VOL: 102, ISSUE: 45, PAGE NO: 30-31
Emma Winterburn, RN
Sexual health coordinator, Teenage Pregnancy Strategy, Dorset County Council; Cecilia Priestley, MBChB, FRcP, is GUM consultant, The Park Centre For Sexual Health, Weymouth, Dorset.
Abstract Winterburn, E., Priestley, C. (2006) Providing condoms for under-16s: confidentiality vs child protection. www.nursingtimes.net.
Abstract Winterburn, E., Priestley, C. (2006) Providing condoms for under-16s: confidentiality vs child protection. www.nursingtimes.net.
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The UK has seen a significant increase in sexual activity among adolescents in recent years and the reduction of sexually transmitted infections and pregnancies in this group has become a national public health priority. Concerns were raised in a sexual health clinic in Dorset over the need to maintain ease of access to condoms while ensuring child protection procedures were adhered to. When a condom registration scheme was set up to act on this concern, it resulted in a drastic reduction in numbers of young people using the service. The scheme was therefore abandoned and an opportunistic pilot study was carried out to assess young people’s views on condom provision. This article reviews the results of the survey and discusses issues of confidentiality versus child protection when working with under-16s.
There has been a significant increase in sexual activity in the under-16s in recent years. For example, up to a third of girls aged 16-19 now become sexually active before their sixteenth birthday (Welling et al, 2001). The reduction of sexually transmitted infections (STIs) and pregnancies in young people has become a national public health priority. The goal of the government’s teenage pregnancy strategy is to halve pregnancies in girls aged under 18 years by 2010 (Social Exclusion Unit, 1999). Despite an improvement in use of contraception at first sexual intercourse, STIs have increased considerably, for example, nationally one in 10 sexually active young people are estimated to be infected with chlamydia (Department of Health, 2001).
Research shows that confidentiality is the most important factor for young people attending a sexual health clinic. Thomas et al (2005) found that 54% of young people would not attend sexual health services that did not offer confidentiality. However, a case study by Munday et al (2002) highlighted the fine balance between confidentiality and child protection. It identified the significance of confidentiality to young people attending sexual health services but recognised the importance of health professionals identifying those who may be at risk of abuse, such as a young person who is forced into having sexual contact or where a large age gap raises concerns relating to ‘power’ within the relationship.
Under-16s are entitled to 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. These guidelines were recently revised to emphasise the importance of building a relationship with the young person, assessing whether their sexual relationship is fully consensual and encouraging the young person to talk to an adult within her or his family (DH, 2004). This article discusses the issues of confidentiality versus child protection implicit in these guidelines when working with under-16s.
Some practical problems emerged in a sexual health clinic based in Weymouth, serving an area recognised as the most socio-deprived in the county. Despite a relatively low average rate of teenage pregnancy in the county, the town’s figures were well above the national average (MacKenzie, 2004). Until March 2005 condoms were freely available for anyone to take from the clinic waiting room. However, some staff raised concerns about lack of documentation in relation to the assessment of competency and child protection concerns in under-16s, and the misuse of condoms by service users - many were being taken and blown up outside the clinic.
Acting on this concern, the clinical staff set up a condom registration scheme to document personal details and nurses’ assessment of competency in accordance with the Fraser guidelines. However, the number of young people using the service reduced dramatically. Before the scheme was set up the clinic received an average of 7-10 requests a day for condoms. In the 10 weeks from 11 March to 19 May 2005 only 62 patients registered and 71 requests for condoms were received. Based on average figures before the scheme we would have expected 350-550 in the same period. Anecdotal evidence suggested this drastic reduction in attendance was due to young people’s concerns about confidentially.
The clinic’s immediate problem was that if young people were not obtaining and using condoms they may have been putting themselves at increased risk of STIs and unwanted pregnancies. It was also a concern that the clinic had lost its previously excellent reputation among young people in the area. As a result the registration scheme was discontinued, but young people were asked to see a nurse before obtaining condoms, instead of them being freely available in the waiting room. We decided to carry out a survey of young people’s views to ensure the service was meeting their needs and ascertain their views on condom provision. We believed that this process would restore their confidence in the service.
A small pilot study was carried out in three secondary schools with a sample of students from years 9 and 10 (ages 13-15). These schools and age groups were chosen to reflect the age and catchment area of the young people attending the clinic. All 150 students present on the day of the study formed the opportunistic sample and were invited to take part. Of these, 147 completed an anonymous self-administered questionnaire. The remaining three were not fully completed.
The questionnaire was introduced following a discussion on sexual health. The young people were told that the sexual health service was trying to improve the availability of condoms to them and increase their use in order to reduce STIs and unwanted pregnancies. Form tutors distributed the questionnaires and explained that participation in the study was voluntary, the results were confidential and that names should be left off the questionnaire.
The aim of the short questionnaire was to establish the young people’s views on accessing condoms. Questions addressed the following points:
- Did they know where to get free condoms?
- Did they mind filling in registration cards?
- What personal 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 they received was confidential?
A total of 147 questionnaires were returned; 30 students were not present at their schools on the day the study was undertaken, while three questionnaires were not fully completed. Of the 147 respondents, 65% said they would be happy to fill in registration cards, but only 42% said they would be happy to give any personal details. Significantly fewer (25%), would be happy to give their name. Only 20% were prepared to disclose their age and 19% were prepared to disclose which school they attended. In relation to contact tracing for STIs, only 5% of respondents stated they would be happy to provide their boyfriend’s or girlfriend’s name (Fig 1).
Results showed that 72% of the young people knew the service was confidential. As a follow-up to the survey the sexual health coordinator carried out a focus group discussion to give respondents an opportunity to see what action we intended to take as a result of the information they gave us and to discuss further their views on confidentiality. It became apparent that many were unsure what confidentiality meant and thought their parents would be informed or that it was best to give false information ‘just in case’. They all knew at least one centre at which they could obtain free condoms, yet 58% believed condoms should be available at school.
Limits to study
The survey was in effect a small pilot study undertaken in response to a local problem and was not standardised. However, the results appear to be of wider significance. Ideally, research using a larger, more geographically diverse sample should be undertaken, within which reliability and validity are tested. This limited study appears to demonstrate the importance of confidentiality to young people.
The government’s teenage pregnancy strategy has supported condom registration schemes, which have been effective in many areas (SEU, 1999). It is possible that better planning, advertising and promotion of our scheme would have ensured its success, as its introduction may have led to young people feeling they were being monitored. The aim of this survey was to identify concerns and reach a solution from a small sample of consumers. It was a simple study in response to an immediate problem, but may well lead to a more substantial piece of work.
Involving the local young people through the survey, educating them about the meaning of confidentiality and highlighting the confidential nature of contract tracing seems to have restored confidence in the service, as attendance for condoms rapidly reverted to its previous level. Service providers should not assume that young people understand the meaning of confidentiality and should take this into account when promoting services aimed at them. This will help young people to feel confident about taking responsibility to protect themselves from unwanted pregnancy and STIs.
Fifty-eight per cent of respondents suggested condoms should be available at school. This is supported by the Teenage Pregnancy Unit (SEU, 1999), which emphasised the importance of advertising sexual health services within schools and building links with services to improve accessibility. In response to this, one of the schools in the area has agreed to allow condoms and emergency contraception to be administered - under strict protocol - to sixth-form students, with the future intent of introducing this to other year groups in the school.
‘Youth-friendly’ sexual health services are vital to improve young people’s sexual health (Stone and Ingham, 2003). The sexual health clinic has learnt from this experience and has now 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.
Sexual health education
In an ideal world young people would wait to be sexually active until they are older and in a stable relationship but it has to be accepted that this will not always be the case. Providing them with contraception and professional advice is a way of minimising harm. Health promotion and preventative education in schools has improved greatly over the past few years, with health and education policies placing greater importance on supporting young people’s social and emotional development as much as their educational needs. The Youth Matters (DfES, 2005) green paper recognised that young people who did not have this holistic support were unlikely to reach their educational potential. 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 currently campaigning to have personal, social and health education made part of schools’ statutory requirement.
Health professionals working with young people to reduce teenage pregnancies and prevent STIs face a potential conflict when providing confidential services to ensure a safe trusting environment that will allow young people to feel at ease. If young people are not asked about their sexual activity there is the risk that the health professional will fail to recognise situations of exploitation and abuse.
Sexual health nurses are bound by their professional code of conduct and are fully aware of child protection procedures. The Sexual Offences Act 2003 does not affect health professionals’ ability to provide confidential advice and treatment on contraception and reproductive health to young people aged under 16 - including those under 13. The Act is intended to safeguard the rights of young people and ensure it is easier to prosecute people who force or pressure young people into unwanted sexual activity. Health professionals working within the remit of sexual health carry out individual assessments on each young person, guided by DH best-practice guidance and the Fraser Guidelines (DH, 2004; Fraser et al, 1985), making a professional judgement as to whether a child is deemed to be at risk (see box). This ruling was recently unsuccessfully challenged in the high courts, with the judge ruling that taking away children’s rights to confidentiality may lead them to choose not to seek help.
Good practice in contraception and sexual health services for under-16s.
Establish a rapport with young people using sexual health services, offer support and give them time to make informed choices by discussing:
- The emotional and physical implications of sexual activity, including the risks of pregnancy and sexually transmitted infections
- Whether their relationships are mutually agreed and whether there may be coercion or abuse
- The benefits of informing their GP and the case for discussion with a parent or carer. Any refusal should be respected
- Any additional counselling or support needs
Fraser guidelines require that health professionals:
- Ensure young people understand any advice they are given
- Do not persuade young people to inform their parents that they are seeking contraceptive advice, or allow their GP to do so
- Are satisfied they are very likely to begin or continue having intercourse with or without contraceptive treatment and that unless they receive contraceptive advice or treatment, their physical or mental health - or both - are likely to suffer
- Young people’s best interests require the health professional to give contraceptive advice, treatment or both without parental consent.
Adapted from DH (2004); Fraser et al (1985)
The Pan-London protocol for working with sexually active young people under the age of 18 (London Child Protection Committee, 2005) is an attempt to bridge gaps between government policies, including recommendations in the Bichard Inquiry Report (Bichard et al, 2004). It advises that all under-13-year-olds attending sexual health services who are believed to be sexually active are reported to the police and social services, and that all partners of under-16-year-olds are checked on a police database. However, the British Medical Association Association and other organisations (2005) criticised these proposals. In a joint statement on confidentiality and child protection in sexual health services they suggested the proposals will discourage young people from coming forward and seeking advice and treatment, leading to the possible alienation of those that are most vulnerable. Young people living in deprived areas may well, due to previous experience, be wary of social services/health professional input. If they believe that seeking help puts them at risk of being reported to the police, they are unlikely to use services, putting them at risk of becoming even more isolated and vulnerable (Rogstad, 2005).
Confidentiality and communication
The report of the inquiry into the well-publicised death of Victoria Climbié (Laming et al, 2003) described the damage caused by lack of communication and poor practice between professionals. While health professionals cannot offer young people complete confidentiality, there clearly needs to be a compromise. The positive steps being taken by the government to tackle this issue are to be commended as they have raised the profile of sexual health. Universal guidance on how agencies are to work together is a positive opportunity, but each individual agency’s role and professional codes of conduct must be taken into consideration and respected, or some extremely valuable services that have built up an outstanding reputation with young people may be lost.
Improving access to condoms in an attempt to minimise harm to young people will continue to be a controversial issue, yet health professionals need to ensure debates on the subject include the views of young people. Those involved in providing sexual health advice and treatment should continue to act in the best interest of young people, safeguarding them from harm. The government, although making commendable efforts to prevent the abuse and exploitation of young people, must also take into account 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. This would lose sight of a vital aspect of any policy or practice related to young people - that the young person’s health and well-being must always be paramount.
Bichard, M. et al (2004) The Bichard Inquiry Report. London: Stationery Office.
British Medical Association et al (2005) Confidentiality of Adolescent Sexual Health Services: Joint Statement. . www.ffprhc.org.uk/admin/uploads/FinalSignedDJTStatement.pdf
Department for Education and Skills (2005) Youth Matters. London: DfES.
Department of Health (2004) Best Practice Guidance for Doctors and Other Health Professionals on the Provision of Advice and Treatment to Young People Under 16 on Contraception, Sexual and Reproductive Health. London: DH.
Department of Health (2001) The National Strategy for Sexual Health and HIV. London: DH.
Fraser, H. et al (1985). The Fraser Guidelines. Gillick v West Wisbech Health Authority: ac 112.
Laming, H. et al (2003) The Victoria Climbie Inquiry: Report of an Inquiry by Lord Laming. London: Stationery Office.
London Child Protection Committee (2005) Working with Sexually Active Young People Under the Age of 18: a Pan-London Protocol../www.londoncpc.gov.uk/documents/Pan-LondonProtocolWorkingwithSexuallyActiveunder18s.doc.
MacKenzie, I. (2004)Annual Report of the Acting Director of Public Health. Bournemouth: Dorset and Somerset NHS Strategic Health Authority.
Munday, P.A. et al (2002) Managing the very young patient: a conflict between the requirements of the Children Act and the VD regulations? Sexually Transmitted Infections; 78: 332-333.
Rogstad, K. et al (2002) Confidentiality and Child Protection in Sexual Health Services. London: British Association for Sexual Health and HIV. www.bashh.org.
Social Exclusion Unit (1999) Teenage Pregnancy. London: Stationery Office.
Stone, N., Ingham, R. (2003) When and why do young people in the United Kingdom first use sexual health services? Perspectives on Sexual and Reproductive Health; 35: 3, 114-120.
Thomas, N. et al (2005) If Confidentiality is Lost Will Young People Still Access Sexual Health Services? Poster. Bath: BASHH/ASTDA Spring meeting (level IV).
Welling, K. et al (2001) Sexual behaviour in Britain: early heterosexual experience. Lancet; 358: 1843-1850.