Response to the Social Exclusion Unit's Consultation on "Teenage Parenthood"

November 1998

SPUC's approach
Responses to specific questions in the consultation paper
Reliability of published research into sex education programmes
Physical and psychological effects of abortion

1. SPUC's Approach

SPUC's remit and activities

The Society for the Protection of Unborn Children (SPUC) is an independent education, research, advocacy and lobby 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 educational programmes and social policy relating to sexual activity insofar as the following considerations apply:

(1) the welfare of unborn children, encompassing the unborn child's right to life and to appropriate social respect and legal protection;

(2) the health and welfare of mothers during pregnancy and after birth, and of women and girls facing the prospect of pregnancy;

(3) 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.

Moral and legal considerations

Because of the profound consequences of sexual activity both for those who participate and, in some instances, for others - not least when it results in the conception of a child - we hold that sexual activity cannot justly be divorced from considerations of one's own dignity and welfare, or the welfare and dignity of others. Some sexual behaviour is so violative of family relationships or of the protection due to the young that the state has a responsibility to prohibit it, by forbidding incest and imposing a minimum age of consent to sexual intercourse.

Bypassing parental involvement

The practice of bypassing parental involvement in the provision of birth control to underage adolescents serves to undermine the protection which the 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.

Marriage and the family

While acknowledging a moral dimension to sexual activity, with emphasis on the welfare of those involved, SPUC does not espouse any particular moral system (such as those found in religious teachings). Nevertheless, we 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.

Extreme attitudes to be avoided

On the one hand, we do not seek to minimise the difficulties which adolescent single mothers may face. On the other hand, it is unhelpful to exaggerate them (in which case the baby is often unjustly regarded as a blight on the mother's life).

The latter view is found among people with very different attitudes to adolescent sexual behaviour. Some tend to vilify adolescents who engage in sexual activity. Others, by contrast, tend to regard unmarried adolescent sexual activity (even under the age of consent) as morally neutral, or even as a good to be advocated, provided that pregnancy is avoided at all costs. SPUC would avoid such extremes.

Birth control methods

We are critical of many aspects of the promotion of contraception, which in our view has helped to foster attitudes hostile to children (particularly before birth, when the child enjoys no more than minimal protection under the law). Contraception in principle is acceptable to some of our members and not to others (generally those who accept only natural methods of planning their families). However, we would emphasise that we distinguish between contraception, that is, an intervention to prevent sexual intercourse resulting in the union of sperm and ovum, and an action causing embryo loss after conception (fertilisation) has taken place.

We oppose hormonal methods of birth control insofar as they have the potential to kill embryos, which applies principally but not exclusively to "post-coital" methods. At the very least, those who supply and promote such methods should explain this mode of action frankly, so that potential users may have the necessary information to make a decision to avoid compromising the survival of their offspring at pre-implantation stage in the event of conception (fertilisation) occurring.

Medical considerations

Fertility is not a disease. Drugs and devices prescribed for contraceptive reasons are therefore not 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 based on medical considerations. The World Health Organisation's definition of "health" as "a state of complete physical, mental and social well-being" is rightly criticised for reflecting the tendency to reduce medical practice from a vocation in which ethical and clinical considerations are paramount, to 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. Considerations of informed consent require that, where a treatment is merely elective, all possible drawbacks and side-effects be discussed with the patient (including the potential to cause embryo loss, which for many women is information of major ethical significance).

In the case of adolescents being prescribed birth control pills it is also essential that the patient's own GP (if different from the prescribing doctor) is informed so that any contraindications arising from the medical history of the girl or her family can come to light and be heeded. We are aware of the medical evidence on the risks associated with hormonal birth control method; we would urge those responsible for social policy 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.

Choice

The concept of choice is widely promoted today as an extension of personal liberty, which in some cases it is. However, in some contexts the notion has arisen that all choices are morally equivalent, or that the "right" choice is merely what the individual wants to do. 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) must inform responsible decision-making.

On the one hand, abortion is promoted as a matter of personal choice. On the other hand, it is defended as a "necessary evil". The tension between the considerations of "choice" and "evil" as applied to abortion can resolved by the conclusion that 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, and indeed cannot adequately be served in isolation from each other.

What is more, in our experience, pressures generated by others, rather than her own free choice, often motivate an expectant mother to contemplate abortion. Many adolescents, especially those under sixteen, are particularly 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.

Abortion and the promotion of contraception

Quite apart from the difference of views within the Society about contraception in principle, we would not consider it in the interests of unborn children to advocate providing adolescents with contraceptives such as condoms. On the contrary, 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. (The Scotsman, 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.

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.

Sex education

Where information about sexuality is imparted 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.

Approaches to sex education (particularly when linked to the provision of birth control methods) 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 Part 3 of this submission.)

2. Response to specific questions in the consultation paper

The Overall Project

1. Why do you think the rate of teenage pregnancy is higher in the UK than in the rest of Western Europe?

Assertions that this is the case should be tested by more research (independent of bodies promoting or providing birth control for adolescents) into the accuracy of statistics on the incidence of induced abortions, "menstrual extraction" procedures (which induce abortion if the woman is pregnant) and post-coital birth control (which can likewise cause embryo loss). Dutch Government statistical information confirms that there is no legal obligation in the Netherlands to report menstrual extractions, and only those that are voluntarily reported are included in the official abortion statistics. (Jaarrapportage 1993, Geneeskundige Hoofdinspecteur van de Volksgezondheit [Annual Report for 1993 from the Chief Medical Inspector for Public Health]) In the absence of reliable data confirming what the practice is in other Western European countries, the attribution to the UK of the highest conception rate among adolescents must be subject to some doubt.

2. By how much do you think it realistic to aim to reduce rates of teenage and underage parenthood and over what period? Why? On what does it depend?

The use of the word "parenthood" here rather than "pregnancy" or "conception" may indicate a shift of perspective. We would reject any implication that the birth of babies to adolescent parents should be avoided by all means, including abortion. On the other hand, we would agree that it is desirable to discourage sexual activity under the age of consent, by which conceptions leading to such births are liable to occur.

Many factors affect the incidence of adolescent pregnancy, and while the proximate biological causes are easily stated, the more remote social and interpersonal factors, and how these interplay are far from simple.

Nevertheless, it is a fair observation that the present high incidence of unmarried adolescent conceptions and births is symptomatic of a trend in negative attitudes of men towards women, attitudes towards the family and the environment in which children are to be conceived and raised. Merely setting a target to reduce the symptoms may fail. Management-type approaches in which the setting of a target seems paramount may be unfeasible in the context of social problems. Measures to address the symptoms should be studied impartially to look at the effects they have. If educational programmes promoting self-respect and abstinence have an effect in one region, a target might usefully be set in another region in relation to such a programme. This would involve using targets in a constructive way, rather than in a way which does not address more critical questions such as the principles on which an approach is based and what types of behaviour it tends to encourage.

3. In your view, what unintended effects do we need to be wary of in developing a strategy on this issue?

Policy-makers should reject approaches which facilitate or otherwise encourage sexual activity in circumstances where (notwithstanding the use of contraception) it is liable to result in pregnancies which leave a young mother and her child particularly vulnerable (please see our comments on p 6 of this submission). This applies especially where the sexual activity is against the law. The unintended effect of actually increasing the incidence of conceptions (recorded or otherwise) can thus more easily be avoided.

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.

4. Why have previous attempts to tackle this issue not succeeded?

We note that the opening remarks of this section of the consultation paper refer 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, and it is now around 8 per thousand.

Evidently, the substantial increase in unmarried adolescent pregnancies was attendant on "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.

5. What approaches do you think would be most successful?

Whatever approach is taken, 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. The only way to guarantee a reduction in unmarried adolescent conceptions is to achieve 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.

Educational strategies, which should always have full respect for the rights and responsibilities of parents, should treat as integral the values of self-respect and respect for others, avoiding superficiality in their presentation of moral choices, and should encourage adolescents to appreciate the case for sexual abstinence (at least in their present circumstances), based on these considerations and on medical grounds. Respect for marriage and the family should be promoted. These concepts should be formulated in non-religious terms where appropriate, but will probably be conveyed most effectively in the context of particular religious traditions (e.g. in denominational schools) where the moral teaching of that tradition is authentically explained (and not manipulated so as actually to subvert its values).

RISK FACTORS AND GROUPS PARTICULARLY AFFECTED

6. Can you substitute or add to this list from your own experience?

The list refers to "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 all have experienced a form of family breakdown.

We agree that parents who did not educate their children about sexuality in any way would be failing in their responsibilities. 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. For these reasons we have reservations about the approach of "peer counselling" (often promoted under the banner of "empowerment of youth"), which lends 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.

7. If, for example, you work with some of these groups, can you give us unpublished data or other information that would throw more light on the extent and nature of some of these connections? (Even information that may seem small scale to you might help us: there are many data gaps at national level).

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.

PREVENTION

8. How do you think sex and relationship education in schools could be improved?

What consitutes "good sex and relationship education" (cited in the opening remarks) is not defined. No details are given to inform respondents as to the content of the programmes which are meant, or on what basis they are said to reduce conception rates. "Conception" itself is not defined, and in this context is likely to mean recorded conceptions (as we have noted, there may be a considerable discrepancy between the two).

Education on sexual matters in schools could be improved by an approach:

which has full respect for the rights and responsibilities of parents;
which does not give children information prematurely;
in which teachers do not give information on particularly intimate matters which it is appropriate for parents, rather than teachers, to give;
in which sexual activity outside marriage is not presented as inevitable for a couple, or separated from moral considerations.

9. How early in a child's schooling should it start and with what?

It is important to distinguish "schooling" from "education", of which schooling is only a part and which is primarily the responsibility of parents. Parents may, when their children ask questions, give information appropriate to the age of the child and, where necessary, to counter incorrect information or unhelpful influences to which the child has been exposed elsewhere. Educational programmes in schools specifically to address sexual matters may be undertaken with full respect for the rights and responsibilities of parents, but it is not necessary or desirable to undertake this in primary schools or before the beginning of adolescence.

10. Who do you think can best conduct sex and relationship education in schools?

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. The emphasis should instead be on avoiding behaviour which is liable to result in pregnancy, not by inculcating an anti-child mentality but by encouraging adolescents to develop self-respect, respect for the dignity and integrity of others, and for the importance of the family.

Groups supportive of the rights of families may be in a good position to offer resources to schools on a range of issues. Accurate information about human development before birth, whether in biology classes or with the help of groups promoting such knowledge, can contribute to awareness of the needs of the unborn child and the prudence of choosing the best circumstances in which conception may occur.

11. What are the obstacles to effective sex and relationship education in schools (e.g. training, confidentiality issues) and how could they be resolved?

"Confidentiality" may imply referral for or provision of birth control methods without parental involvement. This is unacceptable. "Training" of teachers and parents concerned to collaborate in an approach protective of young people's integrity may be addressed by organising meetings and courses in which those who are to be educators can pool experience, knowledge and resources. For the reasons cited in our response to Q6 we would have reservations about the strategy of "peer counselling".

12. What topics should be covered in classes? What do you think should not be covered?

Biology lessons may properly cover reproduction (but it is not essential to basic knowledge of human anatomy to examine techniques of contraception). Personal and Social Education and General Studies may encompass family issues, and, like Religious Education, may involve the study of moral approaches to sexual matters. No course should deal with intimate information which it is appropriate for parents to impart.

13. Do you think boys and girls should be taught together or separately?

It is difficult to make a general prescription on this question, but separating boys and girls has the merit of showing respect for the difference between the sexes.

14. How can sex and relationship education be tailored to the needs of all young people, from different religious and ethnic and cultural backgrounds?

The values taught in Jewish, Christian, Islamic and other religious traditions are protective of the family and human dignity, including respect for the life of the child before birth, and discourage precocious, extra-marital sexual activity. These values are supportive of what social policy on adolescent parenthood should be seeking to achieve, and should be affirmed. Religious teachings should certainly not be manipulated in an educational context, especially where pupils are being instructed in their own faith.

15. How can parents and carers best be involved?

The content of any educational programme involving human sexuality should be explained to parents from the beginning, full respect for their rights and responsibilities should be maintained; in particular, their right to withdraw their children from it must be guaranteed at all times.

16. Do parents need more support in teaching their children about sex and relationships, and if so, how best could this be done?

The type of approach outlined in the answer to Q12 might be useful.

17. Should sex and relationship education be part of the national curriculum?

No. Each school should be free to determine its own approach in collaboration with the parents.

18. Should parents continue to have the right to remove their children from sex education classes?

They have a natural right to do so, since their children's education and protection (from both physical and moral harm) is primarily their responsibility, and the state has a duty to continue to recognise this right.

19. How can classroom based sex and relationships education be linked to other sources of information in or outside the school?

Please see our response to Q10.

20. Are those who teach sex and relationships education routinely kept in touch with wider local cross agency strategies into which their work fits?

We are inclined to consider that educators in general have the resources to form what links they consider appropriate without the creation of more administrative infrastructure.

CONTRACEPTION, SEXUAL HEALTH SERVICES AND ADVICE

21. What do you think are the most effective ways of providing young people, from different social, religious, ethnic and cultural backgrounds with advice and contraception?

For the reasons cited in Part 1 of this submission (please see especially p 6), we do not consider it in the interests of unborn children or of the adolescents who may become their parents to advocate the promotion of contraception.

Even though SPUC does not adopt a position on contraception in principle, and even if one interprets "young people" to mean those over the age of consent, we take issue with the assumption that respondents necessarily consider contraception acceptable, as if there were no arguments against it worthy of consideration, whether moral or (in relation to certain aspects) medical or social.

22. How easily available should condoms and other forms of contraception be? Are there particular settings in which you think it would be unacceptable for them to be available?

This question relates to the availability of birth control methods 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.

23. What measures could be taken to make young people who are sexually active more likely to use contraception?

The message that sexually active young people should be encouraged to use contraception is liable

to make more adolescents feel they ought to be engaging in sexual intercourse in the first place; and

to foster a tendency to regard contraception as an insurance policy - which, in case of failure, admits of a "claim" to abortion. This is completely unacceptable.

24. Do you have evidence of problems with access to contraceptive services and advice for young people?

Our speakers giving presentations in schools on human development before birth have found that pupils are often well informed as to efficacy of hormonal and barrier methods of birth control. This observation supports the finding by Mellanby et al (British Medical Journal vol 311, 414; 12 August 1995) that:

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

(Please see Part 3 of this submission for fuller discussion of this and other studies.)

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.

25. 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. Practice among doctors varies widely as does awareness amongst young people. Should clearer guidance be available about what can, and what cannot, be provided for under 16's without parental consent?

The ruling also included the stipulation that the doctor could only proceed without informing the parents 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 (Family Planning Clinic Services, Summary Information from form KT31, Department of Health, various years) and underage conceptions did not rise.

26. Should emergency contraception (the morning after pill) be promoted more actively?

No. The most basic objection to "post-coital" birth control is that causes embryo loss by preventing successful implantation. Other considerations which should carry weight with public policy-makers include the facts that:

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 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 deregulation of the pill, there should if anything be more safeguards while it continues to be used.

27. Do you know of examples where young people are not being given balanced information about all the options available - i.e. keeping the baby, termination or adoption?

In the course of its work, British Victims of Abortion (affiliated to the SPUC Educational Research Trust) frequently hears of minimal information being given by agencies and abortion providers offering counselling. Some women report experiences like the following:

I wasn't counselled, I was simply told it would be best for me and my future to have an abortion.

My counselling lasted less than ten minutes.

If by "balanced" one means information which is honestly and accurately presented, this standard should be observed by all information providers, particularly by those who are recommending a course of action or presenting it as acceptable. Considerations of informed consent require that all possible drawbacks and side-effects be discussed with the patient when a treatment is elective rather than strictly therapeutic.

At the same time, it would not be reasonable to expect all information providers to present all possible courses of action as equally acceptable. Groups dedicated to promoting the welfare of both the expectant mother and her unborn child may, in response to requests for information or advice, raise considerations about the effects of abortion procedures and their attendant risks. Indeed, it is often necessary in such contexts to supply information not readily available from other sources. However, it would contradict the principles of action on which such groups operate, in a free and democratic society, if they were to facilitate abortion in any way.

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.

GROUPS PARTICULARLY AFFECTED

28. What approaches do you think work best with the groups particularly affected which are listed above?

In the type of approach which we would favour, respect for the human dignity of all would be integral, which would provide a commendable basis for addressing any group, particularly those whose confidence in their own self-worth has been undermined by lack of respect shown to them in the past.

29. Are the answers to any of questions 8 - 27 above different for any of these groups?

We consider that all young people, without discrimination, should be free from exposure to material likely to encourage sexual activity in circumstances where it is prejudicial to their welfare.

GOOD PRACTICE

30. Can you tell us of particular examples of effective preventive (preventative) practice in any of the areas listed above and the results that are being achieved?

If "effective preventive practice" has an acceptable meaning, it would refer to the prevention of the sexual activity liable to lead to unmarried adolescent pregnancy (particularly among those under the age of consent). Please see p. 23 of this submission (in Part 3).

31. Some areas with apparently similar populations have very different rates of teenage conceptions. Do you have local knowledge of cases like this and if so, can you explain what causes the differences?

Cultural factors 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.

SUPPORT FOR TEENAGE PARENTS

32. Can you substantiate or add to this list of risks? How many do you think are connected with young parenthood, and how many to do with other underlying factors such as poverty? Do you have evidence or data to clarify this?

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.

In the case of obstetric problems in adolescent pregnancy, it is well established that, in general, these are attributable to failure to seek antenatal care rather than to the mother's age per se. (Family Practice News, 15 December 1975) It is understandable that girls should have fears about seeking medical attention if they cannot be confident that doctors will not place them under pressure to undergo abortion.

33. How do you think central or local government policies could be reshaped to minimise the risks of social exclusion for young parents and their children? Please be specific, and list things in order of priority if possible.

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.

34. What should be expected of young fathers and how could they be helped to make a contribution?

Schools and social services could, where necessary, facilitate contact between the adolescent father and the baby's mother, involving the parents of both, to encourage the father to take responsibility for supporting efforts to safeguard the welfare of mother and baby during pregnancy and after the birth. (If the baby is to be placed for adoption, this will generally be the end of the father's involvement unless contact is later sought by the adopted child.)

While we would not necessarily recommend parenting classes for schoolchildren in general, those who have babies may benefit from advice from social services or voluntary groups on basic skills which they may be lacking.

3. 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:

(i) 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.

(ii) 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.

(iii) 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:

(a) 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)

(b) 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:

1. Abstinence programmes;

2. School-based skills building combined with factual information;

3. Programmes encouraging vocational development;

4. School-based programmes linked with contraceptive services;

5. School-based and school-linked clinics;

6. One-to-one counselling;

7. Non school-based educational programmes in HIV prevention.

The division of programmes into the above categories is somewhat arbitrary, but:

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.

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 noted, 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.

4. 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 [US] National Cancer Institute, 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.