|
Teenage pregnancy and sexuality Chaired by Pramilla Senenayake
Dr Diana Birch “Are you my sister, Mummy?” - The Youth Support Experience. Introduced by Dr Fay Hutchinson Dr Fay Hutchinson - Contraception and Sexual Education in the Nineties. Dr Pamela Gilles - Young People’s sexuality ; Promises and prospects. Dr Nona Dawson - The Education needs of young mothers. Diana Noble and Dr Gillian Vanhegan - What young people want. Dr Chris Wilkinson - Providing an STD service for Youth Muriel O’Driscoll - Psychosexual Counselling - Sexual Orientation.
Teenage pregnancy and sexuality ‘The Youth Support Experience’ - Dr Diana Birch Teenage Sexuality - Schoolage pregnancies “My mum sent me to the doctors when I was about four months because I hadn’t been on the periods. The doctor said it was just puppy fat, then she sent me back when I was seven and a half months and he said it was just wind. “ (Kirsty - 14. schoolgirl mum). Such a quote is all too common. ... and unfortunately just as common now as when I first recorded those words ten years ago... A sad illustration of how out of touch we can be with the teenager’s view of sexuality and thus fail to provide adequate services , whether it be for guidance, education , practical or medical help for youth. Each year in England and Wales approximately 10,000 schoolgirls become pregnant. Many of these girls will do well with their babies as evidenced in our fifteen year follow up data - nevertheless for those who experience difficulties, it can be depressing to see the cycle repeated in future generations - ‘old girls’ returning to a residential unit to visit their daughters and nieces in the next loop of the spiral. Conception rates have altered disproportionately so that the youngest girls now constitute a higher proportion of the number of school age births than previously indicating that the very young, most vulnerable, girls needing most support are being failed by preventive and educational programmes. Why is this? Why do so many young girls become pregnant and so many young boys become baby fathers? An adult professional stance can lead us to fail to understand the difficulty that our teenage patients are confronted with in growing up; attempting to look at some of the conflicts from the young person’s point of view we are more able to act practically and effectively to help our young patients avoid making the same mistakes that we did at their age. By understanding the belief systems of the adolescent and his or her peer group we can interact with that young person in a way which has relevance and meaning. It is for this reason that the emphasis of work at Youth support is on emotional and motivational aspects of sexuality - beliefs, self concepts and most particularly self worth. We must be forgiven some element of repetitiveness in describing these concepts and their significance since the same basic principles influence so much of the adolescent’s behaviour and thinking patterns. Peer group beliefs “You can’t get pregnant standing up” can be confronted with factual knowledge -sperm can swim uphill! But at a deeper level are what I would describe as magical beliefs. Intrinsic ideas with high emotional content a feeling of instinct and intuition which may have no perceivable basis in current reality. Magical beliefs centre on fundamental concepts; feelings about self, body,control - the nature of life itself. The adolescent is much preoccupied with the question “Who am I?” Confusion arises when “Who am I?” becomes “Who are we?” Acquiring a personal identity becomes a monumental task for a pregnant girl whose identity changes beyond her control; no longer a little girl, but a fertile woman. The role of mother is thrust upon her before she establishes her own identity, hence the belief that she cannot get pregnant and denial of pregnancy. “I knew how girls get pregnant, but never thought it could happen to me” Girls deny that they can become pregnant. They believe they are too young. Belief in the impossibility of pregnancy tends to become almost a magical protection like a lucky charm “It won’t happen to me”. These teenagers are at the stage of concrete reasoning unable to identify with the experiences of others. This explains why health education methods based on shock tactics do not work with this age group. Teenage sexuality is profoundly affected by beliefs about control. Emotional development involves internalising the “locus of control”, assuming responsibility for one’s actions and one’s body. Those maintaining an external locus of control are not in control of when they have sex or whether they get pregnant, are not responsible for their actions or their bodies - pregnancy is something that happens to them. It is a matter of fate. An unplanned pregnancy represents the ultimate loss of control. Even their bodies are acting independently with their wishes. Belief in the autonomous womb explains why teenagers do not believe sex will result in pregnancy. It also explains some of the denial. Belief systems interact in limiting contraceptive use. Hence for young teenagers under the age of 16, it is not so much a matter of availability of contraceptive services which affects sexual practices and conception rates. Much more important is the social situation and life experiences which affect their emotional maturity, motivation and their value systems. A self esteem measure of pregnant schoolgirls and a comparable group of schoolgirl mothers indicated that while painful life experiences and deprivation resulted in an expected fall in self esteem scores, the girls who were pregnant at the time of the testing felt much more positive about themselves than the schoolgirl mothers. Pregnancy seemed to have protective value in conserving self-worth. Girls were finding an alternative value system by which to judge their lives. Seen from a young girl’s viewpoint, pregnancy may not be so undesirable; motherhood is a fulfilment; she takes on a valued role and out of her loveless world creates a baby who will love her. Pregnancy is thus used as a source of self-worth and a false solution to problems. That being so, an alternative solution must be offered. These young people need an alternative source of self-worth in order to ensure that when they become parents this is because they desire parenthood, with all its responsibilities, hardships and joys, not merely as the only perceived escape from a catalogue of problems.
Dr Fay Hutchinson - ‘Contraception and Sexual Education in the 90s’ I have worked in the field of contraception and young people for the past 30 years. I have been asked to talk about contraception and sex education in the 1990s and we are now half way through the 1990s, so we can look both back and forward. I want to begin by asking you a couple of questions. Young people are very much targeted now as a cause of a lot of our social ills - the single parent, the break-up of the families, the cost of the Social Services, and they do seem to be getting a lot of bad publicity - particularly from the media and our very virtuous parliamentarians. Can I as you all if you think there are more pregnancies in the 15 to 19 age group in 1970, 1983 or 1993 (which is probably the last year we have figures for)? Yes, 1970s is correct. Conception rates for young women. 84.4 per 1,000 in 1970 and went down in 1980s and up again in 1990s but not to the rate of 1970s. What about teenage mothers - cause of so much expenditure and fury? Were there more teenage mothers in the 70s, 80s or 90s? 1970s - more than double than we have now. To listen to the media you would think it was the reverse. We have made some advances. What about teenage sexual activity. What do you think the average age of the start of sexual activity is now? Most young people have their first intercourse at the age of 17, but about 20% of them have intercourse before their 16 birthday, and with Diana’s talk and others we have already had today it is clear the really vulnerable ones are the ones who have sex really early - and this is usually because they are no ‘super-sexy’, but because they have been brought up disadvantaged emotionally, physically abused, sexually abused or are very sexualising upbringing, or they are very alone and sex is their only way of seeing that they are of any use to people. Why do they do it? These were some of the reasons they were giving: -‘a natural follow on from what do you ask -physical contact, being in love, peer pressure.Young men seem to be more open to peer pressure than young women. Often trying to prove themselves, show that it does work. When you are asking youngsters why they have sex that first time, the usual answer is ‘well it just happened, I got carries away’. In this young group, about 30% will say they had sex unexpectedly, when in some groups it is 50% say the same time.; This accounts for a lot of the unprotected first sex, people getting caught out when they first have sex, they are not prepared, they are not looking ahead. What has happened in the 1990s in particular is, there was a document called ‘Health of the Nation’ which the department of health published and everyone got rather excited about, and two of the targets which are relevant to us was that we should reduce the teenage pregnancy rate for the under 16s by 50% by the year 2000. And we have figures and figures... basically the rate when the document came out in 1990 was 10.1 per 1,000 girls under 15 who became pregnant in a year, and there has been a drop until the last year we have figures for which has got down to 8.4 in 1994, but there has been a drop and a more noticeable drop in the under 20s. But in the discussion group I was working with earlier today, they seemed to be saying that in their areas they seem to be doubling the rate, and I wonder if it is anything to do with the last pill scare when a lot of young people seemed anxious about going on the pill. The other consequences of the ‘Health of the Nation’ target has been more designated young people centres opened. Sometimes this was a way of not closing family planning clinics and re-naming them young people’s clinics, but not making much difference to the atmosphere or the way in which they were run. Gillian Vanhegan and Diane Noble will be talking much more about what we thinks works to make people feel happy about coming to a centre. So increasing the number of centres that were available locally for them is one thing. We have done a lot of work through Brook in unison with other organisations to establish the confidentiality of consultations for under 16 years old. And this has certainly been valuable as far as a lot of general practitioners go, were there had been much more resistance to seeing under 16 year olds without a parent. And I think that method has just come through and there are a lot of questions about confidentiality, but certainly this is the prime concern of young people that come to us - is it confidential, do you have to tell anyone, and if you say yes, unless you give them the assurance that it is confidential they are not prepared to tell you what is going on. But having said that we respect their confidentiality, that doesn’t mean that we will just say ‘there, there, of course we won’t tell anyone’, if they are in a situation that is harmful to them or dangerous to them, or we feel that they will get parental support, we help counsel them and help them to see that they may need support form elsewhere, or that it wouldn’t be so bad to share the information, but I think one would only do this, one would only bread confidentiality, in very exceptional circumstances and with their knowledge. I think another factor that has come about in the 90s is the increased awareness and availability of emergency contraception. Strangely it seems that those who are against abortion who are also against emergency contraception, which they seem to confuse with a sort of abortion. One would think that they would be relieved that it reduces the number of unwanted pregnancies. But the use of emergency contraception, has really reduced the number of unwanted pregnancies, considerably, but also it has by coming in and asking for emergency contraception that has got young people who are sexually active, or intend to be in the future, coming in to see their doctors or their clinic. It is a time when you can discuss what is going on in their lives, what is happening, what they want. So that is something else which is improved. But I think the most significant thing as far as I am concerned, in the 90s, is that we have become much more aware of the sexual health of young people, and I see this as a positive thing rather than a negative thing. I have tried to find a definition of sexual health which I though would be useful to me in the kind of work which we are doing and would define what I meant by it, and I came up with something like this.... Our aim should be that we enable young people to remain sexually healthy, so that they can have children, when and if they want them. When and if they chose to have an active sex life, help them to minimise the risks of an unwanted pregnancy or sexually transmitted disease. When we are talking of sexually transmitted disease everyone thinks of AIDS and HIV, but in fact the less dramatic diseases, gonorrhoea and chlamydia are more significant if looking at future infertility and ill health. So with that, not only are you wanting young people to take responsibility for their sexual health not only as to whether they will be become pregnant, but also protecting themselves from sexually transmitted diseases. This goes for boys as well as for girls, and is very much influencing what we want, which is to see a wider use of condoms, and what we are certainly advocating to the youngsters who come to see us at the Brook, is that if they are on the pill they should use a condom as well to protect them selves - that you double up. The double up method is taken up quite enthusiastically by the youngsters who are starting their sexual lives, but, as it has been observed before, as they get a bit older and they can see the disadvantages and think they can get away with it, the condom use does tend to be reduced. So, youngsters can develop an experience of enjoyable and rewarding sexual relationships without harming themselves or their partner. Some people get a bit worried by the word ‘relationships’ and think that I am encouraging promiscuity, but practically the majority of people will not be monogamous throughout their sexual life and I am not in the business of helping people to have un-rewarding, un-happy relationships, and I think that people are confident in what they are doing and are not being pressurised, their chances of making a good and enjoyable relationship are much higher. So, sexual health, I think, is a really vital part of the services which we are providing now and should be included. I think we have got to get into a position where we can do more screening in contraceptive clinics, more treatment, to help youngsters keep themselves healthy. One of the things that has interested me over the years, is that we have the pill, we are providing the services, we are all ready and willing to be helpful, we love to see them and it is all confidential.... Why don’t they come?! And there are a whole lot of reasons why youngsters don’t use contraception. Particularly early on in a relationship. And one of the series of reasons is the myths about it. I am just going to run through a number of the ones which I have heard countless times, usually when someone is pregnant. Perhaps this is where sex education might help I suppose. ‘It can’t happen the first time’ - A strongly held belief that you cannot get pregnant the first time you have sex. ‘I thought I was too young’ - Too young for what? I ask. ‘We did it standing up’ - The gravity theory! ‘I went for a wee straight afterwards’ - The flushing theory ‘We only did it once’ - once is enough And then there are a whole of ‘he said myths’ ‘He said he would be careful’, ‘He said not to worry’, ‘He said he would take care of me’, ‘He said “I thought you were on the pill”’. Another one that I realise that I heard ‘He said he would marry me’. Another common myth is the safe period. I was looking at a book that had been written - was the whole issue of a practitioner magazine which was issued in 1923, and was all about birth control and it said there about the fact that they weren’t quite certain when ovulation occurred, but it did seem that the most likely time to become pregnant was just before or just after a period. And that sort of mythery is still around, and a lot of youngsters who said that they thought they were in the safe period, ask them what the safe period was. The other reason for a failure to use contraception is a fear of the side effects, and I could give a whole talk about that! Side effects of all the contraceptives, but particularly the pill. There is also the denial of sexuality - ‘I didn’t think it was going to happen’. First sexual intercourse, not being prepared. There is a great difference between the youngsters who are using contraception at the time they have their first intercourse who tend to have been in the relationship for some time, it has come about gradually, have talked about it, and the youngsters where it just happened, it was unexpected and they were not prepared. There is also irregular sexual intercourse. I think women particularly are rather economical about contraception - they only believe in using it if they are going to get their moneys worth! So if you are only having sex once every six weeks, is it worth it?! But not just with young people, difficulty of communicating with sexual partners, difficulty at actually saying to them ‘are you all right, are you using contraception’, ‘well no I’m not - have you got a condom?’. Reunions, regular use of birth control, difficulties that sort of thing, there are a whole lot of reasons why not only youngsters have difficulty in using birth control. And so I think this is something which can be tackled partly with sex education, but in the clinic practices this is something which we are having to deal with. So what are the changes since the 70s? I think one big change is that there is an increasing choice of places to go to. General practitioners are seeing more young people, and I have some evidence of some interesting work being done in practices, where a doctor is particularly interested in seeing young people. They set up a special time, a special session to see youngsters, you make it known in the practice that one is willing to see people of any age about contraceptives, in confidence. But one of the most interesting developments, which is particularly happening in the North West of England where they are rather advanced in some ways, I have known some practices where doctors have sent letters to youngsters who have been coming up to the age of 16 (now perhaps even 15 or 14), inviting them to come in for a medical consultation, not just about contraception but for a who lot of reasons, but basically to establish a relationship between the doctor and the young person, because this is one of the reasons why young people don’t go to general practitioners - ‘they are too much a friend of my mother’, or they don’t think it is confidential. This establishes the relationship between the doctor and the young person, but where they have had an even higher rate of people coming in for consultations, is where the letters come from the practice nurse. The practice nurse has then been the person who has seen the youngster and given them advice on diet, emotional health, skin conditions, the need for contraception and the practices confidentiality. And I think that it is a really good way of seeing youngsters, because let’s face it they should have a choice where they go for advice and there are not young people’s centres around the country. What about the boys? We haven’t mentioned them much have we? At Brook and at other centres we encourage young men to come in with their partners and take part in the consultation, and that is always a pretty good sign that they are taking some responsibility, that they are trying to help out. But also what about seeing boys for themselves. Where do they get their sex education, where do they get their anxieties dealt with? And with the HIV scare and the sudden promotion with condoms this is become a way of them coming in, but you just don’t hand them the condoms. I think some of our most successful centres, some of our centres in London, are where we have had young male outreach workers, going into schools or youth clubs to do health promotion, and will be available at a drop in centre for young men, so that when the come it seems to diffuse a lot of the excitement or aggression that they sometimes generate which is a reflection of their own anxiety when the sometimes come into what looks like a female centre. At the clinics they are not just taught how to use a condom and when, they are taught about emergency contraception, looking after themselves, about testicular examination so that they can know when their testicles are normal and when they are not, because cancer of the testicle is becoming more common in the younger age group. So, being treated with a respect and in confidence, a number of them will then want to go on and want to talk about their own particular anxieties, often about their sexual performance, their normality or their sexual identity. I think this is an example that would be of great value if we could have more drop-in centres for young men. What about the methods? I don’t think there is anything really new on the horizon. One of the things I would like to see coming in a bit more quickly, there has been talk for sometime about a plastic condom that is not so ‘splitable’ and is warmer and doesn’t reduce sensitivity. We have been promised this for some time but I have not yet seen it. But you know, it seems to be more of the usual refinements at the moment, there doesn’t seem to be anything really new coming in. So I think as much as anything we should be giving youngsters access to contraception when they need it, before they need it and we will use this opportunity to help them with any areas of their sexual health. What about sex education? Well, there have been some improvements in some schools. It has been very much a political football as well hasn’t it? But talking to the youngsters I see, I still get the impression in many schools it is still a question of too little and too late. Also that it is mainly factual information and it doesn’t relate much to the situations that youngsters find themselves in. And this rather saddens me, because I know that from 20 years ago with the FPA Sex Education Unit, we were trying to pursued teacher training colleges to include sex education in their curricular so that teachers would have some background that they could feel a bit more confident a) about their own sexuality perhaps, their own information and b) helping youngsters with sex education. But the answer was ‘the curriculum is over full and we can’t fit this in’. So, it does concern me that a lot of the sex education has been given to people who have not had necessarily the training in it. Because, although the factual information is useful, there is much more value if people can be trained to work in small groups where people can actually discuss issues, they can discuss choices and options, they can look at hypothetical situations - what to do in these situations, what choices are there, they can role play. One of the most interesting things I have seen is doing role plays with young people where you actually change the genders - and you get all the old stereotypes coming out where the girls all say what they think the boys say and visa versa. But to be able to conduct this with a class requires special skills and teachers may not necessarily have this, or they may feel that this is too intimate work. Therefore some schools have used outsiders who are trained to come in and do some sex education, but this is an area which I see a great role for school nurses. They are already in the schools and working partly with the young people. They do need training as well, but they have quite a bit of background that makes them perhaps able to do sex education more easily. So, school nurses are a valuable asset. I think however, that the media have a tendency to polarise views about sex education. So, what does it come down to? I think what strikes me more and more as the years go by is that there is still a great deal of adult anxiety about teenage sexuality. It is seen as threatening, out of control, challenging, destructive, and there seems to be a great need to control it by various means. By limiting information, hoping that by telling them in sex education all the terrible things that might happen, that they won’t do it. But there is no evidence that this works, and we are much better advised to follow a positive policy. Which is really something of the ethos of being able to say to young people quite honestly - ‘We hope that as you grow up you will have an enjoyable and rewarding sexual life, but this doesn’t come easily. It needs thought and consideration to get it right. You don’t get it right by rushing in, being available, hoping for the best, not talking about it with your partner. Because sex can be a wonderful experience or it can be a disaster, and it is up to you to get it right.’ It is really a question of being able to accept that teenagers have a very strong sexual feelings, that they are at their most aroused and most attractive at this stage, and instead of asking them to deny it and control it, help them to give them the choices and the options so that they can develop at their own pace and make their own choices, but without too much damage.
Young People and sexuality: Promises and Prospects for Education Pamela Gillies PhD - University of Nottingham and Health Education Authority Introduction This paper aims to provide a brief overview of the available evidence on sexual health and sexual behaviour of young people with a view to informing the debate on the provision of sex education for primary and secondary school aged children. The paper begins by reviewing available findings from studies of the sexual health of young people. It outlines the UK response in terms of improving access to family planing services for young peoples’ sexual behaviour and what we know about the nature of young peoples’ sexual relationships. It concludes with some observations pertaining to sex education. 1 Teenage Sexuality: Is there a problem? 1.1 Pregnancy, conception and abortion The United Kingdom has one of the highest rates of teenage pregnancy in Europe. Each year there are approximately 70,000 births to teenage girls under the age of twenty. There are 8,000 births every ear to girls under the age of sixteen (Hunt, 1994) and just under one in five young women aged 15 - 19 years have every been married (IPPF, 1994). IN the last ten years there has been a slight increase in the conception rate in the under 20 age group. Whilst over three quarters of all conceptions for all ages lead to births of babies, only two thirds of all those to under twenty year olds do so and just under half of those to under sixteen years olds do so. The difference between conception and birth represents abortions. Between 1972 and 1990, the abortion rate increased in all women. However, the largest proportionally increase in this rate was in young women aged 16 to 19 year old. In the under 15 year age group the rate increased from 1.6 per 1,000 women of this age in 1970 to 3.1 per 1,000 women in 1990 (OPCS, 1991). In 1992 it had risen to 5.14per 1,000 women in the under 15 year olds (OPCS, 1992). Recent data from a study of teenage pregnancy in Scotland have revealed strong relationships between deprivation, conception and the outcome of pregnancy (Boulton-James it al 1995). In the 13-19 year age group, rates of pregnancy increase with increasing levels of deprivation. Young women in the most affluent grouping to have become pregnant. In addition, fewer women in the most affluent category (36%) than the most deprived (73%) went on to give birth. Conversely, 50% of the most affluent women compared with only 14% of the poorest women had their pregnancies terminated. Do we know why? Some have argued that in times of high unemployment young girls are having babies to enjoy the benefits of welfare provision. The available data do not however support this contention (Marsh et al 1996). It has also been suggested that poor access to family planning services may contribute to the problem (IPPF, 1994) but as yet this differential in conception and birth rates is incompletely understood. There is little doubt that unplanned and unwanted pregnancy in young girls is an issue of considerable concern. The government White Paper, Health of the Nation (DOH, 1992), identified sexually transmitted diseases, the transmission of human immuno-deficiency virus (HIV)and sexual health of young people as key areas for the improvement and promotion of the public’s health. The Health of the Nation includes a target of halving conception in young women under 16 years thereby reducing pregnancies from approximately 9.5 per 1,000 reported in 1989 (OCPS, 1993) to 4.8 per 1,000 women aged 16 years by the turn of the century (DOH, 1992). Some limited progress towards achieving this target has been made with rates falling from 9.3 in 1991 to 8.5 in 1992, 8.1 in 1993, but rising again to 8.3 in 1994 (ONS, 1996). 1.2 Sexually transmitted disease, including HIV Because of the way sexually transmitted disease is recorded in genitourinary medicine clinics, there is little data available on cases of STD by age in the younger age groups. The good quality data that does exist is somewhat ‘out of date’! The data available on cases of STD by age in the younger age groups. The good quality data that does exist is somewhat ‘out of date’! The data which is however available for 1988 (DOH, 1993) suggest that not inconsiderable numbers of young people aged 16 to 19 years present with infections. Genital warts and Chlamydia appear to be a particular problem for young women. Although in absolute terms, the numbers of young people under the age of 19 years who had presented with HIV infection in 1988 was small, the situation is of concern given the prognosis of the condition. Self-reported data indicate that 5% of 16 - 24 year olds may have every attended GUM clinics (Johnson et al 1994). Is there cause for panic? Is teenage sexuality a problem? The data shows there is indeed cause for concern about young people having unprotected sexual intercourse. How should we tackle the problem? Three complementary approaches are considered: * To improve sexual health services for young people and access to them. * To improve our understanding of young peoples’ sexuality * To continue to promote sex education in the wider context of social relationships 2 Services: the solution The Department of Health has long recognised the need for specific guidelines regarding the provision of contraceptive and family planning services for young people. The 1989-91 health planning guidelines pointed to the need for separate less formal arrangements for young people building upon the good practice model provided by the Brook Advisory Centres (Wilson et al 1994). By 1994 almost half of the health authorities in the UK were running family planning services for teenagers (IPPF, 1994). A recent review by Aggelton et al (1996) for the HEA suggested that family planning service provision could be improved by being offered in an integrated way, readily accessible, in locations with a young atmosphere, by sympathetic staff and subjected to regular monitoring. This review has been complemented by new Guidelines for Promoting Services (HEA et al, 1996). The encouraging largely downward trend in conception rates may in part be due to improvements in service provision, but further substantial improvements are only likely to occur if continued service developments are supported by other approaches and interventions. Educational provision may be an imprint element of an integrated approach but to devise appropriate programmes we must first understand young peoples’ sexual behaviour. 3 Young peoples’ sexual behaviour and the social context in which it takes place 3.1 Sexual behaviour and condom use Studies from around the UK consistently report that between one third and one half of young people aged 16 years say that they have engaged in penetrative sexual intercourse (eg. Clift et al 1989; Breakwell and Fife-Schaw, 1992a; Currie and Todd, 1993). The average age at first intercourse is 15.2 years for young men and 15.5 years for women (Malbon et al, 1996). The younger the person is when first sexually active, the more likely they are to have sex without contraception and to know a close friend who has had a sexually transmitted disease (Mellanby et al 1993). Young people report that sexual intercourse is more likely to occur if they are drinking alcohol (Robert et al 1994). Contraception usually occurs after first intercourse (Bar-Cohen et al 1990) and the first sexual experience in a relationship is usually mute, with the encounter proceeding through coded physical messages (ingham et al 1991). Girls tend to believe that boys are more knowledgeable sexually therefore wait for them to take the lead in talking about sexual matters (Kent et al 1990; Holland et al 1991). Among those who are sexually active in the 16 - 24 age range, condom use on the last occasion of sex has been reported to range from one in four (Galt et al 1989) to half of those asked (Breakwell and Fife-Schaw, 1992b). A recent survey by the HEA indicates that one third of young women aged 16 to 24 years and just over one half of men reported using a condom on the last occasion of sex (Malbon et al, 1996). Although three quarters of sexually active 16 -21 year olds in one survey reported ever having used condoms (Bowie and ford, 1989) data on consistent use of condoms is scant. Those least likely to report having used a condom on the last occasion of intercourse are those most likely to have had four or more sexual partners in the last year (Bowie and Ford, 1989, HEA, 1993). Lack of condom use is associated with alcohol consumption in young people. Similarly, those young people least likely to perceive themselves to be at risk from STD/HIV infection are those most likely to have two or more sexual partners in the previous year (Galt et al, 1989). Thus it could be argued that those young people with a higher chance of STD infection or unwanted pregnancy due to higher partner change rates are also those least likely to use condoms or contraception or even to perceive themselves at some kind or ‘risk’. Why don’t young people use condoms? Reasons given by young people for mot using contraceptives in first sexual encounters or early on in new sexual relationships include the following (see e.g. Wellings, 1984; Holland et al, 1990; Abrams et al, 1990). * They have poor access to condoms * They think conception is not possible * They did not expect to have sex * They believe it is wrong to use contraceptives * They think their partners won’t like it * Their relationship was not ‘serious’ * Reluctance on the part of young women to accept and express their sexual feelings. Most young people say they use condoms to prevent pregnancy. Some youngsters think teenage pregnancies happen partly because of a failure of use of contraception but also because of carelessness in use, lack of belief that they will get pregnant and pressure from boys on girls to have sex (Roberts et al, 1994). Young people do identify problems in using condoms: * Embarrassment of buying condoms * Condoms are mostly available in daytime hours * Fear of being caught carrying condoms * Practical difficulty in putting them on * Contravenes the romantic codes of sexual interaction * Women fear the impact condom use might have on their reputation Attitudes to condoms among young people of both sexes are however generally positive, (HEA, 1993). In 16 - 19 year olds 38% of men and 23% of women thought it was the mans responsibility to carry condoms and 76% of both sexes believed that is was sensible for women to carry condoms (HEA, 1993). 3.2 Young people’s sexual relationships Young people’s sexual relationships are characterised by serial monogamy. ‘Steady relationships’ may be of short duration and paradoxically, condoms are less likely to be used in a relationship which is, however short in length, regarded as ‘steady’. Trust, with the implicit agreement of fidelity is a key feature in young people’s relationships and penetrative sex occupies an important role since it is perceived as ‘real or ‘grown up’ sex. This has important implications for STD and HIV preventive education programmes. MacIntyre and West (1993) have noted that only 2% of a sample of 18 year olds in Glasgow felt that abstinence from penetrative sex was a form of ‘safer sex’. If the only ‘real’ sex is penetrative then abstinence from that particular activity is never even conceived of as a possibility. Explorations of the nature and meaning of sexual relationships in young people are rare. Holland et al (1990), have found that young women’s sexual behaviour was governed primarily by their concerns about pregnancy and the risk that engaging in sex might damage their personal reputation. ON the other hand they were aware of the social potency of ‘having a boyfriend’ and were strongly attracted to romantic notions of relationships. Thus they tended not to resist male pressure to have penetrative sex because of love, trust and fear of losing their boyfriends. They ‘did’ sex to keep their boyfriends happy but also to keep their boyfriends. The ‘relationship’ aspect of the sexual contact was vital for women. This finding is supported by other work. In reporting their worries about the future, one in three fourteen year old girls in one study mentioned their concern about having an unhappy marriage and about fidelity in relationships (Gillies, 1989). Boys of the same age seemed, however, to lack the imagination to envisage marriage as potentially problematic, since none of them considered it worthy of concern. It could however be argued that perhaps boys have an over-optimistic vision of their future, lack the language in which to discuss such issues or are too shy to discuss them in interview. Holland’s initial exploratory work on the meaning of sex and relationships in young men did not reveal many surprises. Young men appear to define their sexuality in terms of masculinity, use social ‘techniques’ to dominate women who appear to collude in the process (Holland, 1996). Perhaps we need further in-depth work to explore beneath the stereotypes. However, the limitations of available data notwithstanding, the social context of sex appears to be of major importance in shaping and maintaining sexual activity in young people. This needs to be explored further if we are to produce sexual education materials of value. We should not presume that the range of materials currently available to schools are sufficient to the task. In a recent review of the outcome of sexual health education interventions, Oakley et al (1995) stated that future educational interventions should be designed using evidence based reviews of the literature; should have content based on what young people say they want and focus on changing behaviours rather than simply on altering attitudes or improving knowledge. Few could disagree with such statements. I would however argue that preparation and testing of additional sexual education materials based on our current level of understanding of the meaning of sexuality and relationships in young people, will do little to enrich the educational process. In other words our evidence is as yet incomplete, our perspective is limited and our prospects are not promising unless we grasp the nettle and seek to advance a new agenda. 4 Advancing a new agenda for sex education The implications of the above findings for the design of sexual and personal relationship education programmes for young people are clear. If social influences are so important in the development of sexual interactions, behaviours and responses, then sex education must feature early in a young person’s development, properly located in the social context of family, school and leisure activities in which is occurs. Such education must address the meaning of sex for young people as well as the mechanics of sex. ‘Sex drives’ and desires are rarely discussed and often represented as somehow immutable and not open to the influence of cultural cues or stimuli in our everyday social environments. These ‘signs’ can include advertisements for almost anything from alcohol to sports wear, images from the television or the cinema, literature and even the beat of disco music. Young people, very young people, live in a social world. The challenge for sex education for young people is to unpack the social norms and values surrounding adult sexuality and sexual behaviour in contemporary society and to allow discussions to evolve which place sex firmly within a range of diverse social contexts. Vague ‘fears’ about tackling sex education and thereby ‘promoting’ sexual activity in the school years appear to be unfounded. A World Health Organisation review of existing evidence noted that sex education in schools leads to a delay in the onset of sexual activity and a reduction in overall levels of intercourse among teenagers (Baldo et al 1993). In addition, the national sexual lifestyle survey in the UK noted that pupils who report schools as their main source of sex education were less likely to have sex before the age of 16 years and more likely to have used contraception (Wellings et al, 1994). Pupils themselves are supportive of sex education in schools. A survey in Salisbury Secondary Schools found that pupils were particularly keen to discuss the emotional and social aspects of sex with teachers (Evans et al, 1994). A survey by the Health Education Authority found that school pupils welcome the opportunity to talk to teachers about sexual matters and contraception (Meikle, 1994). Whilst, on the whole, more 13 - 15 year olds (65%) are prepared to talk to their teachers about contraception if parents are not informed, almost one in three (31%) would talk to teachers even if their parents were informed. Thus many young people see parents and teachers as partners in the process of sex education rather than opponents. What of parents? Contrary to the generally held beliefs of policy makers in the field of sex education, school-based efforts are likely to find favour with the majority of parents (Kirby, 1992; Went, 1992). The recent National Foundation for Education Research (NFER) Survey of the issue included parent perspectives from a national sample of schools. In this survey, 94% parents reported that schools should play a part in educating children about human sexuality, sexual development and relationships (NFER, 1994). The HEA’s sex education alliance project is currently at the forefront of developing new resources with local schools support and involving parents (HEA, 1994; 1995). The task today therefore is to challenge prevailing assumptions and fashion sensitive ways of integrating sexual and health-related social education into the everyday life and culture of our young. I would argue that school has a pivotal role to play in what must be a cross-sectoral pragmatic approach which traverses lay, professional and disciplinary boundaries.
|