December 15, 2020 -Care in Pediatric and Adolescent Gynecology (PAG) throughout Canada has been significantly impacted since the COVID-19 pandemic caused wide shut-downs of elective services and shifts to virtual care since March 2020. Access to elective services has differed across the country, and some service areas are better suited to care virtually than others. This statement serves to guide practice in the gynecologic care of young girls and adolescents during and after the pandemic and is based on available evidence and opinion of best practice from the CANPAGO committee members and PAG expertise across the country.# Maintenance of Services
PAG care is inclusive of essential services and access to care for these essential services needs to be prioritized and maintained in a similar fashion to all other essential services. Emergency and priority areas for in-person care requiring access to immediate in-person services include but are not limited to:  Confirmed or suspected ovarian torsion  Ovarian masses and suspected malignancies  Genital trauma  Heavy menstrual bleeding with anemia Per the SOGC statement on Contraception in the pandemic 1 , and based in human rights requirements, contraceptive care likewise requires access for our younger patients to contraception counselling and services, IUD insertion and medical and surgical abortion and this needs to be available in a confidential fashion which includes in-person care when required either to provide a confidential environment or for procedures.
Multidisciplinary clinics, which bring together multiple providers in a single space (against current recommendations for gathering or crossing multiple disciplines who may be making different choices about in-person care), are particularly challenging in a virtual environment. Multidisciplinary care clinics, which often note a synergy to the environment for both patients and care providers, may need to be adapted and virtual during the pandemic, but should do their best to maintain their multiple perspectives on care and should resume in their usual format as soon as they are able.

# Virtual Care
As with many other areas of medical care, PAG providers are being required to see many patients virtually through videoconference or telephone call and are needing to adapt and innovate their techniques and experiences. Provincial agencies financing health care across the country are strongly recommended to reimburse appropriately for virtual care and to continue to do so after the pandemic so that virtual care can continue to be used in circumstances in which it provides benefits over and above in-person care.
Explicit consent for virtual care, including that it may limit confidentiality, is recommended and should be documented.

# Special Considerations and Populations in Virtual Care
Some populations are well suited to virtual care and, as in all areas of medicine, may well continue to prefer virtual care long after the pandemic has settled. Patients experiencing cognitive and physical disabilities, for whom clinic attendance in person can often provide challenges in transport and waiting for themselves and their parents and guardians, are one such example. These patients are sometimes seen for menstrual suppression where a physical exam may not be required. Some populations of patients may well prefer virtual care and should be given this option and their choice in virtual or inperson care should be respected. Blood pressure as needed may be attained at required in-person visits to any service.
Other marginalized populations or those with limited access to transportation may also prefer virtual care. Patient preferences should be acknowledged and respected where possible. Virtual care may therefore have future potential to increase the reach of PAG care into marginalized populations or geographically through virtual care where subspecialists are not regularly available. Populations who require translation services can be managed through virtual care with services such as language line offering three-way phone translation. Non-English/French speakers should not be disadvantaged in virtual care.

# Confidentiality During Virtual Care
Care in the adolescent population requires confidentiality and the opportunity for the young patient to converse alone with the care provider for HEEADSSS 2 or SSHADESS 3 history and discussion of any items which the patient prefers to keep confidential from their parent or guardian at that moment. This is clearly easier to do in an in-person encounter where the parent/guardian can be asked to step out of the room and this can be confirmed visually.
In virtual care, the same request of the parent/guardian can be made with explanation of the reason and description of the limits of confidentiality. A parent/guardian can be asked to step out of the room or a phone/computer can be turned off of speaker mode, or the patient can move to a room where they are alone and they can let the care provider know when they are alone. Experience to date suggests this can work well although rapport is more difficult to establish virtually and it cannot be guaranteed that the patient is alone.

# Consent Process in Virtual Care
At times, it may be appropriate to consent for procedures during virtual care. Institutional policies will likely guide the requirement for written consent but flexibility to patient need is encouraged. It may therefore be possible to adopt novel policies for consent, such as the presence of two staff to document consent during a virtual encounter (which may work well for smaller procedures such as IUD insertions), or to delay the signing of a consent form for the day of the procedure if the process and risks/benefits/alternatives relevant to the consent are documented during a virtual encounter or to send documents electronically for e-signature. These solutions may enable the surgical process to proceed without delay and without in-person visits merely for the signing of a form.

# Teaching and Learner Engagement in Virtual Care
As a mostly academic group of providers, we continue to have a duty to teach our trainees (undergraduate and postgraduate medical, nursing, midwifery and allied health professionals). As we ourselves negotiate this changing care environment and virtual care, we should continue to do so with and in guidance of our trainees. Trainees can fit well into virtual clinics and call or video call patients either ahead of their staff provider or with the faculty listening in as they might observe an in-person encounter. Clinics need to adapt their space to safely accommodate care providers and learners who can be socially distant in the clinic space. Virtual care can be provided from outside the main clinic space (such as from home) so long as the learner and staff can each maintain a confidential environment and communicate with one another to conclude the patient encounter. Use of technology, as recommended by the institution for the maintenance of safety and security, should be used at all times. Remote access to electronic records allows for documentation and communication.

# Tools and Resources for PAG providers of virtual care and during Pandemic times
It is recommended that tools and resources to assist, guide and simulate virtual care in children and adolescents, be developed by educators and teaching faculty over time. PAG providers and SOGC and CANPAGO members are encouraged to apply their expertise to this area to support our best care to our patient population at all times. These would best exist in a centralized location (such as the SOGC website) for ease and equality of access).

# Advocacy
It is recommended that providers of care to young girls and adolescents avail themselves of opportunities to remain strong advocates for their patients and their patients' care within their health care organizations, locally, provincially and nationally -through direct care, publications, research, appropriate online and social media presence -to ensure a strong voice for the imperative to provide comprehensive gynecologic care to our patient populations during these pandemic times and in general.