Teens and young adults should be started on long-acting reversible contraceptives before sexual activity commences FOR: An opt-out programme would avoid teen pregnancy and associated costs NEIL PICKERING, SENIOR LECTURER, LYNLEY ANDERSON SENIOR LECTURER and HELEN PATERSON, SENIOR LECTURER, OBSTETRICIAN AND GYNAECOLOGIST, UNIVERSITY OF OTAGO, NEW ZEALAND ....................................................................................................................................................................... Nature confers fertility on young people at an age when, developmentally and socially, at this time in history, a pregnancy is in neither the individual or society’s best interest (Law- lor D, et al. Int J Epidemiol 2011;40:5:1205– 14). Teen pregnancy places significant costs on the individual and society. These include costs to the state to support teen mother and child, opportunity costs for young women missing out on education and future earnings, and opportunity costs of the state benefitting from their contribution and taxa- tion. Moreover, the children of teen pregnancies do poorly in statistics related to poverty, incarceration, and teen pregnancy [Office for National Statistics. Conceptions in England and Wales 2012, Statistical Bulletin (2014), The National Campaign to Prevent Teen and Unplanned Pregnancy (2013)]. Therefore proposals that long acting revers- ible contraceptives (LARCs) should be pro- vided by the state free to all young people before they become sexually active are wor- thy of examination (Battin M. Soc Sci Med 1995;41:9:1203–5). LARCs are effective in reducing teen preg- nancy (Secura G, et al. N Engl J Med 2014;371:14:1316–23). We propose a pro- gramme that is proactive, universal, free, opt- out, and includes sex education about sexually transmitted infection (STI) protection and healthy relationships. A proactive programme is likely to be more effective than waiting for young people to request contraception, as is currently the case (NICE Clinical Guideline CG30, 2014). A free universal programme will ensure all social groups have equal access to the benefits of control over fertility. While targeted and man- dated programmes have been associated with eugenically inspired programmes of sterilisa- tion, in the proposed programme young people and their families may choose to opt-out. Studies thus far have provided no evidence that young people would be harmed or their future fertility put at risk through use of LARCs, but further research will help allay fears (Deans E, et al. Contraception 2009;79:6:418–23). Evidence does not sup- port the fear that LARC use will encourage young people to become more sexually active (Secura G, et al. Obstet Gynecol 2014;123:4:771–6). Nonetheless, a compre- hensive sex education package will mitigate against these concerns. The proposed programme is opt-out. Many countries (including the USA) have seen a decline in teen pregnancy rates through the use of opt-in approaches to contraception (The National Campaign to Prevent Teen and Unplanned Pregnancy 2013). However, an opt-out programme should achieve more than an opt-in programme, for example by ensuring that young people are not disadvantaged by a failure to get around to opting-in. Opting-out seems as good a way of respecting autonomy as opting-in, and shows a greater concern for the fair distribution of the benefits of the pro- gramme. It may be feared that, despite these advantages, an opt-out system will not be acceptable to the public. It is perhaps true that much public policy is motivated by fears of public reaction, for example voter dissatisfac- tion. However, there is a good case for basing public policy on the transparent pragmatic and moral grounds we have put forward here. The state should provide a free LARC pro- gramme to avoid teen pregnancy and its asso- ciated costs. Disclosure of interests Full disclosure of interests available to view online as supporting information. & AGAINST: Pre-emptive use without need or benefit may cause more harm than good ALISON EDELMAN, MD, MPH, ASSOCIATE PROFESSOR, OB/GYN, CO-DIRECTOR, FAMILY PLANNING FELLOWSHIP, USA ....................................................................................................................................................................... Do the benefits outweigh the risks of start- ing a contraceptive method prior to sexual debut? Likely that depends on how soon the debut might occur following method initia- tion. In order to prove my point, let’s deal in extremes and discuss initiating a long act- ing reversible contraceptive (LARC) method ‘pre-emptively’ and remote from sexual debut, as opposed to ‘proactively’ – such as a young woman with an inkling that her first sexual experience may be soon (e.g. school dance, parents out of town, a boyfriend with a car – I could go on but I think you get the point). I will focus my argument around the ‘pre-emptive’ initiation of LARC, as the proactive prevention of pregnancy is a pro- ven public health strategy. ‘Pre-emptive’ use of LARC in a young woman who gains additional health benefits from the method is entirely reasonable. Most clinicians including myself rely on noncontraceptive benefits for the treatment of dysmenorrhoea, irregular bleeding, menstrual migraines, etc. However, we are dealing in hyperbole here and must assume that our young woman in question has no other reason to use LARC. We expose her to the risk of use when she has no immediate need and receives no addi- tional benefits. Although LARC methods are extremely safe, severe adverse events can occur, e.g. Copper T: heavy menstrual bleed- ing; intrauterine device (IUD): perforation, infection; implant: infection, deep placements; or injections: allergic reactions. The more worrisome issue for me, however, is the side effects and/or the bad placement events that a young woman may experience which can bias her forever against LARC use. Nulliparity and/or young age has been associated with higher rates of failed insertion (Dermish AI, et al. Contraception 2012;87:182–6) and more pain with placement (Brockmeyer A, et al. Eur J Contracep Reprod Health Care 2008;13:248–54) as well as ongoing pain, cited as a major reason for removal (Suhonen S, et al. Contraception 2004;69:407–12). Irregular bleeding in addition to perceived or actual weight gain and acne is attributed to hormonal-LARC methods, especially depot medroxyprogesterone acetate (DMPA), which could influence dissatisfaction and discontinua- tion. Although discontinuation rates are low with most LARC methods used for contra- ception (not so for DMPA), this may not be true in a woman using LARC for no reason. As LARC methods are 20 times more effec- tive than short acting methods and the typical failure rates of short acting methods in teens and young women has recently been shown to be worse than realised (18%) (Secura GM, et al. N Engl J Med 2014;371:1316–23) I want to ensure that women have a positive view of these methods. Finally, would a young woman independently choose to use LARC when she has no need and gain no benefit, or is she being coerced? As a huge supporter and provider of LARC to teens and young women, I recognise that LARC methods are incredibly important tools in our fight to prevent unplanned pregnancies as well as their extensive non-contraceptive benefits. However ‘pre-emptive’ use without eminent need or benefit may cause more harm than good. Disclosure of interests Full disclosure of interests available to view online as supporting information.& BJOG Debate 1052 ª 2015 Royal College of Obstetricians and Gynaecologists