What is the general rule for treating minors who have medical problems related to sexual health issues?

Physicians, physician assistants and nurses as well as other health care professionals are asked to provide medical care to minor patients in a variety of settings. As a general rule, they can provide this care when a minor’s parent legal guardian or some one authorized to stand in loco parentis for the minor consents. It is generally recognized that a minor is not able consent to his/her medical care because of his/her age. Even though the traditional, general rule still has viability, exceptions have evolved over time. These exceptions have either been created by the courts and/or enacted by statute.

Pennsylvania, for example, has a general rule for the treatment of minors. In Pennsylvania, the consent of a parent or legal guardian is required before medical, dental or health services are provided to a minor. A minor is considered to be a person under the age of 18. However, the law does permit these services to be provided without the consent of a parent or legal guardian when, in the physician’s judgment, an attempt to secure consent would result in delay of treatment which would increase the risk to the minor’s life or health. 35 P.S. ?10104.

Despite the sensitivity and complexity of the legal issues surrounding consent to sexual health related care for minors, the general rule as well as the recognized exceptions should still be used as the appropriate guideline.

The major exceptions to the general rule that parental consent is required for the treatment of a minor (typically a person 18 or younger) relate to medical emergencies, emancipated minors, mature minor situations and state treatment laws. As with adults, consent is implied during emergency situations. Therefore, a health care professional may provide care to save the child’s life or prevent serious injury. The definition of an emancipated minor varies by state, but typically means a person under the age of 18 who is living independently, is a parent and/or is married. This exception exists in jurisdictions which have recognized the concept that some teenagers have sufficient judgment, skills and capabilities to make their own health care decisions. Some states, acting in the best interests of children, have enacted laws to permit minors to obtain information and/or medical care regarding contraceptive information/devices, pregnancy, HIV testing or substance abuse or venereal disease. Both the scope and applicable age of such statutes varies greatly, and your local law should be consulted to understand what care and/or information may be provided.

Some states have passed laws that set the age of consent for treatment of sexually transmitted disease at less than 18. The minimum age of consent as defined in these statutes varies. In states where such laws exist, the parents would not have access to the medical information. In contrast to these state laws, parents typically may authorize release of medical information of their child under the age of 18, and therefore would also have access to the minor’s medical information.

In Pennsylvania a minor, who is defined as a person under the age of 18, can consent for medical and health services to determine the presence of or to treat pregnancy and venereal disease. See 35 P.S. ?10103. A minor is also permitted to consent and authorize the release of the medical records related to her pregnancy or his/her venereal disease.

Closely related to the question of parental access to this information is the issue of whether parents should be notified of the minor patient’s treatment for a sexual health issue such as a STD. There is no uniform response to this question. It appears that the trend under state laws is that the health care professional need not notify the parent(s) about STD’s but some states make this decision discretionary. One theory is that confidentiality is one of the expectations of the physician-patient relationship and should be extended to minors. Not all agree. Some point to the contractual nature of the physician- patient relationship and question whether a person who is not otherwise able to enter into a contract such as a minor can benefit from one of its implied terms.

In this situation physicians or other health care professionals should refer to their specific state statutes. Some states have passed legislation permitting minors to receive contraceptive information and services while other states only permit minors to only receive information or limit the type of contraception that may be supplied. Even if a state statute permits a physician to provide the oral contraceptive, these statutes generally contemplate a situation in which a child is not accompanied by a parent to the physician’s office in contrast with the situation posed by the question.

Absent a statute giving specific permission to the physician to supply oral contraceptives, the physician should refer to the general rules and exceptions above mentioned. The physician should attempt to obtain the agreement of the child to consult the parent or legal guardian. If the child refuses, then the state statutes should be consulted to determine if there is an exception to parental consent. A common exception would be the emancipated minor exception, which permits the minor to consent. For example, in Pennsylvania an emancipated minor can consent to medical care, which would include the use of oral contraceptives, when he/she is 18 or older, graduated from high school, has married or has been pregnant. 35 P.S. ?10101.

Even if a minor is permitted to consent to receiving/taking oral contraceptives, the physician should consider whether the minor is able to give sufficient information to determine if oral contraceptives are medically appropriate. Consideration should also be given obtaining the minor’s consent for the physician to consult her parent(s). As an alternative, the physician could prescribe other means of birth control in this situation.

Generally, the parent or legal guardian who consents to the medical treatment of his/her child is financially responsible for such treatment. However, some state statutes exempt parents/legal guardians from this obligation when they have not authorized their child’s medical care. If a state statute permits a minor to consent to his/her medical treatment, as with an emancipated minor, the financial obligation would be the minor’s responsibility.

When there is doubt as to a patient’s age or if the minor can consent to his/her treatment, a physician should determine who is responsible for paying for the medical services provided. Clearly, emergency services should not be withheld because of a reimbursement question. Further, it would helpful if the physician’s policy for addressing such questions were communicated before services were provided.