Station 21 · A teenager asks for contraception

Candidates: do not open until you have consulted.

Persona and manner

• Chloe Ward, 15; bright, composed, a little rehearsed; you have looked up what the doctor is allowed to do; you keep your phone face-down on your knee and check it once.
• You are frightened that the doctor will tell your mother and that you will be judged. You become open if the doctor explains confidentiality early and does not lecture.

Opening line (verbatim)

• “I want to go on the pill. I've looked it up and I know you can give it to me without telling my mum. I'd like to start it today if that's OK.”

The story

• If asked: you have a boyfriend, Tyler, who is nineteen; you have been together four months; you met through your cousin; you have had sex “a few times”, the first time two months ago, with condoms “mostly”; once without, three weeks ago. Your period came last week, on time.
• “He's nice. He's not like boys my age.” He has a car and a job at a tyre place; he picks you up from school sometimes; he buys you things.
• If asked, carefully: he has asked you not to tell your mum because “she'd make a fuss about his age”; you have not told your friends how old he is; he sometimes gets annoyed if you do not reply to messages quickly; he has never hit you or forced you.
• If asked about your mum: she is “strict but OK”; you would be in trouble; you cannot tell her. Your dad lives in Leeds and you see him in the holidays.
• School: predicted good grades; a teacher you like, Miss Okafor; you have not told anyone at school.
• Health: no migraines; no clots in the family; non-smoker; you have tried alcohol at parties; no drugs. You have never had a test for infections.
• If asked why the pill and not something else: “I don't want anything that's… inside me. My friend's on the pill and it's fine.”
• If asked what you would do if you were pregnant: “I'd die. I couldn't tell Mum.”

Ideas, concerns and expectations

• Idea: That the pill is simple and the doctor can give it today.
• Concern: Your mum finding out; being judged; being told you are too young; Tyler being “got in trouble”.
• Expectation: A prescription today and nothing said to anyone.

Impact

• Home: your mum works shifts; your brother is ten; you look after him two evenings a week.
• School: Year 11; mock exams next month.
• Tyler: he picks you up; he texts a lot; he does not like you going out with your friends.

Red flags

• Present: A sexual relationship under 16 with a man of 19 who asks her to keep his age secret, controls her contact with friends and buys her things; unprotected sex three weeks ago; no infection screen; a wish for secrecy driven by his instruction as well as her own.
• Absent: No disclosure of force, threats, violence, drugs or exchange of sex for anything; she reports the relationship as wanted; she has an adult she trusts at school.
• Absent: No medical contraindication to the combined pill.

Hidden facts and their triggers

• Tyler's age — released only if asked how old he is; she does not volunteer it
• That he asked her not to tell her mum, and why — released only if asked who knows and whose idea the secrecy was
• That he gets annoyed if she does not reply quickly and does not like her going out with friends — released only if asked what he is like when things are not going his way, or about her friends
• The unprotected sex three weeks ago — released only if asked about condoms in detail, or about pregnancy risk
• Miss Okafor — released only if asked whether there is an adult she trusts

Behaviour

• Minute 1: “I know you can give it to me without telling my mum.”
• Minute 3, if asked how old he is: a pause. “Nineteen. Is that a problem?”
• Minute 6, if the doctor raises safety: “He's not like that.”
• If the doctor explains confidentiality and its limits early and plainly, asks about the relationship with curiosity rather than suspicion, assesses whether she understands the advice and whether the relationship is one she chooses, explains the age difference as the doctor's concern without condemning Tyler, agrees contraception today with a pregnancy test, an infection screen and condom advice, encourages telling her mum without insisting, offers to speak to the school or a youth service with her, and arranges a review: she is wary, then relieved. “So you'll give it to me? And you won't tell Mum?”
• If the doctor refuses because of her age: “Then I'll just get it online.” Stand up.
• If the doctor says her mother must be told: “Forget it.” Leave.
• If the doctor speaks about Tyler as a predator: “You don't know him.” Shut down.

Examination findings, if the candidate states what they would examine and why

• If the candidate explains and asks: blood pressure 112/70; weight 54 kg; height 162 cm; a urine pregnancy test, if arranged, is negative; she declines any other examination today and agrees to self-taken swabs.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Refusing the pill because she is fifteen, so that she says “Then I'll just get it online” and the concern about Tyler is never known (statement C2)
• Hearing “Nineteen” and either ignoring it or treating Tyler as a predator, so that she shuts down (statement R6)
• Promising absolute secrecy, or making telling her mother a condition, instead of explaining the limits honestly (statement R4)

What the examiner is listening for in the last four minutes

By 8:00 the working understanding should have been stated: a fifteen-year-old who can consent to contraception, in a relationship that worries the doctor. The examiner is listening for: the pregnancy test and the pill today with the rules; condoms and the infection screen; the concern about Tyler named as the doctor's, with what will happen next and her told; her mum encouraged as an ally; the review and the route back; the safety-net for missed pills, pregnancy and infection; and her own words on the method, the limits of confidentiality and what happens next.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. A doctor may provide contraceptive advice and treatment to a young person under 16 without parental knowledge or consent if the young person understands the advice, cannot be persuaded to inform their parents or allow the doctor to, is likely to begin or continue having sex with or without treatment, their physical or mental health is likely to suffer without it, and it is in their best interests (the Fraser criteria). GMC — 0 to 18 years: guidance for all doctors, paragraphs 64 to 70, contraception, abortion and sexually transmitted infections, 2007, updated 2018, checked 10 Oct 2026
2. Young people under 16 are owed the same duty of confidentiality as adults; disclosure without consent is justified only where the young person or others are at risk of serious harm, and the young person should be told what will be disclosed, to whom and why, unless doing so would increase the risk. GMC — 0 to 18 years: guidance for all doctors, paragraphs 42 to 53, confidentiality, 2007, updated 2018, checked 10 Oct 2026
3. Sexual activity involving a child under 16 should prompt an assessment of risk; a relationship with a significant age difference, secrecy, gifts, isolation from friends, or a partner who controls contact are among the indicators of child sexual exploitation; concerns are discussed with the practice safeguarding lead and, where the threshold is met, referred to children's social care. GOV.UK (DfE) — Child sexual exploitation: definition and guide for practitioners, indicators of child sexual exploitation; what to do, February 2017, checked 10 Oct 2026
4. Sexual activity with a child under 16 is an offence under the Sexual Offences Act 2003; where the child is 13 to 15, the professional judgement about disclosure takes account of the age difference, power imbalance, coercion, secrecy and the child's own wishes; sexual activity with a child under 13 is always reported. GOV.UK (DfE) — Working together to safeguard children, chapter 1, information sharing; appendix on under-age sexual activity, December 2023, checked 10 Oct 2026
5. The combined hormonal contraceptive pill is UKMEC category 1 for a healthy non-smoking young woman with no migraine with aura and no personal or family history of venous thromboembolism; age under 20 is not a restriction; counsel on the missed-pill rules and start with additional precautions for seven days unless started on day one to five of the cycle. FSRH — Clinical guideline: Combined hormonal contraception, eligibility; starting CHC; missed pills, January 2019 (amended October 2023), checked 10 Oct 2026
6. Offer a pregnancy test where there has been unprotected sex more than three weeks earlier, and offer chlamydia and gonorrhoea screening (self-taken swabs) to all sexually active young people under 25 at a contraception consultation; condoms are advised for infection protection alongside any hormonal method. FSRH — Clinical guideline: Contraceptive choices for young people, STI screening; pregnancy testing; dual protection, March 2010 (amended May 2019), checked 10 Oct 2026
7. Assessing whether a young person has the capacity to consent to treatment depends on their maturity and understanding of what is involved, not on age alone; the assessment and its outcome are recorded, together with the advice given and any encouragement to involve a parent. GMC — 0 to 18 years: guidance for all doctors, paragraphs 24 to 29, assessing the capacity to consent, 2007, updated 2018, checked 10 Oct 2026
8. A person aged 18 or over who intentionally engages in sexual activity with a child under 16 commits an offence, whether or not the child agreed. A health professional who gives a child under 16 contraception, advice on sexual health or treatment to prevent pregnancy or infection does not aid or abet that offence where the purpose is to protect the child's health, safety or emotional well-being and not to obtain sexual gratification or to encourage the activity. UK Parliament — Sexual Offences Act 2003, section 9, sexual activity with a child; section 73, exceptions to aiding, abetting and counselling, 2003, sections 9 and 73, checked 10 Oct 2026
9. A child is anyone under 18. Anyone with concerns about a child's welfare makes a referral to local authority children's social care, immediately where the child is suffering or likely to suffer significant harm; the referral is confirmed in writing and children's social care should acknowledge it and decide on next steps within one working day. Fear of damaging the relationship with the young person is not a reason to withhold a referral. GOV.UK (DfE) — Working together to safeguard children, chapter 1, a shared responsibility; chapter 3, referral and assessment, 2023, checked 10 Oct 2026
10. The clinician can be reasonably certain a woman is not pregnant if she has had no sex since the start of her last normal period, is within the first seven days of a normal period, has used reliable contraception consistently, or has a negative pregnancy test taken at least three weeks after the last unprotected sex. A combined pill started after day five of the cycle needs additional precautions for seven days, and a repeat test is advised if there is any doubt. FSRH — Clinical guideline: Quick starting contraception, excluding pregnancy before starting; starting contraception outside the first five days of the cycle, 2017, checked 10 Oct 2026
11. Contraceptive services for under-25s should be confidential, accessible without a parent, and offer the full range of methods, including long-acting reversible contraception, with a pregnancy test and chlamydia screening where indicated and condoms for protection against infection. Young people under 16 are given contraceptive advice and treatment in line with the Fraser guidelines, and the practice makes clear to young people what confidentiality they can expect. NICE — PH51 Contraceptive services for under 25s, recommendations on confidentiality, access and the range of methods for young people, PH51, 2014, checked 10 Oct 2026
12. The curriculum expects the GP to assess competence and apply the Fraser guidelines when a young person under 16 asks for contraception, to explain confidentiality and its limits, to recognise the indicators of child sexual exploitation, including a relationship with an older partner, secrecy, gifts and control, to discuss concerns with the practice safeguarding lead, and to know when and how to refer to children's social care. RCGP — GP curriculum: Sexual health, consent and confidentiality for under-16s (Fraser guidelines); teenage pregnancy, sexually transmitted infections and child sexual exploitation, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

12 statements, 751 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for SCA-21