More Evidence Supports the Need to Protect Confidentiality in Adolescent Health Care
Article Outline
See Related Article p. 218
Broad agreement exists that adolescents who are depressed or sexually experienced need health care because evidence-based management can improve their health outcomes. Many also agree that adolescents can benefit from preventive health services. The challenge is to assure that adolescents have access to the health care they need and that the care they receive is of high quality. Many factors determine whether adolescents receive necessary, high-quality health care such as availability of skilled providers, accessibility of clinical sites, and a source of payment. Confidentiality is another key factor for this age group because concerns about privacy influence whether many minors will seek health care and openly communicate with health care professionals.
In this issue of the Journal of Adolescent Health, Lehrer et al [1] examine the characteristics of adolescents who cite concerns about confidentiality as at least one of their reasons for having forgone health care. They found that prevalence of several risk characteristics was significantly higher among both boys and girls who report concerns about confidentiality than among those who did not. For boys, the relevant risk characteristics were primarily related to mental health—high depressive symptoms, suicidal ideation, and suicide attempts. For girls, the risk characteristics were more diverse and included sexual activity, birth control nonuse at last sex, prior sexually transmitted infection (STI), past year alcohol use, high and moderate depressive symptoms, suicidal ideation, suicide attempt, and unsatisfactory parental communication.
The findings of Lehrer et al highlight that adolescents who forgo health care are not the worried well. Furthermore, findings substantially contribute to our understanding of the specific health risks of adolescents who forgo care. Adolescents who forgo health care due to privacy concerns are at increased risk for health problems for which evidence-based management is effective—depression, unwanted pregnancy, and sexually transmitted infections. Thus, the advantages of making sure that these adolescents have access to high quality health care are unequivocal.
For these adolescents to have access to high quality health care services, as a society we must make it possible for health care professionals to deliver confidential care to vulnerable adolescents when they need it. Research dating back more than two decades has consistently found that protecting confidentiality can enhance the likelihood that adolescents will receive needed health care and that limiting confidentiality could impede their access to essential care [2], [3], [4], [5], [6], [7], [8], [9], [10]. Adolescents report that concerns about privacy—specifically concerns about whether or not their parents will be informed—limit their use of health care. This has been the case both when adolescents are asked why they did not receive health care [4], [5], and when they are asked what they would do if faced with a mandate for parental notification [2], [3]. Concerns about privacy can influence adolescents’ use of health care by leading them to delay seeking care or to forgo care entirely [5], and affecting their choice of provider [9], [11], their candor in responding to questions about sensitive topics [10], and their acceptance of certain interventions such as pelvic examinations and testing for STIs and HIV (human immunodeficiency virus) [12], [13], [14].
Recognizing the key role that confidentiality can play in assuring that adolescents receive the care they need, health care professional organizations have adopted ethical codes, policy statements, and practice guidelines that support the provision of confidential care to this age group [15], [16]. These ethical principles and policies address not only the general need for protecting confidentiality in heath care for all age groups, including adolescents, but also the importance of addressing the particular needs for confidential services among those adolescents—precisely the ones identified by Lehrer et al—who are sexually actively, have STIs, are using substances, have mental health problems, or experience unsatisfactory parental communications [15]. It is often these young people who have the most pressing needs for health care but who are most likely to be deterred from seeking it by confidentiality concerns.
Consistent with both the evidence gained from research and the guidance provided by health care professional organizations, a framework of laws and policies has been developed over the past several decades in the United States that supports the delivery of confidential health services for adolescents. Specifically, those adolescents who are minors (under the age of 18 years) are legally authorized in most states to access health care related to contraception, pregnancy, STIs, substance use, and mental health concerns without first having to obtain the consent of a parent, if they are capable of giving informed consent [17]. Often when they can obtain these services based on their own consent, adolescents can also expect that the services will be confidential, either because confidentiality is required by law or because health care professionals legally have the discretion to protect it, subject to legal limits related to prevention of harm to self or others and reporting of abuse. The confidentiality protection afforded adolescents can be found in both state and federal laws [17], [18]. Some of these protections have been in place for decades, as in the case of state minor consent laws that also provide confidentiality protection [17] and the federal Title X Family Planning Program [19], whereas others, such as the HIPAA Privacy Rule, are of more recent vintage [18]. However, they are all designed to increase the likelihood that adolescents will receive the health care they need.
Despite remarkable consistency—among research findings, health care professional organizations, and the framework of existing laws and policies—in their support for adolescents having the ability to access confidential health services when they need them, there have been many recent attempts to limit adolescents’ access to confidential health services [20]. These efforts are often motivated by a belief that providing confidentiality protections for adolescents occurs at the expense of parent-teen communication, or that parents’ interests and adolescents’ interests are in conflict. This is not necessarily true. Research has consistently shown that even when confidential services are available, such as in family planning clinics, at least half of adolescents use the services with their parents’ knowledge [2]. Moreover, clinicians who provide confidential care often find that they have the opportunity to encourage parent-teen communication about issues that are tailored to the teen’s specific needs in a way that does not betray the teen’s trust. This is especially important in light of the finding by Lehrer et al that, at least among girls, unsatisfactory parental communication is one of the risk characteristics of girls who cite confidentiality concern as a reason for forgone care.
Efforts to preserve minors’ ability to access confidential health care for issues related to mental health, sexually transmitted infections, unwanted pregnancy, and substance use need to continue. Adolescents who need these services must find their way into the health care system. Only then will health care professionals have the opportunity both to provide effective treatment and to encourage parent-teen communication.
References
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- In: Morreale M, Stinnett AJ, Dowling EC editor. Policy Compendium on Confidential Health Services for Adolescents. 2nd ed.. Chapel Hill, NC: Center for Adolescent Health & the Law; 2005;
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- 42 U.S.C. §§300 et seq. 42 C.F.R. Part 59.
- . Limiting confidentiality of adolescent health services: what are the risks?. JAMA. 2002;288(6):752–753
PII: S1054-139X(06)00638-0
doi:10.1016/j.jadohealth.2006.12.016
© 2007 Society for Adolescent Medicine. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Forgone Health Care among U.S. Adolescents: Associations between Risk Characteristics and Confidentiality Concern , 14 December 2006
