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Minors with STDs and the parents' right to know(02/20/2011) by Larry Siegel, MA, CST, AASECT In the following, Larry Siegel answers this question from one of our readers: "I am doing a paper on minors with STDs and parent right to know. I am interested in the confidentiality policy and also ethics and legal aspects involved. Any information would be helpful." Thanks for writing in with your question. It is certainly a good (not to mention hot) topic and definitely warrants a whole paper. That said, I'm off the hook for not writing a paper for you! I will, however, try to present you with an overview... The right to confidentiality in adolescent health care in general, much less STI and reproductive health care in particular, is often hotly debated. What makes the scope even larger here is the sometimes huge distinctions between what is legal and what is ethical... Legally, there is both constitutional and state-given rights for treatment of minors. The US Supreme Court has recognized that minors, like adults, have a constitutional right to privacy that guarantees them some degree of independence and autonomy in making decisions about their reproductive health. This is also reflected in the federal Medicaid statutes. Because of this, individual states cannot impose blanket parental consent or notification requirements on minors seeking any type of reproductive health care (ie, contraception, childbirth, STI testing and treatment, abortion). If you notice, all laws that have been enacted/attempted by states trying to restrict an adolescent's right to privacy in reproductive health care have had to include an expedient and confidential way of bypassing parental notification by making them prove 2 things: 1) they are mature enough to fully understand the situation, implications, and consequences and 2) that the services they need are truly in their best interest. This "mature minor" doctrine for treating adolescents, especially in regard to emergency treatment, has developed out of many judicial decisions handed down over the years, as opposed to a specific statute. It is what is usually referred to as "common law" principles. I'm attaching a link to a great article on legal issues in adolescent reproductive health care by the NY Civil Liberties Union. I think you'll find it very helpful. Though many have tried, states are unable to completely eliminate a young person's right to confidential STI treatment. Unfortunately, they are able to restrict it greatly, which then poses a real threat to the young person's health. Several studies have shown that adolescents do not trust their doctors and almost 10% reported that their doctors have revealed confidential information to their parents. This leads down a whole new road of ethicality in treating minors. Fortunately, the vast majority of professional health care organizations recognize the rights of adolescents to respect and privacy, independent of their parents. Much of the controversy comes down, in my opinion, to an understanding of confidentiality. Confidentiality is a right that belongs to the client/patent. It does not belong to the provider at any time. Therefore, the client/patient is the only one who has the ability to disclose information about their treatment. After all, it's theirs! It doesn't matter if a client or patient is 14 or 45; they own the right to confidentiality equally. It seems that for some practitioners, their personal beliefs may direct them into disrespecting the adolescent as a person in their own right; believing that as long as they're under 18, they are incapable of understanding what they are doing. Suffice it to say, this is absurd. It also seems that, for many practitioners, their loyalty goes to whoever writes the check for treatment. This is also an attitude that completely invalidates the adolescent as a person. I will leave the plethora of ethical considerations here to your imagination. The UNFPA, the United Nations Population Fund, along with the CDC, Society of Adolescent Medicine, American Academy of Pediatrics, American Medical Association, Advocates for Youth, International Planned Parenthood Federation, American Council of Obstetrics and Gynecology, American Nursing Association, Child Welfare League, and countless other organizations have official policies that prohibit restricting the access of adolescents to appropriate services and the information they need, including on sexually transmitted diseases, contraception, abortion, and sexual abuse. The language typically refers to the need to safeguard the rights of adolescents to privacy, confidentiality, respect and informed consent, while also respecting cultural values and religious beliefs. In this context it is almost universally recommended that countries should, where appropriate, remove legal, regulatory and social barriers to reproductive health information and care for adolescents. It is the professional and ethical obligation of the health care provider to share with the client all relevant information about health choices that are legal and to support that client regardless of the decision the client makes... If the state limits the provision of such information to the client, an unethical and clinically inappropriate restraint will be imposed on the provider and the provider-client relationship will be jeopardized; not to mention the potential health of the adolescent client herself. It is both common sense and common law that all policies and legislation dealing with young people's access to reproductive health care allow them the same rights and protections as adults or married couples. The biggest challenge for your paper, I think, is to look at "ethical" and "legal" in broader terms. For example, few people get in trouble when dealing with things that are both ethical and legal, or unethical and illegal. These parameters tend to be quite clear. However, the fun starts when we get into areas where things are unethical but legal, or illegal but ethical. A lot of adolescent and reproductive health care issues lie in this gray area... Finally, an important aspect of legal and ethical issues relating to minors seeking treatment for STIs: There are many instances where it is determined that a young female was having intercourse with an older male (usually she under 16) and the law requires the practitioner to report it to the abuse hotline. While the legal obligation is clear, some see certain circumstances where it might be more ethical not to report. Similarly, some states require that the sheriff's department or local constabulary be contacted when it's determined that intercourse occurred between minors, especially if there is a significant age difference. Again, the law seems clear. However, there have been times when practitioners have made the judgement not to report in favor of some other less traumatic resolution. It's not always easy to clearly see the line between consenting, sexually precocious minors and the sexual abuse of a minor (by another minor - adults sexually engaging minors are considered, across the board, to be both legally and ethically wrong and few people take issue with readily reporting it to the authorities). As I mentioned previously, there are times when law and ethics almost contradict one another. These are the judgement calls and doing for the best interest of the patient. It's never without some risk. But, hopefully, it's weighed against the potential risk to the young person; the person about whom this decision is being made. I think this is important because by many standards, a minor receiving treatment for an STI demonstrates proof of sexual experience. Several factors would then be assessed and a duty to report might supercede the patient's right to confidentiality. Confidentiality is important, but it not sacred. If there is determined to be a likelihood that a person will harm him/herself or others, the practitioner has a duty to report it to the authorities. The same goes for any evidence or suspicion of abuse; especially sexual. A 12 year old girl is seeking treatment for vaginal herpes and you learn that her partner was her 16 year old brother; a 14 year old boy has condyloma in the anus and he tells you he has sex with older men for money; a 17 year old girl and her 19 year old boyfriend are seeking treatment for chlamydia and she happens to tell you her father raped her when she was 10- but it had come out 3 years ago and her father had undergone treatment. All of these situations legally require a call to the authorities. Are there any factors that can make these situations where it would be more ethical not to do what is legally required? Here a few links to get you started (find the links on the right hand side of this page): http://www.adolescenthealthlaw.org/ - under the umbrella of Advocates for Youth (see their website as well) www.nyclu.org - article on law and adolescent sexual health care www.plannedparenthood.org - also other links to SIECUS and the Alan Guttmacher Institute Also check out the Harvard University website; they have a lot of good publications on adolescent health care. I hope this was somewhat useful, at least in helping you get started. Feel free to write in for other questions and good luck on your paper. Let me know how it turns out. Take care and be well. Larry Siegel, MA, CST, AASECT Clinical Sexologist Manager, Florida Regional Adolescent Sexuality Training Center This article appears in the following topics: |
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