Abstract
The purpose of the study was to assess the use of sexual and reproductive health services by adolescents aged 15 years and younger. A case-note review was conducted at both a genitourinary medicine clinic and a family planning clinic in Edinburgh, UK. The demographics of the attendees, reasons for attending, risk factors, diagnostic tests undertaken and contraceptive advice given differed between the two clinics. Approximately 73% of attendees with documented responses used alcohol and 21% used recreational drugs, 5% reported self-harm, 25% reported being victims of sexual assault, 13% had a current sexually transmitted infection and 6% of girls had already been pregnant. While this group of young people understand the differences in emphasis between the clinics, adolescents may be intimidated and discouraged from attending or may fail to return, and the combination of overlap, together with omissions in cross-clinic function, suggests that for this age group the services of these clinics should be combined.
INTRODUCTION
The rate of sexually transmitted infections (STIs) in young people, aged 16–25, has been increasing for over a decade. 1 Young people make up 12% of the UK population, yet account for more than 50% of all STIs. 2–4 In genitourinary (GU) medicine clinics across the UK, the diagnosis of all STIs rose by 63% between 1998 and 2007, and chlamydial infection alone rose by 150%. 1 There is also an increase in the number of young people having sexual intercourse (SIC) before the age of 16. Approximately 18% of boys and 15% of girls report having SIC by the age of 15. 5 Sex at this early age is also associated with more risky sexual behaviour since adolescents under the age of 16 may have less knowledge of sexual health, less access to contraception, lack the skills to use contraception competently, and may not have the interpersonal abilities to confidently refuse SIC. 5 Adolescents are also more likely to have SIC for the first time while under the influence of drugs and alcohol. 5 This rise in STIs is a public health problem on which governments have spent millions of pounds aiming to promote condom use, improve young people's awareness of STIs and promote better sexual health. As different contraceptive methods have become more widely available, despite the rise in HIV prevalence, it is only recently that awareness of STIs has increased. 6 GU medicine and Family Planning Clinics (FPCs) have a close working relationship and both are frequented by adolescents seeking information and advice on STIs, contraception and pregnancy. GU medicine clinics offer a range of services with an emphasis on STI testing, but also provide contraceptive advice, free emergency and other forms of contraception, and counselling on a range of sexual health topics. In addition, they often offer specialist care in relation to HIV infection, sexual assault and gay men's sexual health. 7 FPCs are better known for dealing with problems related to contraception and pregnancy, but they also provide STI testing, smear tests, and many offer specialist services, including termination of pregnancy and sexual abuse counselling. 8 Since the services of these clinics overlap, it is important to know if there is consensus in the management of problems that are common to both. Equally, it is important to know if there are gaps in services for young people because of a different focus in different clinics, and the desire to avoid unnecessary duplication of services.
METHODS
A case record review was conducted for all patients aged ≤15 years who attended either the GU medicine clinic, Lauriston Place, Edinburgh, UK or the FPC, Dean Terrace, Edinburgh, UK during 2008. These two sites provide services to the city of Edinburgh and surrounding area, a population of over 800,000. 9 The study sample was identified using an age-specific coding system. To provide uniformity from which to review clinic standards, the information was collated from the record of the initial attendance, at which time generally the most detailed history was recorded and most extensive testing done. The information gathered from patients' notes included: demographics (age, gender, race, referral method, postcode), reasons for attendance, patient risks factors which might contribute to poor sexual health (previous STI or pregnancy, alcohol and drug use, history of self-harm, sexual abuse or social work involvement), tests performed at clinic attendance (chlamydia, HIV, other STI testing inclusive of gonorrhoea and syphilis, and pregnancy testing) and patient management (STI diagnosed, contraception advice given, free condoms given, initiation of contraception). The study calculated patient deprivation scores using the Carstairs Index 10 from the 2001 census. This index calculates deprivation levels from postcodes. The variables used to create the score include: overcrowding, household amenities, male unemployment, number of cars and number of household rooms. The scores range from 1 to 7, with 1 being the most affluent, and 7 being the most deprived. The study collated the data using the program SPSS14 (Statistical Package for the Social Sciences) to carry out a statistical analysis, including the chi-square test.
RESULTS
Demographics
A total of 222 adolescents were included in the study, of whom 133 attended the GU medicine clinic and 89 attended the FPC. Table 1 shows the demographic differences between the two clinics. At the FPC, 98% of the attendees were female, compared with 80% in the GU medicine clinic. Statistically significantly more males attended the GU medicine clinic (20.3%) compared with the FPC (2.2%) (P < 0.05). The majority of attendees had deprivation scores of 3–5. In the FPC, those with a Carstairs Index of 1–2 were more numerous than those with Carstairs Index 6–7. The converse was true for those attending the GU medicine clinic. Over 90% of those attending the GU medicine clinic were from Carstairs Index 3–7. The high rate of unknown postcodes among those attending the GU medicine clinic may be due to the desire to preserve anonymity. Of the adolescents who presented to the GU medicine clinic, 40% self-presented and 60% were referred, with the majority of referrals coming from general practitioners, Caledonia Youth, and to a lesser extent, the police. (Caledonia Youth is a charitable organization which provides support for the youths in Scotland in terms of sexual health and relationships. They offer basic STI screening and contraception, as well as education and counselling around sexual health issues.) Along with race, the FPC did not record referral patterns. Social Services involvement was around 25% in both clinic settings, and over 90% of attendees were in school or higher education. If there was no documentation of social services involvement, it was assumed they were not involved and so this may be an underestimate.
Demographic differences of attendees at each clinic
FPC = family planning clinic; GU = genitourinary
Reasons for attending
Figure 1 shows the different reasons for patient attendance at the two clinics. The FPC attendances were primarily due to contraception-related problems and pregnancy, while the GU medicine clinic attendances were mainly due to STI problems and sexual assault. Approximately 25% attended the GU medicine clinic because of sexual assault, where counselling is offered by a health adviser, rather than a specialized sexual abuse counsellor.
Reasons for clinic attendance (excluded from the figure are those with two or more reasons for attending and 12 adolescents who attended the FPC because of menstrual problems). FPC = family planning clinic, GU = genitourinary; STI = sexually transmitted infection
Patient risk factors
Risk factors that might adversely affect reproductive and sexual health are shown in Table 2. In both clinics, alcohol use was between 40% and 50%, and recreational drug use was around 12%. In the GU medicine clinic, previous pregnancy was reported in 6% (data not shown), and a history of previous STI was four times greater (2.2% versus 9%) compared with the FPC. Similarly, a history of self-harm was reported by 5% of those attending the GU medicine clinic. This was not routinely documented at the FPC (data not shown). In both clinics, between 21% and 27% of adolescents used condoms the majority of the time, while 17–24% never used condoms.
Risk factors with the potential to affect adversely reproductive health
FPC = family planning clinic; GU = genitourinary; STI = sexually transmitted infection
Testing and diagnosis
Pregnancy testing and screening for STIs in each clinic is shown in Table 3. Chlamydia screening was the most widely used test, having been taken up by 84% of adolescents in the GU medicine clinic, and 30% of adolescents in the FPC. The numbers who were offered screening but declined was not recorded, but nearly all attendees at the GU medicine clinic and approximately 50% of those attending the FPC, in our estimate, were offered testing. Both the GU medicine and FPC sent their specimens to the Royal Infirmary of Edinburgh Hospital Laboratories where the COBAS TaqMan CT Test v2.0 was used. HIV testing was carried out on 40% of those attending the GU medicine clinic, but none of those attending the FPC. Approximately 62% of adolescents attending the GU medicine clinic were tested for other STIs, compared with only 1.1% of those attending the FPC. Pregnancy testing was performed in 35% of those attending the FPC, and 20% of those in the GU medicine clinic. In total, 28 adolescents tested positive for an STI, 25 in the GU medicine clinic and three in the FPC. All cases in the FPC were due to chlamydia. In the GU medicine clinic, 15 (60%) were due to chlamydia, 6 (24%) due to genital warts, two cases of HSV-2 infection, one of trichomoniasis, and one with both chlamydia and genital warts.
Pregnancy and STI testing in different clinic settings
FPC = family planning clinic; GU = genitourinary; STI, sexually transmitted infection
Contraception advice and initiation of a method
Previous contraceptive use, together with the provision of contraceptive advice at the clinic attendance, is shown in Table 4. In the FPC, 11% of adolescents were already using some form of contraception, and 40% were started on contraception at the first clinic visit. This is in contrast to 34% who were already using contraception at their first visit to the GU medicine clinic, while only 3% were started on contraception at clinic attendance. In both clinics most adolescents were on the oral contraceptive pill (OCP), followed by Depot Progesterone, and then Implanon. Of the contraceptives initiated at the FPC, 60% were started on the OCP and 29% on Implanon. Contraceptive advice was documented as given to 86% of attendees in the FPC, compared with only 62% in the GU medicine clinic. In approximately 20% of attendees in the GU medicine clinic, the advice was considered inappropriate due to circumstances such as sexual assault. At both clinics, free condoms were provided in about 50% of cases.
Contraceptive practices and advice given
FPC = family planning clinic; GU = genitourinary; STI = sexually transmitted infection
DISCUSSION
In this study, we have demonstrated that while GU medicine clinics and FPCs offer a roughly similar range of sexual and reproductive health services, the emphasis is different and this is understood by adolescents. Nevertheless, there are demographic differences in those who attend each clinic with respect to gender and socioeconomic status. The vast majority of FPC attendees were women, but 20% of those attending the GU medicine clinic were men. We were not able to confirm whether this experience was similar in other Scottish or UK GU medicine clinics for this age group. We have confirmed that adolescents under the age of 16 years are at risk of unintended pregnancy, STIs, sexual abuse and self-harm, as well as alcohol and substance abuse. In adolescents, these problems are often interrelated, though the specific complaint for which they attend may mask other underlying concerns. This is in comparison to the needs of older patients, which may be more focused and evident. Often adolescents may be intimidated and discouraged from attending either clinic for sexual and reproductive services in the first instance, or may fail to return. This may be because of fear of being recognized by relatives or parents' friends, other worries about anonymity, lack of parental support or simply fear of the unknown. In addition, for this age group, the overlap of services may be confusing and provide suboptimal care, and there appears to be shortcomings in the breadth of services offered by individual clinics, due to their natural focus.
Many maternity units identify the needs of teenage pregnant women and have a special midwife-led clinic for pregnant teenagers to encourage and improve antenatal attendance. Similarly, some tertiary referral centres have adolescent gynaecology clinics, but these are mainly designed for developmental or endocrine abnormalities and are not available to adolescents who have needs beyond this narrow remit. We feel that a case can be made for a one-stop, combined clinic specifically for adolescents, which would provide all the services currently offered by FPCs and GU medicine clinics, but have the appropriately trained staff to offer more extensive support for adolescent needs and problems. While the adolescents included in this study demonstrated a level of maturity and responsibility in seeking the advice from each of these clinics, the study highlights some worrying findings.
In this group of <16 year olds, 73% of those with documented responses used alcohol, and 21% used recreational drugs. The level of alcohol and drug use was about the same in each clinic, but a large proportion of alcohol and drug use may have gone undocumented. Alcohol is frequently involved in cases of sexual assault and SIC before the age of 16. 5 Adolescence is a unique period in neurodevelopment and behaviour, and both alcohol and recreational drugs have been demonstrated to influence adversely adolescent brain development. 11 Binge drinking, which is a common pattern of alcohol abuse among teenagers, is associated with suicide and the risk of STI acquisition, 12 including HIV. 13
Five percent of the adolescents in our study reported self-harm, and suicide is among the leading causes of death among adolescents. The rate of suicide in young people is rising faster than in other age groups. It is estimated that worldwide, 90,000 adolescents under the age of 19 commit suicide each year due to depression, physical or sexual abuse, loss of friends, academic failure, social isolation, substance abuse and other reasons. 14
Sexual assault disproportionately affects adolescents and young adult women, 15 and 25% of the study group of adolescents attending the GU medicine clinic gave sexual assault as a key reason for their attendance to the service. While all such cases were routinely offered screening for STIs, 16 it is disappointing that there were no specialist sexual abuse counsellors available. In a national survey of 4023 adolescents, 8% (13% of girls and 3.4% of boys) reported some form of child or adolescent sexual assault, 17 and victims are at greater risk for developing anxiety, depression, self-harm behaviours, suicidal ideas, delinquency, substance abuse, dysfunctional personality traits and relationship problems. 18,19 Previous sexual assault has also been strongly linked to behaviours that increase the risk of HIV acquisition. 20–22 Neither the GU medicine clinic nor the FPC in this study routinely asked about a history of sexual assault. Bearing in mind the vulnerability of this group, and the high percentage who presented to the GU medicine clinic because of sexual assault, direct questioning about a history of previous sexual abuse may need to be introduced.
In our study, 6% of attendees had had a previous STI, and 13% were found to have a current STI, mainly chlamydia which is associated with tubal infertility, ectopic pregnancy, salpingitis and epididymitis. 23 Approximately 85% of adolescents attending the GU medicine clinic received chlamydia screening, whereas only 30% were screened at the FPC. Since chlamydia is asymptomatic in over 75% of women, this constituted a missed opportunity to screen young women for chlamydia. In the USA in 1995, there were 12 million STIs, of which two-thirds were in individuals under the age of 25 years, amounting to 10 billion USA dollars in direct and indirect costs. 24 Approximately 40% of chlamydial and gonococcal infections occur in individuals with a previous history of STI, USA and in sexually active adolescents and young adults. The Centers for Disease Control and Prevention (CDC) recommend annual screening for chlamydia in sexually active women within one year of first SIC and screening for gonorrhoea in those at increased risk until the age of 25 years. 25 However, annual screening may not be sufficient for this group. In a study of 444 13–25 year olds, those who had an STI or were the uninfected sexual contact of someone with an STI, were given the appropriate treatment, and were followed up for seven months. After the follow-up period, 53% of female uninfected contacts had become infected, and 73% of those initially infected and treated were re-infected. This suggests that more frequent screening is necessary, even in the contacts of those with STIs. 24 In addition, the CDC recommendations do not have evidence-based recommendations on starting age or periodicity of screening. 25
In an effort to determine the time from first SIC to the first STI, and the time between repeat infection, a cohort of 386 female adolescents aged 14–17 years were followed up every three months. 24 The authors concluded that STI screening for sexually active adolescent women should begin within the first year of SIC, and that those found to be infected with an STI should be re-tested every three to four months. Programmes for the prevention of STI/HIV among young women have been shown to be effective. In a randomized controlled trial of 715 African-American women aged 15–21 years who sought sexual health services, intervention involving group sessions on STI/HIV prevention and telephone follow-up demonstrated a statistically significant reduction in chlamydial infections and significantly enhanced STI/HIV prevention behaviours. 26 It should be stressed that these two studies comprised mainly African-American adolescents, which may not be directly applicable to a predominantly white Scottish adolescent population.
In our group of young adolescents, 6% of girls had already been pregnant and contraceptive advice was necessary in 86% and 62% of those who attended the FPC and GU medicine clinics, respectively. Almost 50% of those who attended the FPC did so for contraceptive-related reasons and another 25% attended because of pregnancy concerns, so it is encouraging that 86.5% were given contraceptive advice and emergency contraception. In contrast, at the GU medicine clinic, with almost 70% of the attendees sexually active and only 34% already using contraception, only 2.8% were started on contraception at the clinic. Among developing countries, the USA and the UK have the highest rate of teenage pregnancy, and the UK has the highest rate in Western Europe. 1 Despite the establishment of a teenage pregnancy strategy in 1999, 27 pregnancy rates among girls under 16 years of age in England and Wales have risen since 2006. 28 However, early childhood interventions and youth development programmes to reduce unintended teenage pregnancy rates are effective. 1 A survey of 14,000 high school students, which examined sexual behaviours that led to unintended pregnancies, found that 48% of students reported ever having had SIC. Seven percent reported having sex before the age of 13 years, 15% reported having sex with four or more lifetime sexual partners, 35% reported being currently sexually active and only 61% of sexually active students reported the use of condoms during last sex. 29 In a survey of 15 year olds in the UK, 35% of girls and 28.9% of boys reported that they had ever had SIC. 30
Many new long-term contraceptives such as injections and implantable devices or intrauterine contraceptive devices are safe for use in young people. Limiting access to comprehensive care, which includes abstinence and all contraceptive methods, but requires pelvic examination prior to the provision of services, is detrimental to the success of prevention programmes and should be discouraged. 31
In this study, we have demonstrated that the young people gaining access to GU medicine and FPC services have multiple sexual and reproductive health needs. In addition, they often engage in other risk behaviours, including drug and alcohol abuse and self-harm. Standalone GU medicine and FPCs, due to the focus of their services, may not provide all the needs of this vulnerable population. This being so, there is a case to be made for setting up specific young people's services that will adequately address all their requirements. The Royal College of Obstetricians and Gynaecologists (RCOG) have recognized the overlap between FPCs and GU medicine clinics by approving Community Sexual and Reproductive Health as a specialty in August 2009 though there is no suggestion that any combined clinics should carry this name. This specialty permits certification of training under the auspices of the RCOG, within the Faculty of Sexual and Reproductive Healthcare, which in 2007 changed its name from the Faculty of Family Planning and Reproduction Healthcare, which had become established in 1993. The modules within the training curriculum include GU medicine and sexual assault, as well as contraception, unplanned pregnancy and abortion care (
CONCLUSION
Young adolescents are at increased risk of drug and alcohol abuse, unwanted pregnancy, sexual abuse, STI and self-harm. We have demonstrated that a non-uniform provision of care exists across the different settings of a FPC and GU medicine clinic. We feel that to provide a better quality of care, at least for this high-risk age group, consideration should be given to combine the role of GU medicine clinics and FPCs.