A 15-year-old asking for contraception and disclosing coerced sex
A 15-year-old girl attends the evening clinic alone and asks for contraception. She says her boyfriend is 22 and that on two occasions intercourse was "not really what I wanted". She is tearful but articulate, is doing well at school and has no current symptoms. She begs you not to tell her parents; her mother teaches at the local school and her father sits on the hospital management committee. A urine pregnancy test is negative and her last menstrual period was 10 days ago. Your jurisdiction sets the age of consent at 18, and any sexual act involving a child under 18 is reportable to the Child Welfare Committee whether or not it was consensual. The clinic's written policy requires parental consent for "major procedures" but says nothing about contraception, and the medical superintendent has previously asked staff to "avoid anything that embarrasses the institution".
1. What do you do in this consultation, and what do you tell her about confidentiality?
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Start from the clinical facts and the legal frame. She is 15, her partner is 22, and she has described sex that was not fully wanted. Under the law in force, this is a reportable sexual offence against a child regardless of apparent consent, and no assurance of absolute confidentiality can honestly be given. She must hear this from me, in plain language, before anything else happens - what I must share, with whom, and what will happen to her afterwards. Telling her after the fact would be a betrayal that damages her trust in health services for years.
Clinically, her last period was ten days ago, so she may be mid-cycle. She is not pregnant on today's test. Offer emergency contraception now as a precaution if there has been unprotected intercourse in the last 72 hours (levonorgestrel 1.5 mg) or up to 120 hours (ulipristal), and discuss a copper IUD within five days. Assess for HIV and STI risk: if exposure was within 72 hours, start HIV post-exposure prophylaxis after baseline testing, and offer STI screening and hepatitis B vaccination status review. Offer a contraceptive method she can use, including a long-acting reversible method, and condoms.
Assess safety: is she at risk from the boyfriend, from her family if they learn, or from self-harm? Make a safety plan, give her a contact number, and involve a child protection focal point. Document the disclosure in her own words, factually and without interpretation.
2. How do you manage the mandatory report, the parental involvement and the pressure from the institution?
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The report is not discretionary. I make it to the Child Welfare Committee and, as required, to the police, and I tell her I am doing so before I do it, ideally with her in the room or on the phone so she hears what is said. I ask her whether she wants to be present when her parents are told, and who she would like with her; the timing and manner of parental disclosure can be negotiated, but disclosure to parents cannot be avoided when a 15-year-old is at risk.
The institutional pressure must be handled in writing. The superintendent's instruction to avoid embarrassment is not a lawful basis for suppressing a report, and a note recording the request and my reasons for not following it should go into the file and to the medical director. Her father's committee membership creates a conflict of interest and a confidentiality risk; I should not discuss her care with him, and if he approaches me I should say so and refer him to the child protection process. If pressure continues, I escalate to the district health authority or the state medical council.
Refusing contraception would not prevent the sexual activity; it would simply add a pregnancy risk to an already unsafe situation. Providing it is part of protecting her.
Finally, I would propose a written clinic policy: a confidentiality statement that names its legal limits, explicit provision for competent minors to consent to contraceptive and STI care, a mandatory reporting SOP with named responsible staff, private consultation space and staff training.