**5. Testing and follow-up**

*Psycho-Social Aspects of Human Sexuality and Ethics*

**4. Confidentiality**

to consent [32].

or not to grant access [33].

found that in adolescents presenting to the ED with non-genitourinary complaints, the prevalence of STIs was 10% [22]. Given the nature of emergency care and lack of continuity, there is concern that patients testing positive but were not treated in the ED may become lost to follow up, and therefore remain untreated [26]. This needs to be balanced with antibiotic stewardship and development of antibiotic resistant organisms associated with overtreatment [27]. This highlights some of the

Where ever they choose to seek care, confidentiality is important to adolescents. Multiple medical and legal organizations recognize the need for providing confidential health care to adolescents and a growing body of research has shown the importance of this, but this comes with challenges [28–30]. According to the Society for Adolescent Medicine, "Confidentiality protection is an essential component of health care for adolescents because it is consistent with their development of maturity and autonomy and without it, some adolescents will forgo care" [28]. A 1997 study by Ford et al. showed that assurances of confidentiality increased the number of adolescents willing to return for a future visit to a physician's office by 10 percentage points, from 62 to 72% (P = 0.001) [29]. Additionally, adolescents who report health risk behaviors have been shown to have an increased likelihood of

complexities of adolescent STI reduction initiatives in the ED setting.

citing confidentiality concerns as a reason for forgone health care [30].

In the United States, each state has legal statues that authorize minors to consent for care under a variety of circumstances [31]. Care that minors are allowed to consent for without a parent usually includes contraceptive services, pregnancy-related care, diagnosis and treatment of STIs, care related to a sexual assault, treatment for drug or alcohol problems, or mental health services. Some states, however, require that a minor be of a certain age (generally around 14 years old) before being allowed

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule creates rights for individuals to have access to their protected health information and to control the disclosure of that information in some circumstances. It contains specific requirements pertaining to the medical records of minors [33]. The HIPAA Privacy Rule provides that, in general, when minors legally consent to health care or can receive it without parental consent, the parent does not necessarily have the right to access the minor's health information. This is all dependent, however, on each individual state's laws. Thus, a health care provider must look to state law to determine whether it specifically addresses the confidentiality of a minor's health information. If state law is silent on the question of parents' access, a health care professional exercising professional judgment has discretion to determine whether

Likely one of the biggest limitations in providing confidential care to adolescents has to do with payment. Most often, parents or parents' health insurance pays for an adolescent's health care. As of the time of publication of this text, there is no legal way to prevent a parent from viewing a billing statement and/or explanation of benefits (EOBs) from the insurance company. EOBs are notifications to policyholders that health care services were provided under a health insurance plan, including those services provided to any dependents covered by the plan. EOBs generally disclose the name and of the provider and the specific laboratory tests used or other services rendered. They are intended to protect policyholders and insurers from fraud and abuse and to explain financial obligations, but can have unanticipated and unintended negative consequences such as a breach of confidentiality [34].

**10**

Testing and follow-up are also areas with unique nuances when it comes to adolescent patients. Methods for testing and/or screening adolescents for gonorrhea and chlamydia include self-obtained vaginal swabs, self-collected urine samples, and provider-collected endocervical swabs. For adolescents, the idea of a provider-collected specimen can be a barrier to seeking care [35, 36]. Self-collected specimens have been shown time and again in the medical literature to be preferred by adolescents over provider-collected specimens [37]. Many studies have also evaluated the utility of these other forms of testing and have found that the sensitivity and specificity of self-collected swabs and urine samples compared to swabs collected by clinicians supports the use of these tests in screening for gonorrhea and chlamydia [38, 39].

Given that adolescents do not always present regularly for preventive health care visits, the acceptability of and ease of collection with self-collected specimens may allow clinicians an opportunity to screen patients in the clinic for STIs who are not presenting for pelvic or urogenital examinations and might not otherwise be screened as regularly as they should be.

Follow up of adolescents can be problematic, especially for those seeking care in emergency departments. ED personnel in one study cited difficulty in reaching adolescents and the ease of empiric treatment to justify the practice of empirically treating STI tested patients and only providing follow-up contact to those who tested positive but were not treated at the ED visit [40]. Confirming that STI-positive patients receive appropriate treatment is a vital component of any screening initiative. Success in contacting adolescents with their results has been found, especially when a confidential cell phone number is used [41, 42]. Reed et al. worked on increasing the proportion of adolescent patients able to be contacted with their test results from 45 to 65% and decreased their lost to follow up rate [43]. This was done almost entirely by focusing on making sure that a confidential phone number was documented in the electronic medical record. They also gave out a card with contact information for a cell phone given to a nurse practitioner who was dedicated to contacting and being available for being contacted by the patients regarding their results. They learned that adolescents often have cell phone plans with limited minutes of talk time, but can still send and receive texts. So while they might not answer their phones or check their messages frequently, they will respond quickly to a text message.

It is important for adolescents to be aware of their test results, even in the case where they have already been empirically treated, as having knowledge about their diagnosis can lead to behavior changes [44]. Dr. Reed's group also followed up, by phone, a convenience sample of adolescent women who were empirically treated in the ED or teen clinic setting for STI [45]. They found that those who believed they had an STI were more likely to abstain from sexual activity and to notify their partners. Those who were treated with antibiotics but did not believe they tested positive for STIs did not change their behavior.
