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Teenage contraception
GP and past Sexual Health and Child Protection Lead for Mid Hampshire PCT, Winchester
E-mail: dwilson155{at}aol.com
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Abstract |
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TOP
Abstract
The GP curriculum and...The UK has the highest teenage birth and abortion rates in Europe. Although the teenage birth rate is falling, there is an upward trend in teenage abortion. The conception statistics of the Office of National Statistics are used for monitoring progress towards the teenage pregnancy strategy's target, which is to halve England's under-18 conception rate by 2010, from a 1998 baseline.
It is reported that approximately 60% of women between 16 and 19 years of age in Great Britain use contraception. There are numerous biosocial issues to consider in consultations in this area. The health professional should be aware of the legal issues of consent and safeguarding as well as providing a confidential service in an appropriate environment.
Taking a full sexual history and being aware of the contraceptive options for this age group are particularly important and contraceptive advice should take into account the high rate of sexually transmitted infections (STIs) in this age group.
A GP should be able to provide access for young people to confidential contraceptive and sexual health advice services that are tailored to meet their needs as set out in ‘Best Practice Guidance on the Provision of Effective Contraceptive and Advice Services for Young People’. (website www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4086914.pdf). Note that the revised guidance must be followed for the provision of contraception to under 16-year-olds. This should include providing young people with rapid access to testing and treatment for STIs including blood-borne viruses, rapid access to emergency contraception, early and easy access to free pregnancy testing, unbiased advice and speedy referral for NHS-funded terminations of pregnancy or antenatal care.
Scientific aspects
Attitudinal aspects
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Sexual behaviour |
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The National Survey of Sexual Attitudes and Lifestyles (2000), which included over 11 000 men and women, aged 16–44 years in Great Britain, found that
- the average (median) age at first heterosexual intercourse was 16 for both men and women; nearly a third of men and a quarter of women aged 16–19 years had heterosexual intercourse before they were 16
- about 80% of young people aged 16–24 years said that they had used a condom when they first had sex
- less than one in 10 had used no contraception at all when they first had sex
- one in five young men and nearly half of young women aged 16–24 years said they wished they had waited longer to start having sex. They were twice as likely to say this if they had been under 15 when they first had sex
- both young men and women aged 16–24 years had an average of three heterosexual partners in their lifetime
- about 1% (0.9% men, 1.6% women) of 16- to 24-year-olds had one or more new same-sex partners in the previous year
- Twenty-nine per cent of young women who left school at 16 years with no qualifications had a child by the age of 17 years.
The Family Planning Association (FPA) produces excellent leaflets for teenagers about sexuality.
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Sexually transmitted infections |
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Young people are significantly at risk from STIs particularly chlamydia, genital warts and gonorrhoea. The National Chlamydia Screening Programme in England in 2005–06 showed that 11.6% of men and 8.8% of women tested positive for chlamydia. Therefore, contraceptive consultations for young people should take into account these often asymptomatic conditions both in the relative protection provided by various methods of contraception as well as any risk of pelvic inflammatory disease that might be caused by invasive intrauterine procedures in the presence of chlamydia.
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Choice of contraceptive services for young people |
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Sources of information about contraception
Box 1 lists some of the many ways that teenagers can access contraceptive services. Teenagers obtain sexual health information from school, family members, friends, Internet, newspapers and magazines. Not surprisingly, there is a wide variation in knowledge and understanding about using different methods and about risk of failure, and particularly about STIs and emergency contraception.
Box 1. Sexual health provider options are
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Holistic assessment of a young person in a contraceptive consultation
Box 2 lists factors to consider when planning a contraceptive service for young people in primary care. This is an area where GPs need to use all their skills in ascertaining the true agenda for the consultation.
| Box 2. Planning an appropriate contraceptive service in primary care An ideal service should seek to provide the following:
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- Observation of body language and the ability to respond appropriately to cues from both the patient and any accompanying person are crucial
- Many teenagers need the support of friends when consulting for contraception for the first time; indeed, it may be the accompanying friend who is actually consulting
- To cover embarrassment and nervousness, groups of young people often appear together and behave in a manner inappropriate for a primary care environment by giggling or being aggressive until they have established their trust in the health professional. It is important to deal with this in a supportive and understanding manner.
- Sometimes the sexual partner may attend—remember this may be a same-sex partner
- Parents or other responsible adults, for example social worker, care home worker, interpreter or other family members, may attend. It is important to establish who the person is and his/her role in accompanying the young person.
- Many young women are brought by family members because of menstrual, mood or skin problems. It may be necessary to request that the teenager has part of the consultation alone to establish whether there are contraceptive needs as well as the presenting complaint. In all cases, check that the patient is happy to have another person in the consultation and make sure that clinical notes, particularly computer screens, are not visible to anyone except the young person consulting.
- Observe the behaviour of the accompanying person particularly in the case of older males who may exhibit controlling or overprotective behaviour during a consultation—this should alert the health professional to the possibility of safeguarding issues
- Although one must be sensitive to cultural and religious issues, health considerations and the legal and human rights of the teenager should remain paramount
- Looked after children are an especially vulnerable group who often experience changing parenting environments and suffer resultant emotional deprivation
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The law relating to contraception for minors |
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A contraceptive consultation with a teenager requires time and sensitivity. First of all, the true reason for consultation needs to be ascertained and then some assessment of the health beliefs and maturity of the teenager should be made. This is essential to enable the Fraser (no longer termed the Gillick) criteria to be adhered to which allow health professionals to provide contraceptive advice and treatment to young people under the age of 16 years without parental consent. The Faculty of Family Planning Guidance quotes them as follows:
The Fraser Criteria
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Good Practice Point: It is useful to have a stamp or computer template which can be completed at each such consultation.
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Child protection |
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The Sexual Offences Act 2003 (which came into force on 1 May 2004) continues to criminalize all sexual activity with a child under the age of 16 years. However, the final decision to prosecute will always lie with the Crown Prosecution Service (CPS). Home Office and CPS guidance suggests that prosecutions are unlikely if the parties involved are close in age and the activity is consensual. Further information is available on the CPS website: www.cps.gov.uk/legal/s_to_u/sexual_offences_act.
In relation to child sex offences, there are three age bands defined by the Act. Always check the exact date of birth of the teenager including month of birth.
- Under 13 years of age—a child has no capacity to consent to any sexual activity. Sex with a child under 13 years, even though it may be consensual, is always a criminal offence
- 14–16 years of age—a child has limited capacity to consent to sexual activity
- 16–18 years of age— the young person has capacity to consent but there is specific protection under the Act for this age group in the case of offences relating to indecent photographs, prostitution, pornography, abuse of trust and familial offences or incest
For GPs and Primary Health Care Staff, it is important that in the context of the law if a health professional is acting in a young person's best interest, he or she is protected from prosecution by the clause:
‘Those who act with the purpose of protecting a child from a sexually transmitted infection, protecting the physical safety of a child, preventing a child from becoming pregnant or promoting the child's emotional well being by the giving of advice will not commit an offence. Section 14(2) and (3)’
When being asked to advise and prescribe to a minor who seeks contraceptive advice, it is vital to consider the following issues:
- Consent—the minor can provide consent if ‘Fraser competent’, having sufficient maturity and understanding to make an informed decision about contraception
- Confidentiality—the clinician is bound by patient confidentiality if the minor is Fraser competent and there does not appear to be any grounds for concern about the child's welfare. If there are child protection concerns, patient confidentiality is secondary to protection of the child's welfare, and consideration should be given to referral to social services and reporting to the police.
- Record keeping—in order to protect the clinician against allegations of negligence or criminal sanctions, it is wise to ensure that a good record is kept of the advice provided to the minor or any person who presents themselves as having authority to provide consent on behalf of the minor. Good record keeping will also be vital if there is a suspected child protection issue.
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History taking for teenage contraception |
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Table 1 lists possible questions to ask a teenager when trying to support the young person in choosing the right method of contraception, and assessing sexual risk and possibility of coercion. In the general practice setting, past history and current medication are usually available but specific enquiry regarding family history—especially in the case of thromboembolic disease—is important. Ask about current medication including over-the-counter medication and complementary therapy, for example St Johns Wort, which interacts with oral contraception. A history of drug and/or alcohol use is particularly important as many instances of unprotected intercourse occur under the influence of these substances in this age group.
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Sexual and gynaecological history
Taking a full sexual history is a real skill and enquiring about the current relationship and the age and sex of the partner, recent and/or contemporaneous relationships should be handled sensitively but thoroughly and without embarrassment on the part of the health professional
It is helpful to be familiar with the level at which teenagers understand sexual issues and to be aware of the slang used for sexual practices. Helpful resources are teenage friendly sexual health websites such as www.teenagehealthfreak.org, and information leaflets for young people produced by the (FPA www.fpa.org.uk).
A full gynaecological history should be taken including past pregnancies/terminations and sexually transmitted diseases. Success and failure of previous contraceptive methods should be assessed.
An understanding of the young person’s contraceptive needs, insight and support are vital and an effort should be made to involve a responsible adult in the decision which will greatly help compliance. It is therefore important to know whether the young person is living at home.
Health promotion
This is an opportunity for health promotion particularly about smoking and the need for barrier methods to ensure double safety both contraceptively and in terms of protection from STIs. It is important to demonstrate correct condom use and not to assume knowledge on the part of the young person.
An enquiry about alcohol quantity and consumption patterns: this will give an idea of risk-taking behaviour to which teenagers are particularly vulnerable. Even the best sexual health knowledge and ability to take precautions will become blurred in the intoxicated state.
Human papilloma virus (HPV) vaccination may also be discussed. Any suggestion of coercive practices should alert the health professional to safeguarding issues. It is important to have good knowledge of accessible child protection support and never to guarantee confidentiality in this area. Your paramount duty to safeguard the child may necessitate the need to involve other agencies and override your duty of confidentiality
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Contraceptive methods and their appropriateness for teenagers |
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Table 2 summarizes the features of the contraceptive options currently available for young people in the UK. In general, teenagers have a lower risk of age-related contraindications to most methods of contraception but other considerations such as smoking, multiple partners and opportunistic and unplanned sexual intercourse combined with poor compliance with regular pill taking make the decision about appropriate contraception even more crucial.
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A teenage pregnancy significantly compromises a young woman's educational and financial prospects even though initially it may be a wanted pregnancy.
The choice of contraceptive must also take into account other conditions prevalent in young women such as eating disorders and their effect on bone density. Other medical conditions such as diabetes mellitus, inflammatory bowel disease, cystic fibrosis and epilepsy and focal migraine all affect the choice of contraceptive method.
| Case study A 15-year-old girl attends your surgery requesting the ‘morning after pill’. As you check her Fraser competence, you discover that she has run away from home and is living with her boyfriend. As the girl is about to leave, you realize that she has come with a man in his late twenties. You immediately want to know more information:
Your receptionist also sees the man and recognizes him as the one who accompanied a 14-year-old girl a few weeks previously who came to see the midwife. More warning bells start to ring and you check the addresses of the two girls. They turn out to be the same, so you contact social services and the police to find out if either of the girls is considered at risk and whether the boyfriend or address is known to them. The boyfriend is well known and has a history of serial offending. He has committed sexual offences in the past. A full investigation is commenced and child protection procedures initiated.
Take home message
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To enhance compliance in young women who have difficulty in remembering pills, long-acting reversible contraception (LARC), such as the intrauterine device (IUD), progestogen injection or subdermal implant. It is good practice to advise young people to use condoms as double protection with other methods for a contraceptive ‘double check’, and to protect against STIs. Inappropriate methods for teenagers include withdrawal and surgical sterilisation.
Although contraceptive methods themselves are largely female oriented, the contraceptive needs of teenage boys must be addressed. Contraceptive services should not only welcome consultation by young men but also have the expertise to deal with their issues and should link in closely with local educational provision regarding personal relationships and sexual health.
Risk awareness
Any risk of breast cancer associated with combined oral contraceptive (COC) use is small; there is no duration of use effect and no consistent associations between injectable progestogens and the risk of breast cancer
- The risk of venous thromboembolism (VTE) on the COC is very low and the progestogen-only pill does not appear to increase the risk of VTE. There is no evidence of weight gain with COC use but it can occur with some progestogen-only methods
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Conclusion |
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A primary care setting can be highly appropriate for the management of teenage contraception. However, there are special skills and environmental considerations that make this area of sexual health provision as different for the practitioner as paediatrics is from adult health.
This article has not attempted to deal in depth with contraceptive methods. Related topics such as The First Prescription of Combined Oral Contraception, Emergency Contraception and Missed Pill Rules can be found in the relevant references below.
Key points
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References |
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BMA. Statement on information sharing in relation to sexually active young people. A response to the revised edition of Working Together to Safeguard Children (2006) Accessed via www.bma.org.uk/ap.nsf/Content/childrensexualhealth [date last accessed 23.09.2008].
Brook Young People's Information Service www.brook.org.uk. Telephone 08000185 023 or text BROOK INFO on 81222.
Crown Prosecution Service. Legal guidance: Sexual Offences Act 2003. Accessed via www.cps.gov.uk/legal/s_to_u/sexual_offences_act [date last accessed 21.10.2008].
Department of Health. Best Practice Guidance on the Provision of Effective Contraceptive and Advice Services for Young People. (2004) Accessed via www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4005591 [date last accessed 30.07.2008].
Department of Health. You’re Welcome Quality Criteria (2007) Accessed via www.everychildmatters.gov.uk/_files/You'reWelcomeQualityCriteria2007.pdf [date last accessed 30.7.2008].
Every child matters. Teenage pregnancy: guidance. Accessed via www.everychildmatters.gov.uk/health/teenagepregnancy/guidance/ [date last accessed 30.7.2008].
Family Planning Association. Teenagers: sexual health and behaviour (2007) Accessed via www.fpa.org.uk/information/factsheets/documents_and_pdfs/detail.cfm?contentid=512 [date last accessed 30.7.2008].
FFPRHC Guidance. Contraceptive choices for young people. (2004)) Accessed via www.ffprhc.org.uk/admin/uploads/YoungPeople.pdf [date last accessed 30.7.2008].
FFPRHC Guidance. First prescription of combined oral contraception (2006) Accessed via www.ffprhc.org.uk/admin/uploads/FirstPrescCombOralContJan06.pdf [date last accessed 30.7.2008].
FFPRHC Guidance. Emergency contraception (2006) Accessed via www.ffprhc.org.uk/admin/uploads/449_EmergencyContraceptionCEUguidance.pdf [date last accessed 30.7.2008].
FFPRHC. Missed pills: new recommendations (2005) Accessed via www.ffprhc.org.uk/admin/uploads/MissedPillRules%20.pdf [date last accessed 30.7.2008].
General Medical Council. 0-18 years: guidance for all doctors. Accessed via www.gmc-uk.org/guidance/ethical_guidance/children_guidance/77_prescibing_medicines.asp [date last accessed 10.9.2008].
Home Office. Guide to the Sexual Offences Act 2003 leaflet. Accessed via www.homeoffice.gov.uk/documents/adults-safe-fr-sex-harm-leaflet?view=Binary [date last accessed 23.09.2008].
Law Society of England and Wales. www.lawsociety.org.uk.
RCGP Curriculum Statement 11: Sexual Health. Accessed via www.rcgp-curriculum.org.uk/PDF/curr_11_Sexual_Health.pdf [date last accessed 30.7.2008].
RCGP and Royal College of Nursing. Getting it right for teenagers in your practice (2002) Accessed via www.rcn.org.uk/__data/assets/pdf_file/0008/78542/001798.pdf [date last accessed 30.7.2008].
Sexual Offences Act. Accessed via cks.library.nhs.uk/knowledgeplus/medico_legal/child_protection_sexual_offences_act_2003 [date last accessed 30.7.2008].
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