Contraception for Teens

Contraception for Teens:
Issues & Dilemma?
Dr. Iskandar Firzada b. Osman
MD (USM), MMed (Family Medicine) (USM),
MAFP (Mal.), FRACGP (Australia), FAFP (Mal.),
Fellow in Adolescent Health (Melbourne)
Family Medicine Specialist
Klinik Kesihatan Jaya Gading, Kuantan
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Part I: Section 2. (1)
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Child under Islamic Law
• The word ‘minor’ means a person who has not completed the age
of 18 years.
• Two different concepts in Syari’ah Law;
– “Baligh” or puberty
– “Mumayyiz” or discretion
• The minority of a male or female terminates when he or she attains
puberty.
• ‘Boy’ – wet dreams as early as 9-11 years old. If none of the usual
signs exist, puberty is established when he has completed his 18
years. (Imam Abu Hanifah)
• ‘Girl’ – menstruation. If no signs exist, puberty is established when
she has completed her 17 years. (Imam Abu Hanifah).
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Act 574: Penal Code
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Mature Minor or
Gillick Competent Child
• The Commonwealth Law position relating to a minor's
competency to consent to treatment was established by
the English House of Lords decision in Gillick v West
Norfolk and Wisbech Area Health Authority [1986]
AC 112.
• That case determined that minors may authorise
(consented) in confidentiality, medical treatment when
they are old enough & mature enough to decide for
themselves, provided they are capable of understanding
what is proposed & of expressing their own wishes.
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http://www.miga.com.au/riskresources/library/11RRFS08.pdf
Defining a Mature &
Competent Adolescent
Adolescent can consent to or refuse treatment & is entitled to
confidentiality (in relation to their parents or guardian) if they are
assessed to be sufficiently mature & competent. This assessment is
not made on the basis of chronological age alone & does not need to
involve an accompanying parent or guardian.
To be considered sufficiently mature & competent, the young person
needs to understand the;
• Nature of the condition for which they seek treatment,
• Nature of the treatment being proposed, including treatment options,
• Possible outcomes of that treatment, &
• Likely outcomes if treatment is not given.
Consent for Treatment and Confidentiality in Young People
The Medical Practitioners Board of Victoria, 2004
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Maturity
In assessing maturity, the following factors are important:
• Age,
• General maturity of speech & bearing,
• Level of independence from parental care,
• Level of schooling,
• The doctor’s prior knowledge of the patient,
• Why the patient came to see the doctor about the issue on their
own,
• Functioning in other aspects of their life,
• Ability to explain the clinical problem for which treatment is sought,
by providing an appropriate clinical history, &
• Ability to understand the gravity & complexity of the treatment
proposed.
Consent for Treatment and Confidentiality in Young People
The Medical Practitioners Board of Victoria, 2004
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Competence
In assessing adolescent’s level of competence & cognitive ability, the
treating doctor needs to be confident that the adolescent has sufficient
understanding & intelligence about:
• The nature of their clinical problem,
• The nature & purpose of the proposed treatment,
• The effects of the treatment including side-effects,
• The consequences of non-treatment,
• Other treatment options,
• Possible repercussions of the treatment – e.g. the consequences if
parents found out, &
• How to carry through the proposed treatment.
Consent for Treatment and Confidentiality in Young People 10
The Medical Practitioners Board of Victoria, 2004
Confidentiality in
consultations
• Doctors owe a duty to patients of any age to keep all information
obtained in the course of the therapeutic relationship confidential.
• Ethical requirement to maintain confidentiality when requested by a
mature minor who is assessed as competent.
• All information should be regarded as confidential until discussion &
negotiation has taken place.
• A clear statement at the beginning of contact with an adolescent that
explains confidentiality policy with exceptions is important.
• The duty of confidentiality does not prohibit encouraging &
empowering adolescent to talk to parents about important issues.
• This maybe the goal of future consultations.
Consent for Treatment and Confidentiality in Young People 11
The Medical Practitioners Board of Victoria, 2004
Adolescent Sexual &
Reproductive Health
• A state of physical, emotional, mental & social
well-being in relation to sexuality; it is not merely
the absence of disease, dysfunction or infirmity.
• Sexual health requires a positive & respectful
approach to sexuality & sexual relationships, as
well as the possibility of having pleasurable &
safe sexual experiences, free of coercion,
discrimination & violence.
WHO, 2006 12
http://www.who.int/reproductivehealth/topics/sexual_health/sh_definitions/en/
Sexually Healthy Teen
• Appreciates their body,
• Take responsibility for their own behavior,
• Communicate effectively & respectfully, &
• Express love & intimacy in a way that is appropriate for
their age.
“most teens will be interested in sex & this does not equal
that they want to be sexual with another. It is okay, & likely
smart & healthy to say no to sex when you are not ready or
willing to be sexual with a partner”
Mary Buxton, LCSW
AASECT Certified Sex Therapist 13
http://www.marybuxton.com/Family_Matters/Sexually_Healthy_Teens/sexually_healthy_teens.html
Consequences of Teen
Pregnancy

Infant

Teen Mom
 Prematurity
 Unwanted pregnancy
 Infant mortality /
infanticide
 Unsafe pregnancy / delivery
 Abuse
 Risk of STI & HIV infection
 Future teen pregnancy
 Unsafe abortion
 Low educational attainment
 Unemployment
 Poverty
 Risk for repeat pregnancy
Santelli & Melnikas, 2010
http://www.guttmacher.org/pubs/FB-ATSRH.html
Klein, JD and the Committee on Adolescence, 2006
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Goals of Contraception for
Teens
• Prevent / decrease pregnancies among
female teens.
• Delay initiation of teen sexual activity.
• Increase use of effective contraceptive
methods.
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http://www.cdc.gov/winnablebattles/Goals.html
Spectrum of Preventive
Activities in Medicine
Healthy
Risk Factor(s)
Health
Issue(s)
Incapacitated
Primordial
Prevention
Primary (1o)
Prevention
Secondary (2o)
Prevention
Tertiary (3o)
Prevention
Activities:
Health
PROMOTION
Activities:
1. Risk(s)
identification
2. Risk(s)
stratification
3. Risk(s)
intervention
Activities:
1. Treat for CURE
2. Manage for
CONTROL
Activities:
1. REHABILITATION
2. PALLIATIVE Care
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Old Chinese saying;
GOOD doctor RELIEVED disease!
BEST doctor CURE disease!
SUPERIOR doctor PREVENT disease!
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Abstinence
How It Works?
• Abstain from sexual intercourse:
– Vaginal, anal, & oral.
– Keeps sperm from joining egg.
Effectiveness = 100%
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http://www.powershow.com/view/103483-YTVjN/Birth_Control_For_Teens_powerpoint_ppt_presentation
Abstinence
Advantages
• No medical or hormonal side effects.
• Endorsed by all religions/faith & culture.
Disadvantages
• People may find it difficult to abstain.
• Women & men often end their abstinence
without being prepared to protect themselves
against pregnancy or STDs.
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http://www.powershow.com/view/103483-YTVjN/Birth_Control_For_Teens_powerpoint_ppt_presentation
Abstinence
Advantages for teens
• Postpone risks.
• Safe sex (“Save sex for marriage”)
• Morally / culturally appropriate.
Health advantages. Women who abstain until
their 20s are less likely to:
• get sexually transmitted infections (STI),
• become infertile, &
• develop cancer of the cervix.
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http://www.powershow.com/view/103483-YTVjN/Birth_Control_For_Teens_powerpoint_ppt_presentation
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Act 574: Penal Code
“Statutory rape”
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Part V: Chapter 2
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The Male Condom
How It Works
• Covers the penis before intercourse with a
sheath made of thin latex or plastic to keep
sperm from joining egg.
Effectiveness = 85 - 98%
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http://www.powershow.com/view/103483-YTVjN/Birth_Control_For_Teens_powerpoint_ppt_presentation
The Male Condom
Advantages
• Inexpensive & easy to buy.
• Latex condoms are the best method to protect
against STDs (“Dual protection”).
Disadvantages
• Uncooperative partners.
• Latex allergies.
• Breakage.
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http://www.powershow.com/view/103483-YTVjN/Birth_Control_For_Teens_powerpoint_ppt_presentation
Emergency Contraception
Provided in two ways:
• Emergency contraception pills
– Reduce the risk of pregnancy if started within 120
hours of unprotected sex.
– They work best when taken within 72 hours.
– Can reduce the risk of pregnancy from 75 to 89%.
– Nausea, vomiting, & cramping are common side
effects.
• Emergency IUD insertion within seven days of
unprotected intercourse is 99.9% effective.
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http://www.powershow.com/view/103483-YTVjN/Birth_Control_For_Teens_powerpoint_ppt_presentation
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What are the barriers to teens
using contraception?
• Health care providers!
• Psychosocial.
• Developmental issues:
– Early adolescence: present oriented, impulsive.
– Middle adolescence: omnipotent, invincible.
• Teens are spontaneous.
• Teens may be ambivalent about pregnancy & STI.
• Teens have inadequate access to information &
confidential care.
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http://www.cdc.gov/winnablebattles/Goals.html
Summary
Dear Dr. Iskandar,
From the legal aspect, it's true that there is no clear rule about
allowing or not allowing adolescent to seek and receive medical
treatment.
However, it is interesting to note that in the Poisons Act, Section 17
(1), it is provided that "no poison shall be sold or supplied to any person
under 18 years of age otherwise than for purposes of the medical
treatment of such person.” And in the interpretation part Section 2 of
the same Act, medical treatment is defined as treatment of human
ailments. This provision indicates as though prescribing medicines for
medical treatment (which is defined as treatment of human ailment) of
the under 18 is allowed. However, there is no reported case law so far
on this particular provision and its true meaning. And this provision is
qualified only for medical treatment. Noting this, contraception may not
fall under this category except probably if the OCP is used for treatment
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and not contraception.
Summary
I must also mention here that there is one provision under Section 3 of
the Civil Law Act 1956 (Malaysian Law) which allows us to apply the
Common Law of England and law of equity in the event of lacuna in the
domestic law (because our legal system is modelled on and has the
influence of English Law). And the Common Law of England in respect
of contraception is described in the case of Gillick v West Norfolk and
Wisbech Area Health Authority which among others, recognised
child's rights to contraception without parental knowledge or consent as
long as it is shown to the satisfaction of the medical practitioner that
she has sufficient understanding of what is involved.
However again, the application of this Common Law is not tested yet as
there is no case law decided by our court so far.
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Summary
Actually Dr. Iskandar, the law is stagnant on this issue and that is
why, I understand things are left to the discretion of doctors to
decide, which the core of my research is, understanding doctors’
practices in respect of treating adolescent. And especially on
contraception, the practice is based on the individual doctor. And when
I interviewed the Head for Adolescent Health at LPPKN, for
contraception they also understand that there is no written policy that it
could only be given to married. So both married and unmarried
adolescent may be entitled to contraception.
This issue is complex because of the ambiguity in the law, but
having said that, I feel that for medical treatment, Section 17 of the
Poisons Act is relevant to consider.
Candidate, PhD in Law, UM, 2015
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Take Home Message
1. non-maleficence = first, do no harm;
2. beneficence = act in best interest of the patient
i.e. do good to patient;
3. justice = fairness & equality, &
4. autonomy = respect patients’ right to refuse or
choose their treatment.
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Thank You
DR. ISKANDAR FIRZADA B. OSMAN
MD (USM), MMed (Family Medicine) (USM),
MAFP (Mal.), FRACGP (Australia), FAFP (Mal.),
Fellow in Adolescent Health (Melbourne)
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