Providing Confidential Reproductive Health Services to Minors

2. Providing Confidential Reproductive Health Services to Minors

3. Objectives • By the end of the presentation, participants will be able to: • Identify why confidentiality is essential to clinical care • Understand the laws regarding minors’ access to reproductive health services • Describe the ways that mandatory consent can affect adolescent reproductive services

4. Outline • Review minors’ access to reproductive healthcare and the right to consent to healthcare from a national perspective. • Provide an overview of the reproductive health services minors can obtain by consent in your state, identifying which services may be confidential.

5. Case Discussion • Michelle is a 15-year-old young woman who has come to your clinic with her mother complaining of an ear infection. Her mother requests to remain in the room for the exam. • Do you allow Michelle’s mother to remain present for the clinical visit?

6. Caring for Adolescents Rule #1: Establish Confidentiality

7. Confidentiality Is Intrinsic to Adolescent Health Service Delivery • Clinically essential • Developmentally expected • Expert consensus

8. Rationale for Confidentiality • Clinically essential • Decision to seek care • Disclosure of behaviors • Follow-up for care • Ford et al. “Confidentiality Assurances” • 562 high school students • Randomized to confidentiality v. no confidentiality • Disclosure 47% v. 39% (p<0.05) • Follow-Up 67% v. 53% (p<0.05) (Ford et al., 1997)

9. Rationale for Confidentiality • Of unmarried sexually active girls <18 yrs • 59% would stop using FP clinics if mandatory parental notification needed to get prescriptions • 1% would stop having sex (Reddy et al., 2002)

10. Rationale for Confidentiality • 76% of teens want confidential services • Without confidentiality • >25% teens believe they would forego care • 17% of teens report they actually have forgone care • Avoid seeking care for STDs/contraception, pregnancy, substance abuse, depression/suicide (Thrall et al., 2000; Ford et al., 1997; Cheng et al. 1995)

11. Rationale for Confidentiality • Confidentiality is developmentally expected • Emotional need for increasing autonomy • Increasing intellectual capacity to give informed consent (Kuther, 2003; Petersen & Leffert, 1995)

12. Rationale for Confidentiality • Professional commitment and consensus • ACOG ’88 • SAM ’92 • AMA ’92 • AAFP ’89 • AAP ’89

13. Establishing Confidentiality:Parental Perspective • Parents are not the enemy • They are experiencing their own adjustment to their child’s adolescence • Opportunity to educate parents about the need for confidentiality in the provider-patient encounter

14. Discuss Confidentiality in Advance • Inform parents about confidentiality policy before visit • Letter home: • Detail when parent will be included in clinical visit and when not • Discuss billing issues (e.g. routine STI testing, etc.) • Display materials discussing importance of doctor/patient confidentiality

15. OUR POLICY ON CONFIDENTIALITY • Our discussions with you are private. We hope that you feel free to talk openly with us about yourself and your health. Information is not shared with other people unless we are concerned that someone is in danger. Sample statement developed by: URMC Department of Pediatrics

16. Meeting the Adolescent and Parent for the First Time • Meet first with adolescent and parent together • Suggest that the adolescent introduce his/her parent • Discuss confidentiality up front • Your level of comfort is important

17. Discussing Confidentiality with Parents and Teens • Lay out the course of the visit • Explain the office/clinic policy regarding visits • Validate parental role in their daughter’s health and well being • Elicit any specific questions or concerns • Direct questions and discussion to the youth while attending to and validating parental input

18. Asking the Parent to“Please step out…” • Invite the parents to have a seat in the waiting room • Assure them that you will call them prior to closing the visit • Invite parent back before close of visit to wrap-up

19. Case Questions for Discussion • After you have asked the mother to “please step out,” Michelle confides in you that she has had unprotected sex and thinks she might be pregnant. • Can she consent to a pregnancy test without the consent of her parents?

20. Minors Can Consent to Many Healthcare Services • States have expanded minors’ authority to consent to medical healthcare. • Signifies recognition that mandated parental involvement can deter teens from seeking services. • Even without relevant specific statutes, physicians commonly provide care to a mature minor without parental consent.

21. Legal Rights Differ by State • Laws vary according to state regarding a minor’s right to confidential care. • State by state factors affecting rights: • Legal definition of “minor” • Conditions of legal emancipation • Parental notification and consent requirements • Mandatory reporting requirements

22. Definition of Minor and Emancipation • In most states, a minor is a person under the age of 18.

23. Legal Emancipation • Some states do not have explicit statutes regarding emancipation. • Conditions can include being married, serving in the military, or being financially independent of parents. • Often minors need to go to court to establish legal emancipation.

24. Title X Exceptions • Dictates that family planning services must be confidential—pre-empts state statutes • Federal Medical Privacy Regulations apply

25. Case Continued • The HCG test confirms Michelle’s pregnancy. You speak with her about her options. • If she so chooses, can she consent to place her child for adoption?

26. Placing a Baby for Adoption • 4/5 of states allow minors to consent to placing their child for adoption either explicitly or by making no distinction between a minor and an adult parent. As of December 2007

27. If she opts for parenthood, can she consent for prenatal care?

28. Prenatal Care and Childbirth • More than half of states allow all minors to consent to prenatal care • Two-thirds of states allow a minor to consent to prenatal care if she: • Has reached a specific age • Is mature enough to understand the nature and consequences of the treatment As of December 2007

29. About one-fourth of states allow, but do not require, physicians to inform parents that the minor is seeking or receiving prenatal care. • About one-third of states have no explicit policy on minors’ authority to consent to prenatal care.

30. If Michelle decides to terminate her pregnancy, does she need to notify her parents?

31. Mandatory Parental Involvement in Minors’ Abortions • A majority of states require parental involvement in a minor’s decision to have an abortion. • About half require parental consent • One-quarter require parental notification • One state requires both consent and notification

32. Judicial Bypass • All of the states that require parental involvement allow for a judicial bypass process. • Several states also permit a minor to obtain an abortion if a grandparent or other adult relative is involved in the decision.

33. Exceptions • Most states that require parental involvement make exceptions under certain circumstances, such as: • In a medical emergency • In cases of abuse, assault, incest, or neglect

34. Additional Restrictions on Abortion: Mandatory Counseling and Waiting Periods for Abortion • More than three-fifths of states require that women seeking abortion receive counseling before the abortion, including specific information detailed by the state.

35. Mandatory Counseling for Abortion (Continued) • About two-fifths of states direct the state department of health to develop the abortion-related materials. • About one-third of the states specify how the information is delivered to women, with several requiring that counseling be provided in person.

36. Most of the states that require counseling also require women to wait a specified amount of time—most often 24 hours— between the counseling and the abortion procedure. • States that require in-person counseling mandate that it take place at least 18 hours prior to the procedure (necessitating two separate trips to the facility).

37. Case Continued • Given that Michelle has unprotected sex, you decide she needs to be screened for STIs. • Can you do this without parental consent? • What about HIV?

38. Consent to Testing and Treatment • All 50 statesand DC allow minors to consent to testing and treatment for STIs. • Several states require that a minor be of a certain age (generally 12 or 14) before being allowed to consent. As of December 2007

39. HIV/AIDS Testing and Treatment • At least 60% of states explicitly include HIV testing and treatment in the package of STI services to which minors may consent • 1 state requires parental notification in the case of a positive HIV test As of December 2007

40. Case Continued • If Michelle’s pregnancy test had been negative, you most certainly would have discussed the possibility of hormonal contraception. • If Michelle had been interested in receiving a prescription for a hormonal methods, would she have needed to get the consent of her parents?

41. Minors and Contraception • Nearly half of the states explicitly allow all minors to consent to contraceptive services. • A small number have no explicit policy.

42. Faces a health hazard (as determined by a doctor) Is married Is a parent Is or has ever been pregnant Is a high school graduate Demonstrates maturity Receives a referral from a specified professional Reaches a certain age Minors and Contraception Half of the states explicitly permit minors to consent in circumstances, such as if the minor:

43. Are Mandated Parental Involvement Laws Medically Beneficial?

44. Mandated Parental Consent? • Research indicates that many parents/guardians are aware of intentions to seek reproductive healthcare • 2005 JAMA study: • 60% of minors reported that a parent or guardian knew they were accessing sexual health services at the clinic (Jones RK, et. al.)

45. Mandated Parental Involvement in Abortions? • 61% of parents are aware of daughters’ decision to have an abortion • 45% of parents are told by their daughters • The majority of parents support daughters’ deciding to have abortions (Henshaw SK, Kost K.. 1992;24:196-207, 213.)

46. Effects of Mandatory Parental Notification and Consent • Four studies measuring the impact of mandatory notification/consent for abortion were completed between 1986 and 2006, in the states of Minnesota, Massachusetts, Mississippi, and Texas

47. Effects of Mandatory Parental Notification and Consent • 1986 Massachusetts study of parental consent: • Small decrease in teen abortions and births • Significant increase in number of minors traveling to neighboring states for abortions • Out-of-state abortions may account for the reduction in in-state abortions (Cartoof V, Klerman L)

48. Effects of Mandatory Parental Notification and Consent • 1995 Mississippi study of parental consent: • Little change in abortion rate • Large increase in the proportion of minors who traveled to other states for abortions • Greater percentage waited until after 12 weeks’ gestation for abortion(Henshaw S, 1995.)

49. Effects of Mandatory Parental Notification and Consent • 2006 Texas study found after PN law went into effect: • Abortion rate among affected teens fell • Birth rates among older white minors increased • Proportion of minors who waited until 18th birthday for abortion increased, resulting in a greater number of second-trimester abortions (Joyce T, et. al. 2006)

50. Political Issues on Mandated Consent/Notification • “Parents’ Rights” • Cannot mandate or legislate adolescent to talk to a parent • Cannot mandate or legislate parental involvement • Providers should seek to improve and expand family’s communication