Managing sexual activity in young people: recognition and criteria for referral (1090)
Scope
Young people under the age of 16 who are engaged in or plan to engage in sexual activity with another person.
Audience
This guidance applies to all Emergency Department (ED) healthcare professionals dealing with young people under the age of 16 who are engaged in or plan to engage in sexual activity with another person. It applies to young people irrespective of their gender or sexual orientation. On the basis of current legislation, this guidance does NOT apply to those aged 12 and under ALL of whom require discussion with a senior ED clinician and referral to Social Work services.
In Scotland the legal age for consent for sexual activity is 16, and it is unlawful for sexual activity to take place with or between young people younger than this (Sexual Offences Scotland Act 2009). However, many young people are engaging in a range of sexual behaviours before the age of 16, including sexual intercourse, with 35-40% of young people having had sexual intercourse before they reach 16.
Sexually transmitted infections (STIs) are common in young people, with around half of all STIs diagnosed in 15-24 year olds. It is estimated that 1 in 10 young people have an STI.
Teenage pregnancy is a concern, with a teenage female having a 90% chance of pregnancy in one year if having unprotected sex.
Sexual activity between young people may be consensual but healthcare professionals have a duty of care to ensure that it is not the result of abuse or exploitation, which the child or young person may not recognise.
Although sexual activity is legal above the age of 16, young people under the age of 18 can be at risk of harm, such as sexual abuse of position of trust or involved in prostitution or pornography.
As well as addressing physical and emotional needs healthcare professionals should consider capacity, consent, confidentiality and child protection when assessing sexually active young people.
The purpose of this guidance is to provide clarification of some of these issues and a framework to facilitate a standardised approach to these young people whilst promoting respectful relationships.
All health care professional dealing with this group have a duty of care to ensure the young person’s health and emotional needs are being met AND to assess whether the sexual activity is abusive or exploitative in any way.
The principles of this guidance are those set out by the UN Convention on the Rights of the Child which state:
- The best interests of the young person are paramount
- Young people should be able to voice their opinion. To facilitate this practitioners need to listen and provide a trusting environment which will encourage young people’s participation
- Health professionals should ensure young people are provided with accurate, age-appropriate information and access to services to enable them to safeguard their sexual health
- Young people should be protected from harm and sexual abuse. Health professionals have a duty of care to appropriately assess information about the nature and circumstances of any sexual activity that comes to their attention.
- Harm reduction/ minimisation through education, support, medical care and the promotion of positive self-esteem to enable the young person to make informed decisions.
Health care professionals should recognise the responsibilities, rights and duties of parents to direct and guide their children
Parents have a right of custody until a child is 16, however this can only be exercised if it promotes the child’s interest.
The young person has a right to seek, consent to and refuse medical treatment provided the health care professional feels the young person is competent to do so. Under the Age of Legal Capacity (Scotland) Act 1991 this requires an assessment by a qualified medical practitioner that the young person understands the proposed treatment and any possible consequences, risks and benefits of that treatment.
Parental consent is NOT required before advice is given to a young person who is deemed to be competent but where possible it is preferable for the young person to have parental support and this should be encouraged where it is safe to do so.
Young people under the age of 16 have the same right to confidentiality as adult i.e. personal information should not be disclosed without consent. Any decision surrounding information sharing is, therefore, dependent on an assessment of current or potential harm to the young person and/ or others.
The young person should be informed how their personal information may be shared within the team and/ or other agencies BEFORE they disclose information they wish to be kept confidential.
Every reasonable attempt should be made to gain consent before disclosing the information to another party.
Where no such child protection concerns exist the confidentiality rights of the young person should be respected.
Any health care professional must be prepared to justify his/ her decision to share information.
Under the Data Protection Act 1998 young people can have access to their medical records subject to a written request for this. Parents are not permitted to see a young person’s health record unless consent is given or the child is deemed too young to understand how to make a request.
There are certain circumstances where practitioners should automatically share child protection concerns, these include:
- If the young person is, or believed to be sexually active and is under 13 years old.
- If the young person is currently 13 or over but sexual activity took place when they were 12 or under.
- If there is any indication the young person is involved in pornography or prostitution
- If the sexual partner is in a position of trust in relation to the young person (note this legislation is applicable to young people up to the age of 18.)
- If the young person is perceived to be at immediate risk
- The sexual activity has been non-consensual
Please also use the risk assessment checklist for sexually active young people. Please note that this guidance does NOT apply to children aged 12 and under, ALL of whom require discussion with a senior ED clinician and referral to Social Work services.
The Sandyford Young Persons’ Team will see sexually active young people (up to the age of 18) for several reasons. The inclusion and exclusion criteria for referral to the Young Persons’ team are set out as below; more information on some specific presentations can be found within this guideline.
Patients can self-refer via the Sandyford website or practitioners can fill in the referral form: YOUNG PERSONS REFERRAL.pdf and send to the Sandyford Young Persons’ Team at Sandyford.Ypteam@ggc.scot.nhs.uk .
Enquires about referral: 0141 211 8146
Inclusion Criteria:
- Risk factors for child sexual exploitation
- These can be found in the guideline Child sexual exploitation, recognition and response: guidance for health staff
- Known child protection concerns and is sexually active
- Sexual assault/abuse (incident occurs >7days ago) AND child is 13 and over AND not willing to report this to the police: can be referred to Sandyford for STI screening and potential referral for counselling.
- If willing to contact police, please use this guidance instead: Child protection pathways where concern for neglect or abuse, RHC ED
- Sexually active and requiring contraception that cannot be provided at RHC
- Symptoms suggestive of a sexually transmitted disease
- Male who has sex with males and is sexually active
- Worried about sexual encounter/possible sexual encounter, requires follow-up STI screening
- Issues with periods/hormones that are having a significant impact on quality of life
- Medically complicated and requiring contraception
Exclusion criteria:
- Child is 12 and under and reports sexual assault
- Acute sexual assault (within 7 days of incident) and aged 13 and over - should be referred directly to Archway rather than using the referral form below, this form may not be picked up for a few days.
- Referrals to Archway can be discussed by calling 0141 211 8175, or the service emailed on archway@ggc.scot.nhs.uk .
- Archway requires that if referring someone aged 13-15 years old, or up to 18 if they have been Looked After and Accommodated, it is a legal requirement that the police are involved. If the young person does not want this, Archway should be called on 0141 211 8175 to discuss options.
- Requiring routine contraception – should discuss with GP
- Requiring emergency contraception – should be dealt with at RHC
- Worries about appearance of genitals
- Gender issues – can be referred to gender services by GP
- Currently pregnant and requesting abortion – should be directed to TOPAR Sandyford Service)
- Please see section Pregnancy for details for how to do this
Please see the NHSGGC guidance, Child sexual exploitation, recognition and response: guidance for health staff for more information on the recognition of CSE and the safeguarding steps that need to be taken.
Please use this guidance in conjunction with the NHSGGC guidance, Child protection pathways where concern for neglect or abuse – RHC ED
Sandyford will see children and young people 13 years old and over who disclose historical sexual assault (>7 days); please note that a NOC will still need to be raised. For children who disclose an acute assault, follow the child protection pathway in the guidance above.
ROUTINE CONTRACEPTION:
Patients routinely requesting contraception such as the OCP should be advised to consult with their GP in the first instance. Advice on barrier contraception should be provided in the interim. If unprotected sexual intercourse (UPSI) is disclosed, consider the need for emergency contraception (EC) and pregnancy testing.
The exception to this would be medically complex patients, who can be referred to Sandyford.
EMERGENCY CONTRACEPTION:
Please see the NHSGGC guidance, Emergency Contraception for indications and exclusions for and types of EC available to adolescents. FSRH guidance recommends that adolescents in need of EC should be offered all 3 methods, including the Copper Intrauterine device (Cu-IUD) (especially because this is the most effective form of EC).
Remember that Levonelle/Emerres (progesterone only EC) has an efficacy window of 72h post UPSI, and ellaOne (ullipristal acetate) has a window of 120h post UPSI. The Cu-IUD is also effective if used within 120h. Both ellaOne and Levonelle/Emerres can be found in the top drawer of the red side of the drug dispensing cupboard in the clean prep room.
If the young person would like a CU-IUD they should phone the main Sandyford line on 01412118130 to ensure they get the CU-IUD fitted within the recommended time frame (120hours post UPSI).
Please see the guidance on pregnancy testing for girls aged 12 years and over for indications and proper documentation.
Young people who are pregnant and do not wish to continue with the pregnancy can be referred to the Sandyford TOPAR services by their GP or can self-refer by calling the Sandyford TOPAR direct line on 0141 211 8620. The line operates Monday-Thursday 8.30am – 7.00pm and Friday 8.30am – 4pm. A voicemail can be left by the young person outwith these times and they will be called back.
In 2021, BASHH published their “National Guideline on the Management of Sexually Transmitted Infections and Related Conditions in Children and Young People”1, which includes data on prevalence, implications for CSA in young people with STIs, guidance on prescribing, and recommendations for service provision.
In the above report, it was determined that between Scotland and England in the years 2009-2014, an average of 6394 individuals under the age of 16 were diagnosed with an STI. In Scotland, 0.8% of these were aged less than 13. Prevalence is much higher in young people 16-19, with 93,713 diagnosed on average per annum. In the under-16’s, the majority of diagnoses are in females, although the difference is less pronounced in the under-13’s; in the under-16s overall, 87% of diagnoses were in females, compared to 62% in the under-13’s. Within the UK, chlamydia remains the most common STI detected in those age 15-24, followed by genital warts, HSV, and gonorrhoea.
Young people who have signs and/or symptoms of an STI can be referred to Sandyford; likewise, if they are concerned about STIs in the context of a past sexual encounter.
Remember to consider the risk of CSA in children presenting with signs of an STI; Section 5 in the BASHH guidelines contains information regarding the significance of individual STIs in relation to sexual abuse.
BBVs that can also be sexually transmitted (hepatitis B, hepatitis C, and HIV) are not discussed in detail in the table below. Please see the BASHH guidelines for implications regarding CSA.
Table: presenting features and CSA implications of STIs in children and young people
|
STI |
Signs and symptoms2 |
Implications for CSA1 |
|
N.gonorrhoea |
Females: can be asymptomatic. Increased vaginal discharge, lower abdominal pain, dysuria, intermenstrual bleeding/menorrhagia (rare), dyspareunia. Males: mucopurulent or purulent urethral discharge, dysuria, testicular or epididymal pain/swelling (rare) Extragenital infections: rectal (may have discharge, perianal pain/bleeding, tenesmus, rectal bleeding), pharyngeal (often asymptomatic but can cause tonsillitis or pharyngitis) |
“If a child presents with confirmed gonorrhoea, the possibility of sexual contact should always be considered and it is likely that the child has been sexually abused. In post-pubertal girls consensual sexual activity should be considered“ |
|
C.trachomatis |
Females: asymptomatic in many. May have vaginal +/- cervical discharge (can be mucopurulent +/- contact bleeding), post coital-bleeding, intermenstrual bleeding, dyspareunia, lower abdominal pain, dysuria, pelvic tenderness, cervical excitation Males: urethral discharge, dysuria Extragenital infections: rectal (may have discharge and discomfort), pharyngeal (usually asymptomatic), conjunctival. Patients can also develop a reactive arthritis |
“If a child presents with a confirmed C. trachomatis infection, the possibility of sexual contact should always be considered and it is likely that the child has been sexually abused. In post-pubertal girls, consensual sexual activity should be considered.” |
|
M. genitalum |
Females: majority are asymptomatic. Can cause dysuria, post-coital bleeding, painful inter-menstrual bleeding, cervicitis, lower abdominal pain Males: majority are asymptomatic. Can cause urethral discharge, dysuria, penile irritation, urethral discomfort, urethritis |
“Research is needed on the prevalence and significance of M.genitalium in children. If M.genitalium is found discuss with a genitourinary physician in case further management is required” |
|
Syphilis |
Syphilis can be congenital or acquired. Acquired syphilis (including that transmitted sexually) classically presents in stages, with a primary, secondary, and tertiary phase. Primary: chancre (usually single, painless, and indurated, non-purulent) Secondary: multi-system . Can present with widespread mucocutaneous rash, mucous patches, condylomata lata, hepatitis, splenomegaly, glomerulonephritis, neurological complications. Latent: asymptomatic stage between secondary and tertiary disease Tertiary: develops many years after initial infection. Comprises gummatous, cardiovascular and neurological complications |
“In a child presenting with syphilis, history, examination and syphilis serology in both the child and mother are needed to determine acquired or congenital disease. Despite the lack of evidence and in view of the fact that syphilis is almost exclusively a sexually transmitted disease in adults, sexual abuse should always be considered if vertical, perinatal or blood contamination have been excluded“ |
|
Anogenital warts |
Often asymptomatic. Can have single or multiple lumps – commonly soft, cauliflower like growths, but can be flat, plaque-like or pigmented. They can cause irritation or discomfort and may bleed. Rarely one may see secondary infection or maceration. |
“A significant proportion of children (31% to 51%) with anogenital warts have been sexually abused. Sexual abuse must be considered in any child presenting with anogenital warts.” |
|
Oral warts |
As above |
“There is insufficient evidence to determine the significance of oral warts in relation to CSA at the current time” |
|
Genital herpes simplex |
May be asymptomatic Local: blistering, painful ulceration, dysuria, vaginal/urethral discharge, tender inguinal lymphadenitis Systemic: fever, myalgia (more common in primary than non-primary/recurrent disease) |
“In children with genital herpes, CSA should always be considered. Autoinoculation needs to be considered” |
|
T. vaginalis |
Females: can be asymptomatic. Causes vaginal discharge (classically described as frothy and yellow), vulval itch, dysuria, offensive odour, vulvitis, vaginitis, “strawberry cervix”, low abdominal discomfort Males: urethral discharge, dysuria, urethral irritation, urinary frequency |
“In girls with a confirmed infection of T. vaginalis, sexual abuse is likely. Consensual sexual activity should be considered” |
|
Bacterial vaginosis* |
Offensive, fishy smelling vaginal discharge – this has a thin, white homogenous appearance, and can be seen to coat the walls of the vagina and vestibule. Not associated with soreness, itching, or irritation. Many are aysymptomatic |
“The finding of BV is currently not helpful in indicating whether abuse has occurred“ (insufficient data exists) |
*Bacterial vaginosis is included as an STI here, as it is included as such in BASHH guidelines. There is debate about whether BV is merely an imbalance in vaginal ecology, or is initiated as a sexually transmitted infection (STI). However, in the BASHH guidance, they state “In pubertal girls, bacterial vaginosis is found in both girls who are both sexually and non-sexually active. However, this is contrary to newer data where no BV was found in young women with no history of vaginal sex, receptive oral sex or receptive digital penetration”.
Dedicated Consultant Paediatrician for Child Protection:
Via RHC switchboard 0141 201 0000
On-call FP/GUM Consultant:
Via Gartnavel switchboard 0141 211 3000
Archway SARC:
The Archway, Sandyford Place G3 7NB: 0141 211 8175
Strathclyde Rape Crisis Centre:
PO Box 53, Glasgow G1 1WE: 0141 552 3200
West of Scotland Social Work
Standby 0141 305 6970/ 6910
Sharedcare Helpline (Sexual Health Advisors):
0141 211 8639
Professional Helpline (staffed by specialist sexual health nurses)
0141 211 8646
Childline Scotland:
For children: 0800 11 11
For professionals: 18 Albion Street, Glasgow: 0870 336 2910