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4.21 Teenage Pregnancy and Sexual Health

SCOPE OF THIS CHAPTER

This chapter reproduces the document issued by the Teenage Pregnancy Unit in Southwark in 2004.

RELATED CHAPTER

'Protocol for Joint Working Between Social Care Staff and the Family Nurse Partnership Where the Mother or Expected Child may be a Child in Need or Looked After'.


Contents

The Context

  1. The Role of Health Professionals in Providing Contraceptive and Sexual Health Advice and Treatment
  2. The Role of Field Social Workers, Residential Social Workers and Foster Carers in Providing Contraceptive and Sexual Health Advice and Treatment  
  3. A Checklist of Actions for Field Social Workers, Residential Social Workers and Foster Carers to Support Implementation of the Guidance in the Context of their Local Teenage Pregnancy Strategy


The Context

This guidance is a specific action point of the Government’s Teenage Pregnancy Strategy for England. It aims to clarify for field social workers, residential social workers and foster carers that they can and should encourage young people to seek sexual health and contraceptive advice and direct them to local services if it appears that the young people are, or are thinking about becoming, sexually active. It includes a section clarifying the role of health professionals in providing these services to young people.

The guidance refers to all young people, including under 16s and gay, lesbian and bisexual young people.

What is the Teenage Pregnancy Strategy trying to achieve?

In 1999, the Government launched a report from the Social Exclusion Unit on teenage pregnancy that set two goals:

  • To halve the rate of conceptions among under 18s in England by 2010 and to set a firmly established downward trend in conceptions among under 16s;
  • To reduce the risk of long term social exclusion for teenage parents and their children by supporting teenage parents in education, training and employment.

To achieve the goals, a comprehensive, cross Government Teenage Pregnancy Strategy was launched. The strategy is implemented nationally by the Teenage Pregnancy Unit and locally through Teenage Pregnancy Co-ordinators, jointly nominated by Local and Health Authorities.

Why is the strategy necessary?

The UK has the highest teenage birth rate in Western Europe - three times as high as France and six times the rate in the Netherlands. While other countries have achieved dramatic reductions in teenage pregnancy rates during he 1980s and 1990s, the UK rates have remained static.

Although many young parents manage extremely well, teenage births carry increased health risks for the young women and their babies. Teenage parents are also more likely than their peers to live in poverty and to be unemployed. Of all teenagers who conceive, 50% of under 16s and more than a third of 16-17 year olds have abortions.

In addition to high conception rates, at least 10% of sexually active teenagers are estimated to have a sexually transmitted infection and Chlamydia rates are increasing fastest among 16-19 year old women. The Government’s Sexual Health and HIV Strategy for England, published in July 2001, seeks to reduce these rates.

How does the strategy aim to prevent teenage conceptions?

Around three-quarters of teenage births and the vast majority of teenage pregnancies that end in abortion are unplanned. Half of under 16s and a third of 16-19 year olds in the UK use no contraception the first time they have sex and many continue not using contraception at all or using it erratically. The proportions of young people not using contraception at first sex are up to double the rates in other countries.

The Teenage Pregnancy Strategy aims to help young people resist peer pressure to have early sex and to use contraception if and when they decide to become sexually active.

This is being done through a combination of: a national media campaign in teenage magazines and local radio, improved sex and relationship education in schools, the provision of effective contraception and advice services which are trusted by young people and support for parents in talking to their children about sex.

Why do field social workers, residential social workers and foster carers need to help young people seek early contraceptive and sexual health advice?

Field social workers, residential social workers and foster carers work with and look after some of the most vulnerable groups of young people who are more likely to have experienced the following risk factors:

Looked after young people

A study of Looked After young people found that a quarter had a child by the age of 16 and nearly half were mothers within 18-24 months after leaving care.

Experience of sexual abuse

Several studies have shown an association between childhood Sexual Abuse and teenage pregnancy.

Educational problems

Low educational attainment among boys and girls, truancy and school exclusion are strongly associated with teenage pregnancy. One piece of research of 50 girls excluded from school showed that 14% had become pregnant during their period of exclusion.

Involvement in crime

One study showed that teenage boys and girls who have been in trouble with the police had twice the risk of becoming a teenage parent. An estimated 25% of young men under 21 in Young Offenders Institutions are already or expectant fathers.

These young people often have low self-esteem and lack the necessary skills and confidence to develop and manage rewarding and safe personal relationships. They may have experienced inadequate parenting and adult role models and have missed out on mainstream school sex and relationship education (SRE).

As part of their Corporate Parenting role, social workers, residential social workers and foster carers have a responsibility to ensure that young people in their care receive high quality SRE and have the information and confidence to access contraceptive and sexual health advice services.

The duty of Councils with Social Services Responsibilities (CSSR) to safeguard and promote the health of children and young people is enshrined in the Children Act 1989. The provision of SRE is part of that duty. In the Quality Protects Programme, CSSR’s are also asked to work with health agencies to help reduce teenage pregnancy among Looked After young people (LAC (2000) 22: HSC 2000/03.)

The guidance aims to:

  1. Clarify for field social workers, residential social workers and foster carers that young people in their care have the same right to confidential contraceptive and sexual health advice as other teenagers; and
  2. Set out the role they can play in providing information and advice about contraception and referring young people to appropriate services.

Guidance about SRE, in the context of promoting health and well being and improving health outcomes for Looked After children, will also be included in revised Department of Health and Social Care (DHSC) Guidance, to be issued early in 2002.

This guidance is set out in three sections:

  1. The Role of Health Professionals in Providing Contraceptive and Sexual Health Advice and Treatment;
  2. The Role of Field Social Workers, Residential Social Workers and Foster Carers in Providing Contraceptive and Sexual Health Advice and Treatment;
  3. A Checklist of Actions for Field Social Workers, Residential Social Workers and Foster Carers to Support Implementation of the Guidance in the Context of their Local Teenage Pregnancy Strategy.


Section 1: The Role of Health Professionals in Providing Contraceptive and Sexual Health Advice and Treatment

Q1. Where can teenagers access free contraceptive advice and treatment?

Young people, including under 16s can get free contraceptive advice and treatment from:

  • NHS contraceptive/family planning clinics;
  • Brook and other young people’s advisory clinics;
  • Their own GP, although most GPs do not supply condoms;
  • Another GP by asking to register for contraceptive/family planning services only;
  • Some NHS Walk In Centres;
  • Some Young People’s Information ‘One Stop’ Shops;
  • Some genito-urinary medicine (GUM) sexually transmitted infection clinics;
  • Some pharmacists providing free emergency contraception under NHS arrangements, using Patient Group Directions;
  • From January 2001 emergency contraception can be bought direct from pharmacists. However the pharmacy licence limits provision to young women aged 16 and over.

Q.2 How can field social workers, residential social workers and foster carers find out which local services to refer young people to?

Each local Teenage Pregnancy Co-ordinator is developing a checklist and directory of local services to help professionals working with young people to make quick and appropriate referrals.

Details of local services are also available from:

R u thinking website

The Brook Service

Q.3 Where can teenagers get advice or treatment for sexually transmitted infections (STIs)?

Young people can get information and advice about sexually transmitted infections from the contraceptive services listed in Q.1. Some may offer a limited screening and treatment service, but most will refer young people to a GUM clinic, usually based in the nearest large hospital.

GUM services should be included in the local directory of services. Details of clinics are also available from the following Helplines:

Health Information Service 0800 665544
National AIDS Helpline 0800 567123
fpa (England) 020 7837 4044
The Brook Helpline 0800 0185 023
R u thinking website

Q.4 Can health professionals give contraceptive advice and treatment to young people under 16 without parental consent?

  • Yes, provided the health professional is satisfied that the young person is competent to understand fully the implications of any treatment and to make a choice of the treatment proposed. The health professional must establish that all of the following criteria are met:
  • The young person understands the doctor’s advice;
  • The doctor cannot persuade the young person to inform his or her parents or allow the doctor to inform the parents that he or she is seeking contraceptive advice;
  • The young person is very likely to begin or continue having intercourse with or without contraceptive treatment;
  • Unless he or she receives contraceptive advice or treatment, the young person’s physical or mental health or both are likely to suffer;
  • The young person’s best interests require the doctor to give contraceptive advice, treatment or both without parental consent.

These criteria were outlined by Lords Fraser and Scarman in 1985, in the House of Lords’ ruling in the case of Victoria Gillick v West Norfolk and Wisbech Health Authority and Department of Health and Social Care (DHSC) and Social Security. They are commonly known, and will be referred to in this guidance, as the Fraser Guidelines.

The Fraser Guidelines specifically refer to contraception but the principles also apply to other treatments, including abortion. They refer to doctors but also apply equally to other health professionals in England and Wales.

Q.5 Do young people under 16 have the same right to confidentiality as older people?

Yes, Health professionals have the same duty of confidentiality to under 16s as they do to older patients.

Q.6 If the young person is not considered competent to consent to treatment, should the consultation remain confidential?

Yes, except in the situations outlined in Q.7.

Q.7 Are there are situations when health professionals may break confidentiality?

The professional codes of doctors, nurses and other health professionals, state that confidentiality may only be broken in the most exceptional situations when the health, safety or welfare of the patient, or others, would otherwise be at grave risk.

The decision whether to break confidentiality depends on the degree of current or likely harm, not solely on the age of the patient.

Wherever possible, young people should be informed before confidentiality is broken, unless to do so would be dangerous for them or others.

Q.8 Do all GPs provide confidential contraceptive advice to under 16s?

No. A minority of GPs will not see a young person under 16 without a parent present. Some state this on notices in the waiting room or information in the practice leaflet.

If there is any doubt about the confidentiality of the service, a young person can ask whether the consultation is confidential before seeing the doctor.

Q.9 What happens if a young person is subject to a Care Order?

Young people under care orders have the same right to confidentiality and treatment from health professionals as other young people. This means that they can ask for and access contraceptive advice from health professionals with the same degree of assurance about confidentiality as a young person who is not subject to a Care Order.

If a health professional does not consider them competent to consent to understand and make a choice of the treatment proposed, either the local authority or the person with Parental Responsibility could give consent to medical treatment, including contraception.

Section 33 (3)(b) of the Children Act gives Parental Responsibility to Councils with Social Services Responsibilities (CSSR) for any young person in respect of whom it has a Care Order. In relation to such a young person, the CSSR could decide to agree to medical treatment, including contraception, without the consent of the parent. In these circumstances, they would normally inform the parents of the decision, unless to do so would not be in the young person’s best interests.

Q.10 Where can young women get free pregnancy testing and pregnancy counselling?

Free pregnancy tests with immediate results are available from Brook Centres, young people’s advisory centres and most NHS family planning/contraceptive clinics. Some NHS Walk in Centres and GUM clinics also provide free tests with immediate results. Pregnancy tests at GPs are usually free but not always available and may involve a wait for the result. Home tests bought from pharmacists are reliable but may not be affordable for some young people.

Unbiased information and advice on the options of continuing the pregnancy, abortion and adoption should be available at all the sources of free pregnancy testing. GPs with a conscientious objection to abortion are contractually obliged to refer on to other services. The practice should make this clear to patients but social workers and carers should check that young people accessing GPs receive the support they need. Other services offering unbiased counselling may be available in some areas.

Availability of and referral to NHS funded abortion services varies between areas. The checklist and directory, available from Local Teenage Pregnancy Co-ordinators, should provide details of local service provision. Services information is also available from the Helplines and websites listed in Q.2.

Q.11 Can a young woman under 16 have an abortion without parental consent?

Yes. Legally, if a young woman is judged competent in accordance with the Fraser Guidelines (Q.4), she can consent to an abortion without parental involvement. However, in practice this is unusual and would only be done in exceptional circumstances when it is considered to be in the young person’s best interests. In such a situation, every effort would be made to help the young person involve another adult for support.

Q.12 Can young people under 16 buy condoms?

Yes. The law does not prevent under 16s from buying condoms from pharmacists, shops or vending machines. Nor does it restrict the seller.


Section 2: The Role of Field Social Workers, Residential Social Workers and Foster Carers in Providing Information and Referring Young People to Contraceptive and Sexual Health Services

Q.13 If asked by a young person, can field social workers, residential social workers and foster carers give details of local contraceptive and sexual health services?

Yes. Field social workers, residential social workers and foster carers can and should give young people, including under 16s, information on sexual health and contraception and details of where and how to access local services.

Q.14 If they believe a young person is likely to become sexually active, can they give them details of local contraceptive and sexual health services and encourage them to access advice?

Yes. If they think the young person is likely to start a sexual relationship, they should actively encourage them to visit a local contraceptive and sexual health service to help minimise any risk taking.

The duty of field social workers, residential social workers and foster carers, irrespective of their personal views, is to promote and safeguard the health and welfare of young people. In addition to providing information about services, they should offer young people support in developing assertiveness and negotiating skills to help them resist any pressure to have early and unwanted sex. This is particularly important for vulnerable young people who, through lack of self-esteem, may feel less able to make their own choices.

The parents of a Looked After Child or young person may express wishes about the sex and relationship education or contraceptive advice they want provided. Whilst every effort should be made to respect these wishes wherever possible, the overriding principle for the residential social worker or foster carer is to safeguard the health and welfare of the young people in their care.

For example, if a young person discloses that they have had unprotected sex, the parents’ views should not be a barrier to immediate referral to a health professional for a discussion about emergency contraception.

Q.15 Can field social workers, residential social workers and foster carers display posters or leaflets about local services?

Yes. When working with teenagers, it would be good practice to display publicity about local contraceptive and sexual health services, alongside information about other relevant community services. The local Teenage Pregnancy Co-ordinator will be able to advise on available posters and leaflets or credit card publicity materials for young people to keep. There may also be local websites with service information.

Q.16 Could field social workers, residential social workers and foster carers take a group of young people to visit a local clinic to find out about local services?

Yes. A visit to a local service would be most effective as part of a wider SRE programme. A doctor, nurse or counsellor from a local clinic could also be invited in to explain what the service offers and to answer young people’s questions. This could be done alongside visits from other community services and organisations. Parental permission would not be required, but it would be good practice to consult with and inform parents about the SRE policy.

Q.17 Can field social workers, residential social workers and foster carers accompany a young person to a local service?

Yes. Apprehension about visiting services deters many young people from getting early contraceptive advice. If a field social worker, residential social worker or foster carer believes a young person is worried about visiting a service and is at risk of pregnancy, they may accompany them to a clinic. Their relationship with the young person may also help in reinforcing the advice from the health professional.

Q.18 Can field social workers, residential social workers and foster carers give young people information about contraceptive methods?

Yes. Field social workers, residential social workers and foster carers can provide young people, including under 16s, with information about contraceptive methods and the importance of using condoms to protect against sexually transmitted infections. They should always ensure that the information is accurate and up to date by checking with the local contraceptive service, health promotion unit or national organisation such as fpa or Brook.

Field social workers, residential social workers and foster carers are not health professionals so they should not give advice on which method of contraception to use. Young people needing to make a contraceptive choice should be encouraged and supported to visit a local contraceptive service. However, if a social worker or foster carer is aware that a young person has had unprotected sex, they should ensure they can access emergency contraception as soon as possible.

Q.19 Could residential social workers and foster carers make condoms available to young people in a residential setting?

Yes. Single condoms may be given to under 16s as part of an information session. However, when providing condoms for contraceptive purposes and the prevention of sexually transmitted infections, social workers and foster carers should follow the Fraser guidelines (Q.4).

Before a decision is taken to make condoms available, social workers and foster carers should ensure that the supply of condoms:

  • Forms part of a broader sex and relationship education programme which includes helping young people resist any pressure to have early sex;
  • Is supported by clear protocols which have been agreed with management and are understood by young people;
  • Complements local service arrangements for the distribution of free condoms;
  • Only supplies condoms with the British Kite Mark and EC standard;
  • Is always accompanied by verbal and written advice about using condoms correctly, information about sexually transmitted infections and services and where to access emergency contraception if the condom breaks or is not used;
  • Is mentioned in the SRE policy.

Q.20 Could health professionals provide a contraceptive service within a residential setting?

Yes. Bringing a health professional into the residential setting can provide young people who need it with much easier access to confidential advice and be an effective way of reaching young people who are reluctant to visit mainstream services.

Young people in contact with field social workers, residential social workers and foster carers often report a lack of confidentiality in their personal lives. They should be made aware that health professionals’ duty of confidentiality includes under 16s and applies in any setting. It may be preferable for a visiting service to offer general health advice as well as a specific contraceptive/sexual health service so that the reason for the consultation is not apparent to either peers or staff in the residential setting.

Taking services out to young people is one of the recommendations of the Best Practice Guidance for the Provision of Effective Contraception and Advice Services for Young People, issued by the Teenage Pregnancy Unit in December 2000.

Q.21 Could field social workers, residential social workers and foster carers do a pregnancy test for a young person?

Yes. Fear and denial often deter teenagers from getting an early pregnancy test. As a result they are more likely to miss antenatal care and to have late abortions.

If a young person suspects they are pregnant, it would be preferable for them to have a pregnancy test at one of the local services. However, if they refuse, the field social worker, residential social worker or foster carer could support them in doing a home pregnancy test. Although home tests are reliable, it would be advisable to have the result confirmed at a clinic. If the test result is negative, a visit to the clinic would also provide the opportunity for the young person to discuss their contraceptive needs and find a method they are happy with.

Q.22 What should they do if the test is positive?

The first priority is to make sure the young person has access to unbiased pregnancy advice on their options of keeping the baby, abortion or adoption. More in depth pregnancy counselling may also be necessary. Whatever choice the young person makes, the field social worker, residential social worker or foster carer should ensure they have the information and support to access antenatal care or NHS funded abortion. Information on relevant services will be available from the local Teenage Pregnancy Co-ordinator.

If the young woman chooses to keep the baby, she should be helped to tell her social worker and/or birth parents to ensure arrangements are made for appropriate housing, healthcare and support.

If abortion is the chosen option, they should encourage the young person to think about future contraception and refer her to a service to help her choose a suitable method. Information about post abortion counselling should also be available.

If adoption is her preferred option, the young woman should be helped to access an adoption adviser through the CSSR or voluntary adoption agency.

If the young person lives in one of the twenty Sure Start Plus areas, they can be referred to a Personal Adviser who will help to broker the advice and support they need whichever option they choose. Other areas may have specialist support projects for pregnant teenagers and teenage parents about which local Teenage Pregnancy Co-ordinators will have information.

When providing support, the field social worker, residential social worker or foster carer should assess the young person’s ability to make an informed choice of her options. They should discuss the benefits of informing the young person’s birth parents, her social worker or another trusted adult and encourage their involvement.

If the health professional does not feel the young person is competent to make an informed choice of her options, the birth parents and/or the CSSR, depending on the child’s legal status, would have to be involved.

Q.23 Can field social workers, residential social workers and foster carers keep information and requests about sexual health and contraceptive advice confidential?

Yes. Field social workers, residential social workers and foster carers should respect young people’s right to confidentiality when discussing sex and relationship issues, including contraception. A disclosure of under age sex is not in itself a reason to break confidentiality.

Q.24 Are there any exceptions to this?

Yes. Field social workers, residential social workers and foster carers are delegated the duty of the CSSR to promote and safeguard the health and welfare of the young person. They therefore have to use their professional discretion to balance the young person’s right to confidentiality with the need to ensure their safety.

If they have reason to think that a young person is being abused or exploited and/or at risk of suffering Significant Harm, they should work with the young person to encourage them to allow the relevant information to be passed on.

If they refuse and the field social worker, residential social worker or foster carer believes the involvement of others is essential for their best interests, they may disclose information without the young person’s consent. They should work within the policies of their local Area Child Protection Committee and the requirements and sex and relationship education policy of their employer and/or the CSSR responsible for the young person concerned. These policies should follow the Government’s inter-agency guidance, Working Together to Safeguard Children.

Policies for social workers and residential social workers and agreements with foster carers should outline arrangements for discussing worrying disclosures with a line manager or senior colleague to discuss the most appropriate action. Information shared with colleagues and relevant agencies should be on a strictly ‘need to know’ basis and governed by the principle of promoting and safeguarding the young person’s health and welfare. The young person should always be kept informed about what information will be given, to whom and for what purpose.

In cases where confidentiality is broken, field social workers, residential social workers and foster carers should ensure that the young person has access to appropriate counselling and support, both during and after any Section 47 Enquiry and/or police investigation takes place.

Q.25 How can field social workers, residential social workers and foster carers work to support parents in addressing sex and relationships issues with their children?

Research suggests that young people growing up in families where sex and relationships are discussed without embarrassment, delay first sex and are more likely to use contraception when they become sexually active. However many parents report difficulties in talking to their children about these issues. This is likely to be exacerbated if the relationship between them is already causing problems.

Field social workers, residential social workers and foster carers in contact with parents should discuss with them the benefits of talking to their children about sex and relationships. If they feel that the teenager is sexually active or about to become so, parents should be encouraged to inform the young person of local confidential services to help ensure the early uptake of contraceptive and sexual health advice.

If appropriate, leaflets can be obtained from the fpa (Family Planning Association) or parents referred to the national helpline, Parentline Plus. Local Teenage Pregnancy Co-ordinators will also know of any local projects providing support for parents in talking to their children about sex and relationships.

Q.26 How can field social workers, residential social workers and foster carers work with the local community to support young people on these issues?

Parental availability and the provision of youth focused activities can both play a role in helping young people avoid unwanted sex and resist peer pressure before they are ready to make their own informed choice. Where appropriate, field social workers, residential social workers and foster carers should contribute to local regeneration planning to help develop projects where adult role models and youth focused services can increase the community support for young people.


Section 3: A Checklist of Actions for Field Social Workers, Residential Social Workers and Foster Carers to Support Implementation of the Guidance in the Context of their Local Teenage Pregnancy Strategy

  • Identify any existing SRE and/or condom provision policies of the project or organisation;
  • Review and develop policies to reflect this guidance;
  • Identify training needs to support field social workers, residential social workers and foster carers in referring young people to contraceptive and sexual health services;
  • Nominate a member of your team/organisation to identify the local Teenage Pregnancy Co-ordinator to:
  1. Find out details of local services and to obtain leaflets, posters and any other relevant publicity material;
  2. Discuss the role field social workers, residential social workers and foster carers can play in the local teenage pregnancy strategy;
  3. Discuss the possible involvement of young people in the review and development of accessible local contraceptive and sexual health and pregnancy support services.

Contact details of Local Teenage Pregnancy Co-ordinators are available from the Teenage Pregnancy Unit on 020 7972 4574, e-mail: MB-Teenage PregnancyUnit@doh.gov.uk or through the Department for Education website.

References

Teenage Pregnancy. A report from the Social Exclusion Unit. 1999.

Seeking Consent: working with children. Department of Health and Social Care (DHSC) 2001.

Talking about sex and relationships - a fact sheet for foster carers. Sex Education Forum and National Foster Care Association. 2001.

Useful organisations

  • Sex Education Forum
    8 Wakley Street
    London EC1V 7QE
    Tel: 020 7843 6052
    National Children's Bureau website

    Provides publications and resources, as well as an information helpline for professionals involved in sex and relationship education.
  • FPA
    2-12 Pentonville Road
    London N1 9FP
    Tel: 020 7837 5432
    FPA (putting sexual health on the agenda) website

    Provides training, consultancy and resources for professionals, as well as leaflets for young people.
  • Brook
    421 Highgate Studios
    53-57 Highgate Road
    London NW5 1TL
    Tel: 020 7284 6040
    Brook website

    Provides a free helpline for young people and resources for young people and professionals.
  • National Foster Care Association
    87 Blackfriars Road
    London SE1 8HA
    Tel: 020 7620 6400
  • Who Cares Trust
    Kemp House
    152-160 City Road
    London EC1V 2NP
    Tel: 020 7251 3117
  • British Agencies for Adoption and Fostering
    Skyline House
    200 Union Street
    London SE1 0LX
    Tel: 020 7593 2000

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