Teenager requesting confidentiality about sexual health
Ms. Aroha Williams, 16, attends alone to a youth clinic. She asks whether you will tell her mother she is here. She says she has a boyfriend of four months and they have been sexually active for two months, sometimes without condoms. She has had no period for eight weeks, feels nauseated in the mornings, and reports vaginal discharge but no pain. She is a Year 11 student, lives with her mother, and says her mother "would kill her" if she knew. She is unsure whether she wants to continue the pregnancy if she is pregnant. She has no other medical conditions and takes no medications. She is tearful but engaged.
1. How do you handle confidentiality, and what do you tell her about your obligations?
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Establish the frame first, before any history. Explain clearly that what she discusses is confidential, and that you will not tell her mother without her agreement in most circumstances. Then explain the exceptions honestly and without drama:
- If you believe she is at serious risk of harm (for example, abuse, coercion, or exploitation), you may need to act to protect her, and you would discuss this with her first wherever possible.
- If she is at immediate risk of serious harm to herself or others.
- Statutory reporting obligations if there is evidence of abuse by an adult.
Capacity and consent for her age: In Australia, a minor can consent to their own healthcare if they have sufficient understanding and maturity (the concept of a mature minor). At 16, she is likely to be able to consent to history, examination, testing, and treatment for sexual health. Assess her understanding: does she grasp the implications of testing, of a possible pregnancy, and of her options? Her engagement and clear reasoning suggest she does.
Reassure and build trust: Acknowledge that coming alone was difficult and that her concerns about her mother are understandable. Ask whether there is any coercion, pressure, or age gap in the relationship - this changes the risk assessment and may trigger protective steps.
Document: Record that confidentiality was discussed, the exceptions explained, and her understanding. Note that she asked you not to involve her mother and that you agreed within the stated limits.
Reasoning: The judgement being tested is whether you can hold confidentiality genuinely while being transparent about its limits, and whether you can assess mature-minor capacity rather than reflexively involving a parent.
2. Outline your assessment and immediate management, including how you would approach the question of pregnancy options.
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Assessment:
- Focused history: last menstrual period, cycle regularity, contraception use, number of partners, any coercion, any symptoms of sexually transmitted infection (discharge, dysuria, pelvic pain, bleeding), vaccination status (HPV, hepatitis B), and mental health screen.
- Examination: general, abdominal, and offer a speculum and bimanual examination only if indicated and with her consent; a pelvic examination is not mandatory to investigate possible pregnancy.
- Investigations: urine or serum beta-hCG; if positive, an ultrasound to establish gestation and location; screening for chlamydia and gonorrhoea (urine or self-collected swab), HIV, syphilis, hepatitis B and C; consider full blood count and blood group if pregnancy is confirmed.
Immediate management:
- Confirm pregnancy status before discussing options in detail, but prepare her for the possibility.
- Treat or refer any infection promptly, and offer partner notification support.
- Contraception counselling for the future, including long-acting reversible contraception, and condom use for STI prevention.
- If pregnant, discuss all options non-directively: continuing the pregnancy and parenting, continuing and considering adoption, and termination - with accurate information about gestation limits, referral pathways, and timeframes in her jurisdiction.
- Offer psychological support and a follow-up appointment regardless of her decision.
- If she wishes, support her to involve a trusted adult, but do not make this a condition of care.
Approaching options: Use open questions ("What have you been thinking about so far?"), reflect her ambivalence, avoid steering, and give information in small amounts with checking of understanding. Explore her values, supports, schooling, and fears without judgement.
Reasoning: The exam tests non-directive counselling, accurate clinical process, and the ability to hold a teenager's autonomy while remaining alert to coercion and safeguarding.