Posted 13th Oct 2016
What do you see as the biggest sexual and reproductive rights issue for young people in Europe?
Well, of course, Europe is a big place, but, overall, I would say freedom of sexual expression for young people. Sexual diversity is still a big issue in some parts of Europe; in many places young people are still assumed to be heterosexual, but are seen as being bit out of order if they are actually sexually active. Most countries do not celebrate or even recognise that young people are sexual beings - very few things are as regulated as young people’s sexuality. Of course protection is important - protection against unwanted pregnancy, sexually transmitted infections and sexual abuse - but efforts to protect young people can have the effect of being restrictive of young people’s rights.
What do you see as the biggest sexual and reproductive health issue for young people in Europe?
I would say abortion, in particular measures which make it more difficult for young people to access services. There are still several countries in Europe where access to abortion is restricted, and even in countries where it is legally available, stigma is often attached to abortion which is not easy to address. Unlike access to services related to contraception or STIs and HIV, it is difficult to normalise young people’s access to abortion. These issues often make it hard for young people to access services as soon as they need them, which means that they often wait too long before seeking abortions.
What needs to be done to make it easier for young women to access abortion services in countries where it’s legal?
Make medical abortion easier to access, backed up with good sex education which includes information about abortion. Make services more open to young people. Increase young people’s awareness of what they can do privately, for themselves, so that no stigma will be attached. We need values clarification for service providers, who can sometimes be very judgmental when young people are at their most vulnerable. And parental consent regulations should be eased. It is important to provide moral support to young people who find themselves pregnant. We also don’t pay enough attention to supporting pregnant young women and girls. In many countries in Europe this isn’t a medical problem as such, but they often face prejudice if not abuse from service providers, instead of the information and services they need to make decisions for themselves and take back control of their lives.
What barriers do young people face in accessing SRH services and education?
Lots, but issues surrounding the age of consent cause particular problems - if sex is illegal for young people under 16 years of age, it is difficult for them to access services. The UK Fraser Guidelines  represent good practice, as they give health practitioners the flexibility to prescribe contraceptives to young people aged under 16 if they believe it is in their best interest. Without such flexibility, if young people below the age of consent come up to a teacher after a sex education lesson to ask their advice about contraception, for example, the teacher may be legally obliged to see this as a child protection issue, and report them. This is a tricky issue to solve.
What is unique about young people’s sexual health rights?
Everyone is a sexual being; the concept of evolving capacity is particularly valuable for young people. The way that sexuality is presented is so important; it’s often presented as a risk, rather than as an integral part of life, contributing to well-being, mental health, etc. Young people are particularly (but not exclusively) susceptible to self-doubt, and concerns related to body image - people jump to sexuality-related issues as the underlying cause, and seek to manage and control them, hardly giving young people the possibility to explore sexuality for themselves.
You’ve been a pioneer in advocating comprehensive sexuality education (CSE), famously likening most sex education to trying to teach young people how to drive by explaining what all the engine components do. Tell us a little about programmes that do talk a bit more about sexuality - can you give us examples of where it’s made a real difference?
The critical requirement for comprehensive sexuality education is that it be comprehensive. It’s important that CSE sets out to give young people the tools to:
- Improve sexual literacy - it’s important to cover what’s under the bonnet, but to do so in language that young people understand
- Become more confident around their own sexuality, and their ability to say yes or no in different situations
- Negotiate safer sex more confidently, and know where to go for resources, and services
- Feel a sense of solidarity - art of a wider community - and recognise how they can help others
- Take control of their own sexuality
- Become critical thinkers in society
It’s difficult to single out CSE programmes, because you have to look at the context of each programme - whether it’s an in-school or out-of-school programme; whether the sessions are in small groups or not. There are particularly good programmes in Sweden, the Netherlands, Denmark and Estonia. Overall, it’s important to focus on what is happening in school; often programmes are more about safeguarding the norms in society, rather than reaching young people with the information and services they need.
As you have pointed out, most societies are not good at acknowledging that young people are sexually active, or encouraging pleasure-positive initiatives that enable young people to be confident in their relationships. Can you tell us how this approach has empowered young people?
Research shows that, if you enjoy your sexuality, it has a direct effect on increasing the chances of you practising safer sex. We know that issues relating to negative experiences of sexuality and low self-esteem are linked to rising suicide rates among young people. We used to talk about sexual pleasure as a missing element in much sex education, but pleasure isn’t really the best term; it can lead to the idea that sex is just about orgasms. It’s better to focus on sexual well-being, so that young people are more confident about sex, and know how to enjoy it. It’s about moving beyond a narrow focus on negative health consequences to embrace positive mental health, encouraging young people to find out what they find pleasurable. Sex-positive is the term that we prefer to use now to cover these things; in particular, finding sex-positive ways of keeping sexuality in sex education.
The LGBT community have succeeded in raising diversity awareness. But have we really made it easier for young people who don’t feel they fit into the heterosexual or gender binary norms?
Some countries have made progress on diversity issues, but some have a long way to go. We’re very good at compartmentalising society, and it’s important to recognise difference - for example being transgender is so different to being gay. There is therefore a need for space for separate, exclusive groups, but evidence suggests that, ultimately, people want to be integrated into society. We have had this experience with HIV - the importance of focusing on difference in order to recognise special needs, but then to integrate diverse groups within society as a whole. In general, societies like to focus on difference, but this isn’t always the best approach.
There’s lots of anxiety about the internet, and pornography as a source of information about sex and sexuality for young people. What is your take on this?
People are right to be worried, but young people are not the biggest consumers of pornography. The most effective antidote is good comprehensive sexuality education, which should include teaching young people to be savvy on the internet. Young people face more bullying and harassment now, but there are really good resources available online, such as Love Matters , which has good information and which comes up under search terms young people are likely to use - young people are unlikely to enter “sex education” into a search engine, for example...
You’ve done a lot of work trying to get people to understand what “youth-friendly” sexual and reproductive health and rights services are. What are the hallmarks of these services?
Youth-friendly was a good term when we started. It implied a focus on confidentiality, respect for young people, and, in general, how to be an “askable” service provider. Providers needed to be open and positive about sexuality, and to recognise the sexual context of their (young) clients. Above all, they needed to ensure that young people felt confident to ask questions; youth friendly services would lead to stigma-free access to services for young people. And, of course, such services would be good for everyone, not just young people. In a sense we have moved beyond that now because service providers shouldn’t really be in control of whether or not young people can access services; as a young person, you need contraceptives in your toolkit. Service providers need to be there as a safety net; ideally young people would know what to ask for. We still tend to see service providers as the gate-keepers, but young people shouldn’t have to secure their permission or approval in this way. The ideal role of the service provider is to create a more equitable relationship between themselves and young people; helping them to ask smart questions, along the lines of the three questions model in Australia . Service users there are encouraged to ask healthcare providers about the options open to them, the pros and cons of each, and how to get the support they need to make the decision that is right for them. These are the basic ingredients of a client-centred approach - giving young people what they need to prepare themselves for a more equitable interaction with their healthcare provider.
Have you seen any programmes working on violence against women, or any other sexual and reproductive health and rights issue, that have effectively engaged young men?
There are great programmes for young men in Sweden, and also in Brazil and South Africa. In particular, programmes are focusing on fatherhood, especially for young fathers who are often in low-paid jobs and who need paid paternity leave. It’s important to remember that young men too have sexual rights and uncertainties; there is so much focus on young girls that this is often forgotten. When I worked in the Netherlands, where I was among the first to work with boys and youth offenders, we also had a growing young migrant population from the Netherlands Antilles. We had a special outreach programme aimed at young migrants, particularly young men, which combined sex education with cultural insights into how to be a young person living in the Netherlands. The influence of social media is very strong and it can be a confusing time for young men. We want to help them to become critical thinkers about what, for example, masculinity might mean for them.
You’re from the Netherlands - a country often held up as an example to the world because of its relatively low teenage pregnancy rates. Can you tell us what you think is particularly good about services available to young people in the Netherlands, and also something you think they could improve, or possibly learn from other programmes you’ve worked with?
In many ways, we were pioneers in the Netherlands; we had relatively good sex education programmes and access to abortion services for young people, whom we accepted and recognised as sexual beings. The gay and feminist movements were valuable in raising awareness of critical issues. But something we were not good at was supporting women into the workforce; in particular we had poor regulations for women returning to work after pregnancy. There is some evidence to suggest that the low teenage pregnancy rates in the Netherlands may have been in part due to good discussions taking place continuously between mothers and daughters, because the mothers were at home. One thing we need to keep on learning is the importance of continuous investment; the job is never done. In Finland, they had good services for young people and low teenage pregnancy rates. Government subsidies for these services were then cut and abortion rates rose. We have to keep on prioritising investment in this area; success means keep going, not job done.
If you had one message for people providing sexual and reproductive health services to young people, what would it be?
Don’t treat the young person in front of you as your own child; they are not your niece or your nephew; they are a sexual being entitled to make their own decisions. Do not start a thought or a sentence with “If you were my own daughter”...
Are there any questions you wish we’d asked you?
No, but I’d like to end by talking a little about what I mean by solidarity, which I’ve mentioned already. We need young people to know what to do when their rights are violated, and of course we need to talk about sexual violence, abuse, child marriage, etc. But there is a life after that, and I think we often fail to think about that, or show solidarity to young women and men who have lived through it. They need to feel confident about sex after an abortion, for example. We often talk about prevention and then stop - female genital mutilation (FGM) is a good example of this. We need to make the greatest effort to stop this practice. But we also need to work with the survivors of FGM; we can learn from women who have survived FGM and have found a way to enjoy sex. We have to move beyond victimising, to help women and men to become resilient again. This kind of solidarity was important in countries in former Yugoslavia where rape had been used as a weapon of war, and mental health support became a core sexual and reproductive health and rights strategy to build resilience and hope in the future.
The eFeature interview was conducted by Karen Newman on behalf of MEDFASH.
The content of all eFeatures represents the views and opinions of the authors. MEDFASH does not necessarily share or endorse the views expressed within them.