The Scottish Government

« Previous | Contents | Next »

Listen

Enhancing Sexual Wellbeing in Scotland: A Sexual Health and Relationships Strategy: Proposal to the Scottish Executive

4 Promoting positive sexual health

Meeting the needs of those facing the greatest barriers to sexual health

4.1 There are many barriers to achieving sexual wellbeing. These may include:

• Individual barriers to empowerment and choice (such as knowledge, attitudes, lack of competence or confidence, perceived or actual lack of confidential services)

• Physical barriers to using services (such as distance, cost, accessibility or lack of services)

• Social barriers to services and knowledge (including staff attitudes and skills, an unwillingness amongst parents and teachers to discuss sex, unacceptability of gender based violence); and

• Cultural barriers at a societal and service level (including ethnic background including attitudes to female genital mutilation, discrimination and stigma, unwillingness to accept sexuality of young people or disabled people and different moral and faith beliefs)

These barriers tend to have the greatest impact on the most disadvantaged in society.

4.2 Implementation of this strategy will go some way towards addressing many of these barriers. For example, by improving the consistency, accessibility, quality, cultural competence and ethos of lifelong learning and appropriate and responsive sexual health services. However, for those who face the greatest barriers specific targeted work will be required. The engagement exercise identified a number of target groups. ^l Whilst the Reference Group lacked the time for a detailed examination of all of these many groups, there is compelling evidence that, in terms of STIs and unintended pregnancies, the following groups are particularly vulnerable and more so if they live in deprived areas:

• Young people under 25, and especially those who are looked after or leaving care, those excluded or under performing at school, those missing school through truanting or chronic illness and those involved in crime ^21;55;98;99

• Children of teenage mothers, particularly daughters ^{32; 100}

• Male and female prostitutes ^m101

• Men who have sex with men ^98;102;103

• Those who have travelled from Sub-Saharan Africa and other areas of high HIV prevalence ^{11; 98;102}

This list is neither comprehensive nor exhaustive as the current evidence has many gaps.

4.3 The National Sexual Health Advisory Committee should identify and prioritise target groups. In conjunction with the Sexual Health & Wellbeing Learning Network ⁿ and taking account of work elsewhere, the Committee should develop a programme to examine, develop and disseminate evidence and guidance on issues for those groups facing the greatest barriers to sexual wellbeing.

Recommendation

4.4 There are different faiths and cultures in Scotland. To be inclusive of everyone, sexual health promotion, sex and relationship education (SRE) programmes, sexual health clinical services and other activities to promote sexual wellbeing must be culturally competent as well as addressing the impact of gender inequality on women. This means they should be:

• Linguistically appropriate, with adequate translation and interpreting service available where necessary

• Respectful of cultural and religious norms of different groups by using sensitive terminology and images

• Able to employ an adequate number of practitioners to deliver same-sex services, information and advice

At a national level, inclusiveness and respect should be demonstrated by involving relevant minority groups in the development of national initiatives that may impact on them.

A broad approach to sexual health promotion

4.5 In Scotland like the rest of the UK, there is a lack of clear, accurate information and open, non-judgemental environments in which individuals of all ages can form their views and develop knowledge about sex, sexuality and sexual health and make their own appropriate choices. As a result, there is a temptation for everyone (including health care and education providers, parents, faith organisations and government) to avoid this sensitive area. This can lead to misunderstanding and lack of knowledge and skills to achieve sexual wellbeing. ³⁶

4.6 The provision of appropriate sexual health promotion and services throughout an individual's life supports a more holistic approach to sexual wellbeing as laid out in the WHO definition ( see paragraph 2.6). There are many opportunities to achieve this including:

• Work through other policies and strategies (for example, alcohol and social inclusion)

• Use of mass communications including working with the media

• Lifelong learning including knowledge and skills acquisition

• Targeted community-based initiatives including peer education and outreach work

• Improved access to and provision of health services

4.7 Everyone involved in sexual health activities, for example teachers, health professionals, social work staff and those in the voluntary sector, has a vital part to play in enhancing knowledge, promoting key messages, and in reaching some of those who are most vulnerable to sexual ill health. This should be assisted through good quality and well resourced specialist health promotion services which have a key role in providing training, support and advice. Sexual health promotion specialists are also key in supporting community-based initiatives for targeted populations.

Recommendations

Acquiring knowledge and skills about sexual health and wellbeing

4.8 Learning about sex occurs throughout life and has many influences. What is (and is not) learnt in early life can affect later experiences. The main sources of information for young people are friends, school, media and parents. ⁴⁴ Health care professionals also have an important role to play, especially in informing adults. However, lifelong learning about sexual health is not just about providing information. It helps people develop values, attitudes and skills so that they can make appropriate choices about their sexual behaviour. Thus, having respect for oneself and others, making considered choices about sexual activity, and acquiring emotional intelligence are key learning outcomes.

4.9 Plans to improve sexual wellbeing either through learning or service provision must be developed with the explicit acknowledgement of the complex range of influences that affect people's lifestyle and beliefs. Therefore a multi-faceted lifelong approach to learning and support should be developed and delivered in an open and non-judgemental way using a multi-sectoral approach. This means involving users, families, peers, schools, tertiary education, health services, voluntary sector, faith organisations, the media, the workplace and the community as a whole.

4.10 Sex and relationships education is not just about school based programmes. It is a community and family responsibility and should involve a range of agencies that have different but complementary roles. It should be grounded in broad-based learning that builds on a wide range of life skills including self-esteem, respect for others, communication and emotional intelligence. It begins informally at an early stage with parents and carers and should continue into adulthood both within the home and at all stages of life.

The role of schools

4.11 The McCabe Report ⁵⁶ emphasised the important role that schools have in providing sex education. As the context for the education of almost all young people from ages 5 to 16, and many beyond these years, schools have an important part to play in fostering healthy attitudes towards relationships, sex and sexuality in young people. Schools, however, are just one of many influences on young people's development and schools do not have sole responsibility for education about sex and relationships; it is a community and a family responsibility. School based sex and relationships education (SRE) should be delivered in a consistent way by professionals who are specifically trained for this role and who are able support and complement the role of parents and carers as educators of children and young people. SRE should link to other relevant areas of the curriculum, such as Personal and Social Education and Religious and Moral Education, and should be co-ordinated through local school co-ordinators and designated local authority officers to ensure consistency and quality.

4.12 There is a broad consensus of most Scottish parents, teachers, professionals and leaders that sexual relationship are best delayed until a young person is sufficiently mature to participate in a mutually respectful relationship (or until marriage in the case of some faith groups). A number of schools (mainly in the United States) have adopted sex and relationships education programmes known as 'abstinence only'. The main aim of these programmes is to delay sexual activity. They may include the development of decision-making and refusal skills, but they do not teach about contraception and condom use or where to access contraceptive services. However, the evidence from these schools is that ' abstinence only' sex and relationships programmes do not lead to a delay in sexual activity or a reduction in pregnancy, and in some instances have been associated with an increase in pregnancies. ^{104;105;106;107;108;109;110} Sex and relationships education programmes described as 'abstinence plus' or 'comprehensive' programmes also aim to delay sexual activity, but combine this with skills development such as communication and negotiation skills, as well as information on sexual health services and contraception. Evaluations from 'abstinence plus' programmes have found no evidence that they encourage either earlier or increased levels of sexual activity amongst young people. When delivered effectively, these can contribute to a reduction in unwanted pregnancies especially when closely linked to services for young people. ^{1;110;111;112} Given the scale of Scotland's teenage pregnancy and sexually transmitted infection problems, as well as the levels of regret and coercion related to sexual intercourse that are being reported by young people, this strategy cannot recommend 'abstinence only' programmes for Scottish schools. The Reference Group's conclusion, like that of the McCabe Report ⁵⁶ is that 'abstinence plus' programmes are the most effective and appropriate programmes for use in Scottish schools.

4.13 The most successful sex education programmes include the following key characteristics: ^{1;21;60;113;126}

• They are multi-disciplinary and take advantage of the skills that can be provided by the range of statutory and voluntary providers in the local community (for example teachers, public health nurses working in schools, peers, health care professionals, voluntary sector staff)

• They are flexible in terms of timing and content and use a range of formats appropriate to the young people (for example small group work, computer based work and mixed sex or same sex sessions with same sex staff where appropriate)

• Teachers are supported in their role as educators through adequate training and links with the wider network of sexual health professionals in the local community

• They are integrated with relevant health care services, within the school if necessary

4.14 SHARE ^q is an example of an abstinence plus (comprehensive) sex education programme which was developed in Scotland. It is well established and is supported by a network of trainers to help with local delivery. SHARE combines active learning, information and skills development on relationships and sexual health for 13-15 year olds: it includes the recognised characteristics of effective programmes. ¹¹⁴ Findings from the SHARE trial indicate that teachers feel more confident in participating in sex education programmes following SHARE training. ¹¹⁵ Pupils also report less regret about their first sexual encounter with their most recent partner and improved knowledge about sexual health and relationships compared with other sex education programmes. ¹¹⁶ There are other programmes and resources, such as the Zero Tolerance Respect initiative ¹⁴⁷, which, though less established than SHARE, have been well evaluated. Scotland should work towards a consistent approach to SRE in all schools, which utilises these programmes as appropriate to the age and stage of young people concerned. This should be developed using knowledge and experience from research and practice and should build on existing good practice and resources that are well evidenced.

Recommendation

4.15 The values, experiences and characteristics of teachers are important to the successful delivery of school based SRE. ¹¹⁷ The benefits of the current SHARE training programme, in terms of the skills and knowledge acquired by teachers have been demonstrated. ¹¹⁵ This training should be built into the revised SRE programme. Once this is ready for implementation, the revised programme and its training should be delivered on a cross-agency basis within Local Authority areas. National guidance and support should flow from Scottish Executive Education and Health Departments reflecting a cross agency approach. This should facilitate more integrated working on sexual health matters and ensure that staff providing sexual health advice, information and education have the appropriate skills and attitudes and a common understanding of the issues.

Recommendations

4.16 Many teachers seek clear guidance on what to cover in SRE and which of the many materials they should use. ¹¹⁸ A number of schools have made progress in developing relevant school policies in line with national guidance and reflecting the views of their school community. For example, denominational schools have developed their own relationships and moral education programme which is currently being implemented (see Supporting Paper 4). Valuable progress is also being made through the Healthy Respect partners in developing an educational curriculum framework, including suggested materials (such as SHARE and Zero Tolerance), with guidance from Learning and Teaching Scotland, Her Majesty's Inspectorate of Education (HMIE) and the Scottish Executive Education Department. To date, this work has been developed in conjunction with a range of organisations based in Lothian: further development of the guidance should include inputs from all national and local agencies with an interest in this area. Healthy Respect partners, in conjunction with all key stakeholders, including relevant faith organisations, should work towards agreeing detailed guidance for everyone delivering school based SRE programmes, including attainment levels and advice on appropriate activities to be used to develop knowledge, attitudes and skills. This framework highlights the general features and key learning objectives for effective SRE as detailed in Box 4 overleaf. Whilst some of these are already being achieved, the proposed framework will help achieve all of these learning objectives.

Recommendations

4.17 Since the publication of the McCabe Report, ⁵⁶ HMIE inspections have taken place. Most Local Authorities are reviewing their practice and developing internal quality assurance processes. The forthcoming HMIE review will provide an up to date picture of the quality and standard of sex education in Scottish schools and the progress made on implementing the initial recommendations of the McCabe Report. ¹¹⁹

Recommendation

4.18 Evidence presented to the Reference Group suggests that not all children and young people have access to comprehensive school based SRE. ¹¹⁸ The implementation of the McCabe Report is part of Scotland's response to this deficit and HMIE inspections are one means of monitoring progress. However, the Reference Group believes that a more robust national and local framework, linked to supporting policies and protocols, is required to ensure further progress. This includes the development of sexual health protocols which clarify the roles and responsibilities of external agencies operating within schools. The McCabe Report supported this as a means of ensuring that everyone, including parents, is fully aware of the implications of partnership activity.

Recommendations

For teachers, implementation of this strategy will mean:

• Being supported in delivering SRE through appropriate training/continuing education and knowledge about service delivery

• Being part of an integrated team delivering school based SRE

• Having clear policy direction regarding roles and responsibilities (including confidentiality)

• Complementing parents and carers who are informed and supported as educators in sex and relationships

4.19 Some innovative out of schools programmes that aim to address the education needs of young people within and outside the school setting have been developed. ^{120;121;122;123} Such programmes link schools programmes with young people's own home or community (for example through youth clubs or work experience) and aim to address some of the wider determinants of sexual health. Peer led education, youth development and mentoring approaches offer a valuable opportunity to target harder to reach groups, including young men, young people excluded from school and those in the criminal justice system. ^124;125 Community education programmes designed to foster ownership, empowerment and involvement have demonstrated a positive impact on the wider issues affecting lifestyles, including sexual health. ¹¹³

Recommendation

Developing closer links between schools and clinical services

4.20 NHS Boards have a duty to ensure that all young people have easy, open and confidential access to holistic health services that meet their needs and cover a range of issues such as relationships with family and friends, emotional problems and general health as well as sexual health. The previous section outlined the importance of good sex and relationships education both within the family context and in schools. However, it is essential that good quality education links to, and complements, health services for young people. Evidence clearly shows that school based SRE is most effective when linked to health services offering information, counselling and health services, including sexual health services, appropriate to young people. ^{1; 20;60;126;127} The engagement exercise reported that this is not happening consistently across Scotland, although a variety of innovative approaches have been developed. For example, school nurses act as a link to a range of local services as part of their supportive role, and health services targeted at young people have been developed within established drop-ins facilities and health centres. ¹¹⁸ The Reference Group heard debate to the effect that health services that incorporate a sexual health element should never be available in schools. Others argued that, especially in rural areas, there are no other easily accessible locations. It is recognised that there is no single solution and the exact location of such services will depend on many factors and should be developed in consultation with young people and their families. There may be several possible locations. However if the school is judged the most appropriate site in terms of access and suitability, discussion should take place with local education authorities in close consultation with the school community in line with national guidance. ¹¹⁹

4.21 The Framework for Nursing in Schools ¹²⁸ builds on the broader social role of the public health nurses working in schools in providing support and counselling to young people and provides an opportunity to develop this further. ¹²⁹ Healthy Respect, through its partnership working, demonstrates the value of having the same staff provide school based services, participate in SRE programmes and deliver services outside the school because familiarity in the school context reduces some of the barriers that prevent young people seeking support.

Recommendations

Higher and further education

4.22 There is an ongoing need for learning on, and support for, sexual health issues beyond secondary school education, especially as diagnoses of STIs and other poor sexual health outcomes for 16-24 year olds are increasing. Sexual health promotion staff and staff in student welfare offices are key to supporting innovative approaches with students. The outreach work being piloted by Healthy Respect partners will highlight the need for commitment by education providers as well as providing useful pointers for further work in addressing the sexual health needs of students in tertiary education.

Recommendation

For children and young people, implementation of this strategy will mean:

• Access to a range of formal and informal learning opportunities delivered in an open and pragmatic way to help develop and maintain respectful relationships and make considered choices about sexual health and behaviour

• Acquisition of appropriate and accurate knowledge and skills so that they are able to make informed and responsible decisions about their own sexual relationships

• Having their learning delivered in a language and/or communication style that is understood and accepted by them

• Being supported by easily accessible and confidential sexual health services and other supportive services including counselling and information

Box 4 : General features and key learning objectives of school based SRE programmes

The role of parents and carers

4.23 From early years, parents influence their child's sexual values and skills. Family and home experiences impact on developing gender identity and sexuality. Good parent-child communication about sexuality can help delay young people's sexual initiation and limit adverse sexual health outcomes. ^{3;130;131;132} Talking about healthy relationships, including respect from an early age also helps children to be more self-confident to make appropriate decisions and choices about their personal life. ^133;134

4.24 Parents have a legal responsibility for the education of their children and play an important part in their lives and their development. In order that they can fulfil this role, parents and carers require the skills and knowledge to talk to their children. Young people report that parents are one of their main informants about sex even though most do not openly talk to their parents about sexual health. ^{3, 44} Parents also find it difficult to discuss sex and sexual health issues with their children. ¹³⁵ Different approaches to discussing issues and the way in which parents talk about sexuality is as important as what they say. The HEBS Think About It campaign reflects the tone and approach accepted by young people. Partnership between parents, schools and health services will promote a more consistent approach to sex and relationships education and reinforce the key messages. ^{126; 135; 137} The McCabe Committee ⁵⁶ recommended greater involvement by parents in school based sex education and schools are beginning to put this into practice but need to continue to make progress.

4.25 The active involvement of parents in SRE programmes is important because:

• Their values influence a young person's attitudes and beliefs

• They are the principal source of continuing support to a young person

• Their relationships can be closely observed by a young person

• Schools are accountable to individual parents and the wider community. ⁵⁶

4.26 Parents are diverse in terms of beliefs and values, family structure, sexual orientation and parenting styles. Work with parents has to reflect this and recognise that giving information through leaflets and newsletters is by itself insufficient. It is essential that schools promote active dialogue with parents and carers to support them in their educative role and demonstrate this in their reports to local authorities and HMIE.

4.27 Initiatives such as New Community Schools, Health Promoting Schools and Healthy Living Centres provide ideal opportunities for working with young people, parents and carers, other agencies and the wider community on sexual health. Examples of promising practice include primary school parent room initiatives and community parent programmes. These demonstrate the value of supporting parents and carers through access to information and services.

Recommendations

For parents and carers, implementation of this strategy will mean:

• Parents of the next generation being better informed and prepared to support their children in sex and relationships education

• Being an equal partner in the sex and relationships education of their children

• Having access to a wide range of information as and when they wish it

• Being supported to develop skills, knowledge and confidence in their role as educator about relationships and sexual health

• Having opportunities to improve their own awareness and communication skills around sexual health

Lifelong learning for adults

4.28 Whilst many individuals can access information and support for sexual health and relationships by themselves, a range of communication methods can help encourage a more open approach to sexual health as well as improved use of services. The proposed national mass communications strategy (paragraphs 3.15 to 3.19) and local activities will support this. For example, website access in public information sites, local learning opportunities developed by users and delivered through Community Learning Plans, and partnerships between community education, the voluntary sector and local communities.

4.29 Little is known about how to effect changes in sexual behaviour or morbidity among the general adult population. There is some evidence in relation to LGBT people ¹³⁸ and gay men, ^139;140 particularly in relation to HIV, ^102;141;142 and for unintended pregnancy in those aged 16 to 19. ^5;21;143;144 Whilst these can give some useful pointers for risk reduction interventions, the current evidence is not sufficient to guarantee that applying lessons from these interventions to different populations and in different areas will be successful. The Reference Group recommends that further research be undertaken as part of the development of a research strategy for Scotland ( see paragraph 5.27)

4.30 Targeting sexual health promotion in locations such as colleges, universities, leisure and entertainment venues has shown some success in improving sexual health knowledge and skills. ^{5;141; 145} This can be linked to information about the role of alcohol and substance misuse in reducing inhibitions and subsequent effects on sexual behaviour, coercion and abuse as recognised by the HIV Health Promotion Strategy ¹⁴⁶ and the Zero Tolerance initiative. ¹⁴⁷

4.31 Sexual harassment and discrimination can often occur in the workplace. However, the workplace can also provide opportunities for individuals to learn to respect sexuality as well as positive sexual health issues. Activities should focus on gender, homophobia, stigma and discrimination as well as "safer sex" advice and information. Sexual health is only tackled at the highest award level of Scotland's Health at Work (SHAW). This should be included at the Bronze and Silver levels. The workplace guide on blood borne viruses including HIV, currently being developed by NHS Health Scotland, will provide employers with pointers for targeted sexual health promotion.

Recommendations

4.32 Physical changes due to illness, physical or sensory impairment or ageing can have sexual implications for all ages. For older people in particular, lack of openness in this generation has been a barrier and service providers do not often acknowledge their sexual health needs. This is especially relevant in relation to sexual dysfunction issues and the increased availability of impotence therapies. Opportunities to encourage openness and improve knowledge about sexual health and service options should be incorporated into staff training programmes and health promotion initiatives for all ages, particularly for disabled people and older people, including those in residential care.

4.33 The different experiences and knowledge of younger people and older lesbian, gay or bisexual (LGB) should be recognised in lifelong learning programmes. Many older people did not have the opportunity to "come out" in their teens or twenties, the age, which is typical for today's generation. This has resulted in a much harder to identify group of older people who are LGB with significant difficulties for them to access information and services.

4.34 People with learning disabilities may need support to express their sexuality and this should be offered in a non-judgemental way. Service providers should be aware of the sensitivities involved and be equipped to help people with learning disabilities express their feelings and needs, for example through the use of appropriate leaflets, communication aids and active learning activities. Where someone else presents their views, care must be taken to ensure that this adequately reflects the individuals needs and wishes.

Recommendations

The role of sexual and reproductive health services

4.35 Lifelong learning about relationships and sexual health must be complemented by accessible, confidential and appropriate clinical services if sexual health is to improve. Many different providers offer a range of sexual and reproductive health services in Scotland, some specific to sexual and reproductive health and others as part of broader health care provision. ^{2, 118} As well as responding to sexual ill health, advice, counselling and support to help individuals maximise their sexual wellbeing play an important part in such service provision. This ranges from simple issues such as choosing the appropriate method of contraception in line with lifestyle to more specialised psychosexual counselling and relationships support.

4.36 There are many examples of good and innovative sexual health services across Scotland. However, there are also wide variations in terms of availability, quality and choice and a number of recognised challenges that limit the impact of these services. (see Box 5). ^2;118 Confusion or lack of knowledge about sexual health or about the range of available services may discourage or delay attendance and result in poor treatment of, or ineffective protection from, preventable sexual ill health problems. There is also a service ethos that does not often acknowledge the broader social and cultural determinants of sexual health and this may reinforce a stereotypical response, for example, targeting screening for chlamydia at women when the evidence indicates that men are just as significant transmission sources. ^{148; 149}

Box 5: Challenges currently facing sexual and reproductive health services

4.37 This strategy seeks to address these challenges with a more cohesive, seamless approach to clinical services and proposes two new distinct but complementary developments to achieve this:

• The first is the creation in each NHS Board area of an integrated tiered service approach for clinical services . A Lead Clinician will support and oversee the provision of specialist clinical input, locality-wide adoption of protocols, data collection, training and the general integration of clinical services.

• The second is the creation of a broader managed sexual health network in each NHS Board area, which encompasses a wider set of sexual health interests over and above clinical services. This network will be overseen by the Director of Public Health and managed by a Local Sexual Health Co-ordinator. Further detail on this managed sexual health network is given in section 5 ( paragraph 5.7).

Recommendation

« Previous | Contents | Next »