Community Pharmacy Young People’s Sexual Health Scheme Dr Tracey Dibble Clinical Lead for Young People’s Sexual Health Services 2013

Agenda Overview of Teenage Sexual Health Fraser Competence Safeguarding Issues Onward Referral – Contraception – STI Testing

Teenage Sexual Health Sexually Transmitted Infections New STI diagnoses rose by 2% in England in 2011 Overall rates remained highest in young adults (15-24 years old), accounting for: –57% of all new gonorrhoea diagnoses –56% cent of all new genital warts diagnoses –43% cent of all new genital herpes diagnoses 2011 data shows a 4% drop in cases of chlamydia in young adults, from approximately 154,000 to 148,000 but this is due to falling numbers of younger adults being screened

Teenage Pregnancy Rates

Consent Agreement for a health professional to provide care Patients can change their minds and withdraw consent at any time For consent to be valid patient must –Be competent to make decision –Have received sufficient information to make it –Not be acting under duress

Competence A patient is competent if he or she can: comprehend information, which has been presented to them in a clear way, believe it, retain it long enough to weigh it up and make a decision. Who is competent: Adults are always assumed to be competent unless demonstrated otherwise Young people aged 16 and 17 Younger children who understand fully what is involved in the proposed procedure

The Fraser Ruling 1985 The young person understands the doctor’s advice The doctor cannot persuade the young person to inform his / her parents The young person is very likely to begin or continue having sexual intercourse with or without contraceptive treatment Unless s/he receives contraceptive advice or treatment the young person’s mental or physical health or both are likely to suffer The young person’s best interests require the doctor to give contraceptive advice or treatment or both without parental consent

Case Scenario 1 Kelly is 15yr, her boyfriend is 16yr – she was taking the COC but ran out of pills last week, they used condoms but the condom burst last night. Kelly is well informed about EC and spoke to her Mum who advised her to attend the pharmacy as it is a Sunday. Is Kelly Fraser competent?

Case Scenario 2 Jasmin is 14yr and has come to the pharmacy with her 15yr old friend Carley. Jasmin says she is interested in a pill to stop her getting pregnant but she appears not to understand when you talk to her about EC, she then denies having had sex at all and she doesn’t have a boyfriend. Both girls seem quite immature. Is Jasmin Fraser competent?

Safeguarding Issues

The Law in England & Wales The legal principle underpinning provision of care for children is that their best interests are paramount (S.1 Children Act 1989) All health professionals have a duty to act in the best interests of their patients Balance between individual’s rights to privacy & safeguarding children

Sex & the Law Sexual Offences Act 2003 Legal age for SI is 16yr – gay & straight Sex with under 13yr = Rape Health Professionals able to provide sexual health advice & treatment to under 16s provided it is in their best interests

Working Together to Safeguard Children 2006 Health Professionals should do a risk assessment when seeing sexually active young people Age of partner, any coercion, vulnerable young person – learning disability / in care Under 13s – report to social care 13-15s – share information if concerned 16-17yrs – can still be vulnerable

Risk Assessment – issues that alert you to potential problems With the relationship: Big age difference Power imbalance Alcohol & Drugs Coercion Aggression Bribery Excessive secrecy Unprotected sex Multiple partners Social circumstances: Not living at home Parents with problems Not attending school No peer group Staying out all night Self harming Depression Pregnancy

What do you ask ? 1.How old are they? 2.What happened? – when they had sex, any condom or other contraception used? 3.Did they have sex with a regular partner or was it a “one off”? 4.How old is their partner? 5.How long have they been together? 6.How long have they been having sex? 7.Did they feel under pressure to have sex? 8.Were they drunk or stoned at the time?

What to do if you have concerns about a young person Concern may be about: They are 12 or under and sexually active They are too young to be treated under the PGD There is a power imbalance or coercion in their relationship Their own behaviour is putting them at risk They are vulnerable in other ways and their sexual activity is adding to this eg in care / homeless Asking for EHC several times

What to do if you have concerns about a young person Step 1 Inform the young person that you are concerned and that you need to contact someone else for advice Step 2 1. Not Urgent - Discuss with a clinician at SCaSH & Fast Track to Clinic 2. Urgent – Discuss with Safeguarding Helpline / Police

Gold Star Scheme Fast Track into SCaSH For vulnerable young women –Are under 16 –Who have accessed twice or more in 6 months –Who are too young or too late to have EHC to the PGD –Who is already a teenage parent –Who is particularly vulnerable (e.g. homeless/looked after/ asylum seeker or refugee) –There were concerns about the young women’s health or safety

Key contacts SCaSH Safeguarding Helpline Social Services (24hrs 7 days /wk) Police Council 1st stop Howden House pm Mon – Fri

Case Scenario 3 Becky, aged 17yr, attends for EC. She has been using condoms with her boyfriend aged 21yr but last night they got “carried away”. She has been seeing him for 2 months & is really happy, which is good because she was quite depressed last year when her parents split up.

Case Scenario 3 Option A On further exploration you discover that Becky met her boyfriend, Andrew, at college where he attends as part of his building apprenticeship. He has met both her parents and they like him. Becky & Andrew appear to have a close & loving relationship & he has been very kind & supportive.

Case Scenario 3 Option B On further exploration you discover that Becky met Andrew at the youth support group that she attends weekly. She is really flattered that he is interested in her as he is “totally gorgeous & really mature”. He is one of the Youth Workers running the group. Before going out with Becky he was seeing another girl in the group.

Case Scenario 4 Keeley, aged 14yr, attends the pharmacy. She wants emergency contraception as she had sex last night.

Case Scenario 4 Option A On further exploration you discover that Keeley has been going out with David (15yr) for nine months & he is well known to her family. They have only just started having sex and they discussed it beforehand & both felt that they were ready. They have used condoms every time but the condom burst last night. Keeley wants to have an Implanon fitted so she can have extra protection in the future.

Case Scenario 4 Option B You are already a bit worried because Keeley seems a very trusting but vulnerable girl. She says she was at a party and was a bit drunk when she had sex. She didn’t really want to have sex but was persuaded into it by this man – she thinks he is about 20yr.

Case Scenario 5 Gemma is 14yr and had sex last night, she says she needs EC.

Case Scenario 5 Option A Gemma had sex for the first time with her 16yr old boyfriend last night. They have been going out together six months and last night they got “carried away”. Gemma did not feel under pressure to have sex and she wants to arrange some reliable contraception like the pill.

Case Scenario 5 Option B Gemma met some boys yesterday – they are friends of her friend – she thinks they are 18 or 19. She went back to a house with them and ended up having sex with both of them. She says “It took me by surprise, I wasn’t really expecting to have sex with them. It was my own choice to have sex, I wasn’t under pressure to have sex – well not much pressure”