© Springer International Publishing AG 2018
Hina J. Talib (ed.)Adolescent Gynecology https://doi.org/10.1007/978-3-319-66978-6_11. Case of a Girl with a Secret
(1)
Division of Adolescent Medicine, Department of Pediatrics, The Children’s Hospital at Montefiore, Bronx, NY, USA
(2)
Pediatric Residency Program, The Children’s Hospital at Montefiore, The Pediatric Hospital for Albert Einstein College of Medicine, Bronx, NY, USA
Keywords
ConfidentialityInformed consentEmancipated or mature minorExplanation of benefitsPatient portalThe assurance of confidentiality in sexual, reproductive, and mental health is an essential element of the therapeutic relationship between adolescents and their health-care providers . Research has shown that adolescents may forgo needed health care for these sensitive concerns if they believe this information will be shared with their parents. To address this issue, laws have been enacted to protect confidentiality when an adolescent seeks care in areas such as sexually transmitted infection testing, contraception, and outpatient mental health services. Confidentiality laws can vary by state and may depend on a practitioner’s assessment of the minor’s ability to make informed decisions regarding his or her health. In some circumstances, however, confidentiality cannot be assured, such as when the adolescent’s safety is at stake. There are also other challenges to preserving confidentiality such as billing for services, the electronic medical record, and patient portals . For this reason, providers should familiarize themselves with the laws regarding adolescent confidentiality in their state and include discussions of confidentiality in each adolescent patient encounter.
E.H. is a 15-year-old girl with no significant past medical history who presents to your office for her annual physical prior to starting her sophomore year in high school. You have been her physician since she was an infant. Her mother has accompanied her to your office. She is weighed, her vital signs are recorded, and she and her mother are placed in an exam room. The patient and her mother state that she has been well since her last visit. She was an honor roll student last year and is planning on taking several Advanced Placement courses in the fall. You are ready to commence the physical exam , and you ask E.H.’s mother to sit in the waiting room while you exam E.H. You explain to E.H. and her mother that in addition to the exam, you will be asking E.H. a series of additional questions. You also explain that anything discussed with E.H. during this time will be kept between yourself and E.H. except if E.H. discloses information that demonstrates she wishes to harm herself or others or is in danger in some other way. You further explain that this confidential interview is a component of every health-care maintenance visit you conduct with an adolescent patient.
Once E.H.’s mother has left the room, you begin to ask questions related to sexual and behavioral health. E.H. states that she and her boyfriend of 1 year have recently started having sexual intercourse, and she is interested in obtaining contraception. E.H. states that she has not told her mother she is sexually active and begs you not to tell her mother. She states that some of her classmates have told her about the oral contraceptive pill, and though she thinks she may like to try it, she is worried about her parents finding out when they receive a bill for your services.
Questions
- 1.
How should providers begin a discussion on confidentiality with patients and parents ?
- 2.
How should providers balance the rights of adolescents’ privacy regarding certain elements of their health with parents’ responsibility to be a part of their adolescent child’s health?
- 3.
What limitations exist to the confidential relationship between health-care provider and adolescent patient?
- 4.
How are confidential health-care services that are provided to adolescent patients paid for without informing their parents whose insurance is billed?
- 5.
In an era of electronic medical records and electronic patient portals , what new challenges have arisen to ensuring confidential health-care services for adolescents?
Discussion
Background
Adolescents exist in a unique place physically, socially, and psychologically. As they grow physically into adults, they also begin to separate emotionally from their parents and begin to develop a distinct set of behaviors, opinions, and values. The practice of adolescent medicine is also distinct in that it encompasses aspects of health and the human experience that are considered very private such as romantic and sexual relationships, reproductive choices, and mental and emotional health. As adolescents begin to assert their independence from their parents, they often want to keep the aforementioned aspects of their life and health private. An adolescent’s fear that his or her parents will discover health information that one wishes to keep confidential is sometimes so strong that some adolescents will defer needed health care to prevent an intentional or unintentional breach of their confidentiality. Therefore, to be an effective adolescent health-care provider, one must examine issues of privacy, confidentiality, consent, and the provider-patient relationship with a different lens than that used for patients of other ages. Because of these unique aspects of adolescence, confidentiality and consent are integral parts of an effective therapeutic relationship with an adolescent patient. In order to ensure the integrity of this relationship, confidential care may be provided to adolescents for selected services, including sexually transmitted infection screening and treatment, mental health services, contraception, and pregnancy, depending on the state of medical practice.
The power of consent and the protection of confidentiality are closely connected in the provision of adolescent health care. Consent in the context of health services is informed permission given without coercion or duress by an individual for medical services or interventions. Minors (defined as anyone below the age of 18 years old) are not legally considered competent to evaluate the significance of medical diagnoses or to assess the potential risks and benefits of recommended medical treatments. Parents or legal guardians, therefore, are in most cases tasked with the right and the responsibility of giving consent for medical care for their minor children. Anyone 18 years or older, on the other hand, is no longer a minor and considered legally capable of giving consent if they have the mental capacity to understand the risks and benefits of medical care.
These general guidelines of consent become more complicated for adolescents. Every state has its laws related to the ability of minors to consent. These decisions encompass reproductive and sexual health such as diagnosis and treatment of sexually transmitted infections, contraception, pregnancy-related care, outpatient mental health and substance abuse services, and sexual assault treatment. In addition to the ability to consent to these services, adolescents may have the right to receive these services confidentially without parental notification except in the case where an adolescent gives explicit permission for confidential diagnoses and interventions to be shared with parents by the provider.
In general, areas outside these protected services still remain in the purview of the parent or guardian. This means that parents have the right to be informed of any test results or medical diagnoses and to give or withhold consent for medical testing or procedures outside of the realm of the confidential areas described above.
Mature and Emancipated Minors
Some minors are entitled to consent for all of their own health care. Emancipated minors are those who are married, are parents, are enrolled in the armed forces, or are financially independent [1]. Minors who are parents may not only have the right to consent to all of their own health care, but also that of their children depending on state law. Pregnant minors also have expanded rights. Pregnant adolescents have the right to confidentiality for all health care related to prenatal care including non-gynecologic issues that could potentially adversely affect a pregnancy [1].
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