SEXUAL HEALTH
Sex arouses such strong reactions among people, governments, religions and the media that very often the importance of sexual health is ignored and not discussed and debated openly. Even if we ignore it, the ubiquitous nature of sex and sexual health means that we ignore it at our peril. The problems of sexual health cannot be suppressed because they merely re-surface as more pressing or acute problems for society.

Currently, sexual health is a problem high on the agenda in Scotland. Why is this? It is clear to those interested in public health in Scotland that sexual health remains a major and, in some respects, a growing problem. This is evidenced by the teenage pregnancy rates in Scotland (which are among the highest in western Europe), increasing numbers of people with sexually transmitted diseases including syphilis, genital Chlamydia and gonorrhoea, and the abuse and violence (psychological and physical) associated with gender such as rape, or sexual orientation such as homophobia. I hasten to add that Scotland is by no means alone in the sexual ill-health it has. But being honest and transparent about its problems is an important step forward and sends a positive message to all concerned that these problems need to be dealt with and not swept under the carpet.

How is Scotland being honest and transparent? The Scottish draft sexual health strategy1 has recently finished its consultation phase. In the draft document, the Chair of the expert Reference Group that produced the draft, Professor Phil Hanlon states, ‘Sex is a positive and fulfilling part of the lives of most people, irrespective of age, culture or faith.’ The draft document is known more correctly as the Scottish sexual health and relationships strategy ‘Enhancing sexual wellbeing in Scotland’. Readers who are interested in the draft document can access it at the following website: http://www.scotland.gov.uk/library5/health/esws-00.asp

The Reference Group had a remit to develop a national sexual health and relationships strategy for Scotland, with particular emphasis on:

For those interested in definitions, Stedman’s concise medical dictionary includes a definition of sex as ‘the physiologic and psychological processes within an individual which prompt behaviour related to procreation or erotic pleasure’. In fact, the Reference Group used the WHO definition of sexual health which, rightly, takes a broad and holistic approach to sexual health: ‘A state of physical, emotional, mental and social wellbeing related to sexuality…sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.’ (http://www.who.int/reproductive-health/gender/sexual_health.html)

I should add that as a public health physician, as well as a citizen, it is evident that Scotland has an ambivalent attitude towards sexual health. All the evidence points to young people becoming sexually active and exploring their sexual orientation at a relatively young age. The popular approach to these issues is to ignore them or not talk openly about them. The official response has never quite been ‘just say no’, i.e. an abstinence approach to sex for young people, but it has been confused. Part of this may be the culture of Scotland of not talking openly about emotional or difficult issues. But I believe it is more than this culture—it is also about Scotland not learning from the evidence from the Netherlands and elsewhere of what works about sexual health policy and practice.

It is important to accept that people do have differing and, sometimes, divergent views on sex, sexuality and sexual health. But the need for policy-makers and practitioners is, while acknowledging these differing viewpoints, to develop an approach that meets the needs of the people of Scotland; in particular, the needs of young people. As the Reference Group stated, such a response incorporates the following values:

The Reference Group recommended 5 ways of meeting its vision of a society that accepts sex as a normal and healthy aspect of life, people valuing their sexual health, having respect for others, and having access to appropriate health services. The 5 ways are through the provision of national leadership, through the provision of local leadership, setting clear national and local targets and goals, using existing mechanisms for consistent and comprehensive delivery, and monitoring progress through public reports.

It will be interesting to see the responses to the draft strategy. I believe the Reference Group has produced a balanced document that takes account of the differing perspectives on sexual health in Scotland. Importantly, the Reference Group had representatives from the Church of Scotland, Catholic Church and Scottish Jewish community who all agreed to the draft strategy. The document also provides a genuinely broad, evidence-based approach to sexual health and well-being. Producing the document was the easy bit (difficult enough though that was) and the much harder test of making a difference in practice is yet to come. It is a test which Scotland dare not flunk.

h. s. kohli
hkohli@htbs.org.uk