NICE issued guidance on young people and contraceptive services today ‘Contraceptive services with a focus on young people up to the age of 25’. It has been widely reported, some of it more excellent/sensible and measured than others. There is a lot in the guidance that is very useful but for the most part the media have picked up on the provision of oral emergency contraception in advance. I hope to provide a bit of reassurance about this, highlight some of what has been missing in the reporting of the guidelines and also offer some criticism about what I think is missing in the guidance itself.
Young women have been able to access the emergency hormonal contraceptive (EHC) pill for free for many years, including from some pharmacists. However this has only been available after an incident of unprotected sex, not before. These guidelines recommend that EHC should be available to young women to keep in advance of future unprotected sex. I think this is a good thing.
I’ve worked with many young women (I worked in a young people’s clinic giving sex education and advice for nearly 10 years till recently) who would have absolutely loved this recommendation. Some young people may not want to use a long-term contraception – maybe they are wary of side effects or not actually having very much penis in vagina sex (more on this later). These young people like to use condoms but would like the safety net of the emergency pill just in case.
Additionally, EHC is more effective the sooner it’s taken, ideally within 24 hours. (The Levonelle 2 pill works up to 72 hours after sex and the Ella One up to 120 hours. The IUD also works up to 120 hours after sex and can remain inside the uterus as a very effective long acting form of contraception.) Even in urban areas which are relatively well served by Reproductive Sexual Health Services, GPs and pharmacies, getting the EHC can be a challenge, especially over a weekend or at the end of December. So a broken condom on a Friday or Saturday night is a particularly bad night for many people. This would dramatically increase access for young people in urban and non-urban areas and would also improve the effectiveness of EHC.
At the same young person’s clinic I did also encounter many many young men who wished to get EHC for their future partners so that they didn’t have to use condoms. This doesn’t mean that we shouldn’t make it more available but it does mean that we need to be aware that we continue to empower young women over their own contraceptive choices (as well as challenging young men over theirs). This is why it’s vital that in addition to increasing access to EHC, condoms and contraception we increase access to the skilled, trained and experienced staff who provide them.
The NICE guidance stressed the importance of trained staff who are able to:
offer culturally appropriate, confidential, non-judgmental, empathic advice and guidance according to the needs of each young person
set aside adequate consultation time to encourage young people to make an informed decision, according to their needs and circumstances
And to provide this in a service which met the minimum quality standards for young people’s services as set out in ‘You’re Welcome.’ This is something which hasn’t been widely picked up on, but if it were I’m sure many parents would find this reassuring.
It’s vital to remember that we don’t just throw EHC, condoms and contraception at young people. There are many barriers to young people’s sexual health which can only really be addressed by spending time with a sexual health professional. Many of these are practical concerns (condoms being uncomfortable, loss of erection, lack of lubrication, worries about side effects) and unpicking some of these can uncover relationships which may be abusive or otherwise problematic. These staff are also trained to follow the Fraser Guidelines about the provision of contraception to under 16s as well as having very clear policies and procedures to safeguard young people where necessary.
One thing which is missing, and is frequently absent from policy guidance in this field, is any mention of any kinds of sex other than penis in vagina. Long-acting reversible contraception, condoms and EHC are all very reliable and effective – but not as effective as (for instance) masturbating each other. I appreciate that pregnancy is usually the result of penis in vagina sex and that this document concerns itself with the provision of contraception to prevent unplanned pregnancy – but why not talk about other kinds of sex?
As Natsal 3 uncovered as well as unplanned pregnancy, young people report sexual difficulties and having had sex against their will (1/10 young women). Isn’t it time that policy started to address how we can equip young people to be able to communicate about what sex they actually might want and enjoy having as well as how to make it safer?
26th March 2014
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