nonbarrier contraceptives are given and when they are evaluated for an unintended pregnancy.

As discussed in Chapters 4 and 5, ensuring confidentiality of services is extremely important, especially for adolescents. Given that most adolescents are unwilling to seek medical attention for an STD unless confidentiality is ensured, adolescents should be able to consent to STD-related services without parental knowledge. Forty-nine states and the District of Columbia currently have laws that give a minor explicit authority to consent to diagnostic and treatment services for STDs (AGI, 1995). Of these states, 16 allow physicians to notify parents of treatment provided. Pending federal legislation may interfere with a minor's ability to consent to STD-related services and could have a harmful impact on efforts to prevent STDs among adolescents. ⁴ As discussed in Chapter 5, billing and claims-processing procedures of some health plans may be a major barrier to confidential STD-related services. The committee believes that parental notification of treatment for an STD, either by providers or indirectly through billing or claim-processing procedures, is likely to discourage adolescents from seeking health care for potential STDs, and thereby increase the potential for STD-related complications and transmission to others.

There are significant numbers of adolescents who are disenfranchised. As documented in Chapter 3, a substantial number of adolescents live in detention facilities and group homes, or are sex workers or runaways or otherwise homeless persons. In addition, a substantial number of these adolescents were sexually abused as children. As a result, these youth often behave in a high-risk manner that puts them at increased risk for STDs and other health problems. All of these young people have significant problems obtaining health care and need access to comprehensive, high-quality health services in general and STD-related services in particular. Although school-based programs will reach the overwhelming number of adolescents, interventions for those who do not attend school should also be developed and implemented.

Therefore, the committee makes the following recommendations:

• A major part of a national strategy to prevent STDs should focus on adolescents, and interventions should begin before sexual activity is initiated, which may be before adolescence is reached. Interventions should focus on preventing the establishment of high-risk sexual behaviors.
• All health plans and health care providers should implement policies in compliance with state laws to ensure confidentiality of STD- and family-planning-related services provided to adolescents and other individuals. The following actions should be taken to ensure confidentiality of services: