The Initial Reproductive Health Visit: ACOG Committee Opinion, Number 811.

The primary goal of the initial reproductive health visit is to provide preventive health care services, educational information, and guidance, in addition to problem-focused care. The initial reproductive health visit should take place between the ages of 13 and 15 years. The scope of the initial visit will depend on the patient's concerns, medical history, physical and emotional development, and the level of care the patient is receiving from other health care professionals. All adolescents should have the opportunity to discuss health issues with a health care professional one-on-one, because they may feel uncomfortable talking about these issues in the presence of a parent or guardian, sibling, or intimate partner. Addressing confidentiality concerns is imperative because adolescents in need of health care services are more likely to forego care if there are concerns about confidentiality. Laws regarding confidentiality of care to minors vary by state, and health care professionals should be knowledgeable about current laws for their practice. Taking care to establish secure lines of communication can build trust with the patient and guardian, support continuity of care, ensure adherence to legal statutes, and decrease barriers to services. Obstetrician-gynecologists have the opportunity to serve as educators of parents and guardians about reproductive health issues. Preparing the office environment to include adolescent-friendly and age-appropriate reading materials, intake forms, and educational visual aids can make the general office space more inclusive and accessible. Resources should be provided for both the adolescent patient and the parent or guardian, if possible, at the conclusion of the visit. This Committee Opinion has been updated to include gender neutral terminology throughout the document, counseling topics with direct links to helpful resources, screening tools with direct links, addition of gender and sexuality discussion, and inclusion of trauma-informed care.

The Initial Reproductive Health Visit: ACOG Committee Opinion Summary, Number 811.

The primary goal of the initial reproductive health visit is to provide preventive health care services, educational information, and guidance, in addition to problem-focused care. The initial reproductive health visit should take place between the ages of 13 and 15 years. The scope of the initial visit will depend on the patient's concerns, medical history, physical and emotional development, and the level of care the patient is receiving from other health care professionals. All adolescents should have the opportunity to discuss health issues with a health care professional one-on-one, because they may feel uncomfortable talking about these issues in the presence of a parent or guardian, sibling, or intimate partner. Addressing confidentiality concerns is imperative because adolescents in need of health care services are more likely to forego care if there are concerns about confidentiality. Laws regarding confidentiality of care to minors vary by state, and health care professionals should be knowledgeable about current laws for their practice. Taking care to establish secure lines of communication can build trust with the patient and guardian, support continuity of care, ensure adherence to legal statutes, and decrease barriers to services. Obstetrician-gynecologists have the opportunity to serve as educators of parents and guardians about reproductive health issues. Preparing the office environment to include adolescent-friendly and age-appropriate reading materials, intake forms, and educational visual aids can make the general office space more inclusive and accessible. Resources should be provided for both the adolescent patient and the parent or guardian, if possible, at the conclusion of the visit. This Committee Opinion has been updated to include gender neutral terminology throughout the document, counseling topics with direct links to helpful resources, screening tools with direct links, addition of gender and sexuality discussion, and inclusion of trauma-informed care.

Adolescent patients and the clinical decision about their health / O paciente adolescente e a deliberação clínica sobre a sua saúde

ABSTRACT Objective: To carry out a review of the literature on adolescents' participation in decision making for their own health. Data sources: Review in the Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (LILACS) and PubMed databases. We consider scientific articles and books between 1966 and 2017. Keywords: adolescence, autonomy, bioethics and adolescence, autonomy, ethics, in variants in the English, Portuguese and Spanish languages. Inclusion criteria: scientific articles, books and theses on clinical decision making by the adolescent patient. Exclusion criteria: case reports and articles that did not address the issue. Among 1,590 abstracts, 78 were read in full and 32 were used in this manuscript. Data synthesis: The age at which the individual is able to make decisions is a matter of debate in the literature. The development of a cognitive and psychosocial system is a time-consuming process and the integration of psychological, neuropsychological and neurobiological research in adolescence is fundamental. The ability to mature reflection is not determined by chronological age; in theory, a mature child is able to consent or refuse treatment. Decision-making requires careful and reflective analysis of the main associated factors, and the approach of this problem must occur through the recognition of the maturity and autonomy that exists in the adolescents. To do so, it is necessary to "deliberate" with them. Conclusions: International guidelines recommend that adolescents participate in discussions about their illness, treatment and decision-making. However, there is no universally accepted consensus on how to assess the decision-making ability of these patients. Despite this, when possible, the adolescent should be included in a serious, honest, respectful and sincere process of deliberation.

RESUMO Objetivo: Realizar uma revisão da literatura sobre a participação do adolescente na tomada de decisão sobre a sua saúde. Fonte de dados: Revisão nos bancos Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) e PubMed. Consideramos artigos científicos e livros entre 1966 e 2017. Palavras-chave: adolescência, autonomia, bioética e adolescência, autonomia, ética, em línguas inglesa, portuguesa e espanhola. Critérios de inclusão: artigos científicos, livros e dissertações que contemplassem a tomada de decisão clínica pelo paciente adolescente. Critérios de exclusão: relatos de caso e artigos que não abordavam a questão norteada nesta pesquisa. Do total de 1.590 resumos, 78 foram lidos na íntegra, e 36, utilizados neste manuscrito. Síntese dos dados: A idade em que o indivíduo é capaz para tomar decisões é motivo de debate na literatura. O desenvolvimento de um sistema cognitivo e psicossocial é um processo demorado, e faz-se fundamental a integração da investigação psicológica, neuropsicológica e neurobiológica na adolescência. A capacidade de reflexão madura não é determinada pela idade cronológica; em teoria, um menor maduro seria capaz de consentir ou recusar um tratamento. A tomada de decisão exige análise cuidadosa e reflexiva dos principais fatores associados, e a abordagem desse problema deve ocorrer por meio do reconhecimento da maturidade e da autonomia que existe no adolescente. Para tanto, é necessário "deliberar" com ele. Conclusões: Diretrizes internacionais recomendam que os adolescentes participem de discussões sobre sua doença, tratamento e tomada de decisão, entretanto não há nenhum consenso universalmente aceito sobre como avaliar a capacidade de decisão desses pacientes. Apesar disso, quando possível, o adolescente deve ser incluído em um processo sério, honesto, respeitoso e sincero de deliberação.

ADOLESCENT PATIENTS AND THE CLINICAL DECISION ABOUT THEIR HEALTH.

OBJECTIVE: To carry out a review of the literature on adolescents' participation in decision making for their own health. DATA SOURCES: Review in the Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (LILACS) and PubMed databases. We consider scientific articles and books between 1966 and 2017. Keywords: adolescence, autonomy, bioethics and adolescence, autonomy, ethics, in variants in the English, Portuguese and Spanish languages. Inclusion criteria: scientific articles, books and theses on clinical decision making by the adolescent patient. Exclusion criteria: case reports and articles that did not address the issue. Among 1,590 abstracts, 78 were read in full and 32 were used in this manuscript. DATA SYNTHESIS: The age at which the individual is able to make decisions is a matter of debate in the literature. The development of a cognitive and psychosocial system is a time-consuming process and the integration of psychological, neuropsychological and neurobiological research in adolescence is fundamental. The ability to mature reflection is not determined by chronological age; in theory, a mature child is able to consent or refuse treatment. Decision-making requires careful and reflective analysis of the main associated factors, and the approach of this problem must occur through the recognition of the maturity and autonomy that exists in the adolescents. To do so, it is necessary to "deliberate" with them. CONCLUSIONS: International guidelines recommend that adolescents participate in discussions about their illness, treatment and decision-making. However, there is no universally accepted consensus on how to assess the decision-making ability of these patients. Despite this, when possible, the adolescent should be included in a serious, honest, respectful and sincere process of deliberation.

Ethical issues arising in the provision of medical interventions for gender diverse children and adolescents.

The care of children and adolescents whose experience of the body is at odds with their gender feelings raises a number of questions that are as much ethical as medical or psychological. In this article I highlight some areas of ethical concern from the point of view of a senior clinician at the nationally commissioned UK Gender Identity Development Service (GIDS). I make the assumption that ethical deliberation is relational and grounded in the natural, social, political and institutional worlds in which the ethical questions arise. I try to show how matters of empirical fact, alongside an appreciation of broad social contexts, and historic and current power relations, provide an essential framework for the ways that ethical choices are framed by key groups of people as they take up different, sometimes opposing, ethical positions. I argue that practising ethically in such a service is not helpfully reduced to a single event, a treatment decision aimed at achieving the morally 'right' outcome, but an extended process in time. In the charged debate surrounding the recognition of these young people's needs, we must do more to promote responsible debate about the scope of sound ethical practice.

Statement on gender-affirmative approach to care from the pediatric endocrine society special interest group on transgender health.

PURPOSE OF REVIEW: The purpose of this Position Statement is to emphasize the importance of an affirmative approach to the health care of transgender individuals, as well as to improve the understanding of the rights of transgender youth. RECENT FINDINGS: Transgender youth have optimal outcomes when affirmed in their gender identity, through support by their families and their environment, as well as appropriate mental health and medical care. SUMMARY: The Pediatric Endocrine Society Special Interest Group on Transgender Health joins other academic societies involved in the care of children and adolescents in supporting policies that promote a safe and accepting environment for gender nonconforming/transgender youth, as well as adequate mental health and medical care. This document provides a summary of relevant definitions, information and current literature on which the medical management and affirmative approach to care of transgender youth are based.

Confidentiality in Pediatric and Adolescent Gynecology: When We Can, When We Can't, and When We're Challenged.

Maintaining confidentiality is an important aspect of adolescent health care. Different states and provinces have laws around the provision of confidential health care to minors for specific health concerns such as reproductive health, mental health and substance abuse. However, there are situations where confidentiality cannot be assured, particularly if the adolescent is being abused. Educating teens and parents about the circumstances in which confidentiality is necessary is sometimes challenging for the clinician. Moreover, with the advent of electronic medical records, patient portals and other requirements to share health information with parents and the adolescent patient, confidentiality is sometimes not easy to assure. The following is the Elsevier Lecture from the 2015 Meeting of the North American Society for Pediatric and Adolescent Gynecology.

Justifications for coercive care in child and adolescent psychiatry, a content analysis of medical documentation in Sweden.

BACKGROUND: There has been considerable interest in normative ethics regarding how and when coercive care can be justified. However, only a few empirical studies consider how professionals reason about ethical aspects when assessing the need for coercive care for adults, and even less concerning children and adolescents. The aim of this study was to examine and describe how professionals document their value arguments when considering the need for coercive psychiatric care of young people. METHODS: All 16 clinics that admitted children or adolescents to coercive care during one year in Sweden were included in the study. These clinics had a total of 155 admissions of 142 patients over one year. Qualitative content analysis with a deductive approach was used to find different forms of justification for coercive care that was documented in the medical records, including Care Certificates. RESULTS: The analysis of medical records revealed two main arguments used to justify coercive care in child and adolescent psychiatry: 1) the protection argument - the patients needed protection, mainly from themselves, and 2) the treatment requirement argument - coercive care was a necessary measure for administering treatment to the patient. Other arguments, namely the caregiver support argument, the clarification argument and the solidarity argument, were used primarily to support the two main arguments. These supportive arguments were mostly used when describing the current situation, not in the explicit argumentation for coercive care. The need for treatment was often only implicitly clarified and the type of care the patient needed was not specified. Few value arguments were used in the decision for coercive care; instead physicians often used their authority to convince others that treatment was necessary. CONCLUSIONS: One clinical implication of the study is that decisions about the use of coercive care should have a much stronger emphasis on ethical aspects. There is a need for an ethical legitimacy founded upon explicit ethical reasoning and after communication with the patient and family, which should be documented together with the decision to use coercive care.

Health Care Issues for Children and Adolescents in Foster Care and Kinship Care.

Children and adolescents who enter foster care often do so with complicated and serious medical, mental health, developmental, oral health, and psychosocial problems rooted in their history of childhood trauma. Ideally, health care for this population is provided in a pediatric medical home by physicians who are familiar with the sequelae of childhood trauma and adversity. As youth with special health care needs, children and adolescents in foster care require more frequent monitoring of their health status, and pediatricians have a critical role in ensuring the well-being of children in out-of-home care through the provision of high-quality pediatric health services, health care coordination, and advocacy on their behalves.

Conscientious objection to abortion and reproductive healthcare: a review of recent literature and implications for adolescents.

PURPOSE OF REVIEW: Conscientious objection to reproductive healthcare (refusal to perform abortion, assisted reproductive technologies, prenatal diagnosis, contraception, including emergency contraception and sterilization, etc.) has become a widespread global phenomenon and constitutes a barrier to these services for many women. Adolescents are a particularly vulnerable group because some providers object to specific aspects of their reproductive healthcare because of their status as minors. RECENT FINDINGS: Recent peer-reviewed publications concerning conscientious objection address provider attitudes to abortion and emergency contraception, ethical arguments against conscientious objection, calls for clarification of the current laws regarding conscientious objection, legal case commentaries, and descriptions of the country-specific impact of policies in Russia and Italy. SUMMARY: Conscientious objection is understudied, complicated, and appears to constitute a barrier to care, especially for certain subgroups, although the degree to which conscientious objection has compromised sexual and reproductive healthcare for adolescents is unknown. Physicians are well positioned to support individual conscience while honoring their obligations to patients and to medical evidence.

Diagnosis and treatment of chlamydia, gonorrhea, and trichomonas in adolescents.

CME EDUCATIONAL OBJECTIVES: 1.Determine and discuss issues surrounding consent, confidentiality, and billing for sexually transmitted infection (STI) care delivery in the adolescent population.2.Review currently available testing modalities for STIs and their applicability in the adolescent population.3.Provide treatment and prevention strategies for the most commonly encountered STIs in the adolescent demographic. Adolescents and young adults, 15 to 24 years of age, carry a disproportionate burden of sexually transmitted infections compared with other age groups in the United States (see Figure 1).1.

Legal and ethical issues in adolescents' health care.

This review examines confidentiality, consent to health care and research involving adolescents in regard to legal and ethical aspects. Adolescents are more likely to seek health care if their provider assures confidentiality, but in providing confidential care a balance should be considered between the needs of the adolescent patient, parents, and provider. The vast majority of countries set the legal age at 18, but from the age of 14 years adolescents' capability for medical decision-making may be considered already similar to adult capacity. Instead of chronological age of consent, permission for consent must take into consideration the adolescent's capacity for understanding the medical treatment or the research in which the adolescent is requested to be involved. At all circumstances adolescent's assent for both medical treatment and research is always mandatory. Involving adolescents in research should be based on a careful assessment of risks and benefits together with understanding of the developing capabilities of the adolescent.

Health rights, health ethics, and adolescence: addressing current challenges, ensuring a just future.

This article presents a discussion of the human rights declarations that address adolescent health, including reference to specific articles in the declarations that address this population; examples of ethical issues related to health that are faced by adolescents, their families, and providers who care for them; and ethical principles and frameworks that can serve as a basis for consideration of these issues. The article also includes examples of circumstances that pose ethical dilemmas for clinicians and adolescent clients and their families.

Law, ethics, and clinical discretion: recurring and emerging issues in adolescent health care.

Varied stakeholders are involved in adolescent health care, with many looking to law to provide clear-cut answers on who can control decisions and when. However, law allows for much clinician discretion, carving out space for contextual sensitivity and clinical determination of maturity. A triad model of decision-making is very often the most appropriate clinical and ethical course. Law's aim is ideally not to impede, but rather to support clinical and ethical wisdom. Drawing on cases in this volume, it is argued that law should not and typically does not, when accurately interpreted and applied, stand in clinicians' way.

Attitude of Lithuanian residents to confidentiality of adolescent sexual and reproductive health care.

OBJECTIVE: To assess the attitudes of Lithuanian residents towards the protection of confidentiality in the sexual and reproductive health care of adolescents. MATERIAL AND METHODS: A public opinion survey was performed in August 2005. A random sample, taking into account age, sex, education, employment, family status, place of residence of 1,054 Lithuanian residents aged 16-74 was interviewed in their households. The topics dealt with in the 23-item questionnaire concerned attitudes towards confidentiality in adolescents' sexual and reproductive health care as well as towards sexual and reproductive health promotion for them. RESULTS: More than half (58%) of the respondents believed that confidentiality is an important issue in case of sexual and reproductive health services that address adolescents. Although only 12% of Lithuanians were ready to agree with the legalization of the right to confidentiality in health care for those younger than 16, at least one-third of the respondents stated that physicians have to protect confidential counselling for 14-15-year-old adolescents on inter alia contraception, pregnancy and sexually transmitted infections. Forty-two percent of the respondents gave top priority to the legal initiative focused on improvement of confidentiality protection. Other promising strategies selected by Lithuanian residents included the development of policies concerning confidentiality protection for minor patients, assuring the privacy of consultations and protecting the medical record keeping system. CONCLUSIONS: The Lithuanian residents surveyed had a positive attitude towards confidential sexual and reproductive health care for adolescents. They stated that guarantees of confidentiality should depend on the reason for the consultation and the age of the patient. The most promising initiatives for the improved protection of confidentiality include strengthening legislation and improving organizational procedures in health care settings.

Balancing liberation and protection: a moderate approach to adolescent health care decision-making.

In this paper I examine the debate between 'protectionists' and 'liberationists' concerning the appropriate role of minors in decision-making about their health care, focusing particularly on disagreements between the two sides regarding adolescents. Protectionists advocate a more traditional, paternalistic approach in which minors have relatively little input into the healthcare decision-making process, and decisions are made for them by parents or other adults, guided by a commitment to the patient's best interests. Liberationists, on the other hand, argue in favour of expanded participation by minors in treatment decisions, and decision-making authority for at least some adolescents. My examination of the debate includes discussion of liberationist shifts that have taken place in the medical community as well as in legal policy and practice, and consideration of recent research on adolescent development. In the final section of the paper, I propose a moderate position that addresses both liberationist and protectionist concerns.

Aspectos psicosociales, éticos y legales en la atención de adolescentes y jóvenes transexuales / Psicosocial, ethical and legal aspects in the attention of adolescent and transsexual youth

Introducción. La transexualidad es el deseo irreversible de pertenecer al sexo contrario del genéticamente establecido y asumir el correspondiente rol y de recurrir si es necesario a un tratamiento hormonal y quirúrgico dirigido a corregir esta discordancia. La revelación de esta identidad sexual esta ocurriendo cada vez más a edades más tempranas. Los profesionales que atienden adolescentes debieran estar preparados para atender adolescentes y jóvenes con identidad sexual transexual. El objetivo de este estudio fue Identificar dificultades experimentadas por adolescentes y jóvenes transexuales y en que ámbitos se encuentran estas dificultades. Material y método: Se realizó un estudio cualitativo, con una muestra de adolescentes y jóvenes transexuales, femeninos y masculinos, consultantes en Cemera y de organizaciones que luchan por los derechos de las personas transexuales. Se realizaron entrevistas semi-estructuradas. Se utilizó el análisis temático de los datos. Los significados e interpretaciones que emergieron fueron constantemente verificados a través de análisis sucesivos. Resultados: Un total de 16 personas transexuales fueron entrevistadas. Los resultados muestran que las personas transexuales experimentan numerosas dificultades en el ámbito familiar, escolar, laboral, social, legal y salud, lo cual dificulta aún más el desarrollo de su identidad sexual, provocándoles además un gran sufrimiento. Conclusiones: Es importante considerar que los y las profesionales de la salud a menudo asumen la heterosexualidad en los adolescentes y jóvenes que atienden y por lo tanto están creando un setting de barreras para la atención de esta población específica e implícitamente la están discriminando.

Introduction: Transsexualism is the irreversible desire to belong to the opposite sex of the one that is genetically established and to assume the corresponding role and turn if necessary to a hormonal and surgical treatment directed to correct this conflict. The revelation of this sexual identity is happening at younger ages. Professionals who see adolescents should be also prepared o see adolescents and young people with a transsexual sexual identity. Objective: To identify the main difficulties experienced by adolescents and transsexual youth. Material and method: A qualitative study was carried out, with a sample of adolescents and transsexual youth, female and male, patients in Cemera and in the organizations that fight for the rights of transsexual people. Semi-structured interviews were executed. A thematic analysis of data was used. The meanings and interpretations which resulted were constantly verified by means of successive analyses. Results: A total of 16 transsexual people were interviewed. The results show that transsexual people experience numerous difficulties in the familiar, educational, work, social, legal and health areas, which makes the development of their sexual identity even more difficult, causing them great suffering. Conclusions: Health professionals frequently assume heterosexuality in adolescents and young people they see and, therefore, they are creating a setting of obstacles for the health care of this specific population and, as a consequence, they are implicitly discriminating it.

Ethics and adolescent care: an international perspective.

PURPOSE OF REVIEW: This update reviews the concepts underlying ethical issues in various contexts and countries, highlighting the evolution in the use of the core values underpinning the field and practice of bioethics as applied to healthcare. RECENT FINDINGS: It stresses the specific position of the adolescent as being a unique individual searching for autonomy and, most of the time, being competent to make decisions regarding the adolescent's own health. It briefly outlines the principles of a 'deliberative' approach in which the practitioner, while keeping in mind the legal context of the country where the practitioner is working, assesses to what extent the adolescent can be considered as competent, and then discusses with the adolescent the medical and psychosocial aspects of the various actions to be taken in a situation, as well as the basic ethical values linked with each of the various options available. The deliberation can involve relevant stakeholders, provided the issues concerning confidentiality have been fully discussed with the adolescent. SUMMARY: This process forces the practitioner, the adolescent patient and those who care for the adolescent patient to look outside their usual frameworks and make a decision that is in the best interest of the young person, and is informed by various ethical values.

Atenção ao adolescente: considerações éticas e legais

Aborda alguns aspectos polêmicos no atendimento ou que implicam tomada de decisão do ponto de vista ético ou legal relacionadas à saúde do adolescente.