SAFEGUARDING/CHILD PROTECTION
As a key part of the duties of a pharmacy professional, appropriate safeguarding of children will be important, working with other organisations and authorities where needed. Evidence of sexual activity/relationships that are inappropriate for a child's age or competence may be an indicator of child abuse.
Children who are under the age of 13 years are considered too young to legally consent to any sexual activity. The GPhC guidelines on Medical Ethics and Practice state that such instances should be reported to Social Services, unless the circumstances are considered to be exceptional and can be backed with documented reasons for not sharing information.
The age of consent in the UK is 16 years, although sexual activity in children under the age of 16 may be consensual, and typically does not lead to prosecution unless involving abuse or exploitation. Guidelines from the FSRH on contraception in young people suggest that 'Practitioners may wish to inform a young person of the law in relation to sexual activity.
Pharmacists can provide contraception and sexual health advice to children under the age of 16, with appropriate assessment and documentation of consent (see 'consent' section). In such cases the duty of patient confidentiality should apply, with consent sought for any decision to share patient information, unless judged that sharing is in the best interests of the child (e.g. to prevent abuse).FSRH guidelines recommend that young patients are made aware of confidentiality policies and the circumstances in which confidentiality may need to be broken. The FSRH also provides guidance on eligibility criteria for different types of contraceptive based on age. It is important to note that the SmPC for Lovima 75 microgram film-coated tablets states that although the product is indicated for women of child-bearing age, the safety and efficacy of Lovima in adolescents below the age of 18 years has not been established.
Various national and local guidelines and frameworks are available regarding appropriate safeguarding of vulnerable patients, including young people = further information about these frameworks can be found in the FSRH guideline (available from https://www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-young-people-mar-2010/). In particular, FSRH recommend that:
Appropriate training on the possibility of exploitation or coercion should be provided to all staff involved in contraceptive services for young people.
Staff should know how to act on child protection issues, in line with local policies/procedures.
Staff should know who to contact for advice.
CONSENT
Obtaining consent is a fundamental component of providing safe, effective patient-centred care. In the setting of provision of healthcare services or treatment, children under the age of 16 years must demonstrate their competence to consent. According to GPhC and RPS guidelines.
In England, Wales and Northern Ireland, the FSRH recommends use of the Fraser Guidelines/criteria (available from https://www.cqc.org.uk/guidance-providers/gps/gp-mythbusters/gp-mythbuster-8-gillick-competency-fraser-guidelines) when considering whether a young person under the age of 16 years is able to consent to the provision of contraception.
FRASER GUIDELINES/CRITERIA
In Scotland, the Fraser Guidelines have no legal authority, and instead, competency is primarily addressed by ensuring that the child meets the criterion of understanding the nature and consequence of treatment. FSRH guidelines recommend assessment and documentation of competence to consent to treatment at each visit for those aged under 16 years.
CONTRACEPTION FOR WOMEN AGED > 40 YEARS
Separate guidance, such as that issued by the FSRH, is needed for women over the age of 40 years as they have a high risk of cardiovascular disease, obesity, and breast and most gynaecological cancers, compared with younger women. The increased risk may affect the choice of contraceptive method. Pharmacists should also make women aware that:
- Contraception does not affect the onset or duration of menopausal symptoms but may mask the signs and symptoms of menopause.
- POPs are not associated with increased risks of VTE, stroke or heart attack and have not been shown to affect bone mineral density.
- POPs can be used until the age of 55 years when natural loss of fertility can be assumed.
COMMON MISCONCEPTION:
'I don't need contraception because I am on HRT'. Hormone replacement therapy (HRT) is not a method of contraception, and premenopausal or menopausal women should still use an effective method contraception in conjunction with HRT can be too low for it to be effective as a contraceptive. Desogestrel may be a suitable method of contraception for women using HRT; however, the recommended method for these women is an IUS.