For teenager, 'confidential' is conditional

By Judy Foreman, Globe Staff, 01/18/99

Adolescence is hard enough, but when it comes to health care, teenagers are caught in a particularly delicate bind. They're old enough to face the same serious issues as adults - contraception, abortion, depression, alcohol or drug use - yet not old enough to have the same guarantees of confidentiality when they seek help.

Granted, confidentiality is not absolute for adults, either. If an adult poses a danger to himself or someone else, or is abusing or neglecting a child or a vulnerable adult, the doctor can, and often legally must, intervene.

But because adults can authorize their own care, and because they pay for it or have insurance that does, they have substantially more rights to confidentiality, at least in theory. Not so with teens.

In Wisconsin, teens can't get any medical care care - except for evaluation of drug overdoses or in life-threatening emergencies - without prior written consent from a parent or guardian.

In most other states, a parent or guardian must authorize non-emergency care (not necessarily in writing), though teens can often be tested without parents knowing, and sometimes treated, for sexually transmitted diseases, including HIV infection, and for pregnancy diagnosis and contraception.

The degree of confidentiality a teenager has also depends on whether he or she is legally "emancipated" or "mature," notes Richard Bourne, associate general counsel for Children's Hospital in Boston.

In Massachusetts, for instance, a judge can decide that a teenaged girl is mature enough to make her own decision about abortion. In some cases, a doctor or other health care provider, rather than a judge, can decide that a teenager, male or female, is mature enough to consent to certain types of care.

But for many teenagers caught between childhood and adulthood, confidentiality can be elusive. Teens often "go to a doctor for advice because they don't want to ask their parents about something or don't want to alarm their parents," says Jeff Maranian, 17, an Arlington High School senior and member of an ongoing teen council convened by Tufts Health Plan to enlighten doctors on how teens want to be treated.

"Confidentiality is extremely important to teenagers," he adds. He has no problem with doctors' telling parents a teen is suicidal. But drug use? "No, that could be worked out between the doctor and patient." Contraception? "I don't think a parent needs to know about that."

Indeed, with some issues like HIV, it may be "safer for the teen if the parent doesn't know about the testing itself," says Nicole Dray, a 16-year-old Lexington High School student who is also on the Tufts council.

"If they feel their parent will flip out about their having the test, they might not have it, which would be bad," she says. "Some parents might think that if a teenager wanted the test, it means they are having sex with lots of partners or are using drugs. It might just mean they had sex once and want to be sure they're okay.

"On the other hand, if they have the test and it's positive, they obviously will have to tell their parents at some point." Several studies back up the notion that teens are more likely to confide in doctors if they know their concerns will be kept confidential, says Dr. S. Jean Emans, chief of the division of adolescent and young adult medicine at Children's Hospital.

Ideally, pediatricians should raise the issue of confidentiality when the child is 10 or 11, says Dr. Michael McKenzie, assistant medical director for pediatrics at Tufts Health Plan.

"I do it in front of the parents. I say, `When you begin to see me by yourself - and that decision is up to the teen - that what we talk about is confidential." He adds that if the teen threatens harm to himself or others, "that may be cause to talk to your parents against your wishes."

And he forewarns: "If I hear something from you that I think your parents need to know and help you with, I will find a way to broker this, to help you talk to your parents about this."

But it gets sticky, especially in "family practice," where everybody in the family has the same doctor. Privacy can also get compromised in schools, where parents may have a right to see school records, including those of a school counselor. And there's even less confidentiality for teens who are delinquent, in jail or on court probation.

Basically, medical and psychiatric care for adolescents boils down to a matter of "conditional confidentiality," says Emans.

Part of the problem is that kids are caught in an "economic trap," says clinical psychologist Gary Schoener, who specializes in ethical and legal issues and runs the Walk-In Counseling Center in Minneapolis.

Like battered women whose husbands pay the bills, teens may see their confidentiality shattered because parents either pay for their care or see insurance records.

What may work best is for the doctor to figure out, with the teenager, how to tell parents what's going on or persuade parents to back off enough to give the teenager some privacy.

Sometimes, it helps to bring parents into the office, instead of just coaching the teen on how to talk to parents. Sometimes, it means persuading a teen to let parents know some things but not everything.

And in some cases, teens find it helpful to turn to the Internet with questions they might be afraid to ask a doctor in person, says Dr. Steven Adleman, medical director of substance abuse services at Harvard Vanguard Medical Associates in Boston. He runs a website,, which, he says, is increasingly being used by teens with questions about their use of alcohol, drugs and tobacco.

"I feel safer asking someone who can't see me," wrote one high school senior concerned about binge drinking. Another teen, an eighteen-year-old high school dropout who uses drugs, wrote, "This site is great for someone like me who is afraid to go to the doctor and afraid that my parents will find out I use drugs."

But even with the best intentions, confidentiality can be jeopardized in situations that no one could have foreseen, says Thomas Grisso, a clinical psychologist and director of forensic training and research at the University of Massachusetts Medical School.

That can happen, for instance, when a teenager has been in psychotherapy for a while. Then the parents divorce, and a custody battle ensues. Sometimes, the court appoints a guardian to protect the teen's interests. But the attorney for one side may subpoena the teenager's therapist.

"Now you have the clinician stuck between his ethical obligation to maintain confidentiality to the child...and the legal order," says Grisso.

The bottom line is not that you shouldn't seek mental health or medical care when you need it. You should. But do so with your eyes open.

"Be neither blindly trusting nor blindly cynical," advises Dr. Harold Bursztajn, who co-directs the Program in Psychiatry and the Law at the Massachusetts Mental Health Center, a Harvard teaching hospital.

"If the doctor raises the question about getting in touch with your parents, go ahead and think of why or why not and talk about it," he says. And if the answer is no, "say what you are afraid of, because there is something there that needs to be addressed, and it may not be in your mind."

Judy Foreman is a member of the Globe Staff. Her e-mail address is: Previous "Health Sense" columns are available through the Globe Online searchable archives at Use the keyword columnists and then click on Judy Foreman's name.