Abstract
Purpose:
Telemedicine can improve access to adolescent health care, but adolescents may experience barriers to accessing this care confidentially. Gender-diverse youth (GDY) may especially benefit from telemedicine through increased access to geographically limited adolescent medicine subspecialty care but may have unique confidentiality needs. In an exploratory analysis, we examined adolescents’ perceived acceptability, preferences, and self-efficacy related to using telemedicine for confidential care.
Methods:
We surveyed 12- to 17-year-olds following a telemedicine visit with an adolescent medicine subspecialist. Open-ended questions assessing acceptability of telemedicine for confidential care and opportunities to enhance confidentiality were qualitatively analyzed. Likert-type questions assessing preference for future use of telemedicine for confidential care and self-efficacy to complete components of telemedicine visits confidentially were summarized and compared across cisgender versus GDY.
Results:
Participants (n=88) included 57 GDY and 28 cisgender females. Factors affecting the acceptability of telemedicine for confidential care related to patient location, telehealth technology, adolescent-clinician relationships, and quality or experience of care. Perceived opportunities to protect confidentiality included using headphones, secure messaging, and prompting from clinicians. Most participants (53/88) were likely or very likely to use telemedicine for future confidential care, but self-efficacy for completing components of telemedicine visits confidentially varied by component.
Conclusions:
Adolescents in our sample were interested in using telemedicine for confidential care, but cisgender and GDY recognized threats to confidentiality that may reduce acceptability of telemedicine for these services. Clinicians and health systems should carefully consider youth’s preferences and unique confidentiality needs to ensure equitable access, uptake, and outcomes of telemedicine.
Keywords: telemedicine, adolescents, adolescent health services, sexual and gender minorities, confidentiality, sexual health, contraception, access to care
In many states, adolescents have a right to consent to and receive confidential health care related to sexual and reproductive health, mental health, and substance use[1]. Confidentiality is a critical component of adolescent care[2,3] and adolescents may forgo care or not disclose concerns if worried about confidentiality[4-7]. Adolescents’ confidentiality concerns may directly impact care-seeking for confidential health services and have been previously associated with decreased contraceptive provision[8] and screening for sexually transmitted infections[9].
Telemedicine has rapidly expanded and shows promise for delivering adolescent-centered care[10-12]. Telemedicine has potential to address adolescents’ barriers to care for confidential health concerns[13] including transportation challenges[14] and access to a relative scarcity of clinicians with specialty expertise in adolescent medicine[15]. Telemedicine may be uniquely impactful by reducing disparities in access to confidential care, including disparities among adolescents from sexual and gender minority groups who may experience greater barriers to accessing care that meets their needs[16-23]. However, telemedicine presents potential risks to adolescents’ confidentiality including challenges ensuring privacy and negotiating caregiver proxy access with electronic health record (EHR)-integrated telemedicine platforms (i.e., videoconferencing technology embedded into the clinician’s EHR and/or the patient’s or proxy’s patient portal)[24,25].
Prior studies have focused on the general acceptability of telemedicine among adolescents but found varied perceptions of its confidentiality[19-22,26-28]. A study of adolescents and their caregivers who used telemedicine in a pediatric primary care setting did not identify confidentiality concerns[27]. However, some adolescents in this study noted insufficient privacy during telemedicine visits and some caregivers felt that they may have confidentiality concerns if telemedicine visits were related to sexual and reproductive health or mental health[27]. Another study of adolescents and their caregivers who used telemedicine in an adolescent medicine subspecialty care setting did detect confidentiality concerns among adolescents but not among their caregivers[26]. Existing studies support the potential for telemedicine to deliver specific adolescent health services including sexual and reproductive health care[28] and gender-affirming care[19-22], but again suggest varied views of confidentiality among adolescent users of these services. Protecting confidentiality is essential to adolescent health care delivery and research focused specifically on adolescents’ confidentiality concerns and needs is merited to guide the safe, effective, and patient-centered use of telemedicine in this population. We examined perceived acceptability, preferences, and self-efficacy of using telemedicine for confidential care among cisgender and gender-diverse youth (GDY) who received care in an adolescent medicine subspecialty practice.
METHODS
Study design and population
We conducted an online survey of a convenience sample of adolescents ages 12-17 who completed a telemedicine visit between March and August 2020 at an adolescent medicine subspecialty practice in Pittsburgh, Pennsylvania. In this study, telemedicine visits consisted of two-way, synchronous communication between a patient, typically located at their home, and a clinician located at a distant clinical site. Telemedicine visits included either audio only or audio and video connection, and no peripheral telemedicine devices were used. Visits used either an EHR-integrated telemedicine platform accessed via a caregiver proxy’s patient portal or an external telemedicine platform (e.g., Doximity, doxy.me) accessed via a link sent to a personal email or phone number. The adolescent medicine subspecialty practice provides adolescent and young adult primary and preventive care as well as a range of specialty services including gender-affirming care, sexual and reproductive health care, mental health care, and care related to substance use or eating disorders. The practice receives Title X funding to provide free and confidential sexual and reproductive health services including on-site testing and treatment of sexually transmitted infections and provision of contraceptives. We over-sampled GDY (61% of those approached) because we anticipated they may have unique barriers to care[29] and perspectives regarding confidentiality[19,20]. To ensure overrepresentation of GDY in our sample, we considered for inclusion all patients seen via telemedicine by 4 clinicians in our gender-affirming care clinic and 4 clinicians in our co-located general adolescent medicine clinic. Following their telemedicine visit, all eligible patients received a phone call or text message explaining the study and a follow-up message with a link to the survey if interested. This study was approved by the University of Pittsburgh institutional review board with a waiver of parental consent.
Measures
The survey included 43 items as part of a larger effort to assess GDYs’ experience and satisfaction with telemedicine for gender-affirming care during the COVID-19 pandemic[20]. Data presented here relate to gender diverse and cisgender adolescents’ perceptions of telemedicine specifically for confidential care. We developed two open-ended survey questions to assess acceptability of using telemedicine for confidential care (“Does a telemedicine visit seem like a good way to talk to a medical provider for a confidential health concern? Why or why not?”) and opportunities for clinicians to enhance confidentiality (“Was there anything the medical provider could have done differently to better protect your confidentiality during the telemedicine visit?”). We developed a Likert-type question assessing preference for using telemedicine for future confidential care (“How likely would you be to use telemedicine for a confidential health concern in the future?”) with 5 response options ranging from “very likely” to “very unlikely”. We reviewed commonly used measures of adolescent health care selfmanagement[30,31] and process maps of telemedicine workflows in our practice to develop 5 Likert-type questions to assess self-efficacy to complete components of telemedicine visits confidentially. Concerning the 5 key components of a telemedicine visit (i.e., schedule a telemedicine visit, access a device, find a private space to talk, talk without being overheard, and pick up medication after the visit), participants were asked “How confident are you that you could do the following things confidentially (i.e., without your parent or caregiver knowing about it)?” with 5 response options ranging from “very confident” to “not at all confident”. Demographic questions assessed gender identity, race and ethnicity, and age. We also assessed travel distance from the participant’s home to the adolescent medicine subspecialty clinic. We divided travel time at 30 minutes based on average willingness-to-travel thresholds among adults,[32] although this does not comprehensively capture all transportation barriers for adolescents. Telemedicine visit characteristics were assessed including visit type (i.e., new vs return), visit format (i.e., audio and video vs audio only), the reason for the visit, and whether a confidential health concern was discussed during the visit. We conducted cognitive interviews of the survey items with adolescent and young adult members of a research advisory group, The Gender Research Stakeholder Program, and revised items as needed prior to administration.
Analysis
Responses to open-ended questions were qualitatively analyzed using content analysis with responses to the two questions analyzed separately. Two authors (JR, KK) developed provisional codebooks through independent line-by-line coding of responses. Following initial coding, the coders discussed emerging codes and defined these in a final codebook. All responses were then recoded independently by the two coders using the final codebook. Codes were compared for agreement and any discrepancies were finalized through interpretive consensus. Using an inductive approach, the research team collaboratively reviewed final codes and aligned these across themes and subthemes emerging as relevant to the use of telemedicine for confidential care. We retained all codes related to conceptually distinct themes or subthemes regardless of frequency to maximize hypothesis generation for future avenues of research. Upon review of final coding of responses to the question asking if their medical provider could have done anything differently to better protect their confidentiality, most participants indicated that their clinician could not have done anything differently to better protect their confidentiality during the telemedicine visit. Therefore, we chose to present all coded responses with suggestions to enhance confidentiality without organizing within themes or subthemes. We calculated descriptive statistics for demographic characteristics, visit characteristics, preferences for telemedicine use for confidential care, and self-efficacy for using telemedicine confidentially and present means and standard deviations or proportions for the overall sample, GDY, and cisgender females.
RESULTS
In total, 266 adolescents were approached to participate. Phone contact was made with 183 and 15 declined to participate at the time of initial contact. The remaining 168 adolescents were sent a link to assent to participate in a one-time online survey. Of these, 88 completed the survey in its entirety (52% response rate). Approximately one-third of participants identified as cisgender female (32%) and two-thirds as gender diverse (45% transfeminine, 14% transmasculine, 6% non-binary or another non-cisgender identity). Three participants (3%) preferred not to indicate their gender identity and no participants identified as cisgender males. Participants had a mean age of 15.6 years and most identified as White Non-Hispanic (80%; Table 1). Many participants would have to travel more than 30 minutes from their home to the adolescent medicine subspecialty clinic to receive in-person care (66%). Most participants were established patients presenting for return visits (66%). The most frequently endorsed reasons for the visit included gender-affirming care (63%), sexual and reproductive health care (34%), and mental health care (20%). 51% of participants reported discussing a confidential health concern during their telemedicine visit.
Table 1.
Participant and Telemedicine Visit Characteristics by Gender Identity (N=88)
| Characteristic | All N (%) (N=88) |
Gender Diversea,b N (%) (N = 57) |
Cisgenderb N (%) (N = 28) |
|---|---|---|---|
| Age, mean (SD) | 15.6 (1.4) | 15.7 (1.3) | 15.5 (1.4) |
| Race/Ethnicity | |||
| White Non-Hispanic | 70 (80) | 48 (84) | 19 (68) |
| Black Non-Hispanic | 4 (5) | 0 (0) | 4 (14) |
| Hispanicc | 6 (7) | 5 (9) | 1 (4) |
| Multiracial or Otherd | 8 (9) | 4 (7) | 4 (14) |
| Travel Distance to Clinic | |||
| 30 minutes or less | 22 (25) | 13 (23) | 8 (29) |
| 31 minutes to 1 hour | 37 (42) | 23 (40) | 14 (50) |
| More than 1 hour | 21 (24) | 18 (32) | 1 (4) |
| Not sure | 8 (9) | 3 (5) | 5 (18) |
| Visit Type | |||
| Return patient | 66 (75) | 45 (79) | 18 (64) |
| New patient | 21 (24) | 11 (19) | 10 (36) |
| Not sure | 1 (1) | 1 (1) | 0 (0) |
| Format of Telemedicine Visit | |||
| Audio and video visit | 69 (78) | 42 (74) | 24 (86) |
| Audio only visit | 19 (22) | 15 (26) | 4 (14) |
| Reason for Visite | |||
| Gender-affirming care | 55 (63) | 55 (96) | 0 (0) |
| Sexual and reproductive health care | 30 (34) | 4 (7) | 26 (93) |
| Mental health care | 18 (20) | 13 (23) | 5 (18) |
| Other | 2 (2) | 2 (4) | 0 (0) |
| Discussed a confidential health concern during telemedicine visit | 45 (51) | 29 (51) | 14 (50) |
“Gender Diverse” includes adolescents who identified as transfeminine (45%), transmasculine (14%), and non-binary or other non-cisgender identities (6%).
3 participants (3%) preferred not to indicate their gender identity and were excluded from analyses comparing cisgender and gender diverse youth.
“Hispanic” includes all who identified as Hispanic regardless of other racial identities indicated.
“Multiracial” includes those who selected multiple racial identities except for those who identified as Hispanic. “Other” includes those who identified as Asian, Native Hawaiian, Pacific Islander, American Indian, or Alaskan Native.
Participants could select more than one option
Perceived Acceptability of Telemedicine for Confidential Care
Participants’ responses to open-ended items reflected four themes (Table 2). Over half of respondents discussed the patient location from which adolescents accessed care as critical to the acceptability of telemedicine for confidential care. Participants recognized the importance of a private space to discuss confidential concerns: “For some people it may be difficult to find privacy in their homes to talk about a confidential health concern” (15-year-old transgender male). Even with a private space accessible, some expressed concerns about being overheard or that caregivers would purposefully listen: “It's very easy for others to listen in or overhear you even if you're in different rooms” (17-year-old transgender male).
Table 2.
Frequency of Themes and Subthemes and Representative Quotes
| Theme | Subtheme | Frequencya | Quote | ||
|---|---|---|---|---|---|
| All | Gender Diverse |
Cis- gender |
|||
| Patient location | Physical space | 29 | 22 | 6 | There aren't many private places to have a conversation in my house. −17-year-old transgender male |
| Potential to be overheard | 18 | 15 | 2 | My house is fairly small so others would be able to hear me. −17-year-old cisgender female | |
| Purposeful listening | 4 | 3 | 0 | My parents like to eavesdrop/listen in. −14-year-old transgender male | |
| Telehealth technology | Perceived security | 4 | 3 | 1 | It is a secure way to communicate with your doctor. −16-year-old nonbinary youth |
| Potential for intrusion | 3 | 2 | 1 | It would be bad if someone "zoom crashed" your session. −14-year-old transgender male | |
| Potential for recording | 1 | 1 | 0 | I know that calls can be recorded. −16-year-old transgender male | |
| Adolescent-clinician relationship | Comfort with clinician | 4 | 2 | 2 | I feel safe to talk about my gender identity with [my clinician]. −12-year-old genderfluid youth |
| Trust in clinician to maintain confidentiality | 3 | 3 | 0 | My doctor made sure my privacy was protected, and then it was just like a face to face visit. −17-year-old transgender female | |
| Quality or experience of care | Likelihood of disclosure | ||||
| Increased | 10 | 4 | 6 | It sometimes feels better to open up within your own home. −16-year-old cisgender female | |
| Decreased | 4 | 2 | 2 | If I want/need to go into detail about certain things I may not be comfortable with that since my parents or siblings are home. −16-year-old transgender male | |
| Interpersonal communication | 3 | 2 | 1 | I feel like the communication is better in in-person visits. -16-year-old cisgender female | |
| Access to care | 3 | 2 | 1 | It definitely makes it easier to get ahold of a doctor faster and easier. −17-year-old transgender male | |
| Potential for physical exam | 2 | 1 | 1 | If something was wrong and they would have to look we would have to make another appointment. −13-year-old cisgender female | |
| Safety | 2 | 2 | 0 | It seems more risky speaking about confidential things over the phone, I'm not really completely comfortable with it at this time. −16-year-old transgender male | |
| Stigma of receiving care | 1 | 1 | 0 | Telemedicine does not require traveling to a designated location for a conversation and as such could reduce the stigma for seeking help. −16-year-old transgender female | |
Frequency represents the number of unique responses in which any theme or subtheme was present.
A few participants identified telehealth technology as a relevant factor in determining the acceptability of telemedicine for confidential care. Perceived security of the telemedicine platform increased acceptability: “I think it is a good way to talk to a doctor for a confidential health concern because the website is secure, and nothing is being written down through the website” (16-year-old cisgender female). Others feared that the technology was not secure, and their confidentiality may be breached by intrusion into the telehealth platform or recording of the visit: “I feel that it may be easier for someone to hack into the call” (17-year-old transgender male).
Some participants perceived that the adolescent-clinician relationship was a key consideration in the acceptability of telemedicine for confidential care. Participants noted a feeling of comfort with the clinician and trust in the clinician to maintain confidentiality as factors increasing the perceived acceptability of telemedicine for confidential care: “I trust [my clinician] not to let anyone hear about things I tell her in confidence” (16-year-old transgender male). Participants characterized clinicians as calm, kind, or caring when describing adolescent-clinician relationships perceived as comfortable and trustful.
Other participants perceived an impact of telemedicine on the quality or experience of care. Many perceived a positive impact through increased comfort with disclosing confidential concerns: “I think it might be a better way because some people might not be comfortable saying things in person” (17-year-old cisgender female). Other participants identified a positive impact through improved access to care or reduced stigma of seeking care: “Telemedicine does not require traveling to a designated location for a conversation and as such could reduce the stigma for seeking help” (15-year-old transgender female). A smaller number of participants perceived a negative impact of telemedicine, feeling less likely to disclose confidential concerns: “It would be easier to talk about confidential things in person” (14-year-old cisgender female). Others perceived a negative impact of telemedicine relative to traditional clinic-based visits due to missed opportunities for physical exams or worsened interpersonal communication including poorer quality communication or fewer opportunities for one-on-one conversations with their clinician. A small number of participants expressed that some adolescents may not be safe using telemedicine for confidential care: “I have access to rooms where I'm not heard by family, and generally feel safe discussing personal things at home. This is not the case for others, though” (17-year-old transgender male).
Participants also identified opportunities for clinicians to increase the confidentiality of telemedicine visits. These included advising adolescents to wear headphones and use secure messaging to ask and answer sensitive questions. Participants also recommended that clinicians frequently ask if it is okay to discuss a confidential concern and request that patients use their camera to scan their room so that clinicians may confirm that no one else is present in the room with the patient.
Preferences and Self-efficacy for Future Use of Telemedicine for Confidential Care
In response to Likert-type items, many participants (53/88) reported being likely or very likely to use telemedicine for future confidential care (Table 3), including many GDY (35/57) and cisgender females (17/28). A strong majority (82/88 overall; 53/57 GDY; 27/28 cisgender females) felt somewhat or very confident they could access a device for telemedicine visits confidentially. Confidence decreased for ability to find a private space to talk (70/88 overall; 42/57 GDY; 26/28 cisgender females), talk without being overheard (61/88 overall; 37/57 GDY; 22/28 cisgender females), confidentially schedule a telemedicine visit (47/88 overall; 29/57 GDY; 16/28 cisgender females), and confidentially pick up medications after the visit (45/88 overall; 26/57 GDY; 17/28 cisgender females).
Table 3.
Participant’s Preferences and Self-Efficacy for Future Use of Telemedicine for Confidential Care by Gender Identity (N=88)
| Characteristic | All N (%) (N=88) |
Gender Diversea N (%) (N = 57) |
Cisgenderb N (%) (N = 28) |
|---|---|---|---|
| Likelihood of telemedicine use for a future confidential health concern | |||
| Very likely or likely | 53 (60) | 35 (61) | 17 (61) |
| Neutral | 23 (26) | 14 (25) | 8 (29) |
| Unlikely or very unlikely | 12 (14) | 8 (14) | 3 (11) |
| Not at all or minimally confident in ability to perform confidentially | |||
| Schedule a telemedicine visit | 27 (31) | 19 (33) | 7 (25) |
| Access a device | 3 (3) | 2 (4) | 0 (0) |
| Find a private space to talk | 10 (11) | 9 (16) | 0 (0) |
| Talk without being overheard | 15 (17) | 11 (19) | 3 (11) |
| Pick up a medication after the visit | 33 (38) | 23 (40) | 9 (32) |
3 participants (3%) preferred not to indicate their gender identity and were excluded from analyses comparing cisgender and gender-diverse youth.
DISCUSSION
Using a mixed-methods approach, we examined perceived acceptability, preferences, and self-efficacy for using telemedicine for confidential health care among a sample of cisgender female and gender diverse adolescents. Adolescents frequently recognized threats to confidentiality related to the location from which they accessed care, however they expressed more variable perceptions of the impact of telehealth technology on the acceptability of telemedicine for confidential care. Although some adolescents were confident in the security of telehealth technology, others expressed concerns that telemedicine visits could be hacked or recorded. Features of the adolescent-clinician relationship including adolescents’ comfort with and trust in their clinician were identified as factors that increase the acceptability of telemedicine for confidential care. Adolescents also perceived that the acceptability of telemedicine for confidential care was impacted by telemedicine’s potential effects on the quality or experience of care, including effects on disclosure of confidential concerns, care quality relative to clinic-based care, and access to care. Overall, most adolescents in our sample were interested in using telemedicine for future confidential care. However, adolescents’ confidence in completing components of telemedicine visits confidentially varied.
Adolescents emphasized the importance of their location when using telemedicine for confidential care. Limited private space in the home and the potential to be overheard by household members were the most frequently cited concerns in this study, in line with prior studies exploring telemedicine acceptability among adolescents.[26-28] Notably, a larger proportion of GDY identified threats to their privacy during telemedicine visits related to their physical space and being overheard as compared to cisgender females. Although telemedicine has outstanding potential to overcome social and structural barriers to accessing care,[12,23] these benefits will be negated if telemedicine does not meet the needs of youth who may be using these services out of necessity more than choice. Further research should seek to understand how home environments affect the acceptability of telemedicine for delivering confidential care, especially among adolescents with fewer resources to access these services in clinic-based settings. Adolescents’ suggestions for clinicians to enhance the confidentiality of telemedicine visits conducted within adolescents’ homes included using headphones or secure messaging, similar to prior recommendations for optimizing telemedicine for adolescents.[10-12,24,25] Although clinician-level efforts remain important, system-level interventions are needed to improve the acceptability and accessibility of telemedicine for youth who experience threats to confidentiality in their homes. Innovations that locate telemedicine access points within community settings that adolescents frequent, such as schools, have potential to overcome this barrier to confidential care.[33]
Adolescents had varying views of the security of telehealth technology. Although some adolescents perceived telemedicine platforms to be secure, others feared intrusion into or recording of visits. Similar concerns about telehealth security have been noted among adults using telemedicine for contraceptive care[28] and adolescents using sexual and reproductive health-focused technologies.[34] Clinicians should discuss the limits of telemedicine security and confidentiality with adolescents. Health systems using telemedicine for confidential adolescent services should weigh confidentiality risks of EHR-integrated telemedicine platforms (via unintended caregiver proxy access)[24,25] versus security risks of external telemedicine platforms[35]. Features of telemedicine platforms and patient portals vary widely and may influence the acceptability of telemedicine for confidential care.[12,24,25] Adolescent patient portals (i.e., patient portals that adolescents access independently of their caregiver proxies) have the potential to increase the security, confidentiality, and acceptability of telemedicine for delivering confidential care to adolescents.[27] Adolescents can partner in local efforts to optimize telemedicine platforms and patient portals used to deliver confidential care.[12,24,36]
Adolescents described comfort with or trust in their clinician as factors increasing the acceptability of telemedicine for confidential care. This aligns with prior research revealing an association between adolescents’ ratings of therapeutic alliance with their clinician and perceived privacy of telemedicine visits.[27] Additional studies have suggested that adolescents may be more accepting of telemedicine for return visits as compared to new visits, which may be mediated by features of an established adolescent-clinician relationship.[20,28] Alternatively, telemedicine has been used to build new patient-clinician relationships and increase the rate of completed referrals from pediatric primary care to mental health care.[37] Further research can elucidate the interaction between telemedicine use and the adolescent-clinician relationship and explore opportunities for telemedicine to initiate or sustain adolescents’ connection to confidential care.
The potential for telemedicine to influence adolescents’ likelihood of disclosing confidential concerns emerged as an important finding of this study. Some adolescents perceived increased comfort with disclosing confidential concerns via telemedicine, while others felt less likely to disclose these concerns. Our prior work revealed that interest in using telemedicine for gender-affirming care was higher among GDY with lower perceived parental support in comparison to those with higher perceived parental support,[19] highlighting that additional factors may influence adolescents’ choice to access services via telemedicine as well as their comfort disclosing confidential health concerns using this modality. Although we recommend that clinicians working with adolescents prioritize universal education and support over disclosure, further research will be important to understand this variability. Future studies can seek to determine how disclosure of confidential concerns during telemedicine visits is influenced by patient-level (e.g., age[28], perceived parental support[19]), visit-level (e.g., visit reason[20,22]), or external (e.g., home environment[26,27]) factors. Adolescents identified additional factors related to the quality or experience of care that influenced the perceived acceptability of telemedicine for confidential care. Many adolescents perceived a positive impact of using telemedicine for confidential care including increased access to care and reduced stigma of seeking care, which may be especially relevant for GDY.[19-22] However, some expressed perceptions of lower quality care compared to in-person care and safety concerns. Further research will be important to understand the effects of telemedicine on adolescents’ care-seeking, receipt of care, and care outcomes, especially among minoritized youth who experience health care inequities in prevailing care settings.[12,23] Standards for measuring and evaluating telemedicine that align with population health and health equity goals will be important to guide responsible expansion and ensure that telemedicine reaches its full potential.[12,38]
Overall, most adolescents in our sample were interested in using telemedicine for future confidential care. However, the proportion endorsing likely or very likely future use (53/88) was somewhat lower than in prior studies assessing adolescents’ intention to use telemedicine for general adolescent care[26] or gender-affirming care[20] or adults’ intention to use telemedicine for contraceptive care.[39] Although included as an exploratory secondary analysis, our findings regarding adolescents’ self-efficacy to complete components of telemedicine visits confidentially have important implications. Adolescents reported lower confidence for confidentially completing components before (i.e., scheduling a visit) and after the visit (i.e., picking up medication), requiring attention to maintenance of confidentiality throughout the entire visit process. Many clinical settings, including the adolescent medicine subspecialty practice in this study, utilize Title X funding to provide free and comprehensive sexual and reproductive health services on-site, including testing and treatment for sexually transmitted infections and contraceptive prescribing and dispensing. These services are crucial for adolescents whose confidentiality would otherwise be breached by the use of a caregiver policyholder’s insurance.[2,40] Expanding critical confidential services will require specific focus and further study to ensure that telemedicine-based service delivery models meet adolescents’ unique health care needs. Home diagnostics for sexually transmitted infections and school- or community-partnered contraceptive provision may be avenues to support confidential care delivered via telemedicine.[12]
This small mixed-methods study should be viewed as exploratory. Our convenience sample was predominantly white, non-Hispanic youth who had completed a telemedicine visit and concerns about the confidentiality of telemedicine may be higher among youth who declined a telemedicine visit. No cisgender males were present in the sample. Additionally, our small sample size may have obscured true differences between cisgender and GDY. Future research should elicit perspectives of diverse samples of non-users of telemedicine, including nonclinical samples or samples of adolescents who use other forms of clinical care, to investigate the hypotheses generated here and ensure equitable access to and outcomes of telemedicine.
Our findings highlight telemedicine’s potential to deliver confidential care to adolescents and suggest areas for present action and future study to ensure services delivered via telemedicine are acceptable to adolescents, sensitive to their unique confidentiality needs, and equitably enhancing adolescent health.
Implications and Contribution:
Despite interest in using telemedicine, adolescents may experience barriers to accessing this care confidentially. This study describes factors identified by adolescents as impacting the acceptability of telemedicine for confidential health care and opportunities for clinicians to enhance adolescents’ confidentiality.
Acknowledgements:
This work was supported by the National Institutes of Health [T32HD087162, T32HD071834, TL1TR001858], the Agency for Healthcare Research and Quality [K12HS026393-03], the UPMC Children’s Hospital of Pittsburgh Scholar Award, and the Seattle Children’s Research Institute Career Development Award. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.
Abbreviations:
- EHR
electronic health record
- GDY
gender-diverse youth
Footnotes
Conflicts of Interest: The authors have no conflicts of interest to report. The first draft of the manuscript was written by Dr. Jacquelin Rankine.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
REFERENCES
- [1].Guttmacher Institute. An Overview of Consent to Reproductive Health Service for Young People. Available at: https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law#.
- [2].Ford C, English A, Sigman G. Confidential Health Care for Adolescents: Position Paper of the Society for Adolescent Medicine. J Adolesc Health 2004;35:160–167. doi: 10.1016/j.jadohealth.2004.03.002 [DOI] [PubMed] [Google Scholar]
- [3].AAP Committee on Adolescence. Achieving Quality Health Services for Adolescents. Pediatrics. 2016;138:e20161347. doi: 10.1542/peds.2016-1347 [DOI] [PubMed] [Google Scholar]
- [4].Santelli JS, Grilo SA, Klein JD, et al. The Unmet Need for Discussions Between Health Care Providers and Adolescents and Young Adults. J Adolesc Health 2020;67:262–269. doi: 10.1016/j.jadohealth.2020.01.019 [DOI] [PubMed] [Google Scholar]
- [5].Zucker NA, Schmitt C, DeJonckheere MJ, et al. Confidentiality in the Doctor-Patient Relationship: Perspectives of Youth Ages 14-24 Years. J Pediatr. 2019;213:196–202. doi: 10.1016/j.jpeds.2019.05.056 [DOI] [PubMed] [Google Scholar]
- [6].Gilbert AL, Rickert VI, Aalsma MC. Clinical conversations about health: The impact of confidentiality in preventive adolescent care. J Adolesc Health 2014;55:672–677. doi: 10.1016/j.jadohealth.2014.05.016 [DOI] [PubMed] [Google Scholar]
- [7].Lehrer JA, Pantell R, Tebb K, et al. Forgone Health Care among U.S. Adolescents: Associations between Risk Characteristics and Confidentiality Concern. J Adolesc Health 2007;40:218–226. doi: 10.1016/j.jadohealth.2006.09.015 [DOI] [PubMed] [Google Scholar]
- [8].Fuentes L, Ingerick M, Jones R, et al. Adolescents’ and Young Adults’ Reports of Barriers to Confidential Health Care and Receipt of Contraceptive Services. J Adolesc Health. 2018;62:36–43. doi: 10.1016/j.gde.2016.03.011 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [9].Leichliter JS, Copen C, Dittus PJ. Confidentiality Issues and Use of Sexually Transmitted Disease Services Among Sexually Experienced Persons Aged 15–25 Years — United States, 2013–2015. MMWR Morb Mortal Wkly. 2017;66:237–241. doi: 10.15585/mmwr.mm6609a1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [10].Barney A, Buckelew S, Mesheriakova V, et al. The COVID-19 Pandemic and Rapid Implementation of Adolescent and Young Adult Telemedicine: Challenges and Opportunities for Innovation. J Adolesc Health 2020;67:164–171. doi: 10.1016/j.jadohealth.2020.05.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [11].Wood SM, White K, Peebles R, et al. Outcomes of a Rapid Adolescent Telehealth Scale-Up During the COVID-19 Pandemic. J Adolesc Health 2020;67:172–178. doi: 10.1016/j.jadohealth.2020.05.025 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [12].Curfman A, McSwain SD, Chuo J, et al. Pediatric Telehealth in the COVID-19 Pandemic Era and Beyond. Pediatrics. 2021:e2020047795. doi: 10.1542/peds.2020-047795 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [13].Curfman AL, Hackell JM, Herendeen NE, et al. Telehealth: Improving Access to and Quality of Pediatric Health Care. Pediatrics. 2021;148:e2021053129. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [14].Elliott BA, Larson JT. Adolescents in mid-sized and rural communities: Foregone care, perceived barriers, and risk factors. J Adolesc Health 2004;35:303–309. doi: 10.1016/j.jadohealth.2003.09.015 [DOI] [PubMed] [Google Scholar]
- [15].Turner A, Ricketts T, Leslie LK. Comparison of Number and Geographic Distribution of Pediatric Subspecialists and Patient Proximity to Specialized Care in the US between 2003 and 2019. JAMA Pediatr. 2020;27514:1–10. doi: 10.1001/jamapediatrics.2020.1124 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [16].Rider GN, Mcmorris BJ, Gower AL, et al. Health and care utilization of transgender and gender nonconforming youth: A population-based study. Pediatrics. 2018;141. doi: 10.1542/peds.2017-1683 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [17].Leonardi M, Frecker H, Scheim AI, et al. Reproductive Health Considerations in Sexual and/or Gender Minority Adolescents. J Pediatr Adolesc Gynecol. 2019;32:15–20. doi: 10.1016/j.jpag.2018.09.010 [DOI] [PubMed] [Google Scholar]
- [18].Whitehead J, Shaver J, Stephenson R. Outness, stigma, and primary health care utilization among rural LGBT Populations. PLoS ONE. 2016;11. doi: 10.1371/journal.pone.0146139 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [19].Sequeira GM, Kidd KM, Coulter RWS, et al. Transgender Youths' Perspectives on Telehealth for Delivery of Gender-Affirming Care. J Adolesc Health. 2021;68:1207–1210. doi: 10.1016/j.jadohealth.2020.08.028 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [20].Sequeira GM, Kidd KM, Rankine J, et al. Gender-Diverse Youth's Experiences and Satisfaction with Telemedicine for Gender-Affirming Care During the COVID-19 Pandemic. Transgend Health. 2022;7:127–134. doi: 10.1089/trgh.2020.0148 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [21].Hedrick HR, Glover NT, Guerriero JT, et al. A New Virtual Reality: Benefits and Barriers to Providing Pediatric Gender-Affirming Health Care Through Telehealth. Transgend Health. 2022;7:144–149. doi: 10.1089/trgh.2020.0159 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [22].Apple DE, Lett E, Wood S, et al. Acceptability of Telehealth for Gender-Affirming Care in Transgender and Gender Diverse Youth and Their Caregivers. Transgend Health. 2022;7:159–164. doi: 10.1089/trgh.2020.0166 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [23].Hamnvik OR, Agarwal S, AhnAllen CG, et al. Telemedicine and Inequities in Health Care Access: The Example of Transgender Health. Transgend Health. 2022;7:113–116. doi: 10.1089/trgh.2020.0122 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [24].Carlson JL, Goldstein R. Using the Electronic Health Record to Conduct Adolescent Telehealth Visits in the Time of COVID-19. J Adolesc Health 2020;67:157–158. doi: 10.1016/j.jadohealth.2020.05.022 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [25].Sharko M, Wilcox L, Hong MK, et al. Variability in adolescent portal privacy features: How the unique privacy needs of the adolescent patient create a complex decision-making process. J Am Med Inform Assoc. 2018;25:1008–1017. doi: 10.1093/jamia/ocy042 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [26].Wood SM, Pickel J, Phillips AW, et al. Acceptability, Feasibility, and Quality of Telehealth for Adolescent Health Care Delivery During the COVID-19 Pandemic: Cross-sectional Study of Patient and Family Experiences. JMIR Pediatr Parent. 2021;4:e32708. doi: 10.2196/32708 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [27].Allison BA, Rea S, Mikesell L, et al. Adolescent and Parent Perceptions of Telehealth Visits: A Mixed-Methods Study. J Adolesc Health 2021. doi: 10.1016/j.jadohealth.2021.09.028 [DOI] [PubMed] [Google Scholar]
- [28].Diaz MF, Colleen G, Gruver R, et al. Providing Contraceptive Health Services to Adolescents & Young Adults by Telemedicine: A Scoping Review of Patient and Provider Perspectives. J Pediatr Adolesc Gynecol. 2022;35:575–584. doi: 10.1016/j.jpag.2022.05.003 [DOI] [PubMed] [Google Scholar]
- [29].Gridley SJ, Crouch JM, Evans Y, et al. Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth. J Adolesc Health 2016;59:254–261. doi: 10.1016/j.jadohealth.2016.03.017 [DOI] [PubMed] [Google Scholar]
- [30].Wood D, Sawicki G, Miller M, et al. The Transition Readiness Assessment Questionnaire (TRAQ): its factor structure, reliability, and validity. Acad Pediatr. 2014;14:415–422. doi: 10.1016/j.acap.2014.03.008 [DOI] [PubMed] [Google Scholar]
- [31].White P, Schmidt A, Ilango S, et al. Six Core Elements of Health Care Transition™ 3.0: An Implementation Guide. Washington, DC: Got Transition, The National Alliance to Advance Adolescent Health; 2020. [Google Scholar]
- [32].Yen W. How Long and How Far Do Adults Travel and Will Adults Travel for Primary Care? Washington State Health Services Research Project Research Brief: Washington State Office of Financial Management, The Health Care Research Group; 2013. Report No.: 70. [Google Scholar]
- [33].Sanchez D, Reiner JF, Sadlon R, et al. Systematic Review of School Telehealth Evaluations. J Sch Nurs. 2019;35:61–76. doi: 10.1177/1059840518817870 [DOI] [PubMed] [Google Scholar]
- [34].Rea S, Zynda A, Allison B, et al. Adolescent Perceptions of Technology-Based Sexual and Reproductive Health Services: A Systematic Review. J Adolesc Health. 2022;71:533–544. doi: 10.1016/j.jadohealth.2022.05.012 [DOI] [PubMed] [Google Scholar]
- [35].Shachar C, Engel J, Elwyn G. Implications for Telehealth in a Postpandemic Future: Regulatory and Privacy Issues. JAMA. 2020;323:2375–2376. doi: 10.1001/jama.2020.7943 [DOI] [PubMed] [Google Scholar]
- [36].Jackman KM, Latkin CA, Maksut JL, et al. Patient Portals as Highly Acceptable Tools to Support HIV Preventative Behaviors Among Adolescent and Young Sexual Minority Men. J Adolesc Health. 2020;67:278–281. doi: 10.1016/j.jadohealth.2020.03.029 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [37].Coker TR, Porras-Javier L, Zhang L, et al. A telehealth-enhanced referral process in pediatric primary care: A cluster randomized trial. Pediatrics. 2019;143. doi: 10.1542/peds.2018-2738 [DOI] [PubMed] [Google Scholar]
- [38].Ray KN, Keller D. Telehealth and pediatric care: policy to optimize access, outcomes, and equity. Pediatr Res. 2022;92:1496–1499. doi: 10.1038/s41390-022-02306-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [39].Stifani B, Smith A, Avila K, et al. Telemedicine for contraceptive counseling: Patient experiences during the early phase of the COVID-19 pandemic in New York City. Contraception. 2021;104:254–261. doi: 10.1016/j.contraception.2021.04.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [40].Sedlander E, Brindis CD, Bausch SH, et al. Options for assuring access to confidential care for adolescents and young adults in an explanation of benefits environment. J Adolesc Health 2015;56:7–9. doi: 10.1016/j.jadohealth.2014.10.262 [DOI] [PubMed] [Google Scholar]