Klein's (1998) survey of 14-19-year-old adolescents indicated that only 8.4% had used confidential services. More than half of the adolescents interviewed did not know where they could go to receive confidential health services. A recent study by Thrall, McCloskey, Ettner, Rothman, Tighe and Emans (2000) reaffirmed the important link between teens' perception of confidentiality and their willingness to discuss health risks such as sexually transmitted diseases, pregnancy prevention and substance abuse.

Confidentiality is a complex concept that involves legal, ethical and moral principles. Confidentiality derives from the bioethical principle of autonomy and accompanies such rules as promise keeping, truthfulness, and privacy (Sigman, Silber, English, & Gans, 2000). There is a strong national consensus endorsing confidential health services for adolescents. Most professional health care organizations have a policy that directly supports adolescents' need for confidential health services (Gans, 1993); for example, the American Nurses Association, the Society for Adolescent Medicine, the American Academy of Pediatrics, and the American Medical Association. Over the past 10 years, these policies have been supported by important national reports, including Adolescent Health (1991) by the US Congress, Office of Technology Assessment; Code Blue: Uniting for Healthier Youth (1989) by the National Commission on the Role of the School and the Community in promoting Adolescent Health; and Turning Points (1989) by the Carnegie Council on Adolescent Development.

Likewise, adolescents report that confidentiality is important in the delivery of health care (Resnick, Blum, & Hedin, 1980). Their reasons included the need to prevent rumors, to avoid punishment from punitive parents and to promote better problem-solving skills. Confidentiality is considered crucial to adolescents' willingness to provide accurate information about sensitive health issues. Recent research documents that counseling of adolescents about risk-taking behaviors by nurses was enhanced by the use of a confidential computerized health assessment tool (Paperny, 1999). Adolescents participating in this study were told that the information they provided was confidential and, as a result, it is believed, answered questions about risk-taking behaviors more honestly. Subsequently, counseling messages could be tailored to specific risk-taking behaviors and were more likely to be relevant to the adolescents' needs. Not only did this tool provide essential information, it, or similar type tools, could also be used to alleviate provider time constraints. On average, each adolescent client reports participating in 10 risk behaviors only 7 of which were discussed by providers during a preventive service visit (Epner, 1998). Similarly, if a teen reports 3 or more risk behaviors, or a relatively severe health problem, even fewer risk behaviors are discussed.

Since confidentiality laws vary from state to state, it is imperative that nurse providers explain their policies regarding confidentiality during an initial clinic interview. These policies need to be explained to both the adolescent patient and parent(s). Providing this explanation in the beginning will help to avoid future misunderstandings. When working with a family over time, nurses have an opportunity to prepare parents for their child's growing need for privacy as a normal part of adolescent development. By beginning early, parents may come to accept confidential visits by their teenagers as part of healthy maturation during adolescence. Empowering parents as "partners" in the care of their teen may alleviate fears that provider is supplanting the parents' role as caretaker. Explaining the clinical importance of confidentiality as well as clearly defining the specific limits of confidentiality will go a long way in getting parental cooperation and acceptance.

Given the array of laws pertaining to informed consent and confidentiality that currently exist, it is no wonder that adolescents and, perhaps even nurses, are confused about how these laws pertain to them. Congress has the ability to intervene to reduce these uncertainties by moving federal and state laws in the direction of greater uniformity. Until this occurs, it may be easier for nurses to encourage their localities and schools to integrate information about legal aspects of adolescent access to health services into health education courses.

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