Adolescence has been described as maturation in three different domains: physical, cognitive, and psychosocial. The timing and tempo of these maturational changes are important in shaping adolescent sexuality and they vary widely from one child to
the next. Puberty, or the development of secondary sexual characteristics, is an early and mid-adolescent process. It tends to start earlier in girls than in boys and may actually start in the preteen years. In fact, in a recent study involving data from private practice sites, the American Academy of Pediatrics reported that normal girls as young as 8 or 9 years may show pubertal breast development or pubic hair growth (29). Cognitive maturation, or the maturation of abstract reasoning capability, also tends to occur in early and mid adolescence. On the other hand, psychosocial maturation, or the maturation of social relationships and behaviors, extends past the mid adolescent years into late adolescence and sometimes into young adulthood.

Competent decision-making requires a certain degree of cognitive and psychosocial maturity; however, particularly in the early and mid adolescence, this maturity may be lacking. With the appearance of secondary sexual characteristics in the early and mid adolescent years comes a heightened interest in sexual experimentation. Risky sexual behavior can emerge, given a combination of limited life experience, limited self-awareness of sexual feelings, and relatively immature psychosocial skills. This trajectory is seen in studies showing that girls who enter puberty early exhibit more high-risk sexual behavior than girls who enter puberty late (30,31).

Although adolescent behaviorists in the early 1900s considered adolescent turmoil and rebellion to be a necessary part of the adolescent experience, recent studies have shown that adolescence is typically not a tumultuous time (32), and that the rate of behavioral disturbance in adolescence is similar to that in the other stages of life (33). Although some risk-taking behavior is essential to adolescent development (34), extreme risk-taking behavior is not. Moreover, extreme risk-taking behavior is not that common in adolescence, contrary to popular perception. A 1993 American Medical Association report on adolescent maltreatment cites numerous studies showing that extreme risk-taking behavior is more common in adolescents who have been abused or neglected and that this behavior itself increases the risk of future maltreatment and victimization (35). This same report states: “Adolescents experience maltreatment at rates equal to or exceeding those of younger children. Recent increases in reported cases of maltreatment have occurred disproportionately among older children and adolescents. However, adolescents are less likely to be reported to child protective services and are more likely to be perceived as responsible for their maltreatment” (35). Perhaps it is too easy for the parents, the neighborhood, or the community to see extreme risk-taking as normal adolescent behavior and to see adolescent maltreatment as a “deserved” consequence of this behavior.

Clearly, there are unique challenges in identifying and addressing adolescent maltreatment. However, there are few, if any, adolescent-focused units as part of child protection. In 1996, a telephonic survey of the 24 county-based child protection offices in the State of Maryland found no evaluation and treatment programs designed specifically to serve maltreated adolescents (E. Kelly, personal communication, 1996). Typically, abused adolescents are served through an array of other programs, as summarized in Figure 7.2.

An adolescent’s risk-taking behaviors and the consequences of those behaviors are strongly influenced by family dynamics. The teen–parent relationship that leads to risk-taking behaviors in the first place can lead to escalation of these behaviors (Fig. 7.3). Increased risk-taking behaviors are seen in authoritarian families in response to excessive restriction and discipline and in permissive families in response to lax parental control and “benign neglect.” Also, parents may be the models for the very attitudes and behaviors their teenage children display, and their failure to acknowledge this may contribute to the problem.

Several issues limit health care access for adolescent patients and hence increase their vulnerability. Chief among these are concerns about confidentiality. Numerous studies have documented that adolescents may not seek medical care for reproductive health issues if parental consent is required (36,37). Recognizing this, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Academy of Obstetricians and Gynecologists have all endorsed the importance of confidentiality in adolescent health care (38,39). In addition, federal law mandates that adolescents have the right to access family planning services, and each state has legislative statutes that allow the provision of reproductive health care services to adolescents without parental consent (40). These “minor consent statutes” were formulated in the 1960s and 1970s after it was recognized that adolescents younger than 18 may self-limit their use of needed reproductive health care services if parental consent is required. These statutes notwithstanding, concerns about confidentiality may determine whether an adolescent decides to seek care following sexual abuse or sexual assault. These concerns are not unfounded. If an adolescent seeks care following sexual abuse, the case must be reported to child protection. If an adolescent seeks care following sexual assault, the provider may feel that it is in the best interest of the adolescent to inform the parent. (See section on the clinical approach to the adolescent patient, in the subsequent text, for further discussion of confidentiality.)

Another issue is whether adolescents have access to health care providers they trust. This is problematic for the teen who sees a particular physician for the first time. How will the teen know whether the provider is comfortable providing confidential care to adolescents? How will the teen decide whether to talk about sensitive sexual health concerns? Can the teen trust the provider to keep these concerns confidential and not tell the parent? Access can also be problematic if the adolescent’s family has been going to the same physician for many years. In such situations, the adolescent may be concerned that the physician will decide that the parents’ need to know is more important than the teen’s need for privacy.

A final issue of access to care is payment for services. This is a problem for both uninsured and insured patients. Adolescents may not understand the importance of health insurance or have the necessary funds to pay for health care out of pocket. If they seek care in an emergency department, problems with insurance and payment may not directly affect their receipt of care, although an itemized bill may be sent to their parents. Parents, in turn, are under no obligation to pay for services that are confidential and provided without their consent, unless the care provided was for an emergency (38,41). If adolescents go to a clinic without active insurance or cash to cover the visit, they are often denied care and referred to an emergency department. This scenario is not infrequent because adolescents and young adults are more likely to be uninsured than individuals from any other age-group (42,43,44).

Even insured adolescents have problems. For adolescents who are covered under their parents’ private insurance, an itemized bill may be sent to the parent following the health care visit. To avoid this, the adolescent may need to arrange to pay for the visit out of pocket. In addition, some private insurers do not pay for family planning. Also, for the adolescent who is on medical assistance, some plans cover family planning services but not the cost of testing and treatment for sexually transmitted diseases.

These health care-access issues are all significant forces shaping the utilization of health care by the adolescent. In many instances, adolescents simply do not go to a physician even though they have significant health care needs. They also may
preferentially use the emergency department for any reproductive health care needs because most emergency departments provide care regardless of insurance coverage.

Legislation has been enacted to address some of the issues of access to health care for the acute sexual assault victim. The Violence Against Women Act of 1994 mandates that states provide forensic examinations free of charge in order to receive federal funds. Despite this, women are sometimes charged for these examinations and are unaware that it should have been free (21).

The adolescent years span a period marked by significant change not only in sexual knowledge, attitudes, and behaviors but also in the teen–parent relationship. The care of the adolescent patient who has been sexually victimized will often involve the parents, and it is therefore important to understand the basic legal rights and responsibilities of both parents and teens and how these change as the teen grows older.

When care is provided to an adolescent patient, it is important to know the parents’ role in the visit. Has the adolescent come to the health care provider alone or with a parent or guardian? Who initiated the visit? Is it the adolescent who wants to be seen or the parent who wants the adolescent to be seen? Does the adolescent have a specific health complaint
or is the adolescent there because the parent has concerns, e.g., does the parent want an examination to see if the adolescent has been sexually active? If the adolescent comes in alone, does the parent know about the visit, or does the teen want everything to be kept confidential? Is the adolescent old enough that any reproductive health concerns, including those following sexual abuse or sexual assault, do not have to be communicated to the parent? Is the adolescent an emancipated minor? The answers to these questions are often not straightforward and will require the provider to consider the specific circumstances and applicable state law.

By law, in most states the age of majority is 18. Once the teen has reached this age, parental consent for health care services is not needed, and in most cases he or she must give permission for any sensitive health information to be shared with the parent.

As discussed earlier in this chapter, all states have minor consent statutes that allow the provision of care to adolescents below the age of majority for certain reproductive health care needs, including care for sexual abuse or sexual assault. In addition, in some states, additional statutes apply for the “emancipated minor,” i.e., the adolescent who is below the age of majority and yet considered to be legally autonomous owing to circumstances of life (e.g., is married or is in the armed forces). The emancipated minor may consent for any and all health care, including that needed following sexual assault or abuse.

However, in caring for adolescents, and especially for those who have been sexually victimized, consent does not imply confidentiality. If sexual abuse has occurred, state law mandates reporting the matter to child protection or the police. If statutory rape has occurred, some would argue that the parent has a right to know and an obligation to intercede. In fact, in the State of Maryland, parental failure to intercede knowing that statutory rape has occurred is considered child neglect. If an adolescent under 18 presents to the emergency department following a self-identified coercive sexual assault and does not want the parent to know, the physician may still decide that it is in the best interest of the adolescent to contact the parent. In Maryland, specific legislative statutes give care providers the right (but not the obligation) to share sensitive reproductive health information with the parents of minors.

In all cases, if an adolescent discloses a history of sexual victimization and wants this to be kept confidential, it is important to ask why. The provider must bear in mind that some teens have valid concerns about sharing information with their parents. For example, if there is a nondisclosed history of maltreatment, the teen may justly fear further abuse if the parents are informed of sexual misadventures or victimization. If there is any concern about contacting the parents, then consultation with a social worker is critical to help address these issues and arrange appropriate follow-up care.

Sometimes it will be clear from the very start that the parent should be included in the clinical encounter. At other times, it will not be clear and the provider will have to decide how to involve the parent as the visit unfolds. In general, if the adolescent is brought to the visit by a parent or guardian, the adolescent should be interviewed alone at some point during the course of the visit. Also, if the adolescent is younger than 18, it may be appropriate to ask the guardian or parent about specific concerns they may have. The provider may decide to interview the parent alone at some point. If this happens, it will be important to talk with the teen afterward to allay fears of being talked about “behind their back.” This being said, if the adolescent has been sexually abused, in most cases the parent will need to be involved, and if the adolescent has been sexually assaulted, in most cases the parent should be involved. In all situations, clinical skill, time, and private space are needed to provide the necessary clinical services in an effective manner that balances the parent’s rights and need to know and the adolescent’s rights and need for confidentiality and autonomy.