When teens and their doctor find themselves in a bind

Preface: As an adolescent medicine physician, I embrace confidentiality. I even wrote about it in this blog! After all, why would my teenage patients disclose private important information to me if I don't protect their privacy? That's why there's HIPAA (Health Insurance Portability and Accountability Act, a law that ensures privacy standards to protect patients' medical records and other health information.

That said, the most difficult part of caring for teenagers is not the wide range of medical and emotional issues they may have but, often, the legal limitations put on me by HIPAA. These limitations often lead to unsolvable situations. Unfortunately, in adolescent medicine, these situations are all too common and usually involve emotional or sexual health….

A teen with STIs who may have infected two sexual partners. A 17-year-old teenager came to my medical office for the first time. He was referred by his girlfriend, who was also my patient. Confidentially, he told me that he had unprotected sex with another person and he wanted to be checked for sexually transmitted infections (STIs). His test came back positive for both chlamydia and "trich" (not surprising as STIs are often found together). I treated him with antibiotics and urged him to tell his girlfriend and his other sexual partner that they should also get treated for these infections. A few weeks later, his girlfriend came in for an asthma follow-up visit. As I always do when I see teenage girls, I asked her how her menstrual periods were and if she was having any problems (from head to toe). She did not say anything about needing medicine for STIs. Under HIPAA, I was not permitted to disclose anything about her boyfriend to her.

A teen who wanted to become pregnant. A 16-year-old girl came to a family planning appointment. She was sexually active but not using birth control because she and her boyfriend wanted to have a baby. She said her mother would not want her to have a baby now as she was still in school. I discussed with her the medical reasons why pregnancy at this age would be high risk. Over the course of an hour, I presented what I felt were compelling reasons for her to wait until she was older to have a baby. To my dismay, nothing that I said changed her mind: she still wanted a baby and she wanted a baby now. I would be violating HIPAA if I shared her desire for a pregnancy with her mom.

A teen who had an eating disorder. A 19-year-old college student came in with the complaint of no menstrual periods for four months. Right away, I could see that she was extremely underweight. I recognized her as I often saw her running. Severely underweight … exercising frequently … the signs pointed to anorexia nervosa. She told me that she had anorexia nervosa in high school, but gained enough weight that her parents, her doctors, and her therapists felt that she was ready to go away to college. She told me that if her parents knew that she was losing weight again they would make her leave college and go home.

After I was confident that she was not in any imminent danger, I arranged for blood tests and a follow-up visit. I explained why exercising at her weight was not safe.  I convinced her to go down the hall immediately after her appointment with me and make an appointment with a psychotherapist. She agreed to hold off on exercise and to make an appointment for therapy. Naturally, I was surprised to see her walk right out of the building (not down the hall) — and later that day I saw her running! Under HIPAA, with the information that the student had given to me, I was not permitted to disclose my concerns to anyone. Even though I knew she was very sick, needed help, and shouldn't be running, my hands were tied.

Postscript: These cases illustrate the frustrating position I often find myself in when taking care of teenagers. Teenagers are responsible for their own bodies yet they sometimes act irresponsibly. So today I'm sharing these problems with you, parents, as I believe that if parents and teens communicate more openly (about sexual and mental health), then perhaps teenagers — and their doctor — would not find themselves in such binds.

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