Feature

Q&A: Improving confidential health care for teens

Photo of Sanjana Pampati
Sanjana Pampati

With STDs on the rise in the United States, appropriate screening and treatment are crucial to curbing transmission. However, this can be difficult when teenagers are worried about the confidentiality of their sexual and reproductive health care.

Researchers reported in MMWR in 2017 that nearly 13% of sexually active adolescents and young adults who were insured through their parents would not seek sexual and reproductive health care because they feared their parents might find out about it. In a review published in the Journal of Adolescent Health, Sanjana Pampati, MPH, an ORISE Fellow in the CDC’s Division of Adolescent and School Health, and colleagues noted that this is one of several studies linking confidentiality with the receipt of recommended health services. Furthermore, confidential health care services can give teenagers an opportunity to learn about the health care system and “become autonomous health care consumers, in line with developmental milestones.”

Infectious Diseases in Children spoke with Pampati about how providers can ensure the confidentiality of teens’ sexual and reproductive health care — and why that may require the help of both patients and their parents. – by Katherine Bortz

Q: What protections do teens in the U.S. have that allow them access to confidential sexual and reproductive health care?

A: All states and the District of Columbia allow minors to consent to STD services, and many states allow minors to consent to contraceptive services. However, there is some variation in the age of access and allowable services across states. Providers should be aware of the minor consent laws in the state in which they practice.

Photo of a teenage girl in a doctor's office with her doctor 
Source: Adobe Stock

Q: What does the research tell us about how adolescents value confidentiality?

A: Studies have shown that adolescents strongly value confidentiality and are more likely to forgo health care in the absence of confidentiality protections. Especially in relation to sexual and reproductive health care, adolescents stress the need for confidential care.

In addition, confidentiality practices have been linked with receipt of recommended sexual and reproductive health services, such as STD testing.

Q: How might a provider best treat an adolescent patient whose parent or guardian refuses to let them speak to the doctor alone?

A: Most parents will be receptive to time alone, but occasionally, refusal to leave the room does occur. The provider can seek to address parental concerns about time alone, but if the parent is still uncomfortable, the visit must proceed covering as much material as appropriate in the presence of the parent.

For example, the sexual history would likely be unattainable and may prove to be harmful to the provider-adolescent relationship if attempted in the presence of the parent. The conversation around certain risk behaviors may shift to talking about what conversations have occurred between the parent and adolescent, any concerns or questions that the parent or adolescent may have and general anticipatory guidance covering these topics.

Strategies that can help parents become comfortable with time alone include setting up an office policy about time alone and presenting it in conjunction with other office policies at the first visit, reminding parents at preteen visits that time alone will begin soon, using normative language to introduce time alone, reinforcing that it is something provided to all adolescents as a developmentally appropriate part of a health care visit and offering time alone consistently at every well-child visit. When possible, providers should offer time alone at acute-care visits also and make sure that parents remain involved and do not feel excluded.

Q: You and your colleagues recommend a “triadic approach” to improving adolescent sexual and reproductive health and maintaining confidentiality that involves parents, adolescents and providers. How will that work, exactly?

A: It may seem a little counterintuitive to think of parental involvement in the context of confidential sexual and reproductive health care for adolescents. But we think all three populations — providers, adolescents and parents — can have an important role in ensuring youth receive the care they need.

In particular, we think parent-provider partnerships are critical. For example, parents and providers can educate adolescents about confidentiality practices, such as time alone, starting from a young age to potentially increase knowledge and comfort with these practices. Providers can supply parents with relevant health education materials and encourage parent-adolescent communication and parental monitoring.

Q: How can providers improve trust with their adolescent patients?

A: Providers can offer adolescents confidentiality assurances, which have been linked with adolescents’ willingness to disclose sensitive information. By providing an assurance of confidentiality, providers can affirm which services will be confidential and outline the limitations of confidentiality in a developmentally appropriate manner.

Providers can also work to create a more youth-friendly environment by making services more accessible and welcoming to young people, which may improve adolescents’ comfort and trust with their provider. This can include having flexible hours, creating physical spaces in which adolescents feel comfortable and providing relevant health education materials to adolescents.

References:

Kahn L, et al. MMWR Morb Mortal Wkly Rep. 2018;doi:10.15585/mmwr.ss6708a1.

Leichliter JS, et al. MMWR Morb Mortal Wkly Rep. 2017; doi: 10.15585/mmwr.mm6609a1.

Pampati S, et al. J Adolesc Health. 2019;doi:10.1016/j.jadohealth.2019.03.021.

Disclosure: Pampati reports no relevant financial disclosures.

Photo of Sanjana Pampati
Sanjana Pampati

With STDs on the rise in the United States, appropriate screening and treatment are crucial to curbing transmission. However, this can be difficult when teenagers are worried about the confidentiality of their sexual and reproductive health care.

Researchers reported in MMWR in 2017 that nearly 13% of sexually active adolescents and young adults who were insured through their parents would not seek sexual and reproductive health care because they feared their parents might find out about it. In a review published in the Journal of Adolescent Health, Sanjana Pampati, MPH, an ORISE Fellow in the CDC’s Division of Adolescent and School Health, and colleagues noted that this is one of several studies linking confidentiality with the receipt of recommended health services. Furthermore, confidential health care services can give teenagers an opportunity to learn about the health care system and “become autonomous health care consumers, in line with developmental milestones.”

Infectious Diseases in Children spoke with Pampati about how providers can ensure the confidentiality of teens’ sexual and reproductive health care — and why that may require the help of both patients and their parents. – by Katherine Bortz

Q: What protections do teens in the U.S. have that allow them access to confidential sexual and reproductive health care?

A: All states and the District of Columbia allow minors to consent to STD services, and many states allow minors to consent to contraceptive services. However, there is some variation in the age of access and allowable services across states. Providers should be aware of the minor consent laws in the state in which they practice.

Photo of a teenage girl in a doctor's office with her doctor 
Source: Adobe Stock

Q: What does the research tell us about how adolescents value confidentiality?

A: Studies have shown that adolescents strongly value confidentiality and are more likely to forgo health care in the absence of confidentiality protections. Especially in relation to sexual and reproductive health care, adolescents stress the need for confidential care.

In addition, confidentiality practices have been linked with receipt of recommended sexual and reproductive health services, such as STD testing.

Q: How might a provider best treat an adolescent patient whose parent or guardian refuses to let them speak to the doctor alone?

A: Most parents will be receptive to time alone, but occasionally, refusal to leave the room does occur. The provider can seek to address parental concerns about time alone, but if the parent is still uncomfortable, the visit must proceed covering as much material as appropriate in the presence of the parent.

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For example, the sexual history would likely be unattainable and may prove to be harmful to the provider-adolescent relationship if attempted in the presence of the parent. The conversation around certain risk behaviors may shift to talking about what conversations have occurred between the parent and adolescent, any concerns or questions that the parent or adolescent may have and general anticipatory guidance covering these topics.

Strategies that can help parents become comfortable with time alone include setting up an office policy about time alone and presenting it in conjunction with other office policies at the first visit, reminding parents at preteen visits that time alone will begin soon, using normative language to introduce time alone, reinforcing that it is something provided to all adolescents as a developmentally appropriate part of a health care visit and offering time alone consistently at every well-child visit. When possible, providers should offer time alone at acute-care visits also and make sure that parents remain involved and do not feel excluded.

Q: You and your colleagues recommend a “triadic approach” to improving adolescent sexual and reproductive health and maintaining confidentiality that involves parents, adolescents and providers. How will that work, exactly?

A: It may seem a little counterintuitive to think of parental involvement in the context of confidential sexual and reproductive health care for adolescents. But we think all three populations — providers, adolescents and parents — can have an important role in ensuring youth receive the care they need.

In particular, we think parent-provider partnerships are critical. For example, parents and providers can educate adolescents about confidentiality practices, such as time alone, starting from a young age to potentially increase knowledge and comfort with these practices. Providers can supply parents with relevant health education materials and encourage parent-adolescent communication and parental monitoring.

Q: How can providers improve trust with their adolescent patients?

A: Providers can offer adolescents confidentiality assurances, which have been linked with adolescents’ willingness to disclose sensitive information. By providing an assurance of confidentiality, providers can affirm which services will be confidential and outline the limitations of confidentiality in a developmentally appropriate manner.

Providers can also work to create a more youth-friendly environment by making services more accessible and welcoming to young people, which may improve adolescents’ comfort and trust with their provider. This can include having flexible hours, creating physical spaces in which adolescents feel comfortable and providing relevant health education materials to adolescents.

References:

Kahn L, et al. MMWR Morb Mortal Wkly Rep. 2018;doi:10.15585/mmwr.ss6708a1.

Leichliter JS, et al. MMWR Morb Mortal Wkly Rep. 2017; doi: 10.15585/mmwr.mm6609a1.

Pampati S, et al. J Adolesc Health. 2019;doi:10.1016/j.jadohealth.2019.03.021.

Disclosure: Pampati reports no relevant financial disclosures.