Adolescent patients and their confidentiality: Staying within legal bounds

A 15-year-old girl (we'll call her "Cindy") comes to your office with an atypical chief complaint: "I want to talk to the doctor." With her mother outside in the waiting room, she tells you that she is sexually active and missed her last period. She's concerned that she might be pregnant. And she doesn't want her mother to know.

For some teenagers, the hardest part of being pregnant, or thinking that they are, is telling their parents. If a physician cannot assure confidentiality about pregnancy (or about any other sensitive health issue), an adolescent may refrain from obtaining health care to keep her parents from learning of her condition.^1,2 Adolescents are more likely to seek care in a setting in which they believe their privacy will be maintained, but state and federal regulations, ultimately, determine the degree of privacy that a patient is afforded.

Despite the 1978 recommendations by the Task Force on Pediatric Education to improve training for adolescent health care, many pediatricians and ob/gyns continue to lack confidence in their ability to address adolescent issues and often do not provide comprehensive care to this age group.^3,4 A study of the availability of adolescent health services and of confidentiality in primary care practices in the Washington, D.C., metropolitan area found that pediatric practices were less likely than family medicine and internal medicine practices to offer adolescents services such as contraception and pregnancy testing.⁵ They were also less likely than family medicine practices to offer adolescents confidential care.⁵ Pediatricians participating in the survey commonly cited lack of equipment and expertise, inadequate staffing, and low patient demand as reasons for not offering the services. While ob/gyns routinely offer contraception and pregnancy testing, they too are often not familiar with the issues of confidentiality that are so critical to success in treating teens.

The physician who is approached by an adolescent in a scenario like the one involving Cindy can make the clinical diagnosis easily enough. The challenge arises in responding to the adolescent's request for confidentiality. Understanding the rights of the adolescent patient and applying them appropriately in the primary care setting can reduce a barrier to care in this population.

What are the rights of an adolescent to confidential health care?

The Society of Adolescent Medicine (SAM) and the American College of Obstetricians and Gynecologists (ACOG) have called for health providers to make their patients aware of the requirements of confidential care and to strike the often difficult balance between maintaining an adolescent's confidences and involving responsible adults when necessary.^10,11