UK Sexual Health & Education Briefing - June 24 2015

Sex and Relationship Education in Schools – A public health imperative and educationally achievable

David Evans - CEO Health Behaviour Group

• “In the context of the recent Education Select Committee recommendation for compulsory PSHE and SRE in schools – what is the latest thinking of making this happen?
• Is the political will (and capital) to remove the rights of parents there? How should the syllabus be constructed so that it can provide the right level, age-appropriate information without garnering hysterical headlines and  alienating parents?
• How far are teachers being prepared to teach PSHE and SRE?”

I’ve been engaged with SRE as a public health concern for over twenty years and I welcome this opportunity to address a few of the questions from my particular perspective.  I hope my contribution adds to this important discourse.

It was back in 1990 that I was first invited by the University of Exeter, Department of Child Health to talk about the development of a sex education programme.  Dr Alex Mellanby and Dr John Tripp were both around 6’4” and sat opposite me in a small office.  It was the first of what I came to call a  ‘Jurassic Park’ moment – when a vulnerable human victim is trapped in an enclosed space being eyed up by  wildly oversized predators.  After a very few pleasantries Alex said,

We want our programme to change behaviour – how do you feel about that?”

“What do you mean?  What sort of behaviour?”

“We want to stop teenagers from having sex.”

“Why?”

“Because early teenage sexual involvement carries a lot of serious health risks.”

I thought to myself,  “Sexual involvement carries risks at any age – why pick on teenagers?”

I said, “That’s going to be hard, can’t you just settle for safer sex?”

Alex said, “It doesn’t seem to work – we want them to postpone sexual intercourse until a time when it really is their decision.  When they are in a worthwhile relationship and when they can manage contraception.”

John said, “A lot of people don’t think we should be trying to change young people’s behaviour, what do you think?”

I franticly though back to my behaviour as a teenager in the seventies and I realised I was the wrong person for the job. On the other hand, I was setting up an experimental theatre company and I was skint.

I kept thinking about what kind of teenager I had been, nobody could make me do anything.

“Well” I said,“You won’t be able to force them – how old are you talking about?”

Alex. “Thirteen year olds, fourteen year olds  - we’ll know if we’ve been successful when we ask them to do a questionnaire at sixteen.”

I couldn’t see much wrong in the general idea.They weren’t aiming for celibacy or total postponement until marriage and I was still young enough to remember the huge pressures I’d felt to become sexually involved long before sixteen – and some of the drastic risks I’d taken.  I asked how they thought they would achieve it.

They didn’t know, but they were interested in what I thought a drama experience could offer.  We talked at length about theatre in education and whether it could influence behaviour.  I said that I’m sure that was one of the original cultural functions of theatre and performance. My involvement in theatre had certainly influenced my behaviour.  They asked me to write-up the notes of the conversation, which I did.  They paid me.  I heard nothing more for over a year.

And then I was asked if I wanted to devise part of the Apause“peer”education training programme.  Sixth formers were to use role plays to help year 9s to say “No” to unwanted sexual involvement. “Do you want to be part of a programme designed to change behaviour?"

I said, “I do.”

I tell this story to illustrate exactly how clear they had been in their intentions and the fact that they thought I should know exactly what the project’s ambitions were before I consented to contribute.

Apause did influence behaviour, the results were published in the BMJ in 1995.It retained its identity as a public health programme with educational benefits.It was commissioned by health and education authorities and at its height ran simultaneously in over 140 schools.

It is a comprehensive sex education programme which encourages young people to use local sexual health services and we have encountered many of the challenges that a statutory SRE curriculum is likely to face.  Curiously, and recent research continues to bear this out, parents are rarely the problem.  Some parents are the problem, a small minority can make a lot of noise. Our experience confirms that it is possible to set up a comprehensive SRE curriculum, including topics which might raise antagonism without offending enough parents to prevent it from functioning successfully. Parents have always had the right to withdraw their children from Apause, but our experience has been that very few do.  My guess is that, within certain parameters, if SRE were made statutory with parents retaining the right to withdraw their children, very few parents would actually exercise that right.

So, what might those parameters be?  I said at the beginning I was going to speak from a public health perspective, and I make no apology for my utilitarian position (1781, coined by Jeremy Bentham (1748-1832) from utility. One guided by the doctrine of the greatest happiness for the greatest number)

Taking a public health viewpoint, whether we’re talking about childhood obesity, drinking, smoking,bullying or sexual health, ultimately improvements can only result because of some kind of behaviour change on a population wide basis. Unlike almost all other curricular areas, health education andSRE aims to help young people adopt or adjust specific behaviours - encouraging those behaviours that reduce the chances of them damaging their health and well-being and, just as importantly, discouraging behaviours which might damage the health and well-being of others.

My guess is that on a purely subjective and intuitive basis, most delegates here would agree that it is the quality of our relationships which make the greatest contribution to our health and sense of well-being.  You won’t need me to list numerous academic studies which show a strong association between poor long term health prospects (both physical and mental) and unsatisfactory and unhappy relationships.  However young families are constituted, the glue that holds them together and gives them resilience and stability, is made up of such qualities as love, mutual respect, commitment, relationship skills and access to basic entitlements such as health services. So, when we talk about sex and relationships education, avoiding unwanted pregnancies and STIs is peripheral to the much greater challenge of equipping young people to manage intimate relationships.

Mellanby and Tripp’s literature review had revealed that on a population basis you can’t scare young people into adopting healthier behaviours.  Even imparting relevant information, by itself, is unlikely to promote healthier choices of behaviour.Work by Doug Kirby shows that SRE curricula that have resulted in healthier behaviours have been underpinned by a well-established theory of behaviour such as social cognitive theory.  Desired behaviours have to be modelled and perceived as ‘normal’, the learners need to identify in some way with the individuals or groups modelling those behaviours.  The behaviours need to be codified such that they can be readily recalled as symbols. The consequences or outcomes of such behaviours need to be seen as beneficial.  If the behaviours are novel and require specific competencies, they need to be practiced.  Even with all these components in place individuals need to have a sufficiency of self-efficacy belief such that they will choose to execute the behaviours when circumstances require it.  Lastly, and by no me least, all these learning processes need to be encountered within a positive affective state.  In short, the learners need to find it enjoyable.

Devising and delivering curricula that achieve all these features is a challenge.  But the good news is that it is possible.

The key to success is, I believe, being explicit about the specific health behaviours that are being promoted.  Age appropriate attitudes, beliefs and  knowledge are brought into the equation in order to support those behaviours.

If I may give the overly simple example of introducing the benefits of contraception to year 9s (13 and 14 year olds).  Bearing in mind latest research by NATSAL shows that only a third of young people will have had sex by 16, how age appropriate is it to dedicate valuable curricular time to giving year 9s demonstrations of, or even practice with, condoms using applicators?  If we want young people to have fulfilling relationships which don’t put them at serious health risk, shouldn’t we be providing models of relationships in which they have decided what, for them, is an appropriate stopping point? Yes, at 13 and 14 they should know about condoms and how to get information about using them.  But parents and the media would have a lot less to get hysterical about if they knew that their children were being taught that most young people their age are not having sex and here are some ways of letting your partner know how far you want to go without having sex. Given the behavioural theory I briefly outlined earlier, it is not difficult to see why, in certain lessons, using peer educators, perhaps aged 16 or 17, as facilitators have proved to be so effective.

In terms of age appropriateness, then, I am not suggesting year 9s should be kept ignorant of medical considerations such as contraception or STIs, rather that the kind of detail and behavioural expectations we might be trying to impart might be better suited to years 10 or 11.  This may seem rather a simplistic example, but I would argue that we may need to take a more nuanced approach to understanding what is age appropriate for the majority of a class at any given age, and for that minority of young people who may already need medical support or advice ensure they know where to seek appropriate information and help outside the classroom environment.

If PSHE and SRE were to be made statutory, it is entirely pertinent to ask how much curricular time will be allocated to the subject.  If, for example, only six hours per year is dedicated to SRE for year 9s ( which in my experience is a lot more than average), how should that time be used?  Should we make an inventory of all the commonest hazards young people may be exposed to, such as child sexual exploitation, pornography, cyber bullying, grooming,  homophobic bullying, unwanted pregnancy and STIs to name a few?And develop an issue-based curriculum aimed at protecting them from these dangers? Or should we attempt to identify an absolute core set of values and behaviours which will give them a powerful sense of healthy normative expectations around relationships.  Such healthy ‘normal’ expectations will serve to protect them against those hazards which are identified through the early warning signals of what is ‘abnormal’.  If they don’t know what a ‘normal’ and healthy relationship looks, sounds and feels like, how are they supposed to have the discernment and resilience to deal with the hazards we already know about? Not to mention those which may be lurking just round the corner?

My point is that given the almost inevitable minimal curricular time that will be made available, the majority of parents, educators and health commissioners must surely be able to agree on a basic, core curricular entitlement.  Provided, that is, that curriculum designers are absolutely explicit about their intended health goals, behaviours and methods.

How far are teachers being prepared to teach PSHE and SRE?

I am not qualified to comment on the whole of PSHE but there is little doubt that most teachers are poorly prepared to teach SRE.  Again, I am taking a public health perspective here, but is it enough for schools to enable young people to make ‘an informed choice’ – as if the provision of information will point people to making healthy choices?  When it comes to adopting healthy behaviours I make no apology for quoting professor PJ Naylor, “Information is essential - but not enough!”

I am running short of time here so I will be attempt to make my points as briefly as possible and trust you will interrogate me further during the Q&A section.

If we want SRE to be behaviourally effective there must be a minimum of curriculum contact time of 12 – 14 hours and that time must be structured according to Kirby’s 17 features common to effective curricula.  If you follow the PSHE Association guidance these conform very closely to Kirby’s findings.

According to an influential group of philosophers, social theorists and performance theorists  who we are, our identities, are determined by the utterances and actions we make and observe.  At the moment of utterance a transformation occurs, or as J L Austin put it ‘My word is my bond’ – this notion is dubbed ‘performativity’.  If we want to promote a behaviour or a normative expectation that coercive sex is entirely socially unacceptable, then the classroom experience needs to provide mechanisms that ensure students have opportunities to state that belief out loud.  They need to have opportunities say what words they would use to assert themselves to resist pressure, what words they would use to tell someone that the pressure they are exerting on someone else is unacceptable.  In short, the classroom becomes a kind of forum in which the students themselves are practicing and promoting their own agency in the matter of making coercive sex an entirely minority and pernicious behaviour.   And the whole experience probably needs to be fun.  Probably it needs to have some element of theatricality to it.

These can be challenging classroom practices to develop and they need to be sanctioned by a robust and explicit curriculum supported by senior management, parents, governors and community leaders.

In looking for a synthesis combining performativity, theatre and health behaviour theory, my PhD thesis will conclude that performativity in the classroom is critical to a behaviourally effective curriculum.  It is entirely achievable.  Our work has shown that by codifying the mechanisms of classroom theatre the preconditions which engender performativity can be created. Novice facilitators of SRE can acquire the performatives which make them effective practitioners.

Which brings me back to my opening anecdote:

There was something about the way in which Drs Tripp and Mellanby had challenged me, made their intentions explicit which gave their eventual offer of work a certain sense of moment. It was portentous.When I agreed using the words, “I do” the act committed me to something that, indeed,came to shape my identity.