Exploring Adolescent-Facing U.S. Clinicians’ Perceptions of Their Contraceptive Counseling and Use of Shared Decision-Making: A Qualitative Study

Introduction

Although contraceptive methods are widely available to many Americans, some individuals who desire contraception still face many barriers to accessing these methods. Adolescents are particularly susceptible to these barriers, and adolescents who desire contraception may not be using their preferred method for many reasons.^1–3 Some adolescents may not be knowledgeable about the variety of contraceptive options available to them, or may face barriers in obtaining a desired contraceptive method from a clinician even if they are well-informed.⁴ Adolescents may not seek contraception if they cannot obtain it confidentially for fear of parental disapproval and potential retaliation such as harassment, abandonment, or abuse.^5,6 Many adolescents may lack physical access to contraceptive and family planning services (e.g., transportation challenges, or inconvenient clinic hours).^7–10 Additionally, many adolescents are hesitant to discuss contraception openly with clinicians for fear of judgment or disapproval.^11–13 Recent literature has shown that clinicians’ biases may influence their contraceptive counseling practices and their patients’ contraception use.^14–19 For example, recent literature has shown how adolescent pregnancy prevention has been weaponized as a poverty reduction strategy and often ignores an adolescent patient’s personal feelings toward pregnancy and contraception.¹⁹

To better support patients in obtaining their preferred contraceptive method, there has been a shift in recent years from efficacy-based counseling, also known as tiered-effectiveness counseling, to shared decision-making (SDM). In the tiered-effectiveness contraceptive counseling model, clinicians discuss contraceptive methods based on effectiveness at pregnancy prevention. Thus, in this model, clinicians will first share information about the most effective methods of contraception (i.e., intrauterine device (IUD) and implant, also referred collectively to as “long-acting reversible contraception” or LARC) before subsequently describing other less effective methods.²⁰ In contrast, SDM is defined as “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.”^21–23 In this definition, SDM aligns with person-centered care, or “providing care that is respectful of, and responsive to, individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions”.^24,25 Patients are seen as experts on their own lives, while clinicians are medical experts, available to support patients and provide factual information to help them make a decision that is right for them.²⁶ While SDM is intended to reduce the influence of clinician bias, in practice it can exacerbate inequity if a clinician tailors a conversation to their assumptions of a patient’s goals or preferences based on perceived demographic or sociocultural characteristics.^27,28 Furthermore while organizations such as the American College of Obstetricians and Gynecologists (ACOG) recommend SDM as the optimal approach for providing unbiased and patient-centered contraceptive counseling, specifically adolescent-facing professional organizations such as the American Academy of Pediatrics (AAP) continue to explicitly promote effectiveness-centered counseling, stating that LARC methods should be considered first-line.^29,30

Previous literature suggests that the SDM model is particularly important and useful for “preference-sensitive decisions”, or those decisions in which the best option depends on the individual’s assessment of the characteristics of two or more medically appropriate options.^21,31 As contraceptive counseling is one example of a patient preference-driven decision, clinicians should utilize the three-part SDM model to promote equitable, authentically patient-driven contraceptive counseling that involves: 1) choice talk (i.e., ensuring all patients understand that there are many options available to them and that they have a choice in selecting a preferred method); 2) option talk (i.e., providing more detailed information about these contraceptive options); and 3) decision talk (i.e., a unique, tailored, bidirectional conversation to assist the patient in selecting a contraceptive method through eliciting the patient’s preferences).^31,32

In this qualitative study, we explored self-reported contraceptive counseling practices among U.S.-based clinicians who see adolescent patients to assess how these practices create barriers or facilitators to SDM and person-centered contraceptive care.

Methods

We conducted in-depth interviews with practicing clinicians who had completed their medical training and counsel their adolescent patients about contraception. Our study team recruited participants at the American Academy of Pediatrics (AAP) annual conference in October 2022. We anticipated a sample size of 15 to achieve thematic saturation.³³

Our study team recruited clinicians through convenience sampling in the exhibit hall of the AAP annual conference. We verbally assessed participant eligibility prior to inviting individuals to interview. To be eligible to participate, participants had to be a practicing healthcare clinician who saw adolescents in their clinical practice and provided contraceptive counseling. In an effort to preserve complete anonymity, we did not collect demographic information aside from individuals’ professional training which was required to verify their eligibility to participate in the study. During the course of the interview, the respondents revealed their practice setting. As these were meaningful for the respondents we used these practice settings in our identification of the subjects in our analysis.

Trained interviewers (MT and JH, both cisgender, white women in their 20s) conducted individual face-to-face interviews with each participant during the conference. Participants verbally consented to an anonymous interview. Each interview lasted an average of 18 minutes. The interviewers used a semi-structured interview guide to ask questions related to the clinician’s patient population, contraceptive counseling practices, and prompts to investigate implicit or explicit biases and stereotypes. The interview guide was based on a review of the literature and frameworks published surrounding contraceptive counseling, as well as asked practice-based questions to understand the participants’ clinical practice. We provided $20 compensation for participation.

We audio-recorded all interviews with permission from the participant. A professional transcription service transcribed each interview. We used thematic content analysis to analyze transcripts. The study team (MT, EM, BB, JH, BA) developed an initial codebook based on concepts and themes deductively derived from the interview guide and existing literature on adolescent contraceptive counseling and the SDM framework, and inductively refined the codebook and added themes during the coding process. All transcripts were double-coded (MT, BB, JH) using Dedoose qualitative analysis software, and this team met weekly to resolve coding discrepancies via discussion to reach consensus. Our study team then reviewed quotes from participants associated with each code. Consistent with qualitative content analysis, codes were applied to excerpts of the transcripts to understand both the content and style of contraceptive counseling. Participants may have given several examples of their counseling throughout a single transcript, each of which aligned with different codes. Therefore, multiple and potentially opposing codes related to SDM concepts may have been applied to the same transcript. We then interpretated emerging themes as aligning or diverging from the SDM components of choice talk, option talk, and decision talk.²¹ We reviewed the frequency of codes in Dedoose after coding was completed, and report here the most frequent themes that relate to the SDM concepts above. Given the limitations of assessing clinical practice through an interview, we operationalized bias as the following. If a participant noted their action or statement as bias, that was termed explicit bias. If a participant responded in a manner that suggested bias based on a patient’s characteristics but did not recognize the statement as biased, we considered that implicit bias.

The University of North Carolina at Chapel Hill Institutional Review Board approved this study.

Results

We interviewed 16 clinicians (15 physicians and 1 nurse practitioner (NP)) who worked in a variety of settings including academic medical centers (n=8), private practice (n=6), school-based clinics (n=1), and the Indian Health Service (n=1). A synthesis of the six main themes of clinicians’ contraceptive counseling processes, and how these themes align with or diverge from each component of the SDM framework (choice talk, option talk, decision talk), is presented below.

Choice talk:

During choice talk, clinicians should inform patients about the various options available to them for contraception and explain to all patients that they have true autonomy in their choice of a medically appropriate contraceptive method, regardless of patient characteristics. In our cohort, many participants noted that they tailored their counseling based on their perceptions of various patient sociodemographic characteristics, including their age and socioeconomic status (SES). Participants were directly asked how their counseling may differ given factors such as race, age, and SES, though many implied rather than explicitly stated that their counseling differs based on patient characteristics when they shared details about their general counseling practices.

Approximately two-thirds of clinicians described employing an age cut-off when determining when to initiate contraceptive counseling with pediatric patients. Several described 11- and 12-year-old patients as being too young to engage in contraceptive counseling. One clinician expressed that they would be concerned if a 12-year-old patient inquired about contraceptive methods and would probe if they were sexually active and in a consensual relationship. Although the clinician noted that these considerations are pertinent for all patients, they are “more inclined to take the extra [step] to ask it in a younger [patient]” (Private practice pediatrician). An NP in a school-based clinic noted that although patients under the age of 12 may not be sexually active or need contraception themselves, they educate about contraception in case the patient “may have a friend who needs this.”

One clinician stated that their counseling was influenced not only by the age of the patient, but also by their perception of the patient’s maturity level. This clinician opposed universal counseling based on age, instead advocating for clinician judgment regarding a patient’s readiness to engage in contraceptive counseling:

…you have to look at the individual [be]cause a 13-year-old may look like and act like a…25-year-old, but you also may have a 13-year-old that may look and act like an 8-year-old, so you really have to pick it out. You can’t just do it across the board – Private practice pediatrician

Beyond perceived age-appropriateness of initiating counseling, clinicians also shared perceptions of the appropriateness of adolescents using certain contraceptive methods. In particular, several clinicians stated that they emphasize long-acting reversible contraception (LARC) for adolescent patients, both for their effectiveness and their perceptions that adolescents are less reliable and more likely to use short-acting methods [e.g., oral contraceptive pills (OCPs)] inconsistently. Clinicians expressed feeling “nervous” because of “non-compliance,” which they believed made OCPs an inadequate or less effective method of contraception for this population. One clinician reported actively dissuading patients from using OCPs, saying: “I try and tell them, ‘If you’re not somebody that can take this regularly and ideally at the same time every day, then even this isn’t the best for you’” (Private practice pediatrician). Some clinicians joked about the idea that OCPs were appropriate for adolescents:

Who’s gonna remind the child? Kids these days, they spend so much time on the phone. [Laughter] No, no, seriously. I have adolescents. You’re lucky if they clean their room. Forget remembering to take the pill. – Academic practice pediatrician

One clinician mentioned specifically “pushing” IUDs for adolescent patients at a younger age, even if the patient did not express a personal interest in that method, because they were concerned that the patient would not take OCPs regularly:

I’m pushing IUDs much, much more and much earlier. Just personally, for both of my children, I know that their girlfriends are on birth control pills, and I was like, “I really would encourage them to get IUDs. I know they’re on pills. I know you don’t wanna talk about this with me, but it just makes me super nervous.” Yeah, I’m definitely pushing the long-actings a lot more. In my case, that would be IUDs. – Private practice pediatrician

This same clinician noted that if a patient said they could not remember to take a medication everyday then “we don’t even need to talk about [OCPs].”

Few clinicians in our study recommended less invasive, non-LARC methods for adolescent patients. A private practice pediatrician noted that they would be “less inclined to recommend the IUD” if the patient was younger and had never had sex or a pelvic exam.

One clinician described tailoring contraceptive counseling discussions around a patient’s familial and socioeconomic circumstances to encourage patients to delay or prevent pregnancy:

It’s making sure that patients are able to live their lives and achieve what they can, especially with, for example, a low socioeconomic group and they are trying to break the poverty cycle… Say, ‘Listen, your mom did a good job raising you and everything, but you see how hard it is for her. You want – you deserve more, and you can do more, so let’s wait a little bit.’ – Private practice pediatrician

Another clinician described how they believe that a patient’s SES, race, and ethnicity may influence contraceptive decision-making, noting that they believe “inner-city” adolescents may not be candidates for certain contraceptive methods because they lack support from family members:

…the socioeconomics comes into consideration if the child is young and the mom is too busy. If she has two jobs or three jobs, she doesn’t have time or does not understand tracking the cycle and all that kind of stuff. Eventually, socioeconomic factors in. It’s not because ‘You’re inner-city poor. This is what you need.’ It’s just life and time and education level factors. – Academic practice pediatrician

When asked explicitly if they believe that their counseling differs depending on patient demographic characteristics, clinicians responded in three main ways: (1) some were conscious of their bias in specific situations (e.g., “I have a few trans male patients, and I think I might not be as great about asking them about contraception” – Indian Health Service clinic pediatrician), (2) others acknowledged unconscious bias that likely influenced their counseling (e.g., “I mean I’m sure I have some unconscious biases, like everyone else does, on different things. I don’t know exactly how that affects what I say…” – Academic practice pediatrician), and (3) others denied counseling patients differently, often describing a conscious effort to standardize contraceptive counseling across patient demographic groups in order to promote equity. For example, when asked whether patient characteristics influence their counseling, one clinician said:

Generally not. It is something I’m very conscious about. I spent ten years in an inner-city practice where almost all of my patients were Latinx and from Spanish-speaking households. My counseling is generally the same as—I perceive it to be the same as what I do now in a more mixed suburban setting. – Academic practice pediatrician

Option talk:

During option talk, clinicians should explore patient preferences and provide more information about each contraceptive method based on a patient’s stated contraceptive goals. Many clinicians in our study reported using a tiered-effectiveness model of sharing contraceptive options during counseling, highlighting the emphasis they place on method effectiveness at pregnancy prevention over other decision-making factors. One clinician described how they emphasize the efficacy of contraceptive methods with patients by stating: “You get three choices: you cannot have sex, you can use highly effective contraception, or you can be okay with getting pregnant. Those are your only choices.” (Indian Health Service clinic pediatrician) When the interviewer asked if they emphasized any particular methods, a private practice pediatrician responded, “Not really…I just explain what’s most effective.” This same clinician mentioned that although they emphasize the effectiveness of each method during counseling, they “try not to push” because “even if they choose something that’s not as effective, it’s better than them not doing anything, so I just try to make sure they have the information, and let them decide.”

Decision talk:

During decision talk, clinicians should engage in a personalized, bidirectional conversation with the patient to further elicit patient preferences and arrive at a decision. When helping patients make a final choice of contraceptive methods, clinicians in our study reported a number of factors that influenced final decision-making and what methods they were willing to recommend for adolescents. These are described below.

a). Guiding counseling conversations: “ask then explain” versus “explain then ask” approaches

The clinicians in this study described two main methods for guiding contraceptive counseling conversations with adolescents: 1) “explain then ask”, and 2) “ask then explain.” Clinicians using the “explain then ask” method reported describing a broad menu of contraceptive options available to the patient, including the clinician’s perceptions regarding the pros/cons and risks/benefits of each option, then asking the patient what they preferred to use, as outlined in the following quotes:

I just explain to them there’s the oral contraception, there’s the injections, implants and IUDs, and then get a feel for which area they’re more interested in. Then we talk more in-depth about whatever they’re more interested in. – Private practice pediatrician

I just started with giving them all the options. We don’t offer every option in our clinic per se, but we can always refer to somewhere that is able to do some of the other things. I just go through all the different options, the pros, the cons, the risk/benefit of each of them and then kind of let them—sometimes they wanna think about it for a little bit. Sometimes they know already what they want, so it’ll just go from there essentially. – Private practice pediatrician

Clinicians using the “ask then explain” method instead started by asking the patient to describe their goals and preferences for using contraception prior to providing information about contraceptive methods that may fit the patient’s needs. For example, a pediatrician in an academic practice described asking their patients:

Is there a contraceptive need? Is it around menstrual suppression or regulation? If we’re talking about it and then they bring it up, then I try to take the conversation forward based on what their interests are and then try to introduce other aspects to it, based on options available.

b). Emphasis on teen pregnancy prevention

Even if they didn’t state they counsel using tiered-effectiveness, many clinicians expressed prioritizing teen pregnancy prevention by promoting contraceptive use among sexually active adolescent patients, often without asking patients about their pregnancy or contraceptive desires. One clinician stating that their “number one goal is preventing pregnancy” (Private practice pediatrician). Another clinician stated that “decreasing the rate of teen pregnancy” was the most rewarding part of talking to adolescent patients about contraception (Pediatrician at a federally-qualified health center).

Some clinicians also described a preference for initiating contraceptive use in adolescent patients before they become sexually active to anticipatorily prevent pregnancy. A private practice pediatrician described a conversation with a patient’s parents in which they recommended that the patient begin contraception despite the patient not being sexually active for the implied purpose of preemptive pregnancy prevention:

‘Why do you think that they can’t have contraception right now?’ They’re like, ‘Oh, well, they’re just too young. They haven’t had sex.’ I’m like, ‘Well, you don’t wanna wait till you have sex to get contraception.’ – Private practice pediatrician

c). Influence of method accessibility on counseling

Many clinicians in our study indicated they were more likely to discuss or recommend contraceptive methods that they can personally provide to the patient. One clinician described feeling less equipped to offer comprehensive counseling about LARC since they are not available in their office:

Since none of us put them in, it’s harder to fully counsel on what that process is gonna be like. Again, they’re open to, ‘Maybe we can start with this and if… you decide you’re gonna be sexually active more often then you can revisit one of the longer-acting contraceptive methods’. – Private practice pediatrician

Additionally, another clinician (Indian Health Service clinic pediatrician) discussed perceiving that accessibility may influence adolescents’ preference for Nexplanon over IUD since “I can put in the Nexplanon that day if they want me to.”

d). Encouraging parental involvement

Many clinicians in our study mentioned navigating parental awareness or involvement in adolescent contraceptive decision-making in two ways: encouraging adolescents to involve their parent in decision-making or proactively ensuring confidentiality.

Although most clinicians described asking parents or guardians to step out of the clinic room during counseling, not all clinicians subsequently managed adolescents’ privacy and confidentiality in the same way. Some clinicians advocated for patients to engage in contraceptive decision-making conversations with their parents, especially if the decision seemed to cause the patient stress. One pediatrician in an academic practice described the following scenario:

It feels like a little sneaky when you have a kid in one room and the parent in the other and you’re trying to have the nurse quickly give this shot to the kid in the other room with their parent not finding out. I think it’s the best option in those situations… to feel out with the adolescent, if they haven’t talked to their parent, why is that, and what would a conversation with the parent look like and try to—because my general line to teens in situations where they’re having to make hard decisions is… most of us make better decisions when we can talk about it with other people.

Notably, the same clinician mentioned that “if I talk to a teen [and] they seem able to consent and make a reasonable decision, then I don’t push as much to talk to someone else about it.” This clinician implies that they would be more willing to accept a patient’s desire to maintain confidentiality if the patient demonstrated a certain maturity level. Furthermore, it is unclear what this clinician considers to be a “reasonable decision”.

e). Protecting privacy and confidentiality

Other clinicians reported proactively supporting patients in maintaining privacy when accessing and using contraception. Some clinicians described using a “cover story” with the patient’s parent or guardian, sharing that a patient was using contraception for a reason other than preventing pregnancy (e.g., menstrual regulation or suppression), regardless of the patient’s own reason for use. One private practice pediatrician explained:

…could we talk about this from a cycle regulation standpoint…’cause obviously if you didn’t include a parent in that [conversation] and not have to try to sneak that medication…from a kid’s standpoint, it just feels easier.

One clinician described providing methods free-of-charge to patients in an effort to reduce costs for patients who may not have financial support from their parent or guardian:

We had grant funding to stock Depo-Provera without cost to patients. We carried OCPs without cost to patients…Teens, they don’t have financial resources, so cost is a big deal and privacy is a big deal. – Academic practice pediatrician

Another clinician described referring patients to another clinic to access affordable out-of-pocket contraception without notifying their insurance provider:

How do we do this confidentially if you don’t really wanna tell your mom about this? Where can you get a $4 script, those kinds of nuances. – Private practice pediatrician

Additionally, one academic practice pediatrician explained that they take care to maintain confidentiality in clinic notes on the electronic medical record, stating that they “often obscure things in my note in a way where I’ll remember what that meant if I see it again, but the parents won’t understand.”

Discussion

Clinicians in our study demonstrated several patterns in contraceptive counseling with adolescents, which may facilitate or create barriers to high quality contraceptive care. Given that SDM has recently emerged as the gold standard for contraceptive counseling by national medical organizations but not the organization from which we recruited out subjects, we outline the ways in which participants’ counseling methods align with or diverge from the SDM model.^29,34 We share a summary of our associated recommendations to better incorporate the SDM framework into contraceptive counseling in Table 1.

Table 1:

Common pitfalls in adolescent contraceptive counseling and recommendations for engaging in shared decision-making elicited from self-reported counseling practices by adolescent-facing clinicians interviewed at the AAP Annual Meeting in Anaheim, CA, 2022

Component of SDM	Pitfall identified through clinician interviews	Recommendation
Choice talk	Sociodemographic characteristics driving counseling (age, SES)	Offer standardized contraceptive counseling to all adolescent patients, including standardized language to present options and use of developmentally tailored contraceptive decision aids; Universal screening for possible contraceptive desire outside of clinician perception
Option talk	Reliance on tiered effectiveness model	Provide additional information regarding all forms of contraception, not limited to a clinician’s preference of method choice
Decision talk	Guiding counseling conversations: “ask then explain” versus “explain then ask” approaches	Explore patient’s goals and preferences using open-ended questions such as “what matters to you?”
	Emphasis on teen pregnancy prevention	Do not assume that an adolescent patient’s first priority in using contraception is to prevent pregnancy or that adolescent patients should prioritize this; rather, elicit the patient’s individual goals and preferences.
	Parental involvement in decision-making and patient confidentiality (i.e. not asking patients about their preference for confidentiality or disregarding a patient’s desire to maintain confidentiality in contraceptive decision-making)	Determine privately if and to what extent the adolescent wants parent to be involved in decision-making, using a cover story or other confidential documentation and billing, if necessary to respect a patient’s confidentiality
	Influence of method accessibility on counseling	Allow patients to seek the contraceptive method that best aligns with their goals and preferences, including those that would require a referral to receive

Choice talk:

In the first phase of the SDM model (“choice talk”), clinicians are expected to provide all patients with the same information about contraceptive options in a manner that clearly conveys that a choice exists.²¹ In our study, we found that many clinicians’ cognitions and behaviors may shape how they present contraceptive options to certain patients, which diverges from SDM.

Though several clinicians in our study explicitly stated that sociodemographic characteristics did not drive their counseling, we found that many clinicians determined when, how, and with whom to initiate contraceptive counseling conversations based on sociodemographic characteristics such as age, SES, and perceived maturity level. While some clinicians might believe that they were engaging in person-centered care by targeting their recommendations to a patient’s perceived contraceptive needs, our study suggests that many of these judgments were made based on clinicians’ a priori assumptions, rather than a patient’s expressed preferences. We found that when clinicians exhibited these biases, they subsequently emphasized or de-emphasized certain contraceptive methods (e.g., utilizing tiered-effectiveness to “push” LARC given concerns that the patient will be noncompliant with short-acting methods, or to break the “poverty cycle” associated with teen childbearing), thus diverging from the choice talk and option talk components of SDM.

Increasing clinician confidence and competence with standardized messaging of all contraceptive options with all patients may be one way to support clinicians’ provision of SDM. Increased awareness of adolescent-focused and co-developed decision aids to support patients in choosing contraceptive methods that fit their reproductive health needs during choice talk may be helpful as none of the participants in our study discussed their availability.^19,35–39 Trainings exist to educate clinicians in person-centered contraceptive counseling, and help them understand and redress the explicit and implicit biases that may shape their approach to contraceptive counseling, such as adultism (e.g., perceptions that adolescents are irresponsible and impulsive), and classism -- all of which were demonstrated by clinicians in our study. In addition to acknowledging and addressing biases, clinicians must also approach counseling with structural competency – a framework used to “recognize, analyze, and intervene upon the structural factors that impact health disparities”.³⁵ Without reflection and active assessment of the factors that influence choice talk, clinicians may not be aware that these social factors are driving their counseling practices, which can potentially reduce patient autonomy and reproductive health equity.

Option talk:

During option talk, it is recommended that clinicians provide more detailed information about all contraceptive method options, even if contrary to the clinician’s preference for efficacy. Many clinicians in our study expressed a bias toward protecting adolescents from pregnancy and a subsequent preference for promoting highly effective forms of contraception. This messaging mirrors the family planning objectives of Healthy People 2030, which references a narrow focus on teen pregnancy prevention, delaying sexual debut, use of effective birth control, and improved access to formal sex education.⁴⁰ When enacted by individual clinicians, this emphasis may inhibit patients’ ability to obtain comprehensive information regarding all contraceptive methods, thus diverging from the option talk component of SDM.

Though we did not assess patient experiences in this study, limiting the presentation of contraceptive options has the potential to contribute to contraceptive coercion, undermine a patient’s willingness and ability to discuss contraception with their provider, exacerbate disparities in contraceptive use, and increase medical mistrust.^41,42 By contrast, person-centered contraceptive care through authentic shared decision-making can increase preferred contraceptive method use, which is associated with significantly higher method satisfaction (10% increase) and more consistent method use (20% increase) compared to use of a non-preferred method.^{26,31,43–46} Furthermore, person-centered contraceptive care also increases patient autonomy and ability to use a preferred contraceptive method.

Decision talk:

Finally, it is recommended that clinicians gather information regarding a patient’s goals and preferences during the third phase of SDM, decision talk, through the use of open-ended questions.³² This final component of SDM involves a unique, bidirectional conversation between the patient and clinician after presenting choices and understanding a patient’s preferences for the options. As previously discussed, clinicians may limit a truly bidirectional, unbiased, supportive conversation due to framing choice talk and option talk through biases related to sociodemographic characteristics and the use of tiered-effectiveness counseling. Scholars have previously described interactions in which clinicians inserted their own preferences and goals into patient interactions, while asserting that patients have autonomy to decide which contraceptive method they use, also known as “agency-without-choice.”⁴⁷ With this phenomenon, clinicians believe that they are providing patient-centered care by allowing adolescents to choose a contraceptive method after explaining a list of options as outlined in choice and option talk. However, many clinicians in our study admitted to “pushing” or emphasizing certain methods that they believed were best for patients during decision talk, potentially superimposing their own preferences based on their beliefs about what is appropriate for a patient even before option talk was elicited.

Some clinicians in our study reported counseling techniques aligned with this aspect of the SDM model, including those who adopted an “ask then explain” approach in which they targeted the contraceptive discussion according to a patient’s values and interests. A systematic review reported a variety of factors influencing adolescents’ contraceptive decision-making, though privacy and autonomy are overarching themes.⁴⁸ One way in which participants’ behaviors aligned with appropriate decision talk was prioritizing confidential care as mandated by state-by-state minor consent laws and best practices by national organizations like the AAP.⁴⁹ Some clinicians reported doing this by using confidential documentation, utilizing confidential or alternative billing, and employing a cover story when needed if discussing contraception initiation with parents. Thus, making time to speak privately with adolescents to understand the influences of familial relationships in each patient’s contraceptive decision-making path was an important way that clinicians stated that they created a safe and open space for patient-specific, personalized decision talk in our study.

Some clinicians reported tailoring decision talk according to what contraception methods are available in their clinic. Accessibility-driven contraceptive counseling is non-comprehensive and therefore contradictory to a patient-driven decision-making process. In this manner, the decision talk phase was shaped by what they themselves can provide (as opposed to all options available including through referrals).⁵⁰

Limitations:

This study has limitations. We draw on data from a convenience sample of pediatric clinicians to support our claims, which may lead to selection bias. Our recruitment approach relied on clinicians being willing to be interviewed about contraceptive counseling practices; therefore, it is possible that we may have skewed our sample towards those interested in discussing or learning about contraceptive counseling. Although the clinicians included in our study represented a wide variety of professional backgrounds and settings, these findings may not reflect the experiences and practice of all pediatric clinicians. Furthermore, we cannot comment on the demographic make-up of our study population as we elected not to collect any information about the participants in order to lower the barrier to participation in case any clinicians were worried about their identities being revealed given the current sociopolitical climate around sexual and reproductive health.

Conclusion:

We found that clinicians in our study frequently utilized non-patient-centered techniques to shape the contraceptive counseling they provided adolescents, including using tiered-effectiveness counseling, pregnancy prevention frameworks, assessments of appropriateness of contraception use based on sociodemographic factors, and counseling based on clinical accessibility of contraception. However, several clinicians did use techniques that align with best practices for SDM, such as providing standardized language to support information provision of all contraceptive options, eliciting patient goals and values, and creating safe spaces for decision-making (e.g., prioritizing privacy and confidentiality). The findings of our study can inform educational innovation and practice changes to support clinicians in providing high-quality, affirming, inclusive contraceptive counseling with adolescent patients, especially through understanding, overcoming, and reducing the influences of their personal biases.