Adolescent STD Prevention: Do Our Policies Get Us Where We Need to Go? Abigail English, JD Center for Adolescent Health & the Law CDC National STD Prevention Conference Chicago – March 11, 2008

A. English, Center for Adolescent Health & the Law Overview How do we view adolescents? What are our goals? What role does knowledge play? What actions need to be taken? What health care needs to be accessible? What role do policies play? Who needs to be involved & how? A. English, Center for Adolescent Health & the Law

A. English, Center for Adolescent Health & the Law Perceptions & Reality Do our perceptions of adolescents match reality? “Teens are healthy” Do we really understand where teens get their information? Parents, school, internet Do we know enough about behaviors & consequences? Virginity pledges A. English, Center for Adolescent Health & the Law

A. English, Center for Adolescent Health & the Law Teens Are Healthy Many teens are healthy, but … Dramatic increases in morbidity during teen years “preventable health conditions with primarily behavioral, environmental, and social etiologies” Adolescents & young adults have highest rates of most STDs of any age group A. English, Center for Adolescent Health & the Law

Where Teens Get Information … … and Share It High rates of “digital” participation Texting, blogging, social networking Posting of images and videos 93% of teens use the internet 64% of teens have created online content 55% have created a profile on a social networking site A. English, Center for Adolescent Health & the Law

Does Reality Match Expectations Case of the virginity pledges Expected to avoid consequences of sexual activity STDs, pregnancy Data suggest unexpected consequences STD infection rates do not differ between virginity pledgers & non-pledgers A. English, Center for Adolescent Health & the Law

Adolescents & STDs: Essential Goals Reduce incidence & prevalence of STDs in adolescents Limit harmful sequelae of STDs for infected adolescents & their sexual partners A. English, Center for Adolescent Health & the Law

Adolescents & STDs: Knowledge is Important Adolescents need to know the basics STDs, prevention, screening, diagnosis, treatment Information must be accurate Sources of information are diverse Knowledge must lead to action A. English, Center for Adolescent Health & the Law

Where Teens Get Information … … and Share It High rates of “digital” participation Texting, blogging, social networking Posting of images and videos 93% of teens use the internet 64% of teens have created online content 55% have created a profile on a social networking site A. English, Center for Adolescent Health & the Law

Does Reality Match Expectations Case of the virginity pledges Expected to avoid consequences of sexual activity STDs, pregnancy Data suggest unexpected consequences STD infection rates do not differ between virginity pledgers & non-pledgers Maybe: less likely to use condoms at sexual debut; less likely to be tested & diagnosed for STDs (Bruckner & Bearman) A. English, Center for Adolescent Health & the Law

Adolescents & STDs: Knowledge  Action Knowledge must lead to action What actions are needed? Refraining from sex, postponing sexual debut Engaging in safer sex Seeking regular preventive, diagnostic, & treatment health services Complying with health care providers’ recommendations A. English, Center for Adolescent Health & the Law

Adolescents & STDs: Comprehensive & Accessible Health Care Prevention Screening & Diagnosis Treatment Age-appropriate & adolescent friendly services A. English, Center for Adolescent Health & the Law

Policies to Promote Knowledge, Action, & Health Care Access Sexuality education Consent Confidentiality Financial access A. English, Center for Adolescent Health & the Law

Sexuality Education Policies Federal funding for “abstinence only” sex education Adults & scientific community favor more balanced approach States beginning to require medical accuracy States increasingly rejecting federal funds in order to offer comprehensive sex education A. English, Center for Adolescent Health & the Law

Consent for Minors’ Health Care Basic rule = parental consent required Alternatives to parental consent Related caretakers Foster parents Court Social worker or probation officer Minor consent A. English, Center for Adolescent Health & the Law

History of Minor Consent Laws Earliest laws enacted in 1950s Consistent pattern of expansion through 1960s & 1970s Few changes in 1980s Attempts to repeal or restrict laws beginning mid-to-late 1990s A. English, Center for Adolescent Health & the Law

Consent Laws in 50 States & DC All states have minor consent laws Some laws based on minor’s status Some laws based on services minor is seeking A few laws allow treatment without consent A. English, Center for Adolescent Health & the Law

Consent Laws Based on Status Emancipated minor Married minor Minor in the armed services Mature minor Minor living apart from parents High school graduate Minor over a certain age Pregnant minor Incarcerated minor A. English, Center for Adolescent Health & the Law

Consent Laws Based on Services (1) “Pregnancy related care” Minors usually may consent Contraceptive services Prenatal & maternity care Minors often may not consent Sterilization Abortion A. English, Center for Adolescent Health & the Law

Consent Laws Based on Services (2) STD/VD prevention, diagnosis, & treatment Reportable disease prevention, diagnosis, & treatment HIV/AIDS testing & treatment Drug or alcohol counseling & treatment Outpatient mental health services Diagnosis & treatment for sexual assault A. English, Center for Adolescent Health & the Law

Rationale for Confidentiality Protection – Health Consequences Avoid negative health outcomes Protect health of adolescents Protect public health A. English, Center for Adolescent Health & the Law

Rationale for Confidentiality Protection – Pragmatic Argument If health care conversations are not private many teens will not seek care Many teens have few opportunities for frank discussion of sensitive topics such as mental health, substance use, and sexuality Young adults need to become independent consumers of health care A. English, Center for Adolescent Health & the Law

Rationale for Confidentiality Protection – Research Findings Research findings on implications of adolescents’ privacy concerns Avoid seeking care Stop using services Go to a different site or provider Decline specific services Limit candor with health professionals A. English, Center for Adolescent Health & the Law

Limits of Confidentiality Mandated Reporting of Abuse/Neglect Concern of imminent serious harm to self or others Insurance Billing Discoverable medical records Validity of signed office agreements A. English, Center for Adolescent Health & the Law

Parents and Adolescents Voluntary communication is important Many parents are supportive Many adolescents choose to inform their parents Mandated communication is often counterproductive Some families are dysfunctional Some adolescents insist on autonomy No inherent conflict exists between interests of adolescents and parents A. English, Center for Adolescent Health & the Law

The Legal Framework for Confidential Care Complex patchwork State & federal law Constitution, statutes, court decisions Reproductive rights Family roles Status of minor children Rights & responsibilities of parents A. English, Center for Adolescent Health & the Law

Relationship of Consent & Confidentiality State & federal laws “Consent & confidentiality” Consent laws may or may not address confidentiality Minor consent laws often contain provisions regarding confidentiality & disclosure Other laws contain confidentiality provisions Consent & confidentiality often linked in clinical practice, ethical guidelines, and professional policies A. English, Center for Adolescent Health & the Law

State Confidentiality Laws State constitutional right of privacy Minor consent Medical confidentiality & medical records Patient access to health records Professional licensing Evidentiary privileges State funding programs A. English, Center for Adolescent Health & the Law

Federal Confidentiality Laws Federal constitutional right of privacy Federal funding programs Title X Medicaid Regulations for federal drug & alcohol programs HIPAA Privacy Rule Importance of state laws in application of federal laws A. English, Center for Adolescent Health & the Law

HIPAA Privacy Rule - Disclosure to Parents If state or other law requires it, provider must disclose If state or other law prohibits it, provider may not disclose If state or other law permits it, provider has discretion to disclose If state or other law is silent or unclear, provider has discretion to grant or withhold access A. English, Center for Adolescent Health & the Law

Confidentiality Provisions in State Minor Consent Laws Explicit protection of confidentiality in minor consent laws Reference to minor consent laws in other statutes Grant of discretion to physician or health care professional to disclose information A. English, Center for Adolescent Health & the Law

Laws Mandating Disclosure Parental notification/consent provisions Child abuse reporting statutes Disclosure requirements when minor is dangerous to self or others A. English, Center for Adolescent Health & the Law

Financial Access is Critical Adolescents & young adults are uninsured at high rates Insured adolescents may not be able to access insurance for confidential care Family planning, public health, & other safety net providers lack sufficient funding A. English, Center for Adolescent Health & the Law

A. English, Center for Adolescent Health & the Law Policies Needed Ensure access to medically accurate comprehensive information about abstinence & contraception in sex education programs Ensure that adolescents may consent for “prevention” as well as diagnosis & treatment for STDs Ensure that confidentiality protections are in place for STD services Ensure that benefit package in public & private insurance covers all relevant preventive, diagnostic, & treatment services for STDs Find ways to enable adolescents with insurance to use the coverage for confidential care A. English, Center for Adolescent Health & the Law

A. English, Center for Adolescent Health & the Law Conclusions Adolescents are healthy … but at risk for STDs Adolescents deserve accurate and comprehensive information Adolescents are capable of giving informed consent to health care Adolescents deserve access to confidential STD care Parents can support comprehensive sex education & access to confidential care Adolescents will benefit from improved financial access to health care for STDs A. English, Center for Adolescent Health & the Law