Confidentiality

Confidentiality LEAH Lecture by Yolanda Evans MD MPH

Overview • Why is confidentiality important? • Laws in Washington • Tips of how to start a visit • Example cases • Final Questions

Why is Confidentiality Important? • Building trust is key • This can take time • To build on trust, the teen has to return to see you • Not all teens come from supportive environments

What Does Research Show? • Having a confidential visit is important to teens • They are more likely to disclose risky behaviors if it’s confidential • They’re also more likely to return for care Ford, C., Millstein, S., Halpern-Felsher, B., & Irwin, C. (1997). Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care. A randomized controlled trial. JAMA , 1029-1034.

What are Barriers? • Providers list ‘time constraints’ as a major barrier to providing confidential care • Parents may also be unwilling to allow a confidential visit (but this is not the norm!) Helitzer, D. L., Sussman, A. L., Urquieta de Hernandez, B., & Kong, A. S. (2011). The "ins" and "outs" of provider-parent communication: perspectives from adolescent primary care providers on challenges to forging alliances to reduce adolescent risk. Journal of Adolescent Health , 404-409.

Age of Consent in WA • In WA state youth of special ages can seek care for certain things without a parent • Mental Health treatment: 13 years • Alcohol and drug treatment: 13 years • Sexually transmitted disease/HIV testing: 14 years • Reproductive health: no age limit

Tips on Confidentiality • Reassure the teen that the conversation is confidential unless they tell you someone is hurting them or they want to hurt someone (including self). • WA state law: 13+ for mental health, 14+ for reproductive health • Ask your questions confidently, without passing any judgment. • Ask the same questions of everyone, regardless of gender! • Example, “Are you sexually active with boys, girls, or both?” • Don’t forget to ask about any unwanted intimate contact

Cases

Sarah • Sarah is a 17 y/o female coming in for a nutrition visit because she is underweight • Her mom and dad are here with her • You tell them you’ll have a time during the visit to meet with Sarah alone • When parents step out, you let her know you’ll have to tell her parents if you’re worried about her safety

Sarah • After learning a bit about her social life, she discloses she’s been restricting her intake, binge eating and purging • With more questioning, Sarah meets criteria for bulimia • She DOES NOT want to disclose to parents What do you do with mom and dad? Do you think she would have told you her eating habits if you hadn’t asked for the time without family?

Ron • Ron is a 15 y/o male who is brought in by his mom for concerns about anger • You talk with them together, then ask mom to step out for a few minutes • You tell Ron the visit can remain confidential unless worried about his safety

Ron • He is hesitant to talk with you, but let’s you know he has a girlfriend • They have been sexually active but his parents don’t know and he’d like to keep it that way • You counsel about safer sex practices and sexually transmitted disease screening What do you tell mom? Are you concerned about ordering the screening tests?

DJ • DJ is a 14 y/o male who comes in for concerns of depression • He is here with his mom and stepfather • You talk with him alone and let him know the visit will remain confidential unless you’re worried about his safety

DJ • DJ opens up about the bullying that is occurring at school and online • He also tells you he is questioning his sexuality, but has not told his parents • At the end of the visit, DJ discloses that a cousin in a different state touched him inappropriately a few years ago and he has never told anyone

DJ • DJ gives you a lot of information including the name of the cousin and location of the incident • He also tells you he has thought of suicide in the past week Now what do you do?

Maria • Maria is a 15 y/o female comes to clinic for heavy menstrual bleeding • She comes in with her entire family (mom, brothers, dad) for each visit • You always offer to meet with her alone, but she declines each time

Maria • Maria ran out of her birth control pills about a month ago, so she comes in for a refill • You offer to speak with her alone and she accepts • She denies sexual activity, drug use, alcohol use • Because she’s been out of pills for a month, a urine HCG is obtained and it is positive

Maria • Her family is waiting outside for her • She continues to deny sexual activity but you counsel her on options for the pregnancy • She leaves without making any decisions Do you have to notify her parents? What about her PCP?

What Cases do you have? • Does anyone in the audience have a case to discuss?

Summary • Confidentiality laws vary by state! • In WA, minors can receive confidential care for certain situations (mental health, substance use, STD screening, reproductive health) • Assuring confidentiality is important to teens, but let them know there are certain things you’ll have to disclose

Questions?

Confidentiality