Confidentiality in adolescent health care
- Amy B Middleman, MD, MPH, MS Ed
Amy B Middleman, MD, MPH, MS Ed
- Section Editor — Adolescent Medicine
- Professor of Pediatrics, Chief of Adolescent Medicine
- University of Oklahoma Health Sciences Center
- Kelly A Olson, MD, MA
Kelly A Olson, MD, MA
- San Jose Clinic
- Section Editors
- Abigail English, JD
Abigail English, JD
- Section Editor — Adolescent Medicine
- Director and President
- Center for Adolescent Health & the Law
- Diane Blake, MD
Diane Blake, MD
- Section Editor — Adolescent Medicine
- Professor of Pediatrics
- University of Massachusetts Medical School
The concepts of informed consent and confidentiality are complex when the patient is an adolescent. This is particularly true when the needs and wishes of the adolescent conflict with the opinions and preferences of the parents .
The laws governing consent and confidentiality in adolescent health care vary from country to country; within the United States, they vary from state to state. The information in this topic focuses on confidentiality in adolescent health care in the United States.
Clinicians who treat adolescents must be aware of the federal and state laws related to adolescent consent and confidentiality. The circumstances in which adolescents may consent for their own care and the confidentiality laws vary from state to state depending upon the adolescent's status as a minor or adult, the service involved, and the provider's level of concern regarding harm to the patient or others.
The basic laws governing consent for health care are state laws; clinicians who treat adolescents need to be aware of the laws in their state. Confidentiality protections are found in both state and federal law. Clinicians who treat adolescents also must be aware that federal and state funding sources may have specific requirements related to confidentiality for particular services. They should be familiar with the consent and confidentiality policies of the facility in which they practice, and they must be aware of potential ways in which confidentiality can be compromised (eg, record keeping, billing statements, insurance).
This topic will provide an overview of confidentiality in adolescent health care, including definitions, exceptions to confidentiality, and potential threats to confidentiality. Determination of minor status and how it relates to consent for specific medical services, which is closely linked to confidentiality, are discussed separately. (See "Consent in adolescent health care".)
- Cutler EM, Bateman MD, Wollan PC, Simmons PS. Parental knowledge and attitudes of Minnesota laws concerning adolescent medical care. Pediatrics 1999; 103:582.
- Weddle M, Kokotailo P. Adolescent substance abuse. Confidentiality and consent. Pediatr Clin North Am 2002; 49:301.
- Policy Compendium on Confidential Health Services for Adolescents, 2nd ed, Morreale M, Stinnett AJ, Dowling EC (Eds), Center for Adolescent Health and the Law, Chapel Hill, NC, 2005. Available at: www.cahl.org/PDFs/PolicyCompendium/PolicyCompendium.pdf (Accessed on October 31, 2012).
- Larcher V. Consent, competence, and confidentiality. BMJ 2005; 330:353.
- Confidential health services for adolescents. Council on Scientific Affairs, American Medical Association. JAMA 1993; 269:1420.
- ACOG educational bulletin. Confidentiality in adolescent health care. Number 249, August 1998. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1998; 63:295.
- Ford CA, Thomsen SL, Compton B. Adolescents' interpretations of conditional confidentiality assurances. J Adolesc Health 2001; 29:156.
- Thrall JS, McCloskey L, Ettner SL, et al. Confidentiality and adolescents' use of providers for health information and for pelvic examinations. Arch Pediatr Adolesc Med 2000; 154:885.
- Jones RK, Purcell A, Singh S, Finer LB. Adolescents' reports of parental knowledge of adolescents' use of sexual health services and their reactions to mandated parental notification for prescription contraception. JAMA 2005; 293:340.
- Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care. A randomized controlled trial. JAMA 1997; 278:1029.
- Lehrer JA, Pantell R, Tebb K, Shafer MA. Forgone health care among U.S. adolescents: associations between risk characteristics and confidentiality concern. J Adolesc Health 2007; 40:218.
- Leichliter JS, Copen C, Dittus PJ. Confidentiality Issues and Use of Sexually Transmitted Disease Services Among Sexually Experienced Persons Aged 15-25 Years - United States, 2013-2015. MMWR Morb Mortal Wkly Rep 2017; 66:237.
- Ford CA, Millstein SG. Delivery of confidentiality assurances to adolescents by primary care physicians. Arch Pediatr Adolesc Med 1997; 151:505.
- Lovett J, Wald MS. Physician attitudes toward confidential care for adolescents. J Pediatr 1985; 106:517.
- Greydanus DE, Patel DR. Consent and confidentiality in adolescent health care. Pediatr Ann 1991; 20:80.
- American Medical Association. Report of the Council of Scientific Affairs. Confidential Care for Minors. Available at: www.ama-assn.org (Accessed on February 06, 2008).
- Ford C, English A, Sigman G. Confidential Health Care for Adolescents: position paper for the society for adolescent medicine. J Adolesc Health 2004; 35:160.
- Committee on Bioethics. Policy statement--Physician refusal to provide information or treatment on the basis of claims of conscience. Pediatrics 2009; 124:1689.
- Boonstra H, Nash E. Minors and the right to consent to health care. The Alan Guttmacher Institute, New York 2000. Available at: www.guttmacher.org/pubs/tgr/03/4/gr030404.html (Accessed on October 31, 2012).
- Hofmann AD. Legal issues in adolescent medicine. In: Adolescent Medicine, Hofmann AD, Greydanus DE (Eds), Appleton and Lange, Stamford, CT 1997.
- The adolescent's right to confidential care when considering abortion. American Academy of Pediatrics. Committee on Adolescence. Pediatrics 1996; 97:746.
- Wartenberg D, Thompson WD. Privacy versus public health: the impact of current confidentiality rules. Am J Public Health 2010; 100:407.
- American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and Society for Adolescent Medicine. Protecting adolescents: Ensuring access to care and reporting sexual activity and abuse. J Adolesc Health 2004; 35:420.
- Glosser A, Gardiner K, Fishman M. Statutory rape: a guide to state laws and reporting requirements. The Lewin Group 2004. Available at: www.lewin.com/publications/publication/75/ (Accessed on October 31, 2012).
- Madison AB, Feldman-Winter L, Finkel M, McAbee GN. Commentary: consensual adolescent sexual activity with adult partners--conflict between confidentiality and physician reporting requirements under child abuse laws. Pediatrics 2001; 107:E16.
- New York Civil Liberties Union. Child Abuse Reporting and Teen Sexual Activity: Clarifying Some Common Misunderstandings (March 2009). http://www.nyclu.org/files/publications/nyclu_pub_child_abuse_reporting.pdf. http://www.nyclu.org/files/publications/nyclu_pub_child_abuse_reporting.pdf.
- Shain BN, American Academy of Pediatrics Committee on Adolescence. Suicide and suicide attempts in adolescents. Pediatrics 2007; 120:669.
- Press BR, Khan SA. Management of the suicidal child or adolescent in the emergency department. Curr Opin Pediatr 1997; 9:237.
- Kachigian C, Felthous AR. Court responses to Tarasoff statutes. J Am Acad Psychiatry Law 2004; 32:263.
- Gostin LO. Surveillance and public health research: privacy and the "right to know" In: Public Health Law and Ethics, 2002. Available at: www.publichealthlaw.net/Reader/ch10/ch10.htm (Accessed on October 31, 2012).
- Schleiter KE. When patient-physician confidentiality conflicts with the law. AMA J Ethics. 2009; 11:146. http://journalofethics.ama-assn.org/2009/02/hlaw1-0902.html (Accessed on July 15, 2016).
- Ethical principles of psychologists and code of conduct. Am Psychol 2002; 57:1060.
- Rae WA, Sullivan JR, Razo NP, et al. Adolescent health risk behavior: when do pediatric psychologists break confidentiality? J Pediatr Psychol 2002; 27:541.
- Hofmann AD. Consent and confidentiality. In: Adolescent Medicine, 3rd ed, Greydanus D, Hofmann AD (Eds), Appleton and Lange, Stamford, CT 1997.
- English A, Ford CA. The HIPAA privacy rule and adolescents: legal questions and clinical challenges. Perspect Sex Reprod Health 2004; 36:80.
- Society for Adolescent Health and Medicine, Gray SH, Pasternak RH, et al. Recommendations for electronic health record use for delivery of adolescent health care. J Adolesc Health 2014; 54:487.
- Roscam Abbing HD. Medical confidentiality and electronic patient files. Med Law 2000; 19:107.
- Spooner SA, Council on Clinical Information Technology, American Academy of Pediatrics. Special requirements of electronic health record systems in pediatrics. Pediatrics 2007; 119:631.
- Committee on Adolescence, Council on Clinical and Information Technology, Blythe MJ, Del Beccaro MA. Standards for health information technology to ensure adolescent privacy. Pediatrics 2012; 130:987.
- Litt IF. Adolescent patient confidentiality: whom are we kidding? J Adolesc Health 2001; 29:79.
- Thompson LA, Martinko T, Budd P, et al. Meaningful Use of a Confidential Adolescent Patient Portal. J Adolesc Health 2016; 58:134.
- English A. Legal Aspects of Care. In: Textbook of Adolescent Medicine, 1st ed, McAnarney ER, Kreipe RE, Orr DP, Comerci GD (Eds), WB Saunders, Philadelphia 1992.
- Morrissey JM, Hofmann AD, Thrope JC. nt and Confidentiality in the Health Care of Children and Adolescents: A Legal Guide, The Free Press, New York 1986.
- English A. Treating adolescents. Legal and ethical considerations. Med Clin North Am 1990; 74:1097.
- Rainey DY, Brandon DP, Krowchuk DP. Confidential billing accounts for adolescents in private practice. J Adolesc Health 2000; 26:389.
- Society for Adolescent Health and Medicine, American Academy of Pediatrics. Confidentiality Protections for Adolescents and Young Adults in the Health Care Billing and Insurance Claims Process. J Adolesc Health 2016; 58:374.
- English A, Gold RB, Nash E, Levine J. Confidentiality for Individuals Insured as Dependents: A Review of State Laws and Policies, New York: Guttmacher Institute and Public Health Solutions, 2012, <http://www.guttmacher.org/pubs/confidentiality-review.pdf>. http://www.guttmacher.org/pubs/confidentiality-review.pdf.
- English A, Summers R, Lewis J, Coleman C, Confidentiality, Third-Party Billing, & the Health Insurance Claims Process Implications for Title X (Washington, DC: National Family Planning & Reproductive Health Association, 2015). http://www.confidentialandcovered.com/file/ConfidentialandCovered_WhitePaper.pdf. http://www.confidentialandcovered.com/file/ConfidentialandCovered_WhitePaper.pdf.
- Fisher M, Marks A, Trieller K, Brody R. Are adolescents able and willing to pay the fee for confidential health care? J Pediatr 1985; 107:480.
- Guttmacher Institute. State policies in brief. Minors' access to contraceptive services. Available at: www.guttmacher.org/sections/adolescents.php (Accessed on October 31, 2012).
- Akinbami LJ, Gandhi H, Cheng TL. Availability of adolescent health services and confidentiality in primary care practices. Pediatrics 2003; 111:394.
- Klerman LV. How legislation and health systems can promote adolescent health. Adolesc Med 1999; 10:23.
- Conard LA, Fortenberry JD, Blythe MJ, Orr DP. Pharmacists' attitudes toward and practices with adolescents. Arch Pediatr Adolesc Med 2003; 157:361.
- American Pharmacists Association. Report of the 2004 APhA House of Delegates. J Am Pharm Assoc 2004; 44:551.
- Alford S, Davis L, Brown L. Pharmacists' attitudes and awareness of emergency contraception for adolescents. Transitions 2001; 12:1.
- Conditional versus unconditional
- Public health perspective
- EXCEPTIONS TO CONFIDENTIALITY
- Child abuse/neglect
- - Consensual sexual activity
- Suicidal ideation or attempt
- Homicidal ideation
- Violent injuries
- Sexually transmitted infections
- Mental health care
- Parental notification
- POTENTIAL THREATS TO CONFIDENTIALITY
- Medical records
- - HIPAA
- - FERPA
- - Electronic records
- - Patient portals
- Payment for services
- - Who is liable?
- - Method of payment
- Ancillary staff
- SUMMARY AND RECOMMENDATIONS