Am Fam Physician. 2004 Mar 1;69(5):1056-1058.
Primary care physicians provide the majority of reproductive health care services for minors.1 As family physicians, we need to emphasize the primary role of the family as an irreplaceable health resource. Ideally, parents play an integral and supportive role in the health of their children. However, in the case of reproductive issues, there are times when parental involvement would be detrimental to care, and confidentiality becomes paramount. Thus, family physicians who provide reproductive health care to adolescents face the complex issues of confidentiality and consent. Furthermore, these issues extend to other adolescent health concerns, including substance abuse, mental health, and sexual orientation. Whether or not physicians choose to provide confidential health care to minors, a basic understanding of this topic and applicable state laws is needed to ensure that care is provided in a manner consistent with ethical and legal responsibilities.
While the majority of physicians support confidential health care when adolescents request it,2 many may not be aware of the evidence of associated health benefits. Perceived lack of confidentiality is a barrier to medical care for minors. Among adolescents exhibiting symptoms suggesting health problems, approximately one third reported foregoing care.3 Among female adolescents receiving contraceptive services at Title X family planning clinics (where confidentiality is assured for minors), 59 percent stated that they would stop seeking any health services if parental notification requirements were imposed.4 Adolescent patients often avoid seeking appropriate care or break continuity of care with a primary care physician, particularly for reproductive health needs, unless assurance of confidentiality is provided.5 Conversely, adolescents are more likely to discuss sexually transmitted diseases, pregnancy prevention, and other sensitive topics when confidentiality is assured proactively by their health care professional.6
Family physicians may be unaware of the legal protections for minors who seek confidential care and the exceptions that exist to the usual parental consent requirements. The need for confidential health care for minors has been recognized by the legal system in the United States. There are many federal and state laws and regulations that provide some exceptions to the general requirement for parental consent to provide medical care to minors (typically for reproductive health, mental health, substance abuse, and emergency services). Most state courts recognize concepts such as the “mature” or “emancipated” minor to determine the right to consent for all medical care and often use specific criteria to determine this (e.g., marriage, high school graduation, pregnancy).7
In general, the right to confidentiality follows from the right to consent to care for particular procedures or services. Under circumstances in which physicians object to maintaining confidentiality in the care of an adolescent, it is ethically and legally necessary to make this clear to the patient before services are provided. If an adolescent requests confidentiality and the physician is unwilling to provide it, this must be made clear to the patient immediately, and the physician should offer a referral to an alternative provider. For example, health clinics funded by Title X legislation are available throughout the United States and are mandated to provide confidential sexual health services to minors. It is not acceptable to provide care and later disclose these services against the wishes of the patient. The only exceptions to this are mandatory reporting of suspected child abuse or when minors are suspected to pose a danger to themselves or others.
The American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists have issued policy recommendations that endorse providing confidential care to adolescents when not doing so would lead to adverse health outcomes.8–10 These recommendations encourage parental participation when appropriate, with the caveat that the participation should not stand in the way of needed care.
The policy recommendations emphasize that the best way to protect the health of adolescent patients is to provide meaningful and timely anticipatory guidance to parents and children, with an eye toward improving family communication and supporting adolescents in their developmentally appropriate transition to independence. When that is not possible or desirable, however, we need to be aggressive in protecting the confidentiality of our adolescent patients. Their health depends on it.
Ian Bennett, M.D., Ph.D., and Peter Cronholm, M.D., M.S.C.E., are clinical professors; Richard Neill, M.D., is assistant professor; and LaRissa Chism, M.D., is a medical student, in the Department of Family Practice and Community Medicine, University of Pennsylvania, Philadelphia.
Address correspondence to Ian Bennett, M.D., Ph.D., Department of Family Practice and Community Medicine, 2nd floor, Gates Bldg., Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104.
1. Udry JR, Bearman PS, for The National Longitudinal Study of Adolescent Health. Carolina Population Center, University of North Carolina at Chapel Hill. Accessed online February 6, 2004, at: http://www.cpc.unc.edu/projects/addhealth.
2. Harvey LK, Shubat SC. Physician opinion on health care issues: 1987. Chicago, Ill: American Medical Association, 1987.
3. Ford CA, Bearman PS, Moody J. Foregone health care among adolescents. JAMA. 1999;282:2227–34.
4. Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls' use of sexual health care services. JAMA. 2002;288:710–4.
5. Klein JD, Wilson KM, McNulty M, Kapphahn C, Collins KS. Access to medical care for adolescents: results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls. [erratum appears in J Adolesc Health 1999;25:312]. J Adolesc Health. 1999;25:120–30.
6. Thrall JS, McCloskey L, Ettner SL, Rothman E, Tighe JE, Emans SJ. Confidentiality and adolescents' use of providers for health information and for pelvic examinations. Arch Pediatr Adolesc Med. 2000; 154:885–92.
7. English A, Simmons PS. Legal issues in reproductive health care for adolescents. Adolesc Med. 1999; 10:181–94.
8. AAFP Statement of Policy on Adolescent Health Care: American Academy of Family Physicians. 2003. Accessed online February 6, 2004, at: http://www.aafp.org/x6613.xml.
9. Counseling the adolescent about pregnancy options. Committee on Adolescence. American Academy of Pediatrics. Policy statement. Pediatr. 1998; 100:938–40.
10. Health care for adolescents. American College of Obstetricians and Gynecologists. ACOG Committee on Adolescent Health Care. 2003.
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