Confidentiality to Consent: Sexual health considerations for Youth
Heather L. Stewart, MD, FAAP Chief, Division of Adolescent Young Adult Medicine, Dayton Children’s Hospital Assistant Professor, Pediatrics, Wright State University Boonshoft School of Medicine Objectives
• Understand Ohio Revised Code laws regarding sexual consent and assault • Define confidentiality rights for minors in Ohio regarding health care • List ideas for educating and empowering teens to make healthy decisions about sex Case 1
• A 15 year old comes in for a stomach ache. After a few minutes, the student tell you it is because “the condom broke” last night and they’re afraid of pregnancy.
• What do you want to ask? • How can you empower this student to make healthy choices? • What information can you provide to the student? • Do you need to report anything? To whom?
3 Age of Consent in Ohio
Age of Student Age of Other Person Legal? Under 13 years old 18 or older No 13-15 years old 13-17 years Yes 18 or older No 16-17 years old 13-17 years Yes 18 or older Yes 18 years old or older 13-15 years No 16 or older Yes
4 Ohio Revised Code Legislating Sexual Consent
• ORC 2907.01 Sex offenses general definitions o “Sexual conduct” = penile-vaginal intercourse (m/f), anal intercourse, fellatio, cunnilingus, “apparatus” (any) • ORC 2907.04 Unlawful sexual conduct with minor o Defines consent ages o Not restricted by sexual identity, uses term “sexual conduct” • ORC 2907.02 Rape o Prevent resistance, incapacitated, less than 13 years, or forceable • ORC 2907.03 Sexual battery o Defines offenders, including those in a position of power like teachers, coaches, police Contrast: Confidentiality vs Consent in Health Care
• Confidentiality protects the student’s right to privacy about health care and personal actions that do not pose an immediate safety risk to the student o Pregnancy test o Reported use of emergency contraception o Talking about trying cigarettes or juuling • Consent describes the legal ability to agree to treatment o Parental permission is not necessary to provide certain types of care, such as testing for sexually transmitted infections, emergency contraception, mental health counseling o Does not always imply confidentiality • Assent describes the student’s agreement with care, different than consent • Dissent describes the student’s disagreement with care, different than consent Do teens think about confidentiality?
• Multiple studies have looked at the effect of confidentiality on care • Teens self-report they are less likely to disclose information or seek care if confidentiality is not assured 1,2 • In one study, 59% would delay or forego ALL sexual health care if parents informed of seeking contraceptives3 oBut only 1% would stop having sex3 1. JAMA 1997; 278:1029-34 2. JAMA 1993; 269:1404-7 3. JAMA 2002; 288:710-4 Confidential Medical Care in Ohio
• Title X federally funded clinics provide confidential testing and treatment for family planning/pregnancy planning and sexually transmitted infections • Ohio law does not specifically require parental consent regarding prescription of contraceptives, so practice varies across the state • Ohio law protects the rights of minors to consent to confidential testing and treatment of sexually transmitted infections o HIV is only STI that requires parent permission before treating o The state requires patients to notify their sexual partners (Public Health can assist) o Expedited partner therapy now covered by Ohio law
8 Other areas of consent
• Ohio minors may consent to health services and forensic exam for criminal sexual assault or abuse, but a parent must be notified of the exam in writing by the provider and mandated reporting to the authorities • Ohio law requires one parent consent for abortion services or judicial bypass • Ohio law allows a pregnant minor to consent to adoption but cannot consent to prenatal care • Minors age 14 and older, can consent to confidential mental health counseling for up to 30 days or 6 sessions • Minors age 12 and older, can consent to confidential diagnosis or treatment of substance use related condition
9 Health Concern Minor Specifications or limits Consent STI testing and treatment Yes HIV treatment requires parent permission Expedited Partner Therapy Yes Only for Chlamydia, Gonorrhea, Trichomonas. Information about STI required for partner Emergency Contraception Yes Birth Control There is no specific ORC covering this Prenatal Care Parent must provide consent Adoption Yes Abortion Parent must provide consent or teen gets judicial bypass (difficult) Sexual assault/rape care Yes Treating provider/facility must send letter to a parent notifying completion of exam for rape/assault Mental health counseling Yes 14+ years, 30 days or 6 sessions without medication Substance use counseling Yes 12+ years old
10 Teen Pregnancy
• Birth rate of US teens age 15-19 years old reached an all-time low of 18.8 births per 1,000 in 2017. (Range 8.1 – 32.8 per 1,000)1 • Majority of the decline attributable to increased consistent contraceptive use • U.S. teen pregnancy rates remain higher than other developed countries • Costs the United States approximately $9.4 billion each year2 • Adolescent pregnancies are unplanned 80% of the time3
1. https://www.cdc.gov/nchs/pressroom/sosmap/teen-births/teenbirths.htm 2. MMWR Vital Signs, Apr 10, 2015/64(13);363-369. 3. ACOG Committee Opinion No. 539, Oct 2012. 2017 Youth Risk Behavior Survey Trend Report
12 Emergency Contraception Information
Ulipristal acetate Levonorgestrel (Plan Copper-T IUD (ella) B One Step) Effectiveness 99.9% 85% Up to 89% (50%) When to Use Up to 5 days after Up to 5 days after Up to 3 days, less unprotected sex unprotected sex effective day 4 and 5 Who Can Use All females/AFAB All females/AFAB All females/AFAB. (not breastfeeding). Less effective if Less effective if BMI>25. BMI>35. May not work if BMI>30. How to Get In office by trained By Prescription Over the counter to doctor or nurse anyone, all ages Sexual health counseling
• Encourage open communication between students and parents/guardians • Know that sometimes this isn’t possible • Don’t make assumptions about sexual behaviors or partners • Role for condoms in all sexual encounters (MSW, WSM, MSM, WSW) • Develop knowledge of local Title X family planning clinics for confidential services • No contraceptive method is 100% effective, except the times they choose not to have sex • But remember, not all student’s are choosing to have sex (abuse, trafficking, dating violence)
14 Case 2
• A 14 year old asks you if sexually transmitted infections are possible with a same sex partner. The student has heard conflicting information, and the kids in health class make homophobic comments.
• What do you want to ask? • How can you empower this student to make healthy choices? • What information can you provide to the student? • Do you need to report anything? To whom? Inclusive Curriculum Helps LGBTQ Youth
2018 Graphic from GLSEN.org
16 Ohio sexual health education
• Ohio Revised Code Sections 3313.60 and 3313.6011 dictates health education curriculum o “Venereal disease education” that emphasizes “abstinence from sexual activity is the only protection that is one hundred percent effective against unwanted pregnancy, sexually transmitted disease, and the sexual transmission of a virus that causes acquired immunodeficiency syndrome.” o Focus from lawmakers on heterosexual relationships and marriage • “Home Rule” means that what students hear and learn varies greatly across the state • Ideally, sexual health education should be comprehensive, medically accurate, age-appropriate (K-12), evidence-informed, and inclusive Comprehensive sexual education
• According to the Sexuality Information and Education Council of the United States (SIECUS), comprehensive sexual health education programs have been shown to have the following positive outcomes: o Improved academic success o Prevention of child sexual abuse, dating violence, and bullying o Delayed sexual initiation (not seen in abstinence only education programs) o Reduced unintended pregnancy, HIV, and other STIs o Reduced sexual health disparities among LGBTQ young people
18 CDC’s 16 Key Sexual Health Education Topics
• How to create/sustain healthy and • Importance of using a condom with respectful relationships another contraception to prevent both STDs and pregnancy • Influences of family, peers, media, technology and other factors on sexual • Communication and negotiation skills risk behavior • Goal-setting & decision-making skills • Benefits of being sexually abstinent • How HIV & other STDs are transmitted • Efficacy of condoms • Health consequences of HIV, other STDs and pregnancy • Importance of using condoms • Influencing/supporting others avoid or consistently and correctly reduce sexual risk behaviors • How to obtain condoms • Importance of limiting number of • How to use a condom correctly sexual partners
19 Intimacy and Relationships
What do you see?
20 Challenges faced by LGBTQ youth
• Establishing a comfortable sense of sexual identity and/or gender identity • Deciding when and to whom to “come out” to • Coping with external homo/transphobia (bullying, harassment) • Coping with internal homo/transphobia • Finding supportive peers, role models, family members
21 “Coming Out” – A personal choice
• Coming out is not a single event o A process of coming to terms with your own sexuality or gender identity, then o Disclosing it to others (safety, rejection, etc.), each time o Can take years, internal and external factors influence the process • During the 1980s, the average age GL people begin the coming out process was between 19 and 23 years. • Current studies report o Questioning and Self recognition of sexuality begins most commonly around 10-13 years old, but can be younger at 7 or 8 years o Many report telling family around 14-15 years old o One study, showed transgender youth came out around 16 years The risk of “coming out” at home LGBTQ youth need support
• LGBTQ people report more • Higher rates of… o Stigmatization/Bullying o Victimization (verbal, physical, o Social isolation sexual abuse) o Discrimination o Suicidal ideation and attempt o Limited access to medical care o Anxiety, depression o Smoking, Alcohol & substance abuse o Homelessness o HIV & STIs o Body image, eating disorders and obesity
24 Mental Health Mental Health Protective Factors Risk Factors • Teens • All Ages • Family connectedness • Family rejection • Perceived caring from • Major stressful events, such other adults as assault, abuse and • School safety homelessness • Lack of access to care • Adults • Connectedness to a gay/lesbian community • Positive sexual identity Physical Attraction SOURCE: National Longitudinal Study of 16.00% Adolescent Health, 2009.
14.00% 13.9% 12.00%
10.00% 10.4%
8.00%
6.00% 6.5%
4.00% 4.2% 3.7% 2.00% 3.2%
0.00% Women Men All Self-identify LGB Same sex partners 2015 Youth Risk Behavior Survey Results 70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0% Ever had sex Current sexual activity Used condoms Used EtOH or drugs before LGB Unsure Heterosexual Let’s talk about sex…
Barriers for safety Barrier Protection for Sexual Health
• 18% risk of pregnancy with condoms alone • Abstinence or condoms are the only methods to prevent STIs o Latex condoms or polyurethane condoms • Use of water-based lubricants to avoid condom breakage o Do not use petroleum-based, like Vaseline • Single use only, and never use 2 condoms at the same time • Condoms come in different sizes, find one that fits o If too tight, may break or have trouble placing on o If too loose, may fall off easily • It is “responsible” of females to have condoms, combat gender stereotypes Case 3
• 17 year old is brought to your clinic for a panic attack that happened in class. The student tells you they were raped last week and the person just texted them.
• What do you want to ask? • How can you empower this student? • What information can you provide to the student? • Do you need to report anything? To whom? Minor’s consent to rape crisis and healthcare
• Ohio minors may consent to health services and forensic exam for criminal sexual assault or abuse, including o Pregnancy testing o Emergency contraception (if appropriate timing) o Treatment for STI prophylaxis/treatment • A parent must be notified of the exam in writing by the provider • Mandated reporting to the authorities in the case of minors 2015 YRBS Trend Report Dating and School Violence 40%
35%
30%
25%
20%
15%
10%
5%
0% Bullying in school Cyberbullying Physical dating Sexual dating Rape/Forced sex violence violence LGB Teens Straight Teens
33 Adolescent intimate partner violence and sexual assault
• Defined as the physical, sexual, psychological, or emotional aggression within a dating relationship, including stalking. • It can occur in person or electronically • It might occur between a current or former dating partner
• A CDC report found that among victims of intimate partner violence, 26% of females and almost 15% of males first experienced some form of violence before the age of 18 years.
www.cdc.gov/violenceprevention/pdf/2015data-briefs508.pdf How can you help right now?
• Listen, just listen. o Ask before you hold their hand, or touch their shoulder • Avoid questions of what the victim did or didn’t do. This conveys blame, even if you don’t mean it to. • The offender took power away from the victim, give it back o Ask before doing things o Inform with options if something must be done • Assess for personal safety o Suicidal thoughts or self-harm o Offender physical location/threats Making a report
• Does the offender live with the minor? o Yes – notify Children’s Services (CSB) o No – notify law enforcement (or Children’s Services) • Have there been threats against the victim? o Secure the student’s safety while you report • Is the victim suicidal or considering self-harm? o Secure the student’s safety by not leaving them alone, find someone to sit with them • The victim doesn’t have to cooperate with law enforcement or medical o We always hope they cooperate but some refuse. o The student is asserting their power in this decision. Important to respect it Resources for victims of sexual or dating violence
• The Rape, Abuse & Incest National Network (RAINN) : www.rainn.org o Leading the national efforts to improve services to victims and ensure that rapists are brought to justice by operating the National Sexual Assault Hotline and educating the public about sexual assault. o Hotline: 800-656-HOPE (free, confidential, and available 24 hours), including LIVE Chat option on website • Love is Respect : www.loveisrespect.org, LIVE Chat, or Text “loveis” to 77054 o National Teen Dating Abuse Helpline • Dating Matters : www.vetoviolence.org/datingmatters/ • National Domestic Violence Hotline : www.thehotline.org
37 Handout Provided by
• Ohio Alliance to End Sexual Violence o Phone 216-658-1381 o Email: [email protected]
• Thanks to the Ohio Alliance for their permission to use the handout “Ohio Age of Consent/Statutory Rape Fact Sheet”
38 Questions?
39 References
• English A, Kenney KE. State Minor Consent Laws: A Summary, 2nd Edition. Chapel Hill, NC: Center for Adolescent Health & the Law, 2003. • https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law • Kann L, McManus T, Harris W, et al. Youth Risk Behaviors Surveillance—United States 2017. MMWR Surveill Summ 2018;67(SS-8):1-114. • Kann L, McManus T, Harris W, et al. Youth Risk Behavior Surveillance—United States 2015. MMWR Surveill Summ 2016;65(SS-6):7-30. • Curtis K, Jatlaoui T, Tepper N, et al. U.S. Selected Practice Recommendations for Contraceptive Use 2016. MMWR Recomm Rep 2016;65(RR-4):1-66. • Gemzell-Danielsson K, Rabe T, Cheng L. Emergency Contraception. Gynecol Endocrinol, 2013; 29(S1):1-14. • American Academy of Pediatrics, Committee on Adolescence. Technical report: contraception for adolescents. Pediatrics 2014; 134:e1257-e1281.
40 References
• 2017 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual, Transgender, and Queer Youth in Our Nation's Schools. glsen.org/nscs • National Guidelines Task Force, Guidelines for Comprehensive Sexuality Education: Kindergarten-12th Grade, 3rd Edition, New York: Sexuality Information and Education Council of the United States, 2004. • Ryan, C. (2009). Helping Families Support Their Lesbian, Gay, Bisexual, and Transgender (LGBT) Children. Washington, DC: National Center for Cultural Competence, Georgetown University Center for Child and Human Development. • Chandra A., Copen C.E., Mosher W.D. (2013) Sexual Behavior, Sexual Attraction, and Sexual Identity in the United States: Data from the 2006–2010 National Survey of Family Growth. In: Baumle A. (eds) International Handbook on the Demography of Sexuality. International Handbooks of Population, vol 5. Springer, Dordrecht. • www.TrueColorsFund.org • Teen Dating Violence, www.cdc.gov/violenceprevention/intimatepartnerviolence/teen- dating-violence.html