Summary
This article highlights the urgent need for more research into the effects of hormonal contraceptives on young girls. While informed consent laws exist, the lack of comprehensive studies on the long-term impacts of birth control on adolescent health—including brain development, bone density, and emotional well-being—poses a significant ethical dilemma. The article argues that regulations mandating further research is essential, not only to guide medical practices but also to empower young women with the information they need to make informed choices about their health. The piece further emphasizes that failing to conduct such research will jeopardize the health of future generations of women.
By Caroline Potter, JHBL Staffer
Over the last three decades, states broadened the scope of the ability of minors to make decisions about their healthcare, including matters related to sexual activity.[1] This shift likely stems from the landmark 1977 U.S. Supreme Court decision in Carey v. Population Services International, which established a constitutional right to privacy for a minor to access contraceptives in every state.[2] The trend suggests that while parental guidance is valuable, many minors are likely to remain sexually active and will seek care only if they can do so privately, without needing to notify their parents.[3] While guaranteeing minors’ access to contraceptive services furthers an essential public health goal of preventing unintended pregnancies, providing adolescent females with information concerning the risks of hormonal contraception bears far more importance.[4] Although broader funding mechanisms and regulations often support research on reproductive health, no specific federal legislation in the U.S. explicitly mandates research on the effects of hormonal contraceptives on adolescent females.[5] Thus, one must question whether young girls are truly capable of making an informed decision about the use of hormonal contraceptives.[6]
Hormonal contraceptives, more often referred to as birth control, are a method used to prevent unwanted pregnancies.[7] In 1916, Margaret Sanger established the first birth control clinic in the U.S., which spurred research that ultimately contributed to the development of hormonal contraceptives.[8] In the 1940s, chemistry professor Russel Marker made a pivotal discovery that advanced birth control research and led to the development of the birth control pill.[9] By the 1960s, the Food and Drug Administration (hereinafter FDA) approved the contraceptive pill as a method of birth control.[10] Since the 1960s, numerous other contraceptive methods entered the market, including Plan B, birth control patches, hormonal intrauterine devices, single-rod implants, vaginal rings, injections for female tubal ligation or occlusion, condoms, and diaphragms.[11]
According to the U.S. Department of Health and Human Services (hereinafter HHS), hormonal contraceptives are generally considered safe for the majority of women.[12] While HHS asserts that birth control can offer benefits to adult women, the agency does not offer insight into the effects of hormonal contraceptives on the developing bodies of teenage girls.[13] This lack of information is concerning, as scientific studies indicate that hormonal contraceptives may adversely affect adolescent female brain development, elevate the risk of depression, impair developmental processes, and contribute to bone density reduction.[14]
The female brain does not mature fully until the mid to late twenties, with significant development occurring during puberty, which precedes this maturation.[15] As a young girl’s body strives to regulate and balance various hormones, the introduction of estrogen and progesterone through contraceptives may potentially cause negative effects, and insufficient data exists to counter this possibility.[16] While teenage girls may appreciate the absence of several negative effects of puberty, such as painful menstruation, they may also forgo the beneficial outcomes associated with neural pruning during this developmental stage.[17] Studies reveal the presence of synthetic versions of hormones, such as estrogen and progesterone, in many hormonal contraceptives, which can cause significant neural effects if an individual takes them while developing into adult form.[18]
Much like the female brain, a female’s bone density typically reaches peak bone mass during the mid to late twenties.[19] Bone density in girls increases during adolescence, but several studies suggest that rather than gaining bone, teenagers who take hormonal contraceptives experience bone density loss of between five to seven percent.[20] One study revealed that teens between the ages of fourteen and eighteen who discontinued taking combined oral contraceptives continued to see smaller gains in spine bone mineral density than non-users, even twelve to twenty-four months after stopping their prescriptions.[21]
Given the limited understanding of the effects of hormonal contraceptives on adolescent development, research discussing the impact of such medications on the female brain and cognition is limited.[22] A number of studies, however, reveal a correlation between the usage of hormonal contraceptives and a subsequent diagnosis of depression.[23] Further data demonstrates that hormonal contraceptives could potentially influence depressive symptoms in women, especially if started at a young age.[24]
Although hormonal contraceptives became available in the 1960s, clinical trials evaluating their effectiveness and safety are predominantly conducted in adult women.[25] This method of researching hormonal contraceptives is concerning because from a biological perspective, a significant difference exists between an adult woman and a teenage girl.[26] Many physicians and scientists attribute the lack of scientific data to a hesitancy in conducting studies on the impact of contraceptives in minor females.[27] If true, this reluctance to conduct research raises the question of whether physicians should prescribe hormonal contraceptives to this population in the first place.[28]
Despite the fact many states require healthcare providers to obtain the informed consent of minor adolescents when prescribing birth control, it is imperative that researchers conduct further scientific investigations to understand the effects of hormonal contraceptives on young females.[29] Scientists do not yet fully understand the impact of hormonal birth control on the adolescent body, especially in relation to brain development, bone health, and emotional well-being.[30] Approximately forty-four percent of girls between the ages of fifteen and nineteen use some form of hormonal contraceptive, highlighting the need for more studies to discover what the far-reaching effects are.[31] Failure to do so prevents young girls from making an informed and safe decision about whether they should take a hormonal contraceptive.[32] The adolescent years involve crucial physical and mental development, and hormones play a pivotal role in these processes.[33]
While medical providers widely prescribe hormonal contraceptives, they possess an ethical obligation to refrain from prescribing medications that lack adequate evidence supporting their safety, ensuring that young girls are safeguarded from potential risks. Considering this, HHS should propose regulations that mandate extensive research into the effects of hormonal birth control on adolescent health. Such regulatory action would not only yield critical data to inform medical practices but also empower adolescent females with the knowledge required to make informed health and reproductive decisions. Moreover, compelling this research would mitigate the risks associated with inadequately validated treatments and facilitate the development of more comprehensive protocols for the safe administration of hormonal contraceptives in developing girls. Absent such research, the medical community risks perpetuating a significant lack of understanding, potentially undermining the health and well-being of future generations of young women.
Disclaimer: The views expressed in this blog are the views of the author alone and do not represent the views of JHBL or Suffolk University Law School.
Caroline Potter is a second-year law student at Suffolk University Law School. Caroline graduated from Suffolk University Madrid in 2023 with a bachelor’s degree in international relations.
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[1] See Marianne Sharko et al., State-by-State Variability in Adolescent Privacy Laws, 149 Am. Acad. Pediatrics 6, 3-6 (May 9, 2022), https://publications.aap.org/pediatrics/article/149/6/e2021053458/187003/State-by-State-Variability-in-Adolescent-Privacy?autologincheck=redirected [https://perma.cc/JSM9-7U9S ] (summarizing state-by-state minor consent policies for contraceptive care).
[2] See Carey v. Population Servs. Int’l., 431 U.S. 678, 693 (1977) (addressing several key issues regarding distribution and advertisement of contraceptives).
[3] See Preventing Teenagers From Getting Contraceptives Unless They Tell a Parent Puts Teens at Risk, Am. C.L. Union (July 18, 2003), https://www.aclu.org/documents/preventing-teenagers-getting-contraceptives-unless-they-tell-parent-puts-teens-risk [https://perma.cc/T6VX-5D3V] (noting restriction on teen access to contraceptives without parental consent ineffective in preventing sexual intercourse).
[4] See Am. Coll. Obstetricians & Gynecologists, Access to Contraception 2 (Jan. 2015), https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2015/01/access-to-contraception.pdf?rev=326fce9f62fa42b983ea4b6c39325956&hash=CFD1BD28FCB0D17A23486A587A480A19 [https://perma.cc/Y7LU-VSSJ] (emphasizing necessity to improve patient knowledge about risks associated with hormonal contraceptives).
[5] See 42 U.S.C. § 285g-5 (2007) (establishing research centers focused on improving methods of contraception). The centers must conduct clinical trials, train healthcare professionals, develop education programs, and disseminate information. Id.
[6] See Informed Consent, Am. Med. Assoc. Code Med. Ethics, https://code-medical-ethics.ama-assn.org/ethics-opinions/informed-consent [https://perma.cc/GL8M-XL83] (explaining physicians’ obligations when seeking patient’s informed consent).
[7] See Birth Control, Nat’l Libr. Med. (May 31, 2024), https://medlineplus.gov/birthcontrol.html [https://perma.cc/L9XN-7Z2N] (discussing various types of hormonal contraceptives).
[8] See Rainey Horwitz, First American Birth Control Clinic (The Brownsville Clinic), 1916, Ariz. State Univ. Ctr. for Biology & Soc’y (Oct. 11, 2019), https://embryo.asu.edu/pages/first-american-birth-control-clinic-brownsville-clinic-1916 [https://perma.cc/9U4X-WXR6] (detailing opening of first birth control clinic in United States).
[9] See Crystal Raypole, From Acacia to IUDs: The History of Birth Control in the United States, Healthline (June 28, 2021), https://www.healthline.com/health/birth-control/history-of-birth-control [https://perma.cc/VS9W-9CQR] (discussing advancement of birth control). Marker learned that women in Mexico had been using wild yam in order to prevent pregnancies for generations. Id. He discovered that by extracting plant-based progesterone from yams he would be able to create the synthetic version, progestin. Id. This development made the production of the pill possible. Id.
[10] See id. (explaining development of FDA’s approval of hormonal contraception).
[11] See id. (outlining development of birth control methods).
[12] See Tessa Madden, Birth Control Methods, Off. on Women’s Health (Jan. 16, 2017), https://womenshealth.gov/a-z-topics/birth-control-methods [https://perma.cc/K4RT-NWCJ] (discussing birth control methods). The HHS notes hormonal contraceptives can present side effects including weight gain, headaches, irregular bleeding, breaster tenderness, and mood changes. Id.
[13] See Jessica Hamzelou, The Unknown Effect of the Pill on Teenage Bones and Brains, New Scientist (July 6, 2016), https://www.newscientist.com/article/mg23130814-300-the-unknown-effect-of-the-pill-on-teenage-bones-and-brains/ [https://perma.cc/8SMN-9VQR] (emphasizing unknown impact of birth control on developing females).
[14] See Bronnick et al., infra note 17, at 2 (explaining neural impact); see also Bachrach, infra note 20, at 6 (discussing association between hormonal contraceptives and loss of bone mass); Anderle, infra note 24, at 6 (explaining hormonal contraceptives could potentially influence depressive symptoms in women).
[15] See The Teen Brain: 7 Things to Know, Nat’l Inst. Mental Health (2023), https://www.nimh.nih.gov/health/publications/the-teen-brain-7-things-to-know [https://perma.cc/V723-LBPT] (noting adolescence is important time for brain development).
[16] See Hamzelou, supra note 13 (discussing pruning process). During puberty, young girls undergo a process known as pruning, which sculpts certain brain circuits into their adult form. Id. During the pruning process, girls experience irregular periods, mood swings, and acne. Id. When hormonal contraceptives are added on top of this process, they suppress the release of the body’s own versions of hormones. Id.
[17] See Hamzelou, supra note 13 (discussing pruning process). Hormonal contraceptives can have a negative and long-lasting, maybe permanent, impact on aspects regulated by the sculpted brain circuits such as sexual behavior and how a person processes rewards. Id. Imposing adult levels of sex hormones on teenagers may disrupt the development of the body’s hormone control system, which is set during adolescence. Id. This ultimately could signal premature development. Id.; see also Marita Kallesten Bronnick et al., The Effects of Hormonal Contraceptives on the Brain: A Systematic Review of Neuroimaging Studies, 11 Frontiers Psych. 1, 2 (Oct. 27, 2020), https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2020.556577/full [https://perma.cc/T9KR-M4LM] (highlighting neural impact of hormonal contraceptive on adolescent brain).
[18] See Bronnick et al., supra note 17, at 2 (explaining neural impact). Adolescence can be seen as a window of both increased opportunity and increased vulnerability, where implications of interference with endogenous processes could be far-reaching and affect emotional aspects of life. Id. at 15; see also Michael L. Lipton et al., Study Finds key Brain Region Smaller in Birth Control Pill Users, Radiological Soc’y N. Am. (Dec. 4, 2019), https://press.rsna.org/timssnet/media/pressreleases/PDF/pressreleasePDF.cfm?ID=2136 [https://perma.cc/F273-AAEG] (highlighting effects of hormonal contraceptives on neural system). In a study evaluating the brain in women taking birth control, findings indicated a dramatic difference in size of brain structures between women taking oral contraceptives and women who did not. Michael L. Lipton et al., supra.
[19] See Barbara J. Campbell et al., Healthy Bones at Every Age, Am. Acad. Orthopedic Surgeons (Aug. 2021), https://orthoinfo.aaos.org/en/staying-healthy/healthy-bones-at-every-age/ [https://perma.cc/GBW4-2AEJ] (noting peak bone mass reached between twenty-five and thirty years old).
[20] See Hamzelou, supra note 13 (emphasizing bone density loss); see also Laura K. Bachrach, Hormonal Contraception and Bone Health in Adolescents, 11 Frontiers Endocrinology 1, 2 (Aug. 2020), https://pmc.ncbi.nlm.nih.gov/articles/PMC7472551/pdf/fendo-11-00603.pdf [https://perma.cc/KA6C-9HJM] (highlighting negative impact of hormonal contraception on bone health).
[21] See Bachrach, supra note 20, at 6 (discussing association between hormonal contraceptives and loss of bone mass). Little to no research has been done on the effects of long-acting reversible contraceptive (hereinafter LARC) forms on bone loss and development. Id.
[22] See Bronnick et al., supra note 17, at 1 (emphasizing need for further research).
[23] See id., at 2 (discussing hormonal contraceptives potential to interfere with neurohormonal regulatory mechanisms and neural structures).
[24] See Christine Anderl, Taking the Pill as a Teenager may Have Long-Lasting Effect on Depression Risk, Univ. B.C. Dep’t Psych. (Sept. 6, 2019), https://psych.ubc.ca/news/taking-the-pill-as-a-teenager-may-have-long-lasting-effect-on-depression-risk/ [https://perma.cc/MSN8-RPJH] (noting correlation between birth control and depression in adolescent females). One study found that women who began using contraceptives in their teens were ten percent more likely to be clinically depressed than women who had never used contraceptive pills. Id. Additionally, these women had a seven percent higher chance of developing depression compared to those who started taking contraceptive pills as adults. Id.
[25] See Hamzelou, supra note 13 (emphasizing few studies conducted in teenage girls).
[26] See id. (noting biological differences between adult and adolescent females). An estimated quarter of girls aged between fifteen and nineteen in the United States are using hormonal contraceptives. Id. With some girls as young as nine-years-old are being prescribed hormonal contraceptives. Id.
[27] See id. (discussing reluctancy to test contraceptives in teens).
[28] See David J. Hilger et al., Hormonal Contraception and the Informed Consent, 85 Cath. Med. Assoc. 375, 376-77 (2018), https://pmc.ncbi.nlm.nih.gov/articles/PMC6322130/pdf/10.1177_0024363918813579.pdf [https://perma.cc/9LDT-25BN] (discussing principles of informed consent).
[29] See id. (discussing informed consent requirements). Informed consent means that the provider has explained the potential risks and benefits of a treatment plan, and the patient has understood and given their consent. Id., at 376.
[30] See Bronnick et al., supra note 17, at 2 (explaining neural impact); see also Bachrach, supra note 20, at 6 (discussing association between hormonal contraceptives and loss of bone mass); Anderle, supra note 24, at 6 (explaining hormonal contraceptives could potentially influence depressive symptoms in women).
[31] See Camelia Davtyan, Contraception for Adolescents, 172 West J. Med. 166, 168 (2000), https://pmc.ncbi.nlm.nih.gov/articles/PMC1070796/pdf/wjm17200166.pdf [https://perma.cc/HRR9-ULMW] (noting contraceptive use amongst adolescent females); see also Bronnick et al., supra note 17, at 2 (emphasizing need for further research).
[32] See Bronnick et al., supra note 17, at 15 (highlighting need for further research to keep adolescent females informed of the associated risks).
[33] See Hamzelou, supra note 13 (emphasizing importance of developments made during adolescent years).