A 16-year-old girl comes to the office for an annual checkup, accompanied by her mother. The patient is a junior in high school and lives with her parents and 2 younger siblings. During the visit, she discloses that she has had sexual intercourse several times with a boy in her class. The patient believes she may be in love and says that the sex is consensual. Her partner is using condoms. When the physician inquires if her parents are aware that she is sexually active, the patient says, "I would never tell them. They are totally against premarital sex. They don't even allow me to date. They would be furious if they knew." Physical examination is normal and urine pregnancy test is negative. Routine laboratory screening for common sexually transmitted diseases is performed, and the patient is educated about safe sex and contraceptive options. The patient asks the physician to say nothing to her parents. The patient is encouraged to contact the physician with any further questions and concerns. She returns 6 months later for a pre-camp physical and tells the physician that she has continued to have sex with her boyfriend. The patient says, "Everything is going well; we have so much in common." On questioning, she admits that her boyfriend is not a boy in her class, but actually her 25-year-old, married, high school art teacher. She says, "We're doing our best to keep the relationship a secret because he is not ready to tell his wife. He promised me that he will leave her eventually." The patient mentions that her boyfriend has been tremendously helpful in developing her artistic ability and believes that he will help her gain admission to a prestigious art college. She says her chances of admission are increased by her A+ art grade and his positive letter of recommendation. Her parents are suspicious about the relationship with the teacher but have avoided discussing it. When asked if she feels coerced into performing any sexual acts, the patient adamantly insists the relationship is consensual. Physical examination is normal and urine pregnancy test is negative. Aside from the age of the patient and the age difference with her partner, which of the following is the most important determining factor as to whether this patient is in an abusive situation?

Question

A 16-year-old girl comes to the office for an annual checkup, accompanied by her mother.  The patient is a junior in high school and lives with her parents and 2 younger siblings.  During the visit, she discloses that she has had sexual intercourse several times with a boy in her class.  The patient believes she may be in love and says that the sex is consensual.  Her partner is using condoms.  When the physician inquires if her parents are aware that she is sexually active, the patient says, "I would never tell them.  They are totally against premarital sex.  They don't even allow me to date.  They would be furious if they knew."  Physical examination is normal and urine pregnancy test is negative.  Routine laboratory screening for common sexually transmitted diseases is performed, and the patient is educated about safe sex and contraceptive options.  The patient asks the physician to say nothing to her parents. The patient is encouraged to contact the physician with any further questions and concerns.  She returns 6 months later for a pre-camp physical and tells the physician that she has continued to have sex with her boyfriend.  The patient says, "Everything is going well; we have so much in common."  On questioning, she admits that her boyfriend is not a boy in her class, but actually her 25-year-old, married, high school art teacher.  She says, "We're doing our best to keep the relationship a secret because he is not ready to tell his wife.  He promised me that he will leave her eventually."  The patient mentions that her boyfriend has been tremendously helpful in developing her artistic ability and believes that he will help her gain admission to a prestigious art college.  She says her chances of admission are increased by her A+ art grade and his positive letter of recommendation.  Her parents are suspicious about the relationship with the teacher but have avoided discussing it.  When asked if she feels coerced into performing any sexual acts, the patient adamantly insists the relationship is consensual.  Physical examination is normal and urine pregnancy test is negative.  Aside from the age of the patient and the age difference with her partner, which of the following is the most important determining factor as to whether this patient is in an abusive situation?

Quizplus · Accepted Answer

Explanation: Open and confidential communication between the physician and the adolescent patient now reveals information that raises concern about possible abusive or coercive sexual encounters. Specifically, the power inequality inherent in the teacher-student relationship and the patient's belief that the teacher will help her gain admission to college are worrisome. The possibility that the patient may be acceding to sexual demands to gain favor with the teacher must be considered. From a legal standpoint, the age of consent varies from state to state, and some jurisdictions may require professionals to report knowledge or suspicion of statutory rape to authorities based on the patient's age alone; others may take into account the age differential in the relationship and whether the partner is in a position of influence. The physician should discuss these concerns with the patient and explain the rationale of a duty to protect her before reporting concerns to state child protective services or law enforcement agencies. During the reporting process, every effort should be made to maintain the physician-patient relationship. (Choice A) The parents' failure to act on their suspicions does not constitute child abuse. If, however, the parents knew that their daughter was in an abusive relationship and did not try to help her, this could be considered a form of neglect. (Choices C and E) The patient's belief that the teacher will leave his wife and the secretive nature of the relationship are worrisome, but they are not as important as the power differential due to the teacher's position of authority. (Choice D) This patient's insistence that the relationship is consensual should not be used to determine if abuse is occurring as it may reflect that she is unaware of or in denial about its exploitative nature. A 16-year-old's perception does not remove the duty to disclose if the relationship appears to be abusive on ethical and/or legal grounds. Educational objective: Sexually active adolescents should be carefully assessed for abusive or coercive sexual encounters. Situations involving sexual partners who occupy positions of power or authority in relation to the teenage patient should raise concerns for coercion. A physician who finds evidence of abuse or exploitation is obligated to notify the state's child protective services or law enforcement agencies. References: Adolescent relationship abuse and reproductive and sexual coercion among teens. (http://www.ncbi.nlm.nih.gov/pubmed/24018873)

A 16-Year-Old Girl Comes to the Office for an Annual