to have an unintended pregnancy or a pregnancy before they are aged 20, indicating structural barriers to contraceptive care and a need for LGTBQ2S+ inclusive care.
• Contraception counseling guidelines specific to people who are LGBTQ2S+ do not yet exist, a significant gap in care for family planning needs.
• Nearly a quarter of patients who are transgender have delayed seeking health care because of the fear of being mistreated, which can impact their ability to seek contraceptive counseling.
• Patient who are LGTBQ2S+ are more likely than straight patients to be uninsured and even those with insurance may face insurance denials because of gender markers in their patient profile.

Youth with disabilities or special health care needs face added barriers to contraception:

• Many individuals with disabilities or special health care needs experience assumptions from providers that they are not sexually active and/or do not need contraception.
• Most individuals with physical disabilities experience problems accessing clinic rooms and examination tables.
• Logistical barriers exist, including lack of accessible transportation, difficulty scheduling appointments around transportation constraints, and lack of understanding from insurance companies and providers about their specific needs.
• People with disabilities who also live at the intersection of another marginalized identity face compounded barriers to accessing care, ranging from lack of language access, to not having their symptoms taken seriously, to having their expressed health goals ignored.
• Contraception education materials are often not tailored for disabilities, such as sight impairment.
• There is limited research on the safety and efficacy of various contraceptive methods for people with disabilities and that may impact if and how a provider recommends or prescribes contraceptives.

Youth from historically underserved communities face added barriers to contraception:

• Medical racism has resulted in a culture of fear and mistrust of health care institutions for some individuals, which can make it more difficult for people who are Black to access contraceptive coverage and care.
  • One study found that IUDs were recommended more often to women of color who are low-income women compared to white women who are low-income.
  • Another study found that women’s preferences regarding contraceptive selection or removal were not honored.
• Youth who are female and Black are less likely than peers who are white to receive education about where to obtain birth control prior to initiating sexual activity.

Access to contraception has significant benefits for adolescents and future generations.

Access to contraception impacts adolescents’ sexual behavior:

• Students in schools that make condoms available without requiring parental notification are less likely to have ever had sexual intercourse than students at schools that don't provide condoms confidentially.
• Moreover, in schools where condoms are readily available, those teens who do have sex are twice as likely as other students to have used a condom during their last sexual encounter.

Meeting the contraceptive needs of adolescents is essential to improving their social and economic well-being:

• Improving and expanding contraceptive services is key to preventing unintended pregnancies.
• Access to contraceptive services increases opportunities for education.

Access to comprehensive contraceptive education, counseling and services are critical for empowering adolescents to maintain bodily autonomy, make informed decisions about their bodies, and attain economic benefits. Efforts to expand access, including pharmacist-initiated prescriptions (also known as pharmacy access), over-the-counter (OTC) sales, and mail-order (MO) purchasing, can reduce barriers to access that adolescents may experience. These strides are critical to adolescents maintaining bodily autonomy and also have a positive impact on public health.

Impacts of a lack of access to contraception.

When youth are unable to freely access contraception services, they are unable to make informed decisions about their body and sexual behaviors or protect themselves from STIs or unintended pregnancies.

Limiting access to contraception can have impacts on all youth, including:

• Foregoing contraception use.
• Stopping access to some or all reproductive health care services.
• Increased risk of unintended pregnancy.
• Increased possibility of exposure to sexually transmitted infections.

Limiting access to contraception can exacerbate existing health disparities, with disproportionate impacts on specific populations of youth.

Youth who identify as women, youth from communities of color, youth with disabilities, and youth who are LGBTQ2S+ are particularly impacted by inequitable access to contraception, as this lack of education can impact their health, safety, and self-identity. Examples of these impacts are outlined below.

A lack of contraception access can harm young women.

• Young women are greatly impacted by parental notification and/or consent laws:
  • One study found that, among adolescents who are female and sexually active, if parental notification was required to receive a contraception prescription:
    • 47% would stop accessing all reproductive health care services from the clinic.
    • 12% would stop using some reproductive health care services or would delay HIV/STD testing or treatment.
    • Nearly all adolescents who are female would stop or delay reproductive health care services and indicated they would continue being sexually active.

A lack of contraception access can harm youth from communities of color.

• Youth of color have unique needs related to STI and pregnancy prevention:
  • A history of systemic racism, discrimination, and long-standing health, social and systemic inequities have created disparities in access to sexual and reproductive health services, leading to:
    • Racial and ethnic disparities in STI and HIV infection.
    • Racial and ethnic disparities in unplanned pregnancy and births among adolescents.

A lack of contraception access can harm youth with disabilities or special health care needs.

• Youth with disabilities benefit from comprehensive sexual and reproductive health care tailored to their individual needs:
  • Youth with special health care needs often initiate romantic relationships and sexual behavior during adolescence, similar to their peers.
  • Youth with disabilities are often not asked about contraception or abortion needs because it is assumed they are asexual, infertile, or incapable of having or consenting to sex.
  • Youth with disabilities can be treated as a monolithic group and contraceptive factors may not be considered for the individual person and their disability, such as their comfort level with different types of contraceptive methods, ease of use, or interactions with other characteristics of their disability, adaptive technologies, or medications they may take.
  • Youth with disabilities or with special health care needs are more like to be under conservatorship or guardianship, leading to a lack in confidential contraceptive services or autonomous decision making.

A lack of contraception access can harm youth who are LGBTQ2S+.

• Youth who are LGBTQ2S+ benefit from gender affirming care:
  • Youth who identify as LGBTQ2S+ may experience unique challenges with insurers, leading some to forego an insurance plan altogether or to stick to the birth gender on their insurance ID cards.
  • Youth who identify as LGBTQ2S+ have federal support for insurance coverage of sex-specific preventive services to people who are transgender.
• Youth who are LGBTQ2S+ have unique needs related to STI and pregnancy prevention:
  • Youth who are LGBTQ2S+ are more likely than their heterosexual peers to report not learning about HIV/STIs in school.
  • Lack of education on STI prevention leaves youth who are LGBTQ2S+ without the information they need to make informed decisions, leading to discrepancies in condom use between youth who are LGBTQ2S+ and heterosexual.
  • Some populations of LGBTQ2S+ people carry a disproportionate burden of HIV and other STIs: these disparities begin in adolescence, when youth who are LGBTQ2S+ do not receive sex education that is relevant to them.