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Enhancing Sexual Wellbeing In Scotland: A Sexual Health Relationship Strategy

The wider factors influencing sexual health and wellbeing

1. Introduction

1.1 Supporting Paper 1 has briefly outlined sexual attitudes, knowledge, behaviour and sexual ill health of people in Scotland. This paper presents further detail about the rationale underpinning the proposed strategy. It presents evidence which clearly indicates that wider social and cultural influences have a considerable impact on both attitudes to sexual health and actual behaviour. Further, that rather than view the wider social context as an 'add-on' to a strategy which is primarily concerned with reducing pregnancies and sexually transmitted infections (STIs), the opposite approach should be taken. This paper advocates a socially-orientated approach which acknowledges the significance of social and cultural factors from the outset and develops the strategy accordingly.

1.2 Scotland is an increasingly sexualised society. Sexual imagery pervades many aspects of the environments in which we live. Other countries, such as the Netherlands and the Scandinavian countries have experienced similar changes in their societies, ¹ but do not have the same burden of sexual ill health. ^2;3 The reasons are multi-factorial and more research is required to reach a better understanding. However, it has been suggested that, unlike these countries, the UK (including Scotland) has failed to appreciate the importance of the social and cultural environment on sexual behaviour and sexual health and, as a result, has failed to adequately equip its population, and particularly its young people, to cope with this new world. ¹

1.3 This strategy has adopted a holistic approach to sexual health, and the Reference Group endorses the World Health Organisation (WHO) definition as:

" A state of physical, emotional, mental and social wellbeing related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled."^a

1.4 Attitudes, expectations and behaviours relating to sexuality and sexual behaviour, as well as the range of sexual health outcomes, are significantly influenced by social and cultural factors. These include socio-economic circumstances and the inequalities these cause, family and parents, gender, sexual stereotypes, ethnicity, faith perspectives, and the media. These influences are explored in more detail in this paper and in Supporting Paper 3 which explores the influence of the media and mass communications.

1.5 Social policy often develops in response to what is happening in society, but it also has an important part to play in leading change on some issues, for example, encouraging widespread use of seatbelts when driving. If we accept the significance of the social context in affecting sexual health this implies the importance of the social policy and legislative framework. Given the link between sexual health, social context and the social policy and legislative framework, it is apparent that sexual health issues cut across many policy arenas which are often out with traditional health fields, for example education and social inclusion. For these reasons an integrated 'joined-up' approach which links the implementation of the sexual health strategy to other related policy areas is vital at both local and national levels.

1.6 A socially orientated approach must also inform the design and delivery of services. This means moving away from an individualistic approach where the emphasis is primarily on the delivery of health services relating solely to the physical outcomes of sexual intercourse. In terms of learning, a socially orientated approach will focus on placing the physical aspects of sex in the broader context of emotions and relationships.

1.7 The determinants described in this paper are not separate and distinct. Many impact on or influence others, for example, societal views of gender can be reinforced within families and the roles that parents adopt. However, for ease of comprehension, the factors are set out in individual sections.

2. Socio-economic status

2.1 Health inequalities are clearly seen in sexual health; those with lower incomes and socio-economic status have poorer general health, including sexual health, than those who are more affluent. ^b1;2;4;5;7;8 Lower social class is associated with an earlier start of sexual activity ^4;9;10 which in turn is linked to subsequent regret, ^11;10;12 less protection against conception and STIs, and more subsequent sexual partners. ^10;13;14 Higher levels of deprivation are associated with less consistent contraceptive use ¹³ and a higher risk of teenage pregnancy. ^{5; 13;15;16} The subsequent outcome of teenage conception varies significantly with more young women from lower socioeconomic backgrounds opting to continue their pregnancy than those from more affluent families. ¹⁷ There is little information about teenage fathers but what there is suggests that those who became fathers before the age of 22 are more likely to come from lower socio-economic groups. ^{6; 16;18;19}

2.2 The geographical distribution of teenage pregnancy confirms this link. Research has found that, in Scotland, those in the poorest areas have conception rates three times higher and birth rates up to ten times higher than those in the most affluent areas. ^{5; 17; 20} This difference increased during the 1980s and 1990s. ⁵

2.3 Low socio-economic status has also been associated with certain STIs and HIV. ¹³ The first HIV epidemic in Scotland was amongst injecting drug users in deprived areas of Edinburgh and Dundee, with the potential for subsequent sexual transmission. Men who have sex with men with lower socio-economic status appear to be more susceptible to sexual ill health than those from more affluent backgrounds. ^21;22 However, although gonorrhoea rates have been shown to be associated with deprivation in London ²³ and Leeds, ²⁴ in both cases ethnicity was a far more important factor, and a recent survey found that chlamydia infection did not vary by social class. ²⁵

2.4 Access to the means to maintain sexual health is important and sexual ill health may in part be explained through difficulty in accessing services especially for those in areas of higher deprivation. However, motivation to maintain sexual health is necessary and evidence suggests that educational and cultural factors are particularly influential and potentially more significant. ^{2;5; 14}

Economic factors and education

2.5 Teenagers from areas of higher deprivation tend to have lower expectations about educational achievement and the benefits of education. Lower expectations and attainment are associated with earlier onset of sexual activity and lower rates of contraceptive use. ^{3; 14} Good educational and employment prospects are associated with higher contraception use and less risky behaviours. ¹⁸ In women, higher levels of education are linked to fewer unwanted pregnancies, fewer babies with low birth weight, and lower rates of infant mortality. ^{2; 26} In addition, girls whose educational achievement declines between the ages of 7 and 16 are at greater risk of teenage parenthood. ²⁶ A substantial proportion of young women who are looked after have a child by the age of 16 and nearly 50% become mothers within 18 to 24 months of leaving care. ^{2; 77}

2.6 Pregnancy and parenthood are positive choices for some young people. However, teenage parenthood is all too often associated with lifelong economic, social and health consequences for both the mother and child and is therefore of considerable social and political concern. 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. ^{5; 14} The incentive to avoid early parenthood stems from having a stake in the future, a sense of hope and an expectation of inclusion in society. ¹ This reinforces the importance of addressing problems in the wider economic and social environment that contribute to the poor life circumstances and dearth of opportunities that exist for the most deprived people in Scotland.

Economic factors and culture

2.7 The role of education as a mediating factor between economic disadvantage and poorer sexual health outcomes may be primarily through its influence on culture. The sexual values and skills of teenagers tend to reflect their community and their socio-economic status. ²⁷ Deeply held cultural beliefs about gender roles in society which encourage sexual risk taking by men and female responsibility for sexual behaviour and sexual health are also an important aspect of this. ²⁸

2.8 Since 1997 the Government has made significant progress in addressing social exclusion and deprivation ^{29; 30;31} and, as part of this, reducing teenage pregnancy is identified as important. ³¹ Sexual health specific health promotion or health care programmes in areas of deprivation are more likely to be effective if they are delivered alongside these broader social inclusion initiatives. It is therefore important that holistic, socially oriented approaches are taken to addressing teenage pregnancy and rising STIs and that the different policies and strategies aiming to combat deprivation and associated problems support each other.

3. Parents and family influences

3.1 Parents and families are fundamental in the development of sexual values, attitudes and skills, as well as in influencing sexual behaviour. ³² Parents influence developing attitudes to sex and to gender identity, which build foundations for different styles of sexuality, and the family provides a moral and value framework which influences sexual conduct. ³²

3.2 Communication about sexuality in the family is likely to increase teenagers' knowledge about sexual health, enable them to communicate more effectively with a sexual partner, and to consider, plan and implement safer sex strategies and more responsible decision making about sex. ^32;33 Evidence has shown that most parents feel that they have a responsibility to discuss sex and sexual health with their children. ³⁴ However, many find this difficult and only half of these parents will actually do so. ³⁴ Even then, discussions with daughters are more likely than with sons. ^{16; 34;35}

3.3 Families in Scotland vary in terms of, for example, ethnic background, sexuality, values and beliefs. Family structure in Scotland is also changing, for example the 2001 census recorded more people as never married and living alone, a slight increase in single parent families, and found that dependent children are now more likely to be in lone parent or cohabiting couple families than in 1991. ³⁶ These changes should be reflected in policies and services, such as Children's Services, in order that they are appropriate and inclusive.

3.4 Associations have been found between family composition and sexual risk- taking. ^37;38 Children from families where both biological parents are present are least likely to be pregnant by 18 years of age ³⁷ or to have high numbers of partners at 15 years. ³⁹ Teenage pregnancy is linked to family history, with the daughter of a teenage mother estimated to be one and a half times more likely to become one herself thus repeating the risk of lifelong socio-economic disadvantage. ^{15; 26; 40;41}

3.4 Sweeting et al. concluded from their own longitudinal data that "school achievement, heterosexual behaviour, pregnancy and experience of drugs were each related to family structure" but that the effects of family structure must be understood in relation to the effects of family processes, and that the latter are probably more important. ³⁷ Important processes include time spent together in family activities, parental support, parental monitoring (in terms of control or restrictiveness), and minimising family conflict. ^{11; 34;37; 42} Young people who report more emotionally available parents were more likely to have intimacy orientated attitudes toward sexual relations, as opposed to physically oriented attitudes, which is linked to delays in first intercourse, higher levels of prior discussion of, and use of, contraception. ³⁴

3.5 Whilst family and home influences can be positive and provide building blocks for establishing and managing relationships and sexual behaviour, the family can also be an unsafe place for women and children if they experience violence, sexual abuse or child abuse. Support is necessary for those who are abused in order to minimise future health and social problems. The National Strategy on Violence Against Women ⁴³ and the linked NHS Guidance on Responding to Domestic Abuse for Health Care Workers in NHS Scotland ⁴⁴ are attempting to tackle this. Implementation should be linked to implementation of this sexual health strategy.

4. Gender

4.1 Although opportunities for women have increased in the last few decades, societal differences between women and men still continue and are often seen as natural. The way society is organised based on notions of men and women, and the resulting economic, social, cultural and domestic behaviours and roles, is critical to sexual attitudes and behaviours. As discussed in the section above, gender roles and stereotypes are learned from infancy through one's family and the wider society, and have an important effect on developing sexuality and, in turn, on sexual behaviour. ³³

4.2 Individual attitudes and sexual norms are learnt differently according to one's sex and gender. ^45;46 There is a dominant view that teenage pregnancy, for example, is primarily a problem of girls. The responsibility of boys is downplayed considerably. ^{28; 33} This is reinforced by the paucity of evidence about teenage parenthood and boys. ¹⁸ In part, this has followed the policy lead as funding for research is largely driven by national and local policy.

4.4 Gender stereotypes are very persistent and throughout adolescence and adulthood people are under social pressure to conform to gender-specific sexual roles that are particularly promoted through the media. ^47;48 Cultural stereotypes tend to suggest that femininity is 'passive' and that women should learn to act in the way men expect, whilst also taking responsibility for protecting themselves and others from risk. Masculinity, on the other hand, is 'active' and involves taking risks and that 'maleness' means that the sexual act is more important than the relationship. ³³ The tendency is for young women to experience sexual activity as part of how they relate to boys and gain approval and social acceptance, while young men experience it as a form of achievement. ^{28; 45;46} Boys who do not fit the dominant stereotypes are often subject to homophobic attitudes. ^{49; 50;51}

4.5 There are significant gender differences in relation to whether or not first sexual intercourse was reported as being 'wanted'. A significant proportion of first sex is unwanted, the proportion being greater the younger the age. ⁵² However, more young men report that their partner was 'equally willing' at first sexual intercourse than young women. ¹¹ More young women than young men report that sexual intercourse either happened too early or shouldn't have happened at all ¹² and report feelings of regret. ¹⁶

4.6 In terms of coercion and consent, being 'forced' at first sexual intercourse is more common for women, especially if first sex occurs before 14 years of age, ^{11; 52;53} ranging from 2% ⁵³ to 7%. ¹¹ When asked if they had come under pressure to have sex this rises to between 20 and 25% of girls.

4.7 Gender also appears to be a significant factor in relation to contraceptive use. Young women are expected to, but often find it difficult to, negotiate the initial use of contraception and to maintain the use of contraception once relationships become more established. ^{47; 54;55} This is reflected in the way that information and services tend to be delivered; despite growing recognition of the inappropriateness of treating women as the guardians of sexual health and fertility, sexual health promotion, school-based sex and relationship education and sexual health services tend to focus on protecting women from the consequences of sexual activity. ³³ The importance of boys and young men protecting their own, as well as their partner's sexual health, has not been a priority. ²⁸ This reinforces stereotypes about women as being both passive in sex, sometimes having little choice, yet being active in assuming responsibility for herself and others, and excludes and disempowers men, perpetuating deeply held negative cultural beliefs about their roles and responsibilities within relationships. ⁵⁶

5. Sexual stereotypes: homosexuality and heterosexism

5.1 Despite increasing acceptance of diversity in many forms in society, lesbian, gay, bisexual and transgender (LGBT) people continue to experience social exclusion and prejudice as a result of discrimination on the basis of their sexual orientation. This is still widely seen as acceptable in Scotland, ¹⁶ as was demonstrated in the reaction to the repeal of Section 2A of the Local Government Act 1986. ⁵⁷

5.2 Fear or dislike of homosexuality in others or oneself (homophobia) and the assumption of heterosexuality as the norm in sexual relationships (heterosexism) create stigma and discrimination. This can lead to feelings of isolation, stress and anxiety for LGBT people ⁵⁸ and create unnecessary divides in society. ⁵⁹ LGBT people are themselves a diverse group with other social determinants impacting on their lifestyle and health such as disability, race, ethnicity and economic factors which can compound their isolation.

5.3 Being excluded from society has an impact on many aspects of the lives of LGBT people, including health, substance use, homelessness and suicide. ^60;61 Migration of LGBT people from rural and suburban areas to urban settings that have a 'gay scene' is a common occurrence but may well add to, rather than reduce, social isolation. Young LGBT people are more likely to engage in risk taking behaviours in response to their social isolation and vulnerability. ⁶² These young people also fear they will not fit into the gay scene and this results in added pressure and impact on mental health. ⁶³ The perception of many of these young people is that homophobia makes them into second class citizens.

5.4 Access to services is difficult for a number of reasons, including risk of identification as being LGBT, lack of appropriate services especially in rural areas, attitudes of health service staff, etc. In particular, services for gay and bisexual men may perpetuate inequality as they tend to focus on sexual health and ignore other aspects such as mental health. ⁶² Lack of services is particularly pertinent for lesbians, as emerging data show higher or similar prevalence of STIs compared to women who have not had sex with women. ⁶⁴ A recent review of the impact of homophobia, heterosexism and social exclusion on the health of LGBT people concluded that the health of LGBT people is largely ignored both by health care services and within the inequalities policy agenda in Scotland. ⁶⁵ However, there are broader moves at the UK and Scottish policy levels to address inequalities experienced by lesbian and gay people, for example improved protection against discrimination on the grounds of sexual orientation.

5.5 Social, school and personal attitudes lead to constraints in dealing effectively with same sex relationships in school based sex and relationships education. ⁶⁶ Supporting Paper 4 discusses education for young people in more detail. Whilst not all teachers or schools are homophobic, a heterosexist assumption underlies Scottish sex education and this perpetuates the invisibility of LGBT sexuality. ⁶⁶

6. Ethnicity and faith

6.1 Little is known about the sexual health needs and outcomes of those who belong to black or minority ethnic (BME) communities as ethnic group information is not collected for routine figures on sexual health. People from BME communities face discrimination in many aspects of their lives, and a lack of information about minority sexual health is also discriminatory because important problems may be ignored. ⁶⁷ However, since there tends to be greater proportions of young people in BME communities than in Scotland as a whole, and young people tend to be more sexually active and thus more at risk of poor sexual health outcomes, there is a need to address sexual health issues with these communities. ⁶⁸

6.2 In addition to the lack of data on BME communities, there are also different cultural expectations and attitudes which may make it difficult to access these groups. The dominance of 'mainstream' cultural values may result in the marginalisation, stigma, and reluctance to access appropriate health services for people from minority groups. Cultural and religious attitudes to sexuality and marriage from within certain ethnic and faith groupings may pose tensions, particularly for those young people who face dissonance between the dominant social norms and those of their family or faith group. ⁷¹

6.3 Evidence from a number of small scale studies suggests that people in some BME communities lack knowledge and have limited access to appropriate and relevant information about sexual health. ^67;68 BME communities are often grouped together but there are vast differences in cultural expectations, attitudes and experience of the sexual aspects of life both between and within these groups. For example, age at first intercourse varies considerably between ethnic groups and shows pronounced gender differences, ⁶⁷ and there are some indications that teenage pregnancy and STIs are more likely in some minority ethnic groups. ^{15; 22; 69; 70}

6.4 Recent epidemiological reports indicate a high prevalence of HIV among people in Scotland who have links with Sub-Saharan Africa. ^72;73 Trends in high prevalence areas globally will be reflected in Scotland, including Scottish residents as well as other more transient communities such as workers from overseas, asylum seekers, and students. Issues related to HIV and other sexually transmitted infections can be particularly difficult for BME communities in Scotland, especially with regard to stigma and discrimination as well as the inaccessibility of many services. Clinic and community approaches need to adapt to meet the needs of these communities. This will require activity at national level to identify need and to encourage adoption of promising and good practice. Work will also be required at a local level to build and strengthen the capacity of HIV and sexual health agencies working with BME communities. Ideally HIV and sexual health issues will be integrated with those of minority ethnicity.

6.5 NHS Fair For All is a major initiative that is seeking to address inequalities experienced by BME communities within the NHS in Scotland ⁷⁴ but has yet to tackle sexual health issues.

7. Disability

7.1 The term 'disability' describes the social exclusion that prevents people with a range of physical, intellectual, sensory and psychological impairments from having full and equal citizenship. ⁷⁵ Disabled people are sexual beings with sexual and emotional needs and desires. However, their sexuality is often ignored, stereotyped or distorted, which may lead to the development of low expectations about sexual relationships and impact up on their self-esteem.

7.2 The sexual health experiences and needs of disabled people are varied and complex, and issues will vary from individual to individual. In promoting the sexual health of disabled people, professionals should have regard to the person and not the impairment. Resources should contain practical information that is specific and appropriate and is in an accessible format for those with sensory impairments and/or intellectual difficulties.

7.3 The overall objective should be to integrate people with physical and learning disabilities more effectively into sexual health services from which they are all too often excluded, and for society as a whole to recognise and respect their right to express their sexuality. ⁷⁶

8. Improving sexual health for everyone, including those needing additional support.

8.1 This paper has briefly discussed the broader social issues influencing sexual health and, in particular, how they relate to some groups in Scotland. From this discussion various barriers to sexual wellbeing can be identified. These can be categorised as:

• individual barriers, such as knowledge, attitudes, lack of competence or confidence;

• physical barriers, such as distance, cost or accessibility;

• social barriers, including staff attitudes and skills, and parents' and teachers' unwillingness to discuss sex with young people; and

• cultural barriers, which include unwillingness to accept young people's sexuality, the gender roles that influence sexual behaviours, and the influence of faith perspectives, culture or ethnicity.

8.2 Many groups face one or more of these barriers and some of these groups have been addressed earlier in this paper. These include, but are not limited to, young people, those with physical or learning disabilities, people living with HIV, LGBT people, those from BME communities, homeless people, victims of domestic abuse, and men and women in prostitution. ^c Barriers are likely to have the greatest impact on those who are most disadvantaged in society.

8.3 If the barriers are recognised and addressed when planning local services for lifelong learning and health care the sexual health of many in these groups will be improved, for example, by improving the consistency, accessibility, quality, cultural competence and ethos of lifelong learning and appropriate and responsive sexual health services. However, there are a number of groups whose sexual health is of particular concern (for whom STIs are increasing and/or unintended pregnancies are high), or those who are particularly hard to reach, for whom additional support will be required. Respondents to the engagement exercise suggested a number of target groups. ^d 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, and those involved in crime ^{18; 26; 77;78}

• Children of teenage mothers, particularly daughters ^{15; 79}

• Male and female prostitutes ⁸⁰

• Men who have sex with men ^{22; 78}

• Those who have travelled from Sub-Saharan Africa and other areas of high HIV prevalence ^{22; 72;78}

This list is neither comprehensive nor exhaustive as the current evidence has many gaps. It should be reviewed as further evidence and information emerge.

8.4 Targeting may not require newly developed or sexual health focussed services; appropriate responses may be to increase the scope of existing services or organisations that are already successfully reaching target groups. These organisations can incorporate basic sexual health information and services either by training the existing staff or by providing specialist outreach. Innovation should be encouraged in reaching the hardest to reach. Specialist services, however, must link with other local services and provide opportunities for referral between services. In all cases care must be taken to avoid reinforcing the isolation and stigma already being experienced.

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