< Previous | Contents | Next >

1999 Health in Scotland

YOUNG PEOPLE'S SEXUAL BEHAVIOUR

Currently there is unprecedented public, political and scientific interest in the sexual behaviour of young people. The Scottish Executive Minister for Health, Ms Susan Deacon, recently announced the development of a Sexual Health Strategy for Scotland, and this will have as one goal the improved sexual health of young people. In England the Social Exclusion Unit's report to the Prime Minister on Teenage Pregnancy was published. Although its remit covers England only, the underlying analysis and the importance given to tackling the problem is shared by the Scottish Executive which will consider the suggested action in the light of the particular circumstances in Scotland. Press reports have highlighted conceptions in children in their early teens; there is even a long-running popular television serial which for the first time has a story-line in which teenage pregnancy is presented as a 'real' issue for families with adolescent children.

In this Report, data from recent academic research in Scotland, and reports from the Information and Statistics Division and Scottish Health Statistics (1999), are reviewed in order to reflect on the extent to which we should be concerned about the sexual behaviour of young people in Scotland, and its sequelae.

Academic research

To date there have been no longitudinal studies of young people's sexual behaviour in Scotland. A consistent methodological feature of cross-sectional research on young people is that studies take place within schools, and thus usually achieve very high response rates. The primary selection bias that occurs is in the non-participation of schools whose head teachers will not grant permission. Refusal of children to participate, or parents withdrawing their children from studies of sexual behaviour, is a minimal difficulty. However, a further problem is that, particularly in cross-sectional studies, children are surveyed at different ages and in different years, thus making comparisons over time difficult. Nevertheless, these studies can provide useful information on young people's sexual behaviour, and help us to understand whether and how this is changing.

In a 1995 survey of 1206 children in six schools in south east of Scotland aged 14/15 years (77.4% of whom were aged 15), the authors found that 27.5% of boys, and 32.7% of girls, reported having had sexual intercourse (Graham et al. 1996¹). This study was concerned with emergency contraception, so no data on condom use are given. Under a third (31.4%) of girls reported using emergency contraception, and just over a quarter of boys (27.4%) said that their girlfriend had used it, but this is not linked to any specific instance of coitus and so is likely to be reported as use ever.

Researchers in the MRC Social and Public Health Sciences Unit at the University of Glasgow undertook the largest UK study of young people's sexual behaviour, in 24 schools in the east of Scotland in 1996/7. The study group comprised 7395 children aged 13/14 years (mean age 14.2 years); these children are representative of 14 year olds throughout Scotland in terms of parents' social class and proportion of one-parent households (1991 census data). They found that 18% of boys and 15.4% of girls reported sexual intercourse; among older children (aged 14.5 years and above) the comparable figures are 20.5% and 19.6%. On the last occasion of intercourse, 60.7% of respondents reported condom use throughout coitus, 8.7% reported withdrawal and 17.4% reported no contraceptive use on this occasion (with no significant difference in reported condom use by gender).

Although there have been no longitudinal studies of young people's sexual behaviour in the UK, three repeat cross-sectional surveys have been undertaken in schools throughout Scotland in 1990 (171 schools; 1412 pupils), 1994 (239 schools; 1373 pupils) and 1998 (261 schools; 1727 pupils). Table 2.8 demonstrates the reported experience of sexual intercourse by these 15-year old children in 1990 and 1998.

Questions on use of contraception were included for the entire sample only in the most recent survey (1998); 66.1% of boys, and 51.4% of girls reported condom use on last occasion of intercourse, and 21% of boys and 24.8% of girls reported no contraceptive use at all.

Table 2.8 Reported sexual intercourse in 15 year old school pupils in Scotland (1990 & 1998) (Todd et al, 1999 Health Behaviours of Scottish Schoolchildren: Sexual Health in the 1990s. Research Unit in Health and Behavioural Change, Edinburgh)

Although the study by Graham and colleagues surveyed children in 1995, and the study by Todd and colleagues took place in 1998, both surveyed pupils aged 15 years. The data generated by these studies are very similar, and suggest that approximately 30% of boys and 35% of girls have had sexual intercourse by the age of 15. The most recent study which will be published by Wight and colleagues in 2000² surveyed younger people (13/14) and therefore reports a lower prevalence of coiarche, although the proportion reporting this increases with age. The Wight et al and Graham et al studies surveyed condom use on last occasion of intercourse, and once again, the figures for reported condom use are very similar in both studies. Approximately 60% used condoms during the last episode of sexual intercourse.

Todd et al provide the best data on change over time, and in the largest number of schools, and are consistent in surveying 15 year old children. Their data suggest an increase of 10% over the period 1990-98 in reported sexual intercourse amongst this group, but no data are available on changes in the use of condoms during this period. We need both repeat cross-sectional studies such as Todd et al, but also longitudinal studies of the same respondents over time, in order to monitor effectively changes in the sexual behaviour of young people in Scotland. Fortunately Wight et al will continue to follow the cohort of young people first recruited to our study in 1996 aged 13/14 to the age of 19 in the first instance, and Todd et al propose to continue to repeat their surveys in 2002, and these data will prove helpful in a variety of ways. In particular, they can be used to determine the effectiveness of sex education, the sexual health needs of young people, and other aspects of reproductive health. It is these to which we now turn, looking first at use of family planning services.

Use of family planning services

The largest users of family planning services are women in the age range 20-34, with 71,704 attendances in 1998 (Scottish Health Statistics, 1999). However, these services have become ever more popular with younger women throughout the 1990s, with nearly twice as many attendees in 1998 as in 1990. This group represent an increasing proportion of all age groups attending (Table 2.9).

Table 2.9 Attendance at Family Planning Clinics by Young Women under 20 years, 1990 - 1998

Although men do attend family planning clinics, only 7,780 did so in 1998 and this includes men of all ages. Many more women are registered with a GP for ordinary contraceptive services (324,765 in 1998)

This doubling of attendances by young women suggests both increased levels of sexual activity (as we shall see in relation to conception, below) but, more importantly, much greater care on the part of young women for their reproductive health and desire to avoidance of pregnancy.

Family planning services remain unpopular with young men (perhaps because of the name of the service, and the association of 'family planning' with women's health needs). Further research needs to be undertaken on the kinds of services that would appeal to young men, and certainly some consideration of their educational needs with regard to contraception.

Teenage pregnancy

Although the teenage pregnancy rate has remained constant throughout the 1990s this is at a level that compares badly with other European countries. After falling from 1990-1995, births to mothers under 20 then rose as a proportion of the total of all births, despite the general trend for the mean age of mothers at first birth to have increased from 24.6 years in 1990 to 26.2 years in 1999 (Scottish Health Statistics, 1999).

As Figure 2.16 demonstrates, delivery rates and abortion rates have remained constant among 13-15 year olds since 1990, with around half of reported conceptions resulting in delivery and the other half being aborted (the number of miscarriages is unknown). Among 16-19 year olds the abortion rate is consistently lower than the delivery rate, although there was a rise in abortions, and a fall in deliveries, in 1998. Within this age group the trend over the period from 1990 is one of a reduction in the proportion of pregnancies coming to term, and an increase in the rate of abortion, with 34% of pregnancies being aborted in 1989 compared to 42.9% in 1999.

Figure 2.16 Outcome of Teenage Pregnancy, 1989-1998, by Age Group at Conception

In an earlier publication (ISD Health Briefing 98/04) there was reported a small rise in the proportion of young women in the 13-15 age group who had had a previous pregnancy (from 3.2% in 1991 to 3.7% in 1997), although there was a fall in the proportion of these that resulted in a delivery (from 25% in 1991 to 16.7% in 1997). The issue of repeat pregnancies in this age group is important and needs to be addressed.

Sexually transmitted infections

One of the key findings of the recent study by Wight et al² was the level of regret that young people reported regarding their sexual behaviour, particularly in relation to the stage at which first intercourse had taken place. Nearly a third (32%) of young women, and over a quarter (27%) of young men, said that their first instance of sexual intercourse had occurred 'too early'. There is an association between early intercourse and subsequent sexual and reproductive morbidity, notably in relation to sexually transmitted infections (STIs)

Genitourinary medicine (GUM) data from the Information and Statistics Division of the NHS in Scotland allow us to monitor change over time in the incidence of STIs in young people. These data are shown from 1990-1999 in Table 2.10.

Table 2.10 New cases reported at GUM clinics: diagnosis of all STIs in men and women, aged 15-19 years, 1990-1999

What is of concern is the increased incidence of all STIs among young people, but particularly young women.

The most recent data are for the year ending 31 March 1999 (ISD, 2000). These show that the 15-19 age group account for 12.3% of total attendances at GUM clinics, with more that twice as many females attending as males. Indeed, nearly a quarter (24.2%) of STIs in female patients are in those under 20 years old. There has been an increase in attendances, compared with 1997/8, of 9.9% in males and 9.1% of females.

Table 2.11 shows some of four of the commonest STIs seen in both young men and women in Scotland (excluding repeat occurrences of disease associated with viral infections eg genital herpes, genital warts, and female-specific disease, notably bacterial vaginosis).

Table 2.11 Common sexually transmitted infections in persons under 20 years old in Scotland, 1998/9

Young women under twenty years old appear to be at much increased risk of infection with Chlamydia trachomatis (80% of cases), genital herpes (88% of cases), and of genital warts (72%). Taking all new episodes in this age group in 1998/9, the rate per 100,000 population was 790.2 for men, and nearly two and a half times greater at 1844.4 for women. Young women in this age group account for 9.4% of all attendances at GUM clinics.

There are a number of possible reasons for the disproportionate burden of disease on young women within their age group. One would be greater sexual activity, and more particularly number of partners, than young men of the same age. There is no strong evidence of such a gender disparity in Scotland, although future research may be able to shed further light on this issue. A more plausible explanation relates to disassortative sexual mixing; that is, young women are having sexual relations with older men. These men are more frequently infected with STIs than males in the under 20 cohort, and therefore the risks of unprotected sex with older males are greater than unprotected sex with their male peers. For example, men in the 24-35 age group have a higher prevalence of STIs than any other age group, male or female. Even controlling for same sex activity amongst some of these men, higher levels of infection in this sexually active male population will result in infections of young women if, as seems likely, there is sexual mixing of these groups. However, in the absence of systematic data on the age of sexual partners of young women in Scotland, this must remain a conjectural explanation. There is the further biological consideration that women are more likely than men to become infected with many of the pathogens causing many common STIs after a single exposure, including being twice as likely to become infected with Chlamydia trachomatis.

Increased attendances in this age group compared to last year (over 9%) do not necessarily mean increased incidence of disease, although given the increased incidence of all STIs in this age group over the last 10 years this is certainly possible. Other factors, such as increased referral by GPs of suspected cases of STIs, greater willingness of patients to use GUM services or even changes in clinic opening hours and access can all affect attendances.

Conclusion

In the absence of repeat cross-sectional representative surveys of the sexual behaviour of young people, we must rely on a variety of data sources to determine whether sexual behaviour has changed in the population of young people under 20 years in Scotland and what the health consequences of any changes may be. Taken together, academic research and statistics on health service use (notably family planning services, teenage pregnancy and genitourinary medicine clinic use), all suggest that there has been an increase in the last ten years in the proportion of young people who are sexually active at an earlier age. Evidence of the increase in the proportion of the 15 year old age group who report sexual debut comes primarily from Todd et al, but the long established association between earlier sexual intercourse and sexually transmitted infections means that an increase in STIs amongst young people lends support to the view that there has been an increase in the number of young people who are sexually active. Such an increase is also supported by the data on family planning clinic attendances, with greater numbers of young women attending, and an increase in the proportion of attendees from the under 20 age group, over the period 1990-1998.

Another potential marker of increased sexual activity is teenage pregnancies. Although there has been no increase in teenage pregnancy, rates remain high compared to other European countries. Other data suggest that, whilst there has been no increase in either deliveries or terminations among women under 20, this may be explained by the increased take-up of contraceptive services. It may be that the relative unpopularity of barrier methods of contraception contribute to the increased incidence in STI's in this age group, particularly among women. Condoms may not be used sufficiently often to prevent morbidity a factor which could have longer term negative reproductive sequelae, notably pelvic inflammatory disease and sub- and infertility.

What can be done to reduce the negative sequelae of sexual activity among young people? There are two areas in which efforts could be directed: prevention and provision of services. In terms of prevention, the introduction of a standardised sex education curriculum would go some way to removing the variability of teaching of this important subject. The Wight et al study described earlier is part of a randomised controlled trial of a new, teacher-led sex education programme in Scottish schools, which, if found to be successful in pedagogic and behavioural terms, will be supported throughout Scotland by the Health Education Board for Scotland. Lothian Health Board has been awarded the Health Demonstration Project Healthy Respect which also uses a modified version of this programme in Edinburgh schools as a model for the rest of Scotland. The aims of sex education include increasing young people's control over the timing and nature of sexual activity, and for some young people this means delaying sexual debut. It also seeks to reduce the unwanted sequelae of sexual activity, notably pregnancy and STIs. However, even improvements in knowledge and understanding of sexual health issues (a pedagogic goal) would be welcome in a population currently ill-served in terms of information provision.

It is clear that in terms of provision of services, family planning clinics are succeeding in attracting increasing numbers of young women. However, these services remain unappealing to young men, and some consideration must be given to their needs. This does not necessarily mean increased access to family planning clinics, although clearly this is where there is expertise available. At present relatively little research has been conducted on young men's sexual and reproductive health needs and this is an area of service development that warrants more detailed consideration.

The increased incidence of STIs among young people reminds us of the public health function of GUM clinics in not only treating disease, but in preventing it through educational activities and contact tracing/partner notification. The increased recognition on the part of these services that they are addressing the sexual health needs of their clients and patients, rather than simply treating infection, is evidence of a commitment to broader issues of health and wellbeing. Certainly reducing the stigma associated with attendance at such services is a key element of improving access and increasing their impact.

Scotland is in need of an integrated Sexual Health Strategy, and the Minister of Health's announcement of the setting up of a working group is welcome. Sex education, family planning, teenage pregnancy, and combating STIs, including HIV, are key areas in which co-ordinated action is needed. This requires a partnership of government, with education, health and local authorities, as well as with non-statutory organisations, and is vital if we are to see improvements in the sexual health of Scotland's young people.

< Previous | Contents | Next >