The Need for Minor Consent and
Confidentiality in Minnesota
In 1995, there was an estimated 688,700 10 -19 year-olds in Minnesota (over 300,000 were 15-19 years old). The health needs of adolescents are generally recognized as being overlooked and often underserved. This is a concern, as adolescence is a critical time for health intervention. Much of adolescent--and early adult--morbidity and mortality is rooted in health risk behaviors that begin in early adolescence, including substance use, sexual behavior, and violence-related activities.

There are three main themes in support of adolescent access to confidential services: clinical recognition that confidentiality facilitates the disclosure of personal information often necessary for diagnosis and treatment; concern that adolescents would not seek care if it was not confidential; confidentiality is consistent with the adolescents' developmental needs to strive for maturity and seek privacy when addressing sensitive issues, just as adults do; and confidentiality is consistent with physicians' professional ethics regarding patient relationships.

Much of the discourse around minor consent and confidentiality focuses on sensitive health care needs, including reproductive health, mental health, and substance use. According to the 1995 Minnesota Student Survey (1995-MSS) of over 100,000 6th-, 9th-, and 12th-graders in over 400 school districts, youth in Minnesota engage in behaviors that may necessitate their seeking confidential health services (MDCFL, 1995).

Sexual activity
among Minnesota Youth
The 1995 MSS showed that 55 percent of 12th-graders reported they were sexually active. The average age for initiation of intercourse among 12th-graders was 15.5 years. However, despite reports by over 80 percent of 12th-graders that they used contraceptives at last intercourse (which could include any method), each day in Minnesota twenty-two 10-19 year-olds become pregnant and 15 girls give birth. And, despite small declines in teen birth rates overall, birth rates among 15-17 year-olds increased 6 percent between 1980 and 1996. Minnesota has one of the nation's highest birth rates among African-Americans. Further, in 1996, 19 percent of births to 15-19 year-olds were second or third births (MDH, 1998). Sexual activity not only results in pregnancy, but in sexually transmitted diseases. In 1996, 40 percent of all chlamydia cases and 30 percent of all gonorrhea cases were among 15-19 year-olds (MDH, 1998). And, sexual activity is not always volitional: according to the 1995-MSS, 4-8 percent of 9th- and 12th-grade females and 3 percent of 9th- and 12th-grade males reported they had been victims of date rape. And 7-15 percent of female public high school students and 3-4 percent of male public high school students reported sexual abuse other than date rape (MDCFL, 1995).

Substance Use
among Minnesota Youth
According to the 1995-MSS, 26 percent of 12th-graders reported weekly cigarette use and 16 percent reported weekly chewing tobacco use. On average, 12th-graders reported age at first tobacco use--and first alcohol use--as 15 years. Monthly alcohol use was reported by 20-21 percent of 9th-graders and 32-42 percent of 12th-graders (MDCFL, 1995).

Mental Health Concerns
for Minnesota Youth
In addition to substance use and involuntary sexual activity, there are other indicators of the mental health needs of Minnesota youth. In the 1995-MSS, perceptions about self varied among 6th-, 9th-, and 12th-graders. Between 16-24 percent of the students reported they had little to be proud of; and 11-20 percent reported feelings of discouragement and hopelessness. Further, Minnesota youth have concerns about their body image, according to the 1995-MSS: about 39 percent of 12th-grade females and 15 percent of males perceived themselves as overweight. Eight percent of females and 2 percent of males reported using vomiting or laxatives to control their weight (MDCFL, 1995).

Barriers to Adolescent
Health Care-Seeking
Many adolescents in Minnesota do not receive comprehensive preventive health care (Zimmerman and Santelli, 1998). Nationally, adolescents have the lowest utilization of health services, are the least likely to use traditional medical services, and are least likely to be insured (Klein, 1994). Barriers to care include reimbursement problems, time constraints, lack of physician training in adolescent health, and adolescent concern about the confidentiality of care. Of current interest is the protection of confidential services for teens in managed care and health maintenance organizations (SAM, 1997; Zimmerman and Santelli, 1997).

The Importance of Confidentiality
to Adolescent Health-care Seeking:
The National Outlook
A growing body of research has shown that minors may delay, or not even seek health care if it were not confidential (Cheng, et al., 1993; Demetriou and Kaplan, 1989; Frost and Kaeser, 1995; Jacard, 1996; Torres, et al., 1980; Ginsburg, et al., 1995; Marks, et al., 1983; Chamie, et al., 1982; Zabin and Clark, 1980; Torres, 1978). For example, in a 1993 study of 6,821 Philadelphia 9th-graders from 39 public schools, 63 percent reported that providers' emphasizing confidentiality of services "definitely would make me more likely to come for care." (Ginsburg, et al., 1995). Similarly, a 1992 study of 1,295 high-schoolers in Massachusetts found that 58 percent had health problems that they would like to keep private from their parents and 25 percent reported they might go without health care if their parents were notified (Cheng, et al., 1993). While there is ample evidence that fear of parental notification is a barrier to health-care seeking, there is no evidence that the availability of confidential care increases the incidence of high-risk behavior.

The Role of Parents in the
Health Care of Adolescents
While allowing adolescents access to confidential health care has sometimes been presented as a "contest of rights" between adolescents and their parents, medical professionals have suggested that the adolescent desire for privacy, including privacy related to certain health services, is better understood as a normal part of adolescent development (AMA, 1994). Developmentally, adolescents are striving for independence (SAM, 1997), and, cognitively, they are usually able to provide informed consent (English, 1990). Like adults, adolescents want privacy in their health care, and this desire is a normal part of the adolescent individuation process. An expert in the field of adolescents and the law stated, "Adolescents' desire for confidentiality is broader and more complex than a simple desire to conceal information from parents" (English, 1990; p. 1103). It has also been suggested that the interests of parents are not usually jeopardized by permitting adolescents to have greater legal support for autonomy in health care decisions, as one can assume that parents have a strong interest in ensuring that their children receive necessary care (English, 1991).

Research and Expert Opinion
on the Role of Parents
While there is general consensus in support of minors' access to confidential health care among professional organizations and in the academic literature, the important role of parents is also very much appreciated. Research generally shows that parents can have a positive impact on the health behaviors and health-care decisions of adolescents (Resnick, et al., 1997; Rosenthal, et al., 1996). The following are excerpts from position statements or syntheses of research literature that both underscore the important role of parents in the health of adolescents and support the need for confidential services.

The law provides basic support for parental authority and involvement in adolescent health care but also recognizes adolescents' need for independence and privacy in numerous situations in which the adolescents' health interests as well as public health interests are at stake. (English, 1991; p.435)

The elimination of mandatory parental consent or notification does not vitiate the desirability of parental involvement or exclude it as a possibility; it only provides a necessary option for optimal health protection. The health professional is in fact the parents' ally--there is no intent to introduce schism into the family unit or abrogate the parental role. (Hofmann, 1980; p.11)

When minors request confidential services, physicians should encourage them to involve their parents. This includes making efforts to obtain the minors' reasons for not involving their parents and correcting misconceptions that may be motivating their objections. (AMA, 1997; p. 194)

Effects of Mandatory
Parental Involvement
on Adolescent Health
There is little evidence that mandatory involvement of parents is beneficial to adolescent health behaviors or outcomes. In fact, survey research in reproductive health services suggests that most adolescents already involve parents in their health care voluntarily, regardless of legal mandates to do so (Torres, et al., 1980; Demetriou and Kaplan, 1989). For example, a study of parental notification laws for abortion in Minnesota found that teens in Minnesota had similar rates of parental notification as teens in Wisconsin, even though Wisconsin did not have a parental notification law. In Minnesota, 65 percent of girls told at least one parent prior to her abortion, compared to 62 percent in Wisconsin (Blum, et al., 1987).

Health-care Provider
Support for Minor Consent and
Confidentiality for Health Care
Clinicians grant confidentiality to adolescent patients, consistent with Minnesota law, in order to facilitate accurate diagnosis and appropriate treatment. They realize that candid and complete information can often only be gathered by speaking to the adolescent patient alone. If the adolescent requests an assurance of confidentiality, it is extended to assure that the patient will not withhold information, delay entry into care, or refuse care. National survey data reflect clinician support for minor consent and access to confidential services. The Upper Midwest Regional Physicians Survey, which included Minnesota, found that 75 percent of the 476 physicians surveyed favored treating adolescents confidentially. Forty-five percent unconditionally favored confidential services, and 30 percent favored confidential services conditionally (only for certain sensitive services) (Resnick, et al., 1992). And, in a national sample of 932 physicians, when asked about adolescents' requests for confidential services for contraception, STD testing, and drug use, respondents said they would provide confidential care 75 percent of the time (Lovett and Wald, 1985).

Consistent with the views of individual health-care providers, many organizations have shown their support formally for minor consent and confidentiality legislation including: the American Academy of Family Physicians; American Academy of Pediatrics; American College of Obstetricians and Gynecologists; American Medical Association; American Public Health Association; National Medical Association; and Society for Adolescent Medicine.

University of Minnesota
Survey of Adolescent
Health-care Providers
In October 1998, faculty and staff from the School of Public Health and the National Teen Pregnancy Prevention Research Center at the University of Minnesota conducted a survey with health care providers in Minnesota to gauge their knowledge about minor consent and confidentiality and their opinions about the impact of those laws on health care delivery. The following are highlights from that study.

Methods

A stratified sampling scheme of health care providers who are affected by minor consent and confidentiality laws was developed. Stratification was based on two criteria: geographic region (Twin Cities and outstate); and primary service type (reproductive health, chemical dependency, and mental health). The survey was conducted by phone and consisted of 25 close-ended and 25 open-ended questions.

Respondents

40 respondents were invited to participate; 30 completed the survey (75 percent response rate); five providers refused to take the survey and five could not be reached. The response rate was highest among reproductive health care providers (93 percent) and lowest among chemical dependency treatment providers (62 percent). The response rate for non-metro providers was slightly higher than for Twin Cities' providers (80 percent vs. 70 percent). Many of the 30 respondents represented clinics that provided more than one service: 70 percent reported providing mental health services; 50 percent reproductive health services; and 40 percent chemical dependency treatment. The majority of the respondents were clinic directors or administrators; 43 percent reported doing some direct clinical practice.

Perceived Parental
Involvement and Related
Clinic/Agency Practices
Respondents were asked about teen communication with a parent or guardian: only 10 percent of respondents thought that all the adolescents they served lived with a parent or guardian. There was variation, by service type, in estimates about how many youth inform their parents about the health care they receive: 58 percent of those who provided chemical dependency treatment thought all of their minor clients informed their parents prior to seeking services; most of those who provided reproductive health services thought that less than half of their clients informed a parent before seeking services; and those who provided mental health services estimated that most of their clients eventually informed a parent about seeking services. Respondents were asked about how often they encouraged minor clients to communicate with--and involve--their parents in their health care decisions. A majority reported that they do so "most of the time" or "always," although there were differences by service type.

Knowledge and Opinions about
Minor Consent and Confidentiality
Laws in Minnesota
More than three-quarters of the providers were aware of current Minnesota laws concerning minor consent and access to confidential services. Respondents were asked if they would support any of the following amendments to the current Minnesota law that would increase parental involvement in the health care of minors: parental access to medical records; mandatory parental notification of health care seeking; and mandatory parental consent for sensitive health care. Respondents were asked to consider these changes as they would relate to each of the three services (i.e., reproductive health, mental health, and chemical dependency). For all three levels of parental involvement and for all three services, the majority of respondents reported they would not approve any changes to Minnesota law. The strongest opinions were held for changes to laws that would affect reproductive health services: none of the respondents supported mandated parental involvement or consent. The most common reasons for not supporting mandatory parental involvement were concerns about barriers to services, harm to youth by increasing health risks, and concerns that teens would not disclose important health information. Respondents also expressed concern about the minority of youth who would be harmed by parental access. They also felt that teens have the ability to make their own decisions and be responsible for them.

When asked whether parental access to records would affect parent/teen communication, 50 percent of the providers said it does affect communication--or it would. Speculation about the potential effect was diverse. Some respondents stated that parental access could have a negative effect and could worsen communication by causing anger or distrust while other respondents stated that parental access could be positive and open doors for communication. When asked whether parental access to records would inhibit their ability to provide services to youth, 60 percent of the respondents said it would because it would create barrier to service: adolescents would be afraid to seek care and it would deter honest disclosure about health concerns with providers.

Conclusions
Threats to the health of young people are strongly related to risky behaviors and the social environments in which adolescents live, learn and work. Evidence from two decades of research, some of it specific to Minnesota, show strong support from health and social service providers regarding the ability of adolescents to provide consent for health care. Major national and state health-care professional organizations have emphasized the importance of adolescents being able to seek and receive services on a confidential basis, particularly when related to issues for which youth might not otherwise seek help. Overall, the research findings and the findings of the recent University of Minnesota survey suggest that reducing or eliminating consent and access would create a barrier to adolescent health-care services and would not encourage better parent-teen communication.

References

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