Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 743-759)

THURSDAY 9 JANUARY 2003

DR TREVOR STAMMERS, MR ROBERT WHELAN AND MS GILL FRANCES

Chairman

  743. Can I welcome our next group of witnesses. This next session is looking at sexual health and sex education and we appreciate your willingness to appear before the Committee. Can I ask you briefly to introduce yourselves, perhaps starting with Ms Frances, and perhaps you can talk a bit about the organisation you work for and how this relates to the area we are looking at.

  (Ms Frances) I am Gill Frances and I am Director at the National Children's Bureau. Our strap line is "to make a difference for children". We have led the field around all aspects of personal and social health education and I run the department that does that and also hosts the Drug Education Forum, the Childhood Bereavement Network, the Sex Education Forum, so all the different components of PSHE and citizenship are held within my department.

  744. Thank you. Mr Whelan?
  (Mr Whelan) I am Robert Whelan and I am the director of the Family Education Trust, which is sometimes referred to in the papers as Family and Youth Concern. We are 30 years old, we are an education charity, we carry out and disseminate research into the causes and the effects of family breakdown with particular reference to the welfare of young people. We are not a single issue group, we deal with a broad range of issues. We were founded by a doctor who had done a lot of work in preventative medicine. He used to run a preventative medicine unit at Middlesex Hospital when this was much more unusual than it is now, so we always look at the preventative approach to the issues that we are dealing with. The problem is that many issues that come up are dealt with as discrete issues whereas in fact they have ramifications, and policy changes in one area can have a knock-on effect in another. We are particularly interested in this field in the effect of the increase in STIs in young people and also we would like to put the emphasis on prevention rather than cure. Obviously screening and early treatment have a role to play but the more important thing, certainly for teenagers, is looking at what sorts of behaviour are likely to expose them to the risk of contracting STIs in the first place.

  745. Thank you, we are grateful for your written evidence to the Committee as well. Dr Stammers?
  (Dr Stammers) Dr Trevor Stammers. I am a general practitioner in south west London and I have been in general practice for about 20 years now. I am also senior tutor in general practice at St George's Hospital Medical School. For several years I have been a trustee of the Family Education Trust and I have had a long-standing interest at the coal face, as it were, in sexual health. It is not possible to be an urban general practitioner and not have an interest in it to some degree. On the wider front, I have written two books relating to sexual health, one relating to violence and intimate relationships and one an A-Z of sexuality from birth to death. I have also been the medical adviser for several resources looking at primary prevention in the field of sexual health. One of the things that struck me about the debate you have had so far is that looking at secondary prevention as exemplified by the chlamydia screening is a very, very difficult task. There has been a recent study that has not yet been published but is available on std conference.org presented in America last year looking at a cohort of 400 teenage women and following them over a 90-day, three-month period and of those 350 young women 15% who used condoms consistently and correctly 100% of the time, self reporting, got chlamydia in that 90-day period. Of those that did not use condoms consistently and correctly 30% did. If you are talking about screening intervals for high-risk populations the time interval could be very short and any secondary prevention method you are looking at is going to be very complicated because sexual behaviour is a complicated matter. Primary prevention is something that has not been given enough weight.

  Chairman: We will come on to the specifics in a moment or two. We are grateful for your introduction. Andy?

Andy Burnham

  746. Looking at the National Survey of Sexual Attitudes and Lifestyles, the NATSAL survey, it shows an extremely clear trend among the young people of Britain. The median age of first sexual intercourse has fallen to 16 years old and has fallen steadily over the last ten years and the average number of sexual partners amongst young people has risen. With those clear social trends in mind, perhaps first to the Family Education Trust but I would also be interested in Gill Frances's view, is postponing the age of first sexual intercourse reversing that trend? Is it a realistic aim?
  (Mr Whelan) I think the research from America indicates that it is not impossible. If you give young people the full facts, this is the important thing, they need to know the real risks, the failure rates and so on before they start engaging in sexual relationships. It is possible to delay age at first intercourse and to reduce the number of partners if you have the right sort of programme. It is extremely difficult but it is possible.

  747. What messages have proved effective in your view in doing that, perhaps in the States?
  (Dr Stammers) May I answer that since I have done most of the writing of the submission for FET. There are many very bad programmes in the States. Those that have proved successful have adopted proven, accepted methods of communication and education in general terms rather than going for a sort of hard-line political message, so I think it is important to strip those contexts out of it using the appropriate methods. Those schemes that involve parents have definitely been shown to work better (and that is obviously good where you have got parents around who are willing to be engaged) and also those that embrace the world from which teenagers come (so the examples and analogies you use have obviously got to be realistic) and those that also target, as we were thinking earlier, boys as well as girls because boys are often a very neglected area and many girls still feel that it is the woman's responsibility and we have to target both. I think there is encouraging evidence particularly from a study in New York just recently that it can be done, but it is difficult. Even a delay of a year or 18 months is very, very valuable and enormously helpful in preventative measures.

  748. When you say involves the parents, what kind of messages is this giving to the young people concerned?
  (Dr Stammers) Being able to talk with parents is in itself a preventative method and one of the things that interests me about the social exclusion report is the graph that shows that in Holland parents, both dads and mums, are communicating on a much greater level with their children about sexual matters. We still have a tremendous British reserve, which is very unhealthy, about talking about sexual problems and sexual issues in general.

  749. It is interesting because I was going to say to you that the Committee visited Holland and saw their fabled openness about sex and all matters relating to young people's sexual health, and of course in Europe they have the highest average age at which people become sexually active. I would have thought you would have given the opposite view. I am interested that you are advocating openness rather than harder messages. I would have thought you would have come from a different perspective.
  (Dr Stammers) I take the view that there is never any benefit in hiding the truth. I have got three teenage children of my own so I know that sexual desires develop much earlier than sometimes the ability to restrain them without appropriate help. It is very, very healthy in a family where children feel they can go to their parents and talk about these issues. That is something that we should be encouraging.

Jim Dowd

  750. Just one point before it moves too far away. You say it has been shown that you have been able to delay the age of first experience by 12 to 18 months and you describe that as very valuable. Why is that valuable? Is it valuable for what you do during that time or is it valuable because it shows a more mature attitude at an earlier date?
  (Dr Stammers) I think it is valuable from many perspectives. One is that everybody on all sides of this debate would be agreed that early sexual activity, say at the age of 14 or under, is much more dangerous, you are much more likely to get infection and the risk of cervical cancer is doubled from first intercourse at 14 rather than later on and the immaturity physiologically of particularly young girls' genitalia proves harmful to them if they engage in sex at an early age. That is one area of benefit. The second area of benefit is that clearly the younger a teenager is the more difficult it is for them to use contraception appropriately. The problem that I encounter time and again in my medical practice is not that kids have no availability of contraception and they do not know the rules about using condoms, but when a quarter of them are drunk at first coitus clearly no amount of instruction is going to be useful in that context. Also when you are 14 there is not usually the emotional maturity to negotiate in the heat of the moment the putting into practice of the rules that you may already know. So I think on both those fronts there is great benefit. The third thing is that we know that if somebody starts having sex at an early age, 12 or 14, by the time they are 20 they are bound to have had multiple partnerings. It is that which is one of the key areas in the enormous epidemic of STIs we are seeing in Britain, so it has benefits on all three fronts.

Andy Burnham

  751. Before I move to Gill Frances, can I ask a final question. Why do you think the trend as identified by NATSAL towards earlier sex is as it is?
  (Dr Stammers) I think there are a whole variety of reasons for it but I do consider the enormous pressure of the sexualisation of society in general to be a huge influence. My young daughter, who is 14, happened to mentioned in passing to my wife the other day, "It just seems whenever you turn the telly on these days there is sex there." My 16-year-old son mentioned to me that a lingerie advert that obviously is very effective at the moment on most bus shelters had caught his eye.

  752. Some members of the Committee found it is the same in Holland, the media there is no different than here but it does not seem to—
  (Dr Stammers) I would agree in some parts of Holland that is true, in rural Holland probably not so. If you are in that environment all the time where all of the pressure is towards sexualisation, getting you turned on or thinking about sex, that is one thing. If you are in a home environment where there are counters to that pressure then that child stands a much better chance of being alright. That is the key thing I would want to communicate. There are positive and negative pressures. If children are just cast out onto the stream of general sexuality out there with no counterweight then heaven help them because a condom will not.

Chairman

  753. Dr Stammers, you are a GP and you will deal with teenagers who come in to see you perhaps for contraceptive prescriptions or whatever. If you had, say, a 14 or 15-year-old girl who came to see you asking for contraception of some kind with some concern about you not passing it on to the parents, how would you deal with this? What is your view? I respect the point you are making about the engagement of parents in sex education. How would you handle that kind of situation where your patient was resisting any contact between yourself and their mother or father?
  (Dr Stammers) I think in that situation the response is quite clear in law and I would agree with it in spirit as well, that that situation is entirely confidential and one's duty is to that 14-year-old girl. You have to explore the circumstances she was in. On some dreadful occasions it may be other family members that are the cause of pressure for her to want to be on contraception so you need to find out what is going on but if she has got a 16-year-old boyfriend and they are already having completely unprotected sex then I would view it as being a responsible position to provide her with contraception, but that in itself is totally inadequate because if one is looking at sexual health overall, if you just give her the pill you may, paradoxically, increase her chances of getting a sexually transmitted infection, so anyone who prescribes the pill particularly to a young girl without also giving her information about the risks she is running of STIs as well as unplanned pregnancy is not doing a proper job.

  754. What I was more concerned about is would you see it as part of your duty to try and encourage her to talk to her parents about her circumstances?
  (Dr Stammers) Absolutely and in a context where there is no sexual abuse going on in the family, the Gillick ruling that one should make enquiry about that and encourage it is probably not carried through in practice as often as it should be. I would certainly want to explore that and one of my catch phrases in these situations is to say it is very difficult for skeletons to remain in cupboards indefinitely in families. They have a nasty habit of tumbling out and you may want to think about that because you have got to hide this for a long time if you do not want your parents to know, and sometimes of course the parents know already.

Andy Burnham

  755. Can I direct some of those general themes to Gill Frances but also ask specifically if you have evidence that delaying first sex brings sexual health benefits to the individuals and generally means they will have better sexual health if they started having sex later on?
  (Ms Frances) The very simplistic answer is yes but, unfortunately, if there were simple answers we would not all be sitting here, so it is a lot more than that. It is the use of the word "aim". When you first asked the question you said was the aim to reduce first sex. What we know from looking at the international research is that if young people are offered broad-based sex education—and, as Trevor quite rightly said, some of the American models are really very poor and do not offer that broad spectrum. It is not enough to tell young people information. I have got loads of information in my head. I know how to change a plug, but I cannot do it unless I undo another one and see what that looks like and then do it. I cannot do it, I am not that skilled about it. So the second most important thing is about young people actually being helped to develop emotional and social skills in which they can then put their knowledge into action. What we have got a lot happening is a lot of telling. Young people are told by their nurse, told by their doctor, told by their teacher, told by their parent and what young people say to us all the time in our research at the NCB is, "We want some of you grown-ups to know what you are talking about and help us." I was saying to one of your researchers when they rang me that one young woman said to me, "I want to be me and I want to be really good at being me, I need your help", and that is the bit we are not good at.

  756. Do you really think any of that can delay what is a huge social trend?
  (Ms Frances) I think it can and it is not in the last ten years, it is since the Second World War.

  757. Since the Beatles.
  (Ms Frances) No, it is before that. If you read your Mary Wesley you would know it happened in the War. So it is a long trend that has been going back a long time. The third thing (which picks up a lot of things we have been saying) is a positive attitude. We have a very negative attitude to sex and these advertisers are not selling sex, they are selling something that is going to make them money. I think that the whole issue of helping young people to have a positive attitude, helping them develop a critical awareness of looking at things and thinking, "Is this for true, is this something that is going to suit me, who I am, living in my family, living in my culture?" It is not just about being given information, that does not work, it is the other two bits which are more important than the actual information. You can get the information from a leaflet when you need it but the sense that you are an important person who has got the confidence to deal with all sorts of challenging things growing up, that is the sort of thing that has got to be taught and learned and you have got to feel confident about it. You have got to be in a culture, in a family, in a school, in a GP practice where it is normal and okay to say, "I need your help, I am stuck with something here." At the moment young people in our country, unlike the ones you met in Holland, if they are worried about something they turn to each other. They do not turn to a grown up, they do not turn to parents, they do not turn to teachers, and the marvellous thing about Holland is that kids do turn firstly to their parents.

  758. It was also slightly different in Sweden where you had clinics just for the under 23s. Do you think there is value in that kind of service?
  (Ms Frances) There are already all these clinics across this country but unfortunately they are patchy and they do not exist in the same explicit way as they do in Sweden. We do have them here but if you set up a clinic in this country, if you broadcast it too much you end up in the tabloid press and everybody jumps up and down and gets very excited. There is this need for us to flatten out this drama around sex. We do it, human beings do it, and we just need to relax about it, and then I think our desire—which is not just our desire, young people often regret their first sex, they want to delay it as well and wish they had—is what the outcome will be. What it should not be is the aim; it will not work if it is the aim.

Chairman

  759. Can I ask a question of the other witnesses. One of the things that has been interesting to the Committee, one or two of us have been struck by it, is that if you look, as we have done, in some detail at Sweden and Holland, which I think most people would argue are more permissive societies, they do have in terms of young people a much more responsible attitude to sex and later first intercourse and less problems in terms of sexual health than we have got, which seems very interesting. Do you have any thoughts on that?
  (Mr Whelan) We are just about to publish a study on sex education and teenage pregnancy in Holland because it is turned into this sort of Utopia where they do everything right.

  Chairman: I would not say it is a Utopia but I was certainly struck by the contrast between our perception of the attitudes there and the outcomes compared to our own.


 
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