1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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