Age

Differing age at menarche

Different populations tend to have different physical and emotional maturity.^[2] Age at menarche of European children is higher than those from the Caribbean or from the Indian subcontinent.

Risk takers

Younger people feel invincible and are more likely to have sex with multiple partners and engage in other risk-taking behaviour such as drugs and alcohol. These factors, with a less than rigorous approach to regular pill taking, result in a higher rate of pregnancy.

The United Kingdom has the highest teenage pregnancy rate in Western Europe:

• Statistics from 2008 show that there were 41,325 conceptions in 15-17 year-olds.
• The birth rate (15-19 year-olds per 1,000 women) of 26.3 is the lowest level for fifty years.^[3]
• 57% of the pregnancies ended in legal abortion.^[4]

Peer pressure, along with media exposure of sex, will put some youngsters under pressure to experiment with sex before they are ready or mature enough to do so:

• There is evidence of increasing use of contraception at first intercourse, but an underlying trend to earlier age at first intercourse (now plateauing) has been found to be associated with a rise in teenage pregnancy and sexually transmitted diseases.^[5]
• There is also the feeling that everyone is 'doing it' (the truth of the matter is that most are 'talking' about it).
• Teenagers tend to be aware of preventing pregnancy but not as aware of sexually transmitted disease or the consequences to fertility.^[6]

Studies of sexual activity and contraceptive use in five developed countries show different teenage pregnancy rates:

• The age of sexual debut varies little across countries, yet American teenagers are the most likely to have multiple partners.
• Adolescent childbearing is more common in the USA (22% of women reported having had a child before the age of 20) than in Great Britain (15%), Canada (11%), France (6%) and Sweden (4%).
• A greater proportion of women in the USA reported no contraceptive use at either first or recent intercourse (25% and 20%, respectively) than reported nonuse in Great Britain (21% and 4%), France (11% and 12%), and Sweden (22% and 7%).^[7]

Emergency contraception - hormonal or coil insertion

Some groups find this an acceptable remedy to contraceptive failure, eg slipped sheath or unprotected sex, when they would not accept termination.

• In some religious groups this is seen as a form of termination, ie interfering with a fertilised ovum.
• In certain risk-taking teenage culture groups this is seen as a form of contraception rather than an emergency intervention.
• One way of remedying this is by making sure that the long-term contraceptive needs of such persons are addressed.
• There is also need to inform culturally isolated women about the availability of such methods.

Culture

Unfortunately, cultural expectations mean that the burden for arranging contraception falls on women. So, despite the wide availability of contraceptive methods, it is still perceived as a woman's problem.^[8]

• Although female sterilisation is more invasive than vasectomy, it is still the more common procedure - approximately 100,000 women and 90,000 men are sterilised annually.
• HIV has resulted in some change with more men using condoms.

Cultural attitudes to premarital sex

There is generally a fairly relaxed attitude to premarital sex in most of the western world these days but, in certain cultures, attitudes are extreme and premarital sex is considered a matter of great shame and a loss of family honour:

• In some circles family honour is so precious that any threat to it can make tolerance, the love of one's children, or common sense disappear.
• The discovery that a girl may be seeing a boy or may be engaged in premarital sex can result in rejection by her family, physical injury or death, regardless of the consequences of such action.
• Therefore, it is very important that confidential information should not inadvertently be passed on to the family, or inadvertently revealed to parents via the computer screen in joint consultations.
• It is also extremely important that the choice of contraception be as effective as possible, ie lowest failure rate possible, as the consequences of an unwanted pregnancy can also be much more devastating for such a person.

Changing attitudes to divorce and remarriage

The Mirena® intrauterine system is as effective a method of contraception as sterilisation, although it is easily removable.^[9][10] Marital splits and altered relationships lead to renewed desire for offspring from the new unions, and reversal of sterilisation does not guarantee conception. Alternatives to sterilisation may be more prudent.

Cultural isolation

Some cultures disapprove of the education of women. This can result in women becoming isolated, particularly when they emigrate with their family to a different country with a different primary language.

A special need exists for their education about the availability of different choices of contraceptive methods so that they can be empowered to control their fertility according to their needs.

Religion

Religious beliefs can limit a patient's contraceptive choices. When 'artificial' contraception is forbidden, a few natural methods may be acceptable:

• Coitus interruptus (withdrawal before ejaculation) is a method practiced by many, as it requires no special arrangements or planning, but a great deal of self-control is required and it is not a particularly effective method (at best, 4% failure rate per annum).
  • Some men feel not ejaculating denies them the climax of intercourse. Ejaculation can take place just as long as it is not in the vagina or in the surrounding area.
• The mucothermic method:
  • This relies on abstinence from intercourse at the most fertile time (around ovulation) of the menstrual cycle.
  • Most of these methods are better suited to older couples where fertility is reduced.
  • This group of patients are less likely to use emergency contraception or seek termination.^[7]

Orthodox religions

These include Judaism, Islam, Hinduism and Sikhism. Orthodox followers of all these religions tend to:

• Regard sex outside marriage as taboo.
• Forbid abortion and regard menses as unclean.
• Extend the taboos against sex before marriage to sex outside marriage, ie adultery.
• Forbid seeing any other man than the husband in intimate circumstances.
• Consider a male physician often as not acceptable, even with a chaperone.

The punishments for adultery or sex before marriage in certain countries/cultures can be death. These cultural taboos are followed more closely in some cultures than in others, even if they are of the same religion.

Other points to note include:

• A married Jewish woman should avoid being alone with a male physician unless other people are in earshot and have access to the room.
• A husband and wife must separate during the woman's menses and for the first 7 days afterwards.
• Contraception is permitted if childbearing would endanger a woman's life or health.
• Termination of pregnancy is also permitted to preserve a woman's health, including her mental health.
• During childbirth the health of the mother is paramount and supersedes all other rules or laws, including those of Sabbath.^[11]
• Hormones from animal sources, eg horses' urine, may cause the same problems as blood products.

NB: medical indications can override many prohibitions.

Christianity

Contraception and abortion are forbidden in Catholicism. Mucothermic methods of contraception are acceptable.

The best course is to ask the patient if there are any special considerations you need to be aware of in view of their religion or background. This gives you a better picture of what they consider important.

Politics of contraception - control and freedom

One of the effects of contraceptive control has been to liberate the tie between sex and reproduction:

• This gives women the freedom to time their pregnancies to fit into a more independent lifestyle.
• It also allows them freedom to follow other paths such as study and employment, and releases them from dependence on the men.
• It has liberated them from uncontrolled large families (they can still have them but now it's by choice)

One of the results of this has been to empower women within their societies.

Contraceptive control can have effects on political control. This means that controlling the availability of certain contraceptive choices can manipulate the population's behaviour, eg some governments or religious organisations may give inducements for using, or not using, contraception.

Population migration

In recent years there has been an increase in movement between countries in Western Europe and asylum-seeking from further afield. This can lead to problems in communication:

• This may involve not only language, but style of communication.
• Communication problems tend to result in a lower quality of care.^[12]
• Their expectations and the manner in which patients present their problems may all differ.

Problems may be experienced when cultures clash, particularly over issues such as attitudes to women and sexual morals.