The Health Protection Agency has released its most recent figures on Sexually Transmitted Infections (STIs) (including HIV) today. This is based on data collected from GU clinics across the UK annually. You can read the main report here. Those who’re of the more thorough/geekier persuasion may also want to look at the data summaries of STIs (including breakdown by region, ethnicity and age) available at STI Epidemiology in England 2009 and Trends in STI diagnoses. I would recommend reading and critically appraising the HPA report and datasets if you are interested in this topic – particularly if you’re writing about it for the media, blogs or using it in health education/practice.

What are the main findings and recommendations of the HPA report?
* Numbers of new diagnoses of sexually transmitted infections (STIs) in the UK rose by 3% between 2008 and 2009, continuing the trend of the past decade.
* The impact of poor sexual health is greatest in young heterosexual adults and in men who have sex with men.
* There is considerable geographic variation in the distribution of STIs with highest rates seen in urban areas of higher deprivation, reflecting concentrations of the population who are at greatest risk.
* Some antibiotics may become less effective (or even ineffective) in treating STIs in the coming years.
* Increasing sexual behaviour risk may be contributing to the rise in STIs and will have done so in men who have sex with men, but much of the change will have been due to the increasing application of more sensitive tests throughout the past decade and to the more recent expansion of Chlamydia screening of young adults in community settings.
* Prevention efforts, such as greater STI screening coverage and easier access to sexual health services, should be sustained and continue to focus on groups at highest risk.
* Health promotion and education remain the cornerstones of STI and HIV prevention through improving public awareness of STIs and HIV and encouraging safer sexual behaviour such as consistent condom use and reductions in both the numbers and concurrency of sexual partnerships.

Why are UK STI rates rising?
Over the past five years there have been several initiatives to improve testing and treatment for STIs. This has included
- more rapid testing (particularly pee in a pot tests) and screening for STIs such as Chlamydia and Gonorrhea
- greater targeting of the under 25s to have said testing (via GPs, community pharmacies, and GU clinics)
- improved data collection on STI rates via individual services and the Genitourinary Medicine Clinic Activity Dataset
- a shift in focus in public health campaigns from STI prevention and normalising condom messaging towards testing/treatment focus
- attempts to make services more accessible to young people with initiatives such as ‘You’re Welcome’
- sexual health services have been modernising and restructuring, with standards of care established and sexual health networks being created to try and improve sexual and reproductive health services

It would be naïve to claim all of these changes are responsible for the identification of record levels of STIs, nor that all of them have been effective. But it is worth noting (and the HPA report acknowledges) that some of the increased detection of STIs will be down to higher levels of screening. So from that perspective the figures are more positive – it tells us we are identifying and treating people with STIs more than in the past.

Alongside these healthcare initiatives there are other, less positive reasons why STI rates are rising in the under 25s. These include:

Our lack of comprehensive, quality sex education
Sex education remains patchily delivered across the UK with some places doing excellently, others not so well or even teaching negative messages (more information here and here). Young people generally are afraid of unplanned pregnancy (and overestimate rates of unplanned pregnancy), but less aware of STIs. This is particularly the case if education focuses on teaching the names of STIs and showing gory symptoms, but doesn’t explain how you get and prevent STIs or talk about how many are symptomless.

Public Health Campaigns
While we have had government led public health campaigns aimed at the under 25s for the past twenty years these have been patchy, underfunded, and subject to numerous changes in messaging resulting in confusing ideas shared (my insider view of the problems with UK government backed sexual health campaigning can be found here). Despite the limitations of sexual health campaigns from the previous government it is worth noting the current coalition appears to be doing little in the way of public health campaigning for sexual health services.

Access to and funding of services
GU clinics have traditionally been referred to as the ‘Cinderella service’ – not as well funded nor respected as other areas of healthcare. Getting appointments also remains a problem with some services struggling to give appointments in 48 hours or less. In many places waiting times can be weeks rather than days. While demands on services continue to increase, along with the workload of staff rising massively, funding to match these demands is not forthcoming. Perhaps unsurprisingly some staff aren’t always sympathetic which can be off putting. Meanwhile despite underfunding, over expectation and cuts, it is generally staff who are blamed if services don’t hit targets.

Aside from getting seen within services is the wider problem of people knowing how to find them. Many clinics still struggle with promoting their services to the public, or being open at accessible times.

To see how it works in practice, try this experiment. Imagine you’re 16 (or thereabouts). You still live at home. You need to find where a sexual or reproductive health clinic is in your area. Your school hasn’t provided you with any advice, you can’t ask your parents and your friends aren’t much help. Without using the internet, how do you find a clinic locally? Look around your neighbourhood. Can you spot any posters or leaflets? Is there information at your pharmacy or GP practice or library? Are there any youth centres or clinics offering support – and if so when are they open? If you find services are there any that are open at times you could get to? (To make it more challenging imagine you were under confident, struggled with literacy or language, or perhaps had very strict parents who needed to know your whereabouts – this may further limit what you would be able to access).

Silo working
While there is plenty of research on sexual health services and initiatives to improve waiting times, accessibility, youth friendliness and treatment/testing options, alongside evaluations of what works within sex education, we sadly do not see much in the way of collaborative working. This is often referred to as ‘silo working’ where individual practices, organisations or individuals may well have great ideas but do not share them together. Alternatively work may be replicated (including mistakes) or opportunities for collaborative practice are missed. While services are overstretched, underfunded and pressurised it is difficult to find the time or enthusiasm to network.

Culture, attitudes and sexual climates
Norms and values relating to sexual behaviour have undoubtedly shifted over the past few decades. Pre and extra marital sex is no longer viewed as taboo by the majority of the UK population. Contraception to prevent pregnancy has enabled people to have sex for pleasure. Discussions about sex within popular culture have become more prevalent and some may argue more explicit, although this has not been matched with education to enable people to negotiate a culture that may well feel more sexualised to some. New technologies, the internet and shifts within publishing have allowed easier access to sexual imagery. These are not in themselves a problem but may become one if people do not have the life skills to interpret what they see and enjoy respectful relationships.

Our media undoubtedly plays a role here by covering sexual health stories with a mix of salacious scandal mongering and moral judgement. Every time sexual health data is released the media’s approach is to hysterically report a crisis and speculate on the reasons for it, but at no point to campaign for any initiatives to improve sexual health. The media COULD help by being supportive about sex education, campaigning for more funds to GU services, highlighting how to access services (for local news) or providing accurate sex advice to help people negotiate pleasurable safer sex.

Confusing/mixed messages on safer sex
STI rates can be reduced by condom use. Many young people do use condoms, but they may not consistently use condoms with partners over time. And they may also not get screened for STIs before using a non barrier method of contraception. The focus on testing and treatment without including prevention messages means some young people assume regular testing is sufficient to cope with STIs. Clinicians and sex educators often give mixed messages with some suggesting regular testing is mandatory, others advocating self management and using barrier methods of contraception is better. So people can be confused about what the right approach to managing their sexual health should be.

Confidence and communication
Evidence suggests young women in heterosexual relationships find it difficult to negotiate condom use, while young men will use condoms but won’t necessarily mention them unless a girl does (for more on condom negotiating styles and gender see, for example here). Varying sexual health initiatives have attempted to encourage girls to carry condoms and insist on their use or enable young men to do the same. Some have also focused on clearer communication and negotiation skills both about safer sex but also around discussing other intimate and pleasurable topics together. Studies on men who have sex with men indicate older men tend to be more aware of condom use but there is still variable use within relationships and condoms tend to be used more for anal sex than during other activities like oral sex or masturbation. Both straight and gay couples can assume condoms only need to go on just before a man is going to ejaculate so have penetrative vaginal or anal sex without a condom, putting one on before a guy comes.

‘Risk’ and ‘responsibility’
Negotiating safer sex is more difficult when alcohol is involved, and most people do not assume their partner is likely to have an STI. When you’re thinking about how much you fancy someone you’re not necessarily considering their sexual history. There can also be the view that STIs are things that happen to dirty, bad or promiscuous people – other people, not you. Sexual health messaging – particularly through education and public health campaigns often overemphasise morality discourses of ‘risk’ or ‘responsibility’. These tend to be ineffective as many young people do not consider being intimate as inherently risky or irresponsible. Such an approach also assumes older adults act in different (and more ‘appropriate’) ways than younger people, which is neither fair nor true. Within much sex education and healthcare lies the subtext that ‘good’ sexual behaviour is always being prepared, always having condoms to hand and always effectively negotiating their correct use, while sober. What may be great in theory often simply does not happen in real life.

How did the media (and public) respond to this story?
The media response to this story was interesting. Most coverage I saw repeated the HPA’s press release pretty much, some adding additional comment about why STI rates were so bad (most of them missing key areas as outlined above). While the coverage was perhaps not as hysterical as recent discussions on young people and contraception or abortion, there was still very much a subtext of blame and judgement among much coverage. Accompanied by a lot of handwringing about the state of our nation’s sexual health with relatively little discussion of what we might do to improve our wellbeing.

The overwhelming majority of coverage did not clarify that much of the increased prevalence in STIs was down to testing initiatives and treatment programmes. The focus suggested the STI rates were solely down to young people having multiple partners.

It seemed most journalists did not consult the HPA report nor particularly interrogate the data. Those called upon to comment were not generally selected from GU services or sexual health research. Instead it seemed anyone who’d ever written something about sex, sex therapists or generalists on the topic were asked to give their opinion about young people and their behaviour rather than appraise or expand upon the HPA data. Some of the comments made by sex experts on twitter, broadcast and print media clearly showed they had also not consulted the HPA report but still commented on its findings. It is very worrying when both a journalist and the person they ask to explain a report have not actually looked at said data.

Additional input from experts and the public shifted the debate towards a more blame-focused narrative generally blaming young people, or repeating memes such as:
- young women are all victims, they cannot make decisions for themselves
- young men are all predators, who are at the mercy of their overactive sex drives
- feminism has caused young women to act like men
- Sex and the City has taught young women to be promiscuous
- Young men are being blamed for STI rates
- Young women are being blamed for STI rates
- Young men’s needs are being ignored
- Young women’s needs are being ignored
- Young people are feckless, irresponsible and simply don’t care about STIs
- ALL young people undoubtedly know ALL about STIs and cannot claim otherwise
- Sex education/pornography/rap music etc is to blame for rising STI rates
- STIs were not a problem for previous generations
- Scaring young people about STIs will put them off having sex and combat this trend
- Young people who get STIs (particularly repeatedly) should be punished/refused access to healthcare
- STI rates are just as bad in the over 40s, if not worse than in the under 25s

While some of these are more extreme than others it does show how often this debate is further hampered by moral and opinion based discussions that have very little to do with the realities of why young people get STIs. Rather than exploring reasons and finding solutions we are encouraged instead to blame, shame and generally judge people who have STIs – not focus on wider causes or feasible solutions.

What can we do about our STI problem?
This is not a case of us having a problem but not knowing what to do about it. Our epidemiological data for STI rates is improving every year, sexual health services are modernising and new initiatives for testing/treatment are available, alongside prevention messages and strategies to promote safer sex. We know quality sex education increases safer sex and the likelihood of people being able to communicate their sexual needs assertively while reducing coercive behaviour. We know that training up teachers and health professionals to talk about sexual health issues with confidence – and to see these issues as important is necessary. We know young people are interested in such information. We know services would work better with more funds and resources, and if collaborative working was encouraged – and if the media supported rather than scuppered sexual health initiatives.

There is no mystery here. We have ample evidence to fix this. We are failing to do so because our debates on this issue focus on blaming young people and those with STIs and not focusing on the systemic problems that need to be fixed. This is not to say people are not responsible for their own sexual health, but with our current haphazard approach we also do not enable people to take control over their sexual wellbeing.

Data like this always tells a story – about people affected by STIs. But it perhaps masks the discomfort, anxiety, nuisance, distress or fear having an STI may cause. It misses what can happen to relationships, people’s self esteem, or future fertility.

It’s very easy to sit in judgement on those who have STIs. Assuming you don’t have one (are you sure?) or you would never have unprotected sex. It is very easy to believe we’re facing rising STIs purely because of feckless youth. But it completely misses the point. This is a major health crisis – and it affects us all.

Sources of help, advice and further resources
Sexual Health Helpline call 0800 567 123
NHS Choices on Sexual Health includes resources, advice materials and the facility to find your nearest sexual health/genito urinary clinic by postcode
Manchester Sexual Health Network has created the most comprehensive list of related links on GU/SRH I’ve found
NHS Evidence – Sexual Health Services links to resources, data and research on sexual health in the UK

Parents across the UK are understandably being made anxious by news reports today suggesting:

Rise in 11 year olds on the pill (Sunday Times)

One thousand girls on Pill at 11: Huge rise in contraceptive prescription for pre-teens without parents knowing (Daily Mail)

Huge rise in 11-year-olds on the pill (Telegraph)

The UK appears afflicted by ‘soaring’ numbers of sexually active girls, who lie to parents, enabled by GPs.

Is it accurate?

No.

Here’s why.

Where did the story come from?
These reports are based on figures from the General Practice Research Database (GPRD), indicating 1000 11-12 year olds annually are prescribed hormonal contraceptives (usually the pill or injection).

This was picked up by firstly the Sunday Times then spread to other newspapers, websites and broadcast media. As we’ll see journalists did not show due diligence in investigating the story.

Are 11 year old girls using hormonal contraceptives?
Yes. But despite the media hype there are many medical reasons why young girls might be prescribed hormonal contraceptives including:
- Heavy periods (resulting in excessive bleeding, vomiting, diarrhoea)
- Acne
- Endometriosis
- Polycystic Ovary Syndrome (PCOS)
- Irregular periods
- Amenorrhea (no periods due to extreme weight loss, anorexia, or side effects of radiation/chemotherapy)

Taking hormonal contraception is, for many girls, a means of ensuring they don’t miss school. It reduces symptoms that could be painful, distressing and single them out for bullying. When the pill is prescribed for medical reasons usually it is parents, in discussion with their daughters, who initiate contact the GP.

Of course hormonal contraception also prevents pregnancy. But being on the pill is not an indicator of having underage sex.

Approximately 26% of young girls have sex before the age of 16 Most are around 14-15. Fewer very young girls have sex and those who do are more likely to be coerced, regret the experience, struggle with access to healthcare and education, and lack family support. They are also far less likely to use any form of contraception. [More information on underage sex here]

What did the GPRD data say about different uses of hormonal contraception?
Unfortunately the data from the GPRD does not break down reasons for prescribing hormonal contraception to young women, so we cannot conclude precisely why they are using it. This hasn’t stopped media speculation it’s primarily for pregnancy prevention, wrongly suggesting all young girls on the pill are sexually active lolitas.

The media says teens don’t need parental consent to talk to a doctor. Is that true?
It is true practitioners do not have to tell parents if a young person consults with them (about any issue), guidance such as Gillick Competence and Fraser Guidelines (specifically for contraception). These set out the circumstances under which young people can get help without parental consent, and when parents or social services need to be involved. All of which happens with the awareness of a young person.

Generally practitioners want a parent or carer to be involved in supporting a young person. So providing health advice on any topic without a parent being involved tends to only happen in specific circumstances (explained in the links above). Before giving any advice practitioners are keen to establish the young person’s situation and find out what options they see themselves as having.

Aside from access to healthcare being a basic human right for any child or teen, there are sometimes very good reasons why a young person needs to talk about sensitive issues to their doctor. This may be when they live within a very strict home, or where their parents are absent or neglect them, or where they are subjected to abuse by their parents (or by others but are not protected by their parents).

So did the media make this story up?
Clearly ‘11 and 12 year old girls prescribed hormonal contraception with parents consent to prevent health problems’ doesn’t have the same salacious ring as ‘sexually active 11 year old girls’. The uncritical coverage does not refer to evidence based practice nor particularly includes reproductive health practitioners. Instead it relies heavily on the Christian Medical Association who have an anti sex education (and anti pre marital sex) agenda.

It wasn’t that the media lied about this story, certainly teens are using the pill for medical purposes and to prevent pregnancy. But this is not new. Doctors have been prescribing hormonal contraception to treat numerous complaints for decades. Just because it’s news to the media doesn’t mean it is not standard clinical practice.

Is sex education to blame?
Several news reports suggested the phenomena of young women using hormonal contraception was down to sex education – or would be made worse if sex education was implemented for young people. Indeed coverage on this was very confused on the actual or possible role of sex education in all this.

Currently sex education is not statutory across the UK and standards of delivery vary widely. Ofsted has recently produced a damning report on the state of UK sex education, while NICE is currently consulting on improving sex and relationships education in the UK. [More on what young people want from sex education here]

It seems much of the press coverage on the GPRD data is aimed at discrediting Ofsted and NICE’s suggestions that sex education be improved and appropriately tailored relationships education could begin with children aged 5.

Why was this coverage so poor?
There is an ongoing crusade by elements of the media to be anti young people, particularly young girls, and against all forms of sex education. And as we’ve already heard scandalous headlines about teenage nymphos sound a lot more exciting than a small subgroup of girls having the pill mainly for medical reasons.

However there are several other important reasons why the coverage was so bad.

Reproductive health is always framed as a two sided, moral debate
As you’ll see from the stories linked at the start of this post the media sets these stories up as moral debates where there are distinct baddies (doctors, trampy teens and anyone offering sex education) and goodies (Christian/Family groups, parents). The media focus is not to explore reasons why young women might use hormonal contraception, but to demonise young women generally and the medical profession alongside them.

Broadcast media tends to take this a step further inviting live debate between practitioners and moral authorities, and most of the calls I took from journalists today were seeking to pitch me into battle – cast in the unwinnable role of the ‘pro sex bogeywoman’ (as @badhedgehog observantly noted on Twitter).

Unsurprisingly this atmosphere does not allow clear information to be shared that might reassure parents or young people. Nor does it challenge poor media coverage, leaving the public still believing that loads of 11 year olds are a. on the pill and b. all promiscuous.

Many journalists have a poor understanding of reproductive health
Discussing this story with journalists provided a fascinating, if frustrating, insight into how many of them simply lack the basic sex education that would enable them to evaluate reproductive health data.

During the course of today I’ve spoken to 15 journalists, mostly working for radio and TV news stations, and 13 of which have been male.

Through these conversations I discovered none of the journalists knew hormonal contraception had medical uses. All of them assumed hormonal contraception was simply used to prevent pregnancy. And because of this assumption it hadn’t occurred to them to find out what else hormonal contraceptives might be used for.

They also were confused over what hormonal contraception was, in several cases not realising the pill was only one form. Most seemed to believe hormonal contraception just meant ‘the pill’. One journalist thought the injection couldn’t be a form of hormonal contraception because it wasn’t ‘a pill’, while another believed the contraceptive injection was ‘worse’ than the pill as it ‘lasted longer’ and made girls ‘more likely to have sex’.

Most of the journalists couldn’t work out why a young woman might opt for a hormonal contraceptive in injection form. They interpreted opting for an injection as easier for some than remembering to take a pill regularly as further evidence of fecklessness. This reinforced for them the stereotype of sexually lax behaviour they associated contraception use with.

Even those who accepted hormonal contraception could have additional uses still returned to the idea the main reason young people were using it was to have sex. Or believed if they were given hormonal contraception it would automatically lead to sex soon after. Or make girls more likely to act in loose ways.

Persuading them parents are mostly involved in decisions of hormonal contraception use with young girls proved pretty difficult. One journalist said ‘you’d go as far as saying a girl should go on the pill if she has heavy and painful period?’. Well, yes if that’s what she and her doctor agreed would help her. This particular journalist then asked me if I could come on air and say the first bit (parents should put their daughters on the pill) but not the second bit (explaining why they’d want to do this). Obviously I refused but you can see how even when presented with evidence to show a story is wrong journalists won’t move away from a particular angle.

Sadly while most journalists I spoke to did seem interested to learn about the medical reasons for using hormonal contraception and finding out more about it, once it became clear I wasn’t willing to participate in a ‘debate’ about whether young girls are sexually active or not, they were not interested in discussing things further. (It could be the journalists I spoke to aren’t representative of the media generally or were trying to make a particular debate point with their questioning, but my interpretation was most genuinely seemed ill informed about reproductive health)

Healthcare agencies, particularly in reproductive health, did not speak up
The whole case has highlighted for me the need for agencies promoting sexual and reproductive health to offer basic training for journalists. There is obviously a great need for many journalists to have information about how to understand clinical data, but also having an awareness of sexual and reproductive health to help them interpret this information.

Sadly the majority of organisations dealing with reproductive health (including NHS Choices, Nursing Times and the Department of Health) remained silent during the day – even when requested directly through twitter and email to get involved. This is sadly a common pattern where organisations miss key opportunities to deliver health information.

While this may be partly due to the way the media frames stories like this and practitioners don’t want to be cast as the bad guy, if enough people spoke out we could achieve so much.

As much as I have criticised the media here it is worth noting there were also many other responsible broadcasters and writers who did want to cover the story but they were struggling to find anyone to talk to them.

We cannot complain about poor media coverage if, as health practitioners and educators, we do not offer our services to ensure accurate information is shared.

How should the media have treated this story?
This really is a non story, but if the media had wanted to report it accurately they should have looked at the reasons why the contraceptive was prescribed, whether parents had consented to their daughter using hormonal contraception, and indicated proportionally how many young people were prescribed the pill for pregnancy prevention without parental consent. Indicating the numbers of 11-12 year olds on the pill as compared to the wider population in this age group would put this in perspective in terms of prevalence. And they should have written this in a way to highlight how to safeguard young people most at risk. Who we know mostly do not seek out medical help and are often also unable to get help within their families.

The take home message is?
Sadly bad science, scaremongering rhetoric and poor journalism makes it difficult for parents and young people to get accurate information. This may result in making young people more excluded from the health care they need.

Unfortunately if we do not challenge it we will continue to leave parents terrified and young people disempowered.

This piece appeared in a shorter form for The Times Science today as Too much too young: most 11-year-olds aren’t on the pill for sex

With grateful thanks to everyone on Twitter today who challenged this story, shared information about young people’s rights, and generally kept me going when I was getting fed up shouting about it!

Over the past couple of years we’ve seen a particular preoccupation with Western media about underage sex. This has included the media frenzy over 13 year old ‘teenage dad’ Alfie Patten through to frequent media features on teenage pregnancy, abortions and parenthood, to more recent documentaries like Channel 4’s ‘Underage and Having Sex’ or ITV This Morning’s debate on the age of consent which I participated in.

These stories have generated a lot of public attention and added to the general anxiety about parenting, sex education, and wider social and moral issues. Most share the common theme of judging young people (and their families), particularly girls (who are more harshly viewed for having sex). Other subgroups of young people are also demonised (the poor, socially excluded or ethnic minorities).

As a result, discussions on the topic are difficult and usually framed in a moral context. Much of the debate hasn’t focused broadly on understanding early sexual debut, or to identify potential solutions to encourage young people to delay, or to identify what pleasurable and safe experiences young people might be exploring. Instead underage sex is mainly framed in the language of STIs, unplanned pregnancy or coerced sex. This often leads to discussions of sex and teenagers that centres around the age of consent – purely in chronological terms – which sex educators and researchers feel is not a very useful indicator of sexual behaviour.

What do we know about this issue?
Public concern over youth sexual behaviour is mirrored by the tone of a lot of the research within this area which tends to focus on early sexual debut with associated negative risk factors (such as STIs, abuse, unplanned pregnancy).

The literature uses a number of different ways to approach the issue from straightforward legal definitions of age of consent, although as you can see from this resource the legal age of consent for girls and boys, gay and straight varies internationally. Unsurprisingly countries with more repressive regimes, gender inequality and homophobic values tend to criminalise homosexual sex while fixing the age of consent for girls at a young age. Go figure who this benefits.

Other definitions refer to more ambiguous concepts such as ‘early sexual debut’ or ‘first sexual encounter’. Even within this what is defined as ‘underage sex’ varies depending on different research projects or educational interventions with some referring to sexual contact and petting which includes penis/vagina intercourse, while others present it as specifically about penis/vagina sex.

Critics have complained the focus of both research and education in this area has focused predominantly on problem based or sex negative consequences for heterosexual audiences. The specific issues of sexual debut for LGBT youth is frequently overlooked, while the experiences of certain BME groups is under researched or based around racial stereotypes.

Seeing underage sex purely in terms of penises in vaginas has been identified as unhelpful for a variety of reasons, most of which are summarised in this excellent discussion from Scarleteen. There is the assumption from many parents, practitioners and the media that if a young person has sex before the age of consent they continue to have regular penis/vagina sex from thereon in. This may be inaccurate as some young people may have ‘sex’ before the age of consent but not have it again until they are older. Linking of penis/vagina sex also tends to focus more negatively on young women – particularly around the idea of ‘losing’ virginity and ‘breaking’ of the hymen – an idea which current research disputes on medical grounds seeing it more as a cultural and religious construct rather than any real physical one-off event.

Why are we so anxious about this issue?
Clearly thinking about young people’s wellbeing is important, but it is often unclear in debates about underage sex what is the specific issue adults are most anxious about? Are they worried about pregnancy risk? Of a young person requiring a termination or having a child when young? Or a young person catching a sexually transmitted infection? Do they fear it may lead to promiscuity? Or are they seeing as an adult a situation that is exploitative but that a young person perhaps does not recognise as such (or maybe is aware of as abuse but is still subjected to)? All of these are reasonable fears and ones parents and teachers do raise. They also talk about fears of their child or children in their care getting a reputation (more so in the case of girls) or their being judged as an unfit parent or teacher if they are associated with a young person who has underage sex. As this issue is so often framed as a moral debate it makes it very difficult for us to articulate exactly what our specific anxieties are about underage sex.

Why do young people have sex before age of consent?
Reasons Young People have sex before the age of consent varies. It can include curiosity and experimentation to wanting to experience pleasure or feel close to a boy or girlfriend. It may be something they feel they need to get out of the way or believe everyone else is doing. Or it may be down to feeling coerced, being forced or just being bored. We generally focus on the more negative issues, particularly in relation to age gap relationships (or relationships that are unequal in other ways). Discussing more positive aspects of underage sex tend to be avoided for fear of encouraging sexual activity, seeming to endorse such practices, or the concern among adults that they are potentially abusive or attracted to children. This, accompanied by a media which is largely negative about teenagers having underage sex, makes it very difficult to have a clear conversation about this issue in a balanced way.

What are the risks to young people?
Clearly it would be remiss to present this discussion without looking at the specific problems linked to young people and underage sex. The well documented negative issues include:
STIs
Unplanned pregnancy
Young parenthood
Regret
Risks to reputation (particularly for girls and for LGBT youth)

However this is still very much focusing around penis/vagina (heterosexual) sex. Discussions with young people about kissing, cuddling, communicating desire via text or talking, and masturbation (alone or with a partner) tend to be a lot more positive. Where the focus is on penis/vagina sex under the age of consent there are subdivisions of problems – so unplanned sex with casual partners where condoms or other forms of contraception are not used are seen as inherently more risky than sexual activities which are part of a longer term relationship with a cared for person and where contraception is used.

Given the stigma associated with the first three issues it is understandable people want to prevent them, but sometimes in focusing on them so negatively there can be unforeseen outcomes. Not least those who do seek terminations or become young parents feeling judged negatively, or perpetuating the myth that any sexual encounter will result in either an infection or pregnancy. Such messages give young people false ideas about sex and make it less likely for them to use contraception (particularly condoms) which in turn has the additional effect of making it more likely they may get an infection or become pregnant. So clearly simply focusing on negative outcomes without putting them in any real context or providing advice about prevention is unhelpful.

Moreover it ignores that many young people are exploring sexual experiences with their peers that they enjoy but feel they cannot discuss for fear they are breaking the law, or feel anxious about as they are led to believe any sexual activity under the age of consent automatically is either abusive and/or has negative consequences.

Are particular young people at risk?
Evidence suggests there are particular groups of young people who are more likely to experience underage sex, although they may differ from the stereotypes we expect from the media. The kinds of things that would make it more likely you have sex underage include:
Lack of parental supervision and support*
Lots of pocket money, lots of free time
Lack of hobbies or after school activities
Reduced aspirations
Exclusion from school*
Socio-economic disadvantage
Low educational achievement*
Being from particular ethnic groups (e.g. in the UK African Caribbean boys and White girls are more likely to have sex before the age of consent)
A large age gap relationship*
Peer pressure/bullying
Low self esteem*
Lack of sex education from home or school
Being in looked after care
* also related to not using contraceptives or getting contraception advice/support

So the issue is not just about having sex before the age of consent, it’s related to how young a person is, how in control of the situation they felt, whether they consented to the encounter, whether they enjoyed it, and whether contraception was used (or the sex was planned). The context of the relationship also matters – in terms of whether it was with someone they felt affection for, how soon into a relationship they had sex, and when/how it ended. Many of these factors interact, so lots of free time + a lack of supervision + a lack of hobbies + few aspirations can work together to create situations where a young person might have sex before they felt ready. However other factors can produce contradictory results so while being disadvantaged economically may seem like a very big risk it tends to only be a real problem if accompanied by low educational achievement. So a young person from a poor background who is in a supportive home and being encouraged to achieve at school plus has aspirations and interests will be less likely to have sex underage than a young person who is from a poor background but also is excluded from or doing badly in education.

Prevention – do we need to make kids ‘just say no’?
Clearly situations which are abusive, coercive or unequal are a problem – particularly those that end in violence, unplanned pregnancy or STIs. Simply focusing on negative outcomes is not particularly helpful as already mentioned, and prevention is not likely to be effective if only couched in negative terms of focused specifically on penis/vagina sex. What would help young people is better sex education that focuses on relationships issues and addresses feelings, emotions, confidence, respect, assertiveness and communication skills. Education that focuses on relationships skills as a lifelong learning experience rather than one-off lessons or ‘big talks’ is vital. Delivery from parents and teachers is considered important, and peers are also very helpful. Shifting discussions from this issue from a moral debate to one about empowerment and wellbeing is vital – and our media could do a lot more to assist on that score. Finally reframing this as a youth wellbeing issue rather than a sex one is really important so we focus on aspirations, goals, interests and activities – supporting young people and making them feel valued and respected. Most importantly listening to young people is essential – and often a lot more reassuring than you might imagine.

‘Sexual Readiness’ – a more accurate measure than age of consent?
Research has indicated that a focus on chronological age within a legal framework does not adequately represent sexual maturity. ‘Readiness’ or ‘preparedness’ for sex may be equally important indicators for sexual debut. Meaning not all young people will be sexually mature at any given country specific age of consent. Some 16 year olds may well feel ready and interested in exploring a sexual relationship but not all will. And what constitutes a sexual relationship may vary among young people. Focusing on feeling prepared for a relationship, being able to negotiate with a partner, plan contraception use and be aware how to explore intimacy together is not something that can simply be expected to happen when a young person passes a particular age. Instead we should focus our attention on multiple factors that include physiological, psychological and biological maturity – and how young people feel about their experiences.

Because the focus of research and teaching practice in this area is negatively focused (often for well intentioned reasons) it means we know very little about what young people think about their sexual experiences. Given many fear they will be judged for admitting to underage sex often they tend to focus on (or be asked about) purely negative outcomes. Although controversial if we do not ask young people about a range of experiences they have encountered relating to sex, then we will not be best placed to offer them the in depth sex education they need. It also makes it difficult to differentiate between consenting and coerced experiences and makes it more difficult to safeguard young people most at risk from exploitation or abuse.

What’s the role of parents here?
Parents are often anxious to discuss sex and relationships issues with young people for fear of encouraging early sexual behaviour or being judged by other parents. It is important to talk about sex and relationships issues (see sources of advice below for more on how to do it). Focusing on the positive aspects of relationships a young person can expect to look forward to as they get older is more useful than simply warning about the bad things that may happen – infections, pregnancy etc. Threatening these are inevitable consequences of underage sex, or implying a young person will be criminalised for having sex underage may make it less likely your teenager will talk to you. Remember, a young person who has questions about sex is not necessarily having sex and may be looking for information or reassurance. If they are considering an intimate relationship then discussions with you can help identify who they are in a relationship with and any causes for concern you need to be aware of (age gaps, potential exploitation, issues of control and contraception). These are not always easy issues for parents to consider and you may find talking to other parents, to your child’s school or college or getting advice from your local outreach/health promotion services could be of use in such a situation.

Parents know their children well and are often excellently placed to put advice and education in context. You may be aware your child is interested in adult relationships and will want to prepare them for this and answer their questions while highlighting what positive and equal relationships are about. Or you may notice your child does not seem to be keen on discussing such topics and you may want to reassure them about relationships at a level appropriate to their maturity – not avoiding topics but ensuring they are covered in a way that best suits the needs of your child. Again, reflecting on the messages you are sharing with other parents or friends can be very useful to ensure you are pitching things at just the right level.

Certainly don’t leave any ‘sex talk’ until your child is over the age of consent for your country or state, they will need information well before this. And remember just because they’ve not asked you doesn’t mean they’re not picking up ideas about sex and relationships from other places (like the media and their peers). Talking about sex and relationships spans your child’s life – it doesn’t have to wait until their 16 and doesn’t stop once they pass this age.

Sources of advice/help
This previous post addresses what young people want in relation to sex education and includes evidence about what young people want to learn about positive relationships. It also links to other posts and resources containing advice on how to talk to young people about sex and relationships.
Hawes, Wellings and Stephenson’s excellent review ‘First Heterosexual Intercourse in the United Kingdom: A review of the literature’ (2010) Journal of Sex Research is essential reading for anyone wanting a systematic overview of the literature on this topic, which clearly outlines the different studies addressing sexual behaviour in young people.

Over this weekend the story broke that pharmacies were going to give teenagers the pill – as a means of tackling teenager pregnancy.

News coverage included:
Teenage girls offered contraceptive pill over the counter in a drive to cut pregnancies – Daily Telegraph

Teenagers to get pill without prescription – Independent

Girls get the pill on demand: now teenagers can get the contraceptive without prescription

Teenage girls to get contraceptive pill in pilot scheme

You’ve got to love these ‘girls get the pill on demand’ style headlines – which kind of ignore the fact that contraception is free and available within the UK – and yes you can ‘demand’ it if you like!

From the press it sounds like girls across the UK are going to get the pill from the pharmacy – is that really the case? Well, before we get to that, let’s look at what we do know about providing contraception via pharmacies.

What’s the evidence?
The papers have not clearly indicated this is a pilot scheme, perhaps in their hurry to promote a shock/horror response they overlooked this. They also seemed to overlook the wider evidence base about oral contraceptive provision, and managing teenager pregnancy.

So what do we know about this issue? Well, we do know our teenage pregnancy rates in the UK are high. Most of those pregnancies are terminated, but the prevalence of termination (particularly repeat terminations) are of concern to healthcare providers. As a result there’s been a push within reproductive/sexual healthcare over the past decade to rethink how contraceptive services are delivered – and how teenage pregnancy rates can be reduced.

There is already an established evidence base that pharmacies can provide some forms of contraception and sexual health support – for example condom sales, testing for Chlamydia and providing emergency contraception (morning after pill).

Here the pharmacy becomes an additional service for providing contraception/sexual health support, alongside existing reproductive health/family planning clinics or GPs.

Young people are frequently blocked from accessing services due to unclear signposting of services (so young people don’t know where they are); restricted opening times which often don’t fit with young people’s timetables; problems with location; uncertainty over what happens in a clinic; worries about confidentiality; or just basic information (many young people still wrongly think you have to pay to get contraceptives).

Add to this problems with sex education and general problems around poverty and social exclusion, there are understandable reasons why young people get pregnant. Culturally we’re often quick to blame them without appreciating the lack of access to information and contraception that affect some teenagers. You can read more about how poverty, lack of education and healthcare barriers contribute to sexual and reproductive health problems here (with an ongoing investigation into the issue reported here)

Part of a response to our current sexual health crisis been a shift to making sexual health less clinical and more about self management. This has been suggested to reduce strain on services and make aspects of care that can be managed in other settings more effective. So pharmacies can be one additional place to deliver care, as might school nurses, or even cafes and nightclubs. More choices and more places to get advice and services are a step to reduce teenage pregnancy and termination rates.

There is no evidence that making sexual health services more accessible increases teenage pregnancy (as some media reports have claimed). Although it’s worth noting that many of the schemes trying to reduce teen pregnancy are being rolled out in areas where teen conception is already very high.

What’s actually happening?
This is a pilot scheme being run in a deprived area of London with a high prevalence
of teen pregnancy. You can read about the area’s history on this issue here. This borough has received charitable trust funding to modernise a variety of services, including sexual health. You can read an independent evaluation of that work here.

Within this modernisation work, practitioners have already investigated delivering sexual health services within community settings, including assessing whether community pharmacies were suitable locations for Chlamydia testing.

This latest pilot is part of an ongoing project looking to modernise, improve and make more accessible sexual and reproductive health services for a resource poor community. All activities have been based upon evidence and completed in consultation with the community.

So rather than the pill being given to all teenagers across the UK, this is simply a pilot scheme to see whether providing the pill to younger people within community pharmacy settings is feasible – and works to reduce teen conceptions. If it does, then the scheme will be rolled out to other pharmacies. If it doesn’t work then alternative approaches will be considered.

Why do we need to be cautious?
My first question about this story is ‘is this really news?’. It created a widespread splash in the papers, but it was actually launched to the press last year, and there was some coverage of the proposed scheme in August 2009 too.

We need to discuss why this story got back into the papers. It isn’t clear. But what is clear is the majority of coverage was judgemental or negative, and has discussed a pilot scheme within the press before it has even really got started. That’s a problem as it can scupper a pilot and mean we never get to see if it can work or not. It can lead to people interfering with the delivery of a service – particularly those who’ve been led by the media to see such a pilot in negative ways.

We don’t know if this will work – that’s the point of a pilot. To investigate and explore. So media coverage should really only happen when a study has been completed – not speculation before it starts, or during any study.

We’ve seen similar problems with the media outing interventions to reduce teen pregnancy in the past. You could be forgiven for believing some media outlets simply don’t want us to tackle the problems we’re experiencing with teenage pregnancy and sexual health.

Generally health evaluations work better if left undisturbed and can be reported faithfully whether they work or not. We really do need to challenge this practice of reporting on pilots until they are finished. Particularly in the restrictive way the media approaches this which is to find a practitioner (usually from a faith based group) to say how such a scheme will inevitably make things worse. What may help more would be to put such schemes within the context of wider evidence, and if you want a debate to talk about whether other approaches – like better sex education, tackling poverty or increasing aspirations for young people – might be equally or more effective.

For the record this pilot scheme does not mean all teenagers are going to be offered the pill. It’s a pilot taking place in a specific part of South London. Even within the pharmacies in the pilot it doesn’t mean that pharmacists will be pouncing on all young women entering their stores and giving them oral contraceptives. Any young woman requesting oral contraception will have consultation and be assessed for competence and the pharmacist can refer to other services if needs be.

Parents don’t need to worry that pharmacists will be slipping the pill to their daughters behind their backs. Even if some journalists have misled them that this will be the case.

For now, all we can do is wait and see if this pilot works. And in the meantime additional focus will continue to address ways for reducing teen pregnancy in
poor/deprived boroughs.

Here’s a roundup of some of the sex/science stories that I’ve been following this past week.

I’m sure pretty much everyone tuned in to see Question Time last Thursday, and to find out what British National Party leader Nick Griffin had to say. I found the programme a bit disappointing, although Griffin did manage to give us a few gems. Including his dislike of school based sex education (he doesn’t agree it ought to be taught to primary school children). And homosexuals, or rather the ‘militant homosexuals’ (seemingly mild mannered ones are fine in Griffin’s book). Men kissing. He doesn’t like that. He finds it ‘creepy’. So if you want to bring down the BNP a well organised gay male snogathon might be a good place to start.

During Question Time Griffin is he tried to discredit Islam by discussing its approach to women. While Islam may be problematic in its treatment of women in places, the BNP hardly does well in this area. Witness their Family Law White Paper (which incidentally also returns to Griffin’s bete noir – the homosexual – as the BNP propose dissolving gay partnerships). Or you might want to see what policy resolution they proposed for teenage mothers at their recent conference:

‘Teenage mothers – the problem and the solution

If an 18-20 year old pregnant woman is married [marriage should not be an option available to 16/17 year olds, even with parental consent] and her husband has a job, then she will be exempt from going in to one of the homes.’

[A reader got in touch asking whether I agreed with the BNP policy for teenagers. The answer is no. They also wanted clarification about why the suggestions above are problematic. Firstly, the BNP state sex education won't make a difference to teen pregnancy rates, yet evidence clearly indicates it does. Secondly they outline a pattern of activity (different babies by different dads to upgrade accommodation) that doesn't happen in reality as much as the tabloid's would have us believe. Many teen mothers live with their families or the baby's father, or if they are in social housing often are placed in bedsits or flats. The most vulnerable mothers are often placed in the most inappropriate housing. I do agree that some young mothers can end up not being mature enough to parent effectively and this plus poverty can cause problems to mother and child(ren). However maturity isn't age related and while some teen mums can struggle, not all do. Mothers who are older may also lack the maturity or social support to parent effectively.

Thirdly, the BNP's report describe teen mums as feckless queue jumpers who get housing above those who've been waiting longer. Although there's no evidence for this happening on any large scale - again often teen mums are housed in bed and breakfast or shared accommodation rather than a home of their own. Withholding to young mothers (single mothers under 21) means they will have no independence or the opportunity to enjoy life. Enforcing a dress code is impractical and patronising (also if you're a young mum then a below the knee skirt and top where no cleavage is on show is not a great outfit when you're busy with a baby and might be breastfeeding). These suggestions imply young mothers will be being punished for having a baby. Parenting classes and support are ideas that are good, but these are already on offer and in most areas considerable effort has been put into providing these for young parents. Certainly the idea that those who do not confirm will be imprisoned and have their baby put into care is draconian and unworkable.

My main concern with the policy is it's not considered evidence, it has not researched what actually happens to young people, and has only focused on teenage girls - ignoring the roles and responsibilities of young men.

This is also discussed over at Lancaster Unity and Sim-O's Good Old Fashioned Values. The issue of what to do about teenage pregnancy is an important and emotive one. I'll be writing a future blog about what contributes to teen pregnancy/motherhood and what we can do about it]

Back to Question Time which also featured Sayeeda Warsi who has opposed gay marriage and school based sex education. In 2007 she said “I will campaign strongly for an end to sex education at seven years and the promotion of homosexuality that undermines family life”. So while Warsi was placed on the programme to challenge Griffin, there was little opportunity for the audience or other panelists to identify that sadly it’s not just the BNP who are promoting homophobic or sex negative policies.

Staying with the topic of bigotry, Jan Moir has tried to explain her recent column about the death of Stephen Gately. Moir’s most recent response does not fully apologise for her column, nor does it put right the inaccuracies about sudden death or sexuality she described. Perhaps it might have been better for Moir to issue a genuine and short apology, or say nothing at all.

Still on negative stories, Ben Goldacre over at Bad Science alerts us to The Spectator’s plans to screen the AIDS denialist movie House of Numbers as a means of encouraging ‘debate’ about AIDS. Goldacre’s blog highlights the problem with the movie (and links to numerous blogs who’ve been challenging the film and how it’s been accepted/promoted by people who ought to know better). Although gossip now suggests the event may be off.

On a more positive note, Halloween is just around the corner (although I promise not to mention the (over 18s) Pumpkin Dildo again this year). So in the run up to the event why not think about something suitably supernatural and consider dating a (real life) vampire? Actually I’ve done little else but fantasise about Edward Cullen of late, so this guide is useful in case he tires of Bella and comes for me. Join me, and check out the Twilight series, or tuck into Susie Bright’s Bitten – a great new gothic erotic anthology.

And if you want some super sex education this week the Kinsey Institute’s running a Sex Research Live event on 28th October where you can find out about your sexual personality and find out more about how we research sex. Or pop to London’s Science Museum (also on 28th) from 6.45pm where you can find out more about sex – including a chance to test your own sexual knowledge. And I’ll be telling you exactly why scientists study sex.