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ENHANCING SEXUAL WELLBEING IN SCOTLAND- A SEXUAL HEALTH AND RELATIONSHIPS STRATEGY: ANALYSIS OF NON-WRITTEN CONSULTATION EVIDENCE ON THE DRAFT SEXUAL HEALTH AND RELATIONSHIPS STRATEGY

CHAPTER TWO SETTING THE CONTEXT

THE CURRENT PICTURE

2.2 The broad and holistic approach to sexual health in the draft strategy was generally welcomed across the range of participants. There was a sense amongst the views expressed that sexual health is a wider cultural issue, even if there is divergence in ideas about how to tackle the issues. There was recognition amongst participants of the wider influences on sexual health, for example of the links with poverty, welfare systems, inequality, discrimination, stigma, powerlessness and drug and alcohol abuse. There was also recognition of wider social and demographic changes and the impact that these have on patterns of marriage and sexual relationships and the wider implications for social policy including health and sexual health services.

2.3 There was concern that the strategy should not just tackle the symptoms of sexual ill health.

"The current proposals here are aimed at tackling symptoms rather than the cause of the problem. The real issue is about who we are and how we value ourselves" (SCF participant).

"We need to find the root here. We're dealing with the branches" (African male group).

Teenage pregnancy

2.5 The links between sexual health and social factors were most frequently discussed in relation to the issue of teenage pregnancies.

"It isn't always an accident - often it is a search for affection. It's also sometimes a way of getting housing. Confidence needs to be built - if young people are self-confident and trained by people who know, they will not get into situations like that. If people are made to feel valued in other areas of life, they won't use pregnancy to feel valued, or use sex itself to feel valued" (SCF participant).

"Motherhood is a role which society validates. When not succeeding in other roles such as a student or employee, motherhood can be a means to achieving appreciation from society" (SCF participant).

2.6 Self-esteem was seen as a crucial factor and some participants expressed the view that there is need to challenge what they viewed as unhelpful attitudes towards sex and relationships. Experience of other countries that do not have the same level of teenage pregnancies as the UK was cited.

"In the Nordic countries where they have well developed welfare systems, they have less people getting pregnant [at a young age]. Social exclusion is the issue! Inequalities are so high, hence these problems - we need to bridge that gap in some way. To tackle the problem we need to help young people, support children of young parents with day care, so that being a teenage mother isn't a problem as she can still be educated or go to work" (African men group).

2.7 All the young mothers interviewed believed they were receiving mixed messages about sex and that there was an element of hypocrisy in accepting that young people could have sex yet rejecting any pregnancies that resulted.

"You're saying it's alright to have sex [at sixteen] but it's not alright to have a bairn" (Young mothers group).

"There's double morals all the time so you don't know. It's OK to have sex at sixteen but you're not allowed to get pregnant at sixteen" (Young mothers group).

2.8 They disagreed with portraying teenage pregnancy as a uniformly negative event which must be avoided and saw such an approach as contributing to the stigma and shame they had experienced surrounding sexual intercourse and pregnancy.

"I think they should also teach you that it's alright to make a mistake. You shouldn't feel like an outcast because you've made a mistake" (Young mothers group).

"What gives them[people generally] the right to put you down for being pregnant?" (Young mothers group).

2.9 They were at pains to challenge any assumptions that young mothers made inadequate parents and explained how their lives had changed to accommodate the needs of their children.

"It doesn't matter what age you are as long as you love your child. They might not have Next or Nike but they've got your love" (Young mothers group).

2.10 Several participants in the SCF discussions argued that it is not necessarily wrong for teenagers to have children and that in taking this view the draft strategy does not recognise cultural diversity.

"It is assumed that it is wrong and unwanted. Young people can make their own decisions and judgements" (SCF participant).

"It is sometimes a cultural norm for young people to marry and have babies at a very young age" (SCF participant).

2.11 There was some questioning of the appropriateness of the focus on reducing teenage pregnancies amongst the SCF participants.

"The term 'teenage' actually refers to those aged 13-19, and so is an unhelpful term. It is completely appropriate to be pregnant at 18/19, in fact this is an ideal time. 'Teenage' is being stigmatised again" (SCF participant).

"Unwanted pregnancies are in fact more common to those aged 20 to 35 than with teenagers" (SCF participant).

2.12 Many views were expressed about widening the focus from teenage pregnancy, to include changing the culture.

"Self-esteem is a very crucial factor. We have to work on making sure that people are making choices (like having a baby) freely. Maybe the real answer is to make sure than young working class women are given a better range of choices in life" (SCF participant)

2.13 This questioning of the appropriateness of the focus on teenage pregnancy does provide support for the recommendation of developing a more comprehensive picture of sexual wellbeing for both sexes and all age groups in Scotland. This research suggests that at the very least there should be additional targets or indicators, as well as those focusing on teenage pregnancy. It also suggests that care needs to be taken in presenting the actual target, which refers to reducing pregnancies amongst those aged 13-15 years old since it appears to be easily interpreted as applying to all teenage pregnancies.

The Wider Influences On Sexual Health

2.15 These wider influences on sexual health and the challenges they represent were acknowledged. Many participants focused on the role of the media and this is discussed more fully in Chapter 3.

"It is encouraging that 'health' is being seen here as wider than just medicine. A social model instead of a medicinal model. However, there has been no mention of commercial sector media and advertising, who use sexual imagery to sell products. If that factor is not covered in a strategy, it will get nowhere" (SCF participant).

"Although a focus on HIV and unwanted pregnancies is important we need to influence young people through the promotion of family values, role models, self-respect, a positive image of sex, jobs, the future and their aspirations" (SCF participant).

"The culture for teens is produced and endorsed by older generations, causing our poor sexual health. All media are selling us sex. Role models are lacking" (SCF participant).

2.16 The discussion amongst the African men looked at the importance of role models, changes to family patterns and the importance of how welfare systems support fathers to support their children through child custody arrangements, child maintenance, benefits and paternity leave.

"It's not what you teach them, but who you are. Boys are mostly raised by their mothers - the only men to teach him are his friends. 100 years ago men were responsible - now there are no men to raise up men" (African men group).

"There are no father figures here [in Scotland]. There are absent fathers - they are always working!" (African men group).

"We need investment in fathers - perhaps mentoring, so that men can be like a big brother to children" (African men group).

"Fathers need more time to spend with their children…even fathers who don't live with their kids. In UK, we lose wages and we still have to pay child maintenance. That's why a lot of fathers are just running away" (African men group).

2.17 Gender inequalities were also recognised as an important part of the wider culture in which sexual relationships take place.

"[we live in a] macho, male-dominated, abusive culture. This is reinforced by the media which increases poor sexual health. How can a strategy address these factors?" (SCF participant).

2.18 In relation to gender roles, the young mothers interviewed were acutely aware of the difficulties they experienced as a result of expectations and assumptions, by their male partners and their parents, about the duties and responsibilities of men and women in relationships.

"We all have boyfriends who think you do everything [for them and the kids]." (Young mothers group).

"It needs to be taught that they [men] have a role, it's not just about going out to work, coming home, dinner on the table" (Young mothers group).

2.19 Some participants did not like the links made with wider social issues such as poverty and wanted to see a greater focus on personal responsibility.

"The issue is more complex than just one of poverty. There is too much emphasis on the link between poverty and poor sexual health" (SCF participant).

2.20 In this respect, there were two broad strands of opinion. The first focused on personal and parental responsibility. The second was based on a perspective that whatever our ideals, we need to recognise the realities of peoples lives. This was more aligned with a 'social model' of the influences on sexual health, the consequences of poverty, the wider culture and lack of self-esteem. The first perspective was evident amongst some of the SCF participants, whilst the second perspective predominated amongst the participants in the other research.

2.21 These strands and tensions were apparent throughout the discussions and led to different proposals for how the strategy should be developed, sometimes in terms of the emphasis that is given to particular proposals and at others, leading to markedly contrasting views as to what is appropriate. Overall, opinion amongst most participants tended to be largely pragmatic, based on the view that 'saying sexual ill health is a bad thing is a moral stance in itself' (SCF participant) and that the strategy needs to reflect the realities of people's lives and a realistic attitude to the issues.

2.22 Amongst those that broadly welcomed the recognition of links between wider social issues and sexual health, some participants were sceptical that this had not been followed through to the recommendations.

"The document quickly moves to health mechanisms and health structures. The recommendations do not reflect the initial sentiments and does not address this broad approach" (SCF participant).

"At present, the medical model supersedes the rest. The emotional and social aspects are treated as subsidiary" (SCF participant).

"The NHS is put at the centre of the document, and this is not a good thing. It is not the most important body with regard to sexual health and relationships promotion" (SCF participant).

"The strategy says it will be broad, but it clearly focuses on health. There is no mention of child abuse, no mention of the commercialisation of sexuality, which happens through the media and also through sex shops and legalised brothels" (SCF participant).

2.23 Participants in the Poverty Alliance discussions welcomed moves towards a more positive and open approach to sexual health and relationships. They identified a need to create a more open approach to sexual health and challenge taboos if real change is to take place.

" Attitudes in this country are all about sex being taboo" (Poverty Alliance group).

2.24 For many participants, particularly men it was often the first time they had openly discussed issues of sexual health.

"Sexual health would never be discussed - it's always about your conquests or what's going on that weekend" (Working men group).

"It's not a thing we really discuss in the open. But men don't often talk about health in general" (Working men group).

2.25 The links between sexual ill health and inequalities and social exclusion and the challenges they represent were acknowledged, but some participants did not like the links made with wider social issues such as poverty, and wanted to see a greater focus on personal responsibility. Others felt that the recognition of links between wider social issues and sexual health, whilst welcome, had not been followed through to the recommendations. Two broad strands of opinion were evident and occur throughout the discussions. The first strand focused on personal and parental responsibility, whilst the second strand called for recognition of the realities of peoples lives and was more aligned with a 'social model' of the influences on sexual health. 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.

Discrimination and stigma

2.27 Discrimination and stigma contribute to sexual ill health in many ways and participants gave examples of how stigma can lead to poor sexual health outcomes. Direct prejudice and judgmental attitudes towards people can exclude people from work; sanction bullying and violence; lead to the denial of risky sexual behaviours; failure to practice safe sex; and induce fear of taking an HIV test. Stigma is a major factor in the failure to use sexual health services. These issues are discussed in more detail in the sections that follow, but some specific comments are highlighted here.

2.28 The power of the labels that society gives people was a strong and repeated theme. For example, some participants reject the use of the term 'prostitutes' in the strategy, which was used to signify that prostitutes have no choices.

"A significant number of women are speaking out about this being a choice. They have a limited range of options - but this is a choice - they should not be ignored" (Sex worker interview).

"The use of the term prostitute is pejorative" (LGBT outreach group).

2.29 Disrespect and stigma contribute to harm to sex workers and former sex workers, both mentally and physically, as much from wider society as from clients.

"the harm that has happened to me as a sex worker has not been about the sex that I've had with strangers. It's been about the societal response to me and my family. That is where the real harm has come from" (Sex worker interview).

2.30 Where such terms are not seen to apply to particular individuals or are explicitly rejected, the labels can cause discrimination and act as barriers to good sexual health and to accessing services. For example, outreach workers discussed how dealing with issues defined as 'LGBT' (lesbian, gay, bisexual, transgender) tends to hide men who have sex with men (MSM), but are married to women. The outreach group of participants suggested whilst this is an issue that faces society as a whole, it is a particular issue amongst older Asian men, as it is more acceptable for younger Asian men to be 'out' on the gay scene.

"We don't assume that people we come across in public sex environments are gay" (LBGT outreach group).

2.31 Whilst labels are often used to target services, labelling can also demonstrate a lack of sensitivity and knowledge of diversity and reinforce stereotypes.

"Lots of different people are put together as "black" - but it doesn't address our needs. We're all very different. Black Africans don't get acknowledged. There's an assumption that if you're black and from Africa you must have all the diseases!" (African women group).

2.32 Young gay men had also experienced prejudice and stigma because of their sexuality.

"It's no different from racism" (Young gay men/care leavers group).

"When I was at school, I would never have turned round and said 'I think I might be gay', there's so much stigma" (Young gay men/care leavers group).

2.33 One of the young mothers had also experienced stigma both as a young mother and relating to her disability.

"When I got pregnant most people said I shouldn't have kids because of my disabilities - that I should be sterilised. I think that's terrible" (Young mothers group).

2.34 Issues of taboo and stigma also make it difficult to discuss sexual issues, particularly amongst older people and this is an issue both for individual patients or residents and amongst professionals in hospitals and residential care.

"There are widespread assumptions of heterosexuality amongst older people, both on wards and in residential care. For elderly men, homosexuality would've been a criminal offence" (Consultant clinician interview).

2.35 The views of participants suggest that the action plan will need to be a comprehensive plan, encompassing equalities, employment, education and justice, as well as health and social care. Issues of discrimination and stigma were a continual theme throughout the discussions and the range of concerns raised by the participants suggests that the need for the strategy to address stigma and discrimination is not confined to stigma and discrimination around HIV and sexuality. It will need to promote a greater knowledge and understanding of diversity, address a number of stereotypes and encourage greater sensitivity and questioning of taken for granted assumptions about sexual behaviour.

A broad and holistic approach to sexual health

2.37 The broad and holistic approach to sexual health in the draft strategy was generally welcomed across the range of participants. Among these participants there was broad agreement that issues of sexual health and wellbeing are fundamentally cultural and that it will take time to make a difference. However, there was divergence in views as to what the appropriate response should or could be. It is here that the tension between different interpretations of 'morality' was most evident.

2.38 Relationships were important to all elements of opinion, although some participants felt that the relationship element is not given sufficient emphasis in the draft strategy.

"The sexual health approach tends to treat people simply as sexual beings, but the emotional stuff is also important" (LGBT outreach group).

2.39 Several participants noted that the draft strategy does not mention love. Some saw this as a contradiction, questioning the point of sex if you leave out love. Others argued that sex and love don't always go together; that adding love to the strategy would discourage access to services and stigmatise people still further.

"The values should call for more than respect, there should be a loving relationship; this is good for individuals and good for society. Sex has become recreational. Ideally sex should be loving, and not just in a mutually respectful relationship" (SCF participant).

"Is this appropriate for government? The call for self-respect is enough, the government cannot dictate for love, this is a strategy and it would not be appropriate to include love in it, but it should be more positive about respect" (SCF participant).

"The strategy is looking to change the culture, yet they only make a nod to faith groups. Traditional morality is being overlooked. The strategy sets out to be neutral, but cannot possibly succeed" (SCF participant).

2.40 Based on these wide ranging perspectives, views differed about whether this is an appropriate area for government involvement. The draft strategy acknowledges that interpretations of 'morality' will vary and the Reference Group did not feel it appropriate for the draft strategy to arbitrate on such matters. Instead, it focused on the key values of self-respect and respect for others, equality of opportunity and a commitment to the rights of people to have sexual relationships free from abuse, violence or coercion.

2.41 Whilst the broad and holistic approach to sexual health in the draft strategy was generally welcomed, participants' views indicate that this is a challenging area for the Scottish Executive, with no single view or interpretation. These discussions show that people believe that the values on which the draft strategy is based are too open to interpretation and that it is not possible to be neutral.

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