Although the legal age of consent for heterosexual sex within the UK is 16 years of age, the proportion of under-16s indulging in heterosexual intercourse is reported to have increased significantly in the last decade.^1–,³ In Scotland, the prevalence of heterosexual intercourse has been reported to be 15.4% in 14 year old girls, increasing to 38% of girls by attainment of their 16th birthday.^4,5 Young adults and teenagers are more likely to engage in high risk behaviour, including unprotected sex and multiplicity of sexual partners,^4–,⁷ and as a result high rates of sexually transmitted infections, and unintended teenage pregnancy represent a significant challenge to western healthcare systems.^8,9

The National Survey of Attitudes and Lifestyles II (NATSAL 2000) reported that early age at first intercourse was associated with teenage pregnancy and abortion,³ and currently the UK has the highest rate of teenage births in Western Europe.^10,11

The recommended strategy to reduce the incidence of teenage pregnancy in the UK includes specific measures advising teenagers about contraception and the use of contraceptives, together with guidance for health professionals on the prescription, supply, and administration of contraceptives to adolescents.¹⁰ In an attempt to reduce the high levels of teenage pregnancy in the UK, which is reported to be 8.9/1000 girls aged 13–15 years, the oral contraceptive is prescribed by both primary care physicians and family planning clinics (FPCs).^10,12 However, the use of FPCs by girls under 16 years of age is anecdotally low, as evidenced by national figures, making the primary care physician the most common source for both advice and prescriptions for the OCP in the youngest and most vulnerable age group. The strategy to prevent teenage pregnancy and sexually transmitted diseases in developed countries such as the UK is to improve access to contraceptive services and to promote safe sex education in early adolescence.^6,7,10,12 While NATSAL II is a rich source of information on teenage sexuality and contraceptive use in girls over 16 years of age, it does not report on the use of the combined oral contraceptive in the significant number of girls aged 10–16 who are also sexually active.^3,7

The aim of the present study was to determine the level of combined oral contraceptive pill prescribing to girls aged 10–16 years in Scotland.

METHODS

In Scotland, women obtain a prescription for the OCP, either from their primary care physician or from an FPC, and to determine the total number of girls prescribed the OCP during the study year, it was necessary to interrogate two separate databases.

RESULTS

DISCUSSION

The twin problems of sexually transmitted disease and teenage pregnancy due to the early age of sexual debut have raised both social and health concerns among policy makers. Epidemiological studies have shed some light on teenage attitudes towards sexual activity and the level of teenage sexuality in the United Kingdom, and it is now widely acknowledged that teenagers are engaging in sexual activity at an increasingly early age.^1–,⁵

In this study the estimated overall prevalence for primary care OCP prescribing to 10–16 year old girls was 4.3%, a figure similar to the 4.2% reported for England and Wales by Rowlands and colleagues.¹⁷ The figure of 4.2% reported by Rowlands et al however also took into account prescribing from FPC outlets, and when OCP prescribing rates from Scottish FPCs are added to our figure of 4.3% (assuming that the two databases are mutually exclusive), the OCP was prescribed to at best 6.6% of Scottish girls 10–16 years of age during the study year. Although in Scotland it is estimated that 15.4% of 14 year old girls and 38% of 15 year old girls are sexually active,^4,5 summing the primary care and FPC results obtained in this study would suggest that even in the very best case scenario, only approximately 4% of 14 year olds, and 10% of 15 year olds are prescribed the OCP, indicating a significant shortfall between those partaking in sexual activity and those prescribed oral contraception. The fact that young women use their primary care physician, rather than an FPC to obtain a prescription/advice for the OCP is not surprising. In the UK the primary care physician acts as the gatekeeper for the healthcare system, and most are qualified to give contraceptive and gynaecological advice. Furthermore, unlike FPCs which tend to function in a manner similar to drop-in clinics, the population is registered with a primary care practice from early childhood, and such practices are readily accessible, situated locally, and so more accessible to young adolescents.

The relatively low overall uptake of the OCP by sexually active teenagers may be indicative of the fact that few teenagers of this age are aware of the sexual health services provided by primary care physicians or FPCs, or in a position to approach their primary care physician or FPC for contraceptive advice on their own, or are reluctant/embarrassed to do so.¹⁸ It may also reflect the sporadic nature of sexual activity in this age group and risk taking behaviour,^19,20 concern about confidentiality,^21,22 or confusion on the part of the adolescent or primary care physician regarding the law as it applies to young children and teenagers.²³ The importance of these issues has been highlighted by the results of a questionnaire survey of 1045 adolescents 13–15 years of age in which only 68% of adolescents reported awareness of the sexual health services offered by their primary care physician. Furthermore, 54% of adolescents believed that they had to be over 16 years of age to access sexual health services and 58% expressed concerns about a possible lack of confidentiality.²² A non-judgmental parental attitude and a good child-parent relationship also appears to be important, both being associated with higher birth control use and a lower probability of both sexual intercourse and pregnancy.²³ Whatever the reason for not using the OCP there is a clear need to improve adolescent participation, awareness, and access to primary care sexual health services.

The estimate of contraceptive use made in this study is not fully comprehensive since it does not include information on condom use, which is reportedly used by approximately 50–60% of 16 year olds,^4,5,24 and the use of depot contraceptive preparations, which are reported to be used by 1.9% of sexually active Scottish girls aged 15 years.⁴

A further important problem when estimating the level of combined oral contraceptive pill use in teenagers is the high discontinuation rate and low levels of compliance. Among adolescents compliance has been reported to be as low as 44–55%, with less than 20% compliant for a full year.^25,26 In the present study, only the first prescription for the OCP was used to estimate the prevalence rate for OCP use. This methodology, which has been previously reported and is considered to provide a reasonable estimate of OCP use in teenagers, identifies those individuals who are contemplating or are partaking in sexual activity and who have overcome the major hurdle of seeking advice in relation to their sexual activity and health.¹⁷

A further important consideration is that the OCP may be prescribed for medical reasons other than contraception, such as the treatment of acne and menstrual irregularities. Consequently it is not safe to assume that all OCP prescribing, identified in this study, was for contraception, although prescriptions from an FPC are more likely to be for this indication alone.