The 14-Year-Old Who Wants Confidential Contraception
A 14-year-old girl presents alone to your clinic requesting birth control. She is in 9th grade, has been dating a 17-year-old boy for three months, and reports she has been sexually active twice, using condoms inconsistently. She denies coercion, states the relationship is consensual, and does not want her parents involved because "they would kill me." She has no chronic medical conditions, takes no medications, and her last menstrual period was two weeks ago. On exam she is normotensive with a normal BMI. She asks specifically for an implant so she "won't have to remember anything." She also mentions her boyfriend sometimes "gets mad when I hang out with my friends." She has no symptoms of STI and no prior pelvic exam.
1. What is the appropriate approach to confidentiality and parental involvement here, and what should you do before prescribing contraception?
Read the worked answer
Confidentiality is the default for adolescent contraceptive care in most states, but it is not absolute. You should explain the limits up front: risk of harm to self or others, and suspected abuse or exploitation. A 14-year-old with a 17-year-old partner is within most states' close-in-age exemptions, but you must know your state's age-of-consent and mandatory reporting thresholds before deciding whether this is reportable.
Before prescribing: (1) private time with the patient, which you have; (2) a HEADSS-type psychosocial assessment including the comment about her boyfriend controlling her friendships - screen for intimate partner violence and reproductive coercion; (3) screen for STI risk (she has inconsistent condom use and a partner who may have other partners) - offer NAAT for gonorrhea/chlamydia, and HIV testing per risk; (4) pregnancy testing before starting a method; (5) blood pressure and review of contraindications (US MEC) - an implant is safe for her.
Do not require a pelvic exam before prescribing hormonal contraception. The controlling-partner comment deserves direct follow-up: ask whether he has pressured her about sex, birth control, or pregnancy. If coercion or abuse is present, confidentiality may yield to safety planning and reporting obligations.
2. She chooses the etonogestrel implant. How do you counsel her, and what do you do about her request that her parents never find out?
Read the worked answer
Counsel on expected bleeding changes (irregular bleeding is common early; many become amenorrheic), placement discomfort, and that the implant is the most effective reversible method. Discuss STI protection separately - the implant does not prevent infection, so condoms remain important, and she should know about expedited partner therapy and emergency contraception backup.
On parental disclosure: respect her confidentiality but be honest that insurance explanation-of-benefits statements can disclose the visit to the policyholder. Offer options - self-pay, confidential billing, or referral to a Title X clinic - and document that you discussed this. Do not promise secrecy you cannot guarantee.
Document capacity assessment: she understands the method, its risks, and alternatives, and is able to articulate her choice. This supports a minor-consent framework. Schedule follow-up to reassess the relationship dynamic; a single visit is not enough to close the safety question.