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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 EIGHT CONCLUSIONS
8.1 The draft strategy acknowledges that it is an ambitious and wide-ranging long-term programme for achieving the vision of a sexually healthy Scotland.
8.2 Amongst these participants, there was a sense that, on the whole, the draft strategy is a welcome document. Generally it was felt that the strategy is timely and there was a sense that it provided a welcome and unusual opportunity to discuss the issues. Sexual health and wellbeing was recognised as a web of complex and interrelated personal, social, cultural, emotional, spiritual and physical factors, by participants and it was felt that on the whole, the draft strategy does adopt a realistic attitude to these issues.
8.3 There were two broad strands of opinion evident in the discussions. One was focused on personal and parental responsibility. The other 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 predominates amongst the other participants and was the stronger theme overall.
8.4 However, there was a tension apparent throughout the discussions and this led to different proposals for how the strategy should be developed and implemented, sometimes in terms of the emphasis that should be given to particular proposals and at others, leading to starkly different views as to what is appropriate.
8.5 The broad and holistic approach to sexual health in the draft strategy was generally welcomed across the range of participants. Moves towards a more positive and open approach to sexual health and relationships were welcomed. It was generally felt that there is a need to create a more open approach to sexual health and challenge taboos if real change is to take place. 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. 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'. 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. This is a challenging area for the Scottish Executive, with no single view or interpretation.
8.6 The wider influences on sexual health were recognised although there was concern that the strategy should not just tackle the symptoms of sexual ill health and that the links between wider social issues and sexual health had not been followed through to the recommendations. However, others did not like the links made with wider social issues such as poverty, wanting to see a greater focus on personal responsibility.
8.7 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. The interpretation of the focus on teenage pregnancies amongst participants 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 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.
8.8 There was a sense that there is need to challenge unhelpful attitudes towards sex and relationships. The power of the labels that society gives people was a strong and repeated theme. Where such terms are not seen to apply to particular individuals or are explicitly rejected, the labels 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. 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.
8.9 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. For a media campaign to be effective, it is clear that 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.
8.10 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 that may also face barriers, such as men and older people. However, specific target groups should be consulted about their needs, not least about 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.
8.11 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. 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.
8.12
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.
8.13 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.
8.14 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 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 a number of stigmas and taboos and address a number of 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.
8.15 There was substantial agreement that greater access to free condoms is important for both men and women, but this will not be sufficient without a wider media campaign to promote their use. There is also a need to promote awareness of the need to use condoms for oral and anal sex and health promotion activities to promote skills development in the use of condoms, perhaps through peer education reinforced by professionals in learning and clinical settings. The difficulties in offering outreach support to prisons and young offenders institutions suggests that these populations should not be excluded from wider measures to protect sexual health.
8.16 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 (amongst GUM clinic attendees not known to be HIV infected who present with a new STI) will need to be sensitively handled to avoid the great potential for misunderstanding. They will need to address concerns about anonymity, racism where assumptions are made about people from Africa, fear of the disease itself and fears of the possible wider consequences of treatment for immigration status.
8.17 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. The development of cultural competence in all tiers of services will be a major challenge.
8.18 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, including all STIs and issues such as the menopause and erectile dysfunction. The needs and views of the target audiences should inform the provision of information on sexual health and services. Information should be provided in a wide range of accessible formats but it is important not to assume that the use of IT is a particularly appropriate way to reach young people.
8.19 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.
8.20 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.
8.21 In terms of the consultation process itself, the sheer number of recommendations made it difficult for the layperson to digest and there was some dissatisfaction expressed with the process. Whilst many welcomed the opportunity to discuss issues of sexual health, it was felt by some that there was insufficient consultation with young people and with parents and schools. This research has itself attempted to address some of those gaps.
8.22 This research has been part of the wider consultation process. Clearly 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 included in the draft strategy 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 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.
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