Editorials

Never underestimate the force of reproduction

Effective contraception for teenagers requires a change in medical culture

Papers p 486

Whether you give weight to the philosophy of a divine human spirit or to the elegant chemistry of evolution, or to both, there is no argument about humankind's drive to reproduce. The strength of that drive manifests in many ways: physically, as the millions of spermatozoa launched with each ejaculation; behaviourally, as the early onset and frequency of sexual activity; institutionally, as the papal preclusions of contraception and abortion; and professionally, as the trivialisation of sexual medicine and fertility control. It was no accident that the first drug to be overtly rationed by the NHS was sildenafil (Viagra). Sexual function was dismissed as a "lifestyle option" rather than an issue of health and wellbeing. But, while sexual intercourse occurs less often, the proportion of humans who will have sex during their lives approaches the proportion that will breathe.¹

Typically, young women who are adequately nourished are fertile. Globally, increasing numbers of young women are becoming sexually active long before they form durable partnerships.² Access to contraception is essential but it may not be enough to contain our relentless drive to reproduce.

In this issue of the BMJ Churchill et al show that before the end of their teen years most young women in the Trent region of the NHS in England consulted their general practitioners about contraception (p 486).³ Yet, for these teenagers, seeking health care related to contraception was predictive of conceiving within a year. How do we explain this apparently paradoxical finding?

Firstly, it was outside the objectives of Churchill et al's study to qualify these ultimately unsuccessful medical encounters other than to determine that the young women who became pregnant had higher scores on measures of social deprivation, consulted general practitioners more often, and that they succeeded in making both "reliable" and "less reliable" contraceptives look decidedly unreliable.³ Some of the young women may have wanted to get pregnant, so those who opted for a termination were compared with those who did not: the former were found to have even greater deprivation scores and were more likely to have been provided with condoms or emergency contraception. Although they had free access to quality health care, could it have been that these sexually active teenagers were at the limit of their ability to seek contraception? That is, were they uncomfortable during the consultation and did they want to keep it to a minimum? If this is the case then they may not have asked enough questions to understand the method that was prescribed nor sought support over time to address their later misgivings. Nevertheless, it is encouraging to see that most of these teenagers took at least the first step in seeking fertility control; doubtless a similar study done a generation ago would have found far fewer consultations about contraception.

Secondly, adults' attitudes towards teenage sexuality vary¹ and teenagers know this. If they are hoping for a non-judgmental response to a request for contraceptive advice teenagers may place trained peers above nurses,⁴ nurses above doctors, female doctors above male, and younger doctors above older. Another recent study by the same group showed that access to younger doctors and female doctors, and to practice nurses, was associated with lower rates of teenage pregnancy.⁵ In Australia, younger doctors and female doctorsparticularly those who more frequently addressed other sexual health issueswere more likely to see younger patients and to diagnose sexually transmitted diseases more often.⁶ Establishing rapport and guiding young people through the issues around healthy sex is problematic for many doctors. Better training methods and services that are more focused on clients need to be evaluated.⁷

But doctors work within their own cultural restraints. Statistics such as the claim that oral contraceptives are "99.9% effective" are perhaps not helpful; this figure is derived from findings from more mature research participants who were in stable relationships.⁸ In the real world high rates of discontinuation make contraceptive efficacy almost a secondary issue.

For teenagers contraceptive choices are complicated by the fact that sexual intercourse is often sporadic, unexpected, or coerced. ^{8 9} Suggested solutions to problems of limited adherence have included providing teenagers with more specific instructions and ongoing support as well as with back-up strategies to use if their primary contraceptive method has lapsed or failed.⁸ But shouldn't we also be open minded about more definitive primary strategies?

The intrauterine contraceptive device is the most commonly used reversible form of contraception in the world. Still smarting from litigation stemming from the pelvic infections associated with earlier products inserted through cervixes harbouring undiagnosed infections, doctors now largely reserve these devices for women who are approaching the end of their fertile years. But we now know better and have better tests to help exclude pre-existing cervical infections. There is even a device that releases levonorgestrel which could possibly even protect against pelvic inflammatory disease.¹⁰

If teenagers could take their fertility control somewhat for granted during the most precarious stage of their sexual careers then the ability to negotiate other complex aspects of their sexual wellbeing could be enhanced. We owe it to them to at least consider the evidence and have the best options at hand.

Basil Donovan, clinical professor. 

Department of Public Health and Community Medicine, University of Sydney, Sydney Hospital, PO Box 1614, Sydney NSW 2001, Australia (donovanb{at}sesahs.nsw.gov.au)

Footnotes

   BD has no association with any manufacturers of contraceptive products and does not insert intrauterine contraceptive devices.

1.	Johnson AM, Wadsworth J, Wellings K, Field J. Sexual attitudes and lifestyles. Oxford: Blackwell, 1994.
2.	Robey B, Rutstein SO, Morris L, Blackburn R. The reproductive revolution: new survey findings. In: Baltimore: John Hopkins University Population Information Program, 1992. (Population Reports 1992; Series M, No 11)
3.	Churchill D, Allen J, Pringle M, Hippisley-Cox J, Ebdon D, McPherson M, et al. Consultation patterns and provision of contraception in general practice before teenage pregnancy: case-control study. BMJ 2000; 321: 486-489[Abstract/Free Full Text].
4.	Jay MS, DuRant RH, Shoffitt T, Linder CW, Little IF. Effect of peer counsellors on adolescent compliance in use of oral contraception. Pediatrics 1984; 73: 126-131[Abstract/Free Full Text].
5.	Hippisley-Cox J, Allen J, Pringle M, Ebdon D, McPhearson M, Churchill R, et al. Association between teenage pregnancy rates and the age and sex of general practitioners: cross sectional survey in Trent 1994-7. BMJ 2000; 320: 842-845[Abstract/Free Full Text].
6.	Temple-Smith M, Keogh L, Mulvey G. Testing for chlamydia and other sexually transmissible diseases in general practice in Victoria. Venereology 1997; 10: 14-18.
7.	Stirland A. Family planning up a gum treethe integration of family planning and genitourinary services in Australia and New Zealand. Br J Fam Plann 1995; 20: 132-136.
8.	International Working Group on Enhancing Compliance and Oral Contraceptive Efficacy. A consensus statement: enhancing patient compliance and oral contraceptive efficacy. Br J Fam Plann 1993; 18: 126-129.
9.	Wight D, Henderson M, Raab G, Abraham C, Buston K, Scott S, et al. Extent of regretted sexual intercourse among young teenagers in Scotland: a cross sectional survey. BMJ 2000; 320: 1243-1244[Free Full Text].
10.	Sturridge F, Guillebaud J. A risk-benefit assessment of the levonorgestrel-releasing intrauterine system. Drug Safety 1996; 15: 430-440[Medline].