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THURSDAY 9 JANUARY 2003 __________ Members present: Mr David Hinchliffe, in the Chair __________ DR MUIR GRAY, Programme Director, National Electronic Screening Library, examined. Chairman
(Dr Gray) I have two jobs, as many of us do these days. I work for the National Health Service and my two jobs are, firstly, I am Programme Director of something called the National Electronic Library for Health, which is run by the Information Authority. Our mission is to make best current knowledge and know-how available to patients and the public to improve clinical practice. For many years I have been in public health and in the knowledge business and it is clear that by putting into practice what we know, we will have a bigger impact on health and disease and any new drug or technology likely to be discovered in the next decade, so the National Electronic Library for Health, we are just reaching the final approval of the full business case, but it is already up there on the website, www.nelh.nhs.uk (Dr Gray) In any programme there are four things, being what population you are going to cover, what is the screening test, what is the diagnostic test and what is the treatment. I think when I received the expert report on chlamydia screening, the main weakness which was revealed during the pilot was regarding a communicable disease like a non-communicable disease. Anyway, the recommendation was that we would screen people every two years. That, I think, has a relevance in something like cervical cancer where the disease develops in you, but with an infection disease, like tuberculosis or chlamydia, there is only one place from where you get the infection and that is from someone who has got the infection. Therefore, I saw this much more as a communicable disease control programme and the first principle that emerged was that the importance is to get coverage rather than frequency of interval. I think the interval is a red herring in a sense. Regular screening for the whole population or a sub-population is not necessarily the best way to go. I think what we learned in the first phase of the pilot was the need to identify high-risk populations, for example, women having their first cervical smear who are a reachable population and women going for their first contraceptive appointment. My advice to the programme, I am not closely involved, but they have asked us to get much more closely involved as we move on, is to identify populations which are easily reachable, like those going for their first cervical smear or for contraceptive advice, and let's make sure that all those people have at least one test and then if they are negative, they should receive clear advice about barrier contraception because I think there is a risk of people believing that this is an easily-treatable disease. Primary prevention is always more important than secondary prevention, so if you are negative, encouraging barrier contraception and encouraging that among the men that you meet, and then if you are positive, effective treatment. I think the study which we set up of re-infection rates and treatment is an important study and we have not received the final report on that yet, so I think we should not use the model of a non-communicable disease and we should look for ways in which we can cover sub-populations of the women comprehensively across the country. I think the test is now very robust, the urine test. Julia Drown (Dr Gray) It is a fine line between what is systematic clinical care and what is screening. I think if you are going to a GUM clinic, then I would call that good clinical practice, so yes, that would be a population, but I would expect that to be happening. The termination of pregnancy, that would be another of the sorts of sub-groups of the population that one could identify. The general approach we are using in screening now is to talk about issuing an invitation to people. I think termination is fairly traumatic for professionals as well as for the woman, but I think the invitation should be there and you could make it much more part of the routine when it came to the contraceptive advice or cervical smear. Those would be the sort of sub-populations and the priorities should cover those sub-populations with a high-quality service before worrying about routine two-yearly screening or whatever, so that is the way to go. (Dr Gray) Yes. (Dr Gray) I think it is a difficult thing. There are all sorts of issues, like whether young women have the same general practitioner as their parents and fears about confidentiality. In general, working through general practice is always complicated. (Dr Gray) Yes, but I think you have to prioritise not because of lack of money, but because of pressure on the service and I think it is much easier for the GU medicine service to relate, say, to the contraceptive services and all the standard practices surrounding them. Our three principles of screening are simplify, simplify and simplify, and when you get 30,000 primary care teams centrally involved in a programme, it just becomes much more complicated in the first phase and from this logistic point of view, I would go for a more focused approach to start off with. (Dr Gray) I think what we have found in some of the early work and some of the research work from the University of Glasgow was that it is very hard to generalise about young men. Some of them were very uninterested in health issues and others were very responsible. I think what we would go for in the first instance because we can reach populations of young women is to be systematic with populations of young women, and I am on the Board of the Health Development Agency and we are working there to look at ways in which the concept of what is good health and looking after yourself and again this idea of extending the invitation to young men, but they do not come through any door very easily for us to catch. Chairman (Dr Gray) I think the best way to reach men is through women. (Dr Gray) Yes, and the general issue of sexual health. In terms of gay men, I have been very impressed in the work I did leading up to the Electronic Library for Health for the last five years. The one community that really made use of the web was the gay male community, so you could practise, I think, good, old-fashioned public health because you have got communities. They are not geographical communities, but they are in socio-ecological terms a society rather than a community and they do not live in the one place, but I think the use of the web has been very interesting. Very early on in our work with the web we found that there were gay men, and we were looking at diagnostic testing and an electronic library for diagnostics, and we found that there were gay men learning about the randomised trials of treatment for HIV, finding the threshold blood level and then trying the blood test in different hospitals to get above the threshold to get the treatment. They were very sophisticated, so I think for gay men, the web and the community development is an approach, but for men who are not gay, I think at all ages it is often through women as the women are now experienced and more organised in the health context. Chairman: But if it is not through women, it might be through male communities and it struck me that sport is an issue here which you could look into addressing. I know it is a wider issue, but it is a focus for men in some cases. Dr Taylor (Dr Gray) The urine test, yes. (Dr Gray) Yes, of the four things in the screening programme, the population, the screening test, the diagnostic test and the treatment, one always has to look at the economics of not buying the best test, and we have got this in Down's Syndrome. The fourth positive(?) is another important issue, but in this test I think sensitivity is very important and in general one always has to look at economics and feasibility, but sensitivity is very important in screening. (Dr Gray) No, I am afraid not. All I can say is that one has to be careful about looking at it. One of our mottos is, "Screening is a programme, not a test", and saving in one part of the programme may lead to costs elsewhere, so simply looking at the costs of any one part of it is not necessarily the best way to do it. John Austin (Dr Gray) Yes, I think there we would need to do some more modelling. The first thing you would do is to decide what populations you want to cover, whether it is women with terminations or not, and then to decide, "Let's get there and get everyone covered with a high-quality test". Then I think you would want to look at, "Well, if we have got X more resources, what would be the next level?" and it might be a second test, but would it be in some populations and not in others. I do not think the model which was originally proposed of all women from 18 to 24 having two-yearly tests is a sensible objective to work towards for a communicable disease programme, so I think the first thing would be coverage. We found in the pilot then the need to manage the positives with the resources in the GU medicine clinics and then you look at a second test. Again it is better to have two tests ten years apart, say, one at 16 and one at 26, for all the population at risk rather than saying, "In some parts of the country, we have managed to get a two-year interval and in other parts we are not covering it at all", so interval will come up, but I think we will try and get the populations covered by a high-quality test in the first instance. Sandra Gidley (Dr Gray) That is why the important distinction is between people who are negative and people who are positive. What the reinfection study will reveal for us is the most cost-effective way of managing and following up positives. That is this subtle boundary between good medical practice and screening. Once someone is positive then I think we would be seeing a protocol for those people coming back for a test in it might be six months and the people who are positive at six months may need to come back at three months. So you will be starting to tailor a follow-up programme for people who are frequently infected with chlamydia. In a sense that is good clinical practice and not population screening. I am absolutely sure that some of the people who are positive will need very intensive offers of follow up. Whether they come or not is another issue. That is why I said there is a sharp distinction between the negatives - and the main measure for negatives is to try not to become positive - but the people who are positive will have repeat tests undoubtedly. (Dr Gray) Again, we have to think of what are the relative responsibilities of a screening programme and the individual woman. The programme has to tell the individual woman that if you change your lifestyle and think you might be infected, you can come forward again for a test, but screening has a degree of proactive approach and there is no way, quite rightly, we would know a woman has changed her lifestyle. So I think the screening programme would always have to offer women who think they are at risk or who think they are now infected or might be infected to come forward, but that would be as takes place at the moment, of a person turning up anxious about a disease and being eligible for a test. That is what we have done with PSA testing. That would play a part in it. It would not be a systematic way for us to identify women who have changed their lifestyle; we could not do that. (Dr Gray) There is no way, thank goodness, the state can know that! That would be part of education. Chairman: Yet! Sandra Gidley (Dr Gray) I do not think there is any way we would find that out. That would be part of the information we would give people that if you change your partner, if you think your partner has had an affair or hear your partner has had an affair with somebody, the service is there for you. That is a service for people who are concerned they might have chlamydia, which I think we should definitely have, but it is different from a population screening programme where we say we are going to identify all women offered cervical smear tests and we are going to give all of them a test unless they say they do not want it. That may be splitting hairs but the National Screening Committee's response is for identifying populations and being systematic but we also say once we get the service set up then people need to be educated as to when they might wish to avail themselves of the programme. It would fall within what I would call a disease control programme, to use WHO language about communicable disease. That is why it is different from non-communicable disease. There must be access for women and education that if you think your risk has changed significantly or you think you have been infected then you are eligible to come to a programme centre and have a test. Julia Drown (Dr Gray) This is an area that is causing a lot of interest to the National Screening Committee at the moment. We see ourselves as a health detection committee, not just an NHS advisory committee. Namely, if women are offered breast screening under the age of 50 by a private provider, the private provider should tell the women under 50 there is no good evidence, and my own view is that the NHS should not necessarily pick up the cost of that. You can buy tests over the counter or off the Internet for anything, that is part of the landscape in which we live and we need to think about the consequences of Internet testing. All I would say again is that screening, as we define it, is a programme not a test and we deal with the consequences of that and decide for example if the women has a positive test then she is eligible for treatment, but what information did you get in the leaflet, is the test of good quality, what sort of quality assurance was there of the test being sold over the counter, are the sorts of issues that we can control so this will play an increasing part in all screening programmes. Julia Drown: So it is something that you are looking at? John Austin (Dr Gray) The discussion I am having with the team is that we can start to develop national standards for testing, quality assurance of testing, information giving and communication. The testing part of the programme is being held, as you know, at ten or 15 sites this year, and I think we need to develop national standards for testing and quality assurance of tests, but the issue of how we manage positives most cost-effectively will be informed by the reinfection study. (Dr Gray) No, I relied largely on the data from the Swedish and American studies. Cost-benefit is always a difficult thing to interpret. What we generally find is that some programmes are either ridiculously cheap and we should get on and do them (like asking everyone if they smoke), some are very, very expensive, and most fall in the middle, and this one falls in about the CABG, so it is in the reasonable category. The bigger problem comes in terms of the cost-effectiveness of different options and we have looked at that in the pilot and the next round will also be looking at, for example, what the difference between method A or method B is because we are dealing with a 50 million total population. Small changes in unit cost can have a very big impact on the Health Service as a whole so the cost-benefit is fairly well established and probably does not need to be re-visited here but cost-effectiveness of different options we need to be alert to and be encouraging studies on all the time. (Dr Gray) Yes. Chairman (Dr Gray) No, I am honoured to be asked. The National Screening Committee has a web site and we have an annual report. I am sure you are all overwhelmed with paper but I would be very pleased to send it to you and I would be very pleased to help this Committee in any way in the future. Chairman: We are very grateful to you for your help today. Please feel free to stay for the rest of the session if you want. Memoranda submitted by The Family Education Trust and National Children's Bureau Examination of Witnesses DR TREVOR STAMMERS, Trustee, and MR ROBERT WHELAN, Director, The Family Education Trust; and MS GILL FRANCES, Director of Children's Development National Children's Bureau, examined. Chairman (Ms Frances) I am Gill Frances and I am a director of the International Children's Bureau. Our catch 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 Network, the Sex Education Forum, so all the different components of PSHE and citizenship are held within my department. (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. (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 per cent who used condoms consistently and correctly 100 per cent of the time, self reporting, got chlamydia in that 90-day period. Of those that did not use condoms consistently and correctly 30 per cent 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 (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. (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. (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 (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 (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. (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 (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. (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 (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. (Ms Frances) I think it can and it is not in the last ten years, it is since the Second World War. (Ms Frances) No, it is before that. If you read your Mary Wesley you would know it happened in the War. It works up from there. 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?" 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. (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 (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. Andy Burnham (Mr Whelan) In the last five years in Holland they have experienced upturns in all of the trends. (Ms Frances) They shut down their young people's clinics because they got complacent, which is really important. (Mr Whelan) We sent a researcher over to Holland and he went into a selection of primary and secondary schools to find out what is being taught because a lot of people talk about Holland as this place where they do everything right and they do not know what they are doing. He found that, in fact, there is no model of Dutch sex education, it varies as much from school to school as it does here, probably more because the schools are not so centrally controlled as they are here, they are much more independent. It does not start at younger ages, it is not more permissive, so whatever is causing those different outcomes (and the outcomes are substantially different between Netherlands and the United Kingdom) it is not a sex education programme, the difference is in the culture. It is a much stronger pro-family culture. Chairman (Mr Whelan) Sorry, we could not get any comparative data. We looked at alcohol consumption. There are various things you cannot get direct comparisons on such as drinking. (Mr Whelan) I think so. First of all, most of the teachers we spoke to said the parents had already told their children about sex before they received sex education. Parents are still the main transmitters of this knowledge. I would like to enter a caveat about relying on sex education to achieve very much. The evidence that health education impacts on people's behaviour is very weak whether you are looking at drugs, diet, smoking, or anything else. The very limited amount of research that has been carried out into the effects of sex education tends to measure increases in knowledge. You interview people before a course and after a course and you can measure whether they know more about a particular subject, but there is a difference between knowing something and putting that knowledge into effect. In the present debate about sexual health and teenage pregnancy much too much weight is being attached to what can be achieved by sex education. (Mr Whelan) Sex education has an impact only at the margin. (Mr Whelan) If you had excellent programmes of sex education it would have some good effect and if you had an absolutely dreadful programme it would have some bad effect, but it is not the major influence on young people's behaviour. It cannot begin to compare with the influence of the media, advertising, Internet, peer pressure. (Mr Whelan) I would be interested to see it. We have been reviewing the evidence and there were two articles in The Lancet only a few months ago which showed that the impact was either negligible or it may even have encouraged it. Chairman: We may be looking at different evidence here. Sandra Gidley (Mr Whelan) I do not think it happened for five years. The percentage of families headed by a single parent is five times greater in this country than it is in Holland, the divorce rate is higher, the out of wedlock birth rate is higher. These are all very important factors in determining whether young people engage in sexual relations at a young age; we know that. There is a mountain of research to show that. If you are growing up in a stable family environment you are less likely to be sexually active at 12 or 13. (Mr Whelan) There has not been an improvement in Holland. Since 1995 - (Mr Whelan) I cannot answer because we have been looking for evidence of age at first intercourse in the Netherlands and we have not found anything that was reliable so I would like to see where this increase has occurred. In the last five years they certainly have had increases in the conception rate, the abortion rate and the STI rate for teenagers. Chairman (Ms Frances) There are various things about Holland, thirty odd years ago they took this on as an issue - I have been doing this work for 20 years - when I came in they had been at it for ten years, massive tv adverts, women going into schools and what they have now is the result of that piece of work. (Ms Frances) Absolutely. We are now in the second generation. We now have the parents who got it first and they changed their society which felt very difficult, if you like, about sex and young people having sex. They changed that once they realised. That historical evidence is interesting to read because they deliberately realised there was a trend happening, realised it was dangerous and they had to help their young people. That is the fragmentism of the Dutch, young people were starting to have sex, they had to do something about it so they got on and did it. I would equate the Teenage Pregnancy Strategy as a very similar process, it just so happens we are thirty years later. (Ms Frances) That is what I am hoping. That is what I believe. (Ms Frances) Yes. (Ms Frances) Sex education is just one piece, it is like a children's jigsaw puzzle, if you take a piece out you cannot see the picture. Sex education is just one bit about it. There is another thing about Holland, it is a much smaller country and there is far less poverty and disadvantage. You are talking about a large middle class. If we were just dealing with the middle class in this country then we would not need - Chairman: The same could be argued for Sweden as well because it is a much less class ridden society. John Austin (Ms Frances) Absolutely, those who have not had the good attention. (Mr Whelan) The other point often not mentioned about Holland is that benefits for teenage mothers are very low and until recently they got nothing at all. They do not get housing, they do not get income support. Over the last couple of years it has changed and it is at the discretion of the municipality but on the whole teenage mothers have to live with their own parents and any benefits they receive are through their own parents. Sandra Gidley (Dr Stammers) I think that the two best examples that I can point to have certainly come into my field of awareness since I wrote this submission. Probably worldwide the most positive evidence that the encouragement of abstinence and marital fidelity can have a very impact on sexually transmitted infection is that of Uganda. There was coverage in the Times recently in having that really as the highlight of the policy in Uganda, with abstinence first, being faithful second and condoms a third important issue, but largely within the context of preventing HIV transmission amongst discordant couples in Uganda. That is the only country in Africa that has seen a substantial reduction in HIV. That speak very loudly. There are a number of articles that have come out about that very recently in the Lancet and elsewhere. In America the only article I am familiar with which I briefly mentioned earlier is about Monroe county which has had an abstinence programme that has reduced the rate of under 16 intercourse and also reduced the unplanned pregnancy rates in that particular county much faster than in the surrounding areas of New York. I can certainly provide a reference for the Committee for that paper if you require it. I would be very happy to do that. It would be fair to say that the evidence as yet is at an early stage because it is only just recently in the States that such programmes have been given the financial clout that enables the good ones to prosper and unfortunately some of the bad ones to get started up as well. I was not convinced by Gill's report on saying no to abstinence because I think a lot of the good was ignored and the bad was magnified. (Ms Frances) We have to disagree. I went across to America and saw these various methodologies. There was not any proof that any of the abstinence stuff worked. I am still shocked that America is spending - it is such a big figure I cannot remember it - something like $60 billion on the methodology that all their own experts say will not work. It is very scary. (Dr Stammers) Does that not happen with condoms now? Doug Kirby says there is no evidence that promoting condoms in schools makes any difference to teenage pregnancy rates at all and yet presumably you would support that as a policy without any evidence whatsoever. (Ms Frances) It is a sexual health preventative. (Dr Stammers) It is not, it does not work, Gill. (Mr Whelan) I would like to add to your point, there is not any substantive evidence of the outcomes of abstinence evidence because it is very recent. There are major studies coming online at the end of this year or the beginning of next year, obviously we all await with interest. The thing that seems extraordinary to me is we have had sex education in schools for 20 to 30 years and there never been any evidence that any of it works. No one has ever tried to measure the outcomes. A few years ago I wrote a piece called "Teaching Sex in Schools", I looked at the research evidence and the outcome of sex education and I was shocked to find there was not any. It is the only subject on the curriculum that is not tested. If you are teaching reading, maths or anything else it is constantly evaluated to see what effect it is having. Sex education is not. It is only that abstinence education is an issue that suddenly everyone is saying, we want hard, fast and incontrovertible proof. Andy Burnham (Dr Stammers) I do not think you can equate the catechism with abstinence education, can you, anymore that you can equate a condom advert with --- Andy Burnham: It was a fairly blanket message. It was do not. Dr Naysmith (Dr Stammers) That is the problem with the concept of a "Just Say No" message if that is the content of your abstinence. There are ghastly sites in America that take this tack, that is the way that you have to go and no reasons are given, that is doomed to fail. That is very different from giving a programme that looks at the nature of sexuality, encourages young people to explore whether there is any meaning in intercourse, other that the sensation of orgasm, and then exploring those issues to see why abstinence may be a good idea. That is very, very different, that is exploration rather than didactic. (Dr Stammers) I think one of the biggest projects that we had in recent years was our survey that was published two years ago where we took a random selection of schools up and down the country and surveyed, I think it was, over 2,000 pupils and surveyed what they thought about many of these issues. Certainly that was a very illuminating piece of research that I am proud to have been associated with. I think that taking on board what young people are thinking is absolutely essential. It was interesting that from that sample that we took, a very, very high percentage of young teenagers, for example, viewed marriage as something that they felt was a goal that they wanted to aim for and ultimately head for. That is something that is often said to the contrary. The difficulty, as exemplified by that example, is if you find out what young people are saying, some of it you will agree with, some of it you will not and then it is a matter of what do you teach and hence the debate. I do think it is essential that it is contextualised and it is made relevant. Another thing that we have done just recently is had some challenge teams, as they are called, over from Canada who have been doing sketches, drama, abstinence drama education and although that has had some controversy in the press the reports back from the schools themselves have been very positive. On every occasion I can honestly say when I have been in a school presenting the kind of viewpoint I have given to you today to sometimes up to 200 sixth formers, the response from teachers and pupils alike has always been positive and they keep inviting me back. I hope that we are in tune with at least the way some young people are thinking. (Dr Stammers) I think it would be fair to say that there was a strong indication that the pressures to do so were very keenly felt by young people but I think we were ---- (Mr Whelan) It was a huge survey, lots of questions, very complicated analysis, but the feeling I got from it was most young people have quite traditional views about the way they would like their lives to turn out. At the same time they are often behaving in a way that makes it unlikely. (Mr Whelan) I think often they have not ---- (Mr Whelan) As I said earlier, I do not think there is a magic programme for sex education that we can devise that is going to solve the huge cultural problems we are facing, which are the sexualisation of the culture and the increasing pressure on young people to be sexually active at early ages. There are some things you can do to oppose it but on the whole it is beyond the reach of sex education. If I can go back to your original question, do we take young people's views into account, any programme that did not take young people's views into account and which did not take into account the culture in which they are living would obviously fail, but that does not mean to say that we accept young people's current views on things as the last word and we do not try to educate them. (Mr Whelan) We take into account the fact that most people want to get married and have children, that is the norm in society, but for a lot of people there is a gap between what they want for their lives and what they are getting. (Mr Whelan) No. This survey that Dr Stammers was talking about was a random survey of about 22 schools. (Mr Whelan) That one was 2,250 13-15 year olds. If I can just give you another example. At the moment we are testing a manual called The Art of Loving Well which is devised to try and help at-risk young people to resist the pressures to get into sex early. That has been tested in six schools and it is spread around the country. It is the usual way in which any educational programme is tested, you find some religious schools, some secular schools, some in urban areas and some in rural areas and you try and correlate. (Dr Stammers) Can I respond with my other hat on because as well as being a trustee of the Family Education Trust, in which capacity I am here this morning, I also work with an organisation that has a wide sex education programme in Northern Ireland called Loveforlife with a website, Loveforlife.org.uk. That has a website which answers young people's questions. It is not possible to do that without being very, very keenly aware of the way in which young people are thinking both in terms of the language that they use and of the fraught world that they are coming from. I think that keeps me at a cutting edge in this area where perhaps in my medical practice the number of teenagers I would see would be relatively small in proportion to older patients. It does keep me abreast of what is going on. As Robert says, I think many of these young people, as I guess all of us are, are looking for meaning and love and one of the difficulties with the area of sex is that it often promises these things but does not necessarily deliver them and that is why there is often this mismatch between the aspiration of young people to find something beautiful and the sad discovery that something dreadful comes along. (Dr Stammers) No, absolutely not, but it certainly does apply to that. Chairman (Mr Whelan) It is possible. First of all, there is no short-term solution to what we are talking about, all the solutions are long-term, that is what is so frustrating about it because we are not going to be around when the results come in. I think parents influence their children more by the way they live than by conversations they have with them about sex. It is the home environment which is the main determinant of whether children become sexually active at a very young age or not. Andy Burnham (Mr Whelan) That is the thrust of our material. We do a video called The 3Rs of Family Life that makes exactly that point, that the decisions they are taking now will affect the way their lives develop in the future. (Ms Frances) It is not about telling them. The whole thing about young people being consulted is not about doing a survey, it is about whoever is going to deliver the sex education, whether it be parents or carers or social workers or teachers, actually engaging with young people and saying "What do you want?" It is about consulting with them and getting young people to participate. In the whole process of helping to set up what is going to happen for them, they will probably learn more from that process and they will learn more about communicating and talking about it than they ever will as the passive receivers of a video or of a programme from a teacher or somebody who has not been properly educated to engage with young people. It is the relationship that you have with the young people that is important. Every piece of work that we do should be engaging them in the task and not saying "What do you think of what we have done?" or "What do you think of what we say?" I think that is a really important facet. Julia Drown (Ms Frances) I think what delighted me about the Teenage Pregnancy Strategy was it said this is a difficult problem that needs lots of solutions. That was really, really helpful. Many families need a nice little leaflet, a bit of help and they will kick in and they will do a nice job and it will be fine but there are a whole bunch of young people that do not come from those sort of situations and that is when they need a key person. I got math GCSE because I fell in love with the teacher, there was no reason for me to pass maths but I got it, she came into my life at the right time, she inspired me, I thought she was wonderful. That is what is important. We do not have those key people who are qualified and skilled- up and feel confident, so our most vulnerable young people in care, on the edge of society, at risk of exclusion. You are in a class of thirty and we need to have extra people round, mentors, personal advisers, a whole bunch people who feel confident talking about sexual matters, so they can pick up those young people and support them through. The ordinary, average stuff is fine for the ordinary, average young person and the rest need something else as well, not instead of, and then they need to fall back into what everyone else is getting. I do not know whether that answers your question. That seems to me to be crucial. We are talking about a percentage of young people here who are not getting pregnant because they do not have any information, they are getting pregnant because it seems to be one positive option in a life where there are not many positive options. (Dr Stammers) It is interesting question as to where the censorship ends and the protection of young people begins. I am not particularly pro widespread censorship, I think it is much better if things can come from the heart or within than imposed from outside. It does seem to me as a society quite paradoxical that we do get into a great drama about paedophilia and child pornography, and quite rightly prosecute those involved in that, but if one were to look at some of the sex education material that is round out there sometimes distinguishing it from some of the stuff that is being prosecuted in some circumstances it may be quite difficult, and that is an issue that needs to be talked about. Sandra Gidley (Mr Whelan) Yes, definitely. There is other research that suggests that some programmes that have the possible effect of delaying first intercourse and reduce the number of partners are programmes that did not address sexuality directly but they did deal with these personality and relationship issues you are bringing up. Young people are not getting pregnant because they think that babies are delivered by Mr Stork under the gooseberry bush. People have a pretty good idea now of the processes you have to go through to produce a baby. Andy Burnham (Ms Frances) I think it is crucial. We now have an extremely good PHSE framework which is linked to the statutory citizenship for children over 11 but under 11 it is not. What is crucial is that PHSE is not statutory, you will have some schools that will take it on and deliver it and see it as one of their core functions and other schools will not touch it at all. That is really, really, really important. That is when sex education sudden flares up as being out of context, it does not have a little home to tuck into. It is when we get into ridiculous conversations about whether we talk to four year old children about sex... Obviously what four year old children need when they first go to school is a broad-based personal sex development or PHSE in which they can build the foundation of who they are, how to communicate and when the time comes the sex and the drugs and the food and the exercise can be popped into it as appropriate. It has a context. (Ms Frances) We have it too. It is a really brilliant piece of work. We also have the National Health in Schools Standards, which is the vehicle to deliver it, but neither of them are statutory. (Ms Frances) That is the other difference in Holland, if they want to survey their schools it is very small, if we want to survey ours we have 26,000 schools and none of us can afford to do that piece of research. What is important for us this year is that the DfES and the DH have put together an evaluation of how PHSE in healthy schools affects learning and children's development. We will have the very first findings of that in August, it is going to be too late for you but it is looking fairly promising and they will be publishing it in December. That is a really, really important piece of evidence that we will have some time this year where we will be able to link personal, social development, learning and health across the same --- (Ms Frances) It has to be. (Ms Frances) Until it is statutory our teachers will not be trained to deliver it. (Ms Frances) If you make it statutory then it means that there is no reason when you are doing your literacy and numeracy you cannot use a reading book or a story book or a discussion topic which is round emotional feelings and what it feels like to be sad or about bereavement or about having a new baby in your family or about puberty. The very good schools are already doing that, they see it as an opportunity, they see it as a perfect opportunity for children to be numerate and literate and emotionally literate. (Ms Frances) The framework is there. We are very proud of it. The teaching professions are happy. What we do not have is schools doing this because schools are saying, "we do not have the time, we have other things to do. It is not statutory and we only deal with statutory". Most importantly teachers only get trained to deliver the statutory framework, they do not get trained to deliver non-statutory. You will have loads and loads of teachers delivering things like talking about bereavement, sex and drugs who have not had the training, which is unfair on the children and deeply unfair on the teachers. (Ms Frances) It is a knock-on. They only train teachers to deliver the statutory curriculum. (Ms Frances) That is the thing to put into place. Chairman: Can I say it is nearly five minutes off one o'clock and I am conscious that we might tie up by one. Can I ask my colleagues to ask brief questions and can we have brief-ish answers to try and get through on time. Dr Naysmith: This area has been partly covered already. There are individuals in society who are more vulnerable perhaps and find it harder to access education in this kind of area. I am thinking of young men in general, and we have covered that already, but maybe particularly young homosexual men, young people who are leaving care, that sort of thing, people who are vulnerable to poor sexual health, teenage pregnancy and the daughters of teenage mothers. All of these are examples of people who would not be covered by the normal programme you are advocating in schools and so on. In relation to the needs of these hard to reach and sometimes particularly vulnerable youngsters, how would you suggest they should be given help and assistance? Chairman (Mr Whelan) It is very difficult. The whole problem with sex education is you are dealing with a group of children of a certain age and they will be at different levels of maturity and girls mature faster than boys, so mixed schools have got particular problems. I do not think there is a simple answer to that. We have got to rely on the discretion of teachers to deal with the issues as they come up in a tactful and professional way and not to proselytize. (Mr Whelan) But we do not have a situation now where teachers are debarred from discussing this area. Chairman: I think a lot of teachers seem to feel that. They are very uneasy about it. When we are looking at sex education I think one of the issues we, as a Committee, have got to address is at what stage is it appropriate for people to be talking about orientation, because it clearly is an issue amongst some of the youngsters who are coming through the system. At the moment, as Doug was implying, there are some very vulnerable people who do not feel that the mainstream sex education in any way addresses their particular concerns and dilemmas. Dr Naysmith: It is not just about gay men. Chairman (Dr Stammers) It depends on the age of the child as to whether it is going to be an issue of whether they are homosexual or whether they have ambivalence about their sexual orientation. I think that work very clearly shows that about 25 per cent of 12-13 year olds may be ambivalent about their sexuality whereas I think it is quite clear that the number of particularly men who have sex with men exclusively is two per cent of the population at the maximum. There is a spectrum of activity that one is dealing with. Dr Naysmith (Dr Stammers) The Ramaphedi Study in the States shows that about 25 per cent of children aged 12-13 would have some degree of ambivalence about their sexual orientation and then it progressively declines. (Dr Stammers) My view is that roughly speaking it is about two per cent of men who within the past five years have had sex exclusively with men. Your question also brings to mind the other issue that where men are having sex with men they are often having sex with women as well and bisexuality is a very common pattern of behaviour also that never gets mentioned or addressed by either the heterosexual or the gay populations because of their defensiveness on that area of ambivalence. Chairman (Dr Stammers) I think that teachers ought to be able to raise these issues and discuss them openly with children at the age of 12 or 13 because that is the age at which the ambivalence is at its greatest. My major concern, however, and I am aware that I can be a very aggressive proselytizer of the things that I believe in too, is at that stage of ambivalence clearly what input is given to those children at that stage could have a major influence on whether they become a part of the much smaller percentage who pursue an entirely homosexual activity pathway later on or those who do not. If we are going to have a lot of stuff propagated about the gay gene and such activity being inevitable and so on, that is deeply worrying and I think many parents will share very grave concerns about that. (Dr Stammers) I agree. (Dr Stammers) I think it is an incredibly difficult dilemma and it is very, very hard always, not just in the sexual arena, to deal with the non-normative and the minority. Certainly, personally speaking, I too have gay patients who from a very early age, I think, were damaged by the refusal of society to acknowledge the existence of homosexuality. I think that must be a very, very detrimental thing to a person's psyche. I am not a coal face teacher for a primary school but if I were I would have thought that would be one of the most difficult issues with which I had to wrestle, particularly in the context of a society that seems to me from top to bottom is deeply homophobic and automatically makes hetero sexist assumptions. You have only got to look at popular programmes on most of the channels to see that that is so. I am not sure that legislation is a way that can be ---- (Dr Stammers) A very difficult issue. (Ms Frances) Very briefly. It is not about sex. Probably every child going up through primary school has an Uncle John and an Uncle Simon, or an Aunty Margaret and Aunty Joan who live together. It is about taking it out of the sexual arena and just saying "Yes, Uncle John lives with Uncle Peter because they love each other". I think it is as simple as that, sex does not come into it. I think it is us and all our old angst about sexuality generally and that can be dealt with, and is dealt with in primary schools across the country very simply just about two people loving each other and living together. You get better presents too, I gather, if you have got two uncles. Dr Taylor (Dr Stammers) Certainly I think that it is a good book and to a certain extent my response to that is a personal one, that having read it I would be happy to give it to my children. I think it was particularly sensitive on the issue that we were talking about earlier of homosexual orientation and he answers very wisely and compassionately on that particular issue. (Dr Stammers) That is right. (Dr Stammers) I think it is a good book for parents of children of all ages because it is never too young to prepare the parents. It is aimed at children probably 11 or 12 upwards who would find it useful. There are others I could recommend for younger children as well, particularly one called Who Made Me? for very young children, that is absolutely brilliant, by Nick Butterworth and Nick Inkpen, two well-known young children's authors. I think the difficulty with the Cohen publications in particular, which I would say I have not read in their entirety and have only seen extracts from, is the extracts did not lead me to want to read the whole thing in their entirety because I think they did begin to move into this boundary area that blurs child abuse from sex education. I think facing up to the reality of that blur, there are pictures from some of those books that I have shown to groups of adults and you can see a physical wince. There are some things that are very, very wrong to show to very young children who cannot understand anything about the contextualisation of sex that we have been talking about. (Dr Stammers) Doing it from grass roots and getting involved is the best way. Where you have a parent who has a vision for inspiring other parents to get involved it can work very well. Often the most successful ventures are where individual parents have suggested to schools that they might have an evening on this subject and have got enthused about it and invite people round. My own experience at my child's middle school is we had such an evening and we had over 200 parents. It was the biggest attendance we have ever had at any parents' event. (Dr Stammers) That is right. Dr Naysmith (Dr Stammers) My primary concern about that is not that it implies a casual attitude about sex but my primary concern is it only looks at one particular target area and that if you are just dishing out the morning after pill and not warning that girl of the risk of other STIs that is doing her a disservice. My personal concerns about these pills being given out with virtually no questions asked at some pharmacies is that is not good sexual health care because she may have got chlamydia and you have done nothing about it. My recommendation would be that there should be a statutory requirement for pharmacy distribution of morning after pills to give those patients a leaflet explaining about the risk of STIs and showing them where they can get help as a bear minimum if we are really interested in getting a global, comprehensive view. I think equally with condoms the message has got across I think it will be difficult to reverse that condom use equals safe sex. It is nothing of the kind, it may be safer with HIV but with other viruses it is not safe at all. We do need to communicate the accurate message that they offer some protection but are far from safe. (Dr Stammers) I do not think it is patronising, I think it is based on what I think we have been agreed on in the sexual arena, that people often do behave irrationally. Some of the patients that I see on a day-to-day basis they will say to me, "I do not know what I was doing I must have been mad, I do not know what got hold of me". We are not dealing with an arena where people necessarily think straight. The girls' primary emphasis, particularly if she is a young girl getting the morning after pill, will only be related to "I must not be pregnant". It is not patronising to try and prevent her getting chlamydia, which would make her infertile as well. I would say I was not doing my job properly if I did not tackle both areas. You mention in your submission, I am not sure if this is Mr Whelan or Dr Stammers, that "there is a gross imbalance in the emphasis given to HIV/AIDS instead of other much more widely prevalent STIs". Is it your view that the case on HIV/AIDS is overstated and the other understated, or should the information given on the other STIs be of the same magnitude as that accorded to HIV and AIDS? How does this imbalance actually manifest itself in its effect on young people's sexual health? (Dr Stammers) I would not want to give the impression at all by making the answer I will give you in a minute that I am not aware of the profound impact that AIDS can make. Certainly I have personally looked after two gay men who died of AIDS at a young age and that was a profoundly moving and deep experience. Having said that, however, nationwide there are, I gather, as are mentioned in the report, more people who die of falling down stairs each year than of AIDS. When I go into a school and ask young people to indicate if they have heard of an STI virtually every hand will go up and when I then say if they have thought of HIV or AIDS to put their hands down, out of a sixth form of about 200 in a public school maybe about half a dozen, a dozen, hands will remain up. I think that is tragic because the vast majority of those young men and women stand an infinitesimally small chance of getting HIV. It is not a very transmissible infection. Even with an HIV infected person, vaginal intercourse will only transmit it one on a thousand occasions but with gonorrhea it is one in two. Looking at evidence regarding the prevalence of these diseases, I think it is tragically understated and we need much, much more in the way of educating young people about non-HIV STIs. Also, we must not become complacent about HIV either because obviously that is fatal, but so can cervical cancer be as well. (Dr Stammers) I think there is too much information about it proportionately, yes, although the two are not necessarily unlinked in as much as at least it is highlighting the fact that there are nasty things out there that can get you and certainly if the HIV message is getting across to that degree it will help to a certain extent to prevent others as well. I think it is because so much of the evidence about the effectiveness of condoms relates to HIV that that is then carried through in the public image that, therefore, they protect against these much more common diseases, which they do not. I think to that extent the information about HIV may be counterproductive. (Mr Whelan) Can I just say I think the reason that people are so unreceptive now to health education messages about STIs is that the AIDS campaign in the 1980s went so completely over the top. (Mr Whelan) No, it was not so successful. (Mr Whelan) As I have said, if you say it is successful you would have to show that health education has an impact on the way in which people behave and that is a very difficult area to prove. (Dr Stammers) It did change behaviour but it was not lasting. (Mr Whelan) That is what I am going to say. It changed behaviour briefly. If you look at the statistics for rectal gonorrhea, which are a pretty good indicator of homosexual activity, they dipped at the end of the 1980s but then they started to climb again because the cataclysm, the holocaust, promised by all these images of coffins and the Grim Reaper with his scythe and so on never happened. Dr Naysmith: It is happening in some South Africa countries now. Jim Dowd (Mr Whelan) What did they do? (Mr Whelan) No, I do not think they did change behaviour. Studies indicate that they did not. (Ms Frances) We stopped giving the message and the figures are going up. That is what is scarey. In a recent piece of work from the HIV Forum, which is also an NCB, they have been doing consultations with young people and whereas ten years ago if I had asked a group of young people what HIV is, what they would do, they would tell me pat but the young people who came to consult with us and help us run the project said the reason why they had come was because they had never been taught about HIV in school. It is not being delivered in school. Also, lots of our children do have family and friends living in other countries where the countries are absolutely devastated by HIV. I do not think we can marginalise HIV, if anything I think we have got to bring it back into the frame and have it very much as part of sex education in schools because it is not being looked after and supported in schools at the moment. Julia Drown (Dr Stammers) The place that has shown me the images that worried me has been the booklet called "Sex in Schools" that looked at the situation in Scotland published by the Christian Institute. If you have a look at some of the images in that that is the kind of thing that is unacceptable and should not be shown to primary school children because they will be terribly thrown and wonder what on earth is going on. (Dr Stammers) I think sometimes focusing on material can blur the importance of the wider issues that we have spoken about this morning, and I am much more concerned about that. If you have dreadful material and good parents at home they ---- (Dr Stammers) ---- are able to counter the material. I am not saying it is not so bad but they can counter the effects of it. (Ms Frances) If you work within the SRE guidance then you will have developed a programme round SRE, whether it be primary or secondary schools, in which the children you are teaching, the young people you are teaching and their parents and carers will have engaged in and looked through the resources. I have never actually met a teacher who would take a weird visual thing into a classroom, teachers by their nature tend to be conventional. It may have happened, it may be happening but I have never, ever seen it. Chairman: Can I thank our witnesses for a very interesting session. Thank you very much. |