Ensuring Adolescents’ Ability to Obtain Confidential Family Planning Services in Title X

[摘要] Since its inception in 1970, the Title X national family planning program has guaranteed confidentiality for all patients receiving its services—including adolescents. Such protections are well grounded in medical and ethical standards and reflect research demonstrating that without access to confidential care, many adolescents would not seek needed health services. Still, socially conservative policymakers and advocates have long sought to undermine the ability of minors to obtain confidential sexual and reproductive health care, based on the premise that the very availability of confidential services promotes sexual activity among young people, undermines parental authority and interferes with parent-child relationships. Historically, attempts to keep minors from confidentially accessing contraceptive, STI and other preventive family planning services under the program have largely failed. Despite the previous failures of these attacks and considerable evidence of their potential harm, social conservatives have never given up the fight. Now, the Trump administration is poised to undermine confidentiality protections in the Title X program, threatening adolescents’ access to needed family planning services nationwide. Title X’s Confidentiality Standards For nearly 50 years, the Title X program has provided affordable and confidential contraceptive, STI and related family planning care to people regardless of age. The Title X statute recognizes the important role that parents and guardians play in many young people’s lives, calling on providers to encourage familial involvement in patients’ decision making “to the extent practicable,” but stopping short of requiring minors to notify or obtain consent from their parents or guardians. Moreover, long-standing program regulations require that Title X‒supported providers guarantee confidentiality for all clients, including minors. 1 This was most recently affirmed in a 2014 program policy notice stating that Title X providers “may not require written consent of parents or guardians for the provision of services to minors. Nor can Title X project staff notify a parent or guardian before or after a minor has requested and/or received Title X family planning services.” 2 Adolescent patients’ confidentiality is also addressed in a comprehensive set of clinical recommendations for the provision of high-quality family planning care to which Title X providers are expected to adhere. These national, evidence-based “quality family planning” guidelines were established in 2014 by the Office of Population Affairs (OPA), which administers the Title X program, and the Centers for Disease Control and Prevention. 3 In keeping with Title X provisions, the guidelines advise that providers should “encourage and promote communication between the adolescent and his or her parent(s) or guardian(s) about sexual and reproductive health,” by supporting both adolescents and adults in such conversations. The guidelines also specifically state: “Confidentiality is critical for adolescents and can greatly influence their willingness to access and use services.” One exception to the program’s standard of confidentiality is that federal law has long required Title X providers to comply with any state laws requiring notification or reporting of child abuse, child molestation, sexual abuse, rape and incest. That requirement reinforces the obligations that clinicians already have to make reports in compliance with state and local reporting laws (as do many other professionals who have frequent contact with young people). Appropriately, states and localities are charged with determining providers’ compliance with these laws. Medical and Ethical Standards Title X’s confidentiality protections also reflect evidence-based recommendations of many leading professional medical organizations. Those recommendations both encourage adolescents to include a parent or guardian in decisions about their medical care as appropriate, while at the same time clearly establishing that minors must be able to obtain care without familial involvement. In a 2017 committee opinion on contraceptive counseling for adolescents, the American College of Obstetricians and Gynecologists (ACOG) affirmed the importance of discussing sexual and reproductive health with young people. 4 ACOG advises a first reproductive health visit sometime between age 13 and 15 that “should encompass a discussion about contraception and STIs in addition to preventive medicine services such as human papillomavirus vaccination.” ACOG also makes clear: “Confidentiality is an essential component of health care for all patients. It is even more crucial for adolescents because the lack of confidentiality can be a barrier to the delivery of reproductive health care services .” ACOG also promotes the use of online patient portals to engage young people in their own care and “to provide age-appropriate venues for confidential communication.” Moreover, if a clinician cannot implement necessary safeguards in their insurance billing, electronic health records or other recordkeeping systems to guarantee adolescents’ confidentiality, ACOG suggests providers refer these patients to a Title X‒supported site for contraceptive services. 4,5 The American Academy of Pediatrics (AAP) echoes many of these directives. In a 2014 report on providing contraceptive care to adolescents, AAP states: “In the setting of contraception and sexual health care…policies supporting adolescent consent and protecting adolescent confidentiality are in the best interests of adolescents.” 6 The report recognizes the body of scientific evidence that supports this view in urging clinicians to pay “careful attention to minor consent and confidentiality,” particularly in obtaining sexual histories and helping adolescents to select and continue using methods of contraception. AAP also emphasizes that adolescents are able to understand and respond appropriately to the kind of “complex messages” conveyed in comprehensive conversations between a clinician and patient about sexual and reproductive health. Other major medical associations—including the American Medical Association (AMA) and the Society for Adolescent Health and Medicine (SAHM)—encourage conversations with parents or guardians in most cases, but make clear that, when state law does not require otherwise, such disclosure should not be mandated in order not to force minors into forgoing care. 7,8 Both the AMA and SAHM also recognize that understanding and consenting to services without familial involvement is a standard of care commensurate with most adolescents’ maturity and self-sufficiency. Promoting Adolescents’ Access to Care Protections for adolescent confidentiality in sexual and reproductive health care—as provided for under Title X and supported by major medical associations—are also backed by research suggesting that undermining these protections would likely have harmful consequences. Specifically, considerable evidence shows that many young people would forgo contraceptive and STI services if they could not obtain such care confidentially, while remaining sexually active and therefore at greater risk for negative sexual and reproductive health outcomes. One recent nationally representative analysis found that among all female adolescents aged 15‒17, a considerable minority (19%) said they would not seek sexual or reproductive health services if their parents or guardians might find out. 9 Among young women aged 15‒17 who had ever had sex, only 22% of those who expressed confidentiality concerns received contraceptive counseling or services in the previous year, compared with 67% of those who did not report such concerns (see figure 1). 9 This suggests that the guarantee of confidentiality is critical for many young women to obtain the methods of contraception that work best for them.

[学科分类] 卫生学

[关键词] adolescents;confidentiality;Title X;youth