Whether teenagers are thinking about having sex for the first time or have been sexually active for a while, it’s vital they are given all the information they need about contraception

MOST TEENAGERS first have heterosexual sex at around the age of 16 years, according to Brook, a charity that provides sexual health services and advice for the under-25s. While most young people will have had sexual intercourse by the age of 20, around 30 per cent of young men and almost 26 per cent of young women report having had intercourse before their 16th birthday.

Official figures released in February 2014 by the Office for National Statistics (ONS) revealed that teenage pregnancies in England and Wales are at an all-time low, with the under-18 conception rate at its lowest level since 1969. Yet lowering them further remains a national priority as teenage pregnancy rates in the UK are still much higher than those in other Western European countries.

New guidance from the National Institute for Health and Care Excellence (NICE), issued in March 2014 with the aim of reducing unwanted teenage pregnancies, says there should be greater access to emergency contraception and condoms for the under- 25s. In addition, healthcare professionals (including pharmacists) who advise young people about contraception should be able to help them compare the risks and benefits of the different contraceptive methods that are available.

Anne Weyman OBE, chair of the independent committee that developed the guidance and former head of the Family Planning Association (fpa), says that young people need good contraceptive advice so that they can choose the right method for them. “

Most sexually active young women use at least one method of contraception,” she says. “The new guidance aims to reduce unwanted pregnancies by ensuring that young people have access to a full range of contraceptive methods, not just pills and condoms, but the longer-acting methods such as contraceptive injections and implants as well.”

Accessible advice

Young people need to be able to access sexual health services easily and quickly. Pharmacies are usually more conveniently located than family planning clinics, which are often based in hospitals. They are also open longer hours and don’t require an appointment. In some rural areas, the local pharmacy may be the only accessible place to obtain sexual health advice.

Debbie Mennim, Brook’s head of nursing, says that pharmacies are a vital outlet when it comes to contraception and sexual health. “Young people, who may not want to visit a GP or sexual health clinic, can drop into a local pharmacy and – if a confidential space is available – talk to a trusted healthcare professional,” she says. “Pharmacy staff can use visual tools to tell young customers that contraception is available, such as leaflets about STI prevention methods, contraception and sexual health at the counter and posters around the pharmacy. Information slips about safe sex could be included in prescription bags, especially when issuing scripts for contraceptives and STI treatments.”

In 2012, a pilot study in Southwark and Lambeth, which has one of the highest teenage conception rates in Europe and the highest in London, looked at the role of trained community pharmacists in the provision of oral contraceptive services under a patient group direction to women aged 16 years and over, many of whom had not used oral contraception before. The pilot was very successful and the evaluation report recommended that the scheme should include under-16s and be rolled out across the country.

According to NICE guidance, healthcare professionals providing emergency contraception must be aware that they can give it to under-16s ‘without parental knowledge or consent, in accordance with best practice guidance’.

“There are clear guidelines that any healthcare professional considering providing contraception to a young person must follow and criteria based in case law that the young person must meet in order to receive treatment,” says Debbie Mennim. “Pharmacy staff require clinical training to ensure the consultation will be safe, as well as training on working with vulnerable young people and on creating a young people-friendly setting.”

Emergency provisions

Emergency hormonal contraception (the ‘morning-after pill’) has been available in community pharmacies in the UK since 2001. According to Katie Phillips, public health manager at Leicestershire Teenage Pregnancy Partnership, young people in Leicestershire benefit from the choice of local pharmacies providing EHC. “We have developed training with pharmacists over a number of years, responding to what young people want,” she says. 

“We find that the most popular pharmacies for teenagers are those on college campus sites or in shopping centres, where teenagers could be going for a number of different reasons, such as to buy make-up and toiletries. It is harder when the pharmacy is located in a small village, as teenagers worry that they are more likely to get noticed by people they know.”

EHC needs to be used as soon as possible after sex and is only effective if taken within a limited time. According to the NICE guidance, healthcare professionals should inform young women that an intrauterine device is a more effective form of emergency contraception than the oral method and can also be used on an ongoing basis.

The recent NICE guidance proved controversial among some patient groups and campaigners, as it recommended that young women under the age of 25 years (including the under-16s) should be able to access emergency contraception in advance of need. There are some arguments that this could promote risky sexual behaviour, but according to the British Pregnancy Advisory Service (BPAS), which supports the guidance, there is no evidence that this would be the case. Guidance from the Royal Pharmaceutical Society states that pharmacists can provide an advance supply of EHC to a patient requesting it at the pharmacy, using their professional judgement as to whether a supply is clinically appropriate.

“The emergency contraceptive pill is more effective the earlier it is taken, so it makes sense for young women to keep it at home,” says Ann Furedi, BPAS chief executive. “Ideally we would like women of all ages to be able to either keep the emergency pill at home or obtain it free of charge from their local pharmacy. At present there’s wide variation in women’s access to this form of contraception, which is an essential back-up for when their regular method lets them down.”

Regular Options

If teenagers are accessing pharmacy for EHC (as a one-off or regularly), it provides an ideal opportunity for pharmacists to discuss wider aspects of contraception and sexual health, including protection from sexually transmitted infections (STIs).

“Pharmacies could put up posters to let teenagers know that they are available for such discussions in private,” says fpa training manager Paul Casey. “It’s important not to make assumptions that certain methods would not be tolerated due to the age or religious/cultural background of the young person. Always be guided by what the young person asks and give accurate information. Be prepared to challenge incorrect statements, such as ‘emergency contraception causes an abortion’, in a direct but patient way.”

Tracey Forsyth, lead contraceptive nurse, says BPAS is planning to run a pilot with a pharmacy in Coventry, aimed at women asking for EHC. “When someone comes into the pharmacy for EHC, they will be offered contraception counselling by a specially trained nurse,” she says. “This is an extension of the BPAS phone counselling service. Contraceptive choice is down to the individual, so we will talk about each woman’s lifestyle, her family and personal history, and why she may not be happy with her current choice of contraception. The pill is not necessarily the best option, so we will discuss the different methods available.”

Genevieve Edwards, Marie Stopes UK director of policy and communications, says that younger women like the convenience of not taking something every day. “There needs to be more awareness of the short-term effectiveness of the pill and the alternative long-term methods,” she says.

In August 2013, research commissioned by Merck Sharp & Dohme (MSD) revealed ongoing access issues regarding longacting reversible contraception (LARC) in the UK, with over twothirds of the women surveyed saying they had not been provided with enough information about these contraceptive methods. Nearly a third of the women surveyed, currently using a form of contraception, said they worried about taking or using their contraception correctly or forgetting to take it. Over threequarters of women said that their GP, nurse or family planning healthcare professional had not discussed LARC options with them.

Confidential service

According to the NICE guidance, healthcare professionals should not be discriminating or judgmental, and should respect young people’s choices and way of life. “In most cases, the discussion is being initiated by the young person coming into the pharmacy for condoms or emergency contraception,” says Ash Soni, president of the Royal Pharmaceutical Society. “It’s about giving the right information using leaflets, POS material and signposting to local services. Listen to what young people have to say and remember that they have come in for advice not a lecture.”

Paul Casey agrees that it’s important not to make assumptions about existing knowledge and/or behaviour. “Don’t assume that a young person who is asking for information about sexual health is sexually active,” he says. “They may just want information from you as someone knowledgeable about the topic.

“Also, don’t assume what a young person might already know. Some schools and parents have given young people high-quality information about sexual health, but some young people will not have had this. Be prepared to go back to basics. Give information in stages and make sure that you give young people time to ask questions about what you have said so that you can clarify any areas of misunderstanding.”

It can be hard to reduce a whole conversation about sexual health to a 30-second over-the-counter chat, says Debbie Mennim, “so it is much better if consultations on sex and contraception take place in an appropriately confidential space if available”. Ideally you’d want time to build up a trusting relationship with a young person asking for advice on sex and contraception, but this isn’t always possible, she says.

“You should always emphasise the confidential nature of any consultation, as young people consistently tell us that confidentiality is one of their top priorities when accessing sexual health services in any setting – GP, clinic or pharmacy. Some questions that you could ask during the consultations are: Why is the young person thinking about having sex? Is this the right time for them? Is there an adult they can trust and talk to?”

Some good advice for pharmacists to consider as the sector takes on a growing role in the sexual health arena.