Contraception in the under-18s

Sexual health specialist nurse Jodie Crossman advises on how to support under-18s with access to contraception.

Over the past two decades, pregnancy rates in under 18s have fallen steadily, with the conception rate reaching an all-time low of 13.1 conceptions per 1,000 people in 2020.¹ Unfortunately this fall has not been mirrored in rates of sexually transmitted infections (STIs) where young people still carry a disproportionate burden of diagnosis.² To continue to reduce unintended pregnancy rates and address the STI rate in young people, all clinicians have a role in discussing contraception and condom use with under 18s who access their services.

This article will explain the main points to consider when discussing contraception with young people. As ever, when discussing contraception and sexual health, it is important not to assume that all patients with a uterus or vagina identify as female – asking a patient’s pronouns at the start of a consultation can help you guide the discussion, and reassures that you provide a safe space for the young person to be themselves.

What are the laws around young people and contraception?

The age of consent (when a young person can legally consent to sex) in the UK is 16, but approximately one third of under 16s will have engaged in sexual activity by this point.³ Mutually consenting sexual activity between two under-16s is unlikely to be prosecuted, although children aged under 13 are legally considered to be unable to consent to sex.⁴ The legal guidance for confidentiality and consent varies across the devolved nations, but a detailed framework for the UK can be found in the General Medical Council guidance document for under 18s.⁵

Specific guidance exists for contraceptive and sexual health services, where maintaining confidentiality is key to encouraging young people to attend and engage with services. Services offering STI testing and contraception have a key role in helping prevent sexual exploitation and abuse of young people. However, confidentiality has to be balanced against the need to safeguard young people from harm. Sexual health services use Fraser Guidelines, which relate specifically to making decisions about sexual health and contraception.⁶ A person aged under 16 should be judged to meet these guidelines by the clinician in order to access services alone. Gillick competency assessment may also be used.

Fraser Guidelines

Under the Fraser guidelines, practitioners should be satisfied of the following:

The young person cannot be persuaded to inform their parents or carers that they are seeking this advice or treatment (or to allow the practitioner to inform their parents or carers).
The young person understands the advice being given.
The young person’s physical or mental health, or both, are likely to suffer unless they receive the advice or treatment.
It is in the young person’s best interests to receive the advice, treatment or both without their parents’ or carers’ consent.
The young person is very likely to continue having sex with or without contraceptive treatment.

How should a safeguarding assessment be done?

Although young people aged over 16 do not need to meet the Fraser competence criteria to access care, any young person may be at risk of child sexual exploitation (CSE). All staff regularly seeing under 18s should complete level 3 safeguarding training³ to fully understand the potential signs of abuse. Under-18s accessing contraceptive and sexual health services should have a safeguarding assessment as part of the consultation. The British Association for Sexual Health and HIV (BASHH) have produced a proforma⁷ which can help to identify areas in a young person’s life which may leave them vulnerable to CSE. These may include an unstable home life, being out of education, poor mental health or substance misuse.

Young people who are otherwise healthy may not often access medical advice, so a consultation about contraception can be a rare opportunity to discuss their lives and identify concerns. Try to be as welcoming and open as possible when engaging with young people. In sexual health, we often talk about ‘professional curiosity’;⁸ rather than treating the proforma as a checklist, we ask open questions to try to understand what life is like for that young person. This can help them feel listened to, and may encourage them to return again for further advice or support.

What do I do if I have concerns?

Every NHS trust or GP practice group should have a named safeguarding lead. If you believe the patient is in immediate danger, they should be kept in the clinic and the police should be contacted. If you have concerns but the patient is safe to leave, these concerns should be shared using the safeguarding procedure for your area. Most safeguarding hubs have a duty worker who can be contacted to discuss any concerns and where to refer for further support. Although teenagers are entitled to privacy, it is good to have a low threshold for information sharing with any concerns, as other agencies may already be involved in their care, and it can help to contribute to the picture. If a young person is looked after by the state, this does not automatically mean their information should be shared, but any new concerns identified in a consultation need to be communicated to their social worker for further input.

What contraception is appropriate for under 18s?

According to the Faculty of Sexual and Reproductive Healthcare (FSRH) UK Medical Eligibility Criteria for Contraceptive Use (UK MEC) there are no age-based restrictions for contraceptive options.⁹ However, some caution should be exercised with the contraceptive injection because of its effect on bone mineral density.³ In the past, nulliparous people have been advised against using intrauterine contraception, but there is no rationale for this and it can be used if it is the patient’s preferred method and they are fully informed about the risks and benefits.³

Discussions about contraception should take into account the young person’s situation, for example whether they will remember pills regularly or if they need a discreet method such as the injection, and exploration of any concerns they may have, for example about weight gain or acne. A discussion about their menstrual cycle and whether they experience irregular or heavy periods may provide an opportunity to identify other health issues such as endometriosis, which would need onward referral to a gynaecologist.

Ideally, long-acting reversible contraception (LARC) methods should be promoted due to their high levels of efficacy and length of action,³ although a full discussion of their risks and benefits is important to help prevent early discontinuation. Quick starting contraception (ie, starting contraception immediately rather than waiting for the next menstrual cycle) is possible in most cases and means that there is no delay to contraceptive access, reducing risk of unintended pregnancy.³ The FSRH provides specific guidance on quick starting.¹³ With any contraception discussion, it is important to highlight that the only method which can help prevent STIs is consistent condom use, and advise regular STI testing, especially with any new sexual partners. This also provides an opportunity to demonstrate safe condom use, and link in with your local c-card (condom distribution) scheme.¹³

Can we consult remotely on contraception with under-18s?

The pandemic led to rapid uptake of remote or telephone consultations by many services. This has been beneficial in some situations – meaning that people can order home tests or repeat contraception without needing to arrange to come into the clinic. However, there were significant concerns that opportunities to safeguard young people may be missed as a result of not seeing them face-to-face.¹⁰ Young people who are being coerced or groomed into sex may not be able to talk openly if the perpetrator is present during the call. They may fear their telephones are being monitored, or that parents will overhear their call.

Now most restrictions are lifted, it is best practice to arrange to see a young person face-to-face where possible. This will allow a safeguarding consultation to be conducted in an environment where the clinician can be satisfied that the patient is alone and is able to talk privately about their needs or concerns. That said, remote consultations have the benefit of increasing access,¹¹ meaning young people who otherwise wouldn’t attend have a route into the service. The Royal College of Paediatrics and Child Health (RCPCH) has published guidelines providing practical advice for using remote consultations safely in young people.¹² A pragmatic approach would be to offer an introduction or advice over the phone, followed up by face-to-face contact to check that the young person has space to discuss any concerns. Whichever consultation medium is used, it is important to fully document the conversation, and whether Fraser or Gillick competence has been established.

Jodie Crossman is nurse team leader at Brighton and Hove Sexual Health and Contraception Service and chair of the British Association for Sexual Health and HIV nurses group

References

Office for National Statistics. Conceptions in England and Wales 2020. April 2022. Link
Public Health England. STI rates remain a concern despite fall in 2020. September, 2021. Link
Royal College of Nursing. Safeguarding children and young people: Roles and competencies for healthcare staff. 2019. Link
UK Government. Sexual Offences Act 2003. Link
GMC. 0-18 years: guidance for all doctors. 2020. Link
NSPCC. NSPCC Learning. Gillick competence and Fraser guidelines. 2020. Link
BASHH. Spotting the signs. A national proforma for identifying risk of child sexual exploitation in sexual health services. 2014. Link
Burton V and Revell L. Professional curiosity in child protection: thinking the unthinkable in a neo-liberal world. Br J Soc Work 2017;48(6):1508-1523
FSRH UK MEC. 2018. Link
Bekaert S and Azzopardi L. Safeguarding teenagers in a sexual health service during the COVID-19 pandemic. Sex Transm Infect 2022;98:219–221
Dixon S et al. Challenges of safeguarding via remote consulting during the COVID-19 pandemic: a qualitative interview study. Br J Gen Pract 2022;72(716):e199-e208
RCPCH. Principles for conducting virtual consultations with children and young people. 2020. Link
FSRH. Clinical guideline: Quick starting contraception. 2017. Link
Brook. C-card distribution schemes. Link