Do you report a patient’s boyfriend for statutory rape if he’s 26 and she’s 14? How would you handle this situation? Would your response vary depending on the patient’s cultural traditions?
Dr. S. Paige Hertweck, chair of the American College of Obstetricians and Gynecologists’ (ACOG) Committee on Adolescent Health Care, responds: A physician seeing adolescents has a primary goal to provide good, confidential health care for the adolescent. However, there are laws within every state that impact how the physician can carry out this important goal.
Before we go further, it’s important to understand that the situation described in this question is quite unusual. Generally, the age difference between an adolescent girl and her partner is not so dramatic. It is far more likely that the clinician will encounter an adolescent girl whose partner is between the ages of 16 and 20. Authors of the 1997 “Fertility, Family Planning and Women’s Health: New Data From the 1995 National Survey of Family Growth,” published as part of the National Center for Health Statistics’ “Vital and Health Statistics” series, report that for those females describing voluntary first intercourse before the age of 16, 7 percent said their partners were between the ages of 20 and 22, and 6 percent said their partners were 23 or older.
In responding to the scenario described above, a physician must consider two separate clinical and legal issues, and for each, the laws that can influence the physician’s actions will vary by state. Physicians aren’t trained in law, but they need to learn about the laws governing such situations so they can make informed decisions. To obtain up-to-date information on state laws, each clinician will have to identify a legal resource within his community or state. Many hospitals have legal departments that can offer guidance. Another resource would be a state medical society.
The first issue to consider is how you want to handle consent and confidentiality regarding minors in your medical practice. Confidentiality is critical to winning the trust of adolescent patients. When they’re concerned their confidentiality will be breached, adolescents will avoid necessary health services. In this case, there are many questions to explore in a confidential session with the 14-year-old girl, assessing what she understands and desires. Was the intercourse consensual? What is her relationship with the man involved? What are her relationships with her family? How does she want her family to be included in any subsequent discussions? Culturally based attitudes and norms (of both the adolescent and the clinician) will influence the entire discussion with the adolescent and any subsequent discussions with her parents. A physician should be aware of this and work to develop his cultural competency skills.
A good resource to help you talk confidentially with an adolescent patient and involve her parents in her care can be found in ACOG’s Health Care for Adolescents, published by its Committee on Adolescent Health Care. The chapter “Confidentiality in Adolescent Health Care” can help you map out a strategy to discuss sensitive issues with an adolescent patient and her parents, before you’re confronted with them. Visit ACOG online
for more information.
Additionally, the Center for Adolescent Health & the Law has produced a 200-page monograph summarizing the minor consent laws for all 50 states and the District of Columbia: State Minor Consent Laws: A Summary, 2nd edition (2003). Information about the monograph can be found at here
or via e-mail at email@example.com
The second issue to consider in this case is what the physician must report about adolescent sexual behavior to either law enforcement or social services under the state’s child abuse reporting law. It is important to realize that there is no uniform legal definition of “statutory rape.” This term is often used to describe sexual intercourse with a minor that is illegal under a state’s criminal law even if it is consensual or voluntary for both partners. It may include sexual intercourse between an adult and a minor as well as sexual intercourse between two minors, depending on state law. Some, but not all, “statutory rapes” must be reported under child abuse reporting laws, again, depending on the state. The ways in which these laws are being interpreted and enforced have become controversial public policy issues in some states.
A difficult issue for the clinician and for public policy in this situation is distinguishing between sexual activity involving minors and older adolescents that is coercive, exploitive and involuntary, and that which is consensual activity between young people of similar age. The other critical issue for the physician is that the fear of reporting may deter adolescents from seeking appropriate health care. If the physician determines that something must be reported, it will be very important to explain to the adolescent patient why it must be reported. Even with this explanation, though, the patient– physician relationship may be lost in the process.
As in every clinical situation, it is important to remember that the primary role of the physician is to provide the best care for the patient and, as such, to ensure that the patient is emotionally and physically cared for whether or not a report is required.
Dr. S. Paige Hertweck is also an associate professor in the division of pediatric adolescent gynecology at the University of Louisville School of Medicine. If you have a question for “MedMentor Q&A,” e-mail it to firstname.lastname@example.org. All questions will be reated confidentially.