Adolescents, Protecting: Ensuring Access to Care and Reporting Sexual Activity and Abuse (Position Paper)
As physicians and other health care professionals, we have an ethical obligation to provide the best possible care for our adolescent patients. A key tenet for all health professionals is to ensure that adolescents have access to the health services they need, including sexual and reproductive health services. A medical evaluation that addresses sexual and reproductive health includes a careful assessment for abusive or unwanted sexual encounters and the reporting of such cases to the proper authorities. Protection of children and adolescents from predatory, coercive, or inappropriate sexual contact is an important goal of all physicians and health professionals. In meeting our ethical obligations to our adolescent patients, as well as to all of our patients who are children under the age of majority, we rely on our professional judgment, informed by clinical assessment, training and experience, to address a patient’s health conditions or a sensitive situation.
As the primary providers of health care to adolescents, we also have an obligation to make every reasonable effort to encourage adolescents to involve parents in their decisions, as parental support can, in many circumstances, increase the potential for dealing with the adolescent’s needs on a continuing basis. If communication between the adolescent and parent cannot be facilitated, access to confidential health care for the adolescent patient must be ensured.
Laws requiring the reporting of sexual abuse exist in every state. There has been a recent trend in using these laws to require the reporting of consensual sexual activity by adolescents. In keeping with the medical and ethical responsibilities that we uphold, the American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG), the Society for Adolescent Medicine (SAM), support the following guidance and principles for our professional members and for broad consideration in the development of public policy:
- Sexual activity and sexual abuse are not synonymous. It should not be assumed that adolescents who are sexually active are, by definition, being abused. Many adolescents have consensual sexual relationships.
- It is critical that adolescents who are sexually active receive appropriate confidential health care and counseling.
- Open and confidential communication between the health professional and the adolescent patient, together with careful clinical assessment, can identify the majority of sexual abuse cases.
- Physicians and other health professionals must know their state laws and report cases of sexual abuse to the proper authority, in accordance with those laws, after discussion with the adolescent and parent, as appropriate.
- Federal and state laws should support physicians and other health care professionals and their role in providing confidential health care to their adolescent patients.
- Federal and state laws should affirm the authority of physicians and other health care professionals to exercise appropriate clinical judgment in reporting cases of sexual activity.
State requirements for reporting sexual abuse and sexual activity vary: Every state has laws that require the reporting of child abuse, including sexual abuse, and every state also has laws that specify when sexual activity with a minor is illegal. Most states utilize age parameters in defining whether consensual sexual intercourse with a minor is illegal under the state’s criminal code; these laws are often referred to as “statutory rape” laws. The state child abuse reporting laws vary widely in terms of whether or not they require reporting consensual sexual activity of a minor – or “statutory rape” – as child abuse.
Most states have laws allowing minors to consent to selected categories of medical care without parental consent. Examples include reproductive health services leading to the diagnosis and treatment of sexually transmitted infections (STI) and the diagnosis of pregnancy. These laws give physicians and other health care professionals the opportunity to practice medicine that responds to the best interest of their patients.
State requirements have a significant impact on adolescents, their health and their families: Physicians and other health care professionals confront difficult choices in meeting their ethical obligations and complying with applicable laws. They are bound by their state reporting requirements. The core ethical obligation in light of these pressures to ensure that their patients are protected from harm and that they will receive essential health care and support at present and in the future. State reporting requirements may be in conflict with a health care professionals personal beliefs, yet adherence to this core ethical obligation while practicing within the law is essential.
However, well-intentioned but rigid laws can lead to outcomes that are both unintended and potentially damaging to the health of an adolescent. When a state’s laws require that sexual intercourse with a minor be reported to law enforcement or child welfare agencies, a sexually active adolescent in a consensual relationship may be placed in the untenable situation of forgoing essential health care (e.g., contraception, screening or treatment for sexually transmitted diseases, etc.) or, if he or she seeks that care, being reported to state authorities. Also, the laws often do not take into consideration varying circumstances such as cases in which parents know about the relationship in which the adolescent is involved. In these situations, the legal implications for the parent may be considerable. A parent who knows about an adolescent’s consensual sexual relationship and assists him or her in seeking health care may be reported under state abuse or neglect laws. Laws should neither interfere with an adolescent’s access to confidential health care nor a parent’s ability to provide health supervision to his or her child.
A significant number of adolescents are sexually active: According to the 2003 Youth Risk Behavior Surveillance Survey, 32% of 9th graders, 41% of 10th graders, 52% of 11th graders, and 61% of 12th graders have ever had sexual intercourse (CDC 2004). [Centers for Disease Control and Prevention, Surveillance Summaries May 21, 2004. MMWR 2004:53 (No. SS02)] Among adolescent girls who are sexually active, more than two-thirds have sexual partners who are the same age or only a few years older, (iii). Enforcement of “statutory rape” and child abuse reporting laws could potentially impact a very large number of adolescents.
Open communication between the health professional and the adolescent is essential. Physicians and other health professionals should ensure that the adolescent has not voiced or otherwise indicated to his or her partner that sexual activity was unwanted or undesirable and that the partner is not placing physical or emotional pressure on the adolescent. Physicians and other health professionals should encourage communication about sexual decision-making between adolescents and their families, and should counsel sexually active adolescents about potential health risks.
The vast majority of reportable cases of sexual abuse and sexual coercion are identifiable through careful clinical assessment. These cases include adolescents in a sexual relationship with a family member, a person of authority (e.g., teacher, leader of a youth organization, etc.), or a member of the clergy. Also included are adolescents who are incapacitated by mental illness, mental retardation, drugs, or alcohol, and are unable to comprehend, make informed decisions about, or consent to, sexual activity. In addition, any intimate relationships that are violent should be considered abusive. Physicians and other health professionals must know their state laws and report such cases to the proper authority, in accordance with state law, after discussion with the adolescent and parent, as appropriate.
The age of the sexually active adolescent, the degree to which the adolescent understands the consequences and responsibilities of sexual activity, and the discrepancy in years between the age of the adolescent and his or her partner are important considerations that must factor into reporting decisions. While a wide discrepancy in age between partners is of concern when caring for the adolescent patient, partner age, by itself, is not indicative of exploitation or abuse. Verbal and physical coercion as well as alcohol and drugs are a few of the strategies used by sexual predators to victimize adolescents. However, sexual abuse and exploitation of an adolescent may occur in any relationship including those where the partners are the same age, younger or older.
It is essential that adolescents have access to confidential health care. The issue of confidentiality of care is a significant access barrier to health care. A recent study of girls under age 18 attending family planning clinics found that 47% would no longer attend if their parents had to be notified if they were seeking prescription birth control pills or devices, and another 10% would delay or discontinue sexually transmitted infection (STI) testing and treatment (Reddy 2003). Mandatory reporting of sexual activity will likely raise barriers and prevent adolescents from seeking health care, thereby exposing them to preventable health risks (e.g., pregnancy, sexually transmitted disease, suicide). The long-term consequences of limiting access to health care for sexually active adolescents may include an increase in the prevalence of STIs, a rise in unintended teen pregnancy, and escalation in the number of mental and behavioral health issues, including the potential of partner violence. If these and other conditions are not diagnosed early and treated appropriately, adolescents may suffer adverse health outcomes.
Adolescents can have a range of problems, including some of such severity as to jeopardize their development and health, their future opportunities, and even their lives. These issues may be independent of, or related to, sexual activity. However, until a physician or health professional can meet with and make a professional assessment of the individual adolescent, these issues can not be identified or addressed.
Legal requirements and interpretation of laws that impede the provider/patient relationship are detrimental to adolescents. The medical community has a long-standing commitment to ensure appropriate protection of confidentiality for their adolescent patients. Physicians and other health care professionals are on the front line in assessing the individual emotional, physical, and behavioral needs of adolescent patients. From this unique vantage point, we are able to provide care and counseling to our young patients and to determine the appropriate course of action required in each circumstance, including whether and when to abrogate an adolescent patient’s confidentiality. Federal and state laws should allow physicians and other health care professionals to exercise appropriate clinical judgment in reporting cases of sexual activity, (e.g., life-threatening emergencies, imminent harm, and/or suspected abuse). Ultimately, the health risks to adolescents are so compelling that legal barriers should not stand in the way of needed health care.
Confidentiality in Adolescent Health Care – consensus statement by AAP, AAFP, ACOG, NAACOG-The Organization for Women’s Health, Obstetric, Gynecologic, and Neonatal Nurses; and the National Medical Associations.
Adolescent Health Care (Confidentiality) – policy of the American Academy of Family Physicians (2001)
AMA policy H-60.965 - Confidential Health Services for Adolescents
AMA policy H-515.989 - Evidence of Standards for Child Sexual Abuse
Access to Health Care for Adolescents: A Position Paper of the Society for Adolescent Medicine Journal of Adolescent Health: 1992;13:162-170
Confidential Health Care for Adolescents: A Position Paper of the Society for Adolescent Medicine - Journal of Adolescent Health: 1997;21:408-415 (updated 2004, in press)
Society for Adolescent Medicine Position Paper on Reproductive Health Care for Adolescents - Journal of Adolescent Health: 1991;12:649-661
Care of the Adolescent Sexual Assault Victim: Policy of the American Academy of Pediatrics (June 2001) Pediatrics 107(6):1476-1479.
American College of Obstetricians and Gynecologists. Confidentiality in adolescent health care. In: Health Care for Adolescents. Washington, DC: ACOG; 2003:25-35.
(2004) (2010 COD)