Minor Consent Laws for Sexually Transmitted Infection and HIV Services

Kimberly M Nelson; Alexandra Skinner; Kristen Underhill

doi:10.1001/jama.2022.10777

. 2022 Aug 16;328(7):674–676. doi: 10.1001/jama.2022.10777

Minor Consent Laws for Sexually Transmitted Infection and HIV Services

Kimberly M Nelson ^1,^✉, Alexandra Skinner ², Kristen Underhill ³

¹Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts

²Department of Health Law, Policy, & Management, Boston University School of Public Health, Boston, Massachusetts

³Cornell Law School, Ithaca, New York

Accepted for Publication: June 8, 2022.

^✉

Corresponding Author: Kimberly M. Nelson, PhD, MPH, Boston University School of Public Health, 801 Massachusetts Ave, Fourth Floor, Boston, MA 02118 (knel@bu.edu).

Author Contributions: Dr Nelson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Nelson, Underhill.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Obtained funding: Nelson, Underhill.

Administrative, technical, or material support: Nelson, Underhill.

Supervision: Nelson, Underhill.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work is supported by the National Institute of Mental Health (R01MH119892; principal investigator, Dr Nelson).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclaimer: The content of this publication is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

Additional Contributions: We thank the study team, Claire D. Stout, BA (Department of Community Health Sciences, Boston University School of Public Health), Will Raderman, MSc (Department of Health Law, Policy, & Management, Boston University School of Public Health), Emily Unger, PhD (Department of Social & Behavioral Sciences, Harvard T.H. Chan School of Public Health), Julia Raifman, ScD, SM (Department of Health Law, Policy, & Management, Boston University School of Public Health), Madina Agénor, ScD, MPH (Department of Behavioral and Social Sciences, Brown University School of Public Health), Michele Ybarra, PhD, MPH (Center for Innovative Public Health Research), Shira I. Dunsiger, PhD (Department of Behavioral and Social Sciences, Brown University School of Public Health), and S. Bryn Austin, ScD (Department of Pediatrics, Harvard Medical School), for their feedback throughout the development of this data set. We also thank the Youth Advisory Board and the 4 law student research assistants who helped code the data. All study team members, the Youth Advisory Board, and the 4 law student research assistants were supported by the above listed funding from the National Institute of Mental Health for their contributions to this project.

^✉

Corresponding author.

PMCID: PMC9382446 PMID: 35972493

Abstract

This study examines current minor consent laws for sexually transmitted infection/HIV services and related confidentiality protections in all 50 states and the District of Columbia.

Adolescents in the US have reported that a significant barrier to seeking sexually transmitted infection (STI) and HIV services is concern that a guardian will find out.¹ To address this barrier, states have enacted statutes granting minors legal capacity to consent to STI/HIV services without their guardians’ involvement. Although reviews of STI/HIV minor consent laws exist,^2,3,4 many are dated, have unclear methodology, provide conflicting information, or lack details needed to serve adolescents, researchers, and clinicians. We examined current minor consent laws for STI/HIV services and related confidentiality protections in all 50 states and the District of Columbia.

Methods

Following best practices for longitudinal surveys of state laws,⁵ we applied a systematic, replicable process of identifying, double-coding, and analyzing state statutes, state regulations, and state and federal case law regulating minors’ legal capacity to consent to STI/HIV testing, treatment, and prevention without guardian permission. We used Westlaw to search, collect, and code laws during June to December 2020 and updated data in October 2021. Laws were divided into consent to (1) health care generally; (2) STI testing, treatment, or prevention; (3) HIV testing, treatment, or prevention; and (4) HIV preexposure or postexposure prophylaxis. We also coded majority age, confidentiality protections, and conditions required before minors can consent (ie, threshold clinician judgments). Detailed procedures, assumptions, and definitions are provided in the eMethods in the Supplement.

Results

All jurisdictions (n = 51) allowed minors to consent independently to STI/HIV testing and treatment (Table). Most states allowed all minors, without a minimum age, to consent to STI (n = 43) and HIV (n = 42) testing and treatment. The remaining states granted minors the capacity to consent to STI/HIV testing and treatment between 12 and 14 years of age. Most states also allowed minors to consent to STI (n = 33) and HIV (n = 35) prevention. Fourteen states specified conditions that must be met for a minor to consent independently (eg, delaying care would substantially increase risk to the minor’s life or health) (Table). Approximately half of states addressed confidentiality protections when a minor independently seeks services for STI testing (n = 27/51), treatment (n = 28/51), or prevention (n = 17/33) or HIV testing (n = 30/51), treatment (n = 29/51), or prevention (n = 18/35) (Table).

Table. Age of Majority and Youngest Age of Legal Capacity of Mentally Competent Minors to Consent to STI and HIV Services and Confidentiality Protections for Minors’ STI and HIV Information in the US, 2021^a^,^b.

State	Age of majority, y	Youngest age of legal capacity to consent, y/confidentiality protections
		STI			HIV
		Testing	Treatment	Prevention	Testing	Treatment	Prevention, including HIV PrEP
Alabama^c	19	All/No	All/No	14/No	All/No	All/No	14/No
Alaska	18	All/No	All/No	18/–	All/No	All/No	18/–
Arizona	18	All/No	All/No	18/–	All/No	All/No	18/–
Arkansas	18	All/No	All/No	All/No	All/No	All/No	All/No
California	18	12/No	12/No	12/No	12/No	12/No	12/No
Colorado	18	All/MC^d	All/MC^d	All/MC^d	All/MC^d	All/MC^d	All/MC^d
Connecticut	18	All/MC	All/MC	18/–	All/MC	All^e or 13/MC	All^e or 13/MC
Delaware	18	All^e^,^f or 12^g/CD	All^e^,^f or 12^g/CD	12^g/CD	All^e^,^f or 12/CD	All^e^,^f or 12^g/CD	12^g/CD
District of Columbia	18	All/CD	All/CD	All/CD	All/CD	All/CD	All/CD
Florida	18	All/MC	All/MC	18/–	All/MC	All/MC	18/–
Georgia	18	All/No	All/No	18/–	All/No	All/No	18/–
Hawaii	18	14/No	14/No	18/–	14/No	14/No	18/–
Idaho	18	All/No	All/No	All/No	All/No	All/No	All/No
Illinois	18	12/MC	12/MC	12/MC	12/MC	12/MC	12/MC
Indiana	18	All/No	All/No	18/–	All/No	All/No	18/–
Iowa	18	All/No	All/No	All/No	All/No	All/No	All/No
Kansas	18	All/No	All/No	All/No	All/No	All/No	All/No
Kentucky	18	All/CD	All/CD	All^e/No	All/CD	All/CD	All^e/No
Louisiana	18	All^g/CD	All^g/CD	All^g/CD	All^g/CD	All^g/CD	All^g/CD
Maine	18	All/CD	All/CD	All/CD	All/CD	All/CD	All/CD
Maryland	18	All/CD	All/CD	All^e/CD	All/CD	All/CD	All/CD
Massachusetts	18	All^h/MCⁱ	All^h/MCⁱ	18/–	All^h/MCⁱ	All^h/MCⁱ	18/–
Michigan	18	All^g/CD	All^g/CD	All^g/CD	All^g/CD	All^g/CD	All^g/CD
Minnesota	18	All/MC^j	All/MC^j	All^e/MC^j	All/MC^j	All/MC^j	All^e/MC^j
Mississippi^c	21	All/CD	All/CD	18/No	All/CD	All/CD	18/No
Missouri	18	All/MC^k	All/MC^k	All/MC^k	All/CD	All/MC^k	All/MC^k
Montana	18	All^g/No	All^g/No	All^g/No	All^g/No	All^g/No	All^g/No
Nebraska^c	19	All/CD	All/CD	All/CD	All/CD	All/CD	All/CD
Nevada	18	All/MC	All/MC	All^e/MC	All/MC	All/MC	All^e/MC
New Hampshire	18	14/CD	14/CD	18/–	14/CD	14/CD	18/–
New Jersey	18	All^l/CD	All^l/CD	All^l/CD	13^g/CD	13^g/CD	13^g/CD
New Mexico	18	All/No	All/No	18/–	All/No	All/No	18/–
New York	18	All/MC	All/MC	All/MC	All/MC	All/MC	All/MC
North Carolina	18	All/MC^m	All/MC^m	All/MC^m	All/MC^m	All/MC^m	All/MC^m
North Dakota	18	14/No	14/No	14/No	14/No	14/No	14/No
Ohio	18	All/No	All/No	18/–	All/No	All/No	18/–
Oklahoma	18	All/MC^k	All/MC^k	All/MC^k	All/MC^k	All/MC^k	All/MC^k
Oregon	18	Allⁿ/No	Allⁿ/No	15/CD	Allⁿ/No	Allⁿ/No	15/CD
Pennsylvania^c	21	All/No	All/No	All^e or 18/No	All/No	All/No	All^e or 18/No
Rhode Island	18	All/No	All/No	16/No	All/No	All/No	16/No
South Carolina	18	All^o or 16^p/No	All^o or 16^p/No	All^o or 16^p/No	All^o or 16^p/No	All^o or 16^p/No	All^o or 16^p/No
South Dakota	18	All/No	All/CD	All/No	All/No	All/CD	All/No
Tennessee	18	All/CD	All/CD	14/No	All/CD	All/CD	14/No
Texas	18	All/CD	All/CD	18/–	All/CD	All/CD	18/–
Utah	18	All/No	All/No	All/No	All/MC	All/No	All/No
Vermont	18	12/No	12/No	18/–	12/No	12/No	18/–
Virginia	18	All/MC	All/MC	18/–	All/MC	All/MC	18/–
Washington	18	14/No	14/No	18/–	14/No	14/No	14/No
West Virginia	18	All/CD	All/CD	18/–	All/CD	All/CD	18/–
Wisconsin	18	All/No	All/No	18/–	All/MC	All/No	18/–
Wyoming	18	All/MC	All/MC	18/–	All/MC	All/MC	18/–

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Abbreviations: All, no lower age limit, all mentally competent minors can legally consent to care; CD, clinician discretion; MC, mandatory confidentiality; No, no confidentiality protections; PrEP, preexposure prophylaxis; STI, sexually transmitted infection.

^{^a}

The following conditions must be met for minors to be legally able to consent to care. Where conditions only apply to minors of certain ages, this is noted in the table by presenting 2 ages of legal capacity to consent: one with conditions and one without. Where 2 superscript letters are presented together, both conditions must be true for minors to consent to care.

^{^b}

A dash (–) indicates that minors do not have the legal capacity to consent to that service.

^{^c}

Age of majority is older than 18 years.

^{^d}

Clinician discretion if minor is younger than 14 years.

^{^e}

In the clinician’s judgment, delaying care would substantially increase the risk to the minor’s life or health.

^{^f}

Reasonable efforts have been made to obtain the consent of the minor’s parent/guardian.

^{^g}

Patient believes themself to have a relevant illness or disease.

^{^h}

Patient believes themself to have a relevant illness or disease or must be in a public clinic.

^ⁱ

Clinician must disclose minor health information to parent/guardian if the condition of said minor is so serious that life or limb is endangered.

^{^j}

Clinician discretion if failure to inform parent/guardian would seriously jeopardize the health of the minor patient.

^{^k}

Clinician discretion if test result is positive.

^{^l}

Patient believes themself to have a relevant illness or disease or clinician believes minor was sexually assaulted.

^{^m}

Clinician discretion if contacted by parent/guardian.

^ⁿ

Disease must be reportable.

^{^o}

Nonsurgical care requires the clinician to deem it “necessary.” Surgical care must be deemed “essential to the health or life of such child in the opinion of the performing physician and a consultant physician if one is available.”

^{^p}

Surgical care must be deemed “essential to the health or life of such child in the opinion of the performing physician and a consultant physician if one is available.”

Discussion

Minors—of any age in most states or at age 12 to 14 years in remaining states—could independently consent to STI/HIV testing and treatment in all US states and the District of Columbia as of October 2021. Most states also allowed minors to consent independently to STI/HIV prevention, including human papillomavirus vaccination and HIV preexposure and postexposure prophylaxis. However, some states required clinicians to apply specific criteria before minors can consent. Most states neglected or only cursorily addressed confidentiality obligations for clinicians who care for independently consenting minors. In states that permit or require that STI/HIV services be kept confidential from minors’ guardians, clinicians will need to identify and implement practices to avoid inadvertent disclosure via insurance billing or electronic health records. Clinicians may need to consult additional state or federal regulations, such as the 21st Century Cures Act, to develop these procedures. This study did not assess municipal or federal law or changes after October 2021.

Minor consent laws are structured to protect clinicians who rely on minors’ independent consent when providing STI/HIV services. These statutes therefore benefit both minors and clinicians, allowing minors to obtain STI/HIV services without involving their guardians, and enabling clinicians to provide these services to minors without risking legal sanctions. Due to low levels of knowledge about these laws and a dearth of institutional policies and procedures to support their use, minors often do not receive the services they need.⁶ Trainings, policies, and procedures that support and routinize the application of these statutes may empower clinicians to rely on them more confidently in practice. Ensuring that clinicians, researchers, and minors understand and trust these minor consent laws may expand access to STI/HIV services for youth.

Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Senior Editor.

Supplement.

eMethods. Coding Procedures, Assumptions, and Definitions Used for Coding Minor Consent Laws for STI/HIV Testing, Treatment, and Prevention Services in the United States

Click here for additional data file.^{(188.6KB, pdf)}

References

1.Leichliter JS, Copen C, Dittus PJ. Confidentiality issues and use of sexually transmitted disease services among sexually experienced persons aged 15-25 years: United States, 2013-2015. MMWR Morb Mortal Wkly Rep. 2017;66(9):237-241. doi: 10.15585/mmwr.mm6609a1 [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Culp L, Caucci L. State adolescent consent laws and implications for HIV pre-exposure prophylaxis. Am J Prev Med. 2013;44(1)(suppl 2):S119-S124. doi: 10.1016/j.amepre.2012.09.044 [DOI] [PubMed] [Google Scholar]
3.English A, Bass L, Boyle AD, Eshragh F. State Minor Consent Laws: A Summary. 3rd ed. Center for Adolescent Health & the Law; 2010. [Google Scholar]
4.Guttmacher Institute . Minors’ access to STI services. Accessed March 23, 2022. https://www.guttmacher.org/state-policy/explore/minors-access-sti-services
5.Anderson ED, Tremper C, Thomas S, Wagenaar AC. Measuring statutory law and regulations for empirical research. In: Wagenaar AC, Burris SC, eds. Public Health Law Research: Theory and Methods. Wiley; 2013:237-260. [Google Scholar]
6.Pampati S, Liddon N, Dittus PJ, Adkins SH, Steiner RJ. Confidentiality matters but how do we improve implementation in adolescent sexual and reproductive health care? J Adolesc Health. 2019;65(3):315-322. doi: 10.1016/j.jadohealth.2019.03.021 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eMethods. Coding Procedures, Assumptions, and Definitions Used for Coding Minor Consent Laws for STI/HIV Testing, Treatment, and Prevention Services in the United States

Click here for additional data file.^{(188.6KB, pdf)}

[jld220044r1] 1.Leichliter JS, Copen C, Dittus PJ. Confidentiality issues and use of sexually transmitted disease services among sexually experienced persons aged 15-25 years: United States, 2013-2015. MMWR Morb Mortal Wkly Rep. 2017;66(9):237-241. doi: 10.15585/mmwr.mm6609a1 [DOI] [PMC free article] [PubMed] [Google Scholar]

[jld220044r2] 2.Culp L, Caucci L. State adolescent consent laws and implications for HIV pre-exposure prophylaxis. Am J Prev Med. 2013;44(1)(suppl 2):S119-S124. doi: 10.1016/j.amepre.2012.09.044 [DOI] [PubMed] [Google Scholar]

[jld220044r3] 3.English A, Bass L, Boyle AD, Eshragh F. State Minor Consent Laws: A Summary. 3rd ed. Center for Adolescent Health & the Law; 2010. [Google Scholar]

[jld220044r4] 4.Guttmacher Institute . Minors’ access to STI services. Accessed March 23, 2022. https://www.guttmacher.org/state-policy/explore/minors-access-sti-services

[jld220044r5] 5.Anderson ED, Tremper C, Thomas S, Wagenaar AC. Measuring statutory law and regulations for empirical research. In: Wagenaar AC, Burris SC, eds. Public Health Law Research: Theory and Methods. Wiley; 2013:237-260. [Google Scholar]

[jld220044r6] 6.Pampati S, Liddon N, Dittus PJ, Adkins SH, Steiner RJ. Confidentiality matters but how do we improve implementation in adolescent sexual and reproductive health care? J Adolesc Health. 2019;65(3):315-322. doi: 10.1016/j.jadohealth.2019.03.021 [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Minor Consent Laws for Sexually Transmitted Infection and HIV Services

Kimberly M Nelson, PhD, MPH

Alexandra Skinner, MPH

Kristen Underhill, DPhil, JD

Abstract

Methods

Results

Table. Age of Majority and Youngest Age of Legal Capacity of Mentally Competent Minors to Consent to STI and HIV Services and Confidentiality Protections for Minors’ STI and HIV Information in the US, 2021^a^,^b.

Discussion

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Cite

Add to Collections

PERMALINK

Minor Consent Laws for Sexually Transmitted Infection and HIV Services

Kimberly M Nelson, PhD, MPH

Alexandra Skinner, MPH

Kristen Underhill, DPhil, JD

Abstract

Methods

Results

Table. Age of Majority and Youngest Age of Legal Capacity of Mentally Competent Minors to Consent to STI and HIV Services and Confidentiality Protections for Minors’ STI and HIV Information in the US, 2021a,b.

Discussion

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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Table. Age of Majority and Youngest Age of Legal Capacity of Mentally Competent Minors to Consent to STI and HIV Services and Confidentiality Protections for Minors’ STI and HIV Information in the US, 2021^a^,^b.