• Sexual Health may be defined as:
- the capacity to enjoy and be in control of one’s own sexuality, whilst recognizing the reciprocal rights of others.
- the right to access information which enhances freedom from fear, shame, guilt, misinformation and other factors that inhibit or impair sexual expression.
- the opportunity for each individual to develop behaviors and skills in order to avoid disorders, disease or other unwanted effects of sexual experience.
(adapted from WHO by HIV/Sexual Health Team, 1994)
And, more concisely:
“the enjoyment of the sexual activity of your choice, without causing, or suffering physical or mental harm.”
(BMA et.al 1998)
These definitions show that sexual health is more than the prevention of unplanned pregnancy and the absence of HIV and other sexually transmitted infections (STIs). It allows us to consider the prejudice around homosexuality and bisexuality and everyone’s right to correct, unbiased information.
These are two factors especially important to young people and should be reflected in the sex education they receive at school and elsewhere.
• Main Health Promotion Messages
Sexual health promotion is based on the themes outlined in the above definitions and includes:
- challenging the attitudes of society and individuals towards sexual behavior and sexuality and encouraging the acceptance of diversity;
- the provision of sex education that is appropriate and relevant to all young people and includes those who are not in main stream schools;
- producing and promoting relevant information in appropriate way
- recognizing the central role of sexual health services in sexual health promotion and supporting the provision and promotion of these services for all ages and sections of the population.
HIV and AIDS
an estimate of 3.5 million people have HIV
In the UK:
Each year there are approx. 2,000 new, positive HIV tests (2,400 in 1999). This represents the number of new infections that we know about. Many people choose not to be tested.
Approx. number of people living with HIV: 23,000; of these:
- Approximately 5,500 have developed an AIDS-defining conditions
- Approx. number who have died of AIDS-related conditions: 12,500
- Approx. number of children with HIV (under 15 when infected): 700
- A little over half (55%) of people living with HIV were infected through sex between men. This proportion is dropping as the number of people infected through heterosexual sex increases.
- (PHLS July 2000)
The four most common STIs are:
- genital warts (93,000 new infections in 1995),
- chlamydia (39,000 new infections in 1995),
- genital herpes (27,000 new infections in 1995)
- gonorrhea (12,000 new infections in 1995)
Young People/teenage pregnancies
The Public Health Laboratory Service has highlighted the poor sexual health of teenagers in the UK (BMJ 1999):
- the number of 16-19 year-olds with gonorrhoea increased by 34%(women) and 30%(men) between 1995 and 1996.
- young women aged 16-19 have the highest rate of chlamydia infection
- the UK has the highest rate of teenage pregnancy in Western Europe
- approx. 8000 conceptions occur each year in under 16 year-olds (this represents 2 per secondary school). Two thirds of these will end in abortion.
The Social Exclusion Unit’s report on teenage pregnancies (June 1999) has further facts and figures on teenage pregnancy, comparisons with other countries, health outcomes for mother and child, and associated socio-economic factors.
Between 2 and 10 per cent of the population identify as gay or lesbian (Wellings et. al 1994). This means that there is likely to be at least one young person in every class in secondary schools who is questioning their sexuality or is not heterosexual and a significant number of people in the UK who are constantly receiving negative messages (at the very least) about themselves and their way of life.
‘Playing it safe’ (Douglas et.al, 1997) provides the following figures:
- 73% of respondents in a survey had been called names in the last 5 years because of their sexuality
- 34% of men and 24% of women had experienced violence because they were gay, lesbian or bisexual
In schools there was evidence to suggest:
- homophobic bullying was common
- it tended to be more severe than general bullying
- it was not always taken as seriously as other forms of bullying by teachers, even being seen as a ‘natural’ reaction of young men
- 40% of gay young people in a survey had attempted suicide.
• Research demonstrating the effectiveness of Health promotion interventions and rationale for approaches used
Sexual behavior occurs within a complex moral, social and political context. It is surrounded by deeply held beliefs, prejudices and taboos. Many religious groups take a dogmatic stand on issues such as homosexuality, contraception and sexual relationships. Reviews of effectiveness of work on sexuality, teenage pregnancies and HIV prevention have highlighted these particular issues and the need for more qualitative research.
We are awaiting a national Sexual Health Strategy, which should pull together the evidence from the different aspects of sexual health and present the way forward for this area as a whole. We expect this to include the National HIV Strategy that will look at issues specific to HIV prevention, treatment and services.
How we measure ‘success’, or the effectiveness of an intervention, is still being debated. One review of evaluation methods (Oakley et al 1995) concluded that randomized-controlled trials are the only effective way of measuring the impact of programmes. Although this paper provides a useful evaluation framework, other authors have suggested that social programmes do not work in this way.
Van de Ven and Aggleton (1999) suggest that effective programmes will have inputs at different levels, for example:
- individual behavior change,
- societal norms/beliefs,
- community action and
- the media.
Therefore to build up a picture of what is effective, we need to collect evidence from a variety of sources and in a number of different ways.
Effective initiatives will improve the sexual health (as defined above) of the target population. They may include enabling individuals to gain greater control over their lives and the choices they can make, but will also have specific aims depending on the area of sexual health being targeted.
Reports on effectiveness, although usually dealing with one specific aspect of sexual health promotion and often concentrating on young people, provide evidence that is relevant to much of our work. We can therefore list a number of characteristics that if included in interventions, should contribute to their effectiveness, irrespective of specific aims of the projects.
Broadly, these characteristics are:
- To respect the diversity of (young) people’s experiences and needs
- To acknowledge (young) people’s entitlement to non-judgemental and good quality information and/or sex and relationships education (SRE)
- To enhance (young) people’s access to services that may prevent unwanted conceptions and other unwanted consequences of sexual activity.
More specifically, interventions should:
- be relevant to the target group – and involve them in planning
- be specific and focused
- explore and challenge attitudes
- raise self esteem and feelings of self-worth
- provide the opportunity to work in small groups
- identify small, manageable changes which may represent reduction of potential harm rather than its elimination
- address the need to support the maintenance of the ‘safer’ behavior
Different areas of sexual health promotion provide us with evidence that effective initiatives will have these characteristics.
a) Teenage pregnancy. Much recent research has concentrated on reducing teenage pregnancy and the results have been presented in five reports by the HEA (1998 a,b, 1999 a,b,c), Effective Health Care 3 (1997) and the government’s report Teenage Pregnancy (SEU 1999).
These identified that the following areas must be addressed in order to reduce teenage conceptions:
- raising expectations among disadvantaged young people, offering realistic alternatives to parenthood
- comprehensive SRE in schools and for ‘excluded’ young people (as below)
- appropriate, accessible sexual health services for all young people
- plus support for teenage parents to reduce the negative effects of teenage parenthood.
These reports also provide evidence of the effectiveness of the wide range of initiatives that have set out to tackle teenage pregnancy rates.
b) Sex and Relationship Education (SRE) is a fundamental aspect of sexual health promotion. The Government has published new SRE guidelines (DfEE 2000) that set out how SRE is to be organised and delivered in schools. They replace the previous Sex Education Guidance, Circular 5/94.
The HPSA Effectiveness Review, ‘Working in the School Setting’ presents a rationale for Personal Social and Health Education that is as relevant to SRE as to health education generally. In addition, there is a Position Paper written in June 2000 setting out our approach to SRE specifically.
SRE aims to provide young people with:
- the opportunity to explore attitude
- skills to help them meet the challenges, choices and responsibilities of adult life
- knowledge that will include STIs and HIV and contraception
The HEA reports on reducing teenage pregnancies, together with the Sex Education Forum (1999) and Effective Healthcare 3 (1997) present the evidence that a successful SRE programme will fulfil the above aims and more specifically will not increase sexual activity, as is so often stated, but will tend to delay first intercourse and increase the use of contraception.
These reports recommend that SRE programmes should:
- Be a part of every school’s Personal, Social and Health Education programme
- begin in primary school with issues appropriate to the age of the children
- empower young people
- include positive aspects of young people’s relationships and sexuality
- provide opportunities for young people to develop skills in sexual negotiation and communication
- address the needs of boys and young men (as well as girls and young women)
- be sensitive to different cultures, religious beliefs and sexuality
- include information on access to local sexual health services – with visits to the school by service staff if possible and: the effectiveness will be further increased when all aspects of sexual health are tackled together so that young people can see how certain skills may be relevant to a number of situations.
c) HIV Prevention Initiatives. Very broadly, these aim to reduce transmission of HIV and other STIs, by increasing safer sexual activities and access to a range of services.
De Carlo (1995) presents a review of prevention programmes that were found to be effective in bringing about behaviour change.
Sigma Research is involved in on-going work in the UK to measure the effectiveness of HIV prevention initiatives on the behaviour of gay men.
Two recent reports set out the implications of the findings for the development of future work.
Members of the Community HIV and AIDS Prevention Strategy (CHAPS) are at present producing a second edition of ‘Making It Count – a national strategy to decrease the incidence of HIV during sex between men’ that will inform the future of HIV prevention work.
These reports suggest that successful programmes will have the following specific characteristics:
- they must be sustained over time to bring about behaviour change and maintain it
- they should improve provision of and access to services that support ‘safer practices’ such as provision of condoms and clean needles.
- timing of initiatives is important eg. SRE before sexual activity has begun
they should seek to modify ‘community norms’ ie. what the target group accepts as normal
d) Sexuality. The particular need in this area is to improve the mental health of particularly young people, who are not heterosexual, or are questioning their sexuality. Initiatives will aim to reduce their isolation by challenging the prejudice and discrimination – including homophobic bullying – they experience and building self esteem and self worth.
Playing It Safe (Douglas 1997) presents the findings of a survey of schools looking at teachers’ attitudes to lesbian, gay and bisexual people, bullying, Section 28 and HIV and AIDS education.
It makes the following recommendations:
- ensure homophobia is included in anti-bullying initiatives, whole school policies and SRE
- training for teachers and governors to increase awareness and knowledge
- effective monitoring of homophobic bullying incidents
AIDS/HIV Quarterly Surveillance Tables, No. 47:00/2, July 2000, PHLS.
Aggleton P et.al. (1998) b. Reducing the rate of teenage conceptions – the implications of research into young people, sex, sexuality and relationships. HEA.
BMA et. al. (1998), Towards a Sexual Health Strategy for England.
Cheesbrough S et.al. (1999) c. Reducing the rate of teenage conceptions – an international review of the evidence: USA, Canada, Australia and New Zealand. HEA.
DeCarlo P (1995) ‘Does HIV prevention work?’ HIV Prevention: Looking back, looking ahead. University of California.
DfEE (2000), Sex and Relationship Education Guidance. DfEE 0116/2000
Douglas N. et. al. (1997) Playing it safe, responses of secondary school teachers to lesbian, gay and bisexual pupils, bullying, HIV and AIDS education and Section 28, University of London.
Henderson L. et al. (1999) Managing unprotected anal intercourse: the perspective of gay men who have not tested HIV positive. Sigma Research.
Hughes K (1999) a. Reducing the rate of teenage conceptions – Young people’s experiences of relationships, sex and early parenthood: qualitative research’.HEA
Kane R and Wellings K (1999) b. Reducing the rate of teenage conceptions – an international review of the evidence: data from Europe. HEA
Meyrick J and Swann C (1998) a. Reducing the rate of teenage conceptions – an overview of the effectiveness of interventions and programmes aimed at reducing unintended conceptions in young people. HEA.
Oakley A et al. (1995) Sexual Health Education interventions for young people: A methodological review . British Medical Journal, 310, pp.158-162
Nicoll A et. al. (1999) ‘Sexual Health of Teenagers in England and Wales: analysis of national data. BMJ 1999, 318: 1321-2.
Teenage Pregnancy: a report by the Social Exclusion Unit, (1999). HMSO.
Weatherburn P et.al. (1999) The facilitation of HIV transmission by other sexually transmitted infections during sex between men. Sigma Research.
• Web sites: