THE UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND

Demographics and a Historical Perspective
1. Basic Sexological Premises
2. Religious and Ethnic Factors Affecting Sexuality
3. Sexual Knowledge and Education
4. Autoerotic Behaviors and Patterns
5. Interpersonal Heterosexual Behaviors
6. Homoerotic, Homosexual, and Ambisexual Behaviors
7. Gender Conflicted Persons
8. Significant Unconventional Sexual Behaviors
9. Contraception, Abortion, and Population Planning
10. Sexually Transmitted Diseases
11. HIV/AIDS
12. Sexual Dysfunctions, Counseling, and Therapies
13. Research and Advanced Education
14. Significant Differences in Sexual Attitudes and Behaviors Among Ethnic Minorities
References and Suggested Readings

Kevan R. Wylie, M.B., Ch.B., M.Med.Sc., M.R.C.Psych., D.S.M., with Anthony Bains, B.A., Tina Ball, Ph.D., Patricia Barnes, M.A., CQSW, BASMT (Accred.), Rohan Collier, Ph.D., Jane Craig, M.B., MRCP (UK), Linda Delaney, L.L.B., M.Jur., Julia Field, B.A., Danya Glaser, MBBS, D.Ch., FRCPsych., Peter Greenhouse, M.A., MRCOG, MFFP, Mary Griffin, M.B., M.Sc., MFFP, Margot Huish, B.A., BASMT (Accred.), Anne M. Johnson, M.A., M.Sc., M.D., MRCGP, FFPAM, George Kinghorn, M.D., FRCP, Helen Mott, B.A. (Hons.), Paula Nicolson, Ph.D., Jane Read, B.A. Hons., UKCP, Fran Reader, FRCOG, MFFP, BASMT (Accred.), Gwyneth Sampson, DPM, MRCPsych., Peter Selman, DPSA, Ph.D., José von Bühler, R.M.N., Dip.H.S., Jane Wadsworth, B.Sc., M.Sc., Kaye Wellings, M.A., M.Sc., and Stephen Whittle, Ph.D. Consulting Editors for this chapter were Maria Bakaroudis, M.A., and James Shortridge, M.A.

* This chapter was coordinated by Kevan R. Wylie, M.B., Ch.B., M.Med.Sc., M.R.C.Psych., D.S.M.

Demographics and a Historical Perspective

KEVAN R. WYLIE

The United Kingdom, composed of England, Wales, Scotland, and Northern Ireland, faces the northwestern edge of Europe. The British Isles, with 94,226 square miles (about the size of New York State), are separated by the English Channel from France on the south, Belgium, the Netherlands, Denmark, and the southern tip of Norway to the east. To the west, across the Irish Sea, is the Republic of Ireland. In 1920, the British Parliament divided Northern Ireland from Southern Ireland and gave each its own parliament and government. A few years later, when Ireland became a dominion and then an independent republic, six of the nine counties of Ulster in the northeast corner of the country chose to remain a part of the United Kingdom.

Geographically and culturally, the main island of the British Isles has three regional entities, England, Scotland, and Wales. The Principality of Wales in western Britain has an area of 8,019 square miles and a population of about three million. After early Anglo-Saxon invaders drove the Celtic people into the mountains of Wales, these people, who became known as Welsh (“foreign”), developed their own distinct nationality. English is the dominant language, with less than 20 percent of the people of Wales speaking both English and Welsh; some 32,000 speak only Welsh. The former kingdom of Scotland occupies the northern third of the main British island. The central lowlands, a belt approximately sixty miles wide stretching from the Firth of Clyde to the Firth of Forth, divides the farming region of the Southern Uplands from the granite Highlands in the north. About three quarters of Scotland's five million people live in the Lowlands, concentrating in the industrial center of Glasgow (population three quarters of a million) and the capital Edinburgh (population half a million). The Hebrides, Orkney, and Shetland Islands are also part of Scotland. England, the heart of the United Kingdom, has a population of close to fifty million people. London, the capital, has a population of about seven million; Birmingham, the second largest city, has a population of about a million.

The United Kingdom of Great Britain also includes the Channel Islands, the Isle of Man, Gibraltar (between Spain and Africa), the British West Indies and Bermuda in the Caribbean, the Falkland Islands and dependencies in the South Atlantic, the Crown Colony of Hong Kong in Asia, and Pitcairn Island in the Pacific Ocean.

According to the 1991 census, the population of the United Kingdom was 55,486,800. Wales had an estimated 1994 population of 2.9 million; Scotland, 5.1 million, and Northern Ireland, 281,000. The 1995 age distribution in the United Kingdom was: below age 14, 19.2 percent; ages 15 to 59, 60.1 percent; and over age 60, 20.7 percent. Ninety-two percent of the population lives in the cities. Ethnically, 81.5 percent are English, 9.6 percent Scottish, 2.4 percent Irish, 1.9 percent Welsh, and 1.8 percent Ulstermen. West Indians, Indians, and Pakistanis constitute about 2 percent of the population. The main religions are Anglican (Church of England) and Roman Catholic.

Life expectancy at birth in 1995 was 74 for males and 80 for females. The birthrate was 13 per 1,000 population and the death rate 11 per 1,000, for a natural increase of 0.3 percent per year. Literacy is 99 percent with twelve years of compulsory schooling and 99 percent attendance. The United Kingdom has one hospital bed per 146 persons and one physician per 611 persons. The per capita domestic product was $16,900 U.S.

B. A Brief Historical Perspective

Until about ten thousand years ago, Britain was connected to the European continent by a land bridge that made it convenient for peoples to migrate back and forth. With the end of the last great Ice Age, and the slow but inevitable melting of the ice masses that covered Europe and North America, the sea level gradually rose, separating the continent from the British Isles with the English Channel. Despite the new obstacle, people continued migrating, as the Celts did to the isles some 2,500 to 3,000 years ago. This Celtic influence can still be found in the language and culture of the Welsh and Gaelic (Irish) enclaves. England became part of the Roman Empire in 43 of the Common Era. The Roman legions withdrew in 410. In subsequent centuries, particularly the eighth through eleventh centuries, waves of Germanic Jutes, Angles, and Saxons competed with Danish invaders for control of the island. In 1066, Duke William led the Norman conquest of Britain, bringing continental feudalism and the French language, essential elements in later English culture.

In 1215, the nobles forced King John to sign the Magna Carta, guaranteeing the rights of the people and the rule of law, and setting the stage for the development of a parliamentary system of government. Defeat in the Hundred Years War with France (1338-1453) was followed by a long civil war, the War of the Roses (1455-1485). While European countries were racked by wars, English culture and a strong economy flourished under the powerful Tudor monarchy and a long period of domestic peace. Establishment of the Church of England in 1534 under the monarch separated England's religious institutions from the authority of Rome. Under Queen Elizabeth I, England became a major naval power, with colonies in the Americas. Britain's trade throughout Europe and the Orient also expanded. Scotland became part of England in 1603 when James VI of Scotland became James I of England. A struggle between Parliament and the Stuart kings, a bloody civil war (1642-1649), and establishment of a republic under the Puritans, ended with the restoration of the monarchy in 1688. The sovereignty of Parliament was confirmed in the “Glorious Revolution” of 1688 and a Bill of Rights in 1689.

The eighteenth century in England was distinguished by a strengthening of the parliamentary system and technical and entrepreneurial innovations that produced the Industrial Revolution. England lost its colonies in the American Revolution, expanded its empire with growing colonies in Canada and India, and strengthened its position as a leading world power. The nineteenth century was marked by extension of the vote in 1832 and 1867, formation of trade unions, development of universal public education, the spread of industrialization and urbanization, and, under Queen Victoria (1837-1901), the addition of large parts of Africa and Asia to the empire.

Britain suffered huge casualties and economic dislocations as a result of World Wars I and II, Although industrial growth returned after the wars, Britain lost its leadership role to other nations. Ireland became an independent republic in 1921, but the Irish question has persisted. In recent years, the socialized medicine, social security support systems have posed increasing questions for the government and people.

1. Basic Sexological Premises

PAULA NICOLSON

Gender roles in the United Kingdom have been influenced both by social class, which has ensured the maintenance of gender segregation, particularly among the upper and working classes, and by fluctuating demographic, political, and cultural changes over the past eighty years that have stimulated shifts in traditional gender-role patterns. For example, during World War II, women were employed in manufacturing, commerce, and agriculture, aided by good state provision of day care for children. Following the demobilization of the male population in the 1950s, however, there was a political emphasis on “pronatalism” in order to replenish the population and to free up employment possibilities for men. In this context, women's responsibility for the mental and physical health of their families was encouraged with a return to traditional gender lifestyles.

Although since the mid 1980s there has been a clear political commitment to seeing men and women as equal, a division of labor remains in the home that spills over into the workplace. This distinguishes men's and women's behavior and expectations along traditional stereotypical lines: Men are seen as powerful, rational, and “naturally” the breadwinners, and women are seen as dependent, emotional, and “naturally” suited to the domestic sphere. Nevertheless, feminist influence, coupled with high levels of male unemployment since the early 1980s among all social classes, has forced many men to take greater responsibility and interest in child care than previously. The resulting image of the “new man,” in touch with his emotions and with nurturing skills, remains, however, a contestable image. Finally, increased educational opportunities have enabled women to enter professional life, a process that has increased since the 1970s, although few women rise above middle-management level.

B. Sociolegal Status of Males and Females

Males and females officially have equal status in the United Kingdom in terms of human rights, but there remain certain sociopolitical distinctions. For instance, many women receive reduced unemployment benefits and pensions because they have not had to pay full contributions during their working lives and have had career breaks. However, women are entitled to a retirement pension at the age of 60, while the retirement age for men remains 65. This is currently the subject of political debate and proposed statutory changes.

The legal age of consent for heterosexual women and men is 16. Only recently was the age of consent for homosexual men reduced from 21 to 18. Further indication of inequality based on sexual orientation is the judgment upholding the ban on both homosexual men and lesbians in the armed services.

The age of heterosexual consent means that it is not legal for doctors to prescribe contraceptives to women and men under the age of 16 without parental consent, a contentious issue that remains unresolved.

Certain legal judgments have demonstrated inequalities in attitudes towards women and men. Some adolescent and older men found guilty of rape, for instance, have received relatively light punishments; in some rape cases, women have been portrayed as guilty of “contributory negligence”; and men who have killed their female partners because they “nagged” or were unfaithful were given light sentences or had the murder charge changed to manslaughter. Conversely, women who killed male partners after years of violent physical and sexual abuse have been found guilty of murder and given long-term prison sentences. This is indicative of the underlying ideology that remains in favor of male domestic authority and the traditional view of the male sex drive as dominant.

Finally, unmarried mothers are frequently portrayed by politicians as being irresponsible, and their entitlement to state benefits has been questioned. However, this has been counterbalanced to some extent by the creation of the controversial Child Support Agency, which has pursued absent fathers for child maintenance.

C. General Concepts of Sexuality and Love

The majority of the population in the United Kingdom are able to choose their sexual partners on the basis of attraction and love. This, however, does not apply among some minority ethnic groups, nor to social class groups where a socially suitable marriage is encouraged.

Since the late 1960s, there has been an increased liberalization of attitudes towards sexuality. The age of first heterosexual intercourse for women has declined from a median age of 21 for those born in the 1930s and 1940s to 17 years for those born between 1966 and 1975. The gap between the age of first intercourse for women and men has narrowed over the past fifty years, and for the current generation of young people, it is virtually the same for both sexes. A sizable minority of both sexes are sexually active before the age of 16. A high proportion of sexually active 16-year-olds do not use contraception (Wellings et al. 1994).

With more people changing sexual orientation over the course of their life, the category “homosexual” is no longer seen as discrete and exclusive (Dance 1994). However, it remains the case that heterosexuality is taken as the norm, and sexual satisfaction is understood to be orgasm for both partners during vaginal intercourse (Nicolson 1993). There has been an increase in availability of health practitioners specializing in sexual problems, and in the willingness of couples and individuals to seek psychosexual counseling when they fail to achieve sexual satisfaction.

Serial monogamy rather than life-time marriage is now the norm in the United Kingdom as in the U.S.A., with fewer people getting married and as many as one in two marriages ending in divorce.

2. Religious and Ethnic Factors Affecting Sexuality

JOSÉ VON BÜHLER

Since the 1950s, Britain has become increasingly a pluralistic country in terms of cultures, ethnicity, and religion. Hinduism mixes with Roman Catholicism, Islam with Judaism, and Methodism with Buddhism. Some of these religions are almost inseparable from their social fabric, culture, and ethnic grouping. Others offer a moral and spiritual framework separate from ethnic practices. The common denominator in the existence of this pluralism is that, apart from the establishment franchise of Anglicanism, which in reality makes it the “state religion,” all religious bodies in the United Kingdom are equal under the law of the land. This equality confers certain rights and privileges in respect of education, worship, social welfare, and democratic political rights.

However, the multifaceted character implied in interdenominationality in many instances is generally not understood by the public at large, or even the members of the various groups. Philosophically and socially, there is frequently a disconnection that does not allow for cross-fertilization of ideas. Nor does it allow for comparative analysis of the positive approach to sexual concepts and even sexual activities in many religions when their scriptures are properly understood! In this climate, it is easy for fundamentalists of every denomination to represent human sexuality in the religious/spiritual content as negative and somehow taboo. This tension was noted in a 1992 report from the Sex Education Forum, an umbrella body for several religious and secular organizations concerned with providing and supporting sex education for young people. The report, An Enquiry into Sex Education: Report of a Survey of LEA Support and Monitoring of School Sex Education (Thompson and Scott 1992), clearly identified: “anxieties concerning ethnicity and religious issues to be a significant barrier to the effective provision of sex education.” Indirectly, the report confirmed that the distance between religious legal equality and ethnic, social, and moral framework patterns and concepts is rather unequal among the various religious and ethnic groups in the United Kingdom.

Prior to the 1950s, the religious influences forming sexual constructs came almost exclusively from “the official church” of England, and “unofficially” from the other Christian denominations. In recent decades, the picture has become more complex. Since midcentury, the Church of England's approach to social morality and sexuality has fluctuated between two poles, the traditionalists and the modernists, or the “permission givers” and the “orthodox moral directors.” With the national religious scene resembling the circular approach of the politicians to sexual knowledge and attitudes, the sociosexual control and influence appears to bounce back and forth between church and state according to a mutually cooperative formula. In many cases, however, liberal attitudes have triumphed, as evidenced by the Church's acceptance of divorce, homosexuality, and contraception. In other cases, the traditionalists have retained a firm moral control. This doctrinal “pendulum” is confusing for the majority of the population who are not experts at moral and theological niceties and subtleties. The people themselves are part of the system of confusion: While expecting clear and definite moral messages from both establishment and Church, they reserve the right to judge the validity of those messages, even when they are biblically based.

With quiet, behind-the-curtains efficiency, the Roman Catholic Church has been influential in shaping national morality and sexuality. Its most authoritarian pronouncements about homosexuality and abortion have been tempered by professions of love for the individual while condemning same-gender sexual activity. To the democratic soul of the British people, Roman Catholic moral doctrine appears autocratic and dictatorial, even while it provides a secure, unchangeable frame of reference that is not answerable to cultural and ethnic differences, a characteristic attractive to the orderly British. Other Christian denominations, such as Methodism and the evangelical Protestant churches, swing between permission and condemnation. Methodists, for instance, accept that sexual learning should present the biologically functional principles and, at the same time, should be equally aware of human relationships and their influence in the happiness of the individual.

Whatever the sexual-moral code of the many Christian traditions in Britain, the individual appears to have the final word in moral choices, as long as these choices are based on “fairness” and “not hurting other people.” Nonetheless, it appears that religious beliefs are still a major influence on sexual attitudes and values. In this regard, for instance, the findings of the research study Sexual Attitudes and Life Styles (Johnson, Wadsworth, Wellings, and Field 1994), regarding first sexual intercourse are rather revealing:

Respondents belonging to the Church of England or other Christian Churches (excluding the Roman Catholic Church) were less likely to experience sexual intercourse before the age of 16, and those from non-Christian religions even less likely to do so. More surprisingly perhaps, given the position of the Roman Catholic Church on sexual behavior, those reporting Roman Catholic affiliation are no less likely than those reporting other affiliations to report intercourse before the age of 16, and if anything slightly more so.

In the ever-swinging pendulum of action and counteraction, an example of final choice control is that of the decision made recently by members of the Church of England regarding homosexuality. Whereas the moral traditionalists within the hierarchy of the Church have tried to reverse the acceptance of gay priests, priest advocates of homosexual rights have topped the polls in the Southward and London dioceses in elections for the Church of England's General Synod, the “church's parliament.”

Nonetheless, Christianity no longer has total influencing control over the sexual morality of the British people. The pluralistic and interdenominational society in existence in Britain has seen to that. The influence of Islam, for instance, is evident in national moral pronouncements because of the increasing number of adherents to the faith and its sexual moral code. In common with Catholicism, Islamic sexual and moral teachings transcend ethnicity and culture. Human sexuality is not a taboo subject but must be dealt with in the context of the family with an open mind and in a way enriching to the individual's developmental and religious perspectives.

The influence of Hinduism and its sexual-moral code on the general population has not been as public. Hinduism is a pragmatic religion, and perhaps because of this pragmatism, issues of sex and sexual activities and practices are rarely discussed. Traditionally, there is an association between religion, erotica, and the highly culturally priced art of love, but in modern culture, one suspects that this connection is the domain of the “literati” and quite foreign to the contemporary Hindu family. Judaism teaches that sexual pleasure is an integral part of the marital/sexual relationship. In its positive view of sexual relations, the principle of pleasure and sharing mutual happiness by a physical relationship is validated.

B. Character of Ethnic Values

As suggested above, ethnicity plays an important part in the development of sexual and moral values, sometimes in connection with and sometimes apart from its religious connections. Four major cultural and ethnic components constitute the United Kingdom, the Irish, Scottish, Welsh, and the English themselves. Even within these groups, geographical position and class are influential. It is interesting to see that, although the various Christian denominations have adherents in every area of the British Isles, the ethnic groupings are numerically visible in the denomination of choice geographically. The Scottish have a tradition of Calvinism and Presbyterianism, the Northern Irish of Orange Protestantism, the Welsh of Chapel Christianity and Methodism, and the English as loyal but convenient subjects of Anglicanism in the tenets of the Church of England. This is, of course, a simplification of the religious/ethnic distribution, but it gives an idea of the association between ethnic values, religious tradition, and the influence of moral-theological principles on sexual values, and the acceptance or denial of sexual behavior. In this mixing pot of cultures, colors, religions, and nationalities, the views are almost infinite, and the British public has an almost inexhaustible amount of choices, although the majority of them are still of the prohibitive (sex-negative) kind. Yet, despite the many ethnic and religious prohibitions of sex, the British show an almost universal acceptance of sex before marriage, teenage sexuality, and the public discussion of topics such as homosexuality that were avoided not too long ago.

The British, according to Johnson, et al. (1994), view sex outside a regular relationship as wrong, monogamy is upheld more by women than men, women show a greater tolerance of homosexuality than men, and, in general, there appears to be an attitudinal trait for permissiveness. In the United Kingdom today, moral, religious, and ethnic influences on sexual attitudes, values, and behavior are no longer a case of Roma locuta est, causa finita est (“Rome has spoken, the argument is closed”), but more one of Vox Populi (“the voice of the people”) with spiritual insurances.

3. Sexual Knowledge and Education

JOSÉ VON BÜHLER AND PATRICIA BARNES

Historically, there has been a reluctance to legislate in the area of sex education in England and Wales. The government has taken formal responsibility for this only in recent years, prior to that issuing general “guidelines” on the general content and moral code. The actual responsibility for the delivery of sex education was undertaken by independent voluntary agencies. Prior to World War II, the focus was on social hygiene, public health, and personal morality, addressing predominantly issues of sexually transmitted disease and unplanned pregnancy.

In the postwar years, educational philosophy and research adopted a sociological perspective and centered on the family. A partnership developed between educational and health establishments, and slowly the form and content of sex education became more concerned with the general well-being of the individual.

In 1968, the government provided funding to the newly formed Health Education Authority and the voluntary agencies, particularly the Family Planning Association (F.P.A.) and National Marriage Guidance Council (N.M.G.C.), to train teachers and provide resources for sex education. Although the political agenda was predominantly preventative in terms of public health, developments in sociological and psychological thinking were woven into educational efforts. These Personal and Social Educational Programs (P.S.E.) inevitably had a heterosexual and reproductive orientation. The medical and nursing professions began to teach from a “humanistic” platform, but it would be some time before a clear definition of humanistic principles in the discussion and delivery of sex education existed. The union of social trends and public policy brought about the beginning of social awareness of a sexuality in which the individual's personal growth mattered and sexual concepts started moving away from the purely biological.

The late 1970s and early 1980s saw the public face of feminism, anti-racism, and gay liberation. The impact on local government and education was in the form of legislation on equal opportunities and antiracist policies. Despite a growing social need and awareness, a formal educational curriculum in sexuality for secondary, higher, and professional education did not exist. Some medical schools experimented, not without problems, with seminars and study days. They were influenced by a growing number of professional counselors and sex therapists, pioneers in the principles of particularity and personal entitlements in the field of sexual development. The Local Education Authorities, for example, were responsible for providing sexual curriculum guidance to schools, but the government did not involve itself in the growing revisionist consensus developing between education, health, and voluntary agencies, which put the person at the center of this consensus.

The political ethos of the 1980s concentrated on a dramatic return to a “new moral framework,” which in essence represented a return to Victorian values. The role and function of the local education authorities and ERA was inherently discredited. The responsibility for sex education in secondary schools (11- to 18-year-olds) suddenly transferred to the individual school governing bodies (H.M.S.O. 1987). The requirement was that sex education should be delivered within a moral framework, and that parents had to be consulted about the curricular nature. In 1987, the Department for Education issued guidelines and specific directives to school governors on the teaching of so-called controversial subjects, such as HIV, AIDS, and homosexuality. The guidelines and directives conveyed a clear public message that sex education was viewed by the government as inherently controversial. This message caused a fundamental dilemma between the needs of pupils and the requirements of the system. This dilemma was also present between the health needs in an age in which sexual awareness became part of a larger social picture and the apparent reluctance of responsible government bodies to accept sex education in its wider context of human sexuality.

At this time, there was politically little to be done regarding sex education in colleges, universities, and medical and nursing education. The academic input in these areas was neither of an official nature nor sufficiently effective to present a case for socially individualistic approaches. In many ways, this was supportive of the political status quo. The legislative disinterest in the activities of higher and professional education in the field of human sexuality and the dedicated work of individuals allowed universities and medical schools to design and deliver functional and integrative programs in human sexuality. Thankfully, these educational programs provided the United Kingdom with practitioners, teachers, and researchers in the field of sexuality since the mid-1980s. At the same time, voluntary agencies became repositories of the considerable body of knowledge and skills in the education and therapeutic interventions in human sexuality. It is difficult to understand today how such dichotomies could exist hand in hand with the World Health Organization's definition of sexual health. That definition clearly affirms the primacy of a “social and personal ethic.” It also affirms the need for “freedom from fear, shame, guilt, false beliefs and other psychological factors inhibiting sexual response and impairing sexual relationships.” University, medical, and professional education and the therapeutic professions tried to synthesize the issues of education and health, particularity by establishing working and investigative groups. The advantage of these groups was that many of their members were experts in the field of human sexuality.

In 1988, Section 28 of the Local Government Act was enacted to prohibit the Local Education Authorities from “promoting homosexuality.” Much confusion ensued. In reality, this clause only applied to the Local Education Authorities' activities and not to educational processes in the classroom. However, this act firmly reestablished the religious/moral influence on sex education.

Also in 1988, a National Curriculum in education was introduced. This differentiated between the “core” or mandatory subjects of mathematics, English, and science that had specific curricula to cover at different key stages and the “noncore” subjects. Sex education was a “noncore” item. In the interest of public health, however, the reproductive and disease components were included in the core science curriculum, and therefore were obligatory to teach.

In 1990, the National Curriculum Council published Curriculum Guidance 5: Health Education, which recommended that the nine health education themes (of which sex education was one) should be coordinated across the curriculum. Four key stages representing age bands were identified to assist delivery of appropriate information in a developmental manner. However, many revisions in both guidance and legislation occurred subsequently with particular reference to the sex education component.

Advised by counselors and sexual and marital psychotherapists, the medical and nursing professions perceived sex education as important in their own clinical effectiveness in the treatment of sexual dysfunction. Some medical schools and nursing colleges established their own sexual health curriculum, but once more the teaching input focused primarily on the organic and health content of sexuality. The integrative delivery of the subject, supposedly suited to increase knowledge and change attitudes both in higher and professional education (von Bühler and Tamblin 1995), depended on the clinical and scientific expertise of a few professionals, who, in many cases, had to fight against long-held concepts and prejudices. This situation led to an educational lottery with little academic cohesion and, of course, the unavoidable controversy between the purely medical and the more-eclectic approach.

Health economics and a realistic awareness of social needs obliged the government to produce the Health of the Nation document in 1992, identifying key areas for intervention. Among the goals listed were the reduction of pregnancies of girls aged 13 to 15 by 50 percent, from 9.5 per 1,000 girls in 1989 to no more than 4.8 per 1,000 girls by the year 2000. England has the highest rate of teenage pregnancies among western European countries. In the document, school sex education was seen as a central means by which the pregnancy targets might be achieved.

Meanwhile an amendment to the Education Act of 1993 was passed without debate in Parliament (effective from September 1994). This required:

1. all secondary schools to have a sex education policy that includes teaching on HIV/AIDS and sexually transmitted disease,

2. biological aspects of sexual behavior to be taught in the science curriculum, and

3. a parental right to withdraw children from all or part of the non-science sex education.

The recent authoritative study by Wellings, Field, Johnson, and Wadsworth (1994), Sexual Behaviour in Britain: The National Survey of Attitudes and Lifestyles, examined trends in age at first sexual intercourse, and these trends show that during the past four decades, the median age at first heterosexual intercourse has fallen from 21 years to 17 years for women and from 20 to 17 for men. The proportion of respondents reporting sexual intercourse before the age of 16 has increased from fewer than 1 percent in women aged 55 and over, to nearly one in five of those in their teens. (Note: This study has also been published as Johnson, et al. 1994, Sexual Attitudes and Lifestyles.)

The people of the United Kingdom need to ask what are the real risks for sexually active children and young people? What are the implications for children who receive either none or fragmented and perhaps unreliable sex education? Human sexual activity is associated with increasing levels of risk and disease, unplanned pregnancy, and marital relationship breakdown. The health and sex education of the British government are far too vulnerable to the swings of political and moral pressures. Adolescent sexuality and sexual activity are realities. Effective sex education should offer adequate information, enable the development of communication and social skills, and provide opportunities to explore attitudes, values, and beliefs in a pluralistic society. The balance of these three elements is crucial if sexual issues for the individual and the nation are to be tackled realistically.

B. Informal Sources of Sexual Knowledge

In common with most western European countries, the media plays an important and increasingly more acceptable role in popular sex education. British television frequently uses specialists in human sexuality and human relationships in research and program presentation. Sex programs are scientifically based in some instances, and in others positive learning occurs through humor and candid discussion of issues. These programs are pluralist. Likewise, radio has increased its importance and credible influence in sex education. Magazines for all ages are available, usually with literary articles of sexual relevance. In 1993, a new educational resource emerged: that of the Sex Education Video in which sexually explicit images are used to teach, for instance, the nature of orgasm and the importance of masturbation. Accustomed to total censorship of more explicit material, the British public still has to pass judgment on these “educational videos.”

Professional and voluntary agencies independent of the government frequently publish books or guides on sexuality covering all aspects of sexual function and meaning, from infertility to menopause, from the realities of being gay to the psychodynamics of marriage. Of course, the newspapers are a good fountain of information reporting on sexual matters, particularly after these have been debated in Parliament. Unfortunately, not all newspapers are married to the truth scientifically or philosophically. The theater, cinema, music, and advertising images are also part of the informal sex education movement. Finally, the United Kingdom is rich in voluntary and professional organizations dealing with sexual and relationship issues whose members are active in teaching and bringing to the notice of the general public the importance of sexual knowledge in ownership of their sexuality.

4. Autoerotic Behaviors and Patterns

MARGOT HUISH

Historically, attitudes regarding masturbation have been negative and condemnatory. Masturbation has been seen both as a sin and as a sickness in the teachings of Judaism and Christianity. Not until the end of the nineteenth century was there a shift from the belief that masturbation was the cause of insanity to the suggestion that it was the cause of neurosis and neurasthenia. David S. G. Kay (1992) comments that:

Following World War I, the major focus shifted from the purely medical to the psychological and to psychiatric analysis of masturbation.... Between the two world wars, medical professionals began to perceive masturbation as a harmless sexual behaviour.... The Psychoanalytic Society reinforced a conviction that masturbation was not the cause of medical or psychiatric disorders. Recidivistically, various preachers and educators continued to reinforce the Judeo-Christian sex ethic with their condemnation of masturbation... [while] psychologists and psychiatrists began to research the relationship between anxiety, guilt and masturbation, since the guilt and anxiety related to masturbation were considered emotionally damaging when transmitted by the family, religion, medicine, law and education.

Despite, or perhaps because of, the Victorian legacy of repression and negative attitudes towards masturbation, the activity is frequently mentioned in some comedy programs on United Kingdom television and radio. However, the subject has also been presented with a refreshingly positive image in television and video sex education programs. This reflects the therapeutic value of masturbation as held by professionals within the psychosexual counseling and therapy practices, which reinforces its “normality” and status as a pleasurable sexual expression in its own right. It is perhaps also reflective of the need to encourage safer sex in the age of HIV and AIDS. Therapists have noticed how clients have responded to the “permission giving” aspects of the recent programs when they discuss masturbation. However, within the multicultural mix in the United Kingdom, there are many who associate masturbation, and especially ejaculation, with illness, fatigue, anxiety, mental illness, and loss of power. The more “open” attitude towards masturbation is reflected in radio phone-in programs and in magazines, especially those geared towards the young.

In a recent sex survey in More! magazine, completed by over 3,000 females aged between 16 and 25 years, 33 percent said they never masturbated, 33 percent did so rarely, 15 percent masturbated once a week, and 14 percent did so more than once weekly. Forty-four percent of the respondents used fantasies during masturbation, but surprisingly, only 11 percent reported masturbation as the best way to reach orgasm - oral sex and penetrative sex scored higher at 41 percent and 28 percent, respectively.

In an unpublished study, Sevda Zeki reported that out of twenty women aged 65 to 74 years, and twenty aged 75 to 91 years, more-permissive attitudes towards sex had significant statistical relationships with higher reported amounts of masturbation and orgasms in masturbation. A higher level of composite knowledge had a significant relationship with higher reported amounts of masturbation, while women who knew the role of the clitoris in achieving orgasm were more likely to masturbate than those who did not understand clitoral function. Women who had the most permissive attitudes towards women masturbating in their later years were more likely to report that they themselves masturbated.

Sex therapists confirm that sexual knowledge, education, and permissiveness are significant in all age groups when considering views, attitudes, and experience of sex in general and masturbation in particular. The impression given by sex therapy clients during history taking is that a small number of male clients report self-masturbation between ages 4 and 10, but the highest percentage recall starting masturbation between 10 and 14 years. Female clients report starting to masturbate anywhere between 10 and 25 years, but far greater numbers are concentrated at 15 years and upwards, with an impression that a significant number of women have never chosen self-masturbation as a way of expressing their sexuality. It is also the impression that male partners are less likely to expect their female partners to self-masturbate, while these same female partners expect that their husbands/boyfriends do masturbate in secret, especially when there is a sexual dysfunction that precludes or limits the opportunity for penetrative sex. Clients, especially female clients, in individual therapy sessions often admit to self-masturbation, but do not wish their partners to know this information. Therapists report a greater acceptance of masturbation among single clients, and point out that there are many people with physical and learning disabilities for whom masturbation may be the only outlet for the expression of sexual feelings.

Project SIGMA, the first British in-depth study of sex, gay men, and AIDS, surveyed 1,083 gay and bisexual men over a four-year period between 1987 and 1991. Self-masturbation was reported during their lifetime by 99.5 percent of men, while 90 percent reported doing so within the previous month (average seventeen times). The percentages by age group of those engaging in self-masturbation during the previous month were: under age 21, 86 percent; 21 to 30, 92 percent; 31 to 40, 94 percent; and 40 plus, 81 percent. As David S. G. Kay (1992) states:

Although the high incidence of masturbation is useful information for encouraging its acceptance by clients, the ability of masturbation to produce orgasm has more therapeutic importance. Masturbation has been used in the treatment of erectile failure, premature and retarded ejaculation, general sexual dysfunction, and primary and secondary orgasmic dysfunction.... There appear to be no rational arguments for regarding masturbation as undesirable as a private form of sexual activity.

5. Interpersonal Heterosexual Behaviors

A/B. Children and Adolescents

DANYA GLASER

Oral-genital contact appears to be very rare, as are attempts to insert fingers or objects into another child's vagina or anus. Coercive, preoccupied or very explicitly imitative behavior is associated with previous significant and inappropriate exposure to adult sexual activity, or sexual abuse of the child.

C. Adults

JANE WADSWORTH, ANNE M. JOHNSON, KAYE WELLINGS, AND JULIA FIELD

In 1990 and 1991, Wadsworth, Johnson, Wellings, and Field undertook a large population survey in Great Britain, The National Survey of Sexual Attitudes and Lifestyles (Johnson et al. 1992, 1994; Wellings et al. 1994). A key aim of this survey was to provide information for models to predict the epidemic of HIV using data on partnerships and activity, but in addition, this study provided valuable information about sexual behavior in the United Kingdom as well as specific information of practical use in the planning of sexual health services - genitourinary medicine clinics, family planning, and sex education - and health promotion strategy.

The national study involved interviews of a random sample of 18,876 men and women aged 16 to 59. The responses were obtained partly through a face-to-face interview and partly from a booklet which was completed by the respondent and sealed in an envelope out of sight of the interviewer to ensure complete confidentiality. Questions were asked about first sexual experiences, sex education, contraception, fertility, numbers and sex of partners, frequency of sexual intercourse, prevalence of different sexual practices, and, for men, contact with prostitutes. Other topics included attitudes towards sexual behavior and AIDS, family of origin and current family circumstances, educational achievements, and employment. The full methodology has been published (Johnson et al. 1994; Wadsworth et al. 1993). Among the more important findings were the following:

1. Age at First Heterosexual Intercourse (Sexarche). The median age at first intercourse for men and women now in their 50s was 20, while for those under 20 it was 17, a decline of three years over three decades. An increase among young people in intercourse under the age of 16 - in Britain the age of legal consent for women - is closely associated with this change. Seven percent of men and 1 percent of women now in their 50s first had intercourse before they became 16, while 28 percent of the men and 19 percent of the women aged 16 to 19 had done so.

2. Number of Partners of the Opposite Sex. The numbers of heterosexual partners reported in different time intervals are shown in Table 1. Very similar proportions of both men and women had no partners in the previous year, in the last five years, or ever. Three quarters of men and women had only one partner in the previous year, while half the men and two thirds of the women had one partner in the previous five years. However, men were more likely to report large numbers of partners than women.

The number of partners was strongly related to age and marital status. Twenty percent of young people, aged 16 to 24, reported no partners in the previous five years, but they were twice as likely as those aged 25 to 34 to report ten or more partners. In contrast, over 80 percent of those aged 45 to 59 had one partner in the previous five years. Married people were less likely to have had more than one partner in the previous year (5 percent of men and 2 percent of women) than single people (28 percent of men and 18 percent of women).

Those who were cohabiting (by their own description as living with a partner of the opposite sex to whom they were not married) were less likely to have had only one partner than those who were married (15 percent of men and 8 percent of women had more than one partner in the last year). Multivariate analysis showed that age and marital status were most strongly associated with numbers of partners, but first intercourse before age 16 was also positively associated with numbers of partners.

Time Interval	Number of Partners	Male (n = 8,047)	Female (n = 10,059)
Ever	0	6.8	5.9
	1	20.9	39.1
	2	10.7	17.0
	3-4	18.6	18.4
	5-9	19.5	13.2
	10+	24.5	6.8
In the past 5 years	0	8.9	9.3
	1	56.4	67.1
	2	10.1	11.3
	3-4	12.2	8.2
	5-9	8.1	3.7
	10+	4.8	0.2
In the past year	0	13.3	14.2
	1	72.5	78.6
	2	8.4	4.9
	3-4	4.1	1.8
	5+	1.8	0.1

Percentages approximated by the General Editor from a bar graph provided by the authors and adapted from Johnson, Wadsworth, Wellings, and Fields, 1994, p. 115.

3. Frequency of Sexual Intercourse. The median frequency of intercourse was three times during the preceding four weeks. But this varied with age as well as with the length and status of the current relationship. Among married or cohabiting people aged 16 to 24, the median frequency was seven times in the previous four weeks. Multivariate analysis showed that in addition to age and marital status, frequency of intercourse was inversely related to the duration of the current relationship, but positively associated with numbers of partners in the last five years.

4. Sexual Practices. For the majority of respondents, sexual intercourse involved vaginal intercourse. Oral sex (fellatio and/or cunnilingus), anal sex, and nonpenetrative sex were less commonly practiced (Table 2). Younger people were more likely to report sexual practices other than vaginal intercourse, as were those in long-term relationships.

	Men (n = 7,870)	Women (n = 9,786)
Vaginal Intercourse	85.6	84.7
Cunnilingus/Fellatio	62.6	56.6
Nonpenetrative Sex	65.6	60.5
Anal Sex	6.9	6.1

Percentages approximated by the General Editor from a bar graph provided by the authors and adapted from Johnson, Wadsworth, Wellings, and Fields, 1994, p. 164.

Those who had more than one partner in the previous year were also more likely to report oral, anal, and nonpenetrative sex than those who had one partner. Oral sex and nonpenetrative sex have become more commonly practiced among respondents who became sexually active in recent decades compared with those who became sexually active in the 1950s and 1960s, but no such trend is shown for anal sex.

5. Sexual Diversity. Sexual experience with a partner of the same sex at some time in their lives was reported by 3.6 percent of the men and 1.8 percent of women. These proportions appear not to have changed with successive generations, but there are pronounced geographical variations, particularly among men. In the previous five years, 1.4 percent of the men had had a male partner in Great Britain as a whole. In greater London, however, this proportion was 4.6 percent, just over three times as many.

Considering only those who have ever had a homosexual partnership (Figure 1), only 9 percent of men and 5 percent of women have been exclusively homosexual throughout their life. In the last year, 19 percent of the men had male partners, 62 percent had female partners, and 10 percent had both male and female partners. Similar patterns were found for women respondents, but a slightly higher proportion had exclusively male partners.

6. Attitudes to Sexual Behavior. Data on attitudes towards sexuality showed that people in Great Britain have a strong commitment to monogamy, together with marked toleration of premarital sex. Fewer than 10 percent of respondents believed that sex before marriage is wrong, but 80 percent of respondents felt that sex outside marriage is wrong.

Commitment to a regular (“steady”) relationship was valued almost as highly as marriage, particularly among women. Homosexual relationships were considered to be wrong by almost 60 percent of women and 70 percent of men. Attitudes towards sexuality varied considerably with experience. For example, fewer than 50 percent of the men who have experienced sex outside marriage considered adultery to be wrong, compared with 80 percent of the men who had not had this experience.

Adapted from Johnson, Wadsworth, Wellings, and Fields, 1994, p. 210.

Frequency of sexual intercourse is strongly related to the duration of the relationship, as well as to the respondent's age. Vaginal intercourse is the most popular form of having sex, and experience of anal intercourse is reported by only about one in twenty respondents, slightly more by men than women. Greater diversity in sexual practices is more likely among those who report more partners.

Patterns of homosexual behavior show geographical variations with a markedly increased prevalence in central London. More than half of those of either sex who have ever had a partner of the same sex have had one or more partners of the opposite sex also. There have been changes in heterosexual behavior across the generations, particularly in the age of first sexual intercourse and the increase in those who have experienced sexual intercourse before the age of 16.

The pattern of partnerships clearly shows that people in Great Britain have larger numbers of partners when they are young and if they have not settled into a committed relationship. Men have more partners than women and nearly a quarter of men reported ten or more partners. There are, however, some differences between couples who are married and those who are living together without being married. In particular, the data suggest that extra relationships are more likely among those who are cohabiting than among married couples.

D. Sex and Persons with Disabilities

TINA BALL

At present, there are several strands contributing to changes in this picture. Some people continue to believe that sexuality should not be considered for those with disabilities. Some parents of young people with congenital disabilities often express fears and anxieties as their children begin to express sexual interests and wish they could stay as “holy innocents.” However, the growing self-advocacy movements and the political movements of people with disabilities have ensured that disabled people's own voices have been heard asserting their sexual natures and needs. An example of this would be the way in which the leadership of the Association to Aid the Sexual and Personal Relationships of People with a Disability (formerly SPOD) has been taken over by people with disabilities.

Professionals have developed a range of sex education approaches and packages for persons with disabilities. Typical of these materials are those designed for people with learning disabilities (Craft 1991; McCarthy and Thompson 1992). Involving parents in these educational initiatives has been shown to be very valuable (Craft and Crosby 1991). Another example is the sex education materials created by people with learning disabilities for their own use (People First 1993).

The incidence of sexual problems is probably higher among people with all kinds of disabilities than it is in the general population. Negative attitudes towards people with disabilities lead to restricted opportunities for the development of sexual relationships; at the same time, an impaired or negative self-image can inhibit healthy sexual functioning. Some kinds of physical disabilities directly cause sexual problems, e.g., spinal cord injuries and multiple sclerosis. The growth in importance of physical treatments for erectile dysfunction, in particular, appears to be leading to a much more active approach to the assessment and treatment of such difficulties in specialist services, with many employing nurses and other health-care professionals to work with persons who have sexual problems linked with or resulting from their disabilities. There remains much room for improvement in this area. The awareness and understanding of the impact of particular disabling conditions on women's sexual functioning and relationships remains less well understood and has certainly received less attention in the literature (Williams 1993).

Sexual dysfunction in people with learning disabilities has also received little attention. Studies have indicated a high level of negative experiences of sex, including dyspareunia in women with learning disabilities (e.g., McCarthy 1993). There is undoubtedly a higher than average incidence of sexual abuse of both women and men with learning disabilities (Turk and Brown 1993). The law recognizes this vulnerability and there are specific laws designed to protect people with learning disabilities from sexual exploitation (Gunn 1991). The complexity of the legal situation at times deters staff members who are working with people with learning disabilities from offering appropriate support and education, especially if they are already uneasy with sexual issues. Several local authorities, health authorities, and voluntary agencies have designed policy statements on sexuality in an attempt to provide clear guidelines for care staff and other professionals (e.g., East Sussex 1992; Hertfordshire County Council 1989). There are also increasing moves to work to prevent and treat sexual abuse in people with learning disabilities (Craft 1993).

E. Incidence of Oral Sex and Anal Sex

KEVAN R. WYLIE

Anal intercourse was practiced by less than 7 percent of all men and women, although a higher percentage of men had experience with it (13.9 percent of men and 12.9 percent of women). It was rarely practiced in isolation from other sexual activities. At the time of the survey legal restrictions made such a practice an offense, which has subsequently been changed. (See also Section 8 on rape.)

6. Homoerotic, Homosexual, and Ambisexual Behaviors

ANTHONY BAINS

The legal situation for lesbians and gay men in the United Kingdom is not a positive one. There are no laws to protect lesbians and gay men from discrimination. Male homosexuality was only partially decriminalized in 1967, for those men over the age of 21, with the stipulation that it would occur in private and with no more than two persons present. The age of consent for sex between men has since been reduced to age 18 (The Criminal Justice and Public Order Act 1994), but this is still two years above that for heterosexuals. Significantly, legislation has never stipulated an age of consent for lesbians, due to the invisibility of, and public refusal to accept lesbian sexuality.

Other examples of discrimination against lesbians and gay men include their being banned from the Armed Forces and being ineligible for marriage under British law. A piece of legislation in the late 1980s also legitimized prejudice and discrimination against homosexuals. Section 28 added a new Section 2A to the Local Government Act of 1986, which states that a local authority shall not “intentionally promote homosexuality or publish material with the intention of promoting homosexuality.” It would appear that such legislation is supported to a significant extent by social attitudes. Wellings et al. (1994) reported that 70.2 percent of men and 57.9 percent of the women surveyed believe that sex between two men is always or mostly wrong.

The experience of institutionalized or personal homophobia and heterosexism can affect the self-esteem of lesbians, gay men, and bisexuals, with implications for their emotional and mental well-being. In the face of such marginalization and stigmatization, the process of “coming out” - informing people of one's homosexuality or bisexuality and thus challenging preconceptions of heterosexuality - can be incredibly empowering. Acknowledging one's own sexual identity, informing those who share one's surroundings, and meeting people who share one's sexual identity to gain support and solidarity can be a major step on the road to healthy self-acceptance for many lesbians, gay men, and bisexuals.

In spite of the oppressive culture towards lesbians, gay men, and bisexuals, or perhaps because of this, strong, diverse lesbian, gay, and bisexual communities have developed, predominantly in the larger cities of the United Kingdom, such as London, Manchester, and Edinburgh. There are networks across the United Kingdom, reaching into the more rural areas, to provide a range of services to lesbians, gay men, and bisexuals, including telephone helplines, counseling, and social groups. There are also numerous lobbying groups from all shades of the political spectrum, working for lesbian, gay, and bisexual rights.

The emergence of HIV and its devastating impact on gay communities has led to a huge community response, with many of the United Kingdom's major national and local voluntary groups being set up by gay men.

Lesbians, gay men, and bisexuals meet each other in a variety of settings, and through various means, at pubs and cafés, saunas, social groups, parties, parks, and other “cruising areas,” as well as through personal advertisements in a variety of publications. Most of the United Kingdom's larger cities and towns have a commercial gay scene and some semblance of a visible lesbian, gay, and bisexual community. The media has also been used to exchange information and promote this sense of community. There are national and local lesbian and gay newspapers, magazines, radio programs, and film festivals. The mainstream-quality media also often run stories and features from a lesbian and gay perspective. Lesbian and gay film seasons and programs have also been screened on television.

The growing confidence among lesbian, gay, and bisexual communities has also been illustrated by the increasing number and scale of festivals and parades around the United Kingdom, where lesbians, gay men, and bisexuals have come together, building and promoting a sense of community. In 1995, the annual Lesbian, Gay, and Bisexual Pride Festival in London attracted approximately 200,000 people.

The lesbian, gay, and bisexual communities of the United Kingdom are diverse, with same-sex desire cutting across age, class, ethnicity, religion, culture, ability, and health status. This is illustrated by the plethora of support and interest groups that have emerged to address these concerns.

7. Gender Conflicted Persons

STEPHEN WHITTLE AND GWYNETH A. SAMPSON

Male transvestism has long been a feature of the theater from the late medieval period when cross-dressing males provided the female characters for the stage. Cross-dressing, or drag as it is referred to, remains popular as a stage act, with artists such as Danny la Rue and more recently Lily Savage gaining national popularity. Female cross-dressing has not had such prominence, the writer Radclyffe Hall and the entertainer Vesta Tilly being notable exceptions in the 1920s and 1930s.

However, transvestism has remained a peripheral activity with little social acceptance on a more personal level. Since the Beaumont Society was organized in the late 1960s to provide advice and safe social meeting venues for heterosexual transvestites, there has been a gradual proliferation of similar groupings. There now exists a variety of organizations and venues throughout the country where men may crossdress in discrete venues. The development of “gay village” areas in the late 1980s and 1990s in many major cities has provided other locales, such as public houses and clubs, where heterosexual and homosexual transvestites may meet and socialize. There is also a large underground network of “contact magazines” that allow homosexual and bisexual transvestites to make sexual contacts. It is difficult to estimate the total number of transvestites in the United Kingdom, as there has been little if any attempt to extrapolate figures.

There is little social acknowledgment of female cross-dressing. Female cross-dressing is generally viewed as belonging to a particular subgroup of lesbian culture, radical lesbians and “butch dykes,” although 1995 witnessed the opening of the first “drag king” club, Naive, in London.

Transsexuals are a much more visible feature of British society, having gained considerable media interest. Newspapers, women's magazines, and television have regular features concerned with transsexualism. Nonetheless, the individual transsexual may be in fact far more hidden than this media interest otherwise portrays. The first recorded transsexual surgery in Britain was performed in 1944 by Sir Harold Gilles, an eminent plastic surgeon, on Michael Dillon, a female-to-male transsexual. Since then, several thousand transsexuals have gained sex-reassignment surgery in the United Kingdom or abroad. Again, little work has been done to count the total number of transsexuals, but estimates based upon the numbers who have attended recognized Gender Identity Clinics put the figure of those who have joined self-help organizations and those who have gained media attention at around 10,000 to 15,000 transsexuals in the United Kingdom (McMullen and Whittle 1995). Several have published highly regarded autobiographical accounts - most notably racing-car driver Roberta Cowell (1954), the climber and London Times journalist Jan Morris (1974), models April Ashley (1982), Caroline Cossey (1991), Tula, and, most recently, journalist Paul Hewitt (1995) and Raymond Thompson (1995).

Some individuals with gender-identity disorder seek medical help and support. In the United Kingdom, this is usually provided by general practitioners and psychiatric services; the number of individuals seeking such help is unknown.

In the United Kingdom, the classification of mental and behavioral disorders is by the ICD-10 Classification of Mental and Behavioural Disorders. Diagnostic criteria from ICD-10 and DSM-IV (Diagnostic and Statistical Manual) identify that the individual has a strong and persistent cross-gender identification, with persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. There is a preoccupation with getting rid of primary and secondary sex characteristics, e.g., requests for hormones or surgery, or a belief that he or she was born the wrong sex. To make a diagnosis, symptoms must have been present for at least two years and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Differential diagnoses include fetishistic transvestism (cross-dressing for sexual excitement), schizophrenia, or temporal lobe epilepsy. The help individuals request includes personal counseling, relationship counseling, education, endocrine therapy, speech therapy, advice on social skills and personal grooming, gender-realignment surgery, and follow-up care after gender reassignment.

Historically, several centers established local Gender Identity clinics - e.g., Charing Cross Gender Identity Clinic was established by psychiatrist John Randell in the early 1970s. The separation of the Purchaser and Provider elements of health delivery in the United Kingdom has now altered the provision of National Health Service care to gender-conflicted persons. Purchasing authorities vary in the help they will purchase locally, and many authorities have not yet developed clear guidelines for purchasing or providing a service for gender-conflicted persons. Some do not purchase a service, others will purchase assessment by a professional - usually a psychiatrist but may be a psychologist or nurse - for diagnosis without any further treatment. A limited number will purchase assessment and therapy. In terms of provision, general practitioners may prescribe endocrine therapy, and some psychiatric services provide counseling, specific training, and medical treatment. The provision of gender-realignment surgery within the National Health Service is very limited; the majority of individuals seek this privately.

There is limited research in the United Kingdom to evaluate the benefits of gender-reassignment therapy, but there is a view that medical interventions can lead to an improved quality of life for the individual. There is also a widely accepted view that hastily undertaken medical and surgical interventions, often conducted at the urgent behest of the applicants, can sometimes lead to disastrous results, including suicide. The small number of specialist National Health Services in the United Kingdom all concur with the guidelines for ethical clinical practice drawn up by the Harry Benjamin International Gender Dysphoria Association.

The majority of transvestites (dual-role transvestism) do not seek clinical treatment or help unless their behavior causes secondary relationship or social difficulties. Fetishistic transvestism is commonly reported as an earlier phase by transsexuals and, therefore, in some individuals may represent a stage in the development of transsexualism.

The current legal position for transsexuals was embodied in the common law decision in the case of Corbett vs. Corbett (1970, All ER, 33-48). In this case, the marriage between a male-to-female postsurgical reassignment transsexual and a male partner was declared to be void. It was held that, for the purposes of marriage, transsexuals would always be of their original sex designation at birth. It has also been held that the birth certificate records in the United Kingdom are a record of historical fact, and hence unalterable unless there was a substantial mistake at the time of registration. As a result, although transsexuals on one level seem to be accommodated by the United Kingdom law in that most of their personal documentation can be altered to show their new gender grouping and their new name, their birth certificate records, which are used as a form of identification for many purposes, will still show their old status and name, and they cannot marry a member of the opposite-gender (i.e., same-sex) grouping. This means that for all legal purposes they remain a member of their natal sex grouping. The iniquities that result from this, not only in terms of personal privacy, but also inadequate protection in employment legislation, have meant that transsexuals in the United Kingdom have taken the government to the European Court of Human Rights on several occasions. The case of Rees v. UK (1987, 9 EHRR 56) led to a compromise solution whereby passports may now record the new name and gender status of the transsexual on production of a sworn declaration of name change and a doctor's letter to the effect that the gender change undergone is permanent.

However, transsexuals have not been satisfied with this solution and are continuing to plead their cause to the government through the campaigning group Press for Change, which provides legal advice and encourages parliamentary lobbying. As of 1995, Press for Change was supporting two cases before the European Commission of Human Rights, one before the European Court of Justice, and had several more waiting on the sidelines.

There are several self-help organizations for transsexuals, and many join these, albeit often only in their initial stages of transition. The largest are The Gender Trust, which predominately caters to male-to-female transsexuals, and the FTM Network, which caters to female-to-male transsexuals. At any one time, both of these organizations have over 350 members. Transsexualism is becoming increasingly socially accepted in the United Kingdom with transsexuals retaining or obtaining high-status job positions, including in education, positions in local government, and high-profile positions in the entertainment industry. It must only be a matter of time before transsexuals obtain full legal recognition of their new status alongside their increased social acceptance.

8. Significant Unconventional Sexual Behaviors

KEVAN R. WYLIE

Any form of sexual contact between adults and children evokes an emotive reaction. Sexual abuse of young children, intrafamilial sexual abuse (usually incestuous), and extrafamilial (usually pedophilia) are all offenses in the United Kingdom. Increasing awareness of child sexual abuse (CSA) has ensured a more-sympathetic approach to dealing with victims. It is accepted that sexual abuse is a traumatic event for most children, and for some, that it is followed by a post-traumatic stress reaction. The advantages and limitations in applying therapy to such a framework in the United Kingdom have been described by Jehu (1991).

There is evidence of an increased number of proceedings against offenders over the last decade, but it remains unclear whether this is a real increase in the number of offenses or improved methods of securing evidence for prosecution. While real or reporting patterns may have changed through the influences of feminism, media attention, academic acceptance, and public sensitization to such crimes, it is probably the case that “old attitudes die hard.” There have been cases in the United Kingdom in which public opinion has turned surprisingly against those reporting child sexual abuse (the Cleveland affair, Orkney ritual abuse, and Rochdale Satanic abuse cases).

Police, social services, educational, and health services are now duty-bound to inform each other when cases of alleged abuse occur. Regional units within the United Kingdom have facilities to record interview sessions on video of children being asked open questions about the alleged abuse. Recent changes brought about by the Criminal Justice Act (1994) allow the use of video disclosure of abuse to a social worker for presentation in court. Video links within the court allow questioning of the minor in a room separate from the court to avoid the minor's facing the offender directly. Social workers have a statutory duty to be involved with families when children are placed on the “At Risk” register and must act on the balance of probability. The police, on the other hand, must establish beyond reasonable doubt that an offense has occurred. Offenders are charged with indecent assault. Inappropriate touching and the circumstances of the event are pivotal in deciding to embark with criminal proceedings. Corroborative statements, whenever possible, and medical evidence is often vital. There is however, no time limit for bringing such offenses to court.

There is currently debate in the United Kingdom regarding the reality of “false memory syndrome,” with cases of abuse being alleged up to twenty years or later than the alleged offenses took place. There are reports in the United Kingdom of men in their 60s and 70s being given short custodial sentences for offenses of sexual abuse or incest that occurred many years previously.

In 1994, prosecution of around 2,000 cases of indecent assault on females under 16 years of age were initiated and around 65 percent of those charged were found guilty. Only half of these were given custodial sentences. The punishment can be ten years imprisonment. It has been argued by Fisher and Howells (1993) that significant social-skill deficits occur in some sex offenders. Where these exist, the deficit is in the cognitive component of social competence. Sex offenders often have major difficulties in establishing and maintaining longer-term intimate relationships, with factors likely to include empathy deficits and inappropriate culturally induced expectations concerning sexual relationships. A recent article presented opinion as to whether a sexual offender should be allowed castration where there is a history of persistent sexual abuse (Alexander et al. 1993).

In law, incest is the act of intercourse by a man with a woman he knows to be his daughter, granddaughter, sister (or half sister), or mother. Three quarters of the cases reported involve father-daughter incest. Incest implies consent - although this is no defense - and is differentiated from unlawful sexual intercourse with a girl under the age of 13 or 16. All are offenses under the Sexual Offenses Act 1956. The punishment for incest is seven years custodial sentence, unless the girl is under 13. If this is the case (effectively constituting rape), the punishment is life imprisonment. The number of persons proceeded against on the offense of incest are a small proportion of those charged with CSA.

The incidence of pedophilia is unknown in the United Kingdom. A small central unit exists to investigate this area, and while the offense is abhorred, limited resources are available to seek out actively and investigate crimes being committed by pedophiles. Several lobby groups now exist to promote awareness of the existence of this problem and the need for active targeting of police time towards preventing the continuation of such practices. Further, to date no national register exists to identify individuals when changing residence. It is not normally the case that such offenders are offered therapy unless supervised probation is ordered. (See also Section 8E below.)

B. Sexual Harassment

HELEN MOTT AND ROHAN COLLIER

Sexual harassment is a widespread problem in British society. What marks it as an “unconventional” behavior, therefore, is not a question of rarity but the fact that it is recognized as wrongful conduct under the law, particularly that relating to the workplace (see below). Its roots in patriarchal society mean that, for the most part, it is women who suffer most from sexual harassment inflicted by men, although the concept has been extended to cover alternative permutations. While sexual harassment, as an exercise in gendered power relations, can be seen to affect women in all walks of life (Wise and Stanley 1987), in general usage, the term is understood to refer primarily to the experience of women in the workplace.

There are as many definitions of sexual harassment as there are theoretical approaches to it, although most contain the common elements of citing conduct based on sex or of a sexual nature that is unwelcome or offensive, and/or detrimental to the interests of the recipient. This emphasis on the recipient creates a tension between objective and subjective standards, so that although the term “sexual harassment” is common currency, people's ideas about what constitutes it can vary widely. Thus, a National Opinion Polls survey in 1991 found that one in six women said they had experienced sexual harassment, but when they were asked whether they had experienced certain kinds of unwanted sexual behavior that offended them, the figure rose to one in three (Collier 1995, 56). The results of this survey, and others like it, suggest that people may be reluctant to label the full range of potentially sexually harassing behaviors as harassment per se.

The likelihood of a formal complaint being made to the authorities in the case of sexual harassment also appears to be low. Davidson and Earnshaw (1991) found that 65 percent of personnel directors in their study believed that between 70 and 100 percent of cases were never reported to them. This supports North American research (e.g., Livingston 1982, who claims that only 2.5 percent of harassment victims took any official action). For reasons such as these, it is therefore very difficult to attempt to quantify the incidence of sexual harassment. Recent surveys in Britain seem to show that, on average, between 30 percent and 50 percent of women claim to have experienced sexual harassment at work (Marks 1991; Industrial Society 1993; London Buses Ltd. 1991; Mott and Condor 1995), although in certain occupations, such as the police force, the figure has been as high as 90 percent (Her Majesty's Inspectorate of Constabulary 1993). The scale of the problem suggests that it is ill-advised to concentrate upon the likely psychological “profile” of the harasser (or, indeed, the recipient). While individual factors may be relevant to individual cases, it is clear that sexual harassment is essentially a social problem.

Legal Penalties

As noted above, it is rare for complaints to reach any level of “authority,” and it is, therefore, rarer still for the legal system to become formally involved. Although not a named civil wrong or criminal offense, sexual harassment cases in Britain can be brought within the ambit of several laws. Presently, most cases are dealt with at Industrial Tribunal under the Sex Discrimination Act (1975). This Act, which is applicable to all institutions, makes it unlawful to discriminate by treating a woman less favorably than a man on the grounds of her sex. It also makes it unlawful to victimize a woman who has complained of sexual harassment, to promise or withhold benefits in exchange for sexual favors, or to subject her to any detrimental action. All of these elements of the Sex Discrimination Act can be relevant to sexual harassment in the workplace, and are applicable to men as well as women, although the scarcity of recorded cases brought by men tends to suggest that this application is more theoretical than practical. Generally, both the individual harasser and the relevant organization will be jointly liable, unless the organization can prove that it has taken reasonable steps to prevent sexual harassment. Complainants can expect to receive monetary compensation (for which there is no upper limit) for financial loss, medical expenses, and damages such as injury to feelings. Tribunals may also require that the organization takes steps to prevent harassment happening again, or to transfer the harasser within the organization.

Cases can also be brought to the Industrial Tribunal under the Employment Protection (Consolidation) Act (1978) when a person has been an employee of the relevant organization for at least two years full-time. Victims of harassment might claim constructive dismissal (if they were in effect obliged to resign), or unfair dismissal if, as a direct or indirect consequence of being sexually harassed, they were dismissed from work. The Tribunal can rule for the reinstatement, reengagement, or for compensation of the injured party (subject to certain financial limits).

The number of cases involving sexual harassment brought to the Industrial Tribunal in Britain under the Sex Discrimination Act has been steadily increasing since 1986. There is concern that the requirement under the Act to prove disparate treatment of the sexes prevents some cases from being adequately addressed. The aim of the Tribunal is to uphold the rights of the victim, and thereby to provide a remedy, such as compensation. This can certainly penalize the perpetrator by the award of damages, but there is no power to punish. For these reasons, legal commentators such as Dine and Watt (1995) have recently called for more victims of harassment to take their cases to the civil or criminal courts, a practice that is currently rare.

In the civil courts, victims of harassment can have wider remedies available to them. For example, they can sue the employing organization for breach of contract through having failed in their implied duty of trust and confidence. The harasser can be sued for the tort of trespass to the person. This would certainly cover actual physical touching, and may well include verbal harassment. Where the harasser has physically touched the victim, they may also be prosecuted in the criminal courts for various offenses, such as assault, indecent assault, or false imprisonment, that are recognized under the criminal law.

In 1991, the EC issued a Code of Practice concerning sexual harassment, following a recommendation asking member states to promote awareness of the unacceptable nature of sexual harassment. This code points out that sexual harassment is a form of sex discrimination and is, therefore, unlawful under the Equal Treatment Directive (1976). The code also provides for the inclusion of harassment on the grounds of sexuality, in addition to gender, as “sexual harassment,” and makes explicit links between racial and sexual harassment. (British theorists such as Kitzinger [1994] have commented upon the secondary victimization of, for example, lesbians and members of other “minority” groups as a part of sexual harassment.) In addition, the code recommends that organizations provide a clear policy prohibiting sexual harassment in the workplace and guaranteeing prompt and efficient action in the event of harassment. Taken together with the current British laws, this Code of Practice should strengthen the hand of those seeking to challenge the prevalence of sexual harassment in the workplace.

Social Response

The category of behavior that we now call sexual harassment has a very long history, although its naming has come relatively very recently. Sexual harassment as a concept came to Britain from North America in the late 1970s and early-80s with the publication of Farley's (1978) and MacKinnon's (1979) highly influential texts. These texts, however, were academic, and it is only-much more recently that “sexual harassment” has passed into the wider domain, so that since the late 1980s, it has been a topic for public discussion and debate. Since that time, there has been coverage in the press of successful Industrial Tribunal cases, and the subject has been addressed as a story line in the two most popular television soap operas. In the year running from May 1993 to May 1994, no less than 90 articles in The Times newspaper discussed sexual harassment.

Women are now much more aware of their rights and have higher expectations in terms of how they are treated at work than in the past. However, a recent study (Mott and Condor 1995) revealed that women continue to find it difficult to confront sexual harassment, as dominant workplace ideologies that legitimize unsolicited sexual behavior and mitigate against confrontation remain. It is also clear that the pervasive and everyday nature of much sexual harassment (especially in the form of sexual remarks and “joking”) in many workplaces makes it unrealistic to expect an immediate changeover to zero tolerance.

There is also evidence that both women (e.g., Mott and Condor 1995) and men (e.g., Watson 1994) sometimes provide explanations for sexual harassment based on a reductionist view, which Watson has termed a “conceptual red herring”: that sexual harassment is primarily a behavior driven by sexual motivation. This approach, which has much in common with early approaches to the phenomenon of rape, can serve to obfuscate the important issues of power, responsibility, and resolution. It is anticipated that, with time, the prevalence of this view will decrease.

Results from many studies have shown that sexual harassment can have a devastating effect for victims, both in terms of their performance at work and their personal well-being. Eighty-six percent of harassment victims in the COHSE (1991) study reported an adverse effect on emotional well-being, while 33 percent said that their quality of work deteriorated. Despite this, and despite the potential risks of litigation, the response of many organizations and trade unions to the problem has not been adequate. In the study mentioned above, over half the employees who complained of harassment felt that their complaints had not been dealt with adequately, and 10 percent found that they, rather than the harasser, had effectively been punished by being transferred to another job or department. An Industrial Society survey (1993) found that 60 percent of British employers had no sexual harassment policy in place.

C. Rape

KEVAN R. WYLIE

Police forces now have dedicated nonpolice-station units where persons alleging rape are counseled. These units often resemble living dwellings rather than the institutional nature of the police station. Within the units are video interview rooms and a medical suite. Premises and facilities of victim examination suites are reviewed by Lewington and Rogers (1995). Should the victim be willing to make a formal statement, attempts to trace the offender take place to allow for questioning of the suspect. It remains the case that victims of rape experience anonymity during court proceedings, while the offender is not offered such protection.

Victims are offered support by Rape Crisis and Victim Support units. Cohn (1990) found that the incidence of rape, as well as assault, burglary, collective violence, and domestic violence, increased with ambient temperature, at least up to about 85° Fahrenheit, and concluded that, in general, the most violent crimes against persons occurred linearly with increasing ambient temperature, while property crimes did not strongly relate to temperature changes.

The issue of “date rape” has started to make an impression in the United Kingdom, although it does not constitute a specific offense as such. The issue of stranger rape has been construed by some as “clumsy seduction.” Marital rape is now accepted as an offense.

Rape is an offense under the Sexual Offenses Act 1956 and there has been a threefold increase in the number of cases in which proceedings have started in the courts in England and Wales over the last decade. Of the 1,625 cases proceeded against in 1994, just under a quarter were found guilty and sentenced. Almost all of these cases were punished with immediate custodial sentences, which is normally life imprisonment. Sentencing has shown a general trend towards an increased length of custodial sentence passed. In sentencing, judges are less likely to regard prior consensual contact as a valid reason for passing noncustodial sentences on convicted rapists (Lloyd 1991).

A number of male partners of rape victims remain seriously troubled many months after the rape (Bateman and Mendelssohn 1989) and have become profoundly worried about their identity as men, shunning their male friends, avoiding sexual contact with their partner, and withdrawing from regular social interaction. They may require intensive psychoanalytic therapy to begin to understand what it means for them that their partner has been raped.

In a review of sexual offenders, rapists were found more likely to report having a current female partner and to have experienced consenting heterosexual intercourse with an adult, than were nonincest offenders against male children. However, no evidence emerged that rapists and nonincest offenders against female children differed significantly in this respect (Bownes 1993). Using the GRIMS and GRISS questionnaires, the investigation found evidence of marital and relationship difficulties and sexual problems among all offense categories of those sentenced for sexual offenses as being substantially higher than those among the general population. A prevalence of 62 percent for marital/relationship dysfunction among offenders who had a current relationship with an adult female partner, and a prevalence of 57 percent for sexual dysfunction amongst offenders who had experienced heterosexual intercourse with an adult, were reported. Treatment programs need to address these elements.

Until recently, buggery with a male under the age of 21, or with a woman or with an animal, led on conviction to punishment with life imprisonment. However, when Section 143 of the Criminal Justice and Public Order Act 1994 came into force on November 3, 1994, the amended Section 12 of the Sexual Offenses Act 1956 (The Acts of Buggery) in effect legalized anal intercourse for consenting couples over 18 years of age, be they gay or heterosexual. About 10 percent of cases are thought to be heterosexual and, unless force accompanies the act, these cases rarely proceed to court. Where anal intercourse occurred as a result of sexual assault, this amendment would obviously not apply.

While Mezey and King (1989) had difficulty in getting victims to cooperate with an interview for their research project on male rape, their results indicated that failure to report to the police was a problem. Most of the assailants and subjects were homosexual or bisexual, and only a few cases conformed to the stereotype of sudden unprovoked attack by complete strangers in a public place. The assault had considerable impact on the subjects' sexual identity. It was concluded that these findings suggest that male victims' immediate and long-term responses were similar to those described by female rape victims.

A study by Hickson et al. (1994) reported the prevalence of nonconsentual sex amongst homosexually active men as 27.6 percent, of which 3.9 percent involved female assailants. A third of the men had been forced into sexual activity, usually anal intercourse, by men whom they had previously had consensual sexual activity with. These results supported that belief that male rape is not usually committed by men identified as heterosexual.

The majority of those persons found guilty of buggery were given immediate custodial sentences. Around 40 percent were found guilty of the 379 cases in which proceedings took place in 1994.

What is commendable is the high detection rate by the United Kingdom police of sexual offenses that are reported as having been committed, particularly for rape, unlawful sexual intercourse with girls under 16, incest, and buggery. There are less-successful detection rates with indecent assault on females aged 16 years and over, when compared to the offenses of indecent assault on females under 16 years of age, with a similar but less marked pattern seen with indecent assault on a male in both age groups. The “clear-up” rates for sex crimes are generally considered to be substantially higher than those for other crimes. There are, of course, an unestimatable number of sex crimes never reaching the police.

D. Prostitution

KEVAN R. WYLIE

The prostitute population is not stable. Women enter and leave, depending upon life circumstances. The risk of HIV through sexual services is very low, and the risk of contracting HIV is much greater through the use of drug injecting. It has been argued that if a sexual act is consensual and does not harm others, it should be acceptable to repeal the laws prohibiting soliciting. By doing so, it would free street working women from harassment, and reduce police and court time of those who are attempting to uphold a law that does little to abolish the “trade” (Carr 1995). The National Vice Squad Survey (Benson and Matthews 1995) found that one third of police vice squads want brothels to be legalized.

Prostitution can constitute one of several offenses. These include “curb crawling” (approaching a prostitute and being a “nuisance”) and soliciting under the Sexual Offenses Act 1985, behaving in an indecent manner in a public place under the Vagrancy Act 1824, loitering or soliciting for the purposes of prostitution under the Street Offenses Act 1959, and procurement of persons for immoral purposes under the Sexual Offenses Acts 1956 and 1967. Women offer sexual services to men within several settings. Such services are usually offered within the so-called red light areas of a town or city. Establishments offering saunas and massage parlors are usually a cover for offering such services. These can range from masturbation of the man (“hand relief”) and oral sex to intercourse (usually with the insistence of using a condom).

Establishments known as brothels exist, usually a house with several rooms being used by women offering sexual services. Such brothels are usually run by a “madam.” The equivalent on the street are girls working for a “pimp.” Both the provider and organizer, as well as the user, can be charged with one or more of the above offenses. The policy of many police forces in the United Kingdom would be to caution a prostitute on a couple of occasions and advise her of support services to try and help her move away from using such activity as the route for financial gain. Often such persons need assistance in severing the link with their “pimp,” to whom they may be in debt or exploited through addiction to drugs. Many of the punishments carry short custodial sentences as an option, although die vast majority are dealt with by fine. The average fine for curb crawlers in 1995 was £110. The exceptions are conviction of living on the earnings of prostitution or exercising control over a prostitute, where a custodial sentence is much commoner. However, cases cannot be brought on the uncorroborated word of a prostitute or solely on police evidence.

Soliciting by a man is an offense usually dealt with by the courts by a fine, if indicted. There is increasing awareness of male prostitution, particularly in the capital city. Such men are called “call boys” and many offer their services to visiting business men in hotels. This is an area where detection by the police is very low. Low levels of reporting occur and usually the police are only aware as a consequence of robbery or associated assault. Of the 124 cases proceeded against in 1994, 89 were found guilty.

It is generally felt that the tolerance towards prostitution in England and Wales is fairly high, provided that such occurs in private. Much of the action of the police is in an attempt to appease complaining residents. An interesting development in the United Kingdom has been the call by the Inland Revenue for disclosure of such income by prostitutes for payment of Income Tax.

In mid-1996, the Government-controlled telephone company, British Telecom, joined Westminster, London's largest borough, in a crackdown on prostitutes who paste sexually explicit business cards advertising their services on the 700 bright red phone kiosks available to the public on the streets. After using computers to locate the offending prostitutes, telephone inspectors notify them they have one week to cease their postings. If the postings continue, the telephone company blocks their incoming calls. In announcing their effort, authorities said their objection “is not with prostitution as such, but with the people who illegally litter and deface the city's streets with this offensive and often pornographic advertising material.” School teachers had complained that schoolchildren have been found collecting and trading the cards, many of which are illustrated.

In early 1996, British Telecom and Westminster sanitation teams, starting as early as 6 A.M. each day, removed 150,000 cards a week, 1.1 million such cards in an eight-week period; an estimated seven million cards are removed in a year. “Vice-carders,” mostly young men hired by a half dozen prostitutes to post their cards, follow the sanitation teams, creating a no-win situation.

In 1991, the last time Westminster officials tried a similar scheme, Oftel, the Government telecommunications-regulating authority, said that blocking incoming calls was a violation of advertisers' rights. Before the current campaign, British Telecom changed its contract for all its customers, stipulating that they cannot advertise their telephone number in public phone kiosks. Whatever the success this effort has in controlling this advertising, it will not stop prostitutes from advertising their sexual services. Prostitution is legal in Britain, and so sex workers will continue advertising in other outlets, such as community newspapers. (See the discussion of pikku bira in Section 8B of the chapter on Japan.)

E. Pornography and Erotica

KEVAN R. WYLIE

Despite such liberalism, there remains tight enforcement against many forms of pornographic material. Possession of adult pornography does not in itself constitute an offense. However, possessing obscene material for gain, whether that be to lend, publish or display, would constitute an offense under the Obscene Publications Act 1959/1964. The law explicitly forbids pornography involving minors and extends to taking indecent photographs of children (Protection of Children Act 1978). The sentence on conviction is three years imprisonment. Possession of photographs of child pornography carries punishment usually by fine (but six months custodial sentence is possible), and associated investigation may ensue for possible child sexual abuse and of pedophilia. A proactive measure against pedophilia exists whereby photographic developers are requested to inform the police when they notice suspicious photographs of young children. The increasing incidence of transfer of pornographic material using personal computers over the Internet has led to rising concern. However a group, Parents Against Injustice (PAIN), campaigns against overzealous misinterpretation of innocent family photographs of children bathing, running in the garden naked, or being bounced on grandfather's knee. The fact is that photographs can be very subjective.

Many book classics were banned under the Obscene Publications Act, and the infamous 1960 obscenity trial prevented copies of Lady Chatterley's Lover and Queen Mab, first published in 1829, from home ownership. Daniel Defoe was one of the earliest English authors to include superpermissive parent figures, incestuous relationships, and lower-class characters who were all sexually uninhibited, passionate, and with responsive female characters. The links between poverty and exploitation and between sexual attitudes and cultural practice has been noted many times over. However, pornography has certainly moved more from the “peep shows” and cinemas to the home, with the increasing numbers of videotapes displaying such material.

Pornographic videotapes are now obtainable through mail order, both within the United Kingdom and from Europe. Self-help videos, like The Lover's Guide had sold 1.3 million copies by late 1995. Although explicit, they are considered educational and have a license. The importation of obscene pornography, however, constitutes a criminal offense, although it is acknowledged that it occurs in considerable volume, given relaxed cross-country border controls within Europe. Political action was taken in 1993 to prevent satellite programming of pornographic material from Red Hot Dutch into the United Kingdom. This involved making it an offense to sell “smart cards” or advertise and publish information about the service. A similar course of action was taken in 1995 to ban the Swedish channel TV Erotica. The 1990 Broadcasting Act forbids programs that might “seriously impair the physical, mental or moral development of minors.”

The United Kingdom now has three subscription-pay-TV adult soft-porn channels, Adult Channel, Television X, and Playboy TV, all of which operate in a scrambled form at nighttime. There are approximately 100,000 subscribers. The Church of England and Methodist Church have sold their shares in the BSkyB company because of this new venture.

9. Contraception, Abortion, and Population Planning

A. Contraception Attitudes and Use

FRAN READER

The Education Reform Act of 1988 places a statutory responsibility on schools to provide a broad and balanced curriculum that “promotes a spiritual, moral, cultural, mental, and physical development of pupils at the school and in society,” and which “prepares pupils for the opportunities, responsibilities, and experiences of adult life.” This philosophy forms the basis of Personal and Social Education (PSE), which is a theme running throughout a child's life a school. Sex education is part of the wider topic of health education. Health education is not a mandatory foundation subject, but it is expected to be a theme that is incorporated across the whole curriculum. School governors have the responsibility to decide whether and/or what sex education should be taught. In Scotland, there is no legislation regarding the teaching of sex education in schools. Each Local Authority decides or delegates the decision to the individual school, and the curriculum guidelines define sexuality and relationships as an important area of health education. In Northern Ireland, heath education is given as one of six mandatory cross-curricula themes in the Education Reform Order of 1989. Sex education is not specifically mentioned, but it is widely accepted and expected to form a major component of health education.

The age of consent for sexual activity is 16 in England, Wales, and Scotland, and 17 in Northern Ireland. Doctors may prescribe contraception to under-16-year-olds (17-year-olds in Northern Ireland). The present legislation in England and Wales follows the House of Lords Ruling in the Gillick case of 1985. The Law Lords ruled that “a girl under 16 of sufficient understanding and intelligence may have the legal capacity to give valid consent to contraceptive advice and treatment including necessary medical examination.” In Scotland, the Age of Legal Capacity Act came into force in September 1991, bringing Scotland in line with England and Wales. In Northern Ireland, a similar legal situation exists, except the medical age of consent is 17.

In 1993, the Government launched its Health of the Nation Initiative. Sexual Health was one of the key sections, with one of the targets being to halve the rate of unplanned pregnancy in under-16-year-olds by the year 2000. This has given backing to initiatives to improve sex education programs and the provision of contraceptive services.

Since 1974, all contraceptive advice provided by the National Health Services and all prescribed supplies were made available free of charge, irrespective of age and marital status. In the United Kingdom, most contraceptive services are provided by either General Practitioners (GP physicians) or by Community and Hospital Clinics. Community and Hospital Family Planning Clinics have always been able to supply condoms free of charge. This has not been available to GPs, although some practices now offer this service. Government policy supports the dual provision and choice to maximize the uptake of services; however, over the past ten years there has been a marked reduction in the number of Community Family Planning Clinics with a shift to GP provision. Since 1990, new contractual arrangements were introduced for GPs that affected their fees and allowances encouraging a greater emphasis on Health Promotion. This system has continued to shift contraceptive care to General Practice. The Community Family Planning Clinics have therefore looked to complement GP services, and specifically target teenagers and vulnerable groups that may have problems in accessing care from general practitioners.

Community Clinics, backed up by specialist contraceptive clinics in hospitals, also tend to provide a wider range of contraceptive methods than are available through General Practice physicians. Snowdens's research in 1985 showed that only 55 percent of the women using Family Planning Clinics were prescribed the pill as opposed to 84 percent of GP patients. This trend has continued. Community Clinics, therefore, remain a service of choice for those women wishing to use the less-common methods of contraception, and they remain the main source of training for physicians and nurses.

Contraception is now recognized as a part of core training for all GPs and obstetricians and gynecologists. Specialists in the field undergo training through the Faculty of Family Planning and Reproductive Health Care, which is part of the Royal College of Obstetricians and Gynecologists. Since the Health of the Nation Initiative, there has been an increasing shift to integrate the community and hospital contraceptive services with community and hospital services for sexually transmitted diseases. Doctors and nurses initially trained in one or the other discipline are now entering into joint training programs. It is now common practice to be advised to use contraception to prevent unplanned pregnancy backed up by either the male or female condom for the prevention of sexually transmitted disease. This message is particularly stressed for couples at the start of all new relationships.

Contraceptive methods currently available in the United Kingdom are combination oral contraception, progesterone-only pills, long-acting injectable progestogens, five-year levonogestrel implants, intrauterine devices with levonorgestrel (IUS), copper intrauterine devices, male and female condoms, diaphragms and cervical caps, natural family planning, and male and female sterilization. The combined oral contraceptive pill is the most common method of contraception used by women under 30. In total, it is used by 22 percent of women between the ages of 16 and 49. Conversely, sterilization is the most common method used over the age of 30, with male and female sterilization being equally represented. In total, 23 percent of 16- to 49-year-olds use sterilization as their method. Condom usage has increased in recent years, and with this a decrease in the use of oral contraceptives. The use of combined oral contraception always fluctuates, tending to fall after a media-publicized concern about safety. In October 1995, the Committee on Safety of Medicines (CSM) raised concern about pills containing the progestogens, desogestrel and gestodene, and an increased risk of venous thrombosis. As with similar pill scares in the past, this is likely to generate a further fall in the uptake of the combined pill as a method of contraception.

Recently introduced methods of contraception include the female condom, Femidom, introduced in 1992. So far, this method has not caught on, and the male condom maintains dominance as the most popular barrier method. The five-year, six-capsule levonorgestrel implant was introduced in 1993. There was an initial enthusiasm for this method that has now diminished because of problems with erratic bleeding in the early months of use and occasional difficulty in the removal procedure. However, the method has settled to take a valid place in the range of contraceptives provided in the United Kingdom popular for women who consider their family complete, but do not wish to take the step of sterilization. An intrauterine device with levonogestrel (IUS) was introduced into the United Kingdom in 1995 with a three-year license for contraceptive use. It is anticipated this license will be extended to five years in the near future, and also extended to include use for the management of menstrual problems. It is anticipated that this new method will be widely accepted in the United Kingdom, particularly for the management of contraception in older women. The United Kingdom is awaiting with interest the introduction of the Unipath Personal Contraceptive System for the accurate electronic prediction of the fertile phase. Trials have been ongoing in the United Kingdom for the past couple of years.

Emergency contraception with both the hormonal and IUD methods are widely available within the United Kingdom through general practitioners, community clinics, sexually transmitted disease (STD) clinics, and accident and emergency departments. There is still considerable confusion in the population about the use of emergency contraception. This relates to it being marketed initially as the morning-after pill, which has led to misunderstandings regarding the duration between unprotected intercourse and the time for the effective use of emergency contraception. In 1995, there has been a wide campaign to promote the use and understanding of emergency contraception. There is currently a debate in the United Kingdom about making hormonal emergency contraception available through pharmacies without a medical prescription.

B. Teenage (Unmarried) Pregnancy

MARY GRIFFIN

The trend in the United Kingdom is increasingly towards teenage mothers not marrying (Family Planning Association 1994). Some prefer to cohabit with their partner, since there is little stigma attached to this, although many maintain a single-parent lifestyle. Indeed, it can be advantageous for teenagers not to marry in terms of welfare benefits and housing, although cohabiting teenage mothers do have the highest rate of reported homelessness (18 percent), according to recent research from the National Child Development Survey (Joseph Rowntree Foundation 1995). The trend away from marriage is reflected in the outcome of conceptions in England and Wales for 1992 for all women under 20, the total number being 93,000, of which 8,300 were conceptions inside marriage. Of the 84,700 conceptions outside of marriage, 37 percent were legally aborted, 58 percent led to maternity outside of marriage, and only 5 percent to maternity inside marriage (OPCS 1992). Looking at live births for 16- to 19-year-olds in England and Wales, in 1983, 56.3 percent were registered outside of marriage, but this had increased to 87.8 percent by 1993 (OPCS). In Scotland, for the 15-to-19 age group, the percentages rose from 54.5 in 1984 to 89.3 in 1994 (General Register Office for Scotland). Even in Northern Ireland, which tends to be more conservative and a few years behind social trends on the mainland, single parents are no longer a rarity and are increasingly accepted without social stigma.

While 16 years is legally the lowest age for marriage in the United Kingdom, parental consent is required up to the age of 18 in England, Wales, and Northern Ireland, but not in Scotland. In the first three regions, written consent of both parents is required, even if they are estranged, so that some teenagers wishing to marry may not be able to do so before the birth of the baby if this legal requirement cannot be fulfilled.

Looking at trends over the last two decades, the introduction of free contraception in 1974 led to a decline in teenage pregnancy rates. In 1973, the total conception rate per 1,000 teenagers in England and Wales was 9.2 for 13- to 15-year-olds (and therefore unmarried) and 75.2 for 15- to 19-year-olds (marital status unspecified). Ten years later, the rates were 8.3 and 56.0, respectively, of which just over half were terminated for the 13-to-15 age group and a third for the 15-to-19 age group. Thereafter, rates increased until a peak in 1990 (10.1 for the 13-to-15 group, with half legally terminated, and 69.0 for the 15- to 19-year-olds, with just under a third terminated) (OPCS). The peak came a year later in Scotland, but there was no particular trend in Northern Ireland.

Several factors probably contributed to this phenomenon. Firstly, the Gillick case, which eventually concluded in 1985 in favor of young people's rights, caused a great deal of confusion over teenagers' access to confidential help and advice, and anxieties still persist (Wareham and Drummond 1994), despite the joint statement referred to by Mrs. Gillick in a letter to the British Medical Journal (Gillick 1994). Secondly, the onset of economic recession led to a decline in young people's job opportunities. A third contributory factor was cuts in family planning clinics, thereby restricting access to services (Brook Advisory Centres 1995). The Government's concern over the rise in teenage pregnancies led to teenage sexual health being identified as one of the key areas targeted for action in their policy document, Health of the Nation (Department of Health, 1992) - a specific aim being to reduce the 1989 conception rate in under-16-year-olds by at least 50 percent by the year 2000. Rates are already falling again and teenagers are far less likely to have a baby today than twenty-five years ago.

In England and Wales, the total conception rate per thousand for 13- to 15-year-olds in 1993 was 8.1 (with 50 percent legally terminated) and for 15- to 19-year-olds, 59.6 with just over one third terminated. In Northern Ireland, the total number of live births to under-15-year-olds for 1990-93 inclusive ranged between 4 to 7, but rose to 11 in 1994. Total live births to 15- to 19-year-olds (marital status unspecified) rose to 1,856 in 1992, but has since fallen to 1,486 in 1994 (General Register Office for Northern Ireland). Since Northern Ireland is not as liberal towards abortion as the other three countries, some pregnant teenagers go to the larger cities on the mainland to obtain abortions. Legally, the situation with regard to abortion in Northern Ireland is a very gray area, and those involved in women's health and welfare agencies are aware that doctors there are increasingly prepared to widen grounds for justifying therapeutic abortion in the interests of a teenager's physical or mental health. This trend may be reflected in the statistics, though official figures for terminations were unavailable due to the legal situation.

With regard to the social background of young parents, longitudinal data from the National Child Development Survey show that half the teenage mothers who were single when their babies were born went on to cohabit with or marry the father. The study found no significant differences in childhood factors between young parents whose babies were born within marriage and those who were single or cohabiting when they gave birth. The data also suggested that the predisposition to have a child when young was independent of any thoughts about marriage, cohabitation, or single parenthood. Sixty-seven percent of those married at the time of conception had planned the pregnancy, compared with 26 percent of those cohabiting, 17 percent who married during pregnancy, and 8 percent who had no live-in relationship before birth (summarized by Joseph Rowntree Foundation 1995).

Despite the expansion of services and increased provision of information for teenagers in the United Kingdom since Health of the Nation, it seems that risk-taking behavior, failure to anticipate risk, lack of knowledge, and errors in the use of contraception are still major causes of unwanted teenage pregnancies (Lo et al. 1994; Pearson et al. 1995; Wareham and Drummond 1994).

C. Abortion

JANE READ AND LINDA DELANEY

Until 1967, most pregnancies could not lawfully be terminated by abortion. The Offenses Against the Person Act of 1861 specifically criminalized both successful and unsuccessful abortion attempts by those who assisted women and by pregnant women themselves (curiously, the former, but not the latter, could be convicted, even if there was found to be no pregnancy). However, as prosecutions under the 1861 Act had to establish that the accused acted “unlawfully,” it became possible to defend a criminal charge by showing that the abortion was carried out in the honest belief, based on reasonable grounds and adequate knowledge, that the continuance of the pregnancy would turn the woman into “a physical or mental wreck”; this was the outcome of the famous case of R. vs. Bourne (1939-1KB 687), brought after an eminent surgeon performed an abortion on a 14-year-old who had been raped and whose mental well-being was said to have been gravely threatened by the resulting pregnancy.

In 1967, Parliament provided statutory defenses by passing the Abortion Act. Substantially amended by the Human Fertilization and Embryology Act of 1990, the Abortion Act of 1967 permits abortion on liberal therapeutic and eugenic grounds if two registered medical practitioners - one would suffice in an emergency - certify the existence of such a ground, and the abortion is carried out by a registered medical practitioner. In brief, the amended law allows abortion when it is performed to prevent grave permanent injury to the mental or physical health of the woman, or risk to her life, or the birth of a “seriously handicapped” child. For these three situations, there is no time limit; in other cases, the limit is the end of the twenty-fourth week of pregnancy.

An important change in the 1967 Act resulting from enactment of the Human Fertility and Embryology Act 1990 is the severance of the link that applied previously with the Infant Life (Preservation) Act 1929. The effect of this has been, paradoxically, a slight liberalization of the Abortion Act as it was between 1967 and 1990. Prior to 1990, women could not, under any circumstance, have their pregnancy terminated after the twenty-eighth week of pregnancy, since, under the Infant Life (Preservation) Act of 1929, this was considered to be the point at which a fetus became viable. Although Clause (a) (given below) states a limit of twenty-four weeks of pregnancy, there is no mention of a time limit for the other three clauses. In effect, the situation in England and Wales is that abortion is rarely done after twenty-two weeks of pregnancy. Essentially, any woman who is considering a decision to terminate her pregnancy, whether as a result of her social, economic, personal, family, or medical circumstances, must have the consent of two medical practitioners before the abortion may be performed.

The clauses in the Abortion Act 1967, as amended by the HFE Act 1990, under which she can do this and to which the two doctors must conform are as follows:

1. that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or of injury to the physical or mental health of the pregnant woman or any existing children of her family, greater than if the pregnancy were terminated; or

2. that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or

3. that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or

4. that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped. (The Abortion Act 1967 as amended HMSO)

There is no requirement on the part of Health Authorities to provide abortion services, and abortion provision is not consistent across the country. In some areas, the service may be relatively available through the Health Service, and in other areas, there will be little provision, and women will either have to pay for a legal termination in the private sector or nonprofit charity sector, as well as possibly having to travel some distance to get to a private clinic.

Social Attitudes Toward Abortion

There is evidence that attitudes toward abortion and provision of abortion have liberalized over the past ten to fifteen years. In a fact sheet on the legal and ethical issues surrounding abortion, the Family Planning Association quotes the British Social Attitudes Survey, in which it was shown that the number of United Kingdom people who felt abortion should be allowed when a woman's health was endangered increased from 87 percent in 1983 to 95 percent in 1989. This trend was consistent when other questions, such as the economic situation of the woman and her family, and the woman's own choice, were considered (FPA Factsheet 6B, 1992, p. 4).

This trend is also reflected in the medical profession. “A national survey of consultant gynecologists in 1989 found that 73 percent believed that a woman should have the right to choose abortion” (Paintin 1992, 968). This same survey, carried out by Savage and Francome, also showed that 87 percent of gynecologists at the Royal College of Obstetricians and Gynecologists had been right to oppose one of the more recent changes to the Abortion Act, the Alton Bill. There seems to be a general understanding that people feel that the current system works quite well.

Incidence

The latest available figures (Office of Population Census and Surveys Monitor, April 11, 1995) show that during 1993 a total of 168,711 abortions were performed in England and Wales, 2 percent fewer than in 1992 when the total was 172,063. The 1992 total figure included both the resident and nonresident figures, with 160,495 resident women obtaining abortions and the remainder being accounted for mainly by Irish women seeking an abortion abroad since it is not legal in the Republic of Ireland. The 1992 TOP (terminations of pregnancy) rate for residents of the United Kingdom was 12.51 per 1,000 women.

The reason most frequently cited by women seeking an abortion was risk of injury to the physical and mental health of the pregnant woman. The main provider was the National Health Service. Section 4 of the Abortion Act of 1967 affords legal protection to health care workers who refuse to participate in abortion on grounds of conscience. Prospective fathers, on the other hand, were, in Paton vs. Trustees of BPAC (1979 - QB 276), denied the right to intervene to prevent an abortion.

There has been little change in the proportion of women seeking abortion since the introduction of the 1967 Abortion Act. In a 1992 article in the British Medical Journal, David Paintin, then a Research Fallow at St. Mary's Hospital, London, observed that: “The lack of change in the proportion of pregnancies ending in legal abortion suggests that the behavior factors that lead to unwanted conception and abortion are intrinsic to our society and that easy availability is not a primary factor in the decision concerning abortion” (Paintin 1992, 967). This is an important point, since those who oppose abortion seem to believe that should abortion become more “freely” available, there would be a marked increase in the number of women who choose legal abortion, and that any “loosening” of the restrictions that pertain to abortion in England and Wales should therefore be opposed. In England and Wales, in 1991, the vast majority of legal abortions - 88 percent - were performed before the thirteenth week of pregnancy (Family Planning Association Factsheet 6A, 1994, Table 6, 7).

D. Population Planning Programs and Policies

PETER SELMAN

Despite the fact that birthrates in the United Kingdom have been falling since the late nineteenth century, and the fertility rate has dropped below replacement level (namely, a Net Reproduction Rate below 1.00) between 1927 and 1943 and since 1973, the population of the United Kingdom has grown steadily, with a reduction in size evident only in the late 1970s, when the population fell from 55,922,000 in 1974-1975 to 55,835,000 in 1978-79. Since then, the population has increased steadily to 58 million in 1992. Experts project the population of the United Kingdom will surpass 62 million by the year 2031, after which a steady decline is expected with the population returning to the 1992 level by the year 2061 (OPCS 1994).

The initial fall in the birthrate occurred, as in most countries, without any government pressure and in the face of opposition to birth control. In England and Wales, the period total fertility rate fell from 4.8 in the 1870s to a low point of 1.72 in 1933 (OPCS 1987). It was at this stage that we find the first signs of concern over population decline, as birthrates fell to below replacement level, and differences in fertility became apparent as middle-class groups married late and had few children while lower-working-class people had a substantially higher fertility. This led to concern about the quality of the population and to the development of the eugenics movement. A number of publications warned of the dangers of depopulation (Charles 1936; Glass 1936; Hogben 1938), a national decline (Reddawa 1939), “race suicide” (McCleary 1943), and a rejection of parenthood (Titmuss 1942). Charles (1938) projected the British population for 1995 at 20 million, a little more than a third of the actual population today.

In 1944, a Royal Commission on Population was set up to consider whether Britain was indeed facing a population decline and whether measures should be taken “in the national interest” to influence future trends. The Royal Commission reported in June 1949, soon after the 1947 crude birthrate was announced as 20.5, the highest Figure since the end of World War I, and the net reproduction rate (NRR) had risen to 1.21. The commission saw this as a temporary aberration and projected a long-term decline in population. The Commission did not, however, recommend any counter action and no official population policy followed. Others were less sanguine (McCleary 1943; Titmuss 1942); in the same year Eva Hubback (1947) projected the 1999 British population at 34 million.

No one predicted that within a decade the birthrate would be rising sharply to the highest level since the end of World War I (Holmans 1963). Nor was there any expectation that migration would play a role in boosting population growth: “The Royal Commission never dreamt that 2.5 million colored immigrants and their descendants would be living in Britain just thirty years after their report” (Coleman and Salt 1992). Restrictions on Commonwealth immigration were introduced in the early 1960s and have since been maintained by both political parties. However, these policies are due more to racist concerns than to any fear of excess population. Nevertheless, it is important to note that, without such immigration and the consequent births to immigrants and their descendants, Britain's population would by now most certainly be in decline.

By 1964, the crude birthrate had risen to 18.5 and the total fertility rate to 2.93 (OPCS 1987), and in 1965 the General Register Office projected a population for England and Whales in 2001 of over 66 million. This led to new concerns about overpopulation. In 1971, a Population Panel was appointed following the publication in that year of a White Paper responding to a report from the House of Commons Select Committee on Science and Technology on the Population of the United Kingdom, which had concluded that “the government must act to prevent the consequences of population growth becoming intolerable for the every day conditions of life.”

The Report of the Population Panel was published in March 1973, by which time the birthrate had fallen substantially and the net reproduction rate was once again below 1.00. It concluded that the population of Great Britain would “almost certainly rise from 54 million in 1971 to around 64 million in the course of the first decade of the next century... [and to] over 80 million around the middle of the next century.” If, however, fertility were to fall rapidly, population could decline to 40 million by 2050, and there would be “profound changes in the age structure” with serious social consequences. Reviewing the implications of anticipated growth, the Panel concluded that “there is no reason to suppose that 64 million (by the beginning of the twentieth century) would be in any way intolerable or disastrous,” but that “to absorb a further 20 million by 2051 could be much more intractable” so that “a slower rate of increase... is clearly preferable.” Less attention was paid to the possibility of a population decline, other than to state that “if there were to be a fall in fertility which led... to an excess of deaths over births, this should not be a cause of public concern.”

No explicit population policy was recommended, although the Government was advised to extend family planning services and inform people about the fact of the population problem. The panel was less happy about persuading people of the advantages of smaller families and opposed fiscal and other disincentives to having children. By 1977, the crude birthrate had fallen to 11.5 and the total fertility rate to 1.66, the lowest levels since records began, and any further measures to discourage parenthood were viewed as inappropriate.

Since then, the crude birthrate has risen again and has remained steady between 13 and 14 since 1985. In 1990, the total fertility was 1.8, below replacement level, but high in comparison with other European countries such as Italy (1.29) and Spain (1.3). The population is, nevertheless, projected to grow until the second quarter of the next century (OPCS 1994). Concern is expressed over the implications of an aging population (Johnson and Falkingham 1992), but there is no overt policy to increase fertility, and recently more concern has been focused on rising divorce rates, the decline in marriage, and the associated increase in childbearing outside marriage, especially among teenagers (Selman 1996).

Despite two substantial reports on population, the United Kingdom has never developed a population policy, which is probably just as well, given the wrong assumptions each report made about the future. Whether this will continue to be the case in the next century, if a significant population decline occurs alongside a more rapidly aging population, remains to be seen.

10. Sexually Transmitted Diseases

PETER GREENHOUSE

The United Kingdom's unique network of specialist clinics (see Section 10B) collect detailed statistics for the Department of Health (HMSO 1995/16), which reflect trends in sexually transmitted diseases (STD) with a high degree of accuracy. These statistics give a better indication of the true incidence of STD in the United Kingdom than those of most other countries, because of the relative low proportion of infections treated outside the National Health Service. It is estimated that over 95 percent of the epidemic STD, namely, syphilis and gonorrhea, are managed at the NHS clinics. The proportion is somewhat less for the more endemic diseases - chlamydia, genital herpes, and genital warts - because of their covert nature, with the proportion for chlamydia being recently reduced by a belated surge of interest among gynecologists, contraceptive care professionals, and general practice physicians. The majority of HIV care is also organized from the NHS clinics (see Section 11).

Control of syphilis and gonorrhea has been particularly successful in the United Kingdom (see Table 3). There are fewer cases of infectious syphilis per year in men in England (194 cases in 1994) than there are clinics in the United Kingdom, 230. The figure for women was roughly half the male figure, 110 cases in 1994. Twenty percent of the male cases were acquired through homosexual contact. The median age for new cases of syphilis is higher than for other STDs, 33 for men and 28 for women. Syphilis has become an imported disease, having been virtually eliminated as a congenital infection, with only one infection reported in 700,000 live births in 1993.

Table 3: Incidence of Gonorrhea and Syphilis, England, 1918 to 1994

	Number of New Cases in Selected Years (in Thousands of Cases)
Disease	1918	1920	1922	1930	1940	1946	1955	1964	1977	1987	1994
Gonorrhea	17.4	37.9	27.9	40.5	26.3	47.4	17.4	37.9	58.7	24.5	11.6
Syphilis	26.8	42.1	24.2	18.9	11.4	24.2	5.0	3.8	4.2	1.8	1.3

Approximated by the General Editor from a line graph supplied by the authors.

Chlamydia trachomatis, the principal preventable cause of pelvic inflammatory disease, infertility, and ectopic pregnancy, is the commonest curable STD in the United Kingdom. All isolation rates for chlamydia substantially underestimate its true incidence, since screening tests are, at best, 75 to 80 percent sensitive, and most infected men and women show no symptoms. The cases identified at NHS STD clinics represent only the tip of the iceberg. The differential age and sex rates for chlamydia (Communicable Disease Report 1995, 122-123) are similar in distribution to those of gonorrhea (Communicable Disease Report 1995, 62-63), herpes and warts (Communicable Disease Report 1995, 186-187), and representative of all STD combined, with highest rates in adolescent women, and a late lower peak in male cases. The peak incidence of 360 cases per 100,000 women aged 16 to 19 years - four times more than in men of the same age - should be compared with observed rates from 9.5 percent to 23 percent in studies of women of this age who are having an abortion. No significant differences were found in the chlamydial isolation rates (of around 10 percent) in women attending clinics for either contraception, abortion, or STD (Radcliffe 1993), although, even nowadays, most women are not routinely screened in the contraception clinics. Chlamydia and nonspecific genital infection rose steadily until 1986, peaking at 157,792 cases, and has shown a slight decline since then, despite improved diagnostic techniques.

At least 85 percent of all pelvic inflammatory disease (PID) is sexually acquired, a minimum of 75 percent due to chlamydia. Around 10 percent of pelvic inflammatory disease is treated in a hospital. The massive drop in gonorrhea in the United Kingdom in 1986 to 1988 was not matched by a significant drop in hospital cases of acute salpingitis. A similar phenomenon in 1970-77 in Sweden alerted Westrom (1988) to the true etiology of salpingitis, and appropriate diagnosis, treatment, contact tracing, and education was initiated. In both countries, salpingitis incidence had doubled between 1965 and 1974. From 1978 to 1983, salpingitis admissions were halved in Sweden (Westrom 1988), but increased by 50 percent from 1975 to 1984 in Britain, which almost two decades later has yet to introduce a similar salpingitis-prevention campaign. Contact-tracing studies indicate very high infection rates of over 70 percent in male partners of women with salpingitis, the vast majority of whom are asymptomatic.

There has been a continuing long-term upward trend in first-attack incidence of both genital herpes and genital warts, full details of which have been published (Communicable Disease Report 1995, 186-187). Herpes is more common in women, increasing from 32 to 98 per 100,000 between 1981 and 1994. Seroepidemiological studies in the United Kingdom show that around 90 percent of men and women aged 25 to 34 have antibodies to both herpes viruses (HSV 1 and 2), of which about one third are HSV 1. Up to 50 percent of oral lesions have been found to harbor HSV 1. Thus, although oral and genital herpes infection is ubiquitous, relatively few individuals suffer overt symptoms, and many will have acquired oral infection in childhood. This information is of considerable value in diffusing the stress of a first-episode attack acquired sexually.

Full details of the minor STDs are also available from published statistics (HMSO 1995/16). Long-term trends in total attendance for all diagnoses shows a continuous increase to a current high of 671,281 in 1993. Records show an increasing proportion of clinic attenders are female, from one seventh in 1950 to one quarter in 1960 and one third in 1970. Now, 51 percent of all attenders are women, with some clinics up two thirds, depending on the extent of contraceptive and other sexual health services provided. These trends are set to continue as the clinical workload comes closer to reflecting the gross disparity in STD morbidity suffered by women.

B. Treatment and Prevention

Thanks to exceptional, far-sighted public-health legislation, the United Kingdom has had specialist clinics offering free and entirely confidential STD advice and treatment in every major town since 1917. Accessible care is available to all regardless of nationality or domicile. Voluntary contact tracing and treatment of partners is facilitated by health advisers, without the intrusion of coercive legislation. The United Kingdom is the only country where Venereology (currently known as Genito-Urinary Medicine) developed as a distinct medical specialty in its own right (Waugh 1990), rather than as a minor adjunct to other fields, such as dermatology in Europe, or infectious diseases and public health in the United States. Consequently, Britain has a well-trained, academically based specialist body, whose numbers have doubled in the last decade as the result of substantial government investment in improved premises, equipment, and expanded support staff. The specialty coordinates clinical care and epidemiologic research, and can implement rapid and consistent responses to changing public-health priorities in the control of STD, having been ideally placed to take the lead in caring for HIV (see Section 11). The advantage of this approach is evidenced by the relatively low prevalence of HIV and other STDs compared to most countries other than Scandinavia (see Section 10A above).

An important disadvantage is that other specialists are poorly trained or are unaware of STD, and are unlikely to be able to broach the subject (Clarke 1995) without either embarrassment or moralism. (This holds the greatest potential for damage in women's heath care.) Not only are most genitourinary physicians untrained in gynecology, most gynecologists and family planning specialists were, until recently, ignorant of the significance of covert STD in their patients. This resulted in considerable morbidity from uterine instrumentation during abortion or IUD insertion, and multiple recurrences of salpingitis due to reinfection from untreated partners, leading to increased chronic dyspareunia, ectopic pregnancy, and infertility.

Despite governmental interference in school sex education policy (see Section 3A), there have been substantial advances in the general level of education on HIV and, to a lesser extent, on contraception, aided by the government's Health of the Nation Initiative on sexual health. Education on conventional STD, however, has been almost entirely neglected. Sexual health education is usually delivered by those without specific knowledge or experience of STD care. Thus the public as a whole, including health professionals, remain largely ignorant in this area. In the recent international survey on STD awareness for the American Social Health Association (Clarke 1995), the United Kingdom compared poorly against five other countries. Only 1 percent of Britons had heard of chlamydia, and 75 percent said that their doctors would not talk about sex or STD. This ignorance, combined with the traditional British attitude of prurience and prudishness about sex, creates the societal taboo of STD. This stigma, causing guilt, shame, and blame, is based on misinformation, fear, and an automatic presumption of infidelity, which is often erroneous due to the very asymptomatic nature of most STD that causes them to be endemic. This major pitfall results in substantial psychosexual trauma that plagues work in all fields of sexology.

A simple solution will be found in the increasing integration of sexual health promotion with clinical service provision. Teaching that most STDs produce no symptoms, can be present for many years, are acquired from partners who are likewise unaware, and may, therefore, have been present before the current relationship, should do much to destigmatize the subject. Furthermore, a national consensus of specialists in public health, family planning, genitourinary medicine, and health education has recently promoted a concise definition of sexual health: “the enjoyment of sexual activity of one's choice without causing or suffering physical or mental harm” (Greenhouse 1994). This same consensus agreed that these specialties should progressively converge to provide services for contraception, abortion, STD/HIV, sexual assault, psychosexual care, and health promotion under the banner of sexual health clinics (Greenhouse 1994). Broadening the scope of these services allows access to more appropriately coordinated care “under one roof.” This is essential for the youngest in the most vulnerable situations, and may persuade people to attend a clinic to check that they are healthy rather than waiting until they are ill. With careful education input, this should improve public understanding, reduce stigma, prevent iatrogenic morbidity, and achieve even more-effective control of STD in clinical situations where they would previously have gone undetected.

11. HIV/AIDS

JANE CRAIG AND GEORGE KINGHORN

London and its surrounds, the Thames regions, have reported 70 percent of all AIDS cases and 65 percent of all recorded HIV infections in the United Kingdom to date. Of these, two thirds (i.e., half of all cases in England and Wales) have been reported from three London districts. Scotland accounts for 6 percent of all United Kingdom AIDS cases and 9 percent of HIV infections.

Overall, the proportion of HIV infections due to homosexual exposure has been relatively large. However, this varies considerably between different parts of the country. In England, Wales, and Northern Ireland, 75 percent of AIDS cases are attributed to infection acquired through sex between men and only 4 percent of cases are attributed to injecting drug use, whereas, in Scotland, these groups account for 41 percent and 36 percent respectively.

The proportion of reports from different exposure categories has also changed over time. The proportion of AIDS cases in the United Kingdom attributable to sex between men has fallen from 95 percent in 1985 to 70 percent in 1994. The proportion attributed to injecting drug use has risen from 1 percent to 9 percent over the same period and, likewise, the proportion of AIDS cases attributed to heterosexual exposure has risen from 4 percent to 19 percent. Similar trends are seen for HIV infections reported in England, Wales, and Northern Ireland. However, the trend in Scotland is somewhat different, where the proportion of HIV infections attributed to sex between men has doubled in the last ten years, while those attributable to injecting drug use has halved. This may reflect the efforts of locally targeted prevention programs among drug users. The proportion of HIV infection in Scotland due to heterosexual exposure has risen, and more so than in the rest of the country. In the United Kingdom as a whole, the majority of heterosexually acquired infections are attributed to heterosexual exposure while in Africa or, increasingly, Asia, rather than other exposure categories such as partners of injecting drug users.

Genitourinary medicine clinics offer a voluntary, open-access, confidential HIV-testing service nationwide. All blood donors have been tested since 1985. There are several ongoing, anonymous, unlinked HIV-seroprevalence studies at selected sites involving women attending antenatal clinics and attendees at genitourinary medicine clinics who are having blood tests for syphilis screening. Most people who request HIV testing are of low risk, and such requests have often been in response to publicity events such as the death of a public figure from AIDS rather than to large-scale government-sponsored AIDS-education campaigns (PHLS AIDS Center, June 1995).

For United Kingdom residents, medical care and treatments are provided free of charge under the National Health Service. It is recognized that a small but significant number of patients choose to travel to inner London for specialist health care, which contributes to the continuing large numbers of reported cases from these centers.

The gay community has become well-organized and motivated with self-initiated prevention and education campaigns. There are also numerous patient-interest and support groups. Safer-sex practices have been accepted by many, although there is some evidence that younger men are ignoring this message as their rates of newly acquired HIV infection are increasing (Miller et al. 1995). Initiatives, such as outreach work among targeted groups rather than didactic health care messages, seem to be more successful and resources are now directed towards such schemes.

National needle- and syringe-exchange programs have been operational since 1990 and there has also been discussion about extending this service to closed communities such as prisons. The government has identified sexual health as a key issue nationally. Targets for the control of sexually transmitted diseases and for the reduction of the rates of unplanned teenage pregnancy have been set (Secretary of State for Health 1992). Each health district has an obligation to educate and increase awareness among its health-care workers and to have a designated HIV-prevention officer coordinating local government and voluntary sector initiatives.

School sex education remains a controversial topic. Opponents often claim that such lessons reduce the age of first sexual activity. At present, attendance at sex education classes is voluntary and parents have the right to withdraw their children. However, recent research suggests that sex education programs can be effective in delaying the onset and frequency of sexual activity and may also result in an increased use of contraception, in particular condoms (Kirby 1993). Effective programs seem to be those focusing on reducing specific risk behaviors, combined with opportunities to improve personal development and communication skills. This has obvious implications for the provision of school-based sex education in the future.

Overall, there is a greater awareness of HIV infection, but risk recognition remains a issue for many, as is reflected by the increasing number of heterosexual infections acquired abroad. Prevention programs need to target such groups, as well as continuing their efforts amongst other high-risk communities.

12. Sexual Dysfunctions, Counseling, and Therapies

KEVAN R. WYLIE

British society appears to be having a reemergence of sexual awareness. After a very conservative attitude towards sex in the first half of the century there was an awakening in the 1960s alongside the increased use of illicit drugs, the emergence of rock and roll, and a “free” society. The permissive society continued into the 1970s and early 1980s, until, like many other countries, the fear of AIDS changed the sexual behavior of many in the mid 1980s. Out of this has grown a more-cautious approach to sexual encounters with others and a reemergence of encouraging more satisfying sexual relationships within a monogamous relationship.

There is wider access to articles and books on sexual fulfillment, and awareness of dysfunction has increased, primarily as a result of articles in the popular press and lifestyle magazines. There is some evidence that there has been a reversal of the age of the First sexual experience of teenagers, and there has been an increase in patients requesting help over the wide spectrum of sexual dysfunction. One area where this has become particularly evident is male erectile disorder, for which a proliferation of treatment centers, both within the health service and in the private sector, has developed. A recent attempt to define sexual dysfunction is “the persistent impairment of the normal patterns of sexual interest or response.”

B. The Availability of Diagnosis and Treatment

Within the United Kingdom, all patients are entitled to free consultation under the National Health Service. The planning and availability of sexual dysfunction clinics varies widely from area to area. Traditionally, these have been within family planning clinics and have gradually been extended by interested clinicians within gynecology, psychiatry/psychosexual, and genitourinary clinics. The family planning association service has been traditionally run by doctors, although there has been a gradual introduction of nursing and psychology staff into these and other treatment clinics. Seminars held by Doctors Balint and Main in the 1960s and 1970s developed the concept of psychosexual medicine and emphasized the importance of using the physical (vaginal) examination in the management of female sexual problems. In the 1980s, patients with male erectile disorder started to be seen within the urology, rather than psychosexual, clinics, although in the 1990s, it is becoming generally agreed that, because around half of these cases are of a psychological nature and a proportion have both organic and psychological components, there is a need for either dual clinics or access to either. There is an increasing awareness of the need to consider cultural factors in sexual dysfunction, and this is particularly important for various ethnic groups.

A nonhealth service organization offering treatment for sexual dysfunction is available from Relate (formerly Marriage Guidance). Paul Brown, a psychologist, showed in 1974 that psychodynamically trained counselors were able to focus specifically on sexual dysfunctions using behavioral approaches. This organization has a network of specially trained sex therapists who have a training in relationship work. This service is not provided free, but clients are charged nominal sums according to their income - typically £20 to £30 per session. Other agencies include the Catholic Marriage Advisory Council and the Jewish Marriage Council. Private facilities for diagnosis and treatment of sexual disorder do exist, but are primarily around major cities or areas where no N.H.S. provision is easily accessible.

Treatment approaches include the traditional medical approach using medication, intracavernous injections, VCDs, etc. Psychotherapeutic treatments are usually based on the behavioral model proposed by William Masters and Virginia Johnson, although increasingly with cognitive and systemic strategies incorporated. Some workers continue to use a dynamic model of working with patients. Increasingly, couple therapy is adopted incorporating both relationship and sexual therapy. Surrogacy services are available from the Birmingham clinic run by Martin Cole.

Specialist services for transsexualism exist, with assessment for reassignment surgery possible at Charing Cross Hospital London and St. James's University Hospital, Leeds.

C. Therapist Training and Certification

There is no central certification body within the United Kingdom. The main association is the British Association for Sexual and Marital Therapists (BASMT), which was formed in 1974. This organization approves certain training courses and provides an accreditation process for individuals to apply for. The majority of new therapists will complete an approved course and a further 200 hours of supervised work, alongside fulfilling other criteria (first detailed in 1992) before accreditation. The approved training courses are listed in Section 13. The address for BASMT is P. O. Box 62, Sheffield, S10 3TL.

Currently, a group of BASMT members (The Committee for European Affairs) meets as an approved task force for the European Federation of Sexology. The goals are to establish a consensus within Europe as to what precisely constitutes a multidisciplinary profession of sexology, and subsequently, to devise European Codes of Ethics and Practice for those defining themselves as sexologists; they also seek to define European standards of training and to draw up a European register of accredited practitioners within given subspecialities of sexology.

Medical practitioners may become members of BASMT. Alternatively, they may follow a training course of seminars run by the Institute of Psychosexual Medicine (IPM) and are subsequently examined to become members of the institute. Members are recognized as competent to receive referrals. A diploma recognizes the skills of those who have been training for two years, but do not wish to make the treatment of sexual problems a specialist field. Contact: IPM, 11 Chandos Street, Cavendish Square, London, W1M 9DE.

The Diploma in Sexual Medicine (DSM) is awarded to doctors who can produce evidence of training and experience, as well as successfully passing written and oral examinations in the fields of sexual medicine. Areas in which the above must be demonstrated are gynecology, sexual medicine, and the physical and psychological aspects of assessing and treating sexual problems. Details are available from the Institute of Obstetrics and Gynaecology, Queen Charlotte's Hospital, Goldhawk Road, London, W6 0XG.

The Royal Medical Colleges do not offer training or accreditation in sexual dysfunction, but membership does reflect postgraduate training and examination to an advanced level within a given speciality. Three relevant colleges are:

Royal College of Obstetrics and Gynaecology, 27 Sussex Place, Regents Park, London, NW1 4RG United Kingdom - The Faculty of Family Planning and Reproductive Health Care (RCOG) have a particular interest in the field of psychosexual medicine.

Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PN, United Kingdom.

Royal College of Psychiatrists, 17 Belgrave Square, London, SW1X 8PG United Kingdom.

13. Research and Advanced Education

KEVAN R. WYLIE

The support and financial availability for research within the United Kingdom remains limited. Several sexological research units exist, including the MRC unit in Edinburgh, and the Institute of Psychiatry and teams in Oxford, Sheffield, and Southampton. There remain many political pressures to frustrate sexological research, with the government declining to finance the United Kingdom National Survey of Sexual Attitudes in Lifestyle in 1989. Political influence is also exerted on education with the Health Education Authority shelving a Pocket Guide to Sex after the government attacked its colloquial frankness.

B. Programs for the Advanced Study of Human Sexuality

Sex education is now compulsory in state secondary schools as a result of the 1993 Education Act, although reference to nonbiological behavior has been removed from the national science curriculum. The training in human sexuality in United Kingdom medical schools for medical undergraduates has been reviewed by Reader (1994). Education and training in human sexuality, including postgraduate training, has recently been considered by Griffin (1995).

Postgraduate training exists for various professions. The courses are usually attended by both medical graduates, as well as workers from other health-care disciplines. As courses expand to the master's level, the qualifications required for entry into these courses become more stringent. These are classified as either an approved course by BASMT or nonapproved. The BASMT approved training courses are:

Diploma in Psychosexual Therapy (Marriage Guidance), Herbert Gray College, Little Church Street, Rugby CV21 3AP United Kingdom.

Master of Science degree in The Theory and Practice of Psychotherapy for Sexual Dysfunction, The Porterbrook Clinic, Whiteley Wood Clinic, Woofindin Road, Sheffield S10 3TL United Kingdom.

Diploma in Psychosexual Health Care, Department of Psychiatry, Withington Hospital, Didsbury, Manchester M20 8LR United Kingdom.

Master of Science degree in Human Sexuality, Human Sexuality Unit, 3rd Floor Lanesborough Wing, St. George's Hospital Medical School, Cranmer Terrace, London SW17 0RE United Kingdom.

Master of Science degree in Therapy with Couples, The Registry, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF United Kingdom.

Certificate in Psychosexual Counseling and Therapy, South East Hants Health Authority, c/o Myrtle Cottage, Selbourne, Nr Alton, Hants GU34 3LB United Kingdom.

C. Sexological Journals and Periodicals

The major sexological journals in the United Kingdom are:

Sexual and Marital Therapy. Editor: Patricia d'Ardenne, Department of Psychological Medicine, William Harvey House, 61 St. Bartholomews Close, London EC1A 7BE, United Kingdom (Published four times a year from 1996).

The International Journal far Impotence Research. Editors: William L Furlow and Gorm Wagner, Smith-Gordon and Company Ltd., Number 1, 16 Gunter Grove, London SW10 0UJ, United Kingdom (Published quarterly).

British Journal of Family Planning. Editor: Jeannette Cayley, RGOG, 27 Sussex Place, Regents' Park, London NW1 4RG United Kingdom.

The Institute of Psychosexual Medicine Journal. Editors: Dr. H. Montford and Dr. R. Skrine, c/o 11 Chandos Street, London (Published 3 times a year).

The British Journal of Sexual Medicine. Editor: Paul Woolley, Hayward Medical Communications Ltd., 44 Earlham Street, Covent Garden, London WC2H 9LA, United Kingdom (Published six times a year).

Journal of Sexual Health. Editor: Dr. Alan Riley, MAP Publishing, Sussex Court, 10 Station Road, Chertsey, Surrey KT16 8BE, United Kingdom (Published ten times a year).

Perversions: The International Journal of Gay and Lesbian Studies. Editors: Neil McKenna and Linda Semple, BM Perversions, London WC1N 3XX, United Kingdom (Published three times a year).

The Journal of Gender Studies. Editors: Jenny Wolmark and Jenny Hockey, University of Humberside, Ing Lemine Avenue, Hill HU6 7RX United Kingdom (Published twice a year).

Organizations dealing with sexuality include the following:

British Association of Sexual and Marital Therapists, P. O. Box 62, Sheffield S10 3TL United Kingdom.

British Association for Sex and Marital Therapy, 7 Grange Park Place, Thruston Road, Wimbledon, London SW20 0EE. United Kingdom. Telephone/Fax: 44-181-241-1201.

Family Planning Association, 27-35 Mortimer Street, London W1N 7RJ United Kingdom. Telephone: 44-71-636-7866; Fax: 44-71-436-3288.

Marie Stopes UK, 6 Grafton Mews, London W1P 5LF United Kingdom. Telephone: 44-71-383-2494; Fax: 44-71-388-1885.

Sex Education Forum and National Children's Bureau, 8 Wakley Street, London C1V 7QE United Kingdom. Telephone: 44-71-278-9441; Fax 44-71-278-9512.

Institute of Psychosexual Medicine, 11 Chandos Street, Cavendish Square, London W1M 9DE United Kingdom.

British Society for Psychosomatic Obstetrics, Gynaecology and Andrology, 11 Chelmsford Square, London NW10 3AP United Kingdom.

Marce Society (Mental illness related to childbearing), c/o Dr. T. Friedman, Liaison Psychiatry Service, Leicester General Hospital, Gwendoeln Road, Leicester LE5 4PW United Kingdom.

Tavistock Marital Studies Institute, The Tavistock Centre, 120 Belsize Lane, London NW3 5BN United Kingdom.

Institute for Sex Education & Research, 40 School Road, Moseley Birmingham B13 9SN United Kingdom.

Relate, Herbert Gray College, Little Church Street, Rugby CV21 3AP United Kingdom.

The following are a list of telephone hotlines available in the United Kingdom:

AIDS Helpline: 0800 567123
Victim Support: 0171 735 9166
Pace (gay & lesbian couples): 0171 700 1323
Spod (people with disabilities): 0171 607 8851
National Association for Premenstrual Syndrome: 0173 274 1709
Rape Crisis Centre: 0133 237 2545
Sex Addicts Anonymous: 0171 472 7278
Survivors (male sex-abuse victims): 0171 833 3737
National Association for the Childless: 0121 359 7359

14. Significant Differences in Sexual Attitudes and Behaviors Among Ethnic Minorities

KEVAN R. WYLIE

Clulow (1993) has considered ethnic and religious differences in couple relationships. The presentation of ethnic minorities to sexual dysfunction clinics pose particular problems to clinicians in addition to the cultural issues mentioned above. There are high expectations that physical remedies will be available (Ghosh et al. 1985). An excellent review of presentation of sexual problems within different cultures, clinical assessment, and their management has recently been presented by Bhugra and De Silva (1993). As newer medications become recognized as having potentially beneficial applications in sexual dysfunction, the clinician may have a further armaturarium towards helping some patients within this group.

The issue of HIV, sexuality, and ethnic minorities, particularly Afro-Caribbeans, is an area where there is increasing interest in the United Kingdom.

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