The Scottish Government

« Previous | Contents | Next »

Listen

[ Previous] [ Contents] [ Next]

Enhancing Sexual Wellbeing In Scotland: A Sexual Health Relationship Strategy

Supporting Access to Clinical Services and Reaching Those in Need of Services

1. Introduction

1.1 This paper complements Supporting Papers 5A and 5C by setting out the issues which sexual and reproductive health services are seeking to address and gives pointers on the review level and practice based evidence to support further practice and the proposed Sexual Health and Relationships Strategy.

Issues Relating to Access

2. Service Configuration

2.1 How services are delivered and the attitudes and outlook of the staff who deliver the service is important for all age groups but particularly so for young people and other vulnerable populations as identified by the Scott Porter review (Butler and Solomon 2002) and by Hosie (2002). Evidence from the Healthy Respect demonstration project (Annual Report 2001) and other initiatives indicates that access to same sex GPs and nurses and nurse led services can influence the outcomes of interventions (Peersman, 1996, Burack 2000, Allen and Hippesley-Cox, 2000). Dehne (2000) found that the integration of STI education for prevention and counselling had a positive impact on user satisfaction and family planning acceptance.

2.2 Butler and Solomon (2002) and Hosie (2002) identified accessibility and acceptability as important issues for those sexual and reproductive health services. Glasier presenting evidence to the HEBS Young People and Sexual Health Seminar cited evidence demonstrating the links between increased contraceptive use and dedicated young peoples services (Glasier, 2002). Allaby (1995) and Clements et al (1999) also demonstrated the value of location to enhance service uptake. Furthermore services might not be viewed as being applicable to both sexes - men view sexual health services being targeted towards women only (HEBS 2002, Gelder 2002). Although there may be a wide range of services (and in different settings) available, they are not always accessible to those who need the service, for example opening times, geographic locations, premises, (due in part to lack of funding resources). Service providers should also recogngnise and reflect the service needs of different life stages of their user population. Older people did not wish to attend family planning services as their needs were beyond the reproductive life stage.

2.3 Hughes and McGuire (1996) found that general practitioners were among the most accessible and available health providers for young people and the most cost effective way of delivering contraceptive services. Sengupta (1998) found that whilst the majority of general practitioners in Scotland were willing to provide contraceptive advice to under 16s, fewer were prepared to provide treatment and of those only half were willing to refer the young person onto further services. This study also found that GPs from minority ethnic communities trained abroad were less likely to provide advice and/or treatment but were willing to refer patients to other services. Burack (2000) also found that attendance was dependant on staff attitudes, staff knowledge of the rights of young people in accessing services, user perception of how confidentiality was dealt with and the availability of same sex practitioners. This supports the findings of the review of sexual health services in Scotland (Butler and Solomon 2002).

2.4 Butler and Solomon (2002) also identified five different models of service provision and examples of promising practice including one stop shops, generic drop in centres and integrated service provision, some involving co-location and others with clear integrated care pathways and referral protocols. Whatever service configuration is adopted, it should reflect the needs of the local population.

Responding to the Needs of People from Black and Minority Ethnic Communities

2.5 There is evidence to suggest that some BME populations are more at risk of STIs or teenage pregnancy compared to others and do not access services. If high risk BME groups have poor access to appropriate services, then infections will persist within these groups with the burden of resistant sequalae. As with other at risk groups, sexual health service providers and sexual health promotion specialists should ensure that their services are sensitive, acceptable and accessible to their local minority communities. Culturally sensitive and innovative approaches to preventing disease will be critical and services will need to be targeted without stigmatising affected communities. This will mean that BME communities should be involved in planning and implementing services and where appropriate be represented on local inter-agency sexual health strategy groups.

Responding to the Needs of Men

2.6 Responding to the high rates of teenage pregnancy depends on increasing the involvement of boys and young men in decisions about relationships, contraception, sexual health and pregnancy. Although the number of men attending contraceptive services has increased in recent years, they still form a small proportion of overall attendances. Guidance from the English Teenage Pregnancy Unit and the review of Boys and Men's Health (Lloyd, 2002) provide useful pointers on ways of working with boys and young men - for example using one to one consultations, drama and theatre activities, offering incentives and sport activities and outreach work in conjunction with other services.

2.7 Gender is an important factor determining the source of health information used. In examining young men's use of sexual health services, Biddulph and Blake (2001) found that the average young man was unlikely to access any help or support at all if he had a problem. Staff attitudes and lack of choice of male practitioners might also be a factor in the decision whether to seek help (Banks 2001). A number of examples of promising practice were highlighted during the engagement exercise undertaken as part of the proposed Sexual Health and Relationships Strategy: these included the Health Opportunities Team in Lothian, the Men's Health Forum and specialist sexual health workers for men based working with Ayrshire and Arran NHS Board. Work being undertaken by fpa Scotland will provide further practice-based evidence of what works with young men who live in areas of deprivation in Scotland.

Gender Issues

2.8 In developing services, providers need to be aware of health limiting behaviours often pursued by males and in particular their learned gendered behaviour. The latter suggests that men should be sexually experienced and competent, are the dominant species, and should conform to stereotypes, especially in relation to sexuality. In addition showing emotions is viewed as "feminine" and may cause problems with intimacy. In some ways, current services perpetuate these myths by focussing sexual health information, advice and services at women and these must be tackled if this imbalance is redressed. No single intervention or approach will work: a multi faceted approach starting at an early age through fathers talking with their sons (and daughters) about relationships and sexual health and continuing through adulthood would be a start. Ingham (2002) also suggests that gender variations are more pronounced among families in deprived areas thus suggesting an initial focus for such work. Duncan (2002) proffers that there may be gender differences in perceived responsibility for sexual health but more research is required to understand the relationship between perceptions of masculinity and attitudes to sexual health.

3. Improving links between services and schools

3.1 Supporting Paper 4 outlined the range of sexual health and relationship education (SRE) interventions for children and young people. Evidence indicates that SRE is more effective when linked to contraceptive and other sexual health services (Hosie 2002, Swann et al 2003). The variety of ways in which schools are working to improve pupils' access to services can be seen as a continuum of involvement ranging from improving information on sexual health services supported by effective signposting and referral systems, to having daily access to multi agency support services on site. This continuum should demonstrate an appropriate response to local need. Whether services are provided in school or in the wider community with better links to schools is dependent on a number of factors. The school is part of a local community and it is the local community as a whole that needs to ensure young people have access to confidential, respectful and professional support services. The key to getting it right for young people is to ask them what they need. The Community Schools Approach presents an opportunity for moving forward the sexual health agenda in a community context. It provides a framework which focuses in a holistic way on young people, families and the community and addresses aspects of social exclusion.

Increasing information in and around the school

3.2 Public health nurses working in schools are a source of information and advice about what services are available and how to access these. In addition to information provided as part of the sexual health and relationships education programme, examples from England have suggested that posters on student notice boards, information in student welfare booklets and general leaflets are useful ways of informing pupils of all health services, including sexual health services. Dedicated young people's telephone helplines in schools as provided in Sweden and Southampton has resulted in an increased number of students using services. (Nash 2000)

Visits by external agencies as part of a planned programme of SRE

3.3 Input by agencies outwith the education sector in classroom SRE sessions can add value by:

• providing accurate up to date information on contraception, sexually transmitted infections, service access

• making local services visible to and making contact with groups of young people less likely to access services (for example young men)

• dispelling myths, addressing misunderstandings, reducing fear of the unknown and reassuring young people about key issues such as confidentiality and physical examinations; and

• providing a bridge to services by introducing a named contact and a familiar face

3.4 This has been shown in the work undertaken by Healthy Respect where there has been improved uptake of services where the same professional provides input to SRE and provides local services.

3.5 Health professionals also play a crucial role in awareness raising, training and supporting school staff, through informal discussions in the staff room, through team teaching and in more formal opportunities for staff, parents and school board members. Working together can help develop shared teaching goals and strategies to provide young people with the knowledge, understanding and skills to be able to access services.

Pupil visits to Sexual Health Services

3.6 Some SRE programmes include visits to community based clinics and evidence suggests that this improves both knowledge about services and future uptake. Hosie identified the value of this in Sweden and Nash reported that planned visits to sexual health services, particularly when linked to telephone access exercises was effective in improving knowledge about service location and facilities and improved likelihood of service use. Jackson and Plant (1997) report on the success of mock sexual health clinics provided as part of SRE. Based on the Swedish model of collaboration between teachers, school nurses and sexual health staff (Sex Education Matters pp 4-5, 2003), they report an increase of 30% of under 16 pupils accessing community family planning clinics after the first pilot year. Forrest et al (2002) assessed the benefits from developing a peer-led education approach in raising awareness of sexual health services: this has been well received by students, teachers and health professionals.

3.7 A number of mobile sexual health services have been established in England. Given the geography of Scotland, there may be merit in exploring this further. Barna (2002) identified the following benefits from mobile services:

• Staff can meet young people in a range of settings including schools, parks, housing estates and youth centres, increasing access to support those reluctant to attend mainstream services

• Mobile provision increase cost effectiveness and sustainability of local sexual health services when suitable venues are provided by partner agencies and organisations such as schools

• Schools and other locations with limited space do not have to provide secure storage facilities

• Young people may have more confidence in confidentiality as seen as separate from school

• Rural young people's needs are better addressed.

4. Confidentiality

4.1 Whilst most services would subscribe to providing confidential services, feedback from the engagement process suggests that users do not perceive services to be confidential and that there is much confusion among professionals about the scope of confidentiality. This especially applies to services in remoter areas and services for young people. The latter must be guided by professional standards and relevant legislation such as The Children Act, the European Convention on Human Rights and the Human Rights Act. For those vulnerable adults over sixteen the Adults with Incapacity Act also may be relevant.

4.2 Although the age of consent is 16 and some young people under this age will engage in consensual sexual activity, the issue of potential child sexual abuse has to be considered. This is sometimes contentious, particularly in terms of information disclosure to other professionals. For professionals working in the NHS, issues relating to disclosure are relatively clear. Young people under the age of 16 who are able to fully understand what is proposed and its implications are competent to consent to medical treatment. If a young person is not judged competent, consent from a parent or carer with parental responsibility is necessary. Whilst it may be preferable that a young person attending a sexual health service has the support of a parent or carer, this might not be a reality. In these circumstances, the young person's wishes, views and confidentiality should be respected. Reddy et al (2002) found that more than half of young women under 18 years would stop using all sexual health services, delay testing for pregnancy or STIs or discontinue specific services if parental notification become mandatory.

4.3 Feedback from the engagement process indicated that individuals tended to use GUM and family planning services as opposed to other services given the experience of these services in dealing with confidentiality tended to inspire greater confidence in users compared to other services. This same confidence needs to be nurtured in primary care if fears about lack of confidentiality are not an obstacle to the role primary care can play in the tiered service approach. With this in mind, the proposed Sexual Health and Relationships Strategy recommends that clear messages about HIV testing and insurance issues should be made nationally and that procedures should be put in place to enable anonymous laboratory test requests from all referrers (the latter is discussed in section 5 on anonymity of testing).

4.4 A number of tools are available to help with confidentiality issues:

• Guidelines on the management of suspected STIs in children and young people have been developed by the UK Specialty Association for Genito-urinary Medicine and the Medical Society for the Study of Venereal Diseases (Thomas et al 2003): these would be of benefit to Scottish practitioners, although the legislative differences in Scotland would have to be borne in mind

• Healthy Respect has prepared a series of confidentiality guidelines for young people, parents, and service providers.

• A toolkit by the Royal College of General Practitioners has been produced for use in exploring confidentiality issues with staff (RCGP 2003).

4.5 Consideration should be given to the lessons learnt from this work and the usefulness of these guidelines as a template for the rest of Scotland.

5. Anonymity of Testing

5.1 In the main, adults over 16 are guaranteed confidential sexual and reproductive health services. However, in some circumstances, for example termination or primary care services, users would prefer anonymity in terms of testing and reporting records. A range of options were explored to address this:

• Maintenance of the status quo: GUM departments currently use an anonymous clinic number system for case notes and laboratory samples whilst all other practitioners use names and addresses. Feedback from agencies working with people living with HIV and AIDs suggest that this may prevent individuals from accessing GP services;

• Practitioners operating in Tiers Four and Five to use GUM type numbers. Whilst extending the anonymity boundaries, this could lead to potential confusion, for example GPs providing a Tier Four service would use the anonymous system for sexual health services but use names and addresses for non sexual health situations

• All samples for STIs taken by any doctor or nurse could be given an anonymous care numbers with the results being stored separately from other records. A bar coding system could be employed. With the advent of computerised records, this would allow the sexual health records to be subject to higher level access and thus only available to the appropriate health care practitioner.

5.2 The proposed Sexual Health and Relationships Strategy recommends the adoption of last option but recognises that currently there may be practical difficulties in implementing this, not least acceptability by service providers and laboratories. Two short term pilot projects on anonymous bar-coding and diagnostic test kits for STIs to assess user and patient acceptability, the impact on laboratory services and identify IT resource requirements should be funded by the Scottish Executive: one of these projects should be managed as part of phase 2 of Healthy Respect and the other involving a remote rural GP practice.

5.3 In respect of requests for laboratory tests, the Sexual Health and Relationships Strategy proposes that these should be anonymised regardless of referral and that NHS Boards should ensure uniformity of recording of patient details across all providers (and thus address anomalies between GUM and primary care record keeping).

6. Sexual Dysfunction

6.1 It is recognised that many professionals working in the field of sexual and reproductive health can identify individuals who would benefit from support and intervention in relation to sexual problems. Feedback from the engagement exercise suggested that across Scotland, service provision was patchy, those services that were available were overstretched with long waiting lists and that individuals requiring support did not always have their needs recognised or be referred to the most appropriate service. In addition, the Reference Group was concerned that the location of these services may add to the stigma that prevents individuals seeking help: for example services located in psychiatric and gynaecology departments may promote the message that such problems are easily fixed, for example through the increased availability of drug therapies for erectile dysfunction. Nevertheless, there are examples of promising practice: for example in Forth Valley the voluntary sector supports the need of patients with sexual dysfunction problems (although funding limits the scope of support available).

6.2 In addition, there is also a need to educationally support health care practitioners in their knowledge and awareness of the issues surrounding sexual dysfunction. This would enable less complex problems to be dealt with at all tier levels, including within enhanced primary care services.

7. Sexual Assault and Rape

7.1 The latest crime statistics reveal that in England since 1985, reports of rape have increased by 400 per cent but convictions by only 40 per cent with only 7.5% of reported cases ending in a successful conviction. (Kershaw, 2000) In Scotland, there were 27 convictions out of a total of 591 reported rapes representing a conviction rate of less than 5% in 1999. (Rape Crisis Scotland, 2003).

7.2 The increase in recorded sexual offences may be due to an increase in reporting by the public and changes in police practice. However, international studies (Macdonald 2001) indicate that the majority of sexual assaults are not reported to the police. Some may specifically seek help and advice for their immediate medical needs from health care services; others may disclose the assault some time later when consulting with a health professional for other medical problems.

7.3 Burton and Kitzinger(1998) documented evidence of widespread acceptance of forced sex and physical violence against women. They found that one in five young men and one in ten young women said it was acceptable to be abusive or violent towards women. The proportions increased when commenting on specific circumstances such as if a female had slept with someone else or were married. Forcing a woman to have sex was widely accepted, particularly by young men and reinforced a widely held belief that women provoke violence through dress or "nagging". Participants identified the need to discuss such issues without judgement so that such attitudes and assumptions could be changed. As part of the Healthy Respect partnership approach, an educational programme has been developed for professionals so that they can identify risk and support young people following sexual assault and/or rape. Positive feedback and over-subscription points to the need for such training on an ongoing basis and supports the findings of the recent NSPCC report on The Choice and Opportunity Project (Pearce 2003).

7.4 In some areas in England (Manchester and southeast London) there are dedicated sexual assault centres offering specialist response to the complainant. They accept referrals directly from the public and offer a forensic assessment including anonymous sampling for those who do not wish police involvement at that stage. Feedback suggests that this is advantageous as delays in reporting to the police normally results in the loss of any medical and forensic evidence. (Rogers 2002). There are no such examples in Scotland despite the evidence that collaborative partnerships between police, procurator fiscal, health and voluntary services can lead to improved personal outcomes, increased reporting and successful prosecution of sexual assault cases. The proposed Sexual Health and Relationships Strategy supports the establishment of a pilot project for victims of sexual assault and rape providing forensic services, appropriate counselling and medical follow-up on a multi-disciplinary basis in order to test its appropriateness in the Scottish context.

8. Female genital mutilation (female circumcision)

8.1 Female genital mutilation is defined as all procedures involving partial of total removal of the external female genitalia or other injury to the female organs whether for ritual, cultural or other non therapeutic reasons (RCOG 2003). It is practiced mainly in Africa and is a cultural practice not related to religion (WHO, 1998). Cases usually occur between grandmother and granddaughter rather than mother and daughter thus indicating a strong familial link (RCM, 1998). We do not know how many young girls have undergone female genital mutilation or how many women have long term health problems, particularly in relation to childbirth and recurrent chronic pelvic and urinary infections.

8.2 Whilst the Prohibition of Circumcision Act 1985 makes it illegal to perform FGM in Britain, obstetricians, gynaecologists, midwives and other service providers may into contact with women who have experienced FGM performed abroad.

8.3 Good practice suggests that:

• Interpretation services should be available if English is not spoken or well understood

• Female practitioners should be available if examination is required

• Questioning and physical examination should be kept to a minimum

• Properly informed consent must be obtained

• Feelings of humiliation and distress should be avoided

• Language used to describe FGM should be respectful and not insulting to individuals, their culture or traditions

8.4 Recognition of the different types of FGM is important as the complications differ in severity and will therefore have implications for practice responses. Information and knowledge to raise awareness about this practice needs to be disseminated to practitioners across all the Tiers of the integrated service approach, including those working in health, social care and voluntary sector in those areas with potential populations at risk of FGM.

9. Conclusion

This paper identifies some of the barriers that might prevent individuals from accessing services and outlines potential resolutions. It complements Supporting Papers 5A and 5C which cover other issues concerning clinical services: all of these will provide the platform for the development of guidance which will be necessary to support the implementation of the proposed Sexual Health and Relationships Strategy.

September 2003

References

Allaby MA. Contraceptive services for teenagers: do we need family planning clinics? BMJ 1995;310:1641-1643
Allen J, Hippisley-Cox J. Teenage pregnancy in the UK: where are we going wrong. Int J Adolesc Med Health 2000; 12(4): 261-273
Banks I. No man's land: men, illness and the NHS. BMJ, 323: 1058-60
Barna, McKeown, Woodhead M . Get real, providing dedicated sexual health services for young people. Save the Children, 2002 (available from www.plymbridge.com)
Biddulph M, Blake S. Moving goalposts. Setting a training agenda for sexual health work with boys and young men. London, Family Planning Association, 2001
Burack R. Young teenagers' attitudes towards general practitioners and their provision of sexual health care. BJGP 2000 50, 550-554)
Burton S, Kitzinger J. Child and Women Abuse Studies Unit, University of North London, 1998
Butler R, Solomon S. Review of Sexual Health Servicesfor young people in Scotland (Scott Porter review). Edinburgh, Health Education Board for Scotland, 2002
Clements S, Stone N, Diamond I, Ingham R. Modelling the spatial distribution of teenage conception rates within Wessex. British Journal of Family Planning, 24: 61-71
Dehne KL, Snow R, O'Reilly KR. Integration of prevention and care of sexually transmitted infections with family planning services: what is the evidence for public health benefits. Bulletin of the World Health Organisation, 2000, 78(5); 628-639
Duncan B. Barriers to service use: an exploration of hetereosexual men's attitudes to sexual health and sexual health provision in Improving the Sexual Health of Men in Scotland. Edinburgh, Health Education Board for Scotland, 2002
Forrest S, Strange V, Oakley A et al A comparison of students' evaluation of a peer delivered education programme and teacher led provision. Sex Education, 2002, 2:3
Gelder U. Boys and young men: half the solution to the issue of teenage pregnancy - a literature review. University of Newcastle, 2002.
Glasier A. Sexual health services for young people in Young People and Sexual Health. Edinburgh, Health Education Board for Scotland, 2002
Healthy Respect Annual Report 2001 ( www.healthyrespect.com)
HEBS. Improving the sexual health of men in Scotland: a report of an expert seminar. Edinburgh, Health Education Board for Scotland, 2002
Hosie A. Sexual Health policy analysis in selected European countries. Edinburgh, Health Education Board for Scotland, 2002. ( www.healthscotland.com)
Hughes D, McGuire A The cost effectiveness of family planning service provision. J Public Health Med, 1996 18: 189-196
Ingham R . Communication about sexuality in Improving the Sexual Health of Men in Scotland. Edinburgh, Health Education Board for Scotland, 2002
Jackson P and Plant Z. Mock sexual health clinics for school pupils. HealthEducation, 1997; 1: 16-18
Kershaw C, Budd T, Kinsholt G, Matinson J, Mayshew P and Myhill A. The 2000British Crime Survey (England and Wales). Home Office Statistical Bulletin, 18/00, 2000
Lloyd T . Boys and young men's health: what works. Health Development Agency, London, 2002
Macdonald R. Time to talk about rape . BMJ 2001; 321: 1034-1035
Nash T. Clinic Based Sex Education: An Exploratory Study - Improving Access through facilitating School and Sexual Health Service Links. Faculty of Health and Social Care Sciences, Kingston University & St Georges Hospital Medical School. 2000.
Pearce J, Williams M, Galvin C. It's someone taking a part of you: a study of young women and sexual exploitation. The National Children's Bureau, 2003
Peersman, G.et al. Review of effectiveness of sexual health promotion interventions for youngpeople. London: Social Science Research Unit, University of London, 1996.
Rape Crisis Scotland website: www.rapecrisisscotland.org.uk
Reddy DM, Fleming R, Swain C. Effect of Mandatory Parental Notification on Adolescent Girls' Use of sexual health care services. JAMA, 2002, 288: 710-714
Rogers DJ. Assisting and advising complainants of sexual assault in the family planning setting. Journal of Family Planning and Reproductive Health Care, 2002; 28:127-39
Royal College of Midwives. Female Genital Mutilation: Position Paper 21. London, 1998
Royal College of Obstetricians and Gynaecologists. Statement No 3: Female Genital Mutiliation. RCOG, 2003
Royal College of General Practitioners . A Toolkit on Confidentiality. London, RCGP, 2003
Sengupta S, Teijlingen ER, Smith BH. GPs, schoolgirls and sex: a cross cultural background comparison of general practitioner attitudes towards contraceptive service provision for young adolescent females in Scotland. The British Journal of Family Planning 1998; 24: 39-42
Swann C, McCormick G, Kosmin M. Teenage Pregnancy and parenthood: a review of reviews. London, Health Development Agency, 2003
Thomas A, Forster G, Robinson A et al. National Guidelines for the management of suspected sexually transmitted infections in children and young people Sex TransmInfect 88;4: 303-311
World Health Organisation. Female Genital Mutilation:An Overview. World Health Organisation, 1998.

[ Previous] [ Contents] [ Next]

« Previous | Contents | Next »