Adolescent Confidentiality:

Encouraging Parent-Adolescent Communication Is Best for Children

American College of Pediatricians – September 2020

ABSTRACT

Research confirms that parents play a vital role in helping teens make healthy choices. Pediatricians therefore serve the best interests of their adolescent patients and their families by forging a strong alliance with both parents and adolescents while doing everything possible to foster open parent-teen communication. If a pediatrician wishes to talk one-on-one with an adolescent patient in order to encourage increasing responsibility for self-care, that conversation can be approached in a way that does not undermine the parent-child relationship. This paper describes a process for building a strong partnership with parents, including sharing scientific information with both teens and parents regarding how to maintain optimal sexual health during the adolescent years.

INTRODUCTION

Confidential health care for adolescents is a departure from what has, until recently, been a strong societal norm. Previously, adolescents were viewed as part of their family in all areas of life, including school and health care. Parents were considered responsible for their children and were expected to make all decisions until the child became an “adult” as defined by state law. Not until the 1970s did states begin to legislate that adolescents could consent to certain forms of “confidential care” without parental knowledge or consent. Following the 1973 Roe v. Wade Supreme Court decision extending the “right to privacy” to a woman’s decision regarding abortion, some states extended that same privacy right to teenagers seeking abortions. Currently, all 50 states allow a minor to access and consent to health care services related to sexually transmitted infections without parental knowledge, 27 states allow an adolescent to independently consent to contraceptive services,1 44 states and the District of Columbia offer confidential alcohol and substance abuse treatment to teens, and 20 states plus the District of Columbia allow minors to consent to outpatient mental health services without parental knowledge.2

Although ACPeds recognizes that adolescents may benefit from confidential health care, it also calls attention to the fact that this may undermine the parents’ right and responsibility regarding their minor child’s welfare and also weaken the parent-child bond. Adolescent confidentiality may not serve the best interest of all adolescents all of the time—particularly if the health goals and values of competent parents are undermined in the process. 

STRONG AND STABLE FAMILIES

Adolescents are appropriately viewed as minors who benefit from “hands-on” parenting during their journey toward greater responsibility and independence. Parental authorization is still required for many activities, including most health care services because society regards this as providing protection for the adolescent. Pediatricians should promote parent-child communication about all health issues, including sexual and mental health, because effective parent-child communication is a strong predictor of healthy outcomes especially during adolescence. Physicians should therefore take every opportunity to facilitate close communication between adolescents and their parents rather than create barriers.

WHAT SCIENCE TELLS US

Three particular aspects of scientific research must be considered to understand the importance of parent-adolescent communication.

1. The adolescent brain is immature

  • Every lobe/aspect of the adolescent brain that has been researched demonstrates an immaturity both functionally via imaging as well as practically.3 

  • This immaturity makes parental influence crucial as the adolescent navigates the many challenges of the teen years.

  • Adolescents are less likely to participate in high-risk behaviors when parents are more involved in their children’s lives and monitor their activities.4 

2. Connectedness with parents promotes optimal health outcomes in adolescents

  • The National Longitudinal Study on Adolescent Health, a large, longitudinal study of more than 40,000 adolescents has provided rich data delineating factors that help teens make healthy choices.

  • In one of the first reports on this study, Dr. Resnick and colleagues found, “Parent-family connectedness and perceived school connectedness were protective against every health risk behavior measure except history of pregnancy.” In other words, except for sexual activity that led to pregnancy, those teens who were most connected to their families were much less likely to participate in high-risk behaviors (such as illegal drug and alcohol use, violence, and criminal conduct),5 while a study in an alternative school in Houston found that higher perceived family connectedness was also associated with a lower incidence of being involved with a pregnancy.6 

  • Studies focusing on father’s influence found an association between the involvement of fathers and decreased adolescent alcohol use,7 drug trafficking and gun carrying,8 poverty,9 incarceration,10 behavioral problems in boys and girls and psychological problems in young women.11 “Positive forms of father involvement (involvement in child-related activities, engagement in multiple forms of involvement and developing a positive father-child relationship) were associated with children’s social and emotional well-being as well as behavioral adjustment and academic achievement.”12

  • Further confirming the benefit of incorporating parents into discussions regarding adolescent sexual health, a study using an intervention called Families Talking Together, found those adolescents whose mothers received a 45 minute session with a health care extender that encouraged parent-adolescent communication were much less likely to experience sexual debut within the next 12 months.13 

3. There is a positive health impact when parents convey their values to their teens

  • Adolescents whose mothers convey a clear disapproval of teens’ engaging in sexual intercourse are less likely to initiate sexual activity. This is especially true when adolescents describe their relationship with their mothers as satisfying and warm. If mothers recommend contraception, however, teens are less likely to perceive strong maternal disapproval of premarital sex.14,15 

This evidence alone is sufficient reason for physicians to promote uncompromisingly open and honest parent-adolescent communication as necessary for achieving optimal adolescent health and well-being.

ETHICAL CONSIDERATIONS REGARDING DOCTOR/ADOLESCENT CONFIDENTIALITY 

Because teens are not yet mature adults, and effective parenting remains crucial, the pediatrician serves the best interest of adolescents and their families by promoting open parent-child communication and avoiding doing anything that could undermine it. This principle is especially relevant when the pediatrician approaches a one-to-one conversation with a teenager during the pediatric visit. How such a conversation is handled can make all the difference in whether parents feel included or excluded, and whether parent-teen communication is supported or subverted. 

Consider a scenario that does not promote open and optimal parent-teen communication: The parent is asked to leave the room so the teen will be “comfortable” talking with the doctor about “sensitive questions.” The parent is told that this conversation with the pediatrician is confidential with only three exceptions: the teen plans to harm himself or others, or is being harmed by someone. Consistent with this approach, one paper’s proposed pediatric protocol recommends the following procedure, beginning with the 11-year-old visit: “After reviewing the nonconfidential information with the parent in the examination room, the parent should be asked to step out of the room so the provider can spend time alone with the adolescent or young adult to review sensitive history questions and allow the adolescent to ask questions he or she might not feel comfortable asking or answering in front of the parent.”16 

Parents in this scenario are left to wonder, “Exactly what is the doctor saying to my child?” Sample questions that the above-mentioned protocol suggests asking adolescents include, “Are you attracted to boys, girls, or both?” “What sexual experiences have you had?” “How often do you use condoms?” Many parents would find such questions objectionable for any number of moral, religious, or privacy reasons. Parents might also wonder:

“What values are being conveyed by the health care information and services the doctor is offering my child without my knowledge? Are those values consistent with what we’ve been trying to teach at home?” 

“Is the pediatrician making a decision—which I won’t know about—to offer my child birth control rather than explaining the benefits of practicing abstinence and encouraging that choice?” 

Parents may also feel that if the doctor asks questions in a non-judgmental way (as in, “What sexual experiences have you had?”), that neutral language coming from a medical authority figure can easily be taken by a teenager as communicating an uncritical or even approving attitude toward adolescent sexual activity, as long as condoms are used. 

Moreover, if at the end of a confidential conversation the parent remains completely or even partly in the dark about what either the teen or physician said in their confidential talk, the physician is placed in an untenable position: trying to build a trusting relationship with the family while being unable to openly discuss with parents their child’s important health issues. 

Equally troubling, this situation puts the physician in the position of being complicit with the adolescent in hiding from parents important health matters discussed in the confidential talk. In the words of one article on the disturbing ethical implications of such a practice, “What are we teaching our adolescents when they find persons in authority willing to help them deceive their parents?” We do well to ask, does such a practice promote respect for either the doctor or the parent?17 

In the next section, we consider: What might it look like if the pediatrician approached care of their adolescent patients in a way that encourages their responsible self-care, simultaneously forges an alliance with parents, and thereby promotes positive parent-teen communication?

EMPOWERING THE ADOLESCENT AND INVOLVING PARENTS

Adolescents are empowered, and thereby helped to mature, by giving them appropriate voice and responsibility in decisions that affect their lives. However, because teenagers are still in the process of maturing, they benefit from parents who foster a high level of connectedness, convey clear values, and monitor their activities in age-appropriate ways. This form of parenting, as the research shows, reduces risk-taking and promotes healthy behavior. 

Here are some ways the pediatrician can encourage the teen’s responsibility for self-care and foster critically important parent-teen communication:

1. Explain to the adolescent and parent(s) how you approach the adolescent pediatric visit and why. This creates a shared understanding that sets the stage for everything else, including how you will handle an issue like a one-to-one conversation. For example, you could say:

As your pediatrician, I am very much interested in seeing you grow into a healthy young adult in all aspects of your life. I would like to make sure you have all the appropriate scientific information that will help you make healthy choices and be the best you can be—physically, academically, emotionally, sexually, and even spiritually. So, one of my goals in today’s visit is to share some facts that relate to taking good care of your health.

My second goal is to encourage you, as a teenager, to take increasing personal responsibility for putting this health care information into practice. Forming healthy habits is something we each have to take responsibility for.

My third goal is to strongly encourage you to stay connected to your parents throughout your teen years. Keep the lines of communication open. Talk about things that matter. Consult them when you have to make important decisions. Studies show that teens benefit in many ways when they stay close to their parents and when parents continue to provide guidance and support.

2. Routinely share scientific information about healthy choices with both parties.

Pediatricians and other health care professionals are in a unique position to provide scientifically accurate information to those they serve. As part of the adolescent visit, for example, parents often want pediatricians to address sexual health issues with their teenager, but want them to do so in a way that does not undermine parental values. Providing scientific information about sexual health demonstrates the pediatrician’s willingness to discuss sensitive issues and can facilitate ongoing parent-teen communication about these matters. 

If, early in the relationship with a family, the pediatrician pro-actively shares information supporting teen sexual risk avoidance as the healthiest choice, then a subsequent one-to-one conversation with the adolescent patient (should that conversation occur) can build on that foundation. The teenager knows upfront that the physician is not going to approve sexual activity as a healthy choice.

In addressing sexual health, pediatricians can share the following information and advice, perhaps over a series of conversations, through a written handout or pamphlet, or both:

Decisions about romantic relationships and whether to be sexually active are among the most important life decisions a teenager makes. Those decisions will affect your life now and in the future. 

Every year, the federal government conducts the Youth Risk Behavior Survey of high school students. Students don’t put their names on it, so they can answer honestly. It turns out that sexual activity among teens, as measured by this survey, reached a high in 1991 and has been declining ever since. In 2017, only a minority of high school students—39.5%--said they had ever had sexual intercourse. Only 28.7% said they were “currently sexually active.” So if you do not get sexually involved as a high school student—and, for the sake of your sexual health, I strongly encourage you not to—you will actually be in the majority.18

I also want to emphasize that if you’ve already been sexually involved, you can make a fresh start. Many people your age have done that. You can’t change the past, but you can choose the future. You can commit to living an abstinent lifestyle and find friends who share your values. Develop a game plan for sticking to your values and for getting back on the right track if you slip off.

Explaining the Benefits of Sexual Risk Avoidance 

Next, the pediatrician can give the young person a clear picture of the many important health benefits of avoiding all the risks of teen sexual activity. This could include the following:

I think it helps a young person to make and stick to the decision to practice abstinence if you know all the benefits of that decision, so let me explain them. Avoidance of sexual activity is the only 100% effective way to avoid pregnancy, sexually transmitted infections, and the negative emotional consequences, such as depression and lowered self-esteem, that often follow teenage sexual relationships. 

Let me share some specific medical facts about the benefits of avoiding sexual activity.

  • One of every four teenage girls in the United States will get pregnant by age 20. Pregnancy is a life-changing event—for you and a child you bring into the world. Only 50% of teen mothers attain a high school diploma by age 22.19 Only approximately 10 % of teen mothers attend college and complete a two or four year program there.20 An unmarried teenage mother often faces a life of poverty. 

  • If, during high school, you become pregnant or cause a girl to become pregnant, that child, if allowed to live in the womb and not put up for adoption, will most likely grow up without a father’s presence and influence. Children born to teenage mothers are at increased risk for many kinds of problems. Those include anxiety, depression, troubles in peer relationships, difficulties in school, dropping out of school, doing drugs, and getting pregnant and having a baby as a teenager.21 

  • One out of four sexually active high school girls will get infected with a sexually transmitted disease. Girls are more at risk for negative long-term health consequences of STDs. Cervical cancer—which is extremely rare in girls who are virgins—kills about 4,000 women in the United States every year.22

  • Genital herpes and HIV (the virus that causes AIDS), can infect both males and females. Although there are medicines to help, there is no cure for these infections. One out of 6 Americans has genital herpes. If a woman has herpes, she can pass that on to her baby during birth, causing death or irreversible brain damage.23

  • Many teens mistakenly think oral sex is safe. But oral sex can transmit human papilloma virus (HPV) from the genitals of one person to the other person’s mouth and throat.24,25 Cancer of the mouth and throat has sharply increased in recent years among young people.26 There is now a vaccine for HPV, available at our office, that can reduce the risk of oral cancer, but refraining from oral sex is the only sure protection.27

  • You may wish to have children someday, but the sexually transmitted infection called chlamydia can make that very difficult. This disease infects at least 1 million sexually active women each year. If the chlamydia bacteria reach your fallopian tubes, they can cause pelvic inflammatory disease (PID) and then scarring of the fallopian tubes. This scarring can narrow or block the tubes through which a woman’s egg must pass in order to be fertilized by a man’s sperm.28 

Teenage girls have a 10 times higher risk of developing pelvic inflammatory disease than older women. After just one infection of PID, a girl has as high as a 8 - 12% chance of not being able to get pregnant and have a baby. After a second infection of PID, there is a 25 - 40 % chance of being unable to have a baby.29

  • Young males who get chlamydia often have urethritis which causes burning sensation during urination.

  • Condoms reduce the risk of these sexually transmitted infections, but they do not eliminate them. Some of these infections can be passed on by skin-to-skin contact in the whole genital area, only part of which is covered by a condom. Sexually active teens are sometimes shocked to find out from their doctor that they have one of these infections; they thought they would be “safe” if they used a condom. But they are not.

The pediatrician might conclude this discussion of STIs by saying something like this:

As your doctor, I want you to take good care of yourself. If you think you may someday marry, you’ll want to bring a healthy body to your marriage. If your body is free of sexually transmitted infections, you will not risk infecting your spouse. The best way to avoid all risk of all sexually transmitted infections is to abstain from all sex outside of marriage.

The Emotional Dangers of Sexual Activity during Adolescence

At some point in the conversation about sexual health, it will be important to point out the emotional dangers of having a sexual relationship before marriage as an adult. A suggested conversation:

There is no condom for the heart. Condoms provide zero protection against the negative emotional consequences of teen sex. Studies find that teenage girls and boys who are sexually active are more likely to get depressed. Teens who refrain from risky behavior (such as sex, illegal drugs, using alcohol) are the least likely to experience depression.30,31 Girls between 12 and 16 who have had sex are three to six times more likely to attempt suicide than girls who are virgins.32 

The Rewards of Waiting

An adolescent’s resolve to abstain from sexual activity can be strengthened by knowing the rewards of waiting. The pediatrician could say: 

I want you to know there are wonderful benefits to making the healthiest choice. The rewards of saving sex for marriage, besides good sexual health, include:

  • dating relationships free of the pressure to have sex

  • greater self-respect

  • greater respect for others

  • a clear conscience 

  • peace of mind

  • a better chance of finding someone who loves you for the person you are, who will make a faithful mate in marriage, and who will be a good role model for your children.

  • a better life for any child you bring into the world, because your child will have two married parents committed to each other and who can share the responsibilities of raising their children. 

3. Some pediatricians choose to offer a one-on-one talk with the adolescent—but in a way that does not alienate parents. For example, in addition to explaining the state laws governing adolescent confidentiality, a pediatrician can share the following information with the patient and parent before speaking individually with the adolescent:

I like to have some one-on-one time with all my teenage patients because I think it is important for them to start taking responsibility for their own health care. If you are comfortable having a one-to-one talk with me, I’d like to do that as part of today’s visit.

However, I like to keep parents in the loop as much as possible because of how important I think parent-teen communication is. After the two of us talk, I’d like us to bring your parents up to speed on what we discussed; okay? If there was something you told me that you feel is hard to talk about with your parents, I can help you with that. That’s what I’m here for. So please let me know. (If state law protects adolescent confidentiality, then that too should be clearly explained to both parent and child at this time). 

CONCLUSION

The American College of Pediatricians understands the potential benefits of allowing adolescents to spend confidential time alone with their pediatrician. However, an inevitable consequence of a confidential doctor-adolescent conversation that withholds important health information from the parent is that it undermines both the parent-adolescent relationship and the parent-pediatrician relationship.  For this reason, ACPeds recommends that adolescent confidentiality be carried out in a fashion that encourages parent-child communication rather than undermines it. 

By offering to actively facilitate what might be challenging family conversations, the pediatrician not only clearly demonstrates a desire to help parents and adolescents bridge the communication divide, but also increases the chances that such conversations will actually occur. Of course, if the adolescent insists on patient confidentiality once alone with the doctor, the pediatrician should respect this in accordance with governing state laws. It is important to realize that some adolescents are reluctant to speak with their parents because they are experiencing abuse in the home. Every effort should be made to identify whether or not this is the case, and if it is, to notify child protective services. 

Principle author: Jane Anderson, MD, FCP

VIew or download a pdf version of this statement.

ADDITIONAL RESOURCES

  1. American College of Pediatricians Position Statement, The Roles, Responsibilities and Rights of Parents, https://www.acpeds.org/the-college-speaks/position-statements/parenting-issues/the-roles-responsibilities-and-rights-of-parents.

  2. William Boudreau, M.D., “Why Is Premarital Sex a Danger to My Physical Health?”, in Tom and Judy Lickona, with William Boudreau, M.D. Sex, Love, and You: Making the Right Decision. (Notre Dame, IN: Ave Maria Press, 2003)

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