Examination of Witnesses (Questions 743-759)
THURSDAY 9 JANUARY 2003
DR TREVOR
STAMMERS, MR
ROBERT WHELAN
AND MS
GILL FRANCES
Chairman
743. Can I welcome our next group of witnesses.
This next session is looking at sexual health and sex education
and we appreciate your willingness to appear before the Committee.
Can I ask you briefly to introduce yourselves, perhaps starting
with Ms Frances, and perhaps you can talk a bit about the organisation
you work for and how this relates to the area we are looking at.
(Ms Frances) I am Gill Frances and I
am Director at the National Children's Bureau. Our strap line
is "to make a difference for children". We have led
the field around all aspects of personal and social health education
and I run the department that does that and also hosts the Drug
Education Forum, the Childhood Bereavement Network, the Sex Education
Forum, so all the different components of PSHE and citizenship
are held within my department.
744. Thank you. Mr Whelan?
(Mr Whelan) I am Robert Whelan and I am the director
of the Family Education Trust, which is sometimes referred to
in the papers as Family and Youth Concern. We are 30 years old,
we are an education charity, we carry out and disseminate research
into the causes and the effects of family breakdown with particular
reference to the welfare of young people. We are not a single
issue group, we deal with a broad range of issues. We were founded
by a doctor who had done a lot of work in preventative medicine.
He used to run a preventative medicine unit at Middlesex Hospital
when this was much more unusual than it is now, so we always look
at the preventative approach to the issues that we are dealing
with. The problem is that many issues that come up are dealt with
as discrete issues whereas in fact they have ramifications, and
policy changes in one area can have a knock-on effect in another.
We are particularly interested in this field in the effect of
the increase in STIs in young people and also we would like to
put the emphasis on prevention rather than cure. Obviously screening
and early treatment have a role to play but the more important
thing, certainly for teenagers, is looking at what sorts of behaviour
are likely to expose them to the risk of contracting STIs in the
first place.
745. Thank you, we are grateful for your written
evidence to the Committee as well. Dr Stammers?
(Dr Stammers) Dr Trevor Stammers. I am a general practitioner
in south west London and I have been in general practice for about
20 years now. I am also senior tutor in general practice at St
George's Hospital Medical School. For several years I have been
a trustee of the Family Education Trust and I have had a long-standing
interest at the coal face, as it were, in sexual health. It is
not possible to be an urban general practitioner and not have
an interest in it to some degree. On the wider front, I have written
two books relating to sexual health, one relating to violence
and intimate relationships and one an A-Z of sexuality from birth
to death. I have also been the medical adviser for several resources
looking at primary prevention in the field of sexual health. One
of the things that struck me about the debate you have had so
far is that looking at secondary prevention as exemplified by
the chlamydia screening is a very, very difficult task. There
has been a recent study that has not yet been published but is
available on std conference.org presented in America last year
looking at a cohort of 400 teenage women and following them over
a 90-day, three-month period and of those 350 young women 15%
who used condoms consistently and correctly 100% of the time,
self reporting, got chlamydia in that 90-day period. Of those
that did not use condoms consistently and correctly 30% did. If
you are talking about screening intervals for high-risk populations
the time interval could be very short and any secondary prevention
method you are looking at is going to be very complicated because
sexual behaviour is a complicated matter. Primary prevention is
something that has not been given enough weight.
Chairman: We will come on to the specifics in
a moment or two. We are grateful for your introduction. Andy?
Andy Burnham
746. Looking at the National Survey of Sexual
Attitudes and Lifestyles, the NATSAL survey, it shows an extremely
clear trend among the young people of Britain. The median age
of first sexual intercourse has fallen to 16 years old and has
fallen steadily over the last ten years and the average number
of sexual partners amongst young people has risen. With those
clear social trends in mind, perhaps first to the Family Education
Trust but I would also be interested in Gill Frances's view, is
postponing the age of first sexual intercourse reversing that
trend? Is it a realistic aim?
(Mr Whelan) I think the research from America indicates
that it is not impossible. If you give young people the full facts,
this is the important thing, they need to know the real risks,
the failure rates and so on before they start engaging in sexual
relationships. It is possible to delay age at first intercourse
and to reduce the number of partners if you have the right sort
of programme. It is extremely difficult but it is possible.
747. What messages have proved effective in
your view in doing that, perhaps in the States?
(Dr Stammers) May I answer that since I have done
most of the writing of the submission for FET. There are many
very bad programmes in the States. Those that have proved successful
have adopted proven, accepted methods of communication and education
in general terms rather than going for a sort of hard-line political
message, so I think it is important to strip those contexts out
of it using the appropriate methods. Those schemes that involve
parents have definitely been shown to work better (and that is
obviously good where you have got parents around who are willing
to be engaged) and also those that embrace the world from which
teenagers come (so the examples and analogies you use have obviously
got to be realistic) and those that also target, as we were thinking
earlier, boys as well as girls because boys are often a very neglected
area and many girls still feel that it is the woman's responsibility
and we have to target both. I think there is encouraging evidence
particularly from a study in New York just recently that it can
be done, but it is difficult. Even a delay of a year or 18 months
is very, very valuable and enormously helpful in preventative
measures.
748. When you say involves the parents, what
kind of messages is this giving to the young people concerned?
(Dr Stammers) Being able to talk with parents is in
itself a preventative method and one of the things that interests
me about the social exclusion report is the graph that shows that
in Holland parents, both dads and mums, are communicating on a
much greater level with their children about sexual matters. We
still have a tremendous British reserve, which is very unhealthy,
about talking about sexual problems and sexual issues in general.
749. It is interesting because I was going to
say to you that the Committee visited Holland and saw their fabled
openness about sex and all matters relating to young people's
sexual health, and of course in Europe they have the highest average
age at which people become sexually active. I would have thought
you would have given the opposite view. I am interested that you
are advocating openness rather than harder messages. I would have
thought you would have come from a different perspective.
(Dr Stammers) I take the view that there is never
any benefit in hiding the truth. I have got three teenage children
of my own so I know that sexual desires develop much earlier than
sometimes the ability to restrain them without appropriate help.
It is very, very healthy in a family where children feel they
can go to their parents and talk about these issues. That is something
that we should be encouraging.
Jim Dowd
750. Just one point before it moves too far
away. You say it has been shown that you have been able to delay
the age of first experience by 12 to 18 months and you describe
that as very valuable. Why is that valuable? Is it valuable for
what you do during that time or is it valuable because it shows
a more mature attitude at an earlier date?
(Dr Stammers) I think it is valuable from many perspectives.
One is that everybody on all sides of this debate would be agreed
that early sexual activity, say at the age of 14 or under, is
much more dangerous, you are much more likely to get infection
and the risk of cervical cancer is doubled from first intercourse
at 14 rather than later on and the immaturity physiologically
of particularly young girls' genitalia proves harmful to them
if they engage in sex at an early age. That is one area of benefit.
The second area of benefit is that clearly the younger a teenager
is the more difficult it is for them to use contraception appropriately.
The problem that I encounter time and again in my medical practice
is not that kids have no availability of contraception and they
do not know the rules about using condoms, but when a quarter
of them are drunk at first coitus clearly no amount of instruction
is going to be useful in that context. Also when you are 14 there
is not usually the emotional maturity to negotiate in the heat
of the moment the putting into practice of the rules that you
may already know. So I think on both those fronts there is great
benefit. The third thing is that we know that if somebody starts
having sex at an early age, 12 or 14, by the time they are 20
they are bound to have had multiple partnerings. It is that which
is one of the key areas in the enormous epidemic of STIs we are
seeing in Britain, so it has benefits on all three fronts.
Andy Burnham
751. Before I move to Gill Frances, can I ask
a final question. Why do you think the trend as identified by
NATSAL towards earlier sex is as it is?
(Dr Stammers) I think there are a whole variety of
reasons for it but I do consider the enormous pressure of the
sexualisation of society in general to be a huge influence. My
young daughter, who is 14, happened to mentioned in passing to
my wife the other day, "It just seems whenever you turn the
telly on these days there is sex there." My 16-year-old son
mentioned to me that a lingerie advert that obviously is very
effective at the moment on most bus shelters had caught his eye.
752. Some members of the Committee found it
is the same in Holland, the media there is no different than here
but it does not seem to—
(Dr Stammers) I would agree in some parts of Holland
that is true, in rural Holland probably not so. If you are in
that environment all the time where all of the pressure is towards
sexualisation, getting you turned on or thinking about sex, that
is one thing. If you are in a home environment where there are
counters to that pressure then that child stands a much better
chance of being alright. That is the key thing I would want to
communicate. There are positive and negative pressures. If children
are just cast out onto the stream of general sexuality out there
with no counterweight then heaven help them because a condom will
not.
Chairman
753. Dr Stammers, you are a GP and you will
deal with teenagers who come in to see you perhaps for contraceptive
prescriptions or whatever. If you had, say, a 14 or 15-year-old
girl who came to see you asking for contraception of some kind
with some concern about you not passing it on to the parents,
how would you deal with this? What is your view? I respect the
point you are making about the engagement of parents in sex education.
How would you handle that kind of situation where your patient
was resisting any contact between yourself and their mother or
father?
(Dr Stammers) I think in that situation the response
is quite clear in law and I would agree with it in spirit as well,
that that situation is entirely confidential and one's duty is
to that 14-year-old girl. You have to explore the circumstances
she was in. On some dreadful occasions it may be other family
members that are the cause of pressure for her to want to be on
contraception so you need to find out what is going on but if
she has got a 16-year-old boyfriend and they are already having
completely unprotected sex then I would view it as being a responsible
position to provide her with contraception, but that in itself
is totally inadequate because if one is looking at sexual health
overall, if you just give her the pill you may, paradoxically,
increase her chances of getting a sexually transmitted infection,
so anyone who prescribes the pill particularly to a young girl
without also giving her information about the risks she is running
of STIs as well as unplanned pregnancy is not doing a proper job.
754. What I was more concerned about is would
you see it as part of your duty to try and encourage her to talk
to her parents about her circumstances?
(Dr Stammers) Absolutely and in a context where there
is no sexual abuse going on in the family, the Gillick
ruling that one should make enquiry about that and encourage it
is probably not carried through in practice as often as it should
be. I would certainly want to explore that and one of my catch
phrases in these situations is to say it is very difficult for
skeletons to remain in cupboards indefinitely in families. They
have a nasty habit of tumbling out and you may want to think about
that because you have got to hide this for a long time if you
do not want your parents to know, and sometimes of course the
parents know already.
Andy Burnham
755. Can I direct some of those general themes
to Gill Frances but also ask specifically if you have evidence
that delaying first sex brings sexual health benefits to the individuals
and generally means they will have better sexual health if they
started having sex later on?
(Ms Frances) The very simplistic answer is yes but,
unfortunately, if there were simple answers we would not all be
sitting here, so it is a lot more than that. It is the use of
the word "aim". When you first asked the question you
said was the aim to reduce first sex. What we know from looking
at the international research is that if young people are offered
broad-based sex education—and, as Trevor quite rightly said,
some of the American models are really very poor and do not offer
that broad spectrum. It is not enough to tell young people information.
I have got loads of information in my head. I know how to change
a plug, but I cannot do it unless I undo another one and see what
that looks like and then do it. I cannot do it, I am not that
skilled about it. So the second most important thing is about
young people actually being helped to develop emotional and social
skills in which they can then put their knowledge into action.
What we have got a lot happening is a lot of telling. Young people
are told by their nurse, told by their doctor, told by their teacher,
told by their parent and what young people say to us all the time
in our research at the NCB is, "We want some of you grown-ups
to know what you are talking about and help us." I was saying
to one of your researchers when they rang me that one young woman
said to me, "I want to be me and I want to be really good
at being me, I need your help", and that is the bit we are
not good at.
756. Do you really think any of that can delay
what is a huge social trend?
(Ms Frances) I think it can and it is not in the last
ten years, it is since the Second World War.
757. Since the Beatles.
(Ms Frances) No, it is before that. If you read your
Mary Wesley you would know it happened in the War. So it is a
long trend that has been going back a long time. The third thing
(which picks up a lot of things we have been saying) is a positive
attitude. We have a very negative attitude to sex and these advertisers
are not selling sex, they are selling something that is going
to make them money. I think that the whole issue of helping young
people to have a positive attitude, helping them develop a critical
awareness of looking at things and thinking, "Is this for
true, is this something that is going to suit me, who I am, living
in my family, living in my culture?" It is not just about
being given information, that does not work, it is the other two
bits which are more important than the actual information. You
can get the information from a leaflet when you need it but the
sense that you are an important person who has got the confidence
to deal with all sorts of challenging things growing up, that
is the sort of thing that has got to be taught and learned and
you have got to feel confident about it. You have got to be in
a culture, in a family, in a school, in a GP practice where it
is normal and okay to say, "I need your help, I am stuck
with something here." At the moment young people in our country,
unlike the ones you met in Holland, if they are worried about
something they turn to each other. They do not turn to a grown
up, they do not turn to parents, they do not turn to teachers,
and the marvellous thing about Holland is that kids do turn firstly
to their parents.
758. It was also slightly different in Sweden
where you had clinics just for the under 23s. Do you think there
is value in that kind of service?
(Ms Frances) There are already all these clinics across
this country but unfortunately they are patchy and they do not
exist in the same explicit way as they do in Sweden. We do have
them here but if you set up a clinic in this country, if you broadcast
it too much you end up in the tabloid press and everybody jumps
up and down and gets very excited. There is this need for us to
flatten out this drama around sex. We do it, human beings do it,
and we just need to relax about it, and then I think our desire—which
is not just our desire, young people often regret their first
sex, they want to delay it as well and wish they had—is
what the outcome will be. What it should not be is the aim; it
will not work if it is the aim.
Chairman
759. Can I ask a question of the other witnesses.
One of the things that has been interesting to the Committee,
one or two of us have been struck by it, is that if you look,
as we have done, in some detail at Sweden and Holland, which I
think most people would argue are more permissive societies, they
do have in terms of young people a much more responsible attitude
to sex and later first intercourse and less problems in terms
of sexual health than we have got, which seems very interesting.
Do you have any thoughts on that?
(Mr Whelan) We are just about to publish a study on
sex education and teenage pregnancy in Holland because it is turned
into this sort of Utopia where they do everything right.
Chairman: I would not say it is a Utopia but
I was certainly struck by the contrast between our perception
of the attitudes there and the outcomes compared to our own.
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