Abstract
One of my favourite aphorisms is that ‘(s)he who frames the question determines the range of solutions’. A prime case of the truth of this is to be found in the current row and apparent impasse over the state of ‘Personal, Social, Health and Economic’ education, in the nation’s schools, and especially those set up in recent years with a religious orientation. The apparent initial success and acclaim of the ‘No Outsiders’ programme in Parkfield Primary School in Birmingham has been followed by an orchestrated campaign of opposition by those, including non-parents, who see this initiative as leading to the premature sexualisation of young children and undermining basic tenets of particular religious faiths. So what are the facts and why should this be considered to be an important public health issue?
A major international study of teenage pregnancy in 46 countries published by the Alan Guttmacher Institute in New York in 1986 still provides the bedrock research against which to understand the enormous differences between developed countries with regard to sexual health and early sexual activity. Among the countries studied, there was a clustering of teenage pregnancy rates at around 40 per 1000 15–19-year-olds per annum in many countries, including the United Kingdom. However, extreme outliers were found, including the very high rate in the United States at 96 per 1000 compared to the 14 per 1000 in the Netherlands. These differences could not be explained by differences in sexual activity among the teenagers of different countries or by greater recourse to abortion. The study went on to conduct detailed qualitative research in six countries representing the range of findings, and the conclusions were no less stark: those countries with the lowest teenage pregnancy rates were the ones where teenage sexuality was accepted and responded to in a positive way through the provision of good quality information, including sex education, together with appropriate, accessible and non-judgmental clinical contraceptive services; in contrast in the United States, as the most extreme high-end country, in many parts, there was strong religious opposition to teenage sex and sex outside marriage, sex education was often vehemently opposed, and teenage friendly contraceptive services were few and far between, while the use of sexual images to promote consumer products was ubiquitous.
The publication caused a media storm in the United States and a great deal of soul searching. It prompted one Boston journalist, Irene Sege, to come to Europe on her own fact-finding tour; over a four-week period she conducted large numbers of focus groups of parents, children and teachers in Amsterdam, and then on Merseyside, which at the time had one of the highest teenage pregnancy rates in the United Kingdom. At the end of the month, her conclusion about the difference was clear – ‘In Liverpool parents don’t talk with their children about sex’, yet the age at which they started to have sex was younger than the Dutch and many more were becoming pregnant.
One country that had taken these insights to heart was Sweden, which had led the sexual revolution in the 1960s after the advent of the contraceptive pill. The model which was developed in Sweden from the 1970s onwards, with a focus on ‘breaking down the conspiracy of silence between the generations’ and ‘Living Together’, took a wide view on what was needed when society was diverging and becoming less homogeneous, together with changes in attitudes and behaviour, rising levels of divorce, the lessening impact of religion, and the increased influence of advertising, media and peer group pressure. Residential workshops were held which brought together senior community leaders from all sectors to explore values that were in common or that differed, to bring forward an evidence base for discussion and to agree commonalities for action. This was followed by systematic media coverage enjoining the public at large in a great debate, school curricula were changed and youth advisory services developed. The outcome was not only reductions of 40% in teenage pregnancy but also in sexually transmitted disease, drug abuse and delinquency. An attempt to replicate this work in Liverpool in the 1980s went as far as the stakeholder residential workshop before it ran into the sands of opposition within the Thatcher administration. However, progress was made, not least in the myth busting that the Catholic school sector in the city would be opposed to sex education; it wasn’t, rather the view taken was that ‘of course they must have sex education, the facts, we will give them the values’; and bringing everybody together paved the way for change in which the teenage pregnancy rates came down in Liverpool before those in other major cities.
Thirty years on our national teen pregnancy rates are about half what they were in the 1980s, but they are still much higher than those of the Netherlands and Sweden and there is much more to be done. A great deal has changed since the 1980s: society has become much more heterogeneous and mostly remarkably accepting of differences in sexual orientation; at the same time, the advent of social media has transformed access to information, including pornography, in ways which can be profoundly disturbing not least for their potential impacts on young minds; we have become all too aware of sexual grooming and exploitation, modern slavery and primitive practices such as female genital multiplication, all areas where sunlight and proper education are the best disinfectant. So what is needed is to cool the rhetoric, take a leaf from Guttmacher, the Dutch and the Swedes, and start talking and listening with the facts on the table and a vision of ‘Living Together’ in all senses of the phrase.