nizations that I am representing today firmly believe that young people must have access to confidential health care services. Every one of our states' laws also provides confidential access to some services for young people, whether for sexually transmitted diseases (STDs), drug addiction or reproductive health care. Concern about confidentiality is one of the primary reasons young people delay seeking health services for sensitive issues, whether for substance use, an unintended pregnancy or for other reasons. While parental involvement is very desirable, and should be encouraged, it may not always be feasible and it should not be legislated. Young people must be able to receive accurate diagnosis and appropriate treatment expeditiously and confidentially.

Let me share a few general examples that underscore the importance of confidentiality of care:

• Reproductive health: Chlamydia is the number one bacterial sexually transmitted disease (STD) in the United States today. Every state allows a minor to give his or her consent for STD services. However, if a young woman comes into the clinic to receive a confidential consultation because she suspects she has chlamydia, or some other STD, it is critical that she not only receive the diagnosis in confidence but also the treatment to address the medical issue. Untreated, this type of problem can lead to serious consequences, including pelvic inflammatory disease or hospitalization.

Eating disorder: Given the societal pressures and images portraying the glamour of being thin, young adolescent women face a range of eating disorders, including bulimia and anorexia nervosa. In the case of bulimia, it may be difficult for a parent to detect this illness and a child may not be forthcoming with a parent for fear of disappointing them. Having access to confidential health care services may be one of the few avenues that an adolescent is able to pursue to address his/her needs.

• Mental Health: Unfortunately, as we all know, mental health issues continue to be associated with a stigma, as well as often linked with substance abuse. For adolescents this stigma can be even more amplified for many reasons. However, we find that a teen may see a physician in confidence for a short period of time to address the feelings of fear or depression or drug use and then, through these consultations, build confidence in being able to talk a parent. Some teens are surprised to learn that their parents are very supportive and will not punish them for their behaviors or illness. Having a buffer of confidentiality is critical to facilitating a positive outcome.

Most adolescents will seek medical care with their parent or parents' knowledge. Making services contingent on mandatory parental involvement (either parental consent or notification) however, may drastically affect adolescent decision-making. Mandatory parental consent or notification reduces the likelihood that young people will seek timely treatment for sensitive health issues. In a regional survey of suburban adolescents, only 45 percent said they would seek medical care for sexually transmitted diseases, drug abuse or birth control if they were forced to notify their parents.

A teen struggling with concerns over his or her substance use, emotional wellbeing or sexual health may be reluctant to share these concerns with a parent for fear of embarrassment, disapproval, or possible violence. A parent or relative may even be the cause or focus of the teen's emotional or physical problems. The guarantee of confidentiality and the adolescent's awareness of this guarantee are both essential in helping adolescents to seek health care.

For these reasons, physicians strongly support adolescents' ability to access confidential health care. A national survey conducted by the American Medical Association (AMA) found that physicians favor confidentiality for adolescents. A regional survey of pediatricians showed strong backing of confidential health services for adolescents. Of the physicians surveyed, 75 percent favored confidential treatment for adolescents. Pediatricians describe confidentiality as "essential" in ensuring that patients share necessary and factual information with their health care provider. This is especially important if we are to reduce the incidence of adolescent suicide and other mental health concerns, substance abuse, sexually transmitted diseases, unintended pregnancies and other preventable risky behaviors.

Many influential health care organizations support the provision of confidential health services for adolescents; here is what they say:

The American Academy of Pediatrics. "A general policy guaranteeing confidentiality for the teenager, except in life-threatening situations, should be clearly stated to the parent and the adolescent at the initiation of the professional relationship, either verbally or in writing."

American College of Obstetricians and Gynecologists. "Parents and adolescents should be informed, both separately and together, that they each have a pri

vate and privileged relationship with the provider. Additionally, they should be informed of any restrictions on the confidential nature of that relationship."

The American Academy of Family Physicians. "The American Academy of Family Physicians supports the appropriateness of parental involvement in medical decision-making for adolescents, especially when they are engaging in precarious or adult behaviors. Whenever possible, family physicians make an effort to facilitate parental contact to help bridge any communication challenges that may arise between parent and child."

The Society for Adolescent Medicine. "The most practical reason for clinicians to grant confidentiality to adolescent patients is to facilitate accurate diagnosis and appropriate treatment..... If an assurance of confidentiality is not extended, this may create an obstacle to care since that adolescent may withhold information, delay entry into care, or refuse care."

The American Medical Association. "The AMA reaffirms that confidential care for adolescents is critical to improving their health. The AMA encourages physicians to involve parents in the medical care of the adolescent patient, when it would be in the best interest of the adolescent. When in the opinion of the physician parental involvement would not be beneficial, parental consent or notification should not be a barrier to care."

American College of Physicians-American Society of Internal Medicine. "Physicians should be knowledgeable about state laws governing the rights of adolescent patients to confidentiality and the adolescent's legal right to consent to treatment. The physician must not release information without the patient's consent unless required by the law or if there is a duty to warn another.”

The American Public Health Association. APHA "urges that... confidential health services (be) tailored to the needs of adolescents, including sexually active adolescents, adolescents considering sexual intercourse, and those seeking information, counseling, or services related to preventing, continuing or terminating a pregnancy."

CONCLUSION

In conclusion, as a physician, a teacher, and most of all, as a parent, who is concerned about the quality and safety of health care for my daughter as well as for the quality and safety of health care for all adolescents in this country, I urge you to reject attempts to restrict adolescents' access to confidential health care services, including prescription drugs or devices.

Thank-you. I would be happy to answer any questions you may have.

Mr. BILIRAKIS. Thank you very much, Dr. Jenkins.
Mr. Heisler.

STATEMENT OF JOHN A. HEISLER

Mr. HEISLER. Mr. Chairman and members of the committee, I want to thank you for the opportunity to come before you and explain why McHenry County, Illinois refuses to take Federal funding that requires us to provide contraceptive services to minor without parental notification.

Our county was forced to deal with an issue of parental notification when we found out that a 12-year-old junior high student was getting chemical contraceptive shots because her 37-year-old teacher was raping her. The McHenry County Board of Health administers a $4 million budget and generally-should I continue?

Mr. BILIRAKIS. Yes, please continue. That is a message to us regarding what is happening on the floor.

Mr. HEISLER. The Department of Health has three divisions: Animal Control, Environmental and Nursing. About 75 percent of the revenues of the health department are derived from grants. In the past, grants were sought out and applied for by senior staff within the department. Grant applications are formally submitted to State and Federal Government over the signature of the health department administrator. Since my county's rejection of the title X grant, all new grant applications and all grant renewals in excess

of $50,000 are submitted to the county board for approval prior to being submitted to the grantor.

The McHenry County Board of Health was created by resolution of the county board, not by referendum. While State statute in Illinois does extend a great deal of authority to the board of health, the ultimate authority comes from the county board who approves its budget and appoints its members.

The title X debate in McHenry County began in January 1997 when it was learned that a 12- or 13-year-old school girl had been driven to the county health department clinic on several occasions by her 37-year-old Crystal Lake Middle School teacher who had been having sexual relations with her for some 18 months to receive injections of the contraceptive drug, Depo-Provera. Unfortunately, Federal title X regulations prevented her parents from being informed.

Her teacher, William Saturday, pleaded guilty to criminal sexual assault charges in September 1997 and was sentenced to 10 years in prison. According to public record, Mr. Saturday was released in February of this year after serving less than half of his sentence. He is currently on parole and living in McHenry County as a registered sex offender.

This teacher could not take or send a 12-year-old girl to his school nurse. He could not take her to a private doctor or physician. He could only take her to a title X program facility where no parental consent was allowed. The title X grant aided him in his crime. In Illinois we protect our children under various State statutes. A minor cannot buy a pack of cigarettes, a drink or even get a tattoo in Illinois because of the potential danger. Furthermore, the school code of the State of Illinois prohibits the administration of any drug or medical attention without parental consent. It is shocking to think that a Federal grant program can circumvent our State code.

As a member of the board of health, the Health Department Oversight Committee and the county board, I began to inquire about the no-parental notification clause of title X. I was not made apparent of the executive review and the executive review of the grant. Hearing no acceptable answers, I asked the health department administrator to check with the Federal Government, and he was told that there would be no exceptions and further that we had to accept the title X grant with the no-parental notification provision or reject it in its entirety. I would like to repeat that. The Federal agency that administers title X essentially gave the parents in McHenry County two options: Take the title X money and be kept in the dark about your kids or reject the money. Ultimately McHenry County did, in fact, reject title X funding.

At the regular county board meeting of October 1997, I made the motion to remove the approximately $47,800 in title X funds from the county budget. In addition, as finance chairman, I restored the gynecological services to poor adult women to the budget from local tax dollars. The message was sent back to Washington, "We cannot be bought. We will not accept your money if it affects our children. We feel it is the parents' right to determine if any child needs medical services. A child in McHenry County cannot be given even an aspirin from the school nurse without parental consent. The board

of health in McHenry County will not circumvent the basic rights of parents by accepting Federal title X funds."

McHenry County has not applied for title X funds since this time. We do not provide contraceptive services to minors without parental consent. We have allocated tax dollars for pre-natal care and all other related gynecological services to that segment of our population that cannot afford medical services or insurance. As with all of our nursing services, we target recipients who do not qualify for Medicaid or have sufficient income to afford medical in

surance.

The debate over the title X grant in McHenry County was stifled by a gag order due to the lawsuits brought against the county by the girl's parents. Elected officials, board members and employees were asked not to discuss the issue as it might have had a detrimental effect on the defense of the county's position.

Mr. BILIRAKIS. Please summarize, Mr. Heisler.

Mr. HEISLER. I have lived in Crystal Lake all my life. My entire family still lives in Crystal Lake, and I think I represent the values of the majority in McHenry County. Unlike other political issues, there was no room for compromise with the Federal title X funds. I believe, at least in this instance, the moral majority did prevail. If the Federal Government continues to mandate that we keep parents in the dark, we will be happy to provide for our own without help from title X funding. Thank you.

[The prepared statement of John A. Heisler follows:]

PREPARED STATEMENT OF JOHN A. HEISLER

Mr. Chairman and Members of the Committee, I want to thank you for the opportunity to come before you and explain why McHenry County, Illinois refuses to take federal funding that requires us to provide contraceptive services to minors without parental notification. Our County was forced to deal with the issue of parental notification when we found out that a 12-year-old junior high school student was getting chemical contraceptive shots because her 37-year-old teacher was raping her. Background:

McHenry County is about 50 miles northwest of Chicago, Illinois. Population is approximately 280,000. McHenry County is the fastest growing county in the State of Illinois.

The County Board is a 24-member board, made up of four elected representatives from each of the six districts within the County.

I have been a member of the County Board since August 1994. I am a member of the Public Health Committee, the Valley Hi Nursing Home Committee and Chairman of the County's Finance Committee. McHenry County has an annual budget of about $130 million and has approximately 1,200 employees including a sheriff's department of 300 officers.

Throughout the County, we have several organizations that are supported by the County budget. These organizations have their own Boards whose members are appointed by the County Board, and each has a "Liaison" member from the County Board with voting privileges. These "Liaison" members are on these Boards to give some fiscal guidance and to promote the general philosophy of the full County

Board.

In the fall of 1994, I was appointed Liaison Member of the McHenry County's Board of Health. The McHenry County Board of Health had eight members (now nine) consisting of two physicians, a dentist, a civil engineer, a nurse, two citizens from the County and the County Board Liaison.

The McHenry County Board of Health administers a $4 million budget and generally sets the policies and standards of conduct for a staff of 100. The Department of Health has three divisions: animal control, environmental, and nursing. About 75% of the revenues of the Health Department are derived from grants. In the past, grants were sought out and applied for by senior staff within the Department. Grant applications are formally submitted to the State or Federal Government over the

signature of the Health Department Administrator. Since the County's rejection of the Title X grant, all new grant applications, and all grant renewals in excess of $50,000 are submitted to the County Board for approval prior to being submitted to the grantor.

The McHenry County Board of Health was created by Resolution of the County Board, not by referendum. While State Statute does extend a great deal of authority to the Board of Health, the ultimate authority comes from the County Board who approves its budget and appoints its members.

Title X:

The Title X debate in McHenry County began in January 1997, when it was learned that a 12-year-old grade school girl had been driven to the County Health Department Clinic on several occasions by a 37-year-old Crystal Lake Middle School teacher who had been having sexual relations with her for 18 months, to receive injections of the contraceptive drug Depo-Provera. Unfortunately, federal Title X regulations prevented her parents from being informed.

Her teacher, William Saturday, pleaded guilty to criminal sexual assault charges in September 1997, and was sentenced to 10 years in prison. According to public records, William Saturday was released in February of this year-after serving less than half of his sentence and he is currently on parole and living in McHenry County as a registered sex offender.

This teacher could not take or send the 12-year-old girl to the school nurse. He could not take her to a private doctor or physician. He could only take her to a Title X program facility where no parental consent was allowed. The Title X grant aided him in his crime.

In Illinois we protect our children under various state statutes. A minor cannot by law buy a cigarette, a drink, or even get a tattoo in Illinois because of the potential danger.

Furthermore, the school code of the state of Illinois prohibits the administration of any drug or medical attention without parental consent. It is shocking to think that a federal grant program can circumvent our state code.

As a member of the Board of Health, the Health Department Oversight Committee (Public Health Committee) and the County Board, I began to inquire as to why the "no-parental notification clause" of Title X was not made apparent in the executive review of the grant. Hearing no acceptable answer, I asked the County Health Department Administrator to check with the Federal Government, and he was told that there would be no exceptions and further that we had to accept the Title X grant with the "no-parental notification" provision, or reject it in its entirety. I'd like to repeat that: The federal agency that administers Title X essentially gave the parents in McHenry County two options: 1) take Title X money and be kept in the dark about your kids or 2) reject the money.

Ultimately, McHenry County did, in fact, reject Title X funding. At the regular County Board meeting of October 1997, I made the motion to remove the approximately $47,800 in Title X funds from the County's Budget. In addition, as Finance Chairman, I restored all gynecological services to poor adult women to the budget from local tax dollars. The message sent back to Washington was: We can't be bought. We will not accept your money if it affects our children. We feel it is the parents' right to determine if any child needs medical services. A child in McHenry County cannot be given even an aspirin from the school nurse without parental consent. The Board of Health in McHenry County will not circumvent the basic rights of parents by accepting federal Title X funds.

McHenry County has not applied for Title X funds since this time. We do not provide contraceptive services to minors without parental consent. We have allocated tax dollars for pre-natal care and all other related gynecological services to that segment of our population that cannot afford medical services or insurance. As with all of our nursing services, we target recipients who do not qualify for Medicaid or have sufficient income to afford medical insurance.

The Debate:

The debate over the Title X grant in McHenry County was stifled by a gag order due to the lawsuits brought against the County by the girl's parents. Elected officials, Board Members, and employees were asked not to discuss the issue as it might have had a detrimental effect on the defense of the County's position. The vocal minority in the community was not under any such restriction. As a result, the public debate was very one sided. Proponents of Title X organized into a group called "Friends of Public Health" and attacked me at home, at work, at church and at Board meetings. Under the gag order, I was not permitted to reply or respond.