The Bratz Debate continues

When I started Contraception Education I would never have imagined the ramifications of the development of Contraception: the Board Game. Far from the purely educational nuts and bolts of preventing pregnancy through contraceptives, the whole thrust of the Government's Teenage Pregnancy Strategy focuses on helping all young people achieve their full potential. It's also about raising their aspirations for their futures, learn delaying, consenting and permission-giving skills and, of course, managing the risks of alcohol and drugs in relation to sex. Teenagers also need to learn how to navigate services and systems to get what they really need. But what I also didn't realise was the full extent of those messages, and how my work with teenagers would soon begin to overlap with junior school-age pupils too.


You may recall my comments in a Manchester Evening News article earlier in the year when I gave my opinion about the sexualisation of girls through play and toys. A recent report published by the American Psychological Association (APA) showed that our culture delivers many messages about sexualisation of adult women and that this, in turn, influences girls. It suggested that parents, schools, and peers sometimes contribute to this, and that girls themselves sometimes take on a sexualised identity.


One theory has suggested that this sexualisation of children may have negative consequences for all young people. The report suggests that images of girls and young women in advertising, merchandising, and the media are harming girls' self-image and healthy development, having cognitive and emotional consequences, consequences for mental and physical health, and an impact on development of a healthy sexual self-image. It goes on to suggest that parents have a role to play in encouraging girls to value themselves for who they are, rather than how they look, and to teach boys to value girls as friends, sisters, and girlfriends, rather than as sexual objects. The report proposes that with the help of their carers and parents, young people can learn 'media literacy skills', which in turn will help them to resist the message that how girls look is what matters.


Meanwhile, along came the Bratz, a prime example of a commercial enterprise which may well insidiously reinforce the very messages which have been highlighted by the APA as potentially harmful. The tiny bodies, the flawless complexion, the symmetrical features, the immaculate hair – looking a certain way, but not actually doing that much.


The MEN article said that my alternative would be 'Geekz': dolls that would care about the environment. I said, amongst other things: "I'd prefer it if a manufacturer somewhere came up with a doll which reinforced the importance of being healthy, happy and looking after your fellow human beings…..Why can't there be a doll which is concerned about reducing its carbon footprint." I would dearly love to see what my friends and family know to be my motto - an image of an ordinary person achieving extraordinary things and a real challenge to male and female stereotyping."

You can read the article and associated comments at www.manchestereveningnews.co.uk/news/s/1000/1000696_bratz_the_dilemma_facing_parents

How Contraception Saves Lives worldwide

Last month I was asked to write an article for The Practising Midwife in which I explored some global perspectives on contraception. Here is an extract from that article.

World population currently stands at more than 6.6 billion, and half of the world’s population is under 25 years old. The United Nations predicts that, if couples average 1.6 children, the world population will peak at 7.7 billion by 2050, and decline to 3.6 billion by 2150 (United Nations 1999). By averaging two children, the world population will rise to 9.4 billion by 2050 and reach 11 billion by the next century before stabilising. By averaging 2.5 children, the world population will increase to 11.2 billion and increase to 27 billion by 2150.

In 1994 the United Nation’s International Conference on Population and Development (the Cairo Conference) identified that population control required an holistic perspective, considering socio-political agendas and economic factors, rather than a focus on contraception alone.

Mortality and morbidity
Birth rates today are highest in the poorest regions (UN 2006). At present, average
expectation of life at birth is 63 years in Latin America, 57 years in Asia and only a little over 46 years in Africa, compared with more than 71 years in the developed regions. Although on average fewer than one in 40 children dies before reaching the age of one year in the developed countries, one in 15 dies before reaching one year in Latin America, one in 10 in Asia and one in seven in Africa. Because of major health threats such as AIDS and malnutrition, in some parts of Africa average life expectancy at birth is estimated to be less than 40 years, and one in four children dies before the age of one year. AIDS has changed the sexual health and contraceptive needs of women, and now protection from infection as well as from pregnancy is required.

Every year, around 530,000 women die during pregnancy or in childbirth. Lifetime risk of maternal death is one in six in Afghanistan, one in seven in Niger, one in 13 in Uganda and one in 14 in Ethiopia.In more developed countries this risk is one in 2,500 (WHO 2004). Additionally, each year 3.3 million babies are stillborn, more than 4 million die within 28 days of birth, and another 6.6 million children die before the age of five, the majority from preventable causes. Less than 1 per cent of these deaths occur in the more developed countries.

Women who are in poor health are more likely to give birth to unhealthy babies, and often cannot provide adequate care. Studies in Bangladesh in the 1980s found that when a mother died, her newborn baby had a very small chance of surviving the first year (PAI 2006). The spacing of births therefore has a powerful impact on the chances of a mother and her child’s survival. In less developed countries children spaced less than two years apart are about 2.5 times more likely to die before the age of five than children spaced three to five years apart. Babies of mothers who have pregnancies close together are often born underweight or premature, develop slowly and have an increased risk of childhood diseases (PAI 2006).

Older children surviving their mother’s death are less likely to eat a balanced diet, and girls often leave education very young to care for younger siblings. Young girls who are not in education are more at risk of teenage pregnancy. Teenage girls are less likely to get antenatal care and are at greater risk of birth complications. Girls aged 15 to 19 are twice as likely – and girls under15 five times as likely – to die in childbirth than young women in their twenties (PAI 2006). Young women are also more at risk of developing sexually transmitted infections and HIV/AIDS. Every year, almost half of all new HIV infections and at least onethird of all new sexually transmitted infections occur in women under 25 (Panchaud et al 2000).

Abstinence is often the only form of sex education and contraception available, and coitus interruptus (withdrawal of the penis prior to ejaculation), natural family planning (fertility awareness) and lactational amenorrhoea are still widely used. Their efficacy is low, although better than nothing, and they offer no protection from infection......

Barrier methods such as the male and female condom are more expensive than the traditional methods, but offer good protection from infection when carefully used. They need to be positively and sensitively promoted as there are myths surrounding contraceptive use in many cultures, and inaccuracies are disseminated sometimes for religious and political reasons. Papers have been published to persuade people not to trust condoms, but to abstain in preference, sometimes falsely claiming that condoms let through infection

Contraception provision in remote areas is more complicated as more resources and expertise are required for hormonal methods, diaphragms and IUDs.

Abortion
Approximately 87 million unintended pregnancies occur each year; more than half end in abortion. About 18 million of those abortions are thought to be unsafe. About 68,000 women die from unsafe abortions every year; more suffer serious complications (WHO 2005). Studies show that contraceptive use correlates with a considerable decline in the abortion rate, and a corresponding reduction in abortionrelated deaths (Senlet et al 2001). In Russia between 1998 and 2001, contraceptive usage increased by 74 per cent and the abortion rate declined by 61 per cent (PAI 2005). In Kazakhstan, contraceptive prevalence increased by 50 per cent in the 1990s, and
abortion rates decreased correspondingly (Westoff 2001). Abortion rates in the Czech Republic have fallen from 116,000 per annum in the late 1980s to 27,600 per annum now, as the percentage of Czech women using birth control pills has quadrupled (Henshaw et al 1999). Women needing abortions will often risk unsafe conditions. The provision of legal abortion helps save lives, but does not increase the use of abortion. In many Latin American and African countries where abortion is illegal or severely restricted, abortion rates are higher than in Western Europe where it is legal. In poor countries, women face a higher risk of death from unsafe abortion. For example, in Africa, one in 150 abortions leads to death compared with one in 85,000 in more developed countries (WHO 1998). It is estimated that 350 million women in developing countries lack access to effective contraceptives (Henry J Kaiser Family Foundation 2004). Politicians can have immense control over access to contraception, abortion and sterilisation. Restrictive abortion policies affect poor people more than wealthy because poorer people rely on the public sector for their health needs whereas women who have money can usually pay for an abortion privately and bypass public policy.

Nevertheless, the United States has a contentious policy known by its opponents the ‘Global Gag Rule’ which denies US Family Planning funding to any national or international organisation that supports abortion. Many international governments condemned the restriction as detrimental to women’s health and a breach of the right of citizens to participate in their own democratic political processes. This is seriously restrictive, as most organisations that deal with contraception do refer for abortion on contraceptive failure.

In the UK, abortion is relatively safe. In 2005 a total of 186,400 abortions were performed on residents of England and Wales; 84 per cent of these were funded by the NHS (ONS/DH 2005). Eighty-nine per cent of abortions were carried out at under 13 weeks’ gestation; 67 per cent at under 10 weeks (ONS/DH 2005). Women seeking abortion do so under the Abortion Act (1967) Amended, which requires two registered medical practitioners to be of the opinion that an abortion is justified in the light of their clinical judgement of all the particular circumstances of the individual case.

Empowering women
Modern methods of contraception can empower women to be independent; economically active; live a longer, healthier life; and provide better for a limited number of children, enabling them to have a much better chance of survival (PAI 2006).
Contraception in the hands of women also enables them to make choices independently of their partners whenever necessary; and when domestic abuse prevails in a culture, contraception and access to abortion can be crucial to a woman’s ability to survive and move on. Women who are not pregnant or bringing up small children on the whole are able to engage in uninterrupted work more easily, and in more developed countries make career progress more quickly. However, some women may feel pressured to work because welfare benefits and maternity and paternity leave provision are inadequate. Fertility and contraceptive use and increased autonomy are linked to the education of women in developing countries (Castro 1995, Saleem and Bobak 2005). This link plays an important role in the development of family planning policies in lower-income countries.

Enforced population control
There is evidence at the structural level that
extreme cases of ‘population control’ have forced women to use contraceptives, have abortions or to be sterilised. Incentives and education The population of India is set to rise above 1 billion by 2050, and this has occupied politicians for decades (National Commission on Population 2000). India was the first country in the 1950s to start a National Family Planning Programme, and in the 1970s the role of the Auxiliary Nurse Midwife (ANM) expanded into population control. ANMs had targets to recruit people to take up contraception and sterilisation, and were denied payment if they underachieved. Another method of persuasion employed in India was the use of incentives. The Indian Family Planning Council in the early 1970s recommended an incentive of food to anyone undergoing vasectomy. Female sterilisation was incentivised again in 2000. Opponents criticised the temporary nature of the incentives. A more recent policy in India discourages marriage before the age of 21 because teenage marriage contributes to population growth. India no longer sets targets on contraceptive use or sterilisation but now strives towards better access to healthcare and a focus on female literacy.

Involuntary sterilisation
Involuntary sterilisation has been reported in Eastern Europe since the 1970s, and was again highlighted in the media in 2003 when it was reported that Romani women in Slovakia continue to be subject to violations of their human rights. A three-month study revealed that coerced and forced sterilisation practices continued in Slovakia against Romani women. The New York Center for Reproductive Rights (2003) conducted interviews with more than 230 women in almost 40 Romani settlements throughout eastern Slovakia. They found instances of coerced, forced and suspected sterilisation of Romani women, along with racially discriminatory standards of care including denial of access to medical records (CRLP 2003).

Social change
Human rights and law can be used as instruments for social change. In Colombia, an organisation called Profamilia established a legal service for women to help them secure reproductive and sexual rights. The service addresses abortion services, prevention of sexually transmitted infections, informed consent, emergency contraception and gender-based violence. As a result of this initiative, the Ministry of Health in Colombia changed some policies and guidelines.

Urbanisation and coercion
By the end of this century the majority of the world’s population will be living in urban areas. Urbanisation is an element of the process of modernisation. Some countries manage this well, but others do not – and in these parts of the world it is uncontrolled, accompanied by overcrowding, slums, deterioration of the environment, unemployment and other socio-economic factors.

China is particularly renowned for its very strict one-child policy. The country’s population is expected to increase to 1.6 billion by 2050 (Heilig 1996). The one-child policy was introduced in the late 1970s and claims to have prevented at least 250 million births since 1980 (Zhu 2003). In the early years of the policy, women who were visibly pregnant for a second time were encouraged to have an abortion, even late into the pregnancy. In addition, hundreds of thousands of women have been sterilised.

The one-child policy restricts couples to having one child, unless either is from an ethnic minority or if they are both ‘only children’. With one child, families receive free education and benefits, which are withdrawn if couples have another child, and they face a fine for every additional birth. In most rural areas, a couple may have a second child after a break of several years. It is therefore more common to find couples in the countryside, where 80 per cent of the population live, with a large number of children. Sons are often preferred as they carry on the family name. More than 90 per cent of all aborted fetuses in China are female (Zhu 2003). Some maintain that this policy has led to the killing of female infants. Men are thought to outnumber women in China by more than 60 million – some estimate 100 million (McCurry and Allison 2004).

For the full article and references please click here or email barbara@contraceptioneducation.co.uk

Media and commercial influences on teens

When I started Contraception Education I would never have imagined the ramifications of the development of Contraception the Board Game.

I am in education, and was originally trying to improve knowldge and awareness of contraception, to prevent unintended pregnancies. The Teenage Pregnancy Strategy (TPS), however goes much much further than that. The thrust of the TPS is to help all young people achieve their full potential, raise their aspirations for their futures, learn delaying, consenting and permission-giving and permission-asking skills, of course also learn how to manage the risks of alcohol and drugs in relation to sex, and learn how to navigate services and systems to get what they really need, improving life chances and tackling poverty and inequality.

In February 2007 I made another connection when I was asked to comments in the MEN about the sexualisation of girls through play and toys. A recent report published by the American Psychological Association showed that our culture delivers many messages about sexualization of adult women and that this in turn influences girls. Parents, schools, and peers sometimes contribute to this, and that girls themselves sometimes take on a sexualized identity . One theory has suggested that this sexualization of may have negative consequences for all young people. The report suggests that images of girls and young women in advertising, merchandising, and media is harming girls' self-image and healthy development having cognitive and emotional consequences, consequences for mental and physical health, and impact on development of a healthy sexual self-image.

It goes on to suggest that parents have a role to play in encouraging girls to value themselves for who they are, rather than how they look, and to teach boys to value girls as friends, sisters, and girlfriends, rather than as sexual objects. The report proposes that with the help of their carers and parents, young people can learn “media literacy skills”, which in turn will help them to resist the message that how girls look is what matters.

Meanwhile, along came the Bratz, a prime example of a commercial enterprise which may well insidiously reinforce the very messages which have been highlighted by the APA as potentially harmful – the tiny bodies, the flawless complexion, the symmetrical features, the immaculate hair – looking a certain way, but not actually doing that much. It was said with tongue in cheek that my alternative was “Geekz”, dolls who would care about the environment.
I said, amongst other things "I'd prefer it if a manufacturer somewhere came up with a doll which reinforced the importance of being healthy, happy and looking after your fellow human beings…..Why can't there be a doll which is concerned about reducing its carbon footprint."

I would dearly love to see a doll representing an ordinary person (I mean someone like you and me, not a model) achieving extraordinary things and really challenging male and female stereotyping.

Read the APA report and associated comments at http://www.manchestereveningnews.co.uk/news/s/1000/1000689_bratz_dangers_or_role_models.html

Final Report of Six Years of Research into Abstinence

A six-year study the final report of which is available to download as a pdf from http://www.mathematica-mpr.com/publications/PDFs/impactabstinence.pdf examined the behaviour of more than 2,000 American teenagers and found that sexual abstinence education does not work and says that the $1.5 billion spent by the US government to promote abstinence over the past ten years has been a waste of money. The study was conducted by Mathematica Policy Research, a nonpartisan firm, which conducts policy research and surveys in healthcare, education, welfare, employment, nutrition, and early childhood.

The study (http://www.mathematica-mpr.com/welfare/abstinence.asp ) followed the sexual behaviour of teenagers from a cross-section of communities in Florida, Wisconsin, Mississippi and Virginia. Their average age was 16. Half of the sample who had received abstinence only education displayed the same sexual behaviour as those who had received sex education in which contraception was discussed. Teenagers from both sample groups had the same average age for their first sexual experience: 14.9 years, and one quarter in both groups had had sex with three or more partners. (Guardian, 16 April 2007, p3; Times, 16 April 2007, p30)

Davina McCall and Let's Talk Sex

The popular TV presenter and celebrity Davina McCall has aligned herself to the campign for compulsory sex and relationships education and the programme Let's Talk Sex was shown again on Channel 4 on 23rd March.

This wonderful programme showed the open and honest approach of teachers and parents in the Netherlands, where teenage pregnancy is not the huge problem it is in the UK, and young people seem much less hung up about sex and relationships.

Davina McCall selected three words which epitomise what sex education should be: EARLY, CONSISTENT and COMPULSORY. At the moment in the UK it is none of these things.

Contraception and Abortion (Parental Information Bill)

Angela Watkinson, Conservative MP for Upminster, presented a 10-minute rule Bill to the Commons today, demanding that doctors inform parents if an under-age child has an abortion. She argues that a rethink on current guidance is needed following a Unicef report which found that 40 per cent of UK children aged under 15 are sexually active. The Contraception and Abortion (Parental Information) Bill also calls for an overhaul of sex education in schools, which Watkinson claims has become little more than 'sex information' with advice on how to get contraceptives.

The Bill will give doctors the right to keep sexual health issues confidential if there is abuse or violence in the family.

Anne Weyman, Chief Executive of fpa, said that such a change in the law would discourage young people from seeking advice on pregnancy, contraception and sexual health. Coverage about this appears in todays Express, Independent and Telegraph today.

BBC Radio 5 Live Debate

At 11.15 last Saturday night Anita Rani's programme on BBC 5 Live, Barbara Hastings-Asatourian was invited to join a phone in debate alongside the radically opposing views expressed by Family Rights Activist Lynette Burrows, famous for being investigated by the police after expressing views perceived by some to be homophobic, against gay couple adoptions.

The feature had been sparked by a piece of today's news all spectacularly reporting the story of a 14 year old student from Paignton Community Sports College, in Devon, herself 6 months pregnant, who had been invited to talk to a group of friends who had become pregnant. She and her parents are reported to be concerned that college used her inappropriately. The school has not yet been able to comment, as it was half term. The papers took the opportunity to sensationalise the vulnerable teenager's situation.

Ms Burrows very early on in the discussion expressed the tired yet extreme argument that teenagers are getting pregnant to get a free house and benefits. Barbara Hastings-asatourian who has been carrying out research into teenage pregnancy now for many years, and who with Julie Wray evaluated the implementation of the Teenage Pregnancy Strategy in Manchester and Salford, knows that is just not the case. Over half of all teenage pregnancies end in abortion, not a strategy for gaining benefits and housing, but one which would be resolved by better sex education and better access to contraceptive services suitable for teenagers. And of those younger teenagers who keep their babies many stay at home with their families, unable to claim benefits in their own right. As they get older the social housing offered to teenage parents is far from ideal, and benefits are no panacea, teenage parents are at risk of poverty, poor nutrition, social isolation, poor housing and poor health.

Teenage pregnancies nationally in the under 18s are down by 11.1% from baseline figures in 1998. In 1998 in England there were 41,089 (rate 46.6 per thousand under 18's), and in 2004 this figure was 39,350 (rate 41.5 per thousand under 18's) the national teenage pregnancy strategy has a target to reduce teenage pregnancy by 50% by the year 2010.

In areas of social deprivation teenagers' aspirations for their futures are known to be less ambitious than their peers in more advantaged areas, and teenage pregancy rates are higher in those areas. That is why the government's teenage pregnancy strategy is so focussed on raising aspirations, preventing pregnancy, getting young parents to stay in education, or return to education, to seek really good childcare and to improve their chances of having a decent lifestyle in the future for themselves and for their children.

In Devon in 2004 there were 405 teenage pregnancies, a rate of 31.2 per thousand under 18's and 46.4% of those ended in abortion, this total is 5.3% less than the 1998 baseline. Devon's teenage pregnancy rate as a whole is below the national average of 41 per thousand, although Paignton Community College provides for 2 deprived areas, and so the teenage pregnancy rate there is slightly higher than average.

However, Paignton Community College is recognised for its positive contribution to teenage sexual health in these difficult circumstances. It has a teenage information and advice centre, Tic Tac, which offers students access to a variety of health professionals. The centre deals with a range of health issues, including contraception and advice, and was highlighted as an example of good practice in Ofsted’s report on Sex and Relationships Education. The Tic-Tac centre includes sexual health advice. The main driver for the centre is to raise attainment, as young people are better able to focus on learning when they are free from health concerns.

The centre is widely publicised through the school’s PSHE programme. Issues raised in PSHE are often followed up in individual appointments. The centre is not a first-aid facility, it provides advice rather than medical treatment. Although broad-based, the majority of young people using Tic-Tac are seeking advice on sexual health issues. Feedback suggests Tic-Tac has led to a much more positive view of health professionals among students. Older students, in particular, are now much more likely to seek advice from mainstream health services.

One of the things the press reported today was the teenager's concern that she may have influenced her peers to decide which way to choose. That is unlikely to be the case as according to national statistics, between 50-60% of teenagers who get pregnant under 16 have an abortion. The figures from the teenager’s friends although not scientifically generalisable, seem to mirror the national trend. So she should be reassured that although she has shared her experiences with her peers, which incidentally is known to be really helpful, she isn’t responsible for their decisions or the national trend.

Peer education is a tried and tested way of educating teenagers, it’s not without its problems, and generally involves training. Sharing experiences is also useful – we shouldn’t be afraid of real experiences – for some people having a baby is a positive thing, for some it perceived to be a way of escaping a miserable life or of finding love in an otherwise hostile world, for some it's none of those. We are all very different and our choices are based on many factors.

Contraception Education have developed fact sheets and resources on www.contraceptioneducation.com to inform people. We have written resources like Contraception the Board Game to get people to think through their choices. BUT sex education just doesn’t exist in all schools in the way Lynette Burrows described on the 5 Live Programme. It is inconsistent around the country, and cannot be judged in that way until it measureable nationally and a statutory part of the national curriculum.

There is a campaign at present to make PSHE statutory, because until PSHE is taken as seriously as the other academic subjects, it loses out in competition with those subjects. Sex education can be exciting and brilliant if it is delivered in a positive environment by teachers who are passionate and properly trained to do it.

Barbara was keen to point out the situation in Western Europe where sex education is part of the curriculum. Countries like France, Sweden and the Netherlands do sex and relationships education , it is taken seriously, it is not taught alongside morals. People in those countries don’t seem to get heated about it, they don't hold up implementation of sex education with erroneous moral arguments. Instead they promote positive loving relationships, and instill a sense of responsibility for each other, including the importance of getting tested (without fear of stigma). In fact they get on with it and they get results, just what we need here in the UK.

In the phone in were three contributors, a father of two who felt that state benefits encourage teenage sex and teenage pregnancy, a 15 year old who felt sex education in school was lacking, and an older man who was in hios 20's before he learned anything about sex. The mixed bag of debate made for a very interesting and stimulating half hours discussion.