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ENHANCING SEXUAL WELLBEING IN SCOTLAND - A SEXUAL HEALTH AND RELATIONSHIPS STRATEGY: Analysis of Written Responses to the Public Consultation
EXECUTIVE SUMMARY
THE CONSULTATION
1.1 In September 2003, the Scottish Executive published proposals for a National Sexual Health and Relationships Draft Strategy,
Enhancing Sexual Wellbeing in Scotland - A Sexual Health and Relationships Strategy. The Scottish Executive commissioned TNS Social to collate, analyse and report on responses to the consultation. The key aim of the analysis was to provide data to further inform the development of the Draft Strategy into a final form.
1.2 The Draft Strategy aims to provide a comprehensive framework for tackling sexual health issues across Scotland. It was commissioned to address Scotland's poor sexual health, as evidenced by the statistics on unintended teenage pregnancies, the rise in STIs and the poor comparison with the sexual health of other nations. As a consequence, an Expert Reference Group was established in August 2002. This group brought together the experience of a range of professionals in the sexual health services and education fields, as well as practitioners and representatives from a range of voluntary organisations and religious groups, in order to guide the development of a Draft Strategy.
1.3 The official consultation process for the Draft Strategy was launched on 12 November 2003 and officially ended on 27 February 2004. However, because of the Executive's desire to hold as wide-ranging consultations as possible, responses were accepted as late as mid-April 2004. Responses to the consultation exercise were invited from a range of key stakeholder groups and individuals, and anyone who was interested was able to submit a response. Overall, 1,394 separate written responses were received from a broad range of respondents. The consultation process also involved a number of consultation events to address any 'gaps' in the consultation and ensure that as wide a range of stakeholders as possible were consulted on their views. This involved engaging directly or indirectly with some of those who are identified as having the greatest barriers to good sexual health. The analysis of the non-written responses to the consultation is reported on separately in the 'Enhancing Sexual Wellbeing in Scotland - A Sexual Health and Relationships Strategy: Analysis of Non-Written Responses to the Public Consultation' (Scottish Executive 2004).
1.4 The analysis of the written responses was approached systematically, starting with each response being read in full. During the initial full reading, a coding frame was developed reflecting the points and issues raised in the responses. The responses were then re-read and the main comments, views and issues were coded and transferred onto a tailored pro-forma. To enable some quantification, the pro forma data was entered into a database. Further analysis was then undertaken using a combination of the database and the raw responses. Responses were categorised by respondent group to reflect the perspective of the response. Broadly, these categories were Individual, Health Professional, Faith Groups, Equalities Groups and organisations representing Young People and/or Education.
1.5 It is extremely important to note that, owing to the very nature of such a consultation process, which invites anyone to participate who wishes to do so, the responses are not based on a representative sample of those potentially affected by, or involved in the delivery of the Draft Strategy. Additionally, as respondents were asked to comment on the Draft Strategy overall, submissions were not based on 'closed questions' (i.e. questions with a limited number of response options such as 'yes/no' or 'agree/disagree') and vary greatly in their depth and nature. For example, some responses comprise a short paragraph commenting on one element, whereas other submissions commented on many recommendations and extended to numerous pages (in some cases with supporting materials attached).
1.6 It should also be noted that, as well as providing feedback on the Draft Strategy, many responses raised further questions on the issues.
BACKGROUND AND CONTEXT
1.7 Many responses did not refer specifically to recommendations in the Draft Strategy but referred to perceptions of the overall spirit of Draft Strategy as set out in the first sections. A key concern raised by many Individual and Faith Group respondents is the position taken in the Draft Strategy on morality, with some believing that it should take a stronger position on morality and sexual behaviour and others believing that the Draft Strategy
has taken a moral position but that this is too liberal.
1.8 Strong responses from Individual and Faith Group respondents emerged in relation to the potential impact of seeking to normalise same sex relationships, as it was believed that this could have the effect of promoting homosexuality. On the other hand, many Health Professionals were very supportive of what they saw as a holistic approach which recognises diversity. Some of the Equality Group responses believed that the Strategy should go further in relation to reducing stigma.
CURRENT PICTURE
1.9 There was clear support for actions to reduce teenage pregnancies complemented by other targets and initiatives focusing on the more comprehensive picture of sexual health and healthy relationships. It was, however, suggested that the Draft Strategy as a whole did not do enough to tackle some of the underlying causes of teenage pregnancies and what many respondents referred to as 'promiscuity' - such as deprivation, for example.
WIDER INFLUENCES
1.10 Generally, responses referring to the National Advisory Committee and Sexual Health Programme Co-ordinator recommendations came from Health Professionals and were broadly positive or positive with qualifications. Respondents did, however, request further clarification about specific roles and how these will fit in with existing structures. Recognition of the powerful role of the media was strongly supported and it was suggested that the Draft Strategy could go further and encourage the media to provide more positive images of sexual behaviour within stable, loving relationships.
PROMOTING POSITIVE SEXUAL HEALTH
1.11 There were mixed views about the Draft Strategy's approach to promoting positive sexual health, with some feeling that the current approach was too clinical at the expense of the social and emotional elements of sexual well-being. On the other hand, some responses were supportive of the Draft Strategy as they perceived it to be holistic.
MEETING THE NEEDS OF THOSE FACING THE GREATEST BARRIERS TO SEXUAL HEALTH
1.12 In relation to accessing services and many other aspects of the Draft Strategy, Equalities Groups (among others) highlighted the need for the particular requirements of different groups to be taken into account (e.g. representation on strategy and advisory groups; the materials used in mass media campaigns; the education materials used for both young people and adults; the need to support parents, teachers, service providers etc. in understanding the needs of particular groups; deciding which are the 'hard to reach' groups and which are those facing the greatest barriers). It is important to note that some respondents indicated that the needs of various groups need to be considered throughout the Strategy itself and in relation to its implementation. The specific groups mentioned included: people with learning disabilities including those with profound and multiple learning disabilities, deaf people, victims of gender-based violence, male and female sex workers, LGBT people, HIV positive people and survivors of child sexual abuse.
ACQUIRING KNOWLEDGE AND SKILLS ABOUT SEXUAL HEALTH
1.13 The role of schools: This element of the Draft Strategy attracted a great deal of attention in the consultation with differing perspectives being taken by Health Professionals (who were generally supportive) and Individual respondents and Faith Groups (who were largely negative). There was a general view among the latter two respondent groups that, either, schools should not have a role in providing sex education or that they should have a role but not along the lines proposed in the Draft Strategy (i.e. Healthy Respect). There was particularly strong opposition among Individual and Faith Group responses to introducing SRE into pre- and primary schools.
1.14 There were mixed and opposing views in relation to having a consistent approach to SRE across Scotland. Broadly speaking, Faith Group and Individual respondents strongly disagreed, while many Health Professionals and Equality Groups agreed (with qualifications).
DEVELOPING CLOSER LINKS BETWEEN SCHOOLS AND CLINICAL SERVICES
1.15 Recommendations relating to closer links between schools and clinical services generated strong feelings, particularly owing to media attention suggesting that this would automatically lead to the provision of contraception and the Morning After Pill to young people 'behind their parents' backs'. However, even if this were not the case, many parents and Faith Groups were strongly opposed to the idea of closer links as they felt it gave out the message to young people that it was acceptable to have under-age sex. Responses from Faith Groups were largely in opposition to developing closer links. Conversely, Health Professionals were generally very much in support of the idea but had some concerns about the practicalities involved.
THE ROLE OF PARENTS AND CARERS
1.16 There were mixed views on the role of parents and carers. Some felt that the Draft Strategy outlined a very positive role for parents and carers while others felt that other elements in the Draft Strategy (such as links between schools and clinics, and sex and relationship education for young people) undermined the role of parents and carers.
LIFELONG LEARNING FOR ADULTS
1.17 This was relatively uncontroversial with only a few comments relating to making sure this is inclusive of all groups in society. There were also particular concerns that the recommendations as they stand do not appear to fully include or utilise the voluntary sector.
THE ROLE OF SEXUAL HEALTH AND REPRODUCTIVE HEALTH SERVICES
1.18 Broadly, recommendations under this heading were only referred to by Health Professionals and similar points were made in relation to all the recommendations. First, that not enough recognition or inclusion is made of existing services in the voluntary and statutory sectors (for example, community pharmacists, nurses and relationship counsellors). Second, there was a strong view that the Draft Strategy does not recognise the existing funding and resource problems within Genito-Urinary Medicine (GUM) and sexual health services and does not identify where additional resources will come from. Third, Health Professionals require further detail about how the Strategy is to be implemented and how it will fit in with existing structures.
1.19 The introduction of a tiered system was broadly welcomed by Health Professionals as a positive model of service delivery. There were, however, some concerns about how this might function in rural areas, how cross border services could be funded and the role of the voluntary sector within the tiered system.
SPECIFIC ACTIONS TO REDUCE SEXUALLY TRANSMITTED INFECTIONS
1.20 Generally, Health Professionals who commented on this section were largely positive about the proposals relating to reducing Sexually Transmitted Infections (STIs) and unplanned pregnancies although there were concerns about some aspects of service delivery and funding.
1.21 Although few Individual and Faith Group responses referred directly to the recommendations in this section, it is clear from many of their general responses that many are not in support of making condoms and other contraception freely available to young people.
1.22 There was support for offering HIV testing to all those attending GUM services but it was noted that, as many people travel to neighbouring health board areas to access services, funding mechanisms should reflect this. It was also suggested that HIV testing should be offered in family planning and reproductive health clinics as well as GUM clinics.
SUPPORTING ACCESS TO SERVICES
1.23 In general, responses were positive about proposals regarding access to services (except in relation to improved access to termination services). Health Professionals were also positive but had particular concerns about funding and resources.
1.24 The proposals relating to accessing termination attracted a great deal of attention and strength of feeling. Over a third of all responses disagreed with the targets to speed up access to termination. A significant minority believed that the proposals were offering termination as a form of contraception and promoting its use as such. Issues around termination are highly emotive and this was clearly demonstrated in the consultation responses. There were perhaps two main differing perspectives from Individual and Faith Group respondents on the proposals relating to accessing termination.
1.25 First, a significant minority are completely opposed to termination as a matter of principle and were offended and angered by this recommendation in the Draft Strategy. Second, over a third of all responses, regardless of their view on the principle of termination, were strongly opposed to enabling access to termination within one week.
1.26 The majority of objections to the proposals focused on the fact that the proposed speed of access would not enable women to make informed decisions based on all the options available. It was felt that there should be more time for pre-termination counselling and more emphasis on alternatives to termination such as adoption. Many responses suggest that the Draft Strategy does not give enough prominence to the alternatives to termination and that there should be more acknowledgement of, and treatment for, post-termination trauma.
1.27 However, other responses from different respondent groups offered an alternative perspective. Health Professionals in particular agreed that services should be more quickly accessible and that there should be equitable services across different areas.
LEADERSHIP AND ACCOUNTABILITY
1.28 Most comments relating to leadership and accountability came from within the health profession. Respondents sought clarity on the proposals, rather than being positive or negative.
CLINICAL SERVICE TARGETS FOR SEXUALLY TRANSMITTED INFECTIONS
1.29 Specific clinical service targets were generally discussed by Health Professionals and were broadly supported. The key points to note are that some professionals believe that the targets should be flexible to reflect issues in different areas and the timescales need to be more realistic as they are currently too tight. Conversely, others thought that some of the targets were too weak and that deadlines could be brought forward.
1.30 Many of the Individual and Faith Group responses noted that the only way to reduce STIs is to promote the idea of sexual activity being within a stable relationship - preferably marriage.
DATA COLLECTION
1.31 Data collection proposals were only discussed by Health Professionals who were generally supportive of the notion that better data was required. Most comments related to the way data collection should be approached and some of the specific actions required to ensure quality data. It was noted that any rigorous data collection would require investment in IT systems to facilitate data collection and that the proposed data collection should be expanded.
STAFFING AND OTHER RESOURCES
1.32 Over half of the Health Professional responses commented specifically on staffing and resources, the considerable majority of which were concerned about whether the necessary level of funding and resources would be available. It was felt that the Draft Strategy was vague about whether, and how much, additional funding would be available and what the nature of this funding would be (e.g. short or long-term). There were particular concerns that 'pump-priming' would not be adequate and that longer-term sustainable funding would be required for effective implementation of the Strategy. All were in agreement that additional funding was necessary, especially as sexual health services are currently perceived to be under-resourced.
EDUCATION AND CONTINUING PROFESSIONAL DEVELOPMENT
1.33 Understandably, responses in relation to Continuing Professional Development (CPD) largely came from Health and Education Professionals rather than Individuals. Just over 100 responses commented on this aspect and the considerable majority were in support, with just a couple being negative owing to concerns about resources. There were also concerns that the voluntary sector appeared to have been omitted from the CPD recommendation.
ADDITIONAL COMMENTS
1.34 There were some particular issues which some respondents thought should have a place in the Draft Strategy - or at the very least be acknowledged as an issue associated with it. Generally, these referred to expanding the scope of the Strategy to cover issues such as coercive sex, date rape, paedophilia and internet 'grooming'. Other responses suggested that more emphasis be given to the potential effect of alcohol and drugs on sexual behaviour.
1.35 Many respondents thought there should be more emphasis about the possible health risks associated with homosexual sex. Similarly, several responses thought there was not enough emphasis on the emotional and medical dangers of under-age sex and sexual activity outside of a stable relationship (preferably marriage) and not enough information about the failure rates of contraception.
OVERALL VIEWS
1.36 The considerable majority of respondents agreed with the Draft Strategy that action was required to deal with the growing problems of unplanned or unwanted pregnancies and sexual ill health. However, there are key differences in attitude among the different respondent groups in relation to what action or approach should be adopted.
1.37 Generally, Health Professionals and Equalities Groups are more broadly positive about the approach adopted in the Draft Strategy while Faith Groups and Individual respondents are much more negative (and Individual responses account for the considerable majority of responses).
1.38 For example, the considerable majority of Social and Medical Professionals were overall positive about the Draft Strategy with just a few reservations and issues. Similarly, two thirds of the Equality Group responses were broadly positive with qualifications.
1.39 Representatives of Education and Young People were more divided in their opinions than the Health Professionals, with around a third being overall positive but almost half being negative about the Draft Strategy. This is likely to be partly owing to the number of responses received from Catholic Schools and Catholic School Boards (Catholic individuals and organisations tended to be very negative about a number of proposals, viewing them as in direct conflict with key principles of the Catholic faith in general and Catholic education in particular).
1.40 Faith Group and Individual respondents were generally more negative about the Draft Strategy, with at least half being negative overall. Additionally, in most other Faith Group and Individual responses, although it was not possible to ascertain the overall view on the Draft Strategy as comments were only made on one or two elements, the comments which were made were negative.
KEY POSITIVE ELEMENTS OF THE DRAFT STRATEGY
1.41 A few elements of the Draft Strategy were seen as very positive by significant minorities of responses as follows:
The Draft Strategy promotes a positive role for parents
Support for the implementation of McCabe Report Recommendations
The Draft Strategy acknowledges the major influence of the media
The Draft Strategy has a comprehensive/broad/holistic approach
The Draft Strategy is very positive about teaching young people about relationships
1.42 There was also general support for the notion that action is required to improve sexual health and reduce the incidence of STIs and unwanted pregnancies and general agreement among Health Professionals that the broad approach outlined by the Draft Strategy was generally appropriate (but with reservations over resources and the fit with existing structures and services)
1.43 The majority of responses (particularly the Individual responses) focused on a few, key elements of the Draft Strategy but did not make any comment on other elements of it. It is likely that some of this lack of comment is because not every respondent read the Draft Strategy in full but it is probably safe to assume that, in some cases, where no comment has been made it is because the proposal is either relatively uncontroversial or is irrelevant to the situation of the respondent. Areas which did not generate much comment tended to relate to clinical services and service delivery (apart from access to terminations and the provision of contraception and the Morning After Pill to young people).
1.44 Generally, there was qualified support for the proposals relating to:
Wider influences on sexual health and the role of the media
Implementing an integrated tiered approach (with inclusion of the voluntary sector)
Lifelong learning for adults (but with reservations about a SHAW approach to sexual health)
Meeting the needs of those facing the greatest barriers to sexual health (apart from some concerns about whether this entails easier access to contraception for young people)
Specific actions to reduce STIs
Supporting access to services (apart from concerns about speedier access to terminations and clinical services in schools)
Leadership and accountability (although further clarity is required)
Clinical targets for STIs
Education and continuing CPD (with adequate resources)
Developing an evidence base for future work (although many respondents feel that research should be undertaken about effective models of Sex and Relationships Education (SRE) before anything is introduced).
KEY AREAS OF CONCERN OR DISAGREEMENT
1.45 Certain elements of the Draft Strategy emerge as key areas of concern and it is important to note the strength of feeling about these issues. There was strong feeling that there should be more emphasis on abstinence and that the Strategy should not reject the abstinence only approach.
1.46 There was widespread concern that the Draft Strategy does not focus enough on marriage, relationships, family, love, fidelity etc. There was strong support for the idea of a Strategy which promotes or encourages the notion that sex should be kept for marriage. Similarly there was much support for the idea of trying to encourage young people to delay the start of sexual relationships until they are older and in a secure relationship. A high number of responses believed that the Draft Strategy should have focused more on morality and appropriate behaviour.
1.47 There were particularly strong feelings in relation to the targets relating to termination - especially the targets to enable termination within 3 weeks of consultation (with the further aim of reducing this to 1 week by 2006). These largely fell into two categories. First, some respondents strongly believe that termination is inherently wrong and should not be allowed. Second, some believe that termination might sometimes be an appropriate option but that women need more time (and counselling and information) to make such an important decision. It was also felt that not enough recognition of the medical and emotional impact of termination was included in the Draft Strategy.
1.48 Many respondents who described themselves as parents and grandparents believe that the Draft Strategy contains elements which undermine the role of parents and does not place enough emphasis on the importance of parenting.
1.49 There were a number of strong negative views in relation the idea of introducing sex and relationship education to younger children. Some of this opposition appears to be driven by the negative presentation of the issue in some sections of the media as respondents mentioned opposition to providing sexually explicit material to pre-school children. It was also felt by many that aspects of the Draft Strategy appear to promote sexual 'promiscuity' and experimentation among young people.
1.50 There was strong opposition among Individuals and Faith Groups in relation to links between clinics and schools. Much of this negative opinion was based on the belief that such clinics would be providing the Morning After Pill to young girls - but there was still opposition, even if this were not the case, as it appears to respondents to condone provision of contraception behind parents' backs.
1.51 There were also strong feelings expressed by Individuals and Faith Groups regarding the position taken in the Draft Strategy in relation to heterosexual and same-sex relationships. Many respondents believed that heterosexual relationships should be promoted as the norm.
1.52 There was a significant lack of consensus relating to the effectiveness of Healthy Respect. Some respondent groups were very positive about it but many parents, grandparents and Faith Groups consider that it would be wrong to introduce Healthy Respect, as they believe its approach has already proved a failure. However, it must be noted that an independent evaluation of Healthy Respect is underway and therefore, no decision has yet been made on the future of Healthy Respect or how learning from the project will be taken forward.
1.53 Other key concerns related to funding, resources and the apparent lack of inclusion of many existing services and organisations. In particular, the voluntary sector (for example Couple Counsellors) felt they had been largely left out of the service delivery models.
1.54 There were criticisms of the presentation of the Draft Strategy Documents, with many respondents - both lay and professional - saying they found it difficult to follow. There was also a perception by some respondents that the Summary did not accurately reflect the content of the Draft Strategy. It was felt that further explanation and interpretation of the Draft Strategy would have been useful.
1.55 In addition to criticisms about the layout and presentation of the Draft Strategy, there were concerns about the way the consultation had been undertaken. These concerns came mainly from Individual respondents and representatives of schools who felt that more attempts should have been made to consult with schools and parents and a copy should have been sent to every parent or at least every head teacher
1. Some representatives of Equalities Groups believed that the Draft Strategy should have been available in different formats such as oral and graphic
2.
1.56 A criticism of the Draft Strategy among professionals is its lack of specific details in relation to implementation of the proposals. Many questions were asked about how the proposals fit within existing frameworks and strategies and it was felt that a detailed implementation plan was required with key target dates, milestones and resources identified.
1.57 As is demonstrated, there are key differences in attitude among the different respondent groups. Although the considerable majority of respondents agreed that action was required to deal with the growing problems of rising unplanned or unwanted pregnancies and increased sexual ill health, there was concern from some respondent groups about the approach laid out in the Draft Strategy to addressing these problems.
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