Research on sexual health amongst young people; challenges and constraints

1. Research on sexual health amongst young people; challenges and constraints Roger Ingham Centre for Sexual Health Research University of Southampton AYPH conference London 23 October 2008

2. range of reactions after early sex note that same physical activity can lead to quite different reactions We just thought about it … you know … like I didn’t want to rush into it and he didn’t either … I never felt I was being pushed into anything and when it happened we both really enjoyed it … I mean it was a bit quick (laughs) but it was still nice I mean I hardly ever have an orgasm with these blokes … I mean its all over too quick ain’t it? … they sort of ask if you’re ok and I sort of moan a bit and they think that’s me saying yea its great and I'm nearly coming (laughs) and so they sort of go for it and before I know it … its all over (giggles) … it’s not funny really is it? I mean I'm left there feeling all horny and he's thinking thank you very much that was great … that’s crap ain’t it?

3. restricted approaches what would survey results look like? what inferences would be drawn? are you sexually active? (eg ‘safe’ vs ‘unsafe’) was a condom used? necessary but nowhere near sufficient

5. plan for today variation in activities and outcomes motivations negative and positive approaches sexual discourses need to move to a common discourse

6. nature versus nurture wide variations globally in many aspects of sexual activity and outcomes amongst young people for example median age of first intercourse (15.5 to 22.9) rates of pre-marital sex (0 to 95 percent) reasons for first sex significance of sex reactions to sex etc. indicates that culture has major impact

7. methodological challenges comparative data cannot perform random control trials difficult to obtain in standardised formats different age groupings in countries stigma and shame may affect reporting little on (sub-)regional variations less policy and research concern in countries with lower rates

8. main sources of data Alan Guttmacher Institute reports (1960s onwards) UNICEF report card Eurostat data HEA commissioned reports (Kane and Wellings, Cheesbrough et al.) European comparative surveys (Hubert et al.) various other pieces (eg Hosie) our own work on UK-NL comparisons

9. accounting for outcome variation any variation, etc. must be manifest in one or both of two ways different levels of sexual activity different rates of effective contraceptive use but data not readily available

10. levels of sex and birth rates

11. births, conceptions and abortions but birth rates do not tell us about conception rates .. .. because some young people have abortions so, combining data from various sources, we can produce the following (and note that percentages married at birth vary considerably – from 61% in Switzerland to 2% in Iceland – and that data are missing from some countries)

12. sex, conceptions and abortions

13. large variations within countries as well in England and Wales, under-18 conception rates vary between local authority areas from c20 to c80 per thousand (national rate is c41) abortion proportions vary between c25 to c75 (overall of 48)

14. beyond numbers so, numbers can tell us a certain amount, but … … there is a need to pay much more attention to what lies behind these numbers explore the wider contexts in which young people develop and absorb discourses about sex and sexual activity - how might they vary? for example …

15. young people’s contexts formal and informal contexts families or equivalents, educational settings, peers, communities, health services, workplaces, the media, religious organisations, leisure sites, etc. cross-cutting issues general economic situation and impact on aspirations, policy and legal contexts, gender issues, discrimination and stigma, etc. (a rather more challenging agenda than analysing a couple of hundred questionnaires from undergraduates on the Theory of Planned Behaviour!)

16. accounting for variations in contexts and outcomes consider four (related) examples discursive frameworks opposition to SRE, etc. deprivation and openness shame and guilt and pleasure

17. why are people involved? different agencies have different priorities: to lower teenage pregnancy rates, by … lowering levels of early sexual activity and/or increasing extent of protected sexual activity and they often work within differing discourses of sexuality …

18. the range of discourses sexual activity variously regarded as: medical / clinical / public health love, commitment and marriage economic exchange religious reputational adult (notion of innocence / guilt) dirty / naughty passionate / pleasurable etc.

19. range of reasons for having sex love and commitment curiosity to gain reputations/status amongst friends to ‘prove’ heterosexuality rebellion curiosity / experimentation to be ‘adult’ pressure / coercion duty (marriage?) transaction of money or goods or services, etc. drunk / drugged just fancied it

20. ‘good’ and ‘bad’ reasons for having early sex consider just a few examples … … in the light of public health discourse, moralistic discourse, human rights discourse coercion alcohol / drugs to acquire a reputation love marriage

21. in the wider context of general discourses about young people do we consider them to be … … a walking bunch of hoodied deficits? or … a resource to be invested in for the future? why and where does it matter? RISK or VULNERABILITY?

22. examples of variations (Sweden) The guiding stars are knowledge instead of ignorance, openness with regards to facts instead of mystifying and an acceptance of young people’s sexuality (or sexual emotions), relationships and love, with or without a partner. The idea is that the sex education should support and prepare young people for a responsible present and/or future sexual life ... Sexual enjoyment is also regarded as a value in itself ... There is no opposition to sex education in Sweden. Sex Ed in Sweden (Katerina Lindahl, RSU)

23. examples of variations (NL) “Dutch sexuality education emerges from an understanding that young people are curious about sex and sexuality and that they need, want, and have a right to accurate and comprehensive information about sexual health ... it encourages young people to think critically about their sexual health, including their desires and wishes … attention is paid on discussing values, establishing personal boundaries, communicating wishes and desires, and developing assertiveness.”

24. examples of variations (NL) “what are often considered taboo or sensitive topics, such as sexual orientation and masturbation, are common themes in Dutch materials” (quotes from Ferguson et al. Sex Education, 2008) note - separation of sexuality education from specific religious viewpoints but based on clear values of respect, responsibility and positivity

25. ... what about in Devon?? … Sex education DVD 'too explicit' Debbie Andalo Tuesday February 27, 2007 EducationGuardian.co.ukGovernors at a primary school in Devon will have the final say on whether children will be able to watch a sex education DVD made by Channel 4 following concerns by two parents that it is too explicit. The Living and Growing programme is the fourth best seller in educational DVDs produced by Channel 4's learning and education arm. But when the programme was shown to a group of 160 parents at Sherwell Valley Primary School, Torbay, to seek their permission to show the DVD to pupils, two parents objected complaining that it encouraged children to touch themselves

26. Nisha and Joe example (fpa) Sex education booklet for six-year olds (Warrington Guardian, 26 September 2008) Sex education for six-year olds (Weston super-Mare Mercury, 29 September 2008) Head teacher said “We would take the idea of this publication into any discussions with governors and staff on those subjects as I do not think we can promote the use of it without first talking about it to see if it is appropriate. The question that also needs to be asked is 'at what age is it appropriate?’ ”

27. Nisha and Joe example (fpa) Previous national chair of the Parent-Teachers Association is quoted as saying: “ giving clinical terminology to children so young is an unfair burden on them. I am sure most parents will agree the truth is the best answer but it is the degree of detail that is so important. It’s unfair to burden very young children with explicit details and then wonder why they say words and do things not acceptable in schools or in society. We cannot expect small children to cope with the amount of information government want primary school to implant into childish minds.” (LifeSiteNews.com, 18 September 2008)

28. the UK in state of confusion effect of oppositional discourses Sept 27, 2008 Catholic schools should "strongly oppose" any proposal for sex education that could sexualise children, a senior Church figure has said (the Most Reverend Vincent Nichols, Archbishop of Birmingham). British compromise (eg right of withdrawal from SRE) media work – need for ‘balance’ (morality discourse) relation to research evidence some dark aspects

29. an example an example from a consultant paediatrician who has developed an abstinence programme in NE (after considering evidence on abstinence programmes): “Proof of efficacy is not the predominant issue for the Christian as it is for the utilitarian secularist. We teach something because we understand it is right to do so” (Richards, 2005, in Triple Helix, CMF) (some other examples removed here)

30. some qualifications certainly not intending to question motives of all Christians or members of any other faith groups (see, for example, Catholics for Choice, and other progressive work within faith groups) but it does no harm to try to understand the discourses within which the key opposition groups are operating and which have a restraining effect on progress in this country and elsewhere

31. further discourses possible associations with deprivation

32. predictors of early parenting(from Berrington, Ingham and Stevenson)

33. but … overall correlation between index of multiple deprivation and conception rates (and abortion proportions) partly linked to aspirations, but not completely – so what else?

34. mechanisms of deprivation possible associated factors: future plans and prospects self-esteem, aspirations of self and others limited talk on sexuality within families higher gendered sexual stereotypes and influence of homophobic attitudes (how biological issues are dealt with is central to the social constructions – for example, the ‘male sexual drive’ discourse, the ‘have-hold’ discourse, etc.) poorer access to services? stronger anti-abortion views (normally)

35. negative discourses many young people’s sexual discourses relate to: shame and guilt (erotophobia) innocence / guilt / naughtiness embarrassment and silences mystification / secrecy alien moralities (abstinence, etc.) prevention / avoidance of this and that and the other strongly gendered differentiation ambiguity of importance (?) of SRE in schools etc.

36. as opposed to … sharing respecting self and others being respected control over own body deciding expressing knowing enjoying

37. some examples of processes? answers to questions about babies honesty of answers from adults naming of body parts reactions of service staff, teachers, etc. opportunity to discuss and share effect of superficial treatment in schools developing own value systems challenges to gender issues challenges to homophobia etc.

38. links between aspects of sexual development from small-scale qualitative research through to large scale survey research (Harriet Hogarth’s PhD) strong links between parental communication, attitudes to bodies, comfort with masturbation, relaxed with opposite sex, better communication, better control, higher contraceptive use, etc. for example (from 16 to 18 year-olds):

39. range of reactions to masturbation [HH: Do you masturbate?] God no … I mean only slags do that, don’t they? Sorry … I mean sex for me is in a relationship its not something you do for sex sake … you know … like … just physical … sex is part of the relationship and then its ok … do girls really touch themselves? I can’t believe that … I know people sometimes talk about … like … I think I’ve read it or seen it on the tele … but that’s for older women or ones who can’t get boyfriends and I think that’s really sad you know like just ‘cos they can’t get boyfriends they touch themselves up … it’s not on you know … ‘cos girls shouldn’t have to do that … you know what I mean? I would never touch myself … you know … I think that’s really disgusting … you know … it’s just not right ‘cos only a boy suppose to touch you there and even then its not that great [laughs]

40. range of reactions to masturbation You know the first I ever touched myself down there … oh my god … it was amazing … I mean really amazing … it was like discovering the pot of honey [giggles] I mean part of me felt really bad you know wrong … dirty … but another part me said I don’t care cos it felt so good … I used to think about it during the day and look forward to going to bed or at least being in my bedroom on my own … god this sounds really awful but that’s how I felt you know when I discovered it … it was like my secret what I mean is that its only after I've done it and I feel all chilled that I think 'oh that’s why I was feeling all sort of tense and stressed' and it really helps … you know … to feel better well not better just calmer ... well that’s how it is for me anyhow ...

41. some potential links? Sex is really important to me … I want something out of it as well and they need to know that … you know … I let them know [HH: How?] well … I tell them … it’s not always easy ‘cos they’re all horny … but sorry … I just say ‘if it’s a quick shag you’re after … forget it ‘cos I'm here too’ … know what I mean? I'm not sure how to put this but being or at least knowing me or at least my body has really helped me … you know … helped me know what I want This is so personal I find it difficult to talk about … I think I have more control over things like I can just put a stop to things that I'm not happy with … you know … when it’s not right

42. potential links with outcomes I really like sex … no … I love it … that’s OK ain’t it? I mean … why shouldn’t I? But I tell you one thing … I always but always insist on a condom … I don’t care what they say … you know all the crap blokes come out with … like ’it don’t feel right’ or ‘ I can't come with one on’ all that malarkey … I just say tough ‘if you ain’t wearing one you ain’t getting it from me’ … ‘cos I just want to be really safe Yea … I sleep with who I want to and most of the time I really enjoy it … it tends to be on my terms … not that the guy knows that … I mean he had to think that its all about him but its not … it’s all about me … I mean if I think he's coming before me … I soon put a stop to that … you know … bring him back to reality

43. summary to summarise: sexual activity as socially constructed range of social and material contexts influence meanings and interpretations more powerful than biological issues (but how biological issues are dealt with is central to the social constructions – for example, the ‘male sexual drive’ discourse, the ‘have-hold’ discourse, etc.) unifying concept of discourses to link the social context with the individual

44. moving towards cultural change and acceptance research supports idea that more ‘open’ and sexually accepting societies with shared discourses have better SH outcomes does NOT imply more (or riskier) sex, or lowering of ‘moral’ values, or the demise of society as we know it on the contrary - based on respect and responsibility need for all working with and for young people to delineate professional from personal discourses, and be confident