Ethics/medicolegal

Question 1

Where does duty of confidentiality in SH originate from?

Answer 1

A duty of enforcement of confidentiality originates from The Public Health (Venereal Diseases) Regulations 1916

The NHS Code of Confidentiality applies to services managing STIs in England and Wales
with an additional duty of enforcement of confidentiality required by the NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Directions 2000

Question 2

Minimum SH that should be taken (BASHH)

Answer 2

Confirm lack of symptoms
Date of LSC and number of partners in the last three months
Gender of partner(s), anatomic sites of exposure, condom use and any suspected infection, infection risk or symptoms in
partners
Previous STIs
For women: last menstrual period (LMP), contraceptive and cervical cytology history.
Blood borne virus risk assessment and vaccination history for
those at risk
Agree the method of giving results
Establish competency, safeguarding children/vulnerable adults Recommend/consider
Recognition of gender-based violence/intimate partner
violence
Alcohol and recreational drug history

Question 3

Additional safeguarding questions for YP?

Answer 3

. Whether parents/carers are aware of the child’s sexual activity;
. Whether parents/carers are aware of the child’s attendance at the clinic
. Whether the child has ever had non-consensual sexual contact;
. Age of sexual partner(s)
. Vulnerability (e.g. self-harm, psychiatric illness, drug or alcohol misuse, where there is an imbalance of power, e.g. youth workers/teachers, or grooming is likely).

Question 4

Sex in under 13 yo

Answer 4

Where children under the age of 13 years report sexual activity, this should be discussed with a senior colleague
Should be discussed in confidence, with the local child protection lead.
Reporting to social service and the police may be indicated but is not mandatory.
Sex in under 13 is offence under Sexual Offences act 2003
Not legally capable to consent
Classes as rape

Question 5

How does Children’s act define a child?

Answer 5

The Children Act 1989 defines a child as ‘a person who has not yet reached 18 years of age’.

Question 6

GMC definition of children/young people

Answer 6

Children; younger children who lack the maturity and understanding to make important decisions for themselves.
Young people; older or more experienced children who can make these decisions.

Question 7

Can under 16 records be disclosed to parents?

Answer 7

Disclosure of records raises specific issues with young people under 16 years and parental/guardian rights.
Records of competent young people should not be disclosed to parents or others without their explicit consent or a court order.

Where the request is from police or social workers in relation to child protection issues, it is advisable to seek advice from the Trust’s solicitors, regulatory bodies and defence associations.

Question 8

Definition of child sexual abuse from Government publication, Working Together to Safeguard Children (2006)?

Answer 8

Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (e.g. rape, buggery or oral sex) or non-penetrative acts.

They may include non-contact activities, such as involving children in looking at, or in the production of, sexual online images, watching sexual activities, or encouraging children to behave in sexually inappropriate ways.

Question 9

Which age group ie children/YP needs to have a risk assessment to consider CSA?

Answer 9

Working together indicates the need to consider CSA in under 18yo old who are sexually active, and perform a risk assessment on under 16 year olds.

Question 10

Do you have to report sexually active under 13 yo to police/social services?

Answer 10

Working together states that there is a presumption of reporting under 13s to social services and the police. It does not advocate mandatory reporting.

Question 11

Which YP can consent to medical investigation/treatment?

Answer 11

Young people under the age of 16 years can consent to medical examination, investigation and treatment if they have sufficient maturity and judgement to enable them fully to understand what is proposed and its implications

Fraser Ruling when applied to contraception
Gillick competence when applied to wider aspects of care, management and consent.

Question 12

Refusal to test by competent young persons- what to do?

Answer 12

The clinician must weigh up the harm to the rights of the child against the benefits of testing and treatment, so that decisions can be taken in the child’s best interests.

The advice of other members of the multi-disciplinary team, an independent advocate or named/designated doctor for child protection may be helpful.

Legal advice should be sought about whether to apply to the court, if testing is thought to be in the best interests of a competent child who refuses.

Question 13

Refusal of testing by parents of a non-competent child or young person what to do?

Answer 13

If parents refuse testing that is clearly in the best interests of a non-competent child or young person then the clinician should involve other members of the multi-disciplinary team, an independent advocate or named/designated doctor for child protection before seeking legal advice.

This also applies if both a young person with capacity and their parents refuse testing.

Consideration must be given to the fact that the parent who is declining consent may be an abuser.

Question 14

Risks of CSE/CSA

Answer 14

• emotional maturity
• psychological wellbeing
• physical development, e.g. pre- or post-pubertal
• drug or alcohol abuse
• age of partner(s)
• number of partners (current and lifetime)
• disclosure of current or previous sexual abuse or exploitation
• other young people who may be at risk, e.g. siblings/other family members,
  friends, vulnerable adults etc
• social networks and support
• age of young person, with decreasing age causing higher concern.
• homelessness
• out of school
• other, e.g. commercial sex work, internet grooming etc
• physical disability affecting communication
• learning difficulties
• presence of an STI or pregnancy

Question 15

Which groups are at increased risk for STI?

Answer 15

Adolescents
People from, or who have visited countries with high rates of HIV and/or other STIs
MSM
History of frequent partner change or sex with multiple concurrent partners
Early onset sexual activity
Previous bacterial STI
Attendance as a contact of STI
Alcohol or substance abuse
Poor mental health
Prisoners
Sex industry workers
Looked after and accommodated adolescents
Those with learning disability
Those with sexual compulsion and addiction

Question 16

What are behaviour change interventions for safe sex?

Answer 16

Motivational interviewing techniques should be used as part of an intensive course of risk reduction counselling in MSM at high risk of HIV infection

Brief (15-20 minute) evidence based behaviour change interventions - increasing motivation to adopt safer sexual behaviours using techniques such as Motivational Interviewing should be provided as part of routine care of those at elevated risk of STI and HIV in GUM clinics

The delivery of safer sex advice, including condom demonstration, based on the characteristics of effective brief behaviour change interventions, should be part of the routine care of all those at continued risk of infection/transmission in GUM clinics

The provision of accurate, detailed and tailored information on safer sex should form part of all sexual health consultations

Question 17

What advice should be given on condom use?

Answer 17

Advice on condom use should be included in discussion with all clients (Except WSW)

Verbal and written information on:
 condom efficacy and limitations
 condom types, sizes
 determinants of condom effectiveness
 motivation for condom use

Question 18

What advice should be given about condom use for anal sex?

Answer 18

Non-oil based lubricant should be applied all over the condom and inside the anus, but not inside the condom, before anal sex

thicker condoms are no less likely than standard condoms to break or slip off than standard condoms during anal sex

Female condoms can be used as an alternative to male condoms for anal sex

Question 19

Does avoiding brushing teeth or flossing before having oral sex reduces risk of HIV and possibly other infections ?

Answer 19

Yes- Evidence level III, B

Question 20

When might you recommend non latex condoms?

Answer 20

Non-Latex condoms are slightly more likely to break than latex condoms

Use non-latex condoms if you have a latex allergy (or if you are using creams or treatments that damage latex condoms)

Question 21

Condom advice

Answer 21

Use a condom every time you have vaginal, oral or anal sex to minimise the risk of transmission of HIV and STI

Even if you don’t use a condom every time, or for every type of sex, use one as often as possible – this is safer than not at all

Even if you occasionally forget, it does not mean it is not worth using a condom next time

 Non-Latex condoms are slightly more likely to break than latex condoms

o Some men prefer the feel of latex condoms and find that they are less likely to lose erection

o Some men find latex condoms easier to put on
 Female condoms are at least as good as male condoms at preventing STIs
 You get better at using condoms the more you practice

Practising opening and using a condom alone, and in the dark, might make it easier to do when you have sex
 Make sure you use a condom of the right size, as condoms are more likely to split if too tight
o The girth (circumference) may be more important than penis length
o A fitted condom is more likely to slip off during withdrawal
 There is no need to use extra lubricant with condoms for vaginal sex – lubricant increases the chance that the condom will slip off
 It isn’t safe just to use a condom when you ejaculate – infections including HIV are can be passed on without ejaculation
 Using two condoms is NOT better than one as they are more likely to break

Question 22

How to put on a condom

Answer 22

o remove all the air from the condom before putting it on
o hold the condom during withdrawal (pulling out)
o don’t unroll it before putting it on
o put the condom on before you start having sex
o if you put it on the wrong way by mistake, use another one - don’t just flip it over

Question 23

How to use condoms for anal sex?

Answer 23

 Ordinary condoms are no more likely than thicker condoms to break or slip off during anal sex

 Put water based lubricant all over the condom and inside the anus, but not inside the condom, before anal sex

 You can use female condoms instead of male condoms for anal sex:
remove the ring at the end of the condom and place on the penis like a male condom

Question 24

Fraser guidelines- UPSSI

Answer 24

UPSSI
Understands
Parents
Sex
Suffer
Interests
YP understands the advice and has sufficient maturity to understand what is involved

doctor could not persuade the young person to inform their parents, nor to allow the doctor to inform them
YP would be very likely to have sex with or without contraceptive treatment

Without contraceptive advice or treatment, the young person’s physical or mental health would suffer

In the young person’s best interest to give such advice or treatment without parental consent.