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Minor consent laws for STI/HIV services increased across US, but limitations persist
As of 2021, all 50 states and Washington, DC allow youth to consent independently to some or all of these services, but the laws remain complex and varied, and confidentiality protections are rare.
Increasing sexually transmitted infection (STI) and HIV testing, treatment, and preventive services use among adolescents is key to decreasing STI and HIV rates among this population in the United States. Youth are disproportionately burdened by these health conditions, particularly among sexual, gender, and racial minorities, and this burden has only worsened over the course of the pandemic.
Minor consent laws provide underage youth the ability to obtain these services without their parents' permission, but these laws are complex, substantially limited, and vary by state, and many adolescents are unaware that these laws even exist.
Understanding the history and limitations of these laws is necessary to evaluate their impacts on access to care, inform clinical practice, identify gaps in legal protections, and increase health equity among US adolescents, according to a new study led by a Boston University School of Public Health (BUSPH) researcher.
Published in the American Journal of Public Health, the study examined how minor consent laws for STI and HIV testing, treatment, and preventive services have changed over the last century in all 50 states and Washington, DC.
The number of states allowing minors to consent independently to STI and HIV services increased considerably, but in many states, these laws remain unclear or narrow in scope, allow doctors to decide which information they disclose to guardians, or fail to address inadvertent breaches of confidentiality through insurance billing and claims.
These disclosures may reveal information about youths' gender identity, sexual activity, or sexual orientation, which could put them at risk of rejection or abuse by their guardians.
"Although there have been substantial gains in minor's legal ability to independently consent to STI/HIV testing, treatment, and prevention services in the US in the last century, there remains significant room for improvement in these laws," says study lead and corresponding author Dr. Kimberly Nelson, associate professor of community health sciences at BUSPH. "Minors have gained the right to consent to STI/HIV testing and treatment without needing a guardian's permission in all 50 states and DC, but their ability to consent independently to STI/HIV prevention services—including the HPV vaccine and pre-exposure prophylaxis (PrEP) for HIV—is still lacking in many states. Clinicians need to be aware of the intricacies of these laws to help minor patients navigate which services they are allowed to independently consent to, as well as payment and insurance loopholes to confidentiality."
For the study, Dr. Nelson and colleagues analyzed state health laws, judicial opinions and regulations between 1900-2021, categorizing minor consent laws by general healthcare; STI/HIV testing, treatment, and prevention; and PrEP or postexposure prophylaxis (PEP).
Between 1900-1959, the laws were extremely limited, and likely reflected increasing concerns that STIs hindered childbearing and marriage. Only nine states had consent laws around STI testing and treatment, and only one state—Rhode Island—had regulations that addressed STI prevention services.
The largest increase in states allowing minors to consent to STI services occurred during the 1960s and 1970s, evolving alongside social advances, such as the Civil Rights Movement, and sexual health advances, such as birth control pills. Laws then continued to increase steadily over the next decades, and by 2021, minors could consent independently to STI/HIV testing and treatment in all 50 states and DC, STI prevention services in 32 jurisdictions, and HIV prevention services in 33 jurisdictions.
But confidentiality protections are still rare and varied in the majority of states, across regions and political party lines, from California, to Alabama, to Iowa. All 50 states and DC allowed minors to consent independently to STI/HIV testing and treatment, but only 13 states mandate confidentiality for STI services, and only 14 states mandate confidentiality for HIV services—and many of these laws grant exceptions, such as the ability for doctors to disclose minors' information if a test is positive or if they are contacted by the adolescent's parent or guardian.
In Massachusetts, doctors can disclose minors' health information to their guardian if they are in a life-threatening condition or face amputation of a limb. The only states that provide mandatory confidentiality laws with no exceptions, are Connecticut, Florida, Illinois, Nevada, New York, Virginia, and Wyoming.
The study also showed that only five states have attempted to protect minors' healthcare payor information from disclosure to guardians.
The researchers urge legal and policy changes that will ensure additional protections for youth.
"Minors who are unable or unwilling to involve their guardians when they are seeking STI/HIV services deserve to have access to these critical services and while these laws help, they do not fully address all of the potential barriers that minors face," Dr. Nelson says. "Policymakers should seek to improve these laws to address their complexity, reliance on clinician interpretation, and the substantial confidentiality concerns that remain."
More information: Kimberly M. Nelson et al, Minor Consent Laws for Sexually Transmitted Infection and Human Immunodeficiency Virus Services in the United States: A Comprehensive, Longitudinal Survey of US State Laws, American Journal of Public Health (2023). DOI: 10.2105/AJPH.2022.307199