1 SUMMARY

The following decision is sought.

1.1 That approval be given to the proposed Department procedure for sexual health and education of service users.

2 REASON(S)

This decision supports Aims 1 and 5 of the Corporate Strategy.

2.1 Sexual health can be defined as The integration of the physical, emotional, intellectual and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication and love. (World Health Organisation). Essential elements of good sexual health are equitable relationships and sexual fulfilment with access to information and services to avoid the risk of unintended pregnancy, illness or infection.

2.2 Social care practitioners often work with service users who have lacked appropriate support or who are facing difficulties or prejudice in developing their sexual health as defined in 2.1 above. This can result in inappropriate behaviour, exploitative/exploited relationships, lack of self-esteem and unintended pregnancy or sexually transmitted infection.

2.3 The procedure provides a framework to underpin work on sexual health and education by social care practitioners with service users and their families. It defines boundaries within which staff should work and promotes current good practice.

3 OTHER OPTIONS CONSIDERED AND REJECTED

3.1 Separate procedures for the new Children's Services Department and Adult Social Care Departments may be proposed in the future as the departments develop. At this stage, it is felt important that a procedure is urgently adopted to provide a framework for current work.

3.2 The Education Department Management Team has endorsed the proposed procedure. They would like to see a Children's Services Department policy in due course but feel there could be value in developing a corporate policy for this area of work. The legal position of Education Department staff working in schools, the Youth Service or employed by schools is complex and a new department policy will take time to develop. Given these difficulties and the current need of social care practitioners for a policy, the Education Department Management Team supported approval of the proposed procedure.

4 Conflicts of interest declared by the decision-maker or other executive member consulted

None

5 Dispensation granted by the standards committee

None

6 Reason(s) for the matter being dealt with if urgent

Not applicable

Approved by: Date of decision:

Councillor Patricia Banks

This procedure will impact on the delivery of the following Corporate Aims - Aim 1 Maximising Life Opportunities and Aim 5 Improving Services. Sexual health can be defined as The integration of the physical, emotional, intellectual and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication and love. (World Health Organisation). Essential elements of good sexual health are equitable relationships and sexual fulfilment with access to information and services to avoid the risk of unintended pregnancy, illness or infection.

1 SUMMARY

1.1 The proposed Department procedure on sexual health and education of service users has been developed to provide a framework of good practice for staff to work within. It follows consultation with service users, staff and managers in all sectors of the Department. The procedure has been cleared by the Council's legal advisers and is in line with government advice for work on these issues.

1.2 The procedure:

1.2.1 outlines the role of staff in this area of work

1.2.2 clarifies the levels of confidentiality that service users may expect and staff may offer

1.2.3 outlines the level of support that staff may offer to service users to access contraception and sexual health services

1.2.4 emphasises an equal opportunities approach to these issues

1.2.5 refers to training opportunities already provided through the Training Coordinator (Teenage Pregnancy) and the County HIV Development Worker

1.2.6 refers to the need for information leaflets for service users and their families to include references to aspects of this procedure where appropriate

1.2.7 recognises the need for more detailed operational advice and guidance to be developed under this over-arching procedure.

2 LEGAL IMPLICATIONS

2.1 The procedure has been approved by the Council's legal department and is in line with the government's current advice on these issues.

3 FINANCIAL IMPLICATIONS

3.1 The Social Services Financial Services Unit has agreed that there are no additional implications.

4 PERSONNEL IMPLICATIONS

4.1 None other than training requirements which will be covered within staff Annual Performance Reviews.

5 IMPACT ASSESSMENT

5.1 In compiling this report account has been taken of the requirements of the Corporate Equalities Plan and Race Scheme. The requirements in the Race Relations Amendment Act which concern carrying out Impact Assessment are confirmed forming part of the programme of work relating to the Department's Service Plans.

6 CONSULTATION WITH LOCAL MEMBERS

6.1 There has been no specific consultation about the procedure with local Members as this is a countywide development.

7 LINK TO EVERY CHILD MATTERS OUTCOMES

7.1 The procedure primarily supports outcomes for young people in the sections, Being Healthy and Staying Safe. By becoming self-confident young people enjoying healthy relationships, they are more likely to Enjoy and Achieve, Make a positive contribution and Achieve economic well-being.

8 KEY POINTS FROM PROPOSED PROCEDURE:

ROLE OF STAFF

8.1 A trusting relationship with their parents/carers that enables open discussions about sex and relationships is considered to be one of the best protective factors for people as they mature. It usually results in delaying sexual activity and reducing the risk of sexual infection or unintended pregnancy.

8.2 The Local Authority has the role of corporate parent for the children and young people that are termed looked after and through its staff, is responsible for delivering this aspect of parenthood.

8.3 There is also a role in our work with vulnerable adults and service users with special needs. We aim to work holistically with people, recognising different aspects of their lives in our assessments. Sexuality is an aspect of people's lives which can be minor or highly significant in their assessed needs.

8.4 Most people are helped to develop their understanding of sex and relationships through lessons at school and by discussions within the family but it is widely recognised that many people in the care of Social Services will have experienced a disrupted education as well as a disrupted home life. They may miss important information, lack advice and be exposed to poor role models and practice by the significant adults and peers in their lives. The Department has a role in educating its service users about sex and contraception, helping its service users to establish personal boundaries within relationships, developing self-esteem and negotiating skills.

8.5 The national curriculum for schools requires children and young people to be educated about human biology, including the menstrual cycle and reproduction but other aspects of sex and relationship education are covered in the Personal, Social and Health Education framework which is non-statutory and of variable quality and content (Ref: Personal, social and health education in secondary schools - Ofsted 2005). The Personal Education Plans of children and young people should include reference to sex and relationship education as appropriate and staff will need to under-pin this work.

8.6 Many service users, particularly those with special needs, are not aware of how and where to access local contraceptive and sexual health services. Good sex and relationships education, coupled with information and access to appropriate local services have been shown to be the best form of prevention. (Health Development Agency, 2003). The Department, through its staff, has a responsibility to assist its service users in knowing how and where to access these services. Issues around maturity, sexual health and relationships should be sensitively included for both genders in Health Reviews, Health Plans, Placement Plans, Pathway Plans, Transition Plans and Care Plans

8.7 The Local Authority shares parental responsibility for children and young people who are accommodated on a Care Order under Section 20 of the Children Act. However, under Section 22 of the Children Act 1989, the Local Authority may do what is reasonable in the circumstances to safeguard or promote a young person's welfare. This includes ensuring that they have accurate information and guidance on sex and relationships education. Some children and young people may be accommodated for relatively short periods of time with their parents/carers continuing to play a real part in their lives, while others may have been accommodated for a long time with little or no parental contact. The degree of involvement by parents/carers needs to be taken into account when deciding, and if necessary, justifying who should be responsible for ensuring that sex and relationships education takes place.

8.8 People develop their sexual identity at different speeds and phases of their lives. Personal circumstances, together with the encouragement and prejudices of peers, family or society may suppress or support this process. Staff should be supportive of this development and the issues that service users may be encountering as they come to terms with their own feelings and identity. Work will often be in partnership with health professionals, particularly for service users with specific health needs/disabilities.

8.9 The Department supports staff in:

8.9.1 Discussing issues around sex and relationships with service users as appropriate to their needs and situations.

8.9.2 Working with service users to develop self-esteem, negotiation skills and boundaries for emotional attachments and sexual activity.

8.9.3 Informing service users about their local contraceptive and sexual health services and assisting them to access services if appropriate.

8.9.4 Supporting service users to develop their own sexual identity.

9 CONFIDENTIALITY

9.1 Service users are very unlikely to discuss their feelings and concerns about sex and relationships with people who they feel will share the content of the conversation with others. This can put them at great risk of sexually transmitted infections, pregnancy, developing psycho-sexual problems affecting their emotional maturity and to abuse.

9.2 Information sharing between staff, particularly by staff in residential settings may lead to a climate where the content of any conversation with a service user about sex and relationships may be recorded for other staff to read. This can severely reduce the level of trust that service users have in their relationships with staff working in these settings.

9.3 Staff have to work within the legal framework covering child protection and abuse of vulnerable adults. This can create a tension over the level of confidentiality that can be offered to a service user.

9.4 The conditions under which confidential advice and information on contraception and sexual health can be provided to young people under 16 are outlined in the Guidance to Social Services (Local Authority Circular (86)3). This guidance is based on the Fraser Guidelines for health practitioners and applies to both children and young people who are accommodated under Section 20 of the Children Act and to those on Care Orders.

9.5 All service users have a right to confidentiality about their discussions with a staff member providing the principles of the Fraser Guidelines contained in the Guidance to Social Services (see 9.4 above) can be met.

9.6 Contraceptive and sexual health advice should be given to service users over the age of 16 who seek it with appropriate support to ensure that:

9.6.1 the service user can understand the advice and what is involved in terms of the social, emotional and moral implications.

9.6.2 the service user can make an informed decision about who else (if anyone) should be told that the contraceptive advice is being sought.

9.7 The Sexual Offences Act, 2003 does not prevent the provision of confidential advice and treatment to young people under 16, including those under 13. An exception has been introduced in statute to make it clear that a person does not commit an offence if he/she acts for the purpose of:

9.7.1 protecting the child from sexually transmitted infection, or

9.7.2 protecting the physical safety of the child, or

9.7.3 preventing the child from becoming pregnant, or

9.7.4 promoting the child's emotional well-being by the giving of advice

9.7.5 as long as he/she does not act for the purpose of causing or encouraging the activity encouraging the offence or the child's participation in it. This exception does not apply if the person is acting for the purpose of obtaining sexual gratification themselves.

9.8 The government advises that confidentiality can only be breached in exceptional circumstances where the health, safety or welfare of a young person or others would otherwise be at grave risk of significant harm. The decision whether to breach confidentiality depends on the degree of current or likely harm, not solely on the age of the service user.

9.9 The Sexual Offences Act 2003 enables prosecution in cases of abusive and exploitative sexual activity. It includes a number of offences that criminalise sexual activity between under 18s and under 16s, however it is not intended that this will lead to prosecution where there has been mutually agreed activity within normal adolescent behaviour by young people of a similar age, regardless of their sexual orientation and where there is no evidence of abuse or exploitation.

9.10 The Department takes the view that line managers need to be able to support staff in developing their skills and to monitor the overall picture within their areas of responsibility. Service users should be informed that a staff member may raise the content of their discussions about sex and relationships with their line manager as part of their supervision process but any issues will remain confidential unless:

9.10.1 the service user is judged not to be competent under either the Fraser Guidelines or the Guidance to Social Services (Local Authority Circular (86)3), or

9.10.2 issues of abuse have been disclosed as defined within procedures for the protection of children and vulnerable adults.

9.11 When a staff member begins to discuss any issue around sex and relationships with a service user, they should quickly make clear the level of confidentiality that they can offer and support the service user to access the health service or other agencies if this is the service user's preference.

9.12 Should a staff member feel that it is necessary to break confidentiality, they should explain their decision at the time unless to do so would be to put the service user at great risk to themselves or others. In such cases, the staff member should discuss their action and reason to break confidentiality with their line manager. Information sharing should strictly be on a need-to-know basis within departmental procedures.

9.13 In situations not affected by child protection or vulnerable adult procedures, where a service user is judged to be competent (see 9.5 above), only a minimum of information about the conversation/issue will usually be recorded on case files.

9.14 All service users and their families/carers (as appropriate) will be made aware of the level of confidentiality offered by the Department. Our aim is to work in partnership with parents/carers where possible but any concerns expressed by the parents/carers must be weighed against concerns for the health and well-being of the service user when working on any aspect of sex and relationships with their child.

9.15 Children and young people have a right to confidentiality as in 9.8 above but, as in the Guidance to Social Services (Local Authority Circular (86)3) staff are encouraged to support the child/young person to talk with their parents or other carers on all issues, including sex and relationships.

10 ACCESS TO CONTRACEPTION & SEXUAL HEALTH SERVICES

10.1 Staff have an important role in supporting service users to access local contraceptive and sexual health services. This is particularly important where a service user is known, or thought to be sexually active.

10.2 It is important that sexual health and contraception is covered in the health reviews and plans of all service users who are, or may be sexually active, both male and female.

10.3 Links may be developed between residential homes and appropriate local health services so that a health drop-in session may be established at the home which can offer confidential treatment and advice, including contraception as appropriate.

10.4 Staff working with female service users who have had unprotected sex should know how and where the service user can access Emergency Hormonal Contraception. Those service users who have difficulties in accessing it should be supported by staff if appropriate.

10.5 If a service user is intending to be sexually active, only condoms will reduce the risk of both sexually transmitted infections and unintended pregnancies. Staff and residential homes working with a number of service users who are sexually active are encouraged to complete training through the Get it on condom distribution course and to make condoms available to service users in line with Section 11 below.

10.6 If a service user suspects that she may be pregnant, it would be preferable for them to have a pregnancy test at one of the local health services. However, if they refuse, a staff member may support them in doing a home pregnancy test as a first step towards helping them to access appropriate health services. Fear and denial often deter teenagers from seeking an early pregnancy test resulting in poor antenatal care or late abortions. Although home pregnancy testing kits are reasonably reliable, it would be advisable to have the test confirmed at a local health service where the issues of possible sexually transmitted infection and methods of contraception can be covered.

10.7 Legally a young woman under 16 can obtain a confidential abortion through the health service providing she meets the terms of the current Abortion legislation and health practitioners judge that she is competent to make the decision under the Fraser Guidelines. Health practitioners will do what they can to persuade the young woman to discuss the issue with her parents/carers but must respect her wish for confidentiality in the rare cases where she refuses to do so. Confidentiality cannot be offered if there are Child Protection issues.

10.8 Social Services staff may be in a difficult position if a young woman under 16 discloses to them that they are seeking an abortion, particularly if they are requesting practical assistance to access a local health service or they are accommodated by the department under Section 20 of the Children Act or under a Care Order. In these cases, the staff member should inform the young woman that whilst she has the right to seek an abortion through the health service, Social Services staff who are aware of her intentions have to discuss the situation with their line manager before they can give assistance in accessing the service, though this should not prevent information on local health services being given to the young woman.

10.9 Confidentiality must be maintained wherever possible (unless there are Child protection issues) if requested by the young woman and information shared with the parent/carer in exceptional cases where assistance to access the service is given, and only after full discussions with the young woman. In such cases the young woman should be supported by a staff member. It is important that this process does not cause too much delay in the young woman accessing health services due to the legally defined time limits for abortion.

10.10 In all cases where staff are aware that a service user has undergone an abortion, support and assistance to post-abortion counselling should be offered according to the needs of the woman and maintaining confidentiality as outlined above.

10.11 Support should also be offered to male service users whose partners have become pregnant. They may also benefit from checking for a sexually transmitted infection and need support to take on their parenting responsibilities or sense of loss if the woman decides upon an abortion.

11 CONDOM SUPPLY BY STAFF

11.1 Only staff who have completed training recognised by the multi-agency Get it on condom distribution scheme in Hampshire and who are approved by their line manager may supply condoms to service users.

11.2 Service users must be judged to be competent under the principles of the Fraser Guidelines or the Guidance to Social Services (Local Authority Circular (86)3) and they should be trained in the use of condoms in line with the advice given by the Get it on course.

11.3 Staff should discuss the service user's sexual activity within the bounds of the confidentiality statement (see 9.8). Our aim is to help service users to resist any pressure to have early or unwanted sex but we also recognise the need to safeguard them from sexually transmitted infections or unintended pregnancy.

12 STAFF BOUNDARIES

12.1 All staff should work within the Code of Practice for Social Workers published by the General Social Care Council. Supervision can be used for guidance and support when staff face issues in working with different personal values to their own.

12.2 Staff need to be conscious that they might become the target of a service user who may be seeking to involve them in confidential discussions as a way of developing an emotional relationship with them. Staff should not use discussions with a service user to disclose information about themselves and if a staff member feels uneasy about working with a particular service user, they should discuss the issue with their line manager.

12.3 The Department does not tolerate staff developing other than a professional relationship with any of its service users. Staff should be aware that the Sexual Offences Act 2003 has brought in several new offences that may criminalise what may appear to be consenting sexual activity between carers and service users, even where they are aged 16+ and competent to give consent under the Fraser Guidelines.

12.4 When issues of abuse are disclosed in confidential conversations, staff must adhere to the Department's procedures for the protection of children and vulnerable adults.

13 SERVICE USERS WITH DISABILITIES

13.1 The procedure applies equally to all service users with any disability at any age. Service users with disabilities often feel that they are denied sexual fulfilment by staff and services that are not willing to treat them in the same way as other members of the community, or to make supportive arrangements.

13.2 In some cases, service users may require physical assistance/devices for sexual activity. For the protection of both staff and service users, staff must consult with their line manager before taking any action to facilitate or offer assistance to service users.

13.3 The Sexual Offences Act 2003 recognises the rights of people with a mental disorder to a full life, including a sexual life. However, in order that they are protected from abuse and exploitation, three new offences have been brought in to cover cases where

13.3.1 a person does not have the capacity to consent to sexual activity due to a profound mental disorder

13.3.2 a person with a mental disorder is induced, threatened or deceived into sexual activity

13.3.3 a person providing care, assistance or services to someone with a mental disorder engages in sexual activity with that person.

14 ETHNICITY, RELIGIOUS & CULTURAL ISSUES

14.1 Staff need to be aware of the viewpoints on sex and relationships held by different religions and traditional within local ethnic communities. These issues should form the background for discussion with service users, when appropriate, as they may impact strongly on their behaviour, relationships and well-being. However, no assumption must be made that a service user will have decided, or will decide, to adopt the viewpoint of their family's religion or traditional culture.

14.2 The service user may need support in coming to terms with the differences between their family's expectations and the lifestyles that they see around them in wider society. This might include helping them to access support to maintain their religious or cultural lifestyle, or support to develop a different lifestyle if this is their intention and they have considered the possible impact of doing so.

14.3 Discussions about sex and relationships with service users should help them to understand and respect the range of lifestyles present in British society.

15 PERFORMANCE STANDARDS

15.1 The Strategic Service Manager (Teenage Pregnancy) and the County HIV Development Worker will review the procedure on an annual basis and in response to any changes in legislation or occurrences that may require change.

15.2 Managers will monitor staff confidence and skills to work on sex and relationships issues as part of their Performance Development Review Appropriate provision should be made in the Team Development Plan.

15.3 The Training Coordinator (Teenage Pregnancy) and the County HIV Development Worker will monitor take-up by Department staff on training opportunities and feedback on training provided in order to maximise its impact.

RECOMMENDATIONS

That the Policy Review Committee advises the Executive Member for Adult Social Care

1. to approve the procedure on Sexual health and education of service users to cover social care practitioners across all sectors of the current Department .

2. to approve the development within the next 18 months of separate procedures for the new Children's Services Department and Adult Social Care Department.

Section 100 D - Local Government Act 1972 - Background Documents

The following documents discuss facts or matters on which this report, or an important part of it, is based and have been relied upon to a material extent in the preparation of this report.

A full list of legislation and documents sourced has been included on page 2-4 of the proposed procedure. All the sourced documents have been published. NB the list excludes:

1. Published works

2. Documents which disclose exempt or confidential information as defined in the Act

Copies of the full draft procedure can be obtained from [email protected]