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Confidentiality and protection when working with under-16s

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VOL: 102, ISSUE: 45, PAGE NO: 30

Emma Winterburn, RN, is sexual health coordinator, teenage pregnancy strategy, Dorset County Council

Cecilia Priestly, MBChB, FRcP, is GUM consultant, The Park Centre for Sexual Health, Weymouth, Dorset

A registration scheme was set up to address child protection concerns for young people accessing free condoms from a sexual health clinic in Weymouth. However, following its introduction numbers of young people using the service reduced dramatically. Anecdotal evidence suggested this was due to concerns about confidentiality. The registration scheme was discontinued but young people were asked to see a nurse before obtaining condoms. A survey was conducted to find out young people's views of the service and condom provision.

A registration scheme was set up to address child protection concerns for young people accessing free condoms from a sexual health clinic in Weymouth. However, following its introduction numbers of young people using the service reduced dramatically. Anecdotal evidence suggested this was due to concerns about confidentiality. The registration scheme was discontinued but young people were asked to see a nurse before obtaining condoms. A survey was conducted to find out young people's views of the service and condom provision.

Method
A small pilot study was carried out in three secondary schools with a sample of 147 students aged 13-15. The students completed a short, anonymous self-administered questionnaire.

The young people were told that the sexual health service was trying to improve availability of condoms to reduce STIs and unwanted pregnancies.

The following points were addressed:

- Did they know where to get free condoms?

- Did they mind filling in registration cards?

- What details were they happy to give?

- Did they mind speaking to a nurse?

- Where would be their preferred place to access free condoms?

- Did they know the service was confidential?

Results
Sixty-five per cent of students said they would be happy to fill in registration cards but only 42% said they would be happy to give personal details. Significantly fewer (25%) would be happy to give their name. Only 20% were prepared to disclose their age and 19% to disclose their school. Only 5% stated they would be happy to provide their boyfriend's or girlfriend's name for STI contact tracing.

Seventy-two per cent knew the service was confidential but a discussion following the survey revealed that many were unsure what confidentiality meant and thought their parents would be informed. They all knew at least one centre from which they could obtain free condoms yet 58% believed condoms should be available at school.

Discussion
Limits to study

The survey was in effect a small pilot study and was not standardised. However, the results may be of wider significance as they appear to demonstrate the importance of confidentiality to young people. The aim was to identify local concerns.

Local outcome
Involving the local young people through the survey, educating them about confidentiality and highlighting the confidential nature of contact tracing seems to have restored confidence in the service. Attendance for condoms has reverted to its previous level. This will help young people take responsibility in protecting themselves from unwanted pregnancy and STIs.

One school in the area has agreed to allow condoms and emergency contraception to be administered - under strict protocol - to sixth-form students, with the aim of introducing this to other year groups. In addition, the sexual health clinic has developed a 'one-stop shop' for young people that has proved extremely popular, reflecting the need to provide services that are specifically for young people.

Providing young people with contraception and advice is a way of minimising harm. Since school has been recognised as the main source of information on sexual health for young people (Welling et al, 2001), the fpa (Family Planning Association) and Teenage Pregnancy Advisory Group are campaigning to make personal, social and health education a statutory requirement.

Confidentiality
Health professionals working to reduce teenage pregnancies and prevent STIs face a potential conflict when providing confidential services to young people. If they do not ask about sexual activity the professional may fail to recognise situations of abuse. The Sexual Offences Act 2003 does not affect health professionals' ability to provide confidential advice and treatment on contraception and reproductive health to people under 16. It is intended to safeguard young people and make it easier to prosecute those who force them into unwanted sexual activity. A professional judgement is made on each young person, informed by the DH (2004) best-practice guidance and the Fraser Guidelines (Fraser et al, 1985) to ensure:

- The young person understands the advice;

- The young person cannot be convinced to involve parents/carers or allow the medical practitioner to do so on their behalf;

- It is likely that the young person will begin or continue having intercourse with or without treatment/contraception;

- It is likely that unless she or he receives treatment/contraception their physical or mental health (or both) will suffer.

- The young person's best interests require contraceptive advice, treatment or supplies to be given without parental consent.

Child protection
The Pan-London protocol for working with sexually active young people (London Child Protection Committee, 2005) advises that those under 13 are reported to the police and social services, and that all partners of those under 16 are checked on a police database. However, the British Medical Association (2005) raised concerns that these proposals may discourage young people from seeking treatment. If they believe that seeking help puts them at risk of being reported to the police, they are unlikely to use services and may become more vulnerable. While health professionals cannot offer young people complete confidentiality with regard to sexual health without potentially putting them at risk, there needs to be a compromise. Guidance on how agencies work together is a positive opportunity but must respect the role of individual agencies and professional codes of conduct.

Conclusion
Improving access to condoms in an attempt to minimise harm to young people is a controversial issue but those in sexual health services must act in the best interest of young people. The government must also realise that a blanket ruling in relation to sexual health and young people would preclude individual professional judgement when balancing the often conflicting issues of confidentiality and child protection.

Background
- The reduction of sexually transmitted infections (STIs) and pregnancies in young people is a public health priority. Despite an improvement in the use of contraception at first sexual intercourse, STIs have increased considerably. For example, nationally one in 10 sexually active young people is estimated to be infected with chlamydia (Department of Health, 2001).

- Confidentiality is the most important factor for young people attending sexual health clinics. Thomas et al (2005) found that 54% would not attend services that did not offer confidentiality. However, Munday et al (2002) recognised the importance of health professionals in sexual health services identifying young people who may be at risk of abuse.

- Under-16s are entitled to receive free confidential contraceptive advice and treatment from health professionals in accordance with the Fraser Guidelines (Fraser et al, 1985), also referred to as Gillick competencies.

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