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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 diversity of choice available within the French education system and the promotion of vocational education as a viable alternative to general academic education offers young people in France many opportunities and reasons to remain in education at least until the age of 17/18 depending on qualification sought. 

Figure 6.3 Lower and Upper Secondary Education systems in France

Source: EC/Eurydice/Eurostat 2000.

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

France, although not as having the same level of gender equality as Finland or the Netherlands, (Hofstede 1998), it is closer to those countries in a positive direction than it is to Great Britain.  The progression from more conservative to more liberal attitudes about sex and sexuality can be seen in the progression of national survey focus which developed from a study of only married women's sexual behaviour in 1971, to a survey of all women regardless of marital status in 1978 and 1988, to a study of all men and women in 1994. 

France has, however, had a difficult history in comparison, for example, to countries in Northern Europe in the promotion of sexual health issues and services, due to the strong nature and influence of Catholicism.  Despite a legal age of heterosexual consent of 16 and the fact that young people under 18 have the right to access contraceptive advice and contraception without parental permission, relatively few areas in France have services available to young people specifically.  Additionally the development of sex education in France, although appearing in public policy as early as 1973, has never really developed beyond the provision of information about biological reproduction.  The arrival of HIV and AIDS and the realisation of the serious implications an HIV epidemic could have, brought about an increase in the diversity of sex education in school, but the focus remained a negative one.  I.e. rather than sex education becoming a promotion of good sexual health it remained focused on the potential negative outcomes of sexual activity.  However, condom promotion in France has been a high profile activity and in addition to the installation of condoms machines in metro and train stations from 1992, at least 10% of high schools now have such machines located on their premises (Kane and Wellings 1999).

With regard to education opportunities in France, the structure of the educational system appears to encourage a continuation for at least 1-2 years beyond the age of 16.  As was suggested to be the case in Finland, this high continuation, especially amongst young women, may provide aspiration to delay parenthood at a young age (Parmontier 2001:pc).  Additionally, in a study of French adolescents' risk taking behaviour, school absenteeism (in particular exclusion) amongst young women was found to be related to practice of unsafe sexual behaviour resulting in pregnancy and/ or STI infection (Choquet and Manfredi 1992).

7 Dutch policy development and teenage sexual health

7.1 Introduction

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

7.2 Overview of sexual health indicators

7.2.1 Pregnancy, birth and abortion rates

Due to the fact that abortion statistics from the Netherlands are not readily available, it is not possible to outline the trend for women under 20 years of age and hence, it is therefore not possible to outline the overall pregnancy trend for that age group.  Of the most recent data that is available (1996) it is possible to estimate that the pregnancy rate for 15-19 year old women that year was 9.6 per 1000 (5.6 birth, 4.0 abortion) (Hosie and Silver 2001).   Figure 7.1 below, outlines the trend in live births to Dutch women under 20 years of age from 1967-1999.

Figure 7.1: Live birth rate per 1000 women age under 20, 1962-1999

Source: UN Demographics 1976, 1983, 1989, 1997; Worldbank 2001.

7.2.2 Abortion ratio

Due to the lack of available abortion data it is also not possible to provide an account of the trend in outcome of pregnancy, however it has been noted the abortion rate in the Netherlands has been relatively low since abortion was legalised which is mostly likely due to the fact that so few teenagers become pregnant and of those who do abortion is not a common option (Ketting 1994).  This means that the abortion ratio amongst Dutch teenagers is skewed towards a live birth as the more likely outcome (510 abortions per 1000 births for women under 20 in 1994), which Kane and Wellings (1999) suggest is because abortion is less acceptable amongst Dutch teenagers.

7.2.3 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 the Netherlands and therefore Table 7.1 below should be viewed with caution. 

Table 7.1: 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, 1995.

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				1.0		1.1		0.9		4		16		20
Gonorrhoea			7.7		7.5		7.8		5		20		25

Source: Panchaud et al,. 2000.

Of the available data from the Netherlands it is possible to note that the reported incidence of syphilis amongst young people is very low, with a rate of only 1.0 per 100000, accounting for 4% 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 gonorrhoea incidence amongst young people in the Netherlands is also reportedly very low, with an overall rate of 7.7 per 100000 for young people aged 16-19.  There is also little difference between genders for gonorrhoea is also, with the male rate in this case being slightly higher that the rate for females.  As a proportion of all reported infections in that age group gonorrhoea accounted for only 5%, increasing to 20% for the age group 16-24.

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).  The incidence of HIV cases in the Netherlands as of the end of 1999 was estimated to be 15000, relatively low in European terms (EuroHIV 2000). 

7.2.4 Coital activity

Research has revealed that the average age at which young people in the Netherlands have their first heterosexual intercourse experience is 17.5 years, estimated to be on average one year later that most of their European counterparts, including Scotland (Francis, 1994).

7.2.5 Contraception use

Ever since the rigorous promotion of contraception to young people in the early 1970s the proportions of reported use of modern contraception was 86% amongst 16-20 year olds (Ketting and Schnabel, 1980), a percentage that is considerably higher than reports of contraceptive use amongst young people in most European countries in the late 1990s (Ross and Wyatt, 2000).   Research has also revealed that more than 50% of Dutch young women are already using the contraceptive pill prior to their first intercourse (Francis 1994) and the popular promotion of the 'Double-Dutch' method of contraception whereby condom use is concurrent with contraceptive pill use to both prevent pregnancy and protect against STIs, has been well received amongst Dutch young people (Rademakers 1991; Silver 1998). 

7.2.6 Education indicators

Table 7.4 below shows the age structure of secondary education in the Netherlands.  The Netherlands, similar to other Northern and Western European countries, has a pattern of high stay-on rates beyond the age of 16, which can in part be explained by the fact that age at which compulsory schooling ends in the Netherlands is 17 if a full-time student and 18 if part-time.  Figure 3c.2 below presents the stay on rates for ages 16-20 for 1996-1997.

Table 7.4: Age structure of secondary education in the Netherlands 

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)
NL	12-16	17 (full time) 18 (part time)	16-17/18	2-3

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

Figure 7.2:Participation rates (as a %) in education at different ages, 1996-7

Source: EC/ Eurydice/ Eurostat 2000.

7.3 School-based sex education policy in the Netherlands

7.3.1 Curriculum location and national guidelines

The issue of sex education for young people in the Netherlands has been a topic of discussion prior to the 20^th century at which point in time it was generally conceived to be advisable that young people were informed.  During the 1930s, however, the issue had "fallen out of favour... and was considered a necessary evil at best.  This remained the general attitude up to the 1960s" (Röling 1993:236) and as a result young people rarely received sex education at school (Silver 1999).  After the sexual revolution of the 1960s and a dramatic rise in teenage pregnancy, the issue of sex education was revisited.  The outcome was a pragmatic attitude towards teenage sexual behaviour and the reduction of (still illegal at that time) abortion (Silver 1998). 

Since the late 1960s, despite there being no statutory obligation for schools to provide sex education until 1993, it has been widely accepted and supported (Silver 1998) and research has shown that it has been incorporated into the educational curricula of approximately 97% of Dutch schools (Clark and Searle 1994).  In the Netherlands, it is not perceived as appropriate for members of government to intervene, "it would be 'unthinkable... not part of his job' for a Dutch government minister to express a personal opinion on a sex education programme" (Sheldon 1997:13).  The lack of official guidelines until 1993 has also meant that decisions about the teaching of sex education, amount of time allocated and content are all decided at the school level and vary across schools and schools streams (see education section).   Sex education is taught from a young age in the Netherlands, both in formal and informal settings, i.e. what is taught within school is reinforced by both family and very supportive and informative media representations²⁴ (Braeken 1994) which all provide consistent rather than conflicting messages about sex and sexuality and attitudes to teenage sexual activity.  Silver claims that "the extent to which consistent messages are conveyed is largely dependant upon a society's attitude to teenage sexuality and sex education" (Silver 1998:14), which explains the Netherlands relative ability to be consistent.

7.3.2 Time allocation

Similar to the provision in Finland, there is no actual subject called 'sex education' in the Netherlands, rather to Dutch young people "sex education is integrated into the whole learning experience process and is treated like any other topic" (Silver 1998:26).  Formal teaching which incorporate aspects of sex education begins in primary school within a subject called 'social coping competence' and continues at the various streams of secondary level education primarily within the subjects of Biology, and 'Care', however the amount of sex education provided depends on each individual school (Silver 2001:pc).  

7.3.3 Teaching environment and teacher training

In the Netherlands, the gendered environment in which sex education is taught will depend on the individual school and whether that school considers it an advantage to make use of a dual provision of single and mixed-sex arenas, although many schools will make use of mixed and single-sex small-group work within mixed classes (Sheldon 1998).  Again, similar to the situation in Finland, if a teachers core subject contains aspects of sex education, i.e. Biology, then the pre-service training that teachers receives will incorporate training on those aspects.  Additionally teacher training on sex and sexuality has been provided by the Netherlands Institute for Health Promotion and Disease Prevention (NIGZ) (Sheldon 1997).  The methods used in schools to teach aspects of sex education vary from school to school, but many recent publications on sex education in the Netherlands note that classroom activities can be very challenging and role play is commonly used to promote communication and negotiation skills (Sheldon 1997; 1998).  Sheldon further notes that young people in the Netherlands appear to respond well to such activities and was quite amazed by the level of maturity young people portrayed in talking about sex and sexuality in class, "They weren't giggly, excited or shy, just talking in a matter-of-fact way about masturbation, abuse, homosexuality, AIDS, condoms, penis size, marriage, the coil and sperm.  They talked too, of choice, responsibility, self-promotion and love" (Sheldon 1998: 1).  This level of maturity in talking about sex has been found in other recent studies (Silver 1998; 2001:pc).

7.3.4 Content

Although the teaching of sex education is generally contained with Biology, the focus of content goes much wider than is generally found in other countries' biological provision.  Generally the education within Biology would cover physical and mental maturation, growing up, puberty, menstruation, hormonal control, masturbation, sexuality, homosexuality, relationships and love, human reproduction, Stds, conception, contraception, pregnancy, miscarriage, abortion, birth, afterbirth, sexual abuse, lifecycle, growing older and euthanasia (Sheldon 1997, 1998; Silver 1998).

7.3.5 Key aims of sex education

The key philosophy of Dutch sex education is summarised by the following pragmatic truism 'you have to accept it to control it' (Sheldon 1997:13) and Dutch commentators have noted that it is exactly this pragmatic attitude which underpins the success of sex education in the Netherlands because it conveys that sex and sexuality are normal parts of life, rather than taboo subjects to be hidden from young people (Silver 1998).  Therefore the central aim of sex education in the Netherlands is not to prevent teenage pregnancy and STI infection by preventing the sexual activity but rather to be pragmatic and accept that some young people are sexually active and to be explicit about the promotion of sexual health.

7.3.6 Use of sexual health experts

With regard to the use of sexual health experts in school-based sex education, it is common for schools to make use of the expertise provided by the Rutgers Institute and the services provided by NIGZ (Vilar 1994; Sheldon 1997; Silver 1998).  Additionally since 1987 the Dutch Health Education Centre has been implementing AIDS education projects into secondary schools, one such activity in 1990, being a contest organised by DHEC for young people inside and outside of school to design a poster, poem story or song about 'Love in the era of AIDS' (Braeken and Reinders 1991).

7.4 Sexual health policy in the Netherlands

7.4.1 Historical development of sexual health policy

Prior to the 1960s, the Netherlands was considered, in relation to sex and sexuality, to be a very conservative country (Silver 1999), however, the beginning of the 1960s saw a number of important changes in sexual attitudes which in turn over the following two decades resulted in a number of important changes to sexual health policy.  In 1962, the contraceptive pill was first introduced to the Netherlands on an experimental basis before doctors were formally able to prescribe it in 1964 (Ketting 1983).  Although available at this point the public provision of contraception was only removed from the Criminal Law Statute Book in 1969 at which point the ban on advertising contraceptives was also lifted.  Also in this year the Rutgers Stichting Institute was set up to make contraceptive advice and provisions available to young people who did not feel comfortable accessing these services at their family doctors and in 1970 the management of Rutgers was separated from the main Dutch family planning association (NVSH). In the early 1970s, emergency contraception, which had also become available in 1964, was covered in the first family planning handbook for doctors in the Netherlands (Glassier et al. 1996) at which time Rutgers also began offering emergency contraception to its clients.

In 1971, the age of heterosexual consent was placed at 16 (Kane and Wellings 1999), although technically the age is set at 12, because between the ages of 12 and 16, a prosecution is only brought about is there is an official complaint, such as exploitation. In the same year, the contraceptive pill became covered by national medical insurance and despite the fact that abortion was still technically illegal, a woman having an abortion and a physician performing one were no longer subject to prosecution.  This was followed in 1972 by the creation of the first NVSH abortion clinic and by 1973 abortion clinics were widely accessible, although abortion remained illegal.  In fact, in total, 7 separate bills were presented to parliament from 1970 to the early 1980s in an attempt to change the almost 100-year old abortion law (Ketting and Schnabel 1980) and although regulations became lax, and repercussions removed, abortion did not become officially legal in the Netherlands until 1985, considerably later than many Western and Northern European countries.

7.4.2 Sexual health policy and young people

Young people in the Netherlands, now have access to sexual health services in a number of locations.  The two main providers are family physicians and the Rutgers Institute, however the Rutgers provisions are limited to large Dutch cities.  The advantage of the Rutgers provision, where available, is that this provision has been created solely for use by young people, unlike the family physician, who is for the general population.  However, although young people in the Netherlands still desire a confidential service (Jones et al. 1986), it appears that the need for access to a sexual health service to be 'hidden' from parental view is not as pressing as in a number of other European countries due to the level of communication that exists between parents and their children regarding sexual health issues.  In a small-scale study of Dutch and English young people, all young women in the study visited their physician to obtain their first trial of the pills with their mother, which "clearly demonstrates that they feel comfortable about their sexuality and in are in control of their sexual activity" (Silver 1998:36).

7.5 Education policy in the Netherlands

Secondary school level of education begins at the age of 12 in the Netherlands and can last for a period of 5 to 8 years (Full and/or part time).  There are three main streams of secondary education and depending on what educational level a pupil is at in the final year of primary will determine what stream they enter at the secondary level²⁵.  In order to understand the descriptive account of the Dutch system Figure 7.3 below, shows the various stages and streams of the secondary level.

Figure 7.3 The secondary education system in the Netherlands

Source: EC/Eurydice/Eurostat, 2000.

Lower secondary education in the Netherlands is a basic three year period (basisvorming), which is provided in three main schools, Middelbaar Algemeen Voortgezet Onderwijs (MAVO) a junior general secondary school (12-16 year-olds), Voorberidend Beroepsonderwijs (VBO) a pre-vocational school (12-16 year-olds), and pre-higher education (3 years).  Having completed lower secondary at one of these schools, pupils would then progress to one of two forms of upper secondary education, general or vocational.  General education is a continuation of pre-higher education at the lower secondary and consists of two streams, Hoger Algemeem Voortgezet Onderwijs (HAVO) which is two years leading to higher education, or Voobereidend Wrtenschappelijk Onderwijs (VWO) which is three years that leads to university.  Vocational education at the upper secondary level can consist of 2-4 years of full/ part-time study.

During the first three years on lower secondary pupils will usually follow a common core curriculum, the level of which will vary depending on the type of school attended.  Pupils are set attainment targets dependant on the stream of education they are following.  The Netherlands is one of only a small number of countries where vocational education is offered at the lower secondary level (18% of young people take this stream) a system that was first piloted in 1979.  In 1993 some changes were made to the organisation of vocational education in particular to the content and attainment targets, to increase the modularisation of the secondary vocational education system.  The result of these changes was the pervious MBO secondary vocational education and the apprenticeship systems were integrated to form a single more coherent framework for vocational education and training (de Bruijn and Howieson 1995).   In 1999, further reforms were introduced to increase pupils' school choice and to introduce more coherent programmes of study for the HAVO and VWO streams (de Bruijn and Howieson 1995).  

The Dutch system appears quite complicated with its varying streams and levels, however, after entry into one particular stream a Dutch pupil is not confined to that stream for the rest of their educational career, dependant on level of attainment, a certain degree of movement is possible between streams.  Equally when a pupil is not coping with a particular level within a stream they have the opportunity to re-sit a year once, if they are still not coping then they would be moved into a lower ability stream.  Due to the ability of movement through streams and levels, it is not uncommon to have a mixture of ages within any one level or stream and as a result, there is stated to be little stigma associated with being in a class with pupils that are younger/older and therefore pupils are encouraged to re-sit levels or move streams rather than to leave school (Silver 2001:pc).  The stay-on rate post-16 remains high in the Netherlands until the age of 17 (90%), at which point the percentage remaining in education decreases by approximately 10% per year group, i.e. 80% at 18, 70% at 19 and 60% at 20 (EC/Eurydice/Eurostat 2000).

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

The Netherlands is one of the most sexually open and gender-equal countries in Europe only surpassed by Norway and Sweden (Hofstede 1998). This score and rank is to be expected when one considers the automatic perception many people worldwide have of the Netherlands as a very sexually liberal country.  When examining the Netherlands' timeline (Appendix 3) it is possible to see that the first national 'sex survey' was conducted as early as 1969, which was repeated in 1981.  The first national study (although many smaller-scale studies have been conducted prior to this date) of young people's sexual health was conducted in 1990 (repeated in 1995), and the questions asked of young people reveal a very normalised view of sex and sexuality and difference.  The Dutch survey is straightforward and explicit, asking questions about participation in stroking over and under clothes, naked fondling, masturbation and manual and oral sex as well as intercourse (Brugman 1995).  Additionally the survey asked young people about experience of sexual fantasies, both hetero and homosexual as well as participation in anal sex.  Perhaps most notable of all, is that out of all the surveys in each of the countries explored in this report, the Netherlands' young people survey was the only one to actually ask (rather than assume by non-response) if a young person had had no sexual experience with another person.

However, the Netherlands has not always been so open or liberal with regards to sex and sexuality.  Prior to the 1960s the Netherlands was in fact one of the most conservative countries in Europe, which retained many strong puritanical elements;

"Along with abortion, family planning in general was traditionally rejected in the Netherlands as an immoral practice, contraception being considered contrary to the purpose of marriage.  Family planning was felt, would alienate a woman from her traditional roles of housewife and mother and eventually would lead to sexual promiscuity." (Ketting and Schnabel 1980: 385-386).

However, Dutch society's pragmatism in the face of adversity, which Silver describes as an age-old "cultural trait of seeking practical solutions to social problems" (Silver 1998:8), meant that when faced with increasing concerns over young people's sexual health and rising rates of teenage pregnancy in the 1960s, the only solution was to be practical.  This 'age-old' pragmatism and tolerance has developed out of necessity.  The Netherlands' population make up is half-Catholic, half-Protestant, with a large Jewish community and in order to survive economically, co-operation in both trade and defence was essential (Sheldon 1997).  Silver (1999) also refers to the Netherlands's historical 'struggle against the water';

 "At first glance this struggle may not seem relevant to an investigation into teenage pregnancy.  However, it is my contention that the practical problem solving skills required to adequately and efficiently defend the land from the sea has significantly affected the collective Dutch mentality, and that this deep-rooted influence must still be relevant today" (Silver 1999:7).

Therefore when exploring the issue of teenage sexual health and the well-known pragmatic Dutch approach to it, it is important to fully understand the Netherlands' political and cultural history in order to comprehend why the Dutch are 'intrinsically' pragmatic in their social policy approaches to certain issues.  It is also important to understand that although the Dutch appear more tolerant of certain issues than is the case in other countries, Silver warns;

"It is important not to give the impression that they necessarily agree with such practices or are all practicing them themselves.  'Liberal' social policies have developed from an intrinsically pragmatic and realistic attitudes towards such issues rather than widespread belief that such practices should be encouraged"(Silver 1999:16).

The Dutch are in fact conscious about portraying their 'normalness' and it is important to Dutch people to appear modest and conventional (Silver 1999).  Their tolerance of others and unconventional behaviour comes as a result of a "strong respect for the privacy of others... where it [is] paramount to tolerate other religious beliefs and behaviours in order to safeguard the right to practice your own" (Silver 1999:17).  Having explored the issue of Dutch pragmatism in brief it is possible to comprehend why the Dutch response to rising teenage pregnancy in the 1960s was, not to prevent sexual activity amongst young people, but rather, "it was considered more appropriate and effective to equip young people with the means to control the potential consequences of their sexual behaviour" (Silver 1999:17).

Finally in relation to delaying parenthood, the Dutch education system offers young people the ability to be flexible in their learning patterns rather than restricted to one type or level of education.  Over the past two generations there has been a strong trend of women remaining in education for longer and delaying parenthood, to the point that the Dutch have been coined "world champion [of] later parenthood" (Beets 1999a:1).  In the Netherlands, parenting at a young age has been reported in British newspapers as being heavily stigmatised, implying that if the British were to stigmatise teenage pregnancy more, it would help to reduce their current rate (Silver 2001;pc).  This opinion, however, is taken out of context, as Silver (2001:pc) explains, that the 'who' that stigmatises is not the adult population, but rather young people themselves, and the 'stigma' is not so much about condemnation of that young person, but rather, 'what a shame - look what you will miss out on as a result of becoming a parent so young'.  So it appears that the young in the Netherlands regulate their own behaviour and as Silver (1998) explained "many of the Dutch [respondents in her study] thought it would be 'stupid' of their friends to become pregnant, "because they know they should be using contraception" (Claus)" (Silver 1998:45), which implies that the message of effective contraceptive use is both normalised and well internalised amongst young people in the Netherlands.

²⁴The Dutch media has played a particularly crucial role in HIV and AIDS campaigns in addition to its general sexual health promotion - see Netherlands's time line for details of AIDS prevention campaigns.

²⁵Occasionally a pupil will sit an extra transition year in between primary and secondary, if it is unclear which stream that pupil should enter.

8 Romanian policy development and teenage sexual health

8.1 Introduction

The purpose of this section is to map and locate the various policy areas within Romania's social and cultural context.  The section begins with a descriptive account of a range of sexual health indictors relating to young people in Romania.   Romania'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 Romania over the last four decades can be found in a timeline in Appendix 3.

8.2 Overview of sexual health indicators

8.2.1 Pregnancy, birth and abortion rates

Due to the illegal status of both abortion and delay in recording births (see section 8.4) from 1996 until 1989, there is little accurate data on pregnancy, birth or abortion data from Romania until the beginning of the 1990s.  From the available data, Table 8.1 below outlines the birth and abortion rates per 1000 women aged 15-19 across three time periods.  This data, especially pre-1990, must however, be viewed with caution as the illegal status of abortion meant that a large proportion of women opted for illegal terminations at that time.  The table also shows the percentage change from the pre to post 1990s at which point abortion became legal, and the change in particular to the abortion rate is exceptionally high.

Table 8.1: Birth and Abortion rates per 1000 women aged 15-19, for selected years.

	1987-1990	1990-1993	1996	Percentage change
Live birth rate	61	49	42	-31%
Induced abortion rate	10	32	32	+220%

Source: Serbanescu 1995; Hosie and Silver 2001.

8.2.2 Abortion ratio

Calculating the abortion ratio for Romania prior to the 1990s is virtually impossible due to the lack of data on numbers of illegal abortions.  In 1994, however, Kane and Wellings (1999) estimated that for every 1000 births to women under 20, there were 898 abortions performed.  Therefore, the more likely outcome of a pregnancy to a women aged under 20 was slightly in favour of a birth rather than an abortion.

8.2.3 STIs and HIV/AIDS

From Table 3d.2 below it is possible to see that the incidence of syphilis amongst young people in Romania in 1996 was 57.5 per 100000 aged 16-19 (which is one of the highest recorded rates for Europe), accounting for 17% of all infections in that age group.  Similarly the incidence of gonorrhoea amongst young people in Romania was considerably higher than many other countries, with a rate of 65.8 per 100000, accounting for a further 22% of all STIs in that age group respectively.Unfortunately data is not available that would break these values by gender.

Data from the WHO/ UNAIDS and EuroHIV appears to suggest that on the whole countries in Central East Europe have, relative to Western and Northern Europe, escaped the HIV/AIDS epidemic.  The HIV epidemic was not noted in Central East European countries until the early 1990s and the principle mode of transmission has been IDU.  The newly diagnosed incidence rate of HIV in 1999 was estimated at 7.3 per million population and the overall AIDS incidence was estimated at 3.5 per million, 8 times lower that Northern and Western Europe (UNAIDS/WHO 2000a; EuroHIV 2000).  Despite the considerably lower incidence rate of HIV, what is particularly devastating about the HIV/AIDS epidemic in Central East Europe is the proportion of HIV/AIDS cases amongst children.  Estimations suggest that 29% of all HIV cases reported between 1997-2000 were amongst children under 13, the majority of which were in Romania, where the cumulative total of HIV cases to children under 13 in 1999 represented 73% of all HIV cases reported.  In 1990, when the reality of Romania's plight was fully recognised after the 1989 revolution, it became apparent that a large proportion of Romanian children had been infected with HIV through multiple injections with non-sterile equipment or blood transfusions (EuroHIV 2000).  Therefore whilst HIV prevalence in the adult population remains relatively low, Romania faces a future in which a large proportion of one single generation will be HIV positive.

Table 8.1: 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, 1995.

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				57.5		u		 u		17		48		65
Gonorrhoea			65.8		u		 u		22		52		74

Source:Panchaud et al,. 2000.

8.2.4 Coital activity

Very few studies have been conducted in Romania on the sexual behaviour of the Romanian population, especially the younger population.  One study which purposively sampled young people from schools in five areas of Romania was, however conducted between 1997-8, which revealed that approximately 25% of adolescents (17-18) and 37% of young people (19-20) had experienced heterosexual intercourse (Alexandrescu and Tuchendria 1999).  This rate of reported sexual activity is considerably lower than most countries in Northern and Western Europe and yet due to the low use of reliable contraception as discussed below, the rates of pregnancy and STIs amongst young people in Romania are considerably higher.

8.2.5 Contraception use

Information from the Alexandrescu and Tuchendria (1999) further revealed that students who were sexually active were no more knowledgeable about contraception than those who were not and 80% of the survey respondents who were sexually active either did not use contraception or relied on withdrawal during intercourse and a high proportion believed totally inaccurate information about the reliability of non-effective methods (rhythm, withdrawal).  Less than 40% believed the contraceptive pill to be an effective method and only 40% were aware that the withdrawal method was not reliable (Alexandrescu and Tuchendria 1999).

8.2.6 Education indicators

Table 8.4 and Figure 8.2 below show the age structure of secondary education in Romania and the stay on rates for ages 16-20 for 1996-1997.  As is discussed in section 8.5, the education system in Romania is still in the early stages of post-Ceausescu development and this is reflected by the relatively low proportion of young people remaining in education beyond 16 during the late 1990s.  The trend however, is for more and more young people in Romania to remain in education post-16, particularly vocational education and this is especially true for young women who now outnumber men in post-16 vocational education by 200% (EC/ Eurydice/ Eurostat 2000; West et al. 1999).

Table 8.4: Age structure of secondary education in Romania 

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)
ROM	11-16	16	16-19/20	4-5

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

Figure 8.2:Participation rates (as a %) in education at different ages, 1996-7

Source: EC/ Eurydice/ Eurostat 2000.

8.3 School-based sex education policy in Romania

Although there is little documentation about school-based sex education in Romania, of what is known, prior to 1980 limited sex education was available in schools, although there was no standardisation of provision across the country.  In the early 1980s Ceausescu's government ordered the removal of sex education from the school curriculum and all forms of contraceptive counselling and education for the whole population were forbidden (Serbanescu et al. 1995).  During Ceausescu's regime the only sex education that young women in Romania received was that "girls were educated to fear men, avoid pleasure, and see sex as a 'necessary evil' accepted only for the sake of establishing a family" (David and Baban 1996:236).  This remained the status-quo until 1989, when Ceausescu's regime was overthrown and one of the first activities of the new government and Ministry of Education was to set up the School's Analytical Programme which allocated 5-6 hours per school year to sex education, however, development has varied greatly across Romania and the vast majority of schools are reported to still have little or no sex education (Alexandrescu and Tuchendria 1999).  Further to this, where schools have attempted to re-introduce sex education into the curriculum, they have often been constrained by a lack of resources, teacher training and resistance by both teachers and parents (Serbanescu et al. 1995).  

8.4 Sexual health policy in Romania

8.4.1 Historical development of sexual health policy

Romania has a very dramatic sexual health policy history, which can only be described as having shifted from one extreme to another, many times (as can be seen from Romania's timeline in Appendix 3).  In 1948 abortion was outlawed and illegal on any grounds, only to be legalised in 1957 and available on request.  This remained the case until Nicolae Ceausescu became president over Romania in 1965 and in 1966 without warning; he ordered that abortion be restricted to women over the age of 45 or who had 4 or more children and modern contraception was to be seriously restricted (David and Baban 1996).  In 1973 a minor change was made to women's access to abortion whereby the age restriction was lowered from 45 to 40 (Hord et al. 1990).  Between 1975 and 1980 the Ceausescu regime had closed the national medical documentation centre, which effectively prevented medial personnel from accessing any up-to-date medical literature; discontinued any advanced training for nurses and any specialised training for doctors including in the fields of obstetrics and gynaecology; and finally in 1980 all contraceptive education and counselling was forbidden (Hord et al.1991).  After 1983, birth rates were no longer published in any official context and in 1986, in order to avoid acknowledging the high proportion of child mortality during the first month of life, a 30-day delay was imposed on the registration of births (David 1992).  In 1984 Ceausescu raised the age restriction for access to abortion first up to 42 and then in 1985 to over 45 as well as raising the number of children one must have before being permitted an abortion to 5 (who all had to be under 18) (Hord et al.1991). 

In 1986 explanation for these various changes became apparent in Ceausescu's speech to the public where he proclaimed, "the foetus is the socialist property of the whole society.  Giving birth is a patriotic duty... Those who refuse to have children are deserters, escaping the law of natural continuity" (Ceausescu 1986 in Hord et al.1991).  This proposed communist ideal was encouraged by continual state intervention in every female's reproductive life.  Employed Women aged 16-45 had to endure a monthly gynaecological exam and if a women chose not to present for an exam she would be denied various rights such as medical and dental care, social security and her pension (David and Baban 1996).  Further to this factories had to achieve a monthly birth quota or the physicians for the factories would not receive full pay (Hord et al.1991).  Special taxes were also applied in a number of situations to encourage maternity for example; individuals who remained single over the age of 25 faced a 10% tax surcharge on their monthly salary and if a married couple did not produce a child within 2 years, they would both have to pay higher taxes (David and Baban 1996). If any medical personnel were found to have carried out an illegal abortion they faced prison sentences of up to 12 years and losing their right to practice medicine (David 1990) and if a women was found to have deliberately induced an abortion, she would face 6 months to 2 years in prison and a financial fine (Hord et al.1991).

By 1985 contraception was completely forbidden and therefore the rhythm method and coitus interruptous had become the predominant methods of contraception.  Some forms of illegal contraception were available on the black market having been smuggled in from Hungary, such as IUDs, contraceptive pills, spermacides and condoms, however, they were expensive, one condom for example would cost a day's wages (Hord et al.1991).

On the 26^th of December 1989 Ceausescu's government was overthrown and a new interim government was formed.  As a sign of how important the state of women's reproductive health was considered to be by the new government, the first ruling of the interim government was to reverse the previous abortion and contraception laws, legalising the availability of both (abortion up to the end of the first trimester) (Hord et al.1991).  By the end of the year the interim government had appointed the National Family Planning Council and the Ministry of Health, and established a section to focus on women and children's health, family planning and the training of medical personnel (Hord et al.1991).  Help was welcomed from organisations such as WHO, United Nations, and the International Planned Parenthood Federation (IPPF) in order to help conduct abortion-related and family planning training (David 1992).

By 1990 the government had established 119 family planning clinics within hospitals and clinics across the country and established the Society for Contraception and Sexuality (SECS) who had the responsibility of informing the public about family planning and modern contraception (David 1992).  In the same year AIDS was recognised for the first time in Romania as it became apparent that a high proportion of Romanian orphans, (approximately 98% of whom had been abandoned by women to scared to have an illegal abortion), had full blown AIDS.  By the end of 1990 93% of cases reported were amongst children under the age of 4 of whom only 3% had contracted HIV perinatally and 75% of whom resided in orphanages (Lakey et al. 1996).  The National Advisory Committee of AIDS was created very quickly to explore avenues for prevention and control and by the end of the year various publications had gone to press including; AIDS magazine; facts/hope; AIDS - a problem for us all; Let's talk about AIDS; What we must know about AIDS; and What's AIDS and HIV-Positive?.  Additionally two programmes were prepared for TV viewing, various articles published in national newspapers and magazines and sex education lectures were organised for high schools (Beldescu 1991), although these have not been reported to have been widely received (Alexandrescu and Tuchendria 1999).

The sexual health focus over the latter half of the 1990s in Romania has been on; educating the public about modern contraception, as abortion is still being used as a method of contraception, due to a lack of knowledge about and trust in modern contraception (Alexandrescu and Tuchendria 1999) and improving medical professionals' training with regard to family planning, as well as encouraging their willingness to promote family planning (Lakey et al. 1996).

8.5 Education policy in Romania

In pre-communist Romania, a secondary education system was developed, based on the French secondary system and Napoleonic model of higher education; the structure being based on the provision of professional schools and a specialist institutions (Sadlak 1993).  After the end of WWII when, geographically, Romania became incorporated into the Soviet-dominated 'communist bloc' and Romanian people faced an era of communist political and ideological reality which in education terms meant a move away from the previous education system in favour of a 'new vision' which encompassed many Soviet educational practices and concepts (Sadlak 1993).  The education system developed rapidly into a uniform and centralized provision aimed at meeting the need of the new socialist economy (Sadlak 1993). 

From the mid-1970s until the overthrow of the Ceausescu's Regime in 1989, the majority of policy and administrative decisions regarding education and in particular science, were made by Ceausescu's wife and her 'cronies', which resulted in a model of education that was 'repressively dogmatic' (Sadlak 1993:79).  Access to advanced or higher education was strictly controlled and correlated to centrally established personnel agendas (Sadlak 1993), and basically young people were encouraged into the socialist workforce rather than encouraged to develop intellectually. 

Since 1989, the Romanian education system has been going through a slow recovery, but the recovery is hampered, particularly in the higher education sector due to a lack of investment (Kukliñski 1993).  Figure 3.4 below, details the current secondary education system in Romania.  From the age of 11 all young people in Romania are expected to attend lower secondary education at the Gimnaziu.  This stage of education ends at the age of 16, which is also the age at which compulsory schooling ends in Romania. At the age of 16 approximately 79% of young people were still in education in 1996/7 (EC/Eurydice/Eurostat 2000).  Young people then have the choice of continuing their education at an upper secondary level either within vocational or general education and either full or part-time.  As is the case in many post-communist countries, a large proportion of young people chose to continue their education within vocational streams.  In Romania, of those who continue at the upper-secondary level in 1996/7, approximately 28% did so at a Liceu (general school) and the remaining 72% did so at a Scoala Profesionalã / Scoala complementarã (vocation school) (EC/Eurydice/Eurostat 2000).   In recent years an increasing number of young people have completed the level of upper secondary in Romania and in 1996/7 more than twice as many young women did so than their male counter-parts (EC/Eurydice/Eurostat 2000). 

Figure 8.3 Secondary education in Romania

11            12            13             14              15                  16                  17                   18                   19                  20
                      Gimnaziu         Lower secondary eeducation	Liceu - upper secondary general education full-time
	Liceu - upper secondary general education part-time
	Scoala Profesionalã - upper secondary vocational education full- time
	Scoala Profesionalã - upper secondary vocational education part-time
	Scoala complementarã - upper secondary vocational education part-time

General secondary education

Vocational secondary education Source: Source: EC/Eurydice/Eurostat, 2000.

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

In relation to this study, whilst Romania has a very high teenage pregnancy rate relative to most of Europe, the second highest incidence of gonorrhoea of the countries explored and an exceptionally high rate of syphilis amongst young people, 'teenage' sexual health has not been highlighted as a 'particular' priority.  This is to say, it is not that it isn't recognised as important, but rather, the effect of Ceausescu's regime has affected the sexual health of the entire population and therefore, first, Romanian authorities have had to redress the serious problems in maternal and child health before focusing specifically on young people.

To explain further, no-one was really aware of the suffering that Romanian people faced as a result of the Ceausescu regime.  It was not until his government was overthrown that disclosures were made about the severe restrictions that had been placed on all Romanian women and their rights to fertility control which have now been reported widely (see Tanner 1989; David 1990, David 1992; Thomas 1990; Hord et al. 1991).  As a result of the abortion and contraception restrictions put in place by Ceausescu, many Romanian women of all ages resorted to illegal abortion if they became pregnant.  Accounts such as the examples in Box 3d.1 below were not uncommon.

Box 8.1 Typical stories of illegal abortion in Romania during the Ceausescu regime

1)"I tried all kinds of manoeuvres. I swallowed quinine, I injected pictocin, I drank coffee and iodine, I ate grated peels from 2kgs of lemons, and every night I used to boil myself in a hot bath while drinking boiled red wine. As the days passed one after another, I became more desperate.  I was already in my fourth month of pregnancy when at last I could find a woman who inserted a catheter into my uterus".

2) "I got rid of my unwanted pregnancy with a catheter.  When I got pregnant for the second time, I did not have the guts to insert the catheter once again because, some months before, a neighbour died, leaving three children alone.  She died from an infection caused by a catheter.  Somebody advised me to hit my bottom against the floor. I fell from the table, striking the floor 50 or 60 times.  After a couple of hours, my bleeding started."

Source: David and Baban 1996:240-241.

As a result, the maternal mortality rate in Romania reached extremely high rates during Ceausescu's regime.  In most westernised countries, where trained professionals are used to perform abortions, the risk of maternal death is generally less than 1 per 100000 abortions, in comparison to 7 maternal deaths per 100000 live births (David 1992).  In Romania, the overal maternal mortality rate rose from 85 per 100000 in 1960 reaching over 170 per 100000 at its peak in 1982 (169 in 1989), which was the highest recorded rate in Europe.  From 1960, until abortion was made illegal in 1966, approximately 30-35% of those deaths were as a result of abortion.  After abortion was made illegal that proportion rocketed to from 35% in 1966 to a height of 88% in 1988 (David 1992).  It has been estimated that of the 5.2 million women in Romania of reproductive age, approximately 20% may be infertile or suffer serious reproductive complications as a result (Hord et al. 1991).

Men also suffered the trauma of abortion, in particular, lasting psychological costs have been noted (David 1992).  The majority of couples would not have sexual relations often because of the fear of pregnancy and when sex took place, it was done so under severe stress (David 1992) and therefore not only were women denied their right to control their fertility but both men and women were denied their right to sexual pleasure.  One final section of the population who suffered greatly as a result of Ceausescu's policies were the many new born babies abandoned at orphanages by women who had been too scared to have an illegal abortion, these orphanages soon became known as 'human warehouses' (David 1992).  It has been estimated that only 2% of orphans in Romania are true orphans and as highlighted before, because of insufficient medical supplies, many of these orphans contracted HIV.

Despite the attempts post-1989 to improve the sexual health of the Romanian population, an understandable distrust in 'government authority' has had the effect that although women are now being told about modern contraception and its value instead of opting for an abortion, there is a great distrust of this information, because it is advice provided by 'government authority'.  Additionally many physicians do not want to give contraception and contraceptive counselling because abortion is more time/cost-beneficial; one abortion could be performed in the amount of time it would take to provide one client with contraceptive counselling (Lakey et al., 1996) and the quicker a woman has an abortion, the quicker she is once again at risk of pregnancy and in turn the sooner she will return to that physician for another abortion.

The 1993 Romanian Reproductive Health Survey (RRHS), explored amongst other things, the planned nature of recent pregnancies, the contraceptive knowledge and practices of women aged 16-44 (Serbanescu et al. 1995).  The study revealed that the concept of family planning was still not well developed in Romania, the proportion of women stating that their recent pregnancy was unwanted rather than planned increased in all age groups and the legislation changes had not had the immediate desired effect on contraceptive practices.  As a result, whilst the total pregnancy rate of women aged 16-44 has steadily risen; the total fertility rate has declined through use of legal abortion as a means of contraception (Serbanescu et al. 1995).  For example for young women aged 16-19, the age specific fertility rate decreased by 20% from 1987-90 (61 per 1000) to 1990-1993 (49 per 1000), but this result did not come through the application of modern contraception, rather a 220% increase in the age specific abortion rate from 10 per 1000 in 1987-1990, to 32 per 1000 in 1990-1993 (Serbanescu et al. 1995).  In fact of all age groups, the greatest increase in abortion was found in the 16-19 age grouping, which shows a great desire amongst young women to delay becoming a parent at that age but without the correct knowledge and trust in modern contraception to prevent the pregnancy in the first place.

The reasons that women of all age groups gave for non-use of modern contraception are shown below and reflect a combination of lack of knowledge, lack of access, personal beliefs, potential medical obstruction and a lack of control within relationships to insist a partner uses a modern method.

1. 70.6% = feared of side effects,

2. 67.3% = their partner preferred traditional methods,

3. 61.1% = had little knowledge of other methods,

4. 38.4% = difficult to obtain,

5. 34.3% = cost,

6. 24.2% = doctor's recommendation,

7. 11.5% = religious beliefs (Serbanescu et al., 1995). 

In addition to the above reasons, despite the high failure rate of traditional methods of contraception, two thirds of traditional-users believed that their methods were either more effective or as effective as the pill or IUD and this belief was not effected by a women's level of education (Serbanescu et al., 1995). 

A more recent study was conducted in 5 high schools within three cities in Romanian in 1997/1998 (response rate 97.5%) to explore young people's sexual knowledge, attitudes and behaviour (Alexandrescu and Tuchendria 1999).  Despite the apparent introduction of sex education into Romanian schools in 1990, this study revealed that although 80% believed condoms to be good protectors against pregnancy, under 40% of the sample believed that the contraceptive pill was an effective method and only 44.8 % knew that the statement of 'withdrawal is a very good method to prevent pregnancy' to be false (Alexandrescu and Tuchendria 1999). 

Therefore, whilst it is clear that there are issues of sexual health concern for young people in Romania, it is also the case for the whole population of reproductive age.  The young people of Romanian have adopted the remains of a legacy of distrust of authority and without sex education which is provided early, before they 'learn' the distrust, the situation will not improve with any great pace.  The Romanian people are a very resilient nation, the have survived a great deal of social and political upheaval and pain and the resorts that women would go to have an illegal abortion to protect themselves and their existing family, shows a great deal of determination.

9 Scottish policy development and teenage sexual health

9.1 Introduction

The purpose of this section is to map and locate the various policy areas within Scotland's social and cultural context.  The section begins with a descriptive account of a range of sexual health indictors relating to young people in Scotland.   Scotland'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 Scotland over the last four decades can be found in a timeline in Appendix 3.

9.2 Overview of sexual health indicators

9.2.1 Pregnancy, birth and abortion rates

As can be seen in Figure 1.8 below, although there has been a small overall increase for both the 13-15 and the 16-19 age groups, the trends are very different between the two age groups in Scotland between 1983 and 1998.  For older teenagers the pregnancy rate peaked at 77.8 per 1000 in 1991, since when the rate steadily declined to 67.6 per 1000 in 1995, although a small rise occurred again from 1995 to 1998 to a rate of 72.4 per 1000, levelling off in 1999 (Hosie 2001).  Therefore although the rate in 1999 is higher than 1983, it has also declined from the peak of 1991.  For women aged 13-15, the trend in teenage pregnancy has been one of a steady increase from 6.2 per 1000 in 1983 to a peak of 9.5 per 1000 in 1996, with a small decline over the two following ears to 8.9 per 1000 in 1998 (Hosie 2001).

Figure 9.1: Pregnancy, birth and abortion rates per 1000 Scottish women aged 13-15 and 16-19, 1983-1998

Source: Hosie 2001; ISD Scotland 2000b.

Looking specifically at the birth and abortion rates for these two age groups, between 1983 and 1998 the live birth rate to Scottish teenagers has changed relatively little overall.  There are, however, some distinct differences in the trends between older and younger teenagers.  As can be seen in Figure 9.1 above, since 1983, the birth rate for 16-19 year olds steadily rose to a peak of 50.4 per 1000 in 1991, since when the trend on the whole has been one of steady decline to 42.6 per 1000 in 1996, with a slight rise to 44.0 per 1000 in 1997 and again in 1998 to 44.3 per 1000 (Hosie 2001).    Amongst 13-15 year olds, the birth rate rose at from 3 per 1000 in 1983 to 4.9 per 1000 in 1997, with a small decline from that peak to 4.4 per 1000 in 1998 (Hosie 2001).    In 1998 of those births to teenagers 93.1% were over the legal age of consent to women aged 16-19.

As can further be seen from Figure 9.1 above, over the same time period there have been similarly differing trends in abortion rates between the two age groups.  For the younger age group the abortion rate rose in line with the birth rate from 3.2 per 1000 in 1983 to 4.8 in 1996, before declining slightly to 4.5 in 1998 and for the older age group the abortion rate rose significantly from 18.3 per 1000 in 1983 to a peak of 29.5 per 1000 in 1998 (Hosie 2001).

9.2.2 Abortion ratio

As has been noted above, the trends for older and younger teenagers differ; this is also the case for abortion ratios.  A 16-19 year old is much more likely to opt for a live birth than a 13-15 year old (was is equally as likely to opt for an abortion as a live birth).  However, amongst 16-19 year olds, as can be deduced from figure 3e.1 above, abortion as a likely outcome of pregnancy is now just over 10% more likely at 40% in 1998, than it was in 1983 (28.7%).

9.2.3 STIs and HIV/AIDS

In Scotland concern has been grown in recent years about the rise in STI rates, in particular amongst young people.  Table 3e.1 below details available information on STIs amongst young people, although as with most of the other countries in this report, this data should be viewed as a minimum estimation.  From the Table it is possible to see that in 1998/9, Scotland had a moderate rate of gonorrhoea of 24.2 per 100000, with very little reported difference between genders and which accounted for 22% of all STIs in that age group in Scotland.  The incidence of chlamydia was also moderate in comparison to Northern Europe, but high in comparison to the rest of Western Europe with a rate of 217.8 per 100000 young people.  The difference between reported incidence between young men and women was a rate approximately 4 times higher for females.  All reported cases amongst 16-19 year olds, account for one quarter of all infections in that age group and when the age grouping is expands to 16-24 year olds, that percentage increases to 61%.

Table 9.1: 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, 1998/9

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			24.2		27.8		24.3		22		23		45
Chlamydia			217.8		354.9		85.7		25		36		61

Source: Panchaud et al., 2000.

9.2.4 Coital activity

Between 1960 and 1990, the proportion of teenagers reporting experience of heterosexual intercourse before turning 16 in Scotland has increased from around 1% to 20% (McIlwaine 1994).  Data from Currie and Todd's (1993) study of Health Behaviours of Scottish School Children, revealed that between one quarter of young men and almost one-third of young women had reported engaging in heterosexual intercourse by age 15-16, in 1992 (Currie and Todd 1993:12).

9.2.5 Contraception use

Although sexually active teenagers in Scotland are now much more likely to use contraception than would have been the case twenty years ago, age has been shown to be a strong determining factor in use of contraception at first intercourse (McIlwaine 1994).  For those aged under 16, no method was reported to have been used at first intercourse by nearly 50% of young women and more than 50% of young men under the age of 16 (see Table 3e.2 below), for over 16s the corresponding figures are 68% of women and 64% of men  (McIlwaine 1994). 

Table 9.2: Contraceptive use by Scottish young men and women at first intercourse (aged 15-16), 1992 

Contraceptive use	Men (%)	Women (%)
Reliable method used	45	52
Non reliable or no method	55	48

Source: Currie and Todd, 1993

9.2.6 Education indicators

Table 9.3 and Figure 9.2 below presents below shows the age structure of secondary education in Scotland and the stay on rates across different school-year groups for 1996-1997. 

Table 9.3: Age structure of secondary education in Scotland

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)
Scotland	12-16	16	16-17/18	1-2

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

Figure 9.2: Participation rates (as a %) in education at different ages, 1996-7

Source: Hosie 2001.

General notes: average age for each year group as follows, 3^rd year = 15, 4^th year = 16, 5^th year = 17 and 6^th year = 18.

9.3 School-based sex education policy in Scotland

9.3.1 Curriculum location and national guidelines

National advice and guidelines regarding the provision of sex education in Scottish schools have gone through a process of great change over the last decade and as recently as the year 2000, further change has been announced.  As this report is concerned with how policy has potentially impacted on the sexual health indictors over the last 2-3 decades, it is important to keep in mind that the recent changes (post-1993) detailed in this report will have had little impact on the sexual health of young people at this point in time.

In Scotland local authorities have the responsibility of the provision of all school education, including sex education (Wight and Scott 1994), although there has never been a legal obligation for schools in Scotland to provide sex education to young people.  The only area that has to be covered by the Scottish Syllabus (national curriculum) is the section on biological reproduction contained with 1^st year Biology (11-13 years of age).  In 1993, the expectations of what sex education should be provided to pupil in Scottish schools changed, as will be discussed below, however, prior to 1993 there were no specific guidelines on the provision of sex education.  Additionally there was no official policy requiring the teaching of HIV and AIDS education, however, as the seriousness of this issue was recognised, the Scottish Office did strong encourage schools to provide some instruction on these issues from the late 1980s (Hosie 2001). 

9.3.2 Time allocations

Prior to 1993, the level of non-curriculum sex education provision in Scottish schools varied considerably.  Wight and Scott (1994) noted that provision would range from 4 to 10 lessons a year with no consistency in approach or content within schools in Eastern Scotland and Hosie (2001) found that provision varied from 2 -10 lessons per year on sex education, which was primarily (with one exception) negative in both tone and content.  The introduction of the 5-14 programme in 1993 meant that schools would be expected to allocate 20% of curriculum time to Environmental Studies.  Whilst sex education as part of a PSE (personal and social education), SE (social education). PSD (personal and social development) or Health education programme would form a part of Environmental Studies, so did Science, History and Geography.  The 5-14 programme only suggested broad time allocations, it did not specify how much for each subject within Environmental Studies and therefore, the amount of time allocated to sex educational aspects could still vary greatly between schools (Hosie 2001).

9.3.3 Teaching environment and teacher training

With regard to the teaching environment, the provision of sex education in Scottish schools has historically been within a mixed-sex arena, as is the case with all education, due to a belief that single-sexed education is perceived as retrogressive (Wight and Scott 1994).  With regard to teacher training, two types of provision existed, pre and in-service training.  Until recent years, the most common form utilised by teachers in Scotland has been in-service training, which could be organised at government, local authority or school level, however, training in sex education has never been perceived as a high priority due to training on the number of changes within core-curriculum subjects taking precedence (Hosie 2001).  Teaching methods in Biology classes would be didactic with use of workbooks, worksheets and sometimes videos.  Within PSE (or alternative) classes, more active teaching methods may be used (Hosie 2001), however, large class sizes would usually mean that traditional methods were more practical.

9.3.4 Content

With regard to the typical content of sex education in Scottish schools, the provision within 1^st year Biology focuses solely on biological reproduction from plants to mammals, including humans.  Some teachers would include more varied topics such as abortion, contraception and STIs, including HIV, but they are not required to do so within official syllabus guidelines (Hosie 2001).  Where schools provided additional non-core curriculum provisions such as within a PSE programme, the content was actually found to be quite consistent (with one exception) in Hosie's (2001) study.  The consistency, however, was to present the negative outcomes of sexual behaviour such as unwanted pregnancy, abortion, STIs and HIV and AIDS, before progressing to discuss prevention and then in some cases relationships.

9.3.5 Use of sexual health experts

Although no official policy exists with regard to utilising sexual health experts within the provision of school-based sex education, schools have been encouraged by their local authorities and the then Scottish Office of Education (SOED) to make use of any additional resources available to them.  In practice, this resource is often limited due to the time constraints of experts and the financial constraints of schools (Hosie 2001).

9.3.6 Policy change post mid-1990s

Since 1993, there have been a number of important changes both in national attitudes towards and guidelines regarding, the need for 'good practice' in sex education provision in schools (Hosie 2001).  The first development was the creation of the 5-14 programme for schools, which effectively provided the first structural guidelines for schools within which to place sex education, as part of the Environmental Studies programme.  A review of this programme towards the end of the 1990s has since recognised that the initial guidelines did not go far enough to highlight the importance of 'Health Education' within the schools curriculum and therefore as of 2001, schools will be encouraged to put in place the revised 5-14 programme, which incorporates Health Education as a subject in its own right, rather than being included within Environmental Studies (Learning and Teaching Scotland: 2000).  The new 5-14 programme now recognises the need to place sex education within a more holistic Health Education programme that explores not just the physical, but also the social and mental health of young people.  The recognition of the important role of self-esteem and the attitudes of respect and responsibility and hence the need to foster these attributes and attitudes is a critical focus of the new Health Education programme.  The programme as a whole (see Learning and Teaching Scotland: 2000) at least at guidance level, appears to have grasped the need to present health and all health-related behaviours from a positive, holistic perspective, rather than being negative in tone and content.  How that translates into practice within schools will remain to be seen.

Other notable developments have been the 3-year pilot study into pre-service teacher training in PSE education, incorporating sex education, which will now be provided as an option for all teachers in training within Scottish institutes of further and higher education (Hosie 2001).  Additionally the pilot sex education project, SHARE, into teacher led sex education has recently been completed and has been evaluated via an RCT in 25 schools in Scotland.  The Scottish Office Education Department is hopeful that positive results from this study can been developed into a package that all schools could potentially utilise in the future  (Hosie 2001).  The Health Education Board for Scotland is also in the process of building a network of trainers who will play key roles in the dissemination of good practice learned from the SHARE programme.

In June 2000, the Working Group of Sex Education in Scottish Schools produced its report on the way forward at levels of government, local authority and schools for the development of the future of sex education in Scottish schools.  Positive aspects of this particular report are the recognition that young people are not a homogenous group, Scotland is a diverse society and in turn, so are the people within it and the need to base sex education on the actual needs of young people is noted (McCabe 2000).  Following the publication of this report, Jack McConnell, Scottish education minister, announced further publication of new materials on sex education on 22 March 2001, including Sex Education in Scottish Schools: Summary of National Advice²⁶.

9.4 Sexual health policy in Scotland

9.4.1 Historical development of sexual health policy

In comparison to many other European countries, British society is generally viewed as having more conservative views with regard to sex and sexuality (Jones et al.1985), however, during the 1960s and 70s Britain was actually a pioneer with regard to developments in sexual health policy (Hosie 2001).   In 1967, the Abortion Law reform Bill entered the statute books, a groundbreaking piece of legislation, which would impact upon the whole of Europe over the decades to follow.  Contraception in many forms has been available in Britain since the early 20^th century but they were not legally sanctioned until 1967.  Under Section 1 of the National Health Service (Family Planning) Act in 1967, a duty was placed on all Scottish Health Authorities to provide contraceptive services to all who requested and then in 1968, FPA (Family Planning Association) policy was changed to allow unmarried women the right to access contraceptive (Hosie 2001).  By 1970, all health clinics in Scotland were legally obliged to provides contraceptive services to all who requested them.

In 1974, family planning clinics previously run by the FPA were taken over and run by the NHS and as a result, local authorities were obliged to provide contraceptive services and contraceptives free of charge.  A Family Planning Circular produced by the Scottish Home and Health Department stated that "family planning services should be available to all who need them and... should be do organised as to avoid any bar to the provision of services to the unmarried" (Bury 1984:37), no mention was made in this or prior documentation about any restriction of the age at which these services could/ could not be provided.  Young people in Scotland can now access sexual health services in a number of locations, the main providers being, their general practice (GP), family planning clinic, specialised youth clinic: provided by their GP, FPC or separate from both, or a Brook advisory centre.  Then in 1983 the additional contraceptive service of emergency contraception was made legally available in Britain as a whole, and was widely advertised by organisations such as Brook²⁷ and the FPA.

Later in 1983 a woman called Mrs. Gillick was to bring about a test case against her health authority for providing contraception to her 16-year-old daughter without her permission, which was to have serious implications for the sexual health of young people in Britain.  The first ruling was made in favour of the rights of young people under 16 to access contraception without parental consent, this was then overturned in 1984, only to finally be overturned again, in favour of young people's rights by the House of Lords in 1985.  Whilst this case technically only affected English law, it has had ramifications for the provision of contraception to young people in Scotland as well.  Following this case the Fraser Guidelines were developed to help advise medical professionals about young people and their health rights, from this developed the 'Gillick competence-test'.  This test is expected to be used by all medical professionals faced with a decision over whether to prescribe contraception to young women under the legal age of consent (16)²⁸. 

In response to the arrival of HIV and AIDS, the lifting of the ban to advertise condoms commercially in 1987 was followed by a large number of government and non-government funded activities which were developed to try and educate the public and prevent the spread of HIV, in particular in 1986 the first large media campaign was launched and ran through till the end of 1987.  This was followed (as can be seen in Scotland's timeline Appendix 3) by almost annual campaigns running through until the end of 1993, however, since 1993 there have been no further national campaigns focusing on HIV and AIDS.

Although concern over teenage pregnancy has been voiced over the last two decades in Britain, there was little direct policy from the British government aimed at responding to this issue until 1992, with the launch of The Health of the Nation (DoH 1992) and its target to reduce the rate of pregnancy to under 16s by 9.4 to 4.8 per 1000 by the year 2000 (from 1989).  Whilst this documentation only pertained to England and Wales, Scotland, not having a policy of its own, also took the lead from this target.  The main sexual health policy development in Britain after this target had been set was an increase in the numbers of places where young people could access sexual health services, mainly though the development of specialised youth clinics.  This development continued for a period of about 5 years from 1992 and coincided with the only noted decline in teenage pregnancy rates over the last two decades (Hadley 1998).

9.4.2 Policy post-devolution

Since the mid-1990s and in particular since Scottish devolution from Westminster took place in 1999, there have been a number of important developments both in policy and government attitudes to teenage sexual health, which are likely to have a direct impact upon the promotion of teenage sexual health in Scotland.  Since the mid-1990s, there has been an increased awareness at the national and local level of the need to base future sexual health provisions for young people on the actual needs and wants of Scottish young people and, that in order to improve young people' sexual health, the focus of any policy needs to be on the more holistic 'sexual health' rather than a narrow focus on reducing teenage pregnancy (Hosie 2001). 

A 1996 Audit of school health services highlighted that the role of the school nurse could be developed beyond its previous 'health-screening' role to that of a primary care resource for young people (PHPU 1996).  In 1999, the Scottish Executive produced the White Paper Towards a Healthier Scotland, and although a key target for young people's sexual health was a reduction in the pregnancy rate of under 16s by 20% by the year 2010, there was also an overall aim to improve young people's sexual health.  Then in March 2000, the Scottish Executive hosted a deliberative seminar with the Health Education Board for Scotland (HEBS), the aim of which was to explore how best to help young people improve their sexual health.  Key findings of this seminar included a recognition that young people's voices must be heard in processes, design, delivery and monitoring of future services for young people (Hosie 2001).

9.5 Education policy in Scotland

The Scottish education system and supportive framework of legislation has always been distinctly separate from the rest of Britain, with a set of Acts applicable only to Scotland.  Local authorities in Scotland are legally obliged to ensure that every pupil of compulsory school age (5-16) is in receipt of adequate and efficient school education provision.  The majority of young people in Scotland will be educated for free at a local authority comprehensive, although a small proportion are provided at cost by Private Independent schools.  Figure 9.3 below sets out the standard secondary education provision in Scottish schools.

Figure 9.3 Education system in Scotland

(11) 12            13            14             15              16              (16)17            (17) 18          post-18
Secondary Comprehensive School Compulsory Lower stage	Secondary Comprehensive School Post-16 upper stage
	Further Education College

Primarily general secondary education, vocational options.

Non-school based post-16 education, vocational and academic options.

Source: Hosie 2001

After completing a stage of primary schooling which starts at the age of 5 (occasionally 4), all young people will enter secondary education (aged 11-12) to complete a further 4-6 years of education.  During the first 2 years of secondary, all pupils will follow a standard programme of education in line with the 5-14 guidelines for education.  When pupils enter the 3^rd year, they will have chosen a range of subjects to focus on and will follow those chosen subjects until the end of the 4^th year.  At the age of 16 pupils can chose to leave the education system or if they chose to remain, they can do so in school for a further 1-2 years to undertake higher level courses (academic and vocational), they can continue their education at a further education college (primarily vocational), or they can take part in youth training which usually involves 1-2 days a week at college training for vocational qualifications.  Historically the qualifications taken at the school level have been examination-orientated and academic.  Prior to the late 1980s, the qualifications available to pupils were the academic exam-based Ordinary ('O') Grades in 4^th year and Higher Grades in 5^th and/or 6^th year, and the option to take Sixth Year studies (CSYS) in the 6^th year.  In 1989-1990, these qualifications changed to Standard Grades (4^th year) and Revised Higher Grades (5/6^th year), some of which incorporated elements of prepared coursework folios as well as examinations.  Additionally at the beginning of the 1990s a system of vocational qualifications was introduced, Scottish Vocational Qualifications (SVQs), if a pupil successfully competed a range of these modular courses, they would be accredited with a 'non-advanced' vocational qualification (national certificate).  For those more inclined to follow a vocational path, a system of vocational qualifications also became available for the upper level of the secondary school, enabling a continuity of vocational study at the school level (as well as FE college) on a wide range of short and modular courses (SCOTVEC modules).  These were the first alternative qualification to academically orientated examinations that had been offered at the school level and their introduction saw the beginning of an increase in the proportion of pupils remaining at school beyond the age of 16 (Hosie 2001).  A further vocational qualification became available in the late 1990s called the General Scottish Vocational Qualification (GSVQ), which is a broad based qualification aimed at those aged 16-19, which can be taken at either school or further education college.

In 1999, further change to assessment and certification of the secondary education system took place, with what appears to be a quite radical change that will affect grades 3-6 of the secondary school.  As of August 1999, all schools have been expected to move from the Revised Higher Grade to a system called Higher-Still, which is a modularised course-work and examination based qualification.  In time 5 levels of Higher-Still are to be implemented, Access (which will be for lower ability academic as well as vocational students - replacing the SCOTVEC modules), Intermediate levels I and 2 (replacing Standard Grades), Higher-Still (replacing RHG) and Advanced Higher (replacing CSYS).  This new system should mean, that instead of leaving school at 16, because of a perceived inability to undertake Higher Grade exams, young people will now have a much greater choice at the upper secondary level, both in academic and vocational courses and may therefore chose to remain in education for at least 2 further years.

In 1996/7, the continuation rate post-16 from 4^th to 5^th year was 60%, with 80% of those pupils then continuing on to 6^th year.  Therefore, the proportion of 6^th year pupils as a percentage of fourth year pupils at 51%, with a further 4% continuing at an FE college, means that a large proportion of young people in Scotland have left education at the age of 16 (Hosie 2001). 

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

According to Hofstede (1998), Britain as a whole is not a culture with strong gender equality, which in turn is less open about sex and sexuality and women have less control over their relationships than men.  This would appear to fit well with the description of Britain as a whole as very conservative in its attitudes towards sex and sexuality (Jones et al. 1986).  When we look to national sexual health surveys in Britain, the first was planned in the height of the AIDS crisis, when it became apparent that very little was known about the sexual behaviour of British people.  The survey was to be run partly by the Health Education Authority in 1989 but was cancelled after the former Conservative prime minister, Margaret Thatcher, overruled the advice of Sir Donald Acheson, her chief medical officer, stating that such a survey would be an invasion of people's privacy.  The study was later completed with Wellcome Trust funds but did not reach the public arena until 1994 (see Wellings et al. 1994; Johnson et al. 1994).

The first national study of young people's sexual behaviour, knowledge and attitudes was conducted as part of Currie and Todd (1993) Health Behaviours of Scottish School Children study (1990), which included data on school children²⁹ (except Strathclyde region).  With regards to the questions asked about behaviour, the study enquired about levels of sexual experience amongst 15-16 year olds including; hugging, kissing on the mouth, light petting (above waist), heavy petting (below waist) and heterosexual intercourse.   The study was then repeated in 1994 and 1998 and the information from these studies was included as part of the HBSC(WHO) studies in 1990, 1994 and 1998 (Ross and Wyatt 2000).  In preparation for the SHARE study into sex education, research was first also conducted on the knowledge, attitudes and behaviour of young people in Scotland, similar to that explored in the school health studies.  This particular research faced many problems of what could and could not be asked of young people about their sexual behaviour.  The original document included the same questions as those noted above, but additional questions were asked of participation in other forms of sexual behaviour such as oral sex, however, for a number of schools, the research team were asked to cover up those questions and one school did not allow any questions to be asked, as it was not deemed appropriate for 14-15 year olds to be asked such explicit questions (Scott 2001).

Although it appears that social attitudes are changing and there is current political determination and commitment aids that process of change by leading by example (e.g. repeal of Section 28³⁰, young people growing up in Scotland have had to try and make sense of the conflicting messages they receive about sex and sexuality and the double standards that prevail with regard to sexual activity. 

"On the one hand, young people are given the message that sex is dirty and not to be spoken about, while, on the other, they are told that sex is everything.  This creates bewilderment in young people.  I would like to see us move towards the way things are in the Netherlands where people are much more open and honest about sex and where adults have come to terms with young people's sexuality" (Redman in Millar 1998:14).

At present the sexual health of young people in Scotland is not as good as it could be.  Teenage pregnancy rates over the last 20 years in Scotland have actually remained relatively unchanged, but, what is noted in comparison with most of Western and Northern Europe, is that the decline of the 1970s witnessed in most countries did not continue through the 1980s and 1990s in Scotland as it did elsewhere.  Since the last national media campaigns on AIDS stopped in 1993 and in turn public condom advertising and awareness went into decline, the rates of STIs amongst Scottish young people have risen and continue to do so (ISD Scotland 2000a).  Whether this is due to increases in testing or actual increases in incidence, either way, the incidences are happening which is a sign that young people have not internalised the 'safer-sex' messages they are given.  What is also of increasing worry is the rising incidence of heterosexual HIV transmission in Scotland and the rising incidence amongst the younger generation (ISD Scotland 2000a).  No-one really knows what the real incidence of HIV is because people do not generally volunteer for testing unless they feel they been placed at risk, but with the rise in STIs, the evidence is there that young people are putting themselves at risk of HIV.  Whilst STIs can cause short-term discomfort and long-term fertility problems, and a pregnancy at a young age may result in early parenthood or an abortion, there remains no cure for AIDS.  Therefore, it is important that the right approach is taken to provide young people with information in terms that they can relate to, as to why 'safer sex' should be important to them and this requires a holistic focus on all aspects of sex and sexuality.

Finally in addition to the role that education policy potentially plays in young people's sexual health in Scotland, in comparison with many of her European counterparts, the proportions of young people remaining in education beyond the age of 16 is very low.  A popular myth first voiced by Margaret Thatcher's Conservative government, is that young people in Britain become pregnant deliberately to get a house and welfare benefits (Selman 2001).  The myth itself is easy to refute when you consider that the majority of teenage pregnancies are unplanned, therefore how could they planned on one hand to gain welfare benefits and yet not planned on the other?  Additionally, if this argument were to hold any weight, one would expect to find higher rates of teenage pregnancy and births to teenagers in countries with higher welfare provisions such as Finland and Sweden, which is not the case. 

Rather than giving credence to this myth, what needs to be considered is what opportunity is available to young people that would make parenting at a young age unattractive and contraceptive efficiency very attractive.  Moore et al. (1995) describe this as the 'opportunity costs' dilemma, whereby, the process by which young women have to decide the perceived benefits of motherhood against the costs of delaying pregnancy.  This, however, suggests intention to become pregnant which is not supported by research (Turner 2000; Selman 2001).  Rather, what Turner (2000) has suggested is, that "the fewer the opportunities that a young woman has, the less motherhood is viewed as problematic" (Turner 2000:309), and that rather than the fewer opportunities being viewed as a reason to conceive, findings of her research suggest that "once pregnant, the reasons for avoiding motherhood [as opposed to abortion] may seem less significant" (Turner 2000:310).  If young people are to be encouraged to avoid parenthood (whether the pregnancy is active or passive) at a young age there first need to be good educational choices and employment prospects available to them if they are to believe in the value of obtaining educational qualifications at school. 

In 1996/7 less than 60% of young people in Scotland remained in education to the age of 18, however, schools have noted that since the changes in certification of school qualifications were introduced and the introduction of GSVQs in particular, more and more people are expressing a desire to remain in school for longer and they also believe that the new system of modular Higher-Still will increase that proportion further (Hosie 2001). 

²⁶ This document can be found at the Learning and Teaching Scotland website -  http://www.ltscotland.com/sexeducation/update.htm  Schools would be expected to use this documentation in conjunction with Scottish Executive Education Department Circular 2/2001 Standards in Scotland 's Schools etc. Act 2000: Conduct of Sex Education in Scottish Schools, the Guidance for Schools and Local Authorities on Effective Consultation with Parents and Carers and A Guide for Parents and Carers.

²⁷ Brook is the national sexual health advisory service for young people in Britain.

²⁸ The test = on being consulted by a young woman under 16 requesting contraception, a doctor must be satisfied that she is mentally capable of comprehending the potential consequences of her sexual activity and if it is in the best interest of the young woman, to provide her with contraception.  If the doctor believes that the answers are positive, then they may provide contraception and advice without parental consent.  If they do not believe the young woman passes 'the 'test', the consultation should still remain confidential even in contraception is not prescribed (Hadley 1998).

²⁹ The term 'children' is used here as that was the terminology used by the authors, it is however questionable as to whether 16 and 16 year olds should be called 'children'.

³⁰ In June 2000, Section 28, which prohibited the 'promotion of homosexuality' by local authorities, was repealed in Scotland.  This is a good example of where Scotland and England have parted company in official opinion.  While the House of Lords in England have twice voted to keep the Clause, Scottish MSPs voted overwhelmingly (99-17) in favour of its repeal.  This was the first major piece of legislation since devolution that differed from Westminster. 

10 Comparative discussion

10.1 Introduction

Drawing on the data presented in the previous section, this section compares the various policy areas and approaches between the five countries.  Noting the importance of the social and cultural context of policy development as well as the need for wider policy approaches to promoting teenage sexual health, the latter half of this section presents a discussion taking each country and its policy approaches as a whole unit of comparison.  The first part of this section, however, presents an analysis of specific policy areas and their potential to positively impact upon young people's sexual health.  In order to explore that impact, a quick comparative overview of some important indicators are presented below.

10.2 Comparative indicator overview

Figure 10.1 below displays an approximated pregnancy rate for a selection of European countries, in order to place the five countries under study within a European context.

Figure 10.1: Approximated pregnancy rates for selected countries per 1000 women aged 15-19 in 1996 (or latest available year)

Sources: Abortion data from ISD Scotland 2001; Singh and Darroch 2000.  Birth data from UN Demographic Yearbooks 1997; ISD Scotland 2001.

General notes

Year for birth and abortion data is 1996 unless noted: 

1998 Birth and Abortion data for Scotland.

1995 Birth data for Bulgaria, Norway and Denmark

1995 Abortion data for England and Wales and Belgium

1992 Birth and Abortion data for the Netherlands

Data for Scotland and the Netherlands - birth and abortion data are for women younger than 20 not just 16-19.

Focusing on the five countries under study, Figure 10.2 below, shows the trend in birth rate, taken as the most reliable indictor of unsafe sexual behaviour.  As can be seen from this figure, Romania stands alone as starting from the highest rate with the most dramatic decline of the time period 1977-1999.  Finland and France are the most similar in trend, both regarding their starting point and pattern of decline over the two decades. Scotland and the Netherlands present a very similar trend of decline in births over the time period, however, the Netherlands started at a rate more than 3 times lower than Scotland and in 1999 this gap remained.

Figure 10.2: Birth rate trend for 5 European countries, 1977-1999.

Source: For data 1977-1995: Hosie 2001. 1999 data: Worldbank 2001

General notes

Rates are the number of live births by age of mother per 1000 corresponding female population.

Rates are computed on female population aged 15-19 with the following exceptions: The Netherlands the age grouping in under 20, in Scotland the age grouping in 13-19.

In the following three parts of this section revisit each policy area in turn, exploring the potential impact that each policy area has had on the sexual health of young people in the five countries explored.  For reference, Table 10.1 below summarises by country, aspects of each policy area, resulting provisions and further indictors for the five countries.

10.3 Sex education policy

The question of how effective school-based sex education is in helping to promote good sexual health practice amongst young people remains a contentious issue.  It has been generally acknowledged that sex education helps to increase knowledge on issues relating to sexual health Goldman and Goldman 1983; Jones et al. 1985, 1986; Bilsen and Visser 1994), however, what remains an issue of debate is the relationship between the acquisition and application of that knowledge (Allen 1987; Thomson 1994; Silver 1998). 

As was presented in Table 4.1 of this report, a range of evidence exists which supports the view that there are a range of factors which when incorporated, make for more effective sex education.  Previous research has shown that the public climate towards sex education is a crucial starting point for effective sex education as this climate will directly affect the level of acceptance of sex education in schools and in turn the level of provision (Vilar 1994).  Of the countries explored, the Netherlands and Finland are the most supportive of pragmatic sex education and in turn present issues of sex and sexuality as 'normalised' aspects of life, which Silver (1998) advocates, underlies the effectiveness of sex education. 

Table10.1: Summery of policy areas and resulting provisions

Sex Education	Finland	France	The Netherlands	Romania pre-1989	Romania post-1989	Scotland
Vilar's access to sex education	9	4	8		1	3
Socio-sexual attitudes	9	4	9	1	3	4
Vilar's Public climate to sex education	9	5	9		1	5
Provision amount	Comprehensive	Limited	Comprehensive	None	Very Limited	Limited
Responsibility for policy development (in order of responsibility)	School, Government Municipality	School	School	None	School	School
Curriculum location	Biology, Health and Family Ed.	Biology	Biology, Social care	None	Biology	Biology, PSE
Teaching environment	Mixed + Single	Mixed	Mixed (some single)	None		Mixed
Teaching Methods	Didatic + Active-learning	Primarily Didactic	Didactic, learning-baed, role playing	Non		Primarily Didactic
Content	Biological, social/ethical Sexual health + positive	Biological, HIV/AIDS +negative	Biological, Social/ethical, sexual health + positive	None	Biological	Biological, HIV/AIDS, limited on relationships +negative
Focus onyoung men specifically	Yes	No	Yes	No		No
Use of sexual health experts	Occasional	Occasional	Common	None	Occasional
Sexual Health
Availability of general public primary care services	Wide Access	Wide access	Wide Access	None	Limited access	Wide access
Availability if youth specific clinics	Being developed	Limited	Well developed	None	None	Well developed
On-site school nurse clinic provision	Universal	None	None	None	None	Very limited
Confidentiality to under 18's	Guaranteed	Guaranteed except abortion	Guaranteed	N/A		Meant to be guaranteed
Cost of contraceptives	Some free/low	Some free/low	Some free/low	Illegal/high	High	Some free/low
Condom Availability	Wide	Wide	Wide	Illegal/Limited	Limited	Wide
Condom advertising on TV	Yes	Yes (1987)	Yes (1969)	No		Yes (1987)
Legal age of consent	16 (14-15 not prosecutable)	16	16 (in practice 12)			16
Reported contraceptive use at 1st intercourse	85%	90%	85%		>30%	45-55%
Estimated average age of 1st intercourse	16	16 (m) 17(f)	17.5			16
Education
Age at end of compulsory schooling	16	15	17 (18)		16-19 (20)	16-17 (18)
Age range of upper secondary	16-19	16-18/19	16-17/18		16-19(20)	16-17(18)
Annual proportion remaining in school poset 16	90%	90%	85%		70%	55%
Access to vocational education at secondary school	High	High	High		High	Being developed, limited

Research has also concluded that sex education which is presented from a positive 'sexual health' perspective rather than focusing solely on teenage pregnancy and other negative outcomes of teenage sexual activity, and which is based on what young people want to knowledge, rather than what adults think they should be told, is more likely to help young people internalise the sexual health messages that they receive (Oakley et al. 1994, 1995; David and Rademakers 1996; Sex Education Forum 1997; HEA 1998).  Again, only sex education in the Netherlands and Finland is provided in such ways, although, it does appear from recent debates that Scottish sex education may be moving more towards this pragmatic and normalised approach (Hosie 2001).

In relation to curriculum location of sex education, research evidence shows that where sex education is provided within a range of curriculum subjects, such as that provided in Finland, and to a lesser extent the Netherlands, can further help to normalise the subject as well as provide a range of differing viewpoints on similar issues and help promote the importance of sex education in relation to other subjects (Silver 1998; Hosie 2001). 

In relation to a suitable teaching environment, research evidence highlights three key elements, which foster the most effective provision, namely; an "open and safe" classroom environment (Silver 1998), aided by the use of both single and mixed-sex arenas; use of active-learning based methods such as role-play and small group discussion (Kirby 1995; Sex Education Forum 1997; HEA 1998) and being taught by staff who are both able and willing (RCOG 1991; Sex Education Forum 1997; HEA 1998).  As can be seen in Table 5.1 above the opportunity for single as well as mixed classes was only available in Finland and the Netherlands and use of active-learning based methods was also more developed in those two countries than elsewhere, although evidence again shows that more Scottish schools are moving in such a direction (Hosie 2001).  In relation to the teacher training in relation to sex education, a surprising finding was that there appeared to be little difference between the training undertaken by teachers in each of the countries (except in Romania where there was none).  Perhaps a key difference was that in Scotland, Biology teachers although providing instruction of human reproductive Biology, did not consider this to be 'sex education'.

Research evidence has also concluded that sex education programmes where; the content that is 'positive' in its presentation of sex and sexuality and goes beyond discussion of human biological reproduction (Oakley et al. 1994, 1995; Sex Education Forum 1997; HEA 1998); which pays particular attention to the needs of young men in relation to sex and sexuality (Winter and Breckenmaker 1991; Hadley 1998; HEA 1998; Meyrick and Swann 1998; Silver 1998; Wood 1998) and which make use of trained sexual health experts in the provision of sex education (Mellanby et al. 1995; Few et al. 1996; Sex Education Forum 1996; Papp 1997; Mayall and Storey 1998), make for more effectively internalised sex education.

In relation to sexual health experts, all countries, (except Romania where there were none), made use to some degree of sexual health experts in the provision of sex education.  In Finland, the Netherlands and France, however, their use was primarily as an added resource in contrast to Scotland, where schools frequently utilised their services to replace teachers (Hosie 2001).  Of particular importance in the current climate of discussion around the potential development role for school nursing, was the use of the, appropriately trained, school nurse in Finland as an additional educational resource as well as an on-site confidential resource for sexual health advice on a one-to-one level.  This facility in Finland highlights the importance that if school nurses are to take on such added responsibilities, it cannot be assumed that they have inherent teaching skills and they must be trained to work specifically with young people.  In relation to the other two factors, again, the Netherlands and Finland were the only two countries to provide the positive presentations and the particular focus on young men's needs that evidence shows to be more effective approaches for sex education. 

As was noted in elsewhere, providing more effective sex education is related to a number of positive outcomes in safer sexual behaviour amongst young people.  Evidence shows that the provision of effective sex education does not increase levels of teenage sexual activity, nor does it encourage early experimentation, in fact, some studies revealed a delay in first intercourse (Baldo et al. 1993; Kirby et al. 1994; Fullerton 1997; NHS CRD 1997; Cheesbrough et al. 1999).  Further to this, evidence concludes that countries with lower teenage pregnancy rates generally have more sex education at the school level (Jones et al. 1985, 1986; David et al. 1990; Baldo et al. 1993) and countries providing easy access to sex education (Vilar 1994), have significantly lower pregnancy rates to teenagers.

In relation to research evidence findings on the range of factors, which culminate to produce more effective sex education, the findings of this report would indicate that the sex education provisions found within Finland and the Netherlands were on the whole, the most effective provision of the five countries studied.  Provision in France and Scotland lagged considerably far behind in almost every aspect of provision and was limited primarily to biological reproduction and warnings about the negative outcomes of teenage sexual activity.  Romania, due to its recent history, has meant that no sex education could be provided until the beginning of the 1990s as law forbade it.  Since this law was removed, attempts have been made to reinstate sex education into the school curriculum, but so far, with little success.

10.4 Sexual health policy

"In order for young people to take responsibility for their sexual health, in addition to adequate knowledge about sex and sexuality, they also require access to advice and contraceptive services to enable them to respond: (Hosie 2001: 356).  Section Two presented research evidence, which illustrated the particular needs of young people when accessing sexual health services, needs which if not met, are barriers to their accessibility and use.

These additional requirements included;

• Geographical ocation of a service and 'visibility' of a service (Zabin et al. 1986; McIlwaine 1994; Clements et al. 1997; Fullerton et al. 1997; Hadley 1998; Cheesbrough et al. 1999; SEU 1999),
• Suitable opening times (Zabin et al. 1986; Clements et al. 1997; Hadley 1998; Turner 2000),
• Confidential services (Jones et al. 1985; Wulf and Lincoln 1985; Jones et al. 1986; Zabin et al. 1986; FPA 1994; Lo et al. 1994; McIlwaine 1994; Dickson et al. 1997; Fullerton 1997; Liinamo et al. 1997: Hadley 1998; SEU 1999; Turner 2000),
• Informal and user-friendly services (Zabin et al. 1986; Peckham 1993; Fullerton 1997; Hadley 1998; SEU 1999),
• Professional attitudes and linguistics (Liinamo et al. 1997; HEA 1998; Aggleton et al. 1999; SEU 1999)
• Services which were inclusive and recognised the needs of young men (Nelson 1997; Hadley 1998; SEU 1999).

Research evidence also shows that young people prefer services that are aimed at young people, exclusively for their use (Peckham 1993; Liinamo et al. 1997; Aggleton et al. 1999; Turner 2000) and located near to or in school and/or youth settings (Zabin et al. 1986; Allen 1991; Peckham 1993; Fullerton et al. 1997; Liinamo et al. 1997).  This report has revealed that with the exception of Romania (where sexual health service provision development since 1990 is still limited), young people in Finland, France, the Netherlands and Scotland can access sexual health services from a range of community locations.  Of those service provisions, however, only the Netherlands had a well-developed system of youth-orientated clinic provision in the community.  This type of service was limited in Finland, France] and Scotland, although developments in this style of provision are growing in both Scotland and Finland.

Although there was limited youth-clinic provision in the wider community in Finland, one service that was available universally and not limited by the geographical location of community youth-clinics, was the school nurse.  In Finland, every school in the country has an on-site school nurse, trained to work specifically with young people. This model is particularly useful for consideration in Scotland for a number of reasons.  First, the school nurse system provides a service that adheres to all aspects of a service that research evidence has shown that young people desire, especially the aspects of confidentiality and lack of visibility to public view; second, due to the geography of Finland, similar to Scotland, having areas of remote and rural population where access to community services is severely limited, the school nurse offers a system of health care for young people which researchers, national government and municipal officers believe has played a key role in the reduction of teenage pregnancy and promotion of young people's health in general, in Finland (Ala-Nikkola 1992; Hemminki 1995; Kosunen 1996; Kosunen and Rimpelä 1996a; Rehnström 1997; Kosunen 2000a, 2000b; Hosie 2001; Väestöliittö 2001); and third, a system of statutory school health provision already exists in Scotland and therefore, although not developed as an on-site facility at present, the framework for developing this style of provision is already in place.

10.5 Education policy

Section Two set out a number relationships that exist between education and teenage sexual health, in particular in relation to teenage pregnancy. This included associations between higher levels of education and;

• Higher levels of sexual knowledge (Kontula and Rimpelä 1988, Turner 2000),
• Higher age of first intercourse (Kane and Wellings 1999),
• More effective contraceptive efficiency (Hoffman 1984; Morrison 1985; Kraft et al. 1991),
• Abortion as the more common outcome of pregnancy (Kane and Wellings 1999)
• A higher age of first birth and smaller number of children over a woman's fertile life course (NHS CRD 1997; Westall 1997; Beets 1999a, 1999b). 

Further illustrated in Section Two was that across a number of European countries relationships exist between a high level of continuation of education or training for those aged sixteen to eighteen and; 

• Significantly lower rates of teenage pregnancy (Jones et al. 1985, 1995; Hosie 2001),
• Significantly higher rates of contraceptive use amongst young people at first intercourse (Morrison 1985; Kraft et al. 1991),
• Significantly higher proportions of abortion to birth as an outcome of pregnancy (Kane and Wellings 1999, Hosie 2001)
• Significantly higher age of first birth (Beets 1999a, 1999b).

Research evidence supports the hypothesis that good educational and employment prospects beyond the compulsory school level are required to provide young people with the motivation required to want continue their education (Simms 1993; Selman and Glendinning 1996; Hadley 1998) and in turn motivate the use of contraceptives, so as to delay pregnancy and parenthood and avoid contracting STIs that could affect their health and in turn their ability to continue their education. 

This research therefore included an exploration of the relationship between educational policy and teenage sexual health.  As could be seen from the individual country studies in Section Three, and Table 5.1 above, the proportions of young people remaining in education post-16 vary greatly between the five countries, with the lowest proportion at approximately 55%, being in Scotland.  This was followed at approximately at 70% in Romania, 85%+ in Finland and the Netherlands and 90%+ in France.  Only in the Netherlands could a higher stay-on rate be attributed in part to the age at which young people are legally permitted to leave school (17 fulltime/ 18 part-time).  In France, which had the highest sty-on rate, the age at which young people could leave school was 15 and in Finland, Romania and Scotland, the age was 16.  This therefore indicates that for the majority of countries, those who remain in education do so voluntarily.  The fact that the continuation is voluntary is significant, because, although "the structuring of an educational provision will play a role in young people's continuation, there must also be a degree of motivation present, for young people to voluntarily undertake something that is not compulsory" (Hosie 2001:366).

Although, the limitations of this study did not allow for a more in-depth exploration as to why this may be the case, data from Hosie's (2001) study revealed that a key difference between the stay-on rates between Finland and Scotland was the level of normalisation of continued education.  This study revealed that in Finland, "young people were expected to, encouraged to and most did continue their education for at least three years after the compulsory level" (Hosie 2001:364) where-as in Scotland, "the only point at which continued education was presented as normalised, was for those young people who had already taken the decision to continue to S5 and S6, the normalised route thereafter being to university or college" (ibid.).  Reasons as to why this continuation in Finland was considered to be normalised was concluded to be the result of a combination of factors including; "the structure of post-sixteen education, the strong emphasis on continued education as a valued commodity during student counselling at the Peruskoulu level and the requirement for young people aged sixteen to twenty-four, who have never been employed since leaving the Peruskoulu, to be applying for a place in continued education in order to obtain welfare benefit" (Hosie 2001:364-5).

One important additional explanatory factor was related to the adequate availability of vocational as well as academic education in school at the post 16 level, preventing the discouragement of young people not wishing or able to pursue more academic work.  In relation to this study, Scotland was the only country where school-level vocational education was notably underdeveloped in comparison to the other four countries.  Although this is an area being actively addressed at the current time in Scotland, the school-level vocational options in the other countries were considerably further developed with separate streams (the Netherlands) and schools (Finland, France and Romania) providing a long tradition of vocational education.  Where the current development in Scotland differs from the other four countries is that rather than developing separate provisions, vocational options are being provided alongside academic subjects, enabling young people to chose separate or combination programmes and teachers in Hosie's (2001) study stated that they were already noting an increased and expressed desire amongst pupils, to remain in school for longer. 

10.6 Comparative discussion by country

Across the five countries explored in this report there exist a wide range of approaches (or lack of them) to the promotion of young people's sexual health.  In some senses, Romania is the easiest to begin with, as it presents a policy picture of what not to do.  The effect of very restrictive sexual health policy, no sex education and encouragement to form part of the socialist workforce rather than develop intellectually until the end of Ceausescu's regime, has produced a nation of young people who: are disillusioned with political authority, have had little educational opportunity, are very uneducated about sex and sexuality, have very limited access to sexual health services and may have suffered irreparable damage to their reproductive health.  Therefore, despite having much lower estimated rates of teenage sexual activity, the rates of teenage pregnancy and STI incidence are considerably higher than most of Europe.  In short, Romania presents a horrific warning as to the effects of restricting people's ability to have control over and look after their reproductive, physical, social and mental health.

Perhaps the most surprising of all cases, is France.  With regard to the rate of births to teenagers, France is to some extent an anomaly.  Despite relatively limited access to school-based sex education or sexual health services designed for young people, a very high proportion of young people report using contraception at first and most recent intercourse (Ross and Wyatt 2000) and the teenage birth rate in France has declined steadily since the mid-1970s, when contraception first became available and its use amongst young people encouraged.   Although condoms are the preferred choice of contraceptive at first intercourse and continued preference for young men, with only 50% of young women continuing to use a barrier method on its own or combined with oral contraceptive use, may mean that although high oral contraceptive use will continue to result in lower rate so teenage pregnancy, young people in France could in the future face increasing risk of contracting both STIs and HIV.

What then motivates young people in France to take on such a high level of contraceptive responsibility and reasons behind their choice of contraceptive are interesting questions.  Potentially the desire to avoid pregnancy could be stronger as a result of; more visible educational and career opportunity if parenthood is avoided at a young age; greater fear of parental reaction to a pregnancy; less social acceptance of parenting at a young age, and in particular the difficulty young women face in obtaining an abortion without parental permission, if they were to become pregnant.  Future research would benefit from exploring these potential links further. 

Both Finland and the Netherlands present countries whose policy reaction towards teenage sexual health has been pragmatic from the outset of increasing rates in the early 1970s.  In Finland's case, all three policy areas developed at the same time and as noted in Section Three, whilst this was not necessarily an intentional joined-up strategy, the result has been that:

"Young people in Finland have been provided with, knowledge about sex and sexuality in a format of sex education that previous research has identified as more likely to be effective, a health service provision that is tailored to young people's expressed needs and wants in a sexual health provision as identified by previous research, and an education system that has actively encouraged voluntary continuation for a very high proportion of young people." (Hosie 2001:267-8). 

The fact that young women can access abortion on the grounds that they are under 17 at the age of conception, presents a message that motherhood under the age of 17 is not advisable.  In addition, there is a strong ethos within schools and society in general that young people should remain in education until the age of at least 19, this is actively encouraged through a benefit system, which provides for those in need (aged 16-24) only if they are actively seeking a place in education.  The universal provision of the school nurse has also meant that all young people in Finland are essentially provided with a primary care facility of their own and encouragement to use this service may have helped remove barriers (real or imagined) in independently accessing health care in general.  Therefore at the stage in life when sexual health services are required, young people are used to taking responsibility for their own health (Kosunen 2000b).  There is, however, little stigma attached to young motherhood, most likely as a result that motherhood under 17 is very rare, the majority of pregnancies at this age end in termination.  For those who continue a pregnancy, moderate benefits are available as regardless of the situation into which a baby is born, the Finnish philosophy is that every child born should have the same opportunity and start in life as the next (NBE official 1998:pc). 

In relation to STIs and HIV, however, as was the case in France, whilst the condom has been the choice of contraceptive for most young people at first intercourse, young women quickly move from reliance of condoms and adopt a more reliable method of contraception, the contraceptive pill (Kosunen 1993, 1996).  Although condoms are available to all young people for sale in a number of venues such as chemists, garages, clubs, pubs etc, the contraceptives that can be provided free of charge³¹ for young women are oral contraceptives, condoms are not available from general health services, unless an individual has a STI (Väestöliittö 1994).  Whilst the high oral contraceptive use may help to explain the decline in pregnancy rate until the mid-1990s, concurrently it may also provide explanation as to the current rates of chlamydia amongst young people in Finland (See Table in 2.2 Section 2).  Of additional concern is that, Finland, until recently had a very low number and rate of HIV incidence, however, since the late 1990s an epidemic amongst IDU has resulted in the number of new cases reported doubling in the space on two years (EuroHIV 2000).  Therefore if condom use is not encouraged in combination with the contraceptive pill, young people in Finland could in the future face increasing risk of both STIs and HIV.

As also noted in Section Three, it appears that Finland's success in the promotion of young people's sexual health may have been halted as a result of cutbacks and changes within the various policy areas explored.  Changes to the education system have resulted in cutbacks in sex education and the most recent school health survey has revealed a significant decrease in young people's knowledge about sex and sexuality (Kosunen et al. 2000).  Changes to the health system have resulted in cutbacks in school health services in particular and school nurses now have less time to devote to one-to-one counselling with pupils.  Concern has already been voiced within STAKES (Hosie 2001; Väestöliittö 2001) as to the visible effects of these changes, and concern grows that a level of complacency has set in over Finland's previous success in improving young people's sexual health, which may be its undoing.

From the mid-1960s there has been a continued focus on improving the sexual health of young people in the Netherlands.  As early as 1969 it was recognised that young people may require a sexual health service of their own, which resulted in the setting up of the Rutgers Institute, which has been a leader in the provision of sexual health services and education ever since.  After contraception became widely available on public health insurance, the birth rate to women under 20 has declined from a high of 17 per 1000 women under 20 (UN 1976) to 5.0 per 1000 in 1999 (Worldbank 2001).  In addition, abortion rates in the Netherlands have always been low and therefore the decrease in birth rate is as a result of pregnancy prevention rather than abortion of a pregnancy.  Since the arrival of HIV and AIDS, awareness campaigns in the Netherlands have continued on almost a yearly basis since 1987.  Recent studies have revealed that whilst these campaigns are not telling anyone anything they did not already know about the prevention of HIV and the need for condom efficiency, the fact that the campaigns are on-going, has acted as a constant reminder (Yzer et al. 2000).  In addition, evaluation of campaigns aimed at young people specifically have shown not only an increase in knowledge and awareness, but also heightened reality of personal risk and the largest behavioural changes have been found amongst those populations at which campaigns have been targeted (de Vroome et al. 1991; de Vroome et al. 1994).  As a result, known rates of STIs amongst young people are low (see Table 2.2, Section 2) and whilst rates of HIV and AIDS incidence in the Netherlands are comparable with most of Western Europe, the proportion of AIDS cases amongst the younger generations (16-19, 20-24) accounts for only 2.4% of all cases throughout the whole population (UNAIDS/WHO 2000b).

The Netherlands presents a picture of the sexual health outcomes that most countries aspire to and yet appear unable to achieve.  What underlies the Dutch success is pragmatism.  Whilst this is widely acknowledged, the level of pragmatism required, has not been replicated as well/ at all in any other country explored in this report.  Being pragmatic about young people's sexual health means that there must be an unequivocal acceptance of teenage sexual behaviour and teenagers' rights to sexual health.  In the Netherlands contraceptive efficiency is the norm, double-Dutch protection is well accepted as a means to pregnancy and STI prevention, and the desire to enjoy life and pursue education without the responsibility of a child at a young age is the social expectation of Dutch youth.  Young people in the Netherlands appear to be regulators of their own behaviour and are willing to adopt one level of responsibility (contraception) in order to prevent the need for another (parenthood).  What has produced this level of collective consciousness and acceptance of behavioural norms amongst Dutch youth, no doubt derives from the history of Dutch society and the resulting collective mentality as a whole, as discussed in Section Three.  However, this does not mean that other countries cannot aspire to a similar situation.  Whilst other countries may not be forced by religion or water to develop such pragmatism, it is important to remember that Dutch society had to adapt from being very conservative and restrictive with regards to beliefs about sexual behaviour, in order to achieve the success it has, in sexual health indicators of its young people. 

In Scotland, during the initial decade after the introduction of contraception and abortion there was a noted decline in teenage birth and overall pregnancy rates, however, since the early 1980s, these rates have changed little overall, simply fluctuating up and down around 45 pregnancies per 1000 women aged 13-19 (ISD Scotland 2000b) over a period of 20 years.  After the arrival of HIV and AIDS, efforts were made to raise awareness via the media and school-based AIDS education, however, the former of which has not been noted since the last media AIDS campaign in 1993 and in turn, since 1994, the rates of STIs and HIV amongst young people have been and continue to rise.

Until the mid-1990s in Scotland, the policy picture was one of; relatively limited access to sex education beyond biological reproduction and a focus on negative outcomes of teenage sexual behaviour; sexual health services that whilst widely available through GPs and FPCs, were not particularly targeted at the needs and requirements of young people; and an education system that did not provide much choice beyond academic exam-based courses at 16 or post-16 level.   From Section Three it is possible to summarise that there has been a lack of a joined-up approach in general in Scottish policy relating to teenage sexual health.  Additionally, elements of each of the policy areas has failed to individually meet the needs of young people by means of knowledge, access to sexual health services and sex education (Hosie 2001).  In addition the compartmentalisation of focus on specific problem issues, such as AIDS in the 1980s and teenage pregnancy in the 1990s, whilst useful from the point of view of resources, is not an effective method of providing a more holistic understanding of sexual health for young people.  Since the mid1990s and in particular since devolution, there appears to have been a shift in both Scottish policy and attitude in general towards teenage sexual health, and in light of revelations from the other countries in this report, Finland and the Netherlands in particular, it does appear that the direction of change in Scotland is to be encouraged.  In particular the focus on teenage sexual health promotion rather than purely on teenage pregnancy prevention appears to be an important step in the direction of being able to start to build policy from an understanding on teenage sexual health needs.   

³¹ The first trial of contraceptive is provided free, the length of time that this trial lasts ranges from three to nine months depending on the Municipality within which the young women is accessing the contraception (Kosunen 2000b).

11 Conclusions and recommendations

11.1 Introduction

Having explored the ways in which five countries with very different social and cultural contexts have approached the issue of teenage sexual health, a number of conclusions and recommendations have been drawn, which are explored in this final section.

11.2 Conclusions and recommendations

One key purpose of undertaking comparative explorations of policy development is to provide policy developers with new ideas, strategies and options.  As Kuronen notes "implicitly or explicitly, the practical and political aim of comparative research, especially in social policy is to find models of policies or provision in one country, to learn from the experience and develop the system in another"(1999: 303).   'Policy borrowing' can, however, be ineffective, most often when a lack of attention is paid to the cultural and social context from which the potential policy solutions are being drawn and for this reason, whilst mapping and locating the various policy developments in each country attention has been paid to such context.  However, equally, the more liberal cultural context of countries such as the Netherlands and Finland should not be used as an excuse to at least try to aspire to their sexual health outcomes for young people.  Social context is an important element of effective policy development and implementation, and therefore it is just as important to develop ways in which to affect social attitude about sex and sexuality, as it is to develop policy to promote it.  This is where social institutions such as government, schools and health services, as well as national media can play an important role in the promotion of young people's sexual health.  In turn policy change could act as a catalyst for cultural change and cultural change for acceptance of policy and policy effectiveness.

However, to effectively promote teenage sexual health, the first step requires an acceptance of teenage sexuality, which is something that until recent years has been notable by its absence in Scotland.  The desire to 'protect children' from sex and sexuality by denying them access to positive promotions of 'good sexual health' within sex education and the media, and instead providing education that is focused only on negative outcomes of sexual behaviour, does more than ill- equip them with required knowledge to be safe and healthy.  It also actively tells young people that they cannot be trusted to make positive choices in their life and in particular regarding their health.  In order to be 'responsible', young people first need to be provided with the tools with which 'to respond' and the knowledge of how to use them, and whilst it does appear from recent policy developments that there is a growing acceptance of acknowledging young people's right to their sexual health in Scotland, it is important that this is not forgotten when sexual health indictors take a while to show the positive effects of change (as they will).  Further to this, public education in particular of parents is important, so as to convey an important message, that by accepting teenage sexual activity this does not mean you are promoting it and that young people will see it as a licence to automatically go out and act on it.  This is no more evident than in the Netherlands, where a pragmatic acceptance for many decades has resulted not only in more liberal and explicit sex education and sexual health services designed for young people but also in better communication between parents and their children about sex and sexuality, an age of sexual initiation of more than a year older than data appears to suggest from Scotland and higher contraceptive use amongst the sexually active. 

The second step requires a continued development of the growing recognition that the focus of any future policy development needs to be on how to help young people to respect and look after their own and others sexual health.  By focusing on single sexual health issue such as teenage pregnancy or HIV or STIs, young people will continue to fail to see the connections between these issues (Selman et al. 2001) and if there is to be any success in attempting to get young people to see the value in Double-Dutch contraceptive efficiency, then a more holistic approach to teenage sexual health is paramount.  Evidence from France and to an even greater extent, the Netherlands, appears to suggest that combining efforts to prevent pregnancy with STI and HIV/AIDS education and repetition of consistent messages, is more effective than any single measure could aim to be.  Additionally, the provision of mixed and single-sex environments for the teaching of sex education in the Netherlands and Finland in particular, is noted for being particularly effective at engaging young men in sex education and promoting the need for respect and responsibility amongst young men.  Although in Scotland, such classes have always been provided in mixed-sex environments, the Working Party on Sex education concluded in its June report (McCabe 2000), that a system of dual-environment provision would be a progressive step forward and it is important that this recommendation be developed.

Thirdly, further consideration needs to be given as to how best to approach the provision of sexual health services to young people, because despite the availability of GP and family planning services throughout Scotland, many young people remain unable to physically access services that they are comfortable with.  In particular for young people living in rural and/ or close-knit communities, services where they are 'visible' to their parents or someone who knows their parents, leaves many with no choice (Scott 2001).  For this reason, and as was suggested within the SNAP report in 1994, the plausibility of a school health service providing an on-site school nurse such as that provided in Finland, should be considered.  Further research on the school health service in Finland because of its universal provision and its applicability to the Scottish system is therefore a strong recommendation to the Scottish Executive.

Fourthly, there must be recognition that not all pregnancies in teenage years are unintended or indeed problematic.  The focus on reducing abortion rates in Finland for example, reflects such acknowledgement and is an important step in portraying to young people that what is being viewed as problematic is not the sexual activity itself, but rather, that abortion reflects a pregnancy that was unintended and subsequently unwanted and therefore should have been prevented.  Whilst there is much concern voiced over the proportions of young women entering motherhood at a relatively young age, not enough focus has been placed on the lack of opportunities for young people in general to have a vision of life as a teenager, such as Dutch young people have, that would be hindered by young parenthood.  The current changes in Scottish course accreditation and course choice at the school level, appears already to be impacting upon young people's desire to remain at school (Hosie 2001), but disaffection from school often begins much earlier than 16 and therefore although potentially in-direct in its impact upon young people's sexual health, encouraging enjoyment of school from an early age is an important part of this puzzle. 

Fifthly, whilst an acceptance of teenage sexual activity and recognition of young people's sexual health rights, needs to underlie any future policy development, what must also be further developed is co-operation between the agencies of health and education at the different levels of policy development and implementation as well as harnessing a positive media involvement.  This is crucial, if an effective joined-up strategy is to be created.  The promotion of young people's sexual health and indeed, the sexual health of the whole population, is everybody's responsibility and whilst different agencies will have differing agendas and opinions on how best to approach the promotion of sexual health, a combination approach will be more effective than any one alone can aim to be

Finally, while at first glance, the exploration of Romania and its policy may seem irrelevant to Scottish policy and culture, its inclusion within this report acts as a solemn reminder of the detrimental effects of restrictive policy.  Whilst it is unthinkable that such a political situation of such extremes could ever arise in Scotland, it is important to acknowledge the horrific outcomes that can occur through the denial of sexual health rights to an entire national, and therefore the potential outcomes if these rights were denied to even one section of a population, such as young people.  In Romania, less young people than in any of the countries explored are sexually active and yet without adequate access to sex education and sexual health services, the rates of pregnancy and STIs continue to remain considerably higher than most of Europe.

Appendix 1 Comparable statistics

Prior to the presentation of statistical data, it is important to first acknowledge the limitations to the data presented:

• It is not possible to present total conception data, as the rate of spontaneous abortion (miscarriage) and stillbirths are often not recorded. 
• Statistical data presented in this report is of a secondary nature and was therefore not created for the purpose of this report.  The data presented is not directly comparable for all countries; however, it is possible to acknowledge the general trends in those rates.
• It is not possible to present an accurate comparative picture of teenage pregnancy rates across Europe, due to the limitations of obtaining like data:
  i)Despite abortion being legal in most European countries, abortion data across European is not complete.  According to David (1992) only 11 countries provide reliable data on abortions with countries such as France, Italy, Germany and Romania providing data, which is either incomplete or inaccurate.
  ii) Pregnancy, live birth and abortion rates are often grouped for comparison. Due to the small numbers of pregnancies under 16 in most countries the most common grouping for teenagers being 16-19.
  iii) In Scotland, due to a significant number of pregnancies under 16, data published on Scottish rates is done so in three groupings namely: 13-16, 16-19 and 13-19.
  iv) With so few pregnancies under 16, some countries, e.g. Finland, include the very small number of those pregnancies within the 16-19-age grouping without including the baseline population data within which those pregnancies occurred.  Whilst others e.g. the Netherlands, will calculate their rates for the under-20s as a whole providing no 16-19 grouping.
• Information on rates of sexual activity and contraceptive use are taken from a number of different national and international studies and is therefore not directly comparable.
• Information on STIs in Europe is very limited, with information on Chlamydia and genital herpes, for example, only becoming available since the 1990s (Panchaud et al. 2000). Due to the 'silent' nature of many STIs, they often go undetected and hence unrecorded.

Comparable terminology

The term 'teenage' is an ambiguous term in any context as it refers to a number of different age groupings, all of which are of concern in relation to STIs, but some of which are of more concern than others in relation to pregnancy and birth.  Throughout this report, reference is commonly made to policy and rates relating to young people, adolescents and teenage. 

For the purpose of this report:

• When referring to the literature, the terminology used will be that of the original author.
• When reference is being made in relation to European trends and rates, unless otherwise noted, the age grouping being referred to is 16-19.
• When reference is made to young people or teenage by the author, unless otherwise noted, the age grouping in 13-19.

Appendix 2 European countries by current type of abortion law

European countries by current type of abortion law

1 On request

2 Rather Broad

3 Rather Strict

4 Very Strict

Norway

 Czech Republic

Finland

Poland

Republic of

Sweden

Slovak Republic

Iceland

Portugal

Ireland

Denmark

Former Yugoslavia

UK (except

Spain

Northern Ireland

Netherlands

  Romania

N. Ireland)

Switzerland

Malta

Belgium

Bulgaria

Luxembourg

Germany

Albania

Hungary

France

Greece

Cyprus

Italy

Turkey

Austria

Former USSR

Source: Ketting 1993.

Definitions for the four categories of abortion laws have been described by Ketting (1993:4) as follows:

• On request: women have a legal right to decide on the termination of pregnancy.  In most cases this right only   applies to the first three months of pregnancy, although there are notable exceptions (like Sweden and the Netherlands).
• Rather broad: abortion is permitted for medical as well as socio-medical or social reasons.  These reasons may include low income, poor housing, young or old age, and having a certain number of children.
• Rather strict: only some narrowly defined circumstances justify performing an abortion.  Specified grounds are often a threat to the woman's physical or mental health, foetal defects and legal indications (rape or incest).
• Very strict: abortion is not allowed on any grounds or only if the pregnancy poses an immediate threat to a woman's life.

Appendix 3 Country time lines

Finnish Time Line

Finnish Time Line³²

 

1944	·         Sex education first introduced into the curriculum of Finnish schools.
1947	·         School Matriculation examination law passed (Asetus Ylioppilastutkinnosta 26.9.1947).
1969	·         Matriculation exam reformed to increase grade scale from 4 to 6.
1970	·         Revised abortion law (previously only available on medical grounds), allowing abortion on social grounds (permission of 2 doctors) and on any women aged under 17 or over 40 at point of conception (permission of 1 doctor).
1971	·         First National study of sexual activity undertaken in Finland. ·         The age of heterosexual consent was legalised at 16, although if both partners are 14-16 it is not prosecutable and if the other party is in a position of authority, the age of consent is 18.
1972	·         Public Health Act (Kansanterveyslaki) 1972, Municipalities obliged to provide sex education, contraceptives and contraceptive counselling, general health counselling and access to abortion when required.  No age limitation.  Obliged to also provide on-site school health services in every school. ·         Development of the comprehensive school (Peruskoulu) system began through reform.
1974	·         Council of State issued new orders to develop a comprehensive school, develop vocational education and allow students who had not undertaken the matriculation exam to go on to higher education.
1976	·         Sex education formally introduced into national curriculum for Finnish schools.
1978    Â	·         Abortion law amendment, all abortions must be performed by the 12th week.
1983	·         Target set to reduce teenager abortion rate by 7% per annum
1985	·         National Board of Education (NBE) produced 1st national curriculum guidelines, on the basis of which municipalities and schools devised their own curriculum.
1986	·         First national AIDS education campaign launched, to coincide with AIDS education programme launched in schools.  Included outdoor advertising, news flashes on TV and radio, newspaper advertising and a video programme that was used in all schools was given national viewing on TV. ·         The first KISS study on young people's sexual behaviour undertaken in Finland.
1987	·         Emergency contraception became legally available. ·         Sexual health magazine Sexteen launched.  Sent annually to all 16 year olds in Finland.  Contains information about sex and sexuality and AIDS. ·         Outdoor AIDS advertising campaign launched, 'AIDS is a deadly souvenir', adverts placed in local and long distance trains, buses, and at airports and harbours. Further news flashes on TV and radio.
1988	·         The second KISS study on young people's sexual behaviour undertaken in Finland.
1990	·         Process of de-centralisation of Finnish Health Care system and Education system began. ·         The First HBSC (WHO) school health study, including questions on young people's sexual behaviour.
1992	·         Second National survey of sexual activity undertaken in Finland. ·         The third KISS study on young people's sexual behaviour undertaken in Finland.
1993	·         Health care funding system de-centralised, responsibility for budget and spending priorities devolved to municipal level.
1994	·         New comprehensive school curriculum launched, changing structure of compulsory and option subjects an in turn level of sex education provision at school level. ·         The second HBSC (WHO) school health study, including questions on young people's sexual behaviour.
1995	·         Cuts in school health service provision noted for 1st time. ·         National school health study piloted.
1996	·         First National School Health Study undertaken, covering 96 municipalities, including information on sexual knowledge, behaviour and attitudes.
1997	·         Launch of Family Planning 2000 programme.
1998	·         2nd National School Health Study, covering 160 municipalities. ·         The third HBSC (WHO) school health study, including questions on young people's sexual behaviour.
1999	·         Third National study of sexual activity undertaken in Finland.
2000	·         Third National School Health Study, covering 180 municipalities.
2001	·         Sexual health magazine Sexteen to be sent to all 16 instead of 16 year olds after expression of need by young people. ·         New comprehensive school curriculum planned, to take effect from 2002, within which the NBE have reported they will most likely re-introduced Health Education as a compulsory subject.

Sources:Ala-Nikkola 1992; Gissler M 1999; Hosie 2001; Kontula & Rimpelä 1988; Kontulaet al. 1992; Kosunen 1993, 1996, 2000a, 2000b; Kosunen and Rimpelä 1996;Kosunen et al. 2000; Liinamo 2000; Liinamo et al, 1997; 2000; Papp 1997;Rimpelä et al. 1996; Sievers et al 1974; Väestöliittö 1994.

French time line

 

1945	·         The heterosexual age of consent was placed at 16 years of age (although sex is not directly illegal before this age).
1959	·         The Berthoin reform extended compulsory schooling by two years from 14 to 16 and created a 2-year observation cycle in secondary education, which all pupils were expected to attend.
1967	·         Contraception became legalised, prior to this the manufacturing, importation and sale of all contraceptives was illegal.
1968	·         Two new qualifications introduced at the upper secondary level of education - the new baccalauréat technologique, to run along side the existing baccalauréat general and the new Brevet d'Etudes Professionnelles (BEP), a broad craft level qualification to complement the traditional Certificate d'Aptitude Professionel (CAP).Â
1971	·         Survey of married women (including contraceptive use and attitudes), first in series on Family and Fertility.
1973	·         The provision of school-based sex education to all young people was introduced into public policy.
1974	·         New law enabled family planning clinics to provide contraceptive treatment as well as advice.
1975	·         The Haby reforms introduced a new upper secondary institution, Lycée Professional (LP), which introduced a vocational institution to complement existing academic and technical Lycées. ·         Abortion became legal.
1976	·         Programme introduced to encourage young people to make use of family planning clinics.
1978	·         Reform of the upper secondary stage of the French education system encouraging integration of the upper level, abolishing all previous tracks through education, instead all pupils must follow a core curriculum in the college of his or her neighbourhood. ·         INED survey, second in Family and Fertility Survey, first to include questions of contraceptive practice and attitudes of all women, including those who were not married.
1981	·         School-based sex education development to include fertility regulation and promote family planning. ·         Large public education campaign, using various mediums of mass media and posters/ billboards etc. to promote message that all citizens had the right to contraceptive advice and contraception.  This included confidential services to young people.
1982	·         The cost of abortion now covered by the social security reimbursement system. ·         Decentralisation law of 2 march 1982 and the legislation completing it altered the balance of power between state and local authorities (region, department and communes), including certain powers over education and training.
1983	·         Vigorous promotion of vocational education as the main alternative to main/ general education began.
1985	·         Sex education introduced into the primary education level curriculum as 'life education'. ·         Introduction of the baccalauréat professionnel (BP).
1986	·         Programme of training adults to be AIDS educators began.
1987	·         APS (association for AIDS prevention) first organisation to carry out peer education activities in AIDS prevention. ·         Law was passed allowing condoms to be advertised. ·         Public health authorities set up a wide spread AIDS information campaign from April - June, including: billboards, handouts, TV and radio spots, 2 major TV programmes, newspaper articles, special features in weekly magazines, telephone hotline, and drug store brochures. ·         Schools were strongly advised by the Ministries of Education and of Health to inform their pupils about HIV and AIDS. ·         The pope visits France and the first anti-abortion group was set up.

 

 

1988	·         Fertility and Family planning survey (FFPS), 3rd in Family and Fertility Series. ·        Creation of a National Fund for Prevention, Education and Health Information.
1989	·         Creation of AFLS, an organisation responsible for co-ordinating, initiating and funding AIDS prevention in France. ·        AIDS awareness mass media general public campaigns began, via media print, audio and visual.
1990	·         The Co-ordination of Associations for the Defence of Abortion and Contraception (CADAC) was set up to raise awareness of pro-choice.
1991	·         Creation of the Committee for Public Health.
1992	·         AIDS and Sexual behaviour study conducted involving those 18 and over. ·         Condom machines first found in metro and train stations. ·         It became illegal to hinder the abortion act.
1993	·         Law introduced encouraging further decentralisation of power to the local level affecting certain aspects of education and training.
1994	·         French school pupils took part in HBSC(WHO) study of health, Including sexual behaviour. ·         INSEE survey, including questions on contraceptive use and attitudes of households - men and women- fourth in FF Series. ·        1994 Report of the High Committee for Public Health on the status of health n France was published, naming HIV, AIDS and STIs as a priority issue.
1997	·         AIDS publicity campaign targeting young people was launched using flyers similar to those used to advertise clubs were distributed in pubs, clubs and record shops.
1998	·         French school pupils took part in HBSC(WHO) study of health,. Including sexual behaviour.

Sources:Bunde-Birouste 1990; Choquet & Manfredi 1992; Gallard 1991, 1994; Kane& Wellings 1999; Toulemon & Leridon 1998; West et al. 1999.

Dutch Time Line

1962	·         Introduction of contraceptive pill on an experimental basis.
1963	·         NVSH (Dutch family planning clinic equivalent) Research and Conference -first time pre-marital sex mentioned in public.
1964	·         The contraceptive pill became available by prescription from family physicians and Emergency contraception became available.
1965	·         Katholiek Nationaal Bureau formed work group on sex education.
1969	·        Seks in Nederland Survey (National sex survey). ·        Rutgers Stichting set up - sexual health service aimed at young people. ·        Public provision of contraception removed from Criminal Law Statute Book and Advertisement ban on contraceptives lifted. ·        Government makes subsidies available for provision of sex education. ·        1911 Wet tegen Zedeloosheid reformed so that contraception could be sold openly.
1970	·         Management of Rutgers Stichting independent from NVSH.
1971	·         The age of heterosexual consent was placed at 16, although between the ages of 12 and 16 a prosecution is only brought about is there is an official complaint, such as exploitation. ·         Induced abortion no longer subject to prosecution, although not technically legal.
	·         Contraceptive pill becomes part of the ziekenfondspakket (services covered by national medical insurance).
1972	·         NVSH starts its first abortion clinic.
1973	·         NVBG becomes Soa-stichting (STI Clinic) and Abortion clinics freely available but still unlawful.
1974	·         Rutgers Stichting commences educational work.
1976	·         Rutgers Stichting 'Egeltjes Aktie' (First safer sex campaign - Hedgehog campaign - hedgehogs do it safely).
1979	·         Fulltime secondary vocational education 2 year modular courses introduced as pilot projects.
1980	·         'Yuzpe method' of emergency contraception introduced.
1981	·         Seks in Nederland Survey (National sex survey).
1985	·         Modularisation of apprenticeship system introduced, ·         Primary education structure changes from 6 years of primary starting at age 6, to 7 years of primary starting at age 5. ·         Induced abortion made fully legal.
1987	·         Rutgers Stichting campaign 'sex-starters' aimed at young people (especially hard-to-reach young people), focusing on communicational aspects of intimate matters, sexual behaviour and contraception. ·         First national AIDS related - safer sex campaign - De condomcampagne. ·         Dutch Health Education Centre (DHEC) began a project to implement AIDS education in all secondary schools.
1988	·         Two small sexual health brochures (one for young men, one for young women) were developed called 'what I would like to tell you', focusing on communication over safer sex. ·         COC (Dutch organisation for homosexuals) produced a small sexual health brochure aimed at young homosexual men. ·         Repeat of Rutgers Stichting campaign 'sex-starters' aimed at young people. ·         AIDS and Youth information campaign, safer sex on holiday campaign, AIDS and the workplace information campaign.
1989	·         'Excuses campaign' - (confronting excuses often used by young people).
1990	·         Jeugd en Seks (first national survey on young people and sexual health). ·         DHEC organised a competition for young people to design a poster, poem or story about 'Love in the era of AIDS' ·         2 international workshops organised about AIDS education for young people, International union of Health Educators (Mass media and AIDS education) and WHO and World assembly of Youth (AIDS education and peer education).Â
1991	·         Cupido campaign - 1992.
1992	·         'Living together' Campaign - to promote tolerance and understanding.
1993	·         Changes to the organisation of vocational content and attainment targets and increased modularisation of secondary vocational education. ·         Fulltime senior secondary vocational education (MBO) and apprenticeship system integrated - development of single framework for vocational education and training. ·         Sex education officially incorporated into national school curriculum. ·         'Ik vrij veilig of ik vrij niet' campagne - 1994 (I have safer sex or no sex campaign).
1995	·         Jeugd en Seks (second national survey on young people and sexual health). ·         'Doe je iets aan?' campagne (Are you going to do something about it? Campaign).
1996	·         Veilig vrijen, soa en chlamydia-campagne -1997 (Safer sex, STI and Chlamydia campaign).
1997	·         Soa zijn overal verkrijgbaar campagne (STIs are everywhere campaign).
1999	·         Curriculum reforms being implemented over pupils school choice and the introduction of more coherent programmes for HAVO (2-year general secondary leading to higher education) and VWO (3-year general secondary education leading to university).

Sources: van Bilsen & Visser1993: Braeken 1994; Braeken & Reinders 1991; Brugman et al. 1995; DeBruijn& Howieson  1995; Clark & Searle1994; David & Rademakers 1996; Doppenberg 1993; Glassier et al. 1996;Hofstede 1994, 1998; Ketting 1983; Ketting & Schnabel 1980; Rademakers1991; Röling 1993; Sheldon 1997, 1998; Silver 1998; 1999; 2001:pc;  Visser & Bilsen 1994.

Romanian Time Line

 

Pre-WWII	·         Pre-communist Romanian secondary and higher education, modelled on the French system and Napoleonic model of higher education, with the structure based on professional schools and specialist institutions.
1948	·         Abortion outlawed. ·         Reform was brought to the education system in order to unify and centralise a system that would support the 'new socialist economy and social order'.
1957	·         Abortion available on request.
1965	·         Nicolae Ceausescu became president over Romania.
1966	·         On 1st October 1966 without prior warning abortion was restricted to women over 45 or who had 4 or more children. Modern contraceptives and induced abortion were only permitted on extremely limited social and medical reasons.
1973	·         Age restriction for abortion was lowered to 40 or over.
1975	·         Ceausescu regime closed the national medical documentation centre, preventing medical personnel from accessing up-to-date medical literature. ·         From the mid-1970s the majority of policy and administrative decisions regarding education and science were made by Ceausescu's wife and colleagues.Â
1978	·         Ceausescu regime discontinued advanced training for nurses.
1980	·         Early 1980s - sex education removed from school curriculum + contraceptive counselling forbidden. ·         Contraceptive education and counselling was forbidden.
1981	·         Ceausescu regime special training for doctors including obstetrics and gynaecology.
1984	·         Age restriction for abortion raised to 42 or over.
1985	·         Access to abortion and modern contraceptives, even further restricted.  Abortion restricted to those over 45 or to women with 5 or more children, all under the age of 18 .
1989	·         Ceausescu's communist dictatorship ended in December 1989. ·         26th December 1989 - abortion and contraception were legalised as a result of public pressure on interim government. ·         National Family Planning Council appointed. ·         The School's Analytical Programme set up by the Ministry of Education, allocated 5-6 hours per school year to sex education. ·         Ministry of Health established a division to focus on women's and children's health, medical training, and family planning.
1990	·         By August, the government had designated 119 family planning centres in hospitals and clinics throughout the country to provide clinical family planning services. ·         Society for Contraception and Sexuality (SECS) established - responsible for informing the public about modern contraception and family planning. ·         AIDS officially recognised as a problem in Romania from January 1990. ·         National Advisory Committee on AIDS developed prevention and control strategy for HIV and AIDS. ·         The following booklets were prepared for publication: AIDS magazine, facts/hope; AIDS - a problem for all; Lets' talk about AIDS; What we must know about AIDS; What's AIDS and HIV-positive and AIDS. ·         Two short movies about AIDS prepared for TV. ·         Articles published in national newspapers and magazines. ·         Sex education lectures were organised in high schools which were followed by discussions about safer sex.
1993	·         RRHS national household survey of women aged 16-44 on reproductive health issues; it was the first nationwide probability survey of reproductive health since 1978.
1997-8	·         School Study on sexual health knowledge and behaviour.

Sources: Alexandrescu &Tuchendria 1999; Beldescu 1991; David 1990, 1992; David & Baban 1996;Frejka 1983; Henshaw & Morrow 1990; Hord et al. 1991; Ketting 1983;Kukliñski 1993; Lakey et al. 1996; Sadlak 1993; Serbanescu et al. 1995 ; Tanner1995; Thomas 1990.

Scottish Time Line

 

1967	·         Abortion Act (Scotland) 1967 (effect from 27th April 1968),  National Health Service (Family Planning) Act in 1967.
1968	·         Voluntary organisations (e.g. FPA) receive government funding to train and resource teachers. ·         Change in FPA policy to allow unmarried women access to contraception. ·         Careers guidance provided in Scottish schools.
1970	·         All health clinics duty bound to provide contraceptive services to all women.
1973	·         National Health Service (Reorganisation) Act 1973.
1974	·         Family Planning Circular issued by the Scottish Home and Health Department, NHS took over Family planning clinics run by the FPA. ·         Local Health Authorities took on responsibly to provide contraceptive services and contraception free of charge. ·         Curriculum Paper 14 in Scotland - considered the role of school and parents should be complementary in sex education.
1976	·         Sexual Offence (Scotland) Act 1976 - the age of heterosexual consent was placed at 16 and whether consent has been given or not, a girl under the age of 13 cannot by law consent to sexual intercourse.
1977	·         National Health Services Act 1977.
1979	·         Conservative Government (Thatcher) comes into power.
1980	·         Revised version of 1974 DHSS Guidance on Family Planning Services.
1983	·         Emergency contraception available in Britain. ·         Gillick ruling lost (England and Wales).
1984	·         Gillick ruling overturned.
1985	·         Gillick ruling lost (House of Lords), followed by the introduction of The Fraser guidelines - 'Gillick competence test'.
1986	·         First govt. TV campaign 'AIDS week' - 1987. ·         Local Government Act 1986 Section 2A - prohibited the promotion of homosexuality in schools.
1988	·         'No-catch' - AIDS campaign.
1989	·         'stay' & 'disco' (TV) women's campaign, holiday campaign, Experts campaign (AIDS). ·         UN Convention on the Rights of the Child 1989. ·         Margaret Thatcher refused to allow government to fund national survey on sexual behaviour.
1990	·         The Health Education Board for Scotland Order 1990. ·         Media campaigns launched - Inhibitions campaign, Personal Testimony 1 - 1991, Condom Normalisation 1 - 1991. ·         Human Fertilisation & Embryology Act 1990. ·         Scotland took the lead in developing the concept of 'The Healthy Promoting School'. ·         Introduction of accreditation of group awards of certain combinations of vocational modules - SVQs. ·         Introduction of Standard Grade examinations to replace 'Ordinary' and 'Revised' Higher Grades to replace the Traditional.
1991	·         Media campaigns launched - Personal Testimony 2 & 3 - 1992, Condom Normalisation 2 & 3 - 1992. ·         Age of Legal Capacity (Scotland) Act 1991.
1992	·         Further and Higher Education (Scotland) Act 1992. ·         Introduction of General Scottish Vocation Qualifications - GSVQs into schools and colleges from September 1992. ·         Media campaigns launched - Personal Testimony 4, Condom Normalisation 4 & 5 Young people's press campaign - 1993. ·         Health of the Nation - A Strategy for Health in England - first target set to reduce teenage pregnancy in England and Wales.
1993	·         Launch of the SOED 5-14 Programme. ·         Holiday travel campaign, lessons 68, have a good journey. ·         Scottish School Health Study covering young people's sexual attitudes, knowledge and behaviour.
1994	·         Welcome Trust National Survey of Sexual Attitudes and Lifestyles (Wellings et al 1994). ·         Staff development resource for teachers published - 'Personal Relationships and Developing Sexuality'.
1995	·         Children's (Scotland) Act 1995.
1996	·         Education (Scotland) Act 1996. ·         HM Inspectors' report 'Issues in Health Education' identified areas of good practice in sex education.
1997	·         Referendums (Scotland and Wales) Act 1997. ·         The Education (Fees and Awards) (Scotland) Regulations 1997.
1998	·         The Scotland Act 1998 - Section 1 ?There shall be a Scottish Parliament?. ·         The Human Rights Act 1998 (UK). ·         Scottish School Health Study covering young people's sexual attitudes, knowledge and behaviour.
1999	·         Scottish devolution from Westminster, Scottish parliament elected May 6th 1999,with full legislative powers - July1st 1999. ·         Towards a Healthier Scotland - A White Paper on Health (Scotland). ·         Standardised pre-service sex education teacher training introduced in Scottish institutions of further and higher education. ·         SEU Teenage Pregnancy Report.
2000	·         Deliberative seminar on Teenage Sexual Health: Edinburgh (HEBS/Scottish Executive). ·         Local Government Act 1986 (Section 2A) - Repeal of Section 28 regarding the 'promotion of Homosexuality' in schools. ·         Standards in Scotland's Schools etc. Act 2000, Education and Training (Scotland) Act 2000. ·         Introduction of Higher Still programme of examination in Scottish schools. 5 levels being phased in to replace the previous Standard Grade, Revised Higher and Sixth Year Studies examinations. ·         Ethical Standards in Public Life etc. (Scotland) Act 2000. ·         Working Group on Sex Education in Scottish Schools established February, report published June 2000. ·         Completion of SHARE programme (teacher-led sex education) trials in Scottish schools. ·         Higher Still PSE provision introduced and Health Education became part of the 5-14 curriculum as a subject on its own.

Sources:Burtney 2000a; Glassier et al. 1996; Hadley 1998; Hosie 2001; Learning andTeaching Scotland 2000;  McCabe 2000;PHPU 1996; Wight & Scott 1994.

 

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