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Complex Situations (SLO7)
A 15 year old girl self presents to the Emergency Department seeking contraception. Which of the following criteria from the Fraser guidelines does NOT have to be met for advice or treatment to be given?
Answer:
The ‘Fraser guidelines’ specifically relate only to contraception and sexual health. They are named after one of the Lords responsible for the Gillick judgement but who went on to address the specific issue of giving contraceptive advice and treatment to those under 16 without parental consent. The House of Lords concluded that advice can be given in this situation as long as:- He/she has sufficient maturity and intelligence to understand the nature and implications of the proposed contraceptive advice or treatment
- He/she cannot be persuaded to inform her parents, or will not allow the practitioner to inform her parents, that contraceptive advice or treatment has been sought
- He/she is very likely to begin or to continue having intercourse with or without contraceptive treatment
- His/her physical or mental health (or both) are likely to suffer unless he/she receives contraceptive advice or treatment
- His/her best interest requires the practitioner to give contraceptive advice or treatment without parental consent.
Gillick Competency and Fraser Guidelines
Complex Situations (SLO7) / Sexual Health
Last Updated: 6th September 2022
Age of Consent
In law, a person's 18th birthday draws the line between childhood and adulthood (Children Act 1989 s105) - so in health care matters, an 18 year old has full autonomy. To a more limited extent, 16 and 17 year-olds can also take medical decisions independently of their parents. The right of younger children to provide independent consent is proportionate to their competence - a child's age alone is clearly an unreliable predictor of his or her competence to make decisions.
Gillick competence is the principle we use to judge capacity in children to consent to medical treatment. Fraser guidelines are used specifically for children requesting contraception or sexual health advice and treatment.
Gillick Competency
Victoria Gillick challenged Department of Health guidance which enabled doctors to provide contraceptive advice and treatment to girls under 16 without their parents knowing. In 1983 the judgement from this case laid out criteria for establishing whether a child under has the capacity to provide consent to treatment; the so-called ‘Gillick test’. It was determined that children under 16 can consent if they have sufficient understanding and intelligence to fully understand what is involved in a proposed treatment, including its purpose, nature, likely effects and risks, chances of success and the availability of other options.
If a child passes the Gillick test, he or she is considered ‘Gillick competent’ to consent to that medical treatment or intervention. However, as with adults, this consent is only valid if given voluntarily and not under undue influence or pressure by anyone else. Additionally, a child may have the capacity to consent to some treatments but not others. The understanding required for different interventions will vary, and capacity can also fluctuate such as in certain mental health conditions. Therefore each individual decision requires assessment of Gillick competence.
If a child does not pass the Gillick test, and therefore is deemed to lack the capacity to consent, then the consent of a person with parental responsibility (or sometimes the courts) is needed in order to proceed with treatment. However, there is still a duty to keep the child’s best interests at the heart of any decision, and the child or young person should be involved in the decision-making process as far as possible.
Fraser Guidelines
The ‘Fraser guidelines’ specifically relate only to contraception and sexual health. They are named after one of the Lords responsible for the Gillick judgement but who went on to address the specific issue of giving contraceptive advice and treatment to those under 16 without parental consent. The House of Lords concluded that advice can be given in this situation as long as:
- He/she has sufficient maturity and intelligence to understand the nature and implications of the proposed contraceptive advice or treatment
- He/she cannot be persuaded to inform her parents, or will not allow the practitioner to inform her parents, that contraceptive advice or treatment has been sought
- He/she is very likely to begin or to continue having intercourse with or without contraceptive treatment
- His/her physical or mental health (or both) are likely to suffer unless he/she receives contraceptive advice or treatment
- His/her best interest requires the practitioner to give contraceptive advice or treatment without parental consent.
Health professionals should still encourage the young person to inform his or her parent(s) or get permission to do so on their behalf, but if this permission is not given they can still give the child advice and treatment. If the conditions are not all met, however, or there is reason to believe that the child is under pressure to give consent or is being exploited, there would be grounds to break confidentiality.
Fraser guidelines originally just related to contraceptive advice and treatment but, following a case in 2006, they now apply to decisions about treatment for sexually transmitted infections and termination of pregnancy.
Age-specific considerations
- Under 13s
- There is no lower age limit for Gillick competence or Fraser guidelines to be applied. That said, it would rarely be appropriate or safe for a child less than 13 years of age to consent to treatment without a parent’s involvement. When it comes to sexual health, those under 13 are not legally able to consent to any sexual activity, and therefore any information that such a person was sexually active would need to be acted on, regardless of the results of the Gillick test.
- Under 16s
- Ethical and legal issues that need to be considered when prescribing contraception for a girl under 16 years:
- Explore their understanding, and consider informing young people of the law in relation to sexual activity.
- The legal age of consent to sexual activity is 16 years in the UK.
- Sexual activity under the age of consent is an offence even if consensual.
- Offences are considered more serious (statutory rape) when the person is younger than 13 years of age.
- Reassure her that the consultation is confidential, but explain the circumstances in which confidentiality may need to be breached (for example, suspected child protection issues, exploitation, or coercion).
- Assess her competency to independently consent to treatment, and document in her case notes that she meets (or does not meet) the Fraser Criteria.
- If the Fraser Criteria are not met, consider breaching confidentiality and seeking parental consent.
- Consider child protection issues.
- If non-consensual sex or sexual abuse is suspected, follow appropriate child protection procedures and refer to a paediatrician if necessary. For more information see the CKS topic on Child maltreatment - recognition and management.
- Counsel her on the emotional and physical implications of sexual activity, including the risks and consequences of pregnancy and the risk of sexually transmitted infections (STIs).
- Ethical and legal issues that need to be considered when prescribing contraception for a girl under 16 years:
- 16 - 17 years
- Young people aged 16 or 17 are presumed in law, like adults, to have the capacity to consent to medical treatment. However, unlike adults, their refusal of treatment can in some circumstances be overridden by a parent, someone with parental responsibility or a court. This is because we have an overriding duty to act in the best interests of a child. This would include circumstances where refusal would likely lead to death, severe permanent injury or irreversible mental or physical harm.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
