Adolescent Consent for Human Papillomavirus Vaccine: Ethical, Legal, and Practical Considerations.

We address ethical, legal, and practical issues related to adolescent self-consent for human papillomavirus (HPV) vaccination. HPV vaccination coverage continues to lag well behind the national goal of 80% series completion. Structural and behavioral interventions have improved vaccination rates, but attitudinal, behavioral, and access barriers remain. A potential approach for increasing access and improving vaccination coverage would be to permit adolescents to consent to HPV vaccination for themselves. We argue that adolescent self-consent is ethical, but that there are legal hurdles to be overcome in many states. In jurisdictions where self-consent is legal, there can still be barriers due to lack of awareness of the policy among healthcare providers and adolescents. Other barriers to implementation of self-consent include resistance from antivaccine and parent rights activists, reluctance of providers to agree to vaccinate even when self-consent is legally supported, and threats to confidentiality. Confidentiality can be undermined when an adolescent's self-consented HPV vaccination appears in an explanation of benefits communication sent to a parent or if a parent accesses an adolescent's vaccination record via state immunization information systems. In the context of the COVID-19 pandemic, which has led to a substantial drop in HPV vaccination, there may be even more reason to consider self-consent. The atmosphere of uncertainty and distrust surrounding future COVID-19 vaccines underscores the need for any vaccine policy change to be pursued with clear communication and consistent with ethical principles.

Commercial sexual exploitation and sex trafficking of adolescents.

PURPOSE OF REVIEW: This review describes the current state of commercial sexual exploitation and sex trafficking of adolescents in the United States and globally, the legal and health implications of this severe form of abuse, and the roles that pediatric and adolescent healthcare providers can play in addressing this issue. Although this form of exploitation and abuse is shrouded in secrecy, pediatric and adolescent healthcare providers are well positioned to respond when it arises. However, awareness and understanding of the issue are generally lacking among healthcare professionals, currently limiting their effectiveness in combating this problem. RECENT FINDINGS: Although the empirical evidence base available to guide clinical care of victims of trafficking remains limited given the secretive nature of the abuse, important contributions to the multidisciplinary literature on this issue have been made in recent years, including the Institute of Medicine's landmark report in the United States. SUMMARY: Commercial sexual exploitation and sex trafficking of adolescents represent a human rights tragedy that remains inadequately addressed. As preeminent advocates for the health and well-being of adolescents, pediatric and adolescent healthcare providers can play a crucial role in advancing efforts not only to intervene but also to prevent further victimization of vulnerable youth.

Sex trafficking of adolescents and young adults in the United States: healthcare provider's role.

PURPOSE OF REVIEW: Sex trafficking of adolescents and young adults is both a human rights violation and a public health problem, globally and in the United States. Healthcare providers, including obstetricians and gynecologists, interact with victims, often while they remain under their traffickers' control, but because of providers' lack of training in identification and response many victims go unrecognized and unaided. This review provides an overview of the definitions of sex trafficking and commercial sexual exploitation, contributing factors, health consequences, recruitment of victims, and identification and response by healthcare providers. RECENT FINDINGS: The literature on definitions and risk factors associated with sex trafficking is growing; however, literature on healthcare providers' role in addressing sex trafficking remains more limited. It is increasingly recognized that healthcare providers have an important role in victim identification and response and as advocates, collaborating with national, regional, and local agencies to increase awareness of sex trafficking as a public health problem and to address the needs of adolescent and young adult victims and survivors globally and in the United States. SUMMARY: As professionals who interact with adolescent and young adult victims of sex trafficking, healthcare providers have an important role: in collaboration with other professionals and agencies they can help to identify, respond to, extricate, protect, and advocate for victims and survivors.

Adolescents, Young Adults, and Vaccine Hesitancy: Who and What Drives the Decision to Vaccinate?

Although vaccines are important for all age groups, issues of vaccine uptake and vaccine hesitancy have particular salience for the adolescent and young adult age group. This article reviews the importance of vaccination for adolescents and young adults, the variability in uptake of different vaccines, the reasons for vaccine hesitancy for this age group, and the legal framework for consent for vaccination. One important difference between vaccine hesitancy for adolescents and hesitancy for younger children or adults is the unique developmental, clinical, ethical, and legal context in which the decision to vaccinate is made.

21st Century Cures Act ONC Rule: Implications for Adolescent Care and Confidentiality Protections.

Ensuring the confidentiality and protection of health information is the standard of care for adolescents. In 2023 and beyond, the protection of personal health information is more critical than ever. The 21st Century Cures Act Office of the National Coordinator for Health Information Technology Rule, with its requirements for the broad sharing of electronic health information and ban on "information blocking," poses serious concerns for confidentiality in adolescent health care delivery. The coronavirus disease 2019 pandemic has rapidly increased the use of telehealth and, thereby, patient portal use for adolescent health records, increasing risks for disclosure. Understanding the legal and clinical underpinnings for confidential adolescent health services and the clinical challenges and health information technology limitations presented by the Office of the National Coordinator for Health Information Technology Rule is key to providing quality adolescent health services while implementing the Rule. A framework is presented to facilitate decision-making in individual cases by clinicians.

From Human Papillomavirus to COVID-19: Adolescent Autonomy and Minor Consent for Vaccines.

Adolescent minors in every state can give their own consent for some health care. Although parent consent is generally required for vaccination, there are exceptions in some states. Completion rates are low for recommended adolescent vaccines; allowing adolescents to consent may improve coverage, although more study is needed on barriers to vaccine completion and the feasibility of changes in consent laws. The COVID-19 pandemic highlights the importance of vaccines and related challenges. This policy brief reviews laws governing adolescent consent for health care, including vaccines, and recommends advocacy to support increased adolescent access to vaccines and improved public health.

Crisis Pregnancy Centers in the United States: Lack of Adherence to Medical and Ethical Practice Standards; A Joint Position Statement of the Society for Adolescent Health and Medicine and the North American Society for Pediatric and Adolescent Gynecology.

Crisis pregnancy centers (CPCs) attempt to dissuade pregnant people from considering abortion, often using misinformation and unethical practices. While mimicking health care clinics, CPCs provide biased, limited, and inaccurate health information, including incomplete pregnancy options counseling and unscientific sexual and reproductive health information. The centers do not provide or refer for abortion or contraception but often advertise in ways that give the appearance that they do provide these services without disclosing the biased nature and marked limitations of their services. Although individuals working in CPCs in the United States have First Amendment rights to free speech, their provision of misinformation might be harmful to young people and adults. The Society for Adolescent Health and Medicine and North American Society for Pediatric and Adolescent Gynecology support the following positions: (1) CPCs pose risk by failing to adhere to medical and ethical practice standards; (2) governments should only support health programs that provide accurate, comprehensive information; (3) CPCs and individuals who provide CPC services should be held to established standards of ethics and medical care; (4) schools should not outsource sexual education to CPCs or other entities that do not provide accurate and complete health information; (5) search engines and digital platforms should enforce policies against misleading advertising by CPCs; and (6) health professionals should educate themselves, and young people about CPCs and help young people identify safe, quality sources of sexual and reproductive health information and care.

Mandatory Reporting of Human Trafficking: Potential Benefits and Risks of Harm.

Human trafficking, including both sex and labor trafficking, has profound consequences for the safety, health, and well-being of victims and survivors. Efforts to address human trafficking through prevention, protection, and prosecution are growing but remain insufficient. Mandatory reporting has the potential to bring victims and survivors to the attention of social service and law enforcement agencies but may discourage trafficked persons from seeking help, thereby limiting the ability of health care professionals to establish trust and provide needed care. States' experience in implementing child abuse laws can be useful in assessing the potential risks and benefits of mandatory reporting of human trafficking.

Rethinking research on sexual exploitation of boys: Methodological challenges and recommendations to optimize future knowledge generation.

Research and policies on child and adolescent sexual exploitation frequently focus on the sexual exploitation of girls and fail to recognize the experiences of sexually exploited boys, including their potentially unique health care and social support needs. This oversight limits the ability of health care and social service providers to offer both targeted and evidence informed care to sexually exploited boys. As a first step in a larger grant to understand the experiences of sexually exploited boys and to develop interventions for this specific population, we conducted a systematic review to address the question, "What is the state of the research on sexually exploited boys internationally?" As we undertook this review, we faced a number of significant challenges that made the process more difficult than anticipated. In this paper we discuss four key methodological challenges we encountered: lack of a consistent definition of child and adolescent sexual exploitation, difficulties in differentiating sexual exploitation as a specific concept within child sexual abuse, failure to disaggregate data usefully across multiple variables, and limited epidemiological studies to inform prevalence. We reflect on how these challenges limited our ability to systematically analyze, synthesize, and interpret the available research. We conclude by making recommendations to improve the state of the research regarding sexually exploited boys with the aim of better informing future policy and practice.

Eligibility and enrollment of adolescents in Medicaid and SCHIP: recent progress, current challenges.

PURPOSE: To examine the effect of recent federal and state policy changes on adolescents' eligibility and enrollment in Medicaid and the State Children's Health Insurance Program (SCHIP). METHODS: By analyzing relevant provisions in federal and state laws, approved state plans and amendments, annual reports and evaluations, and enrollment data provided by states, this article explores the extent to which states have taken full advantage of opportunities to expand Medicaid and SCHIP eligibility for adolescents. RESULTS: Between March 1997 and September 2001, states made significant progress toward expanding Medicaid and SCHIP coverage for adolescents. During that time, the number of states that provided Medicaid coverage to all poor adolescents aged younger than 19 years doubled, most states eliminated the disparities that previously existed in Medicaid eligibility levels for younger children and adolescents, and virtually every state raised the income level at which adolescents are eligible for public coverage in either Medicaid or SCHIP. These changes resulted in an increase in the number of adolescents who are enrolled in Medicaid and SCHIP. Nevertheless, many states implemented other policies that create barriers to adolescents' eligibility and enrollment. CONCLUSIONS: Despite recent expansions of public insurance eligibility, millions of adolescents remain uninsured. Much work remains to address eligibility gaps and to ensure that eligible adolescents are actually enrolled and use services. The current political and economic environment threatens to undermine the ability of adolescents to access services through these important programs.

Primary care providers' willingness to see unaccompanied adolescents.

PURPOSE: To describe primary care practitioners' office policies and willingness to provide medical care for unaccompanied adolescents aged 11-17 years. METHODS: A unique 32-item survey was mailed in June and July, 2001 to 1979 office-based pediatricians and family practitioners randomly selected from the American Medical Association's physician database. The survey included questions regarding demographic information, number of adolescents seen in the practice, office policies regarding adolescents alone in the clinic, and 5-point Likert scales regarding their willingness to see patients in various situations, as well as to see patients in 12 brief clinical scenarios. Predictors of the willingness to see adolescents alone were identified and entered into binomial logistic regression models. Specific policies included on the surveys were coded into groups. RESULTS: Survey responses (n = 710) represented a 36% response rate. This sample included 288 family practitioners and 368 pediatricians; 43.3% of physicians reported having a specific policy regarding seeing adolescents without their parents present. Family practitioners were more likely than pediatricians to report having such a policy (51.3% vs. 38.2%, p =.001,), yet pediatricians reported a higher percentage of adolescents in their practices than family practitioners (22.6% vs. 12.4%, p <.0005). Not having a policy was an independent predictor of "often" or "always" seeing an adolescent alone for routine health maintenance (OR = 2.84, 95% CI 1.91-4.24) and urgent care visits (OR = 3.01, 95% CI 1.90-4.77). Specific policies varied, and many physicians assessed each case on an individual basis. CONCLUSIONS: Specific policies are associated with a decreased willingness of physicians to see adolescents who are unaccompanied by a parent. Carefully developed clinic policies that are consistent with legal guidelines should be implemented in order to maximize adolescents' abilities to access care.