This work concludes that it is the responsibility of health professionals in conjunction with others to educate the child morally, socially and developmentally within sex and relationship education at school. There is little doubt that the midwife has a part to play in this education, especially as childbearing issues form part of the curriculum recommended by the Department for Education and Employment (2000). However, the midwife cannot work in isolation and professionals all need to work in a collaborative approach to educate teenagers. It also recognises that parents also have to accept the same responsibility towards their children and should also work in partnership with the school and health professionals. Teenage pregnancy is a major public health problem, and one important solution identified to combat this is improvement within sex and relationship education. The aim of this chapter is to analyse how the role of the midwife could be incorporated in the teaching of sex and relationship education to teenagers. Despite previous massive public health programmes, teenage pregnancy remains a crucial issue affecting our society. Midwives have a clear sense of responsibility in the public health sector in working to reduce inequalities and improve the health and well-being of people and communities. The Department for Education and Employment (2000) highlights this point and suggests that part of the curriculum in schools is childbearing issues. In past decades, teenage pregnancy has been extensively studied and yet in spite of all that is known, our society has yet to gain control of the problem (Porter 1998). The high incidence of teenage pregnancy and parenthood in the United Kingdom continues to be a complex issue and is of increasing concern to society. From a midwifery perspective, teenage pregnancy is a major challenge because of the increased maternal, fetal and infant morbidity and mortality rates (Sweet 1997). The concerns of teenage pregnancy include the social, psychological and educational health and welfare of the teenager and the subsequent baby (Dignan 2000). Also one cannot ignore the effect on family and society as a whole (Fuglesang 1997). In 1997 a National Task Group was established to explore issues surrounding teenage pregnancy. In 1998 this task was taken on by the Social Exclusion Unit with the main aim of reviewing and suggesting strategies to decrease the incidence of teenage pregnancy and parenthood. The published report demonstrated the enormity of the problem. It stated that in England alone, there are almost 90,000 teenage pregnancies a year, of which approximately 2200 are to girls under the age of 14 years and 7700 to girls under the age of 16 years (Social Exclusion Unit 1999). This is further discussed in Chapter 11. Whilst the incidence of teenage pregnancy varies between areas of the United Kingdom, it is a problem that affects every part of the country; prevalence is high in affluent areas, but even higher in areas of deprivation and poverty (Smith 1993). International comparisons indicate that the incidence of teenage pregnancy in the United Kingdom is greater than in any other developed country except the United States of America, Canada and New Zealand (National Children’s Bureau 1999). Throughout most of Western Europe, the incidence of teenage pregnancy has steadily declined since 1970. However, by contrast, within the United Kingdom the incidence has increased, so that we now have the highest rate of teenage pregnancies within Western Europe (Social Exclusion Unit 1999). To put this into context, the United Kingdom has teenage birth rates twice as high as Germany, three times higher than France and six times higher than the Netherlands (Social Exclusion Unit 1999). Teenage pregnancy has been recognised by the Government as a serious issue that needs addressing and in conjunction with the Social Exclusion Unit (1999) key areas have been identified as part of a national campaign to reduce the rate of teenage pregnancy in the United Kingdom by 50% within the next 10 years. One key issue raised is the present provision of sex and relationship education within schools and its being a possible contributory factor in the high rate of teenage pregnancy. In response the Education Authority, in conjunction with the National Children’s Bureau and the Sex Education Forum, published national guidelines on teaching sex and relationship education. However, these are guidelines only and are open to individual interpretation. At present there is no formal training for the teaching of sex and relationship education and it is left for the school to nominate a member of staff to teach this subject. Whilst the school nurse supports the teacher in this role, she does also have an important role to fulfil in other aspects of child healthcare (Maclean 1997) and therefore limited time is allocated to this support. The expertise of the midwife could be seen as complementary to the role of the school nurse. Yet, part of the strategy from the Social Exclusion Unit (1999) is the review of the content of teacher training courses to ensure sex and relationship education is covered in their initial training. Such training could be seen as unnecessary and a waste of resources when there may be health professionals that could help to provide this type of education. However, the Government has already recognised that the reduction of teenage pregnancy has to be a national effort involving communities, the media, teenagers, parents and many different professionals working together (Social Exclusion Unit 1999). Sex and relationship education within schools has received increasing attention. In general, teenage sex education is criticised as being inadequate in both content and teaching styles (Jobanputra et al 1999). The focus of such education needs to be for teenagers to have the knowledge required to make informed decisions and avoid negative health outcomes. However, there is still public concern over whether sex education increases promiscuity, despite research demonstrating that ignorance about sex is a risk factor for teenage pregnancy and that good sex education helps to delay rather than accelerate sexual activity (Kirby 1995). Sex education within schools needs to be seen as an opportunity to influence teenage behaviour and appears to represent an important part in reducing the incidence of teenage pregnancies (McEwan et al 1994). Sex and relationship education is lifelong learning about physical, moral and emotional development (Department for Education and Employment 2000). It is a legal requirement for schools to provide some aspects of sex and relationship education (National Children’s Bureau 1999). Section 1 (2) of the Education Act (Department for Education 1994) requires all schools to offer a curriculum which: • Promotes the spiritual, cultural, mental and physical development of pupils at the school and of society • Prepares such pupils for the opportunities, responsibilities and experiences of adult life. Whilst there have been no recent changes to the law regarding sex and relationship education, since 1993 there have been a number of national policies that have had an impact on the provision of sex and relationship education within schools. One such policy was the new sex and relationship initiative established as a priority in the ‘Teenage Pregnancy Action Plan’ launched by the Government and the Social Exclusion Unit in 1999. In response to the ‘Teenage Pregnancy Action Plan’ the Department for Education and Employment (2000) proposed that the provision of sex and relationship education within schools be taught from a different perspective. This subject falls into two main categories: firstly sex and relationship education that comes under the science aspect of the national curriculum, which is concerned with anatomy, puberty and biological aspects of sexual reproduction (Box 9.1). The other aspect of sex and relationship education comes under the ‘Personal, Social and Health Education and Citizenship’ framework (Sex Education Forum 1999) (Box 9.2), which aims to support the personal and social development of children and young people. Whilst the Department for Education and Employment (2000) produced the guidelines listed in Boxes 9.1 and 9.2, the content of sex and relationship education is not clearly defined and is open to different interpretation from schools. Governing bodies of schools are required to ensure that their schools offer a programme of sex education. However, the only criteria for such programmes are that they should include sessions on Human Immunodeficiency Virus (HIV), Auto Immune Deficiency Syndrome and Sexually Transmitted Diseases (Department for Education 1994). Obviously many schools address other aspects of sex and relationship education than just the compulsory elements, but if schools choose not to, it is their choice. Schools can justify these actions providing they keep a written statement of their provision of sex and relationship education. In the past sex education in schools had a narrow, reproductive focus and was taught only as part of the National Curriculum for science. The publication of Sex and Relationship Education Guidance (Department for Education and Employment 2000) now suggests that children of all ages should acquire information, develop skills and form positive beliefs, values and attitudes. This should ensure that young people have the opportunity to receive information, examine their values and learn relationship skills that will enable them to resist becoming sexually active before they are ready, and to prevent unprotected intercourse, enabling young people to become responsible, sexually active adults (Sex Education Forum 1999). Sexuality defines our role in society and influences our feelings about relationships (Finan 1997). Walton (1997) suggests that sexuality is concerned with sexual orientation, desires, expressiveness, innate feelings, sexual instincts and identity at every stage of life. The teenager is required to make moral choices, including the choice not to be sexually active. They therefore need to have an understanding of their own sexuality, and yet there is controversy over who teaches these sensitive issues. There is continual debate and opposition from teachers, parents and health professionals as to what needs to be taught to our teenagers. Perhaps the broader emotional and ethical dimensions of sexual attitudes of different professionals need also to be considered. It may then be possible for health professionals to liaise with teachers and parents to provide a better system. So the equation for providing effective sex education is not only what is taught, but also who teaches this subject (Dolby 1998). As a society we have to take adequate steps to ensure our teenagers are educated, or accept the consequences. Historically, school governors in conjunction with schoolteachers have decided on the content of sex and relationship education. It has now been suggested by the Sex Education Forum (1999) that such policies should be developed in consultation with parents, young people, teachers, governors and the wider community. There are clear intentions from the Government and the Social Exclusion Unit (1999) in developing specialist sex and relationship education training for teachers. Whilst there is clearly a need for improved teaching in sex and relationship education, it is unclear who the appropriate people are to teach this subject. Proposals from the Department of Health (1999) include the widening of the midwifery role to inform young people about healthy lifestyles: the midwife may have an effect on the attitudes and values of teenagers. Certainly Bennett and Brown (1999) suggest that a necessary skill of a midwife is the deep perception of the influence of emotions and the effect this can have on an individual’s behaviour. However, Finan (1997) suggests that the family is the most important source for learning about sexuality issues. Parental attitudes and behaviour definitely have a major impact on the behaviour of teenagers, and this is one issue that has been raised in the teaching of sex and relationship education. Briggs (1998) discusses how parents have a tremendous influence over their children despite the decline of traditional values. A study undertaken by Rosenthal and Feldman (1999) focused on this issue and discussed how parents should play a pivotal role in sex and relationship education of their children, because alongside sexuality come questions of values and morals. However, the experience of young people is very different today from that of past generations. Fuglesang (1997) suggests the family is noticeably in decline, with the traditional extended multi-generational families giving way to single parent families, and many young people choosing careers over marriage. Whilst this study was performed in Tanzania, it also describes societies in developed countries. Rosenthal and Feldman’s study (1999) also highlighted that many parents find the task of teaching sex education to their children difficult, feeling ill-equipped to deal with certain issues. The midwife has an important role to play in family relationships, alongside promoting good physical health and positive emotional health (Page 1999). Saito (1998) suggests that the first step in teaching sex and relationship education is to recognise the teenager as a sexual being. This may be easier for the health professional who, understandably, views the teenager in a different light from the teacher. There may be difficulties for the teacher and the teenager who are used to a classroom situation. The frequent contact that teachers have with teenagers can itself act as a barrier to sex education (Eisenberg et al 1997). Eisenberg et al also found in their study that teenagers felt uncomfortable receiving information from teachers and recommended using outside health professionals who could ensure more freedom and less embarrassment because of their anonymity compared to teachers. Wight and Scott (1994) also demonstrated this point in their study, showing that a teacher’s anxiety often exacerbates pupil embarrassment. They also felt that outside speakers show more expertise, are usually easier to talk to, and can deal with problems that teachers find difficult. Sheridan (1997) discusses how the teacher of sex and relationship education needs to be experienced in the field of health education, and the midwife may be seen as an appropriate professional. This is acknowledged by the Department of Health (1999), recognising the diversity of the role of the midwife and the need for better use of the midwife’s knowledge and skills. A study was also undertaken by Kumar-Bhasin and Aggarwal (1999) to explore the perceptions of schoolteachers and their role in teaching sex education to schoolchildren. This study, whilst undertaken in India where the culture is very different, is significant as the United Kingdom has a multi-cultural society where different social, ethnic, cultural and religious backgrounds need to be taken into account. Within India sexuality is still a ‘taboo’ subject and is not openly discussed, despite the need to encourage responsible sexual activity in the teenager. India has an estimated 2.5 million people infected with HIV (Kumar-Bhasin & Aggarwal 1999), which indicates that there are many people having unprotected sexual intercourse and could suggest a high rate of unwanted pregnancy. Despite this, 21% of teachers in this study were against sex and relationship education within schools. This was partly due to their culture, but a high percentage of teachers felt that sex education was linked to increased promiscuity. Interestingly, teachers who felt that sex education was appropriate only thought that the anatomy and physiology aspects were suitable. Aggleton (1989) discusses previous research to suggest that unless sex education is properly re-organised in schools it is a missed opportunity to influence the future sexual behaviour of the individual teenager. There appears to be little doubt that influence within schools can play a major role in shaping the health and lifestyle behaviours of teenagers. Sex education may be more beneficial if centred on teenagers’ needs and discussed by health professionals who have an interest in this speciality. Teachers’ reluctance to discuss sexuality may be due to a lack of knowledge, or even the fact that they may hold conservative values regarding sexuality. Ruusuvaara (1997) suggests that sex education is also coloured by society’s reluctance to accept teenage sexuality. Research has demonstrated the value of the professional nurse and patient relationship, particularly when addressing the complex issues of the reproductive health of the teenager (Meisenhelder 1985, Hanna 1993). Donati et al (2000) also raise this issue and suggest that children should be encouraged to question and explore their attitudes and values within sex and relationship education, to develop the ability to exercise independent choice. A small qualitative study undertaken by Lambke and Kavanaugh (1999) highlighted how teenagers need to be empowered in order to make their own decisions and understand the ramifications of their behaviour. This is an interesting concept as midwifery practice is centred on empowerment of the woman. Donati et al (2000) included in their research both the attitudes and knowledge of teenagers: that is, to provide a quality sex education policy there needs to be collaboration between schools and health professionals. If midwives are not seen as the appropriate professionals to educate teenagers in the UK, perhaps midwives should be concerned with supporting teachers and school nurses in their role as educators of sex and relationship education. The Department for Education and Employment (2000) also raised this issue, and suggested that health professionals have much to offer and should work closely with teachers in supporting sex and relationship education in schools. Many societies emphasise sexuality as a problem and would prefer teenagers to postpone sexual activity until they are older (Ruusuvaara 1997). However, surely this leaves teenagers to form attitudes and values from their peers and the media, and as Ruusuvaara (1997) suggests, to form their own social norms. The concern is that these values and beliefs may not always be part of the prevailing value system that they are growing up in. It needs to be remembered that whoever teaches sex and relationship education within schools, teenagers will form many of their attitudes from sources that are out of the control of parents, teachers or health professionals. There is no doubt that teenagers’ values and the media influence attitudes: sex is seen as associated with humour and excitement, and it is only recently that the dangers of unprotected sex have been described (Shelov et al 1995). In research undertaken by Witte (1997), the need for better sex education was universal, together with the need for teenagers to be explicitly informed of the consequences of their actions. Beitz (1998) discusses how a teenager, just watching television in normal hours, is subjected, over the course of their teenage years, to 14,000 sexual references, innuendos and behaviour with very little regard for birth control, abstinence or personal responsibility. The sexual behaviour of teenage peer groups will also have an influence on the initiation of sexual activity of the teenager. Over the years research has suggested that it is the responsibility of whoever teaches sex education to strongly pursue ways to encourage abstinence in teenagers (Strasburger 1989, Khouzam 1995
Sex education and teenage pregnancy: missed opportunities
SUMMARY
INTRODUCTION
CURRENT LEGISLATION
CURRENT EDUCATORS
FAMILY INFLUENCE
THE SCHOOL
HEALTH PROFESSIONS’ INPUT
THE PEER GROUP AND THE MEDIA
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Sex education and teenage pregnancy: missed opportunities
