A SEXUAL HEALTH STRATEGY FOR SHETLAND

• Introduction
• Why do we need a sexual health strategy?
• National picture
• Local picture
• Ethos of strategy
• Aims
• Conclusion
• References

1. Introduction

Sexual health is

“the capacity and freedom to enjoy and express sexuality without fear of exploitation, oppression, physical or emotional harm.” (Belfield 1999)

The Scottish sexual health strategy, “Respect and Responsibility : Strategy and Action Plan for Improving Sexual Health” endorses  the World Health Organization’s  definition of sexual health as:

“A state of physical, emotional, mental and social wellbeing related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sex experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled”

(WHO)

Furthermore, the fpa  (Family Planning Association) emphasize that sexual health is more than an absence of disease, encompasses social, emotional and physical aspects, and includes a positive approach which respects each persons sexuality.

• The social aspect includes a capacity to enjoy and control sexual and reproductive behaviour in accordance with a personal and
• social ethic
• The emotional aspect allows freedom from fear, shame, false beliefs, abuse, guilt and other psychological factors which might inhibit sexual response and impair sexual relationships
• The physical view supports a freedom from organic disorders, diseases and deficiencies that might interfere with or arise from sexual and reproductive function.

This holistic model of sexual health gives all areas equal emphasis and recognises their interdependence.

2. Why do we need a sexual health strategy?

Shetland has had an inter-agency sexual health strategy since May 2002.

The launch of “Respect and Responsibility”, the national sexual health strategy in February 2005 has added impetus to the work that is taking place and consolidated the strategic direction of this work.

Sexual health will remain a priority within NHS Shetland. The additional funding made available from the Scottish Executive will allow further development of services within this strategic framework.  Much work has been taking place on sexual health locally. This strategy, in line with the national strategy, will continue to  provide a focus for work to improve and promote sexual health and ensure that it is tackled in a coherent manner, Shetland wide.

This work will be focused on a number of levels; individual, family, educational, community and socio-economic (NHS Centre for Review and Dissemination, 1997)

The strong commitment to inter-agency partnership which exists within the original strategy (and is highlighted as necessary by the Scottish Executive) will continue to underpin how this work is done.

There are some specific physical problems that can be prevented by positive sexual health promotion.  The two key areas are unplanned pregnancies and sexually transmitted infections (STIs).  STIs fall into two broad categories: those infections which are predominately transmitted by the sexual act; syphilis, gonorrhoea, chlamydia, genital herpes and genital warts and those which are commonly transmitted by this route but can also occur in other ways; the blood-borne viruses – Hepatitis B and HIV, and candida (thrush) (SCIEH 1999).

STI figures are indicators of the ill health directly associated with the infections and they can also be seen as an indicator of sexual activity; thus an increase in STI figures  can imply an increase in sexual activity.

An equal amount of attention needs to be given to the social and emotional determinants of sexual health. Issues of self-esteem, emotional development, peer pressure, of communication and negotiation, of power and stigmatisation, although harder to measure have just as vital a role to play.

3. National Picture

The launch of the national strategy in February 2005 has clearly mapped out the vision for a sexually healthy Scottish population.

This vision, which has the values of respect for self and others, mutuality and trust as it’s basis, is set beside a somewhat depressing picture of present sexual health.

3.1 Statistics for the UK show a steady increase in the number of sexually transmitted infections, especially gonorrhea and chlamydia; change in the pattern of HIV/Aids infection and an increase in the numbers of unplanned pregnancies in young women.  (Department of Health (2001) National statistics SCIEH)

3.2 The Scottish picture shows a fall in the level of teenage pregnancies – these are not increasing in line with increased sexual activity (Burtney, 2000), however, there is still a lot of work to be done to reduce what is one of the highest rates in Western Europe. Most Sexually Transmitted Infection rates are rising. (SCIEH)

The latest figures show that just over 1% of 13 - 15 year olds required emergency contraception over the year 2001-2002. (Community contraception and reproductive health, ISD Scotland)

3.3 The national Sexual Health Strategy  aims to

• Improve the quality, range, consistency, accessibility and cohesion of sexual health services from primary care to specialist genitourinary medicine services, in line with the principles of providing services which are safe, local and appropriate;
• Support everyone in Scotland , including those who face discrimination due to their life circumstances or their gender, race or ethnicity, religion or faith, sexual orientation, disability or age, to acquire and maintain the knowledge, skills and values necessary for good sexual health and wellbeing; and
• Positively influence the cultural and social factors that impact on sexual health

3.4 The national health demonstration project “Healthy Respect”  is now entering into its second phase. This demonstration project works towards improving the sexual health of young people in Lothian. Its work is centred around self-esteem and confidence, two of the common denominators that enable young people to make informed choices about their relationships and behaviour. This demonstration project acts as a testing ground for good practice and is informing policy and  practice for all age groups throughout Scotland.

4. Local picture

4.1   The Shetland picture is mixed.

• We continue to have a low level of teenage pregnancies. (SCIEH  2005).
• There appears to be a below national average number of people living with HIV and AIDS, and with Hepatitis C, although this is probably comparable to other remote and rural areas (SCIEH, 2004).
• However, the figures for sexually transmitted infections including genital warts and chlamydia are on par with the national figures. (SCIEH, 2005).

4.2 Health Services

The executive lead for sexual health is Dr Sarah Taylor , Director of Public Health. The interim clinical lead is Jane Gilbey , Health Promotion Specialist – Sexual Health.

NHS Shetland provides a range of family planning, maternity, fertility and routine screening services locally as well as counselling and individual advice on sexual health matters via GPs , practice and community nurses.  Other services are provided by NHS Grampian, for example gynaecology (out patient services in Shetland, in-patient services in Aberdeen), laboratory testing for STIs and a Genito Urinary Medicine (GUM) clinic in Aberdeen. Information and resources are available from NHS Health Scotland.

 The services for pregnant women are based on a national framework. Routine testing for HIV in antenatal women was introduced in March 2003.

Health Visitors are involved in multi agency work for child protection, which includes sexual abuse. GPs act as police surgeons for assault.

The launch of the national strategy includes new funding which will be available to improve clinical services within Shetland. The present plan is to employ a half time specialist nurse and, through additional training, increase the skills base and knowledge  of existing practitioners. The intention is to be able to offer a variety of services for the population which gives choice and flexibility.

As well as NHS Shetland there are a range of agencies locally with particular responsibilities which include sexual health.

4.3 Shetland Islands Council

 The national strategy stipulates that a Strategic Lead for sexual health be appointed within the local authority. (Respect and Responsibility pg 17)

4.3.1  Education

Each school has its own programme of study for sex education.  This is an area which is receiving focused work due to guidance from the Scottish Executive, Learning and Teaching Scotland, and the HM Inspectorate, after the repeal of Clause 2A of the Local Government Act (1986).  Recommendations arising from inspections are included in schools targets and development to be introduced into the curriculum as soon as possible, e.g. parental consultation workshops, introduction of sex and relationship education to younger primary pupils.

The national strategy lays out specific responsibilities for the provision of consistent and appropriate sex and relationships education within the school setting and for those excluded from school and, in line with the McCabe report,  involving parents and carers.

4.3.2.   Social work

Parents, carers and professionals all have a responsibility for the sexual health of vulnerable groups e.g. looked after children and those with learning disabilities.

 Advice for individual clients is available, as appropriate, from the Community Nurse (Learning Disabilities), Eric Gray Resource Centre, Laburnum House, and the supported accommodation service(SIC Housing).

There is a social worker with responsibility for HIV matters.

A multidisciplinary child protection committee covers child protection at policy level. At operational level, all social workers are trained in child protection.

Recent work on the child protection procedures now has a section for dealing with individuals who are under age and sexually active.

4.4 Joint Working

NHS Shetland and SIC work together to produce a Health and Community Care Plan as well as providing joint services. Sexual health is highlighted as a priority for health improvement in 2005/6. Existing joint stratgey groups for people with disabilities, older people, children, people who misuse substances  and those with mental health difficulties can be utilised to ensure that sexual health is included on the agenda.

4.5 Charitable and voluntary bodies

The groups within Shetland which fall under the umbrella heading of charitable and voluntary bodies working in the area of sexual health include

• Shetland Youth Information Service – provide information and advice to 12 – 26 year olds, including information on sexuality and relationship issues and education. Also hold a young persons health clinic on a needs led basis – usually weekly
• Life – a national pro-life organization, which, locally, operates a  face-to-face counselling service for those with pregnancy difficulties. It also offers post-abortion counselling. (trying to ascertain if Life is still active in Shetland)
• Natural Family Planning – provision of advice via a phone-line
• Sexual Abuse Survivors – a local group which offers support for people who have connections with sexual abuse. Support is available via meetings, a phone line or website.

4.6 Local Business

There are a range of local businesses within Shetland which do work which can involve risk of infection e.g. hairdressers, ear-piercing and tatooists.  The awareness of this risk varies; advice has been sought from Public Health and Environmental health in the reduction of risks associated with blood-borne viruses.

4.7  Parents, Families and Carers

Families have a key responsibility for sex education and the sexual development of their children. They can provide a positive role model and counter discriminatory value judgements about others’ sexuality. Parents, grandparents and other family members can provide support to school sex education programmes and support to children and young people as they are developing sexually.

Many parents and carers would like more information and support themselves regarding their role in the development of sexuality of their children. (Adams, 2001)

The national strategy  highlights the valuable role parents and carers play in the sex and relationships education of their children.

5. Ethos of the strategy

This strategy is presented with the explicit ideal of equality for all; with the belief that all people, irrespective of age, race, creed, ability, sexual orientation and lifestyle, have the right to positive sexual health, free of harassment.

All existing and planned services, education and training should explicitly reflect this.

6. Aims:

This section identifies the aims of the strategy, the reason for these aims and some of the actions required to achieve the aims.

6.1. To ensure that the promotion and protection of sexual health is coordinated and comprehensive.

Many initiatives have taken place in the past and continue to be delivered to promote sexual health.  Within this strategic framework and now with the national framework we can ensure that work on sexual health is coordinated and comprehensive. 

Actions required:

• To adopt the  action plan with timescales and key responsibilities, which involve all agencies.
• To establish a strategy group and mechanism for monitoring progress towards achievement of the aims of the strategy.

6.2. To develop a culture which supports long-term improvements in Shetland’s sexual health.

“There is a need to work with adults and young people to challenge current cultural stereotypes, and focus on sexual well-being, not just sexual health problems” (Burtney, 2000). 

The process of developing this strategy highlighted that some organizations are reluctant to accept the role that sexuality plays in the provision of their services.

The Scottish Executive now states that schools must consult with parents about sex education though it is accepted that some schools and parents may find the subject and openness of the discussion challenging.

Nearly a third of young people state that their friends are their main sources of information about sexual health; almost as many state that they get their information through the media. (Burtney, 2000)  This is why it is so important to tackle the media in terms of their influence on all age groups, as the media can reinforce stereotypes about sex for adults and young people alike.

Actions required:

• The fostering of an accepting environment, which values and encourages a range of sexual lifestyles.
• Use of images and language which is open, positive and promotes acceptance of diversity, and the challenging of language and images which encourages stigma.
• Specific effort to ensure that sexuality and sexual health is inclusive across age, ability, race, creed, gender and sexual orientation.
• Involvement of the media in supporting the implementation of the strategy.

6.3. Provision of accurate, relevant and accessible information about sexual health

The process of developing this strategy has highlighted the difficulty in accessing clear, accurate, up to date information about services, sexually transmitted infections (STIs), and initiatives which have an impact on sexual health.

Actions required:

• To review information available within various outlets; Health Promotion Resource Centre, GP surgeries, Shetland Youth Information Service, pubs and clubs, community halls, youth clubs, Shetland Alcohol Support Services, Shetland Community Drugs Team and schools.
• To provide accurate, relevant information about sexual health and current services that is easily and readily accessible to all target groups.
• To support agencies in developing programmes which will enable people to make use of information e.g. decision making skills, making healthy choices and applying information to their own circumstances, increasing confidence and skills  to opt out rather through choice rather than exclusion

6.4. Effective sexual health promotion and relationships education

The Community Services Department of Shetland Islands Council has a  joint sex  and relationships education policy. (Community Development and Education Departments)  Individual schools or groups of schools are at different stages of developing sex education policies and programmes.

The Scottish Executive, Learning and Teaching Scotland and recent HM Inspections  (Scottish Executive, Learning and Teaching Scotland, 2000) recommend that a coherent programme for health education, which incorporates sex education and follows curriculum guidelines, should be developed. The sex and relationships education policy from the SIC will provide a starting point for this. Learning and Teaching Scotland recognize the valuable contribution that health professionals (health visitors, health promotion, the school nursing service) can make to a sex education programme within schools and they encourage development of these partnerships. 

A growing body of research indicates that although there can  be difficulties associated with parent-child communication, communication with parents is one of the things which can help delay the age of first intercourse, improve the acceptability and increase the use of contraception among their children. (Burtney, 2000)

In line with the national strategy, steps should be taken to ensure equity of opportunity and access to lifelong learning for effective sexual health promotion and relationships education.

Actions required:

• In line with the national strategy, identify a member of each secondary school’s management team who will be responsible for ensuring that school based sex and relationships education subscribes to current guidance and delivers key learning objectives to all pupils
• To continue to implement recommendations from the Scottish Executive, Learning and Teaching Scotland and recent HM inspections, that a coherent programme for health education, incorporating sex education, be developed.  These recommendations are that each school should have a sex and relationships policy and programme of study which covers early years, ages 5 – 14, and beyond. This is in line with the Health Promoting Schools initiative which all schools should be by 2007.
• Continued effort to implement in schools the national training programme developed by Health Education Board for Scotland/NHS Health Scotland - SHARE (Sexual health and Relationships Education).  This will ensure a multidisciplinary approach to sex and relationships education and assist in accurate and consistent messages being delivered to young people. To provide training updates and support to those teachers using SHARE.
• The further development of school-based sex education programmes which involve parents.
• The meshing of programmes taught in primary schools with those taught in secondary schools.
• The development of health visitor / school nurse and other health professional input to school sex education.
• Continuation of evidence based sexual health promotion from school to further education
• Explore the use of community learning plans as vehicles for sexual health and relationships education to adults

6.5. Targeted health promotion messages which meet the needs of the most vulnerable

A range of research suggests that young people in particular appear to be lacking in knowledge about STIs, especially chlamydia.  They can also be unaware of how to or unwilling to access sexual health services.

Actions required:

• Increase awareness of existence and methods of transmission of sexually transmitted infections.
• Publicize the fact that patients do not have to be registered with a GP to get contraceptive services; it is possible to go to any GP for this service.
• Raise the profile of HIV and other blood-borne viruses and the risks for all sections of the population; heterosexual, homosexual, bisexual, men, women, children, older people,  holiday makers, drug users etc.
• Highlight and reinforce the safer sex message, with emphasis on alternatives to penetrative sex, delaying the start of sexual activity in young people, promotion of the use of condoms, support initiatives which promote decision making and choice including saying no
• Improve information on confidentiality and choice
• Targeting older age groups who may, due to changes in lifestyle and/or circumstances be at risk 

6.6.  A range of services available to meet the needs of the population and appropriate training provided as an ongoing part of this

National recommendations suggest that specific consultations with family planning experts, access to contraception and general health checks should be provided and be accessible to all young people.  The national strategy has made new funds available to NHS Shetland to improve local services.

Existing commitment from NHS Shetland to  fund and provide a young people’s health clinic, to be based in Lerwick will continue. The need to offer choice of services to all patients in all areas is recognised.

Actions required:

• explore the options proposed for the new money and make decisions based on best practice
• NHS Shetland, in partnership with other agencies, to consider the need for service development to ensure holistic and comprehensive services are available locally to meet the sexual health needs of the population.
• To consider the development of the service to particularly meet the needs of vulnerable young people and other vulnerable groups in Shetland.
• To explore ways of increasing the accessibility of services via training of health visitors and other relevant professionals.
• Provision of a range of condoms, dams  and lubricant, which reflect a range of sexuality, ethnicity and health needs, in places which are accessible to all sections of the community
• To raise awareness among health professionals and high risk groups of STIs, and the need for early identification and treatment.
• To provide professional development and training (interagency and multidisciplinary where appropriate) to people who work on sexual health issues and within sexual health services.
• To explore the needs of groups which are under represented in sexual health issues and ensure that policies and programmes are inclusive
• To formalise the young people’s health clinic arrangement with Youth Information Service to ensure sustainability and continuity of service

6.7. Tackling issues of general risk taking in a coordinated way, and the underlying determinants of risk-taking behaviour in all ages.

It is important that this strategy links with other strategic and operational plans which tackle risk-taking behaviour, and the wider factors that contribute to sexual ill-health (social exclusion, poor educational attainment, low self-esteem).

Actions required:

• Links should be established to other relevant strategies, for instance with the Community Plan and Community Safety Partnership, Joint Health Improvement Plan, Drug Action Plan, Plan for Action on Alcohol Misuse, and strategic plans for improving the health of children and young people, and older people.
• Tackling the underlying determinants of risk-taking behaviour in all ages including young people e.g. confidence building, alcohol and misuse of drugs.
• Prevention of the specific dangers arising from risk-taking behaviour such as the transmission of blood-borne viruses and the possible consequences of unprotected sex.

7. Conclusion

The strategy and action plan map out the developments which are to be taken forward over the next three years. By continued strong partnership working  and a commitment to implement the action plan we can make a difference to the sexual health of the people of Shetland.

REFERENCES

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Belfield T.  (1999) Contraceptive handbook 3rd edition. Family Planning Association, London

Burtney E (2000) Teenage Sexuality in Scotland - Evidence into Action –Edinburgh: HEBS

Department of Health (2001) The National Strategy for Sexual Health and HIV. Department of health London

Department of Health  (1998)  Chlamydia trachomatis: summary and conclusions of CMO’s expert advisory group.  Department of Health, London

Fast Forward (2000)  Walk the talk - developing appropriate and accessible  health services for young people.

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