Maintain confidential care for adolescents

Your practice includes confidential care for adolescents, including provision of contraceptives and testing/treatment for sexually transmitted diseases (STDs). But are your office staff communicating the confidentiality of this information correctly to prospective teen patients? If they are not, adolescents may fail to access these important services.

A just-published survey of physicians and their office staff at 170 pediatric, family medicine, and internal medicine practices found that in as many as 63% of practices, office staff answering telephones gave responses that contradicted doctors’ responses when asked if they offer confidential services to adolescents.1

Such findings are troubling, because teens should know they have a right to confidential care and because the information they receive about confidentiality when trying to schedule an appointment may be a deciding factor in whether to seek health care, says Tina Cheng, MD, MPH, director of general pediatrics and adolescent medicine at Baltimore-based Johns Hopkins University. Whether or not teen-agers suspect they may have HIV, or if they are simply looking for contraceptive information, any delay to medical care could have serious consequences, she notes.

"In most cases, it is best for teens to discuss their concerns with parents or guardians; however, if this is not possible, it is desirable that youth get the health care they need," states Cheng. "Legal statutes have recognized this need, and each state legally entitles adolescents to consent to treatment for medically emancipated conditions that may include contraception, pregnancy, diagnosis and treatment of STDs, HIV, substance abuse, and mental health problems."

Providing confidential care for adolescents can be challenging for health practitioners, Cheng acknowledges. Some of the challenges include limited time for office visits; difficulties in maintaining confidentiality in billing, medical records, and follow-up communication; and lack of training in adolescent issues among providers and staff.

"To provide confidential care for teens requires addressing the above challenges and development and dissemination of an office policy," she explains. "Office staff should be aware of the confidentiality policy, and confidentiality should be discussed with parents and teens."

Adolescents are more willing to communicate with and seek health care from physicians who ensure confidentiality. According to a randomized controlled trial in three suburban public high schools, teens are more willing to disclose general information, as well as information about sensitive topics, and more likely to make a return visit if such confidentiality is clearly communicated.2

According to a study of adolescent female patients at Wisconsin family planning clinics, the majority of teens said they would stop using sexual health services if they had to inform their parents that they were seeking contraceptive care.3 The study also found that 99% of girls who would stop going to the clinics said they would continue to have sexual intercourse.

"Not only would these adolescents be using less-effective contraceptive means or nothing at all, but it also would have an impact on the spread of sexually transmitted diseases because some of the girls indicated that they were getting tested for sexually transmitted diseases and would stop doing that," says Diane Reddy, PhD, associate professor and director of health psychology at the University of Wisconsin-Milwaukee and lead author for the paper.

A legal framework developed in the United States during the last 30 years supports the provision of confidential health care to minors in many circumstances.4 All 50 states legally entitle adolescents to consent for treatment for "medically emancipated conditions" that may include contraception; pregnancy; diagnosis and treatment of STDs, HIV, or reportable diseases; treatment of substance abuse problems; and mental health issues.

According to the New York City-based Alan Guttmacher Institute (AGI), many states specifically authorize minors to consent to contraceptive services, testing and treatment for HIV and other sexually transmitted diseases, prenatal care and delivery services, treatment for alcohol and drug abuse, and outpatient mental health care. According to a 2000 review of individual state laws, the institute found:

  • Twenty-five states and the District of Columbia have laws or policies that explicitly give minors the authority to consent to contraceptive services. (To review AGI’s table of state laws, go to its web site, www.agi-usa.org, click on "The Guttmacher Report," "Archive," and "August 2000." Click on the article "Minors and the right to consent to health care."
  • Twenty-seven states and the District of Columbia have laws or policies that specifically authorize a pregnant minor to obtain prenatal care and delivery services without parental consent or notification.
  • All 50 states and the District of Columbia specifically allow minors to consent to testing and treatment for STDs, including HIV. (In three states — California, New Mexico, and Ohio — minor consent law does not apply to HIV treatment.)5

According to the Institute’s survey, no state explicitly requires parental consent or notification for any of these services. However, two states, Texas and Utah, prohibit the use of state funds to provide contraceptive services to minors without parental consent, and Iowa law calls for parental notification if a child receives a positive HIV test. (See definitions of privacy, confidentiality, and informed consent below.)

References

1. Akinbami LJ, Gandhi H, Cheng TL. Availability of adolescent health services and confidentiality in primary care practices. Pediatrics 2003; 111:394-401.

2. Ford CA, Millstein SG, Halpern-Felsher BL, et al. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. A randomized controlled trial. JAMA 1997; 278:1,029-1,034.

3. Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls’ use of sexual health care services. JAMA 2002; 288:710-714.

4. English A, Morreale M. A legal and policy framework for adolescent health care: Past, present, and future. Houston J Health Law Policy 2001; 1:63-108.

5. Boonstra H, Nash E. Minors and the right to consent to health care. Guttmacher Report on Public Policy 2000; 3:4-9.

Definition of Key Terms

  • Confidentiality in a health care setting is defined as an agreement between patient and provider that information discussed during or after the encounter will not be shared with other parties without the explicit permission of the patient. It is best classified as a rule of biomedical ethics that derives from the moral principle of autonomy and accompanies other rules such as promise keeping, truthfulness, and privacy.
  • Privacy means freedom from unsanctioned intrusion. In a health care setting, it involves psychological, social, and physical components in addition to confidentiality.
  • Informed consent describes the process during which the patient learns the risks and benefits of alternative approaches to management and freely authorizes a course of action proposed by the clinician. Informed consent has ethical and legal derivations. Although usually bound together in clinical encounters, confidentiality and consent are different. Confidentiality can occur during an encounter whether or not specific informed consent for a treatment or intervention is given. For example, contraceptive options may be confidentially discussed before informed consent is given for any specific choice.

Source: Society for Adolescent Medicine. A position paper of the Society for Adolescent Medicine. Confidential health care for adolescents. J Adol Health 1997; 21:408-415.