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Sexual health policy analysis in selected European Countries

1 Introduction

The Health Education Board for Scotland commissioned this policy analysis to inform the development of strategic work in the area of sexual health in Scotland.  The report comprises the sections outlined below. 

Section Two: The background to the research will be outlined covering policy and the development of evidence-based policy decisions.

Section Three: Following the introduction of the aims and objectives of this research, section one outlines the methods by which this research was undertaken as well as exploring the rationale behind the choice of countries and indictors utilised within this report.  The section concludes by introducing the wider policy perspective being explored within this report.

Section Four: Map out the key policy areas under exploration in this report.  In doing so a short review of relevant literature is explored in order to provide rationale as to the decisions behind the inclusion of each policy area within this report.

Section Five-Nine: Locate and explore the policy areas within the five countries under focus, namely: Finland, France, the Netherlands, Romania and Scotland, paying particular attention to the social context within which the various policies have been developed.  Each country section begins with a profile of indicators relating to teenage sexual health.

Section Ten: Present a comparative discussion of the five countries, highlighting indictors of success or otherwise of the impact of policy aimed at improving the sexual health of young people.

Section Eleven: Presents the final section of this report, which discusses the main conclusions to this report within the context of implications for the development of an informed strategy for the promotion of young people's sexual health in Scotland.

2 Background

2.1 Policy background

Scottish young people's sexual health has been raised as an issue of concern by government within the White Paper for Health, Towards a Healthier Scotland (SODH 1999).  Whilst the primary sexual health target for young people set within this document is the reduction of pregnancy amongst 13-15 year olds by 20% between the years 1995 and 2010, it further acknowledges the need to look beyond teenage pregnancy as the only issue of sexual health concern for young people.  Both the rising incidence of sexually transmitted infections (STIs), particularly amongst young women under 20 (ISD Scotland 2000a) and the growing concern over the rate of HIV transmission and AIDS ¹ in Scotland, have brought about an awareness that in order to promote 'healthy sexuality' amongst Scotland's young people, a more holistic approach is required.

The acknowledgement of the need for a wider approach is an important first step to developing a strategy for the improvement of young people's sexual health that is more likely to have the desired impact on the rate of teenage pregnancy and STIs, than has been the case until now.  Prior to Scottish devolution (in 1999), policy developed at Westminster tended to reactively focus on individual issues relating to sexual health.  During the 1980s and early 1990s the primary focus was on HIV and AIDS, shifting to a focus on teenage pregnancy through the latter half of the 1990s and early 2000s. 

Whilst the targeting of resources on priority health issues is required in order to tackle specific issues, a narrow focus of this prioritisation can have unfortunate side effects.  For example, since the mid-1990s, the shift in policy focus away from HIV/AIDS² to teenage pregnancy has been problematic in that by focusing on 'pregnancy' alone, the issue of STIs (including HIV) has received little attention and the rates of which have coincidentally risen significantly amongst young people in Scotland since 1994 (ISD Scotland 2000a). 

Consideration should also be given to the terminology being used as well as the politics of that terminology.  From a political point of view, the phrases 'teenage pregnancy' and 'sexual health' do not just highlight two different policy foci; there is also underlying meaning to both (Silver 2001: pc³).  Within the British policy context, 'teenage pregnancy' has continually been used to portray a negative situation.  A clear example of this negative overtone can be seen in the foreword to the SEU report (1999) by the Prime Minister, Tony Blair, who states 'Britain has the worst record on teenage pregnancies in Europe.  It is not a record in which we can take any pride... Our failure to tackle this problem has cost... As a country, we can't afford to continue to ignore this shameful record' (SEU 1999:4)⁴.  'Sexual health' on the other hand can be more positive terminology (although use is also made in terms of illness).  Used in the right context, the use of these two words can portray both an acceptance of sex and sexuality, and the right to be healthy in that sphere of life. 

The fact that the Scottish Executive is pursuing a 'sexual health strategy' rather than a 'teenage pregnancy strategy' from the outset, is potentially, the first step down a policy road that is more likely to impact upon the lives of young people in Scotland for two key reasons.  First, a sexual health strategy portrays an inclusiveness of all young people not just young women.  Second, it provides a platform from which to promote 'good practice' in sexual health, whereby young people can learn that sex is a normal healthy aspect of life and that in appreciating the value of their own sexual health, they can develop an understanding appropriate to their lives about respect, responsibility and safer sex.

2.2 Research background

The narrow focus on specific sexual health issues has not, however, been confined to policy development, it is also reflected within research available to inform policy.  Much research conducted during the 1980s and 1990s, which did focus on reducing teenage pregnancy rates, generally focused on the effectiveness of North American school-based prevention programmes⁵.  From the end of the 1980s, research began to explore the potential of the sex education programmes being utilised throughout Europe (the Netherlands in particular)⁶.  The increased desire for policy to be based on evidence-based research has been growing in recent years and the English SEU report (1999) is a good example of such research, however, the tendency to continue to look to the USA for answers, despite having a teenage pregnancy rate considerably higher than in Britain and despite a large amount of research evidence available from Europe, is still apparent.

Developing from a primary focus on sex education, research during the late-1980s and 1990s, initially in response to the AIDS crisis, increasingly focused on sexual health services.  Recognition of young people's sexual health service needs in relation to pregnancy reduction, however, did not begin to gain momentum until the early to early-mid 1990s.  At this time large research studies including Shucksmith et al.'s study of health advice centres for young people (1993) and the Scottish Needs Assessment Programme (McIlwaine 1994), began to explore the availability of services for young people and the potential importance of setting up specific young people's services.   Towards the mid 1990s research also began to explore the views of young people towards service provision and use (eg Pitts et al., 1996; Aggleton et al., 1999).

One further area of policy interest, although indirect in its prospective impact on young people's sexual health, is education.  Whilst the association between low education achievement and the likelihood of teenage motherhood has been well documented (Jones et al. 1985; Hayes 1987; Hofferth 1987; Kirby et al. 1994; Kiernan 1995; Moore et al. 1995), there has been a general misconception that pregnancy is the reason that young women drop out of school or are low academic achievers.  On the contrary, it is often the case that a young woman had already been performing poorly, had dis-affected herself or been excluded from school, prior to becoming pregnant (Phoenix 1991; Selman 1998; Turner 2000; Selman 2001; Hosie and Selman 2001).

Selman and Glendinning (1996) and the SEU report (1999) were the first reports to formally acknowledge within an English context, that the desired reduction in the rate of teenage pregnancy in England could not be achieved solely by focusing on sex education or services or education, however, they did not go so far as to suggest the value of exploring the impact of a combination of policy areas.  It is common in British political circles to refer now to 'joined-up' thinking and multi-agency working, but so far, the efforts at 'joined-up' working in England have been in the approach to a single issue, teenage pregnancy, rather than approaching the more holistic issue of teenage sexual health through a wider policy awareness and approach. As such, there has been little research in general that has actually explored the potential role that a wider social policy approach could play in the promotion of sexual health amongst young people and this is a crucial starting point for any effective sexual health strategy. 

Within the context of Scottish policy and research informing policy that may impact upon teenage pregnancy and young people's sexual health, this awareness of the need for wider a policy remit is in its infancy, but that key stage of recognition has taken place⁷.  The development of a Sexual Health Strategy is the next phase of an on-going policy process within Scotland.  In order that this strategy has the desired impact, it is important that it both continues to acknowledge the need for a more holistic approach to the promotion of healthy sexuality and draws on existing evidence of 'good practice' and resists the urge to be reactionary to specific issues, such as the rise in STIs over the last 6 years.  One means of combining these two objectives is to explore the policy options utilised directly and indirectly to promote the sexual health of young people in other countries with varying rates of selected indictors in comparison to Scotland.

¹HIV stands for Human Immunodeficiency Virus and AIDS for Acquired Immune Deficiency Syndrome.

²An example of this shift of focus is that the last national media AIDS awareness campaign to take place was during the summer of 1993, with the Holiday travel campaign entitled 'have a good journey'.

³Pc in this instance and throughout the remainder of this report refers to personal communication.

⁴With relevance to England only, the Teenage Pregnancy Unitwas set upin London, and part of their remit was to develop a Teenage Pregnancy Strategy effective from 2000. An English Sexual Health and HIV strategy was also launched, but a year after the Teenage pregnancy Strategy and with no obvious links betweenthe two strategies. Although the English government have developed a 'Teenage pregnancy strategy', they are now in the process of developing a sexual health strategy.

⁵ For example see Zabin et al. 1986; Kenny et al. 1989; Eisen et al. 1990; Kirby et al 1991; Olsen et al. 1991; Eisen et al. 1992; Stout and Kirby 1993; Kirby et al. 1994; Visser and van Bilsen 1994; Kirby 1995; Kirby et al. 1997b; Kirby 1997b.

⁶For example see Meredith 1989; Donovan 1990; Gallard 1991; Koral 1991; Patsalides 1991; Friedman 1992; Kontula et al. 1992; Doopenberg 1993; van Bilsen and Visser 1993; Persson 1993; Braeken 1994; Clark and Searle 1994; Vilar 1994; Wall 1994; Burström et al. 1995; Silver 1998.

⁷See for example, Burtney 2000a, 2000b; Hosie 2001.

3 Research approach

3.1 Research aims

The aim of this research is to add to the Evidence into Action series (Burtney 2000a), which explores issues relating to teenage sexual health in Scotland, by:

1. critically analysing and contrasting a selection of European policy approaches to the promotion of young people's sexual health in comparison to Scotland
2. increasing knowledge about 'good practice' in sexual health promotion for young people in general. 

3.2 Research objectives

The specific objectives of this research are to:

1. map out the key policy areas which impact directly, or indirectly on the promotion of sexual health
2. gather relevant policy statements and information from up to 4 other European countries (see below for details)
3. synthesise the key points of recent⁸ policy developments in the areas most relevant to young people and sexual health (see below) by country
4. as far as possible set the policy developments within the social context of the country in question, e.g. attitudes to sex and teenage sexual activity, contraception and service provision etc
5. provide some indication as to the success or otherwise of the impact of  policy in improving sexual health of young people, in particular teenage pregnancy rates and incidence of STIs, abortion ratios and contraception use at first and last intercourse. 

3.3 Research methods

This report builds in part on doctoral research, which comparatively explored policy relating to teenage pregnancy in Finland and Scotland (Hosie 2001).  Utilising a qualitative structural framework for comparative policy analysis, this report combines both primary and secondary data.

Overall, the research has been largely desk based, making use of personal contacts and relevant web and library search engines⁹.  Use of the various search engines enabled the collection of a wide range of secondary data including;

• Published and unpublished articles,
• Sexual health statistics,
• Relevant policy documentation.

The data was collected and analysed over a period of eight weeks.  Clarification of the policy analysis drawn from this information was then obtained, where possible, though relevant personal contacts.  Additionally, this report made use of the primary data derived from interviews conducted with government officials, local authority/ municipality officials, teachers and school nurses in Finland and Scotland (Hosie 2001), which was re-analysed for the purpose of this report.

3.4 Overview of selected countries

Four countries have been chosen for comparison with Scotland within this report: Finland, France, the Netherlands and Romania.  These particular countries were chosen to provide a cross-section of countries to include Northern, Western and Central Eastern Europe¹⁰.  Additionally, taking the rate of births to teenagers as a comparativevariable, countries were chosen that had rates ranging from the lowest in Europeto one of the highest.  Further to this, two of the countries: Finland and Romaniawere chosen due to the fact that few comparative studies have explored these particularcountries in relation to teenage sexual health, as well as offering two countrieswith polar trends in births to teenagers.  France was included in particular toincorporate a country with a strong religious influence on its culture.  Lastly,the Netherlands was included within this report because, despite the fact thatmuch teenage pregnancy research has focused attention on the Netherlands in recentyears, little research has actually attempted to explain and unpick exactly whyit is that the Netherlands have been so pragmatic in their approach to promotingteenage sexual health over the last three decades.

3.5 Overview of selected indicators

In order to explore the relative merits of any given country's approach to the promotion of teenage sexual health, one means of doing so is by comparing certain sexual health indicators that exist, some of which are collected at a national level, others on a sample basis.  Due to the secondary nature of these statistics and data, however, there are noted limitations to the comparability of information utilised, details of which can be found in Appendix 1.

A range of direct indictors have been chosen for use within this report, namely; pregnancy, birth and abortion rates, abortion ratios¹¹, STI rates and HIV/AIDS incidence rates, as well as, proportional indictorsof sexual activity and effective contraceptive use at certain ages.  In addition,indictors which relate indirectly to the sexual health of young people are exploredwithin this report, in particular the proportions of young people in education16-18.  Of all of the direct indicators explored within this report, teenage birthrates are taken as the most accurate marker of relative success in the promotionof good sexual health as they provide the most accurate indicator.  Collectionof data relating to abortion is incomplete in a number of European countries,(including France and Romania, two of the countries under exploration).

STIs are a public health issue in the majority of European countries; however because of the 'silent' nature of many STIs they often go undetected and unrecorded.  In comparison to concern over teenage pregnancy and HIV an AIDS, over the last two decades, relatively little attention has been paid to other STIs.  There has been a notable rise in STI rates in many European countries over the last decade¹², however, it is not clear whether this rise has occurred as a resultof increased awareness and hence voluntary testing, or an actual increase in incidence¹³(Panchaud et al. 2000).

Data on the proportions of young people who aresexually active and who are non/users of effective contraception come from samplesurveys within each country, which are not necessarily generalisable or due tosurvey differences, not directly comparable. The record of every birth in thecountries explored, however, is a mandatory requirement and therefore the reliabilityof this statistic provides the most accurate comparative indicator.

In addition to these indicators, this report also explores the issue of a country's level of openness with regard to sex and sexuality as well as the level of gender equality.  Silver (1999) has suggested that a useful way of understanding the effect that a country's historical, social and cultural context may have on teenage sexual health is to explore what Hofstede's (1994, 1998) work, which explores gender equality and sexual openness as dimensions of national culture.  Silver (1999) notes that because the concepts of gender relate directly to the interaction between men and women, they are crucial to our understanding of the gendered power relationships between young people.  Hofstede states that 'gender-related values and behaviours are programmed into us in subtle ways and from quite an early age' (Hofstede 1994:88), which Silver (1999) states is 'important for us because the gender-based socialisation of children largely determines the way teenagers and young people relate to one another according to gender, and more specifically, within their (sexual) relationships.' 

3.6 Wider policy perspective

When considering young people's sexual health, regardless of all other factors relating to why young people have sex, the rate of effective contraceptive use will determine the negative outcomes; namely, unintended pregnancy and the contraction of STIs.  The next logical step therefore is to consider why differences in contraceptive use occur and what policies at work in the various countries under exploration may offer by way of explanation as to why these differences in use exist.  In order that young people use contraception three underlying factors which can be affected by policy, must first exist¹⁴:

'First, young people must have knowledge of issues relating to sex, sexuality and contraception (in particular effective use) and knowledge of where to obtain contraceptive advice and services.  They must also have 'real' access to the provisions of such services (including appropriately timed, located and confidential services) and finally they must be motivated enough to use contraception effectively in order to avoid pregnancy (and other negative results of unprotected sex) and parenthood' (Hosie 2001:63).

Each of these three pre-requisites has the potential to be effected by social policy.  The next section of this report, therefore, maps out a number of policy areas that relate to these particular pre-requisites to the effective use of contraception, namely; sex education (knowledge and skills), sexual health (access to services) and education (one potential source of motivation), and examines a selection of literature surrounding each policy area so as to provide explanation as to why each respective policy has been incorporated into this report.

To fully understand the impact that these policy areas could have upon the lives of young people and their sexual health it is imperative to consider them as a whole, joined and working together, rather than as separate entities.  For example, as a result of policy development in sex education and sexual health services, a young person may have good knowledge about sex and sexuality and good access to services, but without the motivation to apply the knowledge and access the services, the result may be non-use of contraception.  Alternatively, as a result of policy development in sexual health services providing good services for young people and education policy encouraging young people to stay on in education and avoid early parenthood, without the sex education to provide knowledge about sex, sexuality, contraception, what services exist and how to avoid parenthood, the result may be non-use of contraception.  In an attempt to understand how these policy areas potentially relate to the issue of teenage sexual health, the Section Three paints a contextual policy picture of five different countries in Europe; Finland, France, the Netherlands, Romania and Scotland.

⁸For the purposes of this research, 'recent' will be defined as up to the last forty years of policy developments.

⁹ Web search engines used: Yahoo.com, Google.com and WEBofSCIENCE.   Library searches used: Stirling University Library, Newcastle University (NCL) social science index, NCL Medical Library database and HEBS Library database.

¹⁰For the purpose of this report, where reference is made to Central East Europe, the countries being referred to are Bulgaria, Czechoslovakia, Hungary, Poland, and Romania.

¹¹The abortion ratio is the figure that represents the proportion of pregnant women in any given age group who chose to opt for an abortion as opposed to a birth.  Therefore if the figure is over 50%, an abortion is more likely, conversely if the figure is under 50% then a birth is the more likely outcome. 

¹²The STIs Chlamydia, genital herpes and human papillomavirus infection have only been officially recorded in Europe since 1990 (Hope and MacAurthur 1996).

¹³All STI statistics except those for Scotland (ISD) are taken from Paunchad et al. 2000, further details of data collection can be found in this article.  High reporting was classified as 70%+ of diagnosed STI cases reported.  Medium as 50-70% of diagnosed cases reflected in national statistics.  And low if fewer than 50% of diagnosed cases are reflected in official statistics.  For syphilis and gonorrhoea, reporting = high in Nordic countries, England and Wales, East Germany and Romania; medium = Switzerland; low = Belgium, France, the Netherlands and West Germany.  For chlamydia, reporting = high in Nordic countries; medium in England and Wales; and low = Belgium, France and Switzerland.

¹⁴It is important to acknowledge that there are other factors not included within this exploration that will impact upon whether or not contraception is used at all, in particular social factors such as gender equality, levels of parental control exerted over young people's (especially young women's) freedom and self-esteem levels in being able to ask or insist that their partner uses contraception; and also access to public transport for example to be able to access some services.

4 Sexual health and social policy: a review of the literature

4.1 Introduction

The purpose of this section is to review a selection of relevant literature surrounding the particular policy areas in relation to sexual health, in order to clarify and provide explanation as to why each policy area is under exploration in this report. 

4.2 School-based sex education and sexual health

The first pre-requisite to effective contraception use set out in the previous section was that of knowledge.  School-based sex education is one means of providing that knowledge to a large audience of young people and whilst a complex relationship exists between the acquisition of knowledge about sex and sexuality and how that knowledge is then internalised into safer practice in personal behaviour, it is a fundamental starting point (Schofield 1994).

4.2.1 What is sex education?

"The meaning, aims and potential effect of 'sex education' vary considerably according to the opinion of research findings, governments, educators, popular culture, media, parents and young people" (Silver 1998:5).  In 1975 the World Health Organisation (WHO) stated that access to knowledge about sex and sexuality should be the right of every individual, and later in 1984, education in matters of sexuality, psycho-social growth and general health for children and young people became a WHO social and health goal for Europe (WHO 1984).

Like it or not, children and young people learn about sex and sexuality through the society in which they live (Hadley 1998).  Information about sex comes from a variety of sources and those most popular to young people, such as friends, are often the least reliable of sources.  "What school-based sex education can do is bring together the information that young people learn from other (often less reliable) sources and provide a safe arena for those young people to separate the myth from reality" (Hosie 2001:66).  The idea that sex education should be less about learning the mechanics of sex and more about how to foster healthy relationships, developing personal and social skills, positive attitudes and beliefs about sexual identity and increase knowledge about sexuality and sexual health, is a definition supported by many organisations including the British Medical Association (BMA 1997), the Rutgers Stichting Institute¹⁵(Braeken 1994) and the Sex education Forum (SEF 1997).

4.2.2 History of sex education in Europe

The development of sex education in Europe over the last half century has varied markedly, in many cases, dependant on the ruling political forces in place and their level of tolerance with regard to teenage sexual activity (Papp 1997).  Contrasting approaches to the provision of sex education have developed primarily from policy debates surrounding teenage pregnancy and STIs, which have been differently weighted across Europe (Kosunen 1996).  Throughout the majority of Western and Northern Europe, concern has primarily focused on the issue of health consequences of early sexual activity (Davis 1989, Kosunen 1996), which has lead to the development of sex education based on the promotion of 'healthy sex and sexuality'.  In contrast in Britain, teenage sexual activity has been approached from a moralistic point of view, which has on the whole, lead to a more restricted form of sex education aimed primarily at preventing teenage sexual activity (Hosie 2001).  Figure 4.1 below presents a picture of the access that young people had to sex education in the mid-1990s across Europe.

Figure 4.1: Access to school-based sex education in Europe

Source: Villar 1994:11

Vilar's review of young people's access to school-based sex education in Europe in 1993 (Vilar 1994) revealed that whilst sex education had been introduced into the school curricula in a large proportion of European countries by the mid 1990s, only Belgium, the Netherlands and the Nordic countries were classed as having adequate provisions (Vilar 1994).  Further to this, the majority of countries classed as having inadequate provisions also focused primarily on the negative outcomes of teenage sexual activity such as teenage pregnancy, STIs and HIV/AIDS, rather than on the promotion of healthy sex and sexuality (Vilar 1994).

4.2.3 How effective is sex education

Debate continues to ensue particularly in Britain and the USA with regard to how effective sex education actually is at impacting upon the behaviour of young people.  In Britain sex education is still accused of  "a variety of social ills including teenage pregnancy and 'moral decay'" (Silver 1998:9).  Over the last twenty years of research into the potential impact of sex education, however, a great deal has been learned, most importantly is the fact that there is no evidence that the experience of sex education has encouraged earlier or increased levels of sexual activity amongst young people (Baldo et al. 1993; Kirby et al. 1994;Fullerton et al. 1997; NHS CRD 1997; Cheesbrough et al. 1999).  Indeed, some studies found that early sex education intervention at school had delayed the onset of sexual activity, actively encouraging young people to wait (Cheesbrough et al. 1999; Wight et al. 2000).  Further to this Wellings et al. (1995) revealed in Britain that young people who had received most of their sex education at school were less likely than their peers who cited parents or friends as their key resource of information, to have had their first sexual intercourse experience by age sixteen. 

With regard to sex education and the effective use of contraception, a variety of studies have indicated that having received contraception education at school, translated into a higher use of contraception at first intercourse (Baldo et al. 1993; Kirby et al. 1994; Wellings et al. 1994; Kirby 1997b; NHS CRD 1997; Cheesbrough et al. 1999).

In relation to teenage pregnancy, international research has highlighted that in countries where there is better access to school-based sex education, teenage pregnancy rates are markedly lower (Jones et al. 1985; David et al. 1990; Baldo 1993 et al.).  By combining Vilar's access chart in Figure 4.1, with pregnancy rates to 15-19 year old women in a number of European countries where pregnancy data was available, Figure 4.2 below confirms that a significant relationship (r_s= 0.70¹⁶) exists between countries with lower teenage pregnancy rates and better access to sex education.

Figure 4.2 Access to sex education and teenage pregnancy rate per 1000 women aged 15-19

General notes:Source of pregnancy data: Singh and Darroch 2000. Source of access to sex education data: Vilar 1994.

Pregnancy data year is 1996 except for Belgium, Czech Rep., France, Italy and Russia (1995).  Vilar (1994) only referred to the UK and so the UK access has been used to calculate both the Scottish and English and Welsh correlations.

4.2.4 Providing effective sex education

As noted in Vilar's research (1994), the provision of sex education in schools is not by itself enough.  Having explored sex education in a number of countries and even within one country sex education can vary from a one-off visit from the local nurse, to a system of sex education provision permeating numerous core curriculum subjects prompting 'healthy sex and sexuality'.   From a review of previous research it appears that there are a number of key components that when combined make for more effective sex education, which are listed in table 4.1 below.

table 4.1: Key components of effective sex education

Socio-sexual attitudes	Positive socio-sexual attitudes and a pragmatic approach to sex education underlie its effectiveness (Silver 1998).
Public climate towards sex education	Public climate plays a central role in how well sex education is accepted into schools and regarded by young people as an important issue (Vilar 1994).
Curriculum location	Permeation - can help to normalise the topic, it becomes neither 'taboo' nor 'sensation' (Silver 1998), but can 'disappear' through lack of commitment to teach it.
Teaching environment	'Open and safe' classroom is necessary for effective teaching (Silver 1998). Providing both mixed and single-sexed arenas can help with sensitive issues and promote communication between the sexes (Hosie 2001). Staff must be willing and capable and require adequate training. Use of active learning-based methods, including discussion and role pay are more effective at increasing knowledge and helping to develop positive attitudes and values (Kirby 1995).
Content	Must not aim to 'scare' young people (David & Rademakers 1996). Needs to be positive in presentation of sex and sexuality rather than negative in either tone or content (Oakley et al. 1994, 1995). Must Incorporate what young people want to know to, not what adults think young people should know (SEF 1997; HEA 1998).
Young men	Sex education historically focused on women (Silver 1998) but there must be a focus on young men's needs, in particular issues of masculinity and sexual stereotypes, if young men are to develop responsible attitudes to their sexual behaviour and respectful attitudes to their partners (Hadley 1998; Wood 1998; HEA 1998).
Inter-agency collaboration	Use of medical professionals, especially the school nurse, can bring benefit to sex education provision, in particular in raising awareness of services inside/ outside of school (Melanby et al. 1995; Few et al. 1996; Papp 1997; Hosie 2001) .Medical professionals should not be expected to have inherent teaching skills, training is paramount (Whitmarsh 1997; Hosie 2001).

4.3 Sexual health services and young people

The second pre-requisite to effective contraception use outlined in Section Two was access to sexual health services.  In order that young people can be responsible for their sexual health, they first require access to certain sexual health services to enable them to respond.  In many European countries, young people can access sexual health services for free (or low cost) through primary care facilities and/or family planning clinics, and in some countries, at clinics developed specifically for use by young people.  Young people's needs, however, are often not met by provisions that have been set up for use by whole populations.  Young people have many additional needs when it comes to accessing sexual health services, needs, which may or may not be met by the range of services available to them.  Research exploring the issue of sexual health service provisions internationally has documented that the ease of access to services is a pre-requisite to their use by young people (Zabin et al. 1986; Peckham 1993; Fullerton et al. 1997; Liinamo et al. 1997; NHS CRD 1997; Hadley 1998; Hosie & Silver 2001).  table 4.2, below, sets out some of the key issues of access that have been raised by previous research on young people and service provision.

Table 4.2: Issues of access to sexual health services

Geographical location	Young people who are sexually active are more likely to attend a service if it is geographically convenient (Cheesbrough et al. 1999).Teenage pregnancy rates have been found to be lower in areas where young people live within 3kms of a 'youth' clinic (Clements et al. 1997).
Hidden from 'parental view'	Young people do not want parents to know they are sexually active (McIlwaine 1994), therefore may chose non-local services or none at all, if no other choice is available.Services, which are not 'sexual health' but 'youth orientated', may help to hide the nature of the visit (Selman et al. 2001). School-based services may help to hide young people's use of a service (Zabin et al. 1986; Fullerton et al. 1997; Hosie 2001).
Suitable opening times	Young people have limited windows of opportunity to seek advice: Services are often only available when young people are meant to be in school (Turner 2000) and often require a bus ride (Clements 1997 et al.)  Sexual activity is often sporadic and unplanned, requiring immediate advice. Longer opening times are critical.
Confidentiality	Unanimously presented as one of the most important keys to access for young people: Confidentiality is essential (Jones et al. 1985; Wulf & Lincoln 1985; Jones et al. 1986; Zabin et al. 1986; FPA 1994; Lo et al. 1994; McIlwaine 1994; Dickson et al. 1997a; Fullerton 1997; Liinamo et al. 1997: Hadley 1998; SEU 1999; Turner 2000, Selman et al. 2001.)
Informal and User friendly	Access starts with the reception staff, an informal and friendly atmosphere, rather than an intimidating one is recommended by research in this area (Zabin et al. 1986; Peckham 1993; Fullerton 1997; SEU 1999).
Professionals' attitudes	Young people need to be treated with respect, this is identified by young people as service providers who:  Are friendly, talk to young people not at them, listen objectively, do not judge and are genuinely interested in what young people are saying (Liinamo et al. 1997; HEA 1998; Aggleton et al. 1999).
'Sex-speak' - Youthful linguistics	Young people prefer professionals to use language they use themselves or to at least explain 'jargon' (Aggleton et al. 1999).  Words such as 'family planning' are irrelevant to young people; they are developing sexual identities not 'planning families' (Hadley 1998).
Inclusive access for and recognition of the needs of young men	Historically aimed at the needs of women (Nelson 1997).  Young men often perceive services as predominantly run as services for and by women (SEU 1999).

4.3.1 Alternative service provision options

One suggestion often raised by young people is that service uptake may be higher if services incorporated more of their needs and were services devised solely for their use, separate from general population provisions (Liinamo et al. 1997; Aggleton et al.1999, Selman et al. 2001). As early as the mid-1980s international research identified that specialised youth clinics which were fully integrated advice centres, providing access to counselling and contraception services and linked to schools, were likely to be the most effective in reducing teenage pregnancy (and STIs) (Jones et al. 1985; 1986). Evidence from Europe also supports the promotion of youth clinics, with countries such as the Netherlands, Sweden, Finland, Denmark, Norway and Switzerland all providing services that are youth-orientated (Hosie 2001).  Following the main period of youth clinic development (although far from universal) during the early 1990s, Britain witnessed the first decline in teenage pregnancy rates in ten years (Hadley 1998). 

International research has generally concluded that the most effective sex education is found in countries which link the sex education and sexual health service provision (Jones et al. 1985; 1986).  Zabin et al. (1986) undertook one of the earliest evaluations into combining school-based sex education with an on-site sexual health advice and contraceptive service in Baltimore, USA.  The key findings of the study were a delay in the onset of sexual activity amongst the young women involved, an increase in contraceptive use amongst those men and women already sexually active prior to the study and a significant decrease in pregnancy rates for the surrounding area.  When the programme was discontinued, however, the pregnancy rate returned to the pre-programme level (Zabin et al. 1986).

Interest in the plausibility of school-based clinics, particularly facilitated by an on-site school nurse has grown in popularity in recent years (David et al. 1990; Kirby 1994; Gulland 1996; Kirby 1997; Hosie 2001).  This style of service, when professionals are trained to work specifically with young people, has much to offer as it can potentially provide a service that fits all of the requirements of young people as identified in table 2.2 above.  Such a service could also offer young people the opportunity to take personal responsibility for all areas of their health, encouraging them to seek help independently of their parents, so when the need for sexual health advice arose, the barrier of independent access to health services would already have been broken down (Hosie 2001).   However, service development should not focus on school-based provision at the expense of provisions outside of school, as not all young people will attend school even if they are legally required to do so (Schofield 1994).

4.4 Education and young people?s sexual health

The third pre-requisite to effective contraceptive use identified in Section Two was motivation.  Accessing sexual health services and applying knowledge to personal behaviour takes motivation and adults frequently underestimate the high level of motivation required for young people to access and use contraception effectively (Hadley 1998).  One source of such motivation has been identified as educational aspiration and achievement at school and in particular at the post-16 level (Hosie 2001).  At present little research has been conducted on the potential impact that educational policy has on the rate of teenage pregnancy and even less, in relation to STIs rates, however, the following part of this section aims to set out some on the key relationships that can be identified between educational achievement and aspiration and pregnancy, bearing in mind that pregnancy is a proxy indictor of unprotected sex in relation to the risk of STIs.

4.4.1 Educational level and achievement

It has been established throughout many industrial countries that young women who are low achievers are twice as likely to be teenage mothers than high achievers (Hayes 1987; Hofferth 1987; Kiernan 1995; Moore et al. 1995).  It is often assumed, however, that the low achievement occurs as a direct result of the pregnancy resulting in a young woman's inability to finish her education, when in fact, growing evidence appears to suggest that many young women have disengaged from education and were low achievers prior to pregnancy (Phoenix 1991, Moore et al. 1995; Selman 1998; Hosie & Selman 2001; Selman et al. 2001).

Although having a good knowledge of sex and sexuality does not automatically translate into safer sexual behaviour, research in Finland has found that young people with higher levels of general knowledge also had a higher level of sexual knowledge (Kontula & Rimpelä 1988).  An increased level of educational attainment has also been significantly related to a higher age of reported first intercourse (Kane & Wellings 1999), and more effective contraceptive use (Hoffman 1984; Morrison 1985).

In relation to pregnancy outcome, it has been documented that the higher the education level of a young woman, the more likely she is to opt for an abortion during teenage years (Kane & Wellings 1999).  A range of hypotheses have been documented including; parental pressure and desire for their daughter to achieve without the burden of a baby (Rattansi & Phoenix 1998; Turner 2000); personal choice and desire to achieve that may be hindered by early motherhood (Moore & Rosenthal 1993; Turner 2000), being more educated has equalled more choice and heightened awareness of how to obtain an abortion; socio-cultural attitudes and attitudes of significant others being either for or against abortion (Simms 1993; Turner 2000); or due to a perceived lack of parental, partner and/or educational support if the pregnancy is continued (Turner 2000).  Although the relationship exists, the reasons for this outcome are far from clear.

In relation to the average age at which women give birth for the first time across Europe, a growing phenomenon in recent decades has been a decline in fertility rates and a delay of motherhood.  The decline started first in Northern and Western European countries before spreading to Southern and Central East European countries.  One explanation for this phenomenon has been that increased levels of educational achievement amongst consecutive generations of women has resulted in an increased desire to be economically active, independent and pursue other life goals before entering motherhood (Beets 1999a, 1999b).

4.4.2 Educational aspiration

In addition to educational achievement, similar relationships have been found in relation to educational aspiration and contraceptive use, abortion ratio, age of first birth and pregnancy rates.  In the mid-1980s research by Jones et al. (1985) indicated that in countries where a higher level of young people stayed on in education or training beyond the age of sixteen, the rates of teenage pregnancy were also lower.  In many European countries, the average age of compulsory schooling ends at sixteen and therefore voluntarily staying in education beyond this age can be taken as a sign of aspiration.  Using this chosen variable as an expression of educational aspiration, it has been shown that a significant relationship exists between the proportions of young people aged 16-18 in education with the rates of teenage pregnancy amongst 16-19 year old women in a number of European countries (Hosie 2001).  The Spearman's correlation coefficient for that relationship being r_s=0.62¹⁷.  Using the same variable of aspiration, significant relationships were also found to exist between exists between high staying on rates and, the outcome of pregnancy more likely an abortion (r_s= 0.78), and higher age of first birth (r_s= 0.61) (Hosie 2001).

Research during the mid-1980s revealed that young people who had high educational aspirations were more likely to use contraception effectively and regularly (Morrison 1985).  In the early 1990s, Kraft et al. (1991) found that in a study in Norway, educational aspiration was the only factor relating to effective contraceptive use at most recent intercourse.

4.4.3 'Fatalism Vs Being in control'

The issue of self-esteem has been related to sexual well-being (Jones et al. 1985; Visser and Bilsen 1994; Cheesbrough et al. 1999) and research internationally has indicated that "young people in general (women in particular) who have higher educational achievements and aspirations are noted to also have higher levels of self-esteem and a feeling that they are in control of their lives instead of simply accepting 'fate' (Hosie 2001:118).  The notion of 'accepting fate' could translate into the non-use of contraception amongst young people and in relation to pregnancy in particular, could foster an attitude that 'if I become pregnant, then that is what is meant to be', resulting in a 'passively conceived' pregnancy¹⁸.  This would be in contrast to young people who have the ability to 'take control' of their lives and have an understanding that they have the ability to control the direction/s in which their lives may go (Hosie 2001).

Cheesbrough et al. (1999) found that some of the most effective sex education programmes (internationally) were those, which tackled issues of self-esteem and aspirations from an early age.  Therefore, fostering educational aspirations, regardless of a given young person's educational ability, could play an important role in helping that young person to take control of their life and pursue their goals.  In turn, perception of control in one area could help young people to take control in other areas of their lives, including their sexual lives.

¹⁵The Rutgers Stichting Institute was established in 1969 in the Netherlands to provide family planning advice for young people.

¹⁶Interpretation of the value r_s is that the closer the value is to -1 or +1 the more significant the correlation, -1 or +1 = perfect correlation.

¹⁷The closer the value of r_s is to +1 or -1, the more significant the relationship.

¹⁸Turner (2000) uses the term 'passively conceived' to describe a pregnancy that 'just happened', i.e. it was neither 'planned' or 'unplanned'.

5 Finnish policy development and teenage sexual health

5.1 Introduction

The purpose of this section is to map and locate the various policy areas within Finland's social and cultural context.  The section begins with a descriptive account of a range of sexual health indictors relating to young people in Finland.  Finland's policy areas are then mapped in turn before exploring the social context within which those policies have developed and the potential impact that those policies have had on sexual health indicators of young people.  A summary for reference of all key policy and other relevant events for Finland over the last four decades can be found in a timeline in Appendix 3.

5.2 Overview of sexual health indicators

5.2.1 Pregnancy, birth and abortion rates

Between the early 1970s and the mid-1990s Finland witnessed a continually declining rate of pregnancy to 15-19 year old women, although a marginal rise was witnessed between 1986 and 1987. Since 1995 however, the declining trend in Finland's pregnancy rate to 15-19 year olds has reversed and the rate has witnessed an overall rise from 20.6 per 1000 in 1994 to 23.2 per 1000 in 1999 (Gissler 1999; STAKES - personal communication 2000).

Exploring the birth and abortion rates individually, as can be seen in Figure 5.1 below, the live birth rate for this age group steadily declined throughout the 1980s and 1990s from 18.9 per 1000 women aged 15-19 in 1980 to 9.0 per 1000 in 1997.  The only temporary halt in the decline occurred between 1987 and 1990 when the rate fluctuated between a low of 11.8 per 1000 and 12.4 per 1000 (Gissler 1999).  Since 1997, however, there has been a rise in the rate of live birth from 9.0 per 1000 in 1997 to 9.7 per 1000 in 1999 (STAKES - personal communication 2000).

In 1970 a new, more liberal abortion law was introduced which placed a particular priority for those aged under 17 at the time of conception.  In turn, the rate of legal abortion rose rapidly throughout the early 1970s and from 1973 the abortion rate for 15-19 year olds has declined steadily (Gissler 1999).  This declining trend continued until 1994, although a marginal rise was witnessed between 1985 and 1987.  Since 1994, however, a more dramatic rise has and occurred and as of 1999, this rate was still rising (Gissler 1999; STAKES - personal communication 2000).

Figure 5.1:Pregnancy, birth and abortion rates per 1000 Finnish women aged 15-19, 1980-1999

Source: Gissler 1999; STAKES 2000 (Personal communication).

5.2.2 Abortion ratio

The pattern of abortion ratio in Finland, is representative of most Northern European countries, whereby a classic U-shape exists, which means that the abortion ratio is highest amongst those women over 35 and under 20.  Although little is known about the younger age groups in Finland, it has been established that between 70-80% of those aged 16 and almost 100% of those aged 15 or younger who become pregnant, will opt for an abortion rather than continue their pregnancy to term (Kosunen 1993b).  For 15-19 year olds, the trend from the beginning of the 1980s until the early-1990s was such that the more likely outcome of a pregnancy to a 15-19 year old would be an abortion.  From 1991-1995, and through the main period of Finland's economic recession, the trend changed whereby it became equally as likely that a pregnancy would result in a live birth as an abortion.  Since 1996, however, the direction of outcome probability has reversed quite dramatically, with the difference between the two outcomes in 1999 being the largest over the 20-year period from 1980-1999 (41.8% birth - 58.2% abortion).

5.2.3 STIs and HIV/AIDS

Estimated reporting rates vary widely across Europe and therefore the data displayed in table 5.1 below, should be viewed with caution and in most cases represents only minimum estimations of true incidence.    However Paunchad et al. (2000) note that countries, of which Finland is one, where 70%+ of diagnosed STI cases are reported, can be classed as high-reporting countries.  From this table it is possible to see that the incidence of syphilis amongst young people in Finland is very low (1.8 per 100000 aged 16-19) and accounts for only 3% of all cases STIs for the age group 16-19.  The reported difference in rates of syphilis was, however, 2-3 times higher for females than males.

From table 5.1 it is also possible to see that the incidence of gonorrhoea amongst young people is low, with a rate of 3.7 per 100000, accounting for 5% of all STIs in that age group.  The reported difference between genders, however, was not noted in Finland for gonorrhoea.

Chlamydia is perhaps one of the most underreported STIs due to its particularly silent nature, especially for women.  Finland is classed as a country where reporting of chlamydia is suspected to be higher than most (Panchaud et al. 2000).  The total rate for young people aged 16-19 in 1996 was 650.8 per 100000, however the different between males and females was the most noted of all infections explored with almost 6 times as many confirmed cases amongst women than men.  The rate of chlamydia as a proportion of all STIs amongst young people aged 16-19 was 22%, when the age grouping is increased to 16-24, chlamydia accounts for 61% of all infections for that age group.

Table 5.1: STI rates per 100000 young people aged 16-19, by type of infection and gender; % of all infections that occur among young people and young adults, by infection, 1996.

Infection				Rate per 100,000 among 16-19 year olds						Of all reported infections % that occur in age group
				Total		           Female		         Male		16-19		    20-24		        16-24
Syphilis				1.8		2.5		1.2		3		6		9
Gonorrhoea			3.7		3.8		3.6		5		17		23
Chlamydia			650.8		1122.1		198.7		22		38		61

Source: Panchaud et al., 2000.

Cumulatively since the early 1980s until 1998, there had been less than 650 cases of HIV transmission reported in Finland (NBE:pc).  Between 1998 and 2001 however, this caseload has almost doubled, which is suspected to be a direct result of an epidemic amongst Intravenous Drug Users (IDU) (EuroHIV 2000).  Concern is now growing about increasing incidence of HIV in Finland, but the reported rate amongst young people is currently very low.

5.2.4 Coital activity

From the first national survey of sexual activity conducted in Finland in 1971, it is possible to determine that the median age of first intercourse had decreased from 20 year of age in 1930 to 18 by the 1960s (Sievers et al. 1974).  The second national study in 1992, established that the proportion of young people who had had first intercourse before the age of 16 had increased from 1% in 1971 to 23% for women and from 13% to 21% for young men (Kosunen 1993).  In 1986, a study into teenage sexual behaviour took place called the KISS¹⁹ study, which was repeated in 1988 and 1992.  The first study revealed that by the 9^th grade (15-16 years of age), 25% of young woman and 21% of young men had had intercourse (Kontula and Meriläinen 1988).  The corresponding figures for 1988, 1990 and 1992 are shown below in table 3a.2.

table 5.2:  Proportions of young people who had experienced intercourse by age 15 in Finland.

Gender	1988*	1990**	1992*
Young men	31%	25%	19%
Young women	30%	29%	31%

Sources:*KISS Study (Kosunen 1993a)

** Health-behaviour in school aged children study (Pötsönen 1993)

5.2.5 Contraception use

From the three KISS studies of 1986, 1988 and 1992, it is possible to see that contraceptive use at first intercourse increased with each survey, although more significantly between 1986 and 1988 than between 1988 and 1992 (Kosunen 1993a).  By 1992, the proportions of young people using no method of contraception had decreased in all age groups, for those aged 15 the percentages had dropped from 28% (young men and young women) to 13% of young men and 20% of young women (Kosunen 1993).  Despite the popularity of the condom at first intercourse amongst Finnish teenagers, young women in Finland tend to move quickly to a more reliable method of contraception (contraceptive pill) (Kosunen 1993a, 1996) and amongst older teenagers, the contraceptive pill is the preferred method (Sihvo et al. 1995).  The findings of Kosunen's study (1993b, 1996) into oral contraception use by Finnish teenagers also concluded that the increased use of oral contraceptives has perhaps reached close to 'saturation level'20 for those in need of regular contraception. 

Table 5.3: Contraceptive use

Contraceptive use	Men	Women
Reliable method	87	80
Non reliable method or none	13	20

 

 

Source: Papp 1997

The availability and use of emergency contraception is a factor associated with low incidence of teenage pregnancy in Finland (Kosunen & Rimpelä, 1996a).  A recent study by Kosunen et al. (1999a, 1999b) using National School Health Study data, revealed that the proportion that had ever-used emergency contraception increased in relation to age, ranging from 2.1% (aged 14-15) to 15.1%  (aged 17) (Kosunen et al., 1999b). However, Kosunen et al. (1999b) state the fact that, of those who had use this method, two thirds had used it only once, should alleviate fear that eased access to emergency contraception would result in it being used as a method of contraception in itself rather than as an emergency.

5.2.6 Education indicators

Table 5.4 below shows the age structure of secondary education in Finland.  Finland, similar to other Northern European countries, has a pattern of high stay-on rates beyond the age of 16, when compulsory schooling ends in Finland.  Figure 5.2 below presents the stay on rates for ages 15-18 for 1996-1997.

Table 5.4: Age structure of secondary education in Finland

Country	Age range of lower secondary education	Age at which compulsory schooling ends	Age range of Upper secondary education	Duration of upper Secondary (in years)
FIN	13-16	16	16-19	3

Sources: EC/ Eurydice/ Eurostat 2000; West et al. 1999.

Figure 5.2: Participation rates (as a %) in education at different ages, 1996-7

Source: EC/ Eurydice/ Eurostat 2000.

5.3 School-based sex education policy in Finland

5.3.1 Curriculum location and national guidelines

Sex education was first introduced into Finnish schools in 1944 and officially became part of the school curriculum in 1976 (Hosie 2001).  In Finland there is no separate subject in the school curriculum called 'sex education', rather, it permeates the curriculum being taught in a range of subjects, primarily in Biology, Physical Education and Home Economics.  The National Board of Education (NBE) produces guidelines stipulating what core compulsory subjects must be part of every pupil's curriculum, minimum hours to be taught and preferred methods of teaching and content for each subject and municipalities can also provided a suggested curriculum framework for schools, although it is not compulsory to follow this.  Therefore although there has never been a legal requirement to teach 'sex education', because aspects of sex education are included within other compulsory subjects, it is mandatory that those aspects be covered.  

5.3.2 Time allocations

In 1994 new curriculum guidelines were produced by the NBE which significantly altered the proportion of compulsory subjects to be taught and in turn has effected upon the amount of sex education provided in Finnish schools.  Prior to 1994 pupils in grades 7-9²¹ of the lower secondary school (Peruskoulu) would expect to receive provision as detailed in table 5.4 below, however, many schools would provide more than the national guidelines stipulated (Hosie 2001).  In addition, due to every school in Finland having an on-site school nurse, pupils could also received one-one confidential advice on aspects relating to their sexual health as well as any other health-related matter by accessing this service.

Table 5.4 Sex education in Finland pre-1994

Curriculum Subject	Location of sex education	Hours of teaching
Biology	Biological reproduction	Min. 3, average 7 hours over 7-9th grades
Physical Education	Health Education	1 hr/week 8th grade
Home Economics	Family Education	1 hr/week 9th grade

Source: Hosie 2001.

5.3.3 Teaching environment and teacher training

As noted in Section Two, a good teaching environment is a key component of effective sex education.  In Finland, the subject Physical Education is generally taught as a single-sex subject, and Biology and Family Education as mixed-sex subjects.  This therefore has meant that pupils would receive sex education both within single and mixed-sex environments, which teachers and officials perceived as particularly useful for the sex education of young men (Hosie 2001).  The training of teachers specifically on the subject of sex education has not been a prominent area of policy development in Finland, with no official policy regarding pre or in-service training.  Pre-service training for all teachers would cover the subject they were to go on and teach and therefore if that subject included aspects of sex education, then their training would be expected to cover that.   Recent research, however, has shown that for subjects other than Biology, generally, this is only the case for recently qualified teachers (Hosie 2001).  Training on issues of sex education would generally be down to the initiative of the individual teacher to undertake courses such as those provided by the Mannerheim Child Welfare Organisation or Väestöliittö²².  In relation to the methods that teachers would adopt, different studies on Finnish sex education have revealed different findings.  Whilst Hosie (2001) found that teachers generally adopted active-learning based methods, in particular co-operative learning, Liinamo (2000) noted that recent research has revealed that the use of active learning-based techniques is not as common throughout other Finnish schools.

5.3.4 Content

With regard to the content of sex education provision in Finnish schools, the permeation of the subject has allowed the same issues to be covered from different approaches and viewpoints.  For example, within Health Education the emphasis would be a sexual health perspective, in Biology, a biological perspective and in Family Education, a legal, social and ethical perspective.  The content of the three classes would include discussions beginning with school mates and early friendships, physical, psychological and social changes at the beginning adulthood: changes of outer appearance, menstruation, wet dreams, masturbation, growing interest in the opposite (or same) sex, dating, experimentation (age, legislation), sexual relations, responsibilities, porn, friendships, affection, trust, constraints of expectations, fears, declaration of independence, breaking away from parents, being part of a gang, opposition of established morals and values and mass delusion.  Discussions would then progress to Intercourse: the act itself, the first time, mutual consent, forcing oneself, rape, virginity, possible pregnancy, contraceptive measures, family planning, childlessness, prevention of STIs, fertilisation and inception of pregnancy, development of the foetus, the various stages of labour, legislation, ethics involved, clinical aspects of abortion, ways of becoming infected with an STI, cures, or in the case AIDS no cures, legislation, sexual orientation, heterosexuality, homosexuality and other sexual preferences (NBE 1998).

5.3.5 Aims and objectives of sex education

The NBE official for Health Education has described the main purpose of all sex education provisions as the "promotion of healthy sex and sexuality" (Hosie 2001:181).  The key aims of sex education in Finnish schools have been described as;

1. Promoting sex and sexuality as normal and healthy aspects of life,

2. An understanding that sexual desire is not something confined to the realm of adulthood,

3. A desire to increase young people's knowledge about sex and sexuality,

4. A desire to impact upon the sexual attitudes and behaviour of young people, and

5. Fostering the attitudes of respect and responsibility for self and partner/s (especially amongst young men)

(Hosie 2001:223). 

5.3.6 Use of sexual health experts

Although there is no official policy regarding the involvement of sexual health experts in school-based sex education provision, due to the school-based location of the school nurse and professional training to work specifically with young people, an expectation at school and government level would be the school nurse acting as a resource for teachers of sex education and if requested by teachers, to teach aspects of sex education within certain classes (usually Biology).  This latter aspect, however, was found to be limited by recent cutbacks in school health services, resulting in cutbacks in the amount of time school nurses would have available for additional activities(Hosie 2001).

5.3.7 Policy change post mid-1990s

In 1994, a new curriculum for the upper level of the comprehensive school was introduced which devolved more curriculum decision making powers to the school level by reducing the proportion of subjects that were to be compulsory and increasing the number of optional subjects that schools could develop.  Two of the hours per week that were removed from the compulsory list were one hour per week of Home Economics and Physical Education, the subjects within which Family Education and Health Education are taught.

5.4 Sexual health policy in Finland

5.4.1 Historical development of sexual health policy

Since the 1960s, Finland has gone through a process of great change in sexual health policy from what Rimpelä et al. (1996:28) have described as from "control policy to comprehensive family planning".  Prior to revision in 1970, abortion was only available under specific medical conditions, and neither the government nor the Lutheran church favoured the availability of contraception (Väestöliittö 1994).  A strong abortion lobby during the 1960s eventually resulted in a new abortion law in 1970 which enabled social as well as medical reasons as grounds, and importantly for young women, the law stipulated that if a woman was under 17 at the point of conception, this alone would be grounds with the permission of one rather than two (the norm) doctors.  In 1978 an amendment was made to this law placing a 12-week time limitation in which an abortion could be performed (Ala-Nikkola 1992).

Following shortly after, the legal age of consent for heterosexual sex was placed at 16.  If, however, both partners were aged 14-15, then the offence would not be punishable and if one partner was in a position of authority then the age of consent would be 18 (Kane and Wellings 1999).  Then in 1972 the Public Health Act (1972) was introduced which placed a statutory obligation on every municipality to provide its population (no age limit) with free access to general health counselling, school health services, contraceptives (free/ low cost) and contraceptive education, sex education and when required, easy access to abortion services (Kosunen and Rimpelä 1996a).  The impact of this new law was visible over the following decade as the rates of abortion declined dramatically and the sexual health of the public improved (Kosunen and Rimpelä 1996a).  The rate of abortion to young women, however, had not declined in line with other age groups which raised concern that although contraceptive and abortion services had increased during the more liberal 1970s, young people's knowledge about sex and sexuality had not (Kosunen and Rimpelä 1996a).  As a result there was a large push for sexual health information and education by and for young people both in the media and schools and during the early 1980s the Finnish Ministry of Health and Welfare began to focus specifically on young people's sexual health (Kosunen and Rimpelä 1996a). 

In 1983, a government target was set to reduce the rate of abortions to young women by 7% per annum and in 1987 emergency contraception became available to all women, providing further reproductive choice if contraception had failed or not been used.  Also in 1987, the magazine, Sexteen, providing information for young people on sexual health issues (with a sample condom) was sent to the home of every 16 year old, which became an annual happening.  Research in recent years has shown that the magazine has had an important impact of young people's sexual health knowledge, with readership of the magazine associated for a number of years with higher levels of sexual knowledge (Liinamo et al. 2000).  Also, at the request of young people, from 2001 the magazine is to be sent to all 15 year olds rather than 16 year olds (Liinamo 2000).

5.4.2 Sexual health policy and young people

As a result of the various developments in sexual health services in Finland, young people can access sexual health services in a number of different locations; municipal health centres, school health services, and NGO (non-governmental organisation) youth clinics.  The municipal centres are geared towards the health needs of the whole population whereas the other two services are provided specifically to meet the needs of young people.  As yet, the development of NGOs is not particularly widespread in Finland and mainly confined to the centre of large cities.  The school health service however is available to all young people of school age.  The school nurse is available on-site every week, usually for between 3-5 days, although her time will be dictated by the size of school and the municipal resources for school health services.  The service provides both scheduled check-ups in certain grades (usually 8^th) as well as the opportunity for young people to visit the nurse whenever they need to.  The school health service effectively, is the health service for young people and has been developed in order to act as in partnership with the municipal centres as the primary health care resource for young people (Hosie 2001).

Some school nurses have the ability to dispense contraceptives on-site, but this ability is a municipal decision, and sometimes varies within municipalities.  Within Hosie's findings (2001) it appears to be the case that where the municipality had adequate NGO services outside of school and was not a rural municipality, the school nurse could not dispense contraceptive, however, where there were not out of school services specifically for young people and the municipality was rural, the school nurse could dispense.  Where the nurse can dispense, this provides an added advantage of the nurse being able to respond quickly to the often sporadic and unplanned nature of teenage sexual behaviour.  When the school nurse cannot dispense, young women will often use the municipal centres to obtain their contraceptives (Liinamo et al. 1997), but they will first have gone through the school nurse to arrange an appointment (Kosunen 2000b).  

5.4.3 Sexual health policy change post mid-1990s

As was the case with the provision of sex education, the provision of school health services also changed in 1994.  As a result of de-centralisation within the health service, in particular funding distribution decisions being devolved to the local level, there has been a noted shift in spending on preventative to curative health.  These changes have impacted upon school health service provision in two key ways; first, the training of school nurses has begun to shift from a specialised training programme to work with young people, to a more general broad-based training to prepare nurses for all kinds of nursing and second, school nurses now generally have responsibility for more than one school or area of health care and hence less time to devote to any one school and its young people (Hosie 2001). 

5.5 Education policy in Finland

In Finland a series of educational reforms, which began in 1972, resulted in the development of the comprehensive school (Peruskoulu) system.  Partial reform began in 1985 when the first NBE curriculum guidelines were produced, around which municipalities and schools were expected to develop their own curriculum (approximately 80% of courses were prescribed by the NBE, leaving 20% as school options).  The compulsory stage of secondary schooling in Finland, which all municipalities are obliged to provide free of charge, is provided between the ages of 7 (occasionally 6) and 16.  The Peruskoulu is divided into two levels, which basically equate internationally to a primary (6 years) and lower-secondary level (3 years).  Although pupils can then leave education, the generally understanding of both pupils and school staff is that after completing this level, all pupils will then progress to complete at least three further years of education at either a high school which leads on to university or a vocational school which leads on to vocational college/ polytechnic.  Alternatively if a pupil's grades are not sufficient to go to the next school that they want, they can remain in the Peruskoulu and undertake a 10^th grade to improve their grades.  Annually 100% of young people will go on from the Peruskoulu to begin 1-3 years of further education, although the drop-out rate will be 5-8% per year (Hosie 2001).  Figure 5.3 below details the secondary education system in Finland.

Figure 5.3: Secondary Education system in Finland.

12     13            14            15            16              16-17          17                       18                          19  /  20
Peruskoulu Upper stage of Comprehensive school	10th grade option	Lukio-High School
		Ammattikoulu -Vocational School

Source: Hosie 2001.

Explanation as to why there is such a high continuation rate in Finland beyond the age of 16 has been suggested to be for the following reasons;

1. The Peruskoulu is considered to be the 'preparation' stage before the 'real' education begins and therefore staying on at school after this stage is considered the 'normal' and advised thing to do.

2. The overall aim of and emphasis within student counselling in Finland school's is to help pupils decided where they will go on to study, as opposed to career choices.

3. Pupils cannot progress to university of vocational college/ polytechnic is they have not competed 3-4 years of upper secondary level education,

4. If pupils do not attended some form of further education, and have never been employed post-school, then from the age of 16-24, welfare benefit can only be claimed if a young person is actively seeking a place in education.

(Hosie 2001:205).

5.6 Young people?s sexual health promotion within its social and cultural context

Finland is a country with a high level of gender equality and openness towards sex and sexuality (Papp 1997; Hofstede 1998).  It has been classed for its more liberal sexual culture, at least since the late 1960s and it has been documented that young people in Finland do not adhere to a double-sexual standard, rather a single-sexual standard exists whereby, all people are entitled to enjoy a healthy sexual life (Papp 1997), further to this more young women in Finland report having had first intercourse by the age 16 than do Finnish young men (32-27% at 16) (Papp 1997; Kosunen et al.2000).

Hofstede (1998) implies that in countries where there is more 'open' discussion about sex and sexuality this can clearly be seen within large-scale studies undertaken to explore sexual behaviour and attitudes (Hofstede 1998).  When exploring Finland's timeline (see Appendix 3), national and young people surveys on sexual health are noted.  The first national study, which was conducted in 1971, not only asked about sexual behaviour and attitudes, but also the level to which Finns enjoyed a healthy sex life (Sievers et al. 1974).  The studies on young people specifically began in 1986 with the KISS study and incorporated questions on knowledge, attitudes and behaviour.  This particular study was repeated in 1988 and 1992, in between which was the HBSC(WHO) study in 1990, repeated in 1994 and 1998 and then the national school health study (SHS) in 1996, 1998, 2000.  Summarising, a study of young people's sexual behaviour, knowledge and attitudes has been conducted at least every two years in Finland and of interest for the behavioural section of the SHS were the questions about different levels of sexual activity including, dating, light/heavy petting, intercourse and masturbation, the latter of which reflects a level of openness not be found in other countries. 

It is important to remember that Finland as a Nordic country has often been ascribed to have always had 'liberal' views about sex and sexuality; this however has not always been the case.  Prior to WWII, sex was a very private issue and in a bid to keep young women 'innocent' they were generally told nothing about sex, not even about menstruation (Väestöliittö 1994).  From the end of WWII until the late 1960s there was a growing awareness of the sexual health needs of the population as a whole, culminating in the new abortion and public health laws of the early 1970s.  From the mid-1970s young people in Finland were not enjoying the same level of sexual health as the rest of the population and in response to their calls for sex education and better services, the government began to respond with a pragmatic attitude to teenage sexual health.  Therefore activities aimed at young people were to improve their sexual health via the promotion of healthy sexuality not by preventing their sexual behaviour.  A good example of where government concern lay was in their setting of a target to reduce abortion, thereby accepting that not all teenage pregnancies were unintended, but rather abortion represented pregnancies that were unintended and subsequently unwanted and therefore should be prevented.  Additionally, the development of the Finnish education system from the early 1970s has actively promoted the idea that young people should be in education and should remain there beyond the age of 16, at least until the age of 19.  In doing so, the system is not only prescribing that young people should delay entering the employment market until this point but in turn also, prescribing the delay of parenthood.

Finland has from the mid-1970s until the mid-1990s witnessed a dramatic decline in the rate of teenage pregnancy to a rate of 20.6 per 1000 (in 1994), which is relatively low in European terms.  This decline has occurred despite increasing levels of sexual activity amongst young people, which Kosunen and Rimpelä (1996) argue refutes the critics' argument in other countries that higher levels of teenage sexual activity will automatically result in higher levels of unintended pregnancy.   Concurrent development within the three policy areas explored has coincided with Finland's dramatic decline in teenage pregnancy.  Although it is unlikely that this combination of educational reform at the same time as developments in sex education and sexual health was developed with that particular issue in mind, however, through retrospective exploration, it is possible to see the potential impact that this combination of policies has had.

What adds further weight to the importance of sex education and school nurse provision in particular, are the changes to both provisions that occurred in 1994.  The de-centralisation of power within both the education and health sectors to the local level has resulted in a number of changes over which commentators in Finland have already voiced concern.  The changes to the Peruskoulu curriculum has been argued to have had negative effects of the provision of sex education (Liinamo 2000; Hosie 2001) as two of the hours that were removed as compulsory subjects were one hour of Physical Education and of Home Economics and in turn the topics within those subjects that have commonly been removed have been the hour of Family Education and Health Education (Hosie 2001).  Not only has this change resulted in a decrease in the amount of sex education generally provided to Finnish pupils (Liinamo 2000), but also it has meant that the only subject within which sex education is now guaranteed to be taught is Biology.  Recent research has highlighted that sex education has; generally become less co-ordinated (Kontula 1997); the focus has shifted from positive promotion of sex and sexuality to emphasising negative outcomes of teenage sexual behaviour (Liinamo 2000); the reduction of Health Education has meant a reduction in a single-sex environment in which to teach sex education, which could have negative implications for the sex education of young men in particular (Hosie 2001); and finally, whilst the proportion of young people experiencing first intercourse by age 16 has increased, the average level of knowledge about sex and sexuality amongst young people in Finland has decreased and the proportion of those reporting condom use has also decreased (Kosunen et al. 2000; Liinamo 2001:pc). 

The changes within the health sector, as described above has already impacted on the style of school nurse training moving from the specialised to the generalised, and the increased workload of school nurses now means that they have less time to devote to their pupils on a daily basis.  Evaluation undertaken by STAKES²³ has already noted some negative effects of the cut-backs on young people themselves and that although sexual health was not yet an individual area of concern, increasing problems of bullying and alcohol abuse had been related to the decreasing level of professional help available to young people in school (Hosie 2001).  Further to this members working on sexual health research at STAKES commented that "complacency about our lower rates, makes them [decision-makers] not worry... but there is a need to worry" (Hosie 2001:323) and at the 2001 European Population Conference, Väestöliittö (2001) noted growing concern about the sexual health of young people, attributing the increase in negative outcomes to the cutbacks in school health services and sex education at school.  And it would appear that these concerns have been realised in that from 1994 to 1999 the rate of teenage pregnancy has continued to rise from 20.6 per 1000 women aged 16-19, to 23.5 per 1000 (Gissler 1999, STAKES 2000:pc).  Although this rise appears relatively small it is important to note because it the first time in thirty years that a rise of any kind has continued over a period of more than one year.

¹⁹ KISS is the project name for a study into teenage sexual behaviour and it is an acronym from the Finnish words meaning maturation, human relationships, dating and sexual behaviour (Kosunen 1996).  This particular study looked at a range of issues including, knowledge of sexual matters and sources of information, age of first intercourse, experience of couple and sexual relationships and contraceptive use.

²⁰Saturation level is used within this context to mean that the contraceptive pill was being used by almost all regularly sexually active young women in need of contraception.

²¹7^th grade = 12-14, 8^th grade = 13-15, 9^th grade = 14-16.

²²Väestöliittö is the Family Federation for Finland based in Helsinki.

²³STAKES is the centre for research on health and welfare issues in Finland, based in Helsinki.

6 French policy development and teenage sexual health

6.1 Introduction

The purpose of this section is to map and locate the various policy areas within France's social and cultural context.  The section begins with a descriptive account of a range of sexual health indictors relating to young people in France.   France's policy areas are then mapped in turn before exploring the social context within which those policies have developed and the potential impact that those policies have had on sexual health indicators of young people.  A summary for reference of all key policy and other relevant events for France over the last four decades can be found in a timeline in Appendix 3.

6.2 Overview of sexual health indicators

6.2.1 Pregnancy, birth and abortion rates

Due to the fact that abortion statistics from France are not reliable and for many years not available, it is not possible to outline the trend for women aged 15-19 and hence, it is therefore not possible to outline the overall pregnancy trend for 15-19 year olds.  Of the most recent data that is available (1996) it is possible to estimate (with 80% accuracy for abortion) that the pregnancy rate for 15-19 year old women that year was 15.8 per 1000 (7.9 birth, 7.9 abortion) (Hosie and Silver 2001).   Figure 6.1 below, outlines the trend in live births to French women aged 15-19 from 1974-1999.

Figure 6.1: French Live Birth rate per 1000 women aged 15-19, 1974-1999.

Sources: Kane and Wellings 1999; Hosie 2001; Worldbank 2001.

6.2.2 Abortion ratio

Due to the lack of reliable abortion data it is also not possible to provide an account of the trend in outcome of pregnancy, however Kane and Wellings (1999) state that for every 1000 births to women under 20 in 1994, there were 863 abortions, in other words the outcome of pregnancy for women under 20 is slightly more skewed towards a birth than an abortion.

6.2.3 STIs and HIV/AIDS

According to Paunchad et al.'s (2000) study into STI prevalence in Europe, fewer than 50% of diagnosed cases are reflected in official statistics from France and therefore Table 6.1 below should be viewed with caution. 

Table 6.1: STI rates per 100000 young people aged 16-19, by type of infection and gender; % of all infections that occur among young people and young adults, by infection, 1996.

Infection				Rate per 100,000 among 16-19 year olds						Of all reported infections % that occur in age group
				Total		Female		Male		16-19		 20-24		16-24
Gonorrhoea			7.7		8.4		7.0		10		24		34
Chlamydia			55.1		110.9		1.6		10		28		38

Source:Panchaud et al,. 2000.

Of the available data from France it is possible to note that the reported incidence of Gonorrhoea amongst young people is relatively low, with a rate of 7.7 per 100000, accounting for 10% of all STIs in that age group, there was also little noted difference between men and women, with the female rate presenting slightly higher than that for males.

The rate of chlamydia incidence amongst young people in France is not reportedly high, with an overal rate of 55.1 per 100000 for young people aged 16-19.  The, difference between genders in France, however, is one of the most striking across Europe with young women having a rate 69.3 times higher than the corresponding rate for men.  The rate of chlamydia as a proportion of all STIs amongst young people aged 16-19 was relatively low at 10%, rising to 38% when the age grouping is increased to 16-24.

In France, the HIV epidemic began in the early 1980s and the principle modes of transmission have been sex between homosexual/bisexual men (HBM) and intravenous drug use (IDU) and EuroHIV estimate that as of the end of 1999 there were 130000 cases of HIV in France (EuroHIV 2000).  The incidence HIV amongst young people in France currently appears to be relatively low.  However, the current HIV and AIDS statistics, show a gradual rise in heterosexual transmission for the 20-29 age group, which could be interpreted to indicate that the actual age of infection could have occurred during the latter stage of teenage years.

6.2.4 Coital activity

Studies on young people's behaviour specifically did not begin until the HBSC(WHO) studies of 1990, 1994 and 1998 and these studies have repeatedly revealed that French young men are generally more sexually experienced than their female counterparts(30%-20%) (Ross and Wyatt 2000).  In most other European countries, whether young women are more or less sexually active than young men at a younger age, this trend tends to level off at age 18.  France is one of the only countries (Italy being the other) where this does not occur.  It has been suggested that this may be a result of a combination of factors, in particular; that young women in France are more able to avoid sexual intimacy until an emotional intimacy has developed and also that parental control over their daughters is more prominent in France than other countries, limiting opportunity for sexual intimacy to take place (Choquet and Manfredi 1992).

6.2.5 Contraception use

Young people in France now have one of the highest reported rates of contraceptive use of young people in Europe (Ross and Wyatt 2000).  In particular condom use is reported to be highest in France amongst those under the age of 25 and in unstable relationships (Kane and Wellings 1999).  In 1995 it was revealed that for young men reported condom use at first and subsequent intercourse remains above 70% (78.9-72.5%).  For young women although the rate at first intercourse was reportedly over 74%, this drops to just over 51% at subsequent intercourse (Kane and Wellings 1999).  This drop in condom use by young women is reflected in a subsequent rise in oral contraceptive use, young women move quickly from relying on barrier methods, to the contraceptive pill (Toulemon and Leridon 1998).  Table 6.2 below outlines the contraceptive use at first intercourse reported in the 1994 WHOHBSC study (Ross and Wyatt 2000), which shows that 89% of young men and 98% of young women reported using some method of contraception at 1^st intercourse.

Table 6.2: Contraceptive use at first intercourse

Condom	Condom	Pill	Pill	Condom + pill		Other	Other	None	None
Male	Female	Male	Female	Male	Female	Male	Female	Male	Female
54	76	2	8	33	10	0	4	11	2

Source: Ross and Wyatt, 2000.

6.2.6 Education indicators

Table 6.3 below shows the age structure of secondary education in France.  As was the case in Finland, reported stay-on rates beyond the end of compulsory schooling are also high in France as can be seen in Figure 6.2.

Table 6.3 Age structure of secondary education in Finland

Country	Age range of lower secondary education	Age at which compulsory schooling ends	Age range of Upper secondary education	Duration of upper Secondary (in years)
FRA	11-15	16	15-18/19	3-4

Sources: EC/ Eurydice/ Eurostat 2000; West et al. 1999.

Figure 6.2: Participation rates (as a %) in education at different ages, 1996-7

Source: EC/ Eurydice/ Eurostat 2000.

6.3 School-based sex education policy in France

6.3.1 Curriculum location and national guidelines

School-based sex education was first introduced into public policy in 1973.  The provision of sex education at this time was limited to the teaching of biological reproduction within natural science classes for those aged 13 and above.  In 1976, however, it had become apparent to providers of family planning services, that young people were not utilising services available to them in part, due to a lack of knowledge.  Therefore in addition to publicity by family planning services in 1976, in 1981 school-based sex education was further developed to include the topic of contraception and fertility regulation from the age of 14, whilst the age at which biological reproduction was first taught was decreased to 12 (Kane and Wellings 1999) and in 1985, sex education was also incorporated into the topic of 'life education' at the primary school level (Gallard 1994).  From the mid-1980s AIDS education activities began to target young people and the school setting was a primary venue for these activities.  AIDS education activities increased in numbers towards the end of the 1980s and in 1987, all French schools were encouraged by the Ministries of Education and Health to provide HIV/ AIDS education for their pupils.  Many of the activities were undertaken by non-governmental and non-profit organisations and included the training of teachers to be AIDS educators and forms of peer education, which although commonplace now, were viewed sceptically at the time (Bunde-Birouste 1991). 

6.3.2 Time allocations

Table 6.4 below, details the provision a French pupil would expect to receive in the lower stage of secondary education.

Table 6.4 Sex education provision in France

Curriculum Subject	Location of sex education	Hours of teaching
Biology	Biological reproduction	1-2 lessons/ year in 5ème (12-13)
		1 lesson/ year in 4ème (13-14)
		1 lesson/ year in 3ème (14-16)

6.3.3 Teaching environment and teacher training

In French schools the subject of Biology, within which sex education is taught, would be taught within a mixed-sex environment.  As is the case in other countries eg Finland, the is no policy regarding the training of teachers to teach 'sex education', however Biology teachers would expect to have been trained to cover all topics in Biology including biological reproduction.  As noted above, however, concern over the issue of HIV/ AIDS brought within it concern over the lack of expertise adults had as AIDS educators and therefore programmes of training adults to be AIDS educators have been in place since the late 1980s. With regard to teaching methods, teachers would commonly utilise didactic methods incorporating the use of science textbooks, which include information on reproductive biology and videos on fertilisation and childbirth (Parmontier 2001:pc). 

6.3.4 Content

With regard to the content of sex education, because of the topic location in Biology and the relative unacceptability to talk about sex education in terms of pleasure and relationships (Gallard 1994), the focus of content would be purely biological with the central aim of increasing knowledge about the biology of reproduction and the dangers of HIV and AIDS.   Sex education in French Biology classes would typically focus on:

1. The functioning of genital organs and biological maturation: physical, psychological and social changes of beginning adulthood, changes of outer appearance and menstruation'

2. Particular focus on the many anxieties that girls have about their periods at age 13-14. 

3. Descriptive account of the different types of contraception; the condom, pills, coil, rhythm method and merits and problems with each method.

4. Two films would be shown, one about the process of egg fertilisation and one about childbirth.

5. HIV and AIDS awareness education, primarily focusing on the dangers of HIV, modes of transmission and the role of the condom in HIV prevention.

(Parmontier 2001:pc).

6.3.5 Use of sexual health experts

Finally, the provision of the core sex education would be taught by teachers alone, generally sexual health experts would only be used for some of the AIDS education and that provision would vary greatly between schools.  When outsiders were utilised for the AIDS education, the methods of teaching would generally be more varied than for the teaching of Biology in school.  These would vary from didactic, non-participatory methods, to information exhibitions and peer education (Bunde-Birouste 1991). 

6.4 Sexual health policy in France

6.4.1 Historical development of sexual health policy

The availability of contraceptives and abortion in France has always been a somewhat contentious issue.  The process of legalising contraceptives began in 1967 when the manufacturing, importation and sale of contraceptives became legally accepted (Jones et al. 1985).  Despite this change in the law it was not until 1974 when that the provision of contraceptives by family planning clinics was legalised.  The following year, abortion became legalised in France, however, in the first few years following the enactment of this law, many doctors and hospitals refused to offer this service to French women (Henshaw 1994).

In 1976, family planning services became aware of the fact that few young people were making use of their services and therefore an awareness campaign was launched to educate young people (in particular under-18s) about their rights to confidential family planning services and contraception (Kane and Wellings 1999).  This was followed in 1981 by a large public education campaign utilising many forms of mass media and advertising on public transport to inform all citizens of their sexual health rights and in particular to reinforce the message that young people were entitled to confidential sexual health services (Kane and Wellings 1999).

France operates an employer-based national insurance scheme, which covers approximately 90% of the population.  This insurance provides approximately 80% cover for a range of medical treatments and in 1982, this range was extended to include abortion services.  For the small proportion of women who are not covered by this insurance, the government may provide assistance at its discretion (Henshaw 1994).  By 1988 the proportion of public hospitals that would perform an abortion had increased to 87%, many of these services, however, remain under-funded, under-staffed, low priority/status work and professionals can refuse to perform on the grounds of 'conscience' (Henshaw 1994).  Additionally, although the legal age of heterosexual consent was set at 16 back in 1945, and young women under 18 are entitled to confidential sexual health advice and contraception, a young woman wishing an abortion under the age of 18 must have parental permission.  As a result women under 18 may attempt to obtain an abortion in the private sector, where the recording of abortions is not enforced (Kane and Wellings 1999).  This being the case is part of the reason offered as to why abortion statistics in France are considered to be incomplete. 

Further explanation as to why the abortion statistics in France are unreliable is due to the fact that because many women face delays in obtaining an abortion that takes them over the allowed 10 weeks within which an abortion must be performed, it is estimated that more than 2000 women annually will travel to England for the procedure (Henshaw 1994).  Following a visit by the pope in 1987, the debate on abortion was publicly raised once again after the creation of the first anti-abortion group and although public support is reported to be high, the anti-abortion lobby in France remains prominent and vocal (Kane and Wellings 1999).  In an attempt to counter the effect of the anti-abortion lobby, in 1990, the Co-ordination of Associations for the Defence of Abortion and Contraception (CADAC) was established to give public voice the pro-choice argument and as of 1992 it became illegal to hinder the abortion act (Kane and Wellings 1999).

Since the mid-1980s HIV and AIDS awareness has been heightened in France, where epidemics have been noted within both IDU and HBM populations.  The first AIDS organisation aimed at prevention work, was set up in 1987 and later in that year a massive public health campaign was run from April through to June incorporating all mass media outlets as well as advertising on public billboards, and the set up of a telephone information hotline (Bunde-Birouste 1991).  Coinciding with the launch of this campaign was the lifting of the previous ban on advertising condoms.  Campaigns such as this have continued throughout the late 1980s and 1990s, the most prominent of which took place in 1989 (general public) and 1997 (aimed specifically at young people), the latter utilising pubs and cubs to distributed information leaflets to reach young people (Bunde-Birouste 1991).  In 1991, a High Committee for Public Health was created and the findings of the 1994 report by this committee raised the issues of HIV/ AIDS and STIs as high priority public health priorities, which have remained priorities since then.

6.4.2 Sexual health policy and young people

Overall, the sexual health service provisions available to young people in France do not differ from those set up for use by the whole population.  It is unusual to find services that have been set up use only by young people and access to those that do exists varies greatly and is dependant on a young person's geographical location (Kane and Wellings 1999).  However access to condoms has been increased since 1992, with machines available in metro and train stations, outside chemists and over 10% of schools (Kane and Wellings 1999).

6.5 Education policy in France

In 1959, the Berthoin reform extended compulsory education for young people from the age of 14 to 16.  At this time the options available to young people were, the academic baccalauréat general, and the traditional vocation qualification, Certificate d'Aptitude Professionel (CAP).  In 1968 further reform aimed to broaden the qualifications available at the school level by introducing two new qualifications to complement the existing ones, these were the new baccalauréat technologique, and the new Brevet d'Etudes Professionnelles (BEP), a broad craft level qualification.  In 1975 the Haby reform brought about the introduction of a new upper secondary education institution, the Lycée Professional (LP), which introduced a vocational institution to complement existing academic and technical Lycées.  Finally in 1978, the whole upper secondary stage of French education was reformed to integrate all of the previous reforms at the upper level, abolishing all previous tracks through education, instead enabling all pupils to follow a core curriculum in the collège (lower secondary) nearest to their home.

In 1982 a decentralisation law was passed which sought to devolve more and more power to the localised levels of region, department and communes.  In practice this meant that many powers relating to education and training were devolved to the local level.  The following year, the French government began a programme of vigorous promotion of vocational education as the main alternative to general education and this was followed by the introduction of the baccalauréat professional (BP) in 1985, which provided a professional vocational version of the baccalauréat which was previously confined to the academic/ general education students.

In France at the age of 11, young people would enter the level of lower secondary education called the collège (see Figure 3b.2 below), where they would remain for four years (6ème-3ème, i.e. years 1-4) and study general education subjects.  After completion of the collège, young people would progress to study at either a general, technological or vocational Lycée. Although young people can technically finish their education at 2ème of any of the three schools, over 90% annually remain in education beyond the age of 16 (dropping to 85% at 17+) (EC/Eurydice/Eurostat 2000).  Within general or technology Lycées pupils will usually complete three years (2ème, 1ème and terminale) to complete either the baccalauréat general (required to enter university) the baccalauréat technologique or the BEP.  Pupils attending a vocational Lycée would study for three years (2ème, 1ème and terminale) to achieve one or more of the CAP, BEP and the baccalauréat professional (West et al. 1999). 

Reasons as to why so many young people remain in education in France at least until the age of 17 (on average over 90%) is most likely due to the fact that 55% of upper secondary French pupils are learning within a vocational institution for a vocational qualification (which can be completed at 17) (West et al. 1999).  From the age of 17, by which time all vocational qualifications except the baccalauréat professional would be completed, the stay-on rate drops slightly to around 85% (West et al. 1999).  The dive