"Enhancing Sexual Wellbeing in Scotland. A Sexual Health and Relationships Strategy"
Scottish Executive, September 2003.

Response from the Society for the Protection of Unborn Children, 27 February 2004.

Introduction

The Society for the Protection of Unborn Children was established in 1967 to rally opposition to the Abortion Bill then being debated in Parliament. Its principal aims are as follows:

(a) To affirm, defend and promote the existence and value of human life from the moment of conception, and to defend and protect human life generally and in particular, whether born or unborn (although principally by the latter).

(b) To reassert the principle laid down in the United Nations' "Declaration of the Rights of the Child" (1959) that "children need special safeguards and care, including appropriate legal protection before as well as after birth".

(c) To defend, assist and promote the life and welfare of mothers during pregnancy and of their children from the time of conception up to, during and after birth.

SPUC agrees that Scotland’s sexual health is poor and that this is a problem that must be addressed. We share the Scottish Executive’s concern over the numbers and rates of teenage pregnancies and the alarming increase in the numbers of STIs while accepting that addressing these issues are only a part of any future sexual health strategy. We welcome this opportunity to respond to the consultation document “Enhancing Sexual Wellbeing in Scotland. A Sexual Health and Relationships Strategy”.

Our organisation is both educational and political. As an educational organisation we work in schools across Scotland and have the opportunity to speak to young people about sexual relationships and their possible consequences, with particular reference to the issue of abortion. We will therefore pay particular attention to the consultation document’s recommendations regarding sex and relationships education and the role that clinical services may or may not have to play in this. As a political organisation we respond to the concerns of constituents across Scotland regarding life issues such as abortion and we will therefore address the recommendations in the document relating specifically to abortion.

We believe that these issues cannot be adequately addressed without reference to the sexual culture in which we live and the resulting sexual attitudes and behaviour that this promotes. We are pleased that the reference group has chosen to consider the wider aspects affecting sexual health and relationships. We will therefore also devote some attention to these issues and to the recommendations made regarding the sexual culture in which we live and how it might be influenced or changed in order to promote better sexual health and wellbeing in Scotland.

We will not be responding to any of the specific recommendations regarding sexually transmitted infections as this is outwith our remit. However, we would like to state that we agree that those who have infections should have access to the treatment required to relieve or cure their infections.

Chair’s Introduction
1.1 Sex is a positive and fulfilling part of the lives of most people, irrespective of age, culture or faith.

The opening sentence of the document causes a great deal of concern. Quite rightly the group recognise that sex can be a positive and fulfilling part of people’s lives, however the assertion that this is true irrespective of age cannot be supported. In this country there is, and of course there should be, a legal age of consent in order to protect young people who are neither physically nor emotionally mature enough to be involved in sexual relationships. While we must recognise that it is a reality that some young people under the age of 16 are involved in sexual activity this should not in any way be condoned and any sexual health strategy aimed at promoting sexual wellbeing must at all times uphold the legal age of consent. In fact the assertion that sex can be positive and fulfilling irrespective of age does not reflect points made elsewhere in the document, which maintain that it is desirable for the initiation of sexual activity to be delayed on the basis of both physical and psychological health and wellbeing. We believe that all aspects of the strategy must promote delay in the initiation of sexual activity in order to protect the health, physical and emotional, of all young people.

1.3 Improving sexual wellbeing therefore requires a holistic approach that incorporates personal, social, emotional and spiritual, as well as physical, aspects of sexuality.

We agree with this statement and are pleased that it is recognised that sexual wellbeing is considered to be much more than simply physical. In attempting to improve sexual health and wellbeing all aspects of the human person must therefore be addressed. This is particularly important in sex and relationships education when young people are forming their own views and opinions and since we know that young people themselves feel that there is too much emphasis on the physical and not enough on the emotional aspects of sexual relationships.

1.4 For many people, issues around sex and relationships are founded in and inextricably linked to personal, societal, and faith-based morality. Interpretations of morality, however, vary from individual to individual, society to society and faith to faith. We do not, therefore, feel it is appropriate for this sexual health strategy to arbitrate on such matters.

While we recognise the truth of the statement that interpretations of morality vary among individuals, we do not agree that the strategy has maintained its position of not arbitrating on such matters. The strategy wishes to develop a consistent approach to sexual health and relationships across Scottish society, however, it is difficult to see how this can be achieved while at the same time recognising and respecting the different views and beliefs of individuals and groups within society.

Sexual relationships affect not only the individual but also their sexual partner as well as wider society, with reference to public health issues and the social and moral culture in which we live. The fact that sex is not a value-free activity is shown by the fact that the strategy promotes its own set of values. These however are not values with which everyone can agree. The reference group’s vision of a society where sex is accepted as a normal and healthy aspect of life (2.5) refuses to stipulate that there are situations and circumstances where sex and its consequences are not a healthy aspect of the lives of individuals. The strategy’s failure to arbitrate on morals should not and must not stop it from distinguishing between those sexual acts and sexual relationships, which are not healthy, this is particularly clear when considered in light of the evidence of supporting paper 1 regarding the rise and incidence of STIs among specific groups. However, this should also be considered in relation to the reality that contraception is not 100 per cent effective at preventing pregnancy and there is therefore a need for couples to consider the possible consequences of sexual intercourse and whether or not that particular relationship would prove supportive of any new life created. Even if a moral stance is not taken the true causes of sexual ill-health in Scotland must be faced and addressed. Addressing these true causes, i.e. our behaviour and attitudes, is part of the responsibility of individuals regarding their sexual health and we welcome the vision that people must “understand the value of their own sexual health, the importance of responsibility and respect for others and have the capacity and means to protect themselves from unwanted outcomes of sexual activity”.

In order to take responsibility and have respect for themselves and others individuals must be aware of the best way in which to protect themselves from the “unwanted outcomes of sexual activity”. For public health reasons it is in the best interests of all people to have information regarding the only way in which to effectively achieve this; through relationships based on faithfulness and commitment where abstinence is maintained prior to entering into such a relationship.

While we agree that there must be services to treat those who are infected, the strategy must promote ways of life, which prevent such services being needed in the first place. Only by promoting relationships based on commitment and faithfulness to one lifelong partner can the strategy fulfil its aim of correcting sexual ill-health. In the same way only relationships based on commitment and faithfulness can provide the necessary security to allow couples to welcome any new life that sexual intercourse creates, thus eliminating the need for abortion to be sought. It is also interesting to note that in supporting paper 1 (2.10) it was found that the majority of people consider sex outside stable relationships as always or mostly wrong. This is something that the strategy should embrace and promote but instead it chooses to remain ‘neutral’ on such issues. Neither commitment nor faithfulness is mentioned throughout the strategy in reference to relationships and in this way the strategy fails to promote the best way of staying sexually healthy, both physically and emotionally.

The other key values of the strategy outlined in 1.5 are very positive and we would agree that these are values that should underpin the strategy and its recommendations. The aims of the strategy are described in 1.6. We would agree that the strategy should aim to “influence the cultural and social factors that impact on sexual health” and should “support everyone in Scotland to acquire and maintain the knowledge, skills and values necessary for sexual wellbeing”. In relation to the third aim of improving “the quality, range, consistency, accessibility and integration of sexual health services” we agree that treatment services must be provided for those who need it, however we would be concerned about how “services” will actually be interpreted. We oppose the promotion of services such as contraception and abortion and oppose these “services” being made even more accessible than they already are; the promotion of contraception will inevitably lead to greater provision and numbers of abortion. One aim should be to reduce the numbers of abortion and the strategy must recognise the fact that the provision of contraceptive services is not how this will be achieved.

Section 3 Setting the context
The current picture
The strategy highlights many of the problems experienced in our present sexual culture. For example, young people becoming sexually active at a younger age and experiencing regret as a result; the problem of the high numbers of unintended pregnancies resulting in abortion; the high level of teenage pregnancy and abortion rates; the social problems that both cause and affect the life aspirations of young people experiencing early sex and teenage pregnancy.

3.3 uses the high numbers of abortion in the 20-30 age group to demonstrate the high number of unintended pregnancies. The strategy then goes on to state
With adequate knowledge, skills and support from health services, including appropriate contraception, many but not all are preventable.

It is true that in order to reduce the number of abortions it is indeed necessary to reduce the number of unintended pregnancies. However, it is not true to say that the promotion of contraception will help to achieve success in this area. Supporting paper 2 (1.5) points to policy changes such as the introduction of seatbelts as aiding changes in behaviour. While it is true that this policy led to people wearing seatbelts a closer look at the facts indicates that it also led to greater risk taking by drivers, as they believed they were now safer and more able to take risks. The same is true of the promotion of contraception and condoms, while it may change peoples behaviour and encourage their use, it will also encourage greater risk taking as people believe themselves to be protected from pregnancy and STIs, when this is not the case.

The evidence of the last 35 years shows and what is agreed even by those heavily involved with family planning is that with the increase in availability of contraception there has been an increase in the numbers of abortions. This is true due to a number of factors. The promotion of contraception as a way of avoiding pregnancy is not 100 per cent effective. As all contraceptives have both a method and a user failure rate, pregnancy can never be an entirely unimaginable or unexpected outcome of sexual intercourse. At the same time the provision and easy availability of contraception promotes lifestyles where sexual activity for pleasure is seen as entirely separate from the act of procreation. The continued promotion of this attitude towards sexual activity means that the promotion of abortion is furthered by an attitude that sees any new life created through sexual intercourse as an undesirable outcome that must be dealt with.

The statistics also show that not only is abortion most common in the 20-30 age group, it is also most common amongst single women.1 Again; this highlights the dangers of the attitudes towards sexual activity and relationships that our current culture promotes. The majority of women who seek abortion do so because they do not feel that they have either the financial or emotional support required to bear and bring up a child. By promoting sexual relationships based on commitment and faithfulness an atmosphere that is open to life and to the bearing of children is created, and where no unintended pregnancy is considered unwanted or undesirable.
Also, while not all pregnancies are preventable, “with adequate knowledge, skills and support from health services” many abortions are preventable. Women need more help to assess the options available to them so that the decisions they make are truly informed and so that abortion is not simply seen as the only solution; such a situation does a great disservice to women in our society since abortion can never be seen as desirable for either the woman or her child. The strategy should therefore propose ways of providing greater support and ways of raising awareness of the support available to women who would otherwise choose to keep their child if such support was in place.

3.4 refers to teenage pregnancy and its outcomes. Teenage pregnancy is understandably a concern because of the effects that it has on the lives of young girls, whether they choose to keep their child or to have an abortion. While it is true that those who are socially disadvantaged are more likely to keep their child than those from more affluent areas, what must be sought is a way to reduce the number of teenage pregnancies as a whole; abortion must not be seen or promoted as a solution to the problem of teenage pregnancy. It is rightly identified that there are social and economic causes of teenage pregnancy; the findings of many scholars, including Dr David Paton of the University of Nottingham’s School of Economics, demonstrate this.2 It is therefore the problems of social deprivation that must be challenged and solved and it is right that the strategy suggests working across departments in order to achieve the aims of reducing teenage pregnancy.

Research into the motivation for early sexual initiation among teenagers highlights the need to address the emotional needs of young people and what they are really seeking by engaging in sexual activity. Hajcak and Garwood state
“ … adolescent sexuality is largely driven by emotional needs that have little or nothing to do with sex. Adolescents have sex when, in fact, they primarily want or need something else, such as affection, to ease loneliness, to confirm masculinity or femininity, to bolster self-esteem, to express anger or escape and satisfy non-sexual needs”3.
These non-sexual needs are often linked to the young person’s sense of self-esteem, which is in turn linked to attitudes towards school and education, socio-economic status and family background. All of these factors therefore have to be addressed. The life aspirations and prospects of young people must be improved so that they have opportunities open to them that enhance their self-esteem and encourage them to seek the fulfilment of non-sexual needs in ways other than through sexual activity.

We see how important this is when we read the evidence provided in Box 1 Sex and young people, pointing to the amount of first sex being reported as unwanted and the subsequent regret; the combination of alcohol and drugs influencing sexual behaviour; and the greater proportion of young people having first sex at a younger age. Promoting contraception to teenagers only gives young people the impression that sexual activity can be pursued without consequences, when the reality is that user failure rates are far higher among young people than in the population at large.4 “Safe sex” is therefore even less of a reality for this demographic and without making young people aware of these facts we will never reduce teenage pregnancy or abortion rates. Targets for reducing these will never be achieved without recognition and the informing of young people about the reality of pregnancy as a result of failed contraception.

In Box 1 Sexual violence and abuse it is interesting and disturbing to note the attitudes towards women highlighted by sexual assault rates and attitudes towards such experiences. Such attitudes are not rectified but instead promoted in a culture where sexual activity is experienced outwith faithful and committed relationships and where abortion is seen as the natural solution to an unintended pregnancy. Such a culture objectifies women as sexual objects to be enjoyed without consequence with abortion serving as only another abuse against women who cannot avoid taking responsibility for any resulting pregnancy. Abortion is never the easy way out for the woman faced without support for an unintended pregnancy but as long as men are able to use abortion to avoid taking responsibility for their sexual behaviour, attitudes towards women will not change. This is reinforced in Box 3 Gender where it is stated that women are seen as the guardians of sexual health and fertility and that the emphasis must change in order that both men and women take responsibility. Such a situation can never be achieved adequately where abortion remains as a ‘get-out’ clause for men and therefore the presented solution to a woman who lacks support.

The wider influences on sexual health
Recommendations
Social justice policies and other policies or initiatives which address social exclusion and lack of opportunity in disadvantaged areas should encompass actions to address sexual health.

Social justice policies must be pursued for their own sake as a good in itself. Addressing social exclusion and lack of opportunity appropriately and adequately should lead to a corresponding fall in teenage pregnancy because young people will feel that they have an investment in the future. “Actions to address sexual health” if only aimed at encouraging contraceptive use will have no effect on teenage pregnancies in deprived areas. The evidence shows that many young people from disadvantaged areas often are aware of and have access to contraceptive services but do not use them as they have no incentive to avoid pregnancy.5 Only by dissuading or encouraging delay in sexual initiation will pregnancy therefore be effectively avoided for this group. Dr David Paton’s research shows that even if greater provision of contraception leads some teenagers to use contraception, due to the fact that the provision of such services will lead to other teenagers initiating sexual activity that they would not have otherwise, the overall effect on teenage pregnancy rates will be negligible and in particular will have no effect on those from the most deprived areas who would not strive to avoid pregnancy in the first place.6

3.12 considers the way in which values, attitudes and expectations are influenced by the culture and social environment in which people live and how these may in turn affect a person’s sexual behaviour. This is indeed true and this very fact highlights the need for the strategy to avoid its position of remaining neutral on the value of particular types of behaviour and lifestyles. In 3.13 the reference group acknowledges the Scottish Executive’s policies aimed at tackling issues such as domestic abuse, parenting skills, drug and alcohol abuse, equality and diversity. On these issues the Executive does not avoid “arbitrating among morals” in order to tell us what is good and bad, what is healthy and unhealthy. Yet in the arena of sexual health the strategy shies away from confronting and addressing the lifestyles and behaviour that lead to a sexually unhealthy Scotland. If values, attitudes and expectations are influenced by culture and social environments then the promotion of a culture which does not distinguish between behaviour and lifestyles that are healthy and unhealthy will see no change in the values, attitudes and expectations that prevail in our current climate. Promoting contraception to young people reinforces the expectation that young people will engage in early sexual activity and attitudes that see no value in delaying sexual activity. On the whole STIs, unintended pregnancies and abortions will not fall when the attitude promoted is that people can engage in sexual activity regardless of the consequences. This will always be true for a society that promotes contraception to reduce pregnancies and STIs because contraception can never achieve either or both for everyone. Contraceptives often fail to prevent pregnancy and barrier contraception provides no protection at all against infections such as HPV and can only reduce the risk of transmission for other infections including HIV. By failing to address these facts the strategy will fail in its aims and will not even achieve the relationships based on equity and respect that it seeks, for no relationship can be considered respectful that does not consider the dangers to the health and wellbeing of those involved.

The media and mass communications
The strategy rightly identifies the media as an influence on attitudes towards sexuality and sexual health, an influence that can often be negative (3.16). However, it also points to teenage girls magazines as “an informative and useful source of information”. The limitations of these sources of information are rightly recognised as they often promote an unhealthy approach to sexual relationships particularly with regard to young teenagers. This medium has become saturated with “information” and “guidance” on sexual matters irrespective of the age of their readership. Far from discouraging sexual initiation these magazines present a picture where sex is both natural and expected for young girls.

This is the type of message identified in 3.17 however it is unclear exactly what is considered to be “positive information about sex and sexual health”. The strategy’s assertion that the Executive’s media campaigns should provide a balance to the information already promoted by the media, is also concerning. The media messages to be promoted by the Executive are likely to centre on the promotion of “safer sex” rather than on refuting the perceived image that ‘everyone is having sex’ and can do so without consequences. The strategy itself in its opening line reinforces the message so often picked up by young people, that ‘everyone is having sex’. It is hard to see then what real impact any media messages based on the strategy’s recommendations will have in delaying sexual activity by young people and promoting genuinely healthy relationships.

The continued promotion of contraceptive services for young people again only reinforces the idea that young people are expected to have sex and does nothing to promote a positive view of sex and sexual health based on the ideal of delayed sexual initiation and the development of relationships of faithfulness and commitment, thus securing sexual health and wellbeing. The reference group’s suggestion that the strategy should “Encourage a cultural shift towards a more open and positive view of sexual relationships and sexual health that is accepting of diversity” seems to suggest that all sexual relationships should be valued and respected regardless of whether or not they actually promote sexual health, which many do not. The early initiation of sexual activity by young people should not be considered healthy, either physically or emotionally. Also, any relationship that is not supportive of the possible outcomes of sexual activity, i.e. pregnancy, should not be considered healthy, particularly with reference to the strategy’s own desire for individuals to be involved in relationships based on equity and mutual respect. This is then at odds with the suggestion that the strategy should raise awareness of ways to reduce poor sexual health outcomes, which should surely mean highlighting those relationships that are not healthy. The media could in fact prove to be a very effective tool in providing information on the benefits of delaying and abstaining from sexual activity. As Boydell and MacKellar point out encouraging delay does not have to be paternalistic and imposing morality.
“It simply provides the information and skills necessary that delay until the young people are older is in their ‘best interest’ and leaves the decision to them”.7

Section 4 Promoting positive sexual health
A broad approach to sexual health promotion
4.5 In Scotland like the rest of the UK, there is a lack of clear, accurate information and open, non-judgemental environments in which individuals of all ages can form their views and develop knowledge about sex, sexuality and sexual health and make their own appropriate choices.

We would agree that there is a lack of “clear, accurate information” but that this is essentially caused by the current climate of providing a “non-judgemental” environment in which to review and assess such information in forming opinions and making choices. This is no more true than in the area of abortion where women are not provided with access to “clear, accurate information” on such issues as foetal development or Post-Abortion Trauma. It would appear that foetal development information is not provided so that the woman’s decision is not ‘influenced’ by this new knowledge. However, providing information informs the choices that people make whatever their situation. It is also true that the deliberate withholding of information will influence the decisions that people make. Ethics therefore requires that we provide everyone will full information in order that they are able to assess the facts for themselves and to make choices based on the full facts. The current climate of creating “non-judgemental” environments has meant that the information available to individuals, not just on abortion but also on all aspects of sexual health and relationships, is not available for fear of ‘moralising’. “Clear, accurate information” must mean the full facts so that the choices individuals make are truly informed in all areas that affect their values and attitudes as well as their health.

Acquiring knowledge and skills about sexual health and wellbeing
4.8 Thus, having respect for oneself and others, making considered choices about sexual activity, and acquiring emotional intelligence are key learning outcomes.

It is vital that everyone has the opportunity to develop respect for themselves and for others and that they have available to them the full information necessary to make considered choices about sexual activity. One of the keys to this is of course the need to acquire emotional intelligence. This is important for all individuals but should be considered with particular reference to sex and relationships education for children and young people. Young people are often led towards sexual activity as a way of fulfilling their emotional needs. These however are often quite different from any sexual needs that they have. Wight et al identify this as being correlated to the feelings of regret experienced by young people engaging in early sexual activity.8 Part of sex and relationships education should therefore focus on talking to young people about their emotional needs and how these needs would be met best. This helps young people to develop “emotional intelligence”. Cohen suggests that helping young people to understand what motivates them towards sexual activity is the best primary intervention in aiding young people to develop the mechanisms to cope with the emotional and social pressures that often lead them into sexual activity, regardless of the fact that this will not meet the needs that they wish to fulfil.9

The role of schools
4.11 School based sex and relationships education (SRE) should be delivered in a consistent way by professionals who are specifically trained for this role and who are able to support and complement the role of parents and carers as educators of children and young people.

It is noted here that school based SRE is there to support and complement the education provided to children by their parents and carers. This is particularly important as parents and carers are the first and principal educators of their children. This is a role that must not be usurped by schools, merely supported and complemented. It must be stressed too that the role of the school must be complementary to the education provided by parents and carers. Parents and carers therefore must be involved in reviewing and approving the sex education materials and programmes used in schools in order to ensure that their views and beliefs are respected.

4.12 discusses the differences between and the relative merits of abstinence only sex and relationships education and comprehensive sex and relationships education. However the discussion of abstinence only education and the decision not to recommend such education programmes is not based on the most recent evidence of the success of these programmes. In supporting paper 4 (3.19 Box 1) the description given of abstinence-only programmes does not accurately reflect the successfully promoted abstinence programmes financed by the Clinton administration in the US. Contrary to what is being suggested such programmes do recognise that some young people are engaging in sexual activity and so they seek to emphasise the benefits, physical, emotional and psychological, of delaying sexual activity and parenthood.10 This sits alongside programmes to develop self-esteem, decision-making, communication and developing relationships and understanding development and autonomy.11 Some programmes have also achieved a delay in sexual initiation and have even reduced teenage pregnancy rates.12 The very positive results of the ABC programme in Uganda where abstinence and being faithful are emphasised above condom use should also serve as a successful example of how the abstinence message does work. From 1989 to 1995 research from Uganda showed that there was a 65% decrease in sexual activity with a non-regular partner, half of Ugandan men and women were faithful to one partner, 11% of women and 14% of men stopped having sex and 2.9% of women and 12.5% of men started using condoms.13 It is also worth noting that the Health Development Agency, a government advisory agency in England and Wales, in January 2004 stated that schools should include abstinence messages in sex education lessons; they consider this to be an important way in which to reduce sexual ill-health among young people.14

The strategy recommends comprehensive sex and relationships education, which aims to delay sexual activity and at the same time develop communication and negotiation skills and provide information on sexual health services and contraception. Supporting paper 4 (3.21) emphasises the evidence from some comprehensive programmes that have not led to increases in sexual activity or pregnancy rates. However, neither have these programmes led to decreases in sexual activity and pregnancy rates.

The strategy gives the example of the SHARE programme (4.14) developed in Scotland. SHARE is being used by the strategy as an example in spite of the fact that it has not yet been fully evaluated and there is no evidence from the interim results that this programme actually works. This does not conform to the expectations of evidence-based policy formation and therefore is a major concern. The interim results from the randomised trial of the SHARE programme found that there was no effect on the quality of relationships; it neither discouraged nor encouraged sexual activity; and it had no effect on reported condom or other contraceptive use.15 It therefore did not succeed in its aim to delay sexual activity and the information provided on sexual health services and contraceptives was to no effect. There is in fact little emphasis on abstinence in the SHARE programme, with only one session out of twenty on developing skills to say ‘no’; even within this session there is little information on the reasons why someone may want to delay sexual activity.16 Findings from the trial highlighted as positives were a decrease in feelings of regret at first sexual intercourse with their most recent partner and better knowledge about sexual health and relationships.17 SHARE is a programme designed for 13-15 year olds. The fact that this age group reported less feelings of regret at first sexual intercourse with their most recent partner suggests that the sole achievement of this programme was in making young people feel better about their sexual experiences, regardless of the fact that they are underage and indulging in risky sexual behaviour with more than one partner. Underage sexual behaviour will always be risky with regards to health, particularly for young girls whose reproductive systems are not ready to cope with the contraceptive pills that are promoted for their use, but also for all young people who are not yet emotionally mature to deal with the consequences of sexual activity. So far SHARE cannot claim to be an example of successful comprehensive sex and relationships education; it is doubtful whether SHARE should even be considered “comprehensive” since the abstinence element of this programme is severely limited. Our sex and relationships education must not condone underage sex and must do better at encouraging delay in sexual activity.

SHARE and any other programme that form a part of the Healthy Respect partnership must be properly evaluated and found to be successful before any recommendations are made regarding its application in schools across Scotland (4.16 Recommendations). Supporting paper 4 (5.3) supports the need for more research into the effectiveness of sex education programmes so that one method is not rejected without proper evaluation and so that we do not embrace methods that have yet to prove their effectiveness. It is therefore of great concern that the Health and Community Care Minister, during the parliamentary debate on the draft sexual health strategy, guaranteed continued funding for Healthy Respect and gave the project his backing, as did many other MSPs, in spite of the fact that it has yet to be properly and independently evaluated.

The strategy rightly states that more emphasis must be placed on the relationships aspect of SRE; indeed young people themselves indicate that this is what is most lacking in the education that they currently receive. The strategy however does not elaborate on what the relationships aspect of SRE will amount to. In order that young people can make informed choices about their health and relationships they must receive full information. This applies to biological and physical information such as that about the true workings of their bodies, particularly with reference to women’s fertility to dismiss the myths often promoted such as ‘women can get pregnant at any time’. Perhaps there is a fear that such information along with other information such as that on the effectiveness of contraception and condoms may discourage their use however as Boydell and MacKellar state
“The need to fulfil the ethical principle of full information disclosure demands that one should trust the consequences to young people and allow them to make their own health choices”.18
This is equally true of the information that is provided on relationships. Young people must be given the opportunity to consider such issues as ‘what are relationships’, ‘what is a sexual relationship’, ‘why do people have sex’, ‘what would they be seeking to achieve by having sex’, ‘what is love and how does it relate to sex and relationships’. In order to make the best decisions young people must be given full information to help them to ask questions of themselves and at the same time they must also be helped to consider the effects of their decisions on themselves and others. It is not enough to simply promote the prevention of harm; young people need information on the pros and cons of all choices so that they are able to see which choices promote their best interests. The choice remains theirs but the best health choices should always be promoted.

4.17 Recommendation
Local authorities should fully implement the McCabe report to support a consistent approach to sex and relationships education throughout Scotland … sex education should be defined as sex and relationships education (SRE), introduced in pre-school, based upon pre-school health guidelines, built upon throughout primary school as part of 5-14 health guidelines and developed through to school leaving age.

While there are many aspects of the McCabe report which are positive and we would support the implementation of many of its recommendations regarding the role of parents and carers in the sex education of their children; we oppose full implementation of the report, in particular with regard to the role of clinical services in schools; see below.

The above recommendation, 4.17, is at odds with what has already been stated in the strategy point 4.10. This states that sex and relationships education “begins at an early stage with parents and carers”. This then appears to go against the recommendation that SRE should be introduced in pre-school. At this early stage of life sex and relationships education remains the responsibility of parents and carers and this should not be infringed upon or undermined by more formal SRE in the pre-school setting.

Children must be protected from early sexualisation through information about sexual relationships before they are ready. The role of parents and carers is therefore the most important in the early years of a child’s life. Wight et al, confirm that
“… the most important baseline factors that influenced sexual experience at age 16 included, family composition and parental monitoring”.19
Parents and carers are best placed to assess the maturity of their children, both emotionally and physically and therefore they must have responsibility for what information and at what age it is provided to their children. Formal sex and relationships education can then begin at the end of primary school and beginning of secondary school where the parents and carers have given approval of the materials to be used. Education on the formation and sustaining of relationships can be appropriate at an earlier age but formal sex education must be delayed until the child is mature enough to cope with the information being provided, otherwise the desired effects cannot be achieved.

The most effective sex education is age appropriate. Emotional intelligence is required before such education will have the desired effect on the behaviour of young people. In light of what we know about young people seeking to satisfy non-sexual needs through early sexual activity, greater consideration must be given to child psychology rather than simply accepting that young people want to have sex. The work of child psychologists in explaining how the thinking and decision-making of children and adolescents develops is most relevant here and should be taken fully on board as it appears that even with knowledge of risk and access to contraception the majority of teenagers do not use them.20 This is because of their lack of ability to assess risks as well as their vision of themselves and the world, where they appear to hold attitudes such as ‘it won’t happen to me’.21

Supporting paper 4 (4.7 and 4.8) highlights the fact that all young people are different and mature at different rates. It is then suggested that those who are most likely to engage in sexual activity should be targeted to help them develop the relevant skills. Considering our knowledge of young people seeking the fulfilment of non-sexual needs through sexual activity, greater care and attempts should be made to address these issues with young people and they should be targeted in order to help them delay sexual initiation rather than simply accepting that they want to and will have sex. After all it is not inevitable that young people will engage in sexual activity and in fact Circular 2/2001 to the Standards in Scotland’s Schools etc Act 2000 states that young people “should be encouraged to understand the importance of self-restraint”.22

With regard to partnership activity and the use of external agencies within schools (4.18) parents and carers must also be allowed to review and approve the information and resources to be used in the education of their children. This is particularly important concerning the use of outside agencies where parents and carers need to be reassured that the information provided will conform to their own values and beliefs and to the ethos of their child’s school. This point is maintained by the McCabe report where it states in 4.11
“The fundamental point is that schools need to promote dialogue and not simply display materials or communicate indirectly with parents through newsletters”.23
The McCabe report also states in 6.4 that parents must be consulted in advance on the use of materials and in 6.6 that parents should be consulted when the school is developing or reviewing its programme of sex and relationships education.24 This is an important point since such programmes may change over time and while they may have gained parental approval initially, in light of any changes continuing approval cannot be assured. In the report’s General Recommendations of the Working Group it is also stated that parents
“Should have opportunities to contribute to the development of school policy and programmes of work”.25
The emphasis on the role of parents and carers in the McCabe report is clear and these particular aspects of the report must be implemented to ensure that schools work in partnership with parents and do not usurp their right to educate their children. These rights are enshrined in The Children (Scotland) Act 1995, highlighted in 2.31 of the McCabe report, which provides the right and responsibility of parents to safeguard and promote the child’s welfare; provide direction to the child; maintain regular contact with the child; and act as legal representative up to the age of sixteen. The parents will then continue to provide guidance up to the age of eighteen.26

For teachers, implementation of this strategy will mean:
Having clear policy direction regarding roles and responsibilities (including confidentiality).

It is most important that parents and carers are involved in the formation of any policies regarding the way in which sexual health matters will be handled between their child and the school involved. The McCabe report recognises in point 5.18 that teachers cannot guarantee confidentiality of any information that is evidence of criminal activity. In reference to sexual relationships, any act of underage sex must be considered a criminal offence in light of the legal age of consent. In 5.19 it is also stated
“If a young person is in moral or physical danger, then the teacher (and school) must act to protect them. Such action may involve disclosure to appropriate people or agencies”.27
Regarding whether or not such information is passed on to parents, the emphasis should be on informing parents unless there are exceptional circumstances that may put the child in more danger, rather than on only informing the parents in exceptional circumstances. Children under the age of 16 are the responsibility of their parents and respect for this must be maintained.

Developing closer links between schools and clinical services
With regard to the above point on the matter of confidentiality, it would be regrettable if the use of external agencies and health professionals within schools were seen as a way of avoiding the need to inform parents of concerns for their child’s health and wellbeing. Implementation of the McCabe report’s recommendations (4.16) on informing and consulting parents on the use of external agencies and the implications of doing so, must be considered essential.28 Parents have the right to know and to protect their children from any resources or services that they consider unsuitable. Confidentiality must never be seen as all-important, the safety of all young people must be our most important guiding principle. Underage sex must always be regarded as a concern and something which all authorities; parents, carers, schools and health professionals, should actively discourage and aim to prevent.

4.20 The strategy does not rule out the possibility of sexual health services being located within schools or health professionals being located on the school site in order to advise young people of where to access services. It is regrettable that this has not been ruled out by the strategy. Parents must be involved in decisions on medical treatment for their children, this is in the interests of child protection and is reflected in current guidelines that do not allow schools to give children paracetamol without prior consent from parents and carers. It is parents who are responsible for picking up the pieces when things go wrong, they therefore have a right to be involved in any decisions that affect the health and wellbeing of their children. This is extremely important for the safety and health of young people, as we know that there have been occasions when young girls have been given contraceptive drugs without the knowledge and consent of parents and who have then reacted to these drugs and in some cases died because the parents were not able to provide doctors with the information required to treat their daughter.

Regarding the use of outside agencies it should be noted that Health Boards are not legally required to consult and be accountable to parents and carers. This is because they do not fall within the legal framework for the conduct of sex education in schools provided by Education Department Circular 2/2001.29 This situation must be remedied in light of the potential to use Health Board agencies in school sex education programmes.

The presence of clinics, services or sexual health professionals on the school site will also undermine any message to young people that underage sex is unacceptable and not to be condoned. Such a situation sends out a mixed message that sexual activity is to be delayed but that ‘since we know you will do it anyway let us help you’. This does a disservice to young people by assuming that they do not have the maturity to assess the full facts and to realise that in all cases sexual activity is best delayed. The McCabe report also states in 4.15
“… education needs the support of confidential counselling and advisory services to be effective”.30
The above statement could be interpreted as meaning that young people must have access to such counselling and advisory services as would be provided by sexual health professionals within schools, responsible for either supplying contraception or for directing young people towards clinics that provide contraception and abortion referral. We would not support the implementation of this due to our concerns over the use of outside agencies and how this affects the rights of parents regarding confidentiality as well as the ways in which this may threaten the safety and proper protection that should be afforded to children and young people. Also, if the sex and relationships education that young people receive is truly adequate and effective then it should succeed in delaying early sexual activity and therefore relinquish the need for such services.

It is also doubtful whether or not the availability of and access to services for young people would actually improve the sexual health of this section of society. Dr Paton’s research demonstrated that a lack of access to services for underage young people, as experienced in England and Wales as a result of the 1984 Gillick ruling, had no impact on either conception or abortion rates for this age group.31 Dr David Paton also recently studied the results from policies in England implemented from 1998 to 2001 to provide sexual health services for young people and found that increases in the numbers of clinics and clinic sessions attended by young people had little impact on teenage pregnancies and did not lead to any reduction in teenage pregnancy rates. He also found that there was a significantly higher rate of diagnoses of STIs and that this was in particular worsened by the shift in policy towards greater provision of the morning-after pill, a very logical conclusion. He concludes that although policies may be aimed at a particular outcome, consideration has to be given to the impact such policies will have on behaviour. He states
“… it appears that some measures aimed at reducing adolescent pregnancy rates induced changes in teenage behaviour that were large enough not only to negate the intended impact on pregnancy rates but to have an adverse impact on … sexually transmitted infections”.32

With regard to health professionals in general and school nurses in particular, 4.21, very few secondary schools in Scotland have a full-time school nurse solely devoted to their school. Where school nurses are peripatetic there is no opportunity for them to build relationships with individual students and to be aware of their circumstances, concerns and needs. Parents and carers and the child’s GP will always be better placed to understand the unique needs of a particular child and these roles must not be usurped by school nurses or health professionals who have no real knowledge of the child. The aim of the strategy should be to empower parents and carers to regain their principal role in the sex and relationships education of their children so that they are the first port of call for their child. This is not only desirable but important for the child to know that they can rely on their parents and carers not only for information but for support in any situation. Any extension of the role of schools, school nurses or health professionals only further undermines the role of parents and carers and their rights and responsibilities in caring for their child.

For children and young people, implementation of this strategy will mean:
We agree with the first three points in this section regarding the need for young people to receive full information in a way that is accessible to them, to enable them to make informed and considered choices regarding sexual relationships. However, we again raise our concerns about the last point of this section.

Being supported by easily accessible and confidential sexual health services and other supportive services including counselling and information

This must not mean that the right to confidentiality is considered more important than the safety of children and young people and we repeat that early sexual activity should always be seen as a danger to their safety. Neither must this mean a further undermining of the role and rights of parents and carers. At the heart of all its proposals the strategy must aim to protect young people and to encourage the delay of sexual activity in order to ensure the protection of their health, both physical and emotional.

Box 4: General features and key learning objectives of school based SRE programmes.
The provision of appropriate and accurate knowledge and skills to help young people become “sexually competent”, ideally delivered at an age and ability appropriate to the individual
Be supported by easily accessible, confidential clinical services including contraception

Sexual competency should not be measured on the basis of regret, willingness, autonomy of decision and contraception use. What we are referring to here is the sexual competence of children and young people, the majority of whom are under the age of 16. In this sense sexual competency should be measured by the ability of the individual to resist and to delay sexual activity since that is what the strategy claims to be aiming for. Again, stressing the need for “easily accessible, confidential” services only sends out a mixed message to young people and further undermines the legal age of consent as something to be upheld and respected.

Develop knowledge of:
How the body is protected from infection
Different methods of preventing pregnancy and transmission of STIs
Options if pregnant

With regard to how the body is protected from infection and the different methods of preventing pregnancy and STI transmission the information provided must be completely honest and factual so that young people have the full facts on which to base their decisions. Young people must be made aware of the failings of contraception in preventing both pregnancy and the transmission of STIs and they must also be aware of the difference between method failure rates and user failure rates which are particularly relevant to this demographic. In supporting paper 4, (2.4 Table 1 Factors associated with early initiation, contraceptive use and teenage pregnancy), effectiveness as a factor relating to contraception is a notable absence. Most importantly, recognition must be given to what the manufacturers of barrier contraception have to say about its effectiveness. Durex state that
“… for complete protection from HIV and other STIs, the only totally effective measure is sexual abstinence or limiting sexual intercourse to mutually faithful, uninfected partners”.33
Such information must be readily available as only with full and honest information can young people truly make informed decisions. Again many more of the general features of SRE must emphasise these facts since in order to make decisions about the best way to protect oneself everyone has to know the inadequacies and failings as well as the benefits and success rates of the available options.

Regarding the options available when pregnant, this is the ideal time to fully educate young people of the facts. Young people must have access to foetal development information and images so that they can see for themselves and assess for themselves the humanity of unborn life. Many people object to the idea of women making decisions about the future of their pregnancy without the knowledge of foetal development while others object to women being given such information at that stage. Young people need information before they reach the point of making decisions so that they can form their own opinions, ones which are truly informed, and which may help them to make any decisions that they face in the future.

Full information must also be given on the range of options available to women who are pregnant; abortion must not be presented in such a way that it is seen as the only and best solution for an unintended pregnancy. The information provided must include how to access services for support during pregnancy and adoption services. These services must be as accessible to women as abortion so that women have a real choice.

The role of parents and carers
4.24 Partnership between parents, schools and health services will promote a more consistent approach to sex and relationships education and reinforce the key messages.

It was pleasing to note during the parliamentary debate on the strategy the overwhelming support of MSPs for the greater involvement of parents and carers in the sex and relationships education of their children. Support for this is something that must be built on. Shona Robison MSP was also correct in pointing out the importance of listening properly to parents and addressing their concerns. The strategy’s recommendations regarding education and the role of schools and health services will fail if they do not have the backing of parents. The involvement of parents and carers in the development of school-based programmes is therefore imperative.

The Netherlands is often quoted as an excellent example for nations trying to lower teenage conception rates, which is often attributed to a greater culture of openness. A closer look at this culture shows that although there exists a liberal intellectual culture, this sits alongside a culture where the traditional family unit is very strong. The research indicates that Dutch teenagers tend to rely less on schools for their sex education and that the real openness is between teenagers and their parents.34 This reinforces the need to protect and develop the role of parents in the education of their children rather than to diminish their role by placing greater reliance on school programmes. All policies of the Executive should therefore be aimed at supporting the traditional family unit and maintaining and developing the role of parents and carers in the sex and relationships education of their children.

Supporting paper 2 (3.4) highlights the positive effects of children living at home with both biological parents and the fact that this leads to a lower incidence of teenage pregnancy. While it is recognised as in (3.3) that family structures have changed and that for less young people it is a reality to live at home with both biological parents, it remains important that the traditional family structure be promoted and supported. The strategy aims to influence our culture and social environment. In recognising the benefits of traditional family structures and the importance of strong family processes such as time spent together, parental support and parental monitoring the strategy must see the benefits to be gained for the health and wellbeing of children and young people by promoting this essential societal structure. It is also well documented that children from two parent-households where the parents are married do better academically, socially and economically.35 The strategy should therefore promote marriage and traditional family structures as good for the health and wellbeing of children and young people. In recognising the need to work across departments and to change social policies as well as health and education policies the strategy must take the opportunity to highlight the need to promote social policies that support families.

It is important that schools and health services work with parents and carers to support and complement the education of their children, therefore schools and health services must take their lead from parents and carers if a consistent approach is to be obtained. Supporting paper 4 (3.7) reports findings that young people want to discuss sex with their parents. The school should therefore never attempt to take the place of or to undermine the role of parents and carers. Parents and carers are the first and most important educators of their children especially with concern for their moral wellbeing. Schools and health services cannot therefore take the principal role and at the same time respect the views and beliefs of all parents and carers. The McCabe report rightly calls for greater consultation between schools and parents and carers and this is essential. Consultation must amount to more than simply informing parents of the details of SRE, and this is rightly recognised in 4.26. It must include parents having the right to access, review and approve SRE materials and resources as well as the use of outside agencies and their materials for schools.

4.23 - 4.27 Recommendations
Any information formulated and provided for parents and carers must be distributed in a sensitive manner. It is at the parents and carers discretion whether or not they choose to use this information, part or all of it, in educating their children. It must be ensured then that this information is not available to the children themselves if it is decided that the best way of distributing the information is through the children at school.

For parents and carers, implementation of this strategy will mean:
Being an equal partner in the sex and relationships education of their children

Parents and carers must not be seen as equal partners in the sex and relationships education of their children. Instead they must be seen as the principal educators supported and complemented by schools and health services. This will ensure that SRE is respectful of the beliefs and values of parents and carers and that it is delivered at an age appropriate to the individual child, as only parents and carers are in a position to assess this. The aim of the strategy should not simply be to create more involvement by parents and carers but to protect and secure their role as the principal educators of their children.

The role of sexual and reproductive health services
4.38 Tier two of the integrated service approach would allow individuals to obtain contraception and sexual health advice without the need to attend their doctor or specialist sexual health service. The dangers of such an approach must be recognised. Individuals need specialist counselling when making decisions about contraception and sexual health. Particularly in the case of hormonal contraception and in the case of drugs such as Levonelle-2 it is essential that women access this through their GP where there is a complete picture of the woman’s medical history and the means by which medical supervision can be continued. This is essential in the case of young girls who have no proven fertility and for whom the effects of drugs such as Levonelle-2 have not been tested.36

4.39 This point suggests that the tiered approach draws on “the wealth of knowledge and experience currently available within Scottish sexual and reproductive health practice”. There must be recognition given and a place for those organisations with experience and expertise in the field of Post-Abortion Trauma. Currently, organisations such as fpa Scotland do not recognise the potential emotional after-effects of abortion and so this is not adequately addressed either pre or post-abortion. Organisations such as British Victims of Abortion and CARE provide post-abortion support for women and men and this work should be recognised and supported so that women and men have access to appropriate care.

Specific actions to reduce STIs
4.42 This explicitly states that STIs “can be prevented through the encouragement of safer sex practices”. However, this is not factually correct and contradicts the definition of ‘safer sex’ used by the strategy, where it is defined as “sexual practices and sexual behaviours that reduce the risk of contracting and transmitting sexually transmitted infections” (emphasis added). The evidence shows that barrier contraception is only effective at reducing the risk of transmission; no condom manufacturer will give a 100 per cent assurance that their product will prevent STIs, simply because this would leave them open to legal challenge. The danger of promoting “safer sex” without a proper acknowledgement of its limitations puts the health and fertility of individuals in danger. Similarly the recommendation that condoms should be made available free of charge wherever women can access free contraception gives the impression that barrier contraception is the best and most acceptable way of preventing the transmission of STIs, when this is not the case. This is also true for the promotion of free hormonal contraception; the impression given is that this is the best and most acceptable way of preventing pregnancy, when again it is not. The continued promotion of hormonal and barrier contraception as the way to prevent STIs and unintended pregnancies will not achieve the required effect of improving Scotland’s sexual health and will certainly not improve the quality of sexual relationships.

Box 7: Clinical service values and principles
Services should offer support and information in making informed choices and developing fulfilling and healthy relationships

There has been no hesitation in the Executive’s campaigns to point out the unhealthy aspects of our lifestyles such as diet, smoking, drinking and drugs; this should equally be applied to the nature of the sexual behaviour and relationships in which individuals become involved. The information and support provided to individuals on the health benefits and dangers of certain activities must therefore be accurate. In order to make informed choices the information available must accurately state the failure rates (method and user rates) of contraception in preventing pregnancy and the transmission of STIs. Counselling and advice should also include a discussion of relationships where there is an awareness of those types of relationships that can lead to both physical and emotional problems. This must include a recognition of the possibility of pregnancy and the types of relationships that are more or less likely to support any new life created through sexual intercourse.

Supporting access to services: Rural areas
4.60 The suggestion that New Community Schools should be considered as a way of providing sexual health services is regrettable and raises the same concerns as were raised in reference to the linking of schools and clinical services more generally. Obviously in rural areas there is a need to ensure that those who require treatment for STIs have access to such services, however these should not be linked to schools. Attaching clinical services to schools could prove to be particularly dangerous by encouraging the attitude that young people should be engaging in sexual activity. When we compare rural and urban rates of teenage pregnancy and abortion, there is a substantial difference. There does not appear to be the same need for contraception and abortion services for young people in these areas as the problems of teenage pregnancy and abortion do not exist to the same extent.37 By attaching such services to schools there therefore remains a risk that this be perceived as the promotion or acceptance of teenage sexual activity as not only inevitable but also desirable.

Supporting access to services: Confidentiality and anonymity
4.62 Concerning the issue of confidentiality with regard to underage young people and vulnerable individuals we are pleased to see that the strategy stresses that the interests of the young person/child must take precedence at all times. It is essential that confidentiality is not seen as the overriding principle when the most important concern should be for the health and safety of the individual concerned and this may require the breaking of confidentiality. In particular, as long as the parents or carers themselves are not implicated in any abuse against the person concerned they should be informed of the circumstances, as they are those closest to the individual and therefore the most capable of providing care and support.

Supporting access to services: Contraception and termination
4.64 Again we restate our opposition to the continued promotion of contraceptive services for the prevention of unintended pregnancy. The link between greater provision of contraception and greater numbers of abortion is clear. As stated previously the promotion of contraception promotes a sexual culture where the creation of life is considered as an unintended and unwanted outcome of sexual intercourse. Such a culture promotes abortion as the solution when contraception fails, as it does not promote relationships that are supportive and welcoming of any new life created. Any further promotion of contraceptive services is therefore to be regretted.

4.65 … early indications suggest that the availability of emergency contraception from pharmacies has helped to improve choice and access.

The greater access and availability of drugs such as Levonelle-2 should not be considered a success. It was heard during the parliamentary debate from Carolyn Leckie, MSP that such drugs should be available free of charge and with greater access; this would be a disastrous policy to promote. Despite the increase in use of this drug there has been no corresponding decrease in the numbers and rates of teenage pregnancy, and no corresponding decrease in the numbers of unintended pregnancies, as measured by the number of abortions reported annually in Scotland. In addition, Levonelle-2 provides no protection against STIs and may in fact encourage sexual risk taking where it is seen as a safety net for the failure or absence of contraception. The provision of this drug does not encourage healthy and respectful sexual relationships where both partners are responsible for the health and fertility of the other. Promoting positive sexual health should not have drugs such as Levonelle-2 at the heart of its strategy when the availability of such drugs encourages irresponsible sexual behaviour and involves a deception where this drug is promoted as an emergency contraceptive without any recognition or information being provided on its potential to act as an abortifacient. Consideration must also be given to the lack of testing on the long-term effects of the drug as well as the effects it may have on the health and fertility of young girls.

4.66 The Reference Group was aware of the variations in service response and inconsistencies regarding gestation limits across Scotland and the restrictions placed on potential service expansion by legal requirements and recommends that this is addressed.

We would like clarification of what is meant by “the restrictions placed on potential service expansion by legal requirements”. Is this a reference to the legal time limits placed on abortion and if so by seeking to address this situation is the strategy recommending that an extension on the time limit be sought? We would vigorously oppose any liberalising of the law in this respect. The existing law already allows abortion up to 24 weeks when many babies are now able to survive outside of the womb before this point and the law also allows abortion up to birth under specific circumstances.

4.66 Recommendation
As a first step, services should ensure access to termination within three weeks of initial consultation. Services should work towards reducing this target to one week by March 2006.

We cannot support any proposal to make access to abortion available within one week of first consultation. Any woman considering abortion needs time to fully consider all of her available options. Often women considering abortion do so because of the fear and panic experienced at the discovery of an unintended pregnancy and the impression of being alone and without support. Adequate crisis pregnancy counselling provides the woman with the time, space and opportunity to assess all of her options properly and in doing so to remove the fear and panic first experienced. Women considering abortion need support so that they can make an informed choice. Abortion is an enormous decision for any woman and one that is not taken lightly, one week therefore does not provide a woman with the necessary time to consider her circumstances and options.

4.67 Recommendations
Lead Clinicians should ensure that there is access to, and provision of, all methods of contraception and that staff have appropriate skills/can demonstrate competency to agreed standards.
Lead Clinicians should ensure that the RCOG guidelines on the “Care of Women requesting Induced Abortion” are adopted by services in their NHS Board area.

Will this first recommendation include the need for staff to provide access to training in methods of natural family planning and that they be competent in providing such training themselves? Natural family planning is a valid and healthy alternative to artificial forms of contraception and it must be promoted as such to ensure that everyone has an informed and real choice about how they choose to plan their family. Where clinicians are not trained to provide such training resources must be provided for training; alternatively resources should be given to organisations that do provide this training and clinicians must be required to promote access to these organisations.

It is essential that prior to making the decision to proceed with abortion women not only have access to but are also provided with clear, accurate and impartial written information, which they can take away and consider prior to finalising their decision. The RCOG guidelines on the information that women should receive are a starting point for the type of information that should be provided, however they are not adequate. Consideration must be given to the need to not only provide women with greater information on abortion, e.g. foetal development information and images and the possibility of Post-Abortion Trauma, but also the need for this information to include full details of the alternatives to abortion. This information is not presently included in the guidelines, which only address the medical aspects of abortion. The information women receive needs to be far more detailed in terms of allowing them to assess all of their options. The current RCOG guidelines are presented as if the woman has already made her decision to proceed with abortion, there is therefore no scope within these to consider the other available options. This may then require the collaboration of groups and organisations other than the RCOG, such as adoption agencies, the social security and benefits agencies as well as voluntary organisations with experience and expertise in the field of Post-Abortion Trauma for example. We urge the Executive to include in their strategy the requirement that all women receive full information regarding all of their options prior to finalising their decision on how to proceed with their pregnancy.

There is also a need to ensure that women actually receive this information with adequate time to consider it before they make their decision rather than the information simply being ‘available’; this should form a part of the statutory guidelines and reporting procedure on abortion.

4.68 recognises that there is a lack of appropriate support available to women and men after abortion, miscarriage and stillbirth. This is reiterated in
Box 5: Challenges currently facing sexual and reproductive health services
Inadequate services to support women and men post termination and following miscarriage and stillbirth

It is to be welcomed that this lack of support is recognised and that this is “mainly due to a failure to recognise the unresolved emotional impact which can continue for many years”. Post-Abortion Trauma must be recognised before adequate provision can be made for appropriate support following abortion. Currently this support is provided by voluntary organisations, which we suggest should have a part to play in educating and informing those providing abortion and also those women seeking abortion. This is why it is so vital that recognition of Post-Abortion Trauma is included in the information that women receive prior to abortion to enable them to make an informed choice.

4.68 Recommendation
Training programmes to enable staff to respond to the sexual and reproductive health needs of women and their families following termination, miscarriage and stillbirth.

It is not clear that this recommendation actually corresponds to what is stated in 4.68. Training on the sexual and reproductive needs of women and their families post abortion, miscarriage and stillbirth is not the same as training on their emotional needs. In order to provide adequate training for staff there must be a proper recognition of the emotional impact of abortion, miscarriage and stillbirth; this does not appear to be what is referred to in the above recommendation.

If appropriate and adequate training on the emotional impact of abortion, miscarriage and stillbirth is to be provided, who is to be responsible for providing this training? Adequate training will not be provided with regards to abortion if those currently working in the field of reproductive health are given responsibility for that training, as it is precisely in this field that there is a failure to recognise the unresolved emotional impact of abortion. It appears that currently there are no organisations in the field of sexual and reproductive health in Scotland, which recognise Post-Abortion Trauma and provide appropriate support. The voluntary organisations, which do specialise in this area must therefore be utilised in providing training to those working in the field of sexual and reproductive health.

The recognition in 4.68 of the unresolved emotional impact of abortion also does not sit well with the recommendation in 4.66 that abortion should be available within one week of first consultation. Women who make a decision in haste and without due consideration for all of the available options are those most likely to suffer the emotional impact of abortion. In recommending abortion within one week of first consultation the strategy is itself failing to recognise the unresolved emotional impact of abortion.

Section 5 Supporting Change
5.1 What is needed is a framework which champions sexual wellbeing at all levels, ensures its high profile among the other competing resource demands and enables all sexual health partners to develop multi-layered responses that will make a difference.

The strategy purposely refuses to place any costing on the implementation of its recommendations. However, as stated in 5.1, there is a desire for sexual health to have a certain level of priority in terms of resources. While we recognise that sexual health is a problem and one that should be addressed, we are concerned about what other areas of the health budget will suffer as a result. There are many other areas of health that require funding in order to address the health problems experienced by our society. Careful consideration must therefore be given to how resources are allocated so that public health issues as a whole are effectively addressed. It has already been noted by the strategy that areas such as social deprivation have a significant effect on the health and wellbeing of individuals, including their sexual health. Resources must therefore be best placed to tackle the causes of Scotland’s ill-health rather than their effects.

Developing an evidence base for future work
5.27 Lack of evidence does not equate to ineffectiveness but rather indicates a need for further research.

This statement is alarming in light of the resources that will be required to finance the recommendations of the strategy. In the current climate, evidence-based policy formation is all-important and yet in the arena of sexual health the reference group does not consider it relevant that there is “little or no evidence of the effectiveness or appropriateness of interventions aimed at influencing the cultural and social determinants of sexual health, sexual health behaviours and sexual morbidity”. It is astonishing that this is not considered important when the whole basis of the strategy recommendations is the apparent need for large-scale intervention. We agree that a sexual health research programme should be set up but feel that this should have been done before the reference group made its large-scale and potentially expensive recommendations. In an area where there is as big a problem as there is currently in the area of sexual health it is extremely important that we get it right, so that we know that the policies put forward will actually make a real difference and therefore that resources are being well spent.

A significant amount of resources have already been spent in this area, particularly in the provision of contraception and abortion services. These policies have so far failed to bring about a reduction in the number of unintended pregnancies and abortions. It appears then that the evidence, which already exists, is being ignored in favour of further promotion of these same policies. Any sexual health research strategy that is set up must therefore examine and properly evaluate previous and current policies and give an honest presentation of how these have succeeded or failed. Only then will we progress to finding and promoting strategies that succeed in challenging our attitudes and behaviour with regard to true sexual health and wellbeing.

References

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16. Boydell P and MacKellar C, Informing Choice. New Approaches and Ethics for Sex and Relationships Education. Scottish Council on Human Bioethics, February 2004, p.42.
17. Wight D, Raab G, Henderson M, Abraham C, Buston K, Hart G and Scott S, (2002) The limits of teacher-delivered sex education: interim behavioural outcomes from a randomised trial, British Medical Journal, 324: 15, pp.1430-1433.
18. Boydell P and MacKellar C, Informing Choice. New Approaches and Ethics for Sex and Relationships Education. Scottish Council on Human Bioethics, February 2004, p.52.
19. Wight D, Raab G, Henderson M, Abraham C, Buston K, Hart G and Scott S, (2002) The limits of teacher-delivered sex education: interim behavioural outcomes from a randomised trial, British Medical Journal, 324: 15, p.1430.
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22. SEED, Circular 2/2001: Standards in Scottish Schools etc Act 2000: Conduct of Sex Education in Scottish Schools. Edinburgh: Scottish Executive, 2001.
23. Scottish Executive, Report of the Working Group on Sex Education in Scottish Schools, (McCabe report). Edinburgh: The Stationery Office, 2000, p.29.
24. Ibid, McCabe report, 2000, pp.41-42.
25. Ibid, McCabe report, 2000, p.46.
26. Ibid, McCabe report, 2000, p.16.
27. Ibid, McCabe report, 2000, p.38.
28. Ibid, McCabe report, 2000, p.30
29. SEED, Circular 2/2001: Standards in Scottish Schools etc Act 2000: Conduct of Sex Education in Scottish Schools. Edinburgh: Scottish Executive, 2001.
30. McCabe report, 2000, p.30
31. Paton D, The Economics of Family Planning and Underage Conceptions. Journal of Health Economics, 2002, 21, 2 (March), pp.27-45.
32. Paton D, Random Behaviour or Rational Choice? Family Planning, Teenage Pregnancy and STIs. Nottingham University Business School, November 2003, p.29.
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