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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 FIVE ACQUIRING KNOWLEDGE AND SKILLS ABOUT SEXUAL HEALTH AND WELLBEING

5.1 The draft strategy acknowledges that learning about sex occurs throughout life and has many influences. However, learning is seen as not just about accessing information but also developing values, attitudes and skills to make appropriate choices about sexual behaviour.

5.2 Much of the discussions focused on sex and relationship education (SRE) in schools, although the strategy makes the case that SRE is not just about school based programmes, but about community and family responsibilities which should involve a range of agencies.

5.3 Reflection amongst all participants including young people, older people and parents about the quality of their own sex education provides insights into views about how best to encourage the acquisition of knowledge and skills about sexual health and wellbeing. Their views and experiences suggested that there is an on-going need to address adults and parents in education about sexual health and wellbeing, as well as children and young people.

The role of schools

5.5 There was considerable agreement amongst many participants on the importance of schools in promoting better sexual health amongst young people.

"There is a feeling that parents are generally happy for there to be sex education in schools, which may even broaden their own knowledge. However, everyone needs to take responsibility for sex education. Parents should neither leave it all to schools, nor complain that schools are doing SRE" (SCF participant).

"Sex education needs to start early, and it needs to be a partnership with support to parents, who currently can be taken by surprise by what is being taught" (SCF participant).

5.6 Participants in one of the Poverty Alliance groups noted that sex education should start at an 'earlier age' and others expressed the view that education should start early.

"They probably need to start very early - even at 5 years they talk about boyfriends and girlfriends. They watch television - there's no point in keeping them in the dark" (African women group).

"It should be included in PSE [Personal and Social Education] in Primary 5. Children ask questions about what they see going on as young as pre-school. If people are taught about the issues earlier, evidence suggests that people adopt a different approach in their lives" (SCF participant).

5.7 This is also a response to changing physical development, although others resisted this idea.

"Girls are having periods earlier so education needs to start earlier" (African women group).

"They need sex education when they are teenagers. They can't handle that kind of information before then. You will damage those children. At 11 years and older, at puberty [is when they need it]" (African men group).

5.8 One young woman participant expressed the view that girls and boys need SRE at different times:

"Girls should be taught at thirteen and boys later on when they're mature enough." (Young mothers group).

5.9 There was also a desire to see SRE tailored to meet the different needs of each age group.

"Introduce familiarity before sexuality for kids in schools with light-hearted introductions linked to talking and communication" (SCF participant).

"SRE needs to be tiered in its' delivery with specific education at primary school level, then for secondary school, then for 18-25 year olds, and develop from there. A consistent message is needed, but specifically aimed at each age bracket. Different groups (and their differing needs) will react better to different mediums of information" (SCF participant).

5.10 There was support for the idea that schools should be required to provide the same information regarding sex and relationships regardless of religion or culture. However, participants also noted that the way that information was provided should be sensitive to differences in culture and beliefs.

5.11 The involvement of parents was seen as very important in ensuring that information was provided sensitively and there was an evident desire amongst some participants to become more involved.

"It is vital that parents are aware of what is being taught to children and there is an awareness of the cultural and faith community" (SCF participant).

"There needs to be openness in devising the teaching materials in agreement with parents. There is a need to work with, not against parents. Parents should be given a programme to work through with their children" (SCF participant).

"Parents see it as their role to talk about sex education, and would welcome getting involved in the programme. There is a need to get parents involved at the planning stage - parents should agree what happens in schools" (SCF participant).

5.12 However, not all parents saw a need to be involved. Some felt that the children already know more than they do.

"I don't think there's a need for parents to educate their children. They get enough of that from both school and the media to grasp the basics" (Working men group).

"The kids educate their parents. Kids are more open with sexual and moral issues than us. In some ways they might shock their parents, but at least it's open and it's there" (Working men group).

5.13 Some young participants agreed and suggested that SRE should enable young people to educate their parents.

"You can educate the kids so that they can go home and educate the parents." (Young gay men/care leavers group).

5.14 There was some scepticism amongst the young participants about the value of SRE based on an expectation that it would not be relevant due to negative experiences and their own disengagement from school-based SRE. However, the majority of young participants strongly supported the principle of having a say in the content and delivery of SRE and all offered opinions and suggestions for improving sex education in schools.

"It's all about choice and schools don't really give you much choice" (Young gay men/care leavers group).

"[ If we have an input] we're more likely to listen." (Young fathers group).

5.15 Any 'top-down' approach to developing learning objectives and outcomes in SRE is unlikely to be effective and may in fact alienate some young people. Particular areas in which participants mentioned that they thought young people should have greater choice include which of their peers they are taught SRE with, who teaches SRE and the environment in which SRE is taught.

5.16 Other participants noted that young people are often not comfortable in school settings.

"There is a gap here - young people can be led like a horse to water, but won't necessarily drink. School and theory is not enough. Loads of kids don't feel comfortable talking to their teachers or parents about sex. Who else can help?" (SCF participant).

5.17 Who young participants prefer to learn about sex and relationships from depends on the quality of their relationships with and perceptions of the approachability of individuals, whether they are parents, professionals or friends. There are marked differences in opinion; whilst parents were the first choice of some, others regarded parents as the least desirable option. The youngest participants who are still at school did not consider them as an option at all. The young mothers made a distinction between their current views on the issue and their own feelings at age fifteen.

"When I was fifteen my mum didn't really speak about it but now I would go to my mum. But when you're fifteen, you're too shy and nervous [ to speak to your mum] " (Young mothers group).

5.18 The young fathers regarded parents as the worst option since they themselves, and their parents, would find talking about sex and relationships embarrassing.

"It would be more embarrassing talking to parents than anyone else." (Young fathers group).

5.19 However, other participants stated that they would talk to their parents.

"There's a more relaxed attitude to sex with my foster parents, at school it's more formal" (Young gay men/care leavers group).

"You feel more comfortable [ talking to parents] , cause it's your own home space" (Young gay men/care leavers group).

5.20 None of the young participants disagreed with the principle of delivering SRE at school, but teachers were not a popular option to deliver SRE. The delivery of SRE by teachers in a school setting raised extremely sensitive issues for the young people relating to relationships, roles and boundaries - personal and professional - between young people and their peers and between young people and teachers. The pupils' relationship with the teacher and the extent to which confidentiality is assured are both key factors affecting the extent to which participants felt comfortable about teachers delivering SRE.

5.21 The age and gender of the teacher were cited as influences on feeling at ease in SRE classes. The ability to access information about sex and relationships on a confidential basis was very important to all the young participants and so lack of trust in teachers represented a significant obstacle to these participants and one participant identified an incident where confidentiality had not been honoured.

5.22 Some participants said they did not feel comfortable about discussing highly sensitive and personal issues with, or asking for personal advice from, teachers with whom they had a professional relationship and saw on a day to day basis. The young men participants felt that the dual role of 'sex and relationships educator' and teacher (of whatever subject) breached acceptable boundaries:

"[ I wouldn't go to a teacher because] you end up in a classroom with them after" (Young men group).

"You go to a PE teacher to run laps, not learn about sex!" (Young men group).

5.23 Other participants felt that they should be taught SRE in an impartial way and that this would be compromised if they knew the person who taught it. Although they showed some ambivalence on this point and did see an advantage in the SRE educator being available within the school for follow-up questions, they saw this advantage as applying to a school nurse or health worker rather than a teacher. They commented that pupils were more likely to 'play up' if SRE was delivered by a teacher (or nurse) known to them, and indicated that familiarity with the person delivering SRE would mean they would not feel free to ask questions.

"It's more likely you and your mates will start taking the mickey in class - you might not ask questions either because you're too embarrassed" (Young gay men/care leavers group).

5.24 Others did not feel at ease with teachers generally: "teachers are scary people, eh?" (Young mothers group). Distrust of teachers was most marked amongst those young men who are currently in a young offenders' institution.

5.25 Other participants recognised that teachers need support too.

"They have a difficult juggling act to carry off. There is room for improvement in training for teachers. Guidance teachers being used as the resource for too many personal issues can ruin their relationship with young people. Quite often young people want to get their sexual health information from sources outside school" (SCF participant).

"Sex education can be problematic for teachers, who may feel ill equipped to address the subject or to provide information and advice" (SCF participant).

5.26 Other participants felt that the type and quality of SRE provided relies too much on individual head teachers and teachers. This will mean that different locations and agencies should be used to provide sexual health information to young people.

"It may be more appropriate to give the information at specialist centres. Young people could be taken from schools to such centres to get appropriate information. If young people were taken to these projects as part of sex education classes at school then this would ensure that young people were able to access the information they required" (Poverty Alliance group).

5.27 The way in which information on sex and relationships was provided was also seen as important.

"Some teachers might not be confident or have the skills to give their students the best information on sex and relationships. This problem could be overcome by bringing in other agencies or professionals to give information to young people. Specialists would ensure that the standard and information was consistent regardless of the specific school or the individual teacher. Specially trained professionals would also be better able to deal with specific questions that some teachers may be unable to answer" (Poverty Alliance group).

5.28 Some young participants favoured a nurse or health worker from outside the school. Others were undecided as to whether they preferred a nurse or health worker from inside or outside the school. Familiarity can bring problems about confidentiality, perceived lack of impartiality and difficulties in asking questions, although use of school-based nurses and health workers makes accessibility for follow up questions less of an issue.

5.29 Youth workers were a popular option, with many young participants viewing them as the best way to deliver SRE. They felt that communication with youth workers was easier and that they can be more open with them: "youth workers are easier to talk to" (Young men group). Learning about sex and relationships in a youth group setting was felt to be an effective way to deliver SRE because it involves learning about serious issues in a fun way. Other participants recognise that this is often a young person's preference.

"Money is required for youth workers to talk to young people - they prefer this outlet rather than turning to teachers or parents" (SCF participant).

5.30 Some young participants said they prefer to discuss sex and relationships with their friends as they feel that this best ensures that there is trust. Other participants had some observations about how best to get messages across through friendship networks.

"Boys have to be educated about sexuality and the consequences of these things. They mostly learn from their friends. If the key person in the group has bad information this will get round. I would deal with the most influential person, make sure that he gets the right information, so that's what will get round" (African men group).

5.31 The young gay men/care leavers particularly like the idea of training other young people to act as peer educators, although others expressed reservations about the use of older or sixth form pupils to do this.

" You tell them something and they could just end up spreading gossip about you" (Young women group).

5.32 A number of other participants also suggested that peer education would be effective, particularly in reducing the number of teenage pregnancies.

"It might be useful to bring in young women who have children to talk about the impact on their lives and their experiences. In many cases this would make the education young people receive, particularly young women, more relevant to them" (Poverty Alliance group)

5.33 Taking young people to specialist projects or services was felt to be valuable by raising awareness of services and of making them more accessible to young people

"An important part of sexual health teaching in schools should be about ensuring that young people know where to go to get the information or services they need" (Poverty Alliance group).

"Hand on heart, they never mentioned sexual health services once [ at school] " (Young gay men/care leavers group).

5.34 Some expressed the view that unless there is consistency a strategy won't work, whilst recognising the practical difficulties of ensuring consistency.

"Parents should not be allowed to take their children out of SRE at school. If the children are not at school, another way must be found to provide that same education. Workers could be trained specifically to achieve this. Schools have a captive audience. Young people do talk to their teachers. The problem is that teachers and pupils do not all have the same relationships" (SCF participant).

"Schools need to be told they are going to provide consistent SRE. Inter-faith schools have groups who teach issues of 'community interest', so there are ways to work with denominational schools in this area. However, response from parents or religious groups can put projects off from doing their work. Workers often feel powerless and afraid in some areas" (SCF participant).

"Being offered full choices and being provided with all information is a matter of human rights. Faith can be taught outside school by faith groups - let education be taught in schools" (SCF participant).

5.35 There were concerns about those excluded from school and those children whose parents make choices on faith grounds to take them out of SRE.

"What happens about children of travelling people or those who are excluded from school? They also need to learn about sexual health and wellbeing" (SCF participant).

"There are cases of children whose parents have removed them from SRE in school. Those children were often more promiscuous than those receiving SRE in school. If children are excluded from SRE, they will pick up bad information on the street instead" (SCF participant).

"What will happen to the children whose parents don't let them receive SRE at school? Alternative outlets are needed to cover where parents fail to deliver the message. Parents will however need support and information" (SCF participant).

5.36 Others expressed the view that looking for a consistent message is unrealistic.

"Denominational schools won't talk about things like the morning after pill. You have to work with people, not impose on them. The strategy is meant to be celebrating diversity, but it's a joke. How diverse is it to have one single message that we all have to sign up to? It's like Orwell's 1984. It would be a shame if the strategy was to be derailed because it left some groups in society behind" (SCF participant)

5.37 A number of issues were raised regarding the content of SRE. Some participants want to see information needs to be given regarding the 'mechanics' of sex. This would include information regarding the risks to health associated with sex, but also appropriate information on how to protect oneself from any risks. Some were blunt.

"Tell them how it is. Give them the facts" (African women group).

5.38 Another aspect to the content of SRE should be accurate information on all aspects of boys and girls bodies. Although this is already part of the curriculum it was felt that both boys and girls (particularly boys) did not understand enough about reproductive and other aspects of each other.

"[Boys] don't understand period pains or PMT and we don't understand [boys]" (Young mothers group).

"The rudimentary sex education I got at school - they taught you about you. They didn't tell you about the other sex! So you were quite ignorant of this other sex that you're supposed to be having sex with anyway or going to have sex with at some stage. It's very difficult to understand the female body. It's this assumption that we all know - and we don't. It might get better respect if you understand the female body and they understand the male body" (Working men group).

5.39 All the young participants felt there was a gap in understanding between the genders. They all made reference to wanting to understand the opposite sex better and that this is something that SRE should address. They wanted to know what members of the opposite sex were thinking and felt it to be desirable to be able to find out about this and share common issues. The young male participants wanted information that went beyond the purely medical or 'mechanical'. Having better knowledge about all these issues would help in improving sexual health and wellbeing. Several young participants highlighted a need to address emotions in particular, to allow them to discuss how to know when you feel ready for sex and relationships.

"I'm not from an affectionate family. We need advice on how to make relationships work" (Young mothers group).

5.40 Other participants also believed that sexual health and relationship education in schools must be appropriate for the needs of those being taught. They noted that the ideas believed by many people, not just young people, were based on myths and feel that the content of sex education should tackle such myths.

"It is important that sexual health information tackles the myths regarding sex, such as the idea that 'everybody is doing it'" (Poverty Alliance group).

5.41 Myths and unhelpful attitudes contribute to the peer pressure that young people feel to be sexually active and embarrassment about being taught SRE with their peers.

"Your mates will take the mickey out of you for being a virgin if you say you haven't had sex" (Young fathers group).

"I lost my virginity at eleven and the only reason for that was peer pressure" (Young gay men/care leavers group).

"It's the fashion, isn't it? Everyone seems to be at it" (Young women group).

"[ I didn't find SRE useful because] there were too many people having a laugh" (Young mothers group).

"When you talk in a meeting at school you're too shy, you don't know if they [the other pupils] are going through the same things as you" (Young mothers group).

5.42 The young participants made some suggestions for addressing these difficulties. These included giving young people a choice as to which of their peers they are taught with, follow-up by a guidance teacher on a one to one basis, having smaller SRE classes and having the option to speak to a health worker.

5.43 There were also calls for a wider focus than avoiding pregnancy and to challenge unhelpful attitudes towards teenage pregnancy and attitudes towards gay, lesbian and bisexual young people.

"People need to be praised because it's a really big thing to bring a bairn into the world" (Young mothers group).

5.44 The young gay men stated that when they had received sex education it had covered only heterosexual sex and relationships and thereby contributed to the stigma they had experienced. They discussed the discrimination and in some cases, abuse that they had experienced and felt strongly that this was largely due to ignorance about homosexuality among peers and parents of their peers. Other participants agreed with this criticism of the omission of homosexuality from SRE: "it's probably why most folk are against gays" (Young women group).

5.45 Several young participants said that they wanted to know more about STIs. Some believed that their own sex education had concentrated too much on pregnancy at the expense of general sexual health including STIs, a view echoed by older participants.

"I'd like to have known more about sexually transmitted diseases other than just HIV. The focus seemed to be on that particular disease, whereas syphilis, crabs etc don't do as much damage to your health in the long term but they have an immediate effect on you and if you don't treat it, then it can have a long term effect" (Working men group).

"Education about AIDS and HIV is getting worse. Education and awareness raising are needed in schools to overturn stigma around HIV and AIDS. However, there could be a danger that HIV could take over the strategy as a key focus. STIs need to be taken on as a whole" (SCF participant).

5.46 There were some comments on the appropriateness and effectiveness of abstinence messages.

"Schools actually teach a realistic message - delay sexual contact. More emphasis is needed on guiding younger people into understanding relationships better, to see them as more than just sex" (SCF participant).

"Schools need to be teaching under 16s about sex, promoting condoms. They already teach about drugs and drink, neither of which are legal. Promoting a healthy attitude to sex is essential. 12 year olds are reaching a level of maturity. They are still young people but many have started having sex, albeit for the wrong reasons. Education is needed on why and how sex can be for the right reasons, an informed choice. Abstinence programmes do not work" (SCF participant)

"Kids these days are going to make their own minds up about their sexuality - what path they want to follow. Whether they have sex now or they wait. They're the ones that are going to decide. We're not going to decide that. That's how it's going to be. They're more independent" (Working men group).

"Young people are getting mixed messages. The ideas of SRE based on abstinence plus are OK but society is behaving differently. What they see happening influences the way they think - the practice they see influences them. Their parents may not be together, so why wait until you are married to have sex?" (African men group)

"There is merit in using a 'just say no' style message, which could be used to point out that things like unwanted pregnancy or STIs could and might happen to you" (SCF participant).

"I had a Catholic schooling and I knew that abstinence was the key. But as I got older and developed emotions, then I started to question 'why abstinence?' If you tell them to abstain, they will do the opposite. It's better to explain the options, them they can make choices that are good for them. You have to find a way to give the best information" (African men group).

"I prefer to tell them 'no sex before marriage'. In Kenya the abstinence message works when it is clear and strong" (African men group).

"It's very hard for a parent to take that moral high ground. We've all gone out and got drunk and done things we shouldn't have done. We're a wee bit hypocritical that way. I don't think it's up to me to preach to my kids. Talk to them and if they want advice, give them advice. But I don't think I can preach to them telling them 'you will not have sex' or 'you will not drink'" (Working men group).

5.47 There was a strong sense amongst participants that SRE should ensure that whilst providing information on the risks associated with sex, it ought to be provided in a non-moralistic way and should also avoid scaring young people about the dangers of sexual activity.

"The education that is provided should be honest and accurate. It should be honest about the risks, particularly to young people, of sexual activity, but this needs to be done within a framework that views sex and relationships as positive" (Poverty Alliance group).

5.48 The young participants also wanted to see a greater emphasis on the positive aspects of SRE rather than a primary focus on the potentially negative outcomes of sexual activity. Some participants would like to see more about relationships and the development of self-esteem.

5.49 There was also a desire for practical information and the young participants also suggested that SRE should include coverage of the law and issues of consent.

"In Catholic school, sex education was not really about putting condoms on or anything - it was just diagrams of a penis and a vagina - and what's that going to tell you? It doesn't educate you about nothing at all!" (Sex worker interview)

"They never tell you nothing about condoms at school. That was in the 1980s - that's when HIV was going about and they still didn't mention anything about condoms. Where to get them, how to use them?" (Sex worker interview).

5.50 However, there were not just concerns about the content of SRE, but also about the ways that schools convey their own attitudes and challenge prejudice.

"There's something about saying that part of sexual health is respect of diversity. The fact that schools tolerated other children bullying my daughter because I was a sex worker. They did not take adequate measures to protect her when it was mistakenly believed that I was HIV positive. We need to be raising our children to respect diversity and challenge the prejudice and bigotry. We learn that when we're young. It's essential that we try to promote respect" (Sex worker interview).

5.51 The draft strategy recommends that the curriculum framework developed by Healthy Respect should be piloted in all Lothian schools and after that, its' potential as a template for school-based SRE in Scotland should be considered. Although few participants commented on this directly there was some scepticism, although others would like to see the C-Card scheme that gives access to condoms made more widely available.

"Access to contraceptive options for students is what is needed. The 'C-Card' scheme from Lothian could be introduced elsewhere" (SCF participant).

5.52 The importance of schools in promoting better sexual health amongst young people was recognised. There was support for consistency in SRE in all schools but also a view that it should be sensitive to differences in culture and beliefs. The ability to access information about sex and relationships on a confidential basis was very important to all the young participants. There was also some scepticism amongst young people themselves about the value of SRE and a lack of trust in teachers presents a significant obstacle to the delivery of SRE by teachers in schools.

5.53 The involvement of parents in SRE was seen as very important to ensure sensitivity in the delivery of SRE, although not all parents see a need to be involved. Some parents felt that children know more than they themselves do or do not feel sufficiently confident to talk to them. Indeed, some young people and parents say that they find it too embarrassing to talk to each other about sex and relationships.

5.54 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 negative, unhelpful attitudes towards gay, lesbian and bisexual young people. There were some comments on the appropriateness and effectiveness of abstinence messages. However, most participants would like to see a positive approach to sex and relationships education. This would provide information on the risks associated with sexual activity, but would discuss relationships, self-esteem and homosexuality. It would tackle myths, avoid scaring young people and be non-moralistic in contrast to a primary focus on the potentially negative outcomes of the expression of sexuality. 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 is also important.

Developing closer links between schools and clinical services

5.56 Young participants had mixed views about accessing sexual health services via schools. Those who supported the idea did so because of the ease of access this would provide.

"If you don't pay attention in class then you can go and find out about these issues in confidence" (Young fathers group).

5.57 Those who did not support school-based access echoed many of the concerns voiced by participants in relation to school-based SRE, largely centred on the perceived lack of confidentiality: "would it be confidential at school?" (Young men group). They said they prefer to deal with those from outside school, whom they know to be bound by confidentiality.

"Knowing that there's someone there that you can go to and they have to keep it confidential would make it slightly easier" (Young gay men/care leavers group).

5.58 A second concern relates to anonymity.

"People see you going in and ask, 'what you going in there for?'" (Young men group).

5.59 To address these concerns it was suggested that advice and treatment be made accessible through youth or community centres, rather than schools.

"[ It would be good to have] a wee centre where you could go - just for young people. For lassies to get the morning after pill. They don't want to go to their health centre in case they see someone [ they know] " (Young men group).

"Perhaps sexual health services could be housed within community centres? A general health clinic might help people get over the stigma of accessing these services. Or mobile services for rural areas?" (SCF participant).

5.60 Alternatively sexual health services could form one aspect of a wide range of services provided at school, so that it would be impossible to tell which particular service a young person was accessing and thus anonymity could be maintained. Suggestions included a 'drop in club' at school. Schools could also signpost young people to sexual health services, for example, by giving young people information leaflets about them, rather than providing them on site. Professionals could also come into the school and speak to classes, giving advice and information on where to go for health services.

5.61 The young participants gave their views on what issues they could imagine using school-based sexual health services for. The young mothers mentioned treatment for STIs and advice and testing on pregnancy. The young women cited information and advice on contraception, pregnancy testing and obtaining the morning after pill as issues for which they could imagine using school-based sexual health services. There was support amongst the young women in this study for making emergency contraception available in schools ⁶.

" I think the morning after pill should be available in school because you're too embarrassed to ask your mum" (Young mothers group).

5.62 One young mother was sceptical about this since she believed easier access to the morning after pill would encourage young people to be irresponsible about contraception. In response, the suggestion was made that there could be a limit to the number of times emergency contraception would be given - " two chances - after that they would have to deal with the consequences" (Young mothers group).

5.63 The young participants also made a number of other suggestions regarding the kind of sexual health services they would like to see. These included parenting skills courses, a free paternity testing service and confidential counselling and advice particularly for young men who discover they have made someone pregnant.

5.64 Amongst other participants there was some support for greater linkages between schools and sexual health services.

"More provision of one to one advice and support should be on offer in schools. Notice boards and sections within the school could have information on sexual health & wellbeing with services advertised" (SCF participant).

" There should be sexual health and relationships counsellors in schools. You could have someone in a room at lunchtimes, a welfare officer. This could be a drop-in room, for people to find out about sexual health issues in private" (SCF participant).

"Within the school setting there has to be joint-working by all involved and a culture fostered of 'all one team' with health staff and teaches working more closely together" (SCF participant).

5.65 However there are also fears that this is an inappropriate development and that parental rights and responsibilities will be eroded.

"Advice should be free and freely available, but not in schools" (SCF participant).

"The parent has a duty of care, but confidentiality rules can mean that parents are not told about health services offered to their children. The responsibilities need to be clarified, for example schools arranging abortions without telling parents. For children under 16, the parents need to be involved in the services offered to their children" (SCF participant).

"[This report] allows for confidentiality to protect the child, letting them access services without the knowledge of the parent" (SCF participant).

"In a school the nurse should give advice, but services should not be promoted within a school" (SCF participant).

"I dislike the confidentiality clause which allows someone in schools to offer services to under 16 year old children on the subject of sex" (SCF participant).

5.66 In relation to the proposal that there should be improved links between schools and sexual health services, issues of trust, confidentiality and anonymity were important to all young participants and were also recognised by older participants. However, trust and confidentiality meant different things to different young people. Some felt comfortable about accessing sexual health services via school, whilst others did not. A number of suggestions were made to address concerns about the anonymity with which school-based services could be accessed, such as locating sexual health services alongside a range of other services at school. Other participants had additional concerns about the appropriateness of schools for the delivery of sexual health services and feared that parental rights and responsibilities would be eroded.

Higher and further education

5.68 Although there were a few comments on this issue, they seemed to endorse the view that the need for sexual health information and services goes beyond school years.

"There is a need to target students more, children will take longer to educate. It is surprising how little people know about sexual health issues. We particularly need to educate them on STIs" (SCF participant).

"The University funds welfare services, but students only get free leaflets. It is hard to promote sexual wellbeing because of a lack of money. They recently ran a Shag-week (Sexual Health Awareness) for students and gave out 2,000 free condoms, and could have given out more. The University does not ring fence funding, so the sexual health money simply comes out of a general pot" (SCF participant).

The role of parents and carers

5.70 Participants clearly would welcome all these measures aimed at parents. For most, positive communication on sex and relationships with their own parents had been minimal. Some acknowledged the gap between the traditional family values with which they grew up and the social values of today.

"We never discussed sex until just before getting married. Now they teach them everything. I think that's good. We're not that open" (African women group).

"Schools should involve parents and it would offer parents the opportunity to learn more themselves" (SCF participant).

5.71 This lack of communication between parents and children was referred to as a 'cycle of embarrassment' which is important to break if progress is to be made.

"I think a big mistake is that there's not enough parents telling their kids about sex education. I never got told and look where I ended up!" (Sex worker interview).

"Parents don't talk to their kids or if they do it's to issue instructions or abstain messages. The whole thing comes back to education and the rapport you have with your parents" (African men group).

"Parents who didn't have education on sexual health find it difficult to educate and speak to their own children on the issue. They need to be equipped to be able to deal with it" (SCF participant).

5.72 Whilst other participants agreed that there is a need to involve and support parents, they said there is also a need to involve young people themselves.

"The need to involve young people and parents in discussing how to take this strategy forward is very important. Young people still feel it is difficult to discuss sexual health matters with their parents. Involving the young people and parents in the content of programmes and the lessons is crucial to their success, subject to an open and non-judgemental approach" (SCF participant).

"It would be valuable to ascertain from young people their views on how to engage with parents on sexual health awareness" (SCF participant).

5.73 Many of the young participants referred to the need to educate older people, such as parents, about sexual health. Some would like to see TV adverts that encouraged parents to be more open about sexual health and relationship issues with their children. Others suggested that parents should go to classes to learn how to talk to their children about sex. They also identified a need to address unhelpful or outdated values and attitudes to sex and relationships amongst older people, regarding gender roles and homosexuality.

"They were brought up in a different environment, so it [educating older people about sexual health] is a good idea" (Young mothers group).

5.74 Some acknowledged that there will be difficulties in getting some parents to engage and some of the young participants acknowledged that they themselves would not want to speak to their own parents.

"Parents do need to be included. However it's hard to get parents to engage. If you talk to parents about sexual health and you find they're not interested. There is a big problem with apathy" (SCF participant).

"Some parents find sex education difficult, and you shouldn't judge them for that. Respect and tolerance are all important" (SCF participant)

5.75 A number of practical ways to support parents and carers were suggested.

"Parents need support as well. Once their children reach a certain age, say, Primary 5, their parents could receive an information pack on how to deal with SRE" (SCF participant).

5.76 The Poverty Alliance group suggested discussion of sexual health and relationships in parenting classes after the birth of a child as it was felt that not enough emphasis is given to the changes that take place after becoming a parent. This point refers not only to supporting new parents to have the skills to be able to communicate with their children in the long term, but also to be better able to cope with the impact of having a child on the relationship between new parents.

"Parenting classes should be given to women when they become parents, after the birth. Just now everything is concentrated on pregnancy" (Poverty Alliance group).

5.77 Parenting classes would address all issues, not just sexual health throughout the life course. These might take the form of workshops that would allow parents to explore different issues. Participants suggested that grandparents also need support. In relation to teenage pregnancy, some participants felt that parents needed support at the time when their child was pregnant. It was also suggested that information on sexual health and relationships should be part of general classes to support parents, rather than focused solely on sex and relationships

5.78 A number of proposals were made in order to make information for parents more available. Traditional sources for health information such as health centres, GPs offices, community health projects and so on, should remain places where good quality accessible information is available. In addition, information should be available in a variety of other formats and sources. Suggestions included better use of the Internet, text updates using mobile phones, and public libraries. Although the Internet was viewed as providing both 'good and bad' information, it was felt that it was an important source that should be used to provide information on sexual health.

5.79 A helpline for parents was also considered to be useful. This would provide information and support on how best to communicate with children and would help ensure that the information that parents provided was accurate.

5.80 Other participants suggested that parents need signposting to the resources that exist such as helplines which can provide important information and reassurance.

" Parents don't know that much about it (sexuality). They need to be less uptight about talking about sex. There are some good phonelines for parents, for example, there's one aimed at parents of LGBT kids, but it's not well advertised" (LGBT outreach group) .

"Young people can be scared of sexuality, especially if they think they're gay. There is nowhere for them to find out, and older people don't know how to talk to them about it. Health workers and parents hold the key roles here" (SCF participant).

5.81 It would also be important to link information on sexual health and relationships to media campaigns to raise awareness, supported by advertising on television and with telephone helplines that parents could use to get information and support, as has been done regarding the dangers of drug and alcohol misuse.

5.82 However, many participants also felt that there was a responsibility on parents to have a more 'open minded' and realistic approach to their children and issues of sexual health and relationships. Better information, provided in a variety of formats, will help achieve this change but parents have to make an effort to better understand the needs and concerns of their children in relation to sexual health and relationship matters. Some participants felt that this was particularly an issue for fathers.

"When my son started going with a girlfriend I spoke to him and I said to him 'watch what you're doing and go to the chemist and just be careful'. But with my daughters - my wife asked me if I was going to talk to them, but I said no. I don't feel it's the man's place to talk to the daughter - but maybe it is?" (Working men group).

"Fathers need to talk to their sons more about sex and relationships. In a family, brothers are often given different information from their sisters. Men are not very good at talking to men about relationships" (SCF participant).

5.83 Participants welcomed the proposals in the draft strategy aimed at parents. They suggested that they would be important to break the 'cycle of embarrassment' between parents and children in discussing sex and sexual health. Better access to information and media campaigns could also all play a role in educating older people. The young participants also identified a need to address unhelpful or outdated values and attitudes to sex and relationships amongst older people, regarding gender roles and homosexuality.

Lifelong learning for adults

5.85 In the discussions amongst these research participants, there was a strong focus on the sexual health issues for young people. Some participants did comment on this and attempted to raise issues for older people as discussed in sections 3.19 -3.20.

"There is a lack of knowledge amongst the older generation. However, we do not need to teach everyone about everything - some LGBT pamphlets are too explicit for some audiences" (SCF participant).

5.86 Others also recognised that there are different sexual health needs for the elderly, disabled and those with learning difficulties. However, there was a sense that the strategy did not go far enough on these issues.

"I am glad to see reference made to people with learning disabilities. However, the issues involved are not addressed, but simply touched on. This is an important gap in the strategy" (SCF participant).

"There needs to be more sensitivity towards sexual activity of people with learning needs. Local authorities need to address these development needs. At present nothing is said on these issues" (SCF participant).

5.87 Participants recognised that wider social change and instability in relationships means that sexual health may be more of an issue for those in mid-life than has been acknowledged.

"We live in a society where people are remaining single for longer periods of time. They're in their mid-30s before they even contemplate marriage. There's a generation now in their 30s and 40s possibly don't have a steady relationship, so maybe they will basically sleep around. It will be part of the norm" (Working men group).

5.88 Assumptions about mutual fidelity in stable relationships mean that many adults do not see themselves as being at risk. Even amongst those that might be aware of risks, there is a danger that they will be complacent, for example in relation to HIV/AIDS.

"Medication for various sexual health diseases is improving, so people may be more complacent. Even if you've got HIV, medication might extend your life for another 10-20 years. People are saying 'there's going to be a cure for it soon'" (Working men group).

"I first heard about it [HIV] when I went to my doctor in the 1980s, when it was first a big scare. Now it's gone down the headlines, and I think folk think it's gone away. It peaked, it's gone, I'll not get it, so that's OK" (Working men group).

5.89 Some acknowledged advantages to being older in the sense that they are more able to discuss sexual health issues than they would have done when they were younger, even at work.

"I know what I am and who I am and I'm quite happy about that. I've nothing to prove. I'm no less a man because I'm talking about my emotions. At 25 it was all the macho man thing and it was all conquests and that. As you get older you're more relaxed and you can talk to people. It's a lot easier. It needs people in our age group to drip feed that down a bit - not just to our kids but to our work colleagues too" (Working men group).

5.90 In relation to older people, there are many challenges for the 'baby boomer' group that are now aged fifty or over and there are a number of issues absent from the strategy that affect those over 65 years old. It was suggested that this might be as much to do with gaps in the research evidence as omission of the issue. The draft strategy proposes that more work be done to define and address the needs of particular groups. Comments made by some participants highlighted some of these issues, although they acknowledged it is difficult to get people to discuss the issues and policy work in this area is in fairly early stages.

5.91 With increasing lifespan, the links between chronic illnesses and sex will be more of an issue. Strokes and cardiac problems for example, affect sexual functioning and sexual response. There may be issues of sexual dysfunction and erectile problems, which make it difficult to use condoms as a protection against STIs and HIV. People with HIV/AIDS are living longer and so there will be emerging issues of growing older with HIV. Participants also suggested that there is also a need to make couple counselling available to older people.

5.92 Participants of all ages also raised the issue of same-sex professional-patient encounters and the inter-generational nature of that encounter and attitudes to it, on both sides.

"Some guys would rather see a male doctor and vice-versa. It's a personal thing. That's sometimes the issue - or you might want to see the older doctor or the younger doctor if you think they're more in tune with what's happening" (Working men group).

5.93 People may have different attitudes in later life and there may also be issues about changing sexuality in later life. For some sexuality or sexual activity is not important, whereas for others it is. Some take the view that 'well, I've had my 3 score years and 10'" (Consultant clinician interview).

5.94 Many of the issues are about assumptions about sexuality, sexual activity and appropriate behaviours that are made by medical professionals and care workers. For example, residents in case homes may wish to develop or continue intimate relationships. Whether they are able to do so may depend on how staff respond to intimate behaviour amongst care home residents.

"The attitudes of staff is crucial and practice varies. Some staff have told the offspring. It's a quality of life issue" (Consultant clinician interview).

5.95 There is a real challenge to cross-cutting policy areas. The Care Standards talk about respect, dignity and the right to privacy ⁷. But participants commented that it is uncertain how the draft strategy would be enabled in care homes, especially round same sex relationships.

"There are issue of attitudes in care home; this is a taboo subject especially around gay men. It is just not recognised. How would a care home cope with a cross-dresser? There is no prospect of secrecy as there might be in a person's own home. It is difficult enough for heterosexual couples to get a shared room. The transsexual group is perhaps the most complicated as gender and sexuality may be different" (Older agency interview)

5.96 They also commented that it is likely that local authorities will interpret the strategy very differently unless they have very clear guidance.

5.97 These comments highlight individual barriers to empowerment and choice, such as knowledge, attitudes, lack of competence or confidence amongst older people themselves. There are also social barriers to services and knowledge, such as the attitudes of the staff they encounter and cultural barriers of discrimination and stigma and an unwillingness to accept the sexuality of older or disabled people. These issues present many challenges to the development of 'cultural competence' amongst staff, which will need to address issues of age and develop targeted and sensitive services appropriate to the needs of older people.

5.98 In relation to the development of sexual health promotion activities for adults, it is likely that both media campaigns and information aimed at parents will go some way to address these issues but will not be sufficient to effect change in sexual behaviour amongst the wider adult population. Many simply don't see themselves as being at risk and there may be a reticence amongst older people in coming forward with sexual problems and prejudice where they do. Attempts to change behaviour in the adult population will also have to address the issues raised in Chapter 3 in the discussion of the use of barrier contraception. It will also be necessary to address issues of abuse and violence, both domestic violence, elder abuse, abuse in residential homes and violence towards sex workers.

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