Case 99: Teenage contraception

 CASE 99: TEENAGE CONTRACEPTION

History

A 14-year-old girl attends a family planning clinic wanting to start ‘the pill’. She has been

with her boyfriend for 8 months. They both agreed that they wanted to start a sexual relationship and have already had intercourse on two occasions where they did not use contraception. She had never been sexually active before. Her periods started 3 years ago and were

initially irregular but she now reports a regular 27-day cycle. She has never had any gynaecological or other medical problems.

She reports that she is happy at school and she is one of three children, with a brother of 21

and sister of 19 years. She lives with her parents in a house locally. She has attended the clinic

with a female school friend.

Examination

There are no examination or investigations findings.

Questions

• What issues are important in determining how this situation should be managed?

• How would you further investigate, advise and manage the situation in this scenario?100 Cases in Obstetrics and Gynaecology

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ANSWER 99

Prescribing of contraception to girls under the legal age of consent (16 years) is guided by the

Fraser rules, which arose from the case of Gillick seeking to stop a doctor from providing

contraceptive advice to her daughter without consulting the parents.

The law allows contraception to be provided as long as the following criteria are met:

• the girl should be encouraged to discuss her sexual activity with a parent or another

responsible adult

• she should consent to intercourse

• she should understand the implications of having sexual intercourse and the contraceptive method chosen

• it is anticipated that she will have sex whether or not contraception is provided and

is therefore at potentially higher physical and psychological harm from an inadvertent pregnancy.

In this case it is clear that the girl will continue to have sex with or without contraception

as she has already done so, and therefore it is in her best interests to prevent pregnancy. She

should be encouraged to discuss the issue with a parent, or failing this perhaps her older sister

or brother.

The age of her boyfriend should be explored – if he is of a similar age then consent is probably

valid. However if there is a significant age discrepancy, e.g. he was over 20 years, then issues

of child protection should be considered and the case should be discussed in the first instance

with a social worker.

Investigation and advice

A urinary pregnancy test should be performed prior to any hormonal contraception, as she

has already had unprotected intercourse.

She should be advised about the different methods of contraception, particularly how to use

them and the importance of compliance. The availability of emergency contraception should

be explained.

She is at risk of sexually transmitted infections, and barrier contraception should be advised

even if she is using the contraceptive pill as her main pregnancy-prevention strategy.

Whichever option is chosen, the girl should be supported such that she is happy to come back

for further review and to check correct usage of the preferred method. Explanation of confidentiality rules will also aid her confidence in your advice.

KEY POINTS

• Contraception may be provided to girls under the age of 16 years without parental

consent subject to the guidance in the Fraser rules.

• Sexually transmitted infections and education about emergency contraception

are an integral part of such consultations