APAUSE  Claire Lewis and Nathan Curry

Nathan: …. I really really like you.

Claire: No.

N: I really like you and I think that’s  what we both want now.

C: How do you think I feel, you putting all this pressure on me.

N: Oh, everybody in school is doing it, I mean everyone’s done it,

C: No means No, don’t you understand?

N: Oh, don’t be like that, it’s not fair on me, I mean, come on, I really love you.

C: Sorry, I am really sorry, but I can’t be doing this right now, we’ll talk about it tomorrow, when…

Claire: OK. Hello, my name’s Claire, and this is Nathan. We’re both are pupils at Exeter College and we’re both 17 years old. What we’ve just shown you is a role-play in the APAUSE programme to show young teenagers that they have the right to say “No” if they want to.

Nathan: APAUSE stands for Added Power and Understanding in Sex Education. It is a project looking at methods of communicating the medical problems of teenage sexuality to 13 and 14-year olds. Part of the course is taught by people like us – peer educators.

C: We ourselves are students and can remember what it’s like being 13 and 14. We’ve been more recently that these pupil’s teachers. And so our word has almost more credibility. We are not trying to give them any thoughts of knowledge, we are simply there saying that you can have power, you are allowed to be confident in these situations.

N: We ask them into the classroom and saying, Hey, not all 16-year olds are having sex, or it’s all right not be to having sex at your age. It gives them a bit more credibility, they know we’ve been there a few years ago, we know what they are going through.

C: I remember when I was 13 or 14 I thought anyone over the age of 16 or under the age of 25 was cool simply because of their age. And so when you’ve got a year 9 pupil who is at an influential stage talking about a sensitive subject like sex with someone they can relate to gives them more confidence.

N: So, how does it work? Well, firstly we as peer educators go through an intensive 2-day course. We firstly learn about contraception, STDs, that sort of thing, so that we know what we are talking about in the classroom. We then learn about how to handle difficult situations. We can’t really say, go and stand there in the corner, so we learn how to deal with the class. We also go to teach the course as part of the team of four. We teach four sessions once a week. First one’s called risk appreciation, second one’s called pressure in relationships, third one’s the power to be me and finally we do a round-up session where we go through what we’ve learned in the three other ones.

C: The sessions are structured using scripts which we learn during training sessions and also given to take away and take a look at before we approach. But we are allowed to ad lib. The scripts are written by John Rees and his fellow workers, I suppose, and they are very adult in their wording, so obviously we change them depending on what the class’s stereotypes are. And to stem mayhem we also establish 2 ground rules in the first session. We don’t have the authority of teachers, like Nathan has said and it’s important to establish a form of respect to which both the peers and pupils must apply. The three rules are: no personal comments. These apply both to the peers and the pupils. We are not allowed to tell them any information about ourselves and in return we do not expect them to talk about themselves to their friends. Secondly, no put downs. You are not allowed to turn to someone and say, that’s stupid for not knowing the answer. And lastly, listen to each other. They’ve got to listen to us and in return we’ve got to listen to them.

N: Session 3 “The power to be me” is a particularly successful and enjoyable session. In this session we use role plays to help young people say “NO” in difficult situations.  being able to resist pressure is useful in all walks of life. But in this session we look specifically at sexual situations.

C: OK. In these role plays we get each member of the class to come up to the front of the classroom and resist a pressure situation put forward by one of the peers. We use methods we discussed beforehand in the classroom with them and saying “No” to a 17 – 18 year old gives these pupils confidence.

N: The role play we showed at the beginning was an example of what we use in a class and hopefully what we want to do by the end of the session we do in the classroom every member of that class can do exactly what Claire did to me or the other way around. We have three simple methods, although it might look complicated, they are three simple methods. These methods are quite simple, they look quite complicated there, it is quite easy, OK. First of all, you say ”No” and keep repeating it, you give no excuses and look them in the eyes. You turn the pressure back on to the other person. Firstly, this is in two parts, you firstly say how you feel, I feel really uncomfortable, I feel really awkward. And then you ask them a question, so that they are back on their defensive, something like, Why do you keep on pressurising me when I’ve already said “No”?

C: OK. We’ve done enough talking, we’d now like you to participate in trying out these exercises.  One of us is going to act as a stage manager, which is me for now and Nathan is going to pick on one willing female.    (audience member chosen)

N: First of all you are just going to say “no”.

C: Look him in the eye and say “No”, simple as that.

N: Three times.

N: So, you know, we’ve been going out for quite a while now, you know, I really like you and I think it’s about time we start having sex.

Answer: No.

N: Come on, I really, really like you, I mean, this is it, this love, I am telling you. Look, everyone’s at school doing it, I mean, all mates go all over me, it’s really good, oh please.

Answer: No.

C: Thank you, well done.

Rees: Now, we need a male volunteer. All you want to say is “not quite” and say how you feel, so you say “I feel really uncomfortable, I feel really awkward”. OK?

C: You know, it’s getting pretty boring in here, do you want to slip out to the back and have a bit of fun. Oh, come on, you know, you’ll enjoy it.

Answer: I feel really uncomfortable.

C: Please, I’ve been watching you all day and…

Answer: That’s made me feel really uncomfortable.

C: OK, finally we are going to pick another woman because there are more of you and I just want you to do what we did before: to say “No” three times and then finally I mean you could walk away, we are not trying to end relationships here, we just want you to get out of an awkward situation.

N: I really like you, you are really attractive.

Answer: No.

N: Come on, all my mates at school say that it’s really nice.

Answer: No.

N: Oh, come on, please, please.

Answer: You make me feel really uncomfortable.

N: Oh, how do you think it’s making me feel, I mean, I am in love with you, you know, I mean I really need this now,

C: Thank you very much.

N: So that part works. And we do that to every member of the class, every single young person has to come up and either say “No” or as we did at the beginning go through all the methods. And so every single person has a chance to turn someone down who is older and at college. And that gives so much confidence. Does it actually work? It’s got a lot of fun for us as well as for them and the main thing is we found is that after APAUSE  they actually discuss sex with other people, they go away and they actually talk about sex, a pretty taboo subject for a lot of 13 and 14 year olds, notable parents in the yellow there and other school friends at the bottom. I mean, think about it, when you are 13 and 14 they don’t really go, hey, guess what, I learned to say “No” today, but they are, they are going away and doing that. So now we pass you over to John, the project manager and he will give you a lot more facts and figures. Thank you very much.

Effective School-based Sex Education   John Rees - APAUSE

How lovely and reassuring to know that there are three young people presenting this today. I think we need to emphasise that this is not an abstinence campaign, as we’ve heard from earlier speakers there is no evidence at all that campaigns of just saying “No” is simply enough, but I think we learnt very effectively from Nathan and from Claire and from our previous speaker a lot of young people are getting themselves into situations where they are not able to stay in control for all sorts of reasons and we need to empower those youngsters to be able to manage their relationships.

The model that we are working on added power and understanding in Sex Education, and the important part here is that it’s very much a multidisciplinary relationship between education and health. We’ve heard from two of our peer educators but we’re also working with school nurses and teachers, the original research that some of you may have seen in the British Medical Journal in 1995 was a research team of a GP and a senior teacher, a model which was going to be very very expensive to reproduce, so we’ve now watered that down slightly to have visiting teachers such as myself working with health professionals, somebody who comes in with a lot more credibility about what it’s like in the clinic or on the ward.. Working in this collaborative fashion with young people. Central and pivotal to that triangle are the teenagers themselves, we need to change the style, the approach, of traditional sex education.

The assertiveness work which you saw from Nathan and Claire we’ve evaluated with a large questionnaire to more than 5000 young people in different schools. We have a number of different schools, some in Exeter, in Devon, in the south-west of England, some in different parts of the country. The students knew very few ways of being assertive. Having had the peer counselling and doing that sort of stuff they were able to show far more assertiveness skills. We said that this is not a knowledge based programme, although young people’s knowledge is not particularly good, simply giving them information doesn’t necessarily empower them to change their behaviour to manage their relationships. As a teacher with twelve, fifteen years’ experience I could try and teach kids to try and spell gonorrhoea but it isn’t necessarily going to stop them catching it.

We’ve asked young students aged 13 and 14 the vast majority of whom are not sexually experienced - why do you think young teenagers might have sex, what are some of the reasons young people might have sex? They replied - because of pressure, because they think their friends are, because they want to look good in front of their mates is an enormously powerful influence on why young people say they think that people become sexually active. Very few of them, perhaps as few as one in six, are suggesting because they’re in love, or because it’s the next stage of their relationships. They’re curious, they want the experience, and we do also have to recognise the role that drugs and alcohol play in this, and of course childhood prostitution is not unknown even in this country. Having said that the money thing tends to be - ‘I’ve taken you to MacDonald’s three times, come on how about it?’. Worth a try perhaps, I don’t know!

Traditional approaches to sex education are not working. Many of you will of read about a researcher from Sheffield University who interviewed a young man of 16, and said tell me, you’ve had 11 years of education in Britain now, what do you know about sex? And sex education? And he said ‘I know how to do it with rabbits, because the teacher showed us a film about rabbits’, looked terribly embarrassed and said ‘of course, when you’re married, people are very much the same’.  I think that we owe more to our young people than that young man was reporting. Again traditional approaches have tended to focus on the needs of girls and young women, and I think we need to show a shift in that. We know that for a lot of young people, sex can have some pretty devastating and negative consequences. Many of you will be very much on the sharp end of sexually transmitted infection and disease, of the special care baby unit, and we’ve already heard from other speakers about the vast numbers of problems this rather grey and dismal slide can lead for young people. That’s not to say that we are anti-sex or anti-relationships. We would expect young people to have multiple partners. But I think what we do need to do is to work with them, and I emphasise the word with them, so that they can manage those relationships to their satisfaction.

With quite a large number of students, 4000 young people a couple of years ago, we’ve divided them into three academic groups, the largest number is this group  who are taking an average number of GCSEs, that’s a 16 year old exam. We’ve got an academic group who are more able, and a group who are taking less GCSEs. Our evidence is slightly contradicts some of the stuff from the NATSEL survey, but in every group of every academic ability, girls are having slightly more sex than boys. Anecdotally with Britain that would sit with my parental experience that our young women of 15 -16 go out with guys of 17, 18, 19. Who do our young men of 15, 16 go out with? Girls who are a couple of years younger. I suspect that there may be cultural differences - I don’t know, that would be fascinating to discuss. The trend then, seems to be, with more academic ability to have slightly less sex. If we sit that against knowledge, we can see that if we could just get people to have more knowledge, we could assume, if we could just get more knowledge, they would have less sex at 16. However the knowledge of the students is almost exactly the same, in fact in a couple of cases, the students who have had sex are slightly more - I’m not sure about that - but maybe in this sort of case, the students who have had sex have actually had to get a little bit more information. I think the message to take away is that we can’t just equate knowledge with them changing their behaviour or managing their relationships.

 Just giving them facts doesn’t enable young people to change their behaviour or manage their relationships. We need to work from a  different premise. And the collaborative goals theory, the social learning from Bandura’s social inoculation theories and so forth, that some of you will be familiar with, say that of course we do have to have some knowledge. If we’re expecting people to make informed decisions, we would expect them to know what they’re talking about, to dispel some of the myths about it - can you get pregnant the first time? Can you get pregnant if you do it standing up? Sex in the bath? No jokes about tap dancing. We need to give them knowledge. But just having that knowledge probably is not enough. We need to change the social soup that they swim in, the thinking that they have, the common understandings. And there’s no point in you me or anybody else lecturing young people and saying ‘of course you realise good communication is an essential part of a relationship’. We need to take them through a series of workshops with teachers, with health professionals, with peers, so that they arrive at some of these conclusions and understandings themselves. And of course if we’re serious, I think, about getting them to manage those relationships, we need them to practise. Practical sex sessions in the classroom may be attractive to 16 year olds, maybe some difficulties for the rest of us to answer, but if we’re serious about them discussing, negotiating contraceptive use, if we’re serious about them resisting unwelcome pressure, the theory says we need to get them to practise that.

So the APAUSE programme, set up in 1991-1992, was to promote the positive emotional aspects of relationships. And from that I hope that there’s a series of objectives which many health professionals, educators, and I hope young people themselves would wish to sign up to. The main intervention in year 7-11, 12 year olds, through to 16 year olds, is part of a rolling programme, a spiral curriculum which we revisit, and I think we’ve heard from some other people this morning, we need to start that much much younger in school. Having said that, I think there’s a very different sort of relationship if we can talk to youngsters, to 4 and 5 year olds about assertiveness techniques - things that go in our bodies, things that go on our bodies, stranger-danger, whatever, we start that process at a young age. But I would suggest to you that young people’s understanding of the reproductive system will be quite different at age 8, 9, 10, that it is at 14, 15, 16, because of the social change, the emotional and psychological development and so forth.

So the APAUSE programme, the results of which I’ll speak to you about in just a moment, are three sessions in year 9, when the students are aged 13, 14, this is adult led, teacher, nurse, three sessions the following year, but the main filler of that sandwich four peer led sessions that Nathan and Claire referred to. The good news is, although this is not a knowledge based programme, that before the young people have the peers input and for this example we trained our adult staff, our teacher nurse teams, to try and deliver some of the stuff that you saw Claire and Nathan doing we changed it slightly. It was ethically difficult for me to sit there with a 13, 14 year old girl and say come upstairs and see my luminous boxer shorts or whatever line was appropriate. We would ask them for other different pressured situations and the school nurse and I would model them. My colleagues would model that. The good news is that as a teacher of 12 or 15 years’ experience I can communicate knowledge slightly better than Nathan and Claire. Having said that for both males and females their knowledge was good the changes in knowledge.

But if we take a social understanding, a cultural soup question, like most teenagers have had sex by the time they are 16. If you are 14 and you think that everyone at 16 is doing it, there’s a lot more pressure on you to do something about that. Most 16 year olds in Britain are not having sex. If I tell them, or nurses, and with no disrespect to any of many colleagues who are sitting here, we can change behaviour, or sorry we can change that social understanding a little bit. But the peers as you can see are overwhelmingly more significant, they are better able to do that than we are. That is not to argue for either peers or adults. I think it’s a question of saying there’s an eclectic mix here, well we can work together, we can work collaboratively with and for our young people.

We’ve asked the young people, having had the APAUSE programme, set against quite a large number of control, comparison schools, ‘what do you think about your sex education?’, fairly soft piece of evaluation, what do you think about your sex education? And having had this style of work that as I say we’re trying to deliver, young people are saying it’s OK, far more having had APAUSE, both boys and girls. Interestingly, the boys’ school sex education is more important, it’s better for them. Girls are getting knowledge from elsewhere and perhaps they know some stuff already. But having had APAUSE, youngsters are saying it’s OK. And those of you who work with young people know that OK is a fairly strong recommendation. With no disrespect to my two colleagues here. They learnt a lot, so schools results are actually showing statistical significance.

Whether or not they should use outsiders, youngsters overwhelmingly are saying we’ve heard from a couple of other speakers and presenters this morning, who are saying we need to get outsiders, not just my normal biology teacher, we need to get people from the GU clinic, we need to get a practise nurse, we need to get people with credibility to work with youngsters in their own setting preferably. And having had APAUSE, it isn’t a question of the grass is always greener, but having had outsiders the students still value them. If we ask them knowledge questions, we can see statistically significant changes, I mean again already young women knowing a lot about contraception, and their general knowledge was pretty good. This is not a knowledge-based programme, but again the knowledge of sexually transmitted diseases, if we were doing GCSE STD in a 16-year-old exam in Britain, large numbers of our young people would be failing. We’ve already heard that.

Let’s have a look at beliefs. If we think that everybody’s doing it, if we think that sex is going to be really good, if we think that it’s all right to pressure people, if we think that girls get a bad reputation and huge gender differences between stereotypically what we think about girls who’ve had a number of partners and boys who’ve had a number of partners, still a lot of gender difference a lot of social difference there. And as you can see, here is an example which is by no means unique, I think perhaps we’ve got some evaluation that other programmes haven’t always had the resources to pick up, but by working in this collaborative style sex education in school can make a difference. The question I think we asked inappropriately is just to say, ‘is it difficult to talk about sex, or to negotiate’ - this is a synthesis of a number of different questions - ‘is it difficult to negotiate contraceptive use?’ And we were really frustrated that we hadn’t made a difference. Having said that I think it’s probably a bad question. We know that it’s difficult to negotiate contraceptive use, we know that these things are not easy to talk about. Maybe we need to shift the question to ask ‘is it simply too difficult to talk about?’.

The results from the APAUSE programme were published in the British Medical Journal and I think were certainly within Britain, unique, possibly within Europe unique, and that youngsters who had this style of work were more likely to have correct knowledge - well they ought to because it’s a very expensive programme. Having said that we are now making it more cost-effective as we train in-house teachers and personally as a teacher myself I can see that pervading into the curriculum is going to be very very important. Those of you who are based in Britain will know, working in schools, about the curriculum review in the year 2000, where I think there are strong indications that at last the government is coming to recognise and education is coming to support the notion that we don’t need just English and Maths and Science, we need personal social education as well. More power to that.

What I want as a parent, as an educator, as a member of society, is for our young people to enjoy happy, rewarding, successful, fulfilling relationships. Those of you who are over 25 will remember that earth-moving is still a possibility within an intimate relationship. It may move a little more slowly or gently, who knows, but I would love to see this for many of us for many of our young people. I think if we work together, with them, we can achieve that.