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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 FOUR PROMOTING POSITIVE SEXUAL HEALTH
4.1 The draft strategy identifies many barriers to achieving sexual wellbeing which tend to have the greatest impact on the most disadvantaged in society. These include: Individual barriers to empowerment and choice (such as knowledge, attitudes, lack of competence or confidence, perceived or actual lack of confidential services) Physical barriers to using services (such as distance, cost, accessibility or lack of services) Social barriers to services and knowledge (including staff attitudes and skills, an unwillingness amongst parents and teachers to discuss sex, unacceptability of gender based violence); and Cultural barriers at a societal and service level (including ethnic background including attitudes to female genital mutilation; discrimination and stigma; unwillingness to accept sexuality of young people or disabled people; and different moral and faith beliefs).
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Meeting the needs of those facing the greatest barriers to sexual health
4.2 This aspect of the consultation process has sought to engage directly or indirectly with some of those who are identified as having the greatest barriers to sexual health. This has included young people
5, female sex workers, men who have sex with men, and those who have lived in or travelled from Sub-Saharan Africa and who have experience of HIV. These groups do not represent the full range of groups identified by the strategy as facing the greatest barriers, but their comments provide many useful insights. Other participants not identified as being from such groups also provided comments of this aspect of the strategy.
4.3 The draft strategy argues that if it is to be inclusive, sexual health promotion, sex and relationship education (SRE) programmes, sexual health clinical services and other activities to promote sexual wellbeing must be 'culturally competent' as well as addressing the impact of gender inequality on women. 4.4 The draft strategy states that cultural competence means that services, education and activities to promote sexual wellbeing should be: Linguistically appropriate, with adequate translation and interpreting service available where necessary Respectful of cultural and religious norms of different groups by using sensitive terminology and images Able to employ an adequate number of practitioners to deliver same-sex services, information and advice
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4.5 Some participants found immediate issue with the way that a particular target group had been identified in the strategy, seen as at odds with the focus on respect.
"My main issue is the footnote about rejecting the term sex worker - [the strategy] talking about prostitutes because prostitutes have no choices. By putting that in it shows an absolute lack of respect for their human and civil rights. I find that so difficult because if you're arguing that every human being is worthwhile, worthy of respect you can't suddenly say 'but this group isn't because we don't believe what they say actually'" (Sex worker interview).
4.6 Others also stated that they believe that the use of the term 'prostitute' is pejorative and acts itself as a barrier to sexual health as people do not see the label as applying to them and therefore may not access appropriate services or resources. This issue is also discussed in sections 2.28-2.29. An example of the rejection of such labels may be due to the scale and casual nature of the exchange.
"Selling sex may be casual - small scale selling sex for cash for the weekend. Men who do this may only take small quantities of condoms" (LGBT outreach group).
"How do you go about getting services to male and female prostitutes? If services are targeted specifically at them, you will miss those who do not categorise themselves as prostitutes as not all men who have sex with men for money see themselves as prostitutes" (SCF participant).
4.7 There was agreement that sex workers should be a target group because of their vulnerability. However, one participant argued that their vulnerability in terms of sexual health is created in respect of their relationships with their loving partners, not the partners that they get paid to have sex with.
"There is clear epidemiological evidence that the vast majority of sex workers who contract STIs do so from their loving, non-paying partners. Within those loving partnerships, it's important for most sex workers not to use condoms because that's what gives them the barrier between the sex they get paid for and the sex that they have with their lovers" (Sex worker interview)
4.8 Taboos and the consequent rejection of labels such as 'gay' can also create vulnerability.
"If a man walks in [to sexual health services] with a wedding ring, don't assume he doesn't have sex with men. For example, he may take extra strong condoms" (LGBT outreach group).
4.9 Other barriers to sexual health and specific groups that should be targeted were also identified, although some suggested that a more generalised approach is needed.
"You are categorising people by stating that some groups face greater barriers to sexual wellbeing. Everyone has barriers to sexual wellbeing at some point in their life. Services have to be in place for all" (SCF participant)
4.10 In terms of specific groups that should be targeted by the strategy, looked after children, people with disabilities and those that have been subject to domestic violence and abuse were mentioned.
"High numbers of people who have come through the care system seem to get pregnant at a younger age. This strategy mentions those coming through care, and promises to investigate further. Looked-after children need specific attention" (SCF participant).
"There is a need to support people with disabilities - it isn't clear to what degree this has been taken into account" (SCF participant).
"People with disabilities have sexual needs. This is an issue of control that at present is pushed under the carpet. Who do they go to for help?" (SCF participant).
"One target of improving sexual health has to be those who have been abused. There is also not enough support and information from the police on violence against women" (SCF participant).
4.11 However, there were also suggestions that other groups may also face barriers, in particular those that may not be conventionally thought of as being 'hard to reach' or having particular needs and who might be 'hidden minorities'. This would include men who don't otherwise have any specific label (such as 'young' or 'gay') and older people.
4.12 It is difficult and unusual for men to discuss sexual health or health in general and this makes targeting their needs difficult.
"Sexual health would never be discussed. For men, it would be just titillation, rather than a serious subject. [It wouldn't be] 'I've got a problem I'm not very sure what to do about it'. You wouldnae go and ask a guy in the pub for advice!" (Working men group).
"Men are often the last people to go to the doctors. Women will have a problem and they'll go. That has to be changed as far as the culture is concerned" (Working men group).
"It's head in the sand kind of stuff. We're a bunch of wimps when it comes to getting needles stuck in us or going to the doctors" (Working men group).
"How do you reach the over 25's? Women tend to go to their GP or other health professional, whereas men do not" (SCF participant)
4.12 A failure to recognise sexual health as an issue for older people, attitudes amongst older people themselves and those amongst those professionals that work with them can also be barriers to sexual health and wellbeing.
"There needs to be information available for older people - more relationships are breaking down and people becoming single again at an older age, needing to know how to protect their health. There are more divorcees, widows, widowers etc. The strategy is too focused on young people" (SCF participant).
"Older people look on sex as a private issue. We have an ageing population, so this is a very important area" (SCF participant).
4.13 Some participants argued that there is a need to recognise the diversity of older people as well as targeting specific needs.
"They reflect the wider society. There is a need to address multiple identities and recognise the cross-cutting strands and a need to be more targeted" (Older persons agency interview).
4.14 The use of labels highlights the difficulties and sensitivities of developing a strategy that truly addresses social, sexual and cultural diversity. The range of barriers and groups that should be targeted identified by participants illustrates the complexity of the task of delivering culturally competent services.
A broad approach to sexual health promotion
4.15 The draft strategy recommends that sexual health promotion appropriate to the local community should be a key strand in NHS Board sexual health strategies. It also recommends that sexual health promotion should be a key activity for all those involved in sexual health learning and service activities and should be supported by sexual health promotion specialists. Resources for sexual health promotion should also be identified in local sexual health strategies so that good quality and well resourced specialist services are able to support local initiatives. |
4.16 The previous discussion of general barriers to sexual health affecting particular groups and communities highlights the need to develop an understanding of what the particular sexual health needs are in any particular community. Participants suggested that this should not just be about gathering statistics; several participants called for specific target groups to be consulted about their needs.
"The health service should provide culturally specific statistics, to create a sexual health 'picture' of each community. The problem with that is that as Scotland gets more and more diverse, the task will get harder, and cost more money" (SCF participant).
"Statistics are useful, but we need absolute access to information to tackle ignorance" (SCF participant).
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The Scottish Executive should be asking young people what their ideas are about this" (SCF participant).
"Consult with young people about what is of use and where they would go to access services" (SCF participant).
4.17 In terms of responsibilities and resources, some participants felt that the draft strategy had overlooked the role that the voluntary sector can play in sexual health promotion.
"Other players in sexual health have been missed out of the strategy - scouts, guides, other youth groups. There are successful self-help groups offering peer support in [our area]" (SCF participant)
"The whole strategy seems to focus on the statutory sector. Most interaction and work with younger people comes through the voluntary sector. Partnership working is missing from this strategy" (SCF participant).
"Access to information when required should be the key. The voluntary sector can provide this" (SCF participant).
"There are people in place already. The document fails to acknowledge counselling for example. Counselling is not voluntary. It needs funding to deal with these issues. Relationship issues are very much related to sexual health. Counselling can play a key role, but it is under-funded" (SCF participant).
"Any and every agency that people feel comfortable approaching, should be linked into the strategy" (SCF participant).
4.18 Others suggested that there were key individuals in communities that can play a part and there was a concern that whilst there is a role for specialists this must not detract from recognition of wider responsibilities for sexual health.
"The responsibility for education should be spread beyond health professionals and educators to people like barmen and others in contact with the community" (SCF participant).
"You need to tell the Pastor - he can tell people through the church, not through the GUM clinics" (African men group).
"Reliable and locally available information is the key. Would an appointed Sexual Health Co-ordinator mean that all other employees would not bother addressing sexual health issues? Co-ordinator's jobs should be about linking up all those working to deliver the strategy. Some see adding new posts and strategies as putting a sticking plaster on a burn. Sexual health needs to be integrated into everyone's work" (SCF participant).
4.19 These comments suggest broad support for the recommendation that sexual health promotion appropriate to the local community should be a key strand in NHS Board sexual health strategies. Specific target groups should be consulted about their needs. There is also a sense that there are wider responsibilities for sexual health and that health promotion activities could make better use of the voluntary sector and key individuals in communities, alongside a role for specialists.
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