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Enhancing Sexual Wellbeing in Scotland: A Sexual Health and Relationships Strategy: Proposal to the Scottish Executive
3 Setting the context
The current picture
3.1 Many people in Scotland experience positive relationships and good sexual health.
However, there is a considerable and growing burden of sexual ill health, with the greatest burden being borne by the most socially disadvantaged.
6;10;23;24;25
3.2 There are various manifestations of sexual ill health, examples of which are given in Box 1. There are many causes of concern. STIs, such as chlamydia, are widespread in Scotland and are increasing. However, sexual ill health is not just about disease, sexual violence and abuse is common and increasingly being reported.
13;14;17; 26 Young people are becoming sexually active at a younger age,
3 and many report feelings of regret.
6;27
3.3 Many women experience unintended or unwanted pregnancies. Whilst the exact numbers of unintended or unwanted pregnancies are difficult to ascertain, termination of pregnancy can be used as a proxy indicator. Most of these occur in women in their twenties and thirties.
20;28 With adequate knowledge, skills and support from health care services, including appropriate contraception, many but not all are preventable.
3.4 Society is deeply concerned about teenage pregnancies despite these being considerably fewer in number than unintended or unwanted pregnancies to women over 19 years.
28 The UK has the highest rates of teenage pregnancy in Western Europe
12 all the UK countries have broadly similar rates. In Scotland around 43 per 1000 girls between 13 and 19 became pregnant in 2001.
29 This rate has been relatively stable since 1993
29 although the pattern has changed with increases observed in the poorest areas.
23 Young women in the most deprived areas are three times more likely to become pregnant in their teens than those from the most affluent areas
30;31 and, as terminations are least likely in the poorest areas,
30 disadvantaged teenagers are nearly ten times more likely to become teenage mothers.
23;32 Even in affluent areas young women in the UK are more likely to become teenage mothers than those of the same age in France or the Netherlands.
3;6;33 While pregnancy and parenthood are positive choices for some young people, for others unintended pregnancy and motherhood are associated with negative social and psychological consequences such as incomplete education, poverty, social isolation and low self-esteem.
3;6;34;35 Daughters of teenage mothers are more likely to become teenage mothers themselves.
6;32 Parenthood brings with it immense responsibility, and parents, and especially young parents, require support and guidance in this role.
3.5 Many people consider sexual ill health to be an issue for only a few high-risk groups,
3 but the statistics show that related problems are likely to affect many people in Scotland at some time in their life. In addition, changing lifestyles and demographic shifts, including an ageing population, mean that the sexual health needs of people in Scotland, and the appropriate responses to those needs, are changing. A flexible and responsive approach which recognises that sexual wellbeing as an issue for all of society is required. Further information about knowledge, attitudes, behaviours and trends in sexual health can be found in Supporting Paper 1. However, it is not currently possible to paint an accurate and comprehensive picture of sexual ill health in Scotland due to incomplete, inconsistent and inappropriate data collection.
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3.6 The disappointing picture illustrated in Box 1 is not inevitable. In the 1970s, teenage pregnancy rates in the UK were similar to the rest of Western Europe.
6 Since then other countries, such as the Netherlands and some Scandinavian countries, have had greater success than UK countries in reducing these rates.
1;3;6;20 Although there have been some notable achievements in Scotland (Box 2), evidence shows that with better co-ordination and a more supportive environment the major improvements in sexual health experienced elsewhere are as achievable in Scotland.
1;20;21
3.7 The key to improving sexual health outcomes is to understand the breadth and complexity of the challenge. In particular, teenage pregnancy is associated with low aspirations, few perceived opportunities, lack of knowledge and skills, and mixed messages that implicitly suggest sex is the norm but that it shouldn't be discussed.
6;23;30 Focusing solely on narrow targets (for example, to reduce negative outcomes such as teenage pregnancy or incidence of STIs) and on action by health care services alone, does not address the range of influences that determine sexual health. To date there has been only limited acknowledgement of the importance of other policies, such as those aimed at raising educational aspirations and self esteem, mainstreaming equality, enhancing social inclusion and addressing alcohol and drug misuse, domestic abuse and homelessness, in influencing sexual health and wellbeing.
3.8 The Reference Group believe that the implementation of the recommendations in this strategy will reduce unintended pregnancies and reduce STIs for all age groups, however specific work will require to be done with, for example, vulnerable young people and black and minority ethnic (BME) communities. This is discussed further in paragraphs 4.1-4.3.
Recommendations
The Scottish Executive should retain their target for reducing teenage pregnancies,gbut should ensure that other targets or indicators complement this in order to give a more comprehensive picture of sexual wellbeing for both sexes and all age groups in Scotland Local Authorities and NHS Boards should ensure that their Community Plans, Local Health Plans and Children's Services Plans complement their local inter-agency sexual health strategies
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Box 1: Sexual health in Scotland: Illustrative examples
Sexual violence and abuse |
In 2001/2002 nearly 200 girls talked to ChildLine of pregnancy because of sexual abuse and/or rape.
26 |
In a survey of over 2000 14-21 year olds, 78% of young men and 53% of young women believed women and girls are 'often' or 'sometimes' to blame for the violence perpetuated against them.
37 |
Amongst 2500 Scottish males in fifth year at high school (average age: 16 years, 1 month), 11% thought they might force a young woman to have sex if she had asked him back home after a drink, and 19% were unsure.
38 |
Seventy per cent of lesbian, gay, bisexual and transgender (LGBT) people in Scotland have been verbally abused or threatened because of their sexual orientation or transgender identity.
14 |
The British Crime Survey of 2000 reported that nearly one in ten women have experienced sexual victimisation including rape, with nearly half of those raped by their current 'partners'. Only 8% of rapists were 'strangers.
39;16 In Scotland, there were 1900 reported crimes of indecency (including rape, attempted rape and indecent assault) in 2001.
13 |
Sexually transmitted infections |
The reported number of lifetime partners is higher for men (6 partners) than women (4 partners), with younger people reporting more partners than older age groups.
3 Approximately 10% of Scottish men and 6% of Scottish women under 44 years report having had more than one sexual partner concurrently in the previous year. This was more likely for younger people.
3 |
There has been a dramatic increase in the incidence of genital chlamydia diagnoses throughout Scotland over the last decade
40 including a 41% rise between 2000 & 2001. A smaller increase of 12% from 10121 cases in 2001 to 11372 in 2002 was observed. The rise in diagnoses in females less than 16 years has been particularly marked. Although much of the increase has been due to increased screening practice, other indicators suggest that the incidence of chlamydia infection, particularly among young people, has increased.
11 |
The second national survey of sexual attitudes and lifestyles (NATSAL) found that people perceive the personal risk of HIV as being low.
3 |
The cumulative total of known HIV-positive individuals in Scotland was 3634 at 31
st March 2003, of whom 2717 (75%) are male and 917 (25%) are female. At least 1347 have died. The prevalence of HIV in Scotland is at its highest level to date and is likely to continue increasing year on year. Accordingly, people who have unprotected sex are at a greater risk of acquiring HIV than ever before. Many HIV infected heterosexuals and gay men in Scotland are unaware of their infection despite having been in contact with services such as genitourinary medicine (GUM) clinics.
41 |
Between 2001 and 2002 there was a 60% increase in rectal gonorrhoea and a 200% increase in syphilis amongst men who have sex with men (MSM). This strongly suggests an increase in the frequency of high-risk sexual behaviour in this population.
11;42 |
Sex and young people |
Most parents feel that they have a responsibility to talk to their children about sex and sexual health, however only around half of parents actually do. Even then, discussions with sons are considerably less likely than with daughters.
43;44 |
The median age of first intercourse has fallen to 16 for both females and males.
3 Twice as many women under 30 (23%) reported heterosexual intercourse before age 16 than women aged over 30 (10%).
3 The proportion of men reporting first intercourse before 16 years has remained fairly constant across the age groups (approx 27%).
3 This suggests that around one in four young people has sexual intercourse before age 16. |
Although more young people report using contraception at first intercourse, 16% of young men and 11% of young women still do not. The proportions are higher amongst those who left school at 16 with no qualifications.
3 |
A significant proportion of first sex is unwanted, particularly for young women, and the younger the person is the more likely it is that the sex is unwanted.
3; 27;45 Amongst 5854 young people in Scotland, 72% of girls who had sex before the age of 14 regretted it, 56% of girls who had sex before 15, and 31% of girls who had sex before 16. The equivalent figures for boys were 35%, 27% and 19% respectively.
38 |
The use of alcohol and other drugs has a considerable influence on sexual behaviour, especially amongst teenagers.
6; 46 Those who are intoxicated are more likely to have sex with someone they have just met, are more likely to engage in risky sexual behaviour and are more likely to regret it later.
47; 48 |
There is still considerable stigma and discrimination of those who are lesbian, gay, bisexual or transgender; LGBT young people are likely to feel isolated, to suffer mental health problems and are several times more likely to report a serious suicide attempt than heterosexual young people.
49; 50 |
Unintended or unwanted pregnancies |
Ten per cent of women report having had a pregnancy terminated.
3 It is estimated that a quarter of these will go on to have a second termination at some time in their reproductive lives.
51 |
The rate of teenage conceptions in Britain is the highest in Western Europe.
12 In Scotland, slightly more than half of the pregnancies to under 16 year olds and two fifths of those in the 16-19 age group are terminated.
28 |
Rates of teenage pregnancy are higher in areas of deprivation than elsewhere.
6;23; 29 During the 1990s the difference in rates of teenage pregnancy between more affluent and more deprived areas widened.
23 |
A large proportion of looked after young people (between 14%
52 and 25%
53) have a child by age 16, and nearly 50% become mothers within 18 to 24 months after leaving care.
54; 55 |
Box 2: Examples of achievements in Scotland
Improvements to the delivery of sex education, in particular the emphasis on involving parents, are flowing from the Report of the Working Group on Sex Education in Scottish Schools.
56 |
The national demonstration project,
Healthy Respect, established as part of the implementation of the
Towards a Healthier Scotland,
18 has provided the opportunity to build knowledge about evidence and good practice in improving sexual health for young people by working through a range of partners.
h |
There are many examples of innovative and successful voluntary sector activities, for example those developed under 'Walk the Talk' initiatives and Caledonia Youth. Some of these have successfully worked with the most vulnerable young people.
2; 57 |
Sexual competence
i in young people has increased with more using condoms, and fewer using no contraception, at first intercourse.
3 |
Whilst the percentage of young people having sex is increasing, teenage pregnancies are not rising in line with this increase.
3 |
Integrated sexual health services which are based on a social model of health, such as the Sandyford Initiative in Glasgow and Highland Sexual Health, have been established with considerable success.
58 |
In accordance with the publication of SIGN Guidelines No.42 on chlamydia screening,
59 the numbers of chlamydia detections, particularly in family planning and GUM clinic settings, have increased dramatically (
see Box 1, Sexually Transmitted Infections). |
Voluntary sector organisations have achieved significant success in championing sexual health and related issues both at national and local levels - effectively responding to and involving individual users, including some who are particularly hard to reach, for example people with HIV and LGBT people.
2 |
3.9 Based on the evidence available, the Reference Group believe that to achieve improvements in sexual health and wellbeing, the following are required:
1;6;21;60
A society which views sexuality in an open and positive way and which values and respects diversity
Acknowledgement of the importance of economic, social and cultural influences on sexual wellbeing, and the inequalities these cause, and appropriate action to address these
Lifelong learning and employment opportunities that encourage future aspirations and build self esteem
Lifelong formal and informal opportunities to learn about relationships and the moral issues therein, sex, sexual health and where and how to access appropriate services
Support from easily accessible, confidential and appropriate clinical services
In addition, an integrated approach which links sexual health policy to other related policy areas at both national and local level is necessary to achieve a significant improvement in Scotland's sexual health. However, the social and cultural contexts within which policies are implemented play a role in determining their effectiveness. Success therefore requires recognition of the wider influences on sexual health in policy development and implementation, and in service delivery. These are outlined briefly in the next section and Supporting Paper 2 provides further evidence.
The wider influences on sexual health
3.10 Health inequalities are clearly seen in many aspects of sexual health.
6;30;60 There is a strong link between social disadvantage and early initiation into sexual activity.
61;62;63 Higher levels of deprivation are also associated with less consistent use of contraception to prevent conception and STIs
62;64 and, particularly for those in public care, a higher risk of teenage pregnancy.
32;65
3.11 Although the link between sexual ill health and deprivation may partly be explained by difficulty in accessing appropriate services,
10;66 other main factors seem to be educational and cultural;
23; 64 those with lower aspirations are more likely to become sexually active at a young age and less likely to use contraception.
23 Conversely, those with good educational and employment prospects are more likely to use contraception.
67 Planning to avoid early parenthood is closely linked with having a stake in the future, a sense of hope and an expectation of inclusion in society.
12 There are also links to the different cultural and social expectations of the lives and experiences of girls and boys.
68;69;70;71 The Reference Group supports the Scottish Executive's actions on, for example, social exclusion and equality as these will have a beneficial impact on sexual health.
Recommendations
The Scottish Executive should ensure cross-departmental representation on the National Advisory Committee on Sexual Health The National Sexual Health Programme Co-ordinator should work with the Social Inclusion Division to ensure that opportunities to improve sexual health through national policy are taken. Social justice policies and other policies or initiatives which address social exclusion and lack of opportunity in disadvantaged areas should encompass actions to address sexual health Local Sexual Health Co-ordinators should ensure that, within NHS Board areas, Community Plans and Local Health Plans address the issues that impact on sexual health, especially in relation to inequalities
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3.12 Values, attitudes and expectations are influenced by culture and the social environment in which people live. Cultural influences include families and the home, gender and sexual stereotypes (including discrimination against those who are homosexual (homophobia) and the assumption of heterosexuality (heterosexism), ethnicity, faith perspective, social attitudes to disabled people, the media, and peer and social pressures. Together these shape each individual's sexuality and sexual behaviour. Many of these influences will cause or reinforce social inequalities which will also affect sexual health. An additional challenge is therefore to ensure that everyone is able to benefit from opportunities to improve sexual wellbeing. The evidence is summarised in Box 3 and Supporting Paper 2 provides further details.
3.13 The Reference Group acknowledges that the Scottish Executive has a number of policies which influence relevant issues such as domestic abuse, parenting skills, drug and alcohol use, equality and diversity. Also, the Scottish Executive is making real efforts to ensure that integrated approaches are being taken to these issues both at national and local level. However, given the concerning increase in sexual ill health, efforts to confront these influences must become more effective.
3.14 Tackling the wider determinants that influence sexual wellbeing on a cross-departmental basis within the Scottish Executive will be crucial to the successful implementation of this strategy.
Recommendations
The National Sexual Health Programme Co-ordinator should seek to influence Scottish Executive policies that cover the determinants of sexual health, including those addressing gender inequalities The National Sexual Health Programme Co-ordinator should work with Scottish Executive colleagues to ensure that policies which impact most on people who are socially excluded include actions to address sexual health, for example, policies aimed at homeless people, those in prison, or young people looked after or leaving care The Scottish Executive should develop an action plan to tackle stigma and discrimination around HIV and sexuality and to encourage a more positive view of sex and sexual health in all Executive policies, as part of the ongoing health improvement agenda
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The mediajand mass communicationsk
3.15 Sexual imagery pervades many aspects of modern society and is often used to sell products. The media is a powerful communication tool and it's portrayal of sex and relationships tends to reinforce stereotypes about differing expectations in activities, behaviours and availability of women and men, and often ignores the risks associated with sexual behaviour.
72;73
3.16 Where sexual health is directly mentioned in the written press, it is often poorly dealt with, for example, by focussing on negative messages, reinforcing the social stigma around sexual relationships and sexual health services, and by sensationalising the issues. Some forms of media (for example teenage girls magazines) can be informative and a useful source of information, however many are limited and tend to reinforce stereotypes.
74
3.17 In the absence of other reliable sources of information and advice, media messages (for example, "everyone is having sex") can lead to pressure and confusion over the realities of relationships and sexuality, particularly for young people. It is therefore important to provide some balance to these messages, including provision of accurate positive information about sex and sexual health. One way of doing this is through the media itself.
3.18 The Reference Group concludes that work with the media is necessary to support action to improve sexual health. Specifically, the approach should:
Encourage a cultural shift towards a more open and positive view of sexual relationships and sexual health that is accepting of diversity
Promote an ethos that encourages relationships based on equity and respect
Challenge gender stereotypes and reinforce the responsibility of both men and women for protecting sexual health
Provide support for parents in communicating with their children about sexual relationships and sexual health
Increase awareness of ways to reduce poor sexual health outcomes
Raise awareness of services at both a local and national level; and
Encourage interaction with the public on sexual health matters.
3.19 The approach should have three broad components; media campaigns to convey key messages and challenge gender and sexual stereotypes; media advocacy to work proactively with the media; and media literacy to develop people's ability to interpret and analyse media messages. It will be important to ensure that national and local activities are linked in order that local services are prepared and able to respond to any increase demand that may arise because of media coverage. Further details about the content of the proposed mass communications strategy is in Supporting Paper 3.
Recommendations
The National Sexual Health Advisory Committee, linking with those with media responsibility in NHS Health Scotland and the Scottish Executive, should develop a mass communications strategy for sexual health which includes the three components (campaigns, advocacy and literacy) and which links work at national and local levels. The National Sexual Health Programme Co-ordinator should oversee the development and implementation of this strategy Campaigns (national and local) commissioned by the Scottish Executive should not use imagery or language that undermines the key sexual health messages that promote relationships based on equity, respect and acknowledgement of diversity National and local media work by NHS Health Scotland and NHS Boards should emphasise the importance of using barrier contraception, in conjunction with other forms of contraception, to protect against STIs and unintended pregnancy
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Box 3: Social and cultural influences on sexual health: A summary of the evidence
Socio-economic status and aspirations Lower socio-economic status is associated with an earlier start of sexual activity
61;62;75 which in turn is linked to subsequent regret,
27;62;76 less protection against conception and STIs, and more subsequent sexual partners, which in turn increases risk of STIs.
62;64 Higher levels of deprivation are associated with less consistent contraceptive use
62;64 and, particularly for those in public care, a higher risk of teenage pregnancy.
23;32;65 Good educational and employment prospects are associated with higher contraceptive use.
6;67 If young people have low aspirations, or see no opportunities for their future, they will see few reasons to justify either postponing sexual activity or using contraception.
6 Planning to avoid early parenthood is inextricably linked with having a stake in the future, a sense of hope and an expectation of inclusion in society.
12
The family The family unit has many forms but remains a core part of society. Increasingly members of the wider family, including grandparents, play a part in bringing up young people. Parents and families are fundamental in the development of sexual values, attitudes and skills, as well as in influencing sexual behaviour.
77 Parents' and other family members' values can influence the young person's attitudes and beliefs; they are the principal source of continuing support to the young person; and their relationships can be closely observed by the young person.
57 Many parents and carers do not feel adequately supported in their role as sex educators and often rely on school based education as the main route through which their children are educated about sex and relationships.
43 However, parents and carers have an important role as educators of their children whether or not they choose to accept it. Even by avoiding discussion, messages about relationships and sexuality are given out to young people, suggesting for example that, in contrast to the culture around them, these issues should not be talked about openly.
57 Family dynamics are crucial to developing positive sexual health. Evidence shows that particularly important aspects include time spent together in family activities, parental support, parental monitoring, and communication about sex and relationships.
76;78;79;80 Cultural and religious attitudes to sexuality and marriage can pose tensions, particularly for young people facing dissonance between the dominant social norms and those of their families.
Gender Gender roles and stereotypes are learned from infancy and have an important effect in shaping sexuality. The tendency is for young women to experience sexual activity as part of developing relationships, approval and social acceptance, while young men experience it as a form of achievement.
71;81; 82 Throughout adolescence and adulthood, people are under social pressure to conform to gender-specific sexual roles that are adopted by society and are particularly promoted through the media.
83 Despite improvements in women's relative power many, particularly young, women still experience pressure to engage in sexual activities they do not wish.
45;71; 76 Women are perceived as being the guardians of sexual health and fertility. Sexual health promotion, education and service provision tend to focus on women
85 and this can perpetuate stereotypes and cultural beliefs about the roles and responsibilities of both women and men.
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Homophobia and Heterosexism Fear or dislike of lesbian, gay or bisexual (LGB) people or of LGB feelings within oneself (homophobia) and the assumption of heterosexuality as the norm in sexual relationships (heterosexism) create stigma and discrimination which lead to feelings of isolation, stress and anxiety for lesbian, gay, bisexual and transgender (LGBT) people.
86;87;88 This is linked to current views about what constitutes acceptable forms of masculinity and femininity. Being excluded from society has a negative impact on many aspects of the lives of LGBT people, including mental health, substance use, homelessness and suicide.
88;89
Ethnicity and Faith There is a lack of information about the sexual health needs and outcomes of those who belong to black and minority ethnic (BME) communities, partly through the lack of disaggregated data by race and cultural origin.
10;90 This in itself is discriminatory, as important problems will not be identified. Available evidence indicates greater sexual ill health in some BME communities.
25;91 BME communities are heterogeneous. Age at first intercourse, gender-appropriate roles, and sexual attitudes, particularly to pre-marital sex and child bearing, vary considerably between and within different faith and BME communities.
92;93 Significantly lower levels of knowledge and use of sexual health services are recorded for all BME communities.
90;94 The dominance of 'mainstream' cultural values may result in people from BME or faith communities being marginalised or stigmatised, and make them reluctant to access appropriate health services for fear that these services will not understand or respect their cultural beliefs or faith perspective.
Disability Society generally is reluctant to acknowledge that people with physical or learning disabilities have a sexual identity. There is often a blanket assumption that disabled people are unable to take responsibility for their own sexuality and fertility.
36 The sexual health experiences and needs of disabled people are varied and complex and issues will vary from individual to individual. Those with communication/sensory impairments may be restricted in their ability to access much of the information and support that is currently available.
Social and peer pressures A considerable proportion of young people report feeling pressure to have sex from peers or society more generally.
6;27;95 There is an association between substance use (including alcohol), unplanned sexual intercourse and other sexual behaviours and regret, especially for young people.
6;27;47;72; 96
The media Sex is often used to sell products in ways which promote unhealthy lifestyles and reinforce gender and sexual stereotypes.
73;97 The media present a range of conflicting views about gender roles, body image and relationships.
72;74 When the media addresses sexual health, it is often poorly dealt with, focusing on negative messages, reinforcing the social stigma around sex and sexual health, and sensationalising the issues.
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