Provisions of the Affordable Care Act that require insurers to cover certain preventative services and allow youth to stay on their parents' health insurance plans until age 26 should help remove some barriers to sexually transmitted infection (STI) testing and other sexual health care for young people. Unfortunately, confidentiality issues are getting in the way for some young people who admitted that they avoid sexual health services out of fear that their parents will find out. This is not surprising as billing procedures often inadvertently let parents know about STI testing, and some adolescents are not given time with their provider away from their parents.
Researchers at the Centers for Disease Control and Prevention (CDC) analyzed data from the 2013-2015 National Survey of Family. For this study, they limited their analysis to sexually active young people ages 15 to 25. They looked at participants' health insurance status, whether they'd been tested for STIs and whether they had been in a room alone with a health care provider in the previous 12 months. The survey also asked whether participants would "ever not go for sexual or reproductive health care because their parents might find out." The researchers did not ask specifically about HIV tests.
The results show that young people did indeed worry that their parents might find out about their use of health care services and that these fears prevented some of them from receiving necessary services. Almost 13% of young people on their parents' health insurance said they would not seek sexual or reproductive health care services because their parents might find out. This response was most common among adolescents 15 to 17 (22.6%) and decreased for those who were older -- 14.1% among those 18 to 19, 8.2 % among those 20 to 22 and 5.4% among those 23 to 25.
This fear was associated with a lower likelihood of STI testing for young women. Specifically, only 17% of young women who were worried that their parent might find out were screened for chlamydia in the past 12 months compared with 39% of those who did not share this fear. This is disturbing because the CDC recommends that sexually active young women under the age of 25 be screened for chlamydia each year. Chlamydia is often asymptomatic, but if left untreated can lead to pelvic inflammatory disease and infertility. Interestingly, the association between fear of parents finding out and STI testing did not hold true for young men: 13% of young men who were concerned that their parents might find out had been tested for an STI in the last 12 months compared with 17% who did not share this fear, but this difference was not statistically significant.
These fears are not unfounded as insurance companies regularly send an explanation of benefits (EOBs) to policyholders that spells out services received by anyone on the plan. In 2016, the American Academy of Pediatrics released a statement calling on insurers to change this procedure. The statement says, "EOBs and similar notices should not be required when individuals insured as dependents obtain sensitive services." It adds: "Health care organizations, clinicians and policymakers should explore all legal options for enabling providers to deliver confidential services in the context of health care billing and insurance claims."
The researchers also looked at whether participants had spent time alone with their health care providers. They found a positive association: 34% of young women who had this experience were screened for chlamydia compared with 14.9% who did not spend any time alone with their providers. Again, this association did not hold up for young men.
As Lynn Barclay, president of the American Sexual Health Association, explained to TheBody.com, "Worry over confidentiality and what parents may find out is absolutely a very real, profound barrier for young people who want STI testing. Health care providers can take some simple steps to address this, such as making time in the clinic visit to talk to the youth with the parents out of the room. There may well be some pushback from parents, so one way to minimize that is sending letters in advance letting them know this is a normal, routine part of the visit and goes a long way in developing rapport with the patient."
The study clearly has implications for health care providers and insurers, but parents should also pay attention to these results. They need to understand that sexual and reproductive health care should become standard as their children grow up and allow their adolescents to have a private relationship with their health care provider, whether that means stepping out of the exam room or throwing away an unread EOB. Of course, it would be even better if parents openly discussed the importance of sexual health care including routine screening for STIs with their young adult children.
Health insurance status was also related to the services young people received. Overall, those young people who were uninsured were the least likely to have received a risk assessment in the past year (38%) but, interestingly, those most likely to have been assessed were on public insurance (51%). Moreover, the analysis showed that, among males, those who had no insurance (24.7%) or were on public insurance (24.9%) were more likely to be screened for STIs than those who were on their parents' private insurance (16.2%) or another private insurance (19.4%).