Learning Capacity Requesting Contraception — Free SCA Practice Case
Young Woman with a Learning Capacity Requesting Contraception
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Sophie Wright
Age
20 years
Consultation Type
VideoAge
20
Reason for Encounter
"Wants to talk about 'the pill'."
Medical Records
- ●PMH: Mild to Moderate Learning Disability (Attends a supported adult college), Epilepsy.
- ●Medications: Carbamazepine 200mg BD.
- ●Allergies: NKDA.
Recent Notes
- ●Last Month: Attended with her mother for a routine epilepsy review. Seizures are well-controlled (seizure-free for 18 months). Notes mention she recently started a new relationship.
Patient Script
For the friend playing the patient role
Character Overview: You are Sophie. You are an energetic 20-year-old. You have a learning disability, which means you sometimes struggle with complex words, numbers, and timelines, but you are very capable of expressing what you want. You recently started dating Liam, who you met at college. You want "the pill" because your friends use it, but you are actually terrified of getting pregnant because your sister just had a baby and it looks really hard. You have come to the doctor by yourself today because your mum thinks you are too young for a boyfriend, but you want to be treated like an adult.
Consultation Flow & Responses:
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The Opening
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If the doctor asks an open question: "Hi Doctor! I came by myself today. I want to go on the pill. My friend Sarah is on it, and she said I need it now because I have a boyfriend."
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Data Gathering
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Layer 1: The Relationship & Coercion Screen (Safeguarding):
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"My boyfriend is Liam. He's 21. We go to the same college."
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"No, he hasn't made me do anything I don't want to. We just kiss right now, but we want to do more soon. We talked about it."
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"Liam is really nice. He buys me chips."
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Layer 2: ICE (Ideas, Concerns, Expectations) - ONLY REVEAL IF ASKED:
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If the doctor asks: "Why do you want the pill specifically?" or "Are you worried about anything?"
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Reaction (The Reveal): "I definitely don't want a baby. My sister just had a baby, and it cries all the time and she looks so tired. I'm worried Liam won't like me if I say no to sex, but I'm more worried about getting a baby. The pill stops babies, right?"
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Layer 3: Practicality & Capacity (The Medical Trap):
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If asked if she can remember to take a pill every day: "I don't know. My mum gives me my epilepsy tablets with my breakfast and dinner. If I have to take it myself, I might forget. Sometimes I forget to brush my teeth."
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Layer 4: The Mother's Involvement:
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If asked what her mum thinks: "Oh, mum doesn't know I'm here. She thinks Liam is a bad idea. She says I'm still a little girl, but I'm 20!"
ICE — Ideas, Concerns, Expectations
(Actor guidance: Sophie does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective. The scripted Layer 2 dialogue above covers the main ICE reveal; the structured detail below provides additional depth if the candidate probes further.)
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Ideas: Sophie thinks "the pill" is what you take to stop getting pregnant — she has learned this from her friend Sarah and sees it as the obvious and only option. She does not understand that there are different types of contraception or that her epilepsy medication might interact with hormonal methods. She has no concept of how the pill actually works — just that it "stops babies."
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Concerns: Her primary fear is getting pregnant. Seeing her sister exhausted with a newborn has made pregnancy feel frightening and overwhelming. Underneath this, she is also worried that Liam will lose interest in her if she refuses to have sex — though she would not frame it that way herself. She is anxious about her mum finding out she is here and being told she is too young or incapable of making her own decisions.
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Expectations: Sophie wants to leave the appointment with something that stops her getting pregnant. She expects the doctor to simply give her "the pill" like her friend got. She also wants to be taken seriously and treated as an adult who can make her own choices.
If Asked — Medical History and Medications
(Actor guidance: Sophie can answer questions about her medical history but uses simple language. She knows she has epilepsy and takes tablets for it, but she does not know the name of the medication or how it works. She relies on her mum for medication management.)
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If asked about her epilepsy: "I've had it since I was little. I used to have fits — like, I'd go all shaky and fall over. But I haven't had one for ages. Mum says it's been more than a year."
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If asked about her epilepsy medication: "I take tablets for it, two a day — one with breakfast and one with dinner. My mum puts them out for me. I don't know what they're called — they're small white ones."
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If asked whether she ever misses her epilepsy tablets: "Not really, because Mum always reminds me. But if she's not there, like if she goes away for the weekend, I sometimes forget the dinner one."
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If asked about any other medical conditions: "No, just the epilepsy. Oh, and I go to a special college because I need extra help with some things."
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If asked about allergies: "No, I'm not allergic to anything."
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If asked about previous contraception use: "No, I've never taken anything like that before. This is the first time."
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If asked about the recent epilepsy review: "Yeah, I went with my mum last month. The doctor said my epilepsy is doing really well and I don't need to change anything."
Social History and Lifestyle Impact
(Actor guidance: Sophie talks about her life naturally and with enthusiasm. She is proud of her independence and her relationship. This information emerges conversationally — she does not deliver it as a monologue.)
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Occupation / daily life context: Sophie attends a supported adult college three days a week where she does life skills, cooking, and art. She loves college and has a good group of friends there, including Sarah. She lives at home with her mum and younger brother. Her mum manages most of her daily routine — meals, medication, appointments. Sophie is working towards doing more things independently, which is a big part of her self-identity right now.
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Lifestyle impact of the condition: The contraception issue is weighing heavily on Sophie. She and Liam have been together for about two months and she knows the relationship is becoming more physical. She is anxious about it every time she sees him — "Every time we're together I keep thinking, what if something happens and I end up like my sister? She can't even go out anymore." She has also been keeping this entire situation secret from her mum, which is stressful for her — "I can't talk to Mum about this stuff. She'd go mental. So I've just been worrying about it on my own." Coming to the GP alone today is a significant act of independence for Sophie, and she wants to feel that it was the right decision.
If Asked — Associated Symptoms
(Actor guidance: These responses are only given if the candidate directly asks about these topics. Sophie answers honestly in her own simple language.)
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If asked about her periods / menstrual history: "Yeah, I get my period. It comes every month, pretty regular. It lasts about four or five days. It's not too heavy or anything — I just use pads. I don't get really bad cramps or anything like that."
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If asked about any bleeding between periods or after sex: "No, nothing like that."
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If asked whether she has had sex before: "No, not yet. We've just been kissing and cuddling. But we want to... soon."
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If asked about any vaginal discharge or symptoms: "No, nothing weird or anything."
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If asked about sexually transmitted infections (STIs) / using condoms: "I don't really know much about that stuff. Sarah said the pill is enough. Do I need something else too?"
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If asked about cervical screening / smear tests: "I don't know what that is. I've never had one."
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If asked about smoking: "No, I don't smoke."
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If asked about alcohol: "Sometimes I have a drink at a party, like cider, but not very often."
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If asked about recreational drugs: "No, I don't do any of that."
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If asked about her mood / mental health: "I'm alright mostly. I get a bit stressed when Mum and me argue about Liam, but I'm not sad or anything."
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If asked about her weight or any recent weight changes: "No, I'm about the same as always."
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If asked about headaches or migraines: "No, I don't get headaches really."
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If asked about any blood clots or family history of clots: "I don't think so. No one in my family has had anything like that — not that I know of."
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If asked about blood pressure: "I don't know. I think they checked it when I came with Mum last time and it was fine."
Negotiation & Collaborative Management Plan
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If the Doctor just prescribes the Combined Pill (COCP):
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Reaction: "Okay, thank you! I'll just take it when I remember." (Note: Candidate fails for prescribing an enzyme-inducing drug interaction and ignoring her inability to remember daily pills).
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If the Doctor tells her she can't have the pill because of her epilepsy medication (Carbamazepine):
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Reaction: "But why? Does the epilepsy pill fight the baby pill? What else can I do? I don't want a baby!"
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If the Doctor suggests the Coil (IUD/IUS):
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Reaction: "A coil? Where does it go? Oh... no, that sounds scary. I don't want anyone looking down there."
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If the Doctor suggests the Implant (Nexplanon) or Injection (Depo-Provera):
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Reaction: "An implant in my arm? Like a tiny matchstick? Does it hurt? ... If you put some numb cream on it first, maybe that's okay. And I don't have to remember it?"
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If the Doctor insists on telling her Mum:
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Reaction: Defensive. "No! You can't tell her! She'll stop me seeing Liam. I'm an adult, you have to keep my secret!"
Safety Netting / Follow-up
- ●If the Doctor asks her to come back next week to decide:
- ●Reaction: "Okay, I can come back next Tuesday. Can you write down what we talked about in simple words so I can read it again?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Contraception and Enzyme-Inducing Antiepileptic Drugs (EIAEDs)
- ●The interaction: Carbamazepine, phenytoin, phenobarbital, primidone, oxcarbazepine, and topiramate (≥200mg/day) induce hepatic cytochrome P450 enzymes (principally CYP3A4), substantially accelerating the metabolism of exogenous oestrogens and progestogens.
- ●Methods rendered unreliable (UKMEC 3): The combined oral contraceptive pill (COCP), standard progestogen-only pill (POP, e.g. desogestrel), combined vaginal ring, and combined transdermal patch all have significantly reduced efficacy and are not recommended for women on EIAEDs.
- ●Methods unaffected by enzyme induction (UKMEC 1): The copper IUD, hormonal IUS (Mirena/Kyleena), and Depo-Provera injectable (medroxyprogesterone acetate) are not affected by EIAEDs and remain highly effective — they work locally or at concentrations too high for induction to meaningfully impair.
- ●The implant (Nexplanon) — use with caution if other methods declined: The CoSRH/FSRH advises that Nexplanon's efficacy may be reduced by EIAEDs (UKMEC 3 in the context of enzyme inducers). It is not recommended as first-line — the preferred approach is to switch to an unaffected method. If the individual declines all alternatives, Nexplanon may be used with clear counselling that contraceptive effectiveness may be reduced, and that condoms must be used consistently and correctly in addition. Earlier replacement is not recommended by CoSRH — the interaction is continuous and pharmacokinetic, so replacing the implant sooner does not restore efficacy while the enzyme-inducing drug remains in use.
- ●Depo-Provera as a pragmatic option: The injectable is explicitly listed by FSRH as unaffected by enzyme-inducing drugs, making it a reliable and practical LARC for women on Carbamazepine. Key considerations at Sophie's age: potential for delayed return to fertility (median 5–6 months, occasionally longer), possible weight gain, and bone density effects with prolonged use — FSRH advises consideration of alternative methods if use exceeds 2 years in young women, though the benefit-risk balance should be individualised.
Emergency Contraception in Women on Enzyme-Inducing Drugs
- ●Oral EC has reduced efficacy: Levonorgestrel (Levonelle) and ulipristal acetate (ellaOne) are both affected by hepatic enzyme induction — their systemic concentrations are reduced, lowering effectiveness. Neither is recommended as the primary EC method for women on EIAEDs.
- ●Copper IUD is the method of choice: The copper IUD is the most effective emergency contraception in any woman (>99% effective up to 72 hours, licensed to 120 hours), and its efficacy is completely unaffected by enzyme-inducing drugs. It should be the default recommendation for emergency contraception in this patient group.
- ●If oral EC is the only option: FSRH guidance recommends doubling the levonorgestrel dose (3mg rather than 1.5mg) if the copper IUD is genuinely unavailable or declined, with clear counselling about reduced efficacy. Ulipristal acetate is not recommended in women on enzyme inducers even at standard dose.
The Mental Capacity Act (MCA) 2005 — Application in Practice
- ●Presumption of capacity: The MCA requires that every adult is presumed to have capacity unless there is specific reason to assess otherwise. A diagnosis of learning disability is never, by itself, sufficient to assume lack of capacity.
- ●The four functional criteria: To have capacity to consent to contraception, Sophie must be able to (1) understand the relevant information, (2) retain it long enough to make the decision, (3) weigh it in reaching a decision, and (4) communicate her decision. All four must be assessed in relation to this specific decision — not to her overall functioning.
- ●Assessment should be proportionate and conversational: A competent GP assesses capacity implicitly throughout the consultation — by the questions asked, the explanations given, and how Sophie responds. There is no requirement for a formal 'capacity test' framing, which would be inappropriate and disempowering.
- ●If capacity is established: Sophie is entitled to exactly the same confidentiality, autonomy, and clinical decision-making rights as any other adult patient. She can consent to and refuse treatment, and she can choose who is or is not involved in her care.
Confidentiality, Autonomy, and Adult Rights
- ●Sophie is an adult with legal rights: At 20, Sophie has full adult status. Her right to confidentiality is absolute unless there is a specific, overriding public interest or safeguarding concern — her mother's disapproval of the relationship does not constitute such a concern.
- ●Confidentiality must be stated explicitly: Sophie has directly asked the doctor not to tell her mother. This should be acknowledged clearly and positively — 'What we discuss today is completely confidential. I won't share it with your mum without your permission.'
- ●Fraser competence does not apply: Fraser guidelines govern the assessment of competence in under-16s to consent to sexual health treatment without parental knowledge. They are not applicable to a 20-year-old adult. Applying Fraser criteria to Sophie would represent a legal error. The MCA is the correct framework.
- ●Supporting independence is a clinical goal: Enabling Sophie to access reproductive healthcare independently — with appropriate adjustments for her communication needs — is consistent with both the MCA's principle of 'supported decision-making' and broader NHS England guidance on healthcare for people with learning disabilities.
Safeguarding Adults with Learning Disabilities
- ●Elevated risk, not assumed vulnerability: Adults with learning disabilities have statistically higher rates of sexual exploitation and coercive relationships. This warrants a safeguarding screen in every relevant consultation — but must be done sensitively, not as a checklist exercise that implies the patient is not believed or is suspected of something.
- ●What to assess: Explore the nature of the relationship (how they met, whether there is a power imbalance, age difference), whether Sophie feels safe, whether she has ever felt pressured to do anything she did not want to, and whether she feels she can say no. In this case, Liam is a peer at her college; the relationship appears consensual and age-appropriate.
- ●Document the screen: Even when no concerns are identified, it is important to document that safeguarding was considered and what was assessed. This protects the patient and the clinician.
- ●Referral threshold: If the screen raises concerns about exploitation, coercion, or abuse, refer to the local adult safeguarding team. Do not wait for certainty — the threshold is reasonable concern, not proof.
Long-Acting Reversible Contraception (LARC) — Selecting the Right Method
- ●LARC is first-line for Sophie on two grounds: (1) EIAEDs render short-acting hormonal methods unreliable; (2) Sophie's self-reported difficulty with daily adherence (dependent on her mother for epilepsy tablets, sometimes forgets the evening dose) makes a 'set and forget' method strongly preferable.
- ●Present options in a balanced, accessible way: Give Sophie a brief description of each suitable method — what it is, how it works, how long it lasts, and what fitting involves — in plain language. Allow her to express preferences and react at her own pace.
- ●The injectable: Given by a nurse every 12–13 weeks. No fitting procedure. Fully effective despite Carbamazepine. Useful if Sophie is anxious about any procedure, though requires regular attendance.
- ●The IUS/IUD: Highly effective, completely unaffected by enzyme inducers, long duration (5–10 years depending on device). Fitting requires a gynaecological procedure which Sophie has expressed clear anxiety about — this should be acknowledged and not dismissed, though the option can remain available for future consideration.
Dual Protection — Contraception Does Not Cover STIs
- ●This is a common misconception: Sophie (via her friend Sarah) believes 'the pill is enough.' This extends to a general assumption that any contraceptive method also prevents infections. This must be corrected clearly and without judgment.
- ●Condom use should be discussed for every new sexual relationship: Regardless of which contraceptive method is chosen, condoms should be recommended for STI prevention — particularly for a first sexual relationship where neither partner has been screened.
- ●Offer STI screening: As Sophie has not yet had penetrative sex, STI screening is not currently indicated. However, this is an appropriate time to introduce the concept and explain what sexual health screening involves, normalising it as routine care.
- ●Signpost sexual health services: Sophie should know she can attend a sexual health clinic (or her GP) for STI testing and that this is confidential.
Accessible Information and Communication Adjustments
- ●Accessible formats are a clinical requirement, not an optional extra: NICE guidance on care for people with learning disabilities and the NHS Accessible Information Standard require that patients are offered information in a format they can understand and use.
- ●'Chunk and check' technique: Deliver one piece of information at a time, then check understanding before proceeding. Teach-back ('Can you tell me in your own words why the pill won't work with your epilepsy tablets?') is more reliable than asking 'Do you understand?'
- ●FSRH Easy Read resources: The Faculty of Sexual and Reproductive Healthcare produces Easy Read versions of contraceptive information leaflets, using simple language and images. These should be offered at the end of the consultation so Sophie can review the discussion at home.
- ●Written summary: Sophie specifically requested a written summary 'in simple words.' This should be provided — either a brief handwritten note or a printed summary — and is an example of a reasonable adjustment under the Equality Act 2010.
- ●Avoid idioms, long sentences, and jargon: Terms like 'enzyme inducer,' 'pharmacokinetics,' and 'UKMEC' are not appropriate for direct patient communication. Plain-language analogies (e.g. 'your epilepsy tablet acts like a fast cleaner that removes the contraceptive before it can do its job') are more effective and demonstrate higher clinical skill.
Mapped to the RCGP curriculum topic: Learning Disability.
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