The consultation process on the draft Sexual Health and Relationships Strategy (SHRS) was launched in November 2003. The draft strategy was written by an independent expert Reference Group and submitted to the Scottish Executive. It contains over 100 recommendations
1. The Minister for Health invited comment on whether the draft strategy provides an acceptable framework for improving sexual health in Scotland or whether there are any points or issues that should be given greater or less emphasis.
The primary aim of this research was to monitor and advise on the consultation process, ensure that the non-written consultation events contributed effectively to the debate and identify and address any 'gaps' in the consultation. It was anticipated that key population groups or their representatives for whom the SHRS is very relevant would not necessarily respond to the consultation exercise. A number of such groups were identified and research conducted to gather their views on the SHRS, by engaging directly or indirectly with some of those who are identified as having the greatest barriers to good sexual health
2. This report summarises the non-written responses to the consultation. This included consultation events organised by the Scottish Civic Forum and the Poverty Alliance and research with young people by Children in Scotland.
Overall the draft strategy was a welcome document. It was felt to be timely and provided a welcome and unusual opportunity to discuss the issues.
The wider influences on sexual health were recognised although some did not like the links made with wider social issues such as poverty, wanting to see a greater focus on personal responsibility. The broad and holistic approach to sexual health in the draft strategy was generally welcomed across the range of participants, as were moves towards a more positive and open approach to sexual health and relationships.
Two broad strands of opinion were evident in the discussions. One had a focus on personal and parental responsibility. The other was based on a recognition of the realities of peoples lives. The first perspective was evident amongst some of the SCF participants, whilst the second perspective predominated amongst the other participants and was the stronger theme overall.
Relationships were important to all elements of opinion, although for some the relationship element is not given sufficient emphasis in the draft strategy. Some question the absence of 'love' from the strategy, whilst others argue that
'the government cannot dictate for love'. The values of the draft strategy are open to interpretation and some participants felt that it is not possible to be neutral.
There was some questioning of the appropriateness of the focus on teenage pregnancy and support for the recommendation of developing a more comprehensive picture of sexual wellbeing for both sexes and all age groups in Scotland. Care needs to be taken in presenting the actual target, which refers to reducing pregnancies amongst those aged 13-15 years old rather than applying to all teenage pregnancies. It was felt that the draft strategy is too focused on young people and much of the discussions also focused on the sexual health of young people.
There is a need to challenge what are seen as unhelpful attitudes towards sex and relationships. Labels that society gives people are not seen to apply to particular individuals or are explicitly rejected and can cause discrimination, act as barriers to good sexual health and to accessing services. The need for the strategy to address stigma and discrimination is not confined to stigma and discrimination around HIV and sexuality.
There was support for a comprehensive media strategy and recognition of the substantial challenges this will present. Any campaign should promote positive messages, avoid fear and sensationalism and not just focus on the use of barrier contraception. A media campaign could play an important role in breaking the 'cycle of embarrassment' through assisting parents in talking to their children.
For a media campaign to be effective, it would need to be linked to other elements of the strategy, including tackling the reluctance and stigma around condom use, including their use for oral and anal sex. It will have to tackle a number of sexual taboos, challenge homophobia, confront sexism particularly in attitudes towards young women and challenge sexual behaviours and assumptions amongst older people and men who pay for sex. It should also signpost people to more information and resources, including information on where to access cheap or free condoms including different types of condoms.
There was substantial agreement that greater access to free condoms is important for both men and women, linked to the need to promote awareness of the need to use condoms and health promotion activities to promote skills development in the use of condoms.
In relation to target groups, in addition to those mentioned in the strategy, 'looked after children', people with disabilities and those that have been subject to domestic violence and abuse were also proposed as well as other groups such as men and older people. Specific target groups should be consulted about their needs, not least about the way that they should be referred to or labelled, which at times has been perceived as at odds with the focus on respect and can act as a barrier to sexual health. Sexual health promotion should be appropriate to the local community, but there are wider responsibilities for sexual health and a need to make better use of the voluntary sector and other individuals in communities, as well as specialists.
The importance of schools in promoting better sexual health amongst young people was recognised and there was support for consistency in SRE in all schools but also that it should be sensitive to differences in culture and beliefs. Some felt it is unrealistic to expect consistency.
The involvement of parents was seen as very important to ensure sensitivity although not all parents see a need to be involved or have the confidence in their own knowledge to discuss sex and sexual relationships.
There was some scepticism amongst young people themselves about the value of SRE and teachers were not a popular option to deliver SRE. Relationships with teachers, their age and gender and the extent to which confidentiality is assured all affect the extent to which young people feel comfortable about teachers delivering SRE. Many prefer youth workers or youth group settings as the best way to deliver SRE.
In respect of the content of SRE, there was support for a wider focus than avoiding pregnancy, calls for more information on STIs and challenges to unhelpful attitudes towards gay, lesbian and bisexual young people. Whilst there were some comments on the appropriateness and effectiveness of abstinence messages, most would like to see a greater emphasis on the positive aspects of SRE rather than a primary focus on the potentially negative outcomes of the sexual activity. While it was recognised that there is a need to address the risks associated with sexual activity, there was a feeling that SRE should also discuss the positive aspects of relationships and address issues such as self-esteem and homosexuality. It was felt that it should tackle myths, avoid scaring young people and be non-moralistic. As well as the content of SRE, the way that schools convey their own attitudes and challenge prejudice, for example, through the treatment of bullying was also highlighted as being important.
Young people had mixed views about accessing sexual health services through schools, largely due to concerns about confidentiality and anonymity. Whilst some others supported closer links between schools and clinical services, there were also fears that this is an inappropriate development and that parental rights and responsibilities will be eroded.
Media campaigns and information aimed at parents will go some way to address the sexual health promotion needs of adults, but will not be sufficient to effect change in sexual attitudes and behaviour amongst the wider population. Many simply don't see themselves as being at risk. Attempts to change behaviour in the adult population will also have to address a number of stigmas and taboos and tackle issues of abuse and violence. There are also attitudinal barriers including an unwillingness to accept the sexuality of older or disabled people. These present many challenges to the development of 'cultural competence' amongst staff in health and social care settings.
Handling HIV testing is a challenging area for the development of cultural competence amongst staff and this evidence suggests that it is a procedure that cannot readily be 'normalised'. Proposals to make it routine will need to be sensitively handled to avoid the great potential for misunderstanding and insensitivity.
The challenges of overcoming the barriers to access to services are substantial. Concerns about confidentiality and anonymity are major barriers for all ages and populations. Embarrassment, stigma and prejudice prevent many people using specialist services such as GUM clinics. Again, the development of cultural competence in all tiers of services will be a major challenge.
More information on sexual health issues and services would be welcomed. The voluntary sector should have an important role in the provision of information on a range of sexual health issues. The needs and views of the target audiences should inform the provision and format of information on sexual health and services.
There was some scepticism about the proposed framework to champion sexual wellbeing at all levels, although some support and recognition of the challenges of the task. There were concerns over accountability, representativeness and bureaucracy. There was a clear preference for resources to be directed to those working at community level, although no consensus on the relative merits of Health Boards and local authorities as lead agencies.
There were also concerns about the level of resources that are to be available to implement the strategy, particularly over the longer term. There was support for the need for training on sex and sexual relationships to encompass those who have a wider remit than sexual health and wellbeing.
This research has been part of the wider consultation process. It does not provide a single definitive view of the draft strategy, but includes a wide range and depth of views on many of the issues amongst diverse groups in the Scottish population. It includes the voices of those who face the greatest barriers to their own sexual health and wellbeing. Whilst there is some common ground, the sometimes challenging, frank and divergent views expressed illustrate the real challenges that any strategy faces. It must reconcile different opinions and interpretations of what should be the appropriate content and address the practical difficulties of changing attitudes, behaviours and the implementation of services to deliver sexual wellbeing in Scotland.
The UK fares badly compared with other developed countries in terms of the sexual health of its population. It has the worst rates of teenage pregnancy in Europe and within the developed world is second only to the USA. Teenage conceptions are both a symptom and a cause of social inequalities. Sexual ill health in Scotland remains poor. Growing numbers of people are being diagnosed with sexually transmitted infections (STIs), which can have significant implications for those diagnosed and for onward transmission. Considerable numbers of people in Scotland report discrimination, abuse and sexual violence related to gender, sexual orientation or HIV status.
In response to growing concerns about Scotland's sexual ill health, in August 2002, the Minister for Health and Community Care appointed an independent expert Reference Group to draw up a strategy for improving sexual health in Scotland, with particular reference to measures:
The consultation process on the draft Sexual Health and Relationships Strategy (SHRS) was launched in November 2003. The draft strategy was distributed to a wide range of consultees and was also made available in electronic format on the Scottish Executive website. In total, over 5000 copies of the SHRS were distributed. The strategy was the subject of debate in the Scottish Parliament on 14 January 2004.