Teenage Sexual Health

The first Birth Control Clinic in the UK was founded in London by Marie Stopes over 80 years ago (FPA 2002). The concept of controlling fertility and family size has met resistance by the church, some medical professionals and society in general. Assisted by political pressure from women’s groups the demand for women to control their fertility has developed, due to which family planning is seen by many as one of the success stories of the 20th century. However Loudon (2008 in Glasier and Gebbie 2008 p8) controversially believes with world population reaching over 6 billion and more than 120 million women in developing countries with no method of preventing pregnancy, the success should be a could do better story.
In the UK the major unresolved problem is Teenage Pregnancy with the number of conceptions in the under 18 year age group for England reaching 40,366 in 2007, (Office of National Statistics 2009). Teenage pregnancy is an important common sexual health issue which is largely preventable and has negative consequences for both the teenagers whom become pregnant and their children, Langille (2007). He continues by stating when compared with babies born to older mothers, those born to teenagers are more likely to have low birth weights, increased risk of mortality, less supportive home environments, poorer cognitive development, in early years increased risk of admission to hospital and if female a high risk of becoming a teenage pregnancy statistic themselves. The teenage mother will often be socially isolated, develop mental health problems and have fewer opportunities in education and employment.

With this in mind the Author identifies Teenage Pregnancy as a contraception and sexual health issue which is a factor in her clinical practice arena which she will adopt as her topic for discussion.

The demographic and health profile of the Author’s clinical practice area highlights that the largest proportion of the population are of working age, the borough has a total population of around 26,000. Unemployment is higher than the borough average and some areas are in the country’s top 10% most deprived, (NHS Walsall 2009). The rate of teenage pregnancy in Walsall was 54.5 in every 1000 15-17 year old females in 2007, and the Author’s clinical area is believed to have a higher than average proportion, (NHS Walsall 2009) with one of the highest rates of termination for the borough. Ong (1994 in Allen 2003 p368) suggests throughout the world teenage pregnancy is more common among those whom have been disadvantaged in childhood and have poor expectations of education or the employment market, in support the media and government reports appear to depict that teenage pregnancy is linked to poverty and low social-status, (Social Exclusion Unit 1999). Although in contrast almost every area of the country is affected by teenage pregnancy; even the most affluent areas in England have teenage birth rates deemed high by European standards, Allen (2003).
In 1998 due to the consistently high rates of teenage pregnancy in the UK, the Teenage Pregnancy Unit was established with an aim of reducing teenage conception by half between 1999 and 2010. The unit was the government’s first coordinated response to attempt to tackle both the causes and consequences of teenage pregnancy, with key areas of approach to reducing the high rates by education, training, contraception and access to effective sexual health advice, also for those whom do become pregnant and decide to continue with the pregnancy receive support for themselves and their children and avoid subsequent pregnancies as a teenager, (DCSF 2009). Within primary care, Next Steps Guidance, produced jointly by the Department of Health and Department for Children, Schools and Families, (2007) highlights that the provision of effective young person focused contraception and sexual health services are not on trajectory in order to meet the target set to reduce teenage pregnancy rates in some areas of the country.
With increasing evidence that young person focused contraception and sexual health services can have a significant impacted on teenage pregnancy (DH 2009), the Author will critically analyse and discuss the physical, psychological, socio-economical and political factors which may influence the sexual behaviour and contraceptive choices of this client group and how the health professional can support them. She acknowledges there is a vast amount of aspects and therefore will discuss those which are not always at the forefront.

Sexual health is defined as the emotional, intellectual and social aspects of sexual being, which are positively enriching and enhance personality, communication and love, (WHO 1975).
Often identified as the transitional years, the teenage years are those of mental and physical development, experimenting and taking risks, for which Allen (2003) states sexual activity as the most perilous. HEA (1998 in Shakespare 2004 p 320) believes society has adopted the belief that teenage pregnancy occurs as the result of reckless behaviour, compounded by evidence to suggest that teenagers are becoming sexually active at a younger age, (Wellings and Kane 1999 in Shakespare 2004 p325).
The Author believes however that the age of the young individual has a physical effect on their choice of contraception, despite the free availability of contraception there is a high proportion of adolescents are having unprotected sexual intercourse. A survey in 1993 showed 66 per cent of pregnant teenagers thought it was illegal to approach a GP or Family Planning Clinic for contraception, (Social Exclusion Unit, 1999) and that their parents would be notified should they try and obtain contraception, also many teenagers told researchers their parents had told them it was illegal to ask for contraception under the age of 16 years.
In fact the law in England, Wales and Northern Ireland consider a child to be a minor until the age of 18 years, however when they reach the age of 16 they may consent to treatment as an adult. The legal position regarding treatment of those under the age of 16 years relies on assessing the capacity to consent by utilising the Fraser guidelines which came into force in 1986, (Glasier and Gebbie 2008). The Fraser Guidelines state the health professional may provide contraception to those under the age of 16 years without the consent of their parents, providing they are satisfied that the young person will understand the advice, they can not persuade them to inform their parent or guardian, that they are likely to continue having unprotected sex and the individual is likely to suffer physically or mentally without contraception advice and treatment. The law states that it is illegal for a man to have sexual intercourse with a girl under the age of 16 years and if the girl is under the age of 13 years this will be seen as child abuse with a maximum sentence of life imprisonment, however the law seems to have little effect on influencing the sexual activity of young people, (Social Exclusion Unit 1999).
Glasier and Gebbie (2008), identify that 30% of men and 26% of women reported their first heterosexual intercourse before the age of 16 years and Little (1997) suggests the age of first sexual intercourse in the UK to be 14 years. In order for health care professionals to adapt and deliver appropriate services for young people they must acknowledge that the majority of teenagers have had sexual intercourse by the end of high school education, (Langille 2007).
The contraception choices of teenagers may vary according to whether their sexual intercourse is a result of one unplanned encounter or an established relationship (Glaiser and Gebbie 2008). NICE (2005) states that in 2003/04 that 25% of women were prescribed the oral contraceptive pill, 23% of males used condoms and only 8% utilised LARCs. Although there is no recommendation to withhold any contraceptive method on the basis of age alone data from the Omnibus ONS Survey on Contraception and Sexual Health 2005/06 suggest that most young people chose condoms with the oral contraceptive pill coming second, (Glasier and Gebbie 2008). Most young people are aware of condoms as a method of contraception and they are available without the need to visit a health provisional and is often the first choice of contraception for teenagers, Glasier and Gebbie (2008).
A vital requirement in reducing teenage pregnancy is the targeted contraception and sexual health services to young people; however this has met with some resistance from some groups who believe it to be fundamentally wrong to provide such services to teenagers as it may increase sexual activity (Scally 1993 in Allen 2003 p 368). However there is no evidence to link an increase due to the availability of contraception, as identified by Dolby (1998 in Allen 2003 p 368).
In a statement written by our former Prime Minister Tony Blair, (Social Exclusion Unit 1999) he acknowledges that there are few societies which find talking to teenagers about sex easy and the issue is often swept under the carpet. He states that whilst he has strong personal beliefs that young people should not have sex before the age of 16 years, the consequences of ignorance can be life shattering and therefore society should be prepared to support and advise teenagers in sexual health and contraception choices.
Unfortunately the personal beliefs of some health professionals can inhibit teenagers from obtaining contraception, research by Cromer and McCarthy (1999 in Sutton 2001 p35) found that 50% of GPs would not see under 16 year olds without parental consent.

The Author found increasing evidence to suggest access to appropriate services for young people to obtain sexual health advice and contraception is also an issue.
Kishen and Belfield (2006) discuss a Taylor Nelson Sofres survey in 2004 which raised concerns in regard to the provision of contraception. They reported restricted access to long acting reversible methods of contraception, variants in access to abortion services, closure of community based specialist clinics and clients including young people being turned away from open access and walk-in clinics due to poor staffing levels and over whelming demand. The Social Exclusion unit (1999) highlighted that location and opening hours are critical for teenagers who may be tied to school and rely on public transport, therefore this survey shows even when teenagers are aware of their rights in law to obtain contraception political factors can inhibit them from accessing the appropriate services required.
The financial situation of the NHS seems to be a political factor influencing an already disadvantaged contraception and sexual health service, (Kishen and Belfield 2006). The Independent Advisory Group on Sexual Health and HIV published and report in 2006 which revealed that a large portion of the £300 million provided for sexual health services was being absorbed by PCTs and Strategic Health Authorities to cover deficits in health care budgets. This resulting in an adverse impact on clients choice and access but also on training and maintaining the quality of contraception care which the specialist community clinics and general practices were able to provide, (Kishen and Belfied 2006).
The Department of Health and the Department for Children, Schools and Families (2007) acknowledged that the provision of young people focused sexual health and contraception services which are trusted by teenagers are the factor most citied as having the biggest impact on contraception rates amongst this client group.
The government has given local authorities the responsibility of introducing changes and new initiatives in an attempt to reduce teenage pregnancy. In February 2008 the Department of Health announced a £26.8 million campaign to improve young people’s access to contraception including £12.8 million to support Primary Care Trusts to provide the full range of contraception. Incentive has been reflected from the NICE endorsement of LARCs in the Quality and Outcomes Framework 2009 (BMA 2009), as process in which to gain support from General Practitioners.
November 2009 has seen the continuation by the NHS launching a new sexual health campaign in the media. TV and radio adverts for ‘Sex, Worth Talking About’ (NHS 2009), are based on the idea of improving young people’s knowledge and understanding in regard to sexual health, whilst improving awareness of contraception choices.
In the Author’s clinical area this campaign is the background to a new Local Enhanced Service agreement currently being developed by the PCT in a bid to initiate further support from GPs to provide and deliver contraception and sexual health services at a location and times convenient for all ages.
Perhaps the UK needs to earn from the success of other countries in terms of accessibility of services. Sutton (2001) argues that the Netherlands and Sweden have no problems with access as contraceptive services are widely advertised, attached to schools and service staff attend classes to promote sexual health advice. As suggested earlier, poverty and low social status have been linked to teenage pregnancy. Socio-economic deprivation and poor education and employment opportunities are factors which can influence a young person’s choice to become sexually active and to use contraception, Glasier and Gebbie (2008).
The SEU (1999) identifies that a daughter of a teenage mother is 1.5 times more likely to become a teenage mother herself. The social class of the family imposes another influence, those from social class V are ten times more at risk of becoming teenage pregnancy statistics than those from social class I, and furthermore children from local authority care have nearly 2.5 times higher risk than those whom have been brought up with both their natural parents.
The Author believes when identifying socio-economic influences on contraception and sexual health it is important to consider there are complex determinants in teenage pregnancy rates. Three quarters of teenage pregnancies are unplanned, (SEU 1999), one quarter remains which must be planned, therefore we should differentiate between the planned and unplanned pregnancies.
As shown some teenage pregnancies are planned, Glasier and Gebbie (2000) suggest this is due to the lack of future alternatives however Ong (1994 in Allen 2003 p 367) believes it is to escape violent unhappy homes, supported by the media which inflicts views of declining morals and the issues of access to housing, benefits, perpetuating the myth that young women have babies for material gain (Kiddy 2002). However Allen (2003) argues that failing to improve the socio-economic status of the teenager, teenage birth is linked to continuing deprivation.
Boys and young men need also to be considered, Wilcox and Gleeson (2003) highlight that they are ‘half the problem and half the solution’ but admit this is a relatively unexplored concept in reducing teenage pregnancy. One important factor to note would be taken from a study discussed by Allen (1988 in Wilcox and Gleeson 2003 p29), which suggests that the partners of those pregnant teenage girls have an average age of 23 years; therefore it is imperative to include boys and young men in strategies to reduce teenage pregnancy.
Unwanted pregnancies are discussed controversley by Morrissey (1998) who criticises some of the well documented explanations such as failed contraception and poor sexual health knowledge. He demonstrates his argument by discussing a case in which a pregnancy was blamed on adolescent ignorance and the family and school’s readiness to be content with a teenager’s failure at school. The assumptions and theoretical explanations never considered the underlying problem of sexual abuse. There is evidence to suggest increasing proportions of teenagers are having unwanted sex. Campbell (2006) states that 39% of teenagers had sex for the first time when one or the other was not equally willing and that 8 out of 10 lost their virginity when they were drunk or when felt pressurised. Leishman (2004) supports this and states aside from the consensual sexual activity there are those whom are faced with sexual exploitation, abuse and pressure to engage in sexual activities.
Sexually competent is defined by Wellings et al (2001in Ritchie 2006 p38) as having sexual intercourse with the absence of duress and regret. Holistic definitions of sexual health should include the ability to develop mutually satisfying relationships, Wilson and McAndrew (2000). Healthcare professionals have a duty to care and with this in mind Bonsu (2005) suggests young people should be asked whether sex is consensual and who and what is the age of their partner, any disclosure of abuse should initiate child protection protocols. Therefore it is preferable to make sexual health clinics open to all ages and for healthcare professionals to explore the benefits of waiting and to explain the detrimental effects of early sexual intercourse.

The Author believes attitudes towards sexual health by society and in families are important psychological factors which can influence teenage sexual behaviour and contraception choices. Young people often report that they are told ‘too little, too late’ and that sex education in schools reflects biology and the mechanics of sex rather than including how to have self confidence and esteem and how to talk about relationships, (SEA 1999).
In the Netherlands and Sweden school sex education is provided by skilled educators and covers issues such as relationships and contraception as discussed by Sutton (2001). Health professionals, parents and schools work together to promote positive attitudes towards the promotion of sexual health. Although sex education has been compulsory in UK schools since 1992, parents have the right to choose to remove their child from such sessions, a right which is not available in the Netherlands and Sweden. Many feel sex education leads to early sexual activity but contrary to believe it can play an important role in delaying sexual activity (Sutton 2001). Glasier and Gebbie (2008) support this by stating that openness within society is associated with better sexual health indicators amongst young people. Societies in general and those with parents whom are open and informative with teenagers are more likely to delay onset of sexual activity and thus resulting in a lower teenage pregnancy rate.
Attitudes are notoriously difficult to change and many parents find it difficult to discuss sex and contraception with the children. Compared with European countries it seems parents in the UK are reluctant to discuss relationships, sex and contraception with their children. The SEA (1999) identified that that many parents felt embarrassed and ill-equipped to broach the subject.

Health promotion strategies to provide effective care and possible solutions for teenage pregnancy do not cover all the physical, psychological, socio-economical and political influencing factors as the Author has demonstrated. Teenage pregnancy is a concern for all those in health care; however strategies predominantly focus on the young female and over look key influences such as boys, men, parents and families. Langille (2007) states some factors are readily modifiable such as knowledge however others can not easily be changed or in fact changed at all. The Author suggests these factors could be the issue of unwanted sexual activity and the political issue of funding.
Despite government initiative and white papers the Author believes over the past decade there has been a continuing deterioration in sexual health and contraception availability for young people. Fullerton (1997) argues that social, environmental and socio-economic influences along with individual characteristics are complex determinants thus making cause and effects of teenage pregnancy difficult to disentangle.

Wilson and McAndrew (2000) believe that sexual health is a right for all individuals regardless of age, gender, race, religion, sexual orientation, economic or social status, political affliction or existing medical condition. They continue by stating that it covers numerous aspects of care and should include the right to access appropriate information and resources to be sexually safe. A teenager’s choice to become sexually active and to use contraception, along with their ability to obtain sexual health advice is influenced by many factors which are individual to the young person. Comprehensive and holistic sexual health promotion is required if teenage pregnancy rates are to be reduced. Health professionals should advocate and offer non-judgemental, respectful and confidential care whilst forging services which are accessible to young people. The Author acknowledges that in short assignment it is difficult to cover all the influencing factors and also to offer effective solutions to the problems raised. However in her clinical area she will endeavour to utilise the information and knowledge gained to provide an appropriate service to teenagers.