A 15-year-old asking for contraception and then disclosing abuse
A 15-year-old girl comes to a CHPS compound with a friend and asks for "the injection to stop pregnancy". She is 15 years and 4 months, in JHS 2, and has come without a parent. On gentle, private questioning she discloses that she has had intercourse several times with a 28-year-old neighbour who "gives her money and phone credit", the last time two days ago. She begs the nurse not to tell anyone: "my mother will beat me and send me to my grandmother's village." The nurse knows the family well; the mother is a church elder and a member of the health committee. The facility has Depo-Provera, implants, condoms and emergency pills, no social worker, and DOVVSU is at the district capital, 40 minutes away. The nurse is the only trained staff member on duty.
1. What should the nurse tell the girl about confidentiality at the start of the consultation, and why is silence not an option here?
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Confidentiality is real but bounded, and the girl must hear the boundary from the nurse before, not after, she discloses.
The nurse should say plainly, in her own words: everything she shares will stay private between the two of them except when someone is hurting her or she is at risk of serious harm, in which case the nurse has a duty to involve people who can protect her - and the nurse will tell her who those people are and involve her in how it happens.
Why silence is not an option:
- In Ghana the age of consent is 16. Sexual intercourse with a 15-year-old is defilement, not a consensual adolescent relationship, whatever the girl believes about consent. This is a protective, not a punitive, matter - the child is the person the law protects.
- The man is an adult using money and a phone to maintain access to a schoolgirl. That pattern predicts repetition and escalation, and other children may be involved.
- There is a stated risk of physical harm and loss of housing at home, which is itself a safeguarding concern.
Note the distinction the girl will not make herself: the consultation remains confidential as far as her health information goes - it is the abuse, not the contraception, that must be shared. The nurse should not promise absolute secrecy, because that promise would be broken within minutes and would destroy the therapeutic relationship.
2. Set out the clinical and protective actions for this visit, in priority order, and state what the nurse should not do.
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Clinical first - she is in front of you now.
- Emergency contraception: levonorgestrel 1.5 mg as a single dose (or copper IUD if trained and available), given the last exposure was two days ago; explain it does not protect against infection and is not an abortifacient.
- Pregnancy test if there is any doubt about timing of last menstrual period; if positive, this becomes a referral for antenatal care and a much more urgent protective decision.
- STI and HIV: risk assessment, HIV counselling and testing with her assent, presumptive treatment or syndromic management per national guidelines, hepatitis B and tetanus status.
- Ongoing contraception she is asking for - Depo or implant may be appropriate, but do not use it as a substitute for the safeguarding response.
- Injuries: ask, and only examine with her agreement and a chaperone; do not perform a forensic examination unless trained and the correct chain-of-evidence procedure is in place.
Protective, in parallel:
- Contact DOVVSU and/or the Department of Social Welfare the same day; the referral is not optional and does not require the mother's permission.
- Agree with her a safety plan and a safe place for tonight; she must not be sent back into a situation where she is beaten or thrown out as the price of disclosing.
What not to do: do not confront the man or the mother yourself, do not promise secrecy, do not delay the report until a 'convenient' time, and do not let her leave without a named person who knows.
3. How should the nurse handle the mother, the community position of the family, and the record - knowing the mother sits on the health committee?
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The mother is told because the child needs protection, but the nurse controls what is shared and why.
- Involve the girl in the conversation as far as possible: who is told, and what. If she fears violence at home, the disclosure to the mother should be made with the social welfare officer or DOVVSU present, or into a safety plan already agreed, not as a bare phone call that sends her home to a beating.
- Frame it protectively: "Your daughter came to me for help and I am obliged to keep her safe. This is about a man who has committed an offence against her." Avoid moralising, which drives families to punish the child and lose the case.
- Conflict of interest must be named, not ignored. The nurse is a health worker first and a family friend/committee acquaintance second. Where the personal relationship could compromise objectivity, the nurse should hand over the protective referral to a colleague or the sub-district supervisor and say so in the record.
- Community pressure from a church elder or health committee member must not change the clinical or legal action. If pressured, the nurse documents the pressure and refers the matter upward to the district health directorate.
Documentation: factual, non-judgemental, dated and timed - what was requested, what was disclosed in the girl's own words, examination findings, emergency contraception given, tests done, referrals made and to whom, who was informed and the girl's stated wishes. The record is her protection and the nurse's.