Contraception in a Minor, Same age Partner

Casebank Counselling
1

Where you are:
You are FY2 in general practice

Who the patient is:
14-year-old Sarah Perkins, who has come to request emergency contraceptive pills.

Other information you have about your patient:
She had unprotected sexual intercourse last night.

What you must do:
Talk to Sarah and address the concerns.

Patient information

  • Opening sentence “Doctor, I am here to request a morning after pill”.
  • You are Sarah Perkins, 14 years old.
  • You have come to the GP practice on your own.
  • You have heard about the morning after pill but you have never used it before.
  • Your LMP was 2 weeks ago.
  • You did not have any unprotected sex other than yesterday night.
  • You have not talked to your parents about this because you fear that they would go mad , your parents still think that you are their little girl and they do not like your boyfriend Paul.
  • You feel that your parents do not really understand how you feel about each other.
  • Paul is your boyfriend and he knows that you have come to the GP to request contraception.
  • You have tried to use condoms but you feel they are not reliable because Paul does not like to use them.
  • Paul is 15 years old.
  • When the doctor asks you how old is Paul, you should reply “he is 15 but what difference does that make, I still love him”.
  • You understand the risk of taking contraception and you know that you should be using condoms for safe sex, but you feel they are not reliable and you don’t want to get pregant.
  • You feel that if you tell your parents, they will shout at you and force you to leave the boyfriend.
  • You had unprotected sexual intercourse last night.
  • Your mum does not support the idea of sexual relationship before marriage because she is a Roman Catholic Christian.
  • You know that the morning after pill will prevent you from getting pregnant.
  • You know that being in a sexual relationship there is a risk of getting pregnant.
  • You know that if you do not use condoms you may get STI infections.

Comments:

  • Listen doctor, Paul and I are having sex and I am trying to be responsible for my actions.
  • I know the risks and complications of our actions and I know what I am doing.
  • I just don’t want to get pregnant.

Questions:

  • Are you going to prescribe me contraception?
  • Will you tell my mum?

Scenario B:

You came to Emergency department because your mother’s friend works as a secretary at the GP.
You are afraid she might tell your mum.

Approach

GRIPS

  • May I know what brought you to the practice today?
  • Can I ask some questions to understand your situation better?
  • Usually it is a practice policy that any one under 16 years of age should attend the practice with their parents.
  • Have you come on your own?
  • And do you parents know that you re here?
  • Ok, Its ok I will see you, now that you are already here.
  • And do your parents know anut your sexual relationship?
  • Is there any particuar reason you have not told your parents about your relationship?
  • Reassure that: We can definitely help with contraception.

Offer confidentiality:

  • Reassure that whatever is discussed will be kept confidential:
  • If she ask you, will tell my parenst?
  • Explain that we would not tell your

Ask about her sexual relationship and assess for abuse.

  • Can I ask you about your sexual life;
  • Are you in a stable relationship ?
  • How long have you been together with your partner?
  • How old is your partner?
  • How has everything been going with your partner?
  • Has your partner ever been aggressive towards you?
  • Has he ever forced you to have sexual intercourse when you didn’t want to?

Menstrual history

  • Last menstrual period?
  • How many days do you bleed?
  • How many days is your cycle?
  • Are your periods regular?
  • Are your periods heavy?
  • Do you experience any pain during your periods?

Previous contrception:

  • What contraception have you tried in the past?
  • What about condoms –have you tried them?
  • How does your partner feel about using condoms?

Assess for Gillick competence :

  • I need to ask you some questions to check that you understand why you need contraception
  • Can you just explain to me why do you need contraception?
  • What would happen if you do not use contraception ?
  • And do you know some of the riks of being in a sexua relationship ?

Assess for Fraser criteria:

  • Do you think you can try and talk to your parens abit yor relationship?
  • Your parents where of your age at one poin-they may undertand .
  • How would you fel if you not prescribed contraception today?
  • If you are not prescribed contraception, do you think that would stop from being in sexual relationship?
  • Would you consider using condoms-they would also protect you from sexually transmistted infection.
  • Contraception does not protect from STI.

Discussion- Fraser criteria: Prescribe contraception only if the following criteria are met:

  • The young person understands the practitioner’s advice.
  • The young person cannot be persuaded to inform their parents or will not allow practitioner to inform parents.
  • The young person is likely to begin or continue to have sexual intercourse with or without protection.
  • The young person’s best interest requires the practitioner to give contraceptive advice or treatment without parental consent.
  • Unless he or she receives contraceptive advice or treatment, the young person’s physical or mental health is likely to suffer.

Rule out pregnancy: Perform a pregnancy test

  • Screen for STIs if she has had unprotected sexual intercourse and explain that sometimes it can be symptomatic
  • Precribe the contraception you have reached agreement with and offer leaflets about contraception

Explain the side effects

  • We will offer you a morning pill. It is one tablet, taken once only. It has got some side effects:
    • Nausea
    • Vomitting
    • Next period may be delayed or early.
    • There may be spotting
    • Diahorrea
    • Breast tenderness

Note:

  • If vomiting occurs within two hours of taking the pill, she will need a take another pill.
  • Explain the pill needs to be taken as soon as possible and it works best within three days.
  • Advise to avoid sexual intercourse until the next period.
  • Explain that no contraception is 100% and if period is late she may need to consider performing a pregnancy test.
  • Provide leaflets about emergency contraceptive pills.

Discuss long term contraception:

  • Explain that emergency pills cannot be used too frequently. So you might need to consider long term contraception. Woud you like me to give you the informationadn you can think about it.

Follow up: Can we make an appoint inmonth time just to see how things are going with you.

Main points:

  • Take history of unprotected sex
  • Assess for gillick competence
  • Encourage to discuss with her parents
  • Assess for any abusive relatioship
  • Offer the pill
  • Explain the side effects of the pill
  • Offer screening for STI and advice her to use condoms as future contraception and prophylaxis of STI.
  • Discuss long term

If patient came to emergency department

  • Prescribe contraception.
  • Advice to see Go for long term contraception and screening for STI