Positive Pregnancy Test: “But, I Am Not Sexually Active!”
I can still recall her young face overcome with concern as she learned of her positive pregnancy test. She was just 16 years old and a relatively new patient at the time. Her situation was complicated by the fact that her grandmother, her legal guardian, was sitting in the waiting room. Grandma had met me prior to the appointment and clarified that, although she respected the fact that I wanted to see her ward alone, she absolutely did not want me “putting ideas into the child’s head” by offering her any form of birth control. Grandma further stated that she would not be here with her granddaughter today if someone had not talked about “these things” with her own teenage daughter 16 years ago.
Confidentiality in our pediatric and adolescent practices
is often the key to engendering confidence and trust within our patients. In their article published in the October issue of Pediatrics in Review, Drs Maslyanskaya and Alderman discuss the need to educate both adolescents and caregivers about the importance of confidential care to ensure the patient’s emotional and physical wellbeing. This applies particularly in the sensitive domains of sexual health, substance use, and mental health. Research has shown that adolescents, if not guaranteed privacy, are less likely to access health services for reproductive and substance use issues. The authors further describe that physicians should consider multiple factors when weighing the ability of the adolescents to interpret health information and make health care decisions autonomously.
Laws regarding confidentiality and consent may vary drastically from state to state, especially with regards to consent for reproductive health needs (including abortion). Maslyanskaya and Alderman advise that pediatricians faced with these dilemmas understand the limits of confidential care for adolescent patients and provide resources relevant to different states in the United States. Physicians should be aware that minors may gain legal status as adults under certain state and federal laws, including the concepts of “mature” and “emancipated” minors. The authors emphasize that federal laws like HIPPA, Title X , SAMHSA and MEDICAID override state laws and, thus, familiarity with both is essential to the provider. Pediatricians should also be aware that there are instances when they must “break” confidentiality, in the best interest of the patient, as in cases of child abuse or when there is a risk of suicide or homicide. For public health reasons, sexually transmitted infections (STIs) also must be reported to the local health department to ensure that partners are treated and to prevent the spread of the disease.
Finally, the authors discuss that, with the increased use of electronic records, pediatricians should ensure that they are careful to protect confidential information. Strategies may include blocking sensitive information from after-visit summaries and advocating for institutional policies restricting the use of internet portals by parents of teenagers.
In our case, the teenager chose to continue the pregnancy and consented to her grandmother being included in the conversation and planning for the future. She was also made familiar with different long-acting reversible contraceptive methods that are available to prevent future pregnancies.
Nupur Gupta, MD, MPH, Editorial Board Member, Pediatrics in Review November 25, 2019