The legal ambiguity around minors' ability to consent without parental involvement to oral contraceptive pills (OCPs) for acne suggests that dermatologists err on the side of caution, according to a Viewpoint article in JAMA Dermatology.
Author Arielle Nagler, M.D., assistant professor at the Ronald O. Perelman School of Medicine at New York University, said
The article’s impetus came from a data "blind spot" in the treatment of acne, particularly regarding use of hormonal therapies — four of which are FDA-approved for acne treatment.
"Combined oral contraceptives (COCs) provide an effective and usually very safe long-term therapeutic option. But we don't have a lot of data on who prescribes for our patients, particularly the COCs. That got me thinking about some of the challenges dermatologists may face when prescribing COCs for acne," said Arielle Nagler, M.D., of NYU School of Medicine. Dr. Nagler authored the article with NYU colleagues Carolyn P. Neuhaus, Ph.D., and Seth J. Orlow, M.D., Ph.D.
Even when COCs are clearly indicated for acne, she said, dermatologists may hesitate to prescribe them, instead referring patients to primary care physicians or gynecologists. Reasons for dermatologists' reluctance include the fact that many are uncomfortable discussing sexual health or are unwilling to spend time on such discussions, although OCP prescriptions for younger females necessitate doing so.
No less formidable an obstacle is the unclear nature of consent laws governing minors with respect to OCPs. By statute or default, all states require parental consent for treatment of minors except in matters related to reproductive and mental health. While 26 states and the District of Columbia allow minors to consent to reproductive health treatments without parental consent or notification, the issue grows muddy regarding OCPs prescribed for acne.
"On the one hand," the authors wrote, "the exception is carved out for matters related to reproductive health, and prescribing OCPs primarily for acne does not constitute a treatment related to reproductive health." But then teens may wish to take OCPs for multiple reasons, including both acne treatment and pregnancy prevention, the authors stated.
Dr. Nagler said that the spirit of minor consent laws is to promote public health by allowing teens to make reproductive health decisions without parental involvement. Studies have shown that adolescents will more likely seek birth-control and STD treatments when parents will not be consulted or notified. "Arguably," Nagler et al. wrote, "the treatment of acne also achieves the goal of improving public health, so allowing minors to consent to OCPs for acne is consistent with the spirit of the law."
But to comply with the letter of minor consent law, Dr. Nagler and colleagues recommend that dermatologists still seek parental consent when prescribing OCPs for acne management. Because the exception to parental consent applies only to reproductive health decisions, they reasoned, "If a parent explicitly objects to OCP prescriptions, it would be prudent for the dermatologist to respect parental rejection of treatment. Legal precedent typically respects parental authority" in such matters.
Because some dermatologists use and may even prescribe OCPs for acne treatment, the authors add that to mitigate physician discomfort and support adolescent decision-making, dermatologists should be trained in counseling patients on OCP use.
PUSHING FOR POLICIES
Meanwhile, absent court decisions that would clarify whether minors need parental consent for OCPs for the primary indication of acne, Nagler et al. recommend that dermatologists craft explicit policies for their own prescribing practices. Examples might range from requiring parental waivers regarding OCP consent, to always obtaining parental consent. Policies also might stipulate when or if parents will be involved in conversations about OCPs.
"Some of the laws are ambiguous about what to do with minors with respect to prescribing COCs, which is inherently related to sexual health but in the case of acne may not be exclusively or at all related to sexual health. And because it's ambiguous whether or not parental consent is needed in many states, we believe it's better for dermatologists to have explicit policies when it comes to prescribing oral contraceptives to minors," Dr. Nagler said.
Rather than broad guidelines developed by the government or the American Academy of Dermatology, she said, "We were thinking more on the individual level because laws vary by state, and because different practitioners may have a different level of comfort" with prescribing OCPs for minors.
Having transparent policies, coupled with physician awareness of consent laws and resources for OCP counseling, will improve care for young women with acne, paper authors said. Having clear practice guidelines may make dermatologists more comfortable discussing OCPs with minor patients, "and patients may feel empowered knowing to what extent their parents will be involved in their care, and having access to reliable information about OCPs."
Since the paper's publication, "people have started talking about some of the issues we raised. And there's definitely a need for better understanding of how and when dermatologists do prescribe oral contraceptives for acne." Dr. Nagler said.
Carolyn P. Neuhaus, PhD; Arielle R. Nagler, MD; Seth J. Orlow, MD, PhD. “Teens, Acne, and Oral Contraceptive Pills: The Need for Greater Clarity on When Teens Can Consent,” JAMA Dermatology. April 2017. DOI: 10.1001/jamadermatol.2016.5096.
Harper JC. "Use of oral contraceptives for management of acne vulgaris: practical considerations in real-world practice." Dermatologic Clinics. 2016;34(2):159-165.
Reddy DM, Fleming R, Swain C. "Effect of mandatory parental notification on adolescent girls' use of sexual health care services." JAMA. 2002;288(6):710-714.
Maradiegue A. "Minor's rights versus parental rights: review of legal issues in adolescent health care," J Midwifery Womens Health. 2003;48(3):170-177.