A survey of middle class adolescents demonstrated that the majority of the teens would be unwilling to seek medical care for sexually transmitted infection, substance abuse or mental health issues if their clinician discussed these issues with their parents. On the other hand, up to ninety-three percent of adolescents would not be concerned if their parents had knowledge of their annual physical examination results or their clinician’s findings in regard to certain physical ailments. A survey done in Massachusetts and published in 1993 showed that 54.7 percent of high school students had never discussed confidentiality with their clinicians, and only one third of the students knew about their right to confidential medical care.
Confidentiality in medical care is important to many adolescents who may be involved in risky behaviors or have psychological or emotional concerns. For gay and lesbian youth, the fear of inappropriate disclosure of information to parents can be a very significant concern since this disclosure could significantly affect family relationships. Without the promise of confidentiality many adolescents will simply not seek medical care. And if adolescents do not know that clinicians can grant them confidentiality, then some will not seek medical care.
In 1993, the Council on Scientific Affairs of the American Medical Association published recommendations in regard to confidential health services for adolescents. These include the following:
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Confidential health care for adolescents is essential
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Physicians should discuss their policies on confidentiality with both adolescents and their parents
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Physicians ought to involve the parents in the health care of their adolescents when it is in the best interest of the patient
Policies on confidentiality are best discussed with the family and the adolescent either at the first visit, or in materials given to the family prior to the visit.
At the age of eighteen years, adolescents are legally able to consent to their own health care. There are no restrictions to this, and the care should be completely confidential. Emancipated minors may also consent to their own medical care. These teens are younger than eighteen years; they could be married, or parents. Most commonly, emancipated minors live apart from their parents and manage their own financial affairs. Mature minors are usually age fourteen years or older. They may consent to medical care (except for surgery or other risky procedures) assuming that their clinician feels they are mature and have the intelligence and understanding to give informed consent to the care. In Massachusetts, adolescents may consent to contraceptive care, emergency contraception and the diagnosis and treatment of sexually transmitted infections.
The clinician-adolescent patient relationship is best served when the care is open and honest. Difficult and sensitive issues may not be resolved unless there is confidentiality. For optimal medical care, confidentiality must be offered to the teen and accepted by the teen. This model differs from the care given to children since information is offered to the parents and the parents often stay with the child throughout the medical visit. And for adult patients, the clinician patient relationship is privileged, so no information is shared with others unless the patient consents. Having the teen and clinician alone for the history and physical examination will help to assure confidentiality. After all, who would be comfortable either asking or answering questions about adolescent sexual activity in the presence of a parent? The concern that asking teens about sexual issues will spur interest in sex is absolutely false.
While it is recommended that clinicians give confidentiality to the adolescents under their care, there are circumstances when confidentiality may be broken. Most commonly, the clinician shares some information about the visit with the parent(s) in the presence of the teen. Not all of the information is shared since confidentiality is usually respected for certain issues including sexuality concerns. However, even if the teen asks that confidentiality be maintained, the clinician is obligated to break confidentiality if the teen’s life is in danger, or if the teen is threatening the life of another individual. In these situations, the judgment of the clinician is essential as to determining when confidentiality may be broken.
Every state has some combination of laws, regulations, court decisions or constitutional provisions that govern the confidentiality of medical information. Confidentiality and privacy of health information is also protected by some federal statues as well as professional codes of ethics promulgated by the American Medical Association. The Health Insurance Portability and Accountability Act (HIPAA) set new standards for the protection of health information as its provisions became effective around 2002 and later. A few states allow the release of confidential information to parents without the adolescent’s permission. Others mandate the reporting of physical or sexual abuse of minors again with or without the consent of the minor adolescent. In a recent survey from The Alan Guttmacher Institute, the following were noted in regard to a teen’s right to consent to reproductive healthcare:
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No state required parental notification or parental consent for a teenager to have contraceptive services, prenatal care or evaluation for sexually transmitted infections
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No state required parental notification or parental consent for a teenager to have treatment for alcohol and drug abuse or outpatient mental health services
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The majority of states required either parental consent or parental notification for teenagers under age eighteen years to have an abortion
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Adolescents may consent to emergency care
If a minor can consent to treatment for substance abuse, then only the minor can consent to release of that information. Since confidentiality laws vary between the states, a minor adolescent could check with his or her clinician to determine the status of confidentiality in their relationship.
In regard to drug testing, most clinicians will require an adolescent to consent to the test prior to ordering it. In certain circumstances if the teen’s competency is doubted or if the teen is at high risk from substance abuse, then consent from the older teen may be waived. As a matter of practice, unless there are extraordinary conditions, many clinicians make it their policy to obtain the adolescent’s consent to drug testing; otherwise, their doctor-patient relationship may be damaged.
Difficulties may arise if an adolescent generates a bill for services at a clinician’s office. For example, if a pregnancy test is performed and the bill to the parents states “pregnancy” test, then a breach of confidentiality will occur. In this case, then teen could arrange to pay for the bill up front, not have the test labeled as “pregnancy” test, or have the bill sent to another address. Or the teen could tell her family that she had a pregnancy test performed. Sometimes pregnancy tests are carried out as an accepted standard of treatment for certain medical problems aside from pregnancy determinations.
Confidentiality between the adolescent and his or her clinician is a cornerstone of their relationship. It is important also for teens to continue to communicate with their parents about their problems. Understandably, some issues such as contraceptive needs, pregnancy concerns or sexual identity issues are not easily discussed with parents. In these cases, the adolescent’s need for confidentiality in the medical relationship is paramount.
Related topics:
AIDS testing, birth control, drug testing, gay and transsexual adolescents, intellectual development, pregnancy, pregnancy termination, substance abuse, unplanned pregnancy
