Date: September 6, 2001

From: MCH Consultant, PAIHS

Subject: Provision of care to adolescents

To: Steve Thompson, FNP

Salt River Clinic

As per your request for clarification, the IHS policy regarding the
provision of pregnancy and gynecological medical care services to
adolescents is as follows:

> "In accordance with applicable State laws, counseling and services
> regarding pregnancy, sexually transmitted diseases and family planning
> may be provided without the parents knowledge and consent. In general
> the IHS policy is to encourage adolescents to involve their parents in
> their health care. It is the adolescent's responsibility to inform
> his/her parents. The health care provider should encourage, counsel
> and support adolescents in the process of involving their parents."

In Arizona, the age of majority is 18. By law, those minors who are
married, emancipated or in the military may consent for their own health
care, including women's health services. No Arizona statue defines
emancipation. Additionally, Arizona has no legislation which
specifically grants or denies minors the right to consent for family
planning or pregnancy-related care. But, there is legislation which
states that minors may specifically obtain evaluation and treatment for
venereal disease and pregnancy diagnosis without parental consent.

AAP, ACOG, federal guidelines, and published Arizona guidelines all
support the right of minors to have access to family
planning/contraceptive and STD services (attached legal opinion "Consent
for treatment of minors" and "Sex and the Law". Therefore, in relation
to their own reproduction, minors are to be treated as adults. These
guidelines reflect an increasing legal and social view of the adolescent
as an individual responsible for his/her own actions, a "mature minor".
A mature minor is commonly considered to be at least age 15 and, through
living at home, demonstrates the cognitive maturity to give informed
consent.

Special concern is recommended when adolescents, 14 years of age and
under, present for care. In early adolescence, many patients have not
reached a development stage where they have the ability to care for an
infant and/or participate in a sharing adult relationship. Early sexual
activity is also known to be associated with other social problems
and/or child maltreatment. When seeing these adolescents, a referral to
social services may be considered to provide additional

assistance and support to these adolescents and their families.

Medical Care Services for the Adolescent Page - 2 -

In response to your question regarding duty to report the pregnancy to a
social service and/or law enforcement agency. As stated previously, it
is true that, especially in the 12-14 year old age grouping, concerns of
possible child maltreatment and/or sexual abuse are raised. And, there
may be a duty to make a report to local authorities, **if there are
indications of child maltreatment and/or statutory violations.** But,
the "automatic" reporting of a teenagers pregnancy, without due cause,
is a violation of the federal privacy act and an "unwarranted invasion
of the pateints' privacy". (See attached opinion July 21, 1993) The
criteria for reporting the sexual abuse of a minor, as defined within 18
U.S.C 2243, is attached.

All primary care providers are encouraged to provide women's health care
services as requested by the adolescent. It is also appropriate, and
prudent, to follow IHS guidelines by documenting the parental
involvement and/or the encouragement of parental involvement. The
exception to this may be colposcopy /biopsy services, which could be
considered a non emergent surgical service. In this case, the best
policy would be to obtain both the adolescent's and parent/guardian's
consent.

Please let me know you have further questions and/or concerns regarding
this issue.

Sincerely,

Dorothy J. Meyer, CNM, MPH

MCH Consultant

Phoenix Area Indian Health Service

cc: Ms. McCraw-Helms

Dr. McGee

Attachments: Confidentiality in Adolescent Health Care (ACOG)

Consent for Medical Services for Children and Adolescents (AAP)

Consent (Chapter 1, Sex & the Law - Arizona Legal Guide on Reproduction,

Sexual Conduct and Families)

Consent for treatment of minors (Legal Opinion, Assistant Regional
Counsel,

Region IX, 1991)

Automatic Reporting of Pregnancies in Teenaged Patients to Bureau of
Indian

Affairs Law Enforcement Officers (Legal Opinion, Field Solicitor, BIA

Phoenix Field Office, 1993)