Response to the Department of Health

Developing a Sexual Health Strategy

November 1999

1. SPUC'S Approach

2. Responses to specific questions in the consultation paper

Annex 1. Reliability of published research into sex education programmes

Annex 2. Physical and psycological effects of abortion

1. SPUC'S Approach

The Society for the Protection of Unborn Children (SPUC) is an independent lobby, education, research and advocacy group, with some 45,000 members of various social, religious and professional backgrounds, committed to promoting the value of human life, particularly the life and welfare of children before birth. We are also committed to promoting the welfare of mothers during pregnancy and after birth.

Our educational and welfare activities include helping expectant mothers avoid abortion, and promoting awareness (particularly among adolescents) of human development before birth and of the needs of expectant mothers and their unborn children. British Victims of Abortion, a counselling and support group affiliated to the SPUC Educational Research Trust, serves those seeking help in coping with the emotional and psychological aftermath of an abortion.

It falls within our remit to evaluate social policy and educational programmes relating to sexual activity insofar as the following considerations apply:

the welfare of unborn children, encompassing the unborn child's right to life and to appropriate social respect and legal protection;
the health and welfare of mothers during pregnancy and after birth, and of women and girls facing the prospect of pregnancy;
the rights and responsibilities of parents where the girl who is or who may become pregnant is a minor., particularly where she is under the age of consent to sexual intercourse.

The Society will be happy to provide on request any additional documentation for any of the data discussed in this submission.

2. Responses to specific questions in the consultation paper

A. The Overall Project

We are developing a national integrated sexual health strategy, which will incorporate the key messages of thge HIV/AIDS Strategy and the Social Exclusion Unit's Report into Teenage Pregnancy. In England and Wales conception rates for teenager [sic] have risen to nearly 90,000 a year. In addition sexually transmitted infections are rising in most age groups.

1. What do you think should be the key priorities of the sexual health strategy?

Our principal concern in addressing any public policy is its actual or likely impact on unborn children and expectant mothers, as well as on those who face the prospect of becoming pregnant.

We submit that the fact that this consultation is being held indicates that current approaches are considered inadequate. We further submit that current approaches are, indeed, fundamentally flawed and demand to be radically reconsidered in the interests of all who are affected.

We propose the following principles which should apply in health policy-making:

The promotion of induced abortion must be excluded from the strategy.
No measures should be taken to make "post-coital" birth control measures more easily available.
The rights and responsibilities of parents must be guaranteed in the treatment of under-16s.
An objective, clinically-based (not ideologically-based) approach to "health" should be adopted.

1. The promotion of induced abortion must be excluded from the strategy.

Our fundamental objection to abortion is based on the injustice of deliberately killing the unborn child. The child in the womb is demonstrably a member of the human family (homo sapiens) and cannot justly be denied the natural right to life, which religious, ethical and legal traditions worldwide recognise as the most basic, inalienable right of an innocent human being.

SPUC is strongly critical of the Social Exclusion Unit's Report Teenage Pregnancy for its presentation of induced abortion as a course of action comparable to adoption or keeping the baby. We object to this approach on legal as well as ethical grounds. The implication that the decisive factor in an abortion is the expectant mother's request corresponds to nothing in law. Current legislation treats induced abortion as a serious criminal offence unless the grounds in the Abortion Act 1967 are met. We submit that the Social Exclusion Unit's Report reflects the fact that the Department of Health has failed to enforce the restrictions in the Act which it is responsible for implementing.

The Social Exclusion Unit's approach also reflects the promotion, widespread today, of the notion of "choice" as an extension of personal liberty. In some contexts this view of choice, or "autonomy", is correct.. However, in some ethical contexts the notion has arisen that all choices are morally equivalent, or that the "right" choice is merely what the individual wants to do. Yet responsible decision-making must be informed by an understanding that some choices are legitimate while others are not, when measured against basic principles such as respect for human life, and not merely judged on the basis of what is legal.

On the one hand, abortion is promoted as a matter of personal choice. On the other hand, it is defended as a "necessary evil". Can opposition to abortion take into account the significance of choice? In our view, it can. The expectant mother's capacity to make a moral choice should be exercised in a way consistent with her own dignity and with the child's basic right to life.

These two values, the mother's dignity and the rights of the child, are not in conflict. Indeed, they cannot adequately be served in isolation from each other.

What is more, in our experience, expectant mothers are often motivated to contemplate abortion by pressures generated by others, rather than their own free choice. In particular, many adolescents, especially those under sixteen, are vulnerable to such pressures. Our point is not that abortion is unobjectionable in the absence of pressure, but that the harm done is compounded by the effective denial of choices in which the welfare of both the mother and the child can be protected.

The promotion of adoption is less likely than the promotion of abortion to give rise to coercion, given the commitment to supporting the birth mother and safeguarding the welfare of the child which is incumbent on those involved in the adoption process. Adolescent expectant mothers should not be discouraged from contemplating adoption if they choose to consider it as a means of providing for their baby's welfare. We are aware of the evidence of the benefits for children of early placement for adoption as opposed to the disadvantages of remaining in care homes or with a succession of foster parents. (Morgan, P, Adoption and the Care of Children, Institute of Economic Affairs, London 1998) Policy-makers should examine this evidence and decide what measures are necessary to ensure the early placement of children who are to be adopted.

2. No measures should be taken to make "post-coital" birth control measures more easily available.

"Post-coital" birth control is intended to cause embryo loss by preventing successful implantation.

While it is not SPUC's policy to comment on the principle of contraception (i.e. measures to avoid conception by preventing the union of sperm and ovum), the Society opposes those hormonal methods of birth control which have the potential to kill embryos. This applies principally (though not exclusively) to "post-coital" methods. We submit that the promotion of the "morning-after pill" as a means of reducing abortions is a deplorable strategy enabling abortion providers to avoid even the minimal constraints of the Abortion Act.

Furthermore, the following considerations should carry weight with health policy-makers:

Although there has been some decline in the number of abortion operations nationwide in some recent years, the massive promotion of "post-coital" birth control has not led to a substantial decrease in the number of operations to induce abortion.
There are contraindications to the use of "post-coital" pills (for example, if the woman has a high risk of thrombosis), and side-effects (the most common of which is vomiting). These pills are high doses of current formulations of regular birth control pills, and from a clinical point of view it is objectionable for such powerful hormonal drugs to be supplied by practitioners other than the woman's own doctor since this increases the chances of her being given an inappropriate prescription.
Furthermore, there is no justification whatsoever for adding "post-coital" pill provision to the workload of already overworked Accident and Emergency Departments. Even if there were no objection in principle to the "post-coital" pill, it would still be objectionable to impose this task on A & E Departments when there are 72 hours after intercourse in which the pill can be taken.
The signal which the promotion of "post-coital" birth control sends to young people is that there is a "quick fix" to the problem of possible pregnancy. This is likely to lead to more inappropriate sexual activity, leaving young girls more vulnerable to pressure and exploitation, while encouraging irresponsibility on the part of those who may have made them pregnant.

Rather than wider availability or even deregulation of the pill, there should if anything be more safeguards while it continues to be used.

While the current availability of pre-implantation abortifacients persists, there can surely be no justification for providers failing to explain its action frankly to potential users.The misleading promotion of the morning-after pill as "contraception" is liable to result in women and girls taking it who do not agree with abortion but are under the impression that the pill acts only as a contraceptive.

3. The rights and responsibilities of parents must be guaranteed in the treatment of under-16s.

The practice of bypassing parental involvement in the provision of birth control to underage adolescents serves to undermine the protection which the legal age of consent is intended to give.

This practice, in fact, serves to facilitate sexual intercourse - with the possibility of pregnancy - in circumstances where the unborn child is particularly vulnerable, given the pressures which are liable to be exerted on the young expectant mother to undergo abortion.

Promoting contraceptive use has not substantially reduced the trend in adolescent pregnancy, and taking into account user failure in addition to method failure, it cannot be expected to do so.

Mellanby et al (BMJ, vol. 311, 12 August 1995) recognise that:

Neither specific teaching about contraception nor improving the contraceptive service consistently increase effective contraceptive use by teenagers. (p.414)

(Please see Annex 1 for a detailed discussion of this and other studies.)

SPUC criticised the consultation paper "Teenage Parenthood" by the Social Exclusion Unit for referring to conception rates solely in relation to recent years. It is necessary to look further back. Whereas the annual conception rate among girls under 16 in England and Wales remained at around 0.8 per thousand from 1945 to 1956 (Russell, Early Teenage Pregnancy, Churchill Livingstone, 1982), OPCS figures published in 1969 showed that the rate had risen to 6.8 per thousand. It had risen to around 8 per thousand by 1998.

Evidently, the substantial increase in unmarried adolescent pregnancies was attendant on the "sexual revolution" of the 1960s, the effects of which persist to a large extent in terms of sexual behaviour, family breakdown and abortion. It is only to be expected that both the short and long term effects of major changes in social attitudes are more marked than the effects of any social strategies which fail to pose a radical challenge to the prevalent ethos. Moreover, strategies which accept the assumptions of a sexually permissive ethos may also, as analysis of trends suggests, aggravate the problem.

The Social Exclusion Unit's consultation paper "Teenage Parenthod" claimed, misleadingly, that:

The Gillick judgement allows doctors to provide confidential services to young women under 16 if the doctor believes the young person has sufficient understanding and maturity.

The House of Lords' ruling in Gillick also included the stipulation that the doctor could proceed without informing the parents only if the girl could not be persuaded to involve them. It is deplorable enough that on the basis of the Gillick case the protection which the legal age of consent was intended to give has been undermined. There is surely no excuse for the stipulations of the judgment being minimised or ignored by policy-makers or birth control providers.

It should be noted that in 1985, when the Appeal Court ruling in the Gillick case was in force, requiring doctors to inform parents that their underage children were receiving contraception, attendance of girls under 16 at birth control clinics in England decreased from 49 to 33 per thousand, and underage conceptions did not rise (cf Family Planning Clinic Services, Summary Information from form KT31, Department of Health, various years).

4. An objective, clinically-based (not ideologically-based) approach to "health" should be adopted.

Fertility is not a disease. Drugs and devices prescribed for contraceptive reasons are therefore "elective" rather than "therapeutic" (curative) treatments, nor can they be considered preventive medicine in the strict sense.

Any offer of treatment should aim to serve the patient's best interests, to which the value of life and of health are integral. Broader considerations may also be taken into account, such the patient's ability to fulfil family and religious goals. Nevertheless, a doctor's approach to restoring, preserving and promoting health should be characterised by its essentially medical basis.

We deplore the fact that this principle has been undermined by the World Health Organisation's definition of "health" as "a state of complete physical, mental and social well-being". This definition has become a charter for approaches to health which have little or no reference to clinical considerations. The WHO's Technical Definitions and Commentary for the International Conference on Population and Development (Cairo, 1994) offer the following attempts to define "sexual health":Sexual health:
Either:

Aims at the enhancement of life and personal relations. (Source: Adapted from ICPD Programme of Action, para 7.2)

or:

Means that people should be able to have a safe and satisfying sex life including a healthy psycho-sexual development, in equal, responsible and mutually respectful relationships.

Apart from one reference to "healthy psycho-sexual development" - an ambiguous term open to sharply opposing interpretations! - the context here is not medical. Those who composed the definitions appear keen to promote their views on the pursuit of sexual activity without reference to key ethical, social or religious frameworks such as marriage and the family. For them to use the promotion of health to do this is highly questionable. We do not argue that the practice of medicine can, or should be, "value-free". SPUC unashamedly aligns its approach to medical ethics with the Hippocratic tradition, as, in general, healthcare professions worldwide were proud to do until the lamentable decline of recent decades. What we do contend is that health professionals and policy-makers should look objectively at whether the radical ideological shift exemplified by the UN/WHO approach has led to improvements in patients' health, particularly in terms of the consequences of permissive sexual behaviour facilitated by health professionals.

From being regarded as a vocation in which ethical and clinical considerations are paramount, medicine has increasingly come to be treated as a mere instrument of patients' demands, even for elective treatments which may not be in their best interests.

While doctors may reasonably undertake some elective treatments provided that these are compatible with the patient's best interests (e.g. cosmetic surgery to remedy a physical defect which causes distress), the prescription of drugs to address a social problem (such as unmarried adolescent sexual activity) is at least highly questionable. Certainly, the potential adverse side-effects of hormonal birth control methods, including remote risk of death, must weigh heavily in the balance even though statistically low, given that these are elective, not therapeutic treatments.

We are aware of the medical evidence on the risks associated with hormonal birth control methods; we would urge the Department of Health to examine the evidence and consider whether, in that light, current policies and guidelines need be to revised.

These observations on the side-effects of elective treatments apply even more strongly where abortion is contemplated. Abortion typically involves a medical or surgical procedure (with the attendant risk of complications, physical and psychological) performed in response to a social problem or personal difficulty, rather than a maternal medical problem. SPUC holds that the remedy to social problems lies in social action, at the level of the family and, where appropriate, voluntary and statutory support services, rather than in the operating theatre, particularly when the "treatment" is aimed at destroying, rather than saving, human life. (Please see Annex 2.)

B. RISK FACTORS &GROUPS PARTICULARLY AFFECTED

Research has shown that there are a number of risk factors and groups particularly vulnerable to the physical and psychological outcomes of sexual activity, e.g.:

young people under 16
young adults of both sexes aged 16-29
gay and bisexual men
people travelling abroad
ethnic groups such as people of African origin and young people of Afro-Caribbean origin
young people in care/leaving care
people with learning disabilities
commercial sex workers
young men

2. Can you offer information from your experience whih supports or adds to this list?

The Social Exclusion Unit's consultation paper "Teenage Parenthood" included a similar list which, significantly, cited "young people who have lived with family breakdown" as particularly likely to become parents in their teens. It is important to recognise that family breakdown may often be a cause of many of the other risk factors cited. For instance, young people who have been looked after by local authorities, young people who are homeless and young offenders may have experienced family breakdown.

While SPUC's remit does not extend to the discussion of sexual ethics per se, we recognise that sexual activity has a moral dimension. We also recognise that the family, founded on marriage, generally provides the environment most conducive to the protection and care of children from conception onwards. If adolescent pregnancy is socially problematic, this is not because of the mother's age per se, but insofar as conception occurs in circumstances where the upbringing of children entails particular difficulties, the young mother often being unmarried and poor, still in full-time education or unemployed.

The widespread incidence of births outside marriage means that many children are growing up without the benefit of the family environment. Married adolescents, especially in a culture favourable to early marriage, have the support which the unmarried adolescent mother is less likely to enjoy - and the inexperience of youth can be a complicating factor in the absence of compensating social support systems.

SPUC has many years' experience of helping expectant mothers, including adolescents, avoid abortion by befriending and providing practical support, and by liaising with other agencies to find appropriate sources of assistance to meet the mothers' particular needs. Our experience is that problems arising from adolescent pregnancy are often addressed primarily in the family, which is as it should be, provided that the family commits itself to the welfare of mother and baby, and is aware that help to meet the needs of adolesent parents is available, if needed, from voluntary and statutory bodies.

C. SEXUAL HEALTH PROMOTION/PREVENTION

3. How do you think we can make sexual health promotion and sex and relationships education more effective?

Where information about sexuality is imparted (particularly to children and adolescents) with the expressed or implied message that there is no moral difference among a number of choices, it is only to be expected that such material may act as a stimulus to sexual activity in circumstances where it is not conducive to the welfare of those who participate. A child conceived in such circumstances is liable to face certain disadvantages (e.g. the absence of a stable family environment) and worse, is liable to be particularly at risk of abortion.

Particularly when linked to the provision of birth control methods, approaches which ignore or undermine values protective of the family and of human life are therefore liable to be ineffective or, worse, to aggravate the incidence of adolescent sexual activity, pregnancy and abortion. Articles which purport to show that school-based contraceptive-oriented programmes are effective in their impact on the incidence of sexual activity must be examined critically, since some such studies at least can be shown to present information in way which does not accurately reflect the import of the studies in question. (Please see Annex 1).

Whatever approach is taken to educational programmes, the objective is to impart information and ideas with a view to influencing behaviour. The question facing policy-makers is what behaviour they wish to encourage or discourage. There will be no reduction in unmarried adolescent conceptions without a reduction in the incidence of the sexual activity which causes it. Policy-makers should not fear to recognise this: it is not a question of looking at a complex problem from an unreasonably narrow moral viewpoint, but of having the honesty to face the implications of the evidence. Those who, on the contrary, avoid this conclusion despite the failure of their own preferred approach, may more fairly be charged with imposing their own moral attitudes, even if doing so may be aggravating the problem.

The following conditions should govern any treatment of sexual ethics in public education, particularly in schools:

it must have full respect for the rights and responsibilities of parents
it must not give children information prematurely
teachers must not give information on particularly intimate matters which it belongs to parents, rather than teachers, to give
sexual activity outside marriage should not presented as inevitable for a couple, or separated from moral considerations.

The right of parents to withdraw their children from sex education classes must continue to be guaranteed by law.

4. How should we particularly target health promotion messages to meet the needs of the identified vulnerable groups?

We would urge a radical re-evaluation of assumptions as to what the needs of the identified groups are. We are concerned that evidence which has been available for over a decade has not been taken into account. For example, we would point to the admission by Dr Judy Bury, former Director of Edinburgh Brook Advisory Centre, that :

There is overwhelming evidence that, contrary to what you might expect, the provision of contraception leads to an increase in the abortion rate. (TheScotsman, 29 June 1981)

Another Brook Advisory Centre director, Jean Malcolm, has reportedly said that:

It's partly because of a greater availability of contraception that there are more pregnancies. I suppose it's almost inevitable. (Edinburgh and Lothian Post, 11 January 1992)

This appears to be the case particularly among adolescents, a group in which the failure of contraceptives is high. (Jones, EF and Forrest, JD (1989). "Contraceptive failure in the United States: Revised estimates from the 1982 National Survey of Family Growth." Family Planning Perspectives, 21, 103-9.) The associated high incidence of abortion may in part be attributed to the hostile attitude towards children which has developed. This often results in a greater keenness to eliminate unplanned babies (regarded as the "mistakes" of contraceptive failure) than to help expectant mothers avoid abortion. We do not consider it in the interests of unborn children to advocate providing adolescents with contraceptives of any kind.

Moreover, the same "service" providers who promote contraceptives often provide the channel for the provision of abortion also. The experience of the United States and Britain shows that the trend of high incidence in unmarried adolescent pregnancy and abortion has occurred in the same period in which contraception has been widely promoted and made available.

With reference to the category "people travelling abroad", we would draw attention to the need to scrutinise assertions that the end of holiday seasons coincide with peak times for abortions. Policy-makers should in any case guard against assumptions that fluctuations in abortion figures can confidently be attributed to specific causes. 5. How might the following be improved in relation to health promotion?

(i) integration / collaboration

One approach which we consider an abuse is the involvement of school nurses to promote - and even to supply - birth control methods to pupils even under the age of consent. Nothing liable to facilitate sexual activity among pupils should be tolerated in schools.

(ii) evidence-based practice

Please see Annex 1.

(iii) targeting

(iv) media involvement

We consider that everyone, without discrimination, should be free from exposure to material likely to encourage sexual activity in circumstances where it is prejudicial to their welfare, or liable to generate risks to the life and welfare of any unborn child who may be conceived.

It is also important to guard against generating pressures on adolescent mothers to undergo abortion, which is a foreseeable effect of approaches focussed on preventing births (rather than on avoiding situations liable to result in conception). Even to propose, in public policy and in the media, that abortion is merely a "choice" often translates on a personal level into the experience of intense pressure on the expectant mother, caused by the (expressed or perceived) unsympathetic attitudes of those around her.

D. SEXUAL HEALTH SERVICES

7. How would you improve services in the next five years in the following areas:

(i) integration/collaboration between services
(ii) cost effectiveness
The argument that compares the cost of an abortion favourably to the costs of maternal and child health care should not be countenanced under any circumstances. This view is economically false as well as morally repugnant. Most people contribute to the economy far more than they draw from it. Moreover, the promotion of abortion and small family size as a social norm are also short-sighted from a demographic perspective, in view of the increasing need to cope with the shift towards an aging population.

Furthermore, to avoid the misdirection of resources we would urge the Department to consider whether certain issues would be better addressed in social services rather than healthcare strategy. For example, from our experience of the needs of young parents, particularly single mothers, we recommend more provision of:

childcare support for young people seeking to continue with their studies;
job schemes where creche facilities are provided along with training and careers advice;
adequate care for children out of school hours to enable a parent to work where there is serious difficulty in making any other arrangements (e.g. because of lone parenthood, absence of family support).

Current provision of such services varies from borough to borough and should be improved where deficient.

8. What are the range of services that need to be available as part of the sexual health strategy?

Please see our responses to Questions 1 and 4.

9. Could you give us your views on how services should be developed to cater for vulnerable groups (see the list on page one), for example outreach work?

Please see our response to Question 5 (iii) and (iv). 10. Give examples of models or innovations in service delivery that you know and that demonstrate good practice / better outcomes. (Feel free to attach highlighted reports where appropriate.)
Successive reports of the Confidential Inquiry into Maternal Deaths in the UK demonstrate that maternal mortality in general, and direct obstetric deaths in particular, are significantly lower in Northern Ireland, where the Abortion Act 1967 does not apply, than in any other region of the United Kingdom. Furthermore, according to UN figures the Republic of Ireland, where induced abortion is not practised, has had a third of the maternal mortality of the UK. In this light we urge the Department of Health to reconsider assumptions about the therapeutic value of abortion, and to consider the inference that the exclusion of abortion is in fact conducive to better outcomes.

11. If more professional groups are going to be involved n the delivery of a sexual health service, could you identify the training issues that will need to be covered?

The Social Exclusion Unit's consultation paper "Teenage Parenthood" referred to "training" in the context of "confidentiality" issues."Confidentiality" may imply referral for or provision of birth control methods to the under-16s without parental involvement. This is unacceptable.We also have grave reservations about the channelling of resources into facilitating "peer counselling". Sexual information learnt only from peers can be unreliable, and cannot be expected to provide adequate formation in developing a sense of moral responsibility in sexual matters. "Peer counselling" seems to lend itself to undermining parental authority and to being informed by the ideologies of those who are inclined to separate sexual behaviour from the moral considerations that should be applied. 12. How could the role of the following groups be developed in providing a sexual health service?

primary care

genitourinary medicine

family planning

gynaecology
We would point out that "family planning" is an inappropriate term in relation to the provision of birth control to adolescents who intend to engage in "recreational" sexual activity. It is unacceptable that any means to facilitate this should be available in schools or clubs used by children under the age of consent. The issue here is not a decision about planning a family, a context which is generally conducive to the protection of the child (before and after birth) in the event of conception, but simply to the avoidance of pregnancy despite the fact that conception is still liable to occur! It is unacceptable to promote "recreational sex" in a way which implies that an unborn child whose conception may result has no rights.

We would also urge the Department of Health to ensure that health service providers observe the stipulation of the International Conference on Population and Development (Cairo, 1994) that in no case may abortion be promoted as a method of family planning.

E. UNDERLYING CAUSES OF SEXUAL ILL HEALTH / REASONS FOR LOCAL VARIATIONS

The reference to sexual ill-health is welcome insofar as it implies the diagnosis and treatment of actual illnesses, rather than the unfeasible pursuit of "complete well-being" proposed by the WHO. At the same time, we would again caution against the tendency to regard fertility itself as a pathology to be combatted.

The Social Exclusion Unit's consultation paper "Teenage Parenthood" referred to "local variations" in the context of teenage conception rates, which implies variations in sexual behaviour itself. Cultural factors in some areas such as religious practice and close-knit families are likely to have an influence in favour of abstinence and tending to a lower incidence of unmarried adolescent conceptions.

Annex 1. Reliability of published research into sex education programmes.

There is a great desire to identify factors that can be influenced by policy decisions and hence reduce conception rates among adolescents. At the same time, the moral values of policy makers predispose them in favour of some policies and against others.

Those conducting research, and those analysing or surveying it also have their moral and ethical viewpoints which often colour the way in which information is presented, even in academic journals. Here we look at two instances of the presentation of information - one from a medical journal, the other from the NHS Centre for Reviews and Dissemination, an academic service body. Both might be expected to present results impartially, but in both cases research is presented with a definite "spin".

Those charged with developing social policies must analyse carefully such studies, look at the methodology employed, the verifiability of the data, and whether the references cited support the arguments made.

1) British Medical Journal, volume 311, 12 August 1995.

Two research reports appear in this edition of the BMJ, preceded by a leading article, which introduces them, and points to a particular interpretation of the results, justifying this in one case with an argument that was actually countered, rather than supported, in the report referred to.

The editorial is headed thus:

Sex and HIV/AIDS education in schools have a modest but important impact on sexual behaviour

The editorial naturally wants to suggest the two studies following are of some significance. While the "modest" scale of the impact of the programmes is undeniable, to call their impact "important" is less easy to justify. The editorial writer (Douglas Kirby) sums up the main conclusion of one of the articles:

having schools as the primary source of sex education might have increased the use of condoms at first intercourse.

We would make three points about this statement:

Figure 5 of the relevant paper (Wellings et al, p.420) indicates NO significant increased likelihood for men using condoms at first intercourse, regardless of what they specified as the "main source" of sexual information, whether school or other. It indicates only a modest increase (just above the level of statistical significance) for girls - but this was not as great among girls who said the school was the main source of sex information as among those who said that a relative (presumably the mother or a sister in most cases) was the main source. (A relative was also marginally more likely than school to influence boys to use condoms at first intercourse, but again this was not statistically significant.) But the "spin" is evident: the stress is on school-based sex education, not parental or home-centred guidance, both in the research paper itself and in the editorial.
Condom use at first intercourse is hardly a very notable influence of a school- based sex education in comparison to other findings in Wellings' report. For example, the proportion of men citing school lessons as their main source of sexual information increased from 7.9% among the oldest age group (45-59) to 27.2% of those in the youngest (16-24), while the proportion of men reporting first intercourse before 16 increased from 10.0% in the oldest group, to 25.4% for the youngest. The authors do not draw this comparison directly, though they do note that "the school has been playing an increasingly important role in the sexual education of the young, particularly for men." Of course, the nature and content of school sex education has changed so drastically that this comparison is not terribly helpful, but it should perhaps suggest that a rethink of the policy is needed.
A further point to note is that no estimate is given of the effect, if any, of condoms at first intercourse on the risks of "conceiving as a teenager", AIDS/HIV infection, other sexually transmitted diseases, cervical cancer, etc.

A deeper problem with the Wellings study, which the authors acknowledge, is that those who start intercourse early are not so likely to be influenced by school sex education which may post-date sexual initiation. So those who say that they got most sexual information from school and that they used condoms when first having sexual intercourse may well have been acting under a different influence altogether.

This point may account for the negative conclusion of the paper - that it provides no evidence to support the concern that school sex education might hasten the onset of intercourse. But more importantly, the article can hardly sustain Douglas Kirby's "spin statement" in the editorial, quoted above, that:

having schools as the primary source of sex education might have increased the use of condoms at first intercourse.

The other study that Kirby's editorial introduces in the BMJ is by Mellanby et al (p.414). Of this he says that it shows that the Mellanby programme delays the onset of sexual activity, in comparison to sex education that the control groups were receiving, which is not described.

While knowledge of contraception was promoted in the programme analysed in this study, it used various strategies aimed directly at decreasing sexual behaviour, something which many advocates of contraceptive-focussed school sex education programmes claim is virtually impossible. And since it is difficult (or perhaps ideologically unattractive to them) they are not willing to try it.

It is clear that certain moral values were adhered to by those conducting the study: they did not use the potentially powerful technique of stigmatising sexual activity - believing this to be intolerant - and increasing tolerance was another objective of the programme.

Negotiation in relationships and assertiveness were among the social skills promoted in the study, which it would seem fair to say in this case produced a modest impact.

Mellanby recognises that:

Neither specific teaching about contraception nor improving the contraceptive service consistently increase effective contraceptive use by teenagers. (p.414)

The remainder of Kirby's editorial stresses that, when one looks at sex education/AIDS prevention studies all together they do not have an effect in hastening first intercourse. It would seem to be implicit in this that some do hasten intercourse and others retard it, but the stress is on the "neutrality of programmes overall". This surely is not good enough. Those programmes that have a positive outcome must be promoted and emulated. Kirby goes on to point out nine factors of effective programmes. These include proscriptive elements such as:

a narrow focus on reducing specific risky behaviour

and

clear reinforcement of individual values and group norms (i.e. morality).

Interestingly, contraceptives as such are not among the nine key factors for success. The list does include:

activities to convey the risks of unprotected sex and how to avoid them

a phrase which could equally cover abstinence or "how to say 'no'" strategies, as "where to go to get your preferred contraceptive".

While the "spin" put on the results of these articles is deeply regrettable, the following example shows an even more disturbing bias.

2) "Preventing and reducing the adverse effects of unintended teenage pregnancies", NHS Centre of Reviews and Dissemination, University of York, Feb 1997, 3,1.

(Referred to below as "NCRD")

This paper is presented in the format of a number of "headline" claims, followed by an analysis of published studies and reports.

Several of these "headlines" are either misleading or unsupported by the data cited in the document. For instance:

NCRD Headline

Increasing the availability of contraceptive clinic services for young people is associated with reduced pregnancy rates.

In contrast to the positive assertion of this headline, NCRD states:

The literature searches revealed a complete lack of UK-based controlled evaluations of the effectiveness or cost-effectiveness of different approaches to the delivery of contraceptive services to young people. [sic] (p.7)
Evaluation of school-based clinics providing health and contraceptive services in the USA have been methodologically weak with poor selection of comparison groups and the results are contradictory. Some show delay in sexual initiation, and reduction in birth rate..." (p.4) [... and presumably the 'contradictory' ones show the opposite.]

NCRD Headline

Contraceptive services should be based on an assessment of local needs and ensure accessibility and confidentiality

Evidence to support this within the report is poor:

Studies show an association between conception rates and the level and type of contraceptive services available locally. (p.7)

The only reference cited in support of it is an article entitled "Adolescent premarital childbearing: do economic incentives matter?" (Lundberg S., Plotnick RD, in the Journal of Labour Economics (J Lab Econ) 1995, 13, 177-200). As this is the only source given, and the text refers to "studies" in the plural, it is presumably a secondary source and as the statement does not specify whether all the studies found a negative association it gives little support to the assertion in the headline. It would seem to defeat the object of this kind of publication to use a secondary source, especially as this is not only a key recommendation but also one which is controversial for many.

There is not the sort of clear evidence of the effectiveness of different approaches to contraceptive counselling and contraceptive provision which could provide a firm basis for decision making. (p.7)
A review of descriptive UK studies [as opposed to controlled evaluations] which examined factors likely to influence the effectiveness of services was carried out. (p.7)

The authors go on to admit the weakness of descriptive studies, but nevertheless, they are sufficiently confident of the review cited to base recommendations on it. The review in question was conducted by the NCRD (the source of the current review), publication "forthcoming". This would seem poor academic practice.

In order to attract young people to use services, they need to be well-advertised, easily accessed outside school-hours (opening times and location), informal and for under 16-year-olds, confidential. (p.7)

The reference cited in support of this statement is not the product of academic researchers, nor even a descriptive study; it is a paper issued by the BMA and other medical bodies in association with the Brook Advisory Centres and the Family Planning Association - organisations committed to birth control programmes.

It should be noted that the factors mentioned (advertising, access, informality, etc) are said to be required "in order to attract young people" - and there appears to be no claim that trying to draw adolescents to use such services will result in any delay in first intercourse or reduction in pregnancy or abortion rates.

NCRD Headline:

School-based sex education can be effective in reducing teenage pregnancy especially when linked to access to contraceptive services.

In support of this contention, NCRD summarises its assessment of sex education programmes under seven headings:

Abstinence programmes;
School-based skills building combined with factual information;
Programmes encouraging vocational development;
School-based programmes linked with contraceptive services;
School-based and school-linked clinics;
One-to-one counselling;
Non school-based educational programmes in HIV prevention.

The headline would appear to suggest that protocols 4 and 5 were the successful ones. This is not reflected in the document, however.

Of number 4, it is said that such programmes increase the use of contraceptives - but this is not the same as reducing teenage pregnancies (this is a highly controversial point - indeed, one randomised controlled trial referred to elsewhere in the NCRD study (p.5) found that a peer-led programme promoting decision- making skills resulted reduced contraceptive use and reduced pregnancy rates (but not in this case by a significant level - at a 95% confidence interval). Another study is reported to have found a significant reduction of pregnancies by combining "peer-led skills and confidence building programmes and access to condoms and transport to contraception clinics." (p.4) Unfortunately the details of this study are not reported. It is not clear whether the reduction was great or small, or even whether it was significant at the 95% confidence interval level. It is not tabulated in the NCRD's table, so presumably it was not a randomised controlled trial.

Four studies are referred to under protocol number 5, but again, none of these appears to have been an RCT. Their results are described by NCRD as "contradictory".

In contrast, the effectiveness of protocols 1, 2 and 3 are nowhere reflected in the NCRD headline recommendations, although there appears to be more evidence for their success.

Protocol 2 includes a reference to the Mellanby study, discussed above. As pointed out, this did show a modest impact on sexual behaviour, in terms of delaying first intercourse (control population odds ratio 1.45 for having had intercourse at time of assessment (15.5-16.5 years of age), compared to intervention group, 95% confidence interval: 1.13-1.87). The impact of the programme appears to have been much stronger on boys than on girls, but separate odds ratios are not quoted by sex.

The NCRD suggest that another programme which did not, like Mellanby's, include information on contraception, was less effective. But they only include data for girls, so it is not possible to judge whether the comparison is valid.

Protocol 3 was apparently fairly effective, one programme having shown a reduction in pregnancy rate. Results are included from a study that reported on a controlled trial (rather than a randomised controlled trial). The controlled trial involving >5,000 pupils, showed a significant reduction in pregnancy rates (odds ratio: 0.39, 95% confidence interval: 0.2, 0.78). Not all of the RCT studies reported included figures for pregnancy rates, but none of those that did showed a reduction significant at the 95% confidence interval. In the light of this, the question must be asked as to why NCRD played down this kind of approach.

It is interesting to note that moral values also appeared to influence the behaviour of men and women in Wellings' study, with both men and women who were Roman Catholics less likely than those of other religions to use condoms and other contraceptives at first intercourse than other groups.

NCRD further criticises protocol 3 by saying that it is difficult to separate the contribution of the various elements of the programmes. This seems a very weak point to make. Furthermore there is no suggestion that the different elements of the favoured protocols - 4 and 5 - have been or could be analysed for their separate elements.

Of protocol 1 (described as "abstinence programmes") NCRD says:

When compared to the usual sex education, abstinence programmes were not found to have any additional effect on either delaying sexual activity or reducing pregnancy. (p.3)

Two references are cited in support: one is by Jorgensen. (Jorgensen, SR. "Project taking charge; an evaluation of an adolescent pregnancy prevention program", FAMR 1991;40, 373-80)

The Jorgensen study (and a six month follow-up - apparently mis-quoted as a six week follow-up) is summarised elsewhere in the NCRD study (p.5). The summary contradicts this statement. The study did apparently indicate a lower rate of participants initiating intercourse (and a much lower rate among boys) in an "abstinence programme". This result is dismissed, presumably because, as a small study, it did not achieve a result significant at the 95% confidence interval. The lack of statistical power in the study must be acknowledged, but to claim in the light of this that such programmes were not found to have "any additional effect" is untrue. (The control for the study is referred to as "usual instruction"). The other study cited is not summarised in NCRD (presumably because it was not a randomised controlled trial), and it is not available to us at present, but it would be important to examine it.

Overall, one must regard as highly misleading the headline claim that "[s]chool-based sex education can be effective in reducing teenage pregnancy especially when linked to access to contraceptive services." Nearly all of the RCT studies presented in summary form in the document show at most an increase in contraceptive uptake from such programmes, not a decrease in pregnancy rates, as NCRD claims. Even the programme which has the most marked increase in contraceptive uptake (Baker C. "Self-efficacy training: its impact upon contraception and depression among a sample of urban adolescent females" [PhD], Seton Hall University, 1990) failed to achieve a statistically significant reduction in pregnancy rates at the 95% confidence level.

A final point to be noted about this study is that among those listed as assisting the study and commenting on the text are Alison Hadley of the Brook Advisory Centre, Joan Walsh of the Family Planning Association, and Caroline Ray of the Sex Education Forum. These organisations are strongly ideologically committed to the provision of contraception to adolescents. If impartiality on a controversial topic was desired, one would have expected bodies critical of the proposed policies to be canvassed as well, or for those with such evident axes to grind to be excluded.

Annex 2. Physical and psycological effects of abortion

Short-term physical complications

Early surgical abortion involves the performance, typically for non-medical reasons, of an invasive surgical procedure on a healthy woman.

Given that the procedure is elective rather than therapeutic, the ethics of exposing the patient to hazards such as perforation of the womb are open to question, even though the incidence of this is commonly said to be between 0.1% and 0.3% - but which has been found to be up to 2% when possible damage is fully investigated. (Am. J. Ob. & Gyn., 1989, vol 161, 406-408) The most basic objection to the procedure is that it involves the deliberate destruction of the unborn child.

Early surgical abortion can cause damage to the cervix leading to loss or premature delivery of a baby in subsequent pregnancy. This is especially the case with adolescents undergoing abortion. (Schults et al, The Lancet, 28 May 1983) Other notable risks include haemorrhage, infection and incomplete abortion. (R. Castadot in Fertility and Sterility, January 1983)

Early chemical abortion by RU486 (mifepristone) led to incomplete abortion in 6% of cases during a UK multicentre trial, and there was serious haemorrhage requiring blood transfusion in 1%. Many women needed narcotic painkillers. (Brit. J. Obs. & Gynae., June 1990) In France, a woman has died and two others are known to have had cardiac complications following the combined drug regimen RU486/prostaglandin. Prostaglandin, when used alone to induce abortion in mid or late pregnancy, can cause cervical lacerations, rupture of the womb, an infection rate of up to 10%, a haemorrhage rate of around 9%, and incomplete abortion in up to 35-46% of cases. (R. Castadot in Fertility and Sterility, January 1983)

Risks to fertility

Apart from direct damage to the womb, induced abortion is associated with a risk of infection leading to infertility. A common cause of post-abortion pelvic infection is the sexually transmitted disease chlamydia. Research has shown that 10-40% of women presenting for abortion have chlamydia infection, and of these 10-25% will develop post-abortion pelvic infection. (Skjeldestad F.E., "Induced abortion: chlamydia trachomatis and postabortal complications. A cost benefit analysis", Acta Obstetrica et Gynaecologia Scandinavica, 67 (6):525-9, 1988. Duthie S.J. et al, "Morbidity after termination of pregnancy in first trimester", Genitourinary Medicine, 63:182-7, 1987).

In other words, between one and ten per cent of all women having an abortion will be affected in this way. According to the British Medical Journal, such pelvic inflammatory disease carried a 17% chance of tubal infertility, a 20% chance of chronic pelvic pain, a 40% chance of deep dyspareunia (painful intercourse) and an 80% chance of menstrual disturbance. There is also a seven-fold increase in the risk of ectopic pregnancy. (Pearce J.M., Pelvic Inflammatory Disease, British Medical Journal 300:1090-1, 1990)

Breast cancer

Mounting evidence points to a link between induced abortion and breast cancer, particularly if it is the woman's first pregnancy that is aborted. The most likely explanation as to why the same association is not found with spontaneous abortion (natural miscarriage) is that in pregnancies up to 12 weeks which end in miscarriage there is typically a subnormal level of hormone secretion, whereas most induced abortions terminate a normally progressing pregnancy. It is plausible that the artificial interruption of the natural processes, including the development of cells in the breast for lactation, leaves those cells more susceptible to cancer-causing agents than if the pregnancy had continued to term.

Dr Janet Daling (who supports the availability of abortion) and colleagues found that among women who had been pregnant at least once, the risk of breast cancer in those who had experienced an induced abortion was 50% higher than among other women. Those at greatest risk had abortions before they were 18. (Journal of National Cancer Institute [US], 86/21: 1584-1592, 1994)

The most comprehensive review of published studies is that by Joel Brind et al (Journal of Epidemiology and Community Health, October 1996), who found a 30% increased breast cancer risk for women who had an induced abortion.

Effects on mental health

Although the subject of Post-Abortion Syndrome is controversial, there is accumulating evidence that abortion can worsen the mental health of women, with a severe effect in a significant proportion of cases.

For example, a review paper published in 1992 found that psychological and psychiatric disturbances occur in association with induced abortion, and that these are "marked, severe or persistent" in approximately 10% of cases. (Zolese G. and Blacker C.V.R., British Journal of Psychiatry, 160:742-9, 1992)

Professor Myre Sim MD (Edin), FRCP (Edin.), FRCPsych, FRCPC, FAPA notes that his own research and that of others has demonstrated that psychosis after childbirth "carries an excellent prognosis and post-abortive psychosis a relatively poor one...there is now considerable evidence that the very measure which is intended to benefit the patient [i.e. abortion] can precipitate a worse state than if she were allowed to go to term." (Abortion: The Facts, Emmess Publications, Victoria, B.C., 1997, p.29) Evidence by the Royal College of Psychiatrists "clearly stated that previous psychiatric disorders predisposed individuals to similar problems after the abortion." (The Physical and Psycho-Social effects of Abortion on Women, Report of the Commission of Inquiry into the Operation and Consequences of the Abortion Act, London, 1994)

Even in a study using old data which claimed that the evidence was inconclusive as to the increased risk of psychiatric disorders following abortion, the researchers nevertheless found that among women who had no previous psychiatric history, there was a significantly increased risk of "deliberate self-harm" in the group of women who had had abortions.* Most of the incidences of self-harm involved taking drug overdoses; none were fatal. (Gilchrist A.C. et al, British Journal of Psychiatry, 167:243-248, 1995) Overdoses are not difficult for family physicians to diagnose, and psychiatric symptoms might have been detected more frequently among women who had had abortions if they were easier for family physicians to diagnose.

Post-abortion counsellor Margaret Cuthill, Co-ordinator of British Victims of Abortion (BVA), observes that "symptoms of repressed grief are most likely to surface from six months to two years after the trauma occurs." (And Still They Weep, SPUC Educational Research Trust, 1996) Thus, although some women report no adverse reaction immediately after abortion, this is no guarantee that adverse reactions will not occur later, triggered by some future stress event - for example, a new pregnancy, the inability to conceive or to complete a pregnancy, or some other major loss or crisis.

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* This was also the case among those women who had been refused abortions. The authors admit that, based on their high reported rate of miscarriage, some women in this group may actually have obtained an abortion, although they state that re-analysis of the data excluding all women who had a miscarriage does not materially affect their findings.