I have been asked on many occasions why single young people in particular need access to confidential sexual health advice; after all, from a Christian perspective isn’t the answer quite simple – abstinence? Everyone has an opinion on this, and Christians even occasionally tell me sexual health is not a good area for a Christian to be working, despite the fact Jesus spent much of his time associating with the weak and vulnerable and, rather than passing judgement, met them at their point of need with wisdom and compassion. I therefore beg to disagree!

Some readers may feel shocked by the examples given. I wouldn’t suggest I always feel comfortable with the situations I encounter! However, my prayer is for God to enable me to treat people with respect and care, to be aware of spiritual needs, to know when and how to challenge unhealthy choices and behaviour, and refer on where there are child protection concerns.

Let’s first consider Georgina and Sophia, two young people that attended one of my clinics:

Georgina - Pregnant at age 15 and in a hostel for single mums when we first met. Then embarked on several unsatisfactory relationships during which time we tried to help her with acceptable contraception. Now at 24, mother to an attractive and self-assured 9 year old daughter and contemplating social work training.

Sophia - aged 20. I diagnose yet another sexually transmitted infection, - Chlamydia. She had ’crabs’ at 14, and her sixteenth birthday present was a first attack of genital herpes. Our hope is that with our help and support she too will be able to take more control of her life and relationships, while we offer non-punitive health education and necessary treatment.

Both need non-judgemental advice and treatment, but it does sometimes feel like damage limitation. Georgina avoided having a second child while still a teenager, a worthwhile goal since many teenage mums cope well enough with one child but a second precipitates a further slide down the social scale and difficulty coping. As can be seen, with sensitive handling Georgina has been able to effect change in her life not only in halting the downward spiral of further unplanned pregnancy, but in turning her life around to become a ‘giver’, not just a ‘taker’.

Sophia continues to attend the young people’s clinic despite continuing to takes risks in sexual behaviour. Preach to her about the rights and wrongs of her current lifestyle and she would stay away, maybe leaving chlamydia infection undiagnosed and untreated, with their legacy of increased risks of infertility and ectopic pregnancy.

Adolescent sexual activity is increasing world-wide in most societies. The World Health Organisation (WHO) interestingly defines adolescence as age 10 to 24! As parents, carers, health professionals or simply informed members of society, we feel that those under 16, the legal age of consent to sex, are the most vulnerable. It follows therefore that limiting the damage caused by unwanted pregnancy or sexually transmitted infections (STIs) is worthwhile.
What about giving contraception to young people under 16 without informing their parents? Does this contribute to increasing sexual activity? Research suggests not, but is not easy to conduct. Marlene presents some interesting issues:

Marlene – age 13 is brought into the clinic by her aunt who says she wants her on the pill right away. I’ve not met them before. Marlene looks sullen, and during the consultation just looks down at the floor, avoiding eye contact.

What thoughts go through my mind?

• Marlene and her aunt may have different agendas. Is Marlene offended that her aunt thinks she is promiscuous or that she is not old enough to look after herself and make her own decisions about contraception? She does not need parental consent for contraception if I judge her to be able to understand and consent to medical treatment.
• Maybe Marlene is embarrassed but also relieved that she does not have to go to the doctor behind her family’s back.
• Does Marlene actually want or need contraception? Is she sexually active and with whom? How old is her boyfriend? It would help if I could talk with Marlene on her own. An adult can’t force her to have treatment that she doesn’t want.
• What does Marlene feel about sex? She may need ‘permission’ to say no to sexual activity or to end a sexual relationship. But telling her she is ‘too young to be having sex’ is unlikely to change her behaviour.
• Is she under pressure to have sex? I’m starting to wonder if there is a child protection issue here.
• Why has she come with the aunt? Does she have parental responsibility because the mother or father is dead or estranged? Has she stepped in because she thinks Marlene’s parents are ignoring the fact that Marlene has a boyfriend.
• Is the aunt colluding with a male family member or friend who is abusing Marlene? This might explain Marlene’s manner, and the aunt’s urgent request for contraception.
• A scary thought - is she not an aunt at all but a ‘minder’? Could Marlene be involved in prostitution, the ‘aunt’s’ role being to make sure Marlene gets advice and treatment without me suspecting she is being paid for sex?

The Bichard enquiry has encouraged health professionals to be more aware of vulnerable young people and the possibility of coercion into sexual activity. A new NHS campaign called “Respect yourself” invites a young person to consider whether they are ready to be having sex and if they could say ‘no’ (see http://www.ruthinking.co.uk/ ).

What qualities to health professionals need to work in sexual health with young people?

• A survey of young people concluded ‘someone with a smile would help’, something I remind myself about most days! It’s more important than the age or gender of the health professional.
• Good communication skills with young people of both genders and all backgrounds, including those who are ‘looked after’.
• Team working.
• Being (almost) unshockable.
• A good understanding of the limits of confidentiality. Most young people are having consenting sex with another young person of similar age, though this is unlawful if one or both are under 16. They are entitled to the same confidentiality as an older teenager or adult. Being familiar with local child protection procedures and contacts is important on the rare occasions when we have to consider breaking confidentiality because of concern about possible abuse.
• Ability to live with uncertainty so that vulnerable young people are not scared off, but feel they can come back and talk more on a future occasion. Sometimes, on a ‘need to know’ basis, it is helpful to share concerns or uncertainties with a colleague, as well as a silent prayer for God’s wisdom.
  

What about young people from Christian families and those with a church background?

John (16) and Claudette (15) are members of the church youth group, where they have taken an active part in discussions about saving sex for marriage. One evening while John’s parents are out things go further than they intended. Next day Claudette’s worry about risk of pregnancy overcomes her fear of being told off, and she phones the youth leader, who is well clued up about where Claudette can get emergency contraception (morning-after pill).
Like other young people, it’s helpful for Charlotte and John to know where they can get emergency contraception and other sexual health advice, not as an encouragement to have sex but so that they or their friends can pick up the pieces if things don’t go according to plan.

In the USA the trade name for emergency contraception is ‘Plan B’, which is exactly what it is. For those with concerns about how the medication works, it will not terminate an established pregnancy and in most cases prevents fertilisation, in other words acts like many other established methods of contraception, such as the pill. While only 98% reliable it is preferable to the anxious waiting and wondering if Claudette is pregnant, and then the dilemma of what next. It can also create an opportunity for Claudette and John to reconsider, maybe in discussion with the church youth leader as well as the clinic, how they want their relationship to continue, whether they will abstain from sex or whether ongoing contraception would be sensible.

If we are honest, we will know of Christian young people who have had sexual relationships outside marriage. Some have become pregnant as a result. Whilst traditional Christian teaching is that sex before or outside marriage is wrong, the fact is that people do make mistakes that they bitterly regret. Life can be very messy and no one can pretend these decisions are easy. My priority as a healthcare professional is to consider the best interests (including child protection issues) of my patients and to engage with couples such as Charlotte and John, to help them avoid making the same mistakes again.

Pharmacies and sexual health advice

Pharmacists providing emergency contraception without a doctor’s prescription have been accused of encouraging promiscuity and handing out pills like sweets. Not true of course. Neither is the embarrassing scenario of a pharmacy assistant holding up a packet of emergency pills and calling out to the pharmacist in front of the whole queue! Pharmacists have a professional code of conduct and have to complete a training programme that includes sign-posting customers to other services for ongoing contraception and sexual health advice. They should have an area for private conversation with a customer to preserve confidentiality, and be aware of local child protection procedures.

Other health needs of young people

Teenage boys and young men are often reluctant to seek advice. Sexual health services are often the first place a young person attends for health advice without a parent. I, and people like me, are well placed to detect and offer help and advice about other issues such as drug and alcohol use (closely related to other risk-taking activity including sex), smoking, eating problems, mental health problems, etc.

In conclusion…

To quote a colleague I met in Nigeria: “young people are complex; fascinating to work with”. I agree, it’s never boring. A few years ago my attention was drawn to the words of Isaiah 50 verse 4: “The Sovereign Lord had taught me what to say, so that I can strengthen the weary. Every morning he makes me eager to hear what he is going to teach me.” I meet many patients who are weary, distressed, confused. And colleagues who, like myself, struggle to understand and work with the pressures faced by patients and the lifestyle choices made. The fact that the Sovereign Lord can continue to teach us so that we have something to give is profound.

For further discussion:

Should Charlotte and John’s youth leader talk to the church child protection co-ordinator about their situation? If so, the youth leader will have to explain to Charlotte and John why confidentiality cannot be maintained in their situation. How can the youth leader support them in talking with their parents?

How can Christian parents, foster carers and youth leaders encourage young people to live up to Christian values, whilst giving realistic support and advice if they make mistakes?

How do we encourage Christian young people to be honest with each other in, for example, seeking STI (Sexually Transmitted Infection) / HIV tests before marriage if either have been sexually active?

If a young person is raped, could they find someone in the church who would provide appropriate support, including (for a girl) considering such options as emergency contraception or a termination if she is pregnant?

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