Sexual Health

 

"Sex is a dimension of life that should be both celebrated and enjoyed. It is a positive and important part of the most intimate relationships. However, it can also lead to ill health, violence and exploitation."

This is the conclusion of a report by the Expert Reference Group tasked with looking into sexual health in Scotland, chaired by Professor Phil Hanlon and including representation from Churches and faith groups alongside medical and sexual health experts. The report forms the basis for a new draft sexual health strategy and is now out for consultation.

The Reference Group’s remit covered three broad aims:

·         to reduce unintended pregnancies and sexually transmitted infections;

·         to enhance the provision of sexual health services; and

·         to promote a broad understanding of sexual health and sexual relationships that encompasses emotions, attitudes and social context.

The report presents a series of disturbing statistics on Scotland's sexual health (see insert sheet), making links with poverty, low aspirations, the family, gender, ethnicity, faith, disability, social and peer pressures and the media. But the debate is not about statistics; as Susan Deacon put it, it is "about teenagers who are grappling with dilemmas in their relationships and are bombarded with sexual imagery on television, through music and the internet and in the soaps. It is about parents who are concerned about the well-being of their youngsters and are struggling to know how best to talk to, advise and protect them. It is about young and not-so-young women who have unintentionally fallen pregnant and are torn in deciding whether to have a termination … (and others)".

A key proposal is the appointment of a National Sexual Health Programme Coordinator (inevitably dubbed a "sex tsar"), supported by a Ministerially-led Sexual Health Advisory Committee. The membership of this Committee, which would oversee the implementation of the strategy, would be reflective of the health, education and voluntary sectors. Annual reporting would be supplemented with a review after five years.

Recognising the sensitivity of issues around sexual health, Health Minister Malcolm Chisholm admitted that "complete consensus may be elusive", but urged respondents not to focus "disproportionately on the points of difference". Professor Hanlon, chair of the Group, has warned that "doing nothing is not an option".

The Current Situation

"Sexual wellbeing is not just about the absence of disease or unintended pregnancy, but encompasses the positive aspects of relationships and sexuality"; therefore the strategy seeks to be "more comprehensive than that in comparable documents".

Despite the media saturation with sexual imagery, the Reference Group argues that Scotland is a society ill at ease with matters of sexuality. The Group's vision for Scotland is "a society that accepts sex as a normal and healthy aspect of life, in which people understand the value of their own sexual health, the importance of responsibility and respect for others and have the capacity and means to protect themselves from unwanted outcomes of sexual activity". The approach is based on a human rights framework, stressing equal rights and respect for the intrinsic value of each individual.

Clearly, sexual ill-health in Scotland is increasing, yet many people view it as something which affects only a high-risk minority. Changing lifestyles and an ageing population (they argue) require a more flexible approach to sexual wellbeing, incorporating personal, social, emotional and spiritual, as well as physical, aspects of sexuality.

Poor sexual health is concentrated among the most socially disadvantaged. While this can be related to difficulty in accessing services, educational and cultural aspects also play a significant role. Young people are becoming sexually active at a younger age with many expressing regret and reporting coercion.

The UK has the highest rate of teenage pregnancy in Europe. While in the 1970s, teenage pregnancy rates were similar to the rest of Western Europe, other countries, particularly Scandinavian states, have been more successful in reducing the rates. 4.3% of 13-19 year old girls became pregnant in 2001. While there has been little change in the overall figure since 1993, there has been an increasing concentration among the most socially disadvantaged, with teenage girls from poorer areas 3 times more likely to become pregnant (and - due to a lower abortion rate in these areas - 10 times more likely to become a teenage mother) than better-off peers. Teenage pregnancy is linked to factors such as incomplete education, poverty, low aspirations and low self esteem, perceived lack of opportunities, lack of knowledge and skills, and mixed messages about sex. Having low aspirations is linked to becoming sexually active at a young age and less likelihood of using contraception, with daughters of teenage mothers more likely to become teenage mothers themselves. The Group wants to see the pregnancy rate among 13- to 15-year-olds cut by 20% by 2010, and a reduction in rates of sexually-transmitted infections (STIs).

Yet the rate of teenage pregnancy is less than that of unintended and unwanted pregnancies which occur among women in their 20s and 30s; this is the group who have the highest rate of terminations – many, though not all, preventable.

Faith and Values

Acknowledging the importance to many of faith-based morality, the report does not strive to "arbitrate on such matters", but (a) to "recognise and embrace the cultural, ethical and spiritual components which impact on an individual’s sexual health"; (b) to support people in reaching and upholding their own values; and (c) to offer services which are sensitive to the range of beliefs and values. Churches and faith groups are acknowledged as having a stake in the issues involved though are not explicitly included in the list of those bodies who should be represented on the proposed National Sexual Health Advisory Committee.

The draft strategy is underpinned by 3 key values: self-respect and respect for others; equal opportunities (including access to services and lifelong learning); and a "real and meaningful commitment to promote and reinforce the rights of people to have mutually respectful, happy, healthy and fulfilled sexual relationships free from abuse, violence or coercion".

Broad Aims of the Strategy

The 3 broad aims of the strategy are:

·         to influence the cultural and social factors that impact on sexual health;

·         to support people in gaining the knowledge, skills and values necessary for sexual wellbeing; and

·         to improve the quality, range, consistency, accessibility and integration of sexual health services.

It is recognised that a focus on achieving targets to reduce teenage pregnancy or STIs alone, will not fully address the issues, and the report calls for a recognition of the role which policies aimed at tackling social exclusion, alcohol and drug misuse, domestic abuse and homelessness, etc, can have on sexual health and wellbeing.

Contentious Issues

Following concerns raised by the Catholic Church’s representative on the panel, the Health Minister has already reassured critics that the provision of the morning-after pill from schools had been ruled out. The Executive are keen to avoid a repeat of the acrimony over "Section 2A", though some MSPs criticised the Minister for failing to grasp this nettle.

Another proposal likely to cause contention is that the time between initial consultation with a doctor and an abortion procedure should be cut from three weeks to one week by March 2006. Since access to termination is currently patchy across Scotland, an initial target of three weeks would be implemented Scotland-wide.

More generally, concerns have been expressed around the role of parents. Some have argued that the creation of a "tsar" and stress on action in schools downgrade what is primarily a parental responsibility. The report does recommend that councils should "ensure schools demonstrate mechanisms to involve parents and carers in SRE programmes in line with the McCabe Report recommendations". However, there are questions as to how this, and proposals for consultations with school boards, are compatible with "a consistent approach to sex and relationships education across Scotland".

Schools and Lifelong Learning

While the panel stress that sex and relationships education (SRE) is about lifelong learning and not simply about young people, schools have a strong role to play in the strategy. The Reference Group recommends that SRE in schools should be inter-disciplinary, linking to areas like Religious and Moral Education, and incorporating a broad range of life skills, including self-esteem, respect for others and communication. Responsibility is seen as resting not only with schools but also with the family and wider community.

The Group reject "abstinence only" sex and relationships education programmes, popular in the USA, on the basis that there is no evidence that they result in significantly delayed sexual activity or cuts in pregnancy, and in some cases have been associated with an increase in pregnancies. They favour "abstinence plus" or "comprehensive" programmes (such as the SHARE programme developed in Scotland) which aim to delay sexual activity, but in conjunction with communication and negotiation skills, and information on sexual health services and contraception. Crucially, the panel recommends that the McCabe Report should be implemented in full to ensure consistency in sex and relationships education throughout Scotland, and that SRE should start in pre-school through to school leaving age.

The report also rejects the view that health services which include a sexual health element should never be available in schools, pointing out that often - particularly in rural areas - there are no other easily accessible locations. The decision on location of services will be taken in consultation with young people and their families; so, a school may be judged the most appropriate site, after discussion between the education authority and the school community.

Action at Local level

A Local Sexual Health Co-ordinator, appointed by each NHS Board, and supported by a local sexual health strategy group, would manage the network of sexual health providers at local level and report annually to the National Sexual Health Advisory Committee: "working in partnership with the voluntary sector and community-based groups (including faith organisations) will be essential to implementing this strategy at national and local levels".

Media

"The general portrayal of sex is that it is something that is done to women - and the younger the better - by men" (Carolyn Leckie MSP). To balance the negative images, misleading information and stereotypes increasingly portrayed in the media, a mass communications strategy for sexual health is advocated. A three-pronged media approach is proposed, encompassing (a) media campaigns to promote key messages and challenge stereotypes, (b) proactive media advocacy, and (c) media literacy to develop people’s ability to interpret and analyse media messages.

What Works?

Although one MSP said in Parliament that "we know what works", there are disputes about the effectiveness of sexual education programmes – about the results both of "abstinence only" programmes in the USA, and of other "comprehensive" programmes in the UK like SHARE: "researchers have said that the £600,000 trial of the SHARE - sexual health and relationships: safe happy and responsible - programme had failed and they revealed that schools that took part had reported a rise in the rate of unwanted pregnancies" (James Douglas Hamilton). If we take seriously the problems (and the people), we need to look dispassionately at evidence to ensure that we do indeed know what works.

Theological Context

It is disturbing that several MSPs during the Parliamentary debate on this complained of "vested and powerful interest groups, which can - and, indeed, do - shout the loudest on so-called moral issues". There seems to be an expectation that comment from churches in this area will be either negative or simplistic, or both; if people believe that "a just-say-no attitude and a religious or so-called moral perspective … mean only that heads are buried in the sand", there is something far wrong. 

There are huge challenges to the churches in what is clearly an area of difficulty for us. We can, however, approach this subject not only with an appreciation of many of the difficulties and complexities involved, but also with an ongoing record of care, concern and action. What we say must come from that, and from the understanding of, and vision for, human relationships that are at the heart of our faith.

Every human being is made in the image of God. Those whose lives are made difficult, dangerous or intolerable by the actions of others, or indeed by their own actions, are to be loved and cared for in Christ’s name. That means being supportive of all that seeks to help people overcome their difficulties and dangers.

For some, the report will be seen as failing to offer a "moral" framework, on issues like promiscuity. However, its authors argue that it has a strong "values base", including respecting diversity and the rights of the individual. They say that both a more prescriptive and a more pluralistic approach were discussed, but the Group felt unable to endorse either. Whether the core value of "respect" is a robust or deep enough base on which to build such a strategy may be something on which churches will wish to comment, but any such comment must also have the humility to recognise that the impact of our preaching (and, arguably, our practice) has not prevented the disturbing picture from which this starts.

We cannot pretend that all churches agree on this, nor that Christian parents and teachers find this an easy area. Which is all the more reason for us to make a creative and critical contribution to a debate that needs to go way beyond sound-bites.

Conclusion

There is broad support for much of what is proposed in the draft strategy, not least "the consensus among parents, professionals and faith groups that sexual relationships are best delayed until a person is mature enough to participate in mutually respectful relationships"; therefore, as Cathy Peattie put it "the strategy must stress the importance of strong, stable and loving relationships, regardless of the particular relationship or family structure involved". The report contains over 100 recommendations (see insert sheet for key points), and the Executive are seeking responses from parents, young people and individuals as well as organisations and professional bodies to "ensure that the final strategy is a fair reflection of the views of people in Scotland". The consultation period ends on 27 Feb.