If your teenage daughter was sexually active and wanted to go on the pill, you’d want to know, right? Well, think back to when you were her age – would you have told your parents?
These questions were the subject of a recent Melbourne study of parental views of adolescent’s right to confidential health care.
The study, which took place in a specialist Adolescent Medicine clinic, found the majority of parents surveyed (86%) believed they should be informed by their adolescent’s treating health professional about their health problems and behaviours, regardless of whether their child agreed.
For clinicians, confidential care underpins best practice in adolescent health. But so does working with parents and families to support young people who have health problems.
These seemingly opposite approaches raise a number of ethical, legal and health-care issues for health professionals who treat young people.
In Australia, confidential health care is a human right enshrined in law. And medical practitioners can be sued for breaching patient confidentiality.
There are many exceptions to this, such as a patient giving permission for their information to be shared – with partners, parents or family members – or when a person is deemed at serious risk of harm to themselves or others.
If a child under 16 years is considered to be at risk of harm then health professionals are mandated by law to notify child protection authorities (except Western Australia, where health professionals are only required to report sexual abuse).
The definition of “risk of harm” varies between jurisdictions, as does the classification of who constitutes a “mandatory reporter”.
While there are many other legal exemptions to confidential health care, these are the most pertinent in the day-to-day clinical care of adolescent patients.
In practice, this means that a teenager who sits in a consulting room with his or her doctor can rely on their doctor to keep confidential any information they disclose unless an exemption applies.
How old is old enough?
There is no lower age limit, and this is the case if the young patient has presented themselves to a health service independently, or if they see you while mum or dad waits in the waiting room.
So imagine Maya, aged 15, nervously attending the family GP by herself for the first time, worried about pregnancy following an unprotected but consensual sexual encounter two days earlier with her 15-year-old boyfriend of several weeks.
Unless this incident led the GP to strongly suspect abuse, assault, or imminent risk of harm to self or others, the doctor is legally bound to keep this information confidential – even if Maya’s mother visits the next day for her routine Pap smear and mentions her concern about Maya’s boyfriend distracting her from her school work.
If Maya wanted to discuss emergency or ongoing contraception with her GP, a different legal framework comes into play. The right to consent to your own medical treatment kicks in at the age of legal majority, which is 18 years.
But common law allows for a medical practitioner to assess a legal minor for their competence to consent to their own treatment. If they’re found to be competent, parental consent is not required, and the adolescent can consent to their own treatment.
Maya would need to satisfy her GP that she has a full understanding of any treatment being proposed (contraception, for instance) and that she voluntarily accepts the treatment.
In South Australia and New South Wales, additional legislation provides for younger teenagers to consent to their own treatment.
Nevertheless, in optimal adolescent health care, the family, cultural and psychosocial environments of each patient are considered. Important ethical issues can arise, and these can intersect with legal issues.
What if the GP believed that Maya’s parents would in fact be tolerant of this new turn in her relationship and would want to support her?
What if the GP also felt that for Maya to keep a secret from her parents this would actually cause her more anxiety than the sexual relationship itself?
The ideal consultation would also include an exploration of these issues with Maya.
The opposite might be true – what if the GP believed that family repercussions for Maya’s sexual activity could be serious, perhaps due to religious or cultural beliefs?
The GP might wish to offer Maya other options for support in this context.
Parents want to know
In the Melbourne study, 40% of parents wanted to be told of their adolescent’s sexual activity, and this rose to almost 60% if their daughter was pregnant or if their son or daughter had a sexually transmitted infection.
Parental desire to be informed about health behaviours or problems was highest for mental health issues, such as depression (87% of parents), eating disorders (81%) and drug use other than alcohol, smoking or marijuana (78%).
It’s understandable why parents want to be informed when mental illness or substance abuse is involved.
Psychological illnesses and substance misuse can impact on an individual’s insight and capacity to care for themselves, and surrounding support persons are part of a “care team”.
When these issues are identified in confidential consultations with adolescents, the law does not change per se, but the practicalities of health care probably do in most situations.
Managing a mental health condition may require treatment from a number of health professionals and the establishment a support network.
Part of the therapeutic armament would include focused discussions with the adolescent about informing and involving parents or carers, being careful not to breach confidentiality in order to gain trust and build a therapeutic relationship.
This applies whether an adolescent patient is 13 or 19, although the young person’s maturity, educational stage and psychosocial needs must be considered in the context of their family and cultural background.
Case by case
Adolescent health care is a challenging area of medicine, not in the least because adolescents are in a “grey area” legally and as individual patients.
There are varying levels of maturity and autonomy that must be assessed for each adolescent and in each clinical situation.
Parents can be the most important source of support for most adolescents and ideally should be involved when their adolescent child has complex or changing health and wellbeing needs.
Nevertheless, the confidential consultation is essential as young people learn to take responsibility for their health and learn to navigate the health system – and the world in general – in their personal quest for maturity and autonomy.
What role should parents play in their teen’s health care? Share your comments below.