Presence and Knowledge of Minor Consent Laws and STI testing in US Adolescents

Abstract

Objective:

To evaluate whether adolescents’ legal capacity to consent independently to sexually transmitted infection (STI) and/or HIV services, and accurate knowledge of their ability, are positively associated with past-year STI/HIV testing.

Methods:

Adolescents (N=5888; ages 13–17 years) from all 50 US states and DC completed an online survey about minor consent laws and STI/HIV services. Legal capacity to consent independently to STI/HIV services was established using existing policy data. Youth were asked which STI/HIV services they could receive without guardian permission in their state, and whether they had been tested for HIV and STI in the past year. We used generalized linear models to calculate odds ratios (ORs) and 95% confidence intervals (CIs) to estimate associations between legal capacity to consent, accurate knowledge of legal capacity, and STI/HIV testing behavior.

Results:

Ability to consent independently to STI services was positively associated with past-year STI testing (aOR=1.19, 95% CI: 1.10–1.72). Similarly, ability to consent independently to HIV services was positively associated with past-year HIV testing (aOR=1.25, 95% CI: 1.02–1.53). Accurate knowledge of legal capacity to consent independently to STI and HIV testing was positively associated with past-year STI and HIV testing, respectively (aOR=2.81, 95% CI: 2.01, 3.36; aOR=2.19, 95% CI: 1.78, 2.92).

Conclusion:

Given the relative magnitude of the associations, adolescents’ accurate knowledge of minor consent laws may be more important to their STI/HIV testing than the laws themselves. Ensuring that adolescents know about their ability to consent independently to STI/HIV services may increase adolescent STI/HIV service use.

Article Summary:

Adolescents testing for STI/HIV was associated with knowledge of their legal capacity to independently consent for services.

Introduction

Compared to older adults, adolescents and young adults ages 13 to 24 years in the United States (US) have disproportionately high rates of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV).^1–3 Increasing STI/HIV testing has been integral to the national strategy to decrease STI/HIV rates among US adolescents.⁴ Yet, adolescent STI/HIV testing rates remain lower than Healthy People 2030 goals.^5,6

Confidentiality concerns are a significant barrier to accessing sexual health care for adolescents. Indeed, 45% of adolescents who report having sex report not testing for STIs due to confidentiality concerns⁷ and 23% state they would not seek sexual health care because their guardian might find out.⁸ Minor consent laws that allow adolescents to consent to STI/HIV services without the involvement of their guardian are meant to address these confidentiality concerns and facilitate testing uptake.^9,10

Minor consent laws vary in scope and can be categorized as allowing minors to consent independently to STI or HIV testing, treatment, or prevention services (e.g., human papillomavirus infection [HPV] vaccination, pre-exposure prophylaxis [PrEP] for HIV). At the time of this study, all states and DC had laws in effect that allowed minors to consent independently to testing and treatment for HIV and at least some STIs, subject to differing age limits (e.g., any age, ≥12 years).^9,11 It is important to note that the scope of medical care covered by minor consent laws varies by state, some laws apply to all medical care while other laws specifically allow independent consent to services for selected STIs (e.g., Texas Family Code §32.003 allows minors to consent independently to diagnosis and treatment only of reportable diseases), all STIs, and/or HIV.^9,12 Only 32 jurisdictions allowed minors to consent independently to any STI prevention services, and 33 allowed minors to consent independently to HIV prevention services.^9,11 Recently, several states have rescinded these permissions via the passage of parental rights laws¹³ and lawsuits that challenge minors’ ability to consent independently to STI/HIV services delivered through Title X program grants are ongoing.^14,15

Research evaluating whether minor consent laws increase adolescent use of STI/HIV services has been mixed and primarily focused on HIV testing and treatment.^16–21 Some studies report a positive association between legal capacity to independently consent and testing and some studies report no association.^16–21 These mixed results may be due to variations in legal coding.⁹ Further, adolescent and provider knowledge of minor consent laws is often low.^16,22,23 Yet research has not assessed how adolescents’ knowledge of minor consent laws relates to their use of STI/HIV services.

To address these gaps, we used legal epidemiological data about minor consent laws^9,11 and data from the Inclusive Care and Access to Resources for Everyone (iCARE) survey to examine associations between adolescents’ legal capacity to consent independently to STI/HIV services, their knowledge of that capacity, and STI/HIV testing. Findings can inform intervention options to maximize the utility of these laws and increase adolescent STI/HIV testing.

Methods

iCARE survey

Participants were primarily recruited through advertisements on Instagram and Facebook between December 2022 and April 2024. We additionally asked youth-focused community-based organizations to share recruitment materials on their social media accounts in states with slower recruitment rates (e.g., Alaska). Eligible participants were 13–17 years old, living in the US, able to complete an online survey in English, and able to complete a capacity to assent assessment.^24,25 Eligible participants then provided informed assent. The protocol, including a waiver of guardian consent, was approved by the Boston University Medical Campus Institutional Review Board. Given our intention to examine the impact of laws at the state level and to have sufficient power to detect interaction terms with small-medium effects, we aimed to recruit 120 participants from each state and DC.

To improve generalizability and reduce self-selection bias due to interest in the study topic, advertisements did not mention the focus of the study and instead made general references (e.g., ‘making a difference’). Advertisements were initially targeted by age and gender, as well as state for states with slower recruitment rates. We endeavored to recruit at least 50% racial/ethnic, 20% sexual, and 10% gender minoritized youth. To promote these targets, some advertisements mentioned specific racial or ethnic groups (e.g., “Calling all Black and African American teens”). During the field period, Meta restricted targeting by gender for youth <18 years of age. In response, we designed advertisements with imagery that our youth advisory board felt might particularly appeal to cisgender boys, who were underrepresented in our sample (e.g., general images or graphics of adolescent boys hanging out and images related to sports, video games, and cars).

We enacted a standard protocol to detect fraudulent responses. Valid responses needed: a non-duplicated email address and phone number; alignment between age reported in the screener and date of birth reported in the survey; a zip code consistent with the state reported; a survey completion time ≥7 minutes; and a low-risk, US-based IP address according to scamalytics.com. Surveys that did not meet these criteria were flagged. These respondents were contacted via text message and email to confirm their information. Those who did not respond or provided incorrect information were excluded. Participants who completed the survey and whose responses were deemed valid received $15, which could be redeemed as an Amazon gift card, a donation to one of four pre-specified charities, or waived.

Figure 1 describes recruitment and enrollment, from initial click to the final analytic sample. Of 12,427 completed surveys, 53% (6,539) were excluded during validity checks, resulting in a final analytic sample of 5,888 adolescents.

Figure 1: iCARE study flow diagram from initial click to final sample of US minor adolescents recruited online December 2022 – April 2024.

Note: Percentages are calculated based upon the sample size in the box above.

Measures

Demographics

Participants self-reported their birthdate (used to calculate age), sex, gender, sexual orientation, race, ethnicity, 5-digit ZIP code of residence (used to determine urbanicity,²⁶ state, and county of residence), and type of health insurance coverage (i.e., public, private, unsure, no insurance). We used publicly available data to assign county-level poverty density²⁷ and state-level HIV density²⁸ based on participant zip code.

We report race and ethnicity because racial and ethnic minoritized youth are disproportionately burdened by STI and HIVs in the US^29,30 due to the deleterious effects of racism and histories of exclusion, mistreatment, and exploitation. Race was assessed using categories required by the National Institutes of Health. Ethnicity was assessed with the question “Are you of Spanish or Latinx origin, such as Latin American, Mexican, Puerto Rican, or Cuban?”

Minor consent capacity and knowledge

Each participant’s legal capacity to consent independently to STI/HIV services was determined using an existing dataset of minor consent laws¹¹ that was updated to cover the survey period (December 2022-April 2024). These laws were combined with participants’ age, state of residence, and date of survey completion (to account for laws that changed during data collection). We collapsed these nuances to capture whether a minor resided in a state where they could independently consent to STI/HIV testing, treatment, and/or prevention services at the time of the survey, at their specific age.

Each participant’s knowledge of minor consent laws was assessed using the question: “In your state, which of the following sexual health services would require you to get your caregivers’ permission?” We asked participants about six services: 1) Getting tested for HIV, 2) Getting treated for HIV, 3) Getting care to prevent HIV, 4) Getting tested for STIs, 5) Getting treated for STIs, and 6) Getting the HPV vaccine. Response options included: “Caregiver permission is required,” “Caregiver permission is NOT required,” “I do not know,” and “Do not want to answer.” Caregivers were defined as “people who do things like sign permission slips for school or take care of you in an emergency. This could be a parent, a guardian or someone else.”

Participants who reported “Caregiver permission is required” or “Caregiver permission is NOT required” for at least one of the six items were asked how they learned about their state’s laws. Response options were: 1) Caregivers, 2) Friends or other teens, 3) School, 4) Healthcare providers, 5) Social media, 6) I looked it up online before taking the survey, 7) I looked it up online during the survey, 8) I guessed, and 9) Somewhere else.

HIV and STI testing

We asked participants if they had ever received an HIV test and, separately, a test for any STI other than HIV. Those who responded yes were asked when their most recent test was. We created binary variables indicating past-year HIV or STI testing.

Analysis

We descriptively assessed the proportions of participants with legal capacity to consent independently to STI/HIV testing, treatment, and prevention services. We also assessed the proportion of participants with accurate knowledge about whether they needed guardian permission to receive each of the six services in their state. We further reported the proportions of participants who inaccurately believed that guardian permission was required (when it was not), and participants who inaccurately believed that guardian permission was not required (when it was). For unadjusted proportions, those who responded that they did not want to answer (<1% of the sample) were removed from the denominator.

We used a series of generalized linear models (GLMs) to evaluate associations. First, we examined the association between having versus lacking legal capacity to consent to the full spectrum of services (prevention, diagnosis, treatment) for any STI, and for HIV.. We made this choice to introduce variability: Almost all participants had the legal capacity to consent independently to STI/HIV testing and treatment but differed in their ability to consent independently to prevention services.

We then examined associations between youths’ accurate knowledge of their legal capacity to consent to STI/HIV testing (compared with inaccurate and ‘Don’t know’ responses) and receiving a past-year HIV or STI test.

Next, in the subsample of participants who reported knowing the law in their state (i.e., responded that “Caregiver permission is required” or “Caregiver permission is NOT required” to at least one of the six items related to STI/HIV services), we examined whether associations between accurate knowledge of ability to independently consent to STI or HIV testing and STI/HIV testing outcomes were moderated by knowledge source: (1) those who said “I guessed” versus those who identified a specific source of their knowledge and (2) those who indicated their knowledge source was healthcare providers/school versus an online source versus family/friends.

Main effect and moderator models were adjusted for age (continuous), gender (cisgender girl, cisgender boy, multiple identities, or another gender identity), sexual orientation (heterosexual, bisexual, gay/lesbian, multiple identities, another identity or unknown/questioning), insurance status (public, private, none, other or unknown), poverty density (county level), and HIV density (state level, only for the HIV testing outcome). All analyses were conducted in R 12.1 with significance level set at 0.05 a priori. GLMs use a likelihood-based approach to estimation, thus making use of all available data without directly imputing missing responses. Adjusted proportions and odds ratios are presented.

Results

The survey took 25 minutes on average to complete (SD=16). As shown in Table 1, mean participant age was 16 years (SD=1.1). Although we did not recruit 120 participants in each state, we had at least 50 participants from every state and DC and ≥120 participants in 39 states. Most participants (77%) lived in a metropolitan area. Almost half (47%) were racial/ethnic minoritized youth. Most (72%) were sexual minoritized youth and 34% gender minoritized youth. Eight percent reported past-year STI testing while 7% reported past-year HIV testing.

Table 1.

Sociodemographic Characteristics of US minor adolescents recruited online December 2022 – April 2024 (N=5,888).

	N=5,888
Age, years	15.88(1.12), Range 13–17
Sex
Female	4,432(75.3%)
Male	1,426(24.2%)
Intersex	11(0.2%)
Do Not Want to Answer	19(0.3%)
Sexual Identity
Heterosexual	1,670(28.4%)
Multiple Identities	1,250(21.2%)
Bisexual	1,121(19.0%)
Pan/Omnisexual	497(8.4%)
Gay	345(5.9%)
Lesbian	261(4.4%)
Questioning/Unsure	237(4.0%)
Queer	213(3.6%)
Asexual	135(2.3%)
Another Sexual Identity	53(0.9%)
Demisexual	27(0.5%)
I don’t understand the question	44(0.7%)
Do not want to answer	35(0.6%)
Gender Identity
Cisgender girl	2,705(45.9%)
Cisgender boy	1,191(20.2%)
Multiple Gender Identities	839(14.2%)
Transgender boy	367(6.2%)
Non-binary	292(5.0%)
Genderqueer	89(1.5%)
Genderfluid	161(2.7%)
Questioning/Unsure	118(2.0%)
Another Gender Identity	63(1.1%)
Transgender girl	16(0.8%)
Pangender	6(0.1%)
Do not want to answer	11(0.2%)
Grade
Before 8th	304(5.2%)
8th Grade	757(12.9%)
9th Grade	1,268(21.5%)
10th Grade	1,816(30.8%)
11th Grade	1,350(22.9%)
12th Grade	247(4.2%)
GED	37(0.6%)
At least one year of college	74(1.3%)
Do not want to answer	35(0.6%)
Type of School
Public, Non-charter	3,899(66.2%)
Public, Charter	798(13.6)
Private	504(8.6%)
Homeschooled	224(3.8%)
Online Public	159(2.7%)
Online Private	124(2.1%)
Not enrolled	47(0.8%)
Do Not Know	115(2.0%)
Do not want to answer	18(0.3%)
Urbanicity
Metropolitan	4,559(77.4%)
Micropolitan	692(11.8%)
Small Town	296(5.0%)
Rural	309(5.3%)
Missing Zip Code	32(0.5%)
Ethnicity, Hispanic or Latinx Origin
Yes	1,217(20.7%)
No	4,619(78.4%)
Do not want to answer	52(0.9%)
Race*
American Indian/Alaska Native	361(6.1%)
Asian	416(7.1%)
Black or African American	1,006(17.1%)
White	4,241(72.0%)
Native Hawaiian or Other Pacific Islander	125(2.1%)
Another Race	503(8.5%)
Do not want to answer	110(1.9%)

^*multiple responses allowable, can sum >100%

Virtually all participants (99.7%) lived in jurisdictions where they had the legal capacity to consent independently to testing and treatment for most STIs and HIV. The 16 participants who lacked capacity were below the age of consent in their state. Two thirds (66%) could consent independently to STI prevention services and 71% could consent independently to HIV prevention services in their state. Participants who could consent independently to STI services were more likely to report past-year STI testing (adjusted proportion 11.0% vs. 9.4%; adjusted odds ratio [aOR]=1.19, 95% confidence interval [CI]: 1.10–1.72). Those who could consent independently to HIV services were more likely to report past-year HIV testing (9.9% vs. 8.1%; aOR=1.25, 95% CI: 1.02–1.53).

Most participants reported that they did not know if they had the legal capacity to consent independently to STI/HIV services in their state (57–63% depending on the type of service, Figure 2). Among those who reported knowing the law in their state (i.e., responded that “Caregiver permission is required” or “Caregiver permission is NOT required”), accurate knowledge was more common than inaccurate knowledge. Most participants who had inaccurate knowledge believed they needed guardian permission when they did not (63%-99%, Figure 3). Of those who reported knowing the law in their state, about half (47%) said they guessed (full range of options presented in Figure 4).

Figure 2: Accurate knowledge of legal capacity to consent independently to HIV/STI services among US minor adolescents recruited online December 2022 – April 2024.

Abbreviations: human immunodeficiency virus (HIV); sexually transmitted infection (STI); Human Papillomavirus (HPV).

Figure 3: Direction of the error among those with inaccurate knowledge of legal capacity to consent independently to STI/HIV services among US minor adolescents recruited online December 2022 – April 2024.

Abbreviations: human immunodeficiency virus (HIV); sexually transmitted infection (STI); Note: “STI prevention’ refers to the HPV vaccine.

Figure 4:

Source of information about legal capacity to consent independently to STI/HIV services among US minor adolescents recruited online December 2022 – April 2024 who reported knowing their legal capacity.

Compared to those with inaccurate knowledge or ‘Don’t know’ responses, participants with accurate knowledge of their ability to independently consent to STI testing had higher odds of a past-year STI test (19.7% vs. 9.4%; aOR=2.81, 95% CI: 2.01–3.36). Similarly, participants with accurate knowledge of their ability to independently consent to HIV testing were more likely to have a past-year HIV test (18.5% vs. 10.1%; aOR=2.19, 95% CI: 1.78–2.92). It is noteworthy that the relative odds and 95% confidence intervals for both associations are higher than those assessing associations between simply having the legal capacity to consent and testing.

In our moderation analyses (Figures 5 and 6), results indicate that the association between accurate knowledge (vs. inaccurate knowledge or ‘Don’t know’) and past-year HIV testing was weaker for those who guessed their response (22.0% vs. 12.0%; aOR=2.20, 95% CI: 1.38–2.96) compared to the association among those who identified a specific source of their knowledge (10.1% vs. 3.1%; aOR= 3.21, 95% CI: 1.25–8.18). Further, associations between accurate knowledge (vs. inaccurate knowledge or ‘Don’t know’) and HIV testing were strongest when participants learned about laws from their school or healthcare providers (25.8% vs. 12.9%; aOR=2.79, 95% CI: 1.50–5.18) or online sources (20.1% vs. 11.0%; aOR=1.68, 95% CI: 1.09–2.87). A similar pattern was seen for STI testing.

Figure 5. Guessing versus having a specific knowledge source as a moderator of the association between accuracy of knowledge and STI/HIV testing outcomes among US minor adolescents recruited online December 2022 – April 2024.

Note: Odds ratios represent results from moderation models and compare the effects of accurate vs. inaccurate knowledge on testing outcomes conditional on guessing versus identifying a specific source for their knowledge.

Figure 6. Source of knowledge as a moderator of the association between accurate knowledge and STI/HIV testing outcomes among US minor adolescents recruited online December 2022 – April 2024.

Note: Odds ratios represent results from moderation models and compare the effects of accurate vs. inaccurate knowledge on testing outcomes conditional on source of information.

Discussion

In this large, geographically diverse sample of US adolescents ages 13–17 years, we found that participants who had the legal capacity to consent independently to the full spectrum of services (i.e., testing, treatment, and prevention) for any STI, and for HIV, were more likely to report past-year STI or HIV testing compared to those who could not consent independently. This association suggests that laws enabling access to prevention services may also be important for increasing STI and HIV testing among adolescents.

Further, unlike prior studies, we explicitly asked adolescents about their knowledge of minor consent laws. Most adolescents in our sample reported that they did not know if they had the legal capacity to consent to STI/HIV services without their guardian’s permission in their state; only a third reported accurate knowledge. Among those who reported knowing whether they could or could not independently consent, almost half reported guessing. Importantly, accurate knowledge of ability to independently consent was strongly associated with past-year testing. Indeed, these associations were stronger than those observed when simply assessing relations between legal capacity to independently consent and testing. This is a substantial advance in our understanding of how minor consent laws relate to adolescent use of STI and HIV services: Adolescent knowledge of their ability to independently consent may be an influential factor.

Additionally, the association between accurate knowledge and testing was strongest when participants reported a source of their knowledge (as opposed to guessing) and when that identified source was school or a healthcare provider (as opposed to online or from family/friends). Further research should assess whether disseminating information about minor consent laws in different environments (e.g., schools, online) affects adolescent knowledge of the laws and, ultimately, STI/HIV service use. Additionally, healthcare organizations who care for minors, including clinicians and staff, should learn about the minor consent laws in their state and disseminate that information to the minors they serve.

Our study has many strengths. To our knowledge, this is the largest study on minor consent laws to have been conducted and uniquely included a sample with at least 50 adolescents in every state and DC. Further, we determined the legal capacity of participants using a contemporary, comprehensive database of state-specific minor consent laws designed for research purposes.¹¹ We also asked participants about their knowledge of minor consent laws and assessed the relationship between knowledge and utilization of services.

Nonetheless, our findings should be interpreted within important limitations. We collapsed several sources of variation across the state laws. Further we did not address any legal conditions, other than age, or payor considerations that may impact minors’ decision to independently seek STI/HIV testing. Although we conducted rigorous checks to ensure response validity, and excluded probable fraudulent responses, we cannot guarantee the accuracy of every response. It is also possible that participants misremembered the timing of their STI or HIV test. Additionally, because we recruited our sample via social media, it is possible that our sample is not generalizable to youth not on social media. It is also possible that youth who are knowledgeable about the laws or use sexual health services would be more interested in taking a survey about these topics. Additionally, most of the sample identified as female, sexual minoritized, gender minoritized, and/or from a metropolitan area, potentially further limiting generalizability. We also required participants to be able to complete the survey in English. Per federal estimates only 5% of children ages 5–17 years report difficulty speaking English,³¹ suggesting that this inclusion criteria likely did not have a large impact on generalizability. That said, our results may not extend to adolescents who do not feel comfortable responding to a survey in English. Finally, due to the cross-sectional nature of the data, it is possible that adolescents who sought testing learned about their rights through those experiences. That said, only a third of the participants who had knowledge of the laws and got tested for STIs or HIV reported that they learned about the laws from their healthcare provider, indicating that most adolescents in our sample who tested learned about the law outside of healthcare interactions.

Conclusion

Using one of the most comprehensive minor consent studies to date, findings suggest that adolescents’ past-year STI and HIV testing is associated with their legal capacity to consent independently to STI/HIV services, and to their accurate knowledge about this capacity. Our results suggest that increasing adolescent use of STI or HIV services may require not just the passage of laws enabling minors to independently consent to these services but also concerted efforts to increase their awareness of these laws. With adolescents shouldering a persistently high burden of STIs and HIV, policymakers who pass minor consent laws, health care organizations that rely upon them, and clinicians who treat minors should take every action to increase access to care, including protecting and advancing minors’ ability to consent independently to vital STI/HIV services and disseminating information about these laws to the minors they serve.

What’s Known on This Subject

Until recently, all 50 states and DC had laws that enable minors to access most STI and HIV services without guardian consent. The effectiveness of these laws in terms of increasing adolescent STI and HIV testing rates remains unclear.

What This Study Adds

Adolescents’ recent STI/HIV testing was associated with their legal capacity to consent independently to STI/HIV services, and with their accurate knowledge of capacity to consent without guardian involvement.

Abbreviations:

aOR

Adjusted Odds Ratio

CDC

Centers for Disease Control and Prevention

CI

Confidence Interval

DC

District of Columbia

GLMs

Generalized Linear Models

HIV

human immunodeficiency virus

HPV

human papillomavirus infection

iCARE

Inclusive Care and Access to Resources for Everyone

OR

Odds Ratio

PrEP

pre-exposure prophylaxis

STI

sexually transmitted infections

SD

Standard Deviation

US

United States

Data Sharing Statement:

Deidentified, limited datasets of individual participant data (including data dictionaries) will be made available upon publication to researchers who provide a methodologically sound proposal for use in achieving the goals of the approved proposal. Proposals should be submitted to knel@bu.edu.