Protecting and Promoting Adolescent Health: A Public Health of Consequence, March 2023

This issue of AJPH presents information on interventions and policies related to two critical determinants of adolescent health and well-being: dating- and relationship-based violence and access to abortion care. Adolescence and young adulthood—roughly ages 15 to 24 years—is marked by cognitive, biological, emotional, and psychosocial development. Successful and healthy development across these domains is foundational for transitioning into healthy adulthood. However, widespread inequities in access to quality education, housing and food security, and culturally and developmentally appropriate health care services, as well as living in unsafe family, peer, or neighborhood environments can disrupt healthy development during this period. Additionally, experiences of dating violence or unintended pregnancy and their associated physical and mental health burdens can undermine successful transition into adulthood. Findings presented in this issue of AJPH on dating violence prevention and access to abortion care for adolescents can inform future policy and practice to protect adolescent health and well-being and ultimately promote successful transition into healthy adulthood.

PREVENTING ADOLESCENT DATING VIOLENCE

The prevalence of dating and relationship violence (DRV) among adolescents and young adults varies across national surveys and local studies because of differences in methodology, sampling, recruitment, definition of DRV, and fear and stigma associated with disclosure. Despite these differences, one thing is clear: DRV is highly prevalent in the United States. Findings from the Centers for Disease Control and Prevention’s 2019 Youth Risk Behavior Survey indicate that 1 in 8 high school students in a relationship in the past year experienced physical violence and that 1 in 12 experienced sexual dating violence. Estimates for both were higher among female as well as lesbian, gay, bisexual, transgender or transexual, and queer (LGBTQ+) high school students. The 2016–2017 National Intimate Partner and Sexual Violence Survey found that 27.1% of female and 21.4% of male respondents experienced sexual or physical violence or stalking by an intimate partner before they were 18 years old.¹ Growing evidence points to cyberdating violence—improper use of social media and technology to harass, control, and abuse dating partners—as having similar harmful effects as in-person dating violence (https://bit.ly/3uYk5vt).

Preventing adolescent dating violence requires effective interventions that can be delivered widely during the preadolescent years. To this end, Farmer et al. (p. 320) conducted a meta-analysis of school-based interventions targeting DRV and gender-based violence (GBV). Included interventions had a stronger impact on reducing DRV than GBV, and intervention influences on attitude and knowledge were short term. Consequently, school-based interventions ought to be considered as one component of a broader range of preventive actions that weaken social acceptance of DRV and GBV.

ENSURING ACCESS TO SAFE ABORTION CARE

In 1979, the US Supreme Court ruled in Bellotti v. Baird that a Massachusetts statute requiring minors younger than 18 years to obtain parental consent to have an abortion was unconstitutional. The court held that parents could not have absolute veto power over a minor’s decision to have an abortion and that all minors, as long as they were deemed mature and fully competent to make the decision, had a right to seek judicial authorization for an abortion.

Currently, 36 US states mandate parental involvement in the form of parental consent from one or both parents before an abortion can be performed or parental notification by the medical provider 24 to 48 hours before the abortion (https://bit.ly/2HsVlE1). In 35 states where abortion care is still legal but parental involvement is mandated, seeking judicial bypass as ruled in Bellotti v. Baird is available but requires overcoming significant hurdles. Most often, these barriers include lack of knowledge of the judicial bypass process and lack of availability of legal support to navigate the judicial system that lead to delays in abortion care seeking, increase associated costs, and limit the type of care available (https://bit.ly/3Qbc5kt).

With the Supreme Court decision in Dobbs v. Jackson Women’s Health Organization (2022) overturning the landmark decision in Roe v. Wade (1973), minors’ ability to obtain abortion care significantly worsened. Stevenson and Coleman-Minahan (p. 316) provide data that sheds light on minors who are forced to travel from states that have newly banned abortion care as a result of the Dobbs decision to states that do not have such bans but do require the adolescent to obtain judicial bypass of parental involvement. Their findings reveal that Florida denied judicial bypass petitions at higher rates during 2020 to 2021 than in previous years. The harmful short- and long-term socioeconomic² and health and well-being outcomes for both adolescents denied judicial bypass and their offspring are well documented (https://bit.ly/3GB8Zn0).

Additionally, Stevenson and Coleman-Minahan offer two key metrics for tracking the burden on minors of parental involvement laws: judicial bypasses granted among minors obtaining an abortion and proportion of bypass denials among all bypasses sought. Providing such information is critical—without it, we lack information and evidence on the population-level burden of parental involvement laws on abortion care among minors. In addition, we lack information on how bypass denials are shaped by subjective judicial opinions on maturity or competence and whether and how these opinions differ for different groups of minors.

PROMOTING A HEALTHY ADOLESCENCE

Shifting the social and cultural norms that enable adolescent dating violence requires family-, community-, and structural-level interventions to bolster the impact of school-based interventions. By moving beyond individual-based interventions, we can shift our attention to policies and practices that change the contexts, structures, and systems that allow acceptance of adolescent dating violence and likely achieve long-term success. For example, equally necessary are intervening in school- and university-based policies on handling DRV and GBV, strengthening the ability of those who have experienced DRV or GBV to take criminal and legal action, providing appropriate counseling services and mental health care, and advocating efforts to support adolescents and young adults who have experienced DRV or GBV.

Additionally, dating violence intervention efforts need to be culturally relevant and appropriate for racially and ethnically diverse youths and LGBTQ+ youths. To achieve this goal, and as described by De La Rue, DRV interventions require an intersectional approach that addresses racial-, gender-, and sexual orientation-based discrimination to address the lived realities that adolescents and young adults navigate to have safe and healthy realtionships.³

Protecting the autonomy of minors to determine whether to continue or discontinue a pregnancy, as decided in Bellotti v Baird, is in line with the reproductive justice framework. As the landscape of abortion care shifts across the United States, we can look to past programs that have successfully assisted minors seeking confidential abortion care. For example, between 2013 and 2022—when parental involvement was still mandated in Illinois—the American Civil Liberties Union of Illinois operated the Judicial Bypass Coordination Project. Over this period, the project provided a hotline that offered information about the judicial bypass process and free legal support for minors seeking abortion care throughout the state (https://www.aclu-il.org/en/pna).

Comprehensive practices and policies that lessen threats to a healthy adolescence, particularly related to DRV and judicial bypass denials for abortion care, are critical public health actions that allow adolescents to flourish, gain independence, and transition into successful adulthood. Attention to both of these distinct, but related, public health issues promotes health not just for this generation of adolescents but for our future.