SEXUAL AND REPRODUCTIVE HEALTH NEEDS

TOPIC: ETHICAL MANAGEMENT ISSUES IN ADOLESCENT HEALTH

BY : PROF DR KHAIRANI OMAR FAMILY MEDICINE DEPARTMENT

DEFINITION OF SEXUAL HEALTH

"A state of physical, emotional, mental and social wellbeing related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sex experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled."
(WHO)

4 PILLARS OF MEDICAL ETHICS

1. NON-MALEFICENCE 2. BENEFICIENCE 3. AUTONOMY 4. JUSTICE (Beachamp and Childress 2001)

NON-MALEFICENCE
DO NO HARM. To remind us that medical practice involves risk and potential harm. We should never expose our patients to such harm unnecessarily through carelessness or a cavalier attitude.

BENEFICENCE
ACTION DONE TO BENEFIT OTHERS.

AUTONOMY
PRINCIPLE OF SELF-RULE OR SELF-GOVERNANCE RESPECT FOR INDIVIDUAL AND VALUE OF A PERSON. IT IS DIFFICULT OR IMPOSSIBLE TO KNOW WHAT IS BEST FOR SOMEONE ELSE. PRECONDITION: THERE MUST BE FREEDOM AND CAPACITY TO CHOOSE.

JUSTICE
In health care ethics, this can be subdivided into three categories: i) fair distribution of scarce resources (distributive justice) ii) respect for peoples rights (rights based justice) iii) respect for morally acceptable laws (legal justice) (Gillon, 1994).

COMMON ETHICAL ISSUES IN ADOLESCENCE

PREGNANCY AND ABORTION STATUTORY RAPE SEXUALLY TRANSMITTED INFECTION CONTRACEPTION

PREGNANCY AND ABORTION ISSUES CASE EXAMPLES

A 15 year old girl came to the clinic for delayed menses for 3 weeks. On further questioning, she admitted that she had slept with her boyfriend a few times. UPT was positive. Madam S brought her pregnant 13 year-old girl to the clinic. Her daughters LMP was 2 months ago. She requested the doctor to refer her daughter for abortion. A 17 year-old single adolescent came to the clinic and was found to be pregnant for 5 months. She told the doctor not to disclose her pregnancy to her parents.

ETHICAL ISSUES TO BE ADDRESSED

Is permission from parents/guardian required before treating the adolescents? 2. Statutory rape 3. Is abortion allowed? 4. Confidentiality issues
1.

PERMISSION FROM PARENTS/GUARDIAN

Is permission from parent/guardian required before treating the adolescent? Yes, permission from parent/guardian is required to treat adolescents aged below 18 years. Children below 18 years old cannot give consent to medical procedures and treatment (Childs Act 2001)

Seksyen 2 Akta Umur Dewasa 1971 [Akta 21] dan Akta Kanak -Kanak 2001[Akta 611] menyatakan bahawa umur dewasa bagi semua lelaki dan perempuan adalah lapan belas (18) tahun dan ke atas. Sehubungan itu, secara umumnya, hanya seseorang yang berumur lapan belas (18) tahun dan ke atas boleh memberikan kebenaran yang sah untuk dirinya dalam tujuan mendapatkan rawatan perubatan.

STATUTORY RAPE
STATUTORY RAPE is defined as sexual intercourse with a female below the legal age of consent. It is different from other types of rape in that force and lack of consent are not necessary for conviction. A defendant may be convicted of statutory rape even if the complainant explicitly consented to the sexual contact and no force was used by the actor. (International Academic Journal) The modern rationale for these laws is grounded in the desire to protect minors from sexual exploitation.

Nadesan and Omar (2002) writes, the consenting age for sexual intercourse in Malaysia is 16 years old. As such, statutory rape is defined as sexual intercourse (regardless of whether WITH or WITHOUT consent) with a girl BELOW 16 years old. This definition is according to Section 376 of the Malaysian Penal Code (or Act 574).

TO WHOM SHOULD WE REPORT?

AKTA-AKTA KANAK-KANAK 2001 (AKTA 611)

IS ABORTION ALLOWED ?
Abortion is legal in Malaysia in the following situations only: When a woman's life is in danger When a woman's physical health is in danger When a woman's mental health is in danger A woman must consent to an abortion, and she must have a medical professional's authorisation.

The Penal Code Act 727: - permit abortion if a medical practitioner was of the opinion, formed in good faith, that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or injury to the mental or physical health of the pregnant woman, greater than if the pregnancy were terminated1 .
1.Population Policy Data Bank maintained by the Population Division of the Department for Economic and Social Affairs of the United Nations Secretariat.

 52nd Muzakarah (Conference) of the Fatwa Committee National Council of Islamic Religious Affairs Malaysia : - termination of pregnancy before 120 days is permissible if continuation of the pregnancy would endanger the health or life of the mother and fetus2.

2. E-fatwa. Portal Rasmi Fatwa Malaysia. Jabatan Kemajuan Islam Malaysia (JAKIM). Hukum Menggugurkan Kandungan Mangsa Yang Dirogol. Available from: http://www.e-fatwa.gov.my/fatwa-kebangsaan/hukummenggugurkan-kandungan-mangsa-yang-dirogol

FLOW CHART FOR MANAGING PREGNANT ADOLESCENT

ADOLESCENT < 16 YRS OLD

SINGLE STATUTORY RAPE REFER TO FMS/M&HO : - - PERMISSION FOR RX & PROCEDURE FROM PARENT/GUARDIAN - COUNSELLING

MARRIED

HEALTH STAFF TO OBTAIN PERMISSION FROM HUSBAND IF HUSBAND IS > 18 YEARS, IF LESS FROM PARENT/GUARDIAN

REFER TO OSCC IN HOSPITAL MED SPECIALISTS, SOCIAL WELFARE & POLICE

ANTENATAL CHECK-UP

CONFIDENTIALITY ISSUES
CONFIDENTIALITY CAN BE BREACHED IN 3 CONDITIONS: 1.The adolescent is at risk of harming herself/himself 2.The adolescent is harming others 3.Others are posing risk to the safety of the adolescent

This is in view that higher authority needs to be involved.

ETHICAL ISSUES ON SEXUALLY TRANSMITTED DISEASES

CASE EXAMPLE : 1. A 16 year-old boy came to the clinic for penile discharge. He admitted that he had slept around with several girls (younger) and had unprotected sex. 2. A 17 year-old boy came to the clinic for similar symptoms but his sexual partners are above 16 years old.

FLOW CHART FOR MANAGING ADOLESCENT WITH STI

ADOLESCENT WITH STI

REFER TO FMS/M&HO

CONSIDER AGE INVOLVED

< 16 YRS OLD STATUTORY RAPE

16 17 YRS OLD

> 18 YRS OLD

OBTAIN PERMISSION FROM PARENT/GUARDIAN REFER TO OSCC TREAT STI

ETHICAL ISSUES ON CONTRACEPTION

CONSIDER AGE SEXUALLY ACTIVE VERSUS NOT ACTIVE

FLOW CHART FOR MANAGING ADOLESCENT ASKING FOR CONTRACEPTION

ADOLESCENT REQUEST FOR CONTRACEPTION (UNMARRIED)

SEXUALLY NOT ACTIVE

SEXUALLY ACTIVE

AGE < 16 YRS OLD COUNSELLING ENCOURAGE ABSTINENCE BEFORE MARRIAGE

AGE 16-<18 YRS OLD PERMISSION FROM PARENT/GUARDIAN

AGE > 18 YRS OLD

STATUTORY RAPE

CONTRACEPTION GIVEN BASED ON ONES RELIGION. MUSLIM RUJUK Keputusan Muzakarah Fatwa ke 90.

KEPUTUSAN MUZAKARAH FATWA KE 90

Kontraseptif boleh diberi kepada pasangan yg sah berkahwin dan bukan yg tidak berkahwin kerana ini menggalakkkan zina.

Memandangkan sekiranya perbuatan ini tidak diatasi boleh mengundang kepada pembuangan bayi, maka ia dibenarkan berdasarkan Kaedah Fiqhiyyah: Apabila berlaku pertembungan antara dua kemudharatan, keburukan yang lebih teruk dipelihara [dicegah daripada berlaku] dengan melaksanakan keburukan yang lebih ringan mudharatnya. Walaubagaimanapun, kemudharatan ini tidak boleh diberikan sewenangwenangnya berdasarkan Kaedah Fiqhiyyah Perkara-perkara dharurat diukur sekadar yang diperlukan. Oleh yang demikian, untuk mengelak daripada pelakuan yang ditegah tersebut berulang kembali, syarat-syarat yang ketat ditetapkan. Ini bermakna, kesemua syarat tersebut perlu dipatuhi.

THANK YOU FOR YOUR ATTENTION