Near the end of her sports physical examination, a 16-year-old girl seems worried. The physician offers her some time without her mother in the room. Once in private, the girl quickly requests a pregnancy test. Although the test result is negative, this is a perfect teaching opportunity.
Adolescents are generally healthy, but they commonly present with high-risk behaviors that are often missed by physicians. In 2007, the leading causes of death for Americans between 15 and 19 years of age were unintended injuries (48.8 percent), homicide (16.7 percent), and suicide (11.1 percent).1 Within the month before a nationwide survey, 42 percent of high school students had consumed alcohol, and 28 percent had ridden in a vehicle with a driver who had been drinking. Furthermore, 34 percent were sexually active; of those, 39 percent had not used a condom the last time they had sexual intercourse.2
Without confidentiality, teenagers may avoid seeking services for sensitive health care needs. For example, in a 2005 study of 1,526 female adolescents presenting to 79 family planning clinics, 40 percent said they would not get contraception from the clinic if parental notification were mandatory, and almost one-half stated that they would subsequently use an over-the-counter method.3 One in five adolescents reported that to avoid parental notification, he or she would resort to using a withdrawal method.3 Some adolescents also worry about loss of confidentiality through ancillary staff or third-party payer access to their medical information.4,5
Although physicians typically prefer to provide health care services to adolescents confidentially,6 many avoid the topic, fearing scenarios such as a teenage girl saying, “I want to start birth control, but please don't tell my mom.” Physicians often do not ask teenagers about common and important age-specific behavioral antecedents of morbidity and mortality, but instead spend considerable time checking for rare physical pathology. In one study, less than one-half of female students and one-fourth of male students who reported a preventive care visit within the previous year acknowledged discussing sexually transmitted infections or contraception during the visit.7
There are numerous reasons physicians pass up opportunities to discuss risky behaviors with adolescents. These include:
Inadequate reimbursement from insurers
Discomfort or inexperience with medical conditions relevant to adolescent care
Unfamiliarity with, or mixed feelings about, the laws and regulations that govern services to minors
Lack of training in managing difficult social situations, such as a parent forbidding an already sexually active teenager to use contraceptives
Physicians inexperienced in addressing risky adolescent behaviors may benefit from consulting various practical references, such as the Bright Futures guidelines.8
The legal dimension of confidentiality in adolescent care is complex because funding sources, state laws, and federal laws, such as the Health Insurance Portability and Accountability Act of 1996,9 regulate which services can be provided confidentially to adolescents (Table 1). A minor can receive emergency care or care for sexually transmitted infections without parental consent in all states.10 In most states, minors can receive substance abuse services11 and contraceptive services10 without parental consent. About one-half of states allow physicians to provide outpatient mental health services to minors without parental consent.12 States also vary as to mandatory reporting of consensual sexual activity between a minor and an adult.13 Consequently, physicians must be familiar with their state's “mature minor” statutes and medical emancipation laws.
|State-specific policies||Center for Adolescent Health and the Law|
|Web site: http://www.cahl.org/programs-and-activities/consent-confidentiality-protections|
|Mental health||Campbell AT. Consent, competence, and confidentiality related to psychiatric conditions in adolescent medicine practice. Adolesc Med Clin. 2006;17(1):25–47.|
|Sexual and reproductive health||Guttmacher Institute|
|Web site: http://www.guttmacher.org|
|Substance abuse||Lallemont T, Mastroianni A, Wickizer TM. Decision-making authority and substance abuse treatment for adolescents: a survey of state laws. J Adolesc Health. 2009;44(4):323–334.|
Members of a group practice that treat adolescent patients should consider jointly establishing practice guidelines regarding provision of confidential services to standardize parental expectations. These guidelines should be created in accordance with the laws applicable to the practice's location, and should explicitly mention foreseeable circumstances in which confidentiality may be broken without consent, such as cases of suspected abuse, significant self-harm or violent injuries, or suicidal or homicidal ideation.
Physicians can learn to navigate conflicts between adolescents and parents. Some parents' discomfort with their teenager receiving confidential care can be assuaged by a written fact sheet or general discussion of the need for confidential services.14 Typically, parents understand the benefits of confidential care but are concerned about not being given important information.15 Thus, initial rapport-building to establish trust is essential. Physicians may then request private time with teenagers by saying to the parents, “This visit is an opportunity for your child to practice taking care of his (or her) own health needs,” or “Students encounter many stressors in school, and I would like to speak to your child about them alone for a few minutes.”
At the same time, parents and physicians should encourage adolescents to assume increasing personal responsibility for their health, because this will facilitate a smooth transition for them to use health care services independently as adults. We all dread hearing that a teenager under our care committed suicide or died in a car crash—but we cannot prevent tragedies if we do not first identify what risks our patients are taking. The adolescent patient's interaction with his or her physician can be among the most meaningful in medicine. By affording adolescents the opportunity to receive confidential care, sports physical examinations, checkups, and other visits can be perfect opportunities to intervene, and that intervention may save lives.