A problem shared: Trust is the key to confidentiality

A teenage patient is sharing a prescription for the Pill with her younger sister. What should you do?

A 19-year-old girl has requested the oral contraceptive Pill several times saying that she had lost either the prescription or the medication on several occasions. On her next visit you enquire about this and she admits that she has been giving the extra Pill to her 15-year-old sister who does not want the GP or her parents to know that she is sexually active. How do you address this?

Dr Manish Bhasin's view

This case highlights the fact that teenagers may not trust their GP when it comes to confidentiality. Recent surveys have shown that most of the teenagers still believe that we will disclose information to their parents.

I would discuss with the elder sister that what she is doing is wrong and illegal. I would also try to explain to her the danger in which she is putting her younger sister because she is not receiving the medical attention and monitoring that taking the oral contraceptive Pill entails.

I would try to develop trust and invite the younger sister to the surgery in a joint appointment. I would then reiterate all the benefits and disadvantages of contraception. It is important to make both girls aware of the risks of deep vein thrombosis and pulmonary embolism. I would also take the opportunity to check against any chances of sexual abuse by asking the age of the younger sister's sexual partner.

Dr Bhasin is a GP registrar in Warrington

Dr Fola Olaleye's view

This situation raises a number of issues and requires a tactful approach. I would arrange an appointment with the younger sister to assess competence as laid out in the Frazier guidelines. If she is competent I would respect her confidentiality and autonomy, and encourage her to approach me when she has health concerns. 

I would explore the possibility of a child protection issue by carefully enquiring about the age of her partner. I would also raise her awareness of STIs and encourage the use of condoms. Hopefully she will confide in me if she has any symptoms suggestive of an STI so that the necessary steps can be taken.

I would also take a urine test and take her history to ensure that she is not already pregnant.

The practice should promote teenage-friendliness with confidentiality training, flexible opening hours and the use of posters guaranteeing confidentiality.

 As for the older sister, while she should be informed that her actions constitute a ground for removal from the surgery list, care should be taken not to estrange her, and an informal verbal warning should suffice.

Dr Olaleye is a GP in the Medway, Kent. He qualified as a GP in February 2006

Dr Barney Tinsley's view

This problem raises issues concerning confidentiality, competency and education.

Ideally, when first prescribing the oral contraceptive Pill to any sexually active woman, I would be keen to impart the usual education, information and warnings associated with moderate to long-term Pill usage, with reviews at three and six months initially. Safe repeat prescribing of the Pill would need to address compliance, abnormal bleeds, BP, smoking, sexual health issues and any other concerns the patient might have.

It is important to assess competency, which cannot automatically be assumed in a 15-year-old girl. A competent 15-year old girl has every right to be prescribed the oral contraceptive Pill without her parents' knowledge.

A satisfactory solution might be achieved by asking the younger girl to attend surgery with her older sister. With both of their consents to share information with each other, and stressing our commitment to patient confidentiality, I would have the opportunity to educate both of them about safe Pill use.

The sisters should be encouraged not to share prescriptions. Issues concerning overall sexual health can also be raised, with special emphasis to be placed on the younger sister.

It should be noted that GPs should be keen to identify young girls under the age of 16 at risk of being sexually exploited by older men. Should this eventuality arise, referral to social services is appropriate.

Dr Tinsley is a salaried GP in Bradford. He qualified as a GP in August 2005

Learning points

  • Be tactful when consulting a teenager about the Pill
  •  Teenagers do not generally trust their GP when it comes to confidentiality.
  •  Explain the dangers of sharing a prescription for the contraceptive Pill.
  •  Assess the competence of  any girl aged under 16 years old.
  •  Encourage younger patients to make an appointment with you to discuss health and safety issues regarding oral contraceptives, and for routine check-ups.
  •  Tactfully investigate the possibility of any child protection issues.
  •  Reassure younger patients about issues of confidentiality
The husband of a patient voices his disappointment in the local hospital. He would like you to speak with the ward to ensure his wife is given a single room and her food improved. He wonders if you need to visit her to confirm his observations. What should you do?

Email mailto:GPregistrar@haymarket.com with your replies by 15 February 2007. We will pay £25 for each reply published.

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