Psych Paper

angie1981

teenage_sex_health.pdf

Home >Psychology homework help >Psych Paper

Teenage sexual health needs: asking the consumers

Carolyn Lester National Public Health Service for Wales, Cathays Park, UK, and

Alexandra Allan School of Social Sciences, Cardiff University, Cathays Park, UK

Abstract

Purpose – In response to rising prevalence of sexually transmitted infection (STI) among teenagers, this study was designed to examine teenage perceptions of sex education, access to services, and attitudes relevant to STI.

Design/methodology/approach – A focus group study was conducted in three schools to discuss the sexual health needs of teenagers. Four single sex groups of 14-15 year olds (two male and two female) comprising six to nine participants met for two one-hour sessions. Interviews were recorded, transcribed and analysed by two researchers.

Findings – Sex education was reported to vary considerably in quality and content both between and within schools. Participants felt that this was due to some teachers being embarrassed, resulting in didactic delivery and lack of discussion. Most participants had received very little information about STI, including how it could be avoided or what to do if infection was suspected. Many felt that it would be useful to have an organised visit to a sexual health/contraceptive clinic as part of the curriculum and that it would also be helpful if clinic staff contributed to their sex education.

Research limitations/implications – Teachers selected participants based on their maturity and willingness to take part, which may have resulted in failure to include those in greatest need of sexual health services.

Practical implications – Teenagers need more comprehensive sex education at an earlier age, delivered by individuals who are expert in the subject and comfortable in its delivery. Information alone is not enough but should be linked to accessible user-friendly services for contraception and general sexual health.

Originality/value – This paper provides information on teenage sexual health needs in general and to the field of STI in particular.

Keywords Sex education, Health services, Sexual health, Consumers

Paper type Case study

Introduction Chlamydia is now the most common sexually transmitted disease in the UK and is most common in women aged less than 20 years. It is estimated that 60-80 per cent of genital chlamydial infections are asymptomatic (Hicks et al., 1999) resulting in infections remaining untreated and subsequent reproductive problems. This study took place in 2002/2003 during rising rates of sexually transmitted infection (STI) (Public Health Laboratory Service, 2001). A chlamydia screening pilot for England (Department of Health, 2002) showed rates of 13.8 per cent for those aged under

The current issue and full text archive of this journal is available at

www.emeraldinsight.com/0965-4283.htm

The authors would like to thank all who took part in the focus groups and staff at Willows, Brynhafren and Barry Boys Comprehensive Schools. They are also grateful to Dr Marion Lyons for advice on medical aspects.

Teenage sexual health needs

315

Health Education Vol. 106 No. 4, 2006

pp. 315-328 q Emerald Group Publishing Limited

0965-4283 DOI 10.1108/09654280610673490

16 years and 10.5 per cent for those aged 16-19. Local opportunistic testing of young people seeking contraceptive advice produced chlamydial infection rates of around 20 per cent, with one location at 50 per cent.

A British Medical Association (2002) report suggested possible explanations for current high STI rates. Though there is increased transmission, there is also greater professional and public awareness, improved access to GUM services, and improvements in diagnostic sensitivity. The report suggests that contributory factors may be inadequate sex education and the absence of recent high profile safer sex campaigns.

Approximately 26 per cent of girls and 30 per cent of boys have had sexual intercourse before the age of 16 (Wellings et al., 2001). A previous local study (Jones et al., 1997) reported that STI education was non-existent in some schools and very poor in others, concluding that sex education, information and service provision requires a holistic approach.

Curricula designed to help teenagers deal with social and peer pressure have had some success in tackling risk-taking behaviour (Kirby, 1992) and it is advisable to consider teenage views when planning sex education (Mellanby et al., 1996; Scott and Thompson, 1992). Adolescents think that sex education should be more positive and that sexual health clinics should be advertised in locations frequented by teenagers (DiCenso et al., 2002).

Research on teenage sexual health has tended to focus on pregnancy rather than STI, but findings can be relevant to both, for example, abstinence programmes showed an increase in pregnancies in partners of male participants (DiCenso et al., 2002). Such programmes may discourage males from carrying condoms while sexual intercourse continues at the original rates, so may also to lead to a rise in STI. Sex education programmes usually improve knowledge (Song et al., 2000) but there is little evidence of change in behaviour (DiCenso et al., 2002).

Success is associated with broader interventions at a younger age, for example, disadvantaged children receiving pre-school day-care are less likely to have teenage pregnancies (Zoritch et al., 1998), suggesting that sexual behaviour is likely to be based on self-efficacy engendered at an early age. Lessons from substance misuse programmes may also be relevant, where a combination of teaching social resistance and general life skills has been shown to be effective (Botvin et al., 1995). However, a recent Health Development Agency (2004) report on STI prevention has stated that there is insufficient evidence to support or discount the efficacy of community development/empowerment in this context.

In 2000 a Sexual Health Strategy for Wales (National Assembly for Wales, 2000) recommended effective sex education, including information on STI, combined with good access to sexual health services. In England the Department of Health has given a commitment to improve sexual health and relationship education in school and to increase access to young person friendly services (DOH, 2004).

Aim of this study The aim of this study was to examine sexual knowledge, attitudes, practice and access to services and to re-visit topics examined in our previous study (Jones et al., 1997) which resulted in improved services for young people. Since, at least the 1980s and probably before (Davis, 1989) sex education has been criticised by some expert teachers, doctors and by teenagers for failing to keep pace with societal norms and for

HE 106,4

316

being too late, and too general. This study set out to examine whether, in the opinion of teenagers, this situation had improved.

Method Year ten pupils (aged 14-15 years) in three schools took part in this study. A mixed comprehensive involved in the 1997 study was included and other schools were single sex comprehensives in an area of high chlamydia prevalence. Sampling was theoretically driven with schools asked to select pupils based on their maturity, and willingness to take part. Parents of the selected pupils were sent a letter explaining the study and giving a researcher’s telephone number for queries. Parents were invited to contact the school if they did not wish their child to take part.

Separate gender groups were held, as experience indicated that this promoted greater openness. Two meetings were convened for each group, led by an experienced young facilitator plus an observer. Focus groups were semi-structured and based around questions which are used as sub headings in reporting results.

Data were analysed based on a “grounded theory” approach, with theories developed inductively from the process of collecting and analysing data. Theories that are produced are, therefore, grounded in the data and the real experience of participants (Glaser and Strauss, 1967). The constant comparison technique was also used, involving reading all of the transcripts to gain an overall “feel” for the data (Atkinson, 1999). Categories were generally researcher led (based on the questions asked) and were interrogated until they reached theoretical saturation in the light of the study’s aims.

Results Groups comprised between six and nine participants and interviews lasted approximately one hour. In all 16 girls and 16 boys took part. The following abbreviations denote the speaker when direct quotes are used: C ¼ Cardiff, V ¼ Vale, B ¼ boys, G ¼ girls. Each participant is allocated a person number with sessions numbered one and two. Thus, CG1.4 would denote Cardiff girls first session, person four. Results are grouped under the core category (question) to which they most closely relate.

What do you think of school sex education? Students approved the practice of year seven concentrating on puberty, but felt that this should move on to sexuality and relationships in years 8 and 9. Sex education had not started soon enough and an early start would help to overcome embarrassment. All groups appreciated the problems of differential maturity and hence the relevance of messages at different ages to different people. Participants discussed the relevance of information to their own situation. The view emerged that sex education should be a practical tool for life and should be an ongoing process, delivered appropriately in each year. It was important that teens should be taught about sex in school, but they wished to be treated with respect and not told how they should think and act.

Style of delivery was important, for example, pupils wanted lessons to be “less patronising” and more relevant, wishing teachers to be sensitive to their increasing emotional and sexual maturity. Sex education was being modified to the intellectual capacity of the “less able” who were also “less mature”. This meant that the less able were getting less sex education, but these were the people most at risk of reckless sexual behaviour:

Teenage sexual health needs

317

CB1.4: See the bottom set is less mature about things and they mess about . . . With the lower set they have a narrower range of things they can do with the class before it breaks up.

CG1.3: I think that’s wrong ’cos the lower bands are the ones having the sexual relationships.

All groups reported variation in the quality and content of lessons within their own school and year group, attributed to teacher embarrassment and consequent poor delivery:

CG1.1: And it depends what teacher you get as well. Mr. . . he was all right talking about it, but say you had Mr – I don’t think he . . . he was too shy and that.

They argued for the inclusion of the emotional side of sex, which was missing in current teaching. Some teachers were uncomfortable delivering sex education, resulting in textbook teaching and reluctance to answer questions or enter into discussion:

VB1.4: With the teachers you can’t have a discussion. It’s like a taboo or hush-hush subject.

Some teachers, however, were respected for their realistic approach and one was commended for highly participatory methods with good class control. To be effective, teachers should be comfortable with their own sexuality and take a relaxed attitude to sex education. They should respect confidentiality and be willing to answer questions frankly.

Role-play and didactic methods were disliked and recall testing considered inappropriate for this subject. Though many were reluctant to watch sexual health programmes at home, they would welcome recording for showing in school. Those who had been given wallet-sized cards with contact numbers thought that this was a good idea. Three of the four groups said that they would like a facility for anonymous written questions to be answered in class. (This had already been tried with some success in one school.) Students would welcome outside experts, such as sexual health clinic staff, to provide sex education modules in school.

How would you feel about peer-delivered sex education? Some thought that using peer tutors would ensure that information was appropriate:

CB1.4: If a peer comes in then you know your learning is relevant to real life.

Most boys preferred teaching by someone more experienced and mature, believing that a tutor close to their own age would have problems controlling teenage boys and would not be taken seriously:

VB1.1: I think we need someone with experience and who’s more mature, but if it was somebody our age, they would mess about a lot.

Girls were unhappy with peer tutors near their own age, believing they would lack credibility but thought that someone of undergraduate age would empathise with pupils and would be listened to.

From where have you learnt most about sex in general? Girls described social networks, some including boys, where they could discuss sex. Some claimed to have learnt most about sex from older boys, in some instances from practical experimentation. Though boys are believed to have fewer opportunities for

HE 106,4

318

discussions with peers, some said that most of their information came from friends. Whereas girls discussed information from magazines, television and school, boys described a different type of interaction:

CB1.4: Yeah, you don’t just sit down and have a conversation and say that this is so and so, but you just mess about and things slip in.

There were no equivalent information sources in publications for boys but many read sex advice sections in girls’ magazines. Some information came from television but this was considered embarrassing if parents were present. Girls said that most of the information from school, they already knew from magazines but needed better explanations about contraception and more on the emotional side of relationships.

Both girls and boys discussed sex with older siblings and found them a good source of information. They stressed the importance of talking about sex in order to understand it better and thought that discussion-based lessons might help to bridge the gender divide. Girls in the single sex school thought that it would be helpful to talk to boys to encourage mutual understanding.

From where have you learnt most about contraception? Main sources were friends and school. When parents were involved, it was often in a negative way, such as threats of what would happen if a girl were to become pregnant. There was some discussion about access to contraceptive advice via the local “family planning” clinic, but only Vale pupils had been informed of services by the school. The title “family planning” was disliked as it implied that the service was not for them. There was emphasis throughout on being “straight to the point” and some thought that contraceptive clinic would be a better title.

Re-visiting the theme of variability, it was said that:

VG1.9: Some of us aren’t being taught about contraception, but we’re also not being taught about emergency contraception. Some people just don’t have any idea what to do.

What have you been taught about using condoms? Vale pupils of both sexes were aware of a source of advice and free condoms at the local clinic:

VB1.1: We get to go down there and get free condoms and useful information and stuff like that.

Again there was a belief that some classes had been given more information than others, but none remembered condoms discussed as protection against STI. Condoms were relatively easy to obtain and free from clinics. Cost was not a major issue and though supermarkets were cheaper, machines were preferred for privacy. Privacy was an important motivator and clinics were generally preferred to shops:

Facilitator: Would you get them from the clinic, or would you rather buy them?

CB2.4: Probably from the clinic.

Teenage sexual health needs

319

What do you know about emergency contraception? Some had been told about emergency contraception in school, but believed that the information had come too late:

CB1.4: Most girls have done it by now and they know it’s stupid . . . I’m gonna wait ’til sixteen but it’s a bit late to teach you now about the morning after pill.

Cardiff girls had been told that they could go to the clinic for emergency contraception and that it could be taken up to two (sic) days after. Vale girls had not been taught about emergency contraception, though they had picked up information from magazines.

What do you know about sexual health services for teenagers? Participants preferred to attend clinics with designated sessions for young people rather than their GP. Cardiff students were unaware of the town centre young people’s clinic and would be more likely to buy condoms from machines. Some knew of a local clinic, but were unsure about details. Girls preferred a non-local clinic for reasons of confidentiality.

Vale students considered the local clinic appropriate to their needs, as it was relaxed and welcoming. A room was provided for socialising with tea and toast available, so they felt that it was good place to “just hang out”. It was open only at lunchtime, however, when they were not “officially” allowed out of the school grounds:

VG1.6: But the school is like, you’re not allowed out of school premises, and then they’re complaining that the girls are getting pregnant.

Accessing services was linked with embarrassment, lack of confidence and worries about what staff and others would think of them:

CG1.3: And ’cos we don’t know very much about it, we would be stuttering and that and they would be talking about us, like that child, she’s just messing around.

The question of an organised school visit to a sexual health clinic received a positive response, illustrated by the following:

CB1.1: I don’t think people would feel that embarrassed then, ’cos I reckon people feel embarrassed otherwise, going to a clinic and asking for stuff.

What do you know about sexually transmitted disease? Most thought that STI was not likely to affect teenagers, with the danger at some undefined time in the future, so it was not worth thinking about. Girls wanted more information and believed that people would be more sensible if they knew more about the effects of STI. All groups had been given very little (if any) information about chlamydia.

CG2.1: We were taught, but she was embarrassed. We just don’t know like how it’s going to affect you.

Knowing about the connection between chlamydia and infertility might not be a deterrent as most girls would not wish to get pregnant when in their teens and would not be thinking about how they would feel in future years. If they had more information about diseases and local prevalence, risks would become more real and

HE 106,4

320

they would take protection more seriously. All groups thought that their understanding was inadequate. Most would be willing to take a urine test but were uneasy about invasive tests, with some doubt about opportunistic testing:

VB1.2: Well, if it wasn’t what I went down there for, I’d go home and think about it but I wouldn’t have it done then.

Methods of information delivery should be relevant: if the medium was deficient, this would distract people from the message. The following is a criticism of a sexual health video:

VG1.4: ’Cos it had this sixties looking guy (general laughter) and he had VD and herpes at the same time.

Facilitator: So you didn’t think it was particularly relevant?

VG1.4: No, I thought it was funny.

Where would you go if you had a sexual health problem? A typical response was:

CB2.3: Well, we haven’t got the confidence to get a contraceptive from the clinic let alone go if you have a disease!

Many felt that embarrassment was a barrier to getting treatment:

CG1.3: I would probably keep it to myself ’cos I would be embarrassed about it . . . I would be ashamed. I wouldn’t go (to the clinic) ’cos I don’t like the thought of people examining me.

In this context, an organised visit to a sexual health clinic was approved because:

CB1.2: It’s good to know that there’s someone there that you can talk to, like in the back of your head you know you can go there with a problem.

The clinic was considered more “confidential” than the GP and girls thought it was important to have a female practitioner. There was some concern about the legal situation of those aged under 16 regarding sexual health advice.

Who should suggest using a condom? All groups agreed that girls were more likely to raise this issue because they would wish to avoid pregnancy. Ideally both partners should be willing to do so but this depended on the quality of the relationship. Girls thought that boys were less mature and were less worried about the consequences of not using a condom. Use was inconsistent among teenagers, and boys had a slightly different perspective on why this might be. There seemed to be a fear of embarrassing or offending a partner, or possibly raising fears about one’s own disease status:

CB2.4: Most of the time girls don’t want to wait for their boyfriend to put a condom on. And you don’t want to say condom in front of them, unless you know they’re OK with it.

As teaching failed to emphasise the role of condoms in preventing STI, boys were unlikely to see this as a matter of self-protection. There was some confusion about the dual purpose of condoms:

Teenage sexual health needs

321

VG2.1: Yeah you know when you’re on the pill, you don’t have to use a johnny do you?

VG2.5: You don’t have to use them, but you have to, to stop getting things.

Facilitator: Do you think if you just said to a boy, “Oh, I’m on the pill” do you think that would make a difference? Would they worry about it?

VG2.1: I reckon most boys would think it was better not to (use a condom).

This illustrates the overriding primacy of concerns about contraception over the risk of STI. Though many claimed that they were responsible and talked about being “safe” this was almost always in terms of unwanted pregnancy.

The question of girls carrying condoms was discussed and, whilst many thought that this was sensible and showed that they were in control, some felt that it “sent the wrong signals”. This idea links to a subsequent discussion on peer pressure where double standards for male and female sexuality were prevalent.

What might stop people using a condom? Though most thought that condoms were readily available, barriers remained. Some believed that shops would refuse to serve those aged under 16. Although condoms were cheaper in the supermarket and free at the clinic, they would prefer to use vending machines because it was less embarrassing. This led to some comments around the random nature of unprotected sex occurring due to seemingly trivial factors, for example:

CG2.3: . . . if you go to the toilets and you haven’t got change, then I think you’ll do it anyway.

Some Vale students ignored school restrictions to attend the local clinic, but the reality for many was denied access to a service planned to meet their needs. This may be a genuine barrier to condom use, as clinic users thought it less embarrassing than a shop.

VG2.4: Thing is, down the clinic you don’t get the funny eyes that they’d give you at the cash desk.

They had doubts about condom machines in school toilets as “people would mess around”. Some thought that parents or governors had already objected to the idea. It was suggested that condoms could be distributed in sex education lessons or made available via the school nurse. Some girls thought that teachers, especially younger women, could keep condoms for access on request.

Many thought that condoms might not be comfortable and that sex was better without. They had discussed this with peers and most agreed. Condoms took a while to put on, especially for the inexperienced, and this would cause embarrassment.

How would you feel about talking to your boy/girlfriend about sex? Girls found it easier than boys to talk seriously about sex and thought it inadvisable to have sex with someone without discussing it first. Discussing sex with a partner would depend on the maturity of the individuals. Girls were generally of the opinion that boys who were not mature to talk about sex were not mature enough to have sex.

Some mentioned traditional values that could support discussion:

CG1.1: If you were with them for ages and you have strong feelings for them, then I don’t think it would be hard.

HE 106,4

322

This also implies the converse: many who have casual sex, not based on a continuing relationship find it impossible to discuss sex with a partner.

Do you think there are pressures on teenagers to behave in certain ways? All thought that peer pressure was involved in sexual behaviour, but were more worried by what they saw as over-emphasis on abstinence by teachers and parents, which was counter-productive. Most adults failed to recognise their increasing maturity.

VB2.2: They treat us in the same way throughout the school . . . They find it really hard to believe that we’re nearly adults.

Adult pressure extended to prohibitions on television programmes that might provide information. Some believed that lack of knowledge might lead to experimentation.

CG2.3: They turn the channel over, so you want to know about it, so you go out and do it!

The issue of gender-related pressure emerged in relation to sexuality. Behaviour seemed to be influenced by dominant heterosexual discourses, as there were specific ways in which each sex was expected to behave. Girls were expected to be experienced, but not too experienced:

CG2.1: It’s weird in this school . . . if you don’t do much you get called frigid. If you do too much, you get called horrible names.

Similarly, concerning theoretical knowledge:

CG2.1: . . . and you get 100 per cent on a sex education test and they’re like, “Ah, why do you know all that?”

Boys reported very different experiences, demonstrating that defining masculine characteristics of sexual objectification, banter and behaviour are prevalent:

CB1.4: No, this is where it’s good to be a boy ’cos if you know too much then you’re a super-stud! . . . You can never have enough experience when you’re a boy.

Here most boys seemed to think this was an advantage, but a later contribution demonstrates resultant peer pressure:

CB2.4: . . . it’s just underlying, that you know that everyone has, and you’re just there like, embarrassed.

Boys could be openly proud of being sexually active, but this might exert pressures on the less experienced, perhaps leading to sexual relationships for which they were not ready.

Do you think that teenagers have an “it won’t happen to me” attitude? Many admitted to this attitude, especially in relation to STI. Referring to risk perception, a boy explained:

CB2.3: Some people know and they’ll still do it. But they think, oh it won’t happen now, but you know it will happen. Like smokers, they know it but they still carry on doing it. It’s like a drug.

Girls were very aware of the need to avoid pregnancy, because it had consequences that would affect their lives in the short term and could not be hidden. They had seen

Teenage sexual health needs

323

its consequences in their own age group, whereas they had never (to their knowledge) encountered anyone who had STI. Lack of concern about STI was thought to be due to the way they were taught:

VB2.2: It’s as if they’re teaching us a fictional story, you know? This man got AIDS and he’s miles away and it’ll never happen to you.

Opinions differed, however, supporting previously expressed beliefs about inter and intra school variation in teaching. Boys wished for a balance of information: they needed to be more aware of STI but not in an alarming way. Girls wanted more practical information about STI, concentrating on immediate effects and treatment. Discussion based sessions were the best way to deal with these issues but this may be difficult to achieve, given comments about teacher embarrassment and uncooperative pupil behaviour.

Discussion The main limitation of this study was that teachers selected participants based on their maturity and willingness to take part, which may have resulted in failure to include those in greatest need of sexual health services. This possibility was confirmed in focus group discussions where some participants indicated that more intelligent and better behaved pupils had been selected.

Though both local studies examined pupil opinion only, there was a high degree of intra and inter group consistency, leading the researchers to believe that they had been given fairly accurate information. Current results resembled those of previous local research, finding that sex education came too late and was inadequate (Jones et al., 1997). Although more “teenage friendly” services had been put in place following the first study, those who took part in the current study were largely unaware of their existence, demonstrating the necessity of collaboration between teachers and service providers. Teachers who are uncomfortable with sex education usually do it poorly, aggravated by inappropriate methods and materials, highlighting the need for expert input. Teenagers have insufficient information and this may apply disproportionately to those of lower ability.

Regarding peer delivery, greater empathy and making the information seem more relevant needs to be balanced against potential lack of respect for people of a similar age. Some difficulties could be overcome by using a scheme such as APAUSE, devised by Exeter University (2003) (www.exeter.ac.uk). Such schemes are popular with participants and can increase knowledge, but there is little evidence of effectiveness in changing rates of unprotected sex. A study of pupil led sex education in England (RIPPLE) reported that by age 16 fewer girls in the peer led group reported intercourse or unintended pregnancies than those in the control arm, though the difference was borderline (Stephenson et al., 2004).

It is believed that, due to strong friendships, girls find it easier to have in depth discussions and Hey (1997) suggests that friendships are a “defining female characteristic”. In the current study social networks were important for gaining understanding by discussing information obtained from the media, and from school. Teacher embarrassment was seen as an important factor in the information different groups received. When teaching about condom use had occurred the connection with protection against STI was not conveyed adequately. Discussions gave no indication

HE 106,4

324

that teenagers were relying on emergency contraception as a substitute for using condoms, so it is unlikely that wider availability of this method has played a significant part in the spread of infection.

The situation regarding the Cardiff school’s local clinic may have deteriorated since the previous study, when a number of pupils had either used the clinic or knew someone who had, whereas during the current research none were clinic users and knowledge was limited. Staff changes both in the school and the clinic may have contributed to this.

Preference expressed during our earlier study (Jones et al., 1997) for a centrally located young people’s clinic led to one being provided, but the Cardiff group was unaware of its existence. (However, the clinic is heavily used by young people.) There was a different problem in the Vale, where pupils were aware of the local clinic but were forbidden to leave the school at opening times, though a number had ignored school restrictions. Better co-operation between schools and service providers is essential if access is to be improved.

The greater confidence that an organised clinic visit might confer is likely to place additional demands on existing STI services. Asymptomatic people can wait several weeks for a first appointment, which may result in non-attendance or further transmission during the waiting period. Furthermore, those who are tested need to be aware of the implications. A qualitative study investigating the psychosocial impact on women of a diagnosis of chlamydia found that most held stereotypical views of people with STI (Duncan et al., 2001) resulting in anxiety and fears about disclosure to partners. The researchers suggested that information should normalise and destigmatise chlamydial infection.

Opportunistic urine testing (as opposed to other methods) was acceptable in the current study and this is supported by recent research (Moens et al., 2003), which found that a cervical swab was unacceptable to younger women. Lothian Health Board in Scotland has introduced postal urine testing and this could be useful in coping with rising demand and reluctance to attend a clinic.

Embarrassment, lack of confidence and worries about the legal status of those below the age of consent were all factors that might prevent teenagers from accessing sexual health services. If transmission of STI among this population is to be controlled effectively, education is an important factor. Unless teenagers are given information about services, they are unlikely to be accessed by those most at risk. Magazines have been criticised by health professionals for giving partial or inaccurate information but this source may not be inferior to the very little sex education that seems to be available in school. Out of date videos failed to get the message across and it seems likely that the video which pupils criticised as “old fashioned” in 1996/1997 (Jones et al., 1997) is still in being shown! The belief that behaviour would change if knowledge improved is, however, questionable. Numerous examples of teen sexual health interventions demonstrate improvements in knowledge but no change in behaviour measured by outcomes such as pregnancy rates (DiCenso et al., 2002).

The function of condoms in preventing STI seems to be a difficult message to communicate to teenagers. Researchers in London schools (Magnusson et al., 2002) found that after an intervention to improve sexual health knowledge, some remained unaware that condoms were the only form of contraception that could prevent STI.

Teenage sexual health needs

325

Lack of protection may be reinforced by prevalent beliefs about female responsibility for contraception.

A recent Health Development Agency review (Ellis et al., 2003) of HIV prevention identified lack of skill with condoms and poor negotiating skills as important factors in sexual behaviour. A demonstration of condom use on a model is of some help, but to gain confidence, boys will need samples to try at home.

In this study embarrassment was an important factor in sex education, accessing condoms and during negotiations with partners. Teenagers are likely to be less embarrassed about access if they are taken to visit a clinic and less embarrassed about negotiating if they are confident about condom use. The widely held belief that sex is better without a condom needs to be balanced against the risk of STI, and many teenagers have insufficient information to make an informed choice.

Conflicts between adult strictures to abstain and male peer pressure to be experienced may make it more difficult to discuss how a sexual relationship should proceed. Some divergence exists between adult and teenage perceptions on the source and nature of pressure. The perception that adult pressure for abstinence is counter-productive is confirmed by previous research (DiCenso et al., 2002). Adult attitudes may also contribute to delay in help seeking if a sexual health problem arises.

Prevalent beliefs about male and female sexuality can result in pressure to conceal or exaggerate sexual experience, fuelled by masculine characteristics of sexual objectification, banter and behaviour (Mac an Ghaill, 1994). An attitude of invulnerability was prevalent, especially concerning STI and insufficient information to understand the risks is likely to be a contributory factor.

There should be more openness applied to STI, which still seems to be a taboo subject for some schools. Teenagers are expressing a need for a trustworthy and confidential source of practical information and most teachers have little training in the field of sexual health. If this important subject is to be taught effectively, it may be necessary to bring in expert advisors.

Conclusions The dominant themes of sex education being variable, too little and too late, are similar to the evidence of young people to the House of Commons Select Committee on Sexual Health (Adler, 2003). Though users’ opinions had been taken into account in planning services in the study area, the fact that participants in one school were unaware of what was available highlights the need for continuous collaboration on information provision between service providers and education authorities. This is also true of the situation of the single sex schools, where an appropriate service was available but not at times when pupils were free to leave the school grounds. The conclusion must be that, if these schools are representative of the UK, there is still some way to go before teenagers are equipped to protect themselves against unintended pregnancy and STI.

References

Adler, M. (2003), “Sexual health (editorial)”, BMJ, Vol. 327, pp. 62-3.

Atkinson, P. (1999), Understanding Ethnographic Texts, Sage, London.

Botvin, G.J., Baker, E., Dusenbury, L., Botvin, E.M. and Diaz, T. (1995), “Long term follow-up results of a randomized drug abuse prevention trial in a white middle-class population”, JAMA, Vol. 273, pp. 1106-12.

HE 106,4

326

British Medical Association (2002), Sexually Transmitted Infections, BMA Publication Unit, London.

Davis, S. (1989), “Pregnancy in adolescents”, Pediatric Clinics of North America, Vol. 36, pp. 665-80.

Department of Health (2002), A Pilot Study of Opportunistic Screening for Genital Chlamydia Trachomatis Infection in England (1999-2000), Department of Health, London.

DOH (2004), “Choosing health: making healthier choices easier”, Public Health White Paper CM 6374, Department of Health, London.

DiCenso, A., Guyatt, G., Willan, A. and Griffith, L. (2002), “Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials”, British Medical Journal, Vol. 324, p. 1426.

Duncan, B., Hart, G., Scoular, A. and Bigrigg, A. (2001), “Qualitative analysis of psychosocial impact of diagnosis of Chlamydia Trachomatis: implications for screening”, BMJ, Vol. 322, pp. 195-9.

Ellis, S., Barnett-Page, E., Morgan, A., Taylor, L., Walters, R. and Goodrich, J. (2003), HIV Prevention: A Review of Reviews Assessing the Effectiveness of Interventions to Reduce the Risk of Sexual Transmission, Health Development Agency, London.

Exeter University (2003), APAUSE, available at: www.ex.ac.uk/sshs/apause (accessed January 2003).

Glaser, B.G. and Strauss, A. (1967), Discovery of Grounded Theory: Strategies for Qualitative Research, Aldine, Chicago, IL.

Health Development Agency (2004), Prevention of Sexually Transmitted Infections (STIs): A Review of Reviews into the Effectiveness of Non-Clinical Interventions, HDA, London.

Hey, V. (1997), Company She Keeps: An Ethnography of Girls’ Friendship, Open University Press, Buckingham.

Hicks, N.R., Fleminger, M., Goldman, D., Hamling, J. and Hicks, L.J. (1999), “Chlamydia infection in general practice”, BMJ, Vol. 318, pp. 790-2.

Jones, S., Hopkins, S. and Lester, C. (1997), “Teenage sexual health through the eyes of the teenager: a study using focus groups”, Ambulatory Child Health, Vol. 3, pp. 3-11.

Kirby, D. (1992), “School-based programmes to reduce sexual risk taking behaviours”, Journal of School Health, Vol. 62, pp. 280-7.

Mac an Ghaill, M. (1994), The Making of Men: Masculinities, Sexualities and Schooling, Open University Press, Buckingham.

Magnusson, J., Kendall, S., Townsend, J., Oakley, L., Gray, S. and Crosti, J. (2002), Evaluation of the Sexual Health Education Team Workshops in Schools in Camden and Islington, University of Hertfordshire, Hatfield.

Mellanby, A.R., Phelps, F.A., Crichton, N.J. and Tripp, J.H. (1996), “School sex education: a process for evaluation: methodology and results”, Health Education Research, Vol. 11, pp. 205-14.

Moens, V., Baruch, G. and Fearon, P. (2003), “Opportunistic screening for Chalmydia at a community based contraceptive service for young people”, BMJ, Vol. 326, pp. 1252-5.

National Assembly for Wales (2000), A Strategic Framework for Promoting Sexual Health in Wales, NAfW, Cardiff.

Public Health Laboratory Service (2001), Diagnoses of Selected Sexually Transmitted Infections (STIs) Seen in Genitourinary Medicine Clinics: England, Wales and Northern Ireland (1995-2000), PHLS, London.

Teenage sexual health needs

327

Scott, L. and Thompson, R. (1992), “School sex education: more a patchwork than a pattern”, Health Education Journal, Vol. 51, pp. 132-5.

Song, E.Y., Pruitt, B.E., McNamara, J. and Colwell, B. (2000), “A meta analysis examining effects of school sexuality education programs on adolescents’ sexual knowledge 1960-97”, Journal of School Health, Vol. 70, pp. 413-6.

Stephenson, J.M., Strange, B., Forest, S., Oakley, A., Copas, A., Allen, E., Babiker, A., Ali, M., Monteiro, H. and Johnson, A.M. (2004), “RIPPLE study team. Pupil led sex education in England (RIPPLE study): cluster randomised intervention trial”, Lancet, Vol. 364 No. 9431, pp. 307-8.

Wellings, K., Nanchahal, K., Macdowall, W., McManus, S., Erens, B. and Mercer, C.H. (2001), “Sexual behaviour in Britain: early heterosexual experience”, Lancet, Vol. 358, pp. 1843-50.

Zoritch, B., Roberts, I. and Oakley, A. (1998), “The health and welfare effects of day-care: a systematic review of randomised controlled trials”, Social Science & Medicine, Vol. 47 No. 3, pp. 317-27.