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Setting up a sexual health clinic in a school

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VOL: 97, ISSUE: 41, PAGE NO: 38

Delya Lane, BMedSci, RGN, RSCN, is a school nurse at the Ivy Lodge Clinic, Sheffield

Patricia Day, BMedSci, PGCE, RGN, is a school nurse at Norfolk Park Health Centre, Sheffield

Becoming a mother at a young age can have a catastrophic effect on the life chances of both the young women involved and their children.

Becoming a mother at a young age can have a catastrophic effect on the life chances of both the young women involved and their children.

Sheffield has a high rate of unplanned teenage pregnancies - 5.4% of under-18s in 1995-1997 (Office for National Statistics, 2000), the fourth highest in the Trent region (Sheffield Health Authority, 2000). There is also a high rate of sexually transmitted diseases among teenagers, with a dramatic increase in infection rates among young women since 1996.

The schools we work at are in areas of social deprivation. They have some of the lowest educational attainment rates in the city and a significant proportion of unplanned teenage pregnancies. Although Sheffield has sexual health services aimed at teenagers, these are based in the city centre, about 20-30 minutes away by bus. Statistics show that not all young people access them.

The most effective way to reduce teenage pregnancies is to link good school-based sex education with appropriate local services (University of York, 1997). Although the provision of contraceptives in schools is a controversial issue (Bloxham, 1997), we thought that it might be an effective way to reduce the number of teenage pregnancies in the area and set up a pilot sexual health clinic to test this theory.

Setting up the pilot sexual health clinic
The Spires youth club, an established club in the grounds of Myrtle Springs School, provided a suitable location for the clinic. It is easily accessible but not actually in the school building. If the pilot was successful, we hoped this would allay the concerns of other schools and they would also allow us to set up clinics.

Initial consultations took place with the youth workers at the Spires centre. They were enthusiastic about the idea and the school's head teacher and family planning consultant were supportive.

Over several months various meetings were held between the school nurse management, the youth worker in charge of the centre and the senior management team at the school. Joint planning by a multi-agency group is strongly advocated by the government. Some teachers voiced concerns about the potential repercussions of providing such a service at a school and these were discussed.

Preparation for the launch of the project was thorough. We identified the need for a male worker to be involved in the project to address the issue of young men's health. Research has shown that this area is often neglected (Ray, 1998). Fortunately, the youth work team leader agreed to become involved. A media campaign was organised to prevent any adverse publicity.

Service provision
We offered the following services at the clinic:

- The provision of condoms in accordance with the Sheffield youth clinic protocols;

- Pregnancy testing;

- Emergency contraception for young women aged 15 and over;

- Group work, during which young people are free to explore issues concerning relationships.

We decided to open the clinic straight after school on Mondays, to attract young people as they left the school grounds. The youth clinic in the city centre is always busiest on Mondays, and this backed our gut feeling that weekends provide young people with increased opportunities for socialising and drinking, potentially increasing the risk of unprotected sex.

Attendance
In the first year of the project, many young people have attended regularly. In particular, an established group of young men attend group sessions most weeks.

Six young women have been given emergency contraception after visiting the clinic. Although the service is still in its early stages, we believe that this is a significant step. As confidence in the service grows, we hope that more young people will be encouraged to use it.

Critical incidents
Initially, the nurses at the project were unable to dispense emergency contraception, so two young women were referred to a local GP. Both were willing to attend and communication between the Spires and the practice was effective. Another young woman arrived too late for emergency contraception and was referred to the central youth clinic. Since January 2001, one of the nurses at the project has been able to dispense emergency contraception in accordance with the local protocol. Three young women have benefited from this provision.

The drop-in nature of the service has enabled easy access to follow-up, and one of the young women has attended on a regular basis to discuss her relationships. She has commented on her feelings of trust towards the workers.

Soon after the service started, a young woman who thought she might be pregnant attended. After a positive pregnancy test she was referred to the city's central youth clinic, and from there to the termination clinic. Her care was then taken over by specialist services in the city.

Group work
Group work is offered to give young people the opportunity to explore issues such as relationships, negotiation skills and communication within relationships, and to improve their self-esteem. Research suggests that these issues are often not tackled in enough detail during school-based sex education (Hudson and West, 1996). Young people who attend the project can opt in and out of group sessions as they wish.

Most regular clients have been young men. This is to be welcomed. As the Social Exclusion Unit (1999) pointed out, 'young men are half the problem and half the solution'.

Most of the subjects covered during the sessions have been at our suggestion, although the young men have been fully engaged in the work. This reflects Ray's (1998) findings that young men in particular are embarrassed about saying what they want and ignorant of the possible content of sex education. A year on from the start of the project, we still find that young men have some difficulty in saying what they would like the group work to cover.

For young men to talk about their emotions and anxieties, they need a safe environment. Many learn about sex through pornographic material, which can portray negative images, particularly of young women. They need positive role models that show them how to express emotions, and the presence of a male youth worker has been crucial.

The setting and style of the project is completely different from school-based work. Youth workers can adopt an informal style and language, and are able to develop a relationship with young people that can enhance the work of other agencies. In this project, most group work is led by youth workers. The nurses take on the clinical aspects of the work and provide individual advice and contraceptives after group sessions. This ensures that we offer a complete service.

Through the group, the young men have discussed a range of subjects including first sexual encounters, their views of young women, asking someone out and negotiation within relationships. Videos and games are often used. They have also explored how the media portrays men and women through popular youth magazines.

Homosexuality has been openly discussed, and three gay teenagers came to talk to the group about homophobia and the reality of being young and gay. This was a particularly challenging session for one group member, who had openly admitted disliking gay people. The group has become a forum for personal growth and understanding. It was interesting and pleasing to hear one young man describe the gay teenagers who talked to the group as 'normal people'.

Sometimes the leaders challenge the teenagers' attitudes and a number of subjects have led to lively debate. These discussions have often related to relationships with girls. The prevailing macho culture of appearing tough and 'knowing it all' leads to sexist behaviour and attitudes. In the group sessions it is possible to challenge this and for young men to begin to talk more honestly about their feelings and attitudes without appearing to be weak or effeminate.

Room for improvement
Although the group work has been highly successful, there have been a number of problems. The fact that a group of young men attend regularly has caused tensions. New members have found it difficult to integrate and some have attended only once.

The young men who come every week do not like new members to join. They say it is boring to go over subjects they have already covered and appear to find new members' attitudes and behaviour immature. The issue of new people joining an established group poses problems that are difficult to resolve, although we hope that some regular attenders may become involved in mentoring.

When young women attend the group they are usually far outnumbered and find it difficult to voice their opinions. The group's dynamics are altered and the session is often difficult to manage because of continuous banter between the sexes. Both the young men and women have requested single-sex groups. This has implications for staffing, as both nurses are sometimes involved in seeing individual clients while the groups meet.

In a recent focus group of regular attenders, some of the young men revealed that they had been called 'gay' by their peers because they attend. Schools are close communities in which information and gossip spread quickly. When a local service is provided, anonymity cannot be guaranteed. It has also been a cause for concern that a number of girls have become pregnant since the project began.

Although the drop-in clinic's success has been recognised both locally and nationally, it cannot provide a comprehensive solution to what is essentially a complex problem. Such services can meet some of the needs of young people that are related to sexuality, but school-based sex education should also focus on relationships and feelings. This should start at an early age and encourage a sense of control and choice. Young men and women need to be given the skills to make decisions about their sexual health and to access services when they need them.

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