Patient Presentation
A 14-year-old female came to clinic for a health supervision visit. She stated that she recently had become sexually active with a single male partner and they were using condoms consistently. She denied any vaginal or abdominal problems. The past medical history and family history were non-contributory. The social history found that she was a high school freshmen who played in the band and got above average grades. She had a good relationship with her parents but had not disclosed the sexual activity.
The pertinent physical exam showed a well-appearing female with growth parameters in 10-25%. Her examination was normal including a pelvic examination. The laboratory evaluation for pregnancy and sexually transmitted infections were negative. The diagnosis of a healthy adolescent with recent initiation of sexual intercourse was made. During staffing, the resident said that he didn’t know the state laws regarding contraception for teenagers in the state. The faculty physician reviewed them with him and noted that each state had slightly different laws. The resident physician talked to the patient and discussed the risks of early sexual activity. He also discussed the proper use of condoms and recommending adding a spermicide if no other contraception was used, and he discussed the pros and cons of other contraceptive alternatives including abstinence, Depo-provera® and oral contraceptives. They also discussed what to do for emergency contraception. He also offered to talk with her parents or to be in the room while she told her parents about her sexual activity. The patient’s clinical course 3 months later revealed her returning to initiate Depo-provera contraception after she had told her parents. Her mother said, “I was really surprised and I’m not happy about it and she knows that. We talked about the risks. But I also don’t want her to get pregnant or have an infection. So that’s why we’re here.”
Discussion
Teenage pregnancy has decreased in recent years but the United States still has one of the highest rates in the world. Education is imperative so children, teens and adults understand the risks of early initiation of sexual intercourse, contraception, sexually transmitted infection prevention and treatment and adolescent gender issues. Confidentiality for seeking care and treatment is imperative for teens.
While family relationships, health care providers and programs that promote and support abstinence and later initiation of sexual activity are extremely important, a high number of pre-teens and teens initiate sexual activity in the pre-teen and teen years. Therefore, confidentiality to seek sexual health care is important. “Sixty percent of teens younger than 18 who use a clinic for sexual health services say their parents know they are there. Among those whose parents do not know, 70% would not use the clinic to obtain prescription contraceptives if the law required that their parents be notified.” (See To Learn More Below). Supports to help teens make good decisions about their current and future health are needed.
Other cases about adolescent sexual health include:
What Are Some of the Complications of Teenage Pregnancy? and How Can I Make My Sexual Interview More Gender Neutral?.
Learning Point
In the United States, some contraceptives are easily available such as male and female condoms and sperimicides, and minors may legally purchase them without a prescription. Other contraceptives require a prescription or are supplied (i.e. Depo-provera injection) by a health care provider. In most states, contraceptive counseling and distribution is confidentially available to minors (i.e. there is no parental notification requirement). Some states do have restrictions which may or may not be enforced.
Abortion services may be more restricted and are highly variable from state to state in the U.S.. Some states have no parental/family notification, some require one or both parents to be notified, some allow other adult family members other than parents to be notified, and some states allow the notification to be waived by a judge. Planned Parenthood has a listing of parental/family notification requirements, here.
Questions for Further Discussion
1. What are the laws regarding confidentiality and treatment for teen sexual health issues in your state or country?
2. How do you counsel teens regarding all contraceptive choices including abstinence?
3. What services and programs are available in the local schools and community to support teen sexual health?
Related Cases
- Disease: Teen Sexual Health | Birth Control
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: Adolescent Medicine | Obstetrics / Gynecology
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Teen Sexual Health and Birth Control.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Maradiegue A. Minor’s Rights Versus Parental Rights: Review of Legal Issues in Adolescent Health Care. MedScape.
Available from the Internet at http://www.medscape.com/viewarticle/456472 (rev. 2003, cited 12/16/2010).
Eisenberg ME, Swain C, Bearinger LH, Sieving RE, Resnick MD. Parental notification laws for minors’ access to contraception: what do parents say? Arch Pediatr Adolesc Med. 2005 Feb;159(2):120-5.
Planned Parenthood. Parental Consent and Notification Laws.
Available from the Internet at http://www.plannedparenthood.org/health-topics/abortion/parental-consent-notification-laws-25268.htm (rev. 8/3/09, cited 12/16/10).
Guttmacher Institute. Facts on American Teens’ Sexual and Reproductive Health
Available from the Internet at http://www.guttmacher.org/pubs/FB-ATSRH.html (rev. 1/2010, cited 12/16/10).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
16. Learning of students and other health care professionals is facilitated.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 