receive funding for services. We were bound to the structure and guidelines set forth by the Programs Guidelines of the Project. On June 19, the twenty-seven members present at the Board meeting voted 14 to 13, with the Chair casting a tie breaking vote, to reject a motion that would have discontinued the Department's acceptance of close to $220,000 in Title X and related funding.

Two issues/concerns were prevalent in discussions with Board members. First, there was concern that if we rejected the funding there would not be another service in place at this time to adequately provide family planning services to low income women. Second, and of most concern to the majority of the Board members, was the treatment of children and adolescents without parental knowledge.

The Judge Executive, Steve Pendery from Campbell County, resolved that the local level may not be the place to deal with the issue of parental notification but, rather, it should be addressed at a State and National Legislative level. While Judge Pendery felt he needed to vote to retain the Title X funding for practical reasons, in the press the next morning Judge Pendery concluded that the Board is not as divided as it seems; "We're a lot closer on this issue than the vote makes it sound."

I voted with the support of my Judge Executive, Gary Moore, to discontinue the Health Department's collaboration with Title X funding and to look for other sources of funding to support a model of Family Planning Services not restricted by the constraints of Title X. On June 20, Judge Pendery's designee sent a letter to Board members requesting that we move forward with letters to all legislators in Kentucky asking for their help in changing the Title X requirements regarding girls under the age of 18 receiving birth control without their parents' knowledge.

It was apparent to most of us on the Board working on this issue that Title X would remain problematic as it currently exists because it erodes parental rights and the parent-child relationship.

Title X and Parent's Right to Know

Mr. Chairman and Members, I know you are well aware that Title X of the Public Health Service Act was established as a federal program in 1970. For many years it has offered low-income women certain "reproductive health" services, including family planning as well as "non-directive" pregnancy counseling and referrals on all "options," including termination of pregnancy.

One-third of the approximately five million women served by the program are teenagers. Unmarried teens may qualify for free services regardless of their parents' income, knowledge of or consent to care. Currently, a teenager may walk into any Title X clinic and receive free prescription contraceptives, including injectables, i.e., Depo-Provera, or emergency contraceptives (the morning after pill) without her parents' knowledge or consent. Congressmen, one of these young girls may easily be your daughter or granddaughter.

To date, our Northern Kentucky clinics' statistics show that of the clients seen and treated this year, looking at numbers for females under the age of 18, only 24% came in with parental knowledge or consent. Approximately 75% of the young women seen in our clinics are seen without parental notification. The clinics have seen and treated girls as young as 12 years old. Example Case:

Just this year, in one of our Northern Kentucky clinics, a 14-year-old girl came in with her boyfriend's mother. Upon initial interview, she denied being sexually active at that time, but it was important to her that her boyfriend and his mother like her. The boyfriend's mother wanted the girl put on some form of birth control so she would not become pregnant when her son had sex with her. Please keep in mind the girl was 14 years old. The adult who brought her in to the clinic was not her mother. The 14-year-olds' mother was not notified. This is the reality of the strings attached to Title X.

Under the auspices of Title X, providers of women's and adolescent health services have fallen into disaster control mode, leaving proactive mediation and behavioral interventions on the back burner. We abet unhealthy practices by offering birth control to sexually active teens, especially young women who are the population at the greatest risk for Human Papillomavirus (HPV) and other STDs. These behaviors of young people need parental awareness, so that they may support and give guidance and dialog that respects the norms and values of the family. A true health model would then provide intervention when necessary that assists parents in parenting, building a bridge rather than a wedge in the parent-child relationship. These high risk behaviors do not need the cloak of government funded clinics providing a "pill" to replace behavior interventions, rather the situation calls for more support for parental communication.

Title X specifies that a minor must be treated as an adult when seeking family planning services, yet these are really children engaging in adult behaviors.

The issue remains that a minor cannot legally sign a contract; the school nurse cannot give her an aspirin; she cannot have her ears pierced in the mall without her parent's OK; yet Title X allows a minor to decide and receive family planning services and FDA approved methods of birth control without a parent's knowledge. Title X is anti-parental rights.

CONCLUSION

Title X means your daughter, your granddaughter, or any minor female, can be put on hormonal medications or be given an emergency contraceptive (morning after pill), without those most knowledgeable her parents or guardians of her health and family health history being able to advise her regarding known risk factors that, in combination with contraindications or adverse effects, could lead to serious future health complications. While the clinician must ask her if she knows her own medical and family medical history (mandatory), it is irresponsible and dangerous to assume that a 13 or 15-year old would have a complete knowledge of such information. Most children are unaware of their family risk factors. It is also unethical for a medical professional to treat a patient and prescribe or dispense medication without a completed personal and family medical history.

Overall, lack of parental notification in the Title X program are affronts to parents' rightful role as the primary educators of their children. Government agencies and counselors cannot replace and should not interfere with the rights and responsibilities of parents, particularly in sensitive matters dealing with human sexuality. Government should protect the role of loving and supportive parents, yet make it possible to terminate the rights of parents who abuse the trust and privilege of being a parent.

Parents must be trusted to monitor their minor children's health and to protect them from the consequences of promiscuous behavior.

Mr. Chairman and Members of the Committee, common sense, wisdom, and sound medical practice would agree that parents have the right to monitor and care for the health and welfare of their children. I implore you to take the necessary steps to reverse the erosion of parental rights and lift the blanket of confidentiality currently mandated under Title X. This completes my prepared statement. Thank you again for this opportunity to testify on the issue of a Parent's Right to Know. I would be happy to respond to any questions you may have at this time. Mr. BILIRAKIS. Thank you very much. Dr. Jenkins?

STATEMENT OF RENEE S. JENKINS

Ms. JENKINS. Good afternoon, Mr. Chairman, members of the committee. I am Dr. Renee Jenkins-is this on? Okay. Start again. Good afternoon. Mr. Chairman, members of the committee. I am Dr. Renee Jenkins here in Washington who has taken care of adolescents for more than 20 years. I am also professor and Chair of the Department of Pediatrics and Child Health at Howard University College of Medicine. I am speaking today on behalf of the American Academy of Pediatrics. My statement also is endorsed and supported by the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians and the Society for Adolescent Medicine.

Most importantly, I too am a parent who shares the same worries about my daughter's health as other parents. My testimony today will cover three key points: One, the importance of parental involvement; two, the importance of confidentiality and access to health care; and, three, concerns about H.R. 4783, the States and Parental Rights Improvement Act of 2002.

Under parental involvement, as clinicians we firmly believe that parents should be involved in and responsible for assuring medical care for our children. Family communication about health care decisions is the desired goal and the health care professions are able

to assist in this effort. We strongly encourage and hope that adolescents communicate with and involve their parents and other trusts adults in important health care decisions. These health care decisions include issues of substance abuse, mental health and reproductive health.

Providing confidential health care services does not preclude working toward the goal of family communication and involvement of parents, as is sometimes inferred. To the contrary, research has shown that adolescents often voluntarily share information with their parents. Clinical experience confirms that this often occurs after they consult privately with their health care provider. My role as a pediatrician is to support, encourage, strengthen and enhance parental communication and involvement in adolescent decisions. without compromising the ethics and integrity of my relationship with adolescent patients.

While there may be circumstances when it is necessary and appropriate for the health care provider to inform parents or guardians of certain health problems facing a minor, for example, when there is a risk of imminent harm, there is a critical need to ensure that an adolescent's health information is protected. Concern about confidentiality is one of the primary reasons that young people delay seeking health care, including health care for sensitive health issues. While parental involvement is both very desirable and should be encouraged, it may not be feasible.

Legislated mandatory parental consent or notification will certainly reduce the likelihood that young people will seek timely treatment for sensitive health issues. Adolescents will rarely admit to the use of the alcohol and drugs in front of their parent. The confidential interview gives them an opportunity to speak to a professional that can help them early and detect underlying depression when it is present and avoid the risk of suicide, for example, and other negative outcomes. When young people have symptoms of sexually transmitted diseases, they often delay going for treatment so long that complications that would normally be avoided occur, sometimes requiring hospitalization.

Having access to confidential care also provides an access point for adolescents to receive other health care services. These include things like cholesterol screening, immunizations, blood pressure monitoring or pelvic exams, services that are critical to the adolescent's health but could be overlooked if the adolescent had not visited a doctor. Ensuring the confidentiality in the delivery of health care services provides a necessary gateway that allows adolescents to simply get in the door so that we as health care professionals can help guide them in appropriate directions that includes parental involvement. Without confidentiality, early care and treatment is too often preempted.

Concerns about H.R. 4783, for reasons outlined in greater detail in our testimony, we oppose this legislation. We believe that this legislation will undermine the Federal guarantee of confidentiality for health care services under the title X program and other child and adolescent health programs. H.R. 4783 would create barriers to health care, especially for low-income young people who need to obtain affordable prescription drugs, including prescriptive contraceptives through federally supported health clinics. The barrier

would also impact health care services outside the scope of reproductive health.

In conclusion, as a physician, a teacher and most of all as a parent who is concerned about the quality and safety of health care for my daughter as well as for the quality and safety of health care for all adolescents in this country, I urge you to reject attempts to restrict adolescents' access to confidential health care services, including prescription drugs or devices. Mr. Chairman, thank you for the opportunity to testify before this committee today, and I will be happy when the time comes to take any questions. Thank you. [The prepared statement of Renee S. Jenkins follows:]

PREPARED STATEMENT OF RENEE JENKINS, PROFESSOR AND CHAIR, DEPARTMENT OF PEDIATRICS AND CHILD HEALTH, HOWARD UNIVERSITY COLLEGE OF MEDICINE ON BEHALF OF THE AMERICAN ACADEMY OF PEDIATRICS

Good afternoon. Mr. Chairman, members of the Committee, I am Dr. Renee Jenkins, a practicing pediatrician who has taken care of adolescents for more than 20 years. I am also professor and chairman, Department of Pediatrics and Child Health, at Howard University College of Medicine. I am speaking today on behalf of the American Academy of Pediatrics (AAP), an organization representing 57,000 pediatricians throughout the nation. In addition, my comments are endorsed and supported by the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians and the Society for Adolescent Medicine.

Each of the organizations supportive of this testimony is fully committed to the health and well-being of adolescents. Specifically, the American College of Obstetricians and Gynecologists is an organization representing 44,000 obstetricians-gynecologists dedicated to health for women of all ages; the American Academy of Family Physicians is one of the largest national medical organizations, representing more than 93,500 family physicians, family practice residents and medical students; and the Society for Adolescent Medicine includes more than 1,400 physicians, nurses, psychologists, social workers, nutritionists and others involved in service delivery, teaching or research on the health and welfare of adolescents. In total, we represent more than 196,000 medical professionals.

It is from these perspectives, and perhaps most importantly as a parent, that I am here today to express our views concerning the issue of parental consent or notification for minors seeking health care services, including prescription drugs or devices. My comments today will also address H.R. 4783, the "State's and Parental Rights Improvement Act of 2002," which we believe would undermine confidential health care services for adolescents. I would like to thank the Committee for this opportunity to present this statement as Congress continues to debate this issue of significance to adolescent health care.

OVERVIEW

The American Academy of Pediatrics and the endorsing organizations firmly believe that parents should be involved in and responsible for assuring medical care for our children. Moreover, we would agree that as parents we ordinarily act in the best interests of our children and that minors benefit from our advice and the emotional support we provide as parents. We strongly encourage and hope that adolescents communicate with and involve their parents and/or other trusted adults in important health care decisions affecting their lives. These discussions include such issues as substance abuse, mental health and pregnancy and pregnancy termination. We know and research confirms that most adolescents do so voluntarily. This is predicated not by laws but on the quality of their relationships. By its very nature family communication is a family responsibility. Adolescents who live in warm, loving, caring environments, who feel supported by their parents, will in most instances communicate with their parents in a crisis including the disclosure of a pregnancy or other urgent health concerns. However, even adolescents reared in the best of household environments will at times be unwilling to make full disclosure of their behaviors because they do not wish to disappoint and hurt loving and caring parents.

Family communication about health care decisions is the desired goal, and health care professionals are able to assist in this effort. Allowing confidentiality of care for adolescents does not preclude the involvement of parents, as it is sometimes presumed. To the contrary, research has shown that adolescents often voluntarily share

information with their parents and clinical experience confirms that this often occurs after they consult privately with their health care provider.

Ensuring confidential care is about striking an important balance among parents, providers and the adolescent patient. While there may be circumstances when it is necessary and appropriate for the health care provider to inform parents or guardians of certain health problems facing a minor (e.g., life-threatening emergency) there is a critical need to ensure that an adolescent's health information is protected. Providing confidential care does not preclude working toward the goal of family communication.

Pediatricians, parents and policy makers know well the number of adolescents that are beginning to use illicit drugs, alcohol and become sexually active. What may start as experimentation with friends often leads to long term dependencies, accidents, injuries, sexually transmitted disease and a myriad of other physical and behavioral issues. In the infrequent cases where communication between adolescents and their parents can not be facilitated, many of these negative outcomes can be avoided if the adolescent has access to confidential health care.

My role as a pediatrician is to support, encourage, strengthen and enhance parental communication and involvement in adolescent decisions without compromising the ethics and integrity of my relationship with adolescent patients. Health professionals have an obligation to provide the best possible care to respond to the needs of their adolescent patients. This care should, at a minimum, include mental health, substance abuse, and services for other psychosocial problems including therapy, crisis management, day treatment, and residential care; comprehensive reproductive health services, such as sexuality education, counseling, mental health assessment; diagnosis and treatment regarding pubertal development; access to the full range of family planning services; pregnancy-related care; prenatal and delivery care; diagnosis and treatment of sexually transmitted diseases and referrals for other health and social services.

We understand that pending legislation, the "State's and Parental Rights Improvement Act of 2002" (H.R. 4783), is, in part, the basis for this discussion today. This legislation would allow states to require parental consent or notification for the purpose of dispensing prescription drugs or devices to minors under federal health care programs, such as the Title X Family Planning program and the Title V Maternal and Child Health Block Grant.

For reasons outlined below, we believe that this legislation would undermine the federal guarantee of confidentiality for health care services under the Title X program and other child and adolescent health programs, and is inconsistent with the policies of the endorsing organizations. In addition, this legislation could have a chilling effect on state programs that may opt to follow the federal recommendation. The stated intent of those who support mandatory parental consent or notification legislation, of the type that H.R. 4783 would allow states to adopt, is that it enhances family communication as well as parental involvement and responsibility. However, the evidence does not support that these laws have that desired effect. To the contrary, there is evidence that these laws may have an adverse impact on some families and that it increases the risk of medical and psychological harm to adolescents. According to the AAP, "[i]nvoluntary parental notification can precipitate a family crisis characterized by severe parental anger and rejection of the minor and her partner. One third of minors who do not inform parents already have experienced family violence and fear it will recur. Research on abusive and dysfunctional families shows that violence is at its worse during a family member's pregnancy and during the adolescence of the family's children." It is for these and other reasons that the American Academy of Pediatrics and other organizations represented today oppose H.R. 4783 and any other legislation that will undermine federal guarantees of confidentiality for adolescents receiving health care services.

Since the involvement of a concerned adult can contribute to the health and success of an adolescent, policies in health care settings should encourage and facilitate communication between a minor and her parent(s), when appropriate. However, concerns about confidentiality, as well as economic considerations, can be significant barriers to healthcare for some adolescents. For example, the potential health risks to adolescents if they are unable to obtain reproductive health services are so compelling that legal barriers and deference to parental involvement should not stand in the way of needed health care for patients who request confidentiality.

CONFIDENTIALITY OF CARE

I would like to turn my attention to the issue of confidentiality—whether adolescents can access health care services, including prescription drugs and devices, without parental consent. The American Academy of Pediatrics and other medical orga