Simulated Patient (Role-Player) Brief

Persona & manner

You are Maya Okafor, 15, in Year 11. Bright and polite, but nervous, you booked this yourself and you’re worried about being judged or “told off”, and frightened the doctor will phone your mum. You speak confidently once you feel safe; if the doctor is brusque, rushed or disapproving you become guarded, give short answers and glance away from the camera. You are alone in your bedroom, door shut, no one else home. Not distressed at baseline, you’ve thought about this and decided to be sensible.

Opening statement (say exactly)

“Hi… um, I wanted to ask about going on the pill. Is that something you can sort out, or do I need to go somewhere else?”

History to give if asked (reveal naturally, roughly this order)

Why now

• You have a boyfriend and have started having sex. You want reliable contraception so you don’t get pregnant.
• When you started: “A couple of weeks ago. Twice.” (If the doctor is warm, say this readily; if cold, minimise: “not really, well, once.”)
• You used a condom both times (“He used one. I made him.”). You want something more reliable as well as condoms.
• Periods started at 12, regular every 28–30 days, last menstrual period (LMP) ~10 days ago, not heavy, no problems.
• Last sex ~5 days ago, condom used, did not break or come off.

Relevant negatives if asked

• No unprotected sexual intercourse (UPSI), condom every time, stayed on, didn’t split. No episode needing emergency contraception (EC).
• No vaginal discharge, pain, abnormal bleeding or urinary symptoms.
• No migraines, no aura, no severe headaches, occasional ordinary headaches only.
• Asthma fine, rarely uses the inhaler. No other medical problems, no other medicines, no herbal remedies, no St John’s Wort.
• Non-smoker. Alcohol only occasionally at parties. No recreational drugs.
• Mood okay, no self-harm, no thoughts of harming yourself.

Background

• Lives with mum and younger brother; parents separated, sees dad some weekends. Gets on okay with mum, “she’d just freak out about the boyfriend thing.”
• Doing GCSEs, predicted decent grades, no bullying, attends regularly.

Hidden / second agenda, the partner’s age (the child sexual exploitation [CSE] safeguarding crux)

• Your boyfriend is 19. You met through your older cousin ~4 months ago. He works shifts at a warehouse. You think the relationship is normal and you “really like him.”
• From your point of view it is consensual and NOT frightening: he has never forced, threatened or hurt you, never made you do anything you didn’t want, never given you money, alcohol, drugs or expensive gifts for sex. No online/stranger element, you met through family.
• BUT you are 15 and he is 19, and you haven’t told your mum his real age (she thinks he’s “a boy from school”). You’re embarrassed about the gap and scared the doctor will “make a big deal of it” or call the police.

Reveal rule (mandatory)

• Do NOT volunteer his age. If asked only “do you have a boyfriend?”, say “yes” and stop.
• Reveal his age (19) ONLY if the candidate asks directly and naturally about the partner (“how old is he?”, “tell me about him”, “how did you meet?”) AND has done something to make you feel safe first (explained confidentiality, or been warm rather than interrogating). If asked coldly/tick-box, give his age but become more guarded: “is that a problem?”
• If the candidate NEVER asks about his age or how you met, do NOT reveal it.
• If, after learning he’s 19, the candidate screens sensitively (does he ever frighten you, ever made you do anything you didn’t want, gifts/money, where you met, who else knows), answer honestly and reassuringly: not coercive, met through family, no gifts/money, never frightened or pressured. You still consider it your own choice.
• If the candidate explains they must share this with someone at the practice to keep you safe, you are initially alarmed (“please don’t tell my mum”) but can be reassured if they explain who and why clearly.

Cues to drop

• “You’re not going to tell my mum, are you?” (confidentiality, drop early)
• Slight hesitation/looking away when asked about the boyfriend: “he’s… a bit older” (soft age-gap cue, only if asked)
• “He’s really nice, he’s not like… it’s not weird or anything” (defensiveness if the tone hardens)

Good vs poor consultation

• GOOD (confidentiality explained early, warm, non-judgemental, open questions, gentle coercion screen): you relax, disclose his age, answer the safeguarding screen honestly, and accept the plan including sharing with the safeguarding lead once it’s explained kindly.
• POOR (rushed, disapproving, moralising, threatens to call your mum, skips confidentiality): you shut down, minimise the sexual history, do NOT volunteer his age, and may say “actually, never mind” / “can I just get the pill or not?”

Findings you can provide (remote, video)

• On camera: you look well, calm, no distress, normal speech, no visible injury. Clearly alone, door shut.
• Audible: normal voice, no breathlessness.
• At home: you do NOT have a blood-pressure machine or thermometer. You know your rough weight (≈58 kg) and height (≈163 cm) from a recent PE class, so can give an approximate BMI if guided, but have no BP reading.
• You CANNOT provide anything needing a clinician (this case needs no examination).
• If asked for a current blood pressure: “I haven’t got one of those machines at home.”

Response to a face-to-face offer

• Classification: OVER-CAUTIOUS regarding a full face-to-face GP appointment. No examination is needed; competence, history, confidentiality and the safeguarding decision can all be done by video. A blood-pressure reading IS required before a combined hormonal contraception (CHC) prescription, a quick nurse/pharmacy check, not a clinical red flag, so it does not warrant a full GP review.
• Obstacle if pushed to attend in person: “Do I have to come in? I don’t really want to keep coming to the surgery, someone might see me, and my mum books the appointments.”
• Trigger to agree to a quick BP check (not a full appointment): agrees readily if told “I just need a blood-pressure reading before that particular pill, the nurse can do it in two minutes, or you can use the machine in the pharmacy.”

Verbatim push-back:

“I’d rather not come in if I don’t have to, can’t you just sort it now?”

Verbatim agreement:

“Oh, okay, if it’s just a quick blood-pressure thing with the nurse, that’s fine.”

Questions you are likely to ask

• “Are you going to tell my mum?”
• “Can I just have the pill today?”
• “Is my boyfriend going to get in trouble?” (only if his age has come up)
• “Will the pill make me put on weight / give me spots / mess up my periods?”
• “Do I still need to use condoms if I’m on the pill?”

Actor latitude

• LOCKED (must not vary): you are 15; boyfriend 19; met through your cousin ~4 months ago; relationship NOT coercive (no force, threats, gifts/money/substances-for-sex, not frightening, no stranger-grooming); condoms used every time and never failed (so no EC, pregnancy reasonably excludable); periods regular, LMP ~10 days ago; mild asthma; no migraine; non-smoker; the reveal trigger for his age; the confidentiality fear; ICE (Ideas, Concerns and Expectations) positions; the OVER-CAUTIOUS classification and the quick-BP-check agree-trigger; the verbatim opening line.
• FLEXIBLE: exact wording of answers and push-back; how guarded vs open within range (driven by the candidate’s warmth); order of secondary disclosures; small talk about school/GCSEs/your brother; phrasing of your worry about your mum.
• Tone: a real, slightly nervous 15-year-old who has plucked up the courage to come, not a script-reader.

Part A, Examiner Marking Guide

Archetype: ethics/safeguarding with a hidden agenda. Centre of gravity = Relating to Others, then Data Gathering; Clinical Management is judged on the competence/confidentiality/safeguarding procedure and safe, non-coercive method choice.

Working diagnosis: a Fraser-competent 15-year-old requesting contraception who is sexually active with a 19-year-old partner, a contraception request PLUS a child-safeguarding (CSE risk-assessment) situation driven by the age/power differential. Differentials to weigh: coercion/exploitation (screen, here reasonably excluded as overt abuse but NOT as a safeguarding concern given the age gap); pregnancy/EC need (low); sexually transmitted infection (STI) risk; lack of competence (excluded after assessment).

Must not miss: the 19-year-old partner, a safeguarding concern that must be recognised and shared with the practice safeguarding lead even when reported as consensual.

Domain 1, Data Gathering & Diagnosis

Positive indicators: opens with an open question and confirms she is alone before sensitive questioning; takes a sensitive sexual history (sexually active, condom use, last UPSI, LMP) sufficient to assess pregnancy risk and EC need; asks directly but warmly about the partner (“how old is he? how did you meet?”); screens the contraceptive-relevant history, migraine/aura, smoking, venous thromboembolism (VTE) or family history, asthma, current medicines (the UK Medical Eligibility Criteria for Contraceptive Use [UKMEC]-relevant points).

Required screen (the “must-do” sweep): partner’s age and the age/power differential; how they met; coercion (force, threats, fear, pressure); transactional element (gifts, money, alcohol, drugs); whether any trusted adult knows; pregnancy/EC need; STI risk.

Negative indicators: goes straight to “which pill?” and never explores the partner; never asks his age; turns the history into an interrogation so Maya shuts down; forgets to confirm pregnancy risk / EC need.

Calibration anchor

• Clear Pass: open question; checks she’s alone; takes the sexual history fluently and non-judgementally; spontaneously asks his age and how they met within ~6 minutes; runs the coercion screen as a connected, caring sweep; confirms pregnancy risk low and no EC needed.
• Pass: gets the key facts including his age, but only after a list-like run or prompted by Maya’s hesitation cue; coercion screen completed but mechanical; pregnancy/EC addressed.
• Fail: sexual history thin; asks IF she has a boyfriend but not his age, or asks his age but does no coercion screen; pregnancy risk not clarified.
• Clear Fail: no structured history; anchors on “she just wants the pill”; partner/age-gap never explored; no safeguarding screen; may proceed to prescribe with no risk assessment.

Domain 2, Clinical Management & Medical Complexity

Positive indicators

• Assesses Fraser competence: Maya understands the advice; cannot be persuaded to involve a parent (explored, not assumed); is likely to continue having sex regardless; her health would suffer without contraception; treating her is in her best interests. Concludes she is competent.
• Frames confidentiality AND its limits early: confidential, with the explicit caveat that information may be shared if there is a serious risk to her safety.
• Makes the safeguarding decision correctly: the age/power differential is a recognised concern even when reported as consensual, so shares with the practice safeguarding lead / named professional, normally with Maya’s knowledge. (Under-16 sex is unlawful; mutually-agreed similar-age activity is usually not prosecuted; the 4-year gap shifts this toward a CSE risk assessment.)
• Offers informed choice without coercion: highlights long-acting reversible contraception (LARC) as most effective (the progestogen-only implant is UKMEC 1, intrauterine contraception [IUC] is UKMEC 2 at her age), with the combined oral contraceptive (COC) / progestogen-only pill (POP) as common choices; she may choose the pill.
• Prescribes safely: first-line COC = monophasic 30 micrograms ethinylestradiol + levonorgestrel or norethisterone, with a current BP and BMI before a CHC prescription (on-file BP >12 months old), so either arrange a quick BP check or start a POP/condoms now; states the start rule and additional-cover. Continues condoms; offers chlamydia screening (under-25); confirms EC not needed; books review within 3 months; safety-nets.

Negative indicators: doesn’t assess Fraser competence, or assumes it from age/articulacy without checking whether she can be persuaded to involve a parent; promises unconditional confidentiality then has nowhere to go when the age gap emerges; EITHER over-reacts (automatic police, breaches confidentiality to the mother, refuses contraception) OR under-reacts (“she says it’s fine, so no action”); prescribes CHC with no current BP and no plan to obtain one; or refuses all contraception pending safeguarding, leaving her at pregnancy risk.

Calibration anchor

• Clear Pass: explicitly works through Fraser competence; frames confidentiality-with-limits up front; on learning he’s 19, calmly explains why this needs sharing with the safeguarding lead and reassures Maya without abandoning her; provides her chosen method safely (correct first-line COC + arranges current BP, or POP/condoms now), continues condoms, offers chlamydia screening, books 3-month review, safety-nets. Holds the safeguarding line AND keeps her engaged.
• Pass: a safe, broadly correct plan, competent, confidential-with-limits, shares appropriately, prescribes safely, with one gap (e.g. forgets current BP before CHC, or safeguarding rationale thin).
• Fail: prescribes unsafely (CHC, no BP/plan), OR mishandles safeguarding (no sharing, or breaches to mother / refuses care), OR omits confidentiality limits.
• Clear Fail: prescribes on autopilot with no competence assessment, no confidentiality framing and no recognition of the age-gap concern; or refuses to help and threatens to tell her mother.

Face-to-face decision (OVER-CAUTIOUS regarding a full GP appointment)

• Positive, concludes the assessment by video; if CHC is chosen, arranges a quick, discreet BP check (nurse/pharmacy) rather than a full appointment; safety-nets.
• Negative, insists Maya attend in person “to be examined” when no examination is indicated (over-medicalising, a barrier to a nervous young person); OR starts CHC with no BP and no plan to obtain one.

Domain 3, Relating to Others

Positive indicators (micro-skills, with case-specific examples)

• Agenda-setting/signposting: “I’d like to ask a few questions, and we’ll definitely sort out a plan for contraception today.”
• Naming and addressing the confidentiality cue early: “What you tell me is confidential. I won’t be ringing your mum. The only time I’d ever need to share something is if I were worried about your safety, and I’d talk to you first.”
• Non-judgemental throughout, does not moralise about her being sexually active or about the relationship; treats her as the decision-maker.
• Picking up and gently exploring the age-gap cue rather than ignoring or pouncing on it: “you mentioned he’s a bit older, how old is he? … thanks for telling me.”
• Shared decision-making: lays out options including LARC and supports her choice without pressure.
• When sharing with the safeguarding lead becomes necessary, does it WITH her, framed as safety not betrayal, and checks how she feels.

Negative indicators: disapproving or moralising tone; ignores the confidentiality worry or over-promises total secrecy; handles the age-gap disclosure with alarm, lecturing or immediate police talk so she regrets disclosing; talks past her as a child to be managed.

Calibration anchor

• Clear Pass: warm, unhurried, non-judgemental; addresses “will you tell my mum?” in the first couple of minutes with confidentiality-and-its-limits; makes Maya feel safe enough to disclose his age and answer the coercion screen honestly; when sharing becomes necessary, frames it as protection, does it transparently with her, and she leaves feeling supported.
• Pass: generally warm and non-judgemental; addresses confidentiality and the partner; Maya stays engaged, though one or two moments feel rushed or awkward.
• Fail: clinical or faintly disapproving tone; confidentiality mishandled; the age-gap conversation alienates Maya so she partly withdraws.
• Clear Fail: judgemental or dismissive; threatens to tell her mother or treats her like a wrongdoer; Maya shuts down and the relationship collapses.

Clear Pass discriminator

Clear Pass candidates do two precision moves a borderline Pass misses. First, they frame confidentiality-with-its-limits BEFORE the sexual history, so the later information-sharing is consistent with what they promised, not a broken confidence. Second, on learning he is 19, they neither under-react (“she says it’s fine”) nor over-react (police/tell mum), but name it plainly as a safety matter, involve the practice safeguarding lead WITH her, and keep delivering her contraception. Pass candidates do the safeguarding OR the rapport well; Clear Pass candidates do both at once.

Part B, Model Consultation & Management

Timing: agenda + confidentiality + history by ~minute 6; competence + ICE + safeguarding explanation by ~minute 9; method + prescription + safety-net + close by minute 12.

B1. Explain the situation (after history, before management)

“Thanks for being so honest, Maya. From what you’ve told me, you understand what you’re asking for and why, so I can help you with contraception even though you’re 15, that’s allowed, and lots of people your age make sensible decisions like this. There’s one thing I want to talk through, which is the age difference with your boyfriend, because part of my job is making sure you’re safe. Is it okay if we cover that and sort out your contraception today?”

Check understanding: “Does that sound fair?”

B2. Respond to ICE (at the start of management)

• Idea (“the pill is sensible”): “You’re right that thinking about reliable contraception is sensible, and there are a few good options.”
• Concern (telling mum / getting him in trouble): “This is confidential, I’m not going to ring your mum. I do need to be straight with you: because there’s quite an age gap, I have to talk to a colleague here whose job is keeping young people safe. That’s not about getting anyone arrested or punishing you, it’s making sure no one’s taking advantage of you, and I’ll do it with you, not behind your back.”
• Expectation (contraception today): “And yes, we can sort out contraception for you today.”

B3. Management plan

1. a) Shared decision-making (verbatim)

“The most reliable methods are the implant or a coil, small, nothing to remember, and fine for someone your age. Then there’s the pill, which lots of people choose. What would you like to hear more about?”

1. b) Non-drug measures

• Continue condoms every time, the pill does not protect against infection.
• Offer chlamydia (and wider STI) screening, recommended for everyone under 25 who is sexually active.

1. c) Medication, Layer 1: what to say to the patient (verbatim)

If she chooses the combined pill:

“The combined pill is very effective if you take it regularly, it stops you releasing an egg.”

“For this pill I need a recent blood-pressure reading, and the one on file is over a year old. Quickest is a two-minute check with our nurse, or the free machine in most pharmacies. Once I’ve got that, I can prescribe it.”

“One pill at the same time each day. If you start within the first 5 days of your period you’re covered straight away; any other time, use condoms as well for the first 7 days.”

“Stop it and contact us if you get bad one-sided calf pain or swelling, chest pain or breathlessness, or a sudden severe headache or migraine with flashing lights or numbness, rare but important.”

“If it doesn’t suit you, come back and we’ll switch you.”

If she prefers to start today without waiting for a BP:

“The progestogen-only pill, the ‘mini-pill’, doesn’t need a blood-pressure check first, so you could start it today.”

“One every day, ideally the same time. Use condoms as well for the next 2 days.”

“Do you have any peanut or soya allergy?” (No, per history.)

Layer 2: prescription detail table

Explicitly NOT prescribed:

• No CHC until a current BP is checked, prescribing CHC blind to BP is unsafe.
• No emergency contraception, not indicated (condoms used every time and did not fail; LMP ~10 days ago; pregnancy reasonably excludable).

Suggested combination for this patient: “Continue condoms every time, offer baseline chlamydia screening, and either (a) start a progestogen-only pill (desogestrel 75 micrograms or a traditional POP) immediately with 2 days’ condom back-up, or (b) if she prefers the combined pill, prescribe a 30 micrograms EE + LNG/NET monophasic COC once a quick nurse/pharmacy BP is documented. Highlight the implant/coil as the most effective options, without pressure.”

1. d) Follow-up

• Review within 3 months to check tolerance, correct use and side effects, and revisit method choice. “Come back any time sooner if there’s a problem.”

1. e) Safety-netting (verbatim)

“If you ever have unprotected sex, or a condom splits, contact us straight away, emergency contraception works best the sooner it’s used.”

“If you miss pills, ring us or check the leaflet and we’ll tell you whether you need extra precautions or emergency contraception.”

“On the combined pill, if you get calf pain/swelling, chest pain, breathlessness or a sudden severe headache, stop it and contact us, or call 999 if severe.”

“If anything in the relationship ever changes, if he pressures you, frightens you, or it stops feeling okay, come straight back to me.”

1. f) Health promotion

• Confirm HPV vaccine done; where to get free condoms and EC locally; brief, light alcohol awareness.

1. g) Referral

• Discuss with the practice safeguarding lead (named GP for child protection), the age gap, the coercion-screen findings, Maya’s awareness and the plan. Signpost to the local young people’s sexual health service for LARC fitting and discreet ongoing access. “I’ll talk to our safeguarding colleague, who’ll help me make sure you’re safe, and I’ll keep you in the loop.”

B4. Ideal close

“So: contraception sorted today, condoms to keep using, a quick blood-pressure check if you go for the combined pill, a chlamydia test if you’re happy, I’ll speak to our safeguarding colleague to keep you safe, and I’ll see you in three months, but come back any time. Does that all make sense?”

Part C, Golden History-Taking Questions

1. “What made you decide to come in today, tell me what you’re hoping for?”
2. “Before we go on, are you somewhere private where you can talk freely?”
3. “Just so you know, this is confidential, I won’t tell your mum. The only time I’d ever share anything is if I was worried about your safety, and I’d talk to you first. Is that okay?”
4. “Are you having sex at the moment, or thinking about starting? And when you have, have you used anything like condoms?”
5. “When was your last period? Was it normal for you?”
6. “Has there been any time you’ve had sex without protection, or a condom that split?”
7. “Tell me about your boyfriend, how old is he, and how did you two meet?”
8. “Does he ever frighten you, or pressure you into things you don’t want to do? Has anyone ever given you money, gifts, alcohol or drugs for sex?”
9. “Does anyone you trust know about the relationship, your mum, an aunt, a friend?”
10. “Do you ever get migraines, headaches with flashing lights, or numbness beforehand? Do you smoke?”
11. “Any medical problems or medicines apart from your asthma inhaler? Any family history of blood clots?”
12. “Would you rather something you take every day, or something you don’t have to think about like an implant?”

Part D, Night-Before Management Checklist

☐  Confidentiality + its limits framed early

☐  Fraser competence assessed

☐  Sexual/pregnancy/EC history taken

☐  Partner’s age established

☐  CSE/coercion screen done

☐  Safeguarding lead involved

☐  Method chosen via shared decision (LARC highlighted, no coercion)

☐  First-line COC = 30 micrograms EE + LNG/NET; current BP/BMI before CHC

☐  Condoms for STI + chlamydia screen offered

☐  Safety-net (EC, missed pills, VTE symptoms, relationship change)

☐  3-month review

Part E, Case Variations

13. Unprotected sex / condom failure 2 days ago → an emergency-contraception case: offer all methods including the Cu-IUD (most effective, offered regardless of age); if oral, choose the ulipristal acetate emergency contraceptive (UPA-EC) versus the levonorgestrel emergency contraceptive (LNG-EC) by timing/ovulation risk; quick-start ongoing contraception (immediately after LNG-EC; delay 5 days after UPA-EC). Pregnancy risk and the safeguarding screen still apply.
14. Partner is also 15 (consensual, met at school) → competence and contraception unchanged; safeguarding threshold lower, mutually-agreed similar-age activity is not usually prosecuted, but still carry out a proportionate risk assessment.
15. Patient is 12 (under 13) → entirely different: under-13s cannot legally consent; a presumption-to-share situation, escalate promptly to the safeguarding lead / social care alongside any care.
16. Coercion disclosed (older partner, gifts/money, fear, met online) → CSE confirmed; urgent safeguarding referral to the named professional / social care / police pathway; contraception/EC still provided; confidentiality lawfully overridden in her best interests, explained where safe.
17. Not Fraser-competent (doesn’t understand, can’t weigh it up, or is being pushed) → do not prescribe on her sole consent; keep the consultation confidential unless safety requires otherwise; work to involve a parent/appropriate adult; still address safety and offer condoms/EC.
18. Migraine with aura emerges → CHC is UKMEC 4 (contraindicated); steer to POP/implant/IUD.

Part F, Why Candidates Fail This Case

• Trap: going straight to “which pill?” and never asking the partner’s age → fails Data Gathering (and the whole case). Fix: always take a sexual history that includes who the partner is, “how old is he, and how did you meet?”, and run a coercion screen.
• Trap: promising total, unconditional confidentiality → fails Clinical Management / Relating to Others when the age gap forces sharing. Fix: frame confidentiality with its safety limits up front, before the sexual history.
• Trap: on hearing “he’s 19”, either shrugging it off or over-reacting (police / telling mum / refusing contraception) → fails Clinical Management. Fix: name it as a safety matter, involve the practice safeguarding lead with her, and still provide her contraception.
• Trap: prescribing the combined pill with no current blood pressure and no plan to get one → fails Clinical Management. Fix: obtain a quick nurse/pharmacy BP before CHC, or start a POP/condoms today.
• Trap: a disapproving or interrogating manner that makes a nervous 15-year-old shut down → fails Relating to Others and Data Gathering. Fix: be warm, unhurried and non-judgemental; pick up cues gently rather than pouncing.

Part G, Revision Card

15 year old wants the pill, attends alone; tests Fraser competence, confidentiality limits, and a child sexual exploitation (CSE) screen.

Diagnosis: Fraser-competent 15-year-old requesting contraception, sexually active with a 19-year-old partner, a contraception request plus a safeguarding concern. Differentials to consider: coercion/exploitation; pregnancy / emergency contraception (EC) need; sexually transmitted infection (STI) risk.

Must-ask history, 8 golden questions

• “What are you hoping for today?”
• “Are you somewhere private where you can talk freely?”
• “This is confidential, I won’t tell your mum. The only time I’d share anything is if I were worried about your safety, and I’d tell you first. Okay?”
• “Are you having sex, and have you used condoms?”
• “When was your last period? Any sex without protection, or a split condom?”
• “Tell me about your boyfriend, how old is he, and how did you meet?”
• “Does he ever frighten or pressure you? Has anyone given you money, gifts, alcohol or drugs for sex?”
• “Any migraines with aura? Do you smoke? Any clots in the family?”

Red flags to screen actively

• Partner’s age / power differential (the crux)
• How they met (rules out online grooming)
• Coercion: force, threats, fear, pressure
• Transactional element: gifts, money, alcohol, drugs
• Whether any trusted adult knows
• Pregnancy / EC need; STI risk

ICE, what to address and the phrase to use

Order is fixed: Idea, then Concern (validate first), then Expectation.

• Idea (the pill is sensible) → “You’re right that thinking about reliable contraception is sensible.”
• Concern (you’ll tell mum / get him in trouble) → “This is confidential, I’m not ringing your mum. Because there’s an age gap I do need to speak to a colleague whose job is keeping young people safe, not to punish anyone, and I’ll do it with you, not behind your back.”
• Expectation (contraception today) → “And yes, we can sort out contraception for you today.”

Management, say this

• Face-to-face: OVER-CAUTIOUS, do not insist on a full appointment; no exam needed. A blood-pressure reading is needed only before combined hormonal contraception, use a quick nurse/pharmacy check.
• Explain: “You understand what you’re asking for, so I can help even though you’re 15.”
• First-line: Combined oral contraceptive, levonorgestrel 150 micrograms + ethinylestradiol 30 micrograms (or norethisterone 500 micrograms + ethinylestradiol 30 micrograms), one tablet OD. Start Day 1–5 = immediately effective; any other time = condoms 7 days. Needs current BP first. Stop and seek help if calf pain/swelling, chest pain, breathlessness, or sudden severe headache/aura.
• Add-on / start-today option: Progestogen-only pill (desogestrel 75 micrograms), no BP needed; condoms for 2 days. Check soya/peanut allergy.
• AVOID: combined hormonal contraception with no current BP, unsafe; EC, not needed here.
• Lifestyle: condoms every time (STI protection); offer chlamydia screen (under-25).
• Follow-up: review at 3 months, tolerance, correct use, method choice.

Safety-net, exact triggers

• 999/ED: sudden severe headache, chest pain, breathlessness, or calf pain/swelling on the pill
• Same-day GP/111: unprotected sex or split condom (EC works best early)
• Earlier review: missed pills; relationship changes, pressure, fear, or it stops feeling okay

The pivot

A relationship the young person calls consensual can still be a safeguarding concern purely because of the age gap.

Clear Pass move

Frame confidentiality-with-its-limits before the sexual history, then on hearing “he’s 19” neither shrug nor over-react, name it as safety, involve the safeguarding lead with her, and still prescribe.

Anchor phrase

“It’s confidential, I won’t tell your mum, unless I’m worried about your safety, and then I’d tell you first.”

Important Disclaimer

This MedDigest consultation is a fictional case, created for educational and revision purposes only. It should not be used for clinical decision-making or as a substitute for your own clinical judgment.

This content is an independent educational resource designed by MedDigest to illustrate clinical principles. It has not been produced, reviewed, or endorsed by NICE or the Royal College of General Practitioners.

Medicine is constantly evolving. For definitive recommendations, always refer to the latest official guidelines and your local clinical protocols.

MedDigest and its authors cannot accept responsibility for any loss or injury resulting from the use of the information contained herein.

References

Clinical guidance

Faculty of Sexual and Reproductive Healthcare (2017, amended 2026) FSRH Clinical Guideline: Emergency Contraception. London: Faculty of Sexual and Reproductive Healthcare. Available at: https://www.fsrh.org/standards-and-guidance/ (Accessed: 31 May 2026).

Faculty of Sexual and Reproductive Healthcare (2019, amended 2023) FSRH Clinical Guideline: Combined Hormonal Contraception. London: Faculty of Sexual and Reproductive Healthcare. Available at: https://www.fsrh.org/standards-and-guidance/ (Accessed: 31 May 2026).

Faculty of Sexual and Reproductive Healthcare (2022, amended 2026) FSRH Clinical Guideline: Progestogen-only Pills. London: Faculty of Sexual and Reproductive Healthcare. Available at: https://www.fsrh.org/standards-and-guidance/ (Accessed: 31 May 2026).

Faculty of Sexual and Reproductive Healthcare (2023, amended 2025) FSRH Clinical Guideline: Intrauterine Contraception. London: Faculty of Sexual and Reproductive Healthcare. Available at: https://www.fsrh.org/standards-and-guidance/ (Accessed: 31 May 2026).

Faculty of Sexual and Reproductive Healthcare (2016) UK Medical Eligibility Criteria for Contraceptive Use (UKMEC). London: Faculty of Sexual and Reproductive Healthcare. Available at: https://www.fsrh.org/standards-and-guidance/ (Accessed: 31 May 2026).

Faculty of Sexual and Reproductive Healthcare (2019) Contraceptive Choices for Young People. London: Faculty of Sexual and Reproductive Healthcare. Available at: https://www.fsrh.org/standards-and-guidance/ (Accessed: 31 May 2026).

Joint Formulary Committee (2025) British National Formulary (BNF). London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk/ (Accessed: 31 May 2026).

Professional and ethical guidance

General Medical Council (2018) 0–18 years: Guidance for All Doctors. Manchester: General Medical Council. Available at: https://www.gmc-uk.org/ (Accessed: 31 May 2026).

Legislation and case law

Age of Legal Capacity (Scotland) Act 1991, c. 50. Available at: https://www.legislation.gov.uk/ (Accessed: 31 May 2026).

Gillick v West Norfolk and Wisbech Area Health Authority [1985] UKHL 7, [1986] AC 112.

Sexual Offences Act 2003, c. 42. Available at: https://www.legislation.gov.uk/ (Accessed: 31 May 2026).

Primary evidence

Trussell, J. (2011) ‘Contraceptive failure in the United States’, Contraception, 83(5), pp. 397–404.

National Institute for Health and Care Excellence (2019) Long-acting reversible contraception (CG30). London: National Institute for Health and Care Excellence. Available at: https://www.nice.org.uk/guidance/cg30 (Accessed: 31 May 2026).