When addressing nursing considerations, the issues identified through considering the box case study 6.1 and the questions posed will help to identify those aspects of the situation which will require further nursing assessment, planning, and, ultimately, the nursing interventions which will help Kylie to address her sexual health needs (see case study below).
ANSWERS TO QUESTIONS
Question 1. What constitutes good sexual health?
Good sexual health can be defined by concrete factors such as the absence of sexually transmissible disease. However, there are more abstract perspectives too, such as freedom of expression of the sexual self.
It is worth considering the definition of sexual health to ensure that all dimensions are identified. The World Health Organisation (WHO 2002) defined sexual health as:
A state of physical, emotional, mental and social wellbeing related to sexuality. It is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.
This rather long statement serves to highlight the complexity of sexual health. Some of the key ideas from a nursing perspective include:
Sometimes we think of sexual health rather narrowly in terms of sexually transmissible infection and unintended pregnancy. While these factors are important, they are not the whole story.
People may need help to achieve the sexual life they want, free of social pressures (such as the peer group for young people), coercion (such as being pushed into engaging in sexual activity against their better judgement or before they feel ready to do so).
Sexual bullying and violence are too common and young people need to be equipped with the skills to protect themselves.
Sexual health is not merely a matter of physiological or mechanical issues. It is important that young people learn how to conduct their sexual lives in a way that is emotionally and psychologically rewarding and satisfying.
Sexually transmissible infections are prevalent among young people and there is evidence that they are rather taken for granted by this age group. However, the long-term consequences of some of these can be severe, for example chlamydia. Misinformation about these infections remains widespread among young people.
Some young people actively opt for early parenthood. However, the UK has among the highest rates of teenage pregnancy in the Western world and this is even more marked in areas of relative deprivation. Many of these pregnancies will be unintended and have the potential to limit the life opportunities of these young parents.
In the light of these factors, it is important for nurses working with children and young people to consider what young people need to be able to protect and improve their own sexual health and wellbeing. Equally significant will be a consideration of factors which serve as barriers to young people being able to act in their own best interests in this central facet of their health. Exploration of these issues will allow the children and young people’s (CYP) nurse to identify their learning needs so that they are equipped with the knowledge and skills necessary to help young people meet their health needs.
SOME FACTS
In Scotland, in 2019, 17,336 diagnoses of chlamydia were made. This represents a 6% increase compared to 2018. (Health Protection Scotland 2021).
In Wales, between 2005 and 2008, 44 per 1000 young women between the ages of 15 and 17 became pregnant. However, this rate was 25.4 per 1000 in 2019. (Teenage Pregnancy.net 2021; Welsh Assembly Government 2010).
In England, between 2019 and 2020 there was a 46% reduction in the number of those diagnosed as having genital warts. This may relate to the pandemic lockdown but remains high compared to similar countries. (UK Government 2021).
In Northern Ireland in 2019, 60% of victims of sexual crimes were girls below the age of 18. (The Strategic Investment Board 2020).
All of these indicators are significantly more negative than those found among our Western European neighbours (UNICEF 2004). These facts indicate rather starkly the need for improvement in sexual health promotion among our young people.
QUESTION 2. WHAT DO YOUNG PEOPLE NEED TO PROMOTE THEIR OWN SEXUAL HEALTH?
The first and most obvious need is for accurate and constructive information in relation to sex. Young people readily identify this need but often have difficulty accessing this information:
While many young people get their sex-related information at home, many parents find it difficult to discuss sex with their children, often because they feel ill-equipped themselves to discuss this matter. This attitude can also lead to young people feeling unable to bring their sexual concerns to their parents (Rhondda Cynon Taff Fframwaith 2009).
The school can play an important role in ensuring the sex education of young people. However, this provision is patchy and variable in quality. Sometimes sex-related information offered is excellent and versatile, tailored to the needs of the young people and covering all aspects of sexuality. On the other hand, some young people receive information relating to the biology of sex with little reference to relationship aspects of a healthy sexual life. Excluded and hard-to-reach young people suffer a further disadvantage in this respect.
For many young people, the principal source of sex-related information is the peer group. This may be unhelpful and inaccurate and lead to negative feelings about sex and sexuality and risky behaviour.
Young people who are gay, lesbian, bisexual, or transgendered can be particularly disadvantaged in this key element of their lives. Their particular needs must be identified and respected, although currently that generally is not the case for most.
This is an area which is sensitive, complex, and rapidly evolving requiring the provision of specialist services. CYP nurses offering a service to these young people must rigorously maintain, among others, two key principles: respect for the young person and their identity and prevention of any harm, physical, psychological, social, etc.
The media offer distorted images of sexuality in our sexualised society. Young people can be led to believe that this is reliable and dependable information and may base their expectations on this.
Expectations of sexuality and sexual health can vary between ethnic, religious, and cultural groups. Sex-related information will have to be couched in formats which are sensitive to these expectations.
Young people need access to services which exist to promote their sexual health:
Contraceptive and sexual health (CASH) services need to be orientated towards the needs of young people and specifically address the needs of this age group.
Sexual health services which offer diagnosis and treatment of sex-related disorders need to be readily available and accessible as well as youth-friendly.
Counselling in relation to sexual wellbeing needs to be available. This is particularly important for those who have experienced sexual coercion or exploitation (Scottish Government 2010).
Dedicated facilities for the support of victims of sexual violence are particularly crucial.
CYP nurses and other professionals who work with young people are in a position to help this group with their informational needs. There are a number of approaches to this (NIHCE 2014) and might still include approaches such as:
Drop-in services offered by specifically prepared professionals. Young people particularly value the services of groups such as school nurses and youth workers.
Educational programmes delivered by specially prepared peer educators can be effective.
Mass health education campaigns can be effective, especially when channelled through media and platforms used by young people.
Projects designed to improve access to contraception services can be very useful (Health Development Agency 2004).
On occasion, the most important role of the CYP nurse is, having assessed sexual health-related needs, being aware of appropriate local services, and being able to refer to these effectively.
QUESTION 3. WHAT PROBLEMS MIGHT YOUNG PEOPLE EXPERIENCE IN MAINTAINING THEIR SEXUAL HEALTH AND WELLBEING?
Being unaware of what good sexual health is and how this can be achieved is the first and most obvious need and can be answered by good educational provision.
Young people sometimes meet professionals and others who have negative, judgemental, flawed, and damaging attitudes and assumptions. This, in place of a proper and comprehensive assessment of need, constitutes a real barrier.
Young people have a real concern for confidentiality in relation to their sexual health needs and can be impeded from accessing services. This can naturally be particularly marked in rural and remote settings. There is some evidence that young people perceive health professionals as being sensitive to confidentiality needs.
Assertiveness and negotiation skills within relationships is something many young people find difficult to achieve.
If an atmosphere conducive to open discussion and questioning is not created, embarrassment can be a real hurdle to communication.
A lack of awareness that substance and alcohol use can lead to errors of judgement and risky behaviour.
Victimisation, exploitation, and abusive relationships are sources of substantial damage to sexual health in every respect.
From consideration of this range of factors, it begins to become evident how care in relation to sexual health for Kylie might be approached. The first step to care will always be to assess need.Refer to Box Activity 6.1
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