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 rela- tionship and have already had intercourse on two occasions where they did not use con- traception. 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.
There are no examination or investigations findings.
· What issues are important in determining how this situation should be managed?
· How would you further investigate, advise and manage this girl?
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 pro- viding 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, for example he was over 20 years, then issues of child protection should be considered and the case should be dis- cussed in the first instance with a social worker.
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.