A pediatrician caught between the law, common sense and a teen’s mom

iStockphoto - All states have laws that allow teenagers to receive confidential medical care under sensitive circumstances. One of the promises with adolescent privacy laws is to give a girl the space to learn to become a woman.

I am the father of two girls, ages 4 and 2. Although my daughters and I have a close relationship, I know that when they get out of sorts — a stuffy nose, a scrape on the knee, a bad dream — it’s Mom they cry for, it’s Mom they need.

I am also a pediatrician, and at work I see mothers making most health decisions for their daughters. Year after year, with each cold, fever and ear infection, it’s Mom watching and caring, giving the Tylenol, calling me for advice. Then, Mom blinks her eyes and that baby girl morphs from child to tween to teen. Her pituitary gland sparks the synthesis of hormones, and we all know what happens to her body.

But what of her mind and soul? Adolescents are ready to challenge authority (i.e., Mom) and take physical and emotional risks as they find themselves.

One day, that teenage girl may come in and, while sitting casually on the exam table, make a request, as a patient of mine once did a few years ago, and say, “I need a pregnancy test.”

A pregnancy test is not something most teen girls want their mothers (or fathers) to know they’ve taken. But in a world where many girls are sexually active by the time they turn 18, it’s not an unusual request. What gave me pause this time was that the girl asked me with her mother sitting in the room.

“Are you sexually active?” I asked.

“No, but my family wants me to have the test because I have a boyfriend.”

Biology, ritual (the bat mitvah, the quincinera) and the law tell us when a girl becomes a woman, but in the doctor’s office, the line is less clear. In today’s pediatrician’s office, girls are often counseled like women beginning at age 11, the age when the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend vaccination for human papillomavirus, which is typically passed during sexual activity.

All states have laws that allow teenagers to receive confidential medical care under sensitive circumstances. In California, where I practice, teens, beginning at age 12, are allowed privacy for, among other things, counseling about birth control, testing for and treatment of sexually transmitted infections, and pregnancy. For me to violate that confidentiality risks prosecution and the loss of my medical license.

“Why don’t I show you where the restroom is so we can get your pregnancy test?” The girl followed me out of the room. I took a quick detour with her into a quiet corner of the office. “I want to ask you privately: Are you sexually active?”

“No.” I sent her to the restroom and asked my medical assistant to run the test.

Teen confidentiality laws and practices have the best intentions, and whatever your social mores, the evidence is clear that they’re best for the health of the adolescent. But putting those laws to work can get messy.

I practice and live in a community where many parents feel the need to hover a little too closely over their offspring. This is especially true when it comes to talking about sex. When I broach the subject — whether to talk about getting a pregnancy test, offering birth control or testing for sexually transmitted diseases — some parents refuse to leave the room. But even if the teen requests a private consultation with me, I cannot force the parent to comply; I can only ask the teen to contact me separately at another time.

Fortunately, I have never had to force a parent to go. I try my best to make them understand that I’m not trying to learn any secrets, that my only goal is to give the best medical advice to her child. Often that’s not enough, and I’m left keeping my advice about avoiding illegal substances or sexuality too generic. If a teen is unwilling to admit to certain behaviors in front of a stubborn parent, I can’t order the right tests (HIV or sceeening for chlamydia) or the right medicines (birth control), and I worry that the teen is at risk.

Even when parents do leave the room, they can still behave disruptively. In one case, a medical assistant reported that a parent had spied, pressing her ear to the door as I carried on a confidential conversation. I’ve also had parents refuse to let their teenager give my office a cellphone number. When we need to speak with such a teen because, say, she tests positive for chlamydia, we’ve had to get acrobatic by enlisting nurses with youthful voices to call home and pretend to be a girl’s friend to try to get her on the phone.

As for the girl who asked for the pregnancy test: When she returned to the exam room, I was faced with an especially tricky situation. While I continued on my routine consultation, there was a knock at the door. My medical assistant peeked in and asked me to step outside. “Her test is positive.”

“Is there an empty exam room I can take her to?” I asked. My medical assistant pointed down the hall and around the corner.

I walked back into the room, practically holding my breath. I looked at the girl, who was sitting on the table, dressed again because we had just about finished. I asked her to follow me outside and to the other room, leaving her mother sitting by herself.

“You’re pregnant. Do you know what you want to do?”

She stared at me quietly. Sometimes when I tell a teen this news, she starts to cry. But this time, my patient just looked at me. “No,” she said.

“What would you like to tell your mother? I’m sure she is wondering what is going on. I think it would be a good idea if we speak to her together.”

“I don’t want to tell her anything right now.”

“Are you sure? She’s probably going to know that the reason we are talking has to do with your pregnancy test. Do you feel unsafe telling her you’re pregnant?”

“No. I’ll tell her later.”

Caught in a pickle between the law and common sense, I walked her back to the room, where her mother waited anxiously. “Is everything okay?”

I answered somewhat stoically. “I’m entitled to protect your daughter’s privacy, and she would like what we discussed to remain confidential for now.” The mom protested, but her daughter would not budge. Instead, mother and daughter left, together but entirely separate. Later I found out that the girl had elected to keep the baby — though, not surprisingly, they found themselves a new personal physician and so we never met again.

One of the promises with adolescent privacy laws, I hope, is to give a girl the space to learn to become a woman. But that day, I worried that the law was getting in the way of that promise, and I questioned its value. That girl should have told her mother, I kept telling myself. It would have been better for her, for her developing child and for her relationship with her own mom. To take responsibility for her choice. That would have made her a woman, confidentiality or not.

I’ve always encouraged teens and their parents to have these conversations openly. Maybe, in the end, that’s really the point at which a girl becomes a woman — not when she needs the laws to protect her privacy from her mom, but when she doesn’t.

Parikh is a pediatrician in Walnut Creek, Calif., and a contributing writer for Salon.com.

 
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