It was great that my 15-year-old female patient, who seemed emotionally disengaged during the routine confidential time at her annual visit, felt comfortable enough to return for advice. On the other hand, it was disconcerting to see her in distress and accompanied by a male classmate instead of her family. After emphasizing our confidentiality policy, she revealed that she and her classmate had engaged in a consensual, unprotected sexual relationship and that she was afraid she was pregnant. She also requested a pregnancy test, and if the test result was negative, she wanted to have birth control for future protection.
After praising her for seeking help, I asked the patient whether we could include her parents in the discussion. She quickly rejected that suggestion, stating that her parents would “disown” her if they found out she was sexually active, because premarital sex violated their personal and family values. She threatened to leave without treatment if I insisted on notifying her parents. However, her parents are also my patients, and I did not want to jeopardize my relationship with them. Moreover, my clinic is situated in a small town, and is the only immediate source of health care available.
The situation presented a dilemma. Should I have declined her requests unless she received parental consent, thus running the risk that she could become pregnant (if not already), spread a sexually transmitted infection (STI), or avoid future health care in this community? Or should I have provided the requested services without parental authorization, at the risk of inadvertently violating applicable law?
The American Medical Association's Principles of Medical Ethics clearly state that physicians “shall safeguard patient confidences and privacy within the constraints of the law.”1 However, the laws in American jurisdictions vary with respect to a minor's ability to consent to medical treatment. Many adolescents forego medical services in sensitive situations out of fear of parental notification, which partially explains why more than 40 out of every 1,000 15- to 17-year-old American girls become pregnant each year.2–5
In light of these considerations, as well as the potential for family conflicts and litigation, physicians who provide confidential services to adolescents should adopt a systematic approach which, though patient-oriented, gives due regard to third parties. Here is an example of a stepwise approach for these situations.
1. KNOW THE STATE AND FEDERAL LAWS
For public health reasons, every American jurisdiction allows physicians to diagnose and treat STIs in minors without parental consent. However, there is greater variation as to whether a minor's consent suffices for provision of contraceptive services. Information on consent requirements is available from the Guttmacher Institute at http://www.guttmacher.org.
2. BUILD RAPPORT
Strong rapport between the medical team and the patient (as well as the patient's parents, if they are involved) is arguably the most important factor leading to successful outcomes in such cases. Good rapport builds trust, engenders additional room for flexibility in patient care, and may even reduce the incidence of lawsuits.6,7
Using the BATHE technique may generate rapport by providing a short psychotherapeutic intervention (less than 15 minutes). The technique allows physicians to assess the background situation, the patient's affect, the problem that is most troubling to the patient, and the patient's manner of handling the problem, and then finally to make a statement that conveys empathy.8 It can be helpful to emphasize self-esteem building and self-empowerment through motivational interviewing. The physician can begin with a statement such as, “It's wonderful to see that you are taking responsibility for your health, and now that you have more control over the decisions about your body and your relationships, it's always important to protect and value yourself.”
3. ADDRESS EMERGENT ISSUES
[ Updated] After giving the patient an overview of the limitations on confidentiality, the physician should obtain the relevant history and consider performing a HEEADSSS assessment (concerning the patient's home life, education/employment, eating habits, activities, drug and alcohol use, sexual history, personal safety, and suicidal ideation), followed by relevant anticipatory guidance.9 Physical examination can be deferred unless the patient is specifically symptomatic, but it is important to screen for, at minimum, gonorrhea, chlamydia, and human immunodeficiency virus. Girls should also take a pregnancy test. The physician can say, “We should order a few lab tests to make sure that you aren't pregnant and that you don't have any infections that can come with unprotected sex.” Empiric treatment for common STIs may also be considered.
Contraceptive services, including emergency contraception, may be provided at this point unless applicable law requires parental consent. The logistics of obtaining, storing, using, and paying for contraceptives may be challenging for adolescents. An open-ended question, such as “What do you know about the different types of birth control?”, is useful because the patient may have misconceptions. Regardless, confidentiality may be broken if a bill is inadvertently sent to the parents' house (parents who are not involved in the decision making are typically not obligated to pay for contraceptives). It may therefore be appropriate to refer the patient to a free clinic that specializes in adolescent care.
If there are concerning historical data, the physician may ask the patient about the age of his or her partner and whether the relationship is consensual. Although rape and incest fall outside the scope of this analysis, states differ with respect to the definition and mandatory reporting of statutory rape. Physicians should exercise case-by-case judgment within the confines of state law.10
4. ARRANGE FOR FOLLOW-UP
Follow-up testing for pregnancy and STIs (and any resulting treatment, if necessary) at a subsequent visit is prudent, and confidential contact arrangements should be predetermined. The physician should also comply with any legal requirement of reporting positive STI screening results to public health authorities for partner notification or, if not required, encourage the patient to notify his or her partner(s). In addition, during this visit the physician can fully reevaluate the patient's physical and emotional well-being, and can discuss all of the outcomes that could result from continuing the sexual relationship.
5. PROTECT CONFIDENTIALITY
The adolescent patient may be wary of having his or her confidentiality compromised by clinic or insurance company personnel. It is important for physicians to mitigate such risks to the degree that they are able to do so (e.g., designating a clinic nurse as a direct contact point, safeguarding medical records). It also is useful to be familiar with the practice styles of subspecialists and pharmacists to whom the patient could be referred.
6. OBTAIN PARENTAL INVOLVEMENT AND CONSENT
At this point, the patient may be less resistant to disclosing a sexual relationship to his or her parents, especially if pregnancy and STIs have been excluded. The physician should renew the recommendation for parental involvement in most cases, because this can improve social support, access to services, and contraceptive use.11 Adolescent patients who refuse further disclosure may agree to discuss a relevant and appropriate noncontraceptive indication for birth control (e.g., dysmenorrhea) with their parents to foster communication.
To summarize this stepwise approach, after pregnancy is excluded, the patient in this case scenario may be prescribed a concealable contraceptive option (e.g., Nuvaring), offered condoms, and if indicated, screened and empirically treated for any STIs. By this point, it is hoped that she has established trust with her treatment team and has agreed to parental involvement.
The initial climate of the joint visit with the patient and her parents may be tense and contentious. This can be lessened by empathetically telling the parents, “It's very refreshing that your daughter has started to take responsibility for her health, she trusts you to be a part of it, and you are willing to be here for her.” After creating a comfortable atmosphere, the physician should encourage the parents to agree to any treatment that has been withheld, including mental health services. The time spent with the patient ultimately facilitates the creation of a new, robust support system for her, and can have a life-changing impact.