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Plenary P1 Adolescent Sexuality Chaired by Chris Wilkinson - King’s College Hospital. London and Pierre-Paul Tellier, Montreal STIs - The Issues for Young People Diane Noble and Gillian VanHegan Gillian VanHegan I am Gillian VanHegan, I am the medical director of London Brook and the spokesperson for Brook UK. As Chris was saying, we across the UK, Brook Advisory Centres, setting up specific advisory centres for young people, those who are aged under 25. We offer quite a range of services. Diane now specifically works for London Brook and these are the range of services that we offer around contraception, unwanted pregnancies, counselling, and basic STI testing. Now I am going to set the scene for you about sexually transmitted infection services that we offer and then Diane is going to tell you about how we’re going to develop these services in the future. As I say, at the moment we have very basic services that we can offer to the young people, because of a lack of resources, mainly financial resources. We can only offer testing at the present time to young women we’re referring for termination of pregnancy, or young women for whom we are inserting intra-uterine devices. We don’t have the funding to offer chlamydia screening to all the under-twenty five’s which would be absolutely ideal. And for those of you in the audience who are not medical I am going to dwell for a little while on the actual STIs. We heard this morning about the prevalence of STIs world-wide. Well, in the UK we know that about 90% of the STIs are in the under 25s. And depending upon which study you look at, chlamydia is very prevalent, 4 times more common than gonorrhoea. The Department of Health study showed that 25% incidents of chlamydia are in young women who were referred for abortion, that was under 20s who were referred for abortion, that was 25% incidents. And the study we did in our Brook Centre in St. Thomas’s hospital showed similar incidents. There have been many other inner city studies and the prevalence rate in those has been about 10 to 15%. Now, why are we so concerned about chlamydia as an infection in young people? Chlamydia is a very hidden insidious infection, in fact in about 70% of young women who have chlamydia they have absolutely no symptoms at all. The young men are more likely to be aware of this infection because it sits in the urethra, they’ll have pains when they pee, they will have possible a discharge from the penis. The young women are blissfully unaware that they are carrying chlamydia. And it’s very concerning because of what we call sequelae, because of the follow on effects of the infection. That is that PID can result from chlamydia infection, in fact about one in ten carriers it’s thought progresses into pelvic inflammatory diseases. After one attack of PID there is about a15% incidence of infertility in a young woman. And if she has 2 or 3 attacks of PID she has an over 90% chance of being infertile. A terrible thing for a young person. As well as infertility we know there is an increase in ectopic pregnancies in young women who’d had PID because of the damage of fallopian tubes any developing ovum will have fertilised and can embed in the fallopian tube and therefore an ectopic pregnancy will develop and this can be a life-threatening situation for a young person when it ruptures and they move rapidly into shock. Despite all this that we know about chlamydia we feel that young people are really very unaware of it. In London Brook over the last few months we’ve been doing an audit asking young people, what do they know about chlamydia? And in the young people we asked 50% of them said yes, we’ve heard the word “chlamydia”. I think many of those probably were saying they had because they didn’t want to seem stupid or because they thought that was what we wanted to hear, because out of that 50% who’d heard the word chlamydia only 50% of them actually knew that it was a sexually transmitted infection and out of those only one in ten know that it could lead to PID and infertility. So there’s a great lack of awareness around chlamydia and we need to inform young people about its prevalence. Not only we are concerned about chlamydia in young people but also of course gonorrhoea. We have five of our Brook centre in London in the South East of London, in the Lambeth, Southwark and Lewisham area where gonorrhoea is 6 to 7 times higher than the national incidence levels of gonorrhoea, and in young women aged under 25, 67% of the test were in this age group, and there is also a high prevalence in the ethnic minorities in South East London. It’s not only chlamydia and gonorrhoea, but there is also a rise in herpes, warts, pubic lice and many other sexually transmitted infections, HIV, hepatitis. As I said, what we can do at London Brook at the moment is only very basic testing. Now, if young people need further testing we refer them to our Genito-Urinary Medicine Departments which are at the moment mainly in hospital settings although there are some individual ones in the communities but mainly in hospitals. So we decided in the six months’ audit last year to look at the numbers of young people whom we’ve referred who actually turned up at the GUM clinic for investigation. With each client we were sending we discussed the relevance of the STI to them, why we were sending them, we gave them a letter and at the bottom of the letter there was a tear-off slip which said, we are trying to track our clients can you please return this slip if they turn up in your clinic. We discussed with the young person a specific clinic that they could go to near to where they worked, or college or where they lived and those who weren’t sure which GUM clinic they wanted to go to we gave them the cross-London list of GUM clinics. You know, for the next six months we correlated the information by the tear-off slips that came back to us, and the doctors who had time at the GUM clinics actually writing back and telling us our clients had turned up there, if the client came back to one of our centres for repeat pill prescription or whatever we said to them, “Did you actually go the GUM clinic to have your STI testing?” Out of 332 clients that we referred we only have evidence that 57 out of these young women actually turned up at the clinic. This is only 17% of the total number that we referred, allowing for the loss of the paper work between the GUM clinic and us and us the GUM clinic, that would still be about a quarter of the young people that we referred who turned up at the hospital clinic for testing. So this says that we do need to be able to offer far wider services actually at out Brook advisory centre, when the young person accesses our service they are not happy to be referred to still another service. I’ll finish off by telling you what we can do for the young people at the moment. And that’s around education. hopefully preventing STIs. We do at the clinics have many leaflets, posters that we give to the young people, we discuss STIs with them at every possible consultation that we really can and define the risk for them. We hope to make as much liaison as possible between the Brook Advisory Centre and GUM clinic at the hospitals. We try to take school groups in to the GUM clinics so that the young people can feel comfortable about where they actually going. And we do share staff, some of us work at the GU clinics and work in Brook as well and we can give a very positive note to the young people about the kind of service that they will get when they access the GU service. We also do a lot of combined training so that our staff at Brook meet the staff from the GU clinic and we are doing a big meeting next February when we are going to be sharing skills between Brook and the STD Department at St. Thomas’s, so to finish off as I said we are at a very basic level as to what can offer to the young people in the centres at the moment but we have great hopes for the future and Diane is going to tell you about some of those. Diane Noble Thanks Gillian. I am going to talk about three things. First of all following on from what Gillian said I am going to talk about why at London Brook we want to set up sexual health centres in the capital. I am going to talk about what we mean by sexual health centre. And finally the issues that we faced and continue to face in developing this service. London Brook is an organisation which now probably spends about just as much time talking about STI as we do about contraception. And I think those of us working in the health field now have such a high awareness about STIs it is really important to keep reminding ourselves the very low level of awareness generally around population and more specifically amongst young people. I’ve got a little story to tell you now. I actually first came to London twenty years ago and that was to go to University, and our college doctor had a mission, and his mission was to put every female student on the pill. It didn’t matter what you went to see him about, you could have a cold, you could have a sprained ankle, you went in there you came back with your packet of pills. So everybody was enjoying themselves and nobody was worrying about getting pregnant and then a shock horror, the word went around that a very popular male student had an STD. Now, I had a house actually sharing with seven other women and we sort of pooled our knowledge and that pooling led to what we had kind of heard about syphilis because it did come up in history classics, but generally people died of it, it was sort of Henry the VIII, it was this thing called VD and that was it, that was what we knew. And we kind of figured that people went to hospital and we sure as hell were not going to ask anybody at the college. I wonder how things have changed. Well, clearly the awareness of HIV and AIDS since mid-eighties has had an impact. But research still highlights the very narrow view of sexual health young people hold. And that narrow view is really summed up by perhaps avoidance of the risk of pregnancy and to some extent avoidance of the risk of HIV and AIDS, but the very low awareness of common STDs and the need to protect from these. Although some young people might now have a knowledge of HIV and AIDS the extent to which they see themselves at risk turning to motivation to protect themselves from that risk, for the majority of young people the risk of HIV they perceive at low. Condom use continues to be erratic, particularly young women who a method of contraception such as the pill. A recent study from the health education authority revealed that only 32% of 16 to 24 year olds had heard of chlamydia. The issue of knowledge of the sexual risk is further compounded by the difficulties young people experience translating the knowledge they do possess into their personal behaviour. They too often lack the skills to manage relationships, to negotiate around sexual activity. Well, to some up the world STI rates we know are high, attendance at GU services we know is low, awareness of common STIs we know is low, perception of risks is low, the transition of knowledge to behaviour is difficult and young people continue to have this narrow view of sexual health. And there is something else I think I need to add to that. National Brook has recently published a survey that they did of 700 Brook clients about teenage magazines. And the question they actually asked was what young people wanted more information about. At the top of the list of those 700 young people was: sexually transmitted infections. So one thing that has changed is that young people are aware I think that perhaps there is something that they need to know about. London Brook strategic plan is to have a number of sexual health centres situated in different geographical areas of London, the North, the South East and West. And later these centres will be different targeted local interventions. The first of these sexual health centres is due to open in Brixton in January 1999. The second, planning permission willing, will be in Camden and will open in April 1999. Let’s have a quick look at a sexual health centre. Well, the sexual health centre will be a walk-in service open at regular times on at least six, hopefully seven days a week. There is a range of services that we be offered and testing and treatment of sexually transmitted infections is the key and this is a comprehensive STI screening and treatment service. The new centre is Brixton is being refurbished to accommodate a wider sexual health service. As you go into the main entrance, there is an education and information room which has a range of sources and which will be a base for education of out-reach staff, so young people will be able to come in and access information without necessarily going through into the more clinical part of the service. All the consultation rooms are multifunctional for counselling or clinical service, and adjoining each consultation room is a separate examination room appropriate for contraceptive or STI work. There is also a primary analysis room for use in STI screening. And that model for the Brixton centre is really providing the blue-print for the future for other centres. A vital part of our strategy is to link local interventions, some of those are existing for us in Brook, we currently have things like, a centre at the sixth form college in Islington, we have peer education projects, we have a project called sexability which working with the young disabled people, and we have a range of satellite clinic sessions. The way that we are hoping to work in terns of targeting interventions is to be able to work very locally, geographically, working with young people in housing estates, particularly around the key centres in some towns like Brixton, and targeting specific groups of young people with emphasis on socially excluded young people, those outside the education system and the health system. Well, I hope you all agree that it’s sounding pretty good up until now, let’s look at some of the issues we face and continue to face in implementing this plan. One of the things that we have achieved is that we‘ve had funding agreed by Lambeth Partnership and Health Authority for comprehensive chlamydia screening and treatment programme at the new Brixton centre and this is a first step, but it’s a very crucial step in the provision of that wider STI service. We are hopeful that it is part of the health actions on initiative in Lambeth, Southwark and Lewisham, further funding is going to be available for a health adviser to be seconded from St.Thomas GUM service to Brixton Brook that would support contact tracing for chlamydia positive clients and build links with GUM services locally. We’re also hoping that funding will be sufficient to allow the GUM staff at St.Thomas’s to do an out-reach session at the Brook clinic. The term sexual health is becoming more common now with GUM and family-planning, GPs are using it. London Brook health centres are based on a very simple idea: if young people don’t go to the existing service, so let’s take the service where they do go, to a familiar and trusted environment. What I really wanted to end by saying is that London Brook is a special service for young people and we believe in a unique position to offer a positive experience of sexual health in its broader sense, a real decrease in the prevalence of STIs among young people is linked to a change in young people themselves from that narrow view of sexual health to a broader view of sexual health, and crucial to this is normalising of STIs, removing the stigma, moving both the preventative work and the treatment of STIs into more settings and bringing it into the main stream. C.W. Thank you for a very good presentation and in the interests of time we won’t have any questions for this speaker, our next speaker is Yuko Matsuhashi, Doctor Matsuhashi is Professor at Hiroshima University of education in Japan, she was trained in adolescent medicine in the USA and addresses international issues in sexuality. Today’s presentation is entitled “Sexual Exploitation of Youth in Japan”.
Sexual Exploitation of Youth in Japan Yuko Matsuhashi Thank you very much. Good morning guests. Minors under the age of 18 should be protected from commercial sexual exploitation by the child welfare law, anti-prostitution law and ordinances for the health of young people. But the punishment for adults who exploited minors has not been clearly defined in Japan. I received 17 leaflets advertising adult video tapes that were thrown into my mail box at home between May and July in 1998. The performers of the first group of video tapes are of 14 to 16 years of age. The second group of video tapes type cast a sort of child in Lolita, they are twelve and thirteen. About 82% of high school boys and in about 51% high school girls surveyed said they had ever watched adult video tapes. Japanese high school girls, now mini-skirts and these white socks in fashion among them. Most of private high schools for girls have their own uniforms. These uniforms are sold at the price from £95 to £250 at the shop for fetishists (known as maniacs). In 1993 almost 800 ordinary school girls were asked the question, will you sell your belongings at the shop for maniacs? 300 hundred girls, that is 38% of them responded, about 64% of girls answered yes they would sell their junior school uniforms, nearly 63% answered yes they would sell their high school uniforms, about 30% replied they would sell their bras and panties, 13% of girls answered to be a performer of adult video tapes. They can get about £4 per one panty. If they sell 10 panties they will get £40 easily. At last in ‘94 girls realised a high school girl is a sought after commodity and uniforms are the symbol of it. Until then girls have hated their uniforms forced to wear by schools and teachers. When the police exposed date-club offices in Tokyo in autumn of ‘94 total of 300 girls under the age of 18 were caught. About 90% of them were high school students. If a man calls up at date club office they give him the location of the office. When he arrives at a date club office he needs to pay £25 for entrance fee, £12.5 for arrangement, £12.5 the award for the girl’s service. So he has to pay total £50. Then he peeps into the room where girls are watching TV or reading comic magazines through a small window. Then he picks up a favourite girl among girls and goes out to town with her. After that it depends on negotiation. But only a few high school girls worked at date club offices. Most of girls hesitated to go there. Propagation of personal communication devices changed the scene. Only 6% of Japanese girls compared to 11% of American high school girls have portable phones. But about 43% of Japanese girls compared to 90% of American girls have beepers. We call beepers pocket communicators. 30% of Japanese girls compared to 10% of American girls use them more than 5 times a day. (summer ’96). Now I’d like to explain the system of telephone club and two shot. I will explain two shot first. A man buys a card which cost £15 for 30 minutes by vending machines in town. Then he dials a number of a trader that is written on the card. Then he can talk to a woman after waiting for a few minutes. Both men and women do not need to go anywhere here. They just need to dial. Call from a woman is free. They can communicate each other by phone. Next is telephone card. A man needs to pay about £15 for entrance fee and rent on their room and phone. Then he is waiting for a call from a woman whose call is free. They can communicate each other by phone. Telephone clubs started in 1985. Hand-bills or leaflets advertising telephone communication are everywhere in town in Japan. This slide shows pocket tissues on which the phone numbers of telephone clubs are written. Once I got 7 pocket tissues when I was walking along a wide road between a big station and a department store. They need to get not only high school girls but also adult women, married women. High school girls and junior high school girls are doing telephone communication such as telephone club Two Shot or message dial. They just chat or talk about sex with strangers. If they want to see each other they can make a promise. After that it depends on their negotiation. They go shopping to buy goods for a girl, go the movie or go to the hotel to take a picture or a video-tape of a naked girl and so on. Of course the purpose of most of men is to have sex with girls. These telephone communications is business affecting public morals. They seem to be new style prostitution starting from mid-eighties. And I heard that similar businesses spread out to Korea and Taiwan. The mass media in Japan do not use direct terms to discuss these matters - they avoid the use of the word rape, they say violence, they never ever use the word rape. About 27% of high school girls compared to 17% of junior high school girls had ever tried telephone clubs in 1995. The current data shows that the number of junior high school girls who experienced calling of telephone clubs has increased from 17% to 31% in 1996. The number of high school girls who experienced it has increased from 27% to 44% in 1996. The reason why they call up telephone clubs is as follows - 70% of them answered that they were curious about telephone communications. Nearly 60% of them answered that they were bored so they did it. 42% of 14-year old girls responded that they wanted to tease somebody. Several girls form a group and one of them calls up and makes a promise to meet. They hide themselves behind something and peep the man who shows up. For them it looks like playing a game. How about their concepts of morals? 53% of girls think that talking about sex with a stranger is a problem but it is OK if she wants to do it. About 23% think it is OK. How do you regard having sex with strangers in exchange for money and goods? 52% of them might not engage in sex for money. 37% answered it is a problem but it is OK if she wants. About 11% answered it is OK. Experience by age of prostitution in girls. More than 2% of junior high and high school girls had ever done prostitution. Why they have sex. Half of them answered that they had sex because they wanted money or they did it because their peer had done it. If they hear one friend had age relationship they think, I can do it because she could do it. If she has done it I will do it. This is their way of thinking. Doing similar behaviour to peers is their value standard. The socio-economic status of families of these girls belong to higher middle or middle classes or sometimes high class. They do not belong to poor families. Their parents discipline is relatively strict. So they are good girls at home. They play good daughters role at home hiding their secret jobs behind. But even if parents notice their daughters secret job they would scold once of course but they would not follow their behaviour. Mothers would behave as if they were afraid of daughters. Parents would not interfere in daughters behaviour. Girls have realised that reverse side of men of their fathers age in Japanese society. At school they play normal students role. Of course they do study ordinarily. Here I need to explain how girls use beepers. If they want to do prostitution they leave the message on message dial. The response from men comes by beeper. Girls set beepers on vibration mode so nobody knows in the classroom if the response comes during the lesson. What are occupations of men who want to have sex with high school girls? Incredibly they are teachers, staff of PDA, policemen, presidents of companies and physicians whose social positions are high. The number of big teams of clubs under the age of 18 in 1995 is 3 times more than the number of 1992. Young girls were often involved in serious trouble in 1992 the number one motivation was curiosity, but in 1996 the number one motivation is money: 46.8%. Some girls have sex with 200 men in 6 months and earned £ 25,000 and deposited £12500. One girl said, man’s penis is like a tampon, I feel nothing. I think other things during the sex. Young girls have also become obsessed with possession of designer clothes and other brand name goods. The interest of the mass media and also the support of one male sociologist have added to the problem. This slide shows the consciousness of sex before marriage in junior high school boys and girls. The answer that it should be avoided is less than 10% in both and boys and girls. About 17% of girls replied it was OK even if there is no love between them. Almost half of boys and girls in high schools answered that it is OK even if there is no love between them. Until 1993 the number of students who had experienced sexual intercourse was higher in boys than in girls. But since 1996 more high school girls have experienced sexual intercourse than boys. I think it is because of age relationships. If girls hesitate to have sex they willing to send their photo pictures both in clothes and bikini swim-suits putting their names down to sell things for men. I investigated my own students of Hiroshima University. The experience of calling up telephone club was 9%. And 9% of them knew girls who are doing under age relationship. About 81% of them thought that under age relationship should be avoided. But 6% answered, I am curious. Why they have come to sell their belongings, pictures of even their own bodies easily? The reasons are as following: girls know well that prostitution is wrong and a crime, but 30% of Japanese men buy sex with cash. They may think that they would be similar to other men. Two: fathers are always busy at work and out of home, girls need fathers. Why fathers are always out of home? I think that couples will not be getting well with each other. About 30% of Japanese fathers compared to 10% of American fathers and 17% of Koreans think that divorce should not be allowed if there are children. The percentage of couples who do not have sex after delivery is gradually increasing. Where are those husbands going? And where are those couples going? Finally some of them would divorce after their marriage of 20 years and over when all their children would have grown up. Divorce rate among people who have been married for 20 years and over is 16% in Japan. Who do they talk to about worries. Besides Japan and Korea mother is the number one person. In 70s mother was the number one person in Japan also. Since 80s number person is friends. Mothers are playing good mothers role. They think that for daughters good mothers are like friends. But girls need real mothers, not friends. They want to be scolded or appraised by parents from the bottom of their heart. The TV programme about the girl who had HIV through under age relationship and would die soon was on the air this summer. Many young women took blood tests for HIV after finishing the programme. Now dying women are framing the plan of the law which protect minors under 18. Thank you. Teenage Abortion Lars Holmberg. A study of the management of young men in the decision-making process at Outpatient Clinics for Adolescents in Sweden (Outpatient Clinic for Adolescents, Borlänge, Child Health Unit, Falun Hospital, Falun, Sweden) The purpose of this study was to obtain knowledge about the opportunities available to Swedish teenage boys and young men for obtaining advice and support during the process involved in making decisions on abortion. The study was carried out at Swedish Outpatient Clinics for Adolescents. We also wanted to obtain knowledge about the staffs’ views of male attitudes and feelings regarding abortion. This knowledge is intended for use in developing models for advice and support in this difficult situation. A questionnaire focused on current management routines and staff experiences of questions and problems taken up by the male partner concerning abortion. Questionnaire answers indicated that the potential father, as well as the mother, requires active care and information together with the partner. There was also a need for individual support and information for male partners requiring engagement of health care professionals who are familiar with the problems involved. INTRODUCTION - Unwanted teenage pregnancies are not uncommon in Sweden today. The number of induced abortions among teenage girls in 1996 was 4,366, a rate of 17.8 per 1,000 girls. The incidence varies geographically and has been influenced by several factors among which are the cost of contraceptives, concerns about side effects of the pill, a tradition of early pregnancies and the level of unemployment. To be or to have been a potential father, potential father refers to the current pregnancy, is of course experienced differently by each individual. The teens and early adulthood are sensitive periods in life when an experience such as termination of a pregnancy can profoundly influence relationships and the mental health of the individuals involved. Many males experience a situation which has been described as a life-crisis, an integral aspect of the male human condition. In order to support potential fathers in this difficult situation, we need more knowledge of how they react and their thoughts and emotions accompanying the decision of whether or not to terminate the pregnancy. Currently we know very little about this aspect of the situation. Although there are a number of studies of young men´s attitudes to the termination of pregnancy, only a few address the problems of those with an experience of personal involvement in a pregnancy. The ultimate decision on whether or not to terminate the pregnancy rests with the girl. But what attitudes are held, which questions and problems are to be faced by the young potential fathers when choosing between termination of pregnancy and becoming a father? The aim of the study was to obtain knowledge on the opportunities teenage boys and young men have for obtaining advice and support during the process involved in making decision on termination of pregnancy and the level of advice and support available to them. The aim of the study was also to obtain knowledge on the staffs´ views on attitudes and feelings of boys and young men. This knowledge is intended for use as a first step towards developing models for supporting young men in the decision-making process after an abortion or when the pregnancy is continued. MATERIALS AND METHODS - The majority of pregnancies are confirmed at the Outpatient Clinics for Adolescents in Sweden. Management differs between the clinics but as a rule the pregnant girl has access to medical and psychological care when deciding about the termination of her pregnancy. The potential father is often invited to meet a member of the staff together with the girl, depending on her attitude to the matter. After an abortion the girl is usually followed up in one way or another by the Outpatient Clinic for Adolescents. Follow-up rarely occurs for the male partner. In the spring of 1995 an investigation was carried out in Swedish Outpatient Clinics for Adolescents regarding the routines and the management of the situation following a positive pregnancy test. The investigation focused on the experiences and impressions of the professionals working in these clinics. A questionnaire was sent to all 150 clinics. The questionnaire contained 15 questions covering the following topics: - Which professions are represented in the staff? - Number of pregnancy tests? - Estimation regarding age structure of the pregnant girls and their partners at the clinic? - Does the partner usually accompany the girl when visiting the clinic and which professional contact, if any, is available for him? - Is the male partner routinely offered individual support? - Examples of questions and problems concerning abortion by the male partner alone and together? - Common reasons for abortion? - Possibilities for the partner to influence the decision on whether or not to terminate the pregnancy? - Examples of worries and common reactions from the boyfriend? The questionnaire was addressed to the head of the clinic with a request that the questions should be answered by the staff together. RESULTS - The questionnaire was answered by 121 clinics, yielding a reply frequency of 81%. All questions were not answered by all clinics. The staff composition varied between the answering clinics, the only category represented at all 121 clinics was the midwife. The others were social worker, gynaecologist, general practitioner, nursing aid, psychologist, paediatrician, registered nurse, venereologist, child and adolescent psychiatrist. Of nearly 15,000 pregnancy tests divided among 113 clinics answering that question approximately 20% were positive. 72% of the girls ranged in the age from 15-20 years, only 3% were younger than 15 years and 25% were older than 20 years. 55% of the partners were younger than 20 years of age. In roughly 25% of the cases the partner accompanied the girl at the visit when the pregnancy test was positive or at the next visit. In most cases both boy and girl together were offered a visit to a midwife and/or a social worker. 19, that means 16%, of the 121 clinics offered individual support routinely to the partner. In those cases a visit to a social worker was the most frequent routine, the next most frequent alternative was a visit to a midwife. According to the impression gained by the staff of the clinics the three most common questions or problems mentioned by both the girl and the boy together were: concerns about bodily complications, particularly sterility (mentioned by 49% of the clinics); practical questions on the performance of the abortion and other questions concerning the procedure (mentioned by 47% of the clinics); secrecy, information to parents, worrying about responses by parents and similar problems (mentioned by 44% of the clinics). Examples of common questions or problems mentioned by the boyfriend were concerns about the female partner’s bodily complications, the practical performance of the abortion, and also a feeling of powerlessness and difficulties in influencing the decision. Reflections and worries concerning their own maturity and age were common. The answers from the clinic staff regarding the three most common reasons for deciding on abortion were too young, unwanted child and social or financial problems. Differences in the type of services offered to the male partners was reflected in the answers in only one area. In clinics offering individual support to the male partner, 47% mentioned problems in the relationship compared to 22% in those not offering this type of service to the male partner. The decision on whether or not to terminate the pregnancy was stated by 84% of the clinics as one of the three main sources of concern for the boyfriend. 53% of the clinics reported male partner concerns about the surgical operation and possible bodily complications such as sterility. As many as 47% mentioned anxiety for emotional or sexual consequences as the main concern for the partner. On the question ”common reactions from the boyfriend” when the girl decided on abortion 90% of the clinics stated relief as a common response, 30% mentioned grief or depression as frequently occurring whilst 22% stated disappointment or irritation. When the girl chose to continue the pregnancy 60% of the clinics reported that pleasure, pride, expectation or happiness were common responses from the boyfriend whilst 47% of them mentioned aggression and 42% disappointment. DISCUSSION - The questionnaire was answered by 81% of the clinics but unfortunately some questions were left unanswered. Fewer answers were given to open questions and those requiring experience of individual support to the partner. A majority of the questions were answered by estimates. In our study the focus was on boys and young men. The staffs’ views of their attitudes and feelings were based on experiences from about 25% of the male partners. The main concern of the potential father was considered to be the decision on whether or not to terminate the pregnancy. The majority of the clinics stated that the partner frequently or rather frequently was allowed to influence or participate in the decision. At the same time there were experiences of difficulty in influencing the decision as well as feelings of powerlessness and of being excluded. Questions concerning one’s own maturity, age and role as father, were given as important considerations in the process of decision-making by the male partner. The age of the couple, the unplanned child and common problems in young people, i.e. social and financial considerations as well as uncertainty, ambivalence or difficulties in the relationship, were given as the most usual reasons for deciding on termination of the pregnancy. It appears that a similar situation exists in Sweden as that revealed in some American investigations: a willingness for serious participation by the male partner in the decision on abortion with a need for emotional support, complicated by the right of the girl to determine whether or not to terminate the pregnancy, indicating the possibility of a conflict of interests. The experience of abortion may challenge the partner at a critical time in identity formation and in moral development. Their feelings, if not appropriately dealt with, may create problems for their girlfriends and professionals in obtaining a smooth resolution and outcome of the pregnancy. It is thought-provoking that only an estimated 25% of the boys accompanied the girl when the pregnancy was confirmed or at subsequent visits, since questions about the practical performance of the abortion and possible bodily complications as well as questions about secrecy and information to others appeared to be essential, for both the girl and the boy. Almost half of the clinics also reported that consequences of abortion were of either an emotional or sexual nature and required discussion with potential fathers, preferably alone. The results differed, with regard to problems in the relationship as the reason for deciding termination, between clinics with experience in seeing the boyfriend alone, 47%, and the remaining clinics, 22%. A possible explanation is that it was easier to have the discussion when the male partner was interviewed alone. The opportunity to express feelings can strengthen resources and facilitate an appropriate solution to the crisis, thereby diminishing problems in the future. The reason for sorrow and disappointment in the male partner, which was apparent in both those involved in continued pregnancy as well as termination, can be explained by the experience of being excluded, powerless or on disagreement with the decision. The reason why a majority of the clinics reported positive reactions when a pregnancy was continued is unknown. More secure relationships or potential fathers of a higher age group are perhaps more common in these cases. CONCLUSIONS - The result of the investigation indicated that the potential fathers benefit from active participation and support including information together with the partner. Consideration should also be given to those questions and problems which require individual support from personnel who have the knowledge and resources to help them in this difficult situation. It is therefore necessary to obtain more information directly from the male partners through qualitative studies and we intend to strive for an improvement in information to and quality of care for this group in Sweden. It is true that only 16% of the clinics routinely offered individual support to the male partner but a good deal of the remaining clinics noted that they were already either planning this or that our questionnaire had raised the idea of providing a similar service. In the future we plan to repeat the investigation in order to find out how far these plans have been implemented. The answers to our questionnaire have given us knowledge on how the potential fathers’ attitudes, questions and problems during decision-making on whether or not to request abortion were interpreted by the staff at Outpatient Clinics for Adolescents in Sweden. We also obtained an insight into how their, hitherto often neglected, needs are met. This knowledge will now be supplemented by a qualitative study through interviews of current cases as a basis for working out methods for developing this service in the future. Chairman: Our next speaker is Doctor Jorge Pelaez Mendosa and I apologise if I didn’t pronounce that right. Doctor Mendoza is an Auxiliary Professor of Obstetrics and Gynaecology at Havana University School of Medicine and he is the President of Juvenile Section of the Society of Obstetrics and Gynaecology in Cuba.
Sexual Practices in Adolescence – Sexual Initiation Jorge Pelaez Thank you. First I would like to thank the organisers of this conference, specifically Dr. Diana Birch for the kind invitation. I am very happy and honoured to be addressing this important meeting. I also want to apologise to the audience because my English is really bad. But I promise I am going to do my best. We listened previously to speaker talking about some problems that are very common during adolescence, abortion, sexual exploitation and STD. Now I am going to talk about the first step in sexual behaviours during adolescence, it is sexual initiation. Risky behaviour in adolescence is very common. We recognise under this a precocious first intercourse, poor recognition of the risks with regard to relations, health concerns, in inappropriate circumstances and places, frequent change of couples, ignorance about sexuality, birth control is not considered, Lack of essential knowledge and use of contraception and insufficient knowledge about STDs and their prevention. Today adolescents are affected by disproportionately high prevalence of unplanned pregnancies, sex transmitted diseases including AIDS and other STDs that affected their reproductive health. Risky sexual behaviour is considered responsible for almost all of these problems. We are going to talk now about sexual initiation and we define that as the first coitus. An intimate experience of communication of the signs of affection existing between two human beings which could take part voluntarily. And precocious sexual initiation we define that sexual relationship that begins before the adolescent’s arrival to consolidation stage between age 17 to 19 years (Bloch and Erickson classification) To remind you this classification covers four stages. First stage is between 12 and 13 years, second stage between 14 and 15 years - motivation manifestation, third stage around 16 to 17 and the fourth stage is over 18 years. We consider that any relationship that begins before this stage is precocious. Masters and Johnson said in 1989 that commitment in a couple does not imply only preoccupation about sexual pleasure but includes direct reciprocal responsibility on birth control as a result of such union, in other words pregnancy. That is not common in a couple of adolescents that are below 18 years. That is another reason why we recognise that the relationship that begin before 18 years is precocious. This is the consequence, the popular consequence of precocious sexual initiation: frustrating experience, favouring sexual dysfunction, continuous change is couples resulting in risky sexual behaviour, increased rate of STD, genital infection and their consequences - cervical changes neoplastic and PID, higher risk of abortion, unplanned pregnancy and their consequence and higher risk of PID and in the medium and long-term consequence, we are talking about infertility and ectopic pregnancy. The main objective of our study is to know the frequency of adolescents attending secondary school that have initiated intercourse, to determine the course that led them to have a precocious intercourse and to study the adolescent environment, establish risks and protective factors for precocious intercourse and to know the characteristic and motivation for the first intercourse. As you can see we develop a history that include a junior high, technical and high school institutions from Havana city where they were randomly selected. A self-responding questionnaire was supplied to all the students who went to classes on the day established by the study. A total number of 2713 filled the questionnaire, 73 were excluded because of incompleteness or mistakes totalling a sample of 2640 students. This is 1425 females and 1215 males. Informed consent was obtained from each individual and institution. Here are some of the results. The majority of the students included in this study were in the second stage of Bloch and Erickson, between 14 and 15 years. There is significant difference between the no-initiation and initiation and it represents that the males have a higher proportion of initiation during adolescence, they also start earlier than women. The higher group is 14 years in males and the higher in female is between 15 and 16 years. Partner in the first intercourse - There is not big difference between male and female, it was the boy or girlfriend the majority of the partner of the partners in the first intercourse. The only difference was in the when the partner was a friend more common in females and if the partner was a relative there was no difference between female and male. In males the paramount motivation behind first intercourse was group pressure and family pressure. In women we had the peer and the partner pressure. And the difference was significant. Where happened the first intercourse? As you can see the majority in both sexes were always in park. I had a lot of problems in finding a correct word because we found in the dictionary alleys I don’t know if it is correct, it is small street, dark street, you know something like this, and parks. But you can see that there is a lot of places, all of them are not good to have a sexual relationship. You can see motel/hotel is very small, beaches, camping, party, even a school. And here the enjoyment by gender concerning the first intercourse. When we asked them, How did you feel in your first intercourse? And we found also a big difference between male and female. Very pleasant - male always. Female – almost nothing. Pleasant – the same, too much male, few female. Fair stresses – more female, indifference – more female, unpleasant, almost every female. The use of contraception in the first intercourse was also a thing that we want to know. And we found that only 14% of the students use contraception in their first intercourse. Why they didn’t use contraception? First – unplanned relationship, that’s very common during adolescence. They were surprised by the relations, they don’t plan it, they didn’t know that they are going to have the first intercourse. Ignorance about contraception, ignorance about the risks of unprotected relations. But you can find some other reasons, but for example, here is very important, I call out-drop effects. So of the first intercourse in the adolescence were all these high risk sexual behaviour. Sexuality information errors. Is it important to prevent and to delay the sexual initiation? – I think so. You see that when there is a very good level of sexual knowledge the percentage who don’t initiate is bigger. When the knowledge level is very bad or bad the majority have been initiated. The sexual information level is protection factor against the proportion sexual initiation. Here is the influence of the peer group in the sexual initiation. We have 2 groups of peers. We divide the adolescents into the peer groups where the majority are initiated, had sexual intercourse and a peer group in which the prevalence is not initiated. When the peer group is initiated the majority of the students included in this study will start the sexual relations. When they are not initiated there is a big difference and the majority have not initiated. And when they ignore peer opinion also the majority have not initiated. And we can conclude in this case when they adolescents ignore if the peer group have or not sexual relations they are free of pressure, of group pressure to start the sexual relation because it is clear that it is not a topic for conversation. Here is the incidence of abortion in the peer group. When the peer group had a high incidence of abortion almost all the students had been initiated. When there is not intention of abortion this thing changed. And when they ignore even big the difference. What about the family? We recognise a very importance to the characteristics in the sexual practice during adolescence. And as you see when the relationship define very good or good you see that the big percentage of the sample have not initiated. When they said that the relations in the family is very bad or bad almost the majority of adolescents have been initiated even when they say that is regular. The closeness with the parent is also a very important topic. When the adolescent lives with both parents the majority has not been initiated the sexual relations. Even when they live with the grandparents or others the difference is very high and almost always has been initiated the sexual relations. Finally I would like to show you the life projects and the importance of this in have a preventing protection factor for sexual initiation. In this study we find that 39% of the sample have a clear and defined life project, 30% - absent and 32% is confused, they are sure about the future. When we connected the life project and the sexual initiation we found that when they have a clear and defined life project they majority of the students have been initiated the sexual relations. That is one of most important protection factors. When there is absent almost all had been initiated, even when they said that they had a confused life project. We arrived to these conclusions that there is high percentage of adolescents that initiate precociously their sexual relationship more frequently males. The majority of adolescents start their first intercourse voluntarily, also through a high degree of pressure from their counterpart and group. The patterns to a group in which the majority have begun sexual relations as well as to belong to a dysfunctional family behaved as a risk factor of precocious sexual initiation. A big majority of adolescents had their first intercourse in inappropriate places and circumstances, did not use contraceptive methods. A high percentage of female referred to a non-pleasant experience during their first intercourse and living with both parents as well as a clear definition of their life plan behaved as a protective factor of the precocious sexual initiation. As recommendation we can say that an intensive work should be developed aimed to elimination, modification of control of reproductive risk factors of relations with special attention to the precocious sexual initiation. The following aspects to be considered: gender perspective, education in sexual health, project for development of youth, psychological and social pressure. Chairman: We move on now to presentation by John Rees, Claire Lewis and Nathan Curry called APAUSE which is a school-based sex education intervention programme. They are from the Department of Child Health Post-Graduate Medical School in Exeter University. Co-chairman: Well, they are getting fed up I think, it’s marvellous that we have young people participating, it’s always important when we are having a youth conference to have those with which we are working with present and passing on their opinion and their knowledge. Thank you.
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