Practice dilemma - Under-age sex

The Dilemma: A 13-year-old girl attended surgery with her mum requesting she be put on the contraceptive pill as she is concerned that the relationship with her 12-year-old boyfriend will become sexual; he is pestering her for sex and mum is keen her daughter doesn't get pregnant. What would you do?

Discussing safe sex and contraception with young patients is vital
Discussing safe sex and contraception with young patients is vital

A GP's response
Dr Alison Glenesk is a GP trainer in Aberdeen

This case is complex, with the possibility of pregnancy and its consequences. One child is just past the age when intercourse would be statutory rape, the other would be committing an illegal act. Also, the patient's mother, though apparently well intentioned, seems to be condoning a sexual relationship.

It is important not to appear judgmental. You should speak to the girl alone to establish if she understands the consequences of her actions and the role of contraception (Gillick competence) and hopefully empower her to make her own decisions regarding a sexual relationship.

You also need to find out the mother's views. If she appears to be irresponsibly condoning her daughter's actions, there may be child protection issues. You should also consider the young man. If he is your patient, you have a duty of care to him, but must respect confidentiality.

Whatever your views, you have a duty to protect your patient from pregnancy if she consents to contraception. Suitable choices at this age are a low-dose combined pill (supervised), or depot injection, with advice about safe sex.

A patient's view
Ailsa Donnelly is a member of the RCGP Patient Partnership Group

In this difficult situation, the girl must be the prime concern. The GP has a responsibility to point out that as both boy and girl are underage a sexual relationship is illegal for both of them, although at 13 years the girl is deemed just old enough to 'give consent'.

It is unclear whether the request for contraception comes from the mother or the daughter, an important distinction which may affect the GP's decision.

The GP should talk to the daughter on her own, assessing her physical, sexual and emotional maturity and whether she is Gillick competent.

Both mother and daughter should be warned about implications of the contraceptive pill and if appropriate there should be discussion of alternatives, involving the boy as well.

Ideally, the GP should refer both boy and girl to an independent agency for independent discussion and advice - this could be a health visitor, social worker or appropriate charity.

A medico-legal opinion
Dr Sonya McCullough is a medico-legal adviser for the Medical Protection Society

This is not yet a sexual relationship. A confidential sexual health service is vital for the welfare of the children. If confidentiality is not maintained, the girl may not return for advice thus putting her and her boyfriend's health at risk. Establish whether she is Gillick competent and understands pregnancy and STIs.

If you feel the patient has capacity to consent to treat-ment, you should consider if treatment is appropriate and if she is going to have sex anyway.

Consider whether her physical or mental health will suffer if she does not receive advice or treatment. A thorough sexual history and documentation is essential.

Although a child may have capacity to consent to treatment, children under 13 cannot legally consent to sex. You therefore need to consider whether the patient is vulnerable to abuse. The younger the patient the lower your threshold for involving the child protection team.

On the positive side, her mother is present in this case. You should encourage young people to involve their parents in making important decisions, but you should usually abide by any decision they make, if they have the capacity.

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