| Early last week mid-morning, the classic thing happened to me that I'm sure happens to many GPs. Amongst the usual elderly patients with the flu and the prescriptions, I see two very young teenage girls sitting in the waiting room. Of course they both came in, as you expect, with one the support person for the other.
As usual in this situation they were both quite attractive and perhaps dressed a little too provocatively for the context with a bit too much make-up for the time of day. The request: the morning after pill. After my initial reassurance that it was no problem for me to give it to them their anxiety levels dropped quite considerably. I gave the patient her medication and a handout and briefly discussed the context. You guessed it: "The condom broke", the male involved was a casual relationship who the patient wouldn't see again, and there was some alcohol involved in the situation. It was the first time the patient had had sex and her accompanying girlfriend was a still a virgin. I discussed the risk of STDs, but there was not a lot of interest from the patient for me to do a vaginal examination and swab there and then. I asked for the patient to return but she never did. I had 15 minutes to sort all this out and at the end of the consultation the friend of the patient asked me whether I thought they were too young to have sex.
There are obviously a lot of issues here and following are a couple of the key issues that come to mind about this situation.
Be non-judgmental
Explain how responsible and clever they are to come in at this stage rather than becoming pregnant and having to confront termination of pregnancy or premature parenthood.
Make a friendly explanation that your job is not to tell them when it is right to start having sex but to remind them that young people who have sex very early are more likely to contract STDs and have less likelihood of having healthy happy long-term relationships.
Discussion of need for ongoing contraception
Issues involving the details of condom use to reduce the risk of breakage or coming off. Rolling the condom to the base of the penis being sure to pull pubic hairs away, retracting the foreskin and using double strength condoms if they keep breaking.
Discussing the commencement of the OCP needs to balance the risk of pregnancy with the risk of starting pubescent girls on the pill when their hormone cycles are still finding their own natural rhythms. Also, does the pill increase the risk of STDs because of the lower likelihood of using a condom if there is no steady partner?
Confidentiality
Confidentiality and the confusing nature of the law in Australia, especially in the 14 to 16 year age group is an issue. In a recent discussion with my medical defense as I understand it, you need to encourage this age group to discuss such matters with their family but if they don't want to and you consider the risk of pregnancy high then you are probably safe to prescribe the OCP and respect confidentiality.
STDs
The need to discuss the risk of contracting STDs such as chlamydia, hepatitis B, herpes and HIV and the need for blood, vaginal swab and urine tests to screen for these. The need for contact tracing if appropriate.
Prevention
Finally, what preventative health strategies can GPs use to reduce the frequency of this scenario?
Rob Trigger practices in Byron Bay on the North Coast of NSW and has a particular interest in youth health issues.
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