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Contents
The
morning after pill shake-up
Availablity of sex education and contraception
It has not worked : under age sex
Another government preaching initiative: alchohol
Over-the-counter from chemists
The pressure of wating customers
Patient group directions (PGD)
How a Patient Group Direction (PGD) works
Free distribution in chemists and youth groups
Medical facts and ethical issues
The effectiveness of the morning after pill?
How safe is MAP compared to the oral contraceptive pill?
The absence of long-term trials
The morning after pill shake-up
The
morning after pill is being made available as never before. This
is the result of two Government initiatives: the first involves
the over-the-counter sale of the drug at chemists; the second involves
free distribution programmes in schools and other places.
Top
Over-the-counter
sale in Chemists
As a result of a Ministerial Order (1) introduced
in December 2000, the morning after pill (MAP) has been available
over-the-counter from pharmacists since January 1st 2001 to women
aged over 16. A vote in the House of Lords on 29th January 2001
will confirm or overturn this move.
The
initial cost has been set at £20, but this is very likely
to fall. Some private clinics are already selling it at £10.(2)
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Free
distribution programmes
In a completely separate move involving another Ministerial Order
(3) the Government has made it possible for the
MAP to be distributed free by school nurses and other health professionals.
Under this Ministerial Order it is also possible for chemists to dispense the drug for free to girls aged under 16 where the local health authority have made an appropriate "Patient group direction".
In a recent highly publicised case, a 15 year old girl, open about her age, was able to obtain the morning after pill from six chemists (4). In fact The Royal Pharmaceutical Society has pointed out that the chemists were acting lawfully under one of the Government's new Patient Group Directions(PGDs) and not under the over-the-counter scheme.(5) The Direction in this case is operated by Lambeth, Southwark and Lewisham Health Authority. A total of 33 chemists have been given power to give out the pills to girls. The Direction is quite specific that there is no lower age limit.
PGDs were originally introduced in August 2000 to ease pressure on GPs by enabling other health professionals to carry out large scale prescription of drugs such as the "flu-jab", Relenza.
But these delegation powers are now being used to enable school nurses to distribute the morning after pill without charge and without parental consent. One newspaper article alone reports that 18 schools are involved in such programmes.(6) Whilst school nurses cannot legally prescribe paracetamol, they will be able to prescribe the morning after pill where a patient group direction is in force.(7)
The
Government has refused to intervene in the free distribution schemes
saying they are a matter for local health authorities. This is disingenuous
since the health authorities are clearly following Government policy.(8)
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The
existing policy
The morning after pill has been available on prescription for several
years. Various forms of the pill have been developed, but it is
a new drug Levonelle-2 which is supplanting previous products.
The involvement of the GP necessarily involves doctors making clinical assessments based on complete knowledge of the patient. Details of any prescriptions are added to the medical record.
Doctors
in all family planning clinics and in many accident and emergency
departments are also able to prescribe the MAP.
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The
Government's new policy
The Government wants to make it more convenient for women to have
access to the MAP. It wants health authorities to take action to
reduce the present high levels of teenage pregnancies.
The Government's White Paper on Teenage Pregnancy aims to halve the rate of conceptions amongst the under 18s by 2010. (9)
Praise for the Government's new morning after pill policy has come from what constitutes the 'sex education establishment' which, broadly speaking, has promoted the 'safer-sex' message with the emphasis on increasingly explicit sex education at ever decreasing ages.
Whilst the 'safer sex' policies have been almost universally adopted for many years in schools and elsewhere, the promised reductions in teenage pregnancies and sexually transmitted diseases(STDs) have not materialised.
In fact the teenage pregnancy rate has not fallen, whilst the prevalence of STDs has rocketed.
This Government's policy is reckless because it
- promotes teenage promiscuity
- encourages unsafe sex
- will therefore increase the incidence of STDs
- risks the health and, in certain cases, the lives of young girls
- has virtually no safeguards
- undermines the role of parents
Rather
than improving the situation the Government's policy will make matters
worse.
|
The "morning after pill" is taken to prevent pregnancy in a 72 hour period following intercourse. The pill acts as a contraceptive, but if conception has already occurred, it prevents the embryo implanting into the lining of the womb. This last mode of action was deemed not to constitute abortion under the 1967 Abortion Act by the Attorney General in 1983.(10) Christians holding to the sanctity of life from conception disagree and say that preventing embryo implantation is a form of abortion. |
Top
Promoting promiscuity
Availability
of sex education and contraception
Sex education has been the norm in secondary schools for twenty
years. In 1991 mandatory content was laid down for all state schools.(11)
Condoms can be bought by anyone - no matter what their age - from most supermarkets and petrol stations. Dispensing machines are widely accessible.
The morning after pill (MAP) has been available through GPs since 1985 (12). Even before this inter-uterine devices (IUDs) were used as an "emergency contraceptive" particularly for older women.
All women can obtain contraception, including the MAP, on the NHS without any prescription charge through their GP.
In addition to the local GP, there are over 1,300 family planning clinics spread throughout the country from where the same contraceptives are available for free. An increasing number of accident and emergency units also make the morning after pill available.
These
contraceptives are also available to girls under 16 even without
parental consent. This follows the ruling in the Gillick
case in 1985.(13) Following this case it has become
commonplace for under 16 year old girls to seek contraceptive advice
through their GP or a family planning clinic.
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It
has not worked : under age sex
The age of first intercourse has been steadily declining. Only 1%
of girls born in 1931 had had intercourse before the age of 16.
For those born in the 1950s it was 5%. For those born in 1974 it
was 24%.(14)
As
the White Paper notes, the number of young people sexually active
by 16 doubled between 1965 and 1991, with the rise most striking
for girls.(15)
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It
has not worked : teenage pregnancies
The teenage pregnancy rate has changed very little over the past
25 years. The crucial difference is marriage and consequently the
costs to the State. If teenagers were marrying in their droves and
having children there would be little or no public concern. Many
would be delighted. This was the case in the 1970s and for most
of that century.
The heart of the problem is that now these teenage mothers are unmarried and as a consequence are dependent on the State for their living costs, including housing. In 1999 the BBC reported that teenage pregnancies cost the taxpayer some £10 billion per year.(16)
Twenty years ago 60% of teenage pregnancies took place within marriage, today the figure is only 10%.(17)
Joint registrations, where the father is much more likely to be cohabiting with the mother and supporting the family, have changed very little in the past few decades. It is births registered solely to single teenage mothers that have dramatically increased.
The
under 18 conception rate has been increasing since 1994. It has
risen from 42 conceptions per 1000 women per year to 47 per 1000
in 1998. (18)
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It
has not worked : abortion
There can be no doubt that contraception can be easily obtained
and that the quantity and explicitness of sex education has dramatically
increased over the past 25 years.
Despite all this, and the provision of the morning after pill which was first licensed and manufactured in 1985 (19), the teenage abortion rates are much higher now than they were 25 years ago.
| Age | 1975 (20) | 1999 (21) | % rise |
| Under 15 | 2.3 | 3.3 | 43% |
| 15 | 7.5 | 8.2 | 9% |
| 16-19 | 17.4 | 26.0 | 50% |
| Rates
of abortions per 1,000 women per year, Residents of England
and Wales. Source : Abortion Statistics Series AB nos.24 and 26, ONS |
The percentage of all pregnancies terminated by abortion has increased
every year since 1993. (22)
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It
has not worked : STDs
The Department of Health have admitted that the UK is in a state
of "poor sexual health" :
"Virtually
all the sexually transmitted infections (STIs) are increasing. The
number of attendances at departments of genitourinary medicine/sexually
transmitted diseases now totals 1 million per year, a doubling over
the last decade. The commonest conditions are genital warts (some
types of which can be associated with the subsequent development
of carcinoma of the cervix), chlamydia and gonorrhoea, which if
untreated can result in ectopic pregnancy and infertility. Chlamydial
infection seen in clinics has risen by 21% between 1996 and 1997,
and a further 13% from 1997 to 1998 (latest figures). Population
surveys have reported rates of chlamydia as high as 20%, particularly
in young women.
There has been no reduction in the annual number of new diagnoses
of HIV made and the latest annual figures (1999) saw the highest
number of new HIV diagnoses ever recorded." (23)
Top
|
In the 1980s much was said about 'safe sex', that is, sex using a condom. In the 1990s the term was changed to 'safer sex'. This change protected condom manufacturers from litigation, but the distinction will be lost on young people. 'Safer sex' materials rarely tell young people of the typical condom failure rate. Medical journals report condoms having a typical failure rate of 14%. This means that with typical use 14% of women will become pregnant over the course of a year. (24) This is much higher than the often quoted 'perfect use' rate of 2% of women per year.(25) Typical failure rate of condoms : % of women falling pregnant per year 15.7%
Family Planning Perspectives,
Alan Guttmacher Institute, 1989 (21) No 3,
p103 A failure rate for pregnancy will always be lower than the failure rate for sexually transmitted diseases since women have 23 non-fertile days where condom failure does not result in pregnancy. Condom
failure can result in infection by an STD on any day of the
month. |
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Promoting promiscuity
Given all the objective facts about the rates of teenage pregnancies,
abortions and STD infections, it is reasonable to question whether
the present policy of safer sex is in fact achieving the many claims
made for it.
The sex education establishment which has promoted safer-sex is the same establishment now promoting the use of the morning after pill.
The availability of the morning after pill further fosters the belief amongst girls that they can have sex without consequences. Unlike the regular contraceptive pill, they do not have to take one every day. Unlike the condom neither they nor their sexual partner have to remember to take one with them. Nor is there the problem of persuading their sexual partner to use one.
For all these reasons the morning after pill is an easy alternative to condoms. That is why use of the MAP is linked to reduced use of condoms.
If the Government goes ahead with all its morning after pill schemes the message will not be lost on young people. Everyone from GPs to health authorities, school nurses to headteachers, from youth workers to the Prime Minister will be going out of their way to make the morning after pill available to them.
It gives the green light to sleeping around. A message which will probably have a much more powerful impact in the statistics than the drug itself.
The
journalist Jeannette Kupfermann commented :
'An over-the-counter sale will do nothing to address the underlying
behaviour that leads to the woman needing emergency contraception
in the first place. It gives her permission to continue in the same
old irresponsible way.' (27)
Top
Pressure
on girls
Could the MAP become a usual method of contraception for some young
women?
The General Household Survey has found that 5% of women aged 16 -17 and 6% of women aged 18-19 had used the morning after pill more than once in a two year period.(28) This is at the levels of availability in 1998.
A woman who regularly used the MAP would be at risk of any number of sexually transmitted diseases. Because pharmacists are forbidden to contact the GP, no one other than the young woman concerned would know how frequently she used the MAP. She would be free to go to any number of chemists. The only limit would be the cost.
Men prefer not to wear a condom because of the loss of sensation during intercourse. Durex, the leading condom manufacturer state that this, along with the smell of latex, are the two main reasons why many men do not like using condoms.(29)
The
Government's Teenage Pregnancy White Paper quotes one boy as saying:
"I have used a condom, but I don't like it, it puts you off.
What's the use of having sex if you don't enjoy it?"(30)
Girls would come under more pressure to have unsafe sex from men who prefer, and may even be glad to pay for, the MAP. Moreover one morning after pill treatment covers a whole weekend. Many young men will consider £20 well spent if it means a 2 day period during which they can have unprotected sex as often as they like. It has already been noted that some clinics sell the pill for £10. The price is bound to fall in chemists.
Sadly there are many young people who think nothing of spending £40 or £50 on drugs or drink at the weekend. So £20 to fund a weekend of hedonism is not out of their price range.
If
the sex education industry is so committed to 'safer-sex', it should
oppose the widespread use of the morning after pill since it will
have such a catastrophic effect on young people's willingness to
use a condom.
Top
Unsafe
sex linked to MAP
The Government cannot avoid the charge of promoting unsafe sex.
Many
women believe that use of the morning after pill lessens the likelihood
that a condom will be used. This would therefore lead to an increase
in unsafe sex and the likelihood of catching sexually transmitted
diseases.
| 572
women who sought emergency contraception in family planning
clinics in North and East Devon were asked: 'Do you think it would be a good idea to make MAP available directly from the chemist?' Half of the women said 'No' because amongst other things 'Women would take more risks; condoms would be less likely to be used; MAP would be used frequently; it would encourage less responsibility for contraception.' (31) |
Top
The risks from a single occasion
The Government's own White Paper warns that in a single act of unprotected
sex with an infected partner, teenage women have a
- 1 % chance of acquiring HIV,
- 30 % risk of getting genital herpes and
- 50 % chance of contracting gonorrhoea.(32)
The
medical dangers of STDs
There are several general principles associated with STDs:
1) Often a patient with one disease is more likely to get another,
for example gonorrhoea with genital warts.
Chlamydia increases the likelihood of contracting HIV
between 3.6 and 5-fold.(33)
2) Several of the important sexually transmitted diseases cause
extremely mild or usually no symptoms in
women. Indeed the first time that a woman may be aware
that she has become infected is when she has developed a complication
of the infection.
3) These diseases cause a range of complications which are often
serious, for example cancer and meningitis,
and which are not exclusively restricted to the genital
region.
4) Young girls and women are particularly vulnerable because
a) Physically the genital tract is immature
and is subject to trauma or tearing during
the sexual act.
b) The epithelium, or skin, of the vagina
in the prepubescent or pubescent girl is very
thin, 2-3 cell layers thick, in contrast to 80 cell layers thick
skin of the mature woman which does not
normally tear during the sexual act. The very thin skin
tears very easily allowing bacteria or viruses (from the sexual
partner) to enter the girl's body tissues.
c) Specific defence mechanisms against infection
are not fully developed.
d) Frequently the sexual partner of a young
girl is an experienced, and potentially
infected, older teenager or man.(34)
5) The use of condoms cannot fully protect a woman from sexually
transmitted disease because of condom failures
and because there are certain conditions such
as genital warts and genital herpes which are transferred by skin-to-skin
contact. Moreover the use of condoms amongst
teenagers drops over time. According to
a study by the research firm Child Trends, 63% of females, ages
15-19 reported condoms use at first sex,
only 28% reported condom use at most recent
sex.(35)
6) Some sexually transmitted diseases are developing into superstrains
which have become resistant to current antibiotic
treatment.(36)
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Serious
risks to health
Sexually transmitted diseases such as chlamydia may cause many unpleasant
complications, the most notable being ectopic pregnancy,(37)
and cancer of the cervix (38).
Cancer
of the cervix may also be caused by having unprotected sex under
the age of 16. Susan Blunt, a consultant obstetrician and gynaecologist,
has written:
"If a girl has sexual intercourse before she is 16, when the
cervix is rapidly growing and dividing, she significantly increases
her cancer risk. The more partners, the greater the risk."
(39)
The
most common STDs
The most common sexually transmitted diseases are
- Gonorrhoea
- Chlamydia
- Syphilis
- Genital Warts
- Hepatitis B and C
- HIV
- Genital Herpes (40)
Trichomona
and thrush are common STDs, they have some unpleasant symptoms but
they do not have significant consequences.
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Don't
preach on sex...
There are many subjects on which Governments have views which they
are keen to promote. From serious subjects such as racism and smoking,
to what we should eat and how to choose a nanny, Government ministers
are happy to preach.
However, when it comes to teenage sex, the Government believes that no-one should moralise or be seen to tell young people that they should be abstaining from sexual activity.
The assumption is that young people will be sexually active, whatever anyone says to them, and that the best that can be done is to help them limit the damage they will suffer as a result.
This harm reduction approach to sex education is almost universal amongst local education authorities, NHS health promotion trusts and groups like the Family Planning Association, Brook and others who together comprise the sex education industry.
The harm reduction approach advocates that young people are simply to be given information to help them make informed choices. Directive advice is out. Even telling young people that they must obey the law on the age of consent is said to be pointless and counter-productive.
The Government has adopted this approach in its White Paper on Teenage Pregnancy. The White Paper comments that there are 90,000 teenagers in England who become pregnant each year. It goes on, "They include 8,000 who are under 16. Some of these teenagers, and some of their children, live happy and fulfilled lives. But far too many do not". (42)
Yet despite this admission that there are 8,000 children involved in illegal sexual activity, telling them that it is wrong, is most definitely out:
"Preaching
is rarely effective. Whether the Government likes it or not, young
people decide what they're going to do about sex and contraception.
Keeping them in the dark or preaching at them makes it less likely
they'll make the right decision." (43)
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...do
preach on smoking
The Government's approach on teenage pregnancies stands in stark
contrast to its attitude to teenage smoking.
Even the title of the Department of Health White Paper - 'Smoking Kills' - indicates a very different approach to this subject. This White Paper states that a key aim of its strategy on smoking is to "protect young people both by making it less likely that they will begin to smoke and by helping them to stop". In line with this approach it proposes, for instance, "minimal tobacco advertising in shops" and "tough enforcement on under age sales".(44)
The Government's policy is to stop teenagers from smoking in the first place and for those that have started, it wants to see them give up. This is clearly preaching.
Such preaching was pursued in this area by previous Governments. The significant falls in the prevalence of smoking show that it has been very successful:
| Prevelance of cigarette smoking (45), percentage of persons aged over 16 | ||
| 1974 | 1998 | |
| Men | 51 | 28 |
| Women | 41 | 26 |
Smoking is addictive and therefore the physical impulse to smoke is hard to restrain. Nonetheless, the Government has sensibly decided that the best way to prevent smoking-related diseases is to encourage people to stop smoking.
It is notable that the Government does not take a harm reduction approach in this area. It does not suggest that young people should be told how to smoke more safely. It does not propose that young smokers should be issued with free filters, available in schools, clinics and youth clubs, to give some protection from smoking related diseases. It does not even suggest treating smoking as a controversial issue where a teacher might say, for example, that, on the one hand, many people smoke and say it is relaxing and beneficial to their mental health, while, on the other hand, medical experts say it is linked to serious diseases such as lung cancer.
The
Government has decided that teenagers should be told that smoking
is a bad thing and that young smokers should be helped to stop.
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Another
Government preaching initiative: alcohol
Alcohol affects the brain: it slows reflexes and impairs judgement.
It is, however, legal and it used to be thought that it was safe
to drive after drinking alcohol as long as consumption was below
a certain level. However, although consuming a small amount of alcohol
before driving is still legal, successive Governments have told
the public: "Don't drink and drive".
The
present Government has continued this sensible policy using the
slogan 'Have none for the road'.(46)
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The
success of abstinence education
On teenage pregnancy, the Government of the USA has adopted a very
different approach to that pursued by the Prime Minister's Teenage
Pregnancy Unit. The main aims of the respective strategies pursued
by Tony Blair and Bill Clinton are in stark contrast.
| Two aims contrasted | |
| President Clinton | Prime Minister Blair |
| A National Strategy to Prevent Teen Pregnancy, US Department of Health and Human Services | Teenage Pregnancy Report, The Social Exclusion Unit |
| 1. Parents and other adult mentors must play key roles in encouraging young adults to avoid early pregnancy and to stay in school. | 1. Reducing the rate of teenage conceptions, with the specific aim of halving the rate of conceptions among under 18s by 2010. |
| 2. Abstinence and personal responsibility must be the primary messages of prevention programmes. | 2. Getting more teenage parents into education, training, or employment, to reduce their risk of long term exclusion. |
The
USA has had an even greater problem of teenage pregnancies than
the UK:
"Beginning in the 1960s and 1970s, various statistical measures
confirmed a dramatic increase in sexual activity by adolescents
as reflected in the consequences.
- The birth rate among unmarried females aged 15 to 19 years increased by 90% from 22.4 per 1,000 in 1970 to 42.5 per 1,000 in 1990.
- The abortion rate among females aged 10 to 19 years rose 94% from 9.7 per 1,000 in 1972 to 18.8 in 1990."(47)
After many years of failing with safer sex education programmes, the US response in many states has been to turn to abstinence-based sex education: teaching young people to say 'no' to sex before marriage. Some 23% of secondary school teachers in the USA teach abstinence education.(48) There are many other teachers who teach "abstinence plus" which promotes sex as being intended for marriage, but also covers contraception.
Each year the US Government gives at least $50 million to support abstinence education.(49) Additional funding from state sources takes the total up to almost $100 million. Funding for safer-sex programmes was less than a third of this amount. (50)
The 1999-2000 Annual Report of the National Strategy to Prevent Teen Pregnancy, reported "a record low US birth rate for teens aged 15-17"; the "lowest rate in three decades' for girls aged 10-14". The report states: "Trends throughout the 1990s have shown a steady reduction in teen birth rates that is now significant for all 50 states. Rates have declined for all adolescent age groups, for all racial and ethnic groups, and for both first and second births to teens. Clearly we are reaping the benefits of this Administration's strong commitment to our National Strategy and renewed efforts by states, localities, private organizations, parents, and youth."(51)
Abstinence-based sex education has not just reduced the teenage illegitimacy rate. Between 1991 and 1999 the prevalence of sexual experience among adolescents decreased by 8%.(52)
Hillary
Rodham Clinton, despite her liberal credentials, has been preaching
the abstinence message:
"After many years of working with and listening to American
adolescents, I don't believe they are ready for sex or its potential
consequences - parenthood, abortion, sexually transmitted diseases
- and I think we need to do everything in our power to discourage
sexual activity and encourage abstinence".(53)
Here in the UK, researchers have begun to consider the importance of developing school sex education programmes that will lead to a decrease in sexual activity. (54) Delaying first sexual intercourse and reducing sexual activity is now considered a worthwhile thing to do.
Clearly it is possible for young people to embrace an abstinence message, even if they have been sexually active in the past. The BMJ have recently reprinted one of the major US textbooks on contraception that endorses abstinence in the following way:
"Secondary abstinence, or celibacy, is the choice of many sexually experienced adolescents and adults. It is not an extremist position in the age of viral sexually transmitted infections." (55)
But despite all this, the current approach of the Government is still: "don't preach". Instead, it adopts the prevailing philosophy that naively says that young people must simply be given as much information as possible about sex and this will lead them to make good decisions.
The fact is, it is not how much sex education children get that is important, but the nature of it. One lesson could seriously undermine a child's belief in good moral values, taught by its parents, if a respected teacher promotes the view that most young people are sexually active and that there is nothing wrong with that.
The UK's sex education industry is scathing about abstinence-based sex education. An article published by the Sex Education Forum, probably the most influential grouping of organisations involved in sex education, referred to the "fear-based abstinence programmes." (56)
The industry is also very defensive about the accusation that more sex education leads to an increase in sexual activity. For example, five pages in the back of the Teenage Pregnancy report are taken up with summarising studies, many of which are said to show that sex education does not increase sexual activity rates. (57) This hardly seems to be the right emphasis.
There
clearly needs to be a re-examination of the sex education industry
and the 'non-judgmental' approach it advocates. Its policies have
been in the ascendancy during a period when teenage abortion rates
and STDs have increased substantially.
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The
inconsistency of approach
The Prime Minister does not "believe young people should have
sex" but is resigned to the fact "that no matter how much
we disapprove, some do". (58)
The statement "no matter how much we disapprove, some do" could be applied to anything of which society disapproves and which has not been completely eliminated. It certainly applies to people who commit crime. It applies to drink driving, smoking and drug taking.
The Government is committed to making "the misuse of drugs less culturally acceptable to young people" (59), but does not seem to believe that the same is possible or even desirable for underage sexual activity.
The great irony is that a single act of unprotected intercourse can be much more dangerous than a single cigarette. As the Teenage Pregnancy White Paper warns a single act of unprotected sex with an infected partner, teenage women have a
- 1 % chance of acquiring HIV,
- 30 % risk of getting genital herpes and
- 50 % chance of contracting gonorrhoea. (60)
Yet, whilst cigarettes are very unhealthy and prolonged use results in many serious and often fatal illnesses, no one would ever argue that such consequences could follow from a single act of smoking.
The strong impression is given that drivers can be persuaded not to give in to the pressure to drink at a social gathering, that smokers and drug users can be helped to overcome addictions, but that teenagers can not be expected to control their sexual desires.
In
the US, they know differently. A 1999 report from the Consortium
of State Physicians and Resource Council found:
"The evidence points to sexual abstinence, not increased contraceptive
use, as the primary reason for the decline in teen pregnancy and
birth rates throughout the 1990s. It appears possible that programs
aimed at producing abstinent behaviour have been more successful
than programs aimed at increasing safer-sex practices in reducing
unintended birth to adolescents. Douglas Kirby, a noted sex education
researcher, was prophetic in 1991 when he noted that "it may
actually be easier to delay the onset of intercourse than to increase
contraceptive practice." (61)
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Over-the-counter from chemists
The
pressure of waiting customers
The pharmacists who are expected to dispense the morning after pill
face considerable difficulties. They are providing a controversial
drug to clients who may well be in an agitated and highly embarrassed
state. In many chemists there is frequently a queue at the pharmacists
counter, each person awaiting advice on their personal medical problems.
In the middle of this, pharmacists are expected to elicit detailed information from female clients anxiously seeking the morning after pill and then to make a judgment as to whether or not she should receive it. The pressure of waiting customers, on top of the seriousness of the request itself, may well result in many pharmacists simply giving the client what she asks in order to defuse the tension. To insist on a lengthy consultation going into all the relevant details might create further embarassment. Actually concluding that the request should be denied may cause the woman to become acutely distressed there and then in the middle of the shop.
A particular source of pressure on chemists will be the knowledge that the woman in front of them may well blame them if they have an unwanted baby as a result of not getting the morning after pill.
Even the basic question of whether the female is over 16 may fall foul to these pressures.
In
theory, chemists are meant to have facilities for confidential consultations.
In practice, few chemists have room for this kind of facility and
a lone pharmacist would be unable to leave a queue of customers
to hold a one-to-one consultation.
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Not
best for patients
Selling the morning after pill without prescription from chemists
has many disadvantages for female patients. The main problems stem
from the fact that the Pharmacist and GP cannot know what each other
is up to. Under the rules on confidentiality they are not permitted
to communicate with each other (see inset). Even if there were no
such rules, it would be impossible on a practical level to arrange
it.
This means that the chemist cannot be certain there are not good reasons why he should decline to give the pill to a particular patient. He only has her word (and her memory) in response to the questions he asks.
Important information that the GP needs to know about his patient in order to properly assess any future problems she may have will not be on her record. It may be unlikely that the patient will advise the GP about her purchase of the morning after pill, since going to the pharmacist and paying for it instead of having it prescribed by the GP may indicate that she wishes to keep the matter secret. Even if she is not embarassed to tell her GP, the accuracy of her record depends on whether she gets around to informing him and how accurately she recalls each occasion.
Dr
George Rae, chairman of the British Medical Association's prescribing
committee warned there was a risk of 'fragmentation' of girls' medical
records, with the risk of serious prescribing errors or complications.
He said: "...unless you have a central electronic record and
the pharmacist and school nurse share this information with the
GP, there is a serious risk of fragmentation" (62)
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Top
The under 16s
The Ministerial Order allowing over the counter sale stipulates
that it is only for over 16s. GPs know the age of their patients
from their official records but pharmacists only have the say so
of the customer before them. It is not uncommon for teenage girls
to lie about their age, usually to get into licensed premises. Teen
magazines regularly contain adverts for fake ID cards on which girls
can falsify their age. There is every prospect that under 16s will
have little difficulty in getting hold of the MAP.
It will be a simple matter to discover which chemists sell the morning after pill with the least fuss and to go there rather than to a chemist who is thorough.
Unlike
a shopkeeper who sells cigarettes to under 16s, there is little
realistic prospect that a chemist would get into trouble for selling
the pill under-age to girls. Although the Medicines Control Agency
could, in theory, bring a prosecution, it is unlikely that there
would be the political will for it given that the same pill is available
to girls under 16 through clinics and school nurses as well as GPs.
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Record
keeping
It will be difficult to assess how chemists are going about dispensing
the MAP from their own records. Chemists say privately that record-keeping
for over-the-counter drugs is often cursory. The Royal Pharmaceutical
Society guidelines state that the record-keeping for the MAP should
not be any different to that for other non-prescribed medicines,
such as paracetamol.(63) A pharmacist wanting
to know what his obligations are will go to the General Legal Requirements
which state that 'Protocols for the sale of non-prescribed medicines
from pharmacies should comply with Standard 12 of the Appendix to
the Code of Ethics".(64) Standard 12 of the
Appendix to the Code of Ethics make no mention of record keeping
for over-the-counter medicines.(65)
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Pressure
to sell
The NHS buys Levonelle-2 at £5, however chemists can only
buy it in at £10. (66) The drug manufacturers
therefore get an extra £5 when they sell the pill to chemists.
The chemist sells Levonelle-2 for £19.99, making £9.99 on every sale. This represents a considerable financial incentive to sell more Levonelle-2.
It is very likely that in the long-term there will be pressure to reduce the price of Levonelle-2. The disparity between the price to the NHS and the price to pharmacists may pull the cost down. Pressure will also come from supporters of the pill who will no doubt claim that the price is off-putting to women.
Pharmacies
currently sell drugs under a retail price maintenance system. Many
believe that this system is unsustainable in view of competition
law. If the price fixing system is abolished this will exert considerable
downward pressure on the price of the morning after pill.
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Patient
group directions (PGD)
There have long been local arrangements enabling nurses to supply
and/or administer prescription only medicines. This may take place
on a hospital ward or, in the case of large scale vaccination programmes,
in other venues such as schools.
However, in August 2000, using a Ministerial Order, (67) these comparatively limited arrangements were extended to many more health professionals. The new system of Patient Group Directions allow them to administer drugs in a wide range of situations. This is done in accordance with a binding protocol (see inset box).
In effect the new Ministerial Order permits health authorities to issue 'blanket' prescriptions to a group of patients using healthcare staff other than doctors. An example of the use of a PGD is to grant nurses the power to give the flu-jab, Relenza.
PGDs have the potential for great usefulness. However the Government's White Paper on Teenage Pregnancy has encouraged several health authorities to use the Directions to allow school nurses to give the morning after pill to girls under 16 without parental consent.
It
is also possible for a PGD to be used to enable chemists to dispense
the MAP for free to girls aged under 16. This is done on an entirely
separate legal basis from the over the counter sale of the MAP.
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|
How
a Patient Group Direction (PGD) works The protocol has to be signed by a doctor and a pharmacist authorised by the health authority. (68) This document then allows named health professionals to supply the specified drug to patients within the terms of the protocol without the need for an individual prescription from a doctor. The range of qualified health professionals who are now entitled to supply or administer medicines under a Patient Group Direction includes nurses (including school nurses), midwives, health visitors, optometrists, pharmacists, chiropodists, radiographers, orthoptists, physiotherapists, and ambulance paramedics. (69) |
Health
action zones (HAZs)
In 1998 &1999, the Government created a total of twenty-six
'health action zones' throughout the United Kingdom in areas of
deprivation and poor health. Their purpose was to tackle health
inequalities and modernise services through local innovation.(70)
HAZs vary in size and include a total of 34 health authorities and
73 local authorities. The zones are intended to encourage close
co-operation between the various statutory authorities and agencies.
In 1999, the Government White Paper on Teenage Pregnancy advocated reducing the number of teenage pregnancies through better access to contraception.(71) This is an area that several HAZs have targeted in their individual health action plans.
Through
the introduction of Patient Group Directions, teenagers can now
be approached with the morning after pill by health professionals
other than doctors, and in familiar surroundings such as a school,
a youth club or in a chemist's shop.
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Free
distribution in schools
Whilst school nurses cannot normally even give a pupil paracetamol,
where an appropriate Patient Group Direction is in force they can
prescribe the morning after pill.(72)
According to press reports, Patient Group Directions giving carte blanche for school nurses to hand out the morning after pill without parental consent have been made in east Kent, Oxfordshire, Derbyshire and South Yorkshire.(73) Only a minority of schools in each local education authority appear to be involved.
The
Oxfordshire BodyZone Project:
School Nurses in Oxfordshire are distributing the morning after
pill in seven schools.(74) Another five schools
are preparing to follow suit.(75) Under the Practice
Group Direction for the project only girls over the age of 14 can
be given the morning after pill and they cannot be given it more
than 8 times a year.(76)
Parents are not entitled to know that their daughter has been given the morning after pill, only whether the school allows the practice in principle. Oxford Community NHS Trust has given a blanket prescription to all its family planning nurses working in schools enabling them to give out this pill. The Trust's director of family planning, Dr. Elizabeth Greenhall, has said: 'It is important that young girls who have had sex get easy access to emergency contraception'. (77)
- This action is being carried out under the 'BodyZone' scheme, a drop-in service which provides health advice covering contraception, bullying, diet, smoking, drugs and stress. It is provided in clinics known as 'BodyZones'.(78)
- These clinics are held mostly in secondary schools, though they are also held outside school premises, e.g. youth clubs.(79)
- The organisers are encouraging pupils to attend the outside clinics and would like schools to develop passes so that pupils can be absent during school hours. The project praises a scheme which uses sixth-formers to administer the passes.(80)
- A welcome form is given to all children on arrival at a clinic. The form states: 'Please note - this is a completely CONFIDENTIAL service… your school/college are not allowed to ask you why you are attending BodyZone.'(81)
- The first option given by the form is to see 'The Sexual Health Nurse (For contraception, pregnancy tests, supplies and advice).'(82)
- The family planning nurse can '…issue condoms, emergency contraception and repeat supplies of the pill and injectables without a doctor present'.(83)
- 'Young people requiring condoms, emergency contraception, repeat supplies of the pill or injection are generally given these by the nurse. They see a doctor every two years as a routine'.(84)
- Schools are encouraged to promote the 'BodyZone' scheme on noticeboards, in assemblies, or even by group visits: 'The new year 7's [11 year olds] are given a guided tour of the facility…This appears to have had the effect of empowering the new pupils to utilise the project- especially the boys!'(85)
- A
survey carried out at one school where the project is being run
revealed that almost half of 14-16 year old girls had used the
service.(86)
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Free
distribution in chemists and youth groups
In a recent highly publicised case, a 15 year old girl, open about
her age, was able to obtain the morning after pill from six chemists
(87). In fact The Royal Pharmaceutical Society
has pointed out that the chemists were acting lawfully under one
of the Government's new Patient Group Directions and not
under the more recent over-the-counter scheme.(88)
The Direction in this case is operated by Lambeth, Southwark and
Lewisham Health Authority. A total of 33 chemists have been given
power to give out the pills to girls. The Direction is quite specific
that there is no lower age limit.
Examples
of other local projects to reduce 'unintended young pregnancy('89)
include
1) In Walsall, West Midlands, a project was started in July 2000
where designated pharmacists have received
training and designation under a patient group direction
to supply emergency contraception. This scheme was started after
concern was raised by members of the HAZ
Steering Group regarding unwanted pregnancies
including teenage pregnancies.(90)
2) Lambeth, Southwark and Lewisham is running a similar scheme.
The funding for this project was £56,000
for 1998/1999 and £66,550 for 2000/2001. Again one of its
aims was to reduce the rates of unwanted teenage pregnancy.(91)
3) In Plymouth, six youth health drop-ins called 'First Steps' were
developed for young people aged 13-25. They are
staffed by qualified youth and health workers and
will offer confidential services including emotional development
and relationship advice, free contraceptive advice
and supplies.
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The
role of the Government
The Government has responded to criticism of the free distribution
schemes by saying they are a matter for local health authorities.
This is disingenuous since the health authorities concerned are
clearly following government policy.(92)
According to a letter from some of the local health chiefs responsible for the Oxfordshire BodyZone scheme, the project receives "money from the Department of Health targeted for the prevention of teenage pregnancy".(93)
The
Teenage Pregnancy White Paper explains that in 1999, £0.6
million of Department of Health money was set aside for a Local
Implementation Fund (94). Health Action Zones
and areas with high rates of teenage pregnancy were invited to apply
for some of this money by submitting plans to the Department of
Health. It was specifically envisaged that supplying contraception
would be included in such plans.(95)
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The
Government has changed the role of the school nurse
Before Patient Group Directions were established, "Nurse Protocols"
governed the ways in which nurses administered drugs to patients.
In
a 1996 Government review of support for pupils with medical needs,
the limited role of the school nurse was made clear :
"The school nurse or doctor may help schools draw up individual
health care plans for pupils with medical needs, and may be able
to supplement information already provided by parents and the child's
GP. The nurse or doctor may also be able to advise on training for
school staff willing to administer medication, or take responsibility
for other aspects of support." (96)
School nurses had an advisory or training role to help teachers who gave medication to pupils. Officially school nurses did not give the medication themselves.
In a 1998 review article on the administration of medicines in schools, Dr Bannon, a consultant paediatritian, deplored the fact that nurses did not adminster drugs in school. He stated that "the school health service has been preventive rather than therapeutic in its focus." (97)
Two major reviews of the role of school nurses therefore seem to indicate that they have not officially been permitted to give out any drugs at all, let alone the morning after pill. Technically health authorities could have established Nurse Protocols to allow school nurses to administer drugs, but they seem not to have done this.
This situation has changed completely since the Teenage Pregnancy White Paper and the setting up of Health Action Zones. Instead of merely advising on contraception, the school nurse now dispenses it.
The
Oxfordshire BodyZone scheme uses Nurse Protocols established in
March 2000 - nine months after the White Paper.
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What
is the lower age limit?
The press has reported that girls as young as eleven will be given
the morning after pill in the schemes involving free distribution
in schools.(98)
In the Gillick court case (which established that doctors could legally give contraception to girls under 16) one of the judges countenanced a ten year old receiving contraceptive advice from doctor. (99) Rather than setting a lower age limit, the court ruled that the key factor in any decision whether to give contraception to a child was that "in the doctor's judgement she had sufficient maturity and intelligence to understand the nature and implications of the proposed treatment." (100)
This factor is, of course, entirely a matter of subjective judgement. There does not seem to be any reason following the logic of the Gillick case as to why a girl under the age of 10 could not be given contraceptive advice. It will be argued that new research has shown that one in six girls start puberty at the age of 8.(101)
The
result is that the law does not protect the rights of parents from
intervention by the State in fundamental areas of family life. The
Gillick case has left the law unclear as to what treatments
and advice a school nurse may give to a child and at what age. As
a consequence, it is unclear how far the rights of parents to bring
up their own children have been eroded.
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Medical facts and ethical issues
How
it is used
Levonelle-2 is a 'progestogen only' drug. It avoids the medical
complications that have arisen from the combined oestrogen and progestogen
morning after pill.
Each
treatment involves taking one Levonelle-2 tablet and then another
12 hours later. The treatment can be taken up to 72 hours after
intercourse, although its effectiveness is prone to decline with
time after intercourse (see inset).
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|
The
effectiveness of the morning after pill Effectiveness at preventing pregnancy 95%
if taken within 24 hours The effectiveness after 72 hours is unknown.(102) |
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How safe is MAP compared to the oral contraceptive
pill?
There are two types of oral contraceptive pill: the progestogen
only pill and the combined pill which contains both oestrogen and
progestogen. Unlike the morning after pill, the oral contraceptive
pill has to be taken daily.
The morning after pill is a powerful drug. A single Levonelle-2 tablet contains the hormone equivalent of five combined oral contraceptive pills (103) or 25 progestogen only contraceptive pills.(104)
There can be no doubt that Levonelle-2 is much safer than the oral contraceptive pill. It is also safer that the previous MAP which contained oestrogen.
But
as Jeannette Kupfermann has commented
"It has taken over 30 years for the problems associated with
taking the contraceptive pill to emerge". (105)
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The
absence of long-term trials
There have been no long-term trials clinical trials of Levonelle-2.
The effect of repeated use over the long term has therefore not
been measured. Most of the studies that have been done to date have
looked at one off use and not repeated prescriptions.
With the MAP it is possible that a young girl may take several packets at once to make sure that it works and that she does not get pregnant.
It
is also possible that a young girl may use Levonelle-2 frequently
as a form of contraception. This could have major implications for
other medication that can be prescribed and for the long-term health
of the girl herself.
The Government says that the wide availability of emergency contraception
is 'to help reduce the number of unwanted pregnancies amongst all
age groups' (106), this would include adolescents
but the studies on this drug to date have not concentrated on the
use of Levonelle-2 on teenage girls.
The Government is laying plans for the widespread distribution of the morning after pill. The key issue for any long term side-effects is the level at which the pill is repeatedly used.
Clearly the Government does not believe that the MAP will be used as a routine form of contraception. The manufacturers of Levonelle are clear that it should not be used in this way, but what if it is?
The contention of this publication is that if chemists are permitted to sell the drug this is precisely what will happen.
|
Known
side-effects Undesirable
side effects Other
side effects include (% of women affected) |
Top
How the morning after pill works
The morning after pill (MAP) works in four ways (109):
1. It prevents the release of an egg from the ovary (if that has
not occurred)
2. It slows down the speed at which an egg passes along the fallopian
tubes
3. It slows down the speed at which sperm travels along the fallopian
tubes
4. Where conception has occurred, it prevents the implantation of
the embryo in the wall of the womb.
A
form of abortion
The term 'emergency contraception' is a misnomer if conception has
already occurred.
In 1983 the Attorney General deemed that preventing the implantation of an embryo was not an abortion for the purposes of the 1967 Abortion Act.(110)
Whilst this has never been tested in the courts, it seems safe to assume that the Attorney General's opinion would be upheld.
Almost all GPs take the same view. Very many GPs who consider themselves 'pro-life' and who would not sign forms for an abortion take the view that the pre-implanted embryo is not a human person that falls to be protected by the law.
The
pregnancy is said to begin at implantation rather than conception.
But Christians who believe that human life begins at conception
do not accept this based on the teaching of the Bible.
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Biblical
teaching on why life begins at conception
For Christians the main sources of teaching that life begins at
conception are the Biblical accounts of the incarnation of Jesus
Christ. The gospels clearly teach that Jesus became a man at his
conception. Matthew 1:20 states: '…that which is conceived
in her is of the Holy Ghost.' The belief that God knows people from
conception is confirmed in Isaiah 44:2. Jeremiah (in 1:5) maintains
this consistent view and from conception King David reminds us all
that we need a Saviour (Psalm 51:5). The Biblical principle at stake
here is expounded at length in Psalm 139 vv13-16: the unborn child,
even with 'an unformed body', is seen by God.
Top
1
Prescription Only Medicines (Human Use) Amendment (No.3) Order 2000,
8 December 2000
2 Eg Marie Stopes International, press release,
9 January 2001 at http://www.mariestopes.org.uk/pr2001_emergency_contrception_.html
3 Prescription Only Medicines (Human Use) Amendment
Order 2000, 17 July 2000
4 The Daily Mail, 6 January 2001
5 The Pharmaceutical Journal Vol 266 No 7130 p 40-42,
The Royal Pharmaceutical Society, 13 January 2001
6 The Daily Mail 8 January 2001
7 DFEE Circular 14/96 Supporting pupils with medical
needs - a good practice guide, page 4 and Bannon M J and Ross E
M Administration of medicines in school: who is responsible? BMJ
1998; 316:1591-1593 (23 May)
8 See page 26
9 Teenage Pregnancy, A White Paper (Cm 4342), The
Social Exclusion Unit, June 1999, page 8
10 See House of Commons, Hansard, 19 July 2000,
Col. 221W
11 Initially through National Curriculum Science,
via the Education (National Curriculum) Attainment Targets and Programmes
of Study in Science, Order 1991 : SI 1991/2897. In the 1993 Education
Act, sex education was made a subject in its own right, rather than
as part of National Curriculum Science. A legal duty to cover teaching
on STDs and the prevention of disease within sex education was placed
on governing bodies.
12 Paintin David (Ed.) The Provision of Emergency
Hormonal Contraception RCOG Press, 1995 page 42 and 93
13 Gillick v West Norfolk & Wisbech Area Health
Authority (1985) 3 WLR 830.
14 Population Trends 100, Summer 2000, The Stationery
Office, page 38
15 Teenage Pregnancy, A White Paper (Cm 4342),
The Social Exclusion Unit, June 1999, page 43. Figures 2 and 3 also
come from the White Paper.
16 The BBC Online, 11 June 1999 at http://news.bbc.co.uk/hi/english/special_report/1999/04/99/
teen_pregnancy/n.../319869.st
17 Teenage Pregnancy, A White Paper (Cm 4342),
The Social Exclusion Unit, June 1999, page 16
18 Population Trends 101, Autumn 2000, The Stationery
Office, Table 4.1
19 Paintin David (Ed.) The Provision of Emergency
Hormonal Contraception RCOG Press, 1995 page 42
20 Figures taken from 1997 Abortion Statistics
Series AB no.24, Office for National Statistics, The Stationery
Office, 1998, Table A, page x
21 Figures taken from 1999 Abortion Statistics
Series AB no.26, Office for National Statistics, The Stationery
Office, 2000, Table 15b, page 16
22 Population Trends 101, Autumn 2000, The Stationery
Office, Table 4.1
23 National Sexual Health and HIV Strategy, Department
of Health, 25th September 2000 at http://www.doh.gov.uk/nshs/background.htm
24 Contraceptive Efficiency, Trussell J in Hatcher
RA, Contraceptive Technology, BMJ Books, 1998, page 800
25 See for example the widely available leaflet
'Your Guide to Contraception', Contraception Education Service/FPA,
2000
26 Kirkman, R Condom use and failure, The Lancet,
(336) 20 October 1990, page 1009
27 Daily Mail, 11 December 2000
28 General Household Survey 1998, ONS, 2000, page
176. These figures are actually for emergency contraception, but