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under-18s should complete level 3 safeguarding training 3 so they fully understand the potential signs of abuse. Under-18s accessing contraceptive and sexual health services should have a safeguarding assessment as part of the consultation. The British Association for Sexual Health and HIV( BASHH) offers a proforma 7 that can help to identify aspects of a young person’ s life that can leave them vulnerable to CSE. These include an unstable home life, being out of education, poor mental health and substance misuse.
Young people who are otherwise healthy may not often access medical services, so a consultation about contraception can be a rare opportunity to discuss their lives and identify concerns. Try to be as welcoming and open as possible. In sexual health, we often talk about‘ professional curiosity’ 8 so rather than treating the BASHH proforma as a checklist, we ask open questions to try to understand what life is like for that young person. This can help them feel listened to and encourage them to return if they need further advice or support.
What should I do if I have concerns? Every NHS trust or GP practice group should have a named safeguarding lead. If you believe a patient is in immediate danger, they should be kept in the clinic and the police should be contacted. If you have concerns but the patient is safe to leave, these concerns should be shared using the safeguarding procedure for your area. Most safeguarding hubs have a duty worker who can be contacted to discuss any concerns and where to refer for further support. Although teenagers are entitled to privacy, it is good to have a low threshold for sharing concerns, as other agencies may already be involved in their care and your observations can contribute to the picture. If a young person is looked after by the state, this does not automatically mean their information should be shared, but any new concerns identified in a consultation should be communicated to their social worker for further input.
What contraception is appropriate for under-18s? According to the UK Medical Eligibility Criteria for Contraceptive Use( UK MEC), issued by the Faculty of Sexual and Reproductive Healthcare( FSRH), there are no age-based restrictions for any contraceptive methods. 9 However, caution should be exercised with the contraceptive injection because of its effect on bone mineral density. 3 In the past, nulliparous people have been advised against intrauterine contraception, but there is no rationale for this and it can be used if it is the patient’ s preference and they are fully informed about the risks and benefits. 3
Discussions about contraception should take into account the young person’ s situation, for example whether they are likely to remember pills regularly or need a discreet method such as the injection, and exploration of any anxieties they have, for example about weight gain or acne. A conversation about their menstrual cycle and whether they experience irregular or heavy periods may provide an opportunity to identify other health issues such as endometriosis, which would need onward referral to a gynaecologist.
Ideally, long-acting reversible contraception( LARC) methods should be promoted due to their efficacy and length of action, 3 although information on the risks and benefits is important to help prevent discontinuation. Quick starting contraception( starting immediately rather than waiting for the next menstrual cycle) is possible in most cases and eliminates delay, reducing the risk of unintended pregnancy. 3 The FSRH provides specific guidance on quick starting. 13 In any contraception discussion, it is important to highlight that the only method that helps prevent STIs is consistent condom use, and to advise regular STI testing, especially if there are new partners. This also provides an opportunity to demonstrate safe condom use, and to link with your local C-card( condom distribution) scheme. 14
Can we consult remotely on contraception with under-18s? The pandemic has led to rapid establishment of remote or telephone consultations by many services. This has been beneficial in some situations, allowing people to order home tests or repeat contraception without coming into the clinic. However, there have been concerns that opportunities to safeguard young people may be missed if they are not seen in person. 10 A young person who is being coerced or groomed into sex may not be able to talk openly if the perpetrator is present during a phone or video call. They may also fear their phone is being monitored or that parents will overhear.
Now most restrictions are lifted, it is best practice to see a young person face to face where possible. This will permit a safeguarding consultation in a setting where the clinician can be satisfied that the patient is able to talk openly about their needs or concerns. That said, remote consultations have the benefit of increasing access, 11 meaning young people who otherwise wouldn’ t attend have a route into the service. The Royal College of Paediatrics and Child Health( RCPCH) has published guidelines that provide practical advice for safe remote consulting with young people. 12 A pragmatic approach could be to offer an introduction or advice over the phone, followed up by face-to-face contact in a safe space. Whichever medium is used, it is important to document the conversation fully, noting whether the Fraser criteria have been met or Gillick competence⁶ established.
References 1 Office for National Statistics. Conceptions in England and Wales 2020. April 2022. bit. ly / 3t8vhW5 2 Public Health England. STI rates remain a concern despite fall in 2020. September, 2021. bit. ly / 3x4AQXK 3 Royal College of Nursing. Safeguarding children and young people: Roles and competencies for healthcare staff. 2019. bit. ly / 3mjHvHo 4 UK Government. Sexual Offences Act 2003. bit. ly / 3MkYKTv 5 GMC. 0-18 years: guidance for all doctors. 2020. bit. ly / 3N9SbEe 6 NSPCC. NSPCC Learning. Gillick competence and Fraser guidelines. 2020. bit. ly / 38FVYu8 7 BASHH. Spotting the signs. A national proforma for identifying risk of child sexual exploitation in sexual health services. 2014. bit. ly / 3GFLrvj 8 Burton V and Revell L. Professional curiosity in child protection: thinking the unthinkable in a neo-liberal world. Br J Soc Work 2017; 48( 6): 1508-1523 9 FSRH UK MEC. 2018. fsrh. org / ukmec 10 Bekaert S and Azzopardi L. Safeguarding teenagers in a sexual health service during the COVID-19 pandemic. Sex Transm Infect 2022; 98:219 – 221 11 Dixon S et al. Challenges of safeguarding via remote consulting during the COVID-19 pandemic: a qualitative interview study. Br J Gen Pract 2022; 72( 716): e199-e208 12 RCPCH. Principles for conducting virtual consultations with children and young people. 2020. bit. ly / 3t7omw613 13 FSRH. Clinical guideline: Quick starting contraception. 2017. bit. ly / 3t9lj6I 14 Brook. C-card distribution schemes. bit. ly / 3x8aNiB
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Jodie Crossman is nurse team leader at Brighton and Hove Sexual Health and Contraception Service and chair of the British Association for Sexual Health and HIV nurses group