The Department of Defense (DOD) has quietly implemented controversial adolescent health policies throughout the military health system (MHS) that kick in when children turn 12 years old.
Because the official policies are hard to find and are not posted publicly at base clinics, most parents are shocked to find out that doctors prefer to treat their adolescent children in a completely parent-free setting. Parents are outraged to be treated as if they cannot be trusted to guide their own children. Here is my story detailing a quest for answers on why online medical record access is limited and why I was being asked to leave the room.
Two years ago, my family made a military move overseas. At our very first well-child visit to the base medical clinic, my child’s doctor, a complete stranger to us — as are most doctors in this transient lifestyle — said I would be required to leave the exam room at the next year’s exam so she could ask my child more “invasive” questions now that she was an adolescent. The next year, I was surprised to learn via the Tricare online portal (TOL) that I was barred from accessing my child’s online medical record from 12 years of age onward (for the new MHS Genesis system, it’s 13). Additionally, as I came to learn, my child was not allowed to have her own password or create her own account until she turns 18.
When I asked the doctor for the reason why, she said it was “above her paygrade.”
Wanting a more precise answer, I submitted an Interactive Customer Evaluation (ICE) comment to the clinic asking for the DOD policy and underlying law that allow for parents to be barred from online medical records. In the end, it took months for DOD to find the policy, and it also involved submitting a Freedom of Information Act (FOIA) request to the Defense Health Agency (DHA) as well as my U.S. senator opening up casework into the matter.
Different State Policies on Medical Records
While I waited for the official policy, which appeared to be a well-kept secret, I researched civilian electronic health records (EHR) systems and civilian policies surrounding adolescent confidentiality and consent.
A June 2022 issue of Pediatrics published by the American Academy of Pediatrics (AAP) revealed that it is difficult for doctors to manage EHR systems when it comes to adolescent privacy because of differing state laws on minor consent and confidentiality. As military families make moves across the United States and overseas every two or so years, it’s crucial for parents to understand that their rights are treated very differently depending on the state.
Though the federal Health Insurance Portability and Accountability Act (HIPAA) gives parents access to their children’s medical records until they turn 18, it cedes this privacy rule to state law, which means parents may lose such access. So, for instance, California law allows minors to obtain an abortion, and no parental involvement or notification is required. Additionally, hospital systems like Scripps restrict parents from online medical records when their children turn 12. On the other hand, Florida law requires minors to notify at least one parent 48 hours before an abortion, and permission must be given — though a judge can bypass this; and parents have the right to access and review their minor children’s medical record, which was clarified by a Parents’ Bill of Rights law.
Another article from adolescent medicine researchers in the same 2022 issue of Pediatrics specifically mentions the complexity around keeping abortion and transgender interventions for young people confidential.
Additionally, researchers in the Journal of Adolescent Health promoted providing different types of access to parents and adolescents. Options included, in part, “permitting full access only to the 13- to 17-year-old adolescents, with parents able to receive only nonconfidential information — an approach that requires actively blocking access to certain information by the parent and requires vigilance and ongoing effort to maintain … or (4) turning off portal access for all patients aged 13-17 years.”
Doctors Want to Be Alone with Kids
In regard to “alone time” with the doctor, the now-highly politicized AAP recommends that practitioners ask parents of adolescents to leave the exam room during well-child checks so they can conduct a psychosocial assessment without parental interference. The implication is clear: Medical personnel can be trusted, but parents cannot.
One tool doctors use for the psychosocial evaluation is the HEEADSSS assessment. “The Psychosocial Interview for Adolescents Updated for a New Century Fueled by Media,” written by U.S. military-associated doctors, is a detailed explanation of HEEADSSS. Some suggested questions from a HEEADSSS survey are: “Tell me about your sexual life. Are you attracted to boys? Girls? Both? Not yet sure?” If the doctor wants specifics, some suggested follow-up questions are: “Are your sexual activities enjoyable?” “How many sexual partners have you had altogether?” “What are you using for birth control? Are you satisfied with your method?”
Parents are rightly outraged to learn these questions could be asked of children as young as 12 while parents are excluded.
DOD Policy When State Laws Conflict
After I had completed my own investigation, the federal government finally found the policy. In answer to my ICE comment, in an email dated March 21, 2023, a lawyer at a military hospital in Italy stated that disclosure of protected health information (PHI) of military minors is guided by the state law where the treatment is received.
But when “states have conflicting laws and that is paired with DoD’s global presence, the default is to preserve patient rights.” DODM 6025.18, DOD’s HIPAA implementation manual, “delegates policy authority to the local medical records committee (DHA) to set policy in the absence of state law. The policy being applied in this case on TOL is in absence of state law and in accordance with DODM 6025.18.” Therefore, “proper authorization from the minor patient must be obtained prior to accessing certain health records. Thus, compliance with these federal guidelines is not a ‘bar’ to a parent viewing protected health records, but a safeguard requiring proper consent by the minor patient via a DD form 2870 if requested on behalf of and for the benefit of the minor patient.”
In other words, on an overseas base, if California’s confidentiality laws that favor adolescent autonomy would conflict with Florida’s confidentiality laws that favor parental access, DHA would decide the policies.
Unelected Bureaucrats Decide
I had reasonably (but incorrectly) assumed that in the absence of state law’s guidance on privacy, the fallback would be federal law, HIPAA, which gives parents access to minor medical records as their minors’ personal representatives until 18. I never thought the fallback would be policy created by unelected bureaucrats at DHA.
I later obtained a policy memo, “Minors and Reproductive Health Care Services (Overseas)” that states that at overseas medical treatment facilities, “where there is no applicable state or federal law, clinicians generally look to the general principles of American law to determine if a minor can self-consent. … Unless modified by host nation law or a SOFA [Status of Forces Agreement], and consistent with the general principles of American law, a mature minor is further defined …as being of sufficient age (age 15 or older) who, in the licensed independent practitioner’s opinion, is also capable of making important decisions on their own behalf.”
In other words, an adolescent health provider can deem a child to be a mature minor based on his or her professional opinion. However, after reading recent research reports by leaders in military adolescent medicine stating that 7-year-old children were mature enough to help direct their transgender medical interventions and claiming that efforts to assist patients in becoming comfortable with their sex are unethical, there is no reason for confidence in the ability of activist-minded doctors to determine maturity levels of minors.
Predictably, I never received a response to my FOIA request submitted to DHA, but thankfully, the agency responded to my senator’s request for information. It was consistent with the ICE result, but the new piece of information I gleaned was that policies created by the Defense Manpower Data Center (DMDC) prevent adolescents from creating their own self-service log-ins. These “policies” were not included, and no further reasoning was provided.
But as is the case in the civilian world, I suspected that the extraordinary measures to prevent military parents in the MHS from accessing online adolescent records and the “requirement” for parents to leave the exam room were in place, in part, to hide so-called gender identity and sexual health conversations and treatment from parents of adolescents.
My suspicions were proven correct when in April, a video that went viral was leaked from a two-day mental health stand-down at an overseas U.S. military base where the base pediatric provider authoritatively stated that she was having conversations with military children about gender identity and sexual health that she was keeping confidential from parents. She stated unequivocally that it was the policy of “Big Navy,” aka DOD, to circumvent parents.
It is now clear that military parents cannot count on the system they once trusted to care for their children. In light of this, it’s more important than ever for parents to push back on these policies, check in with their kids to see if these types of conversations have taken place, and resolve to stay in the exam room with their children, especially if the doctor is a stranger. Nothing less than the health and safety of our children, and the all-important parent-child relationship, is at stake.