Relevant BNF section: 7.3
Among countries of the 'developed world', the teenage birth rate in the UK is second only to that in the USA. The UK rate is nearly five times that in the Netherlands, over three times that in France and over twice that in Germany.1 For example, in the UK in 1998, there were 30.8 births per 1,000 15-19 year-olds.1 There is no single explanation for the high rate.2 It is probably due to a complex interaction between factors such as inadequate sex education; poor communication within families and with sexual partners; poor access to, and mistrust of, health services by young people (including specific concerns about confidentiality); risk-taking behaviour; and erratic use of contraception. With this in mind, here we explore how healthcare professionals can best deliver advice and help on contraception and related sexual health issues to teenagers.
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Relevant BNF section: 7.3
Around one in four young women and one in three young men in Britain say that they first had heterosexual intercourse before the age of 16 years.3 Many later regret such early experience. For example, in a British survey of 16-24 year-olds, about 42% of men and 84% of women who had had first intercourse at 13-14 years of age said that they wished they had waited until they were older.3 Risk factors for early onset of sexual behaviour include low socio-economic status, poverty, poor educational opportunities, being born to a teenage mother and high rates of unemployment.2 Also, low socio-economic status is linked with reduced knowledge of contraception.2
In the UK, the proportion of people reporting use of contraception at first-time sex rose from about two-thirds in the early 1980s to more than 90% in 1999-2001.3 Despite this increase, almost 98,000 teenagers became pregnant in England and Wales in 2000. In all, 8,111 of these conceptions were in girls under the age of 16 years and 395 in girls under the age of 14 years.4 About half the pregnancies in girls under the age of 16 years ended in termination of pregnancy.4
Between 1995 and 2000, the number of diagnoses of sexually transmitted infections (STIs) at genitourinary medicine (GUM) clinics in England, Wales and Northern Ireland rose from around 450,000 to around 600,000,5 and increased again in 2001.6 In 2001, genital chlamydial infection became the most common STI diagnosed in GUM clinics (71,055 cases), and 36% of females diagnosed with such infection (and 42% with gonorrhoea) were aged under 20 years.6 These figures underestimate the problem because they do not include the diagnoses made in patients who are not referred to GUM clinics; many infections are asymptomatic and so not diagnosed; and uptake of GUM services may be poor in certain areas or patient groups. For example, only about 17% of teenagers referred from a primary-care setting actually attend a GUM clinic.7
Teenage use of contraception services
A retrospective UK study in general practice found that 93% of pregnant teenagers had consulted a healthcare professional at least once in the year before conception, 71% had discussed contraception in the consultation and 50% had been prescribed an oral contraceptive.8 Teenagers give two main reasons for not visiting a doctor or other healthcare professional for advice and help on contraception and sexual health. First, they often believe services are not easily accessible or 'user-friendly' enough for them.2 Secondly, they are frequently anxious about the confidentiality of the consultation, in case their parents or carers might be told about the visit.
Teenagers may be unaware that a service is available to them. They also maintain that services are often inaccessible because of their location, opening hours or poor appointment systems.2 A report on teenage pregnancy from the Social Exclusion Unit (which was set up by the Prime Minister in 1997 to help reduce social exclusion) recommended more accessible services, such as lunch-time sessions in schools with a nurse or a doctor who can advise on and/or prescribe contraception, especially emergency contraception.2 Ideally, services for young people should have opening hours suitable for them, such as after school and on Saturdays. When teenagers need help, it is often for an immediate problem and, in general, an appointment system may not be flexible enough for them. Also, teenagers are often sensitive to the atmosphere in a waiting room and may not like to wait with a mixed-age group, for fear that they will meet a relative or neighbour. Therefore, a dedicated open-access service may be preferable. Any service for teenagers should be advertised widely in places where young people pick up information, such as on notice boards in schools and colleges, at clubs, from flyers handed out at concerts and on relevant Internet sites.
Other factors that could reduce accessibility include the atmosphere in which a service is provided, for example, whether staff are perceived to be judgmental.2 In a cross-sectional survey of 826 general practices in England, lower teenage pregnancy rates were associated with the presence of a female or young doctor and more nurse time.9 Services providing advice and help on sexual health and contraception for teenagers must be empathic and non-judgemental and staff should show the same courtesy and respect as that shown to an older person.
All patients have a right to expect that information about them will be held in confidence by their doctors.10 Ideally, contraception and sexual health services should be proactive in reassuring young people about their commitment to confidentiality. For example, this commitment should be clearly stated in advertising and promotional information, and notices about confidentiality should be displayed in a prominent position in waiting areas. Services should also have a confidentiality policy and agreement that is signed by all staff, and ensure that staff have appropriate training to understand what confidentiality means and why it is important.
Confidentiality may only be broken in the most exceptional situations, that is when the health, safety or welfare of the patient or others would otherwise be at grave risk.11 The decision on whether to breach confidentiality depends on the degree of current or potential harm, and not on the person's age. Even if a request for contraception is made by a young person under 16 years who is not considered competent to consent to treatment, a request for confidentiality should still be respected whether contraception is prescribed or not. If a healthcare professional is convinced that it is essential, he or she may disclose relevant information to an appropriate person or authority. In such cases, consent should be sought before any information is disclosed. If the person is unable to consent to disclosure, the healthcare professional must tell him or her before disclosing any information and, where appropriate, seek and carefully consider the views of an advocate or carer. The steps taken to obtain consent and the reasons for deciding to disclose information should be documented in the person's records.10
The first consultation
The initial consultation with a teenager needs time and care, as it could affect the young person's attitude to future attendance for such consultations and possibly the future pattern of contraceptive use. It is important that the healthcare professional finds out what the young person feels is the purpose of the visit, rather than makes unjustified assumptions, including that the young person will automatically reject delaying sexual activity as one of the available choices. Some young people will bring a friend or partner to the visit, and it is important to establish that the consultee is happy for this third party to be present. It is also good practice to ask to see the young person alone at a later stage in the consultation. Young people may not like being asked a lot of questions.12 So it is sensible to explain, for example, that asking about personal or family medical history is needed to help choose a suitable method of contraception. A consultation for emergency contraception will need to include questions about the time of intercourse, which might seem intrusive unless explained.12
Consent in the under 16s
A healthcare professional can give contraceptive advice and treatment to someone under the age of 16 years, provided that they are satisfied that the young person is competent.11 In England, Wales and Northern Ireland, a young person under 16 is competent to consent to contraceptive ad-vice or treatment if he or she understands the healthcare professional's advice; the healthcare professional cannot persuade the young person to inform his or her parents or allow the professional to inform the parents that he or she is seeking contraceptive advice; the young person is very likely to begin or continue to have intercourse with or without contraceptive treatment; the young person's physical or mental health, or both, are likely to suffer unless he or she receives contraceptive advice or treatment; the young person's best interests require the healthcare professional to give contraceptive advice, treatment or both without parental consent.13 In Scotland, the Age of Legal Capacity (Scotland) Act 1991 says that a "person under the age of 16 years shall have legal capacity to consent on his [sic] own behalf to any surgical, medical or dental procedure or treatment where in the opinion of a qualified medical practitioner attending him, he is capable of understanding the nature and possible consequences of the procedure or treatment".11
There may be rare cases when a healthcare professional believes that a young person is being exploited or abused, or is in some danger of so being. In such cases, locally agreed child protection protocols should be followed.14
All contraceptive options should be presented to the young person. Otherwise, there is the danger that the healthcare professional will be seen as paternalistic or judgemental in assuming that, for example, the oral contraceptive pill is the only suitable method. Young people often have several questions that need addressing about potential unwanted effects of contraceptives, such as whether the oral contraceptive pill will give them spots or cause weight gain. Also, they may have strongly held misconceptions about contraception that need to be discussed. Possible unwanted effects with all the methods should be discussed, as should likely failure rates.
Whichever contraceptive methods are chosen, care should be taken to ensure that teenagers understand how they work and how to use them. This includes making sure that they understand the risks of using contraception erratically and how to access emergency contraception if contraception is not used or fails during intercourse. Young people should be encouraged to always carry a condom when they go out and to always use a condom when they have intercourse, regardless of whether other contraception is also used. They should be clearly advised that other methods of contraception do not offer as much, if any, protection against STIs, including HIV.
Appropriately designed and clearly written back-up literature, and information about available telephone and Internet advice* should also be supplied. A time to meet again routinely should be agreed on and it should be made clear that the young person can return again at any time if a problem arises.
* Brook Helpline: 0800 0185023, www.brook.org.uk; Family Planning Association: www.fpa.org.uk; UK government teenage sexual health website: www.ruthinking.co.uk
The effectiveness of different methods of contraception specifically in teenagers is unknown. In a US study, the typical reported failure rates during the first year of use of a contraceptive method for women of all ages were 12% for the male condom; 3% for the oral contraceptive; 0.03-0.4% for injectable progestogens; 0.03-0.04% for implants; 3% for intrauterine devices (IUDs); 18% for the diaphragm or cap; 18% for the withdrawal method; and 21% for spermicides alone.15
Buying condoms from a machine or shop is often considered preferable to the embarrassment of seeing a healthcare professional.16 Partly because of this, condoms are the most commonly used primary method of contraception used by teenagers.16 In England in 2001-2002, for example, 50% of young women aged under 16 years attending a family planning clinic for the first time chose to use the male condom, as did 31% of those aged 16-19 years.17 It is important to advise young people about effective use of condoms and help them with their communication skills with each other, as they are often too shy to discuss condom use with a partner.
In all, 35% of young women aged under 16 years attending a family planning clinic in England in 2001-2002 chose to use a combined oral contraceptive (COC), as did 50% of women aged 16-19 years, while about 2% of under 16 year-olds and 3% of those aged 16-19 years chose to use a progestogen-only pill.17 As far as is known, COCs carry no additional treatment-specific risks when started in a young teenager whose periods are established compared with, for example, in a woman in her 20s.18
In England in 2001-2002, around 4% of young women aged under 16 years and 8% aged 16-19 years attending a family planning clinic for the first time chose to use long-acting progestogen injections, but none chose to use long-acting progestogen implants.17 Teenagers often regard an injection of a long-acting progestogen, such as the Depo-Provera injection, as a convenient method of contraception, as it only needs a visit to the clinic or surgery every 12 weeks. An alternative is the etonogestrel implant (Implanon), a contraceptive device that requires the subdermal insertion of a single rod and is effective for up to 3 years.19 However, both can cause menstrual disturbances.19 Some research has suggested a reduction in bone density in long-term users of Depo-Provera, particularly in those who are smokers or are underweight, and in teenagers (who are building their peak bone mass) but more evidence is needed to confirm this.18
In general, IUDs are used in very small numbers of teenagers (1% in 16-19 year-olds17) because most are nulliparous and they may be at more risk of having an STI, which is a risk factor for pelvic inflammatory disease and infertility. Before insertion of an IUD, a full sexual history should be taken and all sexually active young women should be offered testing for chlamydial infection.20 IUDs should not be inserted as a routine procedure in those with suspected or proven STIs or a history suggesting that their, or their partner's, current sexual behaviour puts them at increased risk of having such an infection, until they have received adequate treatment.20 In teenagers, IUDs are most often used as an emergency contraceptive method. The intrauterine progestogen-only system (Mirena), which releases levonorgestrel directly into the uterine cavity, is currently only used by about 1% of women aged 16-19 years.21 Generally, the cautions and contraindications for this device are as for standard IUDs.
Female barrier methods
In teenagers, the use of female barrier methods, such as the cervical cap, diaphragm or female condom, seems to be negligible,17 partly because they are perceived to have higher failure rates and are often not promoted for use by healthcare professionals.
Teenagers need ready access to emergency contraception. Rigid appointment systems in general practice or restricted hours in family planning clinics can reduce or delay access.2 This might reduce the likelihood of a successful outcome, particularly with hormonal emergency contraception, which is more effective the sooner it is taken.22 In a recent survey of general practice principals, 483 of 486 (99.4%) respondents provided hormonal emergency contraception for under 16s and 48% would fit an IUD.23 In all, 72% said they would provide emergency contraception on a Sunday to a 14 year-old who reported having had unprotected sex the night before, but 1.6% said they would require parental consent to do so. It is important to reassure young women that they are being responsible in asking for emergency contraception and that they can take hormonal emergency contraceptives more than once.24 A consultation for emergency contraception provides an opportunity to discuss future contraception and sexual health.
The hormonal emergency contraceptive levonorgestrel (as Levonelle) has been available for sale for women aged 16 years or older at pharmacies since 2001, but the charge of £24 could be prohibitive for many teenagers. However, an increasing number of areas have walk-in schemes where community pharmacies can supply hormonal emergency contraceptives free of charge under Patient Group Directions. The manufacturer of Levonelle recommends that a woman takes one 750µg tablet as soon as possible (and not later than 72 hours) after unprotected intercourse, followed by another tablet 12 hours later (and no later than 16 hours). If it is more than 3 days since unprotected intercourse took place, use of a copper IUD is an option. An IUD can be fitted within 5 days of unprotected sex at any time in the menstrual cycle. It is a more effective method of emergency contraception,22 and offers women the choice of an ongoing long-term effective method of contraception. However, the risk of post-insertion pelvic infection must be considered and, ideally, the IUD fitting should be accompanied by a suitable course of antibiotic prophylaxis and testing.
There is a high rate of teenage pregnancy in the UK compared to the rest of Europe, and sexually transmitted infections are increasing in people aged under 20 years. The reasons for these problems are complex and it is unlikely that one agency or approach alone will improve the situation. There needs to be a joint effort and consistency of approaches to reducing teenage pregnancy rates. This should include easy, open access to healthcare professionals for all teenagers who seek advice and prescription for contraception, including emergency contraception. Services must be empathic and non-judgemental and staff must show the same confidentiality, courtesy and respect as that shown to adults in general.