Privacy for the Vulnerable: Confidentiality in Adolescent Care

Confidentiality is a critical component of adolescent medical care. As adolescents transition into adulthood, the opportunity to spend time alone with a health care provider fosters independence in discussing health issues, making health care decisions and navigating the health care system.

Compared with younger patients, adolescent patients are more likely to engage in high-risk behaviors, such as substance abuse and sexual activity, and experience mental health problems. Being able to discuss these behaviors and concerns with a health care provider confidentially during adolescence may minimize the behaviors’ potential long-term negative health impacts.

Confidential care has other benefits. Adolescents who receive an assurance of privacy from their health care providers are more likely to seek care, discuss sensitive health topics and return for future care.

Professional medical organizations, such as the American Academy of Pediatrics and the American Medical Association, have long endorsed confidential adolescent care, providing an ethical framework for confidentiality.

Elise Berlan, MD, MPH, a pediatrician in the Division of Adolescent Medicine at Nationwide Children’s Hospital, is an expert on confidentiality and consent in adolescent care. “Perceptions of confidentiality influence adolescents’ decisions to seek care and disclose information,” she says. “Pivotal opportunities to influence adolescent behavior may be missed if confidentiality is not discussed.”

Unfortunately, not all adolescents receive confidential care. Without this privacy, adolescents, particularly females, are less likely to disclose sexual activity and seek reproductive health services.

Confidentiality’s legal framework is complex; providers without adequate training on this framework may avoid discussing confidentiality with their patients. Federally, HIPPA allows adolescents to control the right to release health information under specific conditions, including having the right to consent.

“Minors may consent to their own medical care based on a specific legal framework,” explains Dr. Berlan. In addition to HIPPA, Title X ensures confidentiality for adolescents who seek nonemergency reproductive health services at Title X-funded clinics.

State-level confidentiality laws vary widely and generally fall into two categories: (1) status of the minor (e.g., emancipated) and (2) type of care received (e.g., mental health care, substance abuse care). There is also the common law “mature minor doctrine,” which permits older, unemancipated minors with mature reasoning skills to consent to medical care without parental consent.

In addition to legal complexities, other challenges exist to providing confidential adolescent care. For example, parents may have conflicted feelings about confidentiality; they may agree with confidential care, yet not want to be left out of their child’s health care conversations and decisions. Also, providers may not have sufficient time alone with their adolescent patients. In addition, electronic medical record systems may not be adapted to maintain confidentiality, and parents may become aware of confidential medical services when they receive medical bills.

Despite these challenges, confidential adolescent care is possible. Dr. Berlan recommends that providers set the stage for confidentiality by discussing it early and frequently with patients and their parents. Providers should clearly explain confidentiality’s importance and limitations, she says. Limitations to confidentiality become relevant if the patient indicates an intent to harm themselves or someone else or shares that someone has hurt them.

For parents who decline confidential care, Dr. Berlan advises providers to continue discussing the adolescent patient’s medical care needs and assuring the patient that they are there for them.

References:

1. Pathak PR, Chou A. Confidential care for adolescents in the U.S. health care system. Journal of Patient Centered Research and Reviews. 2019 Winter; 6(1): 46–50.
2. Lewis Gilbert A, McCord AL, Ouyang F, Etter DJ, Williams RL, Hall JA, Tu W, Downs SM, Aalsma MC. Characteristics associated with confidential consultation for adolescents in primary care. Journal of Pediatrics. 2018 Aug;199:79-84.e1.
3. Copen CE, Dittus PJ, Leichliter JS. Confidentiality concerns and sexual and reproductive healthcare among adolescents and young adults aged 15–25. NCHS Data Brief. 2016 Dec;(266):1–8.
4. Brittain AW, Williams JR, Zapata LB, Moskosky SB, Weik TS. Confidentiality in family planning services for young people: A systematic review. American Journal of Preventive Medicine. 2015 Aug; 49(2 0 1): S85–S92.
5. Tebb K. Forging partnerships with parents while delivering adolescent confidential health services: A clinical paradox. Journal of Adolescent Health. 2011 October; 49(4): 335–336.

Image credit: Nationwide Children’s