Confidentiality is a core tenet of health care, particularly important in the area of adolescent reproductive health. But physicians might wonder what their options are for intervening when they learn a teen patient is engaging in unhealthy sexual behavior.
Because of differences in maturation between their cognitive and affective systems, adolescent patients need decision-making support in emotional situations such as pregnancies. Following are four strategies for establishing therapeutic alliance with teens to help them delay having children until their circumstances are less risky.
The AMA Code of Medical Ethics provides guidance to support patient self-determination, such as opinion 2.2.2, “Confidential Health Care for Minors,” which includes steps to take when an unemancipated minor requests confidential care for which the law does not grant the minor decision-making authority.
The following strategies are summarized from an article published in the AMA Journal of Ethics® (@JournalofEthics) by pediatrician Mary A. Ott, MD. Her advice is in response to a case of an adolescent patient who confides in her physician that she’s entered into a “pregnancy pact” with her friends, but applies more broadly.
Dr. Ott bases her advice on the assumption that most adolescents have sufficient cognitive capacity and emotional maturity to make many health care decisions, as well as on evidence that a patient-physician relationship built on a foundation of confidentiality yields good chances of engaging minors in pregnancy prevention.
Assure the patient of confidentiality. Research has shown this makes adolescents more likely to disclose risk behaviors to their physicians. Dr. Ott suggests beginning by saying, “Conversations you and I have about matters of sexuality and drug use are confidential. I want you to be able to discuss things that concern you without fearing that I will tell your parents or anyone else.”
Of course, as mandatory reporters, physicians must break confidentiality when they have a legal obligation to report, such as when a child is a danger to herself or others.
Perform a careful sexual and reproductive history. Questions include: Is the patient in a relationship? Has she ever had sex? If so, what are her sexual practices? Is she using or has she ever used contraceptives?
This would be a good time to also assess potentially life-threatening dangers sometimes seen in sexually active adolescents, such as being coerced by a partner or through sex trafficking. Here too, however, the presence of these threats would trigger a physician’s mandate to report.
Identify the problem behind the problem. Poverty, poor performance in school, lack of opportunity, early dating, the absence of adult supervision, insufficient sex education and limited access to contraceptives also lead to teen pregnancy. Explore details to uncover factors contributing to a patient’s unhealthy or imprudent sexual behavior.
Search for an alternative. Inquire further into a patient’s plans and the social and relationship contexts of her decision-making. If the patient is receptive to it—and when practicing in a state whose consent laws permit it—physicians can also provide access to long-acting reversible contraceptives, which have better continuation rates and lower rates of subsequent pregnancy than other methods.
Keep in mind that confidentiality is limited for adolescents, in large part, because of physicians’ ethical duties to provide care in their best interests until they have the legal right to make decisions for themselves.
Breaking confidentiality is something a physician should take seriously, as therapeutic alliance with adolescents can be particularly fragile. A patient whose confidentiality is betrayed by a physician could become less trustful of health care professionals and therefore might not seek care for sensitive issues in the future.
