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ENHANCING SEXUAL WELLBEING IN SCOTLAND - A SEXUAL HEALTH AND RELATIONSHIPS STRATEGY: Analysis of Written Responses to the Public Consultation

CHAPTER 7: PROMOTING POSITIVE SEXUAL HEALTH

7.1 There was a perception among some respondents that the Draft Strategy as it stands focuses too much on preventing sexual ill-health rather than supporting positive sexual health. A considerable number of respondents also felt that the approach was very medical/clinical and did not focus enough on the social and emotional elements of sexual health and wellbeing. In fact, it was suggested that although the title of the consultation refers to 'Enhanced Sexual Wellbeing', the content focuses on sexual (ill) health.

"The title of this section raises the expectation of positive sexual health, but focuses on the barriers to achieving this and on the particular client groups which should be prioritised to help reduce health inequalities in this area. These are important and require consideration but there is a focus on preventing sexual ill health rather than promoting positive sexual health." (Social Health)

"… the paper does at times seem to place more stress on the medical side, concerning itself more about teenage pregnancy and increased sexually transmitted diseases rather than looking at the positive aspects of relationships and sexuality at all stages in people's lives. (Social Health)

"There should be more of a focus on the emotional rather than physical." (Individual)

7.2 On the other hand, other responses were very positive and supportive of the recommendations in relation to promoting positive sexual health.

"[We are] very pleased to see the strategy is focusing on cultural and social factors, as well as more 'medical' ones. Scotland needs to start seeing sex as less of a taboo subject. We feel that for a lot of the young people we work with, the attitudes towards sex they have encountered have a huge impact on their sexual behaviours." (Education and Young People)

MEETING THE NEEDS OF THOSE FACING GREATEST BARRIERS TO SEXUAL HEALTH

The National Sexual Health Advisory Committee, in conjunction with the Sexual Health & Wellbeing Learning Network, should prioritise, conduct and disseminate evidence which addresses the needs of those groups facing the greatest barriers to sexual wellbeing

7.3 There was support for this recommendation from a broad range of respondent groups. There were, however, some concerns about how these groups are identified and how priorities are set.

"It would be helpful if, in the final version, information is given on how groups will be prioritised, e.g. will there be consultations with those providing services?" (Equalities)

"It should be clarified that the recommendation includes identification of groups facing the greatest barriers to sexual wellbeing." (Medical Health)

7.4 Some of the groups identified as priority groups in the Draft Strategy were not supportive of their inclusion and others were not happy about the language used to describe them.

"The inclusion of the footnote in section 4.2 is deeply offensive to some sex workers […] On what basis are the voices of sex workers who have asserted publicly over the last two decades that their involvement in sex work has been based on choice and those who consider the activities they engage in as 'work' being ignored? Is the sexual health and relationship strategy restricting the aspiration […] to achieve sexual health and wellbeing only to those who do not perceive their involvement in sex work to be a choice or consider it work? […] the inclusion of this statement [footnote] undermines the principles outlined in the Chair's introduction of accepting that 'interpretations of morality, however, vary from individual to individual… We do not, therefore, feel it is appropriate for this sexual health strategy to arbitrate on such matters.'" (Equalities)

7.5 It was noted by some respondents that not enough reference had been made to the needs of particular groups such as Lesbian, Gay Men, Bisexual and Transsexual people, commercial sex workers, transgendered people and transvestites, those not able to give legal consent, older people with dementia, people with hearing difficulties, people with learning difficulties, gypsies, travellers and anyone vulnerable to exploitation or identified as vulnerable.

7.6 It was also suggested that the proposals relating to those in prison should be expanded and all prisoners should be given free condoms, dental dams and clean needles without prescription.

"As in England, health care practitioners should be able to provide condoms to prisoners without it being necessary to obtain a prescription. The general consensus is that the strategy is not radical enough in its approach to prisoners. There is no mention of prevention, education, testing for HIV, counselling, STI testing and treatment." (Medical Health)

7.7 The importance of recognising that there are some particular issues for different ethnic groups was noted - it was noted for example, that some African men are fearful of HIV tests as they believe a positive result will mean they are forced to return to their country of origin.

7.8 On the other hand, there were some concerns that targeting certain groups could result in an increase in stigma and so should be accompanied by campaigns aimed at reducing the stigma associated with particular groups.

7.9 Some of the more general barriers to accessing services were also identified by respondents as needing to be addressed. It was felt that work needs to be done to improve perceptions of confidentiality in relation to sexual health services to encourage people to use them (an issue which is indeed identified in the Draft Strategy). Additionally, respondents suggested that the issue of embarrassment needs to be addressed - perhaps by working on reducing the stigma associated with STIs. These issues are seen to be particularly problematic in rural areas where services are either not available or are 'too local' in that the service provider is known to the individual.

ACQUIRING KNOWLEDGE AND SKILLS ABOUT SEXUAL HEALTH

THE ROLE OF SCHOOLS

7.10 The role of schools in influencing sexual health attracted a lot of attention in the consultation with almost three quarters of all responses commenting. There was clearly a lack of consensus relating to the role of schools both between and within different respondent groups.

7.11 Almost all of those Health Professionals who commented on the Draft Strategy's recommendations regarding the role of schools, were positive about them. Some issues were raised by Medical and Social Health Professionals, largely relating to the delivery and content of SRE (these are discussed in more detail below).

7.12 Overall, two-thirds of responses (largely from Individuals) were negative about some element of the proposed role for schools. There were perhaps two main views among Individual and Faith Group respondents about the role of schools. First, some respondents believed that schools should not be involved at all in providing sex education. Many parents and grandparents believed that children (of most ages) already receive too much information about sex and some thought that schools should have no role in providing sex education as this was the domain of parents.

"I think that parents should decide the appropriate age when their children are ready to receive sex education." (Individual)

"Surely the parents, who know their children better than anyone, should be the ones to impart this knowledge when they judge that the child is ready for it." (Individual)

"I am concerned about the proposals relating to how children are taught sex education in schools and I believe that this is the role of the parents and that parents should be the primary educators of their children when it comes to sex education and that they should decide when their children are at an appropriate age to receive such education." (Individual)

7.13 Second, some individual and Faith Group respondents believed that schools do have a role to play but disagreed about the form and content of school based sex education. There were concerns that the proposed SRE Strategy does not reflect the moral or religious views of a considerable proportion of parents. This view was not restricted to any specific religious group or faith but also had a broad consensus among parents and grandparents.

"I would like to highlight my extreme concerns for the proposals put forward in the sexual health strategy for older children (secondary age children). I think it is terrible to think that our young people are being taught 'safe-sex' messages and being given easy access to contraceptives." (Individual)

7.14 There was a general view among Individual and Faith Group respondents that strategies based on increased sex education have proved to be unsuccessful and there should be a review of research on what kind of approaches to sex and relationship education works.

"Children are already given too much information about sex. I consider this is a contributory factor in teenage pregnancies." (Individual)

7.15 A significant number of respondents felt that current methods of sex education have clearly failed (given the still-rising rates of STDs and unplanned pregnancies) and that the Draft Strategy was merely 'dishing up more of the same'. It was felt that a more fundamental and radical approach is required - based on morality. In particular, many respondents believed that SRE should have more of a focus on relationships, fidelity, trust and marriage, and should aim to prevent under age sex rather than focusing on the provision of information about sex, contraception and sexual health services.

"I feel very strongly that delaying sexual activity should at least be put across in education as a realistic, safe and enjoyable way of living" (Social Health)

"When will it be acknowledged that as the age for sex education drops, so it would appear that the incidence of teenage pregnancies and sexually transmitted diseases increase?" (Individual)

"Basic message seems to be more of the same" (Individual)

"The policy of sex education has clearly failed. We have among the worse rates of teenage pregnancy in Europe." (Individual)

"It is clear that the problems are not caused by ignorance. The inevitable conclusion is that the critical factor relates to the value systems and beliefs which are held by society." (Individual)

"Schools should teach good moral standards" (Individual)

"It is important that young people, in particular, are encouraged to delay the onset of sexual activity until they are in a loving and permanent relationship, preferably marriage. Marriage is the best context for raising children as stated by the Scottish Executive following repeal of Section 28 and reiterated by the Justice Minister on 10 Sep 2003." (Individual)

"… the omission in the Draft of the normal words one would associate with sexual relationships e.g. love, marriage, faithfulness or commitment […] this is very alarming given that under the 5-14 Guidelines Health Education is not just about physical health but is also meant to be about personal and social development" (Individual)

"I would have welcomed more emphasis on the benefits of young people delaying the onset of sexual activity. I have anecdotal evidence of young people telling me in their late teens that they wished they had not been sexually active in their early teens when they did not have the emotional development to cope with it." (Individual)

7.16 Many references were made to apparently successful approaches in other countries, in particular the USA and Uganda, which focus on abstinence approaches.

"Abstinence only has been successful in the US and should be used here" (Individual)

"We oppose your rejection of 'abstinence only' education. Sexual relations should only take place within marriage. Recent media reportage indicates that in America, 'abstinence only till marriage' has been hugely effective." (Individual)

7.17 There were some similar views from some representing Education and Young People.

"A non-judgemental approach is required for clinical services but NOT for education" (Education and Young People)

"Schools should promote abstinence only approach" (Education and Young People)

7.18 There were, however, many responses from representatives of Education and Young People and other groups who did not support abstinence only approaches and endorsed the 'Abstinence Plus' approach.

"[organisation] do not support abstinence-only programmes in schools and welcome the strong position in the Draft Strategy for the abstinence-plus programmes. Continued endorsement of this approach by the Scottish Executive is required and ongoing presentation of evidence from evaluations is important to counter arguments that teaching young people about sex encourages early and unsafe sexual activity. Negative sexual health outcomes for many vulnerable young people are not only or even mainly a result of the information they do or don't receive about sex." (Education and Young People)

"[We] agree that 'Abstinence only' approach does not work but schools need to be aware of the evidence to support 'comprehensive' programmes. There needs to be real commitment to fund this approach and it needs to be nationally driven." (Education and Young People)

"We strongly support the reference group's position on abstinence-only education. Evidence emerging from the United States suggests that abstinence is widely perceived by young people as referring only to abstinence from vaginal penetration which obviously still leaves young people at risk of sexually transmitted infection from oral or anal sex. Moreover, the failure of these programmes to inform young people about contraception of the giving of inaccurate information about failure rates leaves young people uninformed about how to protect their sexual health when they do become sexually active." (Education and Young People)

7.19 Several respondents from different categories and for differing reasons had issues with the name 'Abstinence Plus'. As discussed above, many parents and grandparents and other individuals felt that the focus should be 'Abstinence' rather than 'Plus'. Several health and education professionals suggested that the programme should be described as a 'comprehensive' approach rather than 'Abstinence Plus'. A couple of representatives of Equalities Groups thought that the name focused too much on abstinence and gave negative connotations for those who did not abstain. It was suggested that this would enhance feelings of guilt which could result in more secrecy about sexual activity.

7.20 Many respondents were concerned about how same sex sexual relationships would be dealt with under the SRE programme. There was considerable opposition in Individual responses to same sex relationships being treated in the same way as heterosexual relationships. Many parents and grandparents did not want their children/grandchildren taught anything about same sex sexual relationships.

"We object to children being taught about sodomy and lesbianism." (Individual)

7.21 Other responses were even more vehement in their criticism of the approach of the Draft Strategy, for example,

"Not one of us know of any parent who greets the strategy with anything but profound horror." (Education and Young People)

7.22 On the other hand, as mentioned above, some Equalities Groups said it is important that any local discretion in SRE does not enable some areas to exclude LGBT issues from SRE programmes.

7.23 Given some of the doubts and issues raised about the SRE programme, several respondents noted that there is a need to evaluate programmes using robust methods before they are rolled out and that there is a continuing need for constant and rigorous monitoring and evaluation of the programme.

"[We] support the development of SHARE, but emphasise the need for a rigorous monitoring and evaluation programme, planned in advance of rolling out initiatives." (Social Health)

There should be a consistent approach to sex and relationships education across Scotland. To achieve this, NHS Health Scotland, in partnership with Healthy Respect and other stakeholders, should review the range of programmes available to support SRE across the curriculum, draw on knowledge from research and practice and make recommendations on how to achieve and support a consistent approach to the National Sexual Health Advisory Committee

7.24 Mixed and sometimes opposing views were expressed on the notion of a consistent approach to SRE across Scotland. Some Faith Group and Individual responses strongly disagreed, many Health Professionals agreed and most Equalities Groups agreed but had some concerns (discussed below).

7.25 Typical responses from those in support of a consistent approach to SRE were:

"We believe it is essential that high-quality school-based sex and relationships education is available throughout Scotland irrespective of denominational or religious affiliation of the school." (Medical Health)

"We fully support the approach taken in paragraphs 4.11 to 4.19 around sex and relationships education (…) The present flexibility at Education Authority and school level around SRE does not, in our view, serve young people well and may leave some young people ill-equipped to move successfully into adult life". (Medical Health)

"We commend the requirement to for a robust national and local framework to lend consistency of delivery. Linking school based SRE to other health service is highly desirable and is best achieved if these services are involved in aspects of the delivery of the school SRE programme. The right of parents to withdraw their children needs to be examined […] A Head Teacher's view on morality cannot dictate delivery of PSE in school or our response to young people with questions, worries or admitted sexual activity (within legal parameters)." (Education and Young People)

"There are variations in practice across Local Authorities in terms of content and style of SRE - this doesn't help the deaf community who would like to see much more of a standardised approach to sexual health. Also, deaf schools don't always follow the national curriculum which produces more variation." (Equalities)

7.26 Concerns and issues associated with the proposals for a consistent approach fell into two general categories - those who wanted individual schools to have more choice and those who were concerned that flexibility would enable schools to opt out of some elements of SRE.

7.27 First, many Faith schools and parents and grandparents were concerned that any SRE programme would not reflect religious beliefs. In particular, many Catholic respondents noted that a programme has already been developed for use in Catholic schools (based on Circular 2/2001). Several respondents commented that it was remarkable that the Draft Strategy does not make any reference to Circular 2/2001. It was pointed out in one response that a petition comprising over 1,200 signatures has already been submitted to the Scottish Executive opposing its proposed SRE programme. In addition, it was pointed out that within the terms of the current legislation the delivery of all aspects of educational matters in a Catholic school is subject to the approval of the local Bishop and/or the Scottish Bishop's Conference.

"In recognising that Catholic schools have developed their own relationships and moral education programme (4.16), the problem arises of how this can be compatible with the proposed framework and its attainment levels and learning objectives which run contrary to the beliefs and aims of Catholic schools." (Faith Group)

"It was with some surprise and disappointment then that we have studied the proposed Sexual Health and Relationships Strategy, which despite a stated 'abstinence plus' approach and a welcome commitment to ensure that there is real parental consultation, nonetheless seems to by-pass completely some of the hard-fought principles of Circular 2/2001 and our petition campaign" (Faith Group)

"The Church has statutory rights regarding the provision of sex education in Catholic schools. This is clear in law." (Faith Group)

7.28 Some Faith Groups also had particular concerns about the role of schools in providing SRE, and, in particular, the suggested programme. For example,

"Sex education in schools is already putting off many parents, especially Muslims, from sending their children to state run schools. The addition of the proposed measures will further resolve to strive for the provision of separate schools." (Faith Group)

7.29 It was felt by many that head teachers should maintain the right to decide about SRE in individual schools. The considerable majority of Individual respondents also felt that there was a need to involve parents more closely in the development of SRE materials. Additionally, it was strongly felt that parents and carers need the right to withdraw their children from SRE lessons should they wish to do so.

7.30 Equalities Groups had two concerns - first that SRE should be appropriate to the audience.

"It is unclear to what extent schools for children with emotional/behavioural/learning difficulties [including children 'who have been abused and exhibit sexualised behaviour'] are to be involved in SRE. […] Both care and education staff need support for delivering messages about sex and relationships which are consistent and address the issues facing those children." (Equalities)

7.31 Second it was emphasised that local discretion should not be allowed to enable some schools to opt out of the SRE programme (particularly in relation to LGBT issues).

"There is something of a lack of clarity in this, however. We believe that a 'consistent approach to SRE in all schools' could be interpreted in different ways. Does it mean that all schools will have to adopt an inclusive and holistic approach but still have significant discretion locally to change their programme and not cover topics that they deem appropriate? …[This] would, without doubt, lead to many schools (including faith schools but not limited to them) electing either to omit or severely dilute SRE input around sexuality and safer sex for LGBT people. This can in no way be seen as a 'consistent' approach, would collude with existing bad practice found across the country where LGBT young people are excluded from receiving appropriate SRE, relevant to them." (Equalities)

Local Authorities should ensure that SRE training is delivered on a multi-agency basis to staff working with young people and details provided in local Community Plans. Providers of SRE training should ensure this takes place on a multi-agency basis and includes issues relating to different cultural and religious practices and beliefs.

7.32 These recommendations were fairly uncontentious in themselves (although it must be noted that some respondents felt that any SRE, regardless of multi-agency involvement, was inconsistent with their religious and cultural practices). Again, key concerns were related to resources.

"Agree. This is fundamental and needs to recognise that existing services not necessarily 'joined-up' as well as affirming there is a role for everyone." (Education and Young People)

The curriculum framework developed by Healthy Respect should be piloted in all Lothian schools. Thereafter, the National Sexual Health Advisory Committee should consider its potential as a template for school-based SRE in Scotland

7.33 There was a lack of consensus in relation to Healthy Respect, with many Individual and Faith Group responses indicating a belief that the Healthy Respect approach has been proved not to work.

"Healthy Respect has not been successful. This is evident by the rise in sexually transmitted diseases and teenage pregnancies in the region in which it was piloted." (Individual)

"Healthy Respect, which was used in Lothian, failed - your statistics, yet you propose to use it in Scottish Schools." (Individual)

"Healthy Respect … was piloted in Lothian, the only Health Board area in Scotland to experience a rise in teenage pregnancies in 2002, despite handing out free morning-after pills to underage girls - hardly a clarion call of success for the programme." ⁴ (Individual)

"We do not have confidence in Healthy Respect, which does not promote a message which is compatible with our understanding of human sexuality and has no proven record of success" (Faith Group)

7.34 It must be noted that Healthy Respect's targets are ambitious long-term health outcomes, set over a ten year period to give the project a chance to achieve its objectives. The targets reflect the complexity of achieving change in the highly sensitive area of sexual health for young people. It should also be noted that in Phase One (2001-2004) Healthy Respect worked in and around 10 schools in the NHS Lothian area. There are 62 secondary schools (and 252 primary schools) in total in the area yet the targets set at the start of Healthy Respect were for the whole of Lothian rather than for the specific schools where the project has worked. Healthy Respect was launched in 2001 but its work only began in earnest in the latter half of that year. The project is currently being independently evaluated and no final decision has been made on the future of Healthy Respect or how learning from the project will be taken forward. In planning for the second phase of Healthy Respect, careful consideration will be given to the evaluation findings once they become available. It must also be noted that Healthy Respect does not provide emergency contraception in schools, nor does it have any plans to do so.

7.35 There was, however, a lot of support for Healthy Respect among other respondent groups.

"This is a natural progression as its content is based on common sense not on rocket science or with a fear factor. The recent review of sexual health services for young people commissioned by Healthy Respect confirms views which have been conveyed by young people for many years." (Education and Young People)

"We believe this can make a significant contribution to promoting sexual well being amongst young people. "(Education and Young People)

"While the curricular framework developed by Healthy Respect is worthy of piloting more extensively, this should not be done without careful consideration of the material by schools and parents and carers in each pilot school […] One of the purposes of any pilot of the Healthy Respect material should also take into account consideration of how flexible the material is in meeting the requirements of consultation and adaptation of the material as a result of consultation." (Faith Groups )

7.36 It is important to note that Healthy Respect, as one of three national health demonstration projects is a test bed for new ideas and is currently being independently evaluated. No decision has yet been made by the Scottish Executive on the future of Healthy Respect or how learning from the project will be taken forward. The evaluation of the first phase of Healthy Respect will be carefully considered in planning Phase Two. Healthy Respect is committed to involving key stakeholders in the provision of sexual health and relationships information. Before new services are set up in schools, head teachers, parents, carers and (where applicable) religious authorities will be fully consulted.

Resources to facilitate the Scotland-wide implementation of a single consistent approach to SRE, including multi-agency training, should be provided by the Scottish Executive (from both Education and Health Departments) Local Authorities should fully implement the McCabe Report to support a consistent approach to sex and relationships education throughout Scotland. In line with the McCabe recommendations, sex education should be defined as sex and relationships education (SRE), introduced in pre-school, based upon pre-school health guidelines, built upon throughout primary school as part of 5-14 health guidelines and developed through to school leaving age.

7.37 Generally, comments relating to these recommendations focused on the introduction of SRE into pre-school education. There were mixed views on this which very much varied by respondent group. Some Health Professionals and representatives of Equalities Groups were in support of the proposal to introduce SRE into pre-school education and primary schools but the considerable majority of parents and grandparents and many Education Professionals were not in favour.

7.38 There was particularly strong opposition among Individual and Faith Group respondents to introducing SRE into pre-school education and primary schools. A third of all responses were in opposition to introducing younger children to sex education. It is fair to say that some of the objection on the part of parents, grandparents and Faith Groups was based on a belief that this would mean providing sexually explicit materials to pre-school children. However, the considerable majority of opposition was in principle and against any SRE for younger children (regardless of whether it involved sexually explicit materials). In fact, many parents and grandparents believed that children currently receive too much information about sex from schools and felt strongly that it should be parents who decide when children are ready to learn about sex, particularly as there is much variance in the ages at which children mature.

"Pre-school children being taught anything about sex appals me." (Individual)

"Children will either be bewildered or horrified or want to try it out." (Individual)

"The aim should not be to make children 'sexually competent'" (Faith Group)

"Pre-school, such 'education' surely threatens the rights and duties of parents to discuss such 'intimate matters' at an appropriate age" (Individual)

7.39 On the other hand, there was support for the introduction of SRE into pre-school education by some respondents, particularly where this would highlight relationships.

"[organisation] welcomes the recommendation that SRE should begin in pre-school and be built on as children progress […] as young people repeatedly report that sex education is 'too little too late'." (Education and Young People)

"While there are natural anxieties among parents and carers about involving pre-school children in a sexual health strategy, it is vital that this is seen as the start of a life-long process of learning. By correctly placing the emphasis on relationships for pre-school children; parents and carers will also be made aware of the holistic nature of the approach suggested in the consultation paper." (Faith Group)

7.40 Additionally, there were a small number of respondents who were positive regarding the implementation of the McCabe recommendations.

"I welcome the proposals to fully implement the McCabe Report, in particular, its emphasis on consultation with parents as sexual health education is undertaken. Young people need to be educated on sexual health and relationships in conjunction with their parents being fully informed and involved." (Individual)

Local Authorities and NHS Boards should develop an agreed sexual health protocol highlighting areas of responsibility and referral procedures. The Local Authority Director with responsibility for education services should ensure the delivery of consistent and appropriate SRE in all school settings and for those excluded from school. The Local Authority Director with responsibility for social work services should ensure that children and young people who are looked after have access to SRE and sexual health services, as and when required, and that social work staff are adequately trained and supported to respond to the needs of their clients. A member of each secondary school's management team should be responsible for ensuring that school based SRE subscribes to current guidance and delivers key learning objectives to all pupils

7.41 In relation to these recommendations, respondents noted the importance of involving those related to social work authorities and the voluntary sector, as well as school teachers in SRE.

"The involvement of Social Work authorities and voluntary sector partners in meeting the needs of looked after children and those outside mainstream education or services is important in eliminating the cycle of low self-esteem and exclusion prevalent in those groups acknowledged as being at high risk of sexual ill-health and teenage pregnancy." (Faith Group)

"While the pressures on primary school managers are acknowledged, they also should ensure that a named person has responsibility for this area of the curriculum. This may be achieved by clustering small schools." (Faith Group)

Local Authorities, in conjunction with other Community Planning partners, should develop targeted educational interventions aimed at harder to reach groups in a range of settings outwith mainstream services/locations

7.42 Recommendations regarding provision for excluded and looked after young people and other hard to reach groups were generally supported though there were some reservations in relation to the definition of 'hard to reach groups' and about the particular needs of some groups.

"… there are issues for people with learning disabilities accessing out of hours classes, e.g. transport, additional support." (Equalities)

"…it should be stated who the 'harder to reach groups' are." (Equalities)

" We need information/services that are tailored for deaf people" (Equalities )

7.43 It was suggested that it would be helpful to investigate options for delivering SRE in more informal settings such as youth groups etc. and that there should be more consultation with children and young people about service delivery and programme content.

7.44 It was also proposed that professionals from outside the schools should be involved in the development and delivery of SRE materials for schools (for example relationship counsellors, nurses etc). The role of peer education was also highlighted by one young persons group.

"Young people think there should be more sex education in schools, with more focus on life skills rather than just biological/physical aspects of sexual health [and that] sex education in schools would be enhanced if it involved others such as youth workers, health workers or peers" (Education and Young People)

Other issues

7.45 The need for SRE to focus on trying to prevent sexual violence and sexual coercion, and reduce homophobic bullying was also emphasised by a number of respondents. SRE programmes should also include information on dealing with peer pressure and focus on the consequences of sex

DEVELOPING CLOSER LINKS BETWEEN SCHOOLS AND CLINICAL SERVICES

NHS Boards, in partnership with Community Health Partnerships, Local Authority education departments and other stakeholders, should detail plans to improve links between schools and sexual health services in their Community Plans and Local Health Plans Employers should support public health nurses working in schools, and other nurses who wish to develop their role in providing sexual health advice and services, by providing opportunities for them to update their skills and knowledge and access to resources

7.46 This section of the Draft Strategy attracted a lot of attention with just under half of all respondents commenting. The majority of those commenting were negative (considerably more than three-quarters). There were, however, differences between respondent groups - Health Professionals were generally fairly positive about the idea (although with concerns about how it would work in practice) while Faith Groups and Individuals were largely in opposition.

7.47 The considerable majority of those in opposition were parents and grandparents. In some cases, however, it appeared that peoples' views had been shaped by some media reports rather than by the actual Draft Strategy (several respondents included tabloid newspaper clippings with their responses). There was vehement opposition to the idea that clinics linked with schools would enable young people to access contraception and terminations without the knowledge or consent of their parents or carers. There were particular concerns about school-based clinics providing young women and girls with the Morning After Pill - several responses noted that, despite assurances made by the First Minister ⁵, that this would not happen, they were still not convinced that this was not the intention. A high number of responses noted that it seemed ridiculous that school nurses cannot give children aspirins or sticking plasters but might be able to provide contraception.

7.48 Many parents and grandparents were also opposed to closer links between schools and clinics as they felt that it gives the message to young people that it is acceptable to have underage sex. Many also complained at the fact this would mean the parents would not been involved and informed.

"Availability of condoms or pills at clinics near schools will merely encourage sexual activity." (Individual)

"Sex clinics have no place in schools when the only message is that sex is okay as long as it is safe." (Individual)

"[They will] create for young people a 'safety net' - a false impression that, should they make mistakes, no matter how serious, they can easily be 'rectified'. (Individual)

"Apart from its illegality it is also an infringement of our rights as parents and provides a concrete means of promoting promiscuity among our children regardless of our wishes and what we think best." (Individual)

"I am truly shocked at the idea of "sex health clinics" with "health professionals" based in, or near, secondary schools, a rather degrading and depressing spectacle, not worthy of Scottish Society!" (Individual)

"A strategy which makes available contraception and the morning after pill in circumstances where they can be widely accessed by (or targeted towards) young people surely sends the message that the expectation is that they are likely to be sexually active and irresponsible." (Individual)

"Instructing children too early on sex leads to curiosity and experimentation." (Individual)

"…our concern is that in addition to promoting a message which is contrary to the values of parents, NHS boards are supporting and implicitly encouraging illegal sexual activity by their services aimed at young people. Parental authority should not be undermined for reasons of confidentiality which must always be balanced with respect for the rights of parents who are the principal promoters of the welfare of their children." (Faith Groups)

"Linking schools to adult sexual health services completely excludes parents from information regarding any condoms or pills supplied to under-age children." (Individual)

7.49 A significant proportion of representatives of Faith Groups were also not in support of developing closer links between schools and clinical services - for similar reasons as those expressed by parents and grandparents.

7.50 Some respondents from across the range of respondent groups expressed the view that some kind of 'drop-in' clinic in schools would be useful but that the clinics should be generalist rather than sexual health specific and should not necessarily provide contraception.

"Health services which address all aspects of young people's health were seen as less stigmatising and therefore, more accessible and the young people were much more positive about attending this type of health service. Sexual Health services linked to schools were seen by many as too specific and it was widely believed that pupils would make more use of a general health service which included advice on sexual health, rather than focused upon it." (Education and Young People)

"Alongside links with clinical services, however, closer links should also be established between schools and non-clinical health services […] It is clear that clinical services are less able to work with some of the emotional aspects of sex and relationships." (Equalities)

7.51 Health Professionals and some representing Education and Young People were generally much more favourable to the proposals regarding closer links between schools and clinical services, with particular support for an enhanced role for school nurses (provided resources are made available).

"A more pivotal role for school nurses is strongly endorsed" (Education and Young People)

"[organisation] are mindful of the already heavy burdens on teachers and of the fact that not all feel comfortable delivering this. For this reason we are especially supportive of exploring how the role of the school nurse can be developed to further the aims of improving the sexual health of young people." (Education and Young People)

"There needs to be stronger links in general between schools and other services, e.g. voluntary sector, at present this operates on a hit or miss basis depending on staff, willingness to collaborate etc." (Education and Young People)

"The section on 'How schools can help' is clear […] The provision of a school nurse would also be expected to offer health promotion and consultation on sexual matters. This is particularly important because of social inclusion as well as the delivery of the aims of this document. It would also ensure that all pupils receive information to suit their needs." (Education and Young People)

"We strongly endorse the development of links between schools and clinical services. International research has shown that good and comprehensive sex education combined with easy access to contraceptive services leads young people to delay first intercourse and results in them being more likely to use contraception when they do become sexually active." (Education and Young People)

"[They] should pilot and evaluate school-based services - e.g. Chlamydia screening, emergency and routine contraception." (Medical Health)

"[It] would be helpful for the SE to stress its support for service in schools." (Medical Health)

"We strongly support the recommendations … for the development of closer links between education and clinical services. (…) The flexibility alluded to in paragraph 4.20 is particularly important in rural areas with limited transport infrastructure such as ours."

"There should be the establishment of sexual health services in schools and they should offer emergency contraception, advice on longer-term contraception and chlamydia tests." (Medical Health)

"The importance of acquiring knowledge and skills about sexual health and the role of schools in this area is welcome and also the need to develop closer links between clinical services and all levels of school and education provision: as well as highlighting the role of parents and carers." (Social Health)

7.52 There were some concerns and qualifications among the Health Professionals but these were largely around the detail and practicalities rather than the principle.

"Arrangements must be individually negotiated with local authorities" (Medical Health)

"There needs too be more clarity about what the relationship between public health nurse and school staff will be." (Medical Health)

"There should be reciprocal arrangements for education providers to work with health services." (Medical Health)

HIGHER AND FURTHER EDUCATION

Local Sexual Health Co-ordinators should ensure that proposals to develop sexual health promotion and outreach services by a range of providers to the tertiary education sector are included in each NHS Board inter-agency sexual health strategy

7.53 This was relatively uncontroversial with only a few comments relating to groups who may have particular needs.

"…the requirements of people with learning disabilities should be included. Many colleges already offer classes on other subjects and could extend the range of topics available." (Equalities)

"What would be accessible to people with profound and multiple learning disabilities?" (Equalities)

ROLE OF PARENTS AND CARERS

7.54 Almost half of all responses commented about the role of parents and carers, with three-quarters being in support of the role of parents and carers laid out in the Draft Strategy. Those who were negative tended to think that other elements in the Draft Strategy (such as sex education in schools, closer links between schools and clinics) undermined the role of parents. A third of all responses noted that the Draft Strategy did not provide for a significant enough role for parents or undermined the role of parents. It was felt that there was a contradiction in the Draft Strategy between parents having 'primary responsibility' and being 'equal partners'.

"It seems that parental rights are being eroded more and more by government strategies with no Christian element." (Individual)

"I am the mother of two adults and grandmother of three children of primary school age and am concerned … about how children are taught about sex education in schools at the present time. Most importantly, I think it is the duty of parents to decide on the proper age at which their children are ready to receive sex education or, at the very least, be fully involved in approving sex education materials." (Individual)

"Handing out the morning-after-pill to schoolgirls, without their parents' knowledge, is both unethical and dangerous. It is also totally illogical. Parents have to sign consent for chest X-rays, blood tests, injections, school outings, etc. To sideline the parents on an issue as important as this is completely wrong, especially coming from a government which demands that parents take more responsibility for their children!" (Individual)

7.55 A large body of parents and grandparents also stated that any Draft Strategy must include a mechanism to enable parents who are anti-termination, anti-homosexuality and believe that sex should be kept for marriage, to have their views reflected.

"It is time to listen to parents who advocate an 'abstinence only' stance to these matters." (Individual)

"Need full, independent parental consultation to ascertain their support/reservations in relation to the schools recommendations." (Medical Health)

"The wishes of parents seem to be being pushed to the side; all schools should be instructed to have an open night when all interested parties should have the opportunity to discuss the proposed Sexual Health Strategy and vote on whether they wish to have it implemented in their school." (Individual)

"As a grandmother of children of nursery school age, I do not want my grandchildren indoctrinated about abortion, condoms, homosexuality or any other 'alternative' lifestyle" (Individual)

"I would like to see provision in the proposed legislation for parents who reject the ideas of pre-school sex education, abortion, the morning after pill and homosexuality/lesbianism as 'normal' sexual behaviour to be able to have a say on how their children should be educated in school about healthy relationships." (Individual)

7.56 In contrast, a small number of respondents were positive about the role of parents that was advocated by the Draft Strategy.

"I very much welcome the importance attached to parents being fully consulted and subsequently informed about any proposal relating to their child's sex and relationship education." (Individual)

7.57 A large number of respondents suggested that further (independent) consultation with parents and teachers should be undertaken before anything is introduced into schools and that reference should be made to the European Convention on Human Rights in relation to the Rights of Parents.

Building on the work by Healthy Respect partnerships, NHS Health Scotland and other agencies, the National Sexual Health Programme Co-ordinator and Local Sexual Health Co-ordinators should develop information in a variety of formats targeted at parents and carers for use from pre-school onwards Local Authorities should ensure schools demonstrate mechanisms to involve parents and carers in SRE programmes in line with the McCabe Report recommendations

7.58 There was broad support for these recommendations from a range of respondent groups.

"Agree. This should be prioritised. There are many parents who do take on this role. There are many parents/carers very willing to take on this role and should be supported accordingly. Conversely, there are many who feel unable without support and others who see it as the responsibility of someone else e.g. schools." (Education and Young People)

7.59 However, some stressed that parents' involvement in SRE should not extend to a right to opt-out or veto certain areas for their children.

"There is a need for further attention on parent's "right" to opt young people out of SRE. This may be appropriate for younger children, but need work to determine the age at which a young person should have the right to overrule a parent's decision to opt them out." (Medical Health)

"it would be unacceptable for parents to veto certain areas of the programme, and limit the opportunities for their and others' children to be excluded from important areas of their education. In certain communities, where particular issues might be contentious, there should be some flexibility to accommodate parents' concerns, but key messages and learning objectives should not be dismissed." (Equalities)

NHS Boards, in conjunction with other statutory and voluntary sector interests, should develop programmes for parents and carers to enhance communication skills around relationships and sexual health

7.60 Several responses thought that parents and carers should be supported to provide sexual health education to their own children, through, for example, parenting classes. Additionally, it was felt that parents could be more involved in school-based SRE if children could take home SRE materials to complete with their parents or carers.

"We have identified high levels of demand among parents to be more pro-active in this field. Parents want materials and support to help them deal with sex and relationships issues more effectively" (Education and Young People)

"Additional support and information for parents and carers is essential and improving the links between parents/carers and schools is a positive step. [Organisation] know that many parents and carers struggle with sexual health promotion because of embarrassment and inadequate knowledge and skills." (Education and Young People)

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