Sophia Neman, BA; Stephen R. Humphrey, MD
The overturning of the Supreme Court case Roe v Wade in the case of Dobbs v Jackson Women’s Health Organization has far-reaching implications in medicine, even beyond the field of women’s health. The ruling has obscured state abortion laws, leaving health care providers with questions regarding the legal parameters of reproductive health care.1 Wisconsin, specifically, is now enforcing an 1849 statute, of which the original language prohibits all abortions except in cases that “preserve the life of [the] mother or shall have been advised by two physicians to be necessary for such purpose.”2 Wisconsin Governor Tony Evers voiced disapproval of the 1849 law and suggested that he would grant clemency to persecuted physicians, but this does not clarify the future of abortion access in Wisconsin.3
One specific area of ambiguity is whether pregnancies conceived while patients are prescribed teratogenic medications will fall within the legal exemptions of the abortion. When patients are under the age of 18, additional complexities are introduced. Minor consent laws, confidentiality, and the authority of patients’ guardians must be considered when navigating next steps.
Dermatology is one specialty prescribing teratogenic medications, such as isotretinoin. Isotretinoin is the most effective treatment for patients with moderate-to-severe nodulocystic or recalcitrant acne vulgaris. Isotretinoin has a 20% to 35% risk of teratogenicity in fetuses, and its use is associated with neurologic malformations, thymic disorders, and cardiovascular and craniofacial defects.4,5 The existing gravity of teratogens is now combined with the fact that there are no clear guidelines for abortion if patients become pregnant while prescribed isotretinoin.
Isotretinoin and iPLEDGE
There were 6,740 reported pregnancies among patients taking isotretinoin from 1997 through 2017.6 iPLEDGE is a risk evaluation and mitigation strategy program regulated by the US Food and Drug Administration that outlines strict regulations for contraception, abstinence, and pregnancy testing for patients prescribed isotretinoin. However, the intention of iPLEDGE may be different than its effect. A study found that while iPLEDGE regulations may emphasize treatment risks, this may not translate to reducing the number of pregnancies exposed to isotretinoin.7 It is, therefore, vital to address gaps in patient care for the health of both patients and fetuses.
Gaps in Knowledge about Confidentiality
Patient-physician confidentiality is one such point of conversation. Although dermatologists are cognizant of the importance of discussing reproductive health, provider knowledge of confidentiality and consent laws for minors has been found to be limited.8 Guardians also may have a limited understanding of confidentiality and mixed reactions to being excluded from health care conversations.9 This is uniquely relevant to adolescents, as confidential conversations can be a key step towards developing their own perspective of their health.
Adolescents are more likely to disclose information, pursue treatment, and seek future care once physicians address confidentiality.10 Only up to 43% of adolescents have had time alone with their physicians and may not even know that this is an option.11 Physicians should address these concerns and clarify when guardians and partners will be included or asked to step outside to ensure transparency. One method is to normalize these conversations by assuring them that confidentiality is offered to all patients.
Adolescent Cognitive Development and Sexual Health
Knowledge of cognitive milestones and decisional capabilities can assist providers to tailor conversations about reproductive health accordingly. For example, early adolescents (12-14 years old) have difficulty thinking about the long-term consequences of their actions. Middle adolescents (15-17 years old) are better able to consider the consequences of their actions, but they are more likely to engage in risk-taking behavior, are more susceptible to peer influence, and often have more conflict with their parents. These behaviors tend to subside by late adolescence (18-21 years old).12
Data show that as of 2019, 3% of children engage in sexual intercourse before the age of 13, while 40% of high school students reported having had sex.13 In order to be inclusive to adolescents in different stages of cognitive development and sexual activity, pediatric dermatologists should introduce the concept of confidential care as early as ages 11 years and older. In general, isotretinoin is typically not first-line acne treatment for patients younger than 12 years old. Outside of patients prescribed isotretinoin, the exact age may be tailored to whether the provider has existing rapport with the patient and the age the patient begins menstruating.
Methods to Maintain Patient-Physician Confidentiality
Topics such as electronic health records (EHR), pharmacies, insurance documentation, after-visit summaries, and patient follow-up must be revisited to reinforce confidentiality. One method to protect confidentiality and sensitive information is to create a sensitive note. This note will be visible to the provider but not to the patient or their guardian. Another option is to make an adolescent privacy flag. The flag symbol will be visible, but guardians will not be able to see its content unless the patient consents. Physicians also have created systems of key phrases designed to remind themselves or other providers of confidential information.14 Aside from monitoring sensitive information, some institutions even have been able to provide EHR portal access directly to patients under the age of 18.15
Within confidential conversations, dermatologists should ask patients their sexual preferences, gender identity, and preferred pronouns. Next, they should ask who is aware of this information to avoid sharing confidential information with guardians or partners. Isotretinoin treatment may interfere with gender-affirming hormonal treatment or raise questions among female-to-male transgender patients about their fertility. Due to the sensitivity of these conversations, sexual and gender minority patients may prefer a sexual and gender minority dermatologist.16 Patient-physician confidentiality should be maintained once the appointment has ended as well.
Physicians can contact pharmacies to see if they send automatic messages about prescriptions or have medication sent to a pharmacy preferred by the patient.17 Diagnoses and test results may be excluded from insurance documentation if a minor requests confidentiality.18 Confidential information also can be excluded from the after-visit summary, or the after-visit summary can be given directly to minors. For follow-up purposes, physicians should ask patients under the age of 18 for an alternative phone number and address if communication absolutely cannot be sent to the minor’s home, or, if the home phone number cannot be contacted, to speak in confidence to the patient.19
Keeping these confidentiality practices in mind, it is unclear whether the Wisconsin state legislature will change or clarify how teratogens will be considered in abortion access. In the meantime, there may be some change with how patients will engage with iPLEDGE and whether the percentage of patients choosing abstinence or other contraceptive options will shift. There also may be a change in adherence to selected methods now that there is an added risk of continuing with a pregnancy with birth defects and the added burden of traveling out of Wisconsin for an abortion.
Although the purpose of this commentary is to discuss isotretinoin counseling and confidentiality, this topic may be applied to any prescribed teratogenic medication. Providers outside the field of women’s health may not be providing direct abortion counseling but, nonetheless, should be prepared to advocate for their patients’ safety. Isotretinoin prescription among dermatologists must be acknowledged, specifically, to integrate the limitations of iPLEDGE, frequency of use among adolescents, and possible complications for sexual and gender minority patients.
This knowledge must be applied not only within appointments, but also extend to other methods of communication to ensure that confidentiality is maintained for the duration of isotretinoin treatment or for any other medication that has potential for teratogenicity. Navigating vulnerable conversations should always involve creating a safe space for patients; the court decision in Dobbs v Jackson Women’s Health Organization is a reminder of the importance of confidentiality and its far-reaching implications.
- Dobbs v Jackson Women’s Health Organization, 597 US__(2022).
- AB 116, 1849 Biennium, 1849 Reg. Sess. (Wis. 1849).
- Edelman A. Wisconsin gov. vows to grant clemency to doctors charged under state abortion ban. NBC News. June 27, 2022. Accessed December 20, 2022. https://www.nbcnews.com/politics/wisconsin-gov-vows-grant-clemency-doctors-charged-state-abortion-ban-rcna35479
- Altıntaş Aykan D, Ergün Y. Isotretinoin: still the cause of anxiety for teratogenicity. Dermatol Ther. 2020;33(1):e13192. doi:10.1111/dth.13192
- Lammer EJ, Chen DT, Hoar RM, et al. Retinoic acid embryopathy. N Engl J Med. 1985;313(14):837-841. doi:10.1056/NEJM198510033131401
- Tkachenko E, Singer S, Sharma P, Barbieri J, Mostaghimi A. US Food and Drug Administration reports of pregnancy and pregnancy-related adverse events associated with isotretinoin. JAMA Dermatol. 2019;155(10):1175-1179. doi:10.1001/jamadermatol.2019.1388
- Akinbami LJ, Gandhi H, Cheng TL. Availability of adolescent health services and confidentiality in primary care practices. Pediatrics. 2003;111(2):394-401. doi:10.1542/peds.111.2.394
- Riley M, Ahmed S, Reed BD, Quint EH. Physician knowledge and attitudes around confidential care for minor patients. J Pediatr Adolesc Gynecol. 2015;28(4):234-239. doi:10.1016/j.jpag.2014.08.008
- Duncan RE, Vandeleur M, Derks A, Sawyer S. Confidentiality with adolescents in the medical setting: what do parents think? J Adolesc Health. 2011;49(4):428-430. doi:10.1016/j.jadohealth.2011.02.006
- Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. A randomized controlled trial. JAMA. 1997;278(12):1029-1034. doi:10.1001/jama.1997.03550120089044
- Grilo SA, Catallozzi M, Santelli JS, et al. Confidentiality discussions and private time with a health-care provider for youth, United States, 2016. J Adolesc Health. 2019;64(3):311-318. doi:10.1016/j.jadohealth.2018.10.301
- Maslyanskaya S, Alderman EM. Confidentiality and consent in the care of the adolescent patient. Pediatr Rev. 2019;40(10):508-516. doi:10.1542/pir.2018-0040
- High School Youth Risk Behavior Survey Data. Centers for Disease Control and Prevention. Published 2017. https://nccd.cdc.gov/youthonline/App/Default.aspx
- Stablein T, Loud KJ, DiCapua C, Anthony DL. The catch to confidentiality: the use of electronic health records in adolescent health care. J Adolesc Health. 2018;62(5):577-582. doi:10.1016/j.jadohealth.2017.11.296
- Sharko M, Wilcox L, Hong MK, Ancker JS. Variability in adolescent portal privacy features: how the unique privacy needs of the adolescent patient create a complex decision-making process. J Am Med Inform Assoc. 2018;25(8):1008-1017. doi:10.1093/jamia/ocy042
- Covelli I, Ahrens K, Onchiri FM, Inwards-Breland D, Boos MD. Influence of gender and sexual identity on adolescent skin health. Pediatr Dermatol. 2021;38 Suppl 2:65-72. doi:10.1111/pde.14686
- Bayer R, Santelli J, Klitzman R. New challenges for electronic health records: confidentiality and access to sensitive health information about parents and adolescents. JAMA. 2015;313(1):29-30. doi:10.1001/jama.2014.15391
- Society for Adolescent Health and Medicine; American Academy of Pediatrics. Confidentiality protections for adolescents and young adults in the health care billing and insurance claims process. J Adolesc Health. 2016;58(3):374-377. doi:10.1016/j.jadohealth.2015.12.009
- Alderman EM. Confidentiality in pediatric and adolescent gynecology: when we can, when we can’t, and when we’re challenged. J Pediatr Adolesc Gynecol. 2017;30(2):176-183. doi:10.1016/j.jpag.2016.10.003