Best Practices for Adolescent Sexual and Reproductive Health Care in Clinical Settings

Preserving confidentiality

AAP policy, Bright Futures, and other national medical organizations’ policy highlights the importance of confidentiality in adolescent health care. Preserving confidentiality for adolescent patients supports youth in taking ownership over their own health, facilitates open communication about sensitive topics (eg, sexual health, mental health, and substance use), and supports the transition to adulthood.

When adolescents know their confidentiality is protected, especially over multiple visits, they are more likely to access health care, communicate about sensitive topics regarding behaviors, partners, or gender issues; and return for care. Confidentiality also allows for self-management of an individual’s sexual and reproductive health care.

AAP provides clinical resources and videos to support confidential care for adolescents.

Clinicians can support adolescent confidentiality for sexual and reproductive health care in many ways:

Education:

• Train all office staff and clinicians to discuss confidentiality with all parents and youth beginning at an early age, to set the expectation that patients will begin to have one-on-one time with their pediatric health clinician during adolescence.
• Ensure all clinicians and staff understand state laws surrounding informed consent and confidentiality related to contraceptive services; STI testing and treatment; and HIV testing and treatment.
• Ensure all clinicians and staff know how to detect sexual violence or abuse, and understand the legal requirements for reporting sexual violence or abuse.

Office policies and procedures:

• Develop an office policy that explicitly outlines the right of adolescent patients to confidential care and share the policy with patients and families. Post it in a visible location in your office.
• Require education for clinical and office staff about the importance of protecting adolescent confidentiality in all aspects of care delivery, including medical records, appointments, test results, after-visit summaries, explanation of benefits forms, and follow-up care.
• Consider confidentiality concerns in follow-up care and referrals. For example, when providing a prescription for contraception, refer adolescents, especially minors, to pharmacies where their confidentiality will be respected and where the pharmacist will call the health provider and not the parents with questions about a prescription.
• Clinics that serve an entire community may need to take extra steps to ensure confidentiality for young people, including use of confidential codes and/or separate waiting rooms for adolescents.

Communications with adolescents and families:

• Talk directly with adolescent patients and their families about the protections of confidentiality at every visit and allocate time for a one-on-one conversation between the patient and clinician during every visit. Some examples for talking about confidentiality include:
  • To adolescents: “I want to take a few minutes today to talk about your sexual health, which is a big part of your overall health. Before we get started, I want to make sure that you know that what we talk about is confidential, meaning it’s private between you and I, and I don’t discuss any of this with your parents. Unless there is a concern of your safety or someone else’s safety. Is that OK?”
  • To parents: “Now it’s time for the one-on-one portion of the visit. As you both know, I spend time alone with all my patients ages 11 and above so we can have a confidential conversation. Mrs. Smith, I am going to have you step out so that John gets practice talking about his own health care and answering questions related to his health. This will help John as he transitions to adulthood.”
• Pediatric health clinicians have opportunities with families and caregivers to introduce topics such as healthy sexual development and exploration while limiting risk of harm.
• When talking to adolescent patients about their sexual and reproductive health concerns, encourage them to engage their parent/caregiver or other trusted adult in their care. Many patients choose to involve their parents/caregivers in their reproductive health care. To support them in doing so, offer to talk to the parent/caregiver together during the visit.
• If the patient does not want to engage their parents/caregivers in their care and are not at risk of hurting themselves or someone else, respect their wishes within the limits of your state’s laws around confidentiality.
• Be sure to get a cell number and/or private e-mail address for youth for quick and reliable communications.

Creating an adolescent-friendly office environment.

An adolescent-friendly office culture can facilitate the delivery of patient-centered sexual and reproductive health care.

Specific strategies to promote an adolescent-friendly office environment include:

Incorporating sexual and reproductive health services into the clinic visit:

• Providing the full range of sexual and reproductive health services in one location (eg, screening, counseling, STI prevention and treatment, contraception, pregnancy-related care, abortion), and advertising the breadth of services provided.
• Offering same-day sexual and reproductive procedures or helping adolescents make referral appointments for specialized services, and providing clear directions and instructions, assurances of continuing confidentiality, and information about fees, if any.
• To the extent possible, ensuring continuity of care by making every effort to have adolescents see the same provider at every appointment.
• Involving families in the care of adolescents as much as possible; for example, the provider can “wrap up” the visit with the parent or guardian for nonconfidential issues and/or, if the adolescent or young adult wishes, to disclose anything with the pediatric health clinician present for support.
  • Simultaneously, it is important to educate parents on the benefits of the physician having a parallel, independent care relationship with their child to ease transition of the relationship to primarily focus on the patient/provider, and not the parent/provider, over time.
• Incorporate puberty, sexuality, and sexual health assessment into psychosocial history taking. Example screening questions include:
  • Puberty: “Do you have any concerns about how your body is developing?”
  • Sexuality: “Many people your age begin to have attractions physically or romantically. Have you thought about that? What are the genders of the people that you are attracted to?”
  • Sexual health assessment: “What types of sexual experiences have you had?”
• Encourage transition-planning for youth, with a focus on ensuring that reproductive health care, including contraception and pregnancy care, continues as youth transition from pediatric to adult care.

Offering a range of hours and services that cater to adolescent schedules:

• Offering flexible hours, walk-in hours, same-day appointments, and appointments in the evening and on weekends.
• Offering telehealth appointments to adolescents to increase options for accessing care.
• Following best practices for adolescent telehealth visits (eg, asking if a parent is present in the room, encouraging use of headphones or the chat function to protect the privacy of conversations).

Creating a welcoming office culture:

• Establishing clear, unambiguous policies against discrimination on the basis of sex, age, race/ethnicity, sexual orientation, religion, gender identity, ability/disability, and gender expression. Make sure the health center is a safe place for all patients and staff.
• Hiring diverse, well-trained clinicians and staff, and making efforts to hire candidates that live in the community or reflect the demographics, culture, and language of the patient population.
• Delivering supportive, non-judgmental care to all youth who access the office or clinic.
• Using clinical forms and/or questionnaires that allow patients to write in their own gender and sexual identity and by allowing differentiation between sex assigned at birth and affirmed gender.
• Establishing continuous ongoing training regarding cultural diversity, sexual orientation, gender identity, and cultural norms, particularly those cultures of the adolescents served.
  • Encourage accountability for all clinicians and staff by coordinating training during work hours or building into continuing education requirements.
  • Any culturally appropriate tools, trainings, or interventions should be leveraged to support both clinicians and non-clinician providers alike.

Providing free or low-cost services:

• Offer free or greatly reduced-fee services to adolescents. This can be especially important for STI testing and treatment.
• Set up private billing accounts for adolescents who seek confidential services. Arrange for laboratory fees for confidential tests to be billed directly to the health center. Work out a nominal payment plan with the adolescent. At the same time, bill the adolescent’s insurance for provider time, using confidential codes, so that information forms sent to the parents will not betray youth’s confidentiality.
• Where permitted by state law, dispense free or low cost prescriptions to adolescents.
• Stock exam rooms and bathrooms (not just the waiting room) with baskets of condoms along with signs saying that youth are free to take as many as they like, at no charge.
• School nurses and providers at school-based or school-linked health centers can assist students and families in obtaining health insurance as needed and can represent the school on community coalitions to advocate for increased resources for school-based health care.

Removing barriers to access:

• If possible, offer transportation vouchers or bus tokens to youth who need them. If this is not possible, link with community health centers around the county or geographic area so you can offer youth the option of using a health center closer to home or work.
• Offer a special help-line that adolescents can use to inquire about services, make appointments, and request follow-up care. Where possible, consider establishing a text-messaging line or web page which can provide youth with information about where and when to access youth-friendly health services.
• Offer solutions to increase access for youth with physical disabilities, including wheelchair accessibility and exam table access.

Knowing and collaborating with community resources:

• Building strong referral systems and/or establishing collaborative partnerships with agencies who serve communities of youth with unique sexual health needs, including young parents, youth in foster care, youth who live in homeless shelters, youth engaged in the juvenile justice system, and youth enrolled in substance abuse programs.
• Connecting with local emergency rooms to guide referrals for family planning or contraceptive service needs.
• Involving young people in assessing the policies and services offered in the practice and taking their recommendations seriously.
• Choosing gender-neutral décor for waiting rooms and include art, posters and resources in waiting and examination rooms that is inclusive of diverse races, ethnicities, abilities/disabilities, family structures, relationship types, and gender identities.

Providing strengths-based, trauma-informed, patient-centered care.

Within the context of a sexual and reproductive health visit, pediatric health clinicians can provide strengths-based, trauma-informed, patient-centered care to best meet the needs of each individual patient.

Pediatric health clinicians can consider the following strategies when delivering care:

• Delivering care through a reproductive justice framework, which includes:
  • Ask youth about their priorities and concerns related to sexual and reproductive health without bias or making assumptions:
    • Use unbiased and inclusive language during conversations about behaviors, partners, sexual orientation, gender identity.
    • Ask about and follow patients’ wishes about contraceptive methods (eg, clinicians should not push individuals to use a specific form of contraception, such as LARC).
  • Support each adolescent’s right to body autonomy:
    • Talk with adolescent patients about their bodily autonomy, and ways to proactively assert and protect their autonomy in their healthcare, relationships, and behaviors.
    • Integrate aspects of sex positivity and discussion about the normalcy to find intimacy pleasurable into sexual health counseling.
  • Use patient-centered language:
    • Communicate with adolescents using their vernacular and ask questions about the patient’s goals, rather than making assumptions. Overly medical terminology, even about anatomy may not resonate.
    • Ask patients their pronouns.
    • Ensure that patients can communicate with staff in their own language. This may mean hiring bilingual staff or compensating staff who learn additional languages.
    • Ensure that high-quality adolescent health education materials are available in all the languages that adolescents in the community speak and for various reading levels, include low literacy.
• Provide adolescents with the realistic, unbiased information and education needed to make informed decisions about their sexual health—including choices around contraception, pregnancy, parenting, adoption/kinship care, or abortion—and then provide support to implement whatever decision is made.
• Integrate principles of trauma-informed care into clinical interactions:
  • Leadership commitment by annual reviewing policies and procedures to ensure a safe work environment and setting to provide trauma-informed care, to reduce secondary traumatic stress and burnout, and to promote sensitivity to the needs of trauma survivors.
  • Patient and family empowerment by seeking meaningful input in the development of policies and practices, particularly regarding cultural, historical, and gender issues.
  • Continuous through the Health Care System including primary, secondary, and tertiary prevention strategies.
  • Recruitment and Training of a Trauma-Informed and Compassionate Workforce including all administrators, clinicians, and staff, both clinical and nonclinical.
  • Coordination of Care Across Family-Serving Systems in the Community that establish and support collaborative, interdisciplinary relationships among community and public health agencies that serve the population of focus to coordinate care for those exposed to trauma.

Schools and school-based health centers are in a unique position to provide students with comprehensive sexual and reproductive health care and referrals, due to their accessibility to school-aged children and adolescents and ability to provide health education targeted to young people. School-based health centers support the physical and mental health needs of young people young by providing health services in school or on school grounds and improve access to health care services by decreasing financial, geographic, age, and cultural barriers. School based health centers have been proven to improve student access to health care, improve health outcomes, and reduce health disparities.

Clinicians and staff who provide sexual and reproductive health care to adolescents in school-linked settings can support and expand access in the following ways:

Expanded hours and services:

• Consider being open year-round and not just during the academic school year.
• Ensure the school based health center is open before and after school, not solely during school hours.
• Consider expanding services to include recent graduates.

Policies and procedures:

• School nurses and health providers in school-based health centers can partner with schools to establish policies which allow students to see medical providers during the school day.
• Develop strategies that promote and incentivize transition of care for sexual and reproductive health when students graduate.

Referrals:

• Provide students with referral information along with available community resources to improve access to care.
• School nurses and school-based health center staff can follow-up with students if they are referred to a community health clinic to ensure that the adolescent understood what was discussed during their appointment and to ensure they will follow through with the recommended next steps (e.g., scheduling a follow-up appointment or taking a prescribed medication).

Due to a longstanding history of systemic inequities that impact access to reproductive health care services, the above considerations are particularly important to certain populations of youth. Clinicians and staff who are delivering sexual and reproductive health care should be aware of the following:

• Some populations of youth need extra assurances of confidentiality, including youth that are HIV-positive, older youth, youth who are LGBTQ2S+, and youth who are pregnant and parenting.
• Provision of respectful, strengths-based, trauma-informed care is particularly important for some populations of youth, including youth who are parents, youth who are LGBTQ2S+, youth who are HIV-positive, youth who are historically underserved, and youth who are survivors of sexual or physical assault.
• Integrated care is especially important to some populations of youth, including young adults, youth who are pregnant, youth who are LGBTQ2S+, youth who are HIV-positive, and youth who are survivors of sexual or physical assault.
• Cultural competency is highly important to particular populations of youth:
  • Men who are gay and bisexual often rely heavily on the experiences and recommendations of their peers. Good client-staff interactions with one young man will be likely to come to the attention of other young men who are gay and bisexual. While most adolescents rely heavily on the experiences and recommendations of their peers, youth who are LGTBQ2S+ may be more attune to this because of concerns about discrimination, oppression, and lack of knowledge. Be aware that young males who are gay and bisexual have the same need as their peers who are heterosexual to be treated holistically and to receive optimal care that addresses their physical, emotional, and psychosocial health.
  • Youth of color need to know that they are seen as individuals, not as someone’s stereotype of their race/ethnicity. Remember that any individual adolescent is no more and no less likely than any other to participate in or to avoid risk-taking behaviors. All need the same individual counseling and care.