If residents are exposed to the procedure—something that depends heavily on the patients they happen to see during that month-long rotation—that time frame is “certainly not enough time to learn how to put in an IUD,” said Jane McGrath, the chief of adolescent medicine at the University of New Mexico.
Doctors offered different thoughts on how many times would be enough to become competent in inserting IUDs, but Gold suggested it might take 10 insertions before a physician would feel comfortable administering it.
Pediatricians also may be less comfortable offering IUDs to patients than are other doctors, suggests a 2013 survey published in the Journal of Adolescent Health. The study found that 26 percent of doctors practicing pediatrics or internal medicine provided IUDs or other long-acting contraception—compared with 88 percent of those identified as OB/GYNs or family-medicine providers.
Those who do bring it up often refer patients interested in IUDs to other providers, such as gynecologists, said Annie Hoopes, a pediatrician and adolescent-medicine fellow at Seattle’s Children’s Hospital. But for teens, such referrals can get complicated.
Privacy can be an issue, said Swanson, who doesn’t do the insertion procedure in her office. A teenager may not want her parents to know she’s receiving the birth control, but “if she goes in and sees a gynecologist and the visit is billed,” it’s impossible for the pediatrician to guarantee that won’t appear on an insurance statement.
In those situations, Swanson said, she will send patients to Planned Parenthood or a similar provider, where the visit doesn’t get billed to a parent’s insurance plan.
Teens also don’t always act on the referral, said Marissa Raymond-Flesch, a fellow of adolescent and young-adult medicine at the University of California at San Francisco.
“They may have limited control over their time—particularly if they’re trying to come to receive services confidentially,” she said. That fear of attrition, she added, is a reason her practice has moved to offer IUD insertions in-house. Otherwise, “adolescents could be lost to follow-up.”
And in places where a provider is harder to reach, geography could pose another barrier to teens who don’t get the IUD from their regular doctor.
Meanwhile, conversations with patients and their parents have changed “dramatically” since she began discussing IUDs, Swanson said. Initially, parents would be nervous about IUDs—suggesting, for instance, that they might cause infertility for their daughters. Now, by contrast, both teens and parents seem “very open to” long-acting contraception, she said, and teenage girls are more likely to ask about IUDs without prompting.
Swanson added that, though parents sometimes bring up birth-control issues, she personally waits to raise the subject until the one-on-one portion of a teenager’s visit, when parents are required to leave the room.