An essential part of delivering critical preventive services to youth includes discussing confidentiality and private time (without a parent in the room) between adolescents and young adults (AYA) and their healthcare provider to build trust and promote optimal health and well-being. Previous research has shown that without the assurance of confidentiality and private time, AYA are more likely to forego care, are less willing to discuss potentially sensitive topics, or may not seek care altogether.1 This is especially true for vulnerable populations who may be engaging in substance use or experiencing sexual or physical abuse, psychological distress, or suicidal ideation.

Disparities also exist in access and preventive care utilization by youth of color, LGBTQ and gender diverse youth, immigrants, and non-citizen adolescents and young adults. A recent examination of 4,760 adolescents and emerging adults from a nationally representative sample demonstrated that citizenship was associated with twice the likelihood of having a routine place to access care and double the odds of seeing a mental health professional in the past year compared to non-citizen AYA.2 These findings are especially troubling in the context of the current social and political debate around immigration reform, family separation, and access to public benefits.

The U.S. Preventive Services Task Force and Bright Future Guidelines recommend preventive services, and yet the majority of AYA in the United States do not receive this critical care. Even fewer receive private, confidential time and discussions with their healthcare provider.3 In response, the Adolescent Health Consortium of four national medical societies (the Society for Adolescent Health and Medicine, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists) formed to collaborate on this important topic. Their formative research, discussed below, sheds light on some of the experiences and attitudes held by AYA, parents, and providers.

Do All Adolescents Receive Private Time?

In 2016, a survey of a nationally representative sample of 1,918 adolescents and young adults was conducted to define the factors associated with AYA experiences of private time and confidentiality discussions, as well as the effect of these experiences on improving critical preventive services delivery.1 For males, older age strongly predicted receipt of private time, while for females, independent predictors included older age, other or mixed race, higher family income, and ever having sex. Males also were significantly less likely to report ever having received private time with their provider (49%) and discussing confidentiality (44%) compared to females. Data indicate that males often receive less support for seeking sexual and reproductive health information and services, although they report higher rates of sexual risk behaviors and would benefit greatly from being included in these conversations.4 It also would be valuable and informative to include in future research the experiences of gender-diverse youth, as one may hypothesize there would be significant differences based on existing discrimination, stigma, and bias.

AYA who received private time with a provider and talked about confidentiality reported more positive attitudes toward their providers. They also were more willing and comfortable talking about sensitive subjects, which could enhance adolescents’ likelihood of receiving care. Increased comfort and trust with a healthcare provider also may enhance feelings of autonomy and empowerment critical to having difficult conversations, advocating for themselves, and feeling better prepared during the transition to adult healthcare. Only 43% of youth ages 15-18 and two-thirds of young adults ages 19-26 reported ever having private time with their healthcare provider. Adolescent and young adult females were more likely to report receiving private time if their regular provider also was female, which may imply that young people are more comfortable with a same-gender healthcare provider, or that parents are comfortable leaving youth alone with a provider of the same gender.1

Confidentiality Is Important

Recent research indicates that adolescents and parents often agree about the importance of confidentiality and private time with healthcare providers, but both believe this should begin at an older age (18 years) than the professional recommendation of 13 years.3 In the current era of the #MeToo movement, concerns about private time with healthcare providers may be even more prevalent among parents and adolescents as accounts of healthcare provider sexual abuse are being exposed. Additionally, U.S. history of medical abuse, coercion, and discrimination among people of color may contribute to justifiable mistrust and hesitation by parents and AYA around confidentiality and private time with healthcare providers. Privacy and confidentiality concerns should be validated and addressed by healthcare providers as they work together in partnership with the parents to align themselves with adolescents’ and young adults’ goals for optimal health and well-being.5

These collective findings signify the need for providing universal, standardized education to healthcare providers, adolescents, and parents about the importance of private time and discussions of confidentiality.6 Healthcare providers must acknowledge that all AYA have intersectional lives, and they arrive at their healthcare visits as individuals from diverse backgrounds and experiences. Their identities and development are affected by social determinants of health, such as housing, education, and family stability, as well as structural inequities within the United States such as racism, gender identity discrimination, and poverty. When parents, providers, and young people work in partnership based on shared understanding, trust, respect, and communication, this triadic relationship has the best chance of achieving optimal health outcomes, equity, and justice. (See Resources.)

RESOURCES

  • For providers, parents, and adolescents: Get medically accurate, age-appropriate, affirming, and honest sex education through digital media: https://amaze.org/ 
  • For providers: Physicians for Reproductive Health Adolescent and Reproductive Sexual Health Education Program offers evidence, case-based modules, and patient videos on confidentiality, LGBTQ youth, and adolescent-friendly services: https://bit.ly/2Pl4pwH
  • For providers: Look at the Bright Futures web site for a compilation of current forms and materials on preventive health supervision and health screening for adolescents: https://bit.ly/2sGuufY

REFERENCES

  1. 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 2018;64:311-318.
  2. Hensel DJ, Zervos A. Disparities in health care access, preventative care usage and health outcomes between citizen and noncitizen adolescents and emerging adults in the United States — Data from the National Health and Nutrition Examination Survey. J Adolesc Health 2019;64(suppl):S55.
  3. Song X, Klein JD, Yan H, et al. Parent and adolescent attitudes towards preventive care and confidentiality. J Adolesc Health 2019;64:235-241.
  4. Society for Adolescent Health and Medicine. Advocating for adolescent and young adult male sexual and reproductive health: A position statement from the Society for Adolescent Health and Medicine. J Adolesc Health 2018;63:657-661.
  5. Ford CA. The developmental aspects of patients spending time alone with physicians. J Adolesc Health 2019;64:286-287.
  6. Van Cleave J. New directions to improve preventive care discussions for adolescents and young adults. Pediatrics 2019;143:e20183618.