Providing confidential care for adolescents.

Near the end of her sports physical examination, a 16-yearold girl seems worried. The physician offers her some time without her mother in the room. Once in private, the girl quickly requests a pregnancy test. Although the test result is negative, this is a perfect teaching opportunity. Adolescents are generally healthy, but they commonly present with high-risk behaviors that are often missed by physicians. In 2007, the leading causes of death for Americans between 15 and 19 years of age were unintended injuries (48.8 percent), homicide (16.7 percent), and suicide (11.1 percent).1 Within the month before a nationwide survey, 42 percent of high school students had consumed alcohol, and 28 percent had ridden in a vehicle with a driver who had been drinking. Furthermore, 34 percent were sexually active; of those, 39 percent had not used a condom the last time they had sexual intercourse.2 Without confidentiality, teenagers may avoid seeking services for sensitive health care needs. For example, in a 2005 study of 1,526 female adolescents presenting to 79 family planning clinics, 40 percent said they would not get contraception from the clinic if parental notification were mandatory, and almost one-half stated that they would subsequently use an over-the-counter method.3 One in five adolescents reported that to avoid parental notification, he or she would resort to using a withdrawal method.3 Some adolescents also worry about loss of confidentiality through ancillary staff or third-party payer access to their medical information.4,5 Although physicians typically prefer to provide health care services to adolescents confidentially,6 many avoid the topic, fearing scenarios such as a teenage girl saying, “I want to start birth control, but please don’t tell my mom.” Physicians often do not ask teenagers about common and important age-specific behavioral antecedents of morbidity and mortality, but instead spend considerable time checking for rare physical pathology. In one study, less than one-half of female students and one-fourth of male students who reported a preventive care visit within the previous year acknowledged discussing sexually transmitted infections or contraception during the visit.7 There are numerous reasons physicians pass up opportunities to discuss risky behaviors with adolescents. These include: • Inadequate reimbursement from insurers • Discomfort or inexperience with medical conditions relevant to adolescent care • Unfamiliarity with, or mixed feelings about, the laws and regulations that govern services to minors • Lack of training in managing difficult social situations, such as a parent forbidding an already sexually active teenager to use contraceptives Physicians inexperienced in addressing risky adolescent behaviors may benefit from consulting various practical references, such as the Bright Futures guidelines.8 The legal dimension of confidentiality in adolescent care is complex because funding sources, state laws, and federal laws, such as the Health Insurance Portability and Accountability Act of 1996,9 regulate which services can be provided confidentially to adolescents (Table 1). A minor can receive emergency care or care for sexually transmitted infections without parental consent in all states.10 In most states, minors can receive substance abuse services11 and contraceptive services10 without parental consent. About one-half of states allow Editorials