Contraception in the under-16s: issues of confidentiality and choice of methods
London Brook, 374 Brixton Road, London SW9 7AW, UK Email: firstname.lastname@example.org
- •The rate of teenage pregnancy in Britain is the highest in Europe.
- •Long-acting reversible methods of contraception are highly suitable for young women, including under-16s.
- •Fraser competence must be established in under-16s.
- •It is essential that consultations are confidential and ‘young people-friendly’.
- •To learn about the current statistics for teenage pregnancy in the UK.
- •To understand how to deliver information on contraception in a manner acceptable to young women.
- •To learn about the range of contraceptive methods available to young women and their suitability.
- •To learn how to hold a user-friendly consultation with a teenager.
- •Doctors often see sexually active teenagers without their parents' knowledge and are required to provide them with information about contraception.
- •Can informed consent be obtained from a very young woman for administration of an invasive method of contraception?
- •An awareness of local child protection policies is important.
Please cite this article as: Vanhegan G. Contraception in the under-16s: issues of confidentiality and choice of methods. The Obstetrician & Gynaecologist 2008;10:22–26.
The teenage pregnancy rate in Britain remains alarmingly high (Table 1).1 It is the highest in Europe: six times higher than the Netherlands and twice as high as France or Germany.2 However, whilst about one third of under-16s admit to being sexually active,3 the same as in the Netherlands, Dutch teenagers are far more likely to use reliable contraception at the beginning of their sexual lives. British teenagers have sex and relationship education at school4 but many young people report that they are already sexually active. Teenagers often seem unprepared for the first time they have sex and give various reasons for not using condoms as protection; for instance, ‘We did not have a condom’, ‘We were not expecting to do it that night’ or ‘I did not know him well enough to ask him if he had a condom’.
Teenage pregnancy rates in Britain1
(Crown copyright material is reproduced with the permission of the controller of HMSO.)
There is also a high level of sexually transmitted infections (STIs) in the teenage population in Britain: currently, the highest number of positive tests for Chlamydia trachomatis is found in women under the age of 20 and men in the 20–25 age group.5 Doctors should exercise the opportunities in their role to raise awareness in young people about the risks of unprotected sex, to educate and, of course, to protect them. A teenager will sometimes visit their general practitioner (GP) to consult about a sports injury, a sore throat, acne or other ailments unrelated to sex but this does give the GP an opportunity to discuss lifestyle choices with the young person and, of course, these will include their views on sexual activity. Young women often attend a gynaecological consultation with their mother: there may be an opportunity to see the young woman alone for at least part of the consultation to discuss with her whether or not she is sexually active, as she may not always give a true account with her mother present.
The contraceptive consultation
Young women do, of course, specifically seek help with contraception but this is often a crisis situation, for instance, if they need a pregnancy test or emergency contraception. They will make a choice as to where to attend depending upon their knowledge of services. This is often gained from asking friends or looking on the internet. If the young woman has a good relationship with her GP she will usually seek help at the surgery in the first instance, but in the case of an emergency this can sometimes be difficult as there may be no appointments available.
In some areas the emergency contraceptive or ‘morning-after’ pill is available free of charge to under-16s from the local pharmacist. In this case, the pharmacist is trained to hold the necessary consultation and give advice about ongoing contraception but the latter does still require a prescription.
Some young women seek help at young persons' clinics run by local family planning services, or at specialist young peoples' services, such as the Brook Centres. It is vital that the clinician who sees the young woman is well trained in carrying out this sensitive type of consultation. Clinicians should introduce themselves by name and explain their role, for example, medical or nursing. The views of young people about their ideas for a good consultation have been sought and their first requirement is the assurance of confidentiality by the health professional.6 All health professionals who see young women under the age of 16 without parental consent must adhere to the Fraser guidelines, which emanated from the Gillick v West Norfolk and Wisbech AHA case of 1986 (Box 1).7
- (Box 1 )
[Assessment of Fraser competence]
It is important to ascertain the nature of the sexual activity and whether this was consensual between two young people. Although sex under the age of 16 is not deemed legal in the UK, this occurs sufficiently often at the experimental and risk-taking stage of young peoples' lives for the law to be unenforceable. Sometimes, the young woman will not have indulged in activity that we would consider has put them at risk, for example, close genital contact while fully clothed, but this is a good opportunity for education. On the other hand, the clinician must be alert to any abusive or coercive sexual activity and take necessary action.8 If a clinician is concerned about a case of underage sexual activity he should discuss the case with the child protection lead for his organisation or place of work. In a consensual situation, it is important to ascertain whether this incident was an isolated occurrence or whether the sexual activity is continuing and ongoing contraception is required. The clinician should assess whether it is in the young woman's best interests to be prescribed contraception and whether she is mature enough to comprehend the advice given. They will then be able to discuss contraceptive choices.
The contraceptive pill
The contraceptive pill (‘the pill’) is the method most commonly known to young women and the first choice of contraceptive prescribed by the majority of doctors. However, long-acting reversible contraception (LARC) methods9 may actually be more appropriate for teenagers.
Young women will have some degree of knowledge of contraception and, inevitably, preconceived ideas about certain methods: the clinician needs to explore these and find out what the young woman wants. They may have a rather contrary view about the use of a method such as the pill and feel that it has a role in long-term relationships, not as protection against pregnancy in casual relationships. There is a feeling amongst some young women that starting the pill means making a commitment to a partner that they are not ready to give. It should also be remembered that their information about a method might have come mainly from friends and relatives, not health professionals or through sex and relationship education at school. They may well focus on negative views of the method, such as fear of weight gain, irregular bleeding or fertility problems, maintaining that they know someone who took it and was unable to become pregnant later in life, yet at the same time talking about a friend who became pregnant while taking the pill.
The role of the doctor is to explain the mode of action of the method and to help weigh up the benefits and side-effects. The main benefit to a young woman is, of course, reliability, but the noncontraceptive benefits, such as a reduction in menstrual loss, dysmenorrhoea and the incidence of ovarian cancer, may also be important, although they can seem rather remote issues to a teenager. It is wise to cover potential minor side-effects in this first consultation, for example, breast discomfort or mild headaches, but also to emphasise that these are temporary and will diminish after the first pack or two. Young women seem relatively unconcerned about more serious potential risks such as venous thromboembolism; even so, the relative risk should be put into proportion for them.10
In spite of all the care and attention given in a good and informative consultation, some young women are poor pill users who often forget to take them.11 Older women are able to keep them on display, such as on their bedside table or with their make-up or toothbrush, where they will see them and not forget to take them. However, young women are often unable to do this, as they may be hiding them from their parents. It is helpful to give these women strategies to remember to take the pill daily. The most useful tool is their mobile phone: they should be advised to set a reminder alarm on the phone, as it is generally at their side day and night.
The actual combined oral contraceptive failure rate in the first year of use is 6–8 pregnancies per 100 women. A retrospective study12 of young women in Nottingham who had become pregnant in one year showed that 50% of them had been prescribed the pill by their GP in the year leading up to the pregnancy. The question remains as to why they had not complied with the medication. The conclusion was that the consultations had been shorter than the average GP consultation time, possibly because of embarrassment and discomfort on the part of the young woman and/or doctor. Young women tended to seek out the female partner in the practice for the contraceptive consultation.
The contraceptive consultation with a young woman takes time, as the doctor has to listen to her needs and explain the method in detail. It is advisable to give back-up literature, as the young woman may only remember a small fraction of the discussion. They will have further queries after the consultation to feel secure in their decision to use this method and they should be given a telephone contact number or address of a website (see Websites). Brook has a manned telephone helpline for young people.
The contraceptive patch
Containing ethinylestradiol and norelgestromin, this is marketed as EVRA® and has a place amongst contraceptive choices for young women. It is a means of delivering estrogen and progestogen contraception via the transdermal route. The activity profile is very similar to oral contraception but the advantage to the adolescent is that she only needs to remember to change the patch once a week: However, in the 4-weekly cycle there is one patch-free week: she still has to remember to restart her patches after this.
Long-acting reversible contraception
Bearing in mind the difficulties some young women have with compliance, it is advisable to consider longer-acting contraceptive methods (Box 2). Since the subdermal implant, Implanon® (etonogestrel implant), was licensed in 1999, it has grown in popularity with young women. The National Institute of Health and Clinical Excellence (NICE) produced guidelines in October 2005, Long-acting Reversible Contraception,9 emphasising the role of these methods in young women.
- (Box 2 )
[Use of long-acting reversible methods of contraception in teenagers]
The implant is described in the literature as a contraceptive rod about the size of a hairgrip. Young women do not like this description, as they have a perception of something hard, large and sharp being inserted into their arm. I describe Implanon as a soft, flexible tube and show them the demonstration implant, allowing them to feel and hold it: this makes the method far more acceptable to them. Implanon contains 68 mg etonorgestrel and, in the initial phase, 60–70 micrograms is the daily measurable blood level, falling to 30–40 micrograms after a few weeks. The insertion technique is simple and acceptable to young women, being virtually pain free after local anaesthetic injection.
The main advantage of the method is its high level of efficacy, with a failure rate of 0.1% over 3 years. Minor side-effects, such as occasional skin problems and weight gain, occur in <10% of users. However, irregular bleeding is more common and it is important to counsel the young woman about this problem, which is common with most forms of progestogenic contraception. About 33% of users discontinue the method in less than 3 years because of irregular bleeding.9 The NICE guidance was updated in June 2006 to advise that irregular bleeding is best treated with mefenamic acid or ethinyloestradiol. This method has become more popular with young women in the first 5 years of availability in the UK: in our young peoples' service at the London Brook Centres we inserted 350% more implants in 2005–06 than in 2000–01.
Implants may only be inserted by doctors or nurses who have completed the accredited training of the Faculty of Sexual & Reproductive Healthcare (FSRH) of the RCOG or the Royal College of Nursing and it is important that more clinicians complete the training to increase availability of the method to young women.
The most commonly used injectable contraceptive in the UK is medroxyprogesterone acetate (DMPA, marketed as Depo-Provera®). Young women often choose this method as it has the advantage of 12 weeks' contraceptive protection without the need to remember to take pills daily. While irregular bleeding can occur with the implant, after two to three injections of Depo-Provera amenorrhoea usually develops. Initial counselling about the method needs to cover this side-effect, as young women will become anxious about amenorrhoea and suspect that they are pregnant unless they have been warned to expect this.
There has been evidence of possible reduced bone mineral density with Depo-Provera use in excess of 2 years13 and the Chief Medical Officer issued an urgent communication in November 2004 about the prescription of this method to young women under the age of 19.14 In this case, Depo-Provera should be used only where no other method is suitable or acceptable to the young woman, as per the NICE guideline on LARC.9
Intrauterine devices and systems
The NICE guidance9 emphasises that younger women should not be considered unsuitable for these methods: they can be used in nulliparous young women and there are no restrictions to the use of intrauterine devices (IUDs) or intrauterine systems (IUSs) in adolescents. The slimline IUD already exists for the smaller uterine cavity. In my own experience, working in a young persons' specialist service with very young women, the main use of the IUD is as an emergency contraceptive, where a young woman has had unprotected sex at a fertile time of the cycle and does not present until more than 3 days after the event, or where there have been multiple episodes of unprotected sex since the previous period.
Young women can be anxious about the procedure and a careful explanation of the method, its mode of delivery and the benefits and side-effects usually alleviates this. As the rate of C. trachomatis infection is high in this age group, it is essential to take an endocervical chlamydia swab and to give antibiotic cover for the fitting of the IUD or IUS, as stated in the FSRH guidance on IUDs.15
Some practitioners are concerned about the ethical issue of using an invasive method in a young woman. However, all young women are able to give their consent to the procedure provided that they understand what is to be undertaken, believe in it and retain the information long enough to give informed consent.
The condom is the contraceptive method most commonly used by young people and this is to be encouraged. The methods previously described do not protect the user from STIs: ‘double Dutch’, the use of a contraceptive method and a barrier method, should be encouraged in this age group.
The diaphragm or cap has a relatively high failure rate as a contraceptive option and is rarely chosen by young women because of the pregnancy risk.
There are many contraceptive options for teenagers and, in view of the high unplanned pregnancy rates in this age group, longer acting methods, such as implants, intrauterine methods and injectable contraception, are considered preferable to the contraceptive pill. Doctors need time and the appropriate skills to deliver a good contraceptive consultation to a young woman. It is vital to lay down good contraceptive practice at a young age, as this experience will affect young women's decisions about contraception for the rest of their lives.