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Case History

image A 14-year-old girl attends the clinic to discuss contraception. Her boyfriend is 17 years old and they have not yet had sex. She appears quite embarrassed and asks whether it would be a good idea for her to start the pill. She is very clear that she does not wish her parents to know about the consultation.

How would you approach the consultation?

How would you advise about sexually transmitted infections (STIs)?

What contraceptive methods would you advise?


image Despite a general trend towards later childbearing, teenage pregnancy remains a serious problem.1 The incidence of teenage pregnancy varies widely throughout the world (Figure 24.1). In Europe the highest rate is in the United Kingdom and the lowest in the Netherlands and Switzerland.

Figure 24.1

Births per 1000 women aged 15–19 years. Source: Tripp and Viner 1998.1

Throughout most of western Europe, teenage birth rates fell during the 1970s, 1980s, and 1990s, but in the UK rates have remained high. However, for some young women, particularly from certain ethnic or social groups, teenage pregnancy can be a positive life choice. On the other hand, for many other young women, the costs of teenage pregnancy can be very high, particularly when linked with poverty. These risks include poorer outcomes for the children of teenage mothers as well as for the mothers themselves. Infant mortality among babies of teenage mothers is about 60% higher than among the babies of older mothers. Prevention of unwanted teenage pregnancies is a high priority in many countries and various strategies are used. High-quality evidence shows that health promotion behavioural programmes, using peer educators of a similar age, reduce the prevalence of sexual activity at age 16 years.2,3 Although programmes that promote abstinence have a logical appeal, no high-quality studies have shown the effectiveness of such approaches.

How would you approach the consultation?

Young people often find it difficult to seek advice regarding sexual health for a number of reasons. Embarrassment, concerns about confidentiality and peer pressure can all affect the consultation. It is vitally important to try to ensure that the young person feels at ease and to approach the consultation sensitively and in a non-judgemental manner. Instructions should be clear and concise and backed up with appropriate reading material, and if possible the patient should be seen alone if attending with a partner.

In this case, the patient is 14 years old and there may be child protection issues. The law varies between countries. In the UK, if she is judged to be Fraser competent,4 contraception, sexual health advice and treatment may be provided without parental knowledge or consent, although efforts should always be made to encourage her to discuss things with one or ...

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