Maria Trent, MD, MPH, was studying ways clinicians can leverage technology to care for adolescents years before COVID-19 exposed the challenges and advantages of telehealth.
Dr Maria Trent
Trent, a pediatrician and adolescent medicine specialist and professor of pediatrics at Johns Hopkins University in Baltimore, Maryland, has long believed that the phones in her patients’ pockets have the potential improve the sexual health of youth. The pandemic has only made that view stronger.
“They’re a generation that’s really wired and online,” Trent told this news organization. “I think that we can meet them in that space.”
Her research has incorporated texting, apps, and videos. Out of necessity, technology increasingly became part of patient care during the pandemic. “We had to stretch our ability to do some basic triage and assessments of patients online,” Trent said.
Even when clinics are closed, doctors might be able to provide initial care remotely, such as writing prescriptions to manage symptoms or directing patients to a lab for testing.
Telemedicine could allow a clinician to guide a teenager who thinks they might be pregnant to take a store-bought test and avoid possible exposure to COVID-19 in the emergency department, for instance.
But doctors have concerns about the legal and practical limits of privacy and confidentiality. Who else is at home listening to a phone conversation? Are parents accessing the patient’s online portal? Will parents receive an explanation of benefits that lists testing for a sexually transmitted infection (STI), or see a testing kit that is delivered to their home?
When a young patient needs in-person care, transportation can be a barrier. And then there’s the matter of clinicians being able to bill for telehealth services.
Practices are learning how to navigate these issues, and relevant laws vary by state.
“I think this is going to become part of standard practice,” Trent said. “I think we have to do the hard work to make sure that it’s safe, that it’s accessible, and that it is actually improving care.”
Texts, Apps, Videos
In one early study, Trent and colleagues found that showing adolescents with pelvic inflammatory disease a 6-minute video may improve treatment rates for their sexual partners.
Another study provided preliminary evidence that text messaging support might improve clinic attendance for moderately long-acting reversible contraception.
A third trial showed that adolescents and young adults with pelvic inflammatory disease who were randomly assigned to receive text-message prompts to take their medications and provide information about the doses they consumed had greater decreases in Neisseria gonorrhoeae and Chlamydia trachomatis infections, compared with patients who received standard care.
Trent and her co-investigators are assessing a technology-based intervention for youth with HIV, in which patients can use an app to submit videos of themselves taking antiretroviral therapy and report any side effects. The technology provides a way to monitor patients remotely and support them between visits, she said.
Will Pandemic-Driven Options Remain?
In 2020, Laura D. Lindberg, PhD, principal research scientist at the Guttmacher Institute in New York City, and coauthors discussed the possible ramifications of the pandemic on the sexual and reproductive health of adolescents and young adults.
If telemedicine options driven by COVID-19 are here to stay, adolescents and young adults could be “the age-group most likely to continue that approach rather than returning to traditional in-person visits,” the researchers wrote in Perspectives on Sexual and Reproductive Health. “Innovations in health care service provision, such as use of telemedicine and obtaining contraceptives and STI testing by mail, will help expand access to [sexual and reproductive health] care for young people.”
At the American Academy of Pediatrics 2021 National Conference, Trent described telehealth as a viable way to provide sexual and reproductive healthcare to adolescents and young adults, including anticipatory guidance, contraception counseling, coordination of follow-up care and testing, and connecting patients to resources.
Her presentation cited several websites that can help patients receive testing for STIs, including Yes Means Test, the Centers for Disease Control and Prevention’s (CDC) GetTested page, and I Want the Kit. Planned Parenthood has telehealth options, and the Kaiser Family Foundation compiled information about 26 online platforms that were providing contraception or STI services.
Who Else Is in the Room?
“There’s only so much time in the day and so many patients you can see, regardless of whether you have telehealth or not,” said David L. Bell, MD, MPH, president of the Society for Adolescent Health and Medicine and a coauthor of the Perspectives paper. In addition, “you never know who else is in the room” with the patient on the other end, added Bell, a professor of population and family health and pediatrics at the Columbia University Medical Center and medical director of the Young Men’s Clinic, in New York City.
In some respects, young patients may not be able to participate in telehealth visits the same way they would in a medical office, Trent acknowledged. Encouraging the use of headphones is one way to help protect confidentiality when talking with patients who are at home and might not be alone.
But if patients are able to find a private space for remote visits, they might be more open than usual. In that way, telemedicine could provide additional opportunities to address issues like substance use disorders and mental health, as well, she said.
“Then, if they need something, we have to problem solve,” Trent said. Next steps may involve engaging a parent or getting the patient to a lab or the clinic.
Sex Ed May Be Lacking
The Perspectives article also raised concerns that the pandemic might exacerbate shortcomings in sex education, which already may have been lacking.
“Before the pandemic, schools were a key source of formal sex education for young people,” the authors wrote. “Sex education, which was already limited in many areas of the country, has likely not been included in the national shift to online learning. Even when in-person schooling resumes, missed sex education instruction is unlikely to be made up, given the modest attention it received prior to the pandemic.”
A recently published study in the Journal of Adolescent Health indicates that American teenagers receive less formal sex education today than they did 25 years ago, with “troubling” inequities by race.
Researchers surveyed adolescents about what they had learned about topics such as how to say no to sex, methods of birth control and where to get them, and STIs.
Lindberg and Leslie M. Kantor, PhD, MPH, professor and chair of the department of urban-global public health at Rutgers School of Public Health, Newark, New Jersey, conducted the analysis.
“Pediatricians and other healthcare providers that work with children and adolescents have a critical role to play in providing information about sexuality to both the patients and to the parents,” said Kantor, who also coauthored the Perspectives article with Lindberg and Bell. The new research “shows that doctors play an even more critical role, because they can’t assume that their patients are going to get the information that they need in a timely way from schools.”
By age 15, 21% of girls and 20% of boys have had sexual intercourse at least once, according to data from the 2015-2017 National Survey of Family Growth. By age 17, the percentages were 53% of girls and 48% of boys. By age 20, the percentages were 79% of women and 77% of men. The CDC’s 2021 guidelines on treatment and screening for STIs note that prevalence rates of certain infections — such as chlamydia and gonorrhea in females — are highest among adolescents and young adults.
Those trends underscore the importance of counseling on sexual health that clinicians can provide, but time constraints may limit how much they can discuss in a single session with a patient. To cover all topics that are important to parents and patients, doctors may need to discuss sexual and reproductive health sooner and more frequently.
Young people are getting more and more explicit information from their phones and media, yet educators are giving them less information to navigate these topics and learn what’s real, Kantor said. That mismatch can be toxic. In a December interview with Howard Stern, the pop star Billie Eilish said she started watching pornography at about age 11 and frequently watched videos that were violent. “I think it really destroyed my brain and I feel incredibly devastated that I was exposed to so much porn,” Eilish told Stern.
Researchers and a psychologist told CNN that the singer’s story may be typical. It also highlights a need to be aware of kids’ online activities and to have conversations about how pornography may not depict healthy interactions, they said.
Beyond discussing a plan for preventing pregnancy and STIs, Kantor encourages discussions about what constitutes healthy relationships, as well as check-ins about intimate partner violence and how romantic relationships are going.
“I think for pediatricians and for parents, it’s a muscle,” she said. “As you bring up these topics more, listen, and respond, you get more comfortable with it.”
Trent has served as an advisory board member on a sexual health council for Trojan (Church & Dwight Company) and has received research funding from Hologic and research supplies from SpeeDx. Bell has received funds from the Merck Foundation, Merck, and Gilead. Kantor had no disclosures.
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