National-level data are limited regarding confidentiality-related issues and the use
of sexually transmitted disease (STD) services for adolescents and young adults. Changes
in the U.S. health care system have permitted dependent children to remain on a parent’s
health insurance plan until the child’s 26th birthday and required coverage of certain
preventive services, including some STD services, without cost sharing for most plans
(
1
,
2
). Although these provisions likely facilitate access to the health care system, adolescents
and young adults might not seek care or might delay seeking care for certain services
because of concerns about confidentiality, including fears that their parents might
find out (
3
,
4
). Therefore, it is important to examine STD services and confidentiality-related
issues among persons aged 15–25 years in the United States. CDC analyzed data from
the 2013–2015 National Survey of Family Growth and found that 12.7% of sexually experienced
youths (adolescents aged 15–17 years and those young adults aged 18–25 years who were
on a parent’s insurance plan) would not seek sexual and reproductive health care because
of concerns that their parents might find out. Particularly concerned were persons
aged 15–17 years (22.6%). Females with confidentiality concerns regarding seeking
sexual and reproductive health care reported a lower prevalence of receipt of chlamydia
screening (17.1%) than did females who did not cite such concerns (38.7%). More adolescents
aged 15–17 years who spent time alone with a health care provider (without a parent
in the room) reported receipt of a sexual risk assessment (71.1%) and, among females,
chlamydia testing (34.0%), than did those who did not spend time alone (36.6% and
14.9%, respectively). The results indicated that confidentiality-related issues were
associated with less reported use of some STD services, especially for younger persons
and females. Spending time alone with a provider (i.e., without a parent present)
during a health care visit has been associated previously with higher reported delivery
of sexual health services (
5
) and has been suggested by the American Academy of Pediatrics and Society for Adolescent
Health and Medicine (
6
). Public health efforts related to confidentiality of STD services might be helpful
to increase the use of recommended services among some youths.
To effectively prevent and control the spread of STDs, CDC recommends health services
that include a sexual risk assessment, chlamydia screening for sexually active women
aged ≤25 years, and risk-based testing for other STDs (
7
). Several professional medical organizations have endorsed approaches to maintaining
confidentiality in insurance plan communications (e.g., explanation of benefits) (
4
). This report uses data for sexually experienced persons aged 15–25 years to provide
national estimates of confidentiality-related issues among U.S. adolescents and young
adults and examines that association with the receipt of STD services.
The National Survey of Family Growth conducts in-person interviews with females and
males aged 15–44 years selected from U.S. households and collects information on marriage,
divorce, family life, having and raising children, and medical care.* The survey measures
reproductive health status and evaluates the need for and effectiveness of health
education programs. The 2013–2015 survey included 10,205 respondents with a 69.3%
response rate.
For this report, the data used were primarily collected using audio computer-assisted
self-interviewing. STDs are transmitted by sexual contact; therefore, analyses were
restricted to respondents aged 15–25 years who were sexually experienced, defined
as ever having had any type of sexual contact (vaginal, oral, or anal) with an opposite-sex
or same-sex partner. Confidentiality-related issues in the survey included 1) whether
all respondents aged 15–17 years and those respondents aged 18–25 years who were on
a parent’s private health insurance plan would “ever not go for sexual or reproductive
health care because their parents might find out”; 2) whether respondents aged 15–17
years had “time alone with a provider in the past 12 months without a parent, relative,
or guardian in the room”; and 3) current health insurance status, including being
on a parent’s insurance plan. STD services included receiving a sexual risk assessment
and other clinical services. Receipt of a sexual risk assessment in the past 12 months
was defined as reporting that a doctor or other health care provider asked about at
least one of the following: 1) sexual orientation or sex of their sexual partners;
2) number of sexual partners; 3) use of condoms; and 4) types of sex (vaginal, oral,
or anal). Receipt of other STD services was defined, for females, as receiving chlamydia
testing in the past 12 months; for males, as receiving an STD test in the past 12
months; and for both females and males, as receiving treatment for an STD in the past
12 months.
Demographic characteristics of sexually experienced youths who would not seek sexual
and reproductive health care because of concerns that their parents might find out
were examined, and receipt of STD services was analyzed by demographic characteristics,
sexual risk, and confidentiality-related issues. Analyses were weighted and adjusted
to account for the complex survey design. Differences between groups were assessed
using Wald chi-square tests, with statistical significance defined as p<0.05.
During 2013–2015, overall, 12.7% of sexually experienced persons aged 15–17 years
and aged 18–25 years who were covered by a parent’s insurance plan (13.5% of females
and 12.0% of males) reported that they would not seek sexual and reproductive health
care because of concerns that their parents might find out (Table 1). A significantly
higher percentage of youths aged 15–17 years (22.6%) said they would not seek sexual
and reproductive health services for this reason than did those aged 20–22 years (8.2%)
and 23–25 years (5.4%) (Table 1). Regarding receipt of STD services, persons aged
15–17 years who had time alone with a health care provider in the past 12 months reported
significantly higher prevalences of receiving a sexual risk assessment (71.1%) than
did those who did not have time alone with a provider (36.6%) (Table 2). Youths without
health insurance reported the lowest prevalence of receiving a sexual risk assessment
(38.2%), but the highest prevalence of receiving STD treatment (9.7%), compared with
youths in other insurance categories.
TABLE 1
Percentage of sexually experienced* females and males aged 15–25 years who said they
would not seek sexual or reproductive health care because their parents might find
out,† by demographic and behavioral characteristics — National Survey of Family Growth,
United States, 2013–2015
Characteristic
Estimated pop.
% (95% CI)
p-value
Total
17,077,000
12.7 (10.1–15.4)
—
Sex
Female
8,058,000
13.5 (10.1–16.9)
0.510
Male
9,019,000
12.0 (8.5–15.6)
Age group (yrs)
15–17
4,915,000
22.6 (17.6–27.6)
<0.001
18–19
3,013,000
14.1 (6.5–21.7)
20–22
5,361,000
8.2 (4.2–12.2)
23–25
3,789,000
5.4 (2.4–8.3)
Race/Ethnicity
Hispanic
2,985,000
14.7 (8.3–21.1)
0.161
White, non-Hispanic
10,746,000
12.1 (8.8–15.4)
Black, non-Hispanic
2,115,000
9.9 (4.9–14.9)
Other or multiple race, non-Hispanic
1,232,000
18.5 (8.0–28.9)
Composite sexual risk§
At elevated STD risk
1,981,000
17.1 (9.6–24.7)
0.225
Not at elevated STD risk
14,995,000
12.2 (9.4–15.0)
Abbreviations: CI = confidence interval; STD = sexually transmitted disease.
* Sexually experienced was defined as those who have ever had vaginal intercourse,
oral sex, or anal sex, with an opposite-sex or same-sex partner in their lifetime.
† For respondents aged 18–25 years, this question was only asked if they were on a
parent’s private health insurance plan.
§ Included male-to-male sex, females who had a male sex partner who had sex with other
males, five or more sexual partners, sex in exchange for money or drugs, a sex partner
who injected illegal drugs, or a human immunodeficiency virus–positive partner in
the past 12 months.
TABLE 2
Percentage of sexually experienced* females and males aged 15–25 years who had received
a selected STD-related service in the past 12 months, by confidentiality-related,
sexual risk, and demographic characteristics — National Survey of Family Growth, United
States, 2013–2015
Characteristic
Total
Females
Males
Sexual risk assessment % (95% CI)†
p-value
STD treatment % (95% CI)§
p-value
Chlamydia test % (95% CI)
p-value
STD test % (95% CI)¶
p-value
Total
47.5 (44.8–50.3)
—
6.5 (5.3–7.6)
—
38.6 (35.9–41.2)
—
20.4 (17.5–23.2)
—
Confidentiality-related factors
Would ever not go for sexual or reproductive health care because their parents might
find out**
Yes
48.0 (39.6–56.4)
0.666
5.9 (1.3–10.5)
0.957
17.1 (6.6–27.7)
0.002
13.0 (4.4–21.6)
0.426
No
49.9 (46.1–53.7)
5.8 (3.8–7.7)
38.7 (34.0–43.4)
16.7 (13.0–20.4)
Had time alone with provider in past 12 months (15–17 yr age group only)
Yes
71.1 (62.8–79.3)
<0.001
6.6 (1.1–12.0)
0.072
34.0 (20.9–47.1)
0.021
13.6 (5.5–21.7)
0.424
No
36.6 (30.4–42.9)
1.4 (0.3–2.5)
14.9 (7.3–22.5)
9.5 (4.1–15.0)
Current health insurance
Private insurance, parent’s plan
49.3 (45.3–53.3)
<0.001
5.7 (3.8–7.6)
0.013
36.3 (30.9–41.6)
0.242
16.2 (12.1–20.3)
0.034
Private insurance, other
44.4 (37.1–51.6)
4.1 (2.2–6.1)
40.2 (29.0–51.4)
19.4 (11.5–27.3)
Public insurance
51.9 (46.4–57.5)
7.2 (4.9–9.6)
43.4 (37.8–49.0)
24.9 (18.9–30.8)
No insurance
38.2 (33.6–42.8)
9.7 (6.2–13.2)
35.4 (28.0–42.7)
24.7 (18.4–31.0)
Sexual risk
Received sexual risk assessment in past 12 months†
Yes
—
—
10.9 (9.1–12.8)
<0.001
51.1 (47.1–55.0)
<0.001
42.9 (37.2–48.5)
<0.001
No
—
—
2.4 (1.2–3.6)
18.8 (14.2–23.3)
8.7 (6.3–11.2)
Composite sexual risk††
At elevated STD risk
60.6 (54.3–66.9)
0.001
19.6 (13.4–25.8)
<0.001
61.1 (50.8–71.3)
<0.001
44.4 (32.3–56.6)
0.001
Not at elevated STD risk
45.8 (42.6–49.0)
4.9 (3.8–5.9)
36.9 (33.9–39.7)
15.9 (13.4–18.3)
Demographics
Age (yrs)
15–17
50.9 (45.5–56.4)
0.196
3.5 (1.1–5.9)
0.045
23.5 (16.5–30.4)
<0.001
10.7 (6.6–14.9)
0.002
18–19
51.3 (44.4–58.3)
7.6 (4.5–10.7)
31.4 (24.0–38.9)
15.4 (9.9–21.0)
20–22
47.0 (42.5–51.5)
5.6 (3.9–7.4)
46.1 (40.7–51.6)
20.7 (16.2–25.2)
23–25
44.9 (40.8–48.9)
8.0 (5.6–10.3)
40.6 (35.3–45.9)
27.4 (20.8–34.1)
Race/Ethnicity
Hispanic
49.1 (43.7–54.5)
0.001
5.6 (3.7–7.6)
<0.001
35.8 (28.8–42.7)
<0.001
23.9 (18.5–29.4)
<0.001
White, non-Hispanic
44.0 (40.0–48.0)
4.9 (3.7–6.2)
35.4 (31.3–39.5)
14.3 (11.1–17.5)
Black, non-Hispanic
59.9 (54.9–64.8)
12.6 (9.4–15.9)
56.1 (49.5–62.7)
38.4 (30.3–46.4)
Other or multiple race, non-Hispanic
43.6 (36.1–51.1)
7.2 (2.4–12.1)
35.1 (24.9–45.4)
15.8 (5.9–25.7)
Abbreviations: CI = confidence interval; STD = sexually transmitted disease.
* Sexually experienced was defined as those who have ever had vaginal intercourse,
oral sex, or anal sex, with an opposite-sex or same-sex partner in their lifetime.
† Based on at least one “yes” response to four questions asking whether a doctor or
other medical care provider asked about the sexual orientation or the sex of their
sexual partners, number of sexual partners, use of condoms, and the types of sex they
have (vaginal, oral, or anal).
§ “In the past 12 months, have you been treated or received medication from a doctor
or other medical care provider for a sexually transmitted disease like gonorrhea,
chlamydia, herpes, or syphilis?”
¶ “In the past 12 months, have you been tested by a doctor or other medical care provider
for a sexually transmitted disease like gonorrhea, chlamydia, herpes, or syphilis?”
** For respondents aged 18–25 years, this question was only asked if they were on
a parent’s private health insurance plan.
†† Included male-to-male sex, females who had a male sex partner who had sex with
other males, five or more sexual partners, sex in exchange for money or drugs, a sex
partner who injects illegal drugs, or a human immunodeficiency virus (HIV)–positive
partner in the past 12 months.
Other recommended STD services also were examined by confidentiality-related issues.
Significantly lower percentages of females who reported that they would not seek sexual
and reproductive health care because of concerns that their parents might find out
received a chlamydia test in the past 12 months (17.1%) than did those who did not
report this concern (38.7%). In addition, females aged 15–17 years who had time alone
with a health care provider were significantly more likely to have received a chlamydia
test in the past 12 months (34.0%) than were those who had not had time alone with
a provider (14.9%) (Table 2). Among males, the reported prevalence of receiving an
STD test in the past 12 months did not differ significantly among those aged 15–25
years who would not go for sexual and reproductive health care because their parents
might find out (13.0%) compared with those who would go (16.7%). The prevalence also
did not differ significantly among males aged 15–17 years who had time alone with
a provider in the past 12 months (13.6%) and those who did not (9.5%). Among males,
the reported prevalences of receiving STD testing were significantly higher among
those on public insurance (24.9%) and those with no insurance (24.7%) compared with
those with private insurance (16.2%–19.4%).
Discussion
Overall, 12.7% of sexually experienced persons aged 15–17 years and those aged 18–25
years on a parent’s insurance plan reported that they would not seek sexual and reproductive
health care because of concerns that their parents might find out; these concerns
were most commonly reported among persons aged 15–17 years (22.6%). Not seeking sexual
and reproductive health care because of concerns that their parents might find out
was associated with a lower prevalence of chlamydia testing among females. This finding
is concerning because chlamydia is often asymptomatic, and chlamydia testing is a
recommended preventive service for adolescent and young adult females (
7
). In addition, survey respondents who had time alone with their provider during their
health care visit were more likely to have received a sexual risk assessment (both
males and females) and a chlamydia test (females).
These findings are similar to those found for other sexual and reproductive health
services (
8
). Several medical organizations have emphasized the need for confidentiality for
youths seeking care such as STD services (
6
). Previous research has found that females might have more general and sexual and
reproductive health–specific confidentiality concerns than do males (
9
). Finally, the frequency of STD testing among males with public insurance or no insurance
was higher than among males with a parent’s insurance or private insurance. It is
possible that these males might be seeking services from safety net providers (i.e.,
those who provide health care to uninsured or underinsured populations) who have reduced
or no fees (
10
).
The findings in this report are subject to at least two limitations. First, receipt
of STD services was self-reported and might be subject to social desirability and
recall biases. Second, the survey was cross-sectional, and the confidentiality-related
questions were not directly linked to the STD service questions. Thus, a causal relationship
between confidentiality concerns and receipt of STD services cannot be inferred.
Concerns about maintaining confidentiality for STD services, including privacy issues
such as not spending time alone with a health care provider without a parent in the
room, might limit the use of these services for some youths. Public health practitioners
might consider work to reduce some confidentiality concerns and potentially increase
use of recommended STD services. Some medical organizations suggest that patients
having time alone with a provider during a health care visit can be useful for sensitive
services.
Summary
What is already known about this topic?
Issues related to confidentiality have been associated with youths not seeking care
for some sexual or reproductive health–related services.
What is added by this report?
Nationally, 12.7% of sexually experienced adolescents and young adults who were on
a parent’s health insurance plan would not seek sexual and reproductive health care
because of concerns that their parents might find out. This was highest among persons
aged 15–17 years (22.6%). Overall, these persons reported lower prevalences of receiving
certain recommended sexually transmitted disease (STD) services. However, receiving
a sexual risk assessment (both males and females) and chlamydia test (females) was
higher among persons aged 15–17 years who had time alone with a health care provider
in the past 12 months compared with those who had not.
What are the implications for public health practice?
Confidentiality issues, including concerns that parents might find out, might be barriers
to the use of STD services among some subpopulations. Public health efforts to reduce
these confidentiality concerns might be useful. Some medical organizations suggest
that providers have time alone with patients without a parent in the room.