The age at which sexual activity is legal varies between countries and a detailed description of what is legal when is beyond the scope of this book. However, regardless of country of residence, people aged 16 and under, who are sexually active are at increased risk of STIs and unplanned pregnancy. Whilst being aware of this and the need to protect them from sexual abuse and exploitation, one must also take into account the natural preference of the young person for a confidential sexual health service.
People don’t mature at the same rate and some adolescents could be deemed competent to decide on issues such as the provision of contraception and testing for STIs. In the UK this level of maturity is referred to as Fraser Competence following a ruling on this issue by Lord Fraser in 1985.
In order to decide whether someone has the appropriate maturity the clinician should consider the following issues whilst seeing the patient:
- • Do they believe the information you’ve given them?
- • Do you think they able to weigh up the pros and cons of the treatment/management you are suggesting.
- • Do you think they have the ability to make a clear choice?
- • Have they communicated their decisions to you clearly?
The younger the patient, the less likely it is that they can realistically be regarded as competent. There will also be people aged over 16, perhaps with learning difficulties who will be deemed incompetent to make decisions on sexual health matters.
Even if you decide they are competent, discuss the value of parental support with the young person, but respect their wishes if they do not want to tell their parents. If you decide that they are not competent to decide for themselves you must involve their parent or guardian in any treatment decision.
As well as taking a standard sexual history one must ask about other issues which could increase the chance of the person suffering sexual ill health. In some clinics the receptionist places a card in the notes of any patient aged 16 or under which reminds clinicians of the topics to cover. Use of such a card is encouraged by the UK guideline as a way of ensuring a full and accurate history.
Things to document, issues to cover and questions to ask include:
- • Who else is present at the consultation? Is there a risk of coercion from a relative or partner? (Offer to see alone.)
- • Age of partner (s). Be aware of possible coercion especially if partner more than 3 years older.
- • History of sexual abuse/assault
- • Medical and psychiatric history. Depression and low self esteem are associated with unsafe sex.
- • Drug/alcohol use. Most drugs reduce inhibitions. In the UK there appears to be an increase in alcohol consumption by young women.
- • Employment/college/school — and whether attending. Sexual ill health is more common in children who are playing truant or who are excluded from school.
- • With whom do they live? Both parents? Children’s home? There’s greater risk of problems in those who are in care.
- • Contact with family members if living apart.
- • Other agencies, counsellors, support or social workers.
If you are inexperienced in this area discuss any issues raised with a senior colleague. If the child is under 13 they should ideally be seen by two doctors who together decide on their management.
Even if your patient is under the legal age of consent for sexual activity in most instances you are likely to decide that they are competent to accept management without parental involvement and that their sexual relationships are consensual and non-abusive. However, it is important to plan for the day that you realise that your patient is likely to be in an abusive relationship. How you handle this will depend on whether the assailant is resident with the patient and whether the child is at ongoing risk.