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Commentary on the paper by Krishnamoorthy et al (see page903)
In surveying the prescription of oral contraceptive pill to girls aged 10–16 inclusive, the authors of an interesting paper in this edition note a low overall prescription rate of combined oral contraception.1 This low overall prevalence should be interpreted recognising that those using progesterone only or injectable contraception were not included. Further, prescription rates increase two hundredfold between those under 13 (nearly half the denominator) compared to those of 16, and approximately double between 15 and 16; an age when significant numbers of girls become sexually active and increasingly adopt hormonal contraception in longer relationships with more frequent intercourse. While it is proper to address ways to improve uptake of hormonal contraception by young women at risk of unplanned pregnancy, I suggest that concentrating effort here at the expense of alternative strategies may lead to a “feel good” factor, but is not be the best use of scarce resources.
THE CRISIS OF SEXUAL HEALTH
Teenage pregnancies have remained roughly static in England and Wales since 1975 and in Scotland since 1985,2 in spite of the fact that many more teenagers are using contraception. Further, emergency contraception possibly now prevents up to 15% of all pregnancies in this age group (calculated from the fact that there are at least 25 prescriptions of emergency contraception per 100 female teenagers aged 16–17 per annum,3 and that about 75 pregnancies are prevented per 1000 prescriptions4).
That we are facing a national crisis in sexual health, is reinforced by the extremely worrying rises in sexually transmitted infections (STIs). Chlamydial, gonorrhoeal, and HIV infections (the latter two largely unaffected by increased rates of diagnosis) have increased two- threefold in five years in 15–19 and 20–24 year olds of both genders.2 Few teenagers are aware that their chance of contracting an STI during a single episode of unprotected intercourse, with an infected partner, is many times higher than that of a resulting pregnancy. A significant minority still fail to recognise that hormonal contraception offers no protection from STIs.
WHAT ARE THE UNDERLYING CAUSES?
In a case-control study, half of all teenagers who became pregnant had been prescribed oral contraception in the year before conception; nearly three quarters had discussed contraception with a health professional in that year.5 Among 16–17 year olds, barrier contraception, readily available to men and women from vending machines or over the counter, is used significantly more frequently than hormonal contraception.3 Total numbers using contraception may therefore approach the number who are sexually active. This is consistent with data collected by my own group and others which suggests that around 70–80% of teenagers at an average age of 16 have used contraception both at first and most recent intercourse. However, the age of first intercourse is falling and approximately half of non-virgins have had at least one episode of sexual intercourse without contraception before the age of 16. At age 16–19 and 20–24, around a third of the men and a fifth of the women among the two thirds sexually active have had two or more partners in the past 12 months—that is, 18 or more partners over the nine years.3 It is thus likely that it is inconsistent use of contraception combined with earlier and increased sexual activity6 that have made a major contribution to our failure to lower the rate of pregnancy in this age group in the UK.
WHERE SHOULD WE LOOK FOR SOLUTIONS?
These data suggest that the issue is not primarily the provision of better access to hormonal contraception. We must enable and support teenagers to develop healthier behaviours with improved knowledge, but also more accurate understandings of social norms and enhanced negotiation skills to resist pressure and enable them to postpone sexual debut (early sexual activity is associated with increased risk taking) and to reduce the number of their sexual partnerships. There are few interventions which can claim to achieve this, but there are clues as to how it might be achieved. The evidence that a government led and supported ABC campaign (Abstinence, Be faithful, and if not use a Condom) has been far more effective in Uganda than larger sums expended on safer sex campaigns elsewhere in Africa is strong, if not incontrovertible. Similarly fiscal and religious pressure on schools in the USA to use abstinence programmes has been associated with large falls in teenage pregnancies, though cause and effect cannot be proven. The response from the government in the White Paper “Choosing Health”, emphasising postponement as a strategy, and the recent endorsement of the concept by the Chair of the Sex Education Forum both represent significant U-turns and are to be welcomed. Encouraging postponement of first intercourse (an addictive experience, passed on to new (virgin) partners in future relationships) has the benefits of delaying and thus reducing risk taking, reducing the numbers involved, and affecting perceived norms.
PRIORITIES FOR ACTION
Although teenagers are perceived as risk takers by adults and especially by health promoters, they are actually “risk averse” but rate the risks of being “un-cool” more highly than the distant risk of a pregnancy or STI. This provides a strong clue to appropriate methodologies for health promotion with young people which must address their normative expectations and the impediment to health represented by misunderstandings of peer behaviours. We must encourage the development of healthy values and provide environments, probably peer supported, where young people can improve their self efficacy beliefs that they can achieve health as well as happiness.7 This will only happen when policy-makers and commissioners invest in effective programmes, judged by inclusion of the essential components identified by Kirby8 rather than the current apparently ad hoc allocation of scarce resources.
“Safer sex” is not restricted to discussion and demonstration of condoms. It is notable that in Churchill and colleagues’ study, very few of the young women consulting for contraceptive advice, were given barrier contraception,4 and condoms are not mentioned in this report.1
The evidence is out there, and is strong, that only health promotion that is soundly theory based and faithfully delivered has the potential to enable healthier behaviours and improve health.7,9 We must also work in health promotion and provision to increase simultaneous and effective use of both barrier and hormonal contraception.
These tasks are those where investment in research and provision must be made.
Competing interests: none