01Core principlesThe concepts and mechanisms needed to understand the subject.
Begin with a private, age-appropriate conversation and the actual decision: history, examination, STI testing, contraception, treatment, disclosure or referral. Explain confidentiality and its limits before sensitive questions. Use an interpreter or communication support independent of the accompanying adult. Ask the young person to explain the purpose, options, consequences and follow-up in their own words; a yes or a memorised phrase does not demonstrate understanding.
GMC guidance presumes that 16- and 17-year-olds can consent unless there is reason to doubt. In England and Wales, the Mental Capacity Act 2005 applies from age 16 when an impairment or disturbance of mind or brain causes inability to understand, retain, use or weigh relevant information or communicate the decision. In Scotland, a person aged 16 or over is generally treated under the Adults with Incapacity framework when capacity is absent. Northern Ireland permits consent at 16 and 17 under section 4 of the Age of Majority Act (Northern Ireland) 1969; the Mental Capacity Act (Northern Ireland) 2016 is only partly commenced, so local legal routes must be checked for incapacity.
For under-16s in England, Wales and Northern Ireland, Gillick competence asks whether the young person has sufficient maturity and understanding for the particular decision. Scotland instead uses section 2(4) of the Age of Legal Capacity (Scotland) Act 1991: a person under 16 can consent when the qualified medical practitioner considers that they understand the nature and possible consequences of the treatment or procedure. Ability is not a permanent badge and must be reassessed when complexity or circumstances change.
Fraser guidelines are the contraception-specific application of the Gillick judgment. They support advice or treatment without parental knowledge when the young person understands, cannot be persuaded to involve parents, is likely to continue sexual activity, may suffer harm without care, and treatment is in their best interests. Fraser is not a synonym for Gillick and does not decide consent for every STI test, intimate examination or disclosure. Scotland relies on its statutory understanding test rather than labelling the decision Fraser competence.
Confidentiality applies to young people. GMC guidance says confidential sexual-health services are essential and consultations remain confidential even when treatment is not provided, subject to serious-harm, safeguarding and legal exceptions. Encourage involvement of a parent or trusted adult when safe and helpful, but do not tell them merely because the patient is under 16. Agree a safe route for results because parental portal access, shared devices and post can expose attendance.
The age of consent in criminal law and clinical competence answer different questions. Sexual activity under 16 requires careful safeguarding assessment but is not an automatic rule to tell parents or police. Consider maturity, age and power gaps, position of trust, coercion, payment, drugs or alcohol, secrecy, disability and living circumstances. A child under 13 is legally unable to consent; GMC guidance says information should usually be shared and any decision not to do so should be discussed with a safeguarding lead and recorded.
When abuse or serious harm is suspected, listen without conducting an investigative interview. Ask open questions needed for medical care and immediate safety, record the young person’s words, avoid confronting the alleged source and involve the safeguarding lead. Seek consent to share when appropriate, but do not delay necessary protection or ask if doing so would increase danger. Share relevant information with the proper local agency and follow up if the response does not protect the child.
Operational access differs by nation and locality. England’s NHS pages describe free confidential sexual-health services, including for under-16s. NHS Inform states that anyone can attend in Scotland, including under-16s, and provides a national booking route with stated geographic exceptions. Welsh health boards publish local confidential clinic and young-person pathways. NI Direct directs people to free confidential GUM testing, with some online services limited by age. Check booking, testing, contraception, abortion, SARC and safeguarding contacts for the young person’s nation and health board or trust.
Key points
- Identify age, UK nation and the exact decision. Capacity or competence is decision- and time-specific and improves with suitable communication and private discussion.
- At 16 and 17, presume ability to consent, but the legal framework for absent capacity differs: Mental Capacity Act in England and Wales, adult incapacity law in Scotland, and Northern Ireland’s distinct statutory and common-law position.
- Under 16, England, Wales and Northern Ireland use Gillick competence; Scotland uses section 2(4) of the Age of Legal Capacity (Scotland) Act 1991.
- Fraser criteria concern contraceptive advice or treatment for an under-16; they are not the general test for every examination, STI test, disclosure or treatment.
- Competent young people can receive confidential sexual-health care. Encourage safe parental or trusted-adult involvement but do not make it a condition of care.
- Sex under 16 does not automatically require disclosure. Assess maturity, consent, age and power differences, position of trust, force, substances, payment, secrecy and other vulnerabilities case by case.
- Under-13 sexual activity and abusive or seriously harmful activity usually require prompt sharing through safeguarding routes; explain unless doing so increases danger.
02Mechanisms and patternsImportant relationships and how to distinguish them.
The young person can understand, retain and use the relevant information, appreciate consequences and communicate a voluntary choice for this decision.
Gillick applies in England, Wales and Northern Ireland; Scotland uses the statutory section 2(4) understanding test.
Fraser criteria are limited to contraceptive advice or treatment and do not replace the general competence assessment.
The child is legally unable to consent and information should usually be shared through safeguarding routes after urgent safety assessment.
Power imbalance, position of trust, force, payment, substances, exploitation or inability to understand supports prompt protective sharing.
A parent or companion may provide support, but control, hostility, surveillance or coercion requires private assessment and a safer communication plan.
03Interpreting evidenceInformation, measurements and their limitations.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Age, nation and decision identification - Why
- Select the correct legal and professional framework for the particular choice.
- Interpretation and limitations
- Age alone is insufficient; record the UK nation, decision, urgency and whether capacity or competence is in doubt.
- 02
Supported competence or capacity assessment - Why
- Determine whether the young person can make this decision after barriers are addressed.
- Interpretation and limitations
- Use simple language, interpreter or aids, time and teach-back; disagreement, distress or an unwise choice does not itself prove inability.
- 03
Sexual-safety and exploitation assessment - Why
- Identify coercion, age or power imbalance, position of trust, payment, substances, trafficking and immediate danger.
- Interpretation and limitations
- Assess each case on its merits. Under 13 and abusive or seriously harmful activity have a strong presumption toward prompt sharing.
- 04
Immediate clinical risk assessment - Why
- Detect pregnancy, injury, infection, PEP need, intoxication, self-harm or other urgent care.
- Interpretation and limitations
- Clinical treatment and forensic or safeguarding action can run in parallel; do not delay an expiring intervention for a complete narrative.
- 05
Local pathway verification - Why
- Find the correct sexual-health and safeguarding service for the young person’s nation and locality.
- Interpretation and limitations
- Clinic access, online-kit age, abortion, SARC and agency contacts vary; verify the health board, trust or commissioned service.
04Applied reasoningWorked examples connecting principles to decisions.
01Worked case: confidential testingAssess competence and safety separatelyA 15-year-old requests an STI test without parental knowledge after consensual sex with a similar-age partner and reports feeling safe.+
- 1Speak privately, explain confidentiality and limits, identify the UK nation and ask the young person to explain the proposed tests, results and follow-up.
- 2Assess decision-specific competence using Gillick in England, Wales or Northern Ireland, or the Scottish section 2(4) test, and address communication barriers.
- 3Complete a safeguarding assessment for consent, age and power difference, position of trust, substances, payment, coercion and home safety without assuming abuse from age alone.
- 4If competent and no protective disclosure is justified, provide confidential care, encourage a safe trusted adult, agree a secure result route and document both competence and safeguarding reasoning.
02Under-thirteen disclosureProtect through the safeguarding routeA 12-year-old discloses recent sexual activity and asks that nobody be told.+
- 1Address immediate medical needs and safety, listen without leading questions, preserve the child’s words and explain that help must be involved.
- 2Contact the named safeguarding lead and the appropriate local agency promptly; any exceptional decision not to share requires lead discussion and recorded reasons.
- 3Share only relevant information, avoid confronting the alleged source and follow up whether the child and other children are protected.
03Uncertain understandingSupport before deciding incapacityA young person cannot initially explain the purpose and consequences of treatment.+
- 1Slow down, use accessible language, interpreter or communication aids, address pain, intoxication and pressure, and allow time where safe.
- 2Reassess the specific decision under the correct national framework rather than treating diagnosis or age as automatic incapacity.
- 3If they cannot decide, identify the lawful decision-maker or treatment authority for that nation, involve the young person and seek legal advice for serious disagreement.
05Checking understandingVerify the reasoning, revisit uncertainties and apply feedback.
- Document the decision, age, nation, information given, support used, teach-back, competence or capacity conclusion and voluntary choice.
- Record safeguarding questions and the young person’s own words, advice obtained, information shared, recipient, reason and follow-up.
- Verify that the confidential result channel is safe from parental portals, shared devices, post and controlling partners.
- Follow up referrals and escalate if the receiving service or agency has not acted while risk remains.
- Reassess competence, family involvement and safety when the treatment, disclosure or relationship circumstances change.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Gillick is decision specific
Competence for a simple test today does not prove competence for every future treatment or disclosure.
Fraser has a narrow use
It guides contraceptive advice and treatment for under-16s and is not the universal name for child consent.
Criminal age differs clinically
Sex under 16 prompts safeguarding assessment but does not automatically remove confidential healthcare or mandate parental notification.
Scotland uses statute
Under-16 consent follows section 2(4) of the Age of Legal Capacity Scotland Act rather than a Gillick label.
Under thirteen changes presumption
Because the child cannot legally consent to sex, GMC guidance usually supports prompt protective sharing.
07Common pitfallsFrequent interpretation and management errors.
- 01
Using Fraser guidelines as the consent test for every STI test, examination, treatment and information-sharing decision.
- 02
Applying Gillick terminology across Scotland instead of the section 2(4) statutory understanding test.
- 03
Assuming all under-16 sexual activity must be reported automatically to parents or police without a case-specific safeguarding route.
- 04
Promising secrecy to a child before explaining that serious harm, abuse or legal duties may require sharing.
- 05
Interviewing a young person about consent or coercion while the potentially controlling partner or parent remains present.
- 06
Naming a generic UK referral route without checking the nation, health board or trust and current access rules.