Dilemma: Contraception request raises an abuse concern
A 14-year-old girl attends your emergency surgery requesting the contraceptive pill. It transpires that she has been sexually active for a few months and that her partner is a 30-year-old man. She says her parents are unaware of the situation and she refuses for them to be involved. You discuss the legalities of the situation and discuss with her about talking to social services. She angrily states that if you tell anyone she’ll harm herself or abscond with her boyfriend.
Consult the guidelines and do not make promises you cannot keep
You should usually share information about abusive or seriously harmful sexual activity involving any child or young person, including that which involves:
-A young person too immature to understand or consent.
-Big differences in age, maturity or power between sexual partners.
-A young person’s sexual partner having a position of trust.
-Force or the threat of force, emotional or psychological pressure, bribery or payment, either to engage in sexual activity or to keep it secret
-Drugs or alcohol used to influence a young person to engage in sexual activity when they otherwise would not
-A person known to the police or child protection agencies as having had abusive relationships with children or young people.
But a kneejerk disclosure may be counter-productive perhaps resulting in the patient absconding, so working with the patient towards disclosure with consent will always have a better end result.
Disclosure of information without the patient’s consent is uncommon and the GMC guidance makes it clear that this should be a last resort.
If I was the GP dealing with this situation I would stress at the outset of this consultation that whilst we strive to maintain confidentiality, there are circumstances whereby disclosure is required to protect the patient’s wellbeing. I would try to keep the girl informed to reduce the risk of self-harm/absconding. I would stress that parental involvement is not essential, although preferable.
The circumstances of this case require referral to social care. It is also worth seeking advice from colleagues including the local safeguarding children team, the Caldicott Guardian and your medical defence organisation.
Dr Paula Briggs is a GP in Liverpool and community lead for Sexual Health Services in Sefton
Find out more about her partner and discuss with child protection services
This case is challenging because of the intrinsic tension between teenagers’ perceived ‘right to have sex when they feel ready’ and the need to protect them from sexual abuse.
All the related clinical issues – pregnancy testing, testing for sexual infection, providing contraception and STI protection must be approached with a view to the girl’s best interests and protecting her from harm.
Even if she is Gillick-competent, her boyfriend is breaking the law by having sex with an under-age girl and the clinician should establish her degree of risk.
It is vital to know more about the 30-year-old man – if he turns out to be her uncle, teacher or anyone else in a position of trust with regard to her, this further blurs the boundaries of what constitutes ‘sexual consent’.
Even if he is not in any position of trust, the age gap would give me considerable concerns about sexual exploitation. Threats about self-harming or absconding with the boyfriend are also suggestive of the girl’s vulnerability.
It would be quite inadequate to simply prescribe contraception, perhaps especially of oral contraceptives which have to be taken on a daily basis indefinitely - not easy for a 14 year old to either remember or to keep secret if she is determined not to involve her parents.
I would respectfully but firmly insist that her situation must be discussed with the local child protection services even if she refuses - if necessary seeking defence society advice first.
Dr Trevor Stammers is a former GP and programme director in bioethics and medical law at St Mary’s University College, London
Try to encourage the young person to make their own disclosure
Your initial instinct will be to protect the young person, who is possibly being groomed by an older male.
You should consider whether the patient is competent to make her own decisions. If you feel not, then this could be a case of abuse and it would be appropriate to report it to safeguarding services and/or the police, who would be interested in reviewing a case of a minor being in a relationship with a person more than five years older than the minor.
It is difficult when a young person believes they are mature enough to make their own decisions, particularly when it is a decision you do not think is in their best interests. You should try to encourage the young person to make their own disclosure and provide them with support to do so.
However, if she continued to refuse, it would be helpful to consider guidance that the GMC has provided in Protecting children and young people: the responsibilities of all doctors: ‘If a child or young person with capacity, or a parent, refuses to give consent to share information, you should consider their reasons for refusing, and weigh the possible consequences of not sharing the information against the harm that sharing the information might cause. If a child or young person is at risk of, or is suffering, abuse or neglect, it will usually be in their interests to share information with the appropriate agency.’
In disclosing information to social services and/or the police, you would be able to share your concerns about the patient’s threat of self-harm or absconding.
Dr Zaid A-Najjar is a medicolegal adviser at the Medical Protection Society